EPIDURAL ANALGESIA IN MULTIPY INJURED PATIENTS WITH SEVERE CHEST TRAUMA: TWO CASE REPORTS AND LITERATURE REVIEW.

Multiply injured patients with severe chest trauma have different combinations of associated extra thoracic injuries making their treatment complex. Severe pain is a prominent symptom in a vast majority of severe chest injuries and causes deterioration of respiratory function. Epidural analgesia provides efficient pain relief but its use in this group of patients is burdened with complications, contraindications and technical difficulties. We present two cases in which epidural analgesia was successfully used in polytrauma patients with severe chest injuries and hypoxemic respiratory failure, and discuss advantages, possible pitfalls and complications.

The role of videomediastinoscopy in staging of non-small cell lung cancer.

Lung cancer is the most frequent malignant disease and the leading cause of death from malignant diseases in the world and its incidence is increasing. At the time when diagnosis is established most patients have advanced disease and are not candidates for radical surgical treatment. Patients without distant metastases are subjected to various diagnostic methods to detect metastases in mediastinal lymph nodes that make up the path of lymph drainage from the lungs. The most reliable invasive diagnostic procedures for detecting metastases in mediastinal lymph nodes are videomediastinoscopy and endobronchial ultrasound with transtracheal puncture. In the absence of mediastinal lymph node metastases surgery is the treatment of choice. If mediastinal lymph nodes are positive for metastases multimodal treatment is implemented. At the Department of Thoracic Surgery, Zadar General Hospital, videomediastinoscopy for the staging of primary non-small cell lung cancer has been performed routinely since September 2009.

Negative-pressure in treatment of persistent post-traumatic subcutaneous emphysema with respiratory failure: Case report and literature review.

Subcutaneous emphysema may aggravate traumatic pneumothorax treatment, especially when mechanical ventilation is required. Expectative management usually suffices, but when respiratory function is impaired surgical treatment might be indicated. Historically relevant methods are blowhole incisions and placement of various drains, often with related wound complications. Since the first report of negative pressure wound therapy for the treatment of severe subcutaneous emphysema in 2009, only few publications on use of commercially available sets were published. We report on patient injured in a motor vehicle accident who had serial rib fractures and bilateral pneumothorax managed initially in another hospital. Due to respiratory deterioration, haemodynamic instability and renal failure patient was transferred to our Intensive Care Unit. Massive and persistent subcutaneous emphysema despite adequate thoracic drainage with respiratory deterioration and potentially injurious mechanical ventilation with high airway pressures was the indication for active surgical treatment. Negative-pressure wound therapy dressing was applied on typical blowhole incisions which resulted in swift emphysema regression and respiratory improvement. Negative pressure wound therapy for decompression of severe subcutaneous emphysema represents simple, effective and relatively unknown technique that deserves wider attention.

[Crush syndrome in severe trauma]. / Crush-sindrom (CS) u okviru teske traume.

Crush injury or traumatic rhabdomyolysis is caused by crushing of large muscule mass, usually of the femoral and gluteal compartment. Crush syndrome is general manifestation of crush injury with renal failure (ARF). ARF is caused by deposition of myoglobin in distal tubules. The concentration of serum creatin phosphokinase is an indicator of the extent of injured muscule. The serum concentration of myoglobin is an indicator of the extent of injured muscule and the main cause of development of crush syndrome. In a prospective study the concentration of myoglobin and CPK was measured in 81 patients with injuries of lower extremities and pelvis as a part of severe trauma. The increase of CPK concentration above 1000 U/L was measured in all patients. The increase of CPK concentration above 2000 U/L was measured in 78 (96.3%) patients. The increase of myoglobin concentration of >700 mcg/L was measured in 19 (23.5%) patients. In the group of 19 patients with CPK concentration of >2000 U/L and myoglobin concentration of >700 mcg/L crush syndrome developed in 6 (7.4%) patients with oliguria (urin output <50 ml/h) and the increase of serum potassium, phosphate and creatinine concentrations. The decrease of CPK and myoglobin concentrations was achieved in 5 patients during 10-12 days and 1 patient with associated craniocrebral injury died.

ANESTHETIC MANAGEMENT OF A PATIENT WITH CENTRAL AIRWAY COMPRESSION DUE TO POSTERIOR MEDIASTINAL MASS.

Patients with mediastinal masses present unique challenge to anesthesiologists. Patients with anterior mediastinal masses have well documented cases of respiratory or cardiovascular collapse during anesthesia and in postoperative period. Masses in the posterior mediastinum have been traditionally regarded to carry a significantly lower risk of anesthesia related complications but cases of near fatal cardiorespiratory complications have been reported. We describe anesthetic management of a patient with posterior mediastinal mass compressing the trachea and the left main bronchus presented for left thoracotomy and tumor excision. The patient experienced pain and cough, and exhibited positional dyspnea. Airway was successfully secured with awake nasotracheal intubation and placement of single lumen endobronchial tube.

Effects of high intraoperative inspired oxygen on postoperative nausea and vomiting in gynecologic laparoscopic surgery.

STUDY OBJECTIVE: To assess the efficacy of intraoperative inspired oxygen fractions (FIO(2)) of 0.8 and 0.5 when compared with standard FIO(2) of 0.3 in the prevention of postoperative nausea and vomiting (PONV). DESIGN: Prospective, randomized, double-blinded, controlled study. SETTING: General hospital, postanesthesia care unit (PACU), and gynecology floor room. PATIENTS: 120 ASA physical status I and II women, aged 21 to 76 years, undergoing elective gynecologic laparoscopic surgery. INTERVENTIONS: Patients were randomized to receive a gas mixture of 30% oxygen in air (FIO(2) = 0.3, Group G30), 50% oxygen in air (FIO(2) = 0.5, Group G50), or 80% oxygen in air (FIO(2) = 0.8, Group G80); there were 36 patients in each group. A standardized sevoflurane general anesthesia, postoperative pain management, and antiemetic regimen were used. MEASUREMENTS: Frequency of nausea, vomiting, and both was assessed for early (0 to two hrs) and late PONV (two to 24 hrs), along with use of rescue antiemetic, degree of nausea, and severity of pain. MAIN RESULTS: There was no overall difference in the frequency of PONV at the early and late assessment periods among the three groups. G80 patients had significantly less vomiting than Group G30 at two hours, 3% (1/36) vs. 22% (8/36), respectively, P = 0.028. Nausea scores, rescue antiemetic use, pain scores, and opioid consumption did not differ among the groups. CONCLUSION: High intraoperative FIO(2) of 0.8 and FIO(2) of 0.5 do not prevent PONV in patients without antiemetic prophylaxis. An intraoperative FIO(2) of 0.8 has a beneficial effect on early vomiting only.