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Both the design and purpose of the laryngoscope have been changed significantly since Alfred Kirstein invented his own 'laryngeal mirror' - the autoscope. An initially straight, rigid oesophageal tube has been reshaped into a number of laryngeal blade modifications, suitable for use in various patient subpopulations. A tool initially intended to help otorhynolaryngologists diagnose and treat laryngeal diseases has been transformed into an instrument intended to help anesthesiologists intubate the trachea for the purpose of either anesthesia administration or airway maintenance. As direct laryngoscopy depends greatly upon individual manual skills, there has been almost no beginner who feels no proud of his first successful intubation. Thus, we should never forget the pioneers of laryngoscopy whose curiosity, creativity, and enthusiasm enabled us to give a clear and safe look into the larynx.

Careful assessment of the fluid balance is required in the perioperative period since appropriate fluid therapy is essential for successful patient's outcome. Haemodynamic monitoring allows understanding the physiology of the circulation and changes of fluid balance in the perioperative period. This is diagnostic aid and guide for fluid replacement therapy. Patient's volume status is frequently assessed by different haemodynamic variables that could be targeted as the endpoints for fluid therapy and resuscitation. Fluid balance is the crucial factor in the maintenance of haemodynamic stability, tissue oxygenation and organ function. When the haemodynamic monitoring is applied in a rigorous and consistent manner, it reduces mortality and length of stay as well as costs incurred. There are a number of tests which describe the effectiveness of the invasive haemodynamic monitoring procedures usage. Since the pulmonary artery catheter (PAC) had been introduced into clinical practice it was considered as a golden standard for cardiac output measurements, haemodynamic and fluid balance assessment. Nevertheless, in previous 10 years new minimally invasive and noninvasive simple techniques for haemodynamic monitoring and patient's hydroelectricity status evaluation have been developed. They can replace PAC under different clinical circumstances and some of these techniques additionally allow a more refined perioperative fluid assessment. The aim of this article is to describe actually technique of haemodynamic measurement and assessment of fluid status and therapy in perioperative period.

Summary Purpose To determine frequency, causes, and phenomenology of late seizure recurrence (SR) in patients with juvenile myoclonic epilepsy (JME) after remission of at least 1 year. Methods Among 2722 epileptic patients from tertiary referral center, we retrospectively identified 105 patients (62 females; mean age 22.3±7.2 years) with an established diagnosis of JME. All patients were treated with valproates (83.3%), or lamotrigine, topiramate, phenobarbital, add-on clobazam, or combinations (16.2%). Results The median period of follow-up was 4.2±3.2 (range: 1–17) years. SR occurred in 74 patients (70.5%) after median period of 2.4±3.2 years. Twenty-two patients (29.7%) experienced myoclonic seizures (MS), 13 (17.7%) generalized tonic–clonic seizures (GTCS), 37 (50%) a combination of MS and GTCS, and two (2.6%) a combination of MS, GTCS and absence seizures. SR was associated most frequently with sleep deprivation and AED withdrawal, and rarely with alcohol intake, drug abuse, photostimulation, or menstruation. No provoking factors for SR were identified in 31.1% and 45% of cases with MS and GTCS, respectively. The majority of patients (59/74) had a single SR. A second SR occurred less frequently in patients in whom valproate dosage was increased after the first SR ( p =0.0048). Conclusion Late SR (mainly MS and GTCS) is detected frequently after prolonged follow-up in patients with JME despite the use of best-known therapy, usually due to AED withdrawal or erratic life style. Instead of futile efforts to persuade the patient to conform to restrictive life style, it is probably more efficient to use initial higher doses of AEDs.

Objective: The aim of the study was to present the outcome of surgical treatment of patients with thoracoabdominal aortic aneurysm Crawford type IV, operated on between January 2001 and April 2004. Methods: This study included 42 subsequent patients (40 males, 2 females, age 41-76 years). All patients underwent ultrasonography, angiography, computed tomography or magnetic resonance imaging (MRI). Surgical treatment was performed under combined anesthesia (continuous thoracic epidural analgesia and general endotracheal anesthesia). In two patients thoracophrenolumbotomy was performed at the level of X rib, while others were operated through left lumbotomy after the extra pleural resection of XI rib. We did not perform any spinal cord protection procedures in this type of aneurysm. Reconstruction included interposition of Dacron graft in 20 patients, aortobiiliac bypass in 18, and aortobifemoral bypass in 4 patients with different varieties of visceral branches reimplantation. Results: Thirty - days mortality was 31% (13 patients, two of them intraoperatively). Causes of death were: pulmonary embolism - in 1 patient; hemorrhage - in 2; myocardial infarction - in 4 (two intraoperative); acute renal failure - in 2; multi system organ failure (MSOF) - in 4 patients. Respiratory failure dominated in all cases of MSOF. One patient with acute renal failure had paraplegia also, and that was the only case of neurological complication in whole group. All female patients (2), all patients with ruptured aneurysm (4), acute myocardial infarction (4) and acute renal failure (2) have died. Advanced age (over 70 years) and the need for extensive operative procedure with bifurcated graft use significantly influenced their mortality (p

INTRODUCTION Renal artery aneurysms is relatively uncommon with reported incidence ranges from 0.3% to 1%. However, considering all visceral artery aneurysms the percentage of renal artery aneurysms is relatively high between 15-25%. The distal forms of renal artery aneurysms sometimes require "ex vivo" reconstruction and kidney autotransplantation. CASE REPORT A 75-year-old male presented with the right abdominal and back pain. He suffered from a long history of arterial hypertension and chronic renal failure over the last few months (urea blood = 19.8 mmol/l; creatinine = 198 mmol/l). Duplex ultrasonography showed abdominal aortic aneurysm. Subsequent translumbarangiography revealed juxtarenal abdominal aortic aneurysm associated with distal right renal artery aneurysm. The operation was performed under combined thoracic epidural analgesia and general anesthesia using transperitoneal approach. After the laparotomy, the ascending colon was mobilized and reflected medially followed by Kocher maneuver. The result was visualization of the anterior aspect of the right kidney, the collecting system, ureter as well as the right renal vein and artery with large saccular aneurysm located distally. After mobilization of the renal vessels and careful dissection of the ureter, the kidney was explanted. The operation was continued by two surgical teams. The first team performed abdominal aortic aneurysm resection and reconstruction with bifurcated Dacron graft. The second team performed ex vivo reparation of renal artery aneurysm. All time during the explantation, the kidney was perfused by Collins' solution. The saccular right renal artery aneurysm 4 cm in diameter was located at the kidney hilus at the first bifurcation. Three branches originated from the aneurysm. The aneurysm was resected completely. The longest and widest of three branches arising from the aneurysmal sac was end-to-end anastomized with 6 mm PTFE graft. After this intervention, one of shorter arteries was implanted into the long artery, and another one into PTFE graft. After 30 minutes of explanation, autotransplantation of the kidney into the right iliac fossa was performed. The right renal vein was implanted into the inferior vein cava, and PTFE graft into the right limb of Dacron graft. Immediately following the completion of both anastomoses, large volume of urine was evident. Finally, ureteneocystostomy was performed with previous insertion of double "J" catheter. In the immediate postoperative period, renal function was restored to normal, while postoperative angiography revealed all patent grafts. DISCUSSION The most common causes of renal artery aneurysms are arteriosclerosis, as in our case, and fibro-muscular dysplasia. Very often, renal artery aneurysms are asymptomatic and discovered only during angiography in patients with aneurysmal and occlusive aortic disease. Other cases include: arterial hypertension, groin pain and acute or chronic renal failure. Due to relatively small number of evaluated cases, the risk of aneurysmal rupture is not known. According to some authors, the overall rupture rate of renal artery aneurysm is 5%, however, the rupture risk becomes higher in young pregnant woman. Several standard surgical procedures are available for the repair of renal artery aneurysms. These include saphenous vein angioplasty, bypass grafting, as well as ex vivo reconstruction with reimplantation or autotransplantation. Furthermore, interventional embolization therapy, as well as endovascular treatment with ePTFE covered stent, or autologous vein-coverage stent graft, have been also reported to be successful. CONCLUSION The major indications for surgical treatment of renal artery aneurysms are to eliminate the source of thromboembolism which leads to fixed renal hypertension and kidney failure, as well as prevention of aneurysmal rupture.

Three cases of successful kidney revascularization and recovery of renal function are presented in this study. In all three cases, renal failure and renovascular hypertension were caused by renal artery occlusion associated with aortic aneurysm (two abdominal and one thoracoabdominal). Prior to operation, one patient required dialysis 4 months, one 25 days and one 2 days. After kidney revascularization, renal function recovered immediately in the first case, in the second case after three months, and in the third case after 10 days. In one case, blood pressure restored to normal without medical therapy, while in two other cases blood pressure decreased nearly to normal with minimal medical therapy. In appropriately selected cases, revascularization of the occluded renal artery is recommended for treatment of both renal failure and renovascular hypertension. In such cases, collateral circulation is crucial to enable the preservation of dysfunctional kidney.

Mechanical ventilation of lungs during the long history has gone through different phases, which have been associated with technological and scientific development of its time. This is the most complex process and in spite of many progress it does not solve all problems, maintained of respiratory homeostasis, especially in patients with difficult lungs damage. Therefore, there is an existing need for further development of mechanical ventilation of lungs. Over the past time, a number of innovative approaches or adjuncts to mechanical ventilation have been actively researched. Many of these have shown some promise in improving our ability to provide ventilatory support. Which of these innovations will outlast the future? Based on actual development at innovations of mechanical ventilation, it can be assumed that it will be: protective lung ventilation, special form of gas exchange, weaning from mechanical ventilation, noninvasive and home use ventilators, development in fallowing patient?s condition and pharmacotherapy development.

Objective: Retinal detachment surgery is associated with a high incidence of post-operative pain, nausea and vomiting. Previous studies demonstrated a beneficial role of pre-emptive analgesia using regional anesthetic blocks for this type of surgery. The aim of the present study was to evaluate the pre-emptive analgesic effect of ketorolac in patients undergoing retinal detachment surgery under general anesthesia. Methods: With the approval of the Institutional Ethics Committee and written informed consent, 60 adult patients were randomized prospectively, in a double-masked manner, to receive intravenously either ketorolac 30 mg or saline placebo 30 min before operation. Pain scores at 2, 6, 12, 18 and 24 h after surgery, the number of patients requiring post-operative analgesia, total consumption of analgesics, the incidence of oculocardiac reflex as well as the incidence and severity of post-operative nausea and vomiting were recorded. Results: The ketorolac group required post-operative analgesia less frequently than the placebo group (p < 0.0001). The ketorolac group had significantly lower pain scores at all measurement time points (p < 0.001) and lower intra- and post-operative total consumption of analgesics (p < 0.01). The incidence and severity of nausea and vomiting were lower in patients given ketorolac when compared with placebo-treated patients (p < 0.05). The incidence of oculocardiac reflex was not significantly different between groups (p = 0.14). Conclusions: The use of ketorolac for pre-emptive analgesia is effective in patients undergoing retinal detachment surgery under general anesthesia.

Surgical treatment of two female patients aged 32 and 41 years, with neurological problems causes by type I Takayasu?s aortoarteritis, are presented here. both of them were treated with by pass from ascending aorta to left common carotid and left subclavian arteries, using transsternal approach. During the follow up period (3.5 years for the first, and 2 years for the second patient) both patients were free of neurological symptoms. Corticosteroid therapy was given to the first patient for controlling of active diseases, immediately after the operation and during the first three postoperative months. By this reason an infection at the proximal part of sternal wound was developed. MRI showed involvement of the vascular graft. Due to high risk of reoperation, medical treatment was performed. Takayasu?s aortoarteritis is very uncommon in our country, as well as in other countries which don?t belong to Far East. In cases with hemodinamic important arterial lesions produced disabling symptoms, a standard PTA and reconstructive vascular procedures are indicated. Takayasu?s aortoarteritis is a complex disease. It requires combined diagnostic and therapeutic approaches which produce satisfied long-term results.

Postoperative acute lung injury (ALI) compromises oxygen transfer across alveolar-capillary membrane with consecutive hypoxia, one of its indicators being reduction of oxygenation index PaO2/FiO2 below 40 kPa (300 mm Hg). Management of ALI includes different procedures like mechanical lung ventilation (MLV), drugs and others. One of the new possibilities for treatment of ALI is nitric oxide (NO) inhalation. The aim of this prospective study was to examine the role of NO inhalation in treatment of ALI. 14 patients with ALI developed immediately after operation with extracorporeal circulation (ECC) were included in the study. Group A (n = 8) inhaled NO and group B (n = 6) did not inhale NO during treatment of ALI. All other therapeutic measures were the same in both groups. The groups were similar in relation to demographic data, type of surgery and duration of ECC. PaO2/FiO2 was calculated before operation (T1), immediately after surgery (T2) and after lung recovery, when the need for MLV stopped (T3). The duration of MLV was also registered. PaO2/FiO2 (kPa) in referent times was in group A 54,9 ? 1,6, 33,8 ? 1,2 and 46,2 ? 0,8 and in group B 52,2 ? 1,1, 33,5 ? 1,5 and 47,3 ? 0,9, respectively. There was a statistically significant decrease of PaO2/FiO2 in T2 and T3 vs T1 in both groups (p < 0,05), while the difference between the groups was not statistically significant. The duration of MLV (h) in group B (28,5 ? 1,6) was statistically significantly shorter than in group A (63,1 ? 8,7) (p < 0,01). According to the results of this study we conclude that NO inhalation during ALI after surgery with ECC significantly reduces the duration of MVL and improves pulmonary recovery .

The Carbomedics Prosthetic Heart Valve is a new bileaflet pyrolite carbon prosthesis. This paper reports the preliminary results in 40 patients who underwent mitral valve replacement (MVR) using the Carbomedics Valve in 1988. The operative mortality rate was 5% and the early results have been encouraging, with no valve related complications observed in the first post-operative year.

Physiologically, there is a correlation between cardiac status and pulmonary shunt — cardiac status influences oxygen (0 2 ) content in venous blood (Cv0 2 ) and hypoxic pulmonary vasoconstriction (HPV) 1,2 .