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Background Lung atelectasis are nonventilated parts of lung tissue and occur as a result of the collapse of the pulmonary parenchyma (alveoli). Various therapeutic procedures for inflating the collapsed pulmonary parenchyma, such as bronchial aspiration and/or standard recruitment maneuvers, are not always successful. Case presentation We report a case of a 23-year-old Croatian man with a parapharyngeal abscess on the left side of the neck with spreading of infection in the mediastinum and left side of the thorax and consequent major atelectasis of the left lung. The patient was mechanically ventilated. We decided to apply a new method in which a pulmonary artery catheter was placed (guided by bronchoscope) on the entrance to the lower left bronchus. The pulmonary artery catheter balloon was inflated to achieve bronchial closure. Using another respirator, we ventilated the affected lobe separately with continuously high pressure of 30 cmH2O. After 30 minutes, we removed the pulmonary artery catheter from the lower left bronchus and placed it in the upper left bronchus and repeated the procedure. Our method allowed a significantly longer duration (30 minutes) of continuously high pressure of 30 cmH2O separately to only one of the total of five lobes of the lungs while the other four lobes were simultaneously ventilated continuously with protective ventilation mode. Conclusion Use of a pulmonary artery catheter and two respirators in our patient’s case proved to be a successful method for recruiting the atelectatic lung while maintaining protective ventilation of the lung segments without atelectasis.

Cilj: Istaknuti nedostatke standardnog radiograma pri obradi ozljede vratne kralježnice, posebice u visokorizičnih pacijenata u kojih je zbog patoanatomskih promjena ova dijagnostička pretraga otežana (ankilozantni spondilitis, stenoza spinalnog kanala i osteoporoza). Prikaz slučaja: Prikazali smo obradu ozljede vratne kralježnice u dva visokorizična pacijenta (osteoporotičnog te pacijenta s ankilozantnim spondilitisom). Prijelomi vratne kralježnice češći su u te dvije skupine i mogu nastati blažim padom. Mehanizam ozljede je u oba slučaja bio pad sa svoje visine. Inicijalni neurološki pregled kod oba pacijenta bio je uredan, tek je odgođeni pregled ukazao na neurološki deficit: u prvom slučaju nekoliko sati nakon ozljede, a u drugom slučaju devet dana nakon ozljede. U oba slučaja ozljeda vratne kralježnice bila je dijagnosticirana naknadno učinjenim MSCT-om vratne kralježnice. Zaključak: S obzirom na potencijalno opasne posljedice neprepoznate i neliječene ozljede vratne kralježnice, htjeli smo naglasiti potrebu za daljnjim istraživanjem i kreiranjem adekvatnog algoritma za visokorizične pacijente. Zbog svoje visoke specifičnosti i senzitivnosti, MSCT bi trebao biti metoda izbora pri dijagnosticiranju ozlijede vratne kralježnice u toj grupi pacijenata., Aim: to emphasize the deficiencies of plain film radiographs in the evaluation of cervical spine injuries especially in high-risk patients in which this diagnostic procedure is inadequate due to pathoanatomical changes (ankylosing spondilytis, spinal canal stenosis and osteoporosis). Case report: We presented the evaluation of cervical spine injury in two high risk groups (osteoporotic patient and patient with ankylosing spondilytis). Spinal fractures are more common in those two groups and can result from a simple fall. The mechanism of injury in both cases was falling from its height. Initial neurological status was normal, only secondary approach revealed neurological deficit; in 1. case couple of hours after injury and in 2. case nine days after injury. In both cases, MSCT revealed cervical spine fracture. Conclusion: Considering the potential severe consequences of unrecognized and untreated injuries, we wanted to emphasise the need for further research and implementation of appropriate evaluation algorithm in high-risk patients. Due to its high specificity and sensitivity, MSCT should be the method of choice in diagnosing cervical spine fracture in this group of patients.

Lung ultrasound (LUS) is becoming a valuable tool in assessing patients in the ER, ICU, and on the hospital wards because it is a simple, fast and harmless technique. One of the most distinct artefacts seen with LUS are B-lines, hyperechoic laser-like lines that form in the presence of thickened interlobular septa due to alveo-interstitial syndrome. Many researches have been conducted recently with a goal of correlating B-lines to specific known parameters such as EVLW, PAOP, lung density, and parameters of cardiac failure, either in quantitative or semiquantitative manner. This paper is a short overview of the present known correlations, shortcomings of conducted investigations and differential diagnosis problems and exceptions of B-line artefacts in everyday clinical practice.

Compared to competitive imaging techniques or endoscopy, ultrasound imaging of the upper airway in critically ill patients offers a substantial amount of attractive advantages, in that it is widely available and repeatable, portable, pain-free, relatively inexpensive, and, ultimately, safe. In the following chapter, we describe ultrasonographic anatomy of the upper respiratory organs and consequently present crucial potential applications of ultrasonography in the airway management. We will explore the role of ultrasound in the preintubation assessment, endotracheal tube placement management, double-lumen intubation, the verification of tube position, and the extubation outcome. We also describe the ultrasound-guided percutaneous tracheostomy, the role of ultrasound in laryngeal mask airway, and how ultrasound can be used to improve upper airway anesthesia.

In this issue of the journal, an interesting article by Harsten et al. is published. The authors compared a group of patients who had been given carbohydrate solution and a group of patients who had been given flavoured water (placebo group) 90 min before induction of anaesthesia and again 2 h after the end of surgery. They found no statistically significant difference between the two groups of patients regarding length of stay in hospital, anxiety, headache or thirst.

Introduction Iatrogenic, postcatheterization pseudoaneurysms (PSA) of the femoral artery are a common complication after diagnostic and interventional procedures, with up to 7.7% incidence. Treatment includes surgical repair, ultrasound-guided compression (USGC) repair of the tract of the PSA, or recently ultrasound-guided thrombin injection (UGTI). Large (>1.8 cm) PSA sac with short (3 mm) tract has higher complication ratio such as thromboembolic events after UGTI. Those cases are considered for protective balloon inflation during thrombin injection. The aim of our study was to evaluate the success rate of preventing escape of the thrombin during UGTI with simultaneous manual compression on ipsilateral iliac artery. Methods and results We reported 46 patients, 17 males and 29 females, aged 53–74 years, with iatrogenic, postcatheterization femoral artery PSA. Out of 46 patients, 7 were successfully treated with USGC. The rest of the patients were treated with UGTI with simultaneous manual compression on ipsilateral iliac artery to stop the flow in PSA, and to avoid thrombin escape into the native circulation. Success rate of UGTI with manual compression of ipsilateral iliac artery was 97% with the complication rate of 2.6%. Conclusion Our study confirms that UGTI treatment of the PSA of the femoral artery combined with compression of the ipsilateral iliac artery could be a safe and reliable method of the thrombin escape prevention into the systemic circulation, as good as more invasive and demanding methods.

BACKGROUND: Preoperative fasting is associated with various untoward postoperative health problems. Previous studies have stressed the advantages of preoperative feeding with a carbohydrate-rich drink 2 hours before surgery; this protocol does not increase the risk of gastric-content aspiration but reduces the level of anxiety and thirstiness during the perioperative period. Spinal anesthesia with the local anesthetic bupivacaine can decrease gastric emptying in the early postoperative period. However, the effect of spinal anesthesia on the gastric emptying rate following preoperative feeding is unknown. The aim of this study was to determine the impact of preoperative feeding with a clear carbohydrate-rich drink on gastric emptying early after orthopedic surgery under spinal anesthesia. METHODS: A total of 110 patients scheduled for semi-elective orthopedic surgery under spinal anesthesia were included in a randomized controlled trial. Patients were randomly assigned to two groups: group 1 (56 patients) received a standardized 200 ml of clear carbohydrate-enriched drink orally 2 hours before surgery; group 2 (54 patients) acted as a control group with no preoperative feeding. Gastric emptying was evaluated with a paracetamol test at five time points: 15 min, 30 min, 60 min, 90 min and 120 min after administration of paracetamol. RESULTS: No significant differences were observed between the two groups in paracetamol plasma concentrations or area under the curve during the early postoperative period. CONCLUSION: In patients undergoing spinal anesthesia, preoperative feeding 2 hours before surgery had no influence on the gastric emptying rate, indicating that preoperative feeding does not increase the risk of gastric-content aspiration and can be given safely.

Objective Chest tube thoracostomy is a standard procedure for pleural fluid and air drainage. The aim of this study is to compare the success rate of the targeted tube thoracostomy using two different techniques: a targeted wire-guided (TWG) technique and a classical surgical (CS) technique. Methods The study was performed on 153 human cadavers without documented pleural pathology, mechanically ventilated during the procedure. They were divided into two groups and to each cadaver a software generated random number was assigned. The TWG technique was applied on 76 and the CS technique on 77 cadavers. The TWG and CS groups were divided into four subgroups according to the four intended positions of the chest tube tip (target position in the pleural cavity): back-down-right, front-up-right, front-up-left and back-down-left. The precise position of the chest tube tip after thoracostomy was determined by autopsy. The placement of the thoracostomy tube was marked successful if the chest tube tip was located at an intended position. Results The success rate with the TWG technique was 79%, whereas with the CS technique it was 30%. Conclusion A higher success rate was achieved with the TWG than with the CS thoracostomy technique.

BACKGROUND: Ultrasound-guided regional anesthesia has gained popularity for ankle and foot surgery. The aim of our study was to investigate the sufficiency of anesthesia for ankle surgery as well as duration of analgesia in postoperative period, using minimal invasive ultrasound-guided regional anesthesia, and to compare it with anesthesia and postoperative analgesia following spinal anesthesia. METHODS: This prospective study included 40 adult trauma patients with bimalleolar fracture who were scheduled for surgery. They were randomly assigned and divided in two groups. Patients from the first group underwent an Ultrasound-guided femoro-popliteal block (US-FPB), while a spinal anesthesia (SA) was performed for the second group. The local anesthetic 0.5% bupivacaine was used in both groups. RESULTS: Eighteen patients from the first and nineteen patients from the second group completed the study. Levels of anesthesia were sufficient in both groups without significant differences. Duration of postoperative analgesia was significantly higher in US-FPB group in comparison to SA group (12 ± 3 vs. 3 ± 1 h) (p < 0.001). At the same time, onset of complete sensory motor block was significantly faster in SA group in comparison to US-FPB group (5 ± 1 vs. 8 ± 3 min) (p < 0.001). CONCLUSION: Minimal invasive US-FPB provides sufficient anesthesia for ankle fracture. In comparison to the SA group, patients from the US-FPB group achieved significantly longer postoperative analgesia, while faster onset of anesthesia was noted in SA group.

Study Objective To evaluate the role of a brief ultrasound examination (US) in detecting the correct position of the left double-lumen endotracheal tube (LDLT). Design Prospective, randomized clinical study. Setting Operating room of a university hospital. Patients 50 elective adult thoracic surgery patients who required a LDLT during anesthesia. Intervention and Measurements Patients were randomized to two groups: Group A, who underwent clinical assessment of the LDLT position, and Group B, who were examined clinically and by ultrasound. All 50 patients underwent the same conventional procedure of LDLT placement. In all patients, clinical assessment of LDLT positioning was made by observing chest wall expansion and checking lung compliance by manual ventilation and by auscultation of both lungs. In Group B, a very brief ultrasound (15-30 sec) examination was added. Ultrasound examination included visualization of the pleural movements ("lung sliding") and motion of the diaphragm from both sides before and after selective clamping of the bronchial and tracheal limbs. In both groups, a second anesthesiologist performed bronchoscopy to estimate actual LDLT position. Main Results Sensitivity and negative predictive values in detecting proper LDLT positioning for both methods were 100%. For the clinical assessment alone (Group A), specificity was 22%, accuracy was 72%, and positive predictive value, 70%; for the clinical and ultrasound assessment (Group B), specificity was 50%, accuracy was 88%, and positive predictive value, 86%. Conclusion A brief ultrasound examination added to clinical assessment ensured more precise placement of LDLT than did clinical assessment alone.

Study Objective: To correlate tracheal width as measured by ultrasound with width measured by computed tomography (CT), and to evaluate the possible role of ultrasound in the selection of the proper size of left-sided double-lumen endotracheal tubes (LDLTs). Design: Two independent, prospective, observational clinical studies (Study 1 and Study 2). Setting: University hospital. Patients: Study 1 included 25 patients and Study 2 included 20 adult thoracic surgery patients who required a LDLT during anesthesia. Interventions and Measurements: In Study 1, CT measurements of tracheal width were made at the coronary plane 0.5 cm above the sternoclavicular joint ; CT measurements of the left main bronchus diameter were made 1 cm below the carina. Ultrasound measurement of tracheal width was performed just above the sternoclavicular joint in the transversal section. In Study 2, patients' tracheas were intubated with a LDLT based on ultrasound measurements. The frequencies of incorrect selections of LDLT and unsatisfactory lung collapse were analyzed. Main Results: There was a strong correlation between tracheal width as measured by ultrasound and tracheal width (r=0.882, P

BACKGROUND: Chest tube malfunction, after the tube thoracostomy, is often the result of an inappropriate chest tube tip position. The aim of this study was to analyse the precision of chest tube placement using the targeted wire guide technique (TWG technique) with curve dilator and to compare it to the classical surgical technique (CS technique). MATERIALS AND METHODS: In this clinical study 80 patients with an indication for thoracic drainage, due to pneumothorax or pleural effusion were included. Experimental group contained 39 patients whose chest tube was placed using the TWG technique. The control group contained 41 patients whose chest tube was placed using the CS technique. RESULTS: The comparison of the outcomes of the two techniques applied suggests that the TWG technique was significantly more successful in achieving adequate (precise) chest tube placement, irrespective of patient diagnosis (TWG vs. CS in all patients, 78.4% vs. 36.6%, p

) for intradermal skin test. Methods: We performed a prospective, randomized study in which healthy adult volunteers were divided into the two analgesic pretreatment groups (ice cube group and 4% lidocaine cream group). We chose the same intervention site of anterior aspect of left forearm in both groups. As a pretreatment, an ice cube in the ice cube group and 5 mg of 4% lidocaine cream in the 4% lidocaine cream group was applied, respectively. Intradermal skin test was performed 1 minute after application of an ice cube, and 40 minutes after application of 4% lidocaine cream, considering the respective time to have an enough analgesic effect. 5 minutes after intradermal skin test, pain was assessed using a 100 mm visual analogue scale (VAS). VAS score of each group was compared using Mann-Whitney U test. Results: A total of 35 volunteers were participated in this study (17: ice cube group, 18: 4% lidocaine cream group). There were no differences in demographic characteristics. The Median VAS score was 20 (0, 35) in the ice cube group and 70 (50, 80) in the 4% lidocaine cream group (p

Percutaneous dilatational tracheostomy (PDT) is a widely used and accepted method for long-term ventilation of critically ill patients in many intensive care units (ICUs). However, serious complications related to PDT have been reported, including several cases of intraoperative loss of airway with fatal consequences. (1) Generally, this is the result of the required delicate position of the endotracheal tube (ETT) during PDT, with a partially deflated cuff located at the level of the vocal cords. This position of the ETT may lead to accidental extubation and loss of airway during the procedure, especially in difficult patients with a short, bull neck. On the other hand, too deep a position of the tip of the ETT can lead to accidental punction of Murphy's eye, with impalement of the ETT. (2) Unfortunately, the operator performing the PDT evaluates the correct position of the tip of the ETT on the basis of questionable, indicative, indirect parameters and clinical signs such as: capnography, the curve on the ventilator monitor and respiratory movements of the thoracic wall. Recently, the new, disposable intubating device, Airtraq (Prodol Meditec S.A., Vizcaya, Spain) optical laryngoscope (AL), has been used successfully in difficult airway patients. (3) The AL is a device with internal arrangement of the optical component and exaggerated curvature of the blade that allows excellent viewing of the vocal cords and epiglottis without alignment of the oral, pharyngeal and tracheal axes. Also, the AL has a channel that is used to direct the ETT through the vocal cords, directly or using wireless monitoring, once visualization has been achieved. The wireless monitor allows real-time visualization of all intubating procedures for more than one person. The purpose of our short investigation was to evaluate the usefulness of the AL with wireless monitoring for initial positioning and maintaining an optimal position of the ETT during PDT. We hypothesized that initial positioning of the ETT with the AL should be at least as swift and precise as by classic laryngoscopy, probably with less expressed hemodynamic changes that follow laryngoscopy. We further assumed that continuous monitoring of the ETT position by the AL, with a wireless monitor, would enable optimal airway management during the whole procedure of PDT. After hospital ethical board approval, 30 critically ill adult patients who required a PDT were enrolled (without any exclusion criteria) in the prospective study. All PDT were performed by experienced operators using the guide-wire dilating forceps technique (Portex Ltd, UK) . Bronchoscopy guidance was not used, but in several difficult cases PDT was guided by ultrasonography as previously described. (4) The endotracheal tube was positioned using the AL in the following manner. An appropriately sized (regular for ETT 7.0-8.5 mm ; small for ETT 6.0- 7.5 mm) and well lubricated AL was inserted into the oral cavity on the left side of the ETT and the ETT was gently pushed into the guiding canal of the AL. Then, the AL was slowly drawn over the ETT with its top positioned in the vallecula. The view of the ETT, located between the vocal cords, is optimized by slightly lifting the blade in the vallecula. Then the cuff of the ETT was deflated and the ETT was withdrawn until the cuff was visible partly between and partly below the vocal cords. In this position, the cuff was re-inflated under eye control. After securing a correct ETT position, the AL was delicately fixed with fixing tape and left "in situ" during PDT (figure 1). Thus, the operator has the possibility to control visually on the screen the exact position of the ETT during the whole procedure. The initial positioning of the ETT was done without any problems in all cases. At all times, including during the initial positioning of the ETT, hemodynamic and respiratory parameters were stable, including peripheral arterial O2 saturation as well as end-tidal CO2. Not in one PDT were signs of hemodynamic or respiratory instability observed, nor oxygen desaturation of arterial blood, hypercarby or loss of passable airway. In all performed PDTs the operator had perfect vision of the exact position of the ETT during the whole procedure. In conclusion, the AL with wireless monitoring is very suitable for airway management during PDT and this device offers important additional security for the operator.

One of the most significant features of lung ultrasound (LUS) is comet tail artifacts, also called B-lines or “lung rockets”. The causes of such phenomena are fluid-thickened interlobular septa which are the consequence of increased extravascular lung water (EVLW) or pulmonary edema. The B-lines are defined as a discrete, echogenic, vertical, laser-like signal with a narrow origin in the near field of the image. (1) Functionally, they are a sign of dysfunction of the alveolar-capillary membrane and they can be understood as the ultrasonic equivalent of Kerley B lines on X-ray. The sum of the number of B-lines correlates with the amount of EVLW in the lung and in each scanning site (generally 8 sites, 4 on the right and 4 on the left hemithorax) and may be counted from zero to ten. In addition to the estimated EVLW, detection of B-lines by LUS is a very useful tool for the diagnosis of cardiogenic versus noncardiogenic pulmonary edema and for excluding pneumothorax. However, from a clinical point of view, there are several limitations in the routine detection of B-lines. In critically ill obese patients B-lines are often more difficult to detect and vaguely visible, and sometimes it is tricky to distinguish a B-line from the so-called Z line. When B-lines are numerous, it is not easy to clearly enumerate them, especially when they tend to be confluent and in such cases the distance between B-lines cannot be precisely measured. Also, B-lines are more dynamic than static ultrasound (US) signs and they are therefore partly operator dependent signs. Mainly, for this reason, B-lines are adopted in routine clinical practice as a semiquantitative not quantitative index of EVLW accumulation. (2) In order to maximally reduce the impact of operator experience and inter- or intra observer variability we designed software (figure 1) which calculates the number of B-lines in real time and marks them on the screen for a given time period (10 sec.). The new software was adapted for two ultrasound machines (Aloka SSD 3500 and Philips iE 33) and tested on twenty intensive care unit (ICU) patients in different stages of pulmonary edema. The degree of edema was estimated using lung computed tomography (CT) and by measuring the value of EVLW. Then, the estimated degree of edema was compared with the number of B-lines obtained by the software for each patient. Although ultrasound examinations were performed by five examiners with different levels of experience with LUS, we found excellent correlation between the degree of lung edema and the number of B-lines displayed by the software (r = 0, 85 ; p < 0, 01). In conclusion, we found that this new support software is very useful for more precisely estimating the number of B-lines, regardless of the experience of the examiner. However, accurate assessment of the usability of the new software in routine ICU practice requires further clinical trials.

Objective: To report a case of fatal toxic epidermal necrolysis associated with carvedilol treatment. Case summary: Two days after the initiation of carvedilol treatment, a 70-year old woman presented with skin eruptions in the form of maculous rash with blisters that rapidly progressed to epidermal necrolysis. Although the suspected drug was withdrawn, the reaction was extremely rapid in its development with fatal outcome. Discussion: Carvedilol is not a drug commonly associated with TEN. To our knowledge there are no cases of carvedilol related TEN reported in the literature. Conclusion: Because of the close temporal relationship between the initiation of carvedilol treatment and the appearance of skin eruptions, and because carvedilol was the only new medication the patient had taken, the etiology of TEN was most likely a reaction to this drug. Physicians should be aware of this extremely rare but serious ADR.