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The aim was to determine the effect of regional anesthesia (RA) on postoperative vital functions in contrast to general endotracheal anesthesia (GEA) after the cesarean section.Prospective cohort study included consecutive term pregnant women delivered by cesarean section (GEA, n = 284; RA, n = 249).Higher levels of blood pressure and heart rate, as well as lower levels of pulse oximetry were found for GEA in contrast to RA (p0.001). The application of RA presented less side-effects (p0.05).RA for cesarean section should be preferred when balancing the risks and benefits for the mother and fetus.

Preoperative anxiety is associated with increased morbidity and/or mortality in surgical patients. This study investigated the incidence, predictors, and association of preoperative anxiety with postoperative complications in vascular surgery.Consecutive patients undergoing aortic, carotid, and peripheral artery surgery, under general and regional anesthesia, from February until October 2019 were included in a cross-sectional study. Anesthesiologists assessed preoperative anxiety using a validated Serbian version of the Amsterdam Preoperative Anxiety and Information Scale. Patients were divided into groups with low/high anxiety, both anesthesia- and surgery-related. Statistical analysis included multivariate linear logistic regression and point-biserial correlation.Of 402 patients interviewed, 16 were excluded and one patient refused to participate (response rate 99.7%). Out of 385 patients included (age range 39-86 years), 62.3% had previous surgery. High-level anesthesia- and surgery-related anxieties were present in 31.2 and 43.4% of patients, respectively. Independent predictors of high-level anesthesia-related anxiety were having no children (OR = 0.443, 95% CI: 0.239-0.821, p = 0.01), personal bad experiences with anesthesia (OR = 2.294, 95% CI: 1.043-5.045, p = 0.039), and time since diagnosis for ≥ 4 months (OR = 1.634, 95% CI: 1.023-5.983, p = 0.04). The female sex independently predicted high-level surgery-related preoperative anxiety (OR = 2.387, 95% CI: 1.432-3.979, p = 0.001). High-level anesthesia-related anxiety correlated with postoperative mental disorders (rSince preoperative anxiety affects the postoperative course and almost every third patient experiences anxiety preoperatively, routine screening might be recommended in vascular surgery.

Airway management is a crucial step in treating emergency medical conditions. Numerous complications, which can further worsen the patient's condition, can occur as a result of difficulties in airway management. The most well-known and frequently used tests for assessing the airway in emergencies are the Mallampati class and a series of abbreviated procedures, which are mnemonically called LEMON. They have a significant role in predicting difficult airway management and enabling the medical team to adequately prepare. When securing the airway, it is necessary to provide adequate equipment, monitoring and trained personnel. If an assessment is made that the airway management could prove to be difficult, it is best to follow das algorithms, which not only help doctors secure a problematic airway but also protect them from criminal liability should complications or even death of the patient occur. This way, securing an airway in emergencies can present a very serious, but not insurmountable problem.

Objective: Thyroid dysfunction is a common cause of atrial fibrillation (AF). Incidence of AF is high in patients with both expressed and subclinical hyperthyroidism. The aim of our study was to determine the incidence and predictors of new onset atrial fibrillation (NOAF) in euthyroid patients undergoing thyroid surgery. Subject and Methods: The study included 1,252 euthyroid patients with American Society of Anesthesiologists (ASA) physical status ASA 2 and ASA 3, who were 18 years and older and were in sinus rhythm. Patients without comorbidity and patients with persistent AF were excluded. We investigated the influence of the following preoperative characteristics on the occurrence of NOAF: age, sex, body mass index, ASA score, admission diagnoses, and comorbidity. We noted the influence of difficult intubation of trachea, type and duration of surgery, and time under general anaesthesia. Univariate and multivariate logistic regression were used to determine predictors of occurrence of NOAF. Results: NOAF was noted in 0.72% of patients. Patients with NOAF were older (63.11 vs. 56.81 years) than patients without NOAF, but this was not statistically significant. Significantly more patients from the NOAF group had preoperative heart rhythm disturbance and a history of angina pectoris, in contrast to patients without registered NOAF (p = 0.001; p = 0.017). Multivariate analysis showed that a history of heart rhythm disturbance was an independent predictor of NOAF. Conclusions: Incidence of NOAF during thyroid surgery is similar to the other type of surgery, if the values of thyroid hormones are normal.

Introduction The number of patients in the world who have undergone heart transplantation is increasing, with better and longer survival rates, and therefore the number of patients who undergo various surgical interventions after transplantation is also increasing. This presents a challenge for anaesthesiologists. Case outline A 45-year-old female patient underwent a total thyroidectomy due to suspected thyroid cancer. She had a heart transplant three years earlier. Preoperative preparation included evaluation of cardiac function, consultative examinations by a transplant cardiologist, laboratory and other diagnostic procedures, as well as a detailed analysis of all 20 medications that the patient uses in daily therapy. Common drugs were used for premedication and general endotracheal anaesthesia, with careful dose titration. Medicines were also prepared for the occurrence of heart rhythm disorders, bearing in mind that the heart is denervated, but there was no need for their use. The operation and postoperative course went smoothly and on the third postoperative day the patient was discharged from the hospital in good general condition. Conclusion Preoperative preparation, anaesthesia and postoperative treatment of this patient represented a challenge for our team, which was successfully overcome, considering that this is the first case of operative treatment of a patient with a transplanted heart in Serbia.

Background and Objectives: It has been suggested that intense feelings of fear/anxiety and significant patient concerns may affect the perioperative course. Those findings emphasize the importance of surgical patients’ preoperative feelings. Still, current knowledge in this area is based on a limited number of studies. Thus, we think that there is a need to further explore patients’ preoperative fears, better characterize risk factors and reasons for their occurrence, and evaluate patients’ perspectives associated with anesthesia. Materials and Methods: A total of 385 patients undergoing vascular surgery were preoperatively interviewed using a questionnaire that included demographics and questions related to patients’ fears and perceptions of anesthesia. Statistical analyses included descriptive statistics, Pearson’s χ2 and McNemar tests, and multivariate ordinal logistic regression. Results: The main causes of patients’ preoperative fear were surgery (53.2%), potential complications (46.5%), and anesthesia (40%). Female sex was a predictor of surgery and anesthesia-related fear (OR = 3.07, p = 0.001; OR = 2.4, p = 0.001, respectively). Previous experience lowered the fear of current surgery (OR = 0.65, p = 0.031) and anesthesia (OR = 0.6, p = 0.017). Type of surgery, type of anesthesia, educational and socioeconomic status, and personal knowledge of an anesthesiologist affected specific anesthesia-related fears. Over 25% of patients did not know that an anesthesiologist is a physician, and only 17.7% knew where anesthesiologists work. Level of education and place of residence influenced patients’ perceptions of anesthesia. Conclusions: Anesthesia-related fears are affected by the type of surgery/anesthesia, experience with previous surgery, and personal knowledge of an anesthesiologist. Women, patients with lower education levels, and patients with poorer socioeconomic status are at higher risk of developing those fears. The perception of anesthesiologists is inadequate, and knowledge of anesthesia is poor. Promotion of patient education regarding anesthesia is needed to alleviate those fears and increase understanding of anesthesia.

Introduction. Postoperative nausea and vomiting (PONV) is one of the most common postoperative complications. The incidence in adult population is 20?30%, and it can be up to 80% in high-risk population such as gynecological and laparoscopic surgeries. The objective of this study is to compare the efficiency of the combination therapy in comparison with monotherapy in the prevention of PONV in gynecological and laparoscopic surgeries. Methods. An observational prospective cohort study was conducted on a sample of 64 patients (32 patients per group) treated postoperatively at the Gynecology and Obstetrics Ward of GH Subotica, in the period from January?March 2017. The anesthesiologist in charge administered the combination of dexasone and metoclopramide or granisetron in monotherapy according to protocol to patients for prevention of PONV. Results. The demographic characteristics of patients are homogenous and show a statistically significant difference only in the characteristics of length of smoker status and maximum intra-abdominal pressure during surgery. The total incidence of postoperative nausea in the fifth, 15th and 60th minute was 15.6%, 17.2% and 18.7% respectively, and in the fourth, eighth, 12th, and 24th postoperative hour it was 12.5%, 7.8%, 10.9%, and 6.2%, respectively. The incidence of postoperative vomiting in the fifth, 15th, and 60th minute was 1.6%, 4.7%, and 4.7%, respectively, and in the fourth, eighth, 12th, and 24th postoperative hour it was 1.6%, 3.2%, 1.6%, and 1.6%, respectively. Conclusion. The study proved that the combination effect of dexasone and metoclopramide is not inferior compared to monotherapy with granisetron.

Introduction/Objective Intraoperative variations in blood pressure and/or cardiac dysrhythmias (IOVBP/CD) represent one of the most common causes of morbidity and mortality in surgical patients. The aim of the study was to determine the incidence and risk factors for IOVBP/CD in thyroid surgery patients with comorbidities. Methods The study included 1,252 euthyroid patients with ASA 2 and ASA 3 status (American Society of Anesthesiologists - physical status classification) who underwent thyroid surgery. The following risk factors were examined: sex, age, body mass index (BMI), ASA status, admission diagnoses, type of operation, duration of surgery, time under general anesthesia, difficult intubation of trachea, and coexisting diseases - hypertension, cardiomyopathy, cardiac arrhythmias, angina pectoris, diabetes mellitus, kidney disease. The following intraoperative events were recorded: hypertension, severe hypertension, hypotension, and cardiac arrhythmias. We used Pearson χ2 square test, univariate, and multivariate logistic regression for statistical analysis. Results The majority of patients were female (86.3%). In 903 (72.1%) patients IOVBP/CD were detected. The most common problem was intraoperative hypertension (61.4%). Eight risk factors for IOVBP/CD were registered by univariate analysis: advanced age, ASA 3 status, BMI > 25 kg/m2, duration of surgery, time under general anesthesia, hypertension, and cardiomyopathy as a coexisting disease. The multivariate regression model identified three independent predictors for IOVBP/CD: age, hypertension, and cardiomyopathy. Conclusion IOVBP/CD are common in thyroid surgery. The most common is intraoperative hypertension. Older age, hypertension, and cardiomyopathy as a coexisting disease are independent risk factors for IOVBP/CD., Uvod/Cilj Intraoperativne varijacije krvnog pritiska i/ ili srčane disritmije (IVKP/SD) jedan su od najčešćih uzročnika morbiditeta i mortaliteta hirurških bolesnika. Cilj studije je bio da ispita učestalost i faktore rizika za pojavu IVKP/SD u tireoidnoj hirurgiji kod bolesnika sa komorbiditetima. Metode Ispitivanje je obuhvatilo 1252 eutireoidna bolesnika ASA 2 i ASA 3 statusa podvrgnutih tireoidnoj hirurgiji. Ispitivan je uticaj sledećih faktora rizika: pol, starost, indeks telesne mase (ITM), ASA status, prijemna dijagnoza, tip operacije, trajanje operacije, trajanje anestezije, otežana intubacija traheje, kao i komorbiditeti: hipertenzija, kardiomiopatija, srčane aritmije, angina pektoris, dijabetes melitus, bolesti bubrega. Registrovani su intraoperativno: hipertenzija, hipertenzivna kriza, hipotenzija i srčane aritmije. Korišćen je Pirsonov χ2-test, univarijantna i multivarijantna regresiona analiza za statističku obradu podataka. Rezultati Većinu bolesnika su činile žene (86,3%). IVKP/ SD su registrovani kod 903 (72,1%) bolesnika. Najčešći poremećaj je bila intraoperativna hipertenzija - 61,4%. Univarijantnom analizom je registrovano sedam faktora rizika za pojavu IVKP/SD: godine života, ASA 3 status, ITM > 25 kg/m2, trajanje hirurgije, trajanje anestezije, hipertenzija i kardiomiopatija kao komorbiditet. Multivarijantnom regresionom analizom izdvojila su se tri nezavisna prediktora pojave IVKP/SD: godine starosti, hipertenzija i kardiomiopatija. Zaključak IVKP/SD su česte u tireoidnoj hirurgiji. Najčešća je intraoperativna hipertenzija. Starije životno doba, hipertenzija i kardiomiopatija kao koegzistirajuće bolesti su nezavisni faktori rizika za pojavu IVKP/SD.

While the use of simulation in medical education has a long history, it has seen its greatest strides in the past 15-odd years. It may be defined as imitation, artificial while at the same time faithful, of various clinical situations through well-crafted medical ?scenarios? where, instead of actual people, we use standardized patients: plant, animal, or synthetic models, computerized interactive manikins ? simulators, with audiovisuals, as well as medical equipment used in everyday clinical practice. The fundamental goal of using simulation in medical education is an optimal balance between professional education on the one hand and complete safety and protection of patients on the other. Depending on the available finances and the level of advancement of the healthcare and education systems, medical simulation can take various forms ? from simple improvisation to the creation of a high-fidelity simulation in centers for medical simulation. Our example shows that, even with modest financial means, enthusiasm, creativity, and good ideas make it possible to establish a center for medical simulation. A separate section of the paper is devoted to the staging of a simulation scenario based on the authors? experiences.

The occurrence of cardiac arrest during anesthesia and surgery is nowadays associated with many challenges imposed by 21st century medicine. On the one hand, good education of healthcare practitioners, sophisticated anesthetic techniques and equipment, along with safer anesthetics and improved surgical techniques have significantly reduced the risk of cardiac arrest during the perioperative period. Still, the introduction of new, invasive diagnostic and therapeutic procedures in the aging patients and those with comorbidities carries along new risk and challenges. Epidemiological data indicate that intraoperative cardiac arrest is an extremely rare event. Due to variety of moral and ethical prejudices, intraoperative cardiac arrest is frequently presented as if it has happened in the immediate postoperative period, following surgery and anesthesia. The preventive measures, the etiology and diagnosis of cardiac arrest, as well as the specificities regarding organization and performance of cardiopulmonary resuscitation in the operating room, result in a better prognosis compared to other hospital departments. The article also describes the specifics of cardiopulmonary resuscitation in the catheterization laboratory, while a separate section is dedicated to cardiopulmonary resuscitation following systemic toxicity of local anesthetics. Since intraoperative cardiac arrest and death represent very rare complications, European Resuscitation Council has only recently published Guidelines for Resuscitation for performing cardiopulmonary resuscitation in the operating room ? in 2015.

Intraoperative bradycardia (IOB) is one of the most common cardiac arrhythmias observed in clinical anaesthetic practice. Controlled hypotension, as a strategy of lowering patient's blood pressure during anesthesia has been practiced for decades in head and neck surgery. The aim of our study was to determine the incidence and the risk factors for intraoperative bradycardia in maxillofacial, ear, nose and throat surgery, as well as to determine whether controlled hypotension affects the occurrence of IOB. The retrospective study included 2304 patients who underwent maxillofacial, ear, nose or throat surgery. We studied the influence of: sex, age, comorbidity, type of surgery, duration of anesthesia and controlled hypotension on the occurrence of IOB. IOB was registered in 473 patients (20.5%). Patients with controlled hypotension had IOB significantly more often than patients without controlled hypotension (33.9 vs 15.1%) (p = 0.000). The significant predictors of IOB were: age (OR = 1.158; 95% CI = 1.068-1.256; p = 0.000), sex (OR = 0.786; 95% CI = 0.623-0.993; p = 0.043), ischemic heart disease (OR = 2.016; 95% CI = 1.182-3.441; p = 0.010); ear surgery (OR = 1.593; 95% CI = 1.232-2.060; p = 0.000), anesthesia duration, (OR = 1.006; 95% CI = 1.004-1.007; p = 0.000) and controlled hypotension (OR = 2.204; 95% CI = 1.761-2.758; p = 0.000). IOB is common in maxillofacial, ear, nose and throat surgery, particularly in male, older age and patients with ishemic heart disease. The ear surgery, longer anesthesia duration and controlled hypotension raise the risk for occurrence of IOB.

The objective of our study was to determine the serum concentrations of protein S100B and neuron specific enolase (NSE) as well as their ability and accuracy in the prediction of early neurological outcome after a traumatic brain injury.A total of 130 polytraumatized patients with the associated traumatic brain injuries were included in this prospective cohort study. Serum protein S100B and NSE levels were measured at 6, 24, 48 and 72 hours after the injury. Early neurological outcome was scored by Glasgow Outcome Scale (GOS) on day 14 after the brain injury.The protein S100B concentrations were maximal at 6 hours after the injury, which was followed by an abrupt fall, and subsequently slower release in the following two days with continual and significantly increased values (p0.0001) in patients with poor outcome. Secondary increase in protein S100B at 72 hours was recorded in patients with lethal outcome (GOS 1). Dynamics of NSE changes was characterized by a secondary increase in concentrations at 72 hours after the injury in patients with poor outcome.Both markers have good predictive ability for poor neurological outcome, although NSE provides better discriminative potential at 72 hours after the brain injury, while protein S100B has better discriminative potential for mortality prediction.Cilj studije je bio da se odrede serumske koncentracije proteina S100B i neuron-specifične enolaze (NSE) i njihova sposobnost i preciznost u predikciji ranog neurološkog ishoda nakon traumatske lezije mozga.Sto trideset politraumatizovanih pacijenata sa udruženom traumatskom lezijom mozga je uključeno u ovu prospektivnu kohortnu studiju. Serumski nivoi proteina S100B i NSE su mereni u 6, 24, 48. i 72. satu nakon povređivanja. Rani neurološki ishod je procenjivan Glasgow Outcome Scale (GOS) skorom četrnaestog dana nakon povrede mozga.Koncentracije proteina S100B su bile maksimalne u 6. satu nakon povređivanja i pračene su naglim padom, a zatim sporijim oslobađanjem u naredna dva dana uz konstantno i signifikantno povišene vrednosti (p0,0001) kod pacijenata sa lošim ishodom. Sekundarni porast proteina S100B u 72. satu zabeležen je kod pacijenata koji su preminuli (GOS 1). Dinamiku promena za NSE karakteriše sekundarni porast koncentracija u 72. satu nakon povređivanja kod pacijenata sa lošim ishodom.Oba markera imaju dobru prediktivnu sposobnost za loži neurološki ishod, mada NSE obezbeđuje bolji diskriminativni potencijal u 72. satu nakon povrede mozga, dok protein S100B ima bolji diskriminativni potencijal u predikciji mortaliteta.

The purpose of this study was to compare two groups in postoperative recovery, whether there were any complications and whether the length of their hospital stay differed. One group received intraoperatively a combination of crystalloids and a small colloid dose, while the other group received only the crystalloids intraoperatively.This randomized prospective study included 80 patients with colorectal cancer prepared for major elective colorectal surgery. The patients were randomly assigned to either the control group (CG) which received only crystalloid solutions intraoperatively or to the research group (RG) which received a combination of colloid and crystalloid solutions. Regional and general endotracheal anesthesia techniques were combined in all patients. Goal-directed fluid therapy was administered to patients in both groups. After extubation, patients were transferred in the Intensive Care Unit (ICU). We measured the administered fluids, fluid balance, the volume of received red packed cells (RPC) and fresh frozen plasma (FFP). Recorded were the first bowel movement, the first flatus, the tolerance on oral food, complications by Clavian-Dindo classification, days of patient's recovery delay in the ICU, Surgery Department (SD) and the total length of hospital stay (LOS).Statistically significant differences were present in all parameters of postoperative recovery. RG patients showed better results relative to the CG patients. RG patients were faster in restoring bowel movement and peristalsis, get the first postoperative stool and re-acquire oral food tolerance. According to the Clavian-Dindo classification of complications, no significant difference between these two groups was noted.Goal-directed colloid-crystalloid therapy significantly improved postoperative recovery.

To determine whether there was a correlation between the type of administered infusion solutions intraoperatively with the quantity of administered infusion solutions, differences in values of cardiac output (CO) and cardiac index (CI) and need to use vasopressors and inotropes, between control and research groups.This randomized prospective study included 55 patients with colorectal cancer. Subjects in the control group received only crystalloid solutions intraoperatively and postoperatively. The patients in the research group received a combination of colloid in dosage of 10mg/kg and crystalloid solutions. Patients in both groups were given goal directed fluid therapy.The control group received a significantly larger amount of crystalloid solution per kg of body weight during the entire surgical operation, in comparison with the volume of crystalloids in the research group (mean±SD 50.78±28.13 vs. 31.63±25.60 respectively, p=0.01). During the first hour of the surgery, the control group received a larger quantity of fluid in comparison with the research group (mean±SD 31.14±9.78 vs. 22.17±9.92 respectively, p=0.001). From the beginning of anesthesia until 6th postoperative hr the values of CI were significantly higher in the research group in comparison with the control group.Goal directed fluid therapy with colloids, followed by crystalloids during surgery, decreased the total intraoperative fluid volumes, and provided higher values of CI intraoperatively which were also maintained postoperatively.

Background: To present for the first time a clinical case of a patient with giant neglected and exulcerated tall-cell papillary thyroid cancer, who was surgically treated. Methods: We report a case of a 73-year-old woman with large firm infiltrated and exulcerated anterior neck tumefaction (12 cm in diameter) clinically suspected as anaplastic thyroid cancer. Patient had a goiter for more than 20 years with rapid growth in last months, after that presented with infiltration and exulceration of the skin. Results: Fine needle aspiration biopsy (FNAB) revealed papillary thyroid cancer (PTC). Total thyroidectomy with en-block dissection of the infrahyoid muscles and skin was performed. Lymph node metastasis were not present. Pathologically, goiter and tall-cell papillary carcinoma were present without anaplastic dedifferentiation. Postoperative radioiodine therapy was done, than L-thyroxin suppressive therapy, patient refused transcutaneous radiotherapy. Serum thyroglobulin was 0.15 ng/ml. Vocal cord paralysis and hypocalcaemia were not present. In following 3 years patient did not come to postoperative control, then she came with local recurrence of disease and tracheostomy. Tumor reduction was a second operation which was performed. Pathologically, it was tall-cell papillary carcinoma with regional lymph node metastases. The skin defect was reconstructed with a local transpositional flap. Patient refused radioiodine and transcutaneous radiotherapy and died 4 years after first operation, she was 77-years old. Conclusions: Skin infiltration and exulceration are rare in papillary thyroid cancer but they can be found in patients with neglected and poorly differentiated papillary carcinomas. Exulcerated tall cell papillary carcinoma can be unpredictable even in radically performed operation.

Background Hypotension is a common adverse effect of IV anaesthetics, especially during the induction of anaesthesia. The aim of our study was to determine the incidence and risk factors for intraoperative hypotension (IOH) in thyroid surgery, as well as to determine whether and to what extent IOH affects the occurrence of postoperative hypotension. Material and methods The study included 1252 euthyroid patients, ASA 2 and ASA 3 status (American Society of Anesthesiologists physical status classification), who had thyroid surgery between 2007 and 2011. IOH was defined as a decrease in systolic blood pressure of >20% of baseline values. We studied the influence of demographic characteristics (sex, age, body mass index-BMI), comorbidity, type and duration of surgery, and anaesthesia on the occurrence of IOH. Univariate and multivariate logistic regression were used to determine predictors of occurrence of IOH. Results IOH was registered in 6.5% of patients. The most common operation was thyroidectomy. Patients with IOH were younger, had lower BMI, and significantly less often had hypertension as a coexisting disease. The multivariate regression model identified BMI and the absence of hypertension as a coexisting disease, and as independent predictors of occurrence of IOH. Significantly more patients with IOH had postoperative hypotension (9.9% vs. 2.4%, p=0.000). Conclusions IOH is common, even during operations of short duration and with minimal bleeding. It is necessary to pay special attention to these patients, given that many of these patients remained hypotensive during the postoperative period.

% thyroid nodules KR nema Introduction: Fine-needle aspiration biopsy (FNAB) remains the cornerstone of thyroid cancer diagnosis. The aim of this study was to find how much ultrasound alone and jointly with FNAB, can differentiate benign from malignant nodules, in our circumstances. Patienets and methods: FNwas performed in 203 out of 290 (70 %) patients referred to the Department of Endocrine Surgery, Clinical Center Belgrade in four-year period for ultrasound evaluation of TNs with diameter to or greater than 10 mm. All the patients with suspicious or malignant FNfindings underwent surgery. The Thyroid Imaging Reporting and Data System (TIRADS) classification was used. Results: Patients were aged between 26-88 years (mean 49 years). Out of 203 patients, 49 had an inadequate FNAB, 87 were checked on 6-12-36 months and found benign. Due to incomplete data required for a test 38 patients were excluded. Out of the 116 nodules underwent FNAB, 53 found to be benign, 30 suspicious and 33 malignant. At the final postoperative histopathologic examinations it was found 70 and 46 benign and malignant TNs, respectively The frequency of malignant TNs was slightly higher in the nodules with a diameter over 10mm in diameter than in those under 10mm (p

Subtrochanteric fractures of the femur have a special place because of a significant number of complications following treatment. Powerful loading forces asymmetrically acting to this bone segment, as well as poor vascularization interfere with bone union. There are basically two current approaches in the fixation of subtrochanteric fractures; the first involves a plate with a compression screw and another one is intramedullary (IM) nail, with two options: centromedullary (standard interlocking femoral nail) and cephalomedullary femoral nail with two modifications, reconstructive and trochanteric. All IM nails may be used by open technique or closed minimal invasive method. IM nailing is favoured in view of a shorter operative time, shorter hospitalisation and complications. Indirect fracture reduction and knowledge of biology of bone fracture may result in full success without any bone graft.

Chronic obstructive pulmonary disease is a risk factor for development of intraoperative and postoperative pulmonary complications. Regarding the type and the extent of surgical procedure, patients with COPD are at risk of aggravation of pulmonary function which leads to complicated perioperative course. In order to reduce perioperative complications, preoperative evaluation and preoperative patient preparation are of great importance. Goals of preoperative preparation and anesthesia in patients with COPD are maintaining ventilation-perfusion ratio, preventing development of hipoxemia, intraoperative brochospasm, pneumothorax and disturbances of cardivascular system.

The goal of this article is to present the importance of diabetes mellitus as comorbidity in patients submitting to different surgical procedures. The results of numerous studies that have been presented here showed worst surgical outcome in patients with bad diabetes control. This review considers the elements for preoperative evaluation and preparation of these patients (former therapy, longterm metabolic control, micro and macrovascular complications etc). According to existing data, the goals for preoperative preparation and the regimes for their achievement have been defined. Also, the regimes for blood glucose controle during intraoperative and postoperative period have been evaluated in this article.

Cardiomyopathies are myocardial diseases in which there is structural and functional disorder of the heart muscle, in the absence of coronary artery disease, hypertension, valvular disease and congenital heart disease. Cardiomyopathies are grouped into specific morphological and functional phenotypes: dilated cardiomyopathy, hypertrophic cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and unclassified cardiomyopathies. Patients with dilated and hypertrophic cardiomypathy are prone to the development of congestive heart failure in the perioperative period. Also, patients with hypertrophic and arrhythmogenic right ventricular cardiomyopathy are prone to arrhythmias in the perioperative period. Preoperative evaluation includes history, physical examination, ECG, chest radiography, complete blood count, electrolytes, creatinine, glomerular filtration rate, glucose, liver enzymes, urin analysis, BNP and echocardiographic evaluation of left ventricular function. Drug therapy should be optimized and continued preoperatively. Surgery should be delayed (unless urgent) in patients with decompensated or untreated cardiomyopathy. Preoperative evaluation requires integrated multidisciplinary approach of anesthesiologists, cardiologist and surgeons.

Preoperative preparation of patients with hyperparathyroidism planned to be operated and/or already operated because of some other disease have specific characteristics in function of the type of hyperparathyroidism, primary or secondary. In primary hyperparathyroidism, repercussions of pronounced hypercalcemia on organs and systems are of essential importance. The most important aspect of preoperative preparation of these patients is therefore the treatment of hypercalcemia. In patients with secondary hyperparathyroidism as comorbidity, calcium level is of lesser importance since it stays mostly within reference values. Essential for perioperative preparation of these patients is the fact that they have chronic renal insufficiency and usually are on extrarenal depuration, so that uremic toxic disorders important for the perioperative course should be taken into account. Disorders caused by primary or secondary hyperparathyroidism (and terminal chronic renal insufficiency) must be brough to so-called "stable state" in elective surgical interventions. Preoperative preparation in urgent surgical interventions is focused only on vitally endangering consequences of hyperparathyroidism such as hypercalcemic crisis or extreme hyperkalemia.

The aim of the study was to examine the factors which play a role in the occurrence of differentiated thyroid cancer as related to anaplastic thyroid cancer (ATC). A case–control study was performed during the period 1993 to 2005. The case group comprised of 126 patients with ATC. The control group comprised of 126 patients with papillary thyroid cancer. Cases were individually matched by gender and place of residence. ATC was significantly related to older age (odds ratio = 1.11, 95% confidence interval = 1.07–1.14) and goiter (odds ratio = 1.20, 95% confidence interval = 1.07–1.35).

BACKGROUND/AIM The most effective method for human adult pancreatic islets purification is density-gradient centrifugation. The aim of this study was to analyze the effects of non-automated purification on preservation of functional capacity of human adult pancreatic islet cells. METHODS Human pancreata were obtained after pancreatectomy in the patients with chronic pancreatitis or benign tumors. Pancreatic islets were purified by non-automated method in discontinuous Ficoll density gradient. The samples were divided in 2 fractions: purified (P) and non-purified (NP) cultures. Islets were stained with diphenyl-thiocarbazone. The efficiency of separation was determined by comparing percentage of stained cells in P and NP cultures on day 1, 3 and 7 of shortterm cultivation. Glucose-stimulated insulin secretion was expressed as stimulation index (SI). RESULTS The results obtained showed a statistically significant difference (p < 0.01) between P and NP cultures. P cultures had higher percentages of stained cells (70.43 +/- 3.97%, 73.77 +/- 4.22% and 71.34 +/- 4.69% on the first, third and seventh day of cultivation, respectively) than NP cultures (53.68 +/- 1.71%, 57.14 +/- 3.94% and 43.97 +/- 4.56%, respectively). P cultures had higher values of SI for the first, third and seventh day of cultivation than NP cultures (0.45 +/- 0.08, 0.80 +/- 0.21, 1.28 +/- 0.15 and 0.46 +/- 0.10, 0.752 +/- .0.16, 0.76 +/- 0.11 for P and NP cultures respectively). The difference was statistically significant on day seven (p = 0.01). CONCLUSION Although during purification process islets were exposed to a number of insults that might result in cellular damage and functional impairment, our assessments showed that islets in P cultures preserved their functional capacity better than islets in NP cultures, since they had greater insulin secretion.

The present study attempted to identify the diagnostic significance of procalcitonin (PCT) in acute abdominal conditions as well as the range of concentrations relating to diagnosis of abdominal sepsis. This was prospective clinical study. The study included 98 consecutive patients with acute abdominal conditions, divided in sepsis and systemic inflammatory response syndrome (SIRS) group. PCT concentrations on admission were significantly higher in the sepsis group than in the SIRS group (median [interquartile range] 2.32 [7.41] vs 0.45 ng/ml [2.62]). A cutoff value of 1.1 ng/ml yielded 72.4% sensitivity and 62.5% specificity. In a group of patients with abdominal symptoms lasting for more than 24 h, a cut-off value of 1.1 ng/ml yielded higher sensitivity (82.9%) and higher specificity (77.3%). Our results suggest that PCT measurements may be useful for early, preoperative diagnosis of abdominal sepsis.

Introduction The main causes of reduced glucose levels during metformin therapy appear to be an increase in insulin action in peripheral tissues and reduced hepatic glucose output due to inhibition gluconeogenesis. Objective The purpose of the study was to establish the effect of metformin on fasting and postprandial insulin secretion. Method The study carried out was double blind, controlled, comparative, randomized, multicentric, including two groups of out-patient department (OPD) patients. 43 patients were administered metformin (Tefor ICN Canada), and 46 patients were given placebo. Patients enrolled in the study were newly diagnosed with diabetes mellitus (DM) type 2, glycaemia < 12 mmol/l, and had the Body Mass Index (BMI) > 30 kg/m2. Before treatment, blood biochemistry was done: fasting and postprandial glycaemia, glycosylated haemoglobin (HbA1c) value, fasting and postprandial insulinaemia, blood lipids (total cholesterol, total triglycerides, HDL cholesterol, and LDL cholesterol), and gamma glutaryl transferase (GGT) level. BMI was also established. After 42 days of treatment, fasting and postprandial insulinaemia were tested again. Analysis of the effects of therapy, and identification of co-variants for fasting and postprandial insulinaemia, were done by ANOVA two way and ANCOVA method. Results It was shown that metformin accompanied by diet, as compared to placebo accompanied by diet, lowered the fasting insulinaemia value during six weeks of therapy in obese patients with DM type 2 (24.392 mU/l vs. 25.667 mU/l), interacting both with BMI pre-therapy, and interacting with fasting insulinaemia pre-therapy (p

Aims To provide updated knowledge regarding the airway management and the possibility of difficult intubation in diabetic patients. Materials and methods We preformed a systematic literature review of the English language literature, published over the past 10 years which deals with this subject. Results The vast majority of the modern literature data supports the fact that diabetic population has higher risk for difficult intubation occurrence. The most important characteristics of diabetic patients that are considered to be contributing factors for the difficult intubation are obesity, increased neck circumference and stiff joint syndrome. Conclusion A special attention and thorough preoperative preparation should be given to patients with diabetes. In order to predict and prevent difficult intubation in these patients, further studies are needed to investigate this issue closely.

Background Graves’ disease represents an autoimmune disease of the thyroid gland where surgery has an important role in its treatment. The aim of our paper was to analyze the results of surgical treatment, the frequency of microcarcinoma and carcinoma, as well as to compare surgical complications in relation to the various types of operations performed for Graves’ disease. Methods We analysed 1432 patients (221 male and 1211 female) who underwent surgery for Graves’ disease at the Centre for Endocrine Surgery in Belgrade during 15 years (1996–2010). Average age was 34.8 years. Frequency of surgical complications within the groups was analyzed with nonparametric Fisher’s test. Results Total thyroidectomy (TT) was performed in 974 (68%) patients, and Dunhill operation (D) in 221 (15.4). Carcinoma of thyroid gland was found in 146 patients (10.2%), of which 129 (9%) were a microcarcinoma. Complication rates were higher in the TT group, where there were 31 (3.2%) patients with permanent hypoparathyroidism, 9 (0.9%) patients with unilateral recurrent nerve paralysis and 10 (1.0%) patients with postoperative bleeding. Combined complications, such as permanent hypoparathyroidism with bleeding were more common in the D group where there were 2 patients (0,9%), while unilateral recurrent nerve paralysis with bleeding was more common in the TT group where there were 3 cases (0,3%). Conclusions Frequency of complications were not significantly statistically different in relation to the type of surgical procedure. Total thyroidectomy represents a safe and efficient method for treating patients with Graves’ disease, and it is not followed by a greater frequency of complications in relation to less extensive procedures.

Sepsis-associated acute kidney injury (SA-AKI) severely impacts morbidity and mortality in surgical patients with sepsis. Matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of matrix rnetalloproteinase-1 (TIMP-1) have an important role in pathophysiology of sepsis but they have been unexplored in SA-AKI. We aimed to investigate the role of MMP-9 and TIMP-1 in septic surgical patients with SA-AKI and to evaluate them as diagnostic biomarkers of SA-AKI. This prospective observational study compared 53 major abdominal surgery patients with sepsis divided into SA-AKI (n = 37) and non-SA-AKI (n = 16) group to 50 controls without sepsis matched by age, gender, comorbidities and type of surgery. Blood and urine samples from septic patients were collected on admission to ICU and 24, 48, 72 and 96 h later and once from the controls. The levels of MMP-9, TIMP-1, neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1, urea and creatinine were measured. MMP-9/TIMP-1 ratio and disease severity scores, such as Sequential Organ Failure Assessment (SOFA), were calculated. Septic patients with SA-AKI had higher serum TIMP-1 levels and lower serum MMP-9 levels and lower MMP-9/TIMP ratio, compared to septic patients without SA-AKI and controls. The levels of these biomarkers did not change significantly over time. MMP-9, TIMP-1 and MMP-9/TIMP-1 ratio correlated with urea, creatinine, NGAL, and SOFA scores. Moreover, using the area under ROC curve, we showed that TIMP-1 and MMP-9/TIMP-1 ratio, but not MMP-9, were good diagnostic biomarkers of SA-AKI. We report for the first time the potential diagnostic value of TIMP-1 and MMP-9/TIMP-1 ratio in SA-AKI.

Cognitive dysfunctions are relatively common in postoperative and critically ill patients. This complication not only compromises recovery after surgery, but, if persistent, it minimizes and compromises surgery itself. Risk factors of postoperative cognitive disorders can be divided into age and comorbidity dependent, and those related to anesthesia and surgery. Cardiovascular, orthopedic and urologic surgery carries high risk of postoperative cognitive dysfunction. It can also occur in other types of surgical treatment, especially in elderly. Among risk factors of cognitive disorders, associated with comorbidity, underlying psychiatric and neurological disorders, substance abuse and conditions with elevation of intracranial pressure are in the first place in postoperative patients. Preoperative and perioperative predisposing conditions for cognitive dysfunction and their incidence were described in our paper. These are: geriatric patients, patients with substance abuse, preexisting psychiatric or cognitive disorders, neurologic disease with high intracranial pressure, cerebrovascular insufficiency, epilepsia, preeclampsia, acute intermittent porphyria, operation type, brain hypoxia, changes in blood glucose level, electrolyte imbalance, anesthetic agents, adjuvant medication and intraoperative awareness. For each of these factors, evaluation, prevention and treatment strategies were suggested, with special regard on anesthetic technique.

Anaplastic thyroid cancer (ATC) is one of the most aggressive tumors in human medicine. Despite the multimodal therapy, the average survival of patients is just several months. Fortunately, it is an extremely rare tumor. Most frequently, ATC occurs in the elderly, with the average age of the patients being almost 70 years. It is extremely rare that ATC occurs in people under the age of 40. We report a case of a 33 year old woman with ATC, with the diameter of the tumor being 8x7cm, confirmed by histopathology and imunohistochemistry. In January 2001, a total thyroidectomy was performed, and the tumor was completely resected. Postoperatively, the patient received radiation therapy. Ten years after the surgery, on regular check-ups, the patient is still living and there is no evidence of a recurrent tumor or metastases. This case is instructive for two reasons, as it shows that ATC can occur in younger people and that there is a possibility of long term survival.

Papillary thyroid cancer is after ovarian cancer the most frequent malignant disease of the endocrine system and because of this fact, early detection and appropriate surgical treatment is essential. Radical surgical treatment lower the risk of the disease relapse and postoperative adjuvant therapy with radio iodine is possible as well as postoperative follow up with tireoglobulin measurement. If the total thyroidectomy is performed in highly specialized institution the risk of postoperative complications is acceptable and therefore is the treatment of choice for papillary thyroid cancer. Only the patients with occult papillary thyroid cancer can be treated with hemythyroidectomy. In our series of 410 patients the majority of the patients (85,12%) were in the early phase of the disease and the degree of successfully performed radical surgery for papillary thyroid cancer was very high (tumor reduction was performed in only 1,46% of cases).

The aim of the present paper was to study some characteristics and posibility of surgery of anaplastic thyroid cancer. During five years period in Center for endocrine surgery, we found anaplastic thyroid cancer in 65 patienst (44 female and 21 male), median age 63 years (from 37 to 88 years). Surgical treatment was peerformed in one half (32) anaplastic thyroid cancer patients, at majority of them operative biopsy or tumor reduction only. Radical syrgery was performed in about 10% patients. Posibility of surgery in anaplastic thyroid cancer are very limited. In one third patients there were longstanding goter or thyroid nodul or histological verified dediferentiation of papillary thyroid cancer. This patienst should be operated formerly, before anaplastic transformation.

Thyroid carcinomas arise from follicular cells (papillary, follicular, Hurthle, anaplastic), parafollicular cells (medullary) and stroma (lymphoma, sarcoma?). Gradation and prognostic factors are different for every one of histological type. Most patients with papillary and follicular thyroid cancer have an excellent prognosis. At the other extreme is anaplastic thyroid cancer whose usual mean survival can be measured in months. Exposure to external radiation and living in endemic goiter area increase the frequency of thyroid cancer. Medullary thyroid carcinoma is often familial and may occur in associations with the multiple endocrine neoplasia syndromes.

Primary thyroid lymphomas are rare. Surgery is seldom indicated. The aim of the study is to find out the main characteristics of primary thyroid lymphomas in our patients, indications for surgery and the possibility of treatment, frequency and characteristics of rare thyroid tumors. Method: retrospective study of 1044 patient operated for malignant thyroid tumor. Results: From 1995 to may 2003, we operated upon 15 patients with primary thyroid lymphomas, 2 men and 13 women mean age of 50.12 years (from 22 to 74 years), also one patient of age 69 with insular thyroid cancer. Reason for surgery was thyroid tumor in all, compressive disturbances in 9, among them 4 with asphyxia. Radical total thyroidectomy was performed in 4 (26.7%), whole in others some residual tumor tissue was could not be removed in spite of thyroidectomy in 3, hemithyroidectomy in 2, tumor debulking in 5 and only open biopsy was performed in one patient. There was no operative mortality, no postoperative hypocalcaemia and no recurrent nerve palsy. Histological type of tumor was Non-Hodgkin lymphoma in 13 patients, Hodgkin disease in 2 female patients of age 22 and 24. Hashimoto thyroiditis was present in 3 patients. After surgery, 13 patients were treated with chemotherapy, one patient died one month after the operation and one patient refused chemotherapy. Follow-up data are available for 9 patients and the mean follow-up period was 20 months (1-48months). Three patients died after a month, 2 and 3 years after surgery. Six patients are without local relapse. In one patient who refused chemotherapy, a year after thyroid surgery, resection of large intestine was performed because of lymphoma of the colon. Conclusion: Malignant thyroid lymphomas are rare. They present with rapidly growing thyroid tumor, compression and asphyxia. Surgery is only temporarily effective and it is necessary to start with chemo-radiotherapy as soon as possible. Rare forms of thyroid cancer have to be histological recognized in order to choose the best way of treatment.

Anaplastic thyroid cancer (ATC) is one of the most lethal tumors in human medicine; it is characterized by aggressive local invasion and rapid appearance of distant metastases. Tumor compression on surrounding structures in the neck results in symptoms which dominate the clinical presentation. Hyperthyroidism is an extremely rare clinical feature in ATC which is the consequence of normal thyroid follicle destruction caused by tumor invasion. When the tissue destruction is complete, the hyperthyroid phase is followed by the hypothyroid phase of the disease. Such clinical presentation resembles various thyroiditises, thus the name “malignant pseudothyroiditis” or “anaplastic pseudothyroiditis.” This is a case report of a 67-year-old man, with concurrent development of ATC and clinical thyrotoxicosis. Despite administration of the antithyroid drugs and β-blockers, surgical tumor reduction and adjuvant radiotherapy, the patient died 5 months after the onset of the disease. The literature referring to previous cases of ATC with thyrotoxicosis is reviewed.

Intracardiac leiomyomatosis (ICL) is a rare and dangerous form of intravenous leiomyomatosis (IVL). The case of ICL presented here depicts some diagnostic and surgical difficulties that may arise from the rarity and complexity of this condition. Further, to our best knowledge, neither the mass nor the growth rate of the abdominal part of the presented ICL has been described in the available literature. Finally, this case and extensive literature search allowed us to clarify some important questions pertaining to this entity.

Aims and background Thyroid cancers are relatively rare tumors that appear more frequently in women than in men. Accordingly, most studies focus on studying risk factors for thyroid cancer in women and consequently on various hormonal or reproductive factors that are specific for women. The aim of our study was to examine risk factors for developing well-differentiated thyroid cancer in men. Heretofore, we did not encounter in the literature a study that was solely focused on studying risk factors for well-differentiated thyroid cancer in men. Methods A case-control study was performed from 2005 to 2010. The case group included 204 consecutive well-differentiated thyroid cancers in male patients (180 papillary and 24 follicular including Hürthle cell). The control group comprised the same number of cases. Patients were individually matched by gender, age and place of residence. Statistical analysis included conditional univariate and multivariate logistic regression Methods. Results According to univariate logistic regression, well-differentiated thyroid cancer in men was significantly related to smoking status, duration of smoking, number of cigarettes smoked per day, history of goiter or thyroid nodules, history of non-thyroid cancer, diabetes mellitus, radiotherapy of the head and neck, and history of malignant tumors. According to multivariate logistic regression, it was independently related to smoking status (OR = 0.36; 95% CI, 0.19–0.69), history of goiter or thyroid nodules (OR = 9.19; 95% CI, 1.25–64.58), and a history of malignant tumors (OR = 2.11; 95% CI, 1.19–7.33). Conclusions Risk factors for well-differentiated thyroid cancer in men were goiter or thyroid nodules and family history of malignant tumors. Cigarette smoking was negatively associated with the disease.

Thyroid carcinomas in children and adolescents are rare tumors and the most common among them is papillary thyroid cancer (PTC). Its etiology is still under research and has not been clearly defined thus far, especially in young individuals. The aim of this case-control study was to determine potential risk factors for the development of PTC in children and adolescents. This type of study has not been carried out previously in this age group. A case-control study was carried out during a 15-year period, between 1995 and 2009. The case group included 75 patients with PTC younger than 20 years of age, with the youngest patient being 6.5 years old; 45 patients were female and 30 were male. The control group included the same number of participants, and the cases were individually matched by sex, age, and place of residence. Conditional univariate and multivariate logistic regression methods were applied in data analysis. According to univariate logistic regression analysis, PTC in children and adolescents was significantly related to the following factors: family history of thyroid cancer, family history of residence in an endemic-goiter area, family history of benign thyroid disease, and family history of nonthyroid malignant tumors. According to the multivariate logistic regression method, PTC in children and adolescents was independently related to a family history of thyroid cancer (odds ratio=4.5, 95% confidence interval=1.2-19.8) and a family history of nonthyroid malignant tumors (odds ratio=3.8, 95% confidence interval=1.4-8.7). In conclusion, all of the factors associated with the development of PTC in children and adolescents were related to their family history. (C) 2013 Wolters Kluwer Health vertical bar Lippincott Williams and Wilkins.

We studied the influence of demographic characteristics, comorbidity, and type and duration of surgery and anesthesia on the occurrence of intraoperative hypertension (IOHTA). Logistic regression analyses were used in order to determine the predictors of occurrence of IOHTA. More than 60% of our patients had IOHTA. Multivariate analysis showed that independent predictors for IOHTA were older age, BMI > 25 kg/m(2), and hypertension as a coexisting disease. Hypertension is common during thyroid surgery, and a significant number of patients remained hypertensive during the postoperative period.

Introduction. Anaesthesia affects kidney function by reducing the renal blood flow and glomerular filtration rate. As chronic renal failure (CRF) significantly influences drug metabolism and elimination, we studied the effects of rocuronium bromide (RB) in patients with CRF. Objective. The aim of the study was to examine whether, when using RB in patients with CFR, there are differences regarding the onset time of neuromuscular block (NMB) development, duration time, speed of recovery and cumulative effects of RB. Methods. Prospective study included 60 patients who underwent urologic surgery procedures. The patients were divided into 3 groups: the first group (G1) - 20 patients with CRF and residual dieresis, the second group (G2) - 20 patients with CRF and without dieresis, and third group (G3) - 20 patients with normal renal function (control group). During surgery RB was administrated for muscle paralysis in all patients. Train-of-four (TOF) Guard acceleromyography was used for NMB monitoring. Results. Onset time in three groups was 132.3 s; 139.5 s and 113.2 s (r0.05). The number of RB repeated doses was 3-8, 3-7 and 4-8 (r>0.05). The duration time until spontaneous recovery was 31.8, 31.6 and 29.8 minutes (r>0.01). The recovery index was 16.8, 16.7 and 10.6 minutes (r

Background/Aims: Liver resection is the gold standard in managing patients with metastatic or primary liver cancer. The aim of our study was to compare the traditional clamp-crushing technique to the radiofrequency-assisted liver resection technique in terms of postoperative liver function. Methodology: Liver function was evaluated preoperatively and on postoperative days 3 and 7. Liver synthetic function parameters (serum albumin level, prothrombin time and international normalized ratio), markers of hepatic injury and necrosis (serum alanine aminotransferase, aspartate aminotransferase and total bilirubin level) and microsomal activity (quantitative lidocaine test) were compared. Results: Forty three patients completed the study (14 had clamp-crushing and 29 had radiofrequency assisted liver resection). The groups did not differ in demographic characteristics, pre-operative liver function, operative time and perioperative transfusion rate. In postoperative period, there were similar changes in monitored parameters in both groups except albumin levels, that were higher in radiofrequency-assisted liver resection group (p=0.047). Conclusions: Both, traditional clamp-crushing technique and radiofrequency assisted liver resection technique, result in similar postoperative changes of most monitored liver function parameters.

INTRODUCTION Carotid endarterectomy may be performed under general (GA) or regional anesthesia (RA). The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing carotid surgery. MATERIAL AND METHODS This prospective study included 1098 consecutive patients operated on between 2003 and 2009 (773 underwent cervical plexus block and 325 underwent general anesthesia). RESULTS There were 6 deaths, 3 (0.9%) after GA and 3 (0.4%) after RA (p = 0.272). Neurological complication rates were not significantly different (GA 2.1% vs. RA 1.1%, p = 0.212). Incidence of myocardial infarction was similar (GA 0.31% vs. LA 0.39%, p = 0.840). Shunt placement rate was the same in both groups, 11.1%. Total operating time and carotid clamping time were significantly shorter in RA patients (RA: 92 min vs. GA: 106 min; p < 0.001 and RA: 18 min vs. GA: 19 min; p = 0.040). There was no significant difference in number of reinterventions (RA: 1.0% vs. GA: 0.6%; p = 0.504). Pulmonary complications were common in the GA group (RA: 0 vs. GA 0.9%; p = 0.007). Time to first postoperative analgesic was significantly shorter in the GA group (RA: 226 min vs. GA: 139 min; p < 0.001). CONCLUSIONS Type of anesthesia does not affect the outcome of surgical treatment of carotid disease. However, it should be stressed that fewer respiratory complications, later requirement for first postoperative analgesic, and an awake patient who can continue oral therapy early after surgery, give priority to regional techniques of anesthesia.

Preoperative evaluation of patients with thyroid gland disease, in any kind of surgery, should include the possibility of difficult intubation caused by thyromegaly, the hormonal status (its disbalance), as well as the screening, and therapy of consequences of thyroid imbalance on specific organ systems, especially cardiovascular. It is necessary to select the adequate anesthetics and other pharmacological agents, according to current hormonal status. It is also necessary to select the adequate medications and other therapeutic measures for prevention and treatment of possible complications in perioperative period, some of which are life-threatening (thyroid storm and mixedema coma).

Ageing of population world wide has significant contribution as one of the major risk factor for neurodegenerative disorders. The patients with neurodegenerative as well as other neuological diseases presented the population with possible great need either of small or big surgical intervention. There are several important issues in patients with neurological diseases: the nature, disease duration, therapy, the patient?s ability to live without assistance. Neurological disease may become worst by general and regional anesthesia. Stopping therapy may lead to worsening of neurological diseases. One of the main common threat is the risk of significant cardiorespiratory complications, which is important in assessing operational risk, in preoperative preparation and in terms of postoperative recovery and outcomes of surgical treatment. This has resulted in greater preoperative care by detailed patient history evaluation and examination, patient information and informed consent. Besides the effect of the anaesthetic technique upon the course of the disease, there is also the interaction of drugs administered during anaesthesia and patient medication. Several undiagnosed diseases may be disclosed following a surgical/anaesthetic intervention.

Proper diagnosis of psychoactive substance abuse and addiction, as well as acute intoxication, withdrawal syndrome and overdosing are of great importance in patients who are preparing for surgical intervention. There are some specific details in their preoperative preparation whether they underwent emergency or elective surgery. Good knowledge of the characteristics of psychoactive substance abuse and addiction, interaction of psychoactive substances and anesthetics and any other drugs that could be used in the perioperative period is important especially for anastesiologist. In this work we present key issues for recognizing theese patients as well as some guidelines for adequate preoperative preparation and postoperative care.

Preoperative preparation of the patients with adrenal cortex dysfunction is based on the careful preoperative evaluation of the type and the severity of the disturbance. The dysfunction involving adrenal glands may be: insufficiency (severe, mild, expressed) and hyperfunction (hypercorticism and/or hyperaldosteronism). If we speak about the patients with limited adrenal reserve (Addison?s disease, therapeutic glucocorticoid application etc.) they need necessary corticosteroid supplementation, during preoperative preparation, as well as, during complete perioperative period. Doses needed for the substitution are adjusted according to the severity of adrenal insufficiency and according to the extent of the planned surgical procedure. Patients with Cushing?s syndrome (or other form of hypercorticism), as well as, patients with Conn?s syndrome (or other forms of hyperaldosteronism), do have numerous organ dysfunctions, that are significant in preoperative preparation, anesthesia and for the outcome of the surgical treatment. Common feature for both of the above syndromes is hydroelectrolyte disbalance, with hypokalemia, metabolic alkalosis and hypertension. Disturbances related to the adrenal cortex hyperfunction must be corrected preoperatively, in order to avoid complications. When we speak about hypokalemia it must be promptly corrected even before urgent/vital surgical procedure because it may cause severe intraoperative cardiac arrhythmia.

Arterial hypertension is not an independent risk factor in cardiovascular complications in noncardiac surgery. Nevertheless, preoperative evaluation is necessary and includes estimation of arterial hypertension grade and possible damage of target organs. In patients with first and second grade of arterial hypertension postponement of elective intervention is not necessary, only optimization of therapy. On the other hand, patients with third level arterial hypertension have benefit if intervention is postponed till the reduction of arterial pressure. There is no indication that any of the antihypertensive drug groups has advantage in the preoperative treatment of hypertension. Unlike arterial hypertension pulmonary hypertension increases the risk of cardiac morbidity and mortality in the perioperative period. In patients with pulmonary hypertension, anesthesia and surgery may be complicated with heart failure, hypoxia and arrhythmias. Preoperative and postoperative treatments include calcium channel blockers, prostanoids, endothelin receptor antagonists and inhibitors of phosphodiesterase type 5.

Patients with end stage renal failure (ESRF) present a number of challenges to the anesthesiologist. They may be chronically ill and debilitated and have the potential for multisystem organ dysfunction. Patients with primary renal disease are likely younger and have good cardiopulmonary reserve. Older patients with renal failure secondary to diabetes mellitus or hypertension may suffer the ravages of diffuse atherosclerosis and heart disease. To safely manage these patients we need to understand the benefits and limitations of dialysis, problems related with primary disease, pathophysiological effects of ESRF, and the altered pharmacology of commonly used anesthetic agents and perioperative medications in ESRF. Problems encountered by anesthesiologist in ESRF patients include hypertension, ischemic heart disease, congestive heart failure, anemia, metabolic acidosis, hyperkaliemia, hyponatremia and circulatory collapse. All surgical procedure in patients with ESRF carries significant risk of peri- and postoperative complications (mostly cardiovascular) and even fatal outcome.