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Aim: To report the clinical courses of two patients, one with Hodgkin’s lymphoma (HL) and one with Non-Hodgkin’s lymphoma (NHL), who developed severe refractory acute respiratory distress syndrome (ARDS) and were treated with veno-venous extracorporeal membrane oxygenation (VV ECMO). Case report: Both patients developed chemotherapy-associated febrile neutropenia followed by pneumonia and ARDS, after which they were transferred to the intensive care unit. Their respiratory failure deteriorated despite endotracheal intubation with protective mechanical ventilation, at which point a decision for VV ECMO initiation was made. Both patients had complicated treatment courses and developed severe ECMO-associated complications. The most important complications of ECMO support in our HL patient were cardiac arrest; right atrial laceration with pericardial tamponade which needed surgical treatment; right leg ischemia which required transfemoral amputation; thrombosis within the membrane oxygenator; several septic episodes with severe hemodynamic instability; and right sided tension pneumothorax. Despite all difficulties, the patient was successfully weaned from ECMO. Unfortunately, he died prior to hospital discharge as a result of sepsis with multiple organ failure. The most significant ECMO-induced complications in our NHL patient were severe bleeding incidents, most notably diffuse oropharyngeal and continuous bilateral pulmonary hemorrhage; superimposed bacterial pneumonia; extensive pneumomediastinum and subcutaneous emphysema. Despite all therapeutic efforts, the patient died during ECMO treatment because of respiratory decompensation. Conclusions: The patients with hematologic malignancies (HMs) undergoing ECMO support have poor outcomes, with high rates of severe ECMO-induced complications. Further studies focusing on patient selection and issues concerning prevention, diagnosis and treatment of ECMO-associated complications are needed.

The COVID-19 pandemic is caused by the betacoronavirus SARS-CoV-2. In November 2021, the Omicron variant was discovered and classified as a variant of concern (VOC). Omicron shows substantially more mutations in the spike protein than any previous variant, mostly in the receptor binding domain (RBD). We analyzed the binding of the Omicron RBD to the human ACE2 receptor (hACE2) and the ability of human sera from COVID-19 patients or vaccinees in comparison to Wuhan, Beta or Delta RBDs variants.All RBDs were produced in insect cells. RBD binding to hACE2 was analyzed by ELISA and microscale thermophoresis (MST). Similarly, sera from 27 COVID-19 patients, 58 fully vaccinated individuals and 16 booster recipients were titrated by ELISA on the fixed RBDs from the original Wuhan strain, Beta, Delta and Omicron VOC.Surprisingly, the Omicron RBD showed a weaker binding to ACE2 compared to Beta and Delta, arguing that improved ACE2 binding is not a likely driver of Omicron evolution. Serum antibody titers were significantly lower against Omicron RBD compared to the original Wuhan strain. However, a difference of 2.5 times was observed in RBD binding while in other studies the neutralization of Omicron SARS-CoV-2 was reduced by a magnitude of 10x and more. These results indicate an immune escape focused on neutralizing antibodies.The reduced binding of sera to Omicron RBD adds evidence that current vaccination protocols may be less efficient against the Omicron variant.

Estimation of the epidemiology curve for the COVID-19 pandemic can be a very computationally challenging task. Thus far, there have been some implementations of artificial intelligence (AI) methods applied to develop epidemiology curve for a specific country. However, most applied AI methods generated models that are almost impossible to translate into a mathematical equation. In this paper, the AI method called genetic programming (GP) algorithm is utilized to develop a symbolic expression (mathematical equation) which can be used for the estimation of the epidemiology curve for the entire U.S. with high accuracy. The GP algorithm is utilized on the publicly available dataset that contains the number of confirmed, deceased and recovered patients for each U.S. state to obtain the symbolic expression for the estimation of the number of the aforementioned patient groups. The dataset consists of the latitude and longitude of the central location for each state and the number of patients in each of the goal groups for each day in the period of 22 January 2020&ndash, 3 December 2020. The obtained symbolic expressions for each state are summed up to obtain symbolic expressions for estimation of each of the patient groups (confirmed, deceased and recovered). These symbolic expressions are combined to obtain the symbolic expression for the estimation of the epidemiology curve for the entire U.S. The obtained symbolic expressions for the estimation of the number of confirmed, deceased and recovered patients for each state achieved R2 score in the ranges 0.9406&ndash, 0.9992, 0.9404&ndash, 0.9998 and 0.9797&ndash, 0.99955, respectively. These equations are summed up to formulate symbolic expressions for the estimation of the number of confirmed, deceased and recovered patients for the entire U.S. with achieved R2 score of 0.9992, 0.9997 and 0.9996, respectively. Using these symbolic expressions, the equation for the estimation of the epidemiology curve for the entire U.S. is formulated which achieved R2 score of 0.9933. Investigation showed that GP algorithm can produce symbolic expressions for the estimation of the number of confirmed, recovered and deceased patients as well as the epidemiology curve not only for the states but for the entire U.S. with very high accuracy.

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.

Sepsis is the most severe consequence of bac- terial infections, in other words, a potentially life-threatening condition. During infection, some components of the innate immune response can, under certain circumstances, cause multiple organ dysfunction and tissue damage. Fortunately, timely treatment can prevent the consequences. The algorithms used to solve the problem of predicting sep-sis occurrence are Support-Vector Machine (SVM), K- Nearest Neighbors (KNN) and Ar-tificial Neural Network (ANN). The dataset used for this research consists of 23 different medical parameters for each patient, which is the total of 2277 data-points. For each of the aforementioned algorithms, different combi- nations of parameters were examined as well as different types of kernel functions (SVM), architectures (ANN), and number of nearest neighbors (KNN). The experimental results showed that the ANN approach achieves the highest AUC value (0.992) compared to the other approaches like SVM and KNN. (PDF) Comparison of Three Artificial Intelligence Algorithms for Sepsis Prediction. Available from: https://www.researchgate.net/publication/344152 372_Comparison_of_Three_Artificial_Intelligence _Algorithms_for_Sepsis_Prediction [accessed Sep 07 2020].

COVID-19 represents one of the greatest challenges in modern history. Its impact is most noticeable in the health care system, mostly due to the accelerated and increased influx of patients with a more severe clinical picture. These facts are increasing the pressure on health systems. For this reason, the aim is to automate the process of diagnosis and treatment. The research presented in this article conducted an examination of the possibility of classifying the clinical picture of a patient using X-ray images and convolutional neural networks. The research was conducted on the dataset of 185 images that consists of four classes. Due to a lower amount of images, a data augmentation procedure was performed. In order to define the CNN architecture with highest classification performances, multiple CNNs were designed. Results show that the best classification performances can be achieved if ResNet152 is used. This CNN has achieved AUCmacro&macr, and AUCmicro&macr, up to 0.94, suggesting the possibility of applying CNN to the classification of the clinical picture of COVID-19 patients using an X-ray image of the lungs. When higher layers are frozen during the training procedure, higher AUCmacro&macr, values are achieved. If ResNet152 is utilized, AUCmacro&macr, values up to 0.96 are achieved if all layers except the last 12 are frozen during the training procedure.

Adult basic life support and automated external defibrillation – Interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely deployment of an AED is critical. All CPR providers should perform chest compressions, those who are trained and able should combine chest compressions and rescue breaths in the ratio 30:2. Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%. Adult advanced life support – Continued emphasis on minimally interrupted high-quality chest compressions, paused briefly only to enable specific interventions, including interruptions for less than 5 s to attempt defibrillation. Use of self-adhesive pads for defibrillation. Waveform capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation. Cardiac arrest in special circumstances – Special causes: hypoxia; hypo-/hyperkalemia, and other electrolyte disorders; hypo-/hyperthermia; hypovolemia; tension pneumothorax; tamponade; thrombosis; toxins. Special environments are specialised healthcare facilities, commercial airplanes or air ambulances, field of play, outside environment or the scene of a mass casualty incident. Special patients are those with severe comorbidities and with specific physiological conditions. Post resuscitation care is new to the ERC Guidelines. Targeted temperature management remains, now aiming at 36°C instead of the previously recommended 32 – 34°C. Pediatric life support – For chest compressions, the lower sternum should be depressed by at least one third the anterior-posterior diameter of the chest (4 cm for the infant and 5 cm for the child). For cardioversion of a supraventricular tachycardia (SVT), the initial dose has been revised to 1 J kg–1. Resuscitation and support of transition of babies at birth – For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery of the infant, is now recommended for term and preterm babies. Tracheal intubation should not be routine in the presence of meconium and should only be performed for suspected tracheal obstruction. Ventilatory support of term infants should start with air. Acute coronary syndrome (ACS) – Pre-hospital recording of a 12-lead electrocardiogram (ECG) is recommended in patients with suspected ST segment elevation acute myocardial infarction (STEMI). Patients with acute chest pain with presumed ACS do not need supplemental oxygen unless they present with signs of hypoxia, dyspnea, or heart failure. In geographic regions where PCI facilities exist and are available, direct triage and transport for PCI is preferred to pre-hospital fibrinolysis for STEMI. First aid is included for the first time in the 2015 ERC Guidelines. Principles of education in resuscitation – Directive CPR feedback devices are useful for improving compression rate, depth, release, and hand position. Whilst optimal intervals for retraining are not known, frequent ‘low dose’ retraining may be beneficial. Training in non-technical skills is an essential adjunct to technical skills. The ethics of resuscitation and end-of-life decisions – Ethical principles in the context of patient-centered health care: autonomy, beneficence, non-maleficence; justice and equal access. The need for harmonisation in legislation, jurisdiction, terminology and practice still remains within Europe.

Osnovno održavanje života odraslih i automatska vanjska defibrilacija – Ključna je interakcija između dispečera hitne medicinske pomoći (HMP), laika koji pruža kardiopulmonalnu reanimaciju (KPR) i pravodobne uporabe automat­skoga vanjskog defibrilatora (AVD). Svi pružatelji KPR-a trebaju provoditi kompresije prsnog koša, oni koji su uvježbani i sposobni trebaju kombinirati kompresije prsnog koša s umjetnim disanjem, u omjeru 30 : 2. Defibrilacija u roku od 3 do 5 minuta od kolapsa može rezulti­rati visokim preživljavanjem od 50 do 70%. Napredno održavanje života odraslih – Kontinuirani naglasak na minimalne prekide kompresija prsnog koša visoke kvalitete koje se prekidaju kratko samo da bi se omogućili specifični postupci, što uključuje i prekid na manje od 5 sekunda pri pokušaju defibrilacije. Uporaba ­samoljepljivih elektroda za defibrilaciju. ­Valna kapnografija kako bi se potvrdio i kontinuirano monitorirao položaj endotrahealnog tubusa, kvaliteta KPR-a i omogućio rani nagovještaj povratka spontane cirkulacije. Kardijalni arest u posebnim okolno­stima – Posebni uzroci: hipoksija, hipo/hiperkaliemija i ostali elektrolitski poremećaji, hipo/hipertermija, hipovo­lemija, tenzijski pneumotoraks, kardijalna tamponada, tromboza, toksini. Posebno okružje jesu specijalizirani dijelovi ­bolnice, komercijalni avioni ili letjelice zračnoga medicinskog prijevoza, igrališta, vanjsko okružje ili poprište masovne nesreće. Posebni su bolesnici oni s teškim komorbiditetom i posebnim fiziološkim stanjima. Postreanimacijska skrb novi je odjeljak u smjernicama ERC-a. I dalje se preporučuje ciljana kontrola temperature, sada nastojeći postići 36°C, za razliku od ­prethodno preporučena 32–34°C. Osnovno održavanje života djece – Za kompresije prsnog koša donji dio prsne kosti trebalo bi potisnuti barem trećinu antero-posteriornog promjera (4 cm u dojenčeta i 5 cm u djeteta). Za kardioverziju supraventrikularne tahikardije (SVT) početna je doza revidirana do 1 J/kg. Reanimacija i potpora prilagodbi novorođenčeta nakon rođenja – Kod novorođenčadi koja nije ugrožena odgođeno stezanje (klemanje) pupkovine barem jednu minutu od kompletnog porođaja djeteta sad se preporučuje kod terminske novorođenčadi i nedonoščadi. U slučaju mekonijske plodne vode ne treba raditi rutinsku tra­healnu intubaciju, nego samo pri sumnji na opstrukciju dišnoga puta. Ventilacijsku potporu kod terminske novorođenčadi treba započeti zrakom. Akutni koronarni sindromi (AKS) – Izvanbolničko snimanje 12-ka­nalnog EKG-a preporučuje se kod pacijenata sa suspektnim infarktom miokarda sa ST-elevacijom (STEMI). Bolesnici s akutnom boli u prsištu kod kojih se pretpostavlja da imaju AKS ne trebaju dodatni kisik osim ako ne pokazuju znakove hipoksije, dispneje ili kardijalne dekompenzacije. U geografskim regijama gdje postoje i dostupne su ustanove koje provode perkutanu koronarnu intervenciju (PCI) direktna trijaža i transport na PCI preferiraju se s obzirom na izvanbolničku ­fibrinolizu za STEMI. Prva pomoć – po prvi put uključena u smjernice ERC-a 2015. godine. Principi edukacije u reanimatologiji – Uređaji s povratnom spregom o KPR-u korisni su za poboljšanje brzine, dubine i otpuštanja kompresije te položaj ruku. Dok optimalni intervali ponovnog obučavanja nisu poznati, češće obnavljanje u manjem opsegu moglo bi biti korisno. Trening netehničkih vještina esencijalni je dodatak tehničkim vještinama. Etika u reanimatologiji i odluke o kraju života – Etički principi u kontekstu zdravstvene zaštite usmjerene k bolesniku: autonomija, dobrobit i neškodljivost; pravednost i jednaka dostupnost KPR-a. Još prisutna potreba za usklađivanjem u zakonodavstvu, ovlasti, terminologiji i praksi u Europi., Adult basic life support and automated external defibrillation – Interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely deployment of an AED is critical. All CPR providers should perform chest compressions, those who are trained and able should combine chest compressions and rescue breaths in the ratio 30:2. Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%. Adult advanced life support – Continued emphasis on minimally interrupted high-quality chest compressions, paused briefly only to enable specific interventions, including interruptions for less than 5 s to attempt defibrillation. Use of self-adhesive pads for defibrillation. Waveform capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation. Cardiac arrest in special circumstances – Special causes: hypoxia; hypo-/hyperkalemia, and other electrolyte disorders; hypo-/hyperthermia; hypovolemia; tension pneumothorax; tamponade; thrombosis; toxins. Special environments are specialised healthcare facilities, commercial airplanes or air ambulances, field of play, outside environment or the scene of a mass casualty incident. Special patients are those with severe comorbidities and with specific physiological conditions. Post resuscitation care is new to the ERC Guidelines. Targeted temperature management remains, now aiming at 36°C instead of the previously recommended 32 – 34°C. Pediatric life support – For chest compressions, the lower sternum should be depressed by at least one third the anterior-posterior diameter of the chest (4 cm for the infant and 5 cm for the child). For cardioversion of a supraventricular tachycardia (SVT), the initial dose has been revised to 1 J kg–1. Resuscitation and support of transition of babies at birth – For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery of the infant, is now recommended for term and preterm babies. Tracheal intubation should not be routine in the presence of meconium and should only be performed for suspected tracheal obstruction. Ventilatory support of term infants should start with air. Acute coronary syndrome (ACS) – Pre-hospital recording of a 12-lead electrocardiogram (ECG) is recommended in patients with suspected ST segment elevation acute myocardial infarction (STEMI). Patients with acute chest pain with presumed ACS do not need supplemental oxygen unless they present with signs of hypoxia, dyspnea, or heart failure. In geographic regions where PCI facilities exist and are available, direct triage and transport for PCI is preferred to pre-hospital fibrinolysis for STEMI. First aid is included for the first time in the 2015 ERC Guidelines. Principles of education in resuscitation – Directive CPR feedback devices are useful for improving compression rate, depth, release, and hand position. Whilst optimal intervals for retraining are not known, frequent ‘low dose’ retraining may be beneficial. Training in non-technical skills is an essential adjunct to technical skills. The ethics of resuscitation and end-of-life decisions – Ethical principles in the context of patient-centered health care: autonomy, beneficence, non-maleficence; justice and equal access. The need for harmonisation in legislation, jurisdiction, terminology and practice still remains within Europe

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.

Simulatori i simulacija postali su sastavni i nezamjenjiv dio medicinske edukacije i istraživanja. U većini medicinskih učilišta Zapadne Europe i SAD-a postoje specijalizirane učionice za učenje određenih medicinskih vještina pomoću simulatora i simulacije, koje se ne mogu u potpunosti savladati tijekom boravka na odgovarajućim odjelima, odnosno za vrijeme kliničke nastave. Jedan od zasigurno najvažnijih segmenta u edukaciji studenata medicine i drugih zdravstvenih grana je kardiopulmonalna reanimacija. Zbog specifične važnosti i nemogućnosti učenja ovih postupaka na bolesnicima, neophodno je omogućiti studentima i polaznicima tečajeva oživljavanja uvježbavanje navedenih postupaka na sofisticiranim modelima (tzv. „lutke ili modeli”) u prostoru ili učionici isključivo namijenjenima toj namjeni. Takav edukacijski poligon za uvježbavanje postupaka kardiopulmonalnog oživljavanja (CPR) ustrojen je 2001. godine pod imenom „Kabinet vještina„. Danas u svijetu postoji sve veća potreba za ovakvim centrima edukacije koji uključuju prilagodbu i potrebama „medicinskih laika„, tj. nemedicinskog osoblja, kako bi se educirao širok krug koji će biti u mogućnosti pružiti prvu i potrebnu pomoć na samom mjestu događaja., Simulators and simulations have become an integral and indispensable part of medical education and research. Specialized educational polygons for training of certain medical skills using simulators and simulations, which cannot be fully mastered during stay at clinical departments or during clinical teaching, exist in most medical schools and university hospitals in Western Europe and USA. One of the most important segments in the education of medical students and other health care professionals is cardiopulmonary resuscitation (CPR). Because of specific importance and inability to learn CPR procedures on patients, it is necessary to enable students and course trainees education on sophisticated models (called „dolls or models”) in classroom exclusively created for this purpose. Such educational polygon, for training of cardiopulmonary resuscitation procedures, was established in 2001. In Rijeka and was named „Skills lab”. Today in the world there is an increasing need for simulation training centers that are maximally equipped and adapted for education of non-medical staff („medical-laics”) with a goal to educate people to be able to provide a first and necessary assistance in CPR at the scene of event.

Cilj: U prikazu slučaja željeli smo pokazati rijedak slučaj bolesnika s Fournierovom gangrenom te njegovo kirurško liječenje, zbog velike edukacijske vrijednosti u kliničkoj, urološkoj praksi. Prikaz slučaja: Muškarac star 53 godine prezentirao se s uznapredovalim gangrenoznim promjenama skrotuma i penisa kao i eritemom i otokom suprapubične regije prednje trbušne stijenke, ingvinalne regije, perineuma i unutarnje strane bedara. U bolesnika smo hitno pristupili operacijskom liječenju, pri čemu je učinjena bilateralna orhidektomija i ekstenzivna ekscizija nekrotičnih masa do u zdravu, dobro prokrvljenu kožu i potkožno tkivo. Postavljena je i suprapubična cistostoma za derivaciju urina. Rana je ostavljena da cijeli per secundam intentionem. Tijekom boravka bolesnika na našem odjelu rana je svakodnevno previjana uz dodatnu eksciziju nekrotičnog tkiva. Uz kirurško liječenje bolesnik je primao i parenteralnu antibiotsku terapiju. Na kraju liječenja rana je pokrivena kožnim režnjem, čime su postignuti zadovoljavajući kozmetički rezultati. Rasprava: Fournierova gangrena po život je opasan poremećaj u kojem se infekcija širi duž fascije, uzrokujući nekrozu kože i mekog tkiva. Ova bolest pogađa uglavnom bolesnike s konkomitantnim bolestima kao što su: dijabetes, alkoholizam i bubrežna insuficijencija. Unatoč liječenju, Fournierova gangrena povezana je s visokom stopom smrtnosti, a vremenski interval od nastanka kliničkih simptoma do početka kirurške intervencije najvažniji je prognostički čimbenik. Zaključak: Naš slučaj pokazuje kako je Fournierova gangrena prava urološka hitnoća, te zahtijeva promtno kirurško liječenje., Aim: In our case report we wanted to show a rare case of Fournier’s gangrene and his surgical treatment with high educational value in clinical practice. Case report: A 53- year old men presented with advanced gangrenous changes of the scrotum and penis as well as the erythematous and swollen areas on the anterior abdominal wall, inguinal regions, perineum and inner side of thighs. The patient was rapidly taken to the operating room and underwent bilateral orchiectomy and radical excision of the necrotic masses until the normal skin and fascia were found. Suprapubic urinary diversion was also performed and the wound was left open. During his stay at our Department surgical toilette and banding were performed daily. Along with the surgical treatment all the conservative measures were taken, including proper intravenous hydration and antibiotic therapy. Once a wound properly healed, plastic surgery and grafting was successfully performed giving satisfactory cosmetic results. Discussion: Fournier’s gangrene is a life-threatening disorder in which infection spreads along fascial planes, causing soft tissue necrosis. This disease affects mostly patients with predisposing factors including diabetes, alcohol abuse, paraplegia and renal insufficiency. Despite antibiotics and aggressive surgical debridement, Fournier’s gangrene is associated with a high mortality rate and the interval from the onset of clinical symptoms to the initial surgical intervention seems to be the most important prognostic factor. Conclusions: Our case shows that Fournier’s gangrene remains a true urologic emergency, which mandates aggressive initial surgical treatment.

Cilj: Ishod srčanog zastoja i mjera kardiopulmonalne reanimacije ovisi o implementaciji smjernica ERC-a, kao i njihovom pravovremenom provođenju. Cilj istraživanja bio je utvrditi razlike u provođenju mjera kardiopulmonalne reanimacije unutar pojedinih odjela Kliničkog bolničkog centra (KBC) Rijeka. Ispitanici i metode: Prospektivnom studijom obuhvaćena su 63 bolesnika liječena u KBC-u Rijeka kojima je utvrđen srčani zastoj i nad kojima su provedene mjere kardiopulmonalne reanimacije u razdoblju od 1. lipnja 2011. godine do 1. rujna 2012. godine. Rezultati: U 23 bolesnika (36 %) došlo je do povratka spontane cirkulacije, dok je u 40 bolesnika (64 %) ishod bio letalan. Mjere osnovnog održavanja života (BLS, engl. basic life support) do dolaska tima za reanimaciju poduzete su u svih 63 bolesnika (100 %). U 79 % bolesnika prvi ritam zabilježen na monitoru bio je ritam koji se ne defibrilira (asistolija ili električna aktivnost bez pulsa), dok je u ostalih bolesnika (21 %) početni ritam bio ritam koji se defibrilira (ventrikularna tahikardija bez pulsa ili ventrikularna fibrilacija). U navedenih bolesnika u kojih je došlo do povratka spontane cirkulacije, 6 bolesnika (26 %) imalo je pozitivan neurološki ishod (CPC-vrijednost 1 i 2) dok je 17 bolesnika (74 %) imalo značajna neurološka oštećenja (CPC-vrijednost 3, 4 i 5). Rasprava i zaključak: Kako bi reanimacije imale što bolji ishod neophodno je provoditi edukaciju medicinskog osoblja o mjerama osnovnog i naprednog održavanja života u Jedinicama intenzivnog liječenja i Centrima za hitnu medicinu, kao i na ostalim bolničkim odjelima. Potrebno je uspostaviti tim za reanimaciju i sustav jedinstvenog obavještavanja o vitalno ugroženom bolesniku te standardizirati opremu i materijal na odjelima i mjestima visokog rizika za nastup srčanog zastoja., Objective: The outcome of cardiac arrest and cardiopulmonary resuscitation measures depends on the implementation of the ERC guidelines as well as their timely enforcement. The aim of the study was to determine differences in measures of cardiopulmonary resuscitation (CPR) provided within different departments of Clinical Hospital Centre (KBC) Rijeka. Patients and methods: Prospective analysis covered 63 patients who underwent CPR following cardiac arrest in KBC Rijeka during 15-month study period (June 2011 to September 2012). Results: Return of spontaneous circulation was achieved in 23 patients (36 %), whereas 40 patients (64 %) had lethal outcome. Until the arrival of resuscitation team basic life support (BLS) was provided to all patients (100 %). In most cases (79 %) initial rhythm was non-shockable rhythm (asystole or pulseless electrical activity), while the rest (21 %) were shockable rhythms (pulseless ventricular tachycardia or ventricular fibrilation). After the return of spontaneous circulation 6 patients (26 %) had favorable neurological outcome (CPC-score 1 and 2) while 17 patients (74 %) had significant neurological disorder (CPC-score 3,4 and 5). Discussion and conclusion: In order to improve the outcome it is necessary to provide education in basic and advanced life support for all medical personnel on hospital wards as well as Intensive care units and Emergency medicine department. Rapid response team and the use of ‘track-and-trigger systems’ to detect the deteriorating patient should be organized together with equipment and material normative standards at wards and departments with high risk of cardiac arrest occurrence.

Trijaža je proces određivanja prioriteta liječenja bolesnika, koji se bazira na težini njihova medicinskog stanja. Cilj trijaže je identificirati bolesnike sa životno ugrožavajućim stanjima te im osigurati pravovremenu medicinsku skrb. Postoji više modela provođenja trijaže, a jedan od najučestalijih je Australsko-azijska trijažna ljestvica (ATS) koja se bazira na pet kategorija prema stupnju hitnoće. Trijažu u hitnoj službi provodi medicinska sestra/tehničar koji bi trebali imati višegodišnje iskustvo rada u hitnoj službi. Tijekom godina priljev bolesnika u hitne službe sve je veći, što rezultira prenapučenošću hitne službe velikim brojem nehitnih bolesnika koje mogu pregledati liječnici obiteljske medicine, stoga je svrha trijaže rješavanje prenapučenosti hitne službe i raspoznavanje nehitnih bolesnika od onih životno ugroženih., The purpose of triage is to identify priority patients with life threatening conditions and to reassure and carry prompt and efficient medical care. There are numerous triage scales , and the most common is Austral – Asian triage scale (ATS) which is further divided into five categories. Triage nurses and medical technicians should have significant years of experience in Emergency Department. Emergency department (ED) utilization has increased over last years, leading towards ED overcrowding, mostly by non-urgent patients, which could have been dealt with by general practitioner (GP). Therefore, the purpose of triage is to decrease ED overcrowding by ing non-urgent patients from those in life threatening condition.

Cilj: Procjena vrijednosti dijagnostičkog ultrazvuka kod bolesnika s rupturom medijalne glave gastoknemijusa (MGM), budući da kliničkim parametrima nije moguće procijeniti opseg rupture mišića. Objektivna procjena veličine rupture i njezina klasifikacija važna je u odabiru terapijskog protokola. Metode: Šezdeset (60) bolesnika s tipičnom anamnezom za rupturu MGM-a pregledani su ultrazvukom unutar jednog tjedna od ozljede. Ozljede su klasificirane prema modificiranoj Bourgeoisovoj ultrazvučnoj klasifikaciji u 4 stupnja; 1. stupanj: hipoehogeni, povećani distalni mišićno-tetivni spoj bez prekida mišićne strukture; 2. stupanj: ruptura manja od 2 cm; 3. stupanj: ruptura veća od 2 cm; 4. stupanj: rupture s velikom anehogenom kolekcijom tekućine između soleusa i MGM-a. Rezultati: Ne postoji korelacija između promatranih anamnestičko-kliničkih parametara koji uključuju: mehanizam ozljede, tjelesnu aktivnost, bol za vrijeme ozljede, bol za vrijeme kliničkog pregleda, razliku u opsegu donjeg ekstremiteta u proksimalnoj i distalnoj trećini, opseg pokreta u nožnom zglobu ili lokalizaciju rupture na mišićno-tetivnom spoju, u odnosu na stupanj ozljede procijenjene ultrazvučnim pregledom. Zaključak: Ultrazvuk je korisna dijagnostička metoda koja omogućava procjenu opsega rupture MGM-a i treba se koristiti u cilju individualne pripreme terapijskog protokola kod ovih ozljeda., Aim: To estimate the diagnostic value of ultrasound examination in patients with medial gastrocnemius muscle (MGM) rupture because it is not possible to assess the size of the muscle rupture only by clinical parameters. The assessment and classification of MGM rupture are important for individual adjustment of therapeutic protocol. Methods: Sixty (60) patients with a typical history for a MGM rupture have undergone an ultrasound examination within one week from injury. Injuries were classified according to the modified Bourgeois ultrasound classification in 4 degrees: 1st degree: hypoechoic, enlarged distal muscle-tendon junction without the rupture of muscle structure, 2nd degree: rupture less than 2 cm, 3rd degree: rupture more than 2 cm, 4th degree: rupture with large anechoic collection of fluid between soleus and MGM. Results: There is no correlation between patient’s history and clinical parameters that include: mechanism of injury, physical activity, pain when the injury occurred, pain during clinical examination, difference in circumference of the lower extremity in proximal and distal third, range of motion in the ankle joint or localization of the rupture at the muscle tendon junction, and the degree of injury diagnosed by the ultrasound examination. Conclusion: Ultrasound is a useful diagnostic method which enables the assessment of MGM rupture and should be used for individual adjustment of the therapeutic protocol in these injuries.

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.

All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions per minute, to allow full chest recoil, and to minimise interruptions in chest compressions. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. ELECTRICAL THERAPIES: Much greater emphasis on minimising the duration of the pre-shock and post-shock pauses; the continuation of compressions during charging of the defibrillator is recommended. Further development of AED programmes is encouraged. ADULT ADVANCED LIFE SUPPORT: Increased emphasis on high-quality chest compressions throughout any ALS intervention paused briefly only to enable specific interventions. Removal of the recommendation for a pre-specified period of cardiopulmonary resuscitation before out-of-hospital defibrillation following cardiac arrest unwitnessed by the EMS. The role of precordial thump is de-emphasized. Delivery of drugs via a tracheal tube is no longer recommended, drugs should be given by the intraosseous (IO) route. Atropine is no longer recommended for routine use in asystole or pulseless electrical activity. Reduced emphasis on early tracheal intubation unless achieved by highly skilled individuals with minimal interruptions in chest compressions. Increased emphasis on the use of capnography. Recognition of potential harm caused by hyperoxaemia. Revision of the recommendation of glucose control. Use of therapeutic hypothermia to include comatose survivors of cardiac arrest associated initially with shockable rhythms, as well as non-shockable rhythms, with a lower level of evidence acknowledged for the latter. INITIAL MANAGEMENT OF ACUTE CORONARY SYNDROMES: The term non-ST-elevation myocardial infarction-acute coronary syndrome (non-STEMI-ACS) has been introduced for both NSTEMI and unstable angina pectoris. Primary PCI (PPCI) is the preferred reperfusion strategy provided it is performed in a timely manner by an experienced team. Non-steroidal anti-inflammatory drugs should be avoided, as well as routine use of intravenous beta-blockers; oxygen is to be given only to those patients with hypoxaemia, breathlessness or pulmonary congestion. PAEDIATRIC LIFE SUPPORT: The decision to begin resuscitation must be taken in less than 10 seconds. Lay rescuers should be taught to use a ratio of 30 compressions to 2 ventilations, rescuers with a duty to respond should learn and use a 15:2 ratio; however, they can use the 30:2 compression-ventilation ratio if they are alone. Ventilation remains a very important component of resuscitation in asphyxial arrest. The emphasis is on achieving quality compressions with the rate of at least 100 but not greater than 120 per minute, with minimal interruptions. AEDs are safe and successful when used in children older than 1 year. A single shock strategy using a non-escalating dose of 4 J/kg is recommended for defibrillation in children. Cuffed tubes can be used safely in infants and young children. Monitoring exhaled carbon dioxide (CO2), ideally by capnography, is recommended during resuscitation. RESUSCITATION OF BABIES AT BIRTH: For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery is now recommended. For term infants, air should be used fro resuscitation at birth. For preterm babies less than 32 weeks gestation blended oxygen and air should be given judiciously and its use guided by pulse oximetry. Preterm babies of less than 28 weeks gestation should be completely covered in a plastic wrap up to their necks, without drying, immediately after birth. The recommended compression: ventilation ratio remains at 3:1 for newborn resuscitation. Attempts to aspirate meconium from the nose and mouth of the unborn baby, while the head is still on the perineum, are not recommended. If adrenaline is given the n the intravenous route is recommended using a dose of 10-30 microg/kg. Newly born infants born at term or near-term with moderate to severe hypoxic-ischaemic encephalopathy should be treated with therapeutic hypothermia. PRINCIPLES OF EDUCATION IN RESUSCITATION: The aim is to ensure that learners acquire and retain skill and knowledge that will enable them to act correctly in actual cardiac arrest and improve patient outcome. Short video/computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered as an effective alternative to instructor-led basic life support (BLS and AED) courses. Ideally all citizens should be trained in standard CPR that includes compressions and ventilations. Basic and advanced life support knowledge and skills deteriorate in as little as three to six months. CPR prompt or feedback devices improve CPR skill acquisition and retention.

Osnovno održavanje života odraslih. – Svi spašavatelji, bilo osposobljeni ili ne, kod žrtava kardijalnog aresta moraju primijeniti vanjsku masažu srca. Cilj je pritisnuti prsni koš do dubine od najmanje 5 cm, frekvencijom od najmanje 100 kompresija u minuti, ali i dopustiti ponovo odizanje prsnog koša, te smanjiti prekide u kompresijama. Osposobljeni bi spašavatelji trebali primijeniti i ventilaciju s omjerom kompresija-ventilacija od 30:2. Liječenje strujom. – Mnogo je veći naglasak na smanjivanju trajanja stanki prije ili poslije defibrilacije; preporučuje se nastavak vanjske masaže srca tijekom punjenja defibrilatora. Potiče se daljnji razvoj programa automatskih vanjskih defibrilatora (AED). Napredno održavanje života odraslih. – Naglašena je važnost visokokvalitetnih kompresija na prsni koš tijekom provođenja ALS-a, koje se prekidaju samo kako bi se omogućili specifični postupci. Uklanja se preporuka o potrebi reanimacije tijekom određenog vremena prije defibrilacije nakon kardijalnog aresta izvan bolnice, kojemu nije svjedočilo osoblje hitne medicinske pomoći. Smanjena je uloga prekordijalnog udarca. Primjena lijekova putem endotrahealnog tubusa više se ne preporučuje, već se lijekovi moraju primijeniti intraosealnim (IO) pristupom. Atropin se više ne preporučuje za rutinsku primjenu tijekom asistolije ili električne aktivnosti bez pulsa. Smanjen je naglasak na ranu endotrahealnu intubaciju ako ju ne provodi visokostručna osoba uz najmanji mogući prekid vanjske masaže srca. Povećan je naglasak na uporabu kapnografije. Prepoznat je moguć štetan učinak hiperoksemije. Revidirana je preporuka za kontrolu glikemije. Preporučuje se primjena terapijske hipotermije kod komatoznih bolesnika nakon kardijalnog aresta povezanog s početnim ritmovima koji se defibriliraju, kao i onima koji se ne defibriliraju, za ove druge sa smanjenom razinom dokaza. Početno zbrinjavanje akutnih koronarnih sindroma. – Uveden je pojam infarkt miokarda bez ST-elevacije–akutni koronarni sindrom (NSTEMI-ACS) koji obuhvaća infarkt miokarda bez elevacije ST-spojnice i nestabilnu anginu pektoris. Primarna PCI (PPCI) najpoželjniji je reperfuzijski postupak, uz uvjet da ga obavi iskusan tim i u skladu s vremenskim okvirima. U liječenju bi trebalo izbjegavati nesteroidne protuupalne lijekove, rutinsku intravensku primjenu beta-blokatora i kisik – osim u slučaju hipoksemije, zaduhe ili zastoja na plućima. Održavanje života djece. – Odluka o započinjanju reanimacije mora se donijeti u manje od 10 sekundi. Laike treba podučavati reanimaciji s omjerom 30 kompresija naprama 2 ventilacije, a spašavatelji koji imaju dužnost odgovoriti na poziv trebaju primjenjivati omjer kompresije-ventilacije od 15:2, međutim, ako su sami, mogu primijeniti omjer od 30:2. Ventilacija i dalje ostaje vrlo važna sastavnica reanimacije asfiksijskog aresta. Naglasak je na postizanju kvalitetnih kompresija frekvencije najmanje 100, ali ne više od 120 u minuti, uz minimalne prekide. Automatski vanjski defibrilatori sigurni su i uspješni kada se primjenjuju kod djece starije od jedne godine. Za defibrilaciju kod djece preporučuje se jedna defibrilacija od 4 J/kg čija se jačina ne povećava. Sa sigurnošću se mogu rabi endotrahealni tubusi s balončićem i kod dojenčadi i kod mlađe djece. Monitoriranje izdahnutog ugljikova dioksida (CO2), najbolje kapnografijom, preporučuje se tijekom reanimacije. Reanimacija novorođenčadi na porodu. – Kod neugrožene novorođenčadi sada se preporučuje odgađanje podvezivanja pupčane vrpce od najmanje jedne minute nakon potpunog rođenja djeteta. Za donošenu novorođenčad, tijekom reanimacije pri porodu trebao bi se rabiti zrak. Za nedonoščad mlađu od 32 tjedna gestacije treba razumno primijeniti mješavinu kisika i zraka te primjena treba biti vođena pulsnim oksimetrom. Nedonoščad mlađu od 28 tjedana gestacije trebalo bi neposredno nakon rođenja potpuno do područja vrata omotati plastičnom folijom, bez sušenja. Preporučen omjer kompresija-ventilacija u reanimaciji novorođenčadi ostaje 3:1. Ne preporučuje se pokušavati aspirirati mekonij iz nosa i usta još nerođenog djeteta, dok mu je glava još na međici. Ako se daje adrenalin, preporučuje se intravenska primjena u dozi od 10 do 30 µg/kg. Kod terminske ili gotovo terminske novorođenčadi s umjerenom do teškom hipoksično-ishemijskom encefalopatijom preporučuje se terapijska hipotermija. Načela podučavanja reanimacije. – Cilj je osigurati da polaznici steknu i zadrže vještine i znanje koje će im omogućiti ispravno djelovanje tijekom stvarnoga kardijalnog aresta te poboljšati ishod bolesnika. Kratki video/kompjutorski tečajevi za samostalno učenje, s minimalnom ulogom instruktora ili bez njega, udruženi s praktičnom nastavom mogu se smatrati jednako učinkovitom alternativom tečajevima osnovnog održavanja života (BLS i AED) koje vode instruktori. U najboljem slučaju, svi bi građani trebali biti osposobljeni za standardnu KPR koja uključuje vanjsku masažu srca i ventilaciju. Znanje i vještine osnovnog i naprednog održavanja života smanjuju se u samo tri do šest mjeseci. Uređaji s glasovnim uputama tijekom reanimacije ili povratnim informacijama unaprjeđuju stjecanje i zadržavanje vještina., Basic Life Support. – All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions per minute, to allow full chest recoil, and to minimise interruptions in chest compressions. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. Electrical therapies. – Much greater emphasis on minimising the duration of the pre-shock and post-shock pauses; the continuation of compressions during charging of the defibrillator is recommended. Further development of AED programmes is encouraged. Adult Advanced Life Support. – Increased emphasis on high-quality chest compressions throughout any ALS intervention paused briefly only to enable specific interventions. Removal of the recommendation for a pre-specified period of cardiopulmonary resuscitation before out-of-hospital defibrillation following cardiac arrest unwitnessed by the EMS. The role of precordial thump is de-emphasized. Delivery of drugs via a tracheal tube is no longer recommended, drugs should be given by the intraosseous (IO) route. Atropine is no longer recommended for routine use in asystole or pulseless electrical activity. Reduced emphasis on early tracheal intubation unless achieved by highly skilled individuals with minimal interruptions in chest compressions. Increased emphasis on the use of capnography. Recognition of potential harm caused by hyperoxaemia. Revision of the recommendation of glucose control. Use of therapeutic hypothermia to include comatose survivors of cardiac arrest associated initially with shockable rhythms, as well as non-shockable rhythms, with a lower level of evidence acknowledged for the latter. Initial management of acute coronary syndromes. – The term non-ST-elevation myocardial infarction-acute coronary syndrome (non-STEMI-ACS) has been introduced for both NSTEMI and unstable angina pectoris. Primary PCI (PPCI) is the preferred reperfusion strategy provided it is performed in a timely manner by an experienced team. Non-steroidal anti-inflammatory drugs should be avoided, as well as routine use of intravenous beta- blockers; oxygen is to be given only to those patients with hypoxaemia, breathlessness or pulmonary congestion. Paediatric Life Support. – The decision to begin resuscitation must be taken in less than 10 seconds. Lay rescuers should be taught to use a ratio of 30 compressions to 2 ventilations, rescuers with a duty to respond should learn and use a 15:2 ratio; however, they can use the 30:2 compression-ventilation ratio if they are alone. Ventilation remains a very important component of resuscitation in asphyxial arrest. The emphasis is on achieving quality compressions with the rate of at least 100 but not greater than 120 per minute, with minimal interruptions. AEDs are safe and successful when used in children older than 1 year. A single shock strategy using a non-escalating dose of 4 J/kg is recommended for defibrillation in children. Cuffed tubes can be used safely in infants and young children. Monitoring exhaled carbon dioxide (CO2), ideally by capnography, is recommended during resuscitation. Resuscitation of babies at birth. – For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery is now recommended. For term infants, air should be used fro resuscitation at birth. For preterm babies less than 32 weeks gestation blended oxygen and air should be given judiciously and its use guided by pulse oximetry. Preterm babies of less than 28 weeks gestation should be completely covered in a plastic wrap up to their necks, without drying, immediately after birth. The recommended compression: ventilation ratio remains at 3:1 for newborn resuscitation. Attempts to aspirate meconium from the nose and mouth of the unborn baby, while the head is still on the perineum, are not recommended. If adrenaline is given the n the intravenous route is recommended using a dose of 10–30 µg /kg. Newly born infants born at term or near-term with moderate to severe hypoxic-ischaemic encephalopathy should be treated with therapeutic hypothermia. Principles of education in resuscitation. – The aim is to ensure that learners acquire and retain skill and knowledge that will enable them to act correctly in actual cardiac arrest and improve patient outcome. Short video/computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered as an effective alternative to instructor-led basic life support (BLS and AED) courses. Ideally all citizens should be trained in standard CPR that includes compressions and ventilations. Basic and advanced life support knowledge and skills deteriorate in as little as three to six months. CPR prompt or feedback devices improve CPR skill acquisition and retention.

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.

Purpose of the study: (1) Analysis of competency (resuscitation knowledge and skills) of the candidates in relation to their previous/basic education. (2) Analysis of personal evaluation of the quality of the course in relation to candidates’ competency after the course. (3) Analysis of internal motivation as the most important factor that influences successful acquisition of knowledge and skills at the organised programme of continuous medical education. Material and methods: Between April 2002 and December 2009, 74 European Resuscitation Council (ERC) provider courses (55 Advanced Life Support-ALS and 19 European Paediatric Life Support-EPLS) have taken place in Croatia. Total of 1730 candidates (1328 ALS, 402 EPLS) attended. A questionnaire has been distributed to all attendees by email, handed personally or has been available on the official website of the Croatian Resuscitation Council (CroRC). Subjects covered by the questionnaire were professional background, motivation, knowledge, satisfaction with courses, applicability to everyday practice and changes in attitudes. Results: Preliminary results from 500 questionnaires collected to date show satisfactory competency of candidates in relation to their professional background, ranging from specialists and residents to nurses. Majority of candidates rated these courses with highest grades and would recommend them to other medical professionals. Higher internal motivation and satisfaction of candidates correlated well with course results. Conclusions: Based on the preliminary results from this survey, organized programme of continuous medical education in the field of reanimatology is recognised as a successful educational programme applicable to Croatian medical professionals.

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.

Authors report three cases of patients with iatrogenic, postcatheterization femoral artery pseudoaneurysms successfully treated with percutaneous ultrasound-guided thrombin injection (UGTI). The technique of UGTI is described, as well as advantages and complications of this method. These cases highlight the role of UGTI in the management of the postcatheterization pseudoaneurysms.

Cilj: Prikazati mogućnosti korištenja ultrazvuka u rješavanju kasnih komplikacija nakon kirurškog zbrinjavanja rupturirane Ahilove tetive. Prikaz slučaja: U radu su prikazana dva bolesnika kod kojih se nakon šest i pet godina na mjestu kirurške intervencije zbog rupture Ahilove tetive razvio upalni proces uz formiranje apscesa. Ultrazvučnim pregledom se u oba bolesnika dijagnosticira postojanje apscesa i stranog tijela u smislu zaostalog konca. Pod kontrolom ultrazvuka u operacijskoj dvorani minimalno invazivnim kirurškim pristupom izvade se svi zaostali konci i drenira formirani apsces. Rasprava: Klasični kirurški zahvat je invazivan s mogućnošću propagacije infekcije prema zdravom tkivu te uz mogućnost pogreške u smislu nenalaženja svih zaostalih konaca uzročnika upalnog odgovora. Prikazom ovih dvaju slučajeva dokazali smo da, osim u dijagnostičke svrhe, ultrazvuk može poslužiti kao pomoć pri samom kirurškom postupku u cilju izvođenja minimalno invazivnog kirurškog zahvata. Zaključak: U prikazu slučaja upućuje se na potencijalnu vrijednost minimalno invazivne kirurške tehnike pod kontrolom ultrazvuka kojom se mogu izvaditi zaostali konci i drenirati nastali apsces u bolesnika., Aim: To evaluate the use of ultrasound in management of the long term complications after surgical procedure of the ruptured Achiles tendon. Case report: Authors report two cases of patients who developed tissue inflammation and abscess six and five years after surgery following rupture of the Achilles tendon. Ultrasound examination of the Achilles tendon confirmed abscess and foreign body (stitch) in both patients. A minimally invasive ultrasound guided technique was used for extracting all stitches and drainage of the present abscess in both patients. Discussion: The clasical surgical approach is an invasive procedure with high possibility of widespreading infection into the healthy tissue. There is also the possibility of not finding all stitches which cause inflammation. These two cases emphasize the use of ultrasound not only for diagnosis but also as a help, during the minimally invasive surgical procedure. Conclusion: In this case report we point out the potential value of the minimally invasive ultrasound guided surgery for extracting stitches and drainage of the present abscesses in both patients.

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

To evaluate the effect of metoclopramide on gastric emptying in coronary artery bypass graft (CABG) surgery patients with early enteral nutrition and to evaluate the effect of metoclopramide on motility of the gallbladder in these patients.A prospective, randomized, placebo-controlled, double-blind study of 40 patients treated at cardiosurgical intensive care unit after CABG surgery. The patients were divided into two groups: metoclopramide group (20 patients; age 60-/+9 years; 85% male), and control group (20 patients; age 59-/+8 years; 70% male). In both groups, enteral feeding with isoosmotic enteral formula was initiated by nasogastric tube 18 hours after surgery. After 6 hours, feeding was stopped, and paracetamol solution (1,000 mg) and 10 mg of metoclopramide IV or 2 ml of saline IV were concurrently administered. Blood samples were obtained 15 (t(+15)), 30 (t(+30)), 60 (t(+60)), and 120 (t(+120)) minutes after the administration of paracetamol. Paracetamol absorption was assessed from the plasma paracetamol concentration and the area under the curve (AUC) from 0 to 120 minutes. Sonographic measurement of gallbladder ejection fraction was also performed 15 (t(+15)), 30 (t(+30)), 60 (t(+60)), and 120 (t(+120)) minutes after the administration of paracetamol.The plasma paracetamol concentrations 15, 30, 60, and 120 minutes after the administration of paracetamol were significantly higher in metoclopramide group than in control group: (t(+15)) 5.4-/+2.7 vs 3.3-/+2.5 (Mann-Whitney U test; P=0.017); (t(+30)) 6.7-/+2.4 vs 3.7-/+2.0 (P=0.006); (t(+60)) 7.7-/+2.5 vs 5.1-/+3.2 (P=0.008); (t(+120)) 8.5-/+2.2 vs 5.2-/+2.8 (P=0.005). The AUC value was 34% larger in the metoclopramide group vs control group (574-/+296 vs 429-/+309; P=0.027). There were no significant differences in gallbladder ejection fraction between groups (group metoclopramide vs control group: (t(0)-t(+15)) -2% vs -2%; (t(+15)-t(+30)) 1% vs 4%; (t(+30)-t(+60)) 0% vs -1%; (t(+60)-t(+120)) 1% vs 3%; P=NS).In CABG surgery patients with early enteral feeding, a single dose of intravenous metoclopramide effectively improves gastric emptying, but does not have any prokinetic effect on gallbladder motility.

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