Teh nič ki ured nik / Tech ni cal Edi torMilan Bog da no vić

Izvrš ni izda vač / Exe cu ti ve Publis herUdru že nje ane ste zi o lo ga i inten zi vi sta Srbi je

Dizajn korica / Cover Design Predrag Petković

Prelom i kompjuterska obradaStu dio znak, Ivan ko vač ka 10/2

Otvoreni pristup / Open Access

Adre sa ured niš tva / Edi to rial Offi ceČaso pis SJA IT

Kli ni ka za ane ste zi o lo gi ju i inten ziv nu tera pi juVoj no me di cin ska aka de mi ja, 11000 Beo grad, Crno trav ska 17,

E-mail: jour nal.sja it@yahoo.com

SER BIAN JOUR NAL OF ANEST HE SIA AND INTEN SI VE THE RAPYOffi cial Jour nal of Ser bian Asso ci a tion of Anest he si o lo gists and Inten si vists

Volu me 41; January – March 2019; Issue 1–2

SRP SKI ČASO PIS ANE STE ZI JA I INTEN ZIV NA TERA PI JAČaso pis Udru že nja ane ste zi o lo ga i inten zi vi sta Srbi je

Godiš te 41; Januar – Mart 2019; Broj 1–2

Glav ni i odgo vor ni ured nikEdi tor in Chi ef

Neboj ša Lađe vić

Zame nik ured ni ka / Assi stant Chi ef Edi torDuši ca Sta men ko vić

Sekre tar / Sec re taryGoran Rondović

Ure đi vač ki odbor / Edi to rial Board

Nada Popo vić, SRBRad mi lo Jan ko vić, SRBVoji sla va Neš ko vić, SRBMiodrag Milenović, SRBIva na Budić, SRBMir ko Gra jić, SRBBilja na Sto šić, SRBSve tla na Apo sto lo vić, SRBNemanja Rančić, SRB

Lek tor za srp ski jezikSer bian lan gu a ge edi tor

Mari ja Bog da no vić

Zoka Milan, UKOli ve ra Pot pa rić, UKŽika Petro vić, UKNeboj ša Nick Kne že vić, USAKara ni ko las Mene la os, USAIvan Kan gr ga, USAAndre as Kopf, GER MANYCar sten Ban tel, GR MANYSanja Marić, BIH

Mihail Y. Kirov, RUS SIAXavi ar Gar cia Fer nan dez, SPAINZolt Mol nar, HUN GARYSte fan de Hert, BEL GI UMArash Asfa ri, DEN MARKSha ron Einav, ISRAELDani e la Fili pe scu, ROMA NIAMas si mi li a no Sor bel lo, ITALYDan Lan gri os, FRAN CE

Lek tor za engle ski jezikEnglish lan gu a ge edi tor

Milan Miljko vić

2 SJAIT 2019/1-2

SADR ŽAJ CONTENTS

Anesthesia and perioperative medicine in orthopedic surgerySvetlana Srećković, Darko Milovanović, Nada Stojimanovska, Marija Ostojić, Nebojša Lađević, Nikola Lađević 5

Goiter-related predictors of difficult intubation: case report Suzana El Farra, Dragana Radovanović, Aleksandar Stokić, Duško Manić 21

Burnout among neuro anesthesiologists and intensive care physicians a prospective anonymous blind observational studyElena Sinbukhova, Andrey Lubnin 27

Intraoperative hypoxemia during one-lung ventilation: is it still an anesthesiologists’ nightmare? (hypoxemia during one-lung ventilation)Radmilo J Janković, Milena Stojanović, Anita Vuković, Vesna Dinić, Vladan Cvetanović, Danica Marković 37

Ultrasound application during percutaneous procedures in intensive care unitAleksandar Filipović, Dragan Mašulović, Marija Milenković, Miloš Zakošek, Dušan Bulatović, Milica Stojadinović 45

Godište: 41 I-III 2019 Broj: 1-2 Volume: 41 I-III 2019 Issue: 1-2

Anestezija i perioperativna medicina u ortopedskoj hirurgiji Svetlana Srećković, Darko Milovanović, Nada Stojimanovska, Marija Ostojić, Nebojša Lađević, Nikola Lađević 5

Struma kao prediktor otežane intubacije: prikaz slučajaSuzana El Farra, Dragana Radovanović, Aleksandar Stokić, Duško Manić 21

Burnout among neuro anesthesiologists and intensive care physicians a prospective anonymous blind observational studyElena Sinbukhova, Andrey Lubnin 27

Intraoperative hypoxemia during one-lung ventilation: is it still an anesthesiologists’ nightmare? (hypoxemia during one-lung ventilation)Radmilo J Janković, Milena Stojanović, Anita Vuković, Vesna Dinić, Vladan Cvetanović, Danica Marković 37

Primena ultrazvuka u izvođenju perkutanih intervencija u jedinicama intenzivnog lečenjaAleksandar Filipović, Dragan Mašulović, Marija Milenković, Miloš Zakošek, Dušan Bulatović, Milica Stojadinović 45

4 SJAIT 2019/1-2

Sažetak

Ortopedska hirurgija danas predstavlja veliki izazov za anesteziologe sa aspekta stanja pacijenta, tipa operacije, kao i položaja koji pacijent zauzima u toku operacije. U skladu sa trendom porasta gerijatrijske populacije, orto-pedski pacijenti su najčešće stari sa brojnim komorbidite-tima, ali i mladi, zdravi, najčešće traumatizovani, kod ko-jih postojanje udruženih povreda ima značajan uticaj na izbor tipa anestezije. Prilikom izbora tipa anestezije kod ortopedskih pacijenata neophodno je da se napravi ade-kvatna preoperativna procena i priprema i da se sagleda celokupno stanje pacijenta, a ne samo deo od značaja za hirurgiju. U okviru preoperativne pripreme kod ortoped-skih pacijenata je najčešće neophodna kardiološka, pulmo-loška, ali i neurološka evaluacija, zatim nazalni skrining i dekolonizacija, preoperativna priprema kože, kontrola gli-kemije, kao i primena antibiotske profilakse. Ortopedska hirurgija ima najveći rizik za nastanak venskog trombo-embolizma. Pravovremeno započinjanje tromboprofilakse, kao i njen nastavak posle operacije, kod ortopedskih pa-cijenata je od izuzetnog značaja. Za optimalnu upotrebu adekvatne tromboprofilakse postoji nekoliko objavljenih vodiča sa jasnim preporukama za dnevnu kliničku prak-su. Poznavanje specifičnosti operacije, toka hirurgije, kao i položaja koji pacijent zauzima omogućava obezbeđivanje adekvatnih uslova rada uz minimalne gubitke krvi i kom-plikacije. Smanjenje krvarenja, kako intraoperativno tako i postoperativno, postiže se normovolemijskom hipotenzi-jom, bledom stazom uz pomoć poveske (touriquet), ali i primenom traneksamične kiseline, bilo sistemski ili lokal-no. Kao hirurgija sa velikim postoperativnim zahtevima u analgeziji, u okviru multimodalnog pristupa se sve češće, pored perifernih nervnih blokova, u svakodnevnom radu primenjuje i periartikularno ubrizgavanje lokalnog ane-stetika. Poznavanje specifičnosti, ali i zahteva ortopedske operacije sa adekvatnom preoperativnom pripremom, iz-

Revijalni članak Review article

ANESTEZIJA I PERIOPERATIVNA MEDICINA U ORTOPEDSKOJ HIRURGIJI

Svetlana Srećković1,3, Darko Milovanović2,3, Nada Stojimanovska1, Marija Ostojić1, Nebojša Lađević1,3, Nikola Lađević3

1Centar za anesteziologiju i reanimatologiju, Klinički centar Srbije, Beograd, Srbija 2Klinika za ortopedsku hirurgiju i traumatologiju, Klinički centar Srbije, Beograd, Srbija 3Medicinski fakultet Univerziteta u Beogradu, Beograd, Srbiija

ANESTHESIA AND PERIOPERATIVE MEDICINE IN ORTHOPEDIC SURGERY

Svetlana Srećković1,3, Darko Milovanović2,3, Nada Stojimanovska1, Marija Ostojić1, Nebojša Lađević1,3, Nikola Lađević3

1Center for anaesthesiology and reanimatology, Clinical center of Serbia, Belgrade, Serbia 2Clinic for orthopedic surgery and traumatology, Clinical Center of Serbia, Belgrade, Serbia 3School of Medicine, University of Belgrade, Belgrade, Serbia

Autor za korespondenciju: Svetlana Srećković, Telefon: 0641347274, E-mail: svetlanasreckovic@yahoo.com

Coresponding author: Svetlana Srećković, Telephone: 0641347274, E-mail: svetlanasreckovic@yahoo.com

Summary

Today anesthesia for orthopedic surgery is challenging for anesthesiologist from the patient’s perspective, the type of surgery as well as the patient’s position during the surgery. Patients may be old with numerous comorbidities but also young, healthy trauma patients who have associated in-juries that can have a significant impact on the type of anesthesia. Therefore, it is imperative that the anesthesi-ologist in orthopedic surgery examine the entire patient and not just focus on the area of surgery, but also to make an adequate preoperative assessment and preparation. In the preoperative preparation of orthopedic patients car-diological, pulmological and neurological evaluation is most often needed, nasal screening and decolonization, preoperative skin preparation, glycemic control and the use of antibiotic prophylaxis. Patients undergoing major orthopedic surgery are at highest risk for venous throm-boembolism both during and after surgery, so that the timing of thromboprophylaxis as well as its continuation in orthopedic patients is of exceptional importance. For the optimal use of adequate thromboprophylaxis there are several published guidelines with clear recommendations for daily clinical practice. Understanding the type and course of the surgery as the patient position during sur-gery provide adequate working conditions with minimal blood loss and complications. Reduction of bleeding, as intraoperatively and postoperatively have been achieved by normovolemic hypotension, tourniquet, but also by topical or systemic application of tranexamic acid.As a surgery with high postoperative requirements in analgesia within the multimodal approach, besides the peripher-al nerve blocks, the periarticular injection of local anes-thetics is increasingly used in everyday work. Knowing the specificity and requirements of an orthopedic surgery with adequate preoperative preparation, selection of an-esthesia type and intraoperative plan in order to reduce

doi:10.5937/sjait1902005SISSN 2466-488X (Online)

6 SJAIT 2019/1-2

Uvod

Ortopedska hirurgija danas predstavlja veliki izazov za anesteziologe sa aspekta stanja pa-

cijenta, tipa operacije, kao i položaja koji pacijent zauzima u toku operacije1. U skladu sa trendom porasta, gerijatrijska populacija čini veći deo po-pulacije ortopedskih pacijenata pored mladih, ali najčešće traumatizovanih pacijenata. Postojanje udruženih povreda kod traumatizovanih pacije-nata ima značajan uticaj na izbor tipa anestezije1. Stoga je imperativ da anesteziolog u ortopedskoj hirurgiji sagleda celokupno stanje pacijenta pri iz-boru tipa anestezije, a ne samo deo od značaja za hirurgiju1. Poslednjih godina, ortopedska hirurgi-ja se pomera u smislu izvođenja ambulantnih pro-cedura, postavljajući tako nove zahteve za anestezi-ologa, kao što su izbor pacijenta, adekvatno vreme otpusta i postoperativna kontrola bola2–4. Druga promena je povećan broj procedura u hirurgiji kič-me kod odraslih i dece, koja predstavlja poseban izazov zbog mogućnosti otežanog disajnog puta, produženog boravka pacijenta u položaju pronaci-je, kontroli krvarenja, kao i postoperativnog bola. Preoperativna procena i priprema pacijenata pred-stavlja značajan korak perioperativnog procesa.

Preoperativna evaluacija pacijenata u orto-pedskoj hirurgiji

Na osnovu najnovije NICE (The National In-stitute for Health and Care Excellence, The Uni-ted Kingdom) klasifikacije hirurških intervencija, ortopedske operacije, izuzev artroskopija, spadaju u velike i kompleksne hirurške intervencije5. Sa druge strane, Američko udruženje kardiologa (The American College of Cardiology / American Heart Association – ACC/AHA) klasifikuje orto-pedske operacije kao operacije sa intermedijal-nim rizikom za nastanak kardiovaskularnih kom-plikacija6. Poslednjih godina je prepoznat povišen kardiovaskularni morbiditet i mortalitet nakon ortopedske hirurgije kod gerijatrijske populacije. Povećanju rizika doprinose: komorbiditet gerija-

trijske populacije, ograničen funkcionalni kapa-citet, postoperativni sistemski inflamatorni od-govor, masivni gubitak krvi, kao i postoperativni bol1,6.

Procena funkcionalnog statusa ortopedskih pa-cijenta je otežana samim ortopedskim oboljenjem, a podaci govore da preoperativna procena rizika, pa i koronarna revaskularizacija imaju ograničen uticaj na ishod lečenja1,6. Tako je pokazano da ukoliko se pre ortopedske hirurgije urade perku-tana koronarna intervencija (PCI), kao i kardio-hirurška intevencija, one ne doprinose smanjenju infarkta miokarda i mortalitetu ortopedskih paci-jenata7,8,9. Kod pacijenata kod kojih PCI podrazu-meva i plasiranje stenta, restenoza i tromboza su dodatni rizik za ove pacijente, ukoliko se antiagre-gaciona terapija ukine u cilju smanjenja krvarenja, odnosno rizik od krvarenja je povećan ukoliko se nastavi sa terapijom i preoperativno7,8. Tako je kod pacijenata posle PCI neophodno odlaganje elektivne hirurgije za 6 nedelja ukoliko je plasiran metalni stent ili 6 meseci ukoliko je stent oblo-žen lekom7,8. Tromboza stenta se najčešće klinič-ki manifestuje kao akutni infarkt miokarda sa ST elevacijom i neophodna je hitna reperfuzija9. Upr-kos napretku u dizajnu stentova, perioperativno nastala tromboza stenta i dalje ima visoku stopu moratliteta, pa je neohodna optimizacija inhibicije trombocita u perioperativnom periodu9. Prilikom donošenja odluke, predlaže se pre svega multidi-sciplinarnost, koja zahteva saradnju anesteziologa, hirurga i kardiologa, sa akcentom na individualnoj proceni9. Uzimajući u obzir sve činioce, može se doneti odluka o nastavku dvojne antiagregacione terapije i tokom i posle operacije ili se eventualno može obustaviti klopidogrel i premostiti period do njegovog ponovnog uvođenja sa intravenskim blokatorima trombocita ili isključiti perioperativ-no i vratiti u terapiju posle operacije9. Kao ključ sniženja postoperativnog morbiditeta i moratali-teta, predloženo je ublažavanje hemodinamskog stresogenog odgovora uvođenjem beta blokatora u terapiju10. Beta blokatori se preporučuju kao kontinuirana terapija kod gerijatrijske populacije pacijenata i uvode se kod pacijenata sa visokim ri-zikom u cilju odžavanja frekvence ispod 80/min10.

borom tipa anestezije, kao i intraoperativnog plana, u cilju smanjenja intraoperativnog krvarenja, zahteva prilagođa-vanje svakom pacijentu pojedinačno.

Ključne reči: anestezija u ortopedskoj hirurgiji; periope-rativna priprema ortopedskih pacijenata; totalna proteza kuka; totalna proteza kolena; hirurgija kičme

intraoperative bleeding requires adapting to each patient individually.

Key words: anesthesia for orthopedic surgery; perioperative menagement of orthopedic patients; total hip arthroplasty; total knee arthroplasty; spine surgery

7ANESTEZIJA I PERIOPERATIVNA MEDICINA U ORTOPEDSKOJ HIRURGIJI

Preoperativna respiratorna procena je neop-hodna kod ortopedskih pacijenata, imajući u vidu povišen rizik za nastanak respiratornih komplika-cija, kako zbog prirode samog oboljenja koje može uticati promenom mehanike grudnog koša tako i zbog nemogućnosti mobilizacije11. Primećeno je da gerijatrijska populacija nakon preloma kuka ima niže vrednosti parcijalnog pritiska kiseonika u odnosu na pacijente istih godina u drugoj hirurgi-ji11. Ovome doprinose promene u mehanici grud-nog koša koje su deo fiziološkog procesa starenja (smanjenje FEV1, povećanje closing volume), ali i mikroembolizacija pluća nakon preloma dugih kostiju1. Gojazni pacijenti i oni sa opstruktivnom sleep apneom su pod visokim rizikom od nastanka postoperativnih respiratornih komplikacija12.

Neophodnost neurološke procene posebno se naglašava kod prethodnog postojanja senzornog ili motornog deficita u zoni hirurške intervencije, ukoliko se planira periferni nervni blok1,13. Post-operativni delirijum je treća komplikacija po uče-stalosti kod ortopedskih pacijenata14. Manifestuje se promenom stanja svesti, uključujući akutno na-stalu konfuziju, nemogućnost fokusiranja pažnje, promene u kogniciji, iritabilnost, anksioznost, pa-ranoju i halucinacije13. Delirijum se najčešće razvi-ja akutno, ali ima konfluentan tok tokom nekoliko dana. Hipoaktivna forma delirijuma je izuzetno te-ška za prepoznavanje, jer su pacijenti konfuzni, ali mirni14. Faktori rizika za nastanak delirijuma su godine, upotreba alkohola, preoperativna demen-cija ili kognitivni poremećaj, upotreba psihoaktiv-nih supstanci, komorbiditeti14. Prisustvo hipokse-mije postoperativno, hipotenzije, hipervolemije, abnormalnosti elektrolita, prisustvo infekcije, po-remećaj sna i primena benzodiazepima ili antiho-linergičkih lekova može biti triger za nastanak de-lirijuma. Terapijski izbor varira od praćenja i nege do sedacije i anksiolize. Atipični antipsihotici su aktivni u akutnoj fazi delirijuma14.

Preoperativna priprema, po preporuci nedavno objavljene revizije vodiča za prevenciju hirurških infekcija Svetske zdravstvene organizacije (SZO), kao i revizije vodiča Centra za kontrolu i preven-ciju bolesti (CDC), uključuje nazalni skrining i de-kolonizaciju, preoperativnu pripremu kože, sma -njenje intraartikularno datih kortikosteroida i pri-menjene imunosupresivne terapije, kontrolu glike-mije, kao i primenu antibiotske profilakse15,16.

Nazalni skrining i dekolonizacija

Staphylococcus aureus je odgovaran za nastanak 30% hirurških infekcija. Imajući u vidu da 25%

pacijenata ima nazalnu kolonizaciju, kao i porast meticilin rezistentnog soja (MRSA), predložena je preoperativna dekolonizacija jednokratnom intra-nazalnom primenom mupirocina 2% (SZO)15,16,17.

Pranje celog tela preoperativno smanjuje inci-dencu hirurških infekcija18. Tako se preporučuje korišćenje hlorheksidina, zahvaljujući aktivnosti protiv raziličitih patogena, uključujuči i MRSA19. Prema preporukama SZO i CDC, neophodno je pranje celog tela i to veče neposredno pred hirur-šku intervenciju15,16.

U neoperativnoj terapiji osteoartritisa ili dru-gih inflamatornih oboljenja široko se upotrebljava imunosupresivna terapija bilo sistemski ili u vidu intrartikularnih injekcija. Protokol SZO ne pre-poručuje rutinsko obustavljanje imunosupresivne terapije, već je neophodno da se odluka donese za svakog pacijenta pojedinačno15,20.

U ortopedskoj hirurgiji, a i po protokolu CDC, neophodna je stroga kontrola glikemije neposred-no preoperativno (CDC: vrednost glikemije ispod 200 mg/dl (11,1 mmol/L))15,16. Za profilaktičku primenu antiobiotika u ortopedskoj hirurgiji pre-poručuju se cefalosporini prve generacije21. Van-komicin ili teikoplanin kao dodatak antibiotskoj profilaksi su preporučeni kod pacijenata koji imaju visok rizik za kolonizaciju MRSA-om, kao što su pacijenti u centrima za hemodijalizu i u domovi-ma za stare22. Preporučeno vreme za ordiniranje antibiotske profilakse je sat vremena pre početka planirane hirurške intervencije. Infuziju vankomi-cina treba započeti nekoliko sati ranije, zbog nje-govog produženog vremena ordiniranja. Kada su u pitanju primenjene profilaktičke doze antibiotika, neohodno je njihovo prilagođavanje telesnoj teži-ni pacijenta, kao i ponavljanje doze antibiotika u slučaju produženog operativnog vremena i masiv-nog gubitka krvi23,24. Prema preporukama SZO i CDC, nastavak primene antiobiotika duže od 24 časa se smatra neopravdanim i dovodi do rizika od pojave bakterijske rezistencije, čak i u prisustvu hi-rurškog drena15,16.

Tromboprofilaksa

Venski tromboembolizam (VTE) predstavlja komplikaciju koja se javlja kako tokom tako i nakon hospitalizacije kod ortopedskih pacijena-ta25,26. Procenat njegovog nastanak je izuzetno vi-sok, tako da od 40 do 60% pacijenata ima DVT na-kon ugradnje totalne proteze kuka i kolena, kao i preloma kuka i karlice27. Ovako visokom procentu DVT kod ortopedskih pacijenata doprinose speci-fičnosti ortopedske hirurgije, pre svega upotreba

8 SJAIT 2019/1-2

poveske (tourniquet), imobilizacija, kao i ležanje, što dovodi do venske staze, hirurške manipulacije usled koje nastaje oštećenje vaskularnog endotela, kao i hiperkoagulabilnost kod traume, usled pora-sta tromboplastina i upotrebe polimetilmetakrilata (koštani cement)27. Na osnovu stratifikacije fakto-ra rizika za nastanak venskog tromboembolizma, ortopedski pacijenti su klasifikovani kao pacijenti sa visokim rizikom i kod njih je neophodna prime-na mehaničke i/ili farmakološke profilakse25,26,27.

Mehanička profilaksa VTE

Mehanička profilaksa VTE uključuje mobili-zaciju, primenu graduisanih kompresivnih čara-pa, intermitetnu pneumatsku kompresiju i venske pumpe za stopala25,26,27. Neželjeni efekti, kao što je diskomfort pacijenta, kako u načinu primene profilakse, tako i u dodatnom ograničenju pokreta, potrebi preoperativne, intra i postoperativne pri-mene tokom 72 h, kao i nedostatak jakih dokaza o prevenciji PE i mortaliteta ograničavaju njiho-vu primenu25,26,27. Neadekvatan izbor veličine i podešavanja može da dovede do smanjenja tkiv-ne oksigenacije. Apsolutno su kontraindikovani u slučaju postojanja otvorenih fraktura, insuficijen-cije arterijske periferne cirkulacije, srčane insufi-cijencije, postojanja infekcije ili ulceracije na me-stu primene27. Poslednji vodiči u prevenciji DVT savetuju njihovu istovremenu primenu sa farma-kološkom profilaksom, naročito kod pacijenata sa visokim rizikom za nastanak DVT posle velikih ortopedskih operacija27. Najjednostavniji i najpri-menljiviji metod je rana mobilizacija27.

Farmakološka profilaksa VTE

Primena farmakološke profilakse uključuje pri-menu aspirina, nefrakcioniranog heparina (UFH), niskomolekularnog heparina (LMWH), antagoni-ste vitamina K, inhibitore faktora Xa i nove oralne antikoagulanse25,26,27.

Na osnovu poslednjih objavljenih preporuka, u cilju prevencije DVT kod ortopedskih pacijenata prioritet ima LMWH25,26,27. LMWH se primenju-je 12 sati i više pre planirane ortopedske operacije. Ukoliko su pacijenti koristili oralne antikoagulan-te, neohodno je njihovo isključivanje do 5 dana pre planirane elektivne operacije i procena vrednosti INR-a. Ukoliko je INR > 1,5, potrebno je da se raz-motri primena 1–2 mg vitamina K. Brza korekcija INR kod urgentne hirurgije se postiže primenom vitamina K intravenski 2,5–5 mg, protrombinskog kompleksa ili sveže smrznute plazme. Visok rizik

tromboembolizma kod ortopedskih pacijenata zahteva uključivanje LMWH odmah nakon obu-stave oralnih koagulanata i održavanje vrednosti anti Xa u terapijskom opsegu25–28. Ukoliko se radi o velikim i kompleksnim operacijama, LMWH se nastavlja 48–72 h nakon operacije, a zatim se uvo-di oralni antikoagulant. Kod pacijenata koji su na dvojnoj antiagregacionoj terapiji, odluka o njiho-vom isključivanju ili nastavku se donosi pojedinač-no za svakog pacijenta. Tako dvojna antiagregaci-ona terapija može da se nastavi tokom i posle ope-racije, ukoliko ortopedska intervencija ne može da se odloži zbog stepena hitnosti povrede. Pacijenti sa visokim rizikom za nastanak kardioloških kom-plikacija nastavljaju sa primenom aspirina tokom perioperativnog perioda, a tienopiridini (klopido-grel, prasugrel) se isključuju 5 dana pre i uvode 24 h posle planirane operacije. Ukoliko je nizak rizik od nastanka kardioloških komplikacija, antiagre-gaciona terapija se isključuje 7 dana pre i uvodi se 24 h posle operacije7–9.

U ortopedskoj anesteziji posebno treba da se naglasi i vreme davanja farmakološke trombopro-filakse, imajući u vidu da se veliki broj operacija radi u regionalnoj anesteziji tipa centralnih neuro-aksijalnih blokova ili perifernih nervnih blokova, a kako bi se obezbedili bezbedni uslovi za njeno iz-vođenje (Tabela 1)25–28. Novi oralni antikoagulan-ti (new oral anticoagulants (NOACs) – apixaban, dabigatran, rivaroxaban (transkribovati)) jednako su efikasni kao kumarinski preparati u prevenciji DVT, ali su sigurniji i sa brzim početkom aktivno-sti i kratkim poluvremenom eliminacije, kao i bez neophodnog rutinskog laboratorijskog monito-ringa. Dabigatran se po preporuci proizvođača ne preporučuje pre punkcije, odnosno postavljanja ili manipulacije katetera, dok se kumarinski preparati uključuju tek nakon vađenja katetera28.

Iako je profilaksa DVT efikasnija ukoliko se započne preoperativno, treba imati na umu mo-gućnost povećanog rizika od hirurškog kravarenja. Sa druge strane, sa završenom ortopedskom ope-racijom ne prestaje rizik za nastanak DVT, pa se farmakološka terapija nastavlja27,29–31. U tabeli su date preporuke za nastavak profilakse u zavisnosti od ortopedske operacije (Tabela 2)25–28,31.

9

Tabela 1: Vreme davanja farmakološke profilakse i postavljanja/manipulacije katetera (spinal, epidural, periferni nervni blok)

Vreme pre punkcije/postavljanja katetera ili manipulacije

Vreme posle punkcije/postavljanja katetera ili manipulacije

LMWH profilaktička doza 12 sati 4 sata

LMWH terapijska doza 24 sata 4 sata

UFH – profilaktička doza ≤ 15000 IU/24 h 4–6 sati 1 sat

UFH – terapijska doza i.v. 4–6 sati sc 8–12 sati

1 sat 1 sat

Fondaparin – profilaksa 2,5mg /24 h 36–42 sata 6–12 sat

Rivaroxaban – 10 mg/24 h 22–26 sata 4–6 sati

Apixaban, 2,5mg 26–30 sati 4–6 sati

Dabigatran 150–220 mg Kontraindikovan prema preporuci proizvođača 6 sati

Kumarini INR ≤ 1,4 Nakon vađenja katetera

Acetilsalicilna kiselina nema nema

Klopidogrel 7 dana Nakon vađenja katetera

Tiklopidine 10 dana Nakon vađenja katetera

Prasugrel 7–10 dana 6 sati nakon vađenja katetera

NSAID nema nema

LMWH – nisko molekularni heparin; UFH – nefrakcionirani heparin; NSAID – nesteroidni antiinfla-matorni lekovi

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Tabela 2: Preporuke za nastavak farmakološke profilakse VTE u zavisnosti od tipa ortopedske operacije

Ortopedska operacija

preporuka Trajanje profilakse Nivo dokaza

Atroskopija kolena

ACCP (201226)

NICE (201831)

Bez VTE profilakse ukoliko ne postoji podatak o prethodnoj VTELMWH tokom 14 dana ako: - trajanje anestezije preko 90 min ili - rizik VTE prevazilazi rizik od krvarenja

2B

Prelomi kuka ACCP (2008, 201225,26)

NICE (201831)

LMWH UFH VKA Fondaparin AspirinLMWH Fondaparinux

Minimum 10 do 14 dana, nastaviti do 35 dana 1 mesec

1B 1B 1B 1B 1B

Elektivne operacije

ACCP (2008, 201225,26)

NICE (201831)THA

TKA

LMWH UFH VKA Fondaparin Apixaban Dabigatran Rivaroxaban AspirinLMWH Rivaroxaban Apixaban DabigatranAspirin (75 ili 150 mg) LMWH u kombinaciji sa mehaničkom profilaksom do otpusta Rivaroxaban Apixaban Dabigatran

Minimum 10 do 14 dana, nastaviti do 35 dana

10 dana LMWH, a onda do 28 dana nastaviti aspirin> 14 dana

14 dana 14 dana > 14 dana

1B1B1B1B1B1B1B1B

Hirurgija kičme

Elektivna hirurgija kičme bez dodatnog rizika za VTE

Elektivna hirurgija kičme sa dodatnim rizikom za VTE ili prednji hirurški pristup

Akutna povreda kičme

ACCP (200825)

ACCP (200825)

ACCP (200825)

Bez rutinske upotrebe profilakse VTE

Niske doze UFHLMWHOptimalna upotreba mehaničke profilakse

Rutinska VTE profilaksaLMWH nakon primarne hemostazeMehanička profilaksa i UFH

2C

1B1B1B

1A1B1B

LMWH – nisko molekularni heparin; UFH – nefrakcionirani heparin; THA – totalna proteza kuka; TKA – totalna proteza kolena. Nivo dokaza: A – Podaci su dobijeni iz multiplih randomizovanih kliničkih studija sa niskim lažno pozitivnim i ni-skim lažno negativnim greškama (visoka pouzdanost studija) ili meta-analizom multicentričnih kontrolisanih studija.B – Podaci su dobijeni iz jedne dobro dizajnirane randomizovane studije ili iz velikih nerandomizovanih studija. Randomi-zovane studije sa visoko lažno pozitivnim i/ili negativnim greškama (niska pouzdanost studija).C – Preporuka je doneta na osnovu konsenzusa eksperata i/ili malih studija, retrospektivnih studija, registara.Stepen preporuke I: Postoje dokazi da je određena terapija ili procedura upotrebljiva ili korisna.

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Specifičnosti ortopedskih operacija

Artroskopija

Artroskopije kuka, kolena, ramena, skočnog zgloba i lakta danas se sve više rade kao ambu-lantne procedure2–4. Odluka anesteziologa je na izboru pacijenta za ambulantnu hirurgiju, tipu anestezije, adekvatnom anestetiku, ali i očekivanju pacijenta u nekomplikovanom postoperativnom toku, bez bola. Još uvek ne postoje jasne preporuke kriterijuma za ambulantnu hirurgiju, te tako Ame-ričko udruženje anesteziologa kod pacijenata ASA 3 i 4 statusa insistira na neophodnosti medicinske dokumentacija koja govori u prilog stabilnosti po-stojećih pratećih bolesti. To znači da medicinski nestabilni pacijenti nisu kandidati za ambulantnu hirurgiju. Faktori koji određuju postoperativni tok u ambulantnoj hirurgiji, u smislu njegovog pro-duženja su: bol, muka, povraćanje, neuroaksijalni blok i retencija urina2–4.

Artroskopska hirurgija kolena može da se izvrši u kombinaciji ekstraartikularnog i intraartikular-nog ubrizgavanja lokalnog anestetika, zahtevajući tako kombinaciju anestetika sa kratkim i dugim efektom i morfina, a u cilju obezbeđivanja i odsu-stva postoperativnog bola1. Međutim, ova aneste-zija ne može da obezbedi mišićnu relaksaciju koja je neophodna ako se radi rekonstrukcija ligamena-ta (ligamentoplastika). Te tako izbor anesteziologa može biti spinalna anestezija sa tankim quinque-ovim ili pencil point iglama, kako bi se obezbedili operativni uslovi, ali i prevencija postpunkcionih glavobolja1. Problemi vezani za neuroaksijal-nu anesteziju u ambulantnim uslovima uključu-ju nepredvidljiv početak, ali i regresiju spinalne blokade, retenciju urina i tranzitorne neurološke simptome (TNS)1,32. Tranzitorni neurološki simp-tomi se javljaju do 24 sata od spinalne anestezije i manifestuju se kao bol u glutealnoj regiji koji se širi u obe noge, bez ispada senzibiliteta, motori-ke i funkcije sfinktera. Kod artroskopija kolena se češće javlja ukoliko su pacijenti bili u litotomnom položaju nego u ležećem. Bol po jačini može da ide od srednjeg do jakog i može da traje od dva do pet dana, najbolje se kupira NSAIL-om. Veća učesta-lost TNS je primećena kod spinalne anestezije sa

lidokainom (14%), a najređa sa bupivakainom (< 1%)1,32. Kod artroskopije kolena u ambulantnim uslovima, u cilju obezbeđivanja postoperativne an-algezije, može se dati i periferni nervni blok nervu-sa safenusa. Blok nervusa safenusa dugodelujućim lokalnim anestetikom ima prednost u odnosu na blok nervusa femoralisa, jer ne dovodi do motorne blokade i tako obezbeđuje ranu pokretljivost paci-jenta1,33.

Atroskopije kuka su postale standardne pro-cedure u dijagnostici i terapiji patoloških procesa na kuku. Izvode se u lateralnom ili u položaju na leđima, pri čemu treba da se naglasi mogućnost kompresije pudendalnog nerva držačima. Zbog neophodnosti kompletne relaksacije za ovu proce-duru, izvode se u opštoj ili centralnoj sprovodnoj anesteziji, a u cilju postoperativne analgezije može se dati lumbalni blok1,34.

Artroplastike kuka i kolena

Ugradnja totalne proteze kuka i kolena značaj-no doprinosi poboljšanju kvaliteta života i smanje-nju bola kod pacijenata sa teškim bolestima zglo-bova35. Povećanju ukupnog broja proteza koje se ugrade doprinosi starenje svetske populacije, ali i činjenica da je sve veći broj pacijenata sa nekoliko različitih tipova implantiranih proteza u telu. Naj-češće komplikacije nakon ove hirurgije su kardi-ovaskularni problemi, plućna embolija, pneumo-nija, respiratorna insuficijencija i infekcije, što za-hteva produženi postoperativni monitoring u jedi-nicama intenzivne nege. Zbog toga je neophodna preoperativna medicinska evaluacija u elektivnoj hirurgiji. S druge strane, prelomi kuka kod popu-lacije starih ( > 65 godina) povezani su sa značaj-nim morbiditetom i mortalitetom (jednogodišnji mortalitet je 30%), čemu doprinosi visok procenat perioperativnih kardioloških, pulmoloških kom-plikacija, DVT i postoperativni delirijum35. Post-operativna konfuzija i delirijum se javljaju kod 50% starih nakon preloma kuka. I pored toga što je preoperativna priprema neophodna, odlaganje hirurgije može da pogorša probleme i poveća inci-dencu komplikacija. Međutim, rana hirurgija nije pokazala povećan procenat preživljavanja u odno-su na odloženu kod preloma kuka. U skladu sa tim,

II: Postoje suprotstavljena mišljenja ili dokazi o određenim procedurama ili terapiji IIa: Procena stavova/dokaza je u korist upotrebljivosti.IIb: Primenjivost je manje dokumentovana na osnovu dokaza. III: Primenjivost je mala ili čak štetna. IV: Preporuka je zasno-vana na kliničkom iskustvu grupe koja je učestvovala u pravljenju vodiča.I pored toga što najnoviji vodiči predlažu aspirin kao jedino farmakološko sredstvo u prevenciji VTE kod preloma kuka, kao i artroplastikama kuka i kolena, i dalje postoji skepticizam vezan za njegovu efikasnost27. Buduće studije bi trebalo da razreše i kontraverze u profilaksi VTE kod artroplastika, povreda gornjeg i donjeg ekstremiteta.

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preporuke Američke akademije ortopeda (Ameri-can Academy of Orthopaedic Surgeons – AAOS), kao i NICE su da operativno lečenje pacijenata sa prelomom kuka bude u prvih 48 h od povre-de, a posebno se naglašava značaj kliničke procene kod svakog pacijenta pojedinačno36,37. Pacijenti sa prelomom kuka, pored intenzivnog bola usled preloma, dehidrirani su i anemični, zbog čega je neophodna nadoknada volumena, ali i korekcija anemije pre planirane operacije, uz adekvatnu an-algeziju. Sa druge strane, oni imaju najveću inci-dencu PE i mortaliteta38. Pokazano je da pacijenti koji su primili opštu anesteziju za ovu hirurgiju imaju 4 puta veći rizik za nastanak DVT u odnosu na one koji su primili centralnu sprovodnu aneste-ziju. Epiduralna anestezija i analgezija se kod ovih pacijenata ne preporučuje, zbog započinjanja agre-sivne antikoagulantne terapije koja je neophodna u postoperativnom toku26.

Prelomi karlice su često udruženi sa povredom grudnog koša (21%), glave (16%) i jetre i slezine (8%). Tromesečni mortalitet kod preloma karlice je oko 14%39. Optimalno vreme za stabilizaciju karlice je u prvoj nedelji od traume, međutim često udružene povrede odlažu operaciju1.

Artoplastike kuka

Artroplastike kuka se izvode u prednjem ili la-teralnom položaju. Prednost prednjeg pristupa je u ekspoziciji bez sečenja mišića, ali je ograničen pri-stup femuru i postoji rizik za nastanak povrede n. cutaneus femoralis lateralisa40. Zadnji lateralni pri-stup obezbeđuje odličan pristup femuru i acetabu-lumu, sa minimalnim oštećenjem mišića, ali pove-ćava rizik od zadnje luksacije40. Anesteziolog mora da ima na umu mogućnost otežane oksigenacije kod pacijenata u lateralnom položaju, posebno kod gojaznih i pacijenata sa artritisom, a koja je rezul-tat izmenjenog ventilaciono perfuzionog odnosa, kao i prevenciju kompresije na aksilarnu arteriju i brahijalni pleksus zavisnog ramena1. Kontraverzni su podaci po pitanju nastanka postoperativnih re-spiratornih komplikacija, kao i DVT i PE kada je u pitanju izbor tipa anestezije. Gubitak krvi tokom ovih operacija, naročito ako je u pitanju reviziona hirurgija, može biti od 1 do 2 litre41. U cilju sma-njenja intraoperativnog krvarenja, primenjuje se kontrolisana hipotenzija, kao i traneksamična ki-selina1,41. Kontrolisanom hipotenzijom, održava-jući srednji arterijski pritisak od 50 do 60 mmHg, smanjuje se ne samo intraoperativno krvarenje na svega 200 ml nego se obezbeđuje i bolja fiksacija između proteze i kosti, zbog manjeg krvarenja iz

femoralnog kanala42. Međutim, primećeno je da stariji pacijenti ne mogu da tolerišu ove vrednosti srednjeg arterijskog pritiska bez postoperativnih kognitivnih, kardioloških i renalnih komplikaci-ja43. Cementna fiksacija proteze može da dovede do nastanka hipotenzije, hipoksije i srčanog zasto-ja, kao i sindroma masne embolije (fat embolism syndrome – FES) postoperativno. Nekoliko meha-nizama mogu biti razlog tome, uključujući i em-bolizaciju cirkulacije ostacima koštane srži tokom obrade femoralnog kanala, koja se smatra najvero-vatnijom, zbog mogućnosti vizuelizacije ostataka u desnoj komori srca, ali i toksičnim efektom metil metakrilat monomera u cirkulaciji i oslobađanja citokina tokom obrade femoralnog kanala42,43.

FES je fiziološki odgovor na prisustvo masti u sistemskoj cirkulaciji, koje može da se detektuje kod svakog pacijenta sa prelomom karlice ili femu-ra. On nije sinonim za masnu emboliju i njegova incidenca je manja od 1%1. Klinički se manifestuje respiratornim, neurološkim, hematološkim i kuta-nim znacima i simptomima. Može da nastane na-glo ili da se postepeno razvija u periodu od 12 do 72 sata. Petehijalni raš konjuktiva, oralne mukoze, kože vrata i aksila je patognomoničan za FES44. Simptomi respiratornog sistema se javljaju kod 75% pacijenata sa FES-om, i to kao hipoksemija sa radiološkom potvrdom obostranih infiltrata. Ma-sni embolus u mikrocirkulaciji pluća ili drugih or-gana se metaboliše do slobodnih masnih kiselina, koje dovode do sistemskog inflamatornog odgovo-ra, sa invazijom inflamatornih ćelija i posledičnim oslobađanjem citokina. Terapija FES je suportativ-na simptomatska, obezbeđuje ranu stabilizaciju, a u cilju smanjenja stres odgovora na hipoksemiju, hipotenziju. Iako samo 10% pacijenata sa FES-om zahteva mehaničku ventilacionu potporu, kod većine simptomi prolaze u toku od 3 do 7 dana. Faktori rizika su reviziona hirurgija, dug stem fe-moralne komponente proteze, patološki prelom, postojanje plućne hipertenzije i količina cementa koja je korišćena. Takođe, kod ovih pacijenata je povećana mogućnost embolizacije krvnim ugru-škom usled dislokacije kuka i moguće opstrukcije femoralne vene44,45.

Artroplastike kolena

Artroplastike kolena postaju vodeće ortopedske procedure kod populacije starih. U inervaciji kole-na učestvuju n. tibialis, n. peroneus communis, zad-nja grana n. obturatoriusa i n. femoralis. Izbor op-šte anestezije sa endotrahealnom intubacijom nosi veliki rizik za nehirurške komplikacije u odnosu

13

na centralnu sprovodnu anesteziju (spinal ili epi-dural) ili blok perifernih nerava46–48. Ipak, blokada n. ishiadicusa kod ugradnje totalne proteze kolena sa valgus deformitetom nosi rizik od ranog nepre-poznavanja paralize n. ishiadicusa ili n. peroneusa.

Regionalna anestezija ima prednost i kada je u pitanju kupiranje postoperativnog bola, te se tako preporučuje blokada n. saphenusa, koja omoguća-va ranu mobilizaciju pacijenata. U cilju postopera-tivne kontrole bola, kao i rane mobilizacije, danas se primenjuje multimodalni princip analgezije, u okviru koga je sve češća primena periartikularne lokalne infiltracije46–49. Periartikularnom infil-tracijom se ubrizgava 120 ml rastvora koji sadrži lokalni anestetik (0,5% bupivakaina ili levobupi-vakaina 3 mg/kg), opioid (morfin 5 mg), NSAIL (ketorolak 30 mg) i adrenalin (100–300 mcg) u tri faze tokom implantacije proteze kolena. Prvih 60 ml se infiltriše neposredno pre cementiranja prote-ze i podrazumeva infiltraciju zadnje kapsule, kako posterolateralne tako i posteromedijalne strane. Sa posebnom pažnjom se infiltriše centralni deo, bez duboke aplikacije rastvora, uz obaveznu aspiraci-ju pri svakom ubodu. U ovoj fazi se infiltriše tkivo medijalnog i lateralnog femoralnog recesusa, kao i medijalna i lateralna kapsula u projekciji ranijeg meniskokapsularnog spoja. Sledeća faza se izvodi po  završetku cementiranja  protetskih kompone-nata sa 40 ml pripremljenog rastvora i infiltriše se duž lateralne i medijalne strane artrotomije i retro-patelarno masno tkivo. Po rekonstrukciji zglobne kapsule, infiltriše se subkutano masno tkivo sa pre-ostalih 20 ml pripremljenog lokalnog infiltrativnog anestetika (Slika 1)50,51.

Smanjenju intraoperativnog gubitka krvi, pored hipotenzije i traneksamične kiseline, koja se daje bilo sistemski ili lokalno, doprinosi i periartikular-na lokalna infiltracija, kao i pneumatska poveska. Pneumatska poveska (touriquet) rutinski se kori-stila u ovoj hirurgiji, u cilju smanjenja ne samo in-traoperativnog gubitka krvi nego i obezbeđivanja

beskrvnih uslova za cementiranje proteze. Danas se primećuje njena sve češća kratkotrajna upotre-ba, samo u toku procesa cementiranja, pri čemu se ne preporučuje kod pacijenata sa poznatom neuro-praksijom n. ishiadicusa, neuropatskim bolom i va-skularnom bolešću operisane noge1,52. Postavlja se proksimalno od mesta hirurškog rada i naduvava 100 mmHg iznad sistolne vrednosti krvnog priti-ska. Preporuka je da bude maksimalno postavljena 120 minuta, kako bi se izbeglo oštećenje perifernih nerava. Oštećenje perifernih nerava nastaje kao re-zultat ishemije i mehaničke kompresije. U slučaju potrebe za dužim korišćenjem poveske, neophodno je popuštanje u trajanju od 30 min, kako bi se obez-bedila reperfuzija. I pored toga što su regionalnom anestezijom obezbeđeni adekvatni hirurški uslovi, pacijent može da oseti bol nakon 60 minuta od po-stavljanja i naduvavanja tourniqueta. Za to su od-govorna nemijelizovana C vlakna, usled povlačenja neuroaksijalne blokade1,52. Paraliza n. peroneusa je komplikacija koja se javlja nakon ove hirurgije, sa učestalošću od 0,3 do 10%, pri čemu se smatra da nastaje kao rezultat ishemije i hirurške trakcije52.

Mnogi pacijenti imaju artritis oba kolena i za-htevaju bilateralnu ugradnju proteza53. Ipak, ne postoji jasan stav da li oba kolena treba uraditi u istom aktu ili sekvencijalno sa razmakom od neko-liko meseci53. Ugradnja proteze oba kolena u jed-nom aktu je povezana sa većom incidencom post-operativnih komplikacija, pre svega miokardnom ishemijom, masnom embolijom i trombozom. Učestalost FES-a i srčanih aritmija je znatno veća kod ovih pacijenata, kao rezultat povišenog infla-matornog odgovora1,53. Koristeći postojeće vodiče,

ali i studije koje su pratile pacijente sa ugradnjom proteze kolena, u jednom aktu Urban et ass. su ob-javili preporuke vezane za ovu hirurgiju (Tabela 3)53.

Slika 1: Tri faze infiltracije lokalnog anestetika tokom ugradnje totalne proteze kolena

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14 SJAIT 2019/1-2

Hirurgija na nivou kičmenog stuba

Spinalna hirurgija beleži značajan porast po-slednjih godina, pri čemu uključuje širok dijapa-zon operacija, od mikrodisektomije kod uklješte-nog diska do rekonstruktivne hirurgije deformite-ta kičme, uključujući multiple nivoe rada, prednji, zadnji, lateralni pristup ili kombinaciju i značajan gubitak krvi1, 54–57. Većina operacija ove hirurgije se izvodi u opštoj anesteziji.

Poseban izazov za anesteziologa predstavlja obez-beđivanje disajnog puta kod pacijenata sa postoje-ćim artritisom, kao i kod pacijenata sa povredom ili nestabilnom vratnom kičmom. Najsigurniji način obezbeđivanja disajnog puta kod ovih pacijenata je fiberoptička intubacija. Ona predstavlja standard kod cervikalne nestabilnosti koja zahteva zadnji pristup, pa se preporučuje intubacija sediranog, ali budnog pacijenta i procena pokretljivosti ekstremiteta posle intubacije, a pre uvoda u opštu anesteziju1,57. Imaju-ći u vidu da se neke operacije kod zadnjeg pristupa kičme rade u sedećem položaju, neophodna je do-datna priprema zbog mogućeg venskog embolizma vazduhom. Kompleksni spinalni deformiteti zahte-vaju i prednji i zadnji pristup, pa samim tim i prome-nu pozicije pacijenta tokom hirurgije1,54–57.

Operacije lumbosakralnog dela kičme mogu da se izvode kada pacijent leži na leđima sa raširenim nogama, pri čemu pelvičnom trakcijom tokom ove procedure može biti ugrožena cirkulacija donjih ekstremiteta58. Kod pacijenata u lateralnom polo-žaju tokom operacija torakolumbalne kičme tre-ba obratiti posebnu pažnju na kompresiju zavisne noge, ruke i vrata1,58. Najveći broj operacija kičme ipak se radi u prone poziciji, koja nosi određene komplikacije, i to knikovanje ili pomeranje tubu-sa, edem disajnog puta, hiperekstenziju ili hiperre-fleksiju vrata, kompromitovan protok krvi do mo-zga usled rotacije vrata, pritisak na očne jabučice, povećan intrabdominalni pritisak koji doprinosi intraoperativnom krvarenju, povećavajući pritisak u epiduralnim venama, kompresiju na brahijalni pleksus, n. ulnaris, n. peroneus, n. cutaneus femora-lis lateralis58. Ipak, najčešće postoperativne kom-plikacije nakon single stage multilevel prednjeg, zadnjeg ili oba pristupa, dekompresije i fuzije cer-vikalne kičme uključuju disfagiju (12%), disfoni-ju (4%) i kompresiju disajnog puta (do 14%)58,59. Edem disajnog puta nastaje kao posledica tkivne traume koja može da rezultira potpunom opstruk-cijom, zbog čega neki centri predlažu ostanak intu-biranog pacijenta najčešće do 24 h nakon hirurgije

Tabela 3: Kontraindikacije za ugradnju bilateralne proteze kolena u istom aktu

Starost ≥ 75 god

ASA III

Ishemička bolest srca (pozitivan stres test)

Smanjena snaga leve komore (LVEF < 40)

O2 zavisna bolest pluća

Pacijenti koji su pod povišenim rizikom za morbiditet i mortalitet

IDDM

bubrežna insuficijencija

plućna hipertenzija

asthmabronchiale zavisna od kortikosteroida

morbidna gojaznost (BMI > 40)

hronična bolest jetre

cerebrovaskularna bolest

ASA – Skor fizičkog statusa Američkog društva anesteziologa; BMI – indeks telesne mase; IDDM – insulin zavistan dijabetes melitus; LVEF – ejekciona frakcija leve komore

15

ili do povlačenja edema60. Rizik faktori za nasta-nak respiratornih komplikacija kod ovih pacijena-ta su dužina trajanja hirurgije, količina i tip infu-zionih rastvora, gojaznost, reviziona hirurgija, 4 ili više nivoa fuzije i fuzija C259,60.

Kompleksna korektivna hirurgija kičme uklju-čuje pacijente sa skoliozom, kifozom, kifoskolio-zom i revizionu hirurgiju nakon torakolumbalne fuzije. Promene mehanike grudnog koša ovim deformitetima dovode do smanjenja komplijanse, restriktivne bolesti pluća, zbog čega je neophodna respiratorna preoperativna procena1,61. Hronična hipoksemija, povećavajući plućnu vaskularnu rezi-stenciju, dovodi do plućne hipertenzije sa hiper-trofijom desne komore i uvećanjem desne pretko-more, u cilju čije procene je preoperativno neop-hodan i ehokardiogram1,62.

Visoke torakalne korekcije kičme zahtevaju ventilaciju jednog plućnog krila, koja može biti po-sebno otežana kod pacijenata sa restriktivnim bo-lestima pluća. Ovu hirurgiju prati i veliki gubitak krvi, koji zavisi od hirurške tehnike, dužine trajanja operacije, broja fuzije kičmenih pršljenova, aneste-tika, srednjeg arterijskog pritiska, dilucione koa-gulopatije, abnormalnosti trombocita i primarne fibrinolize1,62. U cilju smanjenja intraoperativnog krvarenja, predlaže se bolje pozicioniranje pacijen-ta, kako bi se smanjio intraabdominalni pritisak, zatim hirurška hemostaza, ali i kontrolisana hipo-tenzija, kao i primena cell savera63,64. Kontrolisa-na hipotenzija kojom se održava srednji arterijski pritisak od 50 do 60 mmHg kod mlađih osoba se dobro toleriše, dok su kod starijih neophodne veće vrednosti63,64.

Postoperativni neurološki deficit je jedna od najčešćih komplikacija ove hirurgije, i da bi se smanjila njena incidenca, predlaže se buđenje pacijenta i provera integriteta kičmene moždine, korišćenjem somatosenzorne evocirane potenci-jale (SSEP), motorne evocirane potencijale (MEP) i elektromiograma65,66. Kako bi se izbegli ugrizi jezika tokom MEP, savetuje se stavljanje zaštite u usta, i njihovu primenu bi trebalo izbeći kod pa-cijenata sa aktivnim epileptičnim napadima, pret-hodno postojećim vaskularnim klipsevima i ko-hlearnim implantima65,66.

Različiti fiziološki faktori mogu da utiču na SSEP i MEP, uključujući hipotenziju, hipotermi-ju, hipokarbiju, hipoksemiju, anemiju i anestetike. Ukoliko se koriste inhalacioni anestetici, s obzirom na to da u dozno zavisnom nivou smanjuju ampli-tudu signala i povećavaju latentnost, neophodno je održavanje njihove koncentracije na 1/2 MAC, bez varijacija tokom operacije. Azot oksidul ne treba

da se koristi kod MEP. Totalna intravenska aneste-zija se uspešno koristi kod SSEP i MEP monitorin-ga. Tako se prilikom korišćenja MEP preporučuju opioidi, midazolam i ketamin, dok mišićni relak-santi ne bi trebalo da se koriste67,68.

Postoperativni gubitak vida je još jedna kompli-kacija hirurgije kičme koja se retko javlja (≤ 0,1%) i može da nastane kao rezultat ishemičke optičke neuropatije, okluzije arterije ili vene retine, što na-glašava značaj pozicioniranja glave tokom ove hi-rurgije69. Međutim, ishemična oftalmopatija može da se javi i u odsustvu vaskularnog oštećenja dru-gih organa, bez hipotenzije i anemije, naglašava-jući tako osetljivost vaskularizacije n. opticusa na varijacije pritiska, dok je pacijent u položaju pro-nacije. Stoga je, u cilju prevencije ishemične oftal-mopatije, pored adekvatnog pozicioniranja glave pacijenta i odsustva pritiska na očne jabučice, ne-ophodno i održavanje normotenzije bez varijacija krvnog pritiska1,69.

Multimodalni pristup je neophodan kod ovih pacijenata, a u cilju kontrole bola postoperativno, kao i postojanja neuropatskog bola1. Neuropat-ski bol nakon hirurgije kičme (failed back surgery syndrome – FBSS) javlja se u odsustvu neuralne kompresije i predstavlja poseban entitet. Jedino je dokazana efikasnost gabapentina kod ovih pacije-nata. Stimulacija kičmene moždine dovodi do po-boljšanja funkcionalnosti pacijenta, kvaliteta sna i odsustva bola, ali invanzivnost procedure ograni-čava njenu primenu. Perkutana epiduralna adhezi-oliza je takođe dala dobre rezultate koji perzistiraju kratko nakon procedure70.

Nedavni podaci i prikazi slučaja neuroloških komlikacija kod pacijenata sa poznatom stenozom spinalnog kanala ili drugog patološkog procesa na njemu, koji su dobili spinalnu anesteziju, uka-zuju na neophodnu obazrivost kod ovih pacijena-ta. Ovome doprinosi svako stanje koje smanjuje prenosivi kapacitet krvi za kiseonik, uključujuči i položaj pacijenta u kom perfuzija kičmene moždi-ne može biti ugrožena. Pretpostavka je da je kod ovih pacijenata autoregulacioni pritisak kičmene moždine zapravo viši (60–65 mmHg) u odnosu na preporučene vrednosti 50 mmHg. S tim u skladu, ASRA kod pacijenata u toku centralne sprovodne anestezije preporučuje održavanje srednjeg arte-rijskog pritiska i maksimalno dozvoljen pad od 25–30% od osnovnih vrednosti71.

Spinalni šok

Spinalni šok je najčešće posledica delovanja di-rektne traume koja dovodi do povrede kičmene mo-

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ždine. Ishemija kičmene moždine tokom perioda hi-potenzije takođe može da dovede do spinalnog šoka, kao i tromboza arterija. Nakon povrede dolazi do razvoja hemoragičnih zona u sivoj masi u toku prva četiri sata od lezije. Ove zone mogu da progredira-ju sa razvojem edema, koji perzistira i do dve nede-lje od nastanka lezije. Klinička slika, kao i terapija zavise od nivoa povrede kičmene moždine, te tako dolazi do kompletnog prestanka motorne, senzorne i simpatičke funkcije distalno od mesta lezije1,72,73.

Do hipoventilacije dovodi lezija nervnih kore-nova od C5–Th7, kao rezultat paralize pomoćne respiratorne muskulature, abdominalne i interko-stalne, pri čemu je funkcija dijafragme očuvana je je ona inervisana nervnim korenovima od C2–C4. Klinički se razvija flakcidna paraliza sa gubitkom somatskog i visceralnog senzibiliteta, parezom creva i gubitkom vazopresornih refleksa. Kod ovih pacijenata je potrebno očuvanje perfuzije kičmene moždine, pre svega održavanjem arterijskog priti-ska i intravaskularnog volumena, kao i sprečava-nje hiperventilacije, koja dovodi do hipokapnije. Lezija od Th1–Th4 dovodi do bradikardije, a kao rezultat se javljaju oštećenja kardioakceleratornih simpatičkih vlakana.

Kod denervisanih skeletnih mišića, usled pro-liferacije acetilholinskih receptora izvan motorne ploče, pri povredi kičmene moždine dolazi do hi-perkalemije usled primene depolarišućih mišićnih relaksanata. Stepen hiperkalemije zavisi od veli-čine denervisane mišićne mase i može da dovede do aritmija, ali i ventrikularne fibrilacije i smrti. Stoga je upotreba depolarišućih mišićnih relak-sanata kod ovih pacijenata kontraindikovana već nakon 48 h od povrede. Posebno treba naglasiti i značaj održavanja temperature tela pacijenata, jer je termoregulacija narušena. Distenzija visceralnih organa, pre svega mokraćne bešike i rektuma, ali i uterusa, kod pacijenata sa povredom kičmene mo-ždine iznad Th5, usled odsustva supraspinalne in-hibicije i simpatičkog nadražaja ispod mesta lezije, dovodi do autonomne hiperrefleksije. Autonomna hiperrefleksija se manifestuje paroksizmima hiper-tenzije sa bradikardijom, aritmijom, sa perifernom vazokonstrikcijom ispod nivoa lezije i vazodilata-cijom iznad nivoa lezije1,72,73.

Gubitak funkcije iznad mesta lezije, koji se viđa nekoliko dana posle povrede, nastaje kao rezultat preuređivanja puteva kičmene moždine. Ovaj proces vremenom se smanjuje, funkcija iznad mesta lezije se obnavlja, iako tačno vreme nije poznato i može da traje od nekoliko nedelja do par meseci. Ako paci-jent preživi inicijalnu povredu, a ostane imobilisan, polje se ispunjava gliotičnim tkivom72,73.

Mikrovaskularna hirurgija

Mikrovaskularna hirurgija gornjih i donjih ek-stremiteta podrazumeva rekonstrukciju, revasku-larizaciju, reimplantaciju i transplantaciju. Ove operacije najčešće zahtevaju mirnog pacijenta u određenom položaju tokom više sati. Funkcio-nalnost mikrovaskularne anastomoze zavisi od adekvatnog protoka, te je zadatak anesteziologa da obezbedi adekvatan perfuzioni pritisak, preve-nira hipotermiju i spreči vazospazam u zoni rada. Danas, kada je u pitanju ova hirurgija, periferni nervni blokovi gornjeg i donjeg ekstremiteta imaju prioritet u odnosu na opštu anesteziju. Oni obez-beđuju blok simpatikusa i time sprečavaju vazo-spazam, ali i adekvatnu postoperativnu analgeziju za razliku od opšte anestezije74-77.

Zaključak

Ortopedska anestezija predstavlja izazov za ane steziologe sa aspekta stanja pacijenta, tipa hiru-rš ke operacije, kao i položaja koji pacijent zauzi-ma u toku operacije. Izbor regionalne anestezije zahteva sagledavanje celokupnog stanja pacijenta, a ne samo regiona koji je od značaja za operaciju. Zbrinjavanje traumatizovanih pacijenata treba da se sprovede u što kraćem vremenskom periodu, uz prethodno postignutu optimizaciju stanja. Paci-jenti kod kojih se planira artroplastika kuka, kole-na ili hirurgija nakon preloma kuka imaju najveći rizik za nastanak VTE, kako tokom tako i posle operacije. Stoga je kod njih imperativ pravovreme-no započinjanje bilo mehaničke i /ili farmakolo-ške profilakse. Za optimalnu upotrebu adekvatne profilakse postoji nekoliko objavljenih vodiča sa jasnim preporukama za dnevnu kliničku praksu. Međutim, kontroverze i dalje postoje kada su u pitanju artroskopije, kao i operacije na gornjim i povrede donjih ekstremiteta, koje bi budućim stu-dijama trebalo da budu razrešene.

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ANESTEZIJA I PERIOPERATIVNA MEDICINA U ORTOPEDSKOJ HIRURGIJI

20 SJAIT 2019/1-2

doi:10.5937/sjait1902021EISSN 2466-488X (Online)

Abstract

Introduction: Preoperative examination and recogniz-ing the risk factors for a difficult airway gives us the time for optimal preparation for difficult airway management. For goiter patients, in addition to the standard risk fac-tors, there are goiter-related factors that may address to suspect of difficult intubation. Case report: Through this case report we summarize the presentation, airway examination and management of a patient with huge goiter. About 25-years earlier he noticed a swelling on the neck which increased in size progressively. Over the years he developed compressive symptoms, such as dysphagia, hoarseness and change in voice quality. All classical risk factors for difficult intubation, as well as goiter-related factors, were preoperatively evaluated. The neck circum-ference, the left displacement of the larynx and the ra-diological findings all pointed to a possible difficulty in airway management. The plan was to perform a direct laryngoscopy using a video-laryngoscope, without using a muscle relaxant, whereas the alternate plan was to use a flexible fibreoptic bronchoscope. The patient’s airway was anesthetized with lignocaine spray into the laryn-go-pharynx 30 minutes and 10 minutes before intuba-tion. Oxygen was administered via facemask. The nasal catheter was placed to provide apnoic oxygenation dur-ing laryngoscopy and intubation. After induction of anes-thesia a smooth video laryngoscopy was performed with-out using a muscle relaxant. A reinforced endotracheal tube with an intubating stylet was inserted without any difficulties in passing and placing the tube. Conclusion: Careful planning and detailed preoperative preparation are of crucial importance for a safe intraoperative and postoperative outcome in thyroid patients.

Key words: goiter; difficult intubation; airway management; video-laryngoscopy

Sažetak

Uvod: Preoperativni pregled i uočavanje prisustva fak-tora rizika pružaju mogućnost adekvatne pripreme za obezbeđivanje otežanog disajnog puta. Kod pacijenata sa uvećanom štitastom žlezdom, pored standardnih, potreb-no je uzeti u obzir i faktore povezane sa strumom, koji mogu da ukažu na mogućnost otežane intubacije. Pri-kaz slučaja: Kroz ovaj prikaz predstavićemo preopera-tivni pregled, procenu i obezbeđivanje disajnog puta pa-cijenta sa ogromnom strumom. Pacijent je pre 25 godina primetio uvećanje žlezde koje se progresivno povećavalo. Tokom godina su se razvili znaci kompresije u vidu disfa-gije, promuklosti i promene kvaliteta glasa. Preoperativ-no su procenjeni svi klasični, kao i sa strumom povezani prediktori otežane intubacije. Uvećan obim vrata, poti-snutost larinksa u levo, kao i radiološke pretrage, uka-zivali su na moguće poteškoće u obezbeđivanju disajnog puta. Plan je bio da se bez upotrebe mišićnog relaksanta izvede direktna laringoskopija upotrebom video-laringo-skopa, dok je alternativni plan bio upotreba fleksibilnog fiberoptičkog bronhoskopa. Pacijentu je disajni put ane-steziran lidokainskim sprejom 30 i 10 minuta pre intu-bacije. Preoksigenacija je sprovedena putem maske za lice. Postavljen je nazalni kateter, kako bi se omogućila i apnoična oksigenacija tokom laringoskopije i intubacije. Nakon uvoda u anesteziju, izvedena je video-laringo-skopija bez upotrebe mišićnog relaksanta. Uz upotrebu intubacionog stajleta, armirani endotrahealni tubus je plasiran bez poteškoća. Zaključak: Pažljivo planiranje i detaljna preoperativna priprema su od ključnog značaja za intraoperativnu i postoperativnu sigurnost pacijenata sa strumom.

Ključne reči: struma; otežana intubacija; obezbeđivanje disajnog puta; video-laringoskopija

Corresponding author: Suzana El Farra, Department of anesthe-siology, intensive therapy and care, Oncology Institute of Vojvodi-na, Put doktora Goldmana 4, 21204 Sremska Kamenica, Telephone: 0640277893, E-mail: andric.d.suzana@gmail.com

Autor za korespondenciju: Suzana El Farra, Odeljenje anestezije, in-tenzivne terapije i nege, Institut za onkologiju Vojvodine, Put doktora Goldmana 4, 21204 Sremska Kamenica, Telefon: 0640277893, E-mail: andric.d.suzana@gmail.com

Prikaz slučaja Case report

GOITER-RELATED PREDICTORS OF DIFFICULT INTUBATION: CASE REPORT

Suzana El Farra1, Dragana Radovanović1,2, Aleksandar Stokić1, Duško Manić1

1Oncology Institute of Vojvodina, Department of anesthesiology, intensive therapy and care, Sremska Kamenica, Serbia 2University of Novi Sad, Medical faculty, Novi Sad, Serbia

STRUMA KAO PREDIKTOR OTEŽANE INTUBACIJE: PRIKAZ SLUČAJA

Suzana El Farra1, Dragana Radovanović1,2, Aleksandar Stokić1, Duško Manić1

1Institut za onkologiju Vojvodine, Odeljenje anestezije, intenzivne terapije i nege, Sremska Kamenica, Srbija 2Univerzitet u Novom Sadu, Medicinski fakultet, Novi Sad, Srbija

22 SJAIT 2019/1-2

Introduction

Maintaining a patient’s airway is essential for adequate oxygenation and ventilation and

failure to obtain such a goal, even for a brief period of time, can be life threatening.1 Thyroid swelling or goiter has been considered a risk factor for dif-ficult direct laryngoscopy, intubation and respira-tory complications. Therefore, preoperative detec-tion of any difficulty in maintaining the airway or intubation during the induction of anesthesia and airway control after thyroid surgery is essential1,2. For goiter patients, in addition to the standard risk factors, there are goiter-related factors that may address to suspect of difficult intubation3.

Through this case report we summarize the presentation, airway examination and manage-ment of a patient with huge goiter.

Case report

A 59 years old male patient, ASA (American Society of Anesthesiologists) physical status grade I, with BMI 32 kg/m2, presented with a huge goi-ter. About 25-years earlier he noticed a swelling on the neck which increased in size progressively. Over the years he developed compressive symp-toms, such as dysphagia, hoarseness and change in voice quality. He had no concomitant morbidities, no past surgical or medical history, and no relevant family medical history.

The patient was scheduled for a near total thy-roidectomy. The procedure was explained to the patient and a written consent was obtained.

Routine preoperative tests were performed. A thyroid hormone profile confirmed the eu-thy-roideal status of the patient. All hematological and biochemical tests were within normal limits.

The patient was conscious and cooperative. He was hemodynamically stable. His physical exam-ination was unremarkable except for a prominent anterior neck swelling, which is shown in Figure 1. On palpation, it was firm, immobile, and nodular. The swelling did not move with deglutition.

Figure 1. Prominent anterior neck swelling

Airway examination showed adequate mouth opening, with inter-incisor distance >5 cm. Mal-lampati score was class I. Dental examination showed an instability of the dental bridge, which required extra caution during intubation. Jaw pro-trusion and upper lip bite tests were normal. There was no restriction in temporo-mandibular joint movement. The mandibulo-hyoid distance was 5 cm. The thyro-mental distance was difficult to measure, because of the left displacement of the larynx (Figure 2). The sterno-mental distance was 22 cm. Flexion and extension of the head and neck was normal – above 90⁰. The neck circumference measured at the level of the thyroid cartilage was 52 cm, while at the level of the maximal bulge of the gland it was 55 cm (Figure 3).

Figure 2. Left displacement of the larynx

23GOITER-RELATED PREDICTORS OF DIFFICULT INTUBATION: CASE REPORT

Figure 3. Neck circumference measured at the level of the thyroid cartilage and at the level of the maximal bulge of the gland

The indirect mirror laryngoscopy revealed no restriction of vocal cord mobility, but showed that the whole larynx was displaced to the left.

The ultrasonography showed a multinodular nature and enlargement of the gland, particularly the isthmus and right lobe. X-ray showed left-sided deviation of trachea. CT-scan showed a huge multinodular goiter. The right lobe was 112 x 84 x 72 mm in size, while the left lobe was 63 x 27 x 25 mm. Consequently, the enlarged lobes had significantly displaced the hyoid bone, trachea and other structures of the neck (Figure 4).

Figure 4. CT-scan showing displacement of the hyoid bone, trachea and other structures

After securing an intravenous line with 17 G cannula in the left upper limb, Midazolam 2.5 mg was administered as a premedication. Standard monitors (electrocardiography, pulse oximeter, non-invasive blood pressure) were attached and the baseline vitals recorded.

The plan was to perform a direct laryngosco-py using video-laryngoscope and to try securing

24 SJAIT 2019/1-2

the airway, whereas the alternate plan was to use a flexible fibreoptic bronchoscope in awake spon-taneously breathing patient. The difficult airway management cart was kept ready.

The patient’s airway was anesthetized with 10% lignocaine spray into the laryngo-pharynx 30 min-utes and 10 minutes before intubation. Each ac-tivation of the metered dose valve delivers 0.1 ml which contains 10 mg lignocaine. The used ligno-caine dose did not exceed the maximum dose.

The patient was placed in a sniffing position. Preoxygenation with 100% oxygen was performed via standard facemask. The nasal catheter was placed to provide apnoic oxygenation during la-ryngoscopy and intubation.

A few minutes before intubation, Fentanyl 50 mcg and Midazolam 5 mg were administered. Af-ter a bolus of 150 mg of Propofol a smooth vid-eo-laryngoscopy was performed without using a muscle relaxant.

The video-laryngoscopy showed left displace-ment of the larynx. After external laryngeal ma-nipulation, which improved the laryngeal view, a reinforced endotracheal tube with an intubating stylet was inserted. There were no difficulties in passing and placing the endotracheal tube.

The breathing circuit was attached, and the tube placement was confirmed with normal and repeat-ed CO2 waves. The endotracheal tube was firmly secured and anesthesia was maintained with O2, N2O, Sevoflurane, Rocuronium and Fentanyl. The patient remained hemodynamically stable throughout the whole procedure.

The thyroidectomy, although being technically difficult and demanding, because of the size of goi-ter (Figure 5), was carried out without any compli-cations.

At the end of the surgery, the patient’s mus-cle relaxation was antagonized using 2.5 mg of Neostigmine and 1 mg of Atropine. Before extu-bation, the cuff leak test was performed to avoid airway obstruction secondary to tracheomalacia. As there was no collapse of the tracheal rings, the patient was successfully extubated. The patient’s condition was postoperatively monitored in the in-tensive care unit. The difficult airway management cart was kept ready.

Discussion

Problems with airway management are the main concern of any anesthesiologist when intu-bating a patient with goiter2,3. Preoperative exam-ination and recognizing the risk factors for a diffi-cult airway gives us the time for optimal prepara-tion, proper selection of equipment and personnel experienced in difficult airway management1.

Thyroid tissue overgrowth may lead to changes in the airway, consequently causing difficulties in intubation procedures. Previously published stud-ies have reported various results and various risk factors for intubating difficulties associated with thyroid gland surgery4.

Thyroidectomy due to huge goiter with a com-promised airway is usually associated with difficult

Figure 5. Resection of huge right lobe

25

airway management at the time of induction of an-esthesia, during and after surgery5. This requires careful pre anesthetic assessment of the patient, disease control status, airway assessment, blood analysis and imaging studies6.

Various noninvasive clinical tests can be per-formed to predict difficult airway maintenance, but there is no precise or ideal scoring system that predicts difficult ventilation, laryngoscopy or intu-bation. Despite numerous studies which included various risk factors, false positive results have been reported, but more importantly, there are false negative values that can mislead anesthesiologists. Increasing number of risk factors analyzed leads to higher specificity, but unfortunately, they are still not sensitive enough7.

In our case, all classical risk factors for difficult intubation, as well as goiter-related factors, were preoperatively evaluated. The neck circumference, the left displacement of the larynx and the radio-logical findings all pointed to a possible difficulty in airway management.

In huge goiter patients, induction of general an-esthesia could be risky because it may precipitate complete airway closure and make facemask ven-tilation and tracheal intubation impossible due to chronic pressure8.

Preoperative anticipation of difficult intuba-tion and evaluation of risk factors for difficult in-tubation is of vital importance so that alternative approach is kept ready to avoid any complication during intubation9.

Awake fibreoptic intubation is widely advocated for the management of the known or anticipated difficult airway10. It is recommended that an ini-tial fibreoptic bronchoscopy to be done to define the extension of the thyroid mass and to rule out obstruction of the airway11. However, fibreoptic intubation can be a challenging technique, contin-uous practice is needed to maintain the skill and usually takes a considerable amount of time to be performed. All these factors have led to the un-deruse of fibreoptic intubation by many anesthe-tists10. A good alternative for difficult intubation is the video-laryngoscope12. Video-laryngoscopes are increasing in popularity and are slowly becom-ing the preferred tool for the management of the difficult airway. There are some potential advan-tages of video-laryngoscopes over fibreoptic bron-choscopes. They seem to be easier and quicker to

use and provide a wider view of the airway, which results in a better view of nearby structures10,12.

In our case, the airway examination and the ra-diological findings showed the presence of a huge goiter which displaced the larynx and trachea, without tracheal narrowing. The patient had no breathing difficulties and he tolerated the supine position. Considering the airway assessment, the expertise and experience of the anesthetists, as well as the patient’s cooperability and consent, the deci-sion was to perform a video-laryngoscopy without using a muscle relaxant. The use of a flexible fibre-optic bronchoscopy in the awake spontaneously breathing patient was kept as an alternative plan.

Another major concern in these patients is tra-cheomalacia, which can complicate both intuba-tion and extubation. Pressure on the trachea ex-erted by the neck mass can cause necrosis to parts of the tracheal wall, which can lead to complete collapse of the airway8. Extubation and the imme-diate postoperative period are certainly high-risk situations in all cases of difficult intubation. As suggested in many case reports and recommenda-tions, the safest way to proceed while suspecting a difficult extubation is the „protected” extubation. Evaluation of airway patency after tube removal re-mains difficult to perform. No perfect tool actually exists to predict or to early detect an airway ob-struction13. A meta-analysis suggested that a cuff leak test appears to have excellent specificity and moderate sensitivity. Cuff leak test works better for ruling in than ruling out the post-extubation air-way obstruction. Given the considerable burden associated with extubation failure, it is useful and reasonable for a cuff leak test to rule in high-risk patients14.

In our case, cuff leak test was performed to rule out tracheomalacia. The patient was successfully extubated and his condition was postoperatively monitored in the intensive care unit.

Definition of a safe time window after extuba-tion is particularly difficult. The only valuable op-tion remains close observation of the patient, but first of all being aware of potential life-threatening complications that might occur at any time13.

Although several studies have tried to predict the occurrence of a difficult airway with the use of a single risk factor or risk factors used in combi-nation, the ideal indicator or set of indicators re-mains elusive15.

GOITER-RELATED PREDICTORS OF DIFFICULT INTUBATION: CASE REPORT

26 SJAIT 2019/1-2

Conclusion

„To be forewarned is to be forearmed”. Careful planning and detailed preoperative preparation are of crucial importance for a safe intraoperative and postoperative outcome in thyroid patients.

References

1. Gupta S, Sharma R, Jain D. Airway assessment: predic-tors of difficult airway. Indian J. Anaesth. 2005; 49(4):257–262.

2. Tripathi M. Goiter and airway control. World Journal of Endocrine Surgery. 2010; 2(1):33–40.

3. Olusomi BB, Aliy SZ, Babajide AM, et all. Goiter-rela-ted factors for predicting difficult intubation in patients sc-heduled for thyroidectomy in a Resource-Challenged Health Institution in North Central Nigeria. Ethiopian Journal of Health Sciences. 2018; 28(2):169–176.

4. Tutuncu AC, Erbabacan E, Teksoz S, et all. The asses-sment of risk factors for difficult intubation in thyroid pati-ents. World J Surg. 2018; 42(6):1748–1753.

5. Ahmed S, Zaeem K, Kashif S, Uddin SS. Anesthetic management of huge multinodular goiter with compromised airway. Editorial Advisory Board Chairman. 2016; 66:275.

6. Naik S, Ranjan N, D’Souza O. Case report and review of literature on anaesthesia management of massive colloid multinodular goitre. International Journal of Scientific Rese-arch. 2018; 7(2).

7. Kalezić N, Milosavljević R, Paunović I, et al. The in-cidence of difficult intubation in 2 000 patients undergoing thyroid surgery: A single center experience. Vojnosanitetski pregled. 2009; 66(5):377–382.

8. Shaikh SI, Atlapure BB. Airway challenges in thyroid surgery. Karnataka Anaesthesia Journal. 2015; 1(1):28.

9. Shah PN, Gupta G. Prediction of difficult endotracheal intubation in thyroid surgery. International Journal of Anest-hesiology Research. 2014; 2(1):6–10.

10. Alhomary M, Ramadan E, Curran E, Walsh SR. Vi-deolaryngoscopy vs. fibreoptic bronchoscopy for awake trac-heal intubation: a systematic review and meta‐analysis. Ana-esthesia. 2018.

11. Ambreesha M, Upadhya M, Ranjan RK, Kamath S. Preoperative fibreoptic endoscopy for management of airway in huge thyroid. Indian J Anaesth. 2003; 47:489–90.

12. Salama AK, Hemy A, Raouf A, Saleh N, Rady S. C-MAC Video laryngoscopy versus flexible fiberoptic laryn-goscopy in patients with anticipated difficult airway: a ran-domized controlled trial. J Anesth Pati Care. 2015; 1(1):101.

13. Sorbello M, Frova G. When the end is really the end? The extubation in the difficult airway patient. Minerva Ane-stesiol. 2013; 79(2):194–199.

14. Kuriyama A, Jackson J. 19: Cuff leak test to predict post-extubation airway obstruction in adults a meta-ana-lysis. Critical Care Medicine. 2018; 46(1):10.

15. Garg R, Dua CK. Identification of ideal preoperative predictors for difficult intubation. Karnataka Anaesthesia Jo-urnal. 2015; 1(4):174.

doi:10.5937/sjait1902027SISSN 2466-488X (Online)

Corresponding author: Elena Sinbukhova “N. N. Burdenko National Medical Research Center of Neurosurgery” of Ministry of Health of the Russia Federation, 16, 4th Tverskaya-Yamskaya St., 125047, Moscow, Russia. E-mail: ESinbukhova@nsi.ru

Original article

BURNOUT AMONG NEURO ANESTHESIOLOGISTS AND INTENSIVE CARE PHYSICIANS A PROSPECTIVE ANONYMOUS BLIND OBSERVATIONAL STUDY

Elena Sinbukhova1, Andrey Lubnin1

1“N. N. Burdenko National Medical Research Center of Neurosurgery” of Ministry of Health of the Russia Federation, 16, 4th Tver-skaya-Yamskaya St., Moscow, Russia, 125047

Dedicated to Two Anesthesiologists who suddenly decided to pass away.

Abstract

Background. Burnout is the phenomenon of depersonalization, emotional exhaustion, and low personal accomplish-ment. Burnout can lead to insomnia, sexual disorders, tachycardia, increased pressure, headache, digestive system disor-ders, destructive behavior, then to the final stage of burnout – a sense of meaningless existence. The aim of this study was to assess the dynamic of burnout among neuroanesthesiologists and intensive care physicians. Methods. Two identical sets of tests were used to determine: burnout, depression, anxiety in our study. To determine the dynamics of these three phenomenon, the tests were repeated after three months in the same group of physicians. Data collection included demo-graphic factors, Maslach Burnout Inventory (MBI) for Medical Personnel, Purpose in life test (Crumbaugh & Maholick), Toronto Alexithymia Scale (TAS), State-adopted Trait Anxiety Inventory (STAI), assessment of depression –HADS, the questionnaire “Burn–out” Boyko VV. Results: Study included 20 neuroanesthesiologists and intensive care physicians who fully completed tests in both study phases. According study phase 1 (Study 1): MBI scale 20 % of participants had high scores in all three subscales of burnout. In study phase 2 (Study-2): according to the scale 40 % of participants had high scores in all three subscales of burnout. High rates in some of three sub-scales of burnout in Study-1: 70% of par-ticipants, had high rates in some of three sub-scales of burnout in Study-2: 95%. Depression was detected in Study-1 in 10% of doctors and in Study-2 in 30% of physicians. Conclusion: Data from our study indicate a significant prevalence of emotional exhaustion, depersonalization, reduction of professional achievements and a high degree of suicidal risks. These data suggest that individual work with neuroanesthesiologists and intensive care physicians, aimed to identify burnout is needed. Burnout prevention measures like psychological support in the form of psychocorrection sessions should be suggested to anesthesiologists and intensive care physicians. The assistance should be specific, targeted to help both the high risk group of physicians and the patient dependent on him.

Key words: Burnout: anesthesiologists and intensive care physicians, Depression, Anxiety.

Acknowledgement: The authors would like to thank neuro anesthesiologists and intensive care physicians for their active participation in this study.

Introduction:

Burnout is the phenomenon of personal defor-mation, the state of physical, emotional and

mental exhaustion, which affects the person as a whole, destroying it and having a negative impact on the effectiveness of professional activity1.

Prolonged exposure to stress can lead the doctor to various consequences, ranging from reducing

cognitive flexibility and speed of decision-making to wrong self-understanding, reduced self-regu-lation, lack of faithful self-motivation and com-mitment, reduced personal participation in work, cynical attitude to people, various psychosomatic problems. Wrong self-consciousness, “not correct” thoughts, no adaptability, closeness of self-percep-tion of “I”, the presence of internal barriers, ignoring problems, presence of various mechanisms of psy-chological protection and ”tunnel“ consciousness

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lead to decrease in the level of auto-sympathy and creates a contradiction in the development of the individual. However, stress is inevitable in the work of anesthesiologists and intensive care doctors, con-stantly working with complex patients, they should be ready for a second to make decisions and take responsibility for the patient’s life. Sometimes un-friendly attitude of surgeons, as well as various so-cial factors and family problems contribute to emo-tional overload. All these can lead to development of emotional burnout. Burnout affects the value meaning-sphere of profession and life.

According to the different stages of burnout from excessive involvement in work to loss of in-terest in work and sense of helplessness sometimes including insomnia, sexual disorders, tachycardia, increased pressure, headache, digestive system disorders, decreased immunity, destructive behav-ior then to the final stage of burnout – a sense of meaningless existence.

Among high stress risk groups there are differ-ent specializations of physicians, including anes-thesiologists and intensive care doctors. Emotion-al burnout poses a threat to mental and physical health and life of anesthesiologists and intensive care specialists and may lead to memory loss, ex-haustion, irritability and intolerance, emotional and/or physical disruptions, depression, suicidal tendencies, various somatic problems and, there-fore, may be a factor of reducing the quality of medical care2-6. Burnout of medical staff leads to decrease in the quality of patient care, medical er-rors and increases the risk of patients’ mortality.7

Materials and methods:

Ethical considerations Ethical approval for this study was provided by the Ethical Committee “N. N. Burdenko National Medical Research Center of Neurosurgery” of Ministry of Health of the Rus-sia Federation, 16, 4th Tverskaya-Yamskaya St., Moscow, Russia (chairman Konovalov A.N.) on 31 of May 2018. All participants of the study signed a written informed consent to participate in this study. Two identical sets of tests were used to de-termine: burnout, depression and anxiety in our study. To determine the dynamics i.e. changes over time, the set of tests was repeated after three months in the same group of physicians. The study

was performed in two phases including the same participants, phase 1 (Study 1) and three months later phase 2 (Study2). Inclusion criteria were the position of neuroanesthesiologist of the anesthesi-ology-intensive care department and intensive care physcians, signed informed consent to participate in the study. Exclusion criteria included unsigned informed consent to participate in the study.

Data collection for the study purposes includ-ed demographic data (age, gender, marital status, children, professional experience etc.), Maslach Burnout Inventory (MBI) for Medical Personnel (in Russian) 8, Purpose in life test (Crumbaugh & Maholick) 9, Toronto Alexithymia Scale (TAS 26) 10, State-Trait Anxiety Inventory (STAI) 11 adapted by Y. L. Hanin, Assessment of depression –HADS 12, and “Burn-out” questionnaire V. V. Boyko. “Burn–out” V. V. Boyko (Russian-language questionnaire)13 consists of three phases and each phase includes four symptoms: phase – tension is a sum of symptoms: experience a traumatic circum-stance, dissatisfaction with yourself, driven into a cage, anxiety and depression; phases – resistance is a sum of symptoms: inadequate selective emotion-al response, emotional disorientation, savings of emotions, reduction of professional achievements; phase – exhaustion is a sum of symptoms: emo-tional deficits, emotional detachment, personal detachment, psychosomatic and psychovegetative syndrome. The result of “Burn-out” questionnaire is the sum of all 12 symptoms.

REDCap (7.4.17  - Vanderbilt University) was applied for data collection. RStudio (Version 1.0.153) was applied for statistical analysis and Microsoft Excel 2016 for histograms. Data were presented as percentage and median (range). Data were analyzed with Wilcoxon paired test. p<0.05 was considered as statistically significant.

Results

Study phase 1 started in June 2018 when 20 neuroanesthesiologists and intensive care phy-sicians fully completed all tests. In this study, we present data on 20 completed test forms. The stud-ied group consisted of 4 female and 16 male phy-sicians, average age were 43,8 (26-79) years, time of practice from 1 to 50 years (average 18,6), week-ly workload from 24 to 96 working hours (aver-

29BURNOUT AMONG NEURO ANESTHESIOLOGISTS AND INTENSIVE CARE PHYSICIANS A PROSPECTIVE ANONYMOUS BLIND OBSERVATION

age 45,8-46 hours), 15 participants were married, three single, one divorced, live together -1. A small number of participants didn’t allow stratification of participants based on gender and age. The change of test results in three months period was assessed.

In Study 1 according to MBI scale 20% (4/20) of participants had high scores in all three sub-scales for burnout, while in Study 2 40 % had high scores in all three subscales of burnout. High rates in some of three sub-scales of burnout in Study 1: 70% of participants had high rates in some of three sub-scales of burnout in Study 2: 95% (P value: Study-1 vs. Study-2: emotional exhaustion p=0.16, depersonalization p=0.39, personal accomplish-ment=0.09). Assessment of burnout dynamics showed changes over time. Obtained results of burnout prevalence in the study indicated the need for preventive measures and correction.

According to Boyko test, high rates in some of three sub-scales of burnout were recorded in Study 1 in 50% of participants and in Study 2 60% of partcicipants (P-value: Study-1 vs. Study-2: phas-es–tension p=0.07, phases–resistance p=0.4, phas-es–exhaustion p<0.0001. Both tests for burnout showed high prevalence of burnout.

High level of situational anxiety was detected in Study 1, 40 % of participants and 75% in Study

2: 75%. High level of personal anxiety was record-ed in 50% of participants in Study 1, and 85% in Study 2. Depression was detected in Study 1 in 10% of participants and in 30% in Study 2. Between two phases significant difference was noticed in per-sonal anxiety (p= 0.031) and depression (p = 0.03).

According to the Purpose in life test– a total value below 50 points may indicate the absence of life goals. In our Study 1 scored from median 78.5 points (51 to 99 points), and in Study 2 me-dian 71 points (51 to 99 points). TAS - increased level of alexithymia may be a contraindication for professionals working in the field of communica-tion. Alexithymic personality features – 74 and more points, not alexithymic - 62 or fewer points. In our studies the median TAS in Study 1: was 73 (64-102) points, in Study 2: median was 73 (range 64 -100) points. Between two phases of the study there was no difference in situational anxiety (p = 1), purpose in life test (p = 0.19) and TAS (p=1).

In addition to the questionnaires, respondents were also asked to answer a series of general ques-tions, which are presented in the Figures below: 2, 3 and 4.

In Study1: in median, doctors estimated the optimism of their future by 5 points (2-10 points). Score equal or higher of 8 points were record-

Table 1 Prevalence of the Maslach Burnout Inventory (MBI) dimensions.

Dimension (level)

n (20) %

Emotional Exhaustion Depersonalization Personal Accomplishment

Study 1 Study 2 Study 1 Study 2 Study 1 Study 2

low 45% 15% 20% 5% 35% 10%

medium 15% 30% 30% 30% 15% 10%

high 40% 55% 50% 65% 50% 80%

Table 2 Prevalence of Burnout according to Boyko test dimensions.

n (20) %

Dimension (level)Phases–Tension Phases–Resistance Phases–Exhaustion

Study 1 Study 2 Study 1 Study 2 Study 1 Study 2

not formed 65% 35% 25% 5% 50% 50%

in the formation stage 25% 40% 25% 35% 25% 15%

formed 10% 25% 50% 60% 25% 35%

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Fig. 1. Anesthesiologists and intensive care physicians in Study-1 and Study-2. Anxiety: situational (ST) and personal (PR), Depression (number of persons); Purpose in life test, Toronto Alexithymia Scale (TAS) (median value).

Fig. 2. Anesthesiologists and intensive care physicians in Study-1 and Study-2. Assessment of your own fatigue during the working week on average from 0 to 10 (where 10 is very tired) (A), Assessment of your own productivity 0 to 10 (where 0 is low) (B), Assessment of how much you love your job from 0 to 10 (C), Assessment of how much you would like to love your job from 0 to 10 (D), If I had the opportunity, I would not work (E) (yes I do not want - number of persons), How opti-mistic you feel about your future from 0 to 10 (F), How many positive feelings you feel today (G), How many positive feelings you felt yesterday (H), Rate your emotional state now on the scale from 0 to 10 (I). (median value).

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Fig. 3. Anesthesiologists and intensive care physicians in Study-1. Frequency of headache (A), use of an-algesics (B), dizziness (C), complaints of heartbeat/pain/discomfort in the heart (D), complaints about the gastrointestinal tract (E), complaints about the respiratory system (F), feeling of lack of air (G), complaints about the genitourinary system (H). (number of persons).

Fig. 4. Anesthesiologists and intensive care physicians in Study 2. Frequency of headache (A), use of an-algesics (B), dizziness (C), complaints of heartbeat/pain/discomfort in the heart (D), complaints about the gastrointestinal tract (E), complaints about the respiratory system (F), feeling of lack of air (G), complaints about the genitourinary system (H). (number of persons).

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ed in 30% of anesthesiologists and intensive care physicians. The lowest score below 4 points was recorded in 45% of participants. In Study 2, the optimism of their future was scored with 4.5 points (2-10 points). Score equal or higher of 8 points was recorded in 30% of participants, while the low-est score from 0 to 4 points was chosen by 50% of participants. Thus, almost every second physician was not optimistic about future of his/her future or him/her self in the future.

The most common somatic complaints based on literature data were investigated (Figures 3 and 4).

Suicidal ideas were also tested and the question “I thought about suicide”: (where 1-yes I thought about it, 5- I never thought) according to the Study 1 was negatively answered by 11 people (55% of re-spondents), and 1 participant confidently replied that he/she thought about suicide, 4 people (20%) – answered that sometimes they think about suicide, 4 people (20%) –answered that they think about suicide rarely. According to the Study 2, about su-icidal ideas, the answer was negative in 10 people (50% of respondents), 2 participants confidently replied that he/she thought about suicide, 5 people (25%) – answered that sometimes they think about suicide, 3 people (16%) –answered that they think about suicide rarely.

Discussion

So far published literature raises attention on large number of doctors and nurses having dif-ferent stages of burnout. Recently published study presented high burnout level in 18.63% nurses, 12.06% anesthesiologists, and even more alarming critical level in 3.74% nurses and 5.90% anesthesi-ologists 14.   Another study noticed that frequency of high-risk responses ranged from 26% to 59% of participants across three categories, however 15% had unfavorable scores in all 15. The study of Dutch anesthesiologists showed psychological distress in 39.4% and burnout prevalence in 18% of all respondents, and difference between the res-idents and consultant anesthesiologists: 11.3% vs. 19.8% 16.    In Serbian hospitals based in Belgrade prevalence of total burnout among anesthesiolo-gists was 6.34%, high emotional exhaustion, high depersonalization and low personal accomplish-ment was 52.7, 12.2 and 28.8%, respectively5.   The

study of anesthesiologists from Southern Brazil showed that 48.7% of participants were positive for burnout, 26.9% for emotional exhaustion, 41.3% for depersonalization and 32.7% for low personal accomplishment 17.  Study performed among an-esthesiologists practicing in US metropolitan area revealed high degrees of burnout in 61.4% emo-tional exhaustion, 31.6% depersonalization and 64.9% low personal achievement 18.  Investigation including Lithuanian cardiac surgeons and cardi-ac anesthesiologists reported in 19.3% physicians emotional exhaustion, 25.9% had high deperson-alization, and 42.3% demonstrated low personal accomplishment at work 19.  

There is variability of burnout incidence among countries and studies. In our research, in Study 1, 70% of the examined anesthesiologists and inten-sive care physicians (MBI) had high rates in some of three sub-scales of burnout and it is close to other studies data. But, in Study 2, 95% of the examined anesthesiologists and intensive care physicians had high rates in some of three sub-scales, and this is 30% higher than in the study in US metropolitan area. High rates in all three sub-scales of burnout syndrome are present in our study, in Study 1, 20 % of the examined anesthesiologists and intensive care physicians, in Study 2, 40%. It is obvious that high prevalence of burnout syndrome requires ac-tion and proposition of potential solutions for this problem.

In recent years, the suicide among physicians in different countries has led to the fact that the top-ic of doctors ‘ health has become more noticeable in research. Suicide does not typically arise from burnout alone, but can be associated with other mental illnesses, such as depression. The risk of su-icide and suicidal ideation increases from 4% dur-ing the pre-internship period to about 25% during the intern year, and increases approximately four-fold in the first three months of the internship year, but the actual highest rate of suicide in physicians is in late middle age 20.

Some of the studies show greater prevalence of depression in physicians and demonstrates the overlap of burnout and major depression 21. De-pression is common in medical professionals, in-cluding anesthesiologists, and it is closely related to the suicide, so it may be a marker for the risk of suicide 22.  Depression as a mood disorder (an emotional disorder) includes anguish, anxiety,

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guilt, anhedonia, apathy, in addition there may be certain violations in the sphere of thinking, mem-ory and attention loss. Various related symptoms such as sleep disorders, digestive system disorders, sexual disorders, fatigue, possible abuse of alcohol or other psychoactive substances that are used to improve mood. Thus, testing of medical profes-sionals’ burnout symptoms should include the study of depression level. For example, according to one study substance use disorder remains one of the commonest sources of impairment among anesthesiologists. One-third of anesthesiologists during their career can have different degrees of impairment, such as physical ailments, depression, burnout, age cognitive decline and others 23.

According to systematic review burnout prev-alence among physicians in the United States ex-ceeds 50%, that means it has reached epidemic proportions and is still rising 24.  Also, systematic review published in 2017 showed increased per-centage of physicians reporting at least one burn-out symptom 25. So, it is an emerging problem of healthcare systems. And although prevalence of burnout greatly varied according to different stud-ies (10%–41% high risk, up to 59% at least moder-ate risk), noted that prevalence among anesthesiol-ogists is relatively high at all career stages. Burnout leads to poorer patient safety and quality of care, resulting in higher risk of errors. No relationship between doctors’ burnout and hospital character-istics, gender, or marital status was not found. And a small number of studies reporting approach war-rants further research in field of burnout among anesthesiologists 25.

The term alexithymia appeared in the scientific literature at the end 1960s. Alexithymia is literally translated as: “without words for feelings”. It is char-acterized by poor differentiation and verbalization of emotions that lose their signal functions, lack of emotional sensitivity which leads to communication difficulties and distant and cold relationships with other people. Having alexithymia people mainly complain of somatic troubles. According to Boyko VV, alexithymia is a psychological characteristic of a person who has the following cognitive features: the difficulty in the definition (identification) and description of their own feelings; difficulty in dis-tinguishing between feelings and body sensations; reduced ability to symbolize, as an evidenced of the poverty of imagination; focus more on external

events than on inner feelings. Alexithymia can be “primary” and “ secondary”. Primary alexithymia is usually irreversible, and it can not be eliminated in the process of psychotherapy. Secondary alexithy-mia can be overcome through psychotherapy, en-couraging the patient to observe and express their emotions13. Increased level of alexithymia may be a contraindication for professionals working in the field of communication. According to the data of Bekhterev Psychoneurological Institute adaptation of TAS technique, average value of alexithymia in several groups were as follows, the control group of healthy people 59.3+1.3 points, the group with psychosomatic disorders 72.09+0.82, the group with neuroses 70.1+1.3. 13 In our studies the me-dian TAS in Study 1 was 73 (64-102) points and in Study 2, 73 (64-100) points. We can hypothesize that the test high scores are dendent on burn out prevalence, and therefore psychological support can play significant role in physicians professional and personal life.

Burnout leads the doctor to a steady decrease in labor productivity, it leads to memory slowness 26 and deterioration, increase in consumption of various stimulation drinks 23,21 and destructive behavior. The emergence of a variety of psycho-somatic disorders (insomnia, sexual disorders, tachycardia, increased pressure, headaches, disor-ders of the digestive system, decreased immunity), etc. At the final stage of burnout there is a sense of meaningless existence, despair, the appearance of suicidal thoughts and committed suicides.27 Based on the importance of the problem and its disastrous consequences for the health and life of the anesthesiologists and intensive care doctors, as well as the life and health of their patients, it is nec-essary to conduct regular testing of doctors aimed at identifying the first symptoms of burnout.

Stress is inevitable in the work of anesthesiol-ogists and intensive care doctors 28, and requires adaptive behavior. It becomes obvious that in cer-tain periods of the proffesional career anesthesi-ologists and intensives should be routinely tested for burnout. Thus, the solution to the burnout problem includes two important points, the first is indentification of employees with burnout, and the second regular preventive psychological work with employees aimed at preventing appearance of burnout symptoms. Psychological interventions should be aimed at developing skills of overcoming

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problems, goal-setting, the ability to resolve con-flicts, time management, the absence of conflict “I am ideal” and “I am real”, proper understanding of oneself, the development of communication skills in the family and the team 28. Based on this there is a question does every large hospital should have psychologist available for consultations in case physicians themselves requires help.

Conclusion

Prevention of burnout syndrome should begin with its diagnosis, also the diagnosis of presence of depression, situational and personal anxiety should be included in the study. The advantage of sharing different burnout scales for greater relia-bility of the results should be noted. Assessment of burnout, depression and other parameters in the dynamics showed that the levels are not constant and can change over time. Future: future research on a larger number of respondents will be able to provide a greater understanding of the results and the conclusions.

Since the results obtained by us indicate a sig-nificant prevalence of emotional exhaustion, depersonalization and reduction of professional achievements, and a high degree of risk of suicide, it is desirable to conduct not anonymous, but indi-vidual work with the staff of anesthesiology- inten-sive care physicians, aimed at identifying burnout, its prevention and psychological support - con-ducting psychocorrection sessions with anesthesi-ologists - intensive care physicians.

Thus, assistance should be specific, targeted to help both the doctor and the patient dependent on him.

References

1. Herbert JF. Staff Burn-Out. Journal of Social Issues 1974; 30(1): 159–165.

2. Lindfors PM, Nurmi KE, Meretoja OA, et al.  On-call stress among Finnish anaesthetists. Anaesthesia 2006; 61(9):856-66.

3. McNamee R, Keen RI, Corkill CM. Morbidity and early retirement among anaesthetists and other specialists. Anaesthesia 1987; 42: 133–40.

4. Svärdsudd K, Wedel H, Gordh T . Mortality rates among Swedish physicians: a population-based nationwide study with special reference to anesthesiologists. Acta Ana-esthesiologica Scandinavica 2002; 46: 1187–95.

5. Milenovic M, Matejic B, Vasic ,et al. High rate of bur-nout among anaesthesiologists in Belgrade teaching hospi-tals: Results of a cross-sectional survey. Eur J Anaesthesiol. 2016; 33(3):187-194,

6. Shanafelt TD, Boone S, Tan L et al.. Burnout and satisfaction with worklife balance among US physicians relative to the general US population. Arch Intern Med 2012; 172:1377–1385.

7. Maslach C, Leiter MP. New insights into burnout and health care: Strategies for improving civility and alleviating burnout. Medical teacher 2016; 39(2):160-163

8. Vodopyanova N., Starchenkova E. Burnout Syndrome. 2nd ed: Peter; St. Petersburg.; 2008. 258c.

9. Purpose in life test (Crumbaugh & Maholick, 1964) http://faculty.fortlewis.edu/burke_b/personality/pil.pdf

10. PsyLab.info http://psylab.info 11. https://www.apa.org/pi/about/publications/caregi-

ve rs/pra ctice-settings/assessment/tools/trait-state 12. http://cpd2002.pisem.net/TEST/HADS.htm 13. Boyko VV. Energy of emotions in communication:

look at yourself and others. Yaroslavl: Avers Press 2004; 338. 14. Misiołek A, Gil-Monte PR, Misiołek H. Prevalence

of burnout in Polish anesthesiologists and anesthetist nursing professionals: A comparative non-randomized cross-sectional study. Journal of Health Psychology 2017, 22(4): 465–474.

15. Hyman SA, Shotwell MS, Michaels DR et al. A Survey Evaluating Burnout, Health Status, Depression, Reported Alcohol and Substance Use, and Social Support of Anesthesiologists. Anesth Analg. 2017;125(6):2009-2018.

16. van der Wal RA, Bucx MJ, Hendriks JC et al. Psychological distress, burnout and personality traits in Dutch anaesthesiologists: A survey. Eur J Anaesthesiol. 2016;33(3):179-86.

17. Freire PL, Trentin JP, de Avila Quevedo L. Trends in burnout syndrome and emotional factors: an assessment of anesthesiologists in Southern Brazil. Psychol Health Med 2016; 21(4):413-423.

18. Downey RL, Farhat T, Schumann R. Burnout and coping amongst anesthesiologists in a US metropolitan area: a pilot study. Middle East J Anaesthesiol. 2012; 21(4):529-34.

19. Mikalauskas A, Širvinskas E, Marchertienė I, et al. Burnout among Lithuanian cardiac surgeons and cardiac anesthesiologists. Medicina (Kaunas). 2012;48(9):478-84.

20. Kuhn CM, Flanagan EM. Self-care as a professional imperative: physician burnout, depression, and suicide. Can J Anaesth. 2017 Feb;64(2):158-168.

21. Walter Wurm, Katrin Vogel, Anna Holl, et al. Depres-sion-Burnout Overlap in Physicians. PLoS One.  2016 Mar 1;11(3):e0149913. doi: 10.1371/journal.pone.0149913.

22. Rose GL,  Brown REJ. The impaired anesthesiologist: not just about drugs and alcohol anymore. J Clin Anesth 2010; V.22 (5): 379-84.

23. Katz JD. The impaired and/or disabled anesthesiologist. Curr Opin Anaesthesiol. 2017; 30(2):217-222.

24. Rothenberger DA. Physician Burnout and Well-Be-ing: A Systematic  Review  and Framework for Action. Dis Colon Rectum. 2017;60(6): 567-576.

3525. Sanfilippo F,   Noto A,   Foresta G, et al. Incidence and

Factors Associated with Burnout in Anesthesiology: A Syste-matic Review. Biomed Res Int. 2017; 2017: 8648925.  doi: 10.1155/2017/8648925.

26. Fernández-Sánchez JC,  Pérez-Mármol JM,  Santos--Ruiz AM, et.al. Burnout and executive functions in Palliati-ve Care health professionals: influence of burnout on decisi-on making. An Sist Sanit Navar. 2018 Jul 27;0(0):62194. Doi:

10.23938/ASSN.0308. 27. Elena V. Sinbukhova, Andrey Yu. Lubnin. Emotional

burnout of anesthesiologists-intensive care doctors. Acmeo-logy №4 2018.

28. Larsson J, Sanner M. Doing a good job and getting something good out of it: on stress and well-being in anaesthesia. British Journal of Anaesthesia. 2010; 105(1): 34-37.

Conflicting interest. – The authors declared no potential conflicts of interests

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Corresponding author: Milena Stojanović Dr Milutina Ivkovića 8/8 Niš, Srbija, mob. +381606240788 milenastojanoviclaci@gmail.com

Sažetak

Ventilacija jednog plućnog krila se koristi iz različitih hi-rurških i ne-hirurških razloga. Ovaj tip ventilacije nosi sa sobom određene rizike za razvoj ventilaciono/perfu-zionih poremećaja različitog stepena povezanim sa late-ralnim dekubitalnim položajem, jednostranom plućnom ventilacijom i otvaranjem grudnog koša. Kako je hipok-semija jedna od posledica jednostrane plućne ventilacije, različite strategije ventilacije se preporučuju u cilju njene prevencije i lečenja. Strategija uključuje određene mane-vre na ventilišućem i ne-ventilišućem plućnom krilu kao i upotrebu određenih lekova koji mogu modulirati i inten-zivirati fenomen jedinstven za plućnu cirkulaciju- hipok-sičnu plućnu vazokontrikciju (HPV).

Ključne reči: hipoksemija, jednostrana ventilacija plu-ća, hipoksična plućna vazokonstrikcija

Sumarry

Lung isolation is used for various surgical and non-surgi-cal reasons. This type of ventilation carries the risk for va-rious degrees of ventilation/perfusion mismatch associa-ted with lateral decubitus position, one-lung ventilation (OLV) and opened chest. According to this, hypoxemia is common consequence of OLV. Among various recom-mended ventilation strategies in order to prevent hypo-xemia, protective ventilation with lower tidal volumes and applied positive end-expiratory (PEEP) pressure give some promising results. Adequate treatment and possibi-lity to predict hypoxemia during OLV is very important for reducing morbidity and mortality. Treatment inclu-des ventilator strategies on both, ventilated and non-ven-tilated lung and applied therapy, which can influence and modulate the magnitude of phenomenon unique for lung circulation - hypoxic pulmonary vasoconstriction (HPV).

Key words: hypoxemia, one lung ventilation, hypoxic pul-monary vasoconstriction

doi:10.5937/sjait1902037JISSN 2466-488X (Online)

Review article

INTRAOPERATIVE HYPOXEMIA DURING ONE-LUNG VENTILATION: IS IT STILL AN ANESTHESIOLOGISTS’ NIGHTMARE? (HYPOXEMIA DURING ONE-LUNG

VENTILATION)

Radmilo J Janković1,2, Milena Stojanović1, Anita Vuković1, Vesna Dinić1, Vladan Cvetanović1, Danica Marković1

1Clinic for Anesthesia and Intensive Therapy, Clinical Center Niš 2School of Medicine, University of Niš, Serbia

Pathophysiological mechanism of hypoxemia during one-lung ventilation

One of the most challenging procedures for anesthesiologist is technique that includes

isolation of one lung from ventilation (One Lung Ventilation – OLV). It is not easy to maintain ad-equate gas exchange during OLV and provide an optimal surgical field, so hypoxemia is an adverse but common consequence of OLV. Hypoxemia during one-lung ventilation (OLV) can be defined as an arterial hemoglobin oxygen saturation of less than 90%, which occurs in 5–10% of patients (that undergo this procedure).1 The underlying pato-physiological cause of hypoxemia is attributed to intrapulmonary shunt. 2

Basic characteristics during anesthesia with OLV are lateral decubitus position, lung isolation and open chest. Using the double – lumen bron-chial tube or bronchial blocker, the lower (depend-ent) lung is ventilated, whereas the upper (non-de-pendent) lung is allowed to collapse when opening the chest. Development of hypoxemia (i.e. arteri-al oxygenation < 90%, or PaO2 < 60mmHg with FiO2=1.0) caused by OLV may be explained by taking into consideration: oxygen storage, dissoci-ation of oxygen from hemoglobin, the relationship between ventilation and perfusion and factors that reduce the effect of hypoxic pulmonary vasocon-striction (HPV). 3

Factors that potentially increase the risk of hy-poxemia during OLV are: right-sided thoracic

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surgery and left side ventilation, high percentage of ventilation or perfusion to the operative lung on preoperative V/Q scan, normal preoperative spirometry, low PaO2 during two lung ventilation (TLV) in lateral position, BMI>30kg/m2, previous lobectomy and contralateral lung collapse surgery.4

Ventilation–perfusion mismatching

The lateral position may significantly alter the normal pulmonary ventilation/perfusion ratio. This position in spontaneously breathing patient does not alter the ventilation–perfusion ratio, since the dependent lung receives more perfusion and more ventilation (contraction of the depend-ent parts of hemidiaphragm is more efficient) than the non-dependent lung. The relationship of ven-tilation and perfusion changes after induction of anesthesia. During controlled positive-pressure ventilation, in terms of ventilation the upper lung is in more favorable position because its higher compliance, whereas perfusion remains greater in the lower (dependent) lung. Use of neuromuscular blocking agents and opening the chest enhance this effect. Perfusion of the non-dependent lung with-out ventilation leads to development a large right-to-left intrapulmonary shunt and consequently to hypoxemia and hypercapnia.5 Due to HPV clini-cally observed shunt fraction is lower than roughly half of the cardiac output (CO) that normally flows through each lung.6 It is generally assumed that due to gravity 60% of blood will flow through the dependent lung, with the remaining 40% perfus-ing through the non-dependent lung. Because to-tal shunt (10% of cardiac output) is roughly equal-ly divided, 55% and 35% of CO participate in gas exchange, respectively. Ventilating the dependent lung only will result in loss of 35% of CO that par-ticipates in gas exchange (non-dependent lung). Hypoxic pulmonary vasoconstriction can decrease non-dependent blood flow by 50% (or 17.5% glob-ally), thus the amount of CO available for gas ex-change should only fall from 90% to 72.5%. That said, because of abdominal content, paralysis, an-esthesia and the weight of mediastinal structures, the dependent lung has reduced FRC and is rela-tively non-compliant.7

The impact of ventilation strategy and pa-tient positioning on intraoperative hypox-emia during one-lung ventilation

In order to prevent acute lung injury (ALI) in thoracic anesthesia procedures, the concept of pro-tective OLV has been widely adopted in the past few years.8 This ventilation strategy includes the use of lower tidal volumes (5-6 ml/kg), positive end-ex-piratory pressure-PEEP (5-10cm H2O), lower FiO2 (50-80%) and permissive hypercapnia, The effects of this ventilation strategy on intraoperative hy-poxemia still remains controversial 9,10 but it looks like hypercapnia, as part of a protective ventilation, is felt to improve HPV and therefore aid oxygena-tion.11 Gao et al. showed in their study that ther-apeutic hypercapnia improves respiratory func-tion, and mitigate OLV-related lung and systemic inflammation.12 Using lower tidal volumes may be associated with derecruitment, worsening intraop-erative atelectasis and intrapulmonary shunt, thus contributing to hypoxemia and hipercapnia.13 This can be prevented by addition of PEEP which can reduce the incidence of atelectasis by preventing lung collapse. Also, prolonging the inspiratory time and adjusting the I:E ratio can be effective in im-proving oxygenation and reducing shunt fraction about one hour after starting the OLV.14

Although for now, there is not enough evidence about which ventilation mode is preferable, pres-sure-control ventilation (PCV) is thought to pro-vide more uniform lung aeration and recruitment as well as lower risk of barotrauma by limiting the peak (<35 cm H2O) and plateau airway pressure (<25 cm H2O). Indeed, initial studies comparing PCV and volume-control ventilation (VCV) dur-ing OLV found improved oxygenation and shunt fraction with PCV15, as well as the risk reduction for post-thoracotomy acute lung injury, but subse-quent investigations failed to highlight benefit of PCV during OLV.8, 16-18

Traditionally, the lateral decubitus position has been found to improve oxygenation during OLV due to gravity redistribution of pulmonary blood flow with diverting roughly 10% of CO to the de-pendent lung.19 On the other hand, Yatabe et al. found better PaO2/FiO2 ratios in patients under-going oesophagectomy in prone position.20 This finding may be explained by the superior V/Q

39

matching in the prone position21 and the lack of compression of the ventilated lung by mediasti-nal structures.22 Additionally, supine positioning during some thoracoscopic procedures also tends to increase the risk of hypoxemia during OLV.23

However, recent animal experiments appear to suggest that anatomic pulmonary vascular factors are more important than gravity per se in terms of pulmonary blood flow distribution (it depends on lung volume, body position and PEEP). In the op-posite of expectations, the blood flow through the dependent lung can be reduced. One of possible ex-planation is that the pressure of mediastinal struc-tures could reduces ventilation of the dependent lug. This consequently provokes hypoxic pulmo-nary vasoconstriction and decreases blood flow.24

Treatment of hypoxemia

Interventions directed to depended lung

One of the most efficient ways to treat hypox-emia during OLV is alveolar recruitment maneu-ver of the dependent lung.25 It can be applied before starting OLV with 10 breaths limited with plateau pressure of 40 cm H2O and PEEP in in-cremental levels of 5-10 cmH2O with maximum PEEP of 20 cm H2O.26 This maneuver can be con-tinued on the dependent lung during OLV in a du-ration of 1 minute and application of 5 cm H2O PEEP.27,28 By increasing the area of ventilated lung parenchyma, this maneuver improves gas ex-change and arterial oxygenation. Furthermore, in major pulmonary resection, the alveolar recruit-ment maneuver has improved arterial oxygenation by reducing intrapulmonary shunt and dead space during OLV.15,29 On the other hand, this strategy may lead to hemodynamic instability by decreas-ing the left ventricular preload, CO and arterial blood pressure30,31, and may also cause barotrau-ma32 and translocation of pro-inflammatory cy-tokines from the alveolar space into the systemic circulation.33 We can conclude that dependent lung recruitment might be effective for arterial ox-ygenation improvement during OLV, however, its final effect can be transient.34

Interventions directed to non-depended lung

When severe hypoxemia occurs, intermittent two-lung ventilation and application of continuous

positive airway pressure (CPAP) to the non-de-pendent lung may be effective. Another advantage of using CPAP is that this maneuver reduces local immune response after OLV, as shown by Verhage et al. during thoracoscopic oesophagectomy.35

However, this technique can interfere with surgical procedure, especially with video-assisted thoraco-scopic surgery (VATS) since it impairs the view of the surgical field. This limits the use of CPAP of the non-dependent lung in clinical practice. In order to overcome this limit, modifications of the standard CPAP technique are proposed. These new techniques include a novel method of fibreoptic bronchoscopic selective oxygen insufflation into a bronchopulmonary segment in order to clear the surgical site36 and intermittent small-volume oxy-gen insufflations.37 In cases of disastrous desatura-tion, clamping the pulmonary artery may improve oxygenation.38,39

Making a compression on the nondependent lung by surgeons is one of the additional maneuver for improving oxygenation during OLV. This con-troversial strategy also decreases CO and system-ic oxygen delivery, but Ishikawa et al. found that administration of an inotropic agent concomitant with lung compression mitigates the decreases in CO and systemic oxygen delivery, while maintain-ing the beneficial effect of lung compression on ar-terial oxygen saturation.40 High-frequency jet ven-tilation and high-frequency percussive ventilation also appear successful in treating hypoxemia dur-ing OLV without impeding surgical exposure.41, 42

Medications

Shunt fraction is the (most important) deter-minant of oxygenation during OLV and therefore agents which increase the pulmonary blood flow in the ventilated lung may significantly improve oxygenation. Selective vasodilatation of the pul-monary vascular bed may be achieved with in-halational agents. Inhaled nitric oxide (NO) has pulmonary vasodilating, bronchodilating and an-ti-inflammatory effects. Prostacycline and Alpros-tadil reduce pulmonary vascular resistance and improve oxygenation, however, all of these agents are expensive and can not be considered a readily available treatment.43,44,45

Almitrinine acts as a selective pulmonary va-soconstrictor which increases HPV and decreases

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the shunt fraction. Intravenous infusion of 8 μg/kg/min of this agent significantly improves oxy-genation. Some authors suggest the combination of almitrinine and NO, however, almitrinine is not yet commercially available in some parts of the world.46,47

Epidural dexmedetomidine has been shown to limit the decrease in PaO2 during OLV without af-fecting systemic or pulmonary hemodynamic pa-rameters.48 This action of dexmedetomidine may be explained by nitric oxide dependent vasodilata-tion mediated by endothelial α 2-adrenoceptor ac-tivation.49 Also, aerosolized epoprostenol has been shown to improve arterial oxygenation and de-crease mean pulmonary artery pressure in patients with acute respiratory distress syndrome, presum-ably through dilation of the pulmonary vascular bed in ventilated regions and flow redistribution from shunt areas.50 Despite limited reports, it seems that epoprostenol may improve critical de-saturation during OLV51 but larger clinical trials are required to establish its safety and efficacy pro-file during OLV.

The influence of anesthetic technique on HPV

As previously stated, HPV is the most impor-tant intraoperative phenomenon in reducing shunt during OLV. This protective physiological reflex occurs with the aim to divert blood flow from hy-poxic areas to the regions of better oxygenation and ventilation, and it can decrease the blood flow in non-ventilated lung for about 50%..(7) The stimuli for HPV are the alveolar oxygen tension and the partial pressure of oxygen in mixed venous blood, but it seems that the first one is more important. The threshold for HPV is alveolar oxygen tension of about 80mmHg, and maximum response is with PaO2 of 25mmHg.52 Various factors (anesthetic agent, CO, acid/base imbalance, lung manipula-tion, vasodilatators) can modulate the magnitude of HPV in the non-ventilated lung. Also, a series of physiological factors can influence the HPV mechanism, like: extracellular pH and PCO2, tem-perature, age and iron status. Pulmonary arterial pressure is increased by hypercapnia, acidaemia, hyperthermia, lower age, iron deficiency.53 Also, surgical trauma may lead to release of vasoactive metabolites and oppose HPV.54 In animal stud-ies, volatile anesthetics have been shown to im-

pair HPV and to increase intrapulmonary shunt fraction or reduce arterial oxygen tension in a dose-dependent manner55,56, while propofol does not seem to affect HPV. However, clinical investi-gations are contradictory regarding the effect of a given anesthetic agent on oxygenation.57-61

A combination of almitrin, which reinforces HPV in non-dependent lung areas and nitrous ox-ide in dependent lung, which reduces pulmonary vasoconstriction, may be useful during hypoxia and OLV. Use of almitirine as a selective lung vaso-constrictor is recommended when other strategies fail to improve hypoxemia.62

One of additional saving maneuvers that can be used for improving oxygenation during OLV is extracorporeal membrane oxygenation (ECMO). The major indications are: severe airway obstruc-tion, emergence loss of airway, extended carinal pneumonectomy, severe emphysema undergoing lung volume reduction, acute respiratory distress syndrome undergoing thoracotomy and decor-tications, tracheoesophageal fistula repair after previous pneumonectomy, oesophagectomy after previous pneumonectomy, segmentectomy after previous contralateral pneumonectomy, thoracot-omy after previous single-lung transplantation, thoracotomy with existing contralateral bronchop-leural fistula and salvage therapy for severe chest trauma.4

Prediction of hypoxemia

Capnometry

The ability to predict which patients are most likely to have impaired arterial oxygenation would allow anesthesiologists to consider applying con-tinuous positive airway pressure (CPAP) to the nondependent lung and positive end-expiratory pressure (PEEP) to the dependent lung at a very early stage in OLV. The percentage of non-depend-ent lung perfusion, is an important predictor of arterial oxygenation during OLV.63 On the other hand, capnometry might be used to estimate the balance of blood flow to both lungs and to predict the occurrence of hypoxemia during OLV.64,65

Two recent studies presented by Fukuoka et al. and Yamamoto et al. found a significant linear relation-ship between ETCO2 and the PaO2/FiO2 ratio af-

41

ter starting OLV, as ETO2 depends on perfusion, it can be predictable parameter OLV hypoxemia occurance.61,66

Tissue oxygenation

At present, cerebral oximetry is the only nonin-vasive monitor available to determine tissue oxy-genation during OLV. Decreased levels of cerebral tissue oxygen saturation obtained by noninvasive cerebral oxygen monitoring were found in the ma-jority of patients during OLV.67 Further research which would determine the final end-organ effects of OLV on other organ systems are necessary and further technical development of noninvasive or-gan monitors is needed.

Conclusion Besides carrying the risk of developing baro-

trauma, one lung ventilation (OLV) carries the risk of developing hypoxemia and hypercapnia due to intrapulmonary shunting and dead space ventilation. Both of these can have a significant ef-fect on perioperative anesthesia management and postoperative complications. Today’s techniques and medications can mitigate these consequences of OLV, but the problem that still remains is the lack of equipment in some medical centers and the fact that some medications are not available in all countries.

The key point in preventing postoperative com-plications in thoracic surgery is applying the right ventilatory strategy. There are no published guide-lines, however, it seems reasonable to use protec-tive ventilation mode to minimize the risk of lung trauma and acute lung injury (ALI). Despite the growing awareness of the importance of protec-tive ventilation, many clinicians still use tidal vol-ume and PEEP outside the recommended levels in everyday practice.

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doi:10.5937/sjait1902045FISSN 2466-488X (Online)

Revijalni članak Review article

PRIMENA ULTRAZVUKA U IZVOĐENJU PERKUTANIH INTERVENCIJA U JEDINICAMA INTENZIVNOG LEČENJA

Aleksandar Filipović1,2, Dragan Mašulović1,2, Marija Milenković3, Miloš Zakošek1, Dušan Bulatović1, Milica Stojadinović1

1Centar za radiologiju i MR, Klinički centar Srbije, Beograd, Srbija 2Medicinski fakultet, Univerzitet u Beogradu, Srbija 3Centar za anesteziologiju i reanimatologiju, Klinički centar Srbije, Beograd, Srbija

ULTRASOUND APPLICATION DURING PERCUTANEOUS PROCEDURES IN INTENSIVE CARE UNIT

Aleksandar Filipović1,2, Dragan Mašulović1,2, Marija Milenković3, Miloš Zakošek1, Dušan Bulatović1, Milica Stojadinović1

1Center for Radiology and MR, Clinical Center of Serbia, Belgrade, Serbia 2Medical Faculty, University of Belgrade, Serbia 3Center for Anesthesiology and Reanimatology, Clinical Center of Serbia, Belgrade, Serbia

Autor za korespondenciju: Aleksandar Filipović, Centar za radio-logiju i MR, Klinički centar Srbije, Pasterova 2, 11000 Beograd, Te-lefon: +381658832505, E-mail: aleksandar.filipovic11@gmail.com

Corresponding author: Aleksandar Filipović, Center of radiology and MR, Clinical center of Serbia, Pasterova 2, 11000 Belgrade, Te-lephone: +381658832505, E-mail: aleksandar.filipovic11@gmail.com

Sažetak

Ultrazvuk može da se koristi pri izvođenju elektivnih perkutanih interventnih procedura (npr. perkutanih biopsija, termalnih ablacija), ali i u tretmanu urgent-nih stanja u jedinicama intenzivnog lečenja (plasiranje centralnog venskog katetera, punkcija pleuralnog ili perikardnog izliva, punkcija ascita). Primenom ultra-zvuka omogućena je vizualizacija punkcijske igle u realnom vremenu, što za rezultat ima povećanu pre-ciznost u radu uz sniženje incidence komplikacija. Za izvođenje perkutanih intervencija pod kontrolom ultra-zvuka neophodna su određena znanja iz oblasti ultrazvuč-ne dijagnostike i praktična iskustva u plasiranju punk-cijske igle ili nekog drugog materijala, istovremeno sa vizuelizacijom putem ultrazvuka. Treba napomenuti da su procedure vođene ultrazvukom bezbedne i efikasne samo ako ih izvodi onaj ko ima dovoljno praktičnog iskustva.

Ključne reči: ultazvuk; perkutane intervencije; jedince intezivnog lečenja

Sumarry

Ultrasound can be used in performing elective percuta-neous intervention procedures (e.g. percutaneous biopsy, thermal ablation), but also in the treatment of emergency conditions in intensive care units (placement of the cen-tral venous catheter, puncture of the pleural or pericardi-al effusion, ascites). With the use of ultrasound, real-time puncture visualization is enabled, resulting in increased precision in work with the reduction of complications. For performing percutaneous ultrasound interventions, certain knowledge in the field of ultrasound diagnostics and practical experience in placing a puncture needle or some other material under the control of ultrasound is necessary. It should be noted that ultrasound procedures are safe and effective only if performed by those who have sufficient practical experience.

Key words: ultrasound; percutaneous interventions; intensive care units

Uvod

Ultrazvuk može da se koristiti pri izvođenju elektivnih perkutanih interventnih procedu-

ra, kao što su perkutana biopsija, termalne ablacije, ali i u tretmanu urgentnih stanja u jedinicama in-tenzivnog lečenja, kao što su plasiranje centralnog venskog katetera, punkcija pleuralnog ili perikar-dnog izliva, punkcija ascita.

Jedna od prednosti savremenih ultrazvučnih aparata, koji su prilagođeni radu u jedinicama in-tenzivnog lečenja, jeste njihova mobilnost, te na ovaj način procedure vođene ultrazvukom mogu

da se izvode neposredno uz krevet na kome leži klinički težak bolesnik. Portabilnost ultrazvučnih aparata je od izuzetnog značaja, jer zbog lošeg opšteg stanja takve pacijente ne bi trebalo trans-portovati u druge jedinice, kao što su angio sale ili hibridne sale, u cilju izvođenja neke od perkutanih intervencija koje bi se mogle izvesti pod kontrolom ultrazvuka i u jedinicama intenzivnog lečenja.

Primenom ultrazvuka omogućena je vizualiza-cija punkcijske igle u realnom vremenu, što za re-zultat ima povećanu preciznost u radu uz redukciju incidence komplikacija1. Za izvođenje perkutanih intervencija pod kontrolom ultrazvuka neophod-

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na su određena znanja iz oblasti ultrazvučne dija-gnostike i praktična iskustva u plasiranju punkcij-ske igle ili nekog drugog materijala pod kontrolom ultrazvuka. Treba napomenuti da su procedure vo-đene ultrazvukom bezbedne i efikasne samo ako ih izvodi onaj ko ima dovoljno praktičnog iskustva2. Pacijenti se u jedinicama intenzivnog lečenja na-laze pod stalnim nadzorom medicinskog osoblja, te se u takvim okolnostima mogu pravovremeno prepoznati i preduprediti eventualne postproce-duralne komplikacije (npr. hemoragija, sepsa), što sveukupno utiče na veću uspešnost i bezbednost ultrazvučno vođenih.

PLASIRANJE CENTRALNOG VENSKOG KATETERA (CVK)

Centralni venski kateter (CVK) najčešće se pla-sira transjugularnim pristupom (Slika 1) ili pristu-pom kroz potključnu venu (v. subclavia).

Slika 1: Transjugularni pristup (isprekidana linija predstavlja mogući tok punkcijske igle duž transver-zalne (slika 1a) ili longitudinalne osovine sonde (1b i 1c))

VJ – jugularna vena, ACC – zajednička karotidna arterija

U slučaju obilnog krvarenja pacijenta i rizika od hemoragijskog šoka, npr. kod teških i po život opa-snih povreda, kada je neophodno plasirati CVK u adekvatnu poziciju u kratkom vremenu, najčešće se koristi pristup kroz v. subclaviu, a punkcija je vođena ultrazvukom3.

Pri izvođenju ovih intervencija, treba se pridrža-vati principa dobre kliničke prakse, naročito u smi-slu obezbeđenja aseptičnih uslova, što u slučaju ul-trazvučno vođene punkcije podrazumeva i prime-nu odgovarajućih sterilnih navlaka za ultrazvučnu (UZ) sondu, primenu sterilnog gela za ultrazvuk ili nekog drugog medijuma (npr. fiziološki rastvor), koji će omogućiti prolaz ultrazvučnih talasa od UZ sonde do tela pacijenta u sterilnim uslovima.

Tehnički aspekt primene ultrazvuka u izvođenju perkutanih punkcija

U slučaju kada je potrebno da se izvede punk-cija većih tečnih kolekcija koje su relativno blizu površine kože (npr. veći ascit, veliki pleuralni iz-liv), punkcija može da se izvede i bez kontinualne primene ultrazvuka. Pomoću ultrazvuka može da se odredi mesto na koži koje bi bilo optimalno za punkciju, a potom se to mesto na koži i obeleži. Nakon adekvatne sterilne pripreme polja, započi-

nje se punkcija, koja nije kontinualno vođena ul-trazvukom, već je ultrazvuk upotrebljen samo u cilju određivanja optimalnog mesta za punkciju. Procedure izvedene na ovaj način se smatraju jed-nostavnim, pa čak i podesnim za individualno iz-vođenje, jer nema potrebe za angažovanjem većeg broja izvođača.

U slučaju kada je potrebna veća preciznost u radu, na primer kada želimo da punktiramo neku malu strukturu kao što je duboka vena, a da pri tome

47PRIMENA ULTRAZVUKA U IZVOĐENJU PERKUTANIH INTERVENCIJA U JEDINICAMA INTENZIVNOG LEČENJA

zadesno ne punktiramo i susednu arteriju, te stvori-mo AV fistulu, pseudoaneurizmu ili obilno krvare-nje, neophodno je da se punkcija izvodi uz kontinu-alnu upotrebu ultrazvuka. To praktično znači da se punkcijska igla sve vreme mora pratiti ultrazvukom tokom punkcije, kako bi se procedura izvela pou-zdano uz izbegavanje komplikacija koje mogu da nastanu lezijom okolnih vitalnih struktura.

Najoptimalnija tehnika perkutanih UZ vođenih procedura je kada je izvodi samo jedan izvođač, tako što će u jednoj ruci držati sondu ultrazvučnog aparata, a u drugoj ruci punkcijsku iglu3. Na taj način onaj ko izvodi punkciju ima bolju orijentaci-ju u prostoru i bolju mogućnost korekcije pozicije sonde ili igle. Polje na koži koje se punktira mora da bude sterilno, a UZ sonda i kabl sonde mora-ju da imaju adekvatnu adhezivnu transparentnu sterilnu prekrivku3. Smatra se da ovakva prepro-ceduralna priprema, u smislu obezbeđivanja prin-cipa antisepse u jedinicama intenzivnog lečenja, ne bi trebalo da traje više od par minuta. U najvećem broju slučajeva procedure se izvode u lokalnoj an-esteziji, dok se u pojedinim slučajevima ove proce-dure izvode u analgosedaciji1,3.

Pozicioniranje ultrazvučne sonde i navođenje pu-nkcijske igle

Ultrazvučnim pregledom, neposredno prepro-ceduralno, treba se orijentisati o lokalizaciji i veli-čini promene/strukture koju je potrebno punktirati, kao i o njenom odnosu sa okolnim strukturama4. Neophodno je da se obezbedi jasna ultrazvučna vi-zualizaciju ciljanog segmenta punkcije1, a potom je potrebno da se sonda postavi u odgovarajuću ravan kroz koju će kasnije proći punkcijska igla, tako da je njen put bezbedan. Bezbedan put za punkcijsku iglu je put na kome se ne nalaze vitalne strukture. Kada su svi ti uslovi ispunjeni i UZ sonda se nalazi u opti-malnoj poziciji za punkciju, trebalo bi da ruka koja drži ultrazvučnu sondu ostane u zadatom položaju, gotovo fiksirana, odnosno pokreti rukom koja drži sondu tokom punkcije moraju biti minimalni.

U jedinicama intenzivnog lečenja najčešće se koristi tzv. free hand tehnika, odnosno tehnika „slobodne ruke”, što praktično znači da se jednom rukom drži UZ sonda, a u drugoj ruci je igla za punkciju. Na ovaj način igla za punkciju nije fiksi-rana nosačem za sondu već je slobodna (eng. free) i nezavisna je od UZ sonde. Ova tehnika pruža veću fleksibilnost i jednostavnost u radu u poređenju sa

drugim tehnikama. Postoje vodiči za punkcijsku iglu koji mogu da se postave na UZ sondu, ali bi upotreba ovakvih složenih uređaja i njihova dezin-fekcija samo otežala izvođenje procedure i odužila intervenciju za izvesno vreme, a koga je u jedinica-ma intenzivnog lečenja uvek malo.

Punkcijska igla tokom punkcije mora sve vreme da bude u ravni sonde, kako bi u realnom vreme-nu pratili čitav tok punkcijske igle i u svakom mo-mentu znali gde se tačno nalazi njen vrh. Samo na taj način može da se obezbedi željena preciznost i efikasnost u radu. Naše iskustvo i iskustvo drugih izvođača3 je da je ovo moguće postići jedino lon-gitudinalnim pristupom, koji podrazumeva plasi-ranje igle tako da ona prolazi kroz ravan u kojoj je i duža (longitudinalna) osovina sonde. To prak-tično znači da se nakon adekvatnog pozicioniranja UZ sonde u poziciju za punkciju, punktira tačka na koži koja se nalazi neposredno uz središte kra-će strane aktivne površine sonde, a tok punkcijske igle mora da bude usmeren tako da ona prolazi kroz ravan u kojoj se nalazi i longitudinalna osovi-na sonde (Slika 2).

Slika 2: Longitudinalni pristup

Nažalost, i pored ispunjenja svih pomenutih uslova, u oko 20% slučajeva nema jasne vizualiza-cije punkcijske igle celim njenim tokom3, naročito

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kod gojaznih pacijenata, jer se igla nekada ne vidi sasvim jasno u hipertrofičnom subkutanom ma-snom tkivu. Drugi mogući uzroci otežane vizua-lizacije igle se javljaju kada „gain” UZ aparata nije adekvatno podešen; ako je pacijent dugo koristio kortikosteroide; ako je na mestu punkcije aplikovan lokalni anestetik, te su nastali hiperehogeni mehuri-ći koji mogu da otežavaju vizualizaciju igle, itd.

U ovakvim okolnostima bolja vizualizacija punkcijske igle može da se postigne na različite načine: primenom igala posebno konstruisanih za pojačanu vidljivost na ultrazvuku, različitim ma-nevrima poput aplikacije fiziološkog rastvora ili manjih količina gasa kroz iglu. Međutim, aplikacija gasa otežava vizualizaciju daljeg toka intervencije.

U slučaju kada se nakon plasiranja punkcijske igle ista ne vizualizuje jasno na monitoru UZ apara-ta, treba da se proveri da li se ciljno mesto punkcije (target) jasno vidi na monitoru UZ aparata i da li je igla u optimalnoj ravni za punkciju. Na monitoru UZ aparata treba da se izmeri rastojanje od mesta punkcije na koži do promene/strukture koja treba da se punktira i da se na taj način odredi dužina igle koja treba da se plasira kroz tkivo do targeta, a nakon toga treba da se odredi i ugao punkcije. Naime, udaljenost targeta punkcije od središta UZ sonde i udaljenost targeta od mesta punkcije na koži su dve varijable od kojih zavisi i ugao punkci-je. Kada su ugao punkcije i dužina punkcije odre-

đeni, punkcijska igla se plasira u longitudinalnoj ravni sonde u skladu sa ovim parametrima.

Neposredno pre ulaska u lumen krvnog suda, igla blago potiskuje prednji zid krvnog suda, a u slučaju kada se punktira tečna kolekcija, igla poti-skuje prednji zid kolekcije. U trenutku kada se vrh igle nađe u tečnosti, izvođač pod rukom oseti da je otpor tkiva kroz koji prolazi igla manji u odnosu na otpor koji je postojao dok je igla prolazila kroz meka tkiva na putu do tečnosti (tečni sadržaj ko-lekcije koja se punktira, a u slučaju punkcije krv-nog suda to je krv). Osim taktilnog osećaja, tokom punkcije vođene ultrazvukom, u najvećem broju slučajeva, postoji i jasna vizualizacija vrha igle na monitoru UZ aparata u trenutku kada igla dospe u tečnu sredinu, jer tečnost predstavlja odličan pro-zor za ultrazvučne talase i poboljšava vizualizaciju igle (Slika 3).

Materijal potreban za perkutane drenaže

U jedinicama intenzivne nege treba da se teži jednostavnosti, a to se može postići i simplifikaci-jom materijala za intervencije. Najveći broj perku-tanih drenaža može uspešno da se obavi pomoću gotovih setova koji sadrže sve što je neophodno. Tako na primer za punkciju pleuralnih izliva po-stoji set koji sadrži odgovarajuću iglu (dužine 6 cm i dijametra 16 G), drenažni kateter, nastavak i

Slika 3: Punkcija apscediranog biloma u jetri Chiba iglom. Jasno se vidi deo igle koji se nalazi u tečnoj sredini, tj. unutar tečne kolekcije, dok se ostatak igle (koji je u subkutanom masnom tkivu i pa-renhimu jetre) ne vizualizuje jasno.

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drenažnu kesu. Ovakvim setom, u najvećem broju slučajeva, može uspešno da se obavi punkcija pleu-ralnih izliva, ascita, perikardnih izliva, dok za neke kompleksnije slučajeve (npr. septirani pleuralni iz-liv sa znacima organizacije ili gušći sadržaj u ple-uralnom prostoru) treba da se primeni silikonski torakalni dren velikog promera.

Osnovni princip kod izbora drenažnog katete-ra je da dijametar katetera zavisi od gustine tečnog sadržaja koji njime treba da se drenira. Što je gu-šći sadržaj, to i kateter mora biti većeg promera, kako bi obezbedio suficijentnu drenažu. Drenažni kraj katetera može biti prav ili povijen (J tip ili „pig tail” tip katetera), a drenažni segment najčešće ima više rupa, kako bi drenaža bila efikasnija. Kateteri mogu da budu plasirani modifikovanom Seldinge-rovom ili trokar tehnikom. Izbor tehnike kojom će se drenažni kateter plasirati zavisi od veličine ko-lekcije i dubine na kojoj se ona nalazi.

Opšte napomene vezane za izvođenje punkcija kontrolisanih ultrazvukom

Pre svake punkcije preporučeno je da se pro-veri koagulacioni status pacijenta, utvrdi priro-da targeta, odredi lokalizacija promene, u smislu utvrđivanja njenog odnosa sa okolnim vitalnim strukturama, kao i bezbednost pristupnog puta (Tabela 1).

Treba napomenuti da ne postoji punkcija bez postproceduralne hemoragije, ali na sreću u na-šoj praksi i u objavljenoj literaturi5,6 je mali broj klinički značajnih hemoragija, koje su zahtevale transfuziju ili neki drugi tretman7, a da su nastale usled perkutanih punkcija.

Literatura

1. Sidhu PS et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Gu-ided Interventional Procedures (Short Version). Ultrashall Med 2015; 36:566–80.

Tabela 1: Preporuke za bezbedno izvođenje ultrazvukom kontrolisanih procedura

Preporuka Objašnjenje

Proveriti koagulacioni status. Jedina apsolutna kontraindikacija za ove procedure je nekorigovana koagulopatija.

Utvrditi prirodu onoga što se punktira.Neophodna je primena doplera kod sumnje na pseudoaneurizmu ili neku drugu vaskularnu strukturu.

Neophodno je dobro poznavanje ultrazvučne dijagnostike i uvid u relevantne podatke iz istorije bolesti.

Karakterizacija promene koja se punktira zasniva se na njenoj ultrazvučnoj prezentaciji i kliničkim manifestacijama.

Odrediti lokalizaciju promene i utvrditi njen odnos sa okolnim vitalnim strukturama.

Subdijafragmalna lokalizacija promene (npr. subdijafragmalno postavljene tečne kolekcije) zahteva jasnu preproceduralnu vizualizaciju dijafragme, kako tokom punkcije ne bi nastala lezija iste i kontaminacija pleuralnog prostora.

Utvrditi da li postoji bezbedan pristupni put.

U slučaju kada se utvrdi da nema bezbednog pristupnog puta za punkciju, odnosno ako bi se na bilo kojoj ruti punkcijske igle od kože do targeta našla neka vitalna struktura, od punkcije se odustaje.

Neposredno postproceduralno ultrazvukom proveriti regiju koja je punktirana.

U cilju detekcije slobodne tečnosti ili tečne kolekcije koja bi mogla da ukazuje na neko aktivno krvarenje.

Pacijent treba da se prati 6 do 12 h, u smislu povremenih provera parametara krvne slike. Sa ciljem detekcije klinički značajne hemoragije.

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2. Nolsoe C, Nielsen L, Torp-Pedersen S, Holm HH. Ma-jor complications and deaths due to interventional ultraso-nography: a review of 8000 cases. J Clin Ultrasound 1990; 18:179–184.

3. Lichtenstein D.A, Whole Body Ultrasonography in the Critically Ill. Springer-Verlag Berlin, Heidelberg, 2010:261–267.

4. Sekiquchi H, Suzuki J, Daniels CE. Making paracente-sis safer: a proposal for the use of bedside abdominal and va-scular ultrasonography to prevent a fatal complication. Chest 2013; 143:1136–1139.

5. Strobel D et al. Incidence of bleeding in 8172 percu-taneous ultrasound-guided intraabdominal diagnostic and

therapeutic interventions – results of the prospective multi-center DEGUM interventional ultrasound study (PIUS stu-dy). Ultrashall Med 2015; 36:122–31.

6. Sharzeki K, Jain V, Naveed A, Schreibman I. Hemorr-hagic complications of paracentesis: a systematic review of the literature. Gastroenterol Res Pract 2014; 2014:1–6.

7. Abudu B, Duncan DP, Deyoung E, Rivera-Sanfeliz G. Ultrasound-guided percutaneous periarterial thrombin injection for paracentesis-related hemoperitoneum. Radiol Case Rep 2017; 13:179–182.