PREOPERATIVE SINGLE ANTHROPOMETRIC SCREENING TESTS OF DIFFICULT FACE MASK VENTILATION AND DIFFICULT DIRECT LARYNGOSCOPY INTUBATION IN PATIENTS UNDERGOING OTORHINOLARYNGOLOGICAL SURGERY: A PROSPECTIVE, OBSERVATIONAL, SINGLE CENTER STUDY.

The aim of this study was to assess preoperative airway history data and single anthropometric screening tests of difficult face mask ventilation (FMV) and difficult direct laryngoscopy intubation (DLI) in otorhinolaryngological surgery. Final analysis included 62 patients aged ≥14 years undergoing elective surgery with endotracheal intubation at a single center during a one-month period. Data on difficult intubation history, airway symptoms and pathology related to difficult airway were prospectively collected. Han scoring classification of FMV and Intubation Difficulty Score (IDS) were used. There were 14 (22.6%) patients with a history of current airway tumors or abscesses. Only two (3.2%) patients were preoperatively evaluated as anticipated difficult airway. Both were slightly difficult to ventilate and scored IDS 5 and IDS 8. FMV was graded as easy in 50 (80.5%), slightly difficult in 10 (16.1%) and difficult in 2 (3.2%) cases. There were 29 (46.78%) slightly difficult DLIs and one (1.6%) case of difficult DLI. The study confirmed clinically relevant incidence of difficulties with FMV and DLI in otorhinolaryngologic surgery patients. However, there should be stronger evidence to identify a single preoperative variable predicting difficult airway.

CHALLENGES IN THE USE OF VIDEO LARYNGOSCOPES.

Despite the lack of uniformity and the need of further investigation, video laryngoscopy continues to gain popularity both inside and outside the operating room. It has quickly become a first line strategy for potential and/or encountered difficult intubation. It is well established that video laryngoscope improves laryngeal view as compared with direct laryngoscopy in patients with suspected difficult intubation and simulated difficult airway scenarios. For novices and experienced anesthesiologists alike, video laryngoscopy is easy to use and the skills involved are easy to master. However, it is important to say that video laryngoscopes may be used in a variety of clinical scenarios and settings because of the video laryngoscope design offering an alternative intubation technique in both anaesthetized and awake patients. The aim of this article is to show and highlight clinical situations in which the use of video laryngoscope is a challenge for an experienced anesthesiologist in solving the airway. Challenges in the use of video laryngoscope with which we deal and encounter in everyday clinical practice that are discussed in this paper are intubation in the prehospital setting and emergency departments, intubation in Intensive Care Unit, intubation in a patient with cervical spine immobilization, and awake video laryngoscopy-assisted tracheal intubation in the obese. We also point out the important role of video laryngoscope as a tool for teaching and training in airway education. Training and education in difficult airway management is essential to improve patient safety at endotracheal intubation in emergency situation.

ALTERNATIVE DEVICES IN AIRWAY VISUALIZATION.

The Macintosh laryngoscope has been the most widely used device for intubation since its invention by Foregger in the 1940s. Recently, video and optic laryngoscopy assisted tracheal intubation has been used widely in patients with difficult airways. Their routine use, however, is not widely practiced. This review will summarize some of the newly available devices to assist tracheal intubation, with their advantages and disadvantages when compared with conventional laryngoscopes. It also presents the reasons to support their use in both elective and emergency airway management.

Comparison of Cormack Lehane Grading System and Intubation Difficulty Score in Patients Intubated by D-Blade Video and Direct Macintosh Laryngoscope: A Randomized Controlled Study

D-blade is a relatively new device in the field of videolaryngoscopy, designed for airway management by enabling indirectoscopic glottic view. In our study, we investigated efficiency of D-blade in comparison with direct Macintosh laryngoscope (gold standard). Fifty-two adult patients with normal airway scheduled for elective surgery in general anesthesia were randomly assigned in D-blade video or direct Macintosh group. In the first video group, patients were laryngo-scoped and intubated by D-blade, and in the second group laryngoscopy and intubation were performed by Macintosh laryngoscope. Glottic view was evaluated according to Cormack Lehane grading system (C-L), while duration of intubation and easiness of intubation were evaluated according to the intubation difficulty score (IDS). Additionally, hemodynamic parameters were recorded before and after induction. There were no statistically significant between-group differences in time to intubation, easiness of endotracheal tube insertion, C-L, and IDS. In comparison with direct Macintosh laryngoscope, D-blade showed similar but still favorable characteristics. In our opinion, D-blade is a useful device in airway management and should be used in daily anesthesiologist work.

USE OF RECOMBINANT ACTIVATED FACTOR VIIa IN A-SIX-MONTH-OLD CHILD DUE TO MASSIVE HEMORRHAGE DURING ELECTIVE SURGERY FOR CHOROID PLEXUS CARCINOMA: CASE REPORT.

We present the use of recombinant activated factor VIIa (rFVIIa) in a 6-month-old infant that suffered massive bleeding and subsequent coagulation disturbances during elective surgery for choroid plexus carcinoma in the lateral ventricle. The administration of rFVIIa resulted in good hemostasis. No intra- or postoperative thromboembolic complications were observed.

[Croatian guidelines for perioperative enteral nutrition of surgical patients]. / Hrvatske smjernice za perioperativnu enteralnu prehranu kirurskih bolesnika.

Nutritional status of patients significantly affects the outcome of surgical treatment, whether it's about being obese or malnutrition with loss of muscle mass. Inadequate nutritional support in the perioperative period compromises surgical procedures even in patients who are adequately nourished. In this paper, particular attention was paid to malnourished patients, and their incidence in population hospitalized in surgical wards can be high up to 30%. Special emphasis was paid to the appropriateness of preoperative fasting and to the acceptance of new knowledge in this area of treatment. The aim of this working group was to make guidelines for perioperative nutritional support with different modalities of enteral nutrition. The development of these guidelines was attended by representatives of Croatian Medical Association: Croatian Society for Digestive Surgery, Croatian Society for Clinical Nutrition, Croatian Society of Surgery, Croatian Society for Endoscopic Surgery, Croatian Trauma Society and the Croatian Society of Anesthesiology and Intensive Care. The guidelines are designed as a set of questions that arise daily in clinical practice when preparing patients for surgery and after the surgical treatment, which relate to the assessment of nutritional status, perioperative nutritional support, duration of preoperative fasting period and the selection of food intake route. Assessment of nutritional status and the use of different modes of enteral nutrition should enter into standard protocols of diagnosis and treatment in the Croatian hospitals.

The influence of postoperative epidural analgesia on postoperative pain and stress response after major spine surgery--a randomized controlled double blind study.

Major spinal surgery is associated with severe postoperative pain and stress response, bowel dysfunction, and a potential for chronic pain development. Epidural analgesia has been shown to be advantageous compared to intravenous analgesia alone. The aim of the study was to investigate whether postoperative addition of epidural levobupivacaine to intravenous opioid analgesia offers advantage over intravenous opioid analgesia alone. Eighty-one patients scheduled for spinal fusion were enrolled in the study and randomized into two groups. Postoperatively, group A received 0.125% epidural levobupivacaine and group B received saline. Both groups also received intravenous piritramide as a rescue analgesic. Pain intensity, rescue analgesic consumption, blood glucose, cholesterol and cortisol levels, postoperative blood loss, paresthesia, time to first postoperative defecation, and length of hospital stay were recorded. Sixty-eight patients completed the study. The visual analog scale score (mean 2 vs. 4, p = 0.01), consumption ofpiritramide (25 mg vs. 51.5 mg, p = 0.01) and metamizole (1400 vs. 1875 mg, p < 0.01), incidence of nausea (6% vs. 28% p = 0.02) and blood loss (450 mL vs. 650 mL, p < 0.05) were significantly lower in group A. Bowel recovery and first postoperative defecation also occurred earlier in group A (6% vs. 45%, p < 0.01). Blood cortisol, glucose and cholesterol levels and the incidence of paresthesia did not differ between the groups. In conclusion, after spinal fusion, postoperative epidural administration of levobupivacaine provides better analgesia and fewer side effects with no impact on stress response.

Anesthetic management of acute cervical spinal cord injury in pregnancy.

The incidence of traumatic spinal cord injury is 11,000 per year, with 55% of the injuries occurring between the age of 16 and 33, 18% of these in women of reproductive age. Diagnostic and early spinal decompression along with maintaining the mean arterial pressure to improve spinal cord perfusion and a high progesterone level in pregnancy for its neuroprotective and anti-inflammatory effect have the leading role in neurological recovery and clinical outcome. We present a case of a patient in the 17th week of pregnancy who sustained luxation fracture of the C5 and C6 vertebrae and tetraplegia as passenger in a road accident. The early operative treatment and appropriate anesthetic procedure resulted in good clinical outcome with complete neurological recovery.

General recommendations for the management of aneurysmal subarachnoid hemorrhage.

Subarachnoid hemorrhage is a neurologic emergency and a detrimental cerebrovascular event with a high rate of death and complications. Recommendations have been developed and based on literature search, evaluation of the results of large international clinical trials, collective experience of the authors, and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. The aim of these guidelines is to provide current and comprehensive recommendations and to assist physicians in making appropriate decisions in the management of subarachnoid hemorrhage. Evidence based information on the epidemiology, risk factors and prognosis, as well as recommendations on diagnostic work up, monitoring and management are provided, with regard to treatment possibilities in Croatia.

Recommendations for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage.

These are evidence based guidelines for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage, developed and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. They consist of recommendations for best monitoring, medical treatment and interventions based on the literature, evaluation of the results of large international clinical trials, and collective experience of the authors.

Unilateral spinal anaesthesia in a patient with Osteogenesis Imperfecta with a lower leg fracture: a case report.

Osteogenesis Imperfecta is a rare, genetically determined disease with several possible complications in anaesthesia. Anaesthesiologists therefore pay special attention to the treatment of patients suffering from Osteogenesis Imperfecta since they commonly suffer from a difficult airway and intraoperative positioning difficulties. We report here the case of unilateral spinal anaesthesia in a patient suffering from Osteogenesis Imperfecta type I. A 28-year-old patient diagnosed with Osteogenesis Imperfecta type I was admitted to the hospital due to lower leg fracture requiring surgical treatment. The patient had blue sclerae, triangular-shaped face, macroglossia, scoliosis of thoracic and lumbar parts of the spine, pectus carinatum and thrombocytopenia. Upon the correction of thrombocytopenia, unilateral spinal anaesthesia with hyperbaric levobupivacain was chosen in order to avoid possible complications typical for general anaesthesia. Consequently, unilateral spinal anaesthesia with a customized local anesthetic could be consdered as a safe anesthetic method for such patients.

Difficult airway in advanced Bechterew's disease: case report.

Advanced Bechterew's disease presents with increasing ossification of spinal column, from lower lumbar segments upwards, first causing impossibility to place spinal block in lumbar region, and later, due to stiffness of cervical spine, difficult intubation because of inability to extend and/or flex the neck during direct laryngoscopy and intubation. Mask ventilation, on the other hand, usually is possible. We report a case of a 77-year-old man scheduled for elective hernioplasty, with recently advanced Bechterew's disease. According to the recently accepted Mainz algorithm, we first intended to perform awake intubation through the nose by fiber bronchoscope. The bronchoscope passed easily down to tracheal bifurcation, but placing the endotracheal tube was unexpectedly impossible due to the consequences of broken nose the patient had suffered at the age of 8. Fiber bronchoscope was therefore retracted, and we used the Bonfils rigid fiberscope after induction of general anesthesia, achieving intubation in first attempt.

Difficult airway management at Sestre Milosrdnice University Hospital Center.

Difficult airway has gained increasing interest due to a relatively high number of adverse effects following unsuccessful intubation. Besides traditional techniques, several alternative methods are available today. It is crucial for the anesthesiologists and intensive care physicians to maintain sufficient oxygenation and ventilation of the patient. Hypoxia is one of the most frequent causes of death or severe neurologic defects in anesthesia. Therefore, it is necessary to have an easy alternative to secure the airways in critical situations.

Difficult airway management with bonfils fiberscope in case of emergency: acute abdomen with ileus.

This clinical report describes an emergency case of a 49-year-old man, ASA E III status, with clinical symptoms of acute abdomen and ileus, who was scheduled for urgent surgery. Predictors of difficult intubation (Mallampati test Class III, short thyro-mental (< 6 cm) and sterno-mental distance (<10 cm) with limited mouth opening (inter-incisor gap < 3 cm) were associated with significant comorbidity (rheumatoid arthritis, heart disease, obesity (body mass index 32.6 kg m-2), cervical spine mobility and generalized vascular disease). A specialist experienced in airway management decided on one attempt of Bonfils fiberoptic intubation as primary intervention and urgent tracheotomy, if needed, as secondary intervention. Immediately after assuming supine position on the operating table, the patient lost consciousness and cardiac arrest developed. Successful intubation with oxygenation was followed by cardiopulmonary resuscitation. Upon stabilization of the patient's vital functions, urgent surgery was performed. In the emergency case presented, we succeeded quickly to secure the airway with Bonfils fiberoptic intubation, which allowed for appropriate oxygenation and starting resuscitation. The high risk of the possible aspiration was avoided by timely provision of airway in the experienced anesthetist's hands.

Difficult airway management in a polytraumatized patient with osteogenesis imperfecta and multiple congenital spinal and thoracic deformities and severe kyphoscoliosis: case report.

Airway management in a polytraumatized patient with severe spinal and thoracic deformities demands detailed investigation of anatomical characteristics of the head, neck and airways, as well as thoracic configuration, before attempting endotracheal intubation. This enables the physician to predict a difficult airway and prepare for difficult airway management. We present a case of a 50-year-old polytraumatized patient with multiple congenital bone deformities associated with the syndrome of osteogenesis imperfecta and severe kyphoscoliosis, unable of lying on his back due to gibbus, who was successfully intubated in first attempt using video laryngoscope and only mild sedation. In patients with such severe multiple deformities, the use of video laryngoscope or Bonfils rigid endoscope should be mandatory in order to ensure success of intubation in first attempt and to avoid the possible aspiration of gastric contents.

Extubation strategy following difficult intubation.

Airway management relates to the period of tracheal intubation, maintenance of endotracheal tube in situ, and finally extubation. Problems related to difficult extubation still pose significant challenge for both anesthesiologists and intensivists. This article reviews current approach to extubation strategy following difficult intubation. Guidelines and algorithm may be helpful in order to ensure safe management of the patient during this delicate period of airway management.

Successful use of recombinant factor Viia in traumatic liver injury--a case report.

The paper describe the use of rFVIIa in the management of massive bleeding in a patient with polytrauma involving liver injury. An 18-year-old girl with severe polytrauma sustained during a bus-car collision. She had multiple musculoskeletal injuries, severe concussion of the liver with amputation of the left liver lobe, disruption of the left hepatic vein from the inferior vena cava, and impaired hemostasis. Acute bleeding (> 5 L) was not improved by conservative methods and a single dose of rFVlla 90 pg/kg was administered. Infusion of rFVlla resulted in an immediate clinical effect with rapid improvements in blood laboratory measurements and coagulation parameters. rFVIIa should be considered as an adjunctive treatment for the control of hemorrhage in severely injured patients with uncontrolled bleeding and impaired hemostasis.

Peripheral regional analgesia with femoral catheter versus intravenous patient controlled analgesia after total knee arthroplasty: a prospective randomized study.

The aim of this study is to compare the effects of femoral analgesia (FA) with 0.25% levobupivacain and intravenous patient controlled analgesia (PCA) with morphine on postoperative pain assessed by a visual-analog scale (VAS) score and their complications during the first 24 postoperative hours after the a total knee arthroplasty in a prospective randomized study. Secondary outcomes included: morphine use, patient satisfaction, complication of analgesia and duration of hospital stay. We analyzed 71 patients with an ASA score of II or III. The patients were randomized into two groups: group PCA (n = 36) was given the PCA pump, which contained morphine; and group FA (n = 35) was given first a bolus dose, then a continuous infusion 0.25% levobupivacain via a femoral catheter. The assessment of VAS was performed every 2 hours. There were no differences between the PCA and FA groups regarding demographic characteristics, operation duration, ASA score distribution, duration of hospital stay and satisfaction with analgesia (although there were more satisfied patients in the FA group). Significant differences were noted in the quantity of morphine used (higher values were in the PCA group; p < 0.001). More complications were recorded in PCA group (p < 0.001). The VAS score was lower in the FA group (p < 0.001). The highest difference occurred 4 hours after the operation, with the PCA group having significantly higher VAS score values compared to the FA group. Femoral analgesia leads to a stronger pain relief with less side effects, less morphine use and more patient satisfaction than intravenous PCA with morphine.

Inadequate face mask ventilation--clinical applications.

Face mask ventilation is a life saving technique. This article will review aetiology and patophysiological consequences of inadequate mask ventilation. The main focus will be on circulatory changes during induction of anesthesia, before and in a short period after intubation that could be attributed to inadequate mask ventilation in humans.

Local or spinal anesthesia in acute knee surgery.

The aim of the study was to assess the efficacy, safety and complications of two anesthetic techniques including local and spinal anesthesia. A total of 436 patients received local (LA group = 250) or spinal (SA group = 186) anesthesia during a year period. SA group received 0.5% Bupivacaine 5 mg/mL. LA group received portal injection (5 mL lidocaine 2% with adrenaline) and intra-articular injection into the knee (10 mL lidocaine 2% with adrenaline). The following parameters were assessed: intraoperative pain (10 cm VAS: 0 = no pain, 10 = extreme pain), surgical operating conditions, patient satisfaction score (1 = very satisfied, 4 = very unsatisfied), postoperative analgesia, and time to discharge. In LA group, 97.6% (244/250) of patients experienced no pain throughout the procedure. Only six (2.4%) patients required conversion to general anesthesia. In SA group, two patients required conversion to general anesthesia. In both groups, 93.6% of patients were either satisfied or very satisfied with their anesthesia. The need ofpostoperative analgesics was higher in SA compared with LA group (p = 0.001). The mean postoperative stay was significantly shorter in LA than in SA group (p = 0.001). Ninety-four percent of LA and only 68% of SA patients were discharged from the hospital within 2 hours of the procedure. The rate of complications differed significantly between LA and SA groups (p = 0.037). Outpatient arthroscopy of the knee under local anesthesia is a simple, reliable, and safe alternative to spinal anesthesia, for patients in whom intraarticular disorders requiring diagnostic arthroscopy and arthroscopic surgery.