Croatian Medical Journal最新文献

Aim: To investigate the influence of preoperative polycythemia on postoperative outcomes.

Methods: We retrospectively reviewed the postoperative outcomes of 1196 elective non-cardiac surgery procedures (minor, 36%; intermediate/major, 64%) performed under general anesthesia at the General Hospital of Šibenik-Knin County, Croatia, between January 1, 2023 and January 1, 2024. Patients were stratified preoperatively as having anemia, normal hemoglobin, or polycythemia. The primary outcome was a 30-day postoperative composite outcome consisting of death, thrombosis, major bleeding, and the need for red blood cell transfusion.

Results: Anemia, normal hemoglobin levels, and polycythemia were recorded preoperatively in 152 (12.7%), 1000 (83.6%), and 44 (3.7%) of patients, respectively. Patients with polycythemia were the youngest, more frequently men and smokers, and had the lowest frequency of prior venous thromboembolism (VTE). Patients with anemia were the oldest and most frequently had comorbidities, cancer, and prior VTE, used anticoagulants, and underwent intermediate/major surgeries. The composite outcome was recorded in 91 procedures (7.6%) and was most frequent in patients with polycythemia (18.2% vs 9.2% vs 6.9%; P=0.016). Patients with polycythemia also most frequently had postoperative bleeding (18.2% vs 7.9% vs 6.5%; P=0.011) and did not need postoperative red blood cell transfusions (P=0.003). The associations of preoperative polycythemia with the postoperative composite outcome and bleeding remained significant in multivariate models adjusted for surgery risk, sex, comorbidities, physical status, and antiplatelet or anticoagulant use. Patients with polycythemia did not experience deaths or thrombotic events.

Conclusion: Patients with polycythemia require comprehensive preoperative assessment. Future studies are needed to investigate the pathophysiological mechanisms underlying the observed effects.

Aim: To compare the effects of an in-house prepared honey solution (HS) and a commercial carbohydrate beverage (CCB) on postoperative stress response, gastric motility, and self-reported comfort in patients undergoing laparoscopic cholecystectomy.

Methods: This randomized controlled trial enrolled 55 adult patients (the American Society of Anesthesiologists physical status I-II) undergoing laparoscopic cholecystectomy at the University Hospital Center Rijeka from January 1, 2022, to December 31, 2022. Participants were randomly assigned to receive either HS (n=20), prepared from diluted chestnut honey, or CCB (n=35). Both solutions were administered in the volumes of 800 mL the evening before surgery and 400 mL two hours before anesthesia. Stress response and inflammation were assessed by measuring cortisol and interleukin 6 levels at six standardized time points. Gastric motility was evaluated with a paracetamol absorption test, and patient-reported outcomes were recorded postoperatively using a visual analogue scale.

Results: The HS group exhibited higher cortisol and interleukin 6 levels at multiple perioperative time points compared with the CCB group (P<0.05). However, they had significantly improved gastric motility, with higher paracetamol concentrations 15 to 180 minutes post-ingestion (P=0.028-0.001). Additionally, HS group reported reduced thirst, nausea, and pain, but had lower appetite and well-being scores.

Conclusion: While HS represents a potential natural and cost-effective alternative to CCB, further studies are needed to determine its role within preoperative nutrition strategies for enhanced recovery after surgery.

Aim: To compare regional anesthesia without opioid administration following subcutaneous mastectomy and breast reconstruction with implants in the pre-pectoral plane with general anesthesia in terms of pain relief, opioid consumption, and hospital stay duration.

Methods: This randomized controlled study enrolled patients who underwent mastectomy with reconstruction of the breast either with permanent implants or tissue expander placement in the pre-pectoral plane. A total of 40 patients met the inclusion criteria. The regional anesthesia group (n=20) received a pectoralis muscle block (PECS I), thoracic paravertebral block (TPVB), and serratus anterior muscle plane block (SAP) following a uniform protocol, and the control group (n=20) underwent general anesthesia. Pain was assessed by using the numeric rating scale (NRS) from 30 minutes after surgery up to ten days postoperatively.

Results: NRS pain scores were significantly higher in the regional anesthesia group, independent of the patients' physical daily activity level, even up to 10 days after surgery. Opioid consumption and length of hospital stay did not differ significantly.

Conclusion: Regional anesthesia using a combination of a TBVP, PECS I, and SAP has a long-lasting and satisfactory analgesic effect without the introduction of opioids. In the future, a novel gold standard protocol should be established that can be offered to every patient undergoing breast surgery.

We present a case of a 57-year-old male patient (American Society of Anesthesiologists status IV) undergoing open cholecystectomy under unilateral thoracic paravertebral block (TPVB) and sedation. The patient had severe heart failure, a reduced ejection fraction of approximately 16%, and an implanted subcutaneous implantable cardioverter-defibrillator. Using ultrasound, we identified the thoracic (Th) paravertebral spaces on the right side at four levels (from Th6 to Th9) and administered 3.5 mL of 0.5% levobupivacaine per level, for a total of 14 mL. Twenty minutes after TPVB application, we confirmed sensory blockade from the Th5 to Th10 dermatomes. Ten minutes into surgery, during liver capsule retraction, the patient experienced some pain (5/10 on the visual analogue scale, VAS). The pain was successfully treated with rescue analgesia of 10 µg of intravenous (IV) sufentanil and a sedation dose of 50 mg IV propofol. The surgery lasted 45 minutes and was completed uneventfully. For continued intraoperative sedation, we used 10 mg/h remimazolam, maintaining hemodynamic stability. Nine hours after surgery, the patient reported a VAS pain score of 5 and received 75 mg of IV diclofenac sodium, with no further analgesia required. The patient was discharged on postoperative day six. In conclusion, the application of TPVB combined with remimazolam sedation could present a feasible anesthetic and analgesic technique for open cholecystectomy in high-risk cardiac patients.

Aim: To evaluate the incidence of severe adverse cardiovascular events during orthotopic liver transplantation and the early post-transplant period, and to determine the factors associated with these events.

Methods: We retrospectively reviewed the medical records of 291 patients who underwent orthotopic liver transplantation at University Center Merkur, Zagreb, Croatia, from 2013 to 2015. Data on corresponding donor characteristics were sourced from the Eurotransplant database. Severe adverse cardiovascular events were defined as myocardial infarction, malignant arrhythmia, pulmonary embolism, cardiac failure, cardiac arrest, and death.

Results: The incidence of severe adverse events was 8.9%. Univariate analysis demonstrated a positive predictive value linking severe adverse cardiovascular events with metabolic liver disease, an elevated model for end-stage liver disease, an international normalized ratio, and the preoperative administration of vasopressors. Multivariate analysis identified significant predictors of adverse events: liver metabolic diseases (odds ratio [OR] 4.88; 95% confidence interval [CI] 1.48-16.09; P=0.009), donor arterial hypertension (OR 2.68; 95% CI 1.01-7.18; P=0.049), prolonged cold ischemia duration (OR 1.22; 95% CI 1.01-1.49; P=0.044), and increased recipient age (OR 1.09; 95% CI 1.03-1.16; P=0.005).

Conclusion: The occurrence of severe adverse cardiovascular events is markedly greater than previously documented. We propose the use of a scoring system including known risk variables to identify patients at risk of adverse cardiovascular events, hence improving surveillance for an early intervention.