Opiate Analgesia Treatment Reduced Early Inflammatory Response After Severe Chest Injuries.

BACKGROUND: The frequency of severe chest injuries are increased. Their high morbidity is followed by systemic inflammatory response. The efficacy of pharmacological blockade of the response could prevent complications after chest injures. AIM: The aim of the study was to show an inflammatory response level, its prognostic significant and length of hospital stay after chest injures opiate analgesia treatment. METHODS: Sixty patients from Department of Thoracic Surgery with severe chest injures were included in the prospective study. With respect of non opiate or opiate analgesia treatment, the patients were divided in two groups consisted of 30 patients. As a inflammatory markers, serum values of leukocytes, neutrophils, C-reactive protein (CRP) and fibrinogen in three measurements: at the time of admission, 24hours and 48 hours after admission, were followed. RESULTS: Statistically significant differences were found between the examined groups in mean serum values of neutrophils (p=0.026 and p=0.03) in the second and the third measurement, CRP (p=0.05 and 0.25) in the second and the third measurement and leukocytes in the third measurement (p=0.016). 6 patients in group I and 3 in group II had initial stage of pneumonia, 13 patients in group I and 6 in group II had atelectasis and 7 patients from group I and 4 from group II had pleural effusion. The rate of complications was lower in group of patient who were under opiate analgesia treatment but without significant difference. The length of hospital stay for the patients in group I was 7.3±1.15 days and for the patients in group II it was 6.1±0.87 days with statistically significant difference p=0.017. CONCLUSION: The opiate analgesia in patients with severe chest injures reduced level of early inflammatory response, rate of intra hospital complications and length of hospital stay.

Atmospheric pressure changes are associated with type a acute aortic dissections and spontaneous abdominal aortic aneurysm rupture in tuzla canton.

AIM: The aim of this study was to investigate a relationship between seasonal variation and incidence of type A acute aortic dissection (AAD) and spontaneous abdominal aneurysm rupture (rAAA) in Canton Tuzla, Bosnia and Herzegovina. PATIENTS AND METHODS: A total of 81 cases, 41 AAD and 40 of ruptured AAA were identified from one center over a 6-year, from 2008 till 2013. In 2012 were admitted (45.6% or 36 patients). RESULTS: Seasonal analysis showed that 19(23.4%) patients were admitted in spring, 15(18.5) in summer, 26(32%) in autumn and 21(25.9) in winter. The most frequent period was autumn/winter with 47 or 58% patients. A causal link between atmospheric pressure (AP) and incidence of rAAA and AAD on seasonal and monthly basis was found.

Incarcerated Morgagni hernia in an octogenarian with incidental right-sided colonic malignancy.

We present an incarcerated Morgagni hernia in an octogenarian with incidental right-sided colonic malignancy who was admitted to clinic due to abdominal pain and symptoms of intestinal obstruction. An 85-old male patient had a history of constipation, abdominal distension, pain, vomiting, nausea and radiographic features of bowel obstruction and mediastinal mass in right lower chest. Under suspicion of acute intestinal obstruction due to transverse colon herniation in thorax through Morgagni foramen, emergent laparotomy was performed. Morgagni foramen was located on the right-sided anterior diaphragm and Morgagni hernia which contained of incarcerated transverse colon, greater omentum and 70 cm small bowel after releasing the adhesions was gently reduced. In the same time right-sided colon malignancy was found. Morgagni foramen measuring 7 cm in diameter was sutured first and decompressive bypass ileocolic anastomosis was created. The role of emergent surgery, even in advanced age, is emphasized.

The influence of cardiopulmonary by-pass on respiratory function in patients who underwent coronary disease surgery.

AIM: The study is designed to show influence of cardiopulmonary by-pass (CPB) on respiratory function in patients who underwent cardiac surgery. PATIENTS AND METHODS: With respect on operative technique the patients were divided into two groups consisted of 40 patients, who underwent with or without CPB. On the bases of the hemodynamic measurements and counting alveolar arterial oxygen difference (A-a)DO2, saturation of mixed venous blood (SvO2), direct intrapulmonary shunt (V/Q) and hypoxemic score (PaO2/FiO2) preoperative and postoperative respiratory function in these patients is assumed. There were one preoperative and four postoperative measurements. RESULTS AND DISCUSSION: Statistically significant difference is found between the examined groups between mean values of alveolar arterial oxygen difference (A-a)DO2 in three postoperative measurements (p = 0.035, p = 0.015 and p = 0.011), direct intrapulmonary shunt (V/Q) in four postoperative measurements (p = 0.037, p = 0.023, p = 0.014 and p = 0.04), saturation of mixed venous blood (SvO2) in four postoperative measurements (p = 0.01, p = 0.023, p = 0.020 and p = 0.020) and hypoxemic score (PaO2/FO2) in four postoperative measurements (p = 0.018, p = 0.028, p = 0.017 and p = 0.038). The comparative analyses of parameters of respiratory function in both groups showed increased degree of acute lung injury (ALI) in group of patients underwent CPB. CONCLUSION: Early discovering parameters of acute lung injury in early postoperative period in patients underwent cardiac surgery with cardiopulmonary by-pass can prevent development of postoperative complications and duration of hospitalization. Key words:

Influence of Remifentanil/Propofol Anesthesia on Ventilator-associated Pneumonia Occurence After Major Cardiac Surgery.

UNLABELLED: The study is designed to evaluate the influence of remifentanil/propofol anesthesia on ventilator-associated pneumonia (VAP) occurrence and respiratory support (RS) time after major cardiac surgery. MATERIAL AND METHODS: In retrospective-prospective study we investigated the respiratory support time and VAP occurrence in group of 47 patients with remifentanil/propofol and 35 patients with fentanil/midazolam anesthesia after major cardiac surgery in period June 2009-December 2011. Groups are divided in subgroups depending of who underwent cardiac surgery with or without cardiopulmonary by pass (CPB). RESULTS: The time of respiratory support (RS) was the shortest in remifentanil group without CPB (R/Off 63min ± 44.3 vs R/On 94min ± 49.2 p=0,22), but was longer in fentanil group (F/Off 142 min ± 102.2 vs F/On 212 min ± 102.2 p=0.0014). The duration of RS of ON pump remifentanil group was shorter than in ON pump fentanil group (R/On 94 min vs F/On 212 min p=0.0011). The time of RS of OFF pump remifentanil group was lower than in Off pump entangle group (R/Off 63min ± 44,3 vs F/Off 142min ± 102.2 p=0,021) with statistically significance. Ventilator-associated pneumonia was detected in 7 patients (8.5 %). Six patients (17.1%) were from entangle group and one patient (2.1%) from remifentanil group. The most common isolates were Pseudomonas aeruginosa in all patients and both Pseudomonas aeruginosa and Klebsiella pneumonia in one patient. CONCLUSION: The remifentanil anesthesia regimen in cardiac surgery decreases length of respiratory support duration and can prevent development of VAP. The role of remifentanil anesthesia in preventing VAP, as one of the most important risk factor of in-hospital mortality after cardiac surgery is still incompletely understood and should be investigated further.

Risk factors in the development of postoperative complications after reconstructive surgery on the thoracic aorta.

Aim To determine risk factors responsible for developing postoperative complications after the thoracic aorta reconstructive surgery. Methods Medical records of 100 patients, who had undergone elective or emergency thoracic aorta reconstructive surgery at the Clinic for Cardiovascular Surgery, University Clinical Center Tuzla, were analysed. Intraoperative data as cross-clamp time (CCT), duration of cardiopulmonary bypass (CPBT) and hypothermic circulatory arrest time (HCAT) were evaluated. Univariate analysis was used to show risk factors for developing postoperative cardiac, respiratory, surgical and renal complications. Results Between May 2019 and April 2021, 48 Bentall procedures (BP), 23 ascending aortic replacements (AAR), 20 BP and coronary artery bypass grafting (CABG) and 9 aortic valve replacements (AVR) with AAR were performed. Incidence of postoperative complications in the elective and emergency groups was as follows: respiratory 20% vs 38% (p=0.049), cardiac 18% vs 70% (p=0.015), renal 16% vs 48% (p=0.027) and surgical 4% vs 6% (p>0.05). Intrahospital 30 days morbidity was 44% with mortality rate of 13%. The results showed that CPBT>180 minutes was a risk factor for respiratory (p=0.034), cardiac (p=0.020) and renal (p=0.027) postoperative complications after acute type A aortic dissection surgery. Conclusion CPBT > 180 min is a risk factor for postoperative development of respiratory, cardiac and renal complications. Postoperative cardiac and renal complications were associated with longer HCAT.

Influence of donor age on renal graft function in first seven post transplant days.

Increasing gap between demand and availability of human kidneys for transplantation has forced a re-evaluation of the limits on donor age acceptability. The present study included 74 patients who underwent kidney transplantation in University Clinical Centre Tuzla. In an observational cohort study we assessed impact of donor age on post transplant renal function by analyzing following parameters: 24 hour urine output, creatinine clearance (Cr Cl) and glomerular filtration rate (GFR). Depending on donor age recipients were allocated in to two groups. Group I included patients who received renal graft from donors age up to 55 years, and Group II encountered recipients who received renal graft from donors older than 55 years. Our goal was to determine whether donor age over 55 years significantly diminishes renal graft function in first seven post transplant days. No statistically significant difference was found between Group I and II regarding 24 hour urine output. From second to fifth postoperative day creatinine clearance values were higher in the group of patients who received kidney from donors older than 55 years (47+/-19, 1 vs. 44, 4+/-20, 8). On the fifth, sixth and seventh post operative day GFR was significantly higher in patients who received renal graft from donors age up to 55 years (p<0, 0161). Our data showed no significant difference in observed variables between the two groups, thus indicating that utilization of renal grafts from donors' age > 55 years is acceptable and may considerably expand the donor pool.

Percutaneous Transluminal Angioplasty of Subclavian Artery Lesions.

INTRODUCTION: Percutaneous transluminal angioplasty (PTA) is one of the treatment options for stenotic and obstructive lesions of the subclavian artery. AIM: To evaluate initial and long-term results of percutaneous transluminal angioplasty of subclavian artery lesions. METHODS: During period February 2016 to December 2017, 26 patients (12 men and 14 women) with significant subclavian artery stenosis and occlusion were admitted and underwent PTA. All patients were symptomatic. All PTA procedures were performed with the patient under local anesthesia, through the femoral artery (n=22), brachial artery (n=4), or combined route (n=6). In 7 patients, we performed direct stenting, while in the other 15 patients we performed predilatation before stent implantation. The follow-up protocol consisted of regular clinical examinations in 1, 3, 6 and 12 months post-procedural, and annually thereafter with duplex ultrasound monitoring. RESULTS: Initial technical success was achieved in 22 of 26 procedures (84.61%), 100% in stenotic lesions and 55.5 % in total occlusions. Fourth of nine occlusions could not be recanalized by PTA. These patients were managed surgically. The 30-day mortality rate was 0% for the entire group. No patients required reintervention for recurrence of symptoms and the stents remain patent at period of 12 months post-procedural. CONCLUSION: The minimal invasive technique, the markedly lower complication rate, the high long-term patency, patient's comfort and the decreased hospital stay have made endovascular repair the primary choice of treatment in the majority of cases, especially in patients with stenotic lesions and high-risk patients. We consider PTA of subclavian artery stenotic/obstructive lesions should be the first therapeutic option.

New-onset atrial fibrillation after percutaneous coronary intervention or coronary artery bypass grafting for left main disease.

Aim To determine the prevalence of new-onset atrial fibrillation (NOAF) following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) and its effect on 6-month cardiovascular outcomes. Methods This prospective study included 40 patients diagnosed with LMCAD, in the period from 2017 to 2018. The patients with LMCAD and low or intermediate SYNTAX score were randomized to PCI with zotarolimus-eluting stents versus CABG. Outcomes were analyzed according to the development of NOAF during the initial hospitalization following revascularization. Results Among 40 patients without atrial fibrillation on presentation, NOAF developed 3.1±1.3 days during hospitalization in three CABG treated patients, and one PCI treated patient. One patient that was CABG treated developed NOAF after two months. Patients with versus patients without NOAF had a significantly longer duration of hospitalization, probably because they were discharged on anticoagulant therapy. Myocardial infarction was presented in one CABG treated patient after 3 months, and also in one PCI treated patient after 4 months. One patient died 2 months after the operation, and one developed stroke 5 months after the CABG operation. Conclusion The NOAF was common after CABG, but extremely rare after PCI, and it occurred almost exclusively following CABG. There was a clear statistical tendency for all-cause death, cardiovascular death and stroke at 6-month follow-up period.

Incidence of Cardiac Dysfunction After Brain Injury.

INTRODUCTION: Cardiovascular complications in patients with subarachnoid hemorrhage are considered to be a neurally mediated process rather than a manifestation of coronary artery disease. AIM: The aim of study is to show the incidence and type cardiac complications after traumatic and spontaneous SAH. PATIENTS AND METHODS: The study had prospective character in which included 104 patients, with diagnosed subarachnoid hemorrhage (SAH), in the period from 2014 to 2017. Two groups of patients were formed. Group I: patients with SAH caused by the rupture of a brain aneurysm. Group II: patients with SAH after traumatic brain injury. RESULTS: Electrocardiogram (ECG) abnormalities was predominant after traumatic brain injury 74 %, with statistically significant difference atrial fibrillation 42.5 % (p = 0.043) and sinus bradycardia 31.4 % (p = 0.05). Hypertension are predominant in patients with spontaneous SAH with statistically significant difference (15 (27.7%) vs 36 (72%) p=0.034) and hypotension in group II (10 (18.5%) vs 2 (4%) p = 0.021 ) with traumatic SAH patients. The time in Intensive Care Unit (ICU) for traumatic SAH group was 6.1 ± 5.2 days and 3.9 ± 1.16 for spontaneous SAH group with statistical significance (p = 0.046). Respiratory support time was longer in traumatic SAH group (39.4 ± 23.44 vs. 15.66 ± 22.78) with p = 0.043. CONCLUSION: Cardiac dysfunction in patients with subarachnoid hemorrhage are considered to be a neurally mediated process rather than a manifestation of coronary artery disease. Early treatment of cerebral injury could be reduce incidence of cardiac complications after traumatic brain injury. Cardiac dysfunction in patients with SAH is still very high, despite substantial qualitative progress in their treatment.

Respiratory risk factors in development of postoperative complications after the lung resection.

The objectives of the study were to identify possible associated respiratory risk factors and to assess incidence of overall postoperative complications after the lung resection. We reviewed 110 patients who underwent lung resections due to malignant neoplasms or benign lung diseases. The risk of postoperative complications was evaluated using the univariate analysis. Results confirmed that low FEV1, postoperative high PaCO2, ASA-status and advanced age were factors associated with development of postoperative complications.

Atmospheric pressure changes are associated with type A acute aortic dissections and spontaneous abdominal aortic aneurysm rupture in Tuzla Canton.

AIM: The aim of this study was to investigate a relationship between seasonal variation and incidence of type A acute aortic dissection (AAD) and spontaneous abdominal aneurysm rupture (rAAA) in Canton Tuzla, Bosnia and Herzegovina. PATIENTS AND METHODS: A total of 81 cases, 41 AAD and 40 of ruptured AAA were identified from one center over a 6-year, from 2008 till 2013. In 2012 were admitted (45.6% or 36 patients). RESULTS: Seasonal analysis showed that 19(23.4%) patients were admitted in spring, 15(18.5) in summer, 26(32%) in autumn and 21 (25.9) in winter. The most frequent period was autumn/winter with 47 or 58% patients. A causal link between atmospheric pressure (AP) and incidence of rAAA and AAD on seasonal and monthly basis was found.

Mediastinal lymph node metastasis pattern in clinically N0 non-small-cell lung cancer patients who underwent surgical resection.

The aim of this study was to evaluate the incidence, clinical data and patterns of mediastinal lymph node metastasis (pN2) in non-small-cell lung cancer patients who underwent systematic mediastinal lymph node dissection (SMLND). We retrospectively studied 140 consecutive patients [125 male and 15 female, mean ages 54.61 +/- 9.23 years (range, 21-75)], underwent SMLND and major lung resections due to non-small lung cancer (NSCLC), from January 2005 till December 2009. Preoperative clinical staging for mediastinal lymph node metastasis was negative (cN0) in all patients. SMLND was defined as a complete removal of mediastinal lymph nodes. Clinicalpathological data were compared according to the pN stage. Lymph node metastasis to the mediastinum was confirmed in 13 (9.28%) patients. In squamous cell cancer pN2 were in 8 (5.71%) cases out of 82 cases with cN0. On the other side in the adenocarcinomas pN2 were in 5 (3.57%) cases out of 48 with cN0. Unvaried analysis revealed central tumor site as predictive factor for mediastinal lymph node involvement. The upper mediastinal compartment was infiltrated in 12 (8.57%) cases, middle in 8 (5.71%) and lower in 3 (2.14%) cases. Pneumonectomy was the most performed surgical procedure in pN2 patients. We concluded that SMLND improves pTNM staging in lung cancer patients who underwent major lung resections with central location of the tumour.

[Respiratory risk factors in development of postoperative complications after lung resection]. / Respiratorni rizicni faktori u razvoju postoperativnih komplikacija nakon resekcije pluca.

The objectives of the study were to identify possible associated respiratory risk factors and to assess incidence of overall postoperative complications after lung resection. We reviewed 110 patients undergoing lung resections because of malignant neoplasms or benign lung diseases. The risk of postoperative complications was evaluated using unuvariate analysis. Results confirmed that low FEV1, postoperative high PaCO2, ASA-status and advanced age were factors associated with development of postoperative complications.