15 - 19 mai 2013

Sinaia
Centrul Internaional de Conferine
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Al 39-lea Congres al Societii Romne

de Anestezie i Terapie Intensiv
Al 7-lea Congres Romno - Francez
de Anestezie i Terapie Intensiv
Al 5-lea Simpozion Romno - Israelian
de Actualiti n Anestezie i Terapie Intensiv
Al 12-lea Congres al Asistenilor
de Anestezie i Terapie Intensiv
Al 11-lea Congres al Societii Romne de Sepsis
15 - 19 mai 2013
Sinaia
Centrul Internaional de Conferine Casino
Vol. 20
supliment 1
mai 2013
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JURNALUL ROMN DE
ANESTEZIE I TERAPIE
INTENSIV

Volumul 20, supliment 1, mai 2013


Culegerea de Rezumate Stiinifice
a Congresului SRATI 2013
15 - 19 mai 2013


Centrul Internaional de Conferine Casino Sinaia














Sediul redaciei:
Clinica ATI, Str. Croitorilor 19-21, Cluj-Napoca
Tel.: 0264-433 969
Fax: 0264-433 335
E-mail: iacalovschi@hotmail.com
ISSN 1582-652X



AL 39-LEA CONGRES AL SOCIETII ROMNE DE
ANESTEZIE I TERAPIE INTENSIV
THE 39
TH
CONGRESS OF THE ROMANIAN SOCIETY OF
ANAESTHESIA AND INTENSIVE CARE

AL 7-LEA CONGRES ROMNO- FRANCEZ DE ANESTEZIE I
TERAPIE INTENSIV
THE 7
TH
ROMANIAN-FRENCH CONGRESS OF ANAESTHESIA
AND INTENSIVE CARE

AL 5-LEA SIMPOZION-ISRAELIAN DE ACTUALITI N
ANESTEZIE I TERAPIE INTENSIV
THE 5
TH
ROMANIAN-ISRAELI SYMPOSIUM OF UPDATES IN
ANAESTHESIA AND INTENSIVE CARE

AL 12-LEA CONGRES AL ASISTENILOR DE ANESTEZIE I
TERAPIE INTENSIV
THE 12
TH
CONGRESS OF ANAESTHESIA AND INTENSIVE CARE NURSES

AL 11-LEA CONGRES AL SOCIETII ROMNE DE SEPSIS
THE 11
TH
CONGRESS OF THE ROMANIAN SOCIETY OF SEPSIS









REZUMATE TIINIFICE
SCIENTIFIC ABSTRACTS
























CONFERINE
CONFERENCES
Complicaii pulmonare la donorul aflat n moarte cerebral
Pulmonary Complications in Brain Death Donor
Ioana Grinescu
Spitalul Clinic de Urgen Floreasca, Bucureti, Romania

Modificrile sistemice care apar la pacienii n moarte cereral au impact la ni!elul tuturor organelor potenial
transplantaile" #le apar la ni!el cardio$!ascular, pulmonar, endocrin i imunologic i lipsa unei inter!enii terapeutice
prompte poate duce la moarte somatic" %e&!oltarea unor strategii eficiente pentru resuscitarea i meninerea
integritii funcionale a organelor presupune n'elegerea mecanismelor care stau la a&a acestor modificri
fi&iopatologice comple(e"
)lm*nii sunt organele cele mai !ulneraile, la doar +,$-,. din pacienii donatorii de organe reali&*ndu$se prele!area
acestora" %ei foarte frec!ent, consecina tulurrilor fi&iologice ma/ore care nsoesc moartea cereral, disfuncia
pulmonar se datorea& i altor cau&e precum aspiraia, pneumonia, contu&ia, le&iuni pulmonare asociate !entila'iei
mecanice"
Interaciunea cord$pulmon de!ine esenial n special la aceti pacieni, la care controlul central este aolit i 0furtuna1
2emodinamic consecuti! procesului de anga/are este responsail n mare parte pentru in/uria pulmonar acut"
Rspunsul 2emodinamic la pacienii n moarte cereral este tipic ifa&ic3 iniial descrcare masi! de catecolamine
re&ult*nd 2ipertensiune se!er, succedat de 2ipotensiune necesit*nd de cele mai multe ori suport !asopresor" Studiile
au artat c n cadrul acestor tulurri 2emodinamice se produce o reacie inflamatorie important la ni!elul tuturor
organelor i n special la ni!el pulmonar" Studii pe animale au demonstrat modificarea raportului neutrofilelor, precum
i creterea ni!elului cito4inelor proinflamatorii at*t plasmatic, c*t i la ni!elul lic2idului ron2oal!eolar" 5istopatologic
s$au e!ideniat rupturi la ni!elul memranei al!eolo$capilare" )re!enia cri&ei 2ipertensi!e prin tratament cu alfa
antagoniti poate pre!eni aceste modificri"
Scopul terapiei intensi!e este de a minimi&a apariia complicaiilor pulmonare fie ele 0intrinseci1 6asociate procesului
inflamator 7 sau 0e(trinseci1 6infecioase, asociate !entilaiei mecanice etc"7" 8entilaia mecanic protecti! i
respectarea msurilor de asepsie sunt foarte importante n !ederea unei une funcionaliti a plm*nilor
posttransplant"

The systemic physiologic changes that occur during and after brain death affect all organs suitable for transplantation.
Major changes occur in the cardiovascular, pulmonary, endocrine and immunological systems, and, if untreated, may
soon result in cardiovascular collapse and somatic death. Understanding these comple physiological changes is
mandatory for developing effective strategies for donor resuscitation and management in such a !ay that functional
integrity of potentially transplantable organs is maintained.
The lungs are the organs most often deemed medically unsuitable, and only "#$%#& of lungs from multiple organ donors
are used for transplantation. 'lthough brain death has great physiological conse(uences, pulmonary dysfunction is often
associated !ith other complications such as aspiration, pneumonia, contusion, )'*+.
,eart$lungs interaction is very important especially in these patients and recent studies prove that hemodynamic storm
is responsible for lung injuries.
Brain death is characteri-ed by t!o hemodynamic phases. +nitially massive sympathetic discharge results in a
hypertensive crisis, follo!ed by neurogenic hypotension. Up regulation of proinflamatory mediators occurs in all organs
and lung injury develops. .tudies on animals !ith induced brain death sho!ed significant increase in blood neutrophil
CD""b/CD"0 epression and pro inflamatory cyto1ine levels in serum and bronchoalveolar lavage. 'lso rupture of the
capillary alveolar membrane !as demonstrated, the most reproducible hypothesis is that hemodynamic changes are
responsible for these inflammatory phenomena. 2limination of the hypertensive response by alfa adrenergic antagonist
pretreatment prevents inflammatory lung injury.
The goal of intensive care therapy is to minimi-e respiratory complications, either intrinsic 3directly related to central
control loss and hemodynamic storm4 or associated to mechanical ventilation 3)'*+4. *ung protective ventilation and
aseptic maneuvers are important for reducing )'*+.







Managementul potenialilor donatori intoxicai cu alcooli toxici n Clinica ATI Oradea
Management of Potential Donors +ntoicated !ith Deadly 'lcohols !ithin +CU 2mergency Clinical County
5radea
Carmen )anti9
Spitalul Clinic :ude'ean de Urgen', Sec'ia ;<I, =radea, Rom*nia

Introducere3 )rele!area de organe de la donatorii n moarte cereral declara'i dup into(ica'ie acut cu alcooli to(ici
6etanol > metanol7 diali&a'i n primele - ore de la internare este posiil"
Metode3 ?n perioada + ianuarie $ @+ martie -,+@ s$au internat n Clinica ;<I +- pacien'i into(ica'i cu alcooli to(ici, A
ra'iB @ femei cu !*rste ntre C, 9i DE ani, acido& metaolic se!er p2 F,E$F,F fiind instituit 2emodiali&a" <;M, #GG,
Sp=-, )8C, presiunea arterial in!a&i!, diure&, uree, creatinin, transamina&e, ga&e arteriale, p2, ionograma au fost
monitori&ate continuu"
Re&ultate3 %in cele +- ca&uri admise n ;<I, - pacien'i au supra!ie'uit cu tulurri gra!e de !edere, F pacien'i au fost
declara'i n stare de moarte cereral 9i C pacien'i au decedat prin oprire cardiac pe !entila'ie mecanic" S$a fcut
screening !iral 9i s$a o'inut acord de prele!are organe la C din cei F pacien'i declara'i n moarte cereral" )rele!area
multiorgan s$a reali&at de la @ donatori 6ficat, rinic2i, cornee7" ;l C$lea donator a pre&entat oprire cardiac iresuscitail
cu C, minute nainte de prele!are 9i s$a considerat eligiil doar cornea"
Conclu&ii3 #ste necesar reconsiderarea po&i'iei fa' de pacien'ii into(ica'i cu alcooli to(ici care a/ung n stare de moarte
cereral"
<ransplantul de rinic2i, ficat 9i cornee s$a fcut n condi'ii optime, dup prele!area de la donatorii into(ica'i, al cror
management s$a fcut corect de ec2ipa medici aneste&i9ti 9i asisten'i de terapie intensi!"

5bjective of .tudy6 The organ prelevation from brain death donors declared after acute intoications !ith toic alcohols
3ethanol 7 methanol4, after undergoing dialysis for the first t!o hours after admittance in hospital is possible.
Material and Method6 Bet!een the "
st
of 8anuary and the 9"
st
of March %#"9, +CU admitted "% patients intoicated !ith
deadly alcohols, : men/ 9 !omen the ages bet!een ;# and 0<, severe metabolic acidosis 3ph =,< $ =,=4 !arranting for
hemodialysis. M'P, 2>?, .p5%, C)P, invasive arterial pressure, diuresis, urea, creatinin, transaminases, arterial gases, ph
and ionogram !ere constantly monitored.
@esults6 Arom the "% admitted cases, % patients survived !ith severe vision deficiencies, = patients !ere declared brain
death and ; patients died through cardiac arrest on mechanical ventilation. ' viral screening !as underta1en and an
agreement !as reached for prelevating organs in ; of the = brain death declared. The multi$organ prelevation !as
reali-ed in 9 donors 3liver, 1idney, and cornea4. The fourth donor had suffered cardiac arrest ;# minutes before the
prelevation and only the cornea !as thus usable.
Conclusions6 ' reconsidering of the position to!ards patients intoicated !ith noious alcohols is necessary because,
once they are brain dead, they become eligible donors.
The 1idney, liver and cornea transplant !as underta1en in optimal conditions, after prelevating from intoicated donors
!hose management !as also underta1en correctly by the team of anesthesiologists and intensive care assistants.

Recuperarea precoce post transplant hepatic: utem stabili un algoritm!
2arly @ecovery after *iver Transplantation6 Can Be Develop an 'lgorithmC
%ana <omescu
Institutul Clinic Fundeni, Bucure9ti, Rom*nia

Introducere3 <ransplantul 2epatic 6<57 repre&int tratamentul de elecie pentru pacienii cu oal 2epatic terminal"
)rognosticul acestora depinde de muli factori inclu&*nd3 statusul preoperator al pacientului, managementul
intraoperator 9i managememtul precoce postoperator" Scopul acestui studiu a fost de determinare a factorilor asociai
cu un prognostic defa!orail i implementarea unui protocol fast$trac4 6F<7 n c2irurgia transplantului 2epatic"
Material i metode3 ;u fost anali&a'i retrospecti! un numr de HC de pacieni transplantai 2epatic n Institutul Clinic
Fundeni n perioada ianuarie -,+- $ martie -,+@"
Re&ultate3 %intre pacieni, -+,D.6nI-+7 au fost transplantai 2epatic cu fragment de la donator !iu, iar H+,F. de la
donator aflat n moarte cereral" Scorul M#J% mediu n momentul transplantrii a fost de +E 6ntre D$@,7" Un scor
M#J% ridicat nu s$a asociat cu creterea mortalitii la -D de &ile post<5" %up implementarea F<, durata medie de
staionare n Unitatea de ?ngri/ire )ostaneste&ic 6);CU7 a sc&ut de la +, &ile la H,E" F< s$a corelat cu o scdere a
incidenei complicaiilor pulmonare 6pK,,,,+7" Scorul M#J%$La 6pI,,,,A7, instailitatea 2emodinamic intraoperatorie
6pK,,,,+7, !entilaia mecanic prelungit 6pI,,,,A7, disfuncia renal acut 6pK,,,,+7 i encefalopatia 6pI,,,C7 s$au
asociat unei staionri prelungite n );CU"
Conclu&ii3 ?n e(periena noastr, managementul intraoperator i precoce postoperator repre&int elemente c2eie n
creterea supra!ieuirii pacientului i grefei 2epatice" Criteriile fast trac4 pot fi aplicate n siguran, duc*nd la
muntirea prognosticului pacienilor"

+ntroduction6 *iver transplantation 3*T4 represents a !idely accepted treatment for patients !ith 2nd .tage *iver Disease.
5utcome of the procedure may be dependent on multiple factors including6 patient status prior to surgery,
intraoperative and early postoperative management. The aim of this study !as to determine factors associated !ith a
poor prognosis and increase postanaesthesia care unit stay and to establish a fast$trac1 protocol 3AT4 and early
discharge criteria for patients undergoing *T.
Material and Method6 Be retrospectively analy-ed D; patients !ho under!ent *T at Aundeni Clinical institute bet!een
8anuary %#"% and March %#"9.
@esults6 5f all patients, %",0& 3nE%"4 under!ent living$related *T and D",=& under!ent *T from cadaveric donors. The
median M2*D score at the time of *T !as "< 3range 0$9#4. ' high M2*D score did not associate !ith a poor prognosis
defined as %0 days mortality 3pE#,<=;4. 'fter applying AT the median duration of P'CU stay decreased from "# days to
D,< days. AT !as associated !ith a decrease incidence of pulmonary complication 3pF#,##"4. M2*D$Ga score 3pE#,#<4,
intraoperative haemodynamic instability 3pF#,##"4, prolonged mechanical ventilation 3pE#,##:4, early onset of acute
1idney injury 3pF#,##"4, encephalopathy 3pE#,#;4 !ere independent ris1 factors for prolonged P'CU stay.
Conclusions6 +n our eperience intraoperative and early postoperative management represent 1ey points in assuring both
patient and graft survival. AT criteria are safe to be applied and improve patient outcome.

Rolul tromboelastogramei n managementul coagulopatiei n cursul transplantului hepatic
The @ole of Thromboelastogram in the Management of Coagulopathy During *iver Transplantation
=" Gostian
)itiM$Salpetriere 5ospital, )aris, France

=iecti!e3 Studierea efectelor implementrii unui protocol de transfu&ie intraoperatorie a&at pe tromoelastogram
sau pe teste clasice de coagulare, n timpul transplantului 2epatic"
Material i Metode3 %up aproarea comitetului de etic al spitalului, toi pacienii aduli supui unui transplant 2epatic
n spitalul nostru au fost nrola'i n acest studiu prospecti!, desc2is, pe o perioad de doi ani 6-,++$-,+@7" )acien'ii cu
insuficien 2epatic fulminant nu au fost inclu9i n studiu, nici pacien'ii supu9i unui retransplant, sau cu un numr de
tromocite preoperator KE,",,, sau firinogen de +gBdl" )e de alt parte, pacienii cu s*ngerare intraoperatorie de mai
mult de +JB+E min au fost e(clu9i din studiu" <oi pacienii au semnat un consimm*nt informat pentru participarea la
acest studiu" #i au fost randomi&a'i n - grupe3 cei monitori&ai n timpul inter!eniei c2irurgicale folosind
tromoelastograma <#G, respecti! cei monitori&a'i cu a/utorul testelor standard de coagulare 6<), <C;, firinogen7"
<rigger$ul transfu&ional a fost specificat pentru fiecare grup n parte"
Re&ultate3 AF de pacieni au fost inclui n studiu, ns @ pacien'i au fost e(clu9i din cau&a unui episod de s*ngerare
c2irurgical intraoperatorie masi!" Ja pacienii monitori&a'i prin intermediul <#G, au fost transfu&ate semnificati! mai
pu'ine unit'i de plasm proaspt congelat 6medie NS%O, F"- NH"@O unitile !s +-"C N+,"DO de uniti7" )e de alt parte,
n grupul <#G au fost transfu&ate mai multe unit'i de firinogen 9i mai multe unit'i plac2etare, ns fr semnifica'ie
statistic" )ierderea intraoperatorie de s*nge n grupul <#G a fost mai puin important, ns, din nou, fr a a/unge la o
semnifica'ie statistic"
Conclu&ii3 Ca i n ca&ul pacien'ilor cu politraumatisme sau n c2irurgia cardiac, tromoelastograma poate fi utili&at n
timpul unui transplant 2epatic pentru a detecta rapid orice de&ec2iliru n 2emosta&a medical, permi*nd astfel
aneste&istului s identifice 9i s corecte&e proleme specifice, fie prin transfu&ie, fie prin mi/loace farmacologice"

5bjectives6 To study the impact of implementing a transfusion protocol based on the T2? or classical tests of
coagulation, during liver transplantation.
Material and Method6 'fter approval of the 2thics Committee of the hospital, all adult patients undergoing liver
transplantation in our hospital !ere enrolled into this prospective, open pilot study, over t!o years, 3%#""$%#"94.
Patients !ith fulminant hepatic failure !ere not included from the study, as !ell as the patients undergoing a
retransplantation, or !ith a preoperative platelet count F <#.### or fibrinogen F" g/dl. 5n the other hand, patients !ith
an intraoperative blood loss of more then "*/"< min !ere ecluded form the study. 'll patients !ere as1ed for an
informed consent for the participation to this study. They !ere randomi-ed into % groups6 those monitored during
surgery using point$of$care T2? analysis, and those monitored using standard laboratory measures of blood coagulation.
.pecific trigger points for transfusion !ere established in each group.
@esults6 := patients !ere included in the study, but 9 patients !ere ecluded due to a significative intraoperative
bleeding. +n patients monitored via T2?, there !as significantly less fresh$fro-en plasma used 3mean H.DI, =.% HD.9I units
vs "%.; H"#.0I units4. 5n the other hand, there !as a trend to!ard more fibrinogen and more platelets being transfused
in the T2? group, !ithout reaching a statistical significance. +ntraoperative blood loss in the T2? group !as less
important, again !ithout reaching statistical importance.
Conclusions6 *i1e in trauma patients or in cardiac surgery, thromboelastography may be used during liver
transplantation to rapidly detect any imbalance in the medical hemostasis, thus allo!ing the anesthestist to correct the
specific problem, either through transfusion or by pharmacological means.

rotecia cerebral: "purarea extracorporeal a glutamatului
Brain Protection6 2tracorporeal .cavenging of ?lutamate
;" Plotni4
Soro4a Medical Center, Ben Gurion Uni!ersitQ of t2e Lege!, FacultQ of 5ealt2 Science, %epartment of ;nest2esiologQ
and Critical Care, Beer S2e!a, Israel

?lutamate is released in high concentrations after various brain insults. Previous studies in humans and animals have
demonstrated that glutamate plays a crucial role in causing secondary neuronal damage follo!ing brain injury. +t has
been demonstrated that infusions of blood glutamate$lo!ering drugs in rats are associated !ith improved neurological
outcomes after traumatic brain injury 3TB+4, ischemic stro1e and subarachnoid hemorrhage 3.',4 irrespective of the
mechanism by !hich this reduction !as achieved. 2tracorporeal methods of blood glutamate reduction may serve as an
effective !ay to definitively eliminate glutamate from the blood, improving the brain$to$blood glutamate efflu.
2tracorporeal methods of glutamate elimination 3hemodialysis 3,D4, hemofiltration 3,A4 and peritoneal dialysis 3PD4
have several important advantages. Airst and foremost, these methods definitively eliminate ecess glutamate from
different compartments, rather than redistribute or reversibly converse. .econd, considering that majority of
pharmacological options listed above cannot be used for treatment of humans since they have not yet undergone the
re(uired safety trials, etracorporeal methods have been !idely used in many conditions in +CU patients may therefore
be applied for this indication. 2tracorporeal removing systems, such as hemodialysis effectively and consistently remove
many amino acids including glutamate, and improving amino acids profile to!ard normal one. .imilar etracorporeal
removing systems may be usefully applied precisely for elimination of glutamate ecess in different neurodegenerative
conditions and provide neuroprotection. Unfortunately, hemodialysis may have several limitations6 first, a significant
proportion of the patients are admitted, suffering hemodynamic instability, particularly hypovolemia or in shoc1. .econd,
anticoagulation !hich may be detrimental for patients suffering from multiple trauma or isolated head injury because of
ris1 of bleeding, is preferred for hemodialysis procedures in order to prevent clot formation in the setJs tubing.
Continuous ,A or PD may circumvent some of these limitations. Be eamined effect of PD on blood glutamate levels and
sho!ed that PD is capable of reducing of blood glutamate levels. Currently, a study evaluating efficacy of ,A to reduce
blood glutamate levels in +CU patients is on the !ay.

#olosirea soluiilor saline hipertone n trauma cerebral $ Osmolalitatea %i efectele ei asupra lichidului
cefalo$rahidian %i asupra &olumului cerebral %i &ascular
The Use of ,ypertonic .aline for Brain +njury $ 5smolality and +ts 'ffect on C.A, Brain and )ascular )olume
R" S2apira
Soro4a Medical Center, %i!ision of ;nest2esiologQ and Critical Care, Beer S2e!a, Israel

Traumatic brain injury is the result of a primary lesion !hich can not be treated and secondary lesion in !hich the cell is
not dead but rather is dying. Mostly the brain injury is complicated and etended by hypotension and hypoia. Cerebral
edema due to brain injury compromises increases the intracranial pressure 3+CP4.
The development of cerebral edema/brain !ater accumulation happens in all pathologists states6 traumatic,
cerebrovascular, infectious etc.. ,istorical the stages of brain edema are divided to cytotoic and vasogenic edema.
Brain injury is relats to both vasogenic and cytotoic phases.
Treatment for high intracranial pressure is aimed at reducing the volume of at list " of the 9 intracranial compartments,
brain tissue, blood, and cerebrospinal fluid 3C.A4. Treatment can be either conservative !hich includes
diuretic/hyperosmolar therapy or surgical in special occasions. Duretic/,yperosmolar therapy is one treatment
intervention in the care of patients !ith severe brain injury resulting in cerebral edema and high +CP. The effect of
hyperosmolar solutions on brain tissue !as first studied nearly "## 3":":4 years ago by Beed and Mc>ibben !ho !ere
the first to describe the effect of osmotherapy in laboratory animals. They !ere the first !ho sho!ed the correlation
bet!een high osmolality and decreased brain volume. .ince that time, mannitol %#& 3about ""## m5sml/l4 has become
the most !idely used hyperosmolar solution to treat elevated +CP. +ncreasingly, hypertonic saline solutions are being
used as an adjunct to mannitol in basic science research and clinical studies. ,yperosmolar solutions are effective in
reducing elevated intracranial pressure through % distinct mechanisms6 plasma epansion !ith a resultant decrease in
blood hematocrit, reduced blood viscosity, and decreased cerebral blood volumeK but the most important is the creation
of an osmotic gradient that dra!s cerebral edema fluid from brain tissue into the circulation. Moreover, it reduces first
and in the most dramatic !ay the C.A formation and resistant toreabsorbtion !hich affects the +CP.
The purpose of this lecture is to improve the understanding of the role of hyperosmolar therapy in the treatment of brain
injury and the use of mannitol and hypertonic saline.

'edarea pentru di&erse proceduri
Procedural .edation
:" Sic2eleTs4i
Ben Gurion Uni!ersitQ in t2e Lege!, FacultQ of 5ealt2 Sciences, Roseftal 5ospital, #ilat, Israel

' techni(ue of administration of sedatives or dissociative agents !ith or !ithout analgesics to induce a state that allo!s
the patient to tolerate unpleasant procedures !hile maintaining cardiorespiratory function. Procedural sedation and
analgesia 3P.'4 is intended to result in a depressed level of consciousness that allo!s the patient to maintain
oygenation and air!ay control independently.
The number of noninvasive and minimally invasive procedures performed outside of the operating room has gro!n over
the last decades.
Understanding the efficacy and safe administration of the drugs is essential to the practitioner performing interventional
procedures.
'.' "::=6 .edation/'nalgesia 3past6 Conscious sedation46 ' state that allo!s patients to tolerate unpleasant procedures
!hile maintaining ade(uate cardiorespiratory function and the ability to respond purposefully to verbal command
and/or tactile stimulation.
Deep sedation 3past6 deep sedation46 Patients !hose only response is refle !ithdra!al to painful stimuli are li1ely to be
deeply sedated, approaching a state of general anesthesia, and should be treated accordingly.
?eneral 'nesthesia 3past6 ?eneral 'nesthesia46 Complete loss of a!areness of the environment accompanied by loss of
protective reflees.
Minimal .edation6 Describes a drug$induced state during !hich patients are sedated but still able to respond
appropriately to verbal commands. The eyes of patients under minimal sedation remain open. Used for6 *umbar
puncture, .imple fractures reductions 3in combination !ith local anesthetics4, +ncision and drainage of small abscesses.
Lour monitor6 5ygen 7 5ygen saturation.
Moderate .edation6 Patients sedated to the point at !hich their eyes are closed but open in response to verbal
commands alone or to light tactile stimulation. Usually have an intact air!ay and maintain ventilatory function !ithout
support. Lour monitor6 5ygen saturation, Cardiac monitoring, Blood pressure measurements and direct observation of
the patients air!ay.
Deep sedation6 The ability to independently maintain ventilator function is usually impaired, and patients often re(uire
assistance in maintaining a patent air!ay. Patients can (uic1ly progress to the level of ?eneral 'nesthesia. .o, you must
be prepared to provide ventilator supportM The ventilatory status of deep sedated patients must be monitoredMM Lour
monitor6 The same 7 Capnography6 +t provides a graphic display of ventilatory status that can be used to detect
respiratory depression before it becomes clinically apparent. The end tidal C5% value increases as the respiratory rate
decreases in an event of hypoventilation.
2(uipment you must for sedation6 5ygen, Cardiac monitor, 5ygen saturation, G+BP, Capnograph, .uction, 'mbu, ?ood
illumination, Defibrillator, *aryngoscope and endotracheal tubes, 2mergency trolley and drugs should be in each location
!ith ade(uate staff trained to support and help the emergency room doctors. Post sedation symptoms6 )omiting6 "#$
%#&, Gausea6 "#$;#&, .ore throat6 %<&.
Ben-odia-epines6 )ery common drugs for sedation. Their effect 3aniolysis or hypnosis4 depends on the amount of ?'B'
receptors occupied and can be reversed promptly by an antagonist !hich competes !ith Ben-odia-epines for the same
site at ?'B' receptor. Bide margin of safety not causing ?eneral 'nesthesia. Be careful !ith alcohol, 2lderly patients,
Cirrhotic patients, in all this cases can depress the respiratory centers causing 'PG2' more than in other patients. They
metaboli-ed by hepatic oidation and ecreted by the 1idneys. The most common are6 Dia-epam, Mida-olam,
*ora-epam. The antagonist6 Aluma-enil 3'neate4.
Metaboli-ation6 Promptly patient arousal after a single dose or interruption of drug infusion. 2cretion by 1idneys.
'nesthesia dose6 % mg/1g. +t has respiratory and cardiovascular depressant effectsM
2tomidate6 +mida-ole derivate, rapid onset of action and minimal effects on respiratory and cardiovascular system. )ery
good for intubation and cardioversion BUT6 Gausea, )omiting, Myoclonus, .ei-ures, Pain at injection site and
tromboflebitis. Prolonged used has sho!n increased mortality of patients, probably due to suppression of adrenal
steroidogenesis.
Aentanyl6 Beatryl$'lfentanyl$@emifentanyl.
,ighly lipophilic opioid, producing analgesia !ithin " to % minutes of +) administration. +ts duration of action is only 9#
to =# minutes. *ess histamine release than Morphine, BUT6 @2.P+@'T5@L D2P@2..+5G M5@2 A@2NU2GT*L T,'G
M5@P,+G2. .5, B,2G L5U U.2 A2GT'GL* L5U MU.T U.2 PU*.2 5OLM2T@L 'GD 2GD T+D'* C'PG5?@'P,L. B2
C'@2AU** B+T, T,2 .2C5GD P+C>M
Morphine 35pioids derivate46 5pioids bind specific endorphin receptors that suppress the detection of pain peripherally,
modify pain transmission in the spinal cord and thalamus, and alter the perception of pain in the corte. Cause
respiratory depression, nausea, vomiting, constipation and urinary retention. Morphine +) is the opioid analgesic agent
!ith !hich all other opioids are compared, it reaches its pea1 of action in "<$%# minutes and has a duration of action of
9$; hours. *oading dose for acute severe pain6 #."$#."< mg/1g +) follo!ed by #. #< mg/1g every "< minutes until pain is
relieved. Because Morphine have hydrophilic nature, this results in delayed transport across the blood brain barrier3BBB4
and then, delayed onset of action. But because that, also longer duration of action 3;$< hours4.
The antagonist6
Galoone6 +s an opioid antagonist and can give +), +M or through the endotracheal tube. +t is usually given in repeated
titrated doses 3#.%mg +)4 until the adverse effect of the opioids is reversed. Be careful6 Galoone !ith no circulating
MorphineM
Gitrous 5ide6 Commonly 1no!n as Plaughing gas or s!eet airP. 't room temperature, it is a colorless, non$flammable
gas, !ith a slightly s!eet odor and taste. +t is used in surgery and dentistry for its anesthetic and analgesic effects.
Can cause6 'nalgesia, depersonali-ation, di--iness, euphoria, sound distortion, hallucinations, aniolytic effect, rapid
recovery and lo! cost, slo! going in to anesthesia, can increased nausea and vomiting because increased the vestibular
system pressure and gastric pressure.
Contraindications6 C5PD patients, chronic bronchitis, >no!n psychiatric disorders. Be careful !ith the use in ear or
abdominal trauma.
2ntono6 +s a pain relieving gas miture and consists of t!o gases6 G%5 Gitrous 5ide <#& 7 5% <#&. 2ntono does not
!or1 immediately. +t ta1es about < minutes to ta1e effect. .ide effects6 Gausea, Tiredness, Dry mouth, Tingling
sensation, usually in the fingers 3due to hyperventilation4. ' mouthpiece attachment held bet!een your teeth and close
your lips around the mouthpiece. Breathe in and out through your mouth only. 2ntono !or1s only !hen you breathe in.
+ts side effects !ear off (uic1ly once the patient has stopped breathing it in, normally !ithin a minute. ,o!ever, the
patient should rest for about 9# minutes before start to !al1 around again. 2ntono is administered through a facemas1
or mouthpiece. The facemas1 is connected to an 2ntono supply through a demand valve system !hich allo!s the
2ntono to be self$regulated by the patient. The demand valve is operated by the act of inhalation of the patient and
closed do!n !hen the patient ceases to inhale. +n nearly all cases is self$administered but it may be administered by
attendant medical personnel. .hould not be used for more than a total of %; hours, or more fre(uently than every ;
days, !ithout close clinical supervision and hematological monitoring. .hould not be used in any condition !here gas is
entrapped !ithin a body and !here its epansion might be dangerous6 'rtificial, traumatic or spontaneous
pneumothora, 'ir embolism, Decompression sic1ness, follo!ing a recent dive, .evere bullous emphysema, after
myringoplasty, ?ross abdominal distension, prolonged or fre(uent use of 2ntono may result in megaloblastic marro!
changes, myeloneuropathy and subacute combined degeneration of the spinal cord. 2ntono is non flammable but
strongly supports combustion and should not be used near sources of ignition. .mo1ing should be prohibited !hen using
2ntono. Chec1 that hands are clean and free from any oils or grease. Bhere alcohol gels are used to control
microbiological cross$contamination, ensure that all alcohol has evaporated before handling 2ntono cylinders of
e(uipment. 2ntono inactivates )it. B"%, Potentiates the effect of Methotreate, 'dditive effects in combination !ith
5pioids or Ben-odia-epines. Gitrous 5ide passes into all gas containing spaces in the body faster than Gitrogen passes
out. Prolonged eposure may result in bo!el distension, middle ear damage and rupture of ear drums. G%# is eliminated
unchanged from the body mostly by the lungs. G%5 is a potent analgesic and a !ea1 anaesthetic. +nduction !ith G%5 is
relatively rapid, but a concentration of about D#& is needed to produce unconsciousness.
Thiopenthal 3Pentothal46 +nduced general anesthesia of short duration and controlled convulsions. Contraindications6
Porphyria, C5PD, acute asthma, severe shoc1, myotonic dystrophy, hypersensitivity.
>etamine 3>etalar46 The best and ideal drug for conscious sedation in children. >etamine is best described as a
Pdissociative sedationP Pa trance li1e cataleptic state characteri-ed by profound analgesia and amnesia, !ith retention
of protective air!ay reflees, spontaneous respiration and cardiopulmonary stabilityP, do not re(uire s1eletal muscle
relaants. Dose +)6 "$% mg/1g 3or 9$; mg/1g +M4 7 'tropine +) #. #% mg/1g 7 Mida-olam +) #.#< mg/1g. Bhy 'tropine
and Mida-olamC
.ide effects6 Mild and self$limiting but, any!ay6 Transient 5ygen desaturations$5ygen, Alashing over face and torso,
secretions$'tropine, ,allucinations$Mida-olam. +deal for6 *aceration repair, especially of the lip, tongue and bucal
mucosa, manipulation and reduction of upper limb fractures, incision and drainage of abscesses, removal of foreign
bodies.

A&em ne&oie de examenul clasic n aneste(iologie!
Do Be Geed Aormal 2aminations in 'naesthesiologyC
Sue 5ill
Sout2ampton Uni!ersitQ 5ospital, Sout2ampton, UG

There is a consensus that education is essential to provide an anaesthesiologist !ith the 1no!ledge and eperience to
practise unsupervised in an operating theatre, an +CU or a pain clinic. 'lthough a number of different approaches can be
used to provide that education, opinions vary considerably on the role of formal eaminations, particularly for
assessment rather than for appraisal.
My definition of a formal eamination is one that ta1es place a!ay from the normal !or1place, is assessed by doctors
!ho do not normally !or1 alongside the candidate and has a published, pre$defined structure. The candidate should
1no! the structure of the eamination, the place it ta1es in relation to the curriculum they are follo!ing and the scoring
system used. There are t!o distinct types of eamination used to assess medical proficiency6 a !ritten eamination and
an oral eamination.
The !ritten eamination is used to assess the 1no!ledge level of the candidate, both factual 3single step 1no!ledge4 and
application of basic principles to clinical practice 3t!o$step reasoning4. The oral eamination is used to assess
understanding of 1no!ledge gained and ho! it might be applied in clinical practice. +n an oral eamination, it is also
possible to assess communication s1ills and organisational ability. These eaminations reflect the lo!est t!o levels of
MillerJs pyramid6 1no!ledge 3Q1no!sR4 and theoretical application of 1no!ledge 3Q1no!s ho!R4. The uppermost level of
MillerJs pyramid Qsho!s ho!R is best assessed in the clinical setting $ !or1place based assessment. This progress
through a medical specialty is of particular relevance to anaesthesiology, !hich does not form a core part of teaching at
medical school. Ae! doctors !hen they start their training in anaesthesiology have any 1no!ledge of the subject. There
is a lot to learn, both practically and theoretically, particularly in the first year.
Bith so much to learn and little eperience to dra! upon, ho! does the ne! recruit identify !hat is importantC '
curriculum guides the trainee but does not al!ays identify !hat is essential and !hat is less so at different stages of
training. The 2uropean Curriculum identifies !hat is re(uired by the end of training for all anaesthesiologists across our
continent.
,o! do formal eaminations fit into this demanding eperienceC There are several issues to consider6
S 2ams can drive learning
S Progress can be monitored by independent assessors
S @elative performance against peers can be judged
S .uccessful performance demonstrates ac(uisition of 1no!ledge and understanding
S +mproved patient safety
Got all people enjoy the eperience of formal eaminations despite possessing the necessary 1no!ledge, understanding
and (ualities re(uired to be a successful anaesthesiologist $ as judged by their teachers and mentors. +s there a real need
for an independent opinionC + believe this is essential in a !orld of mobility across regions and countries, but not all
2uropean countries re(uire formal eamination success in order to be registered !ith their professional medical bodies.
2mployment should be based on competition and not sinecure6 possession of independent credentials demonstrating
timely ac(uisition of relevant 1no!ledge and understanding is often a re(uirement for reaching a shortlist.
The issue of patient safety is of immense importance6 is there evidence that anaesthesiologists !ho perform !ell in
formal eaminations provide patients !ith a better, safer service than those !ho struggleC .uch evidence is difficult to
tease out from morbidity and mortality statistics6 our outcomes are intimately ent!ined !ith our surgical colleaguesJ
performance.
There is little doubt in my mind that an itinerant !or1force !hich needs to provide evidence of successful completion of
a training programme in order to move across borders or continents are better placed if they provide credentials such as
completing formal, professional eaminations. +t cannot guarantee patient safety, but allo!s future employers to be
confident that an understanding of both scientific theory and clinical understanding has been demonstrated.
The 2.' 2aminations Committee provides the infrastructure for a pan$continental eamination but recognises that this
in itself is not sufficient to develop a platform for ac(uiring and demonstrating 1no!ledge and understanding of
anaesthetic principles. Aormal assessment can supplement local appraisal and recently the 2.' 2ducation subcommittee
for 5*' 35n$line 'ssessment4 has been formed and !ill no! run regular assessments !ith immediate feedbac1 on
performance, !ith (uestions similar to those seen in the 2D'+C itself. The first 5*' !as run in 'pril %#"9 and !ill be a
regular feature in the 2amination calendar.
The net development !ill be ,5*'6 ,ome 5n$*ine 'ssessment, !here the trainee can re(uest mini$eaminations on
their selected topics in their o!n home that !ill provide immediate feedbac1 on performance. Batch this spaceM
.',6 </;/"9

Strategia n sngerarea perioperatorie
Perioperative .trategy of ,aemostasis
%aniela Filipescu
Institutul de Boli Cardio!asculare 0)rof" %r" C"C" Iliescu1, Bucure9ti, Rom*nia

.ignificant haemorrhage may be encountered in a variety of surgical procedures. Treatment protocols for perioperative
bleeding recommend the use of allogeneic blood products 3e.g., pac1ed @BCs, AAP, platelets4 3"4, sometimes in fied
ratios 3%4. ,o!ever, transfusion of allogeneic blood products increases morbidity and mortality 394, and fied ratios
might not improve outcomes 3;4.
The 2uropean .ociety of 'naesthesiology 32.'4 issued for the first time a guideline !hich aims to provide an up$to$date
revie! and synthesis of the evidence and recommendations that may guide practitioners to!ards safe and cost$effective
strategies for minimising severe perioperative bleeding and maimising blood conservation 3<4.
Before surgery or invasive procedures, the first step of haemostasis management is the use of a standardi-ed
(uestionnaire on bleeding and drug history of the patient and his/her family. This !as sho!n to be superior to the
routine use of conventional coagulation screening tests such as a PTT, PT and platelet count in elective surgery.
Preoperative platelet function testing is recommended only in addition to a positive bleeding anamnesis or to identify
decreased platelet function caused by medical conditions and anti$platelet medication. Patients on oral anti$coagulant
therapy re(uire prothrombin comple concentrate 3PCC4 and vitamin > before any other coagulation management steps
for severe perioperative bleeding.
During perioperative active bleeding a target haemoglobin concentration of D$: g dl$" is recommended. ,igh inspiratory
oygen fractions should be used to prevent arterial hypoia. Maintaining perioperative normothermia and correcting
hypocalcaemia and acidosis are also recommended.
Transfusion algorithms incorporating predefined transfusion triggers based on point$of$care 3P5C4 coagulation
monitoring assays should be used to guide haemostatic intervention during intraoperative bleeding, especially in
cardiovascular surgery. P5C tests of haemostatic function enable tailoring haemostatic therapy and differentiation
bet!een microvascular and surgical bleeding 3=4. The potential reductions in allogeneic blood product transfusion and
re$eploration rates have important implications for overall patient safety and healthcare costs 3D4.
.everal coagulation factors or pharmaceutical products influencing coagulation and/or fibrinolysis have been used to
lessen surgical bleeding and eliminating or reducing blood transfusion re(uirements. The ideal haemostatic agent has to
clot inappropriate haemorrhage and not normal vessels, has to be easy to store and use, and has to be monitored by a
validated laboratory assay, inepensive and !ithout side effects. To be adopted in clinical practice, an agent must be
efficacious, but safety remains a major concern. 5bviously, there is no such ideal agent, yet.
Aibrinogen concentrate is indicated if significant bleeding is accompanied by at least suspected lo! fibrinogen levels
3F".<T%.# g *T"4 or thrombelastography/ thromboelastometry signs of functional fibrinogen deficit. The initial fibrinogen
concentrate dose is %<$<# mg 1g$". Cryoprecipitate is indicated if there is no fibrinogen available.
PCC 3%#$9# +U 1g$"4 can also be administered in case of bleeding and prolonged clotting times 3D4. ,o!ever, prolonged
+G@/PT alone is not an indication for PCC, especially in critically ill patients.
+n cases of on$going or diffuse bleeding and lo! clot strength, despite ade(uate fibrinogen levels, AO+++ deficiency is
suspected and AO+++ concentrate 39# +U 1g$"4 can be administered.
The use of recombinant activated A)++ 3rA)++a4 should be restricted to its licensed indication since outside these
indications the effectiveness of rA)++a to reduce transfusion re(uirements and mortality remains unproven and the ris1 of
arterial thromboembolic events as !ell as costs are high 304. ,o!ever, if other haemostatic measures failed, rA)++a could
be administered, ideally, before haemostasis is severely compromised. The optimum dose is :#T"%# Ug1g$", and this can
be repeated. ,ypofibrinogenemia, thrombocytopenia, hypothermia, acidosis and hyperfibrinolysis should all be treated
before rA)++a is used.
*ysine analogues 3traneamic acid, $aminocaproic acid4 reduce perioperative blood loss and transfusion re(uirements
3:4. This can be highly cost$effective in several settings of major surgery and trauma. Traneamic acid doses of up to %<
mg1g$" are usually recommendedK these can be repeated or follo!ed by continuous infusion 3"$% mg1g$"h$"4.
Under specific conditions 3inherited and ac(uired von Billebrand syndrome, mild haemophilia4, desmopressin might
reduce blood loss. ,o!ever, a Cochrane analysis sho!ed that desmopressin does not significantly reduce the ris1 of
eposure to allogeneic @BC transfusion 3"#4 and there is no clear indication for perioperative use of desmopressin in
patients !ithout a congenital bleeding disorder.
Measures to support and monitor haemostatic therapies are important for (uality improvement and may offer effective
approaches for limiting blood transfusion and decreasing perioperative bleeding. ,o!ever, many of the current
indications are based on retrospective studies and there is an urgent need for !ell$designed clinical trials.
@eferences6
". *iumbruno ?M, Bennardello A, *attan-io ', et al. @ecommendations for the transfusion management of patients in the
peri$operative period. +. The pre$operative period. Blood Transfus %#""K :3"46 ":$;#.
%. >ashu1 8*, Moore 22, 8ohnson 8*, et al. Postinjury life threatening coagulopathy6 is "6" fresh fro-en plasma6pac1ed red
blood cells the ans!erC 8 Trauma %##0K =<3%46 %="$%D#.
9. Batson ?', .perry 8*, @osengart M@, et al. Aresh fro-en plasma is independently associated !ith a higher ris1 of
multiple organ failure and acute respiratory distress syndrome. 8 Trauma %##:K =D3%46 %%"$%%D
;. .nyder CB, Beinberg 8', Mc?!in ?, 8r., et al. The relationship of blood product ratio to mortality6 survival benefit or
survival biasC 8 Trauma %##:K ==3%46 9<0$9=%.
<. >o-e1$*angenec1er ., 'fshari ', 'lbaladejo P, 'ldecoa 'lvare- .antullano C, De @obertis D, Ailipescu D,
Aries D, ?Wrlinger >, ,aas T, +mberger ?, 8acob M, *ancX M, *lau 8, Mallett ., Meier 8, @ahe$Meyer G, .amama CM, .mith
', .olomon C, )an der *inden P, Bi11elsY ', Bouters P, Byffels P. ?uidelines on the
management of severe perioperative bleeding. 28' %#"9 3submitted4.
=. Beber CA, ?Wrlinger >, Meininger D, et al. Point$of$care testing6 a prospective, randomi-ed clinical trial of
efficacy in coagulopathic cardiac surgery patients. 'nesthesiology %#"%K ""D3946 <9"$<;D.
D. ?Wrlinger >, Dir1mann D, ,an1e '', et al. Airst$line therapy !ith coagulation factor concentrates combined
!ith point$of$care coagulation testing is associated !ith decreased allogeneic blood transfusion in cardiovascular
surgery6 a retrospective, single$center cohort study. 'nesthesiology %#""K ""<3=46 ""D:$"":".
0. *in L, .tan!orth ., Birchall 8, Doree C, ,yde C. @ecombinant factor )++a for the prevention and treatment of
bleeding in patients !ithout haemophilia. Cochrane Database .yst @ev %#""K 3%46 CD##<#"".
:. ,enry D', Moey '8, Carless P', et al. 'nti$fibrinolytic use for minimising perioperative allogeneic blood
transfusion. Cochrane Database .yst @ev %##"K 3"46 CD##"00=.
"#. Carless P', ,enry D', Moey '8, et al. Desmopressin for minimising perioperative
allogeneic blood transfusion. Cochrane Database .yst @ev. %##;K3"46CD##"00;. @evie!.

Ce ar trebui s spunem familiei! )iomar*eri +i prognosticul dup oprirea cardiac
Bhat .hould + Tell the AamilyC Biomar1ers and Prognostication after Cardiac 'rrest
S2aron #ina!
5ereT Uni!ersitQ Sc2ool of Medicine, S2aarei Pede4 Medical Center, :erusalem, Israel

,ypoic brain injury remains a leading cause of mortality and morbidity after cardiopulmonary resuscitation 3CP@4.
.urvivors !ho have suffered such injury despite return of spontaneous circulation often re(uire costly intensive care
admission, rehabilitation, and ongoing treatment of chronic complications. ,o!ever, science has yet to provide us !ith a
tool !hich accurately predicts poor outcome after CP@.
.everal biomar1ers have been put for!ard as potential predictive tools after CP@. ,o!ever, current 'merican 'cademy
of Geurology guidelines for predicting outcome in comatose survivors of CP@ recommend using only Geuron .pecific
2nolase 3G.24 for prediction. The guidelines suggest that performance of additional research on biomar1ers is re(uired in
order to establish a clearer vie! of the relationship bet!een biomar1er levels and patient outcome.
Most studies of biomar1ers in post$@5.C patients have sought simple cutoff points. Clear cutoff points have not been
found 3even for G.24, and are not biologically li1ely to be found. Use of brain biomar1ers for predicting death after
cardiopulmonary resuscitation 3CP@4 is also limited by ethical/cultural controversy concerning the li1elihood of
misclassification of potential survivors. Ainally, fe! clinicians !ould agree to cease ongoing resuscitation efforts on the
basis of the results of blood tests alone, but many physicians !ould not hesitate to modify treatment in accordance !ith
a calculated li1elihood of success based on a mi of clinical and laboratory data. .ince these clinical challenges remain
unaddressed, clinicians remain almost clueless regarding the most li1ely outcome for their patient.
?iven the dra!bac1s of biomar1ers noted above, ris1 stratification 3calculated through use of mied clinical and
laboratory data4 !ould be the preferred clinical approach to patient management after CP@. .imilar models are being
used today to direct treatment of both heart disease and cancer. This lecture !ill eplore the concept of using a mied
clinical$biomar1er model to predict patient outcome after CP@. .uch a tool !ould be invaluable to clinicians as they
approach the families of their patient to discuss patient prospects and future therapy.

,iagnosticul mor-ii cerebrale: Implica-iile din legisla-ia israelian
Brain Death Determination6 +mplications of the +sraeli *a!
#" Segal
;ssuta Medical Centers, %epartment of ;nest2esia, Intensi!e Care and )ain Medicine, Israel

Q+ 1no! !hen one is dead, and !hen one livesK
.heZs dead as earth. *end me a loo1ing$glass,
+f that her breath !ill mist or stain the stone,
Bhy, then she lives.R
>ing *ear

Diagnosing death may be comple. Determining death by brain death criteria is an important part of managing patients
!ith devastating neurological injury or disease. +t is !ell accepted no! that certain clinical criteria can predict !ith
absolute certainty the impossibility of survival, and this has become the medical, ethical and legal basis for determining
death in patients !hose somatic functions can still be supported in the +CU.
The situation of a patient on a ventilator, !ith medications directed to maintaining cardiac, renal and gastrointestinal
function, yet is still determined to be dead, is relatively ne! and could only occur in modern +CUs !ith the technology
available no!.
The concept of death by neurological criteria, i.e. diagnosing death in a person !hose brain is irreversibly and completely
destroyed, has been recogni-ed by the la! in many countries. The state of >ansas !as the first to pass a brain death bill
in ":D#, and this !as the basis for the Uniform Declaration of Death 'ct !hich !as since adopted by most states in the
U., and states that death can be diagnosed in a patient !ho sustained irreversible cessation of circulatory and
respiratory functions or irreversible cessation of all brain functions including the brain stem. The ,arvard criteria 3":=04
H"I and the presidentZs commission 3":0"4 for brain death determination re(uired that brain death be determined only
after t!o eaminations !ith %; hours bet!een the t!o, an 22? eamination !as re(uired and evidence for complete
death of all central nervous tissue !as essentially a prere(uisite for the diagnosis. *ater guidelines modified the
re(uirements and most countries and societies do not re(uire ancillary tests and brain death can be determined
clinically, and complete destruction of all central nervous tissue is not re(uired $ for eample patients may be diagnosed
!ith brain death even if there is no Diabetes +nsipidus !hich !ould be a prere(uisite if all brain tissue !ere non$
functioning.
Because the decision of !hat death is is actually a social decision rather than a medical one, in some places the legal
situation is such that certain religious groups are allo!ed by the la! to object to the diagnosis of brain death. This does
not mean that they are allo!ed to demand resources to be utili-ed in the care of !hat is deemed to be a futile medical
situation. +n Ge! 8ersey and Ge! Lor1, for instance, persons are allo!ed to re(uest that death not be determined in the
care of their family member for religious reasons, and this prevents the medical institution from determining death by
neurological criteria. H%I
+n +srael, partially as a response to the lo! numbers of brain death acceptance by family members and partly due to
religious considerations a brain death la! !as passed in %##:. The la! specified a number of changes to the then
current practice of brain death determination. The procedure no! re(uires 'pnea testing as a mandatory component,
an ancillary test to prove loss of blood flo! or complete cessation of brain electrical activity is re(uired, and physicians
are only able to participate in brain death determination after undergoing special training !hich includes medical and
religious teaching. The familyZs !ishes, for eample, to prevent disconnection from mechanical ventilation, are no!
sanctioned by the la!, and thus families may re(uest ongoing care even after brain death !as determined. +t should be
noted that the family may only demand care !hich is relevant to ventilation and not necessarily full medical therapy.
The la! is uni(ue in that it states very specifically the method by !hich brain death can be determined, and does not
only state $ as the UDD', !hat is brain death.
The la! !as passed despite firm objections of the +sraeli .ociety of Critical Care Medicine. Aollo!ing the la!, as
predicted by the +.CCM, the number of brain death determination decreased significantly. There !ere less physicians
!ho !ere credentialed to perform brain death determination, and the resistance of families to the procedure !as also a
significant component. 5ther problems !ere the inability to perform an 'pnea test, !hich, even in a patient !ith proven
loss of blood flo! to the brain, cannot be diagnosed as brain dead.
's epected, religious families did not increase their !illingness to have brain death determined, or to agree to organ
donation, yet in some cases, secular families !ho may be !illing to donate organs could not do so because of the
problems in legally determining brain death.
'fter the first year of a dramatic reduction in brain death determination, there !as an increase to almost baseline levels
of before the la!. H9I ' more recent publication from the same group describes and increase in organ donation and in
signers of donor cards. H;I ,o!ever this may be due to a second la! !hich !as passed in +srael that prohibits payment
for organs and essentially reduced the options for travel to other countries for transplants 3transplant tourism4.
Be cannot predict right no! ho! the behavior of the population and the medical teams !ill impact the diagnosis of
brain death in +srael in the future. This !ill obviously have a dramatic effect on critical care resource utili-ation and on
transplant medicine.
@eferences6
". ' definition of irreversible coma6 report of the ad hoc committee of the ,arvard Medical .chool to eamine the
definition of brain death. 8'M' ":=0K%#<699D$9;#
%. http6//!!!.la!rev.state.nj.us/UDD'/UDD'M#D#:%#"%.pdf
9. Cohen 8 et al Brain death determination in +srael6 the first t!o years eperience follo!ing changes to the brain death
la!$opportunities and challenges. 'm 8 Transplant. %#"% .epK"%3:46%<";$0.
;. *avee 8 et al Preliminary mar1ed increase in the national organ donation rate in +srael follo!ing implementation of a
ne! organ transplantation la! 'm 8 Transplant. %#"9 MarK"93946D0#$<

Complica-iile hemodinamice n blocurile neuraxiale
,emodynamic Complications of Geuraial Bloc1ade
5" 5addad
La&aret2 5ospital, ;nest2esia %epartment, La&aret2, Israel

.ince the first spinal anesthesia done by 'ugust Bier in "0:0, our clinical eperience !ith the neuraial bloc1ade had a
great success, today !e consider this techni(ue of anesthesia as safe and !ell established method, fre(uently used by
anesthesiologists !orld!ide. 'dvantages of central neuraial bloc1ade include the avoidance of general anesthesia and
its associated ris1s, as !ell as the provision of ecellent post$operative analgesia !hen using a continuous techni(ue.
Central neuraial bloc1ades are considered safe, provided preventive measure are ta1en, patients are monitored
ade(uately, and complications treated promptly.
The most common hemodynamic serious complications from neuroial bloc1ade are hpotension and bradycardia. During
the last three decades, several articles !ere published in the literature describing cardiac arrests fatalities, mainly during
spinal anesthesia. These fatalities !ere described as unepected and etremely rare. T!o large prospective studies
reported an overall incidence of =.< cases of cardiac arrest for every "#.### spinal anesthetics. .uch figures are fre(uent
compared !ith a rate of one case of cardiac arrest for every "#.### epidural anesthetic, and ".D cases of cardiac arrests
for every "#.### anesthetics in general. ' high '.' physical status and advanced age of patients could contribute to
such cardiac arrest fatalities, but these t!o factors !ere sometimes absent. +n a closed claim analysis reported ";
arrests !ith si mortalities in young healthy patients undergoing minor surgical procedures. 5f the eight survivors, seven
had serious neurological damage
The circulatory etiology of this complication during neuraial bloc1ade is directly or indirectly related to the bloc1ade of
the sympathetic afferents that produce vasodilatation on the arterial and venous side of the circulation, causing
hypotension, reduced venous return to the right heart, and imbalance bet!een the sympathetic and the
parasympathetic system, !hich, if not treated promptly, initiate reflees that cause severe bradycardia and cardiac
arrest.
Conclusion6 .erious complications resulting from spinal and epidural anesthesia are rare, because of this rarity, their
eistence might be omitted and overloo1ed in usual clinical practice. 'ccurate preoperative evaluation, ta1ing in
consideration the ris1 factors for the development of this complication, preparedness, vigilance and ade(uate
monitoring, may decrease the occurrence of this complication and improve patient safety.
.afety lies in fear[ Billiam .ha1espeare.

.europatia diabetic/ Aspecte noi
Diabetic Geuropathy. Ge! 'spects
#dit2 Blan
JadQ %a!is Carmel Medical Center, 5aifa, Israel

Diabetic neuropathy is a common complication of both type " and type % diabetes. Geuropathy plays a major role in the
development of foot ulcers, !hich cause an enormous effect on (uality of life for the patient 3especially if amputation
becomes necessary4 and is also responsible for a very large health and social services ependiture. %#$9#& of individuals
!ith type % diabetes develop neuropathy. Type " diabetics usually develop neuropathy after more than "# years of living
!ith the disease. DM is predicted to afflict %%# million people !orld!ide, 9#$=#& of patients !ith DM develop long$term
complications of peripheral neuropathy, "#$%#& of these patients eperience pain as a steady aching or burning pain
3hyperalgesia, allodynia, and paresthesia4. Patients !ith Peripheral Geuropathic Pain eperience significant Comorbid
.ymptoms6 difficulty sleeping, lac1 of energy, depression, aniety. Painful diabetic neuropathy may interfere !ith
general activity, mood, mobility, !or1, social relations, sleep, leisure activities and enjoyment of life. Therefore, the
treatment of DG is comple and multidisciplinary. This presentation shall discuss ne! aspects in the treatment of
Diabetic Geuropathy6 2vidence Based @ecommendations of +'.P 3Pain,%##D, Dvor1in4. Ge! ?uidelines given by G+C2
3Gational +nstitute for ,ealth and Clinical 2cellence $ U>4, 2AG. ?uidelines 3%#"# 2uropean 8ournal of Geurology4 on the
pharmacological treatment of neuropathic pain, the ne! recommendations of +'.P Congress, Milano %#"%. 'll of this
+nstitutes recommend for the first line treatment in DG6 Pregabaline, Duloetine, ?abapentine, and for the second line$
5pioids or combinations. These recommendations are based on large @CTs from Conchrane data base and Medline. Gon$
pharmacological treatments6 2lectrical stimulation 3spinal drug delivery, sympathetic neurolytic boc1, nerve ablation4
alone or in combination !ith drug therapy give a significant improvement in the (uality of life.

'indromul durerii cronice postchirurgicale
Chronic Postoperative Pain .yndrome
;" Leam'u
Uni!ersitQ of Jouis!ille S=M, %epartment of ;nest2esiologQ and )erioperati!e Medicine, Gentuc4Q, US;

?n ultimii ani sindromul durerii cronice postoperatorii 6%C)=7 a stimulat interes crescut din partea aneste&i9tilor"
Sindromul %C)= are o inciden' !ariail raportat n literatur" Se pare c are mecanisme patofi&iologice multiple, cu o
important component neuropatic" #(ist mul'i factori predispo&an'i, n legtur at*t cu pacientul, c*t 9i cu tipul de
c2irurgie" ?n aceast pre&entare se !or discuta factorii de risc, predictorii, ca 9i teoriile patofi&iologice care stau la a&a
modalit'ilor de pre!enire a sindromului %C)="
;nalge&ia multimodal este central n pre!enirea 9i tratamentul sindromului %C)="
Biliografie3
+"<et&laff :#, Jautsen2eiser F, #stafanous FG" %r" George Crile$#arlQ contriutions to t2e t2eoretic asis for tTentQ$first
centurQ pain medicine" Reg ;nest2 )ainMed -,,CU-A3F,,$F,E" -"Ge2let 5" Surgical stress and postoperati!e outcome$
from 2ere to T2ereV R;)M -,,FU @+6+73 CH$E- @"S2ite )F, Ge2let 5" Impro!ing pain management" S2at are t2e
unresol!ed issuesV ;nest2esiol -,+,U ++-3 --,$--E" C"Ge2let 5, %a2l :B" ;nest2esia, surgerQ, and c2allenges in
postoperati!e reco!erQ" Jancet -,,@U @F-3+A-+$D E"Soolf C:" )ain3 Mo!ing from SQmptom Control toTard Mec2anism$
Specific )2armacologic Management ;nn Intern Med" -,,CU+C,3CC+$CE+" F"Soolf C:" Central Sensiti&ation$Unco!ering
t2e Relation etTeen )ain and )lasticitQ" ;nest2esiologQ -,,HU +,F3DFC$H H" )er4ins FM, Ge2let 5" C2ronic pain as an
outcome of surgerQ" ; re!ieT of predicti!e factors" ;nest2esiologQ -,,,U A@3 ++-@$++@@" D" Ge2let 5, :ensen <S, Soolf
C:" )ersistent postsurgical pain3 ris4 factors and pre!ention" Jancet -,,FU @FH3 +F+D$+F-E" A" Lira/ G, RoTot2am %:"
)ersistent postoperati!e pain3 T2ere are Te noTV Britis2 :ournal of ;naest2esia -,++U +,H6+73 -E$-A" +," Ge2let 5,
Rat2mell :)" )ersistent postsurgical pain" <2e pat2 forTard t2roug2 etter design of clinical studies" ;nest2esiol -,+,U
++-3 E+C$E+E"

Chronic postoperative pain 3CP5P4 syndrome has stimulated increased interest for anesthesiologists in recent years. +ts
incidence is variably reported in the literature. CP5P appears to have multiple pathophysiologic mechanisms !ith a
strong neuropathic component. Predisposing factors are multiple, both patient$related and surgery$related. @is1 factors,
predictors, and pathophysiologic theories considered in the preventative strategies of CP5P !ill be revie!ed. Multimodal
analgesia is central in the prevention and treatment of CP5P syndrome. @eferences6
".Tet-laff 82, *autsenheiser A, 2stafanous A?. Dr. ?eorge Crile$2arly contributions to the theoretic basis for t!enty$first
century pain medicine. @eg 'nesth PainMed %##;K%:6=##$=#<. %.>ehlet ,. .urgical stress and postoperative outcome$
from here to !hereC @'PM %##=K 9"3"46 ;D$<% 9.Bhite PA, >ehlet ,. +mproving pain management. Bhat are the
unresolved issuesC 'nesthesiol %#"#K ""%6 %%#$%%<. ;.>ehlet ,, Dahl 8B. 'nesthesia, surgery, and challenges in
postoperative recovery. *ancet %##9K 9=%6":%"$0 <.Boolf C8. Pain6 Moving from .ymptom Control to!ard Mechanism$
.pecific Pharmacologic Management 'nn +ntern Med. %##;K";#6;;"$;<". =.Boolf C8. Central .ensiti-ation$Uncovering
the @elation bet!een Pain and Plasticity. 'nesthesiology %##DK "#=60=;$D D. Per1ins AM, >ehlet ,. Chronic pain as an
outcome of surgery. ' revie! of predictive factors. 'nesthesiology %###K :96 ""%9$""99. 0. >ehlet ,, 8ensen T., Boolf C8.
Persistent postsurgical pain6 ris1 factors and prevention. *ancet %##=K 9=D6 "="0$"=%<. :. Giraj ?, @o!botham D8.
Persistent postoperative pain6 !here are !e no!C British 8ournal of 'naesthesia %#""K "#D3"46 %<$%:. "#. >ehlet ,,
@athmell 8P. Persistent postsurgical pain. The path for!ard through better design of clinical studies. 'nesthesiol %#"#K
""%6 <";$<"<.

'indromul durerii regionale complexe
Comple @egional Pain .yndrome
S" Brill
<el ;!i! Medical Center, <el ;!i!, Israel

Comple regional pain syndrome 3C@P.4 is a chronic pain condition that is believed to be the result of dysfunction in the
central or peripheral nervous systems. Typical features include dramatic changes in the color and temperature of the
s1in over the affected limb or body part, accompanied by intense burning pain, s1in sensitivity, s!eating, and s!elling.
C@P. + is fre(uently triggered by tissue injuryK the term describes all patients !ith the above symptoms but !ith no
underlying nerve injury. Patients !ith C@P. ++ eperience the same symptoms but their cases are clearly associated !ith a
nerve injury. 5lder terms used to describe C@P. are Prefle sympathetic dystrophy syndromeP @.D, Pcausalgia, .udec1Zs
atrophy. Pathophisiology6 there are fe! theories trying to eplain this disease6 "4 sympathetic pain results from tonic
activity in myelinated mechanoreceptor afferents, %4 +nput causes tonic firing in neurons that are part of a nociceptive
path!ay. 94 'bnormality in the peripheral nervous system. @ecent interest has focused on an immune$mediated
mechanism. C@P. occurs in approimately "$"<& of peripheral nerve injury cases. +t usually occurs secondary to
fractures, sprains, and trivial soft tissue injury. The incidence after fractures and contusions ranges from "#$9#&. The
upper etremities are more li1ely to be involved than the lo!erK !omen predominate in a range of =#$0#& of cases.
There is no cure for C@P., but the symptoms can be improved. The main focus is on relieving the symptoms and helping
people !ith this syndrome live as normal a life as possible. Physical and occupational therapy should be started as early
as possible. .tarting an eercise program and learning to 1eep joints and muscles moving may prevent the disease from
getting !orse and help you perform everyday activities. Medications may be used, including pain medicines, steroids,
certain neuropathic pain drugs, bone loss medications, and antidepressants. Psychological support is essential, such as
cognitive behavioral therapy or psychotherapy. .urgical or invasive techni(ues can be tried6 nerve bloc1, .pinal cord
stimulator and surgical sympathectomy. .urgical or invasive techni(ues may be tried6 nerve bloc1s, .pinal cord
stimulator, and surgical sympathectomy. Prognosis is better !ith an early diagnosis. +f the condition is not diagnosed
(uic1ly, changes to the bone and muscle may get !orse and may not be reversible.

0ltrasonografia &ersus ghidarea radiologic $ ,eci(ie medical
Ultrasound )ersus O$@ay6 ' Bin$Bin Medical Decision
;" Grunfeld
S2ea 5ospital <el 5as2omer, Ramat Gant, Israel

+s there anyone !ho doesnZt !ant to be successful in his professionC +t all depends on the 1no!ledge, eperience,
technological base. The medical literature provides medical evidence and level of recommendation. +s everything clearC +
donZt thin1 + have a real ans!er. Most studies !ere performed by ultrasound eperts, !hich may limit the ability to
generali-e results to less eperienced practitioners. + shall present the Ultrasound and O$ray techni(ues in the diagnosis
and guide in our every day !or1. The use of O$ray in the diagnosis and guidance suffers of lac1 of accuracy in the
evaluation of the soft tissue, but it is very helpful in special circumstances. Many times the Ultrasound is used in the ne!
situations !hich do not overlap the recommendation of the fluoroscopy. +s the ultrasound vs. $ray a medical decisionC
The ans!er is Les, but not as a situation of competition, rather a situation of integrating the case itself !ith the
technological basis, !ith the accuracy of the data obtained, !ith the up to date medical information provided and the
personal eperience. ?eneral conclusions6
"4 U. to be superior or e(ual to the comparator techni(ue, and none sho!ed that ultrasound guidance !as clearly
inferior or dangerous.
%4 ultrasound offers proven advantages in bloc1 characteristics, particularly reduced onset time and improved
intermediate measures of success 3bloc1 specific4.
94 no evidence that ultrasound eliminates complications. Bhat !e do epect in the futureC Maybe U. !ith the needle
passing through U. probeC Maybe a useful CT mobile 3C$arm4C Maybe. The solution to a problem ... determined other
problems. .o must beM This is mechanism for advancement. The presentation is based on the epression P' picture is
!orth "### !ordsMP.

articularitile hemodinamicii centrale %i periferice la pacienii n &1rst
Peculiarities of Central and Peripheral ,emodynamics in 2lderly Patients
S" Wandru, <" <&l!an, =" ;rnut, <" ;mrosii, C" #remia
Centrul La'ional Wtiin'ifico$)ractic Medicin Urgent, C2i9inu, Repulica Moldo!a

?naintarea n !*rst se asocia& cu modificri at*t morfologice, c*t 9i func'ionale ale sistemului cardio!ascular" Ja ni!elul
cordului cre9te rigiditatea miocardic, se reduce progresi! timpul umplerii diastolice precoce 9i rata umplerii
!entriculare, se ma/orea& contriu'ia atriului st*ng la reali&area !olumului telediastolic" Ja ni!elul sistemului !ascular
cre9terea rigidit'ii arterelor este responsail de cre9terea presiunii sistolice 9i a 2ipertrofiei !entriculare st*ngi care
contriuie la accentuarea rigidit'ii miocardice 9i apari'ia disfunc'iei diastolice" =dat cu a!ansarea n !*rst scade
rspunsul la stimularea X$adrenoreceptorilor 9i Y$adrenoreceptorilor, este diminuat reglarea arorefle( a frec!en'ei
contrac'iilor cardiace"
Scopul studiului a constat n studierea particularit'ilor 2emodinamicii centrale 9i periferice la pacien'ii n !*rst" ; fost
utili&at metoda reografiei, care permite studierea intensit'ii circula'iei centrale 9i periferice, e!aluarea tonusului
!ascular"
Studiul a fost efectuat pe patru loturi de pacien'i3 +7 pacien'i cu !*rsta de la +D ani p*n la E, aniU -7 pacien'i cu !*rsta
de la E+ ani p*n la F, aniU @7 pacien'i cu !*rsta de la F+ ani p*n la H, aniU C7 pacien'i cu !*rsta de la H+ ani p*n la DD
ani"
Re&ultatele in!estiga'iilor au elucidat modificri esen'iale ale parametrilor studia'i 6deitul cardiac, !olumul taie,
!olumul telediastolic 9i telesistolic, indicele cardiac, dicrotic 9i diastolic, lucrul !entricului st*ng, presiunea pulsatil,
telediastolic a !entricului st*ng, presiunea !enoas central, re&isten'a !ascular sistemic, presiunea sistolic,
diastolic 9i medie, timpul de rsp*ndire a undei pulsatile, timpul de umplere !ascular lent si rapid7 la pacien'ii n
!*rst n compara'ie cu pacien'ii din primul lot"

'geing is associated !ith both morphological and functional changes of the cardiovascular system. The major changes
associated !ith ageing in the human heart include increased myocardial stiffness, progressively reduced early diastolic
filling and ventricular filling rate, increased atrial contribution to left ventricular end$diastolic volume. 'ge$related
elevated artery stiffness is responsible for the rise in systolic pressure and left ventricular hypertrophy !hich contributes
to increased myocardial stiffness and diastolic dysfunction. The responsiveness to \$ and ]$adrenoceptors stimulation
decreases !ith ageing as !ell as baroreceptor refle regulation of the fre(uency of heart rate.
The aim of this investigation !as to study the peculiarities of central and peripheral hemodynamics in elderly patients by
using the method of rheography.
The study !as carried out on four groups of patients6 "4 aged "0$<# years old, %4 aged <"$=# years old, 94 aged ="$D#
years old, ;4 aged D"$00 years old.
The results of investigations sho!ed essential changes of the studied parameters 3cardiac output, stro1e volume, end
diastolic and end systolic volume, cardiac inde, dicrotic and diastolic indees, left ventricular !or1, pulsatile pressure,
left ventricular end diastolic pressure, central venous pressure, systemic vascular resistance, systolic, diastolic and mean
pressure, vascular filling time4 in the group of elderly patients in comparison !ith young patients.

2estionarea tratamentelor medicamentoase cronice n perioada perioperatorie
Management of Chronic Drug Treatments in the Perioperative Period
;" Beli
Uni!ersitatea de Stat de Medicin 9i Farmacie 0Licolae <estemi'anu1, Catedra ;neste&iologie 9i Reanimatologie,
C2i9inu, Repulica Moldo!a

=iecti!3 #!aluarea corectitudinii gestionrii tratamentelor medicamentoase cronice n perioada perioperatorie"
Material 9i metode3 Studiu comparati!, retrospecti!, de co2ort, Spitalul de Urgen', C2i9inu, Repulica Moldo!a 6E+
pacien'i7 !s" C5U dZ;ngers, Fran'a 6CD pacien'i7, ;S; @, eneficiari de colecistectomie laparoscopic" ?nregistrate toate
tratamentele medicamentoase cronice 6<MC7" Gestionarea perioperatorie a <MC comparat cu recomandrile M;);R,
-,,H" Re&ultatele pre&entate drept pre!alen'a prescrip'iilor <MC, . 9i 6erori de gestionare perioperatorie, .7"
Re&ultate3 C5U dZ;ngers3 antiulceroase A-., JMS5 DD., ;ILS DE., antiagregante DE., anti2ipertensi!e HE., statine
FH., etalocante F,., analge&ice centrale EC., en&odia&epine CC., antidiaetice orale C,., diuretice -H.,
antiaritmice -+., electroli'i 6G>7 +E., anticoagulante indirecte +@., insulin +@., antianginoase +,., corticosteroi&i
D., antidepresi!e F., anti2istaminice F., antiiotice C., la(ati!e C., !asodilatatoare C., J$tiro(in C., antiemetice
-., citostatice -., ron2odilatatoare -., 2erale -., antigutoase -." Spitalul de Urgen'3 anti2ipertensi!e FA. 6-A.7U
antianginoase -A.U insulin -D.U antidiaetice orale -F. 6+E.7, antiagregante -F. 6+E.7U diuretice -F. 6-@.7U
en&odia&epine +C., anticoagulante indirecte D. 6-E.7U in2iitori fosfodiestera& D.U antiepileptice F.U
ron2odilatatoare F.U nootrope F.U antidepresi!e C. 6E,.7U ;ILS C.U fermen'i pancreatici C.U 2epatoprotectoare C.U
etalocan'i -.U corticosteroi&i -."
Conclu&ii3
+" Constatate diferen'e semnificati!e n spectrul, grupele 9i numrul <MC n C5U dZ;ngers 6Fran'a7 !s" Spitalul de
Urgen' 6C2i9inu, Repulica Moldo!a7U
-" Pero erori de gestionare a <MC perioperatoriu la pacien'ii din C5U dZ;ngersU
@" ?n lipsa unui referen'ial $ nregistrate erori frec!ente de gestionare perioperatorie a <MC la pacien'ii din Repulica
Moldo!a pentru antidepresi!e, anti2ipertensi!e, anticoagulante indirecte, diuretice, antidiaetice orale 9i
antiagregante"

5bjective6 'de(uacy assessment of the chronic drug treatments 3CDTs4 management in the perioperative period.
Material and Method6 Bas performed a comparative, retrospective, cohort study. Bere recorded all CDTs from <"
patients, treated at Chi^in_u 2mergency ,ospital 3C2,4, @epublic of Moldova and from ;0 patients, treated at University
'ngers ,ospital 3'U,4, Arance. 'll patients !ere '.' 9, after laparoscopic cholecystectomy. 'de(uacy of CDTs
perioperative management !as compared through M'P'@ %##D recommendations. @esults are presented as CDTs
prescriptions prevalence 3&4 and 3prevalence of management errors, &4.
@esults6 'U,6 proton pump inhibitors :%&, *MB, 00&, G.'+Ds 0<&, antiplatelet drugs 0<&, antihypertensives D<&,
statins =D&, betabloc1ers =#&, central analgesics <;&, ben-odia-epines ;;&, oral antidiabetics ;#&, diuretics %D&,
antiarrhythmics %"&, electrolytes 3>74 "<&, indirect anticoagulants "9&, insulin "9&, antianginal "#&, corticosteroids
0&, ..@+s =&, ,"$bloc1ers =&, antibiotics ;&, laatives ;&, vasodilators ;&, *$thyroin ;&, antiemetics %&, cytostatics
%&, bronchodilators %&, herbal %&, antigout %&. C2,6 antihypertensives =:& 3%:&4K antianginal %:&K insulin %0&K oral
antidiabetics %=& 3"<&4, antiplatelet drugs %=& 3"<&4K diuretics %=& 3%9&4K ben-odia-epines ";&, indirect
anticoagulants 0& 3%<&4K PD2i 0&K antiepileptics =&K bronchodilators =&K nootropes =&K ..@+s ;& 3<#&4K G.'+Ds ;&K
pancreatic ferments ;&K hepatic protectors ;&K betabloc1ers %&K corticosteroids %&.
Conclusions6
". .ignificant differences in the CDT spectrum, groups and number !ere found bet!een 'U, and C2,K
%. `ero errors of CDTJ perioperative management !as found among 'U, patients.
9. Are(uent errors of perioperative CDT management !ere identified in C2,, especially for antidepressants,
antihypertensives, indirect anticoagulants, diuretics, oral antidiabetics and antiplatelet agents.

Terapia antiinfecioas inhalatorie la pacientul critic
Inhaled Antibiotic Therapy in Critically Ill Patient
%" Corneci
Uni!ersitatea de Medicin 9i Farmacie 0%r" Carol %a!ila1, Bucure9ti, Rom*nia

;dministrarea agen'ilor antiinfec'io9i pe cale in2alatorie a fost studiat e(tensi! la pacien'ii cu firo& c2istic 9i
ron9iecta&ii" Rspunsul fa!orail o'inut la ace9ti pacien'i, inciden'a n cre9tere n sec'iile de terapie intensi! a
germenilor multire&isten'i, precum 9i concentra'iile ridicate de antiiotic care pot fi o'inute n sput prin in2ala'ie au
re!igorat n ultimul deceniu interesul pentru antiioterapia in2alatorie la pacien'ii din terapie intensi! cu infec'ii
pulmonare se!ere, altele dec*t firo&a c2istic"
%e9i 8;< 6tra2eo$ron9ita asociat !entila'iei mecanice7 a fost considerat un pas intermediar spre 8;) punctul de
!edere actual al ;merican <2oracic SocietQ 6;<S7BInfectious %iseases SocietQ of ;merica 6I%S;7 este c aceasta
repre&int o entitate distinct" Sunt e(per'i care recomand tratamentul antiiotic al 8;<, n special la acei pacien'i cu
oli pulmonare asociate sau cu Teaning dificil, n timp ce alte opinii sunt pentru tratamentul 8;< doar atunci c*nd sunt
identifica'i germeni multire&isten'i" N+,@O"
;ntiioterapia in2alatorie a fost propus pentru tratamentul 8;< cu scopul pre!enirii 8;) 9i pentru tratamentul 8;)"
Sunt trialuri randomi&ate care sus'in c diminuarea ncrcturii acteriene tra2eo$ron9ice prin antiioterapie
in2alatorie repre&int o metod eficient de pre!enire a 8;) N-,C,EO" Ma/oritatea e(per'ilor 9i e!iden'ele actuale nu
recomand utili&area in2alatorie a antimicroienelor pentru pre!enirea 8;) N-,HO" Center for %isease Control 6US;7 9i
Canadian Critical Care SocietQ nu recomand n pre&ent utili&area in2alatorie a antiioticelor pentru pre!enirea 8;) NDO"
Utili&area in2alatorie a agen'ilor antimicroieni n 8;) se a&ea& n pre&ent pe un consens de opinie care recomand
acest tip de tratament doar ca ad/u!ant la terapia sistemic" ;ceast metod suplimentar de tratament nu este
recomandat de unele grupuri de e(per'i a fi utili&at de rutin, ci doar n ca&urile selec'ionate de 8;) cu germeni
multire&isten'i N+,-,DO" Monoterapia antiiotic in2alatorie este sus'inut de pu'ine studii care nu au nc suficient
putere de con!ingere 9i nu este recomandat n pre&ent"
G2idul canadian de aordare a pneumoniei no&ocomiale 65;) 9i 8;)7 are ni!el de recomandare C$- pentru
administrarea in2alatorie a antiioticelor doar ca terapie ad/u!ant n ca&urile cu germeni multire&isten'i sau n ca&ul
e9ecului terapiei antiiotice parenterale 6C$-3 e!iden'e slae pro!enite din trialuri nerandomi&ate, co2orte sau studii
[case$controlled17N+-O"
Concentraia antibioticului la locul infecei pulmonare
<erapia antiinfec'ioas eficient a infec'iilor tractului respirator presupune o'inerea unor concentra'ii adec!ate 9i
pentru suficient timp la locul infec'iei3 'esut ron9ic, paren2im pulmonar, stratul fluidic e(tracelular, secre'ii
intraluminale 6sput7 9i celule inflamatorii"
;gen'ii lipofilici 6carapenemi, aminoglico&ide, eta$lactami7 penetrea& u9or ariera nefenestrat a !aselor pulmonare,
indiferent de pre&en'a inflama'iei 9i atinge ni!ele eficiente n secre'iile ron9ice" Cu toate acestea, s$a oser!at c
aminoglico&idele administrate sistemic 6gentamicin, toramicin7 reali&ea& concentra'ii sc&ute 6+,$@,.7 n stratul
fluidic epitelial al!eolar NDO" ?n sc2im, agen'ii nonlipofilici 6c2inolone, macrolide, tetracicline, clindamicin7 depind de
pre&en'a inflama'iei pentru a penetra aceast arier" ;stfel, reali&area de concentra'ii eficiente la locul infec'iei prin
administrarea sistemic a agen'ilor antiinfec'io9i este limitat de pre&en'a inflama'iei, a arierei !asculare nefenestrate
9i de /onc'iunile str*nse ale epiteliului al!eolar N+@O"
;dministrarea in2alatorie de antiiotic reali&ea& concentra'ii semnificati! mai mari at*t n sput 9i epiteliul ron9ic, c*t
9i n paren2imul pulmonar n compara'ie cu administrarea intra!enoas N+,H,DO" Instila'ia tra2eal de agen'i
antiinfec'io9i determin concentra'ii crescute ale drogului n sput 9i c2iar sistemic N+CO, dar nu reli&ea& o distriu'ie
omogen n cile aeriene inferioare"
Concentra'iile sc&ute de antiiotic n lumenul cii aeriene o'inute prin administrarea sistemic au poten'ial de a
induce formarea de iofilme" ;ntiioterapia in2alatorie poate reali&a concentra'ii crescute de antiiotic n lumen 9i
astfel poate suprima formarea iofilmului 9i poate reduce inciden'a germenilor multire&isten'i"
;sor'ia sistemic a antiioticului administrat in2alator poate fi crescut la pacien'ii cu 8;) datorit infec'iei 9i
inflama'iei, dar ni!elurile sanguine de antiiotic sunt inadec!ate pentru a trata infec'ia sistemic care apare frec!ent la
pacien'ii cu 8;)" ;ceste este moti!ul pentru care nu este recomandat ca antiioterapia in2alatorie s fie utili&at ca
singur metod antiinfec'ioas n 8;)"
Antibiotice utili(ate inhalator
Solu'ia ideal pentru u&ul in2alator treuie s fie steril, apirogen, lipsit de pre&er!an'i 9i cu p5$ul, osmolalitatea 9i
salinitatea a/ustate pentru a se e!ita iritarea cilor aeriene" Manipularea solu'iei se !a face steril ntruc*t contaminarea
acesteia !a a!ea drept consecin' pneumonia no&ocomial"
<oramicina in2alatorie 6<oi\, Bramito\7 este o solu'ie steril, fr pre&er!an'i, apirogen, cu p5 de F 9i salinitate
a/ustate pentru a fi neuli&at" Reali&ea& concentra'ii ridicate n sput, cu asor'ie sistemic minim" ;re un spectru
de ac'iune larg asupra germenilor Gram negati!i, inclusi! )" aeruginosa, efectele actericide fiind dependente de
concentra'ie" %o&a recomandat este de @,, mg de dou ori pe &i 6adul'i 9i copii peste F ani7" #fectele ad!erse includ
tinitus, to(icitate !estiular 9i alterarea !ocii NHO"
; fost utili&at cu re&ultate une pentru eradicarea )" aeruginosa la pacien'ii cu firo& c2istic" ?n 8;) re&ultatele au
fost mai une n compara'ie cu gentamicina, dar studiile sunt pe un numr mic de pacien'i"
Gentamicina a fost utili&at in2alator [off$lael1 cu re&ultate satisfctoare de asemenea n firo&a c2istic 9i n
tra2eoron9it, n do&e de D,$+-, mg la D ore"
Colistimet2atul sodic 6)romi(in\, <adim\, Colistine\, ColomQcin\ Colistin ;ntiiotice\7
Msurtorile concentra'iei de colistin la ni!elul stratului de fluid epitelial al!eolar o'inut prin administrare sistemic a
condus la re&ultate contradictorii" Colistinul este o molecul cu greutate molecular mare 9i lipofilicitate redus care ar
e(plica !alorile mici ale concentra'iei gsite la aceste msurtori" = e(plica'ie a eficacit'ii, totu9i, a colistinului
intra!enos n infec'ia pulmonar cu germeni multire&isten'i este pre&en'a inflama'iei n &onele afectate 9i fa!ori&area,
astfel, a difu&iei la locul infec'iei"
?n contrast, concentra'ia de colistin n stratul fluidic epitelial atinge !alori ridicate n administrarea in2alatorie"
Concentra'ii ridicate ale antiioticului n sput o'inute n urma administrrii su form de aerosoli se nt*lnesc la
ma/oritatea pacien'ilor 9i sunt men'inute apro(" D$+- ore N+CO" <oate acestea sunt argumente pentru a asocia terapia
in2alatorie cu colistin celei intra!enoase cu acela9i drog"
Re!igorarea colistinei ca ultim linie de aprare a coincis cu cre9terea inciden'ei n ultimile dou decenii a tulpinilor
multire&istente de )" aeruginosa 9i ;" aumannii" Re&ultatele fa!oraile o'inute n ultimii ani cu colistin intra!enos n
tratarea acestor tulpini multire&istente 6-E$F-. rat fa!orail de rspuns la tratament7 sunt limitate de amploarea
redus a studiilor"
#(perien'a acumulat prin pu'inele trialuri care au inclus colistina in2alator ca ad/u!ant al antiioterapiei intra!enoase
6inclusi! cu colistin7 este nc 9i mai limitat 9i contradictorie prin prisma prognosticului pacientului n compara'ie cu
loturile martor NH,+,,++,+EO" Important este c n aceste studii nu au fost raportate tulpini de )" aeruginosa 9i ;"
aumannii re&istente la colistin, iar rata de rspuns la tratament este ridicat" <erapia in2alatorie cu colistin asociat
antiioterapiei intra!enoase cu spectru larg, dar fr s includ colistin parenteral nu este recomandat de pu'inele
studii efectuate p*n n pre&ent"
?n Marea Britanie 9i c*te!a state europene este disponiil preparatul special formulat pentru in2alare )romi(in\ 6UG7 cu
ec2i!alen'a + mg I +-"E,, UI 6D, mg I + milion UI7" %o&a/ul n in2alare cu acest produs este de + milion UI la +- ore
pentru pacien'ii peste C, Gg 6E,,",,, UI la +- ore su C, Gg7, cu posiilitatea cre9terii do&ei la -",,,",,, UI la D ore n
ca&ul infec'iilor recurente" )entru administrarea n respira'ie spontan pe masc 6flu( de o(igen de D lBmin7 este
recomandat do&a de +",,,",,, UI NE,HO"
?n Statele Unite colistinul nu a fost nc aproat de ctre F%; 6Food and %rug ;dministration7 pentru utili&area
in2alatorie"
?n Rom*nia e(ist preparatul Colistin ;ntiiotice\, pulere pentru solu'ie perfu&ail $ flacoane de +",,,",,, UI, care
nu con'ine pre&er!an'i 9i ar putea fi utili&at in2alator" ;utori&a'ia actual de punere pe pia' nu are inclus nc 9i
aceast posiilitate de administrare"
Reac'iile ad!erse sistemice ale colistimet2atului sodic includ tulurri neurologice tran&itorii 6pareste&ii periorale, !erti/,
!orire dificil7 9i nefroto(icitate dependent de do&" ?n acest sens, se !a administra cu precau'ie la pacien'ii cu
insuficien' renal 9i se !a e!ita asocierea cu aminoglico&ide" Suprado&area poate determina loc neuro$muscular 9i
stop respirator" Colistimet2atul sodic administrat prin neuli&are poate determina ron2ospasm, dar de intensitate mai
mic dec*t colistinul sulfat" = prolem te2nic este apari'ia prin neuli&are a spumei aundente, ceea ce limitea&
posiilitatea unei do&ri e(acte a medicamentului"
Colistinul in2alator este recomandat n pre&ent s fie utili&at ca ad/u!ant al terapiei intra!enoase la pacien'ii cu 8;) cu
germeni multire&isten'i urmrind atent func'ia renal 9i e!it*ndu$se drogurile nefroto(ice NEO" %o&ele 9i durata
tratamentului sunt nc n studiu" %urata terapiei n di!erse studii a !ariat ntre H$+C &ile, dar este posiil ca aceast
durat s poat fi redus la H &ile 6sunt necesare studii suplimentare7NHO"
;&treonamul, un monoactam nou cu acti!itate antipseudomonal, este studiat cu re&ultate promi'toare p*n acum
pentru eradicarea infec'iei cu )s" ;eruginosa la pacien'ii cu firo& c2istic"
;mfotericina B in2alatorie a fost administrat su form de deo(Qc2olate sau lipo&omal pentru profila(ia 9i
tratamentul infec'iilor fungice cu ;spergillus la pacien'ii cu risc mare 6oli 2ematologice, neutropenie7, dar metoda
rm*ne nc n fa&a de cercetare"
)entamidina in2alatorie n do& de @,, mgBlun este utili&at n profila(ia pneumoniei cu )neumocQstis carinii la
pacien'ii cu ;I%S"
;lte antiiotice utili&ate in2alator n pre!enirea 9i tratamentul 8;) sunt ami4acina 9i !ancomicina, dar sunt necesare
studii suplimentare pentru a certifica utilitatea acestora NDO"
Loua genera'ie de neuli&oare, disponiilitatea formelor farmaceutice de antiiotice faricate special pentru
administrarea in2alatorie 9i !iitoarele trialuri controlate randomi&ate !or staili locul ocupat de antiioterapia
in2alatorie n tratamentul infec'iilor pulmonare se!ere la pacientul de terapie intensi!" #ste posiil ca acest tip de
tratament s repre&inte n !iitor modalitatea principal de pre!enire a 8;), dar aceasta !a treui demonstrat prin
studii riguroase" Indica'iile clinice, do&a/ul antiioticului administrat in2alator 9i profilul de siguran' impun, de
asemenea, cercetri suplimentare"
Biliografie3
+" ;u$Sala2 <, %2and R" In2aled ;ntiiotic <2erapQ for 8entilator$;ssociated <rac2eoronc2itis and 8entilator$
;ssociated )neumonia3 an Update" ;d! <2er 6-,++7 -D6A73H-D$HCH
-" MacIntQre LR, Ruin G" S2ould ;erosoli&ed ;ntiiotics Be ;dministered to )re!ent or <reat 8entilator$;ssociated
)neumonia in )atients S2o %o Lot 5a!e CQstic FirosisV Respir Care -,,HUE-6C73C+F]C-+
@" Lseir S, Fa!orQ R, :o&efoTic& # et al" ;ntimicroial treatment for !entilator$associated trac2eoronc2itis3 a
randomi&ed, controlled, multicenter studQ" Critical Care -,,D, +-3RF-
C" )almer JB, Smaldone GC, C2en :: et al" ;erosoli&ed antiiotics and !entilator$associated trac2eoronc2itis in t2e
intensi!e care unit" Crit Care Med -,,DU @F3-,,D$-,+@
E" Falagas M#, Siempos II, Bli&iotis I;, Mic2alopoulos ;" ;dministration of antiiotics !ia t2e respiratorQ tract for t2e
pre!ention of ICU$ac^uired pneumonia3 a meta$analQsis of comparati!e trials" Crit Care -,,FU+,6C73R+-@"
F" ;grafiotis M, Siempos II, Falagas M#" Fre^uencQ, pre!ention, outcome and treatment of !entilator$ associated
trac2eoronc2itis3 sQstematic re!ieT and meta$analQsis" Respir Med" -,+,U+,C3@-E$@@F
H" %2and R" <2e Role of ;erosoli&ed ;ntimicroials in t2e <reatment of 8entilator$;ssociated )neumonia" RespiratorQ
Care :ulQ -,,H, 8ol E- no H3 DFF$DDC
D" JuQt C$#, Comes ;, Lies&4oTs4a ;, <rouillet :$J, C2astre :" ;erosoli&ed antiiotics to treat !entilator$associated
pneumonia" Current =pinion in Infectious %iseases -,,A, --3+EC$+ED
A" Ioannidou #, Siempos II, Falagas M#" ;dministration of antimicroials !ia t2e respiratorQ tract for t2e treatment of
patients Tit2 nosocomial pneumonia" : ;ntimicro C2emot2erap" -,,HUF,3+-+F$+--F"
+," Mic2alopoulos ;, Gasia4ou SG, Mastora P et al" ;erosoli&ed colistin for t2e treatment of nosocomial pneumonia due
to multidrug$resistant Gram$negati!e acteria in patients Tit2out cQstic firosis" Critical Care -,,E, A3RE@$REA
++" 5amer %5" <reatment of Losocomial )neumonia and <rac2eoronc2itis Caused Q Multidrug$Resistant
)seudomonas aeruginosa Tit2 ;erosoli&ed Colistin" ;m : Respir Crit Care Med 8ol +F-" pp @-D]@@,, -,,,
+-" Rotstein C, #!ans G, Born ; et al" ;MMI Canada Guidelines3 Clinical practice guidelines for 2ospital$ac^uired
pneumonia and !entilator$associated pneumonia in adults" Can : Infect %is Med Microiol 8ol +A Lo + :anuarQBFeruarQ
-,,D
+@" Giem S, Sc2entag ::" Interpretation of ;ntiiotic Concentration Ratios Measured in #pit2elial Jining
Fluid";ntimicroial ;gents and C2emot2erapQ,:an" -,,D,p" -C]@F
+C" Marc2and S, Goin ), Brillault : et al" ;erosol <2erapQ Tit2 Colistin Met2anesulfonate3 a Biop2armaceutical Issue
Illustrated in Rats" ;ntimicroial ;gents and C2emot2erapQ, Sept" -,+,, p" @H,-]@H,H
+E" ;ntoniu S;, Co/ocaru I"" In2aled colistin for loTer respiratorQ tract infections" #(pert =pin" %rug %eli!" 6-,+-7
A6@73@@@$@C-

Aspiraia pulmonar intraaneste(ic
Pulmonary 'spiration During 'naesthesia
I" ;calo!sc2i
Uni!ersitatea de Medicin i Farmacie 0Iuliu 5aieganu1, Clu/$Lapoca, Rom*nia

;spira'ia pulmonar a con'inutului gastric a fost semnalat n anul +ACF de ctre C"J" Mendelson la un numr de FF
paciente operate pentru seciune ce&arian" Repre&int o complicaie intraaneste&ic se!er, asociat cu o moriditate
i mortalitate ridicat" ?n pre&ent, regurgitarea i aspiraia pulmonar ocup locul E ntre complica'iile care apar n cursul
aneste&iei generale" Se aprecia& o inciden' de un ca& la -,,,$@,,, aneste&ii, mai frec!ente la copii" Factorii care cresc
riscul de aspira'ie sunt c2irurgia de urgen' 6+BDH@ ca&uri fa de +BCECC n c2irurgia de elec'ie7, aneste&ia n ostetric,
intua'ia tra2eal n prespital, precum i !*rsta peste F, ani" Riscul cel mai ridicat de aspira'ie l au pacien'ii cu stomac
plin, gra!idele, 9i cei cu motilitatea gastrointestinal alterat 6esofagit de reflu(, 2ernie 2iatal7"
;spiraia sucului gastric produce pneumonit de aspira'ie, cunoscut 9i ca sindromul Mendelson, repre&ent*nd o
afectare c2imic a parenc2imului pulmonar" )entru producerea le&iunilor este necesar un p5 al lic2idului aspirat de su
-,E 9i un !olum de cel pu'in -E ml 6,,C mlB4g7" Clinic se manifest prin tuse, ta2ipnee, ron2ospasm sau, ntr$o prim
fa& asimptomatic, conduce dup -$E ore la instalarea unei insuficien'e respiratorii se!ere 6;JI, ;R%S7"
Se!eritatea complica'iei, cu e!oluie spre decesul pacientului n pofida tratamentului aplicat, impune aplicarea
msurilor de profila(ie, const*nd n asigurarea unei perioade de post nainte de aneste&ie 9i practicarea induc'iei 9i
intua'iei tra2eale n sec!en' rapid"
ostul preaneste(ic
?n pre&ent numeroase studii au demonstrat c postul prelungit nu este necesar i n multe ca&uri poate fi duntor,
ntruc*t agra!ea& tulurrile metaolice postagresi!e"
?n a&a cuno9tin'elor de fi&iologie pri!ind e!acuarea gastric, g2idurile europene i americane stipulea& necesitatea
postului preaneste&ic, dar limitea& inter!alul de timp la - ore pentru lic2ide clare 9i F$D ore pentru solide, laptele fiind
considerat aliment solid 6+7"
Inducia n sec&en rapid
#ste a doua modalitate de profila(ie a aspira'iei tra2eo$ron9ice 9i parcurge mai mul'i pa9i 6-7" Studiile consacrate
acestui suiect au scos n e!iden' importan'a unora dintre msurile propuse 9i au pus n discuie limitele altora"
Utilitatea preo(igenrii a fost demonstrat de #dmar4 i cola", !entila'ia pe masc cu o(igen +,,. determin*nd
prelungirea duratei apneei fr 2ipo(emie la H minute 6@7" Utili&area Succinilcolinei pentru rela(area muscular n
induc'ie rm*ne standardul de aur al procedurii" #fectele secundare produse de Succinilcolin repre&int un de&a!anta/,
dar eneficiul precurari&rii este minim" )entru e!itarea efectelor secundare se recomand nlocuirea Succinilcolinei cu
Rocuronium, un rela(ant muscular nedepolari&ant cu timpul de laten' cel mai scurt, apropiat de cel al Succinilcolinei"
)rin administrare de Sugammade(, durata lung a locului neoruomuscular poate fi scurtat, su timpul de
antagoni&are spontan al locului produs de Succionilcolin 6C7" In/ectarea unei do&e mici de opioid este necesar
ntruc*t ameliorea& condi'iile de intua'ie 9i asigur stailitate 2emodinamic n timpul intua'iei" Se prefer do&e mici
de FentanQl sau ;lfentanil"
%intre sec!en'ele induc'iei i intua'iei rapide, dou recomandri sunt contro!ersate3 recomandarea de a nu !entila
pacientul n cursul apneei dup administrarea de Succinilcolin 9i eficien'a presiunii pe criocoid 6mane!ra Sellic47, ca
msur de pre!enire a regurgitrii" S$a constatat c n E@. din ca&uri, esofagul este lateral fa' de corpul !erterei CE
fa' de care se reali&ea& compresiunea esofagului prin apsare pe cricoid 6E7" %e asemenea, presiunea pe cricoid poate
produce complica'ii 9i este practicat incorect de mul'i aneste&i9ti" Cu toate c eficien'a manoperei este pus la ndoial
n multe centre, apsarea cricoidului n cursul induc'iei n sec!en' rapid continu s fie men'inut ca un gest
oligatoriu n g2idurile societ'ilor de aneste&ie"

Referine3
+" Smit2 I", Gran4e )",Murat I" et al" )erioperati!e fasting in adults and c2ildren3 guidelines from t2e #uropean SocietQ of
;naest2esiologQ" #uropean :ournal of ;naest2esiologQ -,++U -D3 EEF$EFA
-" Fried #B" <2e rapid se^uence induction re!isited3 =esitQ and Sleep ;pnea SQndrome" ;nest2esiologQ Clinics Lort2
;merica -,,EU -@3EE+$EFC"
@" #dmar4 J, Gosto!a$;2erdan G, #nlund M et al" =ptimal o(Qgen concentration during induction of general anest2esia"
;nest2esiologQ -,,@U AD3 -D$@@"
C" Sorensen MG, Bretlan C, Got4e MR"et al" Rapid se^uence induction and intuation Tit2 rocuroniu$sugammade(
compared Tit succinQlc2oline3 a randomised trial" Britis2 :ournal of ;naest2esia -,+-U +,D3FD-$FDA"
E" Smit2 G:, %oranoTs4i : , Rip G et al"Cricoid pressure displaces t2e esop2agus3 ;n oser!ational studQ using magnetic
resonance imaging" ;nest2esiologQ -,,@U AA3 F,$FC"

Implementarea unui program de mbuntire a calitii ntr$o secie de terapie intensi&
+mplementing a Nuality +mprovement Program in an +ntensive Care Unit
8" G2erg2ina, G" Licolae, Iulia Cndea, ;lina Balcan, %" Costea, R" )opescu
Spitalul Clinic :udeean de Urgen Constana, Rom*nia

Conceptul de calitate este un concept general ce comport sensuri multiple, de natur social, filo&ofic, economic 9i
te2nic, fiind utili&at n di!erse domenii de acti!itate" Calitatea ngri/irilor de sntate !i&ea& asigurarea unui act
medical sigur, eficace, eficient, ec2itail, n timp util 9i centrat pe pacient" Implementarea de&ideratului ngri/irilor
medicale de calitate presupune adoptarea standardelor profesionale ce traduc calitatea n termeni opera'ionali,
stailind astfel ni!ele minim acceptate sau de e(celen' ale performan'ei medicale" Medicii interesai de muntirea
calitii actului medical treuie s neleag modelul managerial3 structur$proces$re&ultat, i s selecte&e aspectele ce i
interesea& i pe care doresc s le munteasc" )a9ii c2eie pentru iniierea, ameliorarea, e!aluarea, precum i
susinerea unui program de muntire a calitii sunt3
$ moti!area, munca n ec2ip, conducerea
$ prioriti&area 9i alegerea unui proiect
$ pregtirea pentru proiect
$ e!aluarea mediului
$ crearea unui sistem de colectare a datelor
$ crearea unui sistem de raportare a datelor
$ introducerea unor strategii de sc2imare a comportamentului"
?muntirea calitii nu este o sarcin pentru o singur persoan sau pentru o singur specialitate, este necesar
anga/amentul comun al ntregii ec2ipe interdisciplinare din sec'ia de terapie intensi!"
<oate !ocile treuie ascultate i respectate, deoarece toat lumea contriuie cu ce!a la reali&area actului medical"
?muntirea calitii este mai degra o cltorie continu, dec*t un proiect discret, limitat n timp"
%e$a lungul timpului au e(istat mai multe interpretri ale no'iunii de calitate, elementul comun al di!erselor aordri
fiind repre&entat de defini'ia conform creia calitatea repre&int ansamlul de propriet'i 9i caracteristici ale unui
produs sau ser!iciu, ce i confer acestuia capacitatea de a satisface ne!oi e(plicite sau implicite 6Standardul IS= DC,-7"
?n sistemul sanitar, calitatea ca 9i atriut oligatoriu al acti!it'ii medicale, a repre&entat o preocupare constant pentru
furni&orii ser!iciilor de sntate, pacien'i 9i societate n ansamlul ei, e(ist*nd la ni!el na'ional o politic coerent 9i
compre2ensi! de implementare a programelor de management al calit'ii"
)rin =rdinul comun al pre9edintelui Casei La'ionale de ;sigurri de Sntate, al Ministrului Snt'ii 9i Familiei 9i al
pre9edintelui Colegiului Medicilor din Rom*nia nr" EEABDHCB C,+HB-,,+ s$au nfiin'at nucleele de calitate n toate
unit'ile spitalice9ti din 'ara noastr, acestea asigur*nd constant 9i permanent monitori&area calit'ii ngri/irilor
medicale"
%in punct de !edere practic, calitatea ngri/irilor medicale se define9te ca un concept dinamic cu mai multe dimensiuni
6profesional, cultural, etic etc"7, influen'ate n mod direct 9i dependente fiecare n parte de perspecti!a pacientului,
perspecti!a personalului medical, conte(tul social, organi&a'ional 9i de mediu specific acti!it'ii sanitare"
Implementarea de&ideratului ngri/irilor medicale de calitate presupune adoptarea standardelor profesionale ce traduc
calitatea n termeni opera'ionali, stailind astfel ni!ele minim acceptate sau de e(celen' ale performan'ei medicale
6+-7"
?n sec'iile de terapie intensi! calitatea demersului terapeutic de ngri/ire a pacien'ilor critici, este urmarea respectrii
unui ansamlul de principii 9i metode organi&ate ntr$o strategie gloal ce !i&ea& asigurarea unui act medical sigur, n
timp util, eficace, eficient, ec2itail 9i centrat pe pacient"
Repere de calitate n acti&itatea medical din secia de terapie intensi&
%in punct de !edere func'ional, sec'ia de terapie intensi! repre&int un sistem social cu o structur formal, a&at pe
rela'ii sociale repetate 9i staile, ntre indi!i&i califica'i n domeniul ngri/irilor de terapie intensi!, a cror ac'iune
comun define9te scopul 9i identitatea sistemului"
;cti!itatea de terapie intensi! este desf9urat de o ec2ip medical comple(, format din3 medici, asistente,
personal au(iliar sanitar 9i alte categorii de personal pregtit 9i autori&at, conform reglementrilor n !igoare, fiecare
memru al ec2ipei de ngri/ire a!*nd atriu'ii ine stailite, complementare"
Situa'iile limit ce caracteri&ea& specialitatea ;<I 6resuscitarea cardiorespiratorie 9i strile postresuscitare, strile de
moarte clinic, moartea cereral, prele!area de organe, comele prelungite, tratamentul strilor terminale etc"7 implic
o gam larg de inter!en'ii 6medicale, de nursing, psi2ologiceBemo'ionale, spirituale 9i sociale7 adaptate specificului
pacien'ilor critici 9i familiilor acestora"
;cti!itatea unei sec'ii de terapie intensi! impune n mod oligatoriu respectarea standardelor de un practic
medical, utili&ate ca reper de e!aluare a calit'ii ser!iciilor furni&ate"
#laorarea unui program de munt'ire a calit'ii ngri/irilor medicale are ca punct de plecare modelul tridimensional
descris de %onaedian3 structur $ proces $ re&ultat 6+C73
$structura3 repre&int prima component a modelului de calitate n ngri/irile de sntate 9i poate fi definit ca modul n
care este organi&at propriu$&is sistemul de ngri/ire" Sunt !i&ate caracteristicile relati! staile ale furni&orului de ngri/iri
medicale 6te2nicile, instrumentele 9i resursele pe care le are la dispo&i'ie7, caracteristicile organi&a'iei 9i infrastructurii
unde se desf9oar actul medicalU
$procesele3 repre&int acti!it'ile ce au loc n cadrul stailit ntre furni&or 9i pacient 6proceduri de pre!en'ie, diagnostic
9i tratament, documentare, rela'ie medic$pacient etc"7" Furni&area unor ngri/iri de nalt calitate ntr$o sec'ie de terapie
intensi! necesit sincroni&area unui numr mare de procese clinice 9i non$clinice" %e multe ori, procesele non$clinice
6de e(emplu managementul organi&a'ional7 pot a!ea un rol esen'ial n una desf9urare a demersului terapeutic de
ngri/ire a pacien'ilor critici influen'*nd n mod semnificati! finalitatea efortului depus de ntreaga ec2ip medical 6@7"
$re&ultatele3 e(prim sc2imrile sur!enite n starea de sntate a pacien'ilor critici" ?n mod tradi'ional clinicienii au
utili&at ca unic mi/loc de e!aluare a calit'ii demersului terapeutic, re&ultatele o'inute e(primate prin indicatori
statistici a/usta'i la particularit'iile 9i gradul de risc specific fiecrui pacient n parte"
Modelul tridimensional al calit'ii ngri/irilor medicale descris de %onaedian permite identificarea oportunit'ilor de
munt'ire a calit'ii la orice ni!el al practicii medicale din sec'ia de terapie intensi!"
)unctul de plecare al unui plan de management al calit'ii l repre&int identificarea prolemelor definite prin diferen'a
dintre ceea ce e(ist 9i ceea ce se dore9te, sau altfel spus, dintre performan'a o'inut 9i re&ultatele a9teptate"
Re&ol!area prolemelor 9i munt'irea ser!iciilor medicale furni&ate se reali&ea& cel mai ine atunci c*nd msurile
aplicate sunt parte a unui program de management al calit'ii ce presupune standarde 9i indicatori de calitate 6++7"
)entru asigurarea standardului de calitate al ngri/irilor medicale n sec'ia de terapie intensi! este necesar respectarea
9i ndeplinirea criteriilor de e!aluare 9i monitori&are a performan'ei, comportamentului, circumstan'elor sau strilor
clinice specifice 6:oint Commission of ;ccreditation of 5ealt2 Care =rgani&ation7 6+@7"
?n pre&ent e(ist nou repere de calitate ce pot defini practica medical, 9i anume3
$ competen'a profesional $ apreciat prin ni!elul de cuno9tin'e, ailit'ile 9i performan'a memrilor ec2ipei medicaleU
$ accesiilitatea $ u9urin'a cu care pacien'ii pot o'ine ngri/irea de care au ne!oie, atunci c*nd au ne!oieU
$ eficacitatea $ procedurile 9i tratamentul aplicat conduc la o'inerea re&ultatelor dorite, ngri/irea fiind aordat ntr$o
manier corect, fr eroriU
$ eficien'a $ acordarea ngri/irilor necesare, corespun&toare, la costurile cele mai miciU
$ rela'iile interpersonale $ aprecia& modul n care se reali&ea& interac'iunea dintre memrii ec2ipei medicale, dintre
personalul medical 9i pacien'i, precum 9i ntre ec2ipa de ngri/ri 9i comunitateU
$ continuitatea $ pacientul eneficia& de un set complet de ser!icii de sntate de care are ne!oie, ntr$o ordine ine
determinat, fr ntrerupere, sau repetarea procedurilor de diagnostic 9i tratamentU
$ siguran'a $ risc minim pentru pacient de complica'ii sau efecte ad!erse ale tratamentului ori alte
pericole legate de furni&area ser!iciilor de sntateU
$ infrastructura fi&ic 9i confortul $ cur'enie, confort, intimitate 9i alte aspecte importante pentru
pacien'iU
$ alegerea $ pacien'ii 9i familiile lor sunt implica'i n procesul de luare a deci&iiilor medicale, n re&ol!area prolemelor ce
'in de de sntatea lor 6+,7"
)rocesul de munt'ire a calit'ii ngri/irilor medicale !i&ea& n mod clasic e!aluarea a dou componente esen'iale3
$calitatea te2nic 6profesional7 $ aprecia& ni!elul de competen' e(primat prin3
$ respectarea protocoalelor 9i a g2idurilor de practic medical
$ folosirea msurilor de control al infec'iilor
$ informarea 9i consilierea pacien'ilor 9i familiilor acestora
$ management eficient"
Respectarea acestor repere de calitate asigur un mediu de munc eficace 9i eficient cu repercusiuni po&iti!e asupra
re&ultatelor tratamentului aplicat, gradului de satisfac'ie al pacientului 9i al furni&orului ser!iciilor medicale"
Gradul de satisfac'ie al personalului medical are legtur cu calitatea actului medical, dar 9i cu condi'iile n care acesta
se desf9oar, put*nd fi folosit drept criteriu de e!aluare a calit'ii ngri/irilor de sntate 6C7"
$calitatea interpersonal 6perceput de pacient7"
?n mod oi9nuit pacien'ii nu posed ailitatea sau cuno9tin'ele necesare e!alurii competen'ei furni&orului, dar 9tiu
cum se simt, cum au fost trata'i, dac ne!oile sau a9teptrile lor au fost ndeplinite" Gradul de satisfac'ie al pacientului
influen'ea& n mod direct re&ultatul ngri/irilor 9i e(prim modul n care furni&orul !ine n nt*mpinarea !alorilor 9i
a9teptrilor sale fr a aprecia n mod oiecti! calitatea ngri/irilor acordate"
Algoritmul implementrii unui program de mbuntire a calitii ngri3irilor medicale
Implementarea unui program nou de munt'ire a calit'ii ser!iciilor medicale sau munt'irea unui program de/a
e(istent presupune respectarea unui proces etapi&at ce include o serie de pa9i esen'iali3
4/ "&aluarea contextului %i specificului acti&itii medicale
?munt'irea calit'ii este o atitudine, un model cultural ce ar treui s re&one&e n ntreaga sec'ie de terapie intensi!"
Funda'ia succesului unui program de munt'ire a calit'ii este repre&entat de o moti!a'ie puternic, o colaorare
armonioas n cadrul ec2ipei medicale 9i o conducere adec!at"
Calitatea ngri/irilor furni&ate pacien'ilor n sec'ia de terapie intensi! este influen'at n mod direct de !alorile 9i
reperele culturii organi&a'ionale" Se impune o sc2imare de paradigm n organi&area ser!iciilor medicale fiind necesar
trecerea de la 0cultura eroului1 la 0cultura sistemului1, 9i acest lucru este posiil prin adoptarea unui set de msuri ce
!i&ea& monitori&area 9i munt'irea performan'ei clinice, astfel nc*t ngri/irile furni&ate s fie c*t se poate de sigure
9i de eficiente 6E7"
#(emplul cel mai potri!it pentru aceast sc2imare de perspecti! l repre&int industria aeronautic" ;tunci c*nd
planificm o cltorie cu a!ionul, !om alege loca'ia, momentul, e!entual costul, dar nu ne interesea& niciodat ce pilot
anume !a asigura cursa respecti!" Le a&m pe faptul c pilotul de la ora @ este la fel de un ca 9i pilotul de la ora H"
<ot astfel, n sec'iile de terapie intensi! calitatea ngri/irilor medicale ar treui s fie uniform, de la spital la spital, de la
tur la tur" Lu ar treui s e(iste diferen'e ntre modul n care este tratat pacientul internat la ora @ 9i pacientul
internat la ora H" %ac oala este aceea9i, atunci pacientul ar treui s eneficie&e de aceea9i calitate a ngri/irilor
acordate indiferent de memrii ec2ipei medicale implicate"
?munt'irea calit'ii nu este o sarcin pentru o singur persoan sau pentru o singur categorie de personal, este
necesar implicarea ntregii ec2ipe din sec'ia de terapie intensi!, ,,toate !ocile treuie au&ite 9i respectate deoarece
fiecare contriuie cu ce!a1 6A7"
Succesul unui program de munt'ire a calit'ii este adesea re&ultatul implementrii mai multor proiecte indi!iduale
su o conducere interdisciplinar" ?munt'irea calit'ii este mai degra o cltorie continu dec*t un proiect discret,
limitat n timp"
5/ rioriti(area proiectelor poteniale %i alegerea proiectului de nceput
)rimul pas pentru ini'ierea unui program de munt'ire a calit'ii este identificarea prolemelor, oportunit'ilor 9i
resurselor disponiile 6+E7"
)rimul program treuie s fie fe&ail 9i cu 9anse mari de reu9it pentru ca ulterior ec2ipa medical s$9i construiasc
proiectele !iitoare spri/inindu$se pe succesul ini'ial"
?n alegerea proiectului de nceput !om utili&a modelul tridimensional al calit'ii ngri/irilor medicale urmrind unul din
cele trei aspecte distincte ale calit'ii ser!iciilor furni&ate3
$ structura3 de e(emplu$organi&area ec2ipei de gard
$ procesul3 de e(emplu$profila(ia tromo&ei !enoase profunde
$profila(ia ulcerului de stres
$strategii de pre!enire a pneumoniei asociate de !entilator
$strategii de pre!enire a infec'iilor de cateter !enos central
$protocolul se!rrii de !entilator
$!entila'ie nonin!a&i! pentru insuficien'a respiratorie 2ipercapnic"
$ re&ultatele3 de e(emplu$ rata de detuare neplanificat
$rata reac'iilor ad!erse medicamentoase gra!e
$gradul de satisfac'ie al familiilor pacien'ilor critici
$readmisiile neprogramate la -CBCD ore de la e(ternarea din sec'ia de terapie intensi!
$mortalitatea"
6/ regtirea pentru proiect
)regtirea adec!at pentru proiect presupune opera'ionali&area msurilor ce se doresc a fi implementate 9i elaorarea
unui plan de proiect 6-7"
%e e(emplu, pregtirea pentru un proiect ce !i&ea& profila(ia tromo&ei !enoase profunde !a urmri3
$ identificarea metodelor prin care tromoprofila(ia este msurat de rutin
$ identificarea g2idurilor de practic medical cu pri!ire la profila(ia tromo&ei !enoase profunde
$ colectarea datelor preliminare"
)lanul de proiect !a include3 o list de sarcini, o e!aluare a ugetului 9i o planificare n timp 6D7"
7/ "&aluarea contextului
#ste necesar o e!aluare ini'ial a mediului n care se desf9oar acti!itatea medical utili&*nd modelul tridimensional3
structur $ proces $ re&ultat" ;!em astfel posiilitatea s identificm poten'ialele ariere, surse de re&isten',
oportunit'i 9i resurse ce pot influen'a n mod direct una desf9urare a proiectului" ?n aceast etap se pot efectua
studii calitati!e de identificare a pattern$ului comportamental 9i modelului cultural specific participan'ilor la procesul de
ngri/ire"
8/ Crearea unui sistem de colectare a datelor
)entru succesul unui program de munt'ire a calit'ii ngri/irilor medicale este esen'ial e(isten'a unui sistem de
colectare a datelor care s furni&e&e cu acurate'e o imagine a punctului de plecare 9i totodat s permit documentarea
munt'irilor scontate"
8om urmri unitatea de anali&, re&ultatul o'inut 9i metoda de colectare a datelor"
9/ Crearea unui sistem de raportare a datelor $ care s permit clinicienilor 9i tuturor celor interesa'i s identifice 9i s
n'eleag prolema c*t 9i sc2imarea urmrit prin programul de munt'ire a calit'ii propus"
:/ Introducerea de strategii care s sc2ime comportamentul clinicienilor 9i s produc munt'irea calit'ii ser!iciilor
furni&ate"
Succesul algoritmului implementrii unui program de munt'ire a calit'ii depinde de sincroni&area eforturilor
memrilor unei ec2ipe interdisciplinare su o conducere puternic, energic 9i eficient, care s fie capail s
transforme un grup de oameni cu oiecti!e indi!iduale ntr$o ec2ip cu scopuri comune 6+7"
;rmoni&area colaorrii memrilor unei ec2ipe medicale se poate o'ine respect*nd principiul ;M=, conform cruia
memrii unei ec2ipe treuie s ai ;BIJI<_`IJ# necesare 6cuno9tin'e, deprinderi 9i e(perien'7 pentru a$9i desf9ura
acti!itatea, treuie s fie M=<I8;`I n a o face, 9i treuie s li se ofere =)=R<ULI<;<#; de a$9i asuma deci&ia 9i
responsailitatea pentru ceea ce fac 6H7"
"&aluarea unui program de mbuntire a calitii ngri3irilor medicale
#!aluarea 9i men'inerea unui program de munt'ire a calit'ii ngri/irilor medicale repre&int un proces continuu ce
are ca oiecti! principal munt'irea strii de sntate a pacien'ilor critici din sec'ia de terapie intensi!"
Reali&area acestui de&iderat presupune o aordare 2olistic a procesului de ngri/ire, n centrul acti!it'ilor medicale
afl*ndu$se pacientul ce nu mai este perceput simplist ca un indi!id ce are o anumit prolem de sntate, ci ca o
persoan cu emo'ii, triri, sentimente, principii, !alori, credin'e 6+F7"
#!aluarea permanent a calit'ii ser!iciilor medicale furni&ate presupune3
$ colectarea periodic de date care s documente&e sc2imarea scontat
$ adaptarea strategiilor de sc2imare a pattern$ului comportamental la e!olu'ia transformrilor a9teptate
$ focali&area pe colaorarea interdisciplinar
$ aprecierea spri/inului din partea conducerii spitalului"
?munt'irea continu a calit'ii ngri/irilor medicale este un proces ciclic, care nu se finali&ea& niciodat, re&ol!area
unei proleme implic focali&area pe o alt prolem 9i nceperea altui ciclu de munt'ire, su auspiciile preocuprii
constante de asigurare a ma(imului de eneficii n condi'iile eficien'ei 9i eficacit'ii costurilor implicite 6F7"
Biliografie3
+" ;le(andru,G2" Managementul ser!iciilor medicale" #ditura #fiCon )ress, Bucure9ti, -,+,
-" ;udet ;$M:, %otQ MM, S2amasdin :, Sc2oenaum S" Measure" Jearn and impro!e3 p2QsicianZs in!ol!ement in ^ualitQ
impro!ement" 5ealt2 ;ffairs -,,EU-C3DC@$DE@"
@" Cat2arina #" :acoi, 5endrie4 C" Bos2ui&en, Ines Ruppi, 5uiert :" %inant, Geertrudis ;"M" !an den Bos" aualitQ of
r2eumatoid art2ritis care3 t2e patientZs perspecti!e" International :ournal for aualitQ in 5ealt2 Care, -,+-U +F 6+73 H@$D+"
C" #pstein ;M" )erformance measurement and professional impro!ement3 approac2es, opportunities and c2allenges"
5ealt2 SQstems, 5ealt2 and Sealt2" S5= Ministerial Conference on 5ealt2 SQstems, :une -,,D"
E" :an Main&" %efining and classifQing clinical indicators for ^ualitQ impro!ment" International :ournal for aualitQ in
5ealt2 Care, -,++U +E 6F73 E-@$E@,"
F" :ones CB, MaQer C, Mandel4e2r JG"Inno!ations at t2e intersection of academia and practice3 facilitating
H" :uran, :"M", aualitQ Control 5andoo4, #ditura McGraT 5ill, LeT Ror4, -,++"
D" Gim CS, Ju4ela M), )are42 8I et al" <eac2ing internal medicine residents ^ualitQ impro!ement and patient safetQ3 a
lean t2in4ing approac2" ;m : Med aual -,+,U-E6@73-++$H"
A" Melic2ar J" <ransforming care at t2e edside for nurse facultQ3 can continuous ^ualitQ impro!ement transform
nursing educationV : Lurs #duc -,++ Lo!UE,6++73F,@$F,C"
+," Mocean,F",Bor&an,C",Managementul calit'ii si planificarea strategic n managementul organi&a'ional din sntatea
pulic"#ditura ;lma Mater, Clu/$ Lapoca, -,,A
++" Leale G, 8incent C, %ar&i ;" <2e prolem of engaging 2ospital doctors in promoting safetQ and ^ualitQ in clinical
care" : RoQal Soc Med -,,HU+-H3DH$AC"
+-" =pincaru,C",Gle'escu,M",Imri,#"Managementul calit'ii ser!iciilor n unit'ile sanitare"#ditura
C"L"I"Coresi,Bucuresti,-,,C
+@" Regulamentul intern al spitalelor aproat prin ordinul ministrului snt'ii AE,B-F",H"-,,C
+C" Scoala La'ional de Sntate )ulic si Management Sanitar" Managementul Spitalului" #ditura )ulic 5 )ress,
Bucure9ti, -,,F
+E" `'u, M", =prean, C", =prean Cristina, Managementul strategic si al de&!oltrii duraile n organi&a'ia a&at pe
cunostin'e, #ditura ;GIR, Bucure9ti, -,,H"
+F" Sorld 5ealt2 =rgani&ation" Inno!ati!e Care for C2ronic Conditions" Building Bloc4s for ;ction" Gene!a3 S5=, -,,-"

The concept of (uality is a general concept that carries multiple meanings, social, philosophical, economic and technical.
Nuality of health care has been defined as care that is safe, timely, effective, efficient, e(uitable, and patient$centered.
+mplementing the (uality health care re(uires the adoption of professional standards that translate (uality in
operational terms, establishing minimum acceptable levels or ecellence of medical performance. Critical care clinicians
interested in (uality improvement should understand structure$process$outcome model and select aspects they are both
interested in and able to improve. The 1ey for initiating, improving, evaluating, and sustaining a (uality improvement
program are6
$ motivation, team!or1, leadership
$ prioriti-e and choose a project
$ prepare for the project
$ do an environmental scan
$ create a data collection system
$ create a data reporting system
$ introduce strategies to change behavior
Nuality improvement is not a one person or one$discipline tas1K it re(uires the shared commitment of the entire
interdisciplinary +CU team.
'll voices need to be heard and respected since everyone has something to contribute.
Nuality improvement is a continuous journey rather than a discrete, time$limited project.



;ocurile srii: <ipernatremia
.alt ?ames6 ,ypernatremia
Ru(andra Copotoiu, Raluca Solomon, :" S&eder/esi, :udit Go!acs
Uni!ersitatea de Medicin i Farmacie <*rgu Mure, Rom*nia

5ipernatremia este definit ca o cretere a !alorii La plasmatic peste +CE mmolBl"
5ipernatremia ca i de&ec2iliru 2idroelectrolitic este mai rar n seciile de terapie intensi!, dar mortalitatea asociat
este mai mare 6p*n la H,.7" ;ordul ei este similar cu cel al celorlate de&ec2ilire 2idroelectrolitice, i anume
recunoaterea gradului de urgen nainte de iniierea terapiei, anticiparea i pre!enirea efectelor secundare asociate
tratamentului i demararea algoritmului diagnostic"
5ipernatremia este cau&at de un deficit de ap iBsau un aport crescut" )rimul mecanism este incriminat n prespital, al
doilea este iatrogen" %istincia dintre afectarea acut i cronic se face n funcie de durata n care 2ipernatremia a
crescut 6!aloare limit CD de ore7"
<ratamentul depinde de mecanismul implicat i presupune3
Identificarea i tratarea cau&ei
Calcularea deficitului de ap
?nlocuirea a E, . din acesta n +-$-C de ore
Corectarea s nu se fac mai rapid de - m#^BlB2 6acut7 i ,"E m#^BlB2 6cronic7
Restul deficitului se corectea& n urmtoarele CD de ore"
%eficitul se calculea& astfel3
S% I N,"F ( <BSO ( N6La sericB+C,7 $ +O, unde <BS repre&int greutatea ideal"
Cantitatea de !olum de administrat este3
R8 6l7 I S% ( N+B6+$b7O, unde b repre&int raportul dintre concentraia sodiului n lic2idul utili&at i serul fi&iologic
i&otonic 6+EC m#^Bl7"

,ypernatremia is defined as serum sodium concentration greater than ";< mmol/l.
,ypernatremia is less common in the +CU, but there is an increased mortality 3up to D#&4. The clinical approach is similar
to other electrolyte disorders, namely one has to identify the degree of emergency prior to therapy, to anticipate and
prevent side effects due to therapy and the initiation of the diagnostic algorithm.
Mechanisms involved in hypernatremia are6 a large deficit of !ater or a solute gain. The first one develops outside the
hospital, !hile the second is in hospital treatment$induced.
The distinction bet!een acute or chronic imbalance is done on the duration of the rise in serum sodium concentration
3cut$off point of ;0 hours4.
The effective treatment depends on the basis of the electrolyte disorder, namely6
+dentify and treat the cause
Calculate !ater deficit
@eplace half of the deficit over "%$%; hours
Do not correct more rapidly than % m2(/*/h 3acute4 and #.< m2(/l/h 3chronic4.
@eplace the remaining deficit over ;0 hours.
The !ater deficit is determined according to the follo!ing formula6
BD E H#.= TBBI H3Ga serum/";#4 $ "I, !here TBB is the ideal total body !eight.
The replacement volume is determine as follo!s6
@) 3l4 E BD H"/3"$O4I, !here O is the ratio of the sodium concentration in the resuscitation fluid to the sodium
concentration in isotonic saline 3"<; m2(/l4.

Apneea obstructi& de somn/ Implicaii pentru aneste(ist
.leep 'pnea. 'naesthetic +mplications
I" ;calo!sc2i
Uni!ersitatea de Medicin 9i Farmacie 0Iuliu 5a'ieganu1, Clu/$Lapoca, Rom*nia

;pneea ostructi! de somn 6;=S7 este o afectare a somnului produs de ostruc'ia repetiti!, par'ial sau total a cii
aeriene superioare asociat cu oprirea complet sau par'ial a respira'iei pentru o perioad de peste +, sec" )erioadele
de apneeB2ipopnee, respecti! 2ipo(emieB2ipercaptnie din cursul somnului sunt un factor independent de risc pentru
de&!oltarea unor suferin'e precum 2ipertensiunea pulmonar 9i sistemic, 9i pentru moriditate 9i mortalitate
cardio!ascular, c2iar 9i deces cardiac suit n cursul nop'ii" Riscul cre9te cu durata 2ipo(emiei 9i numrul episoadelor
de apneeB2ipopnee din cursul somnului" Se!eritatea ;=S este msurat prin inde(ul de apneeB2ipopnee care arat
numrul de episoade de oprire a respira'iei n decurs de o or" <endin'a de colaare a faringelui se produce n cursul
inspira'iei c*nd se creea& o presiune negati! intraluminal contraalansat de ac'iunea mu9c2ilor dilatatori ai
faringelui" ;=S sur!ine cel mai frec!ent la oe&i, la H,. dintre pacien'ii cu oe&itate morid" %epunerea grsimii
perifaringian fa!ori&ea& ngustarea lumenului faringelui 9i instalarea apneei de somn" Cu toate acestea, factorul
declan9ator este repre&entat de deprimarea mecanismelor ner!oase compensatorii" ?n cursul somnului R#M
mecanismul de control ner!os este deprimat, faringele colaea& 9i se instalea& apneea" )rin modificrile ioc2imice
consecuti!e 62ipo(emie 9i 2ipercapnie7 este stimulat acti!itatea mu9c2ilor dilatatori 9i la ni!el ner!os central" )acientul
se tre&e9te, faringele se desc2ide 9i a!em o scurt perioad de 2iper!entila'ie care reduce ni!elul sang!in al
mediatorilor c2imici, iar pacientul readoarme" Cercul se nc2ide 9i urmea& o nou perioad de apnee"
)acientul cu ;=S pre&int un risc aneste&ic ridicat care treuie cunoscut 9i asumat de ctre aneste&ist" S$a demonstrat
c pacien'ii c2irurgicali cu ;=S au de&!oltat un numr semnificati! mai mare de complica'ii postoperatorii comparati!
cu pacien'ii care nu au a!ut ;=S" Riscul complica'iilor intraaneste&ice este ridicat, n special la pacien'ii la care ;=S nu a
fost diagnosticat preoperator" Standardul de aur pentru diagnostic este efectuarea polisomnografiei ntr$un laorator
speciali&at, dificil de reali&at n practica clinic curent" <otu9i,
s$au o'inut re&ultate une 9i prin utili&area unor c2estionare, dintre care c2estionarul S<=)$Bang are o nalt
sensiilitate pentru depistarea ;=S"
;neste&istul este confruntat cu urmtoarele riscuri3 o !entila'ie pe masca facial dificil, dificult'i la intua'ia tra2eal,
riscul ostruc'iei faringiene dup e(tuare 9i dificult'i n asigurarea liert'ii cii aeriene n perioada postoperatorie"
)entru e!itarea complica'iilor perianeste&ice se recomand aplicarea urmtoarelor msuri3
$ e!itarea premedica'iei cu sedati!eBopioideU
$ a9e&area pacientului n po&i'ie semi9e&*nd sau 0pe ramp1U
$ facilitarea !entila'iei pe masc prin efectuarea triplei mane!re 9i utili&area de canule oro$faringieneU
$ !entila'ia pe masc n regim de C);) sau BI);)U
$ preo(igenarea pacientului 6@$E min cu o(igen +,,.7U
$ utili&area succinilcolinei pentru rela(area muscular la induc'ieU
$ intua'ia cu ron2oscopul fle(iil dac se anticipea& o intua'ie dificilU
$ o foarte un antagoni&are a miorela(antului, pentru a e!ita ostruc'ia poste(tuare 6de luat n considerare
administrarea de Sugammade(7"
)acientul necesit o atent supra!eg2ere n perioada postoperatorie, a!*nd ca oiecti! principal men'inerea liert'ii
cii aeriene"
Biliografie selecti!3
+" C2ung S;, Ruan 5, C2ung F" ; sQstematic re!ieT of ostructi! sleep apneea and its implications for anest2esiologists"
;naest2 ;nalg -,,DU +,H3 +EC@$+EF@"
-" Isono S" =structi!e sleep apneea of oese adults" ;nest2esiologQ -,,AU ++,3 A,D$A-+
@" C2ung F, SuramanQam R, Jiao R, Sasa4i #, S2apiro C, Sun R" 5ig2 S<=)$Bang score indicates a 2ig2 proailitQ
ostructi!e sleep apneea" Br : ;naest2 -,+-U +,D3 HFD$HHE

,elirul postaneste(ic
Postanaesthetic Delirium
C" %" Pdre2u
Uni!ersitatea de Medicin 9i Farmacie 0Iuliu 5aieganu1, Clu/$Lapoca, Rom*nia

Un numr destul de mic de pacieni se tre&esc din aneste&ie n stare de agitaie, de&orientai, uneori necesit*nd c2iar
imoili&are" ;stfel de tulurri comportamentale pot aprea mai frec!ent la pacienii tineri care sunt preoperator
e(cesi! de an(ioi n legtur cu inter!enia c2irurgical sau au o team ne/ustificat de durerea pe care o pot resimi n
perioada perioperatorie" %e asemenea, pacienii !*rstnici pre&int nt*r&ieri n recuperarea cogniti!, acest aspect
a!*nd ca re&ultat o stare de confu&ie, delir i agitaie" Incidena delirului postoperator se estimea& a fi de +,$+E. la
pacienii !*rstnici care au suferit o inter!enie c2irurgical" %e cele mai multe ori delirul apare dup un inter!al relati!
de luciditate de una sau mai multe &ile postoperator i este cea mai frec!ent form de delir la pacienii !*rstnici"
#tiologia delirului postoperator este multifactorial" Un ni!el adec!at de neurotransmitori, cum sunt acetilcolina sau
dopamina, este necesar pentru o funcie cogniti! normal, pentru meninerea ateniei i pentru un ritm somn$!eg2e
normal" %e&ec2ilirele 2idroelectrolitice sunt frec!ente la copii i la pacienii !*rstnici" Lu par s e(iste diferene n
incidena delirului dup aneste&ia general sau regional" <ratamentul cu FentanQl, morfin, )ropofol nu au fost
semnificati! asociate cu riscul apri'iei delirului" Mida&olamul a fost asociat cu riscul crescut de apari'ie al delirului"
Medicamentele anticolinergice pot pro!oca delirul postoperator, mai ales la persoanele !*rstnice i de aceea este ine a
se e!ita la astfel de pacieni" Medicamentele neuroleptice 6Clorproma&ina 9i 5aloperidolul7 sunt cel mai frec!ent
utili&ate pentru tratamentul pacien'ilor cu delir postaneste&ic"

' small number of patients a!a1en from anaesthesia in an agitated condition, !hich may re(uire physical restraint. The
incidence of this behavior seems to be increased in young patients !ho are apprehensive about the findings at operation
as !ell as individuals !ho epressed in the preoperative period an unusually great fear of pain. Conversely, elderly
patients may be slo!er than younger patients to demonstrate recovery of cognitive function. The incidence of the
postanaesthetic delirium is estimated to be "#& to "<& of elderly patients undergoing surgery. +nterval delirium occurs
after a lucid interval of one or more days after an operation and is the most fre(uent form of postanaesthetic delirium in
elderly patients. 2mergence delirium occurs !ithin minutes of regaining consciousness and is more often present in
children. The etiology of postanaesthetic delirium is multifactorial. 'n ade(uate supply of neurotransmitters including
acetylcholine and dopamine are necessary for normal cognitive function, attention, and normal sleep$a!a1e cycle. Aluid
and electrolyte imbalance are common problems in the children and elderly patients. There is no difference in the
occurrence of delirium follo!ing general or regional anaesthesia. The possibility of postanaesthetic delirium can be
minimi-ed by avoiding the administration of long$acting amnestic drugs 3ben-odia-epines4 and anaesthetic drugs
3injected and inhaled4 !ith slo! rate of clearance. 'nticholinergic drugs may be best avoided in elderly patients.
Geuroleptic agents 3chlorproma-ine and haloperidol4 are the most common drugs used to treat patients !ith
postanaesthetic delirium.

Anafilaxia n obstetric
'naphylais in the Parturient
M" 8ercauteren
Uni!ersitQ 5ospital, ;ntTerp, Belgium

'naphylais in the obstetric patient may be an additional challenge to the anaesthetist because t!o lives are in danger,
resuscitation may be compromised !hile, as opposed to non$obstetric situations, the procedure is mostly continued,
converted from labour into a surgical delivery or accelerated if already started.
.ymptoms mostly affect the cardiovascular, respiratory and cutaneous system. +n obstetric anaesthesia the most
important situations !hich may be confused !ith anaphylais, are local anaesthetic induced sympathetic bloc1ade and
toicity, high/total spinal bloc1, haemorrhagic shoc1, bronchial asthma, upper air!ay edema, laryngopathia, hereditary
angio$oedema, and pulmonary embolism3venous thrombus, air or amniotic fluid4.
'lthough anaphylactic reactions during anaesthesia in general are the most fre(uent follo!ing the use of neuromuscular
bloc1ing drugs 3GMBD4, such reactions in the obstetric literature are rare due to the lo! number of general anesthesia
procedures no!adays !hile restricted to succinylcholine, still the mainstay for rapid se(uence intubation. The most
commonly reported allergic reactions during delivery are actually related to late, antibiotics and oytocin.
*ate causes +g2 mediated reactions. .ymptoms occur 9#$=# min after the start of the eposure. 's there may be no
relationship !ith any drug administration, the diagnosis of an allergic reaction is seldom made promptly, causing a
significant delay in the start of accurate treatment. Patients !ith atopy, asthma, spina bifida, spinal cord injury, allergy
to tropical fruits, multiple prior surgical procedures, or !ho are themselves health care !or1ers, are at ris1 for an
anaphylactic reaction to late. Parturients may also be more at ris1 than gynaecological copunterparts. 'ntibiotics may
induce several types and clinical manifestations of allergyK common culprits are ampicillin, penicillin, ceftriaone and
cefa-olin !ith an incidence of %.: cases per "##.### deliveries . Aortunately they are mostly given after the delivery.
'llergic reactions may occur to uterotonic drugs but as they are in the hands of the obstetrician, the anaesthetist may
not be present at the moment a reaction occurs. Bith respect to colloids, detrans have fallen out of favour because of
the potential to cause anaphylais and coagulopathy. ?elatins have also largely been abandoned because of an allergic
potency as high as " in 9##. .tarches may be considered a safer alternative as allergy seems to occur in less than " in
%<## patients, but allergic reactions are still possible. @eactions to local anaesthetics are generally rare. The ris1 is higher
for esters than for amide substances. Go obstetric cases have been reported yet !ith ropivacaine or levobupivacaine.
.urprisingly, anaphylactoid reactions have been found to occur !ith ranitidine, an anti$histamine $% receptor antagonist
used for aspiration prophylais. This is of particular concern because ,% bloc1ers are often recommended as a secondary
treatment option !hen anaphylais occurs. Ainally solitary allergic events have been reported !ith several other drugs
and substances during delivery as !ell as during pregnancy or after delivery such as insect stings, G.'+Ds, iron, induction
agents, opioids, metabisulfite[
+nitial management consists of discontinuing the administration of the suspected trigger. +f bronchoconstriction is the
sole symptom, lo! dose volatile anaesthetics may be continued. 5ygenation and even endotracheal intubation should
be performed immediately if the air!ay appears to be compromised, especially because the parturient may already be
at ris1 for intubation difficulty. To compensate for intravascular fluid loss, +) crystalloids 3preferably no colloids4 are
administered. *eg elevation !ill increase the circulating volume by more than half a litre. +n order to increase venous
return, parturients !ith severe hypotension should be turned into the left lateral position unless emergency delivery of
the foetus is !arranted or cardiac massage is mandatory.
The cornerstone of successful therapy is adenaline. Because of its $adrenergic effects it is more useful than the pure $
adrenergic agonists. The dose of intravenous adrenaline depends on the severity of symptoms. +f the patient is
hypotensive, +) boluses of <$"# Ug of are given every "$% min. +n the case of cardiovascular collapse, boluses up to "## Ug
are administered every minute together !ith closed chest cardiac compressions. 2ndotracheal use is no longer
recommended unless solitary bronchospasm. 's the placental perfusion depends highly on the systemic blood pressure,
one should ta1e care that raising the maternal blood pressure is not achieved at the epense of significant constriction of
the uterine arteries. 2phedrine, still the most commonly used vasopressor in obstetric anaesthesia, is a direct acting
adrenergic agonist and an indirect sympathomimetic. Despite its general vasoconstrictive effects, the uterine vessels
may be selectively spared unless high doses are given. ,o!ever, for the treatment of anaphylactic shoc1, even high
doses may fail to correct hypotension. The (uestion arises !hether adrenaline can be given !ithout any restriction in
obstetric anaphylais. .mall doses of "#$%#Ug may result in a 9#$;#& reduction of the uterine blood flo!, at least in
normotensive subjects. Aatal neonatal outcomes have been reported after resuscitation !ith adrenaline though unclear
!hether the shoc1, hypoaemia or the administered substances !ere responsible. 5n the other hand adrenaline doses
up to a"mg and infusion during ; hours has enabled the delivery of vigorous babies. Phenylephrine, a selective T
adrenergic agonist, has constrictive effects upon the foetal blood supply, but doses up to "##Ug did not seem to
compromise neonatal outcome because the increase of maternal blood pressure may out!eigh the increased resistance
of the uterine vasculature. +n parturients noradrenaline should be avoided because of the combination of uterine
vasoconstriction !ith hypertonicity.
,istamine$" receptor antagonists compete !ith histamine at the receptor sites but the only available one for +) use i.e.
prometha-ine causes hypotension and sedation. ,istamine$% receptor antagonists are controversial because they may
aggravate bronchoconstriction due to unbloc1ed histamine$" receptor activity. Corticosteroids are of limited benefit in
acute anaphylais as they re(uire "%$%; h to !or1. @efractory cases may be treated !ith a choice of substances being
used and reported !ith variable success rates.
+n conclusion, the most incriminated agents actually in obstetric anesthesia are late, antibiotics, oytocin and colloids.
Treatment consists of instant interruption of the suspected trigger, "##& oygen, air!ay support including intubation,
volume epansion, and vasopressors !here necessary. +t is important for all members of the care team to reali-e that
first and foremost, the mother is the primary focus of care. This fact is sometimes lost even upon the obstetrician, and
!hile the foetus is also of clinical importance, its needs should never supersede the motherJs.

Managementul cii aeriene dificile la gra&ida cu obe(itate $ Accentul pe siguran-a pacientului
'ir!ay Management in the 5bese Parturient $ 2mphasis on the PatientZs .afety
<" #&ri
Solfson Medical Center, 5olon, Israel

The authors of the recent PConfidential 2n(uiries into maternal and childZs healthP anesthesia report !rote the follo!ing
statement6 P'nesthesia is clearly not a diseaseK it is an intervention and all anaesthetic 3air!ay4 deaths may be
considered iatrogenic and potentially preventableP. Considering this and the fact that !e ta1e care of the lives of both
the mother and the fetus, this lecture emphasi-es some safety aspects of the air!ay management in the obese
parturient.
The lecture !ill shortly go over the maternal mortality !ith its changing trend over the decades, mentioning that despite
the progresses that have been made over the years, the incidence of failed intubation in pregnant patients remained the
same since ":0;6 "6%##. Aurther, the problematic of the definition of air!ay difficulty is emphasi-ed. Despite the lac1 of
scientific evidence, it is clear that air!ay management is more difficult in obese parturients. The lecture describes some
of the reasons for this, as !ell as the application of some techni(ues, maneuvers and air!ay e(uipment designated to
overcome these difficulties.
Ainally, the lecture describes the presumed role of algorithms in improving the safety of air!ay management in the
obstetric patients.

Remifentanil pentru analge(ie la na+tere
@emifentanil Use in 5bstetrics
8" Manica
<ufts$LeT #ngland Medical Center, Boston, US;

Despite the fact that epidural analgesia is the Qgold standardR in labor, there are certain situations !hen a neuraial
bloc1 is contraindicated.
2ither a patient absolutely refuses a labor epidural or if there are any medical contraindications 3thrombocytopenia,
local or generali-ed infection4, then an epidural cannot be placed.
Aor these conditions, the use of @emifentanil, an ultra$short narcotic, has been recently sho!n to provide satisfactory +)
pain relief for the laboring patients.
This lecture !ill focus on the follo!ing objectives6
". Discuss the pharmaco1ynetics of @emifentanil
%. @evie! the use of @emifentanil in labor
a. 'n alternative to other narcotics
b. 'n alternative to epidural analgesia
c. Discuss the maternal and fetal safety
9. Discuss the implementation of a @emifentanil PC' program
;. Discuss some of the most recent published complications of @emifentanil PC'

Mar*eri serologici n trauma multipl $ =sindromul de disfuncie imunologic>
.erological Mar1ers in Multiple Trauma $ P+mmune Dysfunction .yndromeP
Ioana Marina Grin'escu
Spitalul Clinic de Urgen', Bucure9ti, Rom*nia

<rauma multipl determin un rspuns inflamator sistemic comple( 2ormonal, metaolic 9i immunologic, a crui
intesitate se corelea& cu gra!itatea le&iunilor" ?n ca&urile necomplicate, rspunsul inflamator sistemic este limitat n
timp, predictiil, e(ist*nd un ec2iliru ntre mediatorii pro 9i antiinflamatori"
;ni de &ile, studiile s$au a(at pe identificarea !alorilor optime ale tensiunii arteriale, tulurrile la ni!elul
microcircula'iei, coagulopatie etc" ?n conceptul actual, disfunc'ia imunologic st la a&a e!olu'iei ctre starea critic"
<rauma este o afec'iune multisistemic, cu apari'ia precoce a M=F" ;gresiunea declan9ea& simultan dou rspunsuri
antagonice3 proinflamator 6SIRS7 9i cel antiinflamator6C;RS7" ;cesta din urm nu apare ca un mecanism compensator la
SIRS, ci este declan9at ca un rspuns direct la agresiune" S$a considerat c apari'ia M=F timpurie reflect un de&ec2iliru
ntre cele dou fenomene, dependent de intensitatea n timp a fiecruia dintre acestea" ;cest concept corela n mod
direct mortalitatea posttraumatic cu M=F timpuriu de statusul 2iperinflamator"
<eoria clasic a SIRS 9i C;RS nu reflect corect rspunsul imun celular"
Comple(ul de molecule pro$inflamatorii care determin disfunc'ie celular, alturi de un rspuns anti$inflamator
e(agerat, repre&int proail defini'ia sindromului de disfunc'ie imun" )acien'ii au semne clinice de SIRS 9i disfunc'ie
multipl de organ mediat imun 9i, n acela9i timp, au o susceptiilitate crecut pentru sepsis" #(ist n mod clar o
elierare de mediatori inflamatori endogeni <LF alfa, IJ+, F, D 9i acti!area complementului" ?n acela9i timp,
2iporeacti!itate imunologic a fost demonstrat la mai toate celulele implicate at*t n imunitatea nati! 6neutrofile,
monocite, macrofage7, c*t 9i n cea do*ndit 6limfocitele B, <, LG7" #ste sigur c trauma multipl asocia& un rspuns
inflamator sistemic intens 9i acti!area sistemelor imunologice"
?n comparatie cu pacien'ii cronici, cei traumatici sunt e(pu9i unei serii de agresiuni 62its7" )rima este repre&entat de
traum, ulterior de necesitatea inter!en'iilor c2irugicale primare 6%amage Control SurgerQ7" <oate acestea determin
epui&area sistemului imun 9i e(pun pacientul unui risc crescut de sepsis" %in acest moti!, momentul pentru inter!en'iile
finale reconstructi!e este am*nat p*n la optimi&area statusului imun"
Studiile pri!ind sindromul de disfunc'ie imunologic aduc n permanen' informa'ii noi, interesul fiind e(trem de mare
dat fiind influen'a pe care o are asupra mortalit'ii 9i moridit'ii" Cunoa9terea c*t mai e(act a e!olu'iei acestui
sindrom poate decide momentul optim pentru inter!en'iile seriate impuse de ilan'ul le&ional al pacientului"

.evere injury or multiple trauma evo1e a systemic inflammatory response !hich consists of hormonal, metabolic and
immunological components and the etent correlates !ith the magnitude of the tissue injury. +n uncomplicated trauma
patients the systemic inflammatory response is temporary, predictable and !ell balanced bet!een pro$ and anti$
inflammatory mediators.
'fter years of elaborated studies regarding optimal blood pressure, optimal microvascular perfusion, management of
coagulopathy etc. no!, general believe is that immune failure is 1ey to understanding critical illness.
Trauma is a multisystemic syndrome !ith development of early M5A. +njury determines t!o simultaneously and
antagonist systemic ans!ers6 pro$inflamatory 3.+@.4 and anti$imnflamatory 3C'@.4. C'@. does not represent a
compensatory mechanism for .+@., but a direct reaction to aggression. Classic theories considered early M5A as a result
of imbalance bet!een intensity of these t!o immune reactions and correlated early M5A and death !ith
hyperinflammatory status.
The classic conception of .+@. and C'@. fails to ade(uately describe the situation at an immune cellular level.
The miture of RproinflamatoryR molecules driving cellular failure alongside over$-ealous counter$regulatory processes is
perhaps best described as a Qcomple immune dysfunction syndromeR. Clinically patients sho! signs of persistent
inflammation and immune mediated organ damage !hile simultaneously remaining highly susceptible to secondary
infections. There is an important release of endogenous inflammatory mediators including TGA alfa, +*", =, and 0 and
complement activation. +n the same time immune hypoactivity has no! been demonstrated in almost all immune cell
types including innate actors 3neutrophiles, monocytes, tissue macrophages4 as !ell as in adaptive ones 3lymphocytes T,
B, G>4. +t is undoubtedly true that trauma is associated !ith profound degree of systemic inflammation and immune
activation.
+n contrast to the scheduled surgical patient, the trauma patient is eposed to several events or hits. The first hit is the
trauma and the second the necessary damage$control surgery. +n response to these hits the immune system might be
ehausted !ith increased ris1 of infection and sepsis. The final reconstructive surgery is often postponed to avoid
another hit to the immune system. The timing of the final surgery is !idely discussed.
The purpose of this conference is to highlight ne! opinions on this bJcomple immune dysfunction syndromeJJ !ith
profound implications in choosing right time for surgery and prognostic value on survival.

#actori de predic-ie n AR,'$ul posttraumatic
Prediction Aactors in Posttraumatic '@D.
Jiliana Mirea, Ioana Marina Grinescu
Uni!ersitatea de Medicin i Farmacie 0%r" Carol %a!ila1, Clinica ;<I, Spitalul Clinic de Urgen, Bucureti, Rom*nia

;R%S$ul poate complica e!olu'ia at*t a unei traume penetrante, dar mai ales a unei traume nepenetrante, fiind un
important factor de cre9tere a mortalit'ii 9i moridit'ii postraumatice" %in punct de !edere e!oluti! au fost descrise
dou forme de ;R%S posttraumatice: ;R%S$ul precoce, ce apare n primele -$@ &ile de la ini'ierea !entila'iei mecanice,
de oicei n conte(tul 9ocului 2emoragic 9i ;R%S$ul tardi!, la sf*r9itul primei sptm*ni de e!olu'ie, de data aceasta n
conte(t de sepsis $ sd" de disfunc'ie organic multipl"
)osiilitatea de pre!enire a ;R%S$ul posttraumatic este o c2estiune care nc nu are un rspuns categoric" )e l*ng
se!eritatea traumei ca factor poten'ial de risc pentru apari'ia ;R%S$ului mai treuie lua'i n considerare 9i al'i factori
fi&iopatologici 6aspira'ia, contu&ia pulmonar, pneumonia etc"7, dar, parado(al, 9i factori care 'in de tratament" ;stfel,
setarea parametrilor !entilatori 6!olumul tidal7 9i o(igenarea proast au fost identifica'i ca factori predicti!i
independen'i n de&!oltarea ;R%S$ul posttraumatic precoce"

'cute respiratory distress syndrome is a complication of both blunt and penetrating trauma and a major contributor to
morbidity and mortality. The incidence of '*+/'@D. in trauma patients has been reported to have a bimodal distribution
!ith an early pea1 on day %$9 after the initiation of mechanical ventilation, related to hemorrhagic shoc1 and a late pea1
on day D$0, more related to multiple organ failure and sepsis. +mportant unresolved (uestions include !hether !e can
prevent '@D. and even !hether !e create it. +nitially, only the severity of trauma !as evaluated as a potential ris1
factor for the development of '*+/'@D.. )entilator settings 3tidal volume4 and a poor oygenation have been identified
recently as independent predictors of early '*+/'@D. 3!ithin D% h after mechanical ventilation4, among other major ris1
factors as aspiration, pneumonia and lung contusion and treatment variables. These findings support the hypothesis that
therapeutic strategies, as !ell as the severity of injury, contribute to the development of '*+/'@D. in these patients.







In3uria renal acut posttraumatic/ repleia &olemic cu hes ?h@drox@eth@l starchA/
Posttraumatic 'cute >idney +njury 3'>+4. Aluid @esuscitation !ith ,2. 3,ydroyethyl .tarch4.
Ioana$Gariela Cucereanu$Badic
Spitalul Clinic de Urgen' 0Floreasca1, Bucure9ti, Rom*nia

In/uria acut renal posttraumatic este o complica'ie se!er, c2iar dac nu foarte frec!ent la pacien'ii cu traum
6pre!alen'a de la ,,+ la su +,.7" #tiologia acesteia este scderea perfu&iei renale, sindromul de stri!ire 9i radomioli&a"
<rauma adominal cu de&!oltarea sindromului de compartiment intraadominal are 9i ea un rol important n etiologia
in/uriei renale posttraumatice" ?n ciuda progreselor fcute n terapia de sustitu'ie renal de&!oltarea insuficien'ei
renale este gre!at de o mortalitate semnificati! 9i cel mai important lucru este e!itarea apari'iei acesteia"
Resuscitarea lic2idian n traum este un suiect intens contro!ersat n ceea ce pri!e9te solu'iile de resuscitare3
cristaloi&i, coloi&i sau amele" Lumeroase meta$anali&e nu au demonstrat un eneficiu e!ident al utili&rii coloi&ilor 9i
cum ace9tia sunt mai scumpi recomandrile au fost de a utili&a cristaloi&i pentru resuscitare" Ma/oritatea acestor studii
au fost efectuate ns asupra pacien'ilor critici, mul'i dintre ei septici" <rialul FIRS< 6Fluids in Resuscitation of Se!ere
<rauma7 $ un studiu dulu$or, randomi&at, ce a comparat resuscitarea cu 5#S sau cu solu'ie salin ,,A. la pacien'ii
traumati&a'i, a conclu&ionat c mar4erii iologici ai resuscitrii 9i func'ia renal au fost mai une la pacien'ii care au
primit 5#S +@,B,,C dup traum penetrant"

'cute 1idney injury 3'>+4 is a serious complication after trauma even if not very common 3the prevalence rate varies from
#," to less than "#&4. '>+ etiology in these settings is decreased renal perfusion, the crush injuries and rhabdomyolysis.
'bdominal trauma and intraabdominal compartment syndrome plays also an important role. '>+ is associated !ith a
significant ris1 of morbidity and mortality despite replacement therapies and the most important is to avoid the
occurrence of '>+. Aluid resuscitation in trauma is a subject !ith many controversies regarding the use of crystalloids,
colloids or both. Meta$analyses concluded that colloids !ere not associated !ith any improvement in survival and since
the crystalloids are cheaper they are recommended as the fluid of choice. The majority of these studies !ere done in
intensive care unit in critically ill patients, most of them !ith sepsis. The A+@.T trial 3Aluids in @esuscitation of .evere
Trauma4 $ a double$blind randomi-ed controlled trial comparing the resuscitation !ith ,2. 3hydroyethyl starch4 or #,:&
saline in trauma patients concluded that biochemical mar1ers of resuscitation and renal function !ere better in patients
!ho received ,2. "9#/#,; after penetrating trauma.

In3uria renal acut postraumatic: Influena tipurilor de terapie de substituire renal
Posttraumatic 'cute @enal +njury +nfluence of Different Types of @enal @eplacement Therapy
Irina Juca$8asiliu, Ioana Marina Grinescu
Spitalul Clinic de Urgen' 0Floreasca1, Bucure9ti, Rom*nia

Insuficiena renal acut este o complicaie ma/or la pacieni criticii, incidena put*nd a/unge la @,$C,., iar E. dintre
ca&uri !or necesita terapie de sustituie renal"
Sindromul uremic acut a fost descris nc din cel de$al doilea r&oi mondial la pacienii cu le&iuni prin stri!ire, iar
mecanismul patogenic este considerat a fi un grad de isc2emie, respecti! de alterare, a flu(ului sanguin renal"
Sindromul de radomioli& este definit ca le&iune muscular ce permite elierarea n circulaia sistemic de miogloin,
proteine i electrolii" ;socierea cu insuficiena renal acut a fost clar demonstrat"
=dat depite msurile terapeutice de pre!enie, terapia de sustituie renal treuie instituit prompt"
%ei nu e(ist recomandri clare pri!ind momentul optim al instituirii terapiei de sustituie, studiile recente arat c
criteriile RIFJ# pot fi folosite n acest scop"
Utili&area memranelor speciale i a ratelor crescute de ultrafiltrare permit un clearance al miogloinei de p*n la C ori
mai mare fa' de metodele con!enionale"
)acienii traumatici repre&int ns o categorie aparte din punct de !edere al riscului crescut de s*ngerare" Coagulopatia
pree(istent sau pre&ena traumatismelor craniene impune efectuarea diali&ei fr anticoagulant sau utili&*nd
anticoagularea regional cu citrat"
?n conclu&ie, managementul corect al insuficienei renale acute la pacienii traumatici presupune iniierea precoce a
terapiei de sustituie renal, utili&area memranelor de diali& speciale fr creterea suplimentar a riscului de
s*ngerare"

'cute 1idney injury 3'>+ 4 is a major complication of critical illness, occurring in 9#$;#& of all critically ill patients, and in
its severe form re(uiring renal replacement therapy in approimately <& of patients.
.ince Borld Bar ++ so called Qacute uremia syndromeR !as described in crush injury victims and ischemia or some form
of alteration in renal blood flo! has been thought to play a pivotal role in the pathogenesis of '>+.
@habdomyolysis is Qa syndrome that involves damage and brea1do!n of s1eletal muscle, causing myoglobin and other
intracellular proteins and electrolytes to lea1 into the circulationR. The association bet!een rhabdomyolysis and acute
renal failure 3'@A4 has been recogni-ed for many years.
5nce preventive measures !ere ta1en and still, patient developed '>+, @@T should be initiated promptly.
There is no consensus on Q!henR to initiate @@T. 2arly initiation probably improves outcomes. This can be suggested by
@+A*2 Class as a surrogate of timing.
Using high cut$off haemodialysis and high ultrafiltration rates in patients !ith rhabdomyolysis and acute 1idney injury
allo!s a much better clearance of myoglobin 3almost ;#ml/min4than conventional methods 3F0ml/min4.
5ne very important aspect is that traumatic patients may have an increased bleeding ris1 3preeisting
coagulopathy,traumatic brain injury etc.4. +n these situations @@T should be administered !ithout anticoagulation or
!ith regional citrate anticoagulation.
+n conclusion, proper management once '>+ is installed in traumatic patients means early initiation of @@T using high
cut$of membranes and high ultrafiltration rates, !ithout anticoagulation or using regional citrate method.

Analge(ia multimodal la pacientul critic cu traum toracic
Multimodal 'nalgesia to the Critically +ll Patient !ith Thoracic Trauma
%aniela )a!elescu, Jiliana Mirea, Irina Juca$8asiliu, Ioana Marina Grin'escu
Spitalul Clinic de Urgen' 0Floreasca1, Bucure9ti, Rom*nia

<rauma toracic este o cau& semnificati! de moriditate 9i mortalitate la adul'i 9i copii" #ste principala cau& de deces
la -E. din pacien'ii cu traum toracic 9i determin decesul la nc E,. din pacien'ii politraumati&a'i, de oicei prin
2ipo(ie 9i 2ipo!olemie" 8*rsta peste FE ani, le&iunile asociate, un scor ISS c+E, un numr crescut de fracturi costale 9i
necesar transfu&ional cresc mortalitatea prin traum toracic" %urerea este adesea cea mai important prolem n
managementul le&iunilor toracice staile, cu moriditate tardi! semnificati!" %urerea n trauma toracic, una dintre
cele mai se!ere tipuri de durere acut, este frec!ent sue!aluat 9i insuficient tratat, cu inciden' crescut de
de&!oltare a durerii cronice"
%urerea moderat$se!er este un acti!ator potent al 0rspunsului la stres1" Stimularea continu a acestui rspuns
determin efecte negati!e pe multe func'ii fi&iologice" %urerea se!er este o cau& ma/or de insuficien' respiratorie
prin restric'ia !entilatorie, respira'ii superficiale, tuse ineficient 9i clearance neadec!at al secre'iilor"
Cau&e acute de durere dup trauma toracic sunt3 le&area coastelor 9i a ner!ilor intercostali, plgile, stri!irea
parenc2imului pulmonar, plasarea tuurilor de dren" ;ordarea multimodal a terapiei durerii este a&at pe locarea
mecanismelor fi&iopatologice de producere a acesteia 9i implic multiple sedii la diferite ni!ele ale cilor de transmitere
a durerii, multiple 'inte 9i multiple clase analgetice" Un regim analgetic adec!at treuie s includ o aordare sistemic,
cominat cu locuri regionale sau aordri centrale" ;cest regim cre9te satisfac'ia pacientului, atenuea& rspunsul la
stres 9i ameliorea& prognosticul"

Thoracic trauma is a significant cause of mortality in adults and children. +t is the leading cause of death in %<& of
thoracic trauma and it causes death in additional <#& of multiple trauma patients as a result of hypoia and
hypovolemia. 'ge over =<, associated injuries, an +..a"<, multiple rib fractures, blood transfusions increase mortality
attributable to thoracic trauma. Pain is often the most important consideration in the management of chest injuries !ith
significant delayed morbidity Pain in thoracic trauma, one of the most severe type of acute pain is underestimated and
undertreated !ith high incidence of chronic pain development. Moderate$to$severe pain is a potent activator of the
,,stress responseR. 5ngoing stimulation of this response have detrimental effects on many physiological functions. '
severe pain is a major cause of the respiratory insufficiency due to ventilatory restriction, shallo! breathing, inefficient
cough and difficult clearance of secretions. 'cute causes of pain after thoracic trauma are6 disruption of ribs and
intercostal nerves, inflammation of chest !all structures, the !ound or crushing of lung parenchyma, placement of chest
tubes. ' multimodal approach of pain control is based on bloc1ing the physiopathological mechanisms of pain and
implies multiple sites at different levels of pain transmission path!ays, multiple targets and multiple drugs. 'n
appropriate analgetic regimen should include a systemic approach combined !ith nerve bloc1 approaches and neuraial
approaches. This regimen increases patient satisfaction, attenuates the stress response and improves patient outcome.



=Be(iuni ascunse> n traumatismul toracic/ re(entare de ca(
Hidden Injuries in Blunt Thoracic Traua! Case "eport
Ioana Marina Grinescu, Sdndd&$Jale Cadr, ;ndreea Blnescu, %iana =prea
Spitalul Clinic de Urgen' 0Sf" )antelimon1, Bucureti, Rom*nia

?n traumatismele toracice e(ist 0le&iuni ascunse1, cum ar fi le&iunile aortice, care, la pacientul politraumati&at, pot fi
omise, deoarece, n pofida se!eritii, manifestrile clinice pot fi paucisimptomatice i nespecifice sau mascate de
le&iuni coe(istente mult mai e!idente clinic" %e asemenea, asena le&iunilor toracice e(terne nu elimin posiilitatea
unei ree aortice, o treime din ca&urile raportate n literatur nefiind nsoite de semne clinice e(terne de traumatism
toracic" %iagnosticul se a&ea& pe un inde( nalt de suspiciune clinic a&at pe anticiparea le&rii aortei ntr$un conte(t
sugesti! al cinematicii traumei" Interpretarea in!estigaiilor standard i recomandarea consecuti! a unor in!estigaii
mai specifice pun diagnosticul i g2idea& repararea adec!at a le&iunilor" 8 pre&entm ca&ul unui pacient de CE de ani,
ocupant dreapta, cu centur de siguran, ntr$un !e2icul care a suferit o coli&iune frontal cu decelerare rusc, oferul
fiind decedat la locul accidentului" #!aluarea primar, secundar i in!estigaiile standard nu au e!ideniat le&iuni
toracice traumatice, cu e(cepia unor e(coriaii superficiale" %up D ore, pacientul a pre&entat rusc dispnee i durere
toracicU e(aminarea radiologic i C<$ul spiral au pus diagnosticul de pseudoane!rism aortic istmic posttraumatic, iar
pacientul a fost transportat la sala de operaie pentru repararea c2irurgical a le&iunii" %oar -,. dintre pacienii cu
le&iuni traumatice ale aortei supra!ieuiesc un inter!al de timp suficient pentru a fi tratai" Magnitudinea reei aortice,
asociat cu le&iunile coe(istente i comoriditile medicale determin alegerea momentului i a inter!eniei pentru
repararea le&iunilor aortice"

+n blunt thoracic trauma, attention must be paid to the Qhidden injuriesR, li1e blunt aortic injuries, !hich, in major
trauma, can be easily overloo1ed because, despite their severity, the clinical manifestations are often deceptively
meager and nonspecific or mas1ed by the more cspectacularR coeisting injuries. 'lso, the absence of eternal evidence
of a chest injury does not eliminate an aortic tear, in literature, one third of the cases having no eternal signs of chest
trauma. The 1ey of the diagnosis is the high inde of clinical suspicion based on the anticipation of the aortic injury !ith
suggestive trauma cinematics. +nterpreting the standard trauma series and subse(uently ordering the more specific tests
are the steps in providing the ade(uate definitive management. Be present the case of a ;<$years$old male, occupant,
restrained, in a vehicle !hich had a high speed frontal collision, !ith the driver dead at the scene. 5n arrival, the primary
and secondary survey and the standard trauma series revealed no posttraumatic thoracic injuries, ecept for superficial
lacerations. 'fter 0 hours he developped sudden shortness of breath and thoracic pain. @adiologic eamination and the
CT scan revealed an isthmic pseudoaneurysm, and the patient under!ent surgical repair. 5nly %# percent of patients
!ith blunt aortic injury survive long enough follo!ing the injury to be treated. The grade of injury and the patientJs
coeisting lesions and comorbidities determine the timing and type of aortic repair.

Organi(area unui ser&iciu intraspitalicesc de terapia durerii acute
+n$,ospital 'cute Pain Therapy Department
;" Leam'u
Uni!ersitQ of Jouis!ille S=M, %epartment of ;nest2esiologQ and )erioperati!e Medicine, Gentuc4Q, US;

<ratamentul durerii acute 6<%;7 s$a modificat sustan'ial n ultimii ani datorit unor importante descoperiri n medicin"
%urerea este acum pri!it mai degra ca o oal dec*t ca 9i un simptom, analgesia multimodal este folosit e(tensi!,
iar te2nicile cu g2ida/ ultrasonic au sc2imat aordarea aneste&iei regionale de ctre aneste&i9ti" Cu toate acestea,
aneste&ia regional este nc suutili&at n Statele Unite ale ;mericii, n ciuda unor do!e&i 9tiin'ifice de control mai un
al durerii n compara'ie cu aneste&ia general 6+, -7, mai ales n anumite grupuri de pacien'i 6@7 9i tipuri de opera'ii 6@, C,
E, F, H7" Cu toate c nu prea demult in/ec'iile intramusculare intermitente de opiacee au fost folosite curent pentru
controlul durerii postoperatorii, ast&i analgesia controlat de pacient permite titrarea analge&icelor intra!enoase n
func'ie de necesitatea specific" ?n plus, n ultimii -E de ani aneste&i9tii au folosit tot mai mult aneste&ia regional, n
special peridural, pentru controlul durerii acute postoperatorii" ?n consecin', s$au de&!oltat c*te!a modele de ser!icii
intraspitalice9ti de terapia durerii acute postoperatorii 6D, A73 ser!icii conduse de aneste&i9ti 6E, F7, ca 9i ser!icii conduse
de surori medicale speciali&ate n tratamentul durerii 6+,7" ?n pre&entare se !or discuta a!ana/ele 9i de&a!anta/ele
c*tor!a modele de ser!icii intraspitalice9ti de tratamentul durerii" 8or fi amintite personalul 9i ec2ipamentul necesar
unui astfel de ser!iciu, ca 9i educarea personalului implicat" )entru a putea utili&a mai ine acest ser!iciu
intraspitalicesc, scopul practicii lui ar treui s se e(tind dincolo de perioada imediat postoperatorie, s includ 9i
stratificarea preoperatorie a riscului 6++7, pentru a facilita mai ine recuperarea postoperatorie 9i a pre!eni sindromul
durerii postoperati!e cronice 6+-7"
Biliografie3
+" <ig2e ):, Brennan M, Moser M, Boe&aart ;), Bi2orac ;" )rimarQ paQer status is associated Tit2 t2e use of ner!e loc4
placement for amulatorQ ort2opedic surgerQ" Reg ;nest2 )ain Med" -,+-U @H6@73 -EC$-F+" -" Jiu SS, Strodtec4 SM,
Ric2man :M, Su CJ" ; comparison of regional !ersus general anest2esia for amulatorQ anest2esia3 a meta$analQsis of
randomi&ed controlled trials" ;nest2 ;nalg" -,,EU+,+3+F@C$C- @" 5ad&ic ;, ;rliss :, Gerimoglu B, Garaca )#, Rufa M,
Claudio R#, 8lo4a :%, Rosen^uist R, Santos ;C, <2Qs %M" ; comparison of infracla!icular ner!e loc4 !ersus general
anest2esia for 2and and Trist daQ$case surgeries" ;nest2esiologQ" -,,C U+,+3+-H$@-" C" Steinroo4 R;" #pidural
anest2esia and gastrointestinal motilitQ" ;nest2 ;nalg" +AADUDF3D@H$CC" E" 5el :R, %ilger :;, BQer %#, Gopp SJ, Ste!ens
SR, )agnano MS, 5anssen ;%, 5orloc4er <<" ; pre$empti!e multimodal pat2TaQ featuring perip2eral ner!e loc4
impro!es perioperati!e outcomes after ma/or ort2opedic surgerQ" Reg ;nest2 )ain Med" -,,DU@@3E+,$H F" Manion SC,
Brennan <:" <2oracic epidural analgesia and acute pain management" ;nest2esiologQ" -,++U++E3+D+$ H" MulroQ MF,
Jar4in GJ, 5odgson )S, 5elman :%, )olloc4 :#, Jiu SS" ; comparison of spinal, epidural, and general anest2esia for
outpatient 4nee art2roscopQ" ;nest2 ;nalg" -,,,U A+3DF,$C" D" RaTal L" +, Qears of acute pain ser!ices ] ac2ie!ements
and c2allenges" R;)M +AAAU -C3FD$H@" A" Brei!i4 5" 5oT to implement an acute pain ser!ice" Best )rac Res Clin
;nest2esiolU +F3 E-H$ECH" +," JQnc2 M" )ain3 t2e fift2 !ital sign" Compre2ensi!e assessment leads to proper treatment"
;d! Lurse )ract -,,+U A3 -D$@F" #rratum3 ;d! Lurse )ract -,,CU +-3D" ++" Upp :, Gent M, <ig2e ):" <2e e!olution and
practice of acute pain medicine" )ain Med -,+@U +C6+73+-C$+CC " #pu -,+- %ec +@" +-" Ge2let 5, :ensen <S, Soolf, C:"
)ersistent postsurgical pain ris4 factors and pre!ention" Jancet -,,FU @FH3 +F+D$+F-E"

'cute pain management 3'PM4 has changed significantly in recent years due to important advances in medicine. Pain is
no! regarded as a disease process rather than a symptom, multimodal analgesia is !idely used, and ultrasound
techni(ues changed anesthesiologistsJ approach to regional anesthesia. ,o!ever, regional anesthesia is still
underutili-ed in the United .tates, despite evidence of better postoperative pain control outcome compared to general
anesthesia 3", %4, especially in certain populations 394 and surgeries 39, ;, <, =, D4. Bhile not too long ago intermittent
intramuscular injections of opioids !ere largely used for postoperative pain control, no! patient controlled analgesia
allo!s patients to titrate analgesics intravenously according to their needs. +n addition, over the past %< years
anesthesiologists became enthusiastic in using regional analgesia, notably epidurals, for perioperative pain control. 's a
result, several models of in hospital pain services !ere developed 30, :46 the Qanesthesiologist$ledR pain service 3<, =4, the
Qpain nurse$ledQ acute pain service 3"#4, etc. 'dvantages and disadvantages of several in hospital pain services !ill be
discussed. Training, staffing and e(uipment re(uirements !ill also be considered. +n order to better ta1e advantage of an
acute pain service, its scope should epand beyond the immediate postoperative period, to include pre$operative ris1
stratification 3""4, to facilitate recovery and rehabilitation after surgery, as !ell as to prevent chronic postoperative pain
3"%4.
@eferences6
". Tighe P8, Brennan M, Moser M, Boe-aart 'P, Bihorac '. Primary payer status is associated !ith the use of nerve bloc1
placement for ambulatory orthopedic surgery. @eg 'nesth Pain Med. %#"%K 9D3946 %<;$%=". %. *iu .., .trodtbec1 BM,
@ichman 8M, Bu C*. ' comparison of regional versus general anesthesia for ambulatory anesthesia6 a meta$analysis of
randomi-ed controlled trials. 'nesth 'nalg. %##<K"#"6"=9;$;% 9. ,ad-ic ', 'rliss 8, >erimoglu B, >araca P2, Lufa M,
Claudio @2, )lo1a 8D, @osen(uist @, .antos 'C, Thys DM. ' comparison of infraclavicular nerve bloc1 versus general
anesthesia for hand and !rist day$case surgeries. 'nesthesiology. %##; K"#"6"%D$9%. ;. .teinbroo1 @'. 2pidural
anesthesia and gastrointestinal motility. 'nesth 'nalg. "::0K0=609D$;;. <. ,ebl 8@, Dilger 8', Byer D2, >opp .*, .tevens
.@, Pagnano MB, ,anssen 'D, ,orloc1er TT. ' pre$emptive multimodal path!ay featuring peripheral nerve bloc1
improves perioperative outcomes after major orthopedic surgery. @eg 'nesth Pain Med. %##0K996<"#$D =. Manion .C,
Brennan T8. Thoracic epidural analgesia and acute pain management. 'nesthesiology. %#""K""<6"0"$ D. Mulroy MA,
*ar1in >*, ,odgson P., ,elman 8D, Polloc1 82, *iu ... ' comparison of spinal, epidural, and general anesthesia for
outpatient 1nee arthroscopy. 'nesth 'nalg. %###K :"60=#$;. 0. @a!al G. "# years of acute pain services T achievements
and challenges. @'PM ":::K %;6=0$D9. :. Breivi1 ,. ,o! to implement an acute pain service. Best Prac @es Clin
'nesthesiolK "=6 <%D$<;D. "#. *ynch M. Pain6 the fifth vital sign. Comprehensive assessment leads to proper treatment.
'dv Gurse Pract %##"K :6 %0$9=. 2rratum6 'dv Gurse Pract %##;K "%60. "". Upp 8, >ent M, Tighe P8. The evolution and
practice of acute pain medicine. Pain Med %#"9K ";3"46"%;$";; . 2pub %#"% Dec "9. "%. >ehlet ,, 8ensen T., Boolf, C8.
Persistent postsurgical pain ris1 factors and prevention. *ancet %##=K 9=D6 "="0$"=%<.





Terapia inter&enional n durerea cronic
Chronic Pain6 +nterventional Management
;" Grunfeld
S2ea 5ospital <el 5as2omer, Ramat Gant, Israel

The multitude of treatments in chronic pain is the indirect image of the compleity of etiology and pathogenesis. 't the
same time, it represent the image of the failures of these treatments. Therefore the development and improvement of
the eisting ones is re(uired. . Physical rehabilitation, occupational medicine, behavioral medicine, medical d
complementary/alternative medicine, surgery d other intervention$ all these are categories of treatment for the patient.
Bhat should not be forgotten is the patientZs adaptation to the conditions of his life. Arom this comple + !ill present
various invasive treatments in chronic pain. +nvasive treatments can be blind, guided O$ray, CT$guided, guided
Ultrasound. +nvasive treatments may be !ith the injection of anesthetics substances, steroids, neurolitic substances.
+nvasive treatments are neuromodulator, neurolysis. The presentation is based on the image of these treatments and
less on polemics of medical evidence and the level of recommendation.

Bidocaina n tratamentul durerii acute +i cronice
*idocaine in 'cute and Chronic Pain Management
;dela 5ilda =nuu
Spitalul Clinic :udeean de Urgen, Clinica de =rtopedie i <raumatologie, Clu/$Lapoca, Romania

Jidocaina, -$ 6dietilamino7 $ L$ 6-,F$dimetilfenil7 acetamida, a fost sinteti&at n +AC@ i este cunoscut ca aneste&ic local
i antiaritmic 6clasa +B7"
)otenialul analgetic al Jidocainei e(ercitat prin administrare intra!enoas, oral sau prin aplicare topic, a fost !alidat,
iar indicaiile sale n durerea cronic sunt de/a stailite" Cu toate acestea, efectele administrrii sistemice a lidocainei n
tratamentul durerii acute postoperatorii repre&int n continuare un suiect de cercetare i contro!erse"
;dministrarea de Jidocain pe cale intra!enoas i$a do!edit efectele analgetice, antiinflamatoare 6Cassuto -,,F7 i
proprietile anti2iperalgice 6GaTamata -,,-7"
Mecanismul principal de aciune este loca/ul canalelor de sodiu !olta/ dependente centrale i periferice" %e asemenea,
Jidocaina interacionea& cu canalele de potasiu, de calciu i nu n ultimul r*nd, antagoni&ea& receptorii LM%;
6Sugimoto -,,@7"
Jidocaina determin in2iiia descrcrilor neuronale ectopiceBaerante, at*t la ni!el periferic c*t i la ni!elul
ganglionilor rdcinilor dorsale" ;cest proces se reali&ea& la concentraii plasmatice mult mai /oase dec*t cele necesare
locrii conducerii ner!oase periferice"
,urerea acut
Studiile clinice au artat c administrarea intraBpostoperatorie 6imediat7 a Jidocainei determin o analge&ie medie i
reducerea consumului postoperator de opioide" Ja acestea se adaug stimularea funcionalitii intestinale cu reluarea
mai rapid a tran&itului intestinal 6prin mecanism nepreci&at7 i reducerea duratei de spitali&are 6Groudine +AAD, Marret
-,,D7"
#(ist diferene pri!ind analge&ia determinat de administrarea de Jidocain i"!" ntre c2irurgia adominal 6colon,
inter!eniiBlaparoscopice, prostat, sfera genital etc"7 i alte tipuri de inter!enii 6ortopedice, tonsilectomie, Qpass
coronarian etc"7 6McCart2Q -,+,, %e =li!eira -,+-7"
?n pre&ent, Jidocaina i"!" este recomandat n terapia durerii postoperatorii n c2irurgia colonului, atunci c*nd aneste&ia
peridural este contraindicat, iar analogul su oral 6Me(iletine7 este recomandat n tratamentul durerii n ca&ul
inter!eniilor nonestetice ale s*nului 62ttp3BBTTT"postoppain"orgB7"
,urerea cronic
Metaanali&ele au artat c lidocaina i analogul su oral, Me(iletine, sunt eficiente n reducerea durerii neuropate,
centrale i periferice 6<remont$Ju4ats -,,E, C2allapalli -,,E, auon -,+,7, precum i n alte forme de durere cronic"
#ficiena analgetic a Jidocainei n tratamentul durerii cronice este de durat medie i limitat n timp"
Sunt enumerate efectele administrrii de lidocain n principalele sindroame dureroase cronice, sunt preci&ate
protocoalele de lucru acceptate la acest dat precum i efectele secundare pe care acest metod de tratament le
determin"
Jidocaina este considerat a fi un analge&ic ad/u!ant util n terapia durerii acute i cronice"
?n momentul actual indicaiile lidocainei n terapia durerii cronice sunt definite i reglementate, ns n terapia durerii
acute sunt necesare studii suplimentare care s optimi&e&e protocoalele administrare, precum i cadrul c2irurgical n
care aceast metod poate fi enefic"

*idocaine, % $ 3diethylamino4 $ G $ 3%,= dimethylphenyl4 acetamide !as synthesi-ed in ":;9 and is 1no!n as a local
anaesthetic and a class "B antiarrhythmic drug.
The analgesic effects of intravenous, oral or topic lidocaine !ere established as !ell as the recommendations for its use
in chronic pain syndromes.
2ven so, the effects of systemic lidocaine administration, in acute postoperative pain, are open to continuous research
and debates.
+ntravenous *idocaine proved analgesic, antiinflammatory and antihyperalgesic effects 3Cassuto %##=, >a!amata %##%4.
2ven if central and peripheral voltage$gated sodium channel bloc1 represents the main !ay to eert its action, *idocaine
also bloc1s GMD' receptors 3.ugimoto %##94 and inhibits ectopic/ aberrant neuronal discharge in peripheral fibers as
!ell as in dorsal root ganglia. This process ta1es place at *idocaine plasma levels much belo! those needed to bloc1
peripheral action potential.
Acute pain
Clinical studies sho!ed that perioperative *idocaine infusion determined medium analgesia and reduced postoperative
opioid consumption. 'lso, its administration speeds the return of bo!el function 3un1no!n mechanism4 and shortens the
duration of hospital stay 3?roudine "::0, Marret %##04.
There are differences regarding analgesia lidocaine infusion bet!een abdominal surgery 3colic, laparoscopic, prostate,
genital area4 and other surgeries 3orthopaedic, tonsillectomy, coronary bypass4 3McCarthy %#"#, De 5liveira %#"%4.
Go!adays, lidocaine is recommended for open and laparoscopic colectomy. The oral analog of lidocaine, metileine is
also recommended after non$aesthetic breast surgery 3http6//!!!.postoppain.org/4.
Chronic pain
Metaanalysis sho!ed that *idocaine and its oral analog, meiletine, are effective in lo!ering pain scores in central and
peripheral neuropathy, and also in different other types of chronic pain 3Tremont$*u1ats %##<, Challapalli %##<, Nuon
%#"#4.
*idocaine offers medium analgesia !ith limited duration in neuropathic pain.
Be are going to present *idocaine infusion effects in chronic pain syndromes, accepted protocols, as !ell as its side
effects.
*idocaine is a valuable analgesic adjuvant in chronic and acute pain therapy.
't the moment there are clearly defined recommendations for *idocaine infusion in chronic pain management, but there
is still little data as far as acute pain therapy is concerned.

#actori ce contribuie la mbunt-irea re(ultatelor n aneste(ia pediatric
+mproved 5utcome in Pediatric 'naesthesia6 ' @evie! Contributing Aactors
M" Somri
Bnai Pion Medical Center, Bruce Rappaport FacultQ of Medicine, <ec2nion, Israel Institute of <ec2nologQ, 5aifa, Israel

+ntroduction6 'naesthesia$related adverse outcomes have been the subject of etensive debate for the past fe! decades.
*andmar1 papers and statements applied critical incident analysis techni(ues borro!ed from fields such as aviation, in
order to eamine the causes and consider possible preventative strategies for such outcomes 3also termed Qpreventable
mishapsR4. By highlighting ho! imperfections in clinical practice could lead to errors and thus patient harm, these
innovative analyses provided anaesthetists !ith ne! insights on !hich they could act to promote anaesthesia patient
safety H", %I. 'lthough this specific term !as not used at the time, these analyses brought significant changes in
anaesthetic practice. The 'merican .ociety of 'nesthesiologists 3'.'4 !as created in ":0;, the 'nesthesia Patient .afety
Aoundation 3'P.A4 !as founded in ":0<, and the Closed Claims Project !as initiated in mid$":0< by the '.' Committee
on Professional *iability 3CP*4. These institutions !ere involved in and focused on the development and implementation
of patient safety statements. Bet!een ":0< and "::9, the CP* had evaluated a total of %;## closed anaesthesia
malpractice claims in the paediatric and adult populations. "#& of claims involved patients younger than "= years of
age. @espiratory events !ere found to be more common in paediatric than in adult claims 3;9& v 9#&4, as !ell as
mortality$related claims 3<#& v 9<&4. Aurthermore, anaesthetic care !as judged less than appropriate in paediatric
claims 3<;& v ;;&4. Ainally, an estimated 0:& of paediatric events could have been prevented by pulse oimetry or
capnometry H9I. These findings accelerated the adoption of monitoring standards. +n the follo!ing years, studies
analysing anaesthesia$related adverse outcomes implicated major human error and e(uipment failure amongst other
factors. +n addition, they described the contributions of novel anaesthetic agents and ne! practices for dealing !ith
perioperative adverse events in paediatric surgery. 'lthough these observations may not apply universally, they
emphasise the importance of understanding, anticipating, and dealing !ith perioperative adverse effects in order to
inform patient management and to improve paediatric anaesthesia outcomes. ' major development in the field has
been the recognition that paediatric patients should be cared for by paediatric anaesthetists or physicians !ho can
demonstrate the e(uivalent in terms of specific eperience. +n this revie!, !e highlight the evidence on adverse
outcomes related to paediatric anaesthesia and discuss the factors !hich have influenced outcome trends over the past
fe! decades such as introduction of ne! anesthetics agent, improvement in pediatric anesthesia (ualification and
introduction of recent anesthetics techni(ues 3<4 . +n addition, !e present important issues !hich may drive the future
course of paediatric anaesthetics and pediatric neurocognitive outcomes 3=4.
@eferences
". Cooper 8B, Ge!bo!er @., *ong CD, McPee1 B 3":D04. Preventable anesthesia mishaps6 a study of human factors.
'nesthesiology ;:3=469::$;#=. %. Cheney AB, Posner >, Caplan @', Bard @8 3":0:4. .tandard of care and anesthesia
liability. 8'M' %="3""46"<::$=#9. 9. Morray 8P, ?eidusche1 8M, Caplan @', Posner >*, ?ild BM, Cheney AB 3"::94. '
comparison of pediatric and adult anesthesia closed malpractice claims. 'nesthesiology D03946;="$D. ;. .omri M, Coran
'?, Mattar +, Tes-ler C, .haoul @, Tom1ins 5, Tome @, Mogilner 8?, .u1hotni1 +, ?aitini * 3%#""4. The postoperative
occurrence of cardio$respiratory adverse events in small infants undergoing gastrointestinal surgery6 a prospective
comparison of general anesthesia and combined spinal$epidural anesthesia. Pediatr .urg +nt %D6""D9$0. <. .omri M,
Matter +, Parisinos C', .haoul @, Mogilner 8?, Bader D, 'sphandiarov 2, ?aitini *' 3%#"%4. Comparing the effect of
combined spinal T epidural anesthesia versus general anesthesia on the recovery time of intestinal function in young
infants undergoing gastrointestinal surgery6 ' randomi-ed, prospective controlled trial. 8 Clin 'nesth 3in press4. =.
>al1man C8, Peelen *, Moons >?, )eenhui-en M, Bruens M, .innema ?, de 8ong TP. Behavior and development in
children and age at the time of first anesthetic eposure. 'nesthesiology %##:K ""#60#<$"%.

<emofiltrarea n terapia intensi& a insuficien-ei renale de cau( medico$chirurgical
@ole of ,aemofiltration in the +ntensive Care for @enal Aailure of Mied Medical and .urgical 2tiology
C" )aiu, =ana <rifan, Mi2aela Munteanu, 8" Munteanu, <" Cioanu
Spitalul Clinic de Urgen pentru Copii 0Sf" Maria1, Iai, Rom*nia

)re&entm ca&ul unei paciente n !*rst de - ani i @ luni, internat n secia noastr prin transfer dintr$un spital
/udeean, la -C de ore dup inter!enia c2irurgical pentru in!aginaie intestinal cu e!oluia postoperatorie gre!at de
apariia semnelor de insuficien respiratorie" Ja pre&entare, pacienta era n stare general gra!, cu talou clinico$
iologic sugesti! pentru un sepsis gra! cu semne de insuficien multipl de organ3 cardio$respiratorie 6edem pulmonar
acut, 2ipertensiune arterial7, renal, acido$a&ic i 2idro$electrolitic, neurologic, 2epatic i 2ematologic" ?n aceste
condiii, la metodele farmacologice de terapie intensi! s$a asociat 2emofiltrarea !eno$!enoas continu pe cateter
femural" #!oluia lent fa!orail 6+F &ile de 2emofiltrare, controlul 2ipertensiunii arteriale cu tripl asociere de
anti2ipertensi!e7 a fost marcat de decelarea unui sindrom nefrotic cu remisiune clinic i parial iologic la e(ternarea
pacientei, dup @, de &ile de spitali&are"

Be present the case of a % year and 9 months old girl transferred in our intensive care unit from another hospital, %;
hours after being operated for intussusception !ith postoperatory respiratory distress. 't admission, the patient !as in
critical state, !ith clinical and biological findings consistent for severe sepsis associated !ith multiple organ failure6
cardiorespiratory 3acute pulmonary edema, arterial hypertension4, renal, nervous, hepatic and hematological failures,
and acid$base and electrolytical disorders. Continuous veno$venous haemofiltration through a femural catheter !as
initiated in addition to the pharmacological therapy. The slo!ly improving evolution 3"= days on haemofiltration, arterial
hypertension controlled by associating three antihypertensives4 !as mar1ed by the diagnosis of a nephrotic syndrome in
total clinical and partial biological remission at the patientZs discharge, after a 9#$day hospitalisation.

,iali(a peritoneal acut la sugar
'cute Peritoneal Dialysis for +nfants
R" <aacaru, Constana )ic4, Juminia Ilie, ;driana Guri', Irinel <rante, Rodica Sirg2ie, B" Grigorescu 6-7, etefania
Balamat
Spitalul 0Marie Curie1, Bucure9ti, Rom*nia

%iali&a peritoneal acut este indica'ia de elec'ie pentru epurare e(trarenal la sugari 9i copii mici unde accesul !enos
poate fi o prolem" Indica'iile sunt suprancrcarea lic2idian, de&ec2ilirele electrolitice, acido&a metaolic, uremia,
olile metaolice, to(ine e(ogene, postc2irurgie cardiac, oligurie" Contraindica'iile sunt 2ernia diafragmatic,
gastros4i&is, omfalocel, oclu&ia, perfora'ia intestinal, infec'ii ale peretelui adominal" Montarea cateterului de diali&
se face c2irurgical, diali&a put*nd ncepe imediat sau la +- $ -C ore de la montare" Se ncepe cu !olume mici +, mlB4g
care se cresc p*n la C,$E, mlB4g" Concentra'ia de gluco&, ce poate !aria ntre +,-E. 9i @,HE., se alege n func'ie de
necesarul de ultrafiltrare" ?n func'ie de necesarul de diali& se poate modifica durata ciclului de sc2im sau concentra'ia
de gluco&, durata scurt 9i cantitatea mic 6D,,mlBm-7 fa!ori&*nd ultrafiltrarea, iar ciclul lung 9i !olumul mare
6+-,,mlBm-7 fa!ori&*nd eliminarea to(inelor uremice" #ste recomandail monitori&area presiunii intraperitoneale 9i
adaptarea !olumului 9i a duratei ciclului la toleran'a fiecrui pacient" Complica'iile sunt cele mecanice, 2ernia
omilicalBing2inal, durerea, reflu( gastroesofagian, dispnea, 2idrotora( sau infec'ioase $ peritonita" 8a fi pre&entat
ca&ul unui copil de E luni cu megacolon congenital cu repetate inter!en'ii c2irurgicale, colostomie, sepsis,
tromocitopenie, insuficien' renal acut, 2ipertensiune arterial, con!ulsii, insuficien' respiratorie acut, prote&at
respirator +C &ile, care a eneficiat de diali& peritoneal timp de @- &ile"

'cute peritoneal dialysis is the method of choice renal replacement therapy in neonates, infants and small children !ith
limited vascular access. +ndications are6 fluid overload, electrolyte/acid$base imbalances, symptomatic uremia, oliguria
preventing ade(uate nutrition, oliguria follo!ing recent cardiac surgery, inborn errors of metabolism, encephalopathy,
hyperammonaemia, severe metabolic acidosis. Contraindications are abdominal !all defects 3gastros1isis,
omphalocelle4 or abdominal !all infection, bo!el distension, perforation, adhesion or resection, diaphragmatic hernia.
Dialysis catheter is surgically inserted and the cycles can begin in a fe! hours, progressively increasing the volume from
"# ml/1g to a maimum of ;#$<#ml/1g. The glucose concentration of dialysis peritoneal fluid can be adjusted according
to ultrafiltration needs from ",%<& to 9,D<& glucose, a short d!ell time favoring ultrafiltration and long d!ell time
promote uremic toin removal. +t is recommended to monitor intraperitoneal pressure and adapt the instilled volume to
individual tolerance. Complications can be mechanical umbilical/inguinal hernia, gastroesophagian reflu, abdominal
pain, hydrothora, and infection $ peritonitis. Be !ill present a case of a < mo child !ith repeated abdominal surgeries
for congenital megacolon, colostomy, respiratory failure, convulsions, arterial hypertension, uremia, oliguria, sepsis,
thrombocytopenia. ,e !as intubated and ventilated for "; days, and !as on peritoneal dialysis for a total of 9% days,
until his renal function start to recover.

'indromul de acti&are macrofagic $ terapie intensi&
Macrophagic 'ctivation .yndrome $ +ntensive Care
F" Rusu, Gariela Ionescu
Spitalul Clinic pentru Copii 0Grigore ;le(andrescu1, Bucure9ti, Rom*nia

=iecti!e3 Sindrom comple(, pu'in cunoscut, at*t n practica curent, c*t 9i n descrierile monografice din literatura de
specialitate, cu punct de plecare frec!ent la pacien'ii ce au pre&entat artrit /u!enil idiopatic"
Material 9i metod3 %ate teoretice din literatur care au fost regsite la o pacient n !*rst de +F ani internat n
ser!iciul de terapie intensi! a Spitalului de Urgen' pentru Copii 0Grigore ;le(andrescu1 9i managementul specific
aplicat acestui ca&"
Re&ultate3 ;plicarea in!estiga'iilor 9i tratamentului indicat de datele de specialitate nu au dus la o'inerea unei
munt'iri a e!olu'iei, ci a condus spre insuficien' 2epatic, coagulopatie, insuficien' respiratorie, disfunc'ie
neurologic printr$o proliferare necontrolat a limfocitelor < 9i macrofagelor n organele 'int 6plm*ni, ficat creier,
rinic2i7 cu e!olu'ie nefa!orail 9i sf*r9it letal al pacientei"
Conclu&ii3 %iagnosticat tardi!, la o pacient cu factor predispo&ant 6!irus #stein Barr7, n ciuda msurilor de <I, c*t 9i a
tratamentelor descrise n literatura de specialitate, e!olu'ia a fost nefa!orail, aceasta fiind n concordan' cu datele
din literatur, la care mortalitatea este de E,."

5bjective6 +t is a comple syndrome, less 1no!n, both in the current practice and in the monograpfic descriptions of the
medical literature, encountered fre(uetly !ith pacients presenting juvenile idiopathic arthritis.
Material and Method6 Theoretical data coming from research !ere present at a "=$year$old patient at the intensive care
unit of the Q?rigore 'leandrescuR Children 2mergency ,ospital and the specific management !as applied to this
particular case.
@esults6 @unning the ade(uate investigations and the proper treatment indicated by the research data did not enhance
the patientJs evolution, but led to a liver disfunction, respiratory failure, coagulopathy, neurological disfuntion due to an
uncontrolled proliferation of the T limphocites and of the macrophages !ithin the targeted organs 3lungs, liver, brain,
1idneys4. The infavourable evolution led to the patientJs death.
Conclusions6 Despite the intensive care measures applied and the treatment described by the specialty literature to a
patient predisposed 32bstein Barr )irus4 and diagnosed rather later, her evolution !as unfavourable, in accordance !ith
the medical literature that states that <#& of the case are fatal.

Tuberculo(a la copilul n terapie intensi&
Tuberculosis in Pediatric +ntensive Care Unit
;nca #lena Malo9, ;driana )opa
Spitalul Clinic :ude'ean de Urgen', Craio!a, Romania

S5= a estimat c, n -,,H, o treime din popula'ia lumii era infectat cu MQcoacterium tuerculosis" ;pro(imati! ++.
dintre ace9tia sunt copii su +E ani" ?n 'rile de&!oltate tuerculo&a la copil este rar, HE. dintre ca&uri de tuerculo&a la
copil fiind n cele -- 'ri cu cea mai mare inciden' a olii" Rom*nia, de9i nu se numr printre acestea rm*ne una
dintre 'rile europene cu moriditate 9i mortalitate crescut determinate de infec'ia acilar" Copilul mic este mai
susceptiil pentru formele diseminate de oal, iar C,. dintre copiii su - ani infecta'i !or de&!olta tuerculo&"
Imaturitatea func'ional 9i morfologic a copilului face ca apari'ia formelor acute, uneori fulminante, inclu&*nd
insuficien' multipl de organe, 9ocul septic, sindromul de detres respiratorie acut, s nu fie rar" %iagnosticul de
tuerculo& la copil este dificil deoarece lipse9te o defini'ie standard, manifestrile clinice sunt nespecifice, frec!en'a
manifestrilor e(trapulmonare este mai mare, confirmarea de laorator incert, mai ales la copilul su E ani unde
ca&urile cu frotiuri po&iti!e sunt su D." #!aluarea copilului suspect de tuerculo& include3 anamne&a minu'ioas,
e(amenul clinic, confirmarea acteriologic, in!estiga'ii rele!ante pentru locali&are, intradermoreac'ia la tuerculin,
interferon$gamma release assaQs, ns n conte(tul men'ionat diagnosticul la copil este adesea pus pe rspunsul clinic 9i
radiologic la tratamentul empiric sau postmortem" %atorit particularit'ilor de e!olu'ie la copil, n terapia intensi!
pediatric !or continua s fie admise ca&uri cu tuerculo&" )rognosticul gra! dat de nt*r&ierea sau asen'a
tratamentului impune un grad crescut de suspiciune pentru etiologia acilar n ca&urile cu diagnostic incert 9i e!olu'ie
nefa!orail"

B,5 estimated that in %##D one third of the !orldJs population has been infected !ith Mycobacterium tuberculosis.
Arom this around ""& are children under "< years. +n developed countries children tuberculosis is relatively rare, D<& of
cases being in the %% highest TB$burden countries. 2ven though @omania isnJt among them, it remains one of the
2uropean countries !ith high mortality and morbidity due to tuberculosis. .mall children are more prone to
disseminated forms, in fact ;#& of infected children under % years !ould develop tuberculosis. 'cute evolution or even
fulminate !ith multiple organ system failure, septic shoc1, acute respiratory distress syndrome is not rare, secondary to
functional and morphologic immaturity of children systems. The diagnosis of tuberculosis in children is often challenging
because a standard definition is absent, etrapulmonary manifestations are more fre(uent, laboratory confirmation is
difficult, especially in children under < years, !here positive smear cases are less then 0&. 'ssessing the child !ith
suspected tuberculosis is based on6 careful history, clinical eamination, tuberculin s1in test, interferon gamma release
assays, bacteriological confirmation, relevant investigations for locali-ation of infection. +n circumstances mentioned
above the diagnosis is often made by clinical and radiological response to empiric therapy or postmortem. Due to severe
prognosis in delayed or absent treatment, a high inde of suspicion for bacillar infection should have for cases !ith
uncertain diagnostic and unfavorable evolution.

'indromul de detres respiratorie acut ?AR,'A dup re(ec-ii pulmonare
'@D. after Pulmonary @esections
R" Stoica, Geno!e!a Cadar
Institutul de )neumologie 0Marius Lasta1, Bucureti, Rom*nia

In/uria acut pulmonar 6;cute Jung In/urQ $ ;JI7 i forma sa cea mai se!er, sindromul de detres respiratorie acut
6;cute RespiratorQ %istress SQndrome $ ;R%S7, este o complicaie gra!, cu o mortalitatea general de peste E,."
%atorit criteriilor neuniforme de diagnostic incidena real a ;JI dup re&eciile pulmonare este diferit raportat, n
cele mai multe dintre studii fiind n /ur de @. i mai mult de A. pentru ;JIB;R%S post$pneumonectomie" %iagnosticul
clinic respect criteriile de ;#CC din +AAC, sindromul fiind caracteri&at de 2ipo(emie acut, modificri radiologice
pulmonare i de caracteristici ale 2emodinamicii" Mecanismul principal fi&iopatologic este legat de mediatorii pro$
inflamatorii elierai n timpul in/uriei c2irurgicale pulmonare directe, alte cau&e e(tra$pulmonare put*nd fi, de
asemenea, implicate" Ca i n ;JIB;R%S de alte etiologii terapia este n principal de susinere a funciilor organelor !itale"
?n ma/oritatea ca&urilor este indicat strategia de !entilaie 0pulmonar protecti!1" Moartea este datorat cel mai
frec!ent sindromului de disfuncie multipl de organe 6M=%S7" )re&entarea unui ca& clinic sulinia& principalele etape
de diagnostic i tratament al ;R%S post$pneumonectomie"

'cute lung injury 3'*+4 and its most severe form, 'cute @espiratory Distress .yndrome 3'@D.4, is a serious complication
!ith more than <#& overall mortality. The real incidence of '*+ after pulmonary resections is reported differently, due to
lac1 of uniformity in the criteria of diagnosis, in most of the studies being around 9& and more than :& for post$
pneumonectomy '*+/'@D.. The clinical diagnosis respects the criteria of '2CC from "::;, underling acute hypoemia,
chest radiology changes and haemodynamic characteristics. The main pathophysiological mechanism is lin1ed to the
pro$inflammatory mediators released during direct lung injury but other etra$pulmonary causes could also be involved.
*i1e in other etiologies of '*+/'@D. therapy is mainly supportive providing vital organ functions. Mechanical ventilation
!ith Plung protective strategyP is indicated. Death fre(uently occurs !ith multiple organ dysfunction syndrome 3M5D.4.
' clinical case discussion emphasi-e the main steps in diagnosis and treatment of post$pneumonectomy '@D..

Aneste(ia pentru chirurgia toracic la 2roote 'chuur <ospital
Thoracic 'nesthesia in ?roote .chuur ,ospital
%aniela 8i9u
Spitalul Groote Sc2uur, %epartamentul de ;neste&ie, Cape <oTn, ;frica de Sud

Spitalul Groote Sc2uur, cunoscut n ntreaga lume ca spitalul unde a a!ut loc primul transplant de inim, este un spital
academicBuni!ersitar unde c2irurgia toracic se practic n tratamentul multidisciplinar al olna!ilor din pro!incia Capul
de 8est a ;fricii de Sud" C2irurgia toracic face parte din %epartamentul de C2irurgie Cardiotoracic i ca atare, a fost,
poate nc mai este, 0Cenureasa1 disciplinelor c2irurgicale"
%e la limitrile impuse iniial de lipsa de nelegere a fi&iologiei ca!itii toracice desc2ise precum i de lipsa
ec2ipamentului i medicamentelor adec!ate tratrii din punct de !edere aneste&ic a acestor concepte complicate, i
p*n la inter!eniile c2irurgicale comple(e din &iua de a&i, desfurate minimalistic in!a&i!, drumul a fost lung i
complicat" ;cest drum e(prim progresele te2nologiei, ale farmacologiei i, mai presus de toate, determinarea,
ncpnarea i re&istena n faa olii, durerii i suferinei"
Bolile pleuro$pulmonare, n special inflamatorii, olile esofagiene, patologia cilor aeriene, olile pericardului, masele
mediastinale, tumorile de perete toracic, condiiile diafragmului i de canal c2ilos, precum i traumatismele de torace,
toate repre&int suiectul c2irurgiei toracice i confrunt aneste&itii la Groote Sc2uur"
?n ultima decad, tuerculo&a re&istent la medicamente a crescut gloal, i proail !a continua s creasc, n special n
situaii cu resurse limitate ca ;frica de Sud" ;pariia tuerculo&ei e(trem de re&istente la medicamente n ultimii ani, cu
toate prolemele legate de controlul infeciei, n special lipsa facilitilor de i&olare, re&istena crescut la droguri,
pre&ena coinfeciei cu 5I8, i cu toate riscurile adugate personalului medical, sunt doar c*te!a din prolemele din &iua
de a&i"

?roote .chuur ,ospital, famous throughout the !orld as the hospital !here the first heart transplant too1 place, is a
tertiary/academic hospital !here thoracic surgery is performed as multispeciality, multidisciplinary approach to treating
patients in the Bestern Cape Province of .outh 'frica. Thoracic surgery is part of the Cardiothoracic .urgery Department
and, as such, !as, and maybe still is, a QCinderellaR of the surgical disciplines.
Arom the limitations imposed initially by the lac1 of understanding of the physiology of the open chest and lac1 of
appropriate e(uipment/drugs to deal !ith these comple anaesthetic issues, to todayJs comple surgical interventions
performed by means of minimally invasive approaches, the road !as long and challenging. +t epresses the
advancements in technology, pharmacology, and maybe above all, it epresses determination, stubbornness, and
endurance, in the face of disease, pain, and suffering.
Pleuro$pulmonary disease, specifically inflammatory disease, oesophageal disease, air!ay pathology, pericardial
disease, mediastinal masses, chest !all tumours, conditions of the diaphragm and the chyle duct, as !ell as chest
trauma, are all represented in the spectrum of pathology that constitutes the subject of thoracic surgery and that
confronts the anaesthetists at ?roote .chuur.
+n the past decade, the prevalence of MD@$TB has increased globally, and li1ely !ill continue to increase in many areas,
especially in resource$poor settings, li1e .outh 'frica. The emergence of OD@$TB in the last couple of years !ith all its
problems of infection control, particularly lac1 of isolation facilities, increased drug resistance, the presence of ,+) co$
infection, and the added ris1s of all these to the health care personnel, in an environment of limited resources, are just a
fe! of the challenges of today.

"&itarea hipoxemiei n aneste(ia toracic
'voiding ,ypoemia in Thoracic 'nesthesia
R" :an4o!if
Uni!ersitQ of Lig, Sc2ool of Medicine, %epartment for ;nest2esia and Intensi!e Care, Lig, Seria

Pathophysiological Base o# Hypo$eia in Thoracic Anesthesia
,ypoaemia is an adverse but inevitable conse(uence of one$lung ventilation 35*)4. Patients !ho re(uire 5*) for
thoracic surgery are placed in the lateral decubitus position. The lo!er, dependent lung is ventilated, !hereas the upper,
non$dependent lung is allo!ed to collapse !hen opening the chest. Development of hypoaemia 3i.e. arterial
oygenation F:#&4 caused by 5*) may be eplained by ta1ing into consideration6 oygen storage, dissociation of oygen
from haemoglobin, the relationship bet!een ventilation and perfusion, and factors that reduce the effect of hypoic
pulmonary vasoconstriction 3,P)4. +n the patient breathing spontaneously in lateral decubitus position, the ventilation$
perfusion relationship is normal because both ventilation and perfusion are greater in dependent than that in the non$
dependent lung. The relationship of ventilation and perfusion changes !hen the patient is paralysed. +n this situation,
positive pressure ventilation is directed preferentially to the non$dependent lung, !hereas perfusion remains greater in
the dependent lung. This increases the volume of dead space !hich leads to hypercapnea. During one$lung ventilation,
some perfusion still remains in not ventilated lung, despite ,P). Thus, there may be a substantial increase in shunt and
therefore hypoaemia. Due to ,P) clinically observed shunt fraction is lo!er than roughly half of the cardiac output that
normally flo!s through each lung.
%entilation Strategy and Patient Positioning
+n the aim to reduce the incidence of postoperative acute lung injury, the concept of implementing protective 5*) have
been !idely adopted into thoracic anesthesia practice in past fe! years 3"4. The effects of protective 5*) on
intraoperative hypoemia still remains controversial 3%, 94, but it loo1s li1e hypercapnea as part of a protective
ventilation strategy is felt to improve ,P) and therefore aid oygenation 3;4. Theoretically, the s(uare pressure
!aveform of pressure$control ventilation 3PC)4 is thought to provide more uniform lung aeration and recruitment.
+ndeed, initial studies comparing PC) and volume$control ventilation during 5*) found improved oygenation and shunt
fraction !ith PC) 3<4, but subse(uent investigations failed to highlight benefit of PC) during 5*) 3=$04.
Traditionally, the lateral decubitus position has been found to improve oygenation during 5*) due to gravity
redistribution of pulmonary blood flo! !ith diverting roughly "#& of C5 to the dependent lung 3:4. 5n the other hand,
Latabe et al. found better Pa5%/Ai5% ratios in patients undergoing esophagectomy in prone position 3"#4. This finding
may be eplained by the superior )/N matching in the prone position 3""4 and the lac1 of compression of the ventilated
lung by mediastinal structures 3"%4. 'dditionally, supine positioning during some thoracoscopic procedures also tends to
increase the ris1 of hypoemia during 5*) 3"94. ,o!ever, recent animal eperiments appear to suggest that anatomic
pulmonary vascular factors are more important than gravity per se in terms of pulmonary blood flo! distribution 3";4.
Treatent o# Hypo$eia
The application of alveolar recruitment maneuver to the ventilated lung is one of the most efficient !ays to treat
hypoemia during 5*) 3"<4. 'lveolar recruitment increases the area of ventilated lung parenchyma, thus improving gas
echange and arterial oygenation. Aurthermore, in major pulmonary resection, the alveolar recruitment maneuver has
improved arterial hypoemia by reducing intrapulmonary shunt and dead space during one$lung ventilation 5*) 3"=,
"D4. 5n the other hand, aforementioned strategy may cause hemodynamic instability !ith a significant decrease in left
ventricular preload, C5 and arterial blood pressure 3"0, ":4, and also barotrauma 3%#4, and translocation of
proinflammatory cyto1ines from the alveolar space into the systemic circulation 3%"4. 'lthough lung recruitment on the
dependent lung may be effective for improving arterial oygenation during 5*), the effect can be transient 3%%4.
+ntermittent t!o$lung ventilation and application of continuous positive air!ay pressure 3CP'P4 to the non$dependent
lung are consistently effective in treating hypoemia during 5*). ,o!ever, interference !ith surgery limiting their use,
especially for video$assisted thoracoscopic surgery 3)'T.4 because it impairs the vie! of the surgeon. +n the aim to
protect surgical eposure, modifications of the standard CP'P techni(ue including novel method of selective insufflations
of oygen into a bronchopulmonary segment remote from the site of surgery 3%94 or intermittent small$volume oygen
insufflations have been proposed 3%;4. +n cases of disastrous desaturation, clamping the pulmonary artery may improve
oygenation. This controversial strategy also decreases C5 and systemic oygen delivery but +shi1a!a et al. found that
administration of an inotropic agent concomitant !ith lung compression mitigates the decreases in C5 and systemic
oygen delivery, !hile maintaining the beneficial effect of lung compression on arterial oygen saturation 3%<4.
,igh$fre(uency jet ventilation and high$fre(uency percussive ventilation also appear successful in treating hypoemia
during 5*) !ithout impeding surgical eposure 3%=, %D4.
2pidural demedetomidine has been sho!n to limit the decrease in Pa5% during 5*) !ithout affecting systemic or
pulmonary hemodynamic parameters 3%04. This action of demedetomidine may be eplained by nitric oide dependent
vasorelaation mediated by endothelial ] %$adrenoceptor activation 3%:4. 'lso, aerosoli-ed epoprostenol has been
sho!n to improve arterial oygenation and decrease mean pulmonary artery pressure in patients !ith acute respiratory
distress syndrome, presumably through dilation of the pulmonary vascular bed in ventilated regions and flo!
redistribution from shunt areas 39#4. Despite limited reports, it seems that epoprostenol may improve critical
desaturation during 5*) 39"4 but larger clinical trials are re(uired to establish its safety and efficacy profile during 5*).
,P) is believed by most studies to be the most important intraoperative phenomenon in reducing shunt during 5*). This
effect occurs !hen there is a reduction in alveolar partial pressure of oygen to bet!een ; and 0 1Pa. ' large number of
factors 3anesthetic agent, C5, alveolar oygen tension, mied venous oygen tension, acid/base imbalance, temperature
changes, lung manipulation, vasodilators4 can modulate the magnitude of ,P) in the nonventilated lung. +n animal
studies, volatile anesthetics have been sho!n to impair ,P) and to increase intrapulmonary shunt fraction or reduce
arterial oygen tension in a dose$dependent manner 39%, 994, !hereas propofol does not seem to affect ,P). ,o!ever,
clinical investigations are contradictory regarding the effect of a given anesthetic agent on oygenation 39;$904.
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"#. Latabe T, >itaga!a ,, Lamashita >, et al. Better postoperative oygenation in thoracoscopic esophagectomy in
prone positioning. 8 'nesth %#"#K %;60#9$=.
"". Gyren ., @adell P, *indahl .?, et al. *ung ventilation and perfusion in prone and supine postures !ith reference to
anestheti-ed and mechanically ventilated healthy volunteers. 'nesthesiology %#"#K ""%6=0%TD.
"%. Pelosi P, Croci M, Calappi 2, et al. The prone positioning during general anesthesia minimally affects respiratory
mechanics !hile improving functional residual capacity and increasing oygen tension. 'nesth 'nalg "::<K 0#6 :<<T=#.
"9. Darlong *M. )ideo$assisted thoracic surgery for superior posterior mediastinal neurogenic tumour in the spine
position. 8 Minim 'ccess .urg %##:K <6;:$<".
";. Chang ,, *ai$Aoo1 .8, Domino >B, et al. .patial distribution of ventilation and perfusion in anestheti-ed dogs in the
lateral postures. 8 'ppl Physiol %##%K :%6D;<$%.
"<. Tusman ?, Boehm .,, .ipmann A., Maisch .. *ung recruitment improves the efficiency of ventilation and gas
echange during one$lung ventilation anesthesia. 'nesth 'nalg %##;K :06"=#;T#:.
"=. Tusman ?, Bohm .,, Mel1un A, et al. 'lveolar recruitment strategy increases arterial oygenation during one$lung
ventilation. 'nn Thorac .urg %##%K D96"%#;$#:.
"D. Tusman ?, Bohm .,, .ipmann A., et al. *ung recruitment improves the efficiency of ventilation and gas echange
during onelung ventilation anesthesia. 'nesth 'nalg %##;K :06 "=#;$#:.
"0. .yring @., 5tto CM, .pivac1 @2, et al. Maintenance of end$epiratory recruitment !ith increased respiratory rate
after saline$lavage lung injury. 8 'ppl Physiol %##DK "#%699"$:.
":. ?arutti +, Martine- ?, Cru- P, et al. The impact of lung recruitment on hemodynamics during one$lung ventilation. 8
Cardiothorac )asc 'nesth %##:K %96<#=$0.
%#. Meade M5, Coo1 D8,?riffith *2, et al. ' study of the physiologic responses to a lung recruitment maneuver in acute
lung injury and acute respiratory distress syndrome. @espir Care %##0K <96 ";;"T:.
%". ,albertsma A8, )ane1er M, Pic11ers P, et al. ' single recruitment maneuver in ventilated critically ill children can
translocate pulmonary cyto1ines into the circulation. 8 Crit Care %#"#K %<6 "#T"<.
%%. *umb 'B, ?reenhill .8, .impson MP, .te!art 8. *ung recruitment and positive air!ay pressure before etubation does
not improve oygenation in the postanaesthesia care unit6 a randomi-ed clinical trial. Br 8 'naesth %#"#K "#;6 =;9TD.
%9. >u CM, .linger P, Baddell T>. ' novel method of treating hypoemia during one$lung ventilation for thoracoscopic
surgery. 8 Cardiothorac )asc 'nesth %##:K %960<#T%.
%;. @ussell B8. +ntermittent positive air!ay pressure to manage hypoia during one$lung anaesthesia. 'naesth +ntensive
Care %##:K 9D6;9%T;.
%<. +shi1a!a ., .hirasa!a M, Aujisa!a M, et al. Compressing the nondependent lung during one$lung ventilation
improves arterial oygenation, but impairs systemic oygen delivery by decreasing cardiac output. 8 'nesth %#"#K %;6
"DT%9.
%=. 2nder 8, Brodo!s1y M, Aal1 ), et al. ,igh$fre(uency jet ventilation as an alternative method compared to
conventional one$lung ventilation using double$lumen tubes6 a study of ;# patients undergoing minimally invasive
coronary artery bypass graft surgery. 8 Cardiothorac )asc 'nesth %#"#K %;6 =#%TD.
%D. *ucangelo U, 'ntonaglia ), `in B', et al. ,igh$fre(uency percussive ventilation improves perioperatively clinical
evolution in pulmonary resection. Crit Care Med %##:K 9D6"==9T:.
%0. 2lha1im M, 'bdelhamid D, 'bdelfattach ,, et al. 2ffect of epidural demedetomidine on intraoperative a!areness
and postoperative pain after one lung ventilation. 'cta 'naesthesiol .cand %#"#K <;6 D#9T:.
%:. Aigueroa OA, Poblete M+, Boric MP, et al. Clonidine$induced nitric oide dependent vasorelaation mediated by
endothelial ]%$adrenoceptor activation. Br 8 Pharmacol %##"K "9;6 :<DT=0.
9#. Balmrath D, .chneider T, .chermuly @, et al. Direct comparison of inhaled nitric oide and aerosoli-ed prostacyclin in
acute respiratory distress syndrome. 'm 8 @espir Crit Care Med "::=K "<96 ::"T=.
9". @aghunathan >, Connelly G@, @obbins *D, et al. +nhaled epoprostenol during one$lung ventilation. 'nn Thorac .urg
%#"#K 0:6 :0"T9.
9%. +shibe L, ?ui O, Uno ,, et al. 2ffect of sevoflurane on hypoic pulmonary vasoconstriction in the perfused rabbit lung.
'nesthesiology "::9K D:6 "9;0$<9.
99. *oer .', .cheeren TB, Tarno! 8. Desflurane inhibits hypoic pulmonary vasoconstriction in isolated rabbit lungs.
'nesthesiology "::<K 096 <<%$=.
9;. @eid CB, .linger PD, *enis .. ' comparison of the effects of propofol$alfentanil versus isoflurane anesthesia on
arterial oygenation during one$lung ventilation. 8 Cardiothorac )asc 'nesth "::=K "#6 0=#$9.
9<. 'be >, .himi-u T, Ta1ashina M, et al. The effects of propofol, isoflurane, and sevoflurane on oygenation and shunt
fraction during one$lung ventilation. 'nesth 'nalg "::06 0D6 ""=;$:.
9=. Bec1 D,, Doepfmer U@, .inemus C, et al6 2ffects of sevoflurane and propofol on pulmonary shunt fraction during
one$lung ventilation for thoracic surgery. Br 8 'naesth %##"K 0=6 90$;9.
9D. Prus-1o!s1i 5, Dalibon G, Moutafis M, et al6 2ffects of propofol vs sevoflurane on arterial oygenation during one$
lung ventilation. Br 8 'naesth %##DK :06 <9:$;;.
90. Au1uo1a G, +ida ,, '1amatsu ., et al. The association bet!een the initial endtidal carbon dioide difference and the
lo!est arterial oygen tension value obtained during one$lung anesthesia !ith propofol or sevoflurane. 8 Cardiothorac
)asc 'nesth %##:K %96 DD<T:.

<emopti(ii %i hemoragii intraal&eolare
,emoptysis and +ntraalveolare ,emorrhages
F" )urcaru, %aniela Cernea
Spitalul Clinic :ude'ean de Urgen', Craio!a, Rom*nia

5emopti&ia const din eliminarea de s*nge din cile aeriene suglotice" ?9i are originea n sistemul arterial ron9ic sau n
ruptura unui !as pulmonar n arorele ron9ic" 5emopti&ie masi! se consider c*nd !olumul de s*nge e(pectorat n -C
de ore este ntre @,,$E,, ml" ?n 2emoragia intraal!eolar, s*ngerarea 9i are originea n circula'ia pulmonar 9i are un
sistem de presiune sc&ut" #ste produs de le&iunea arierei al!eolo$capilare de cau& to(ic, imunologic, neopla&ic
etc" #tiologia s*ngerrilor arorelui tra2eo$ ron9ic" ;par n foarte multe circumstan'e3 oli oncologice, to(icitatea unor
citostatice, radioterapie, cau&e cardiace, 2emostatice, infec'ii, !ascularite, <BC, B)=C 6prin suprainfec'ie sau de&!oltarea
unui cancer7 etc" %iagnosticul include3 anamne&, e(amen clinic, imagistic, endoscopic, arteriografie" #!aluarea gra!it'ii
'ine de - factori3 amploarea 2emoragiei 9i semne de insuficien' pulmonar ostructi!" Conduita terapeutic n
2emopti&ie" <ratamentul !a fi adaptat di!erselor forme clinice 9i momente e!oluti!e 9i !a 'ine seama de3 amploarea
2emoragiei, impactul asupra func'iei pulmonare 9i etiologia s*ngerrii" 8or fi respectate c*te!a principii terapeutice3 ci
aeriene liere, !entila'ia pulmonului care nu s*ngerea&, sursa 2emoragiei care treuie locali&at 9i controlat"
<ratamentul include3 ameliorarea 2emato&ei, controlul 2emoragiei, toaleta ron9ic, tamponamentul local,
emoli&area, inter!en'ia c2irurgical n scop 2emostatic dac celelalte metode tarapeutice nu dau re&ultat"

,aemoptysis consists of removing blood from subglottis air!ay. +t is originated in bronchial arterial system or vessel
rupture a lung bronchial tree. +t can be considered massive haemoptysis !hen coughed blood volume in %; hours is
bet!een 9##$<## ml.
+n intraalveolara bleeding, bleeding originates in the pulmonary circulation and has a lo! pressure system. +s produced
by alveolar$capillary barrier damage due to toic immunologic, neoplastic etc. 2tiology bleeding tracheo$bronchial tree.
5ccur very many circumstances6 oncologycal diseases, toicity of chemotherapy, radiotherapy, cardiac, haemostatic,
infection, stro1e, tuberculosis, C5PD 3by severe infection or development of cancer4 and so on. Diagnosis includes6
history, clinical eamination, imaging, endoscopy, arteriography. 'ssessment of severity you on % factors6 the etent of
bleeding and signs of pulmonary insufficiency obstructive. Treatment should be adapted to different forms clinical and
evolutionary times and !ill ta1e into account6 the etent of bleeding, the impact function etiology of pulmonary
bleeding. .ome therapeutic principles !ill be observed6 air!ay free ventilation of lungs that do not bleed, bleeding
source to be located and controlled. Treatment includes6 improving haematosys, control bleeding, bronchial toilet, local
treatments, embolisation, surgical haemostatic purposes if other therapeutic methods do not !or1.

.oua defini-ie a AR,'
'@D. Definition6 Ge! Criteria
%" Sndesc
Uni!ersitatea de Medicin i Farmacie 08ictor Bae1, <imioara, Rom*nia

;R%S 6;cute RespiratorQ %istress SQndrome7 a fost definit pentru prima dat n +AAC, ntr$o conferin' de consens
americano$european care a stailit urmtoarele criterii3
+7 deut acut
-7 2ipo(emie, cu raportul )a=-BFi=- mai mic de -,,
@7 infiltrate ilaterale pulmonare la radiografia pulmonar
C7 e(cluderea 2ipertensiunii atriale st*ngi
%e$a lungul timpului, criteriile de definire ale ;R%S au fost criticate, fiind considerate incomplete 9i de natur s cree&e
confu&ii" )rincipalele 0acu&a'ii13 nu este definit foarte clar caracterul deutului acutU criteriul imagistic este insuficient,
put*nd duce la confu&iiU msurarea !alorii presiunii atriale st*ngi nu se face de rutinU criteriile nu au n !edere
posiilitatea apari'iei ;R%S 9i la pacien'i cu insuficien' !entricular st*ng" `in*nd cont de aceast situa'ie, n mai -,+-
un panel de e(per'i condus de Marco Ranieri, Gordon Ruenfeld 9i ;rt2ur Sluts4Q, cu sus'inerea oficial a #uropean
SocietQ of Intensi!e Care Medicine 6#SICM7, ;merican <2oracic SocietQ 6;<S7 9i SocietQ of Critical Care Medicine 6SCCM7,
au pulicat noile criterii de diagnostic, care includ urmtoarele nout'i3
$ termenul de [;cute Jung In/urQ1 6;JI7 a fost eliminatU
$ un raport )a=-BFi=- ntre -,,$@,, 6care definea ;JI7 este ec2i!alent n noile criterii cu ;R%S u9orU
$ deutul acut este definit ca o afec'iune care a deutat cu cel mult H &ile nainte de apari'ia ;R%SU acut se aplic 9i la
acuti&area unei patologii respiratorii croniceU
$ opacit'ile ilaterale pot fi depistate at*t prin Radigrafie, c*t 9i prin C< pulmonarU
$ nu este necesar e(cluderea insuficien'ei cardiaceU ;R%S poate aprea 9i la pacien'i cu insuficien' cardiacU singurul
criteriu rm*ne ca insuficien'a respiratorie s nu fie e(plicail total de insuficien'a cardiac sau de supraincarcarea
!olemicU n ca& de duiu se recomand o e!aluare oiecti! $ de regul ecocardiografia"
$ ;R%S a fost mpr'it n trei clase de se!eritate, preci&*ndu$se 9i prognosticul estimat, n urma anali&ei retrospecti!e a
unei co2orte de peste CC,, pacien'i3

'e&eritatea AR,' aO5C#iO5 Mortalitate estimat
U9or -,, ] @,, -H.
Mediu +,, ] -,, @-.
Se!er K +,, CE.

Cu!inte c2eie3 ;R%S, insuficien respiratorie, diagnostic

'@D. !as first defined by an american$european consensus conference held in "::;, !ith the follo!ing criteria6
$ sudden onsetK
$ hipoemia !ith a Pa5%/Ai5% ratio less than %##K
$ bilateral infiltrates on chest O$rayK
$ eclusion of left atrial hypertension.
These criteria raised criticism6
$ no eplicit criteria for defining QacuteRK
$ high interobserver variability in interpreting chest O$raysK
$ difficulties identifying / ruling out cardiogenic or hydrostatic pulmonary edemaK
$ Pa5% / Ai5% ratio is sensitive to changes in ventilator settings.
's a result, ne! criteria !ere published in May %#"%, reali-ed in a Berlin meeting of a panel of eperts, endorsed by The
2uropean .ociety of +ntensive Care Medicine 32.+CM4, The 'merican Thoracic .ociety 3'T.4 and The .ociety of Critical
Care Medicine 3.CCM4.
The main changes brought by these ne! criteria are6
$ Q'cute lung injuryR no longer eists. Under the Berlin definition, patients !ith Pa5%/Ai5% bet!een %##$9## !ould no!
have Qmild '@D.K
$ the acute onset is defined as !ithin D days of some defined event, including the !orsening of chronic respiratory
symptomsK
$ bilateral opacities consistent !ith pulmonary edema must be present but may be detected on CT or chest O$rayK
$ there is no need to eclude heart failure in the ne! '@D. definitionK
$ the ne! criterion is that respiratory failure simply be Qnot fully eplained by cardiac failure or fluid overload,R in the
physicianJs best estimation using available information. 'n Qobjective assessmentQ$ meaning an echocardiogram in most
cases $ should be performed if there is no clear ris1 factor presentK
$ the ne! Berlin definition for '@D. !ould also categori-e '@D. as being mild, moderate, or severe.
>ey !ords6 '@D., respiratory failure, diagnosis

)locuri oculare: trecutD pre(ent %i &iitor
2ye Bloc1s6 Past, Present, Auture
B" ;teleanu
Uni!ersitQ 5ospital of Sales, Cardiff, UG

2ye bloc1s represent a safe, simple and reliable choice of anaesthesia for intraocular surgery.
' large proportion of patients presenting for ophthalmic surgery are elderly, !ith significant medical co morbidities and
etensive drug therapy. Aor some of them, general anaesthesia might be a ha-ardous or even unacceptable choice. 2ye
bloc1s !ould offer a perfect anaesthetic alternative for these patients.
Per$operative preparation, conduct and techni(ue of eye bloc1s vary considerably !orld!ide.
The different techni(ues of local anaesthesia for eye surgery evolved over the last several decades. Both a1inetic and
non$a1inetic methods are described. .harp and blunt needle techni(ues are in use.
Previously considered the gold standard, the retrobulbar bloc1 !as replaced, as a result of a relatively high incidence of
significant complications, !ith the peribulbar bloc1, surpassed in the :#fs by the even safer and less painful .ubTenon
bloc1. Today, in the U>, for selected cases boo1ed for phacoemulsion and intraocular lens insertion, there is a significant
trend of replacing even the .ubTenon bloc1 !ith topical anaesthesia 3local anaesthesia eye drops4.
?uidelines for eye bloc1s !ere published by a 8oint Committee of @oyal College of 'naesthetists and @oyal College of
5phthalmologists as early as %##". ' more recent guideline for cataract surgery !as published in .eptember %#"#.
Before embar1ing on any type of eye 3local4 anaesthesia, a rigorous anaesthetic preassessment system needs to be in
place. This !ill allo! early diagnostic of uncontrolled hypertension, significant dyspnoea, +nsulin$dependant diabetes
mellitus, tremor, pathology re(uiring therapeutic anticoagulation etc., as !ell as relevant ophthalmic pathology, medical
and/or surgical.
>no!ledge of relevant anatomy of the orbit and its contents is paramount for the safe practice of eye bloc1s.
'ccepted standards of monitoring have to be maintained throughout procedure. 'dditional oygenation, as availability
of assistants reassuring the a!a1e patient throughout procedure is very important. +n selected cases, limited amount of
sedation could be carefully used in titrated increments.
Use of topical local anaesthetic eye drops pre$bloc1 is essential.
@igorous asepsis should be maintained.
*ocal anaesthesia for eye surgery could be classified as6
$ Topical 3non$a1inetic4
$ Blunt cannula techni(ue 3.ubTenon bloc14
$ .harp needle techni(ues 3a1inetic46 Peribulbar and @etrobulbar bloc1s.
Presentation !ill focus on the 9 main eye bloc1s, i.e. blunt and sharp needle techni(ues, !ith a particular emphasis on
peribulbar and .ubTenon bloc1s. 'dvantages/disadvantages of both are compared/contrasted. @elevant complications
are discussed.
+n conclusion, in many patients eye bloc1s represent the optimal choice of anaesthesia for intraocular surgery.

.utri-ia la pacientul oncologic chirurgical
Gutrition in .urgical 5ncologic Patient
Ioana Marina Grin'escu
Uni!ersitatea de Medicin i Farmacie 0%r" Carol %a!ila1, Clinica ;<I, Bucureti, Rom*nia

Ca9ecsia neopla&ic complic frec!ent e!olu'ia olii canceroase, aduc*nd un plus de mortalitate 9i moriditate" #ste un
sindrom comple( caracteri&ar prin scdere n greutate in!oluntar, persistent, progresi!, cu rspuns sla la suportul
nutriional standard" Consecina cea mai important !a fi sunutriia, cau&at de dou elemente ma/ore: modificrile
metaolice comple(e induse de rspunsul inflamator sistemic caracteristic i scderea aportului de nutrieni datorit
anore(iei, saietii precoce, asteniei" <ulurrile metaolice sunt profunde 9i comple(e: alterarea toleran'ei la gluco&
prin cre9terea re&isten'ei la insulin, pierderea depo&itului adipos prin o(idarea lipidelor 9i cre9terea ni!elului seric de
trigliceride, pierderea masei musculare prin proteoli&" Inter!en'ia c2irurgical !a duce la elierarea suplimentar de
2ormoni de stres, mediatori proinflamatori, cito4ine etc, cu impact ma/or asupra metaolismului 9i statusului
nutri'ional" Fr un suport nutriional adec!at pacientul !a de!eni malnutrit, cu riscuri perioperatorii crescute"

Cacheia occur fre(uently in cancer patients and it is responsible for ecess morbidity and mortality. Cacheia is a
comple syndrome characteri-ed by a chronic, progressive, involuntary !eight loss !hich is poorly or only partially
responsive to standard nutritional support and it is associated !ith undernutrition because of anoreia, early satiety and
asthenia. Undernutrition is usually attributable to t!o main components6 comple metabolic alterations due to the
activation of systemic proinflammatory processes doubled by a decreased nutrient inta1e. The main metabolic alteration
are: impaired glucose tolerance due to insulin resistance, a loss of fat as !ell as by enhanced plasma levels of
triglycerides, a loss of muscle mass because of the s1eletal muscle proteolysis. .urgery, li1e any injury to the body elicits
a series of reactions including release of stress hormones and inflammatory mediators, i.e. cyto1ines. This release of
mediators to the circulation has a major impact on body metabolism and nutritional status. Bithout proper nutritional
support the patient !ill become severely manourish !ith poor surgical outcome.

Obstrucie complet a cilor aeriene cu un corp strin: O alt pro&ocare aneste(ic
Complete 'ir!ay 5bstruction by Aoreign Body6 'nother 'nesthetic Challenge
<" #&ri
Solfson Medical Center, 5olon, Israel

' case report presents the challenging management of complete air!ay obstruction by foreign body from the
anesthesiologistZs point of vie!. The case report is follo!ed by a brief revie! !ith description of the clinical picture of
air!ay obstruction and its management, including the use of some nonconventional management alternatives such as
foreign body etraction bac1ed by life$sustaining etracorporeal membrane oygenation $ 2CM5 $ in cases of failed
oygenation. The revie! is concluded by proposing an air!ay obstruction management algorithm.
This brief revie! does not include any discussion on the complete air!ay obstruction resulting from a failed intubation$
ventilation scenario caused by difficult air!ay.

Managementul pacienilor cu patologie subglotic de ci aeriene mari
Management of the Patients !ith .ubglotic Big 'ir!ays Pathology
Geno!e!a Cadar 6+7, R" Stoica 6+7, M" ;le(e 6+7, Florica 8aleria Legru 6-7
6+7 Institutul de )neumofti&iologie 0Marius Lasta1, Bucure9ti, Rom*nia
6-7 Spitalul Uni!ersitar, Bucure9ti, Rom*nia

)atologia suglotic a cilor aeriene mari ridic deseori dificulti de management perioperator din punct de !edere
aneste&ic, moti!ele principale fiind3 deoseirea radical fa de aordul oinuit al cilor aeriene, dificultatea intuaiei
iBsau !entilaiei, raritatea ca&urilor 6lipsa de e(perien7U frec!ent mrac caracter de urgen si lipsa unor protocoale
clare n domeniu"
%in punct de !edere al managementului aneste&ic, patologia suglotic a cilor aeriene mari mrac @ aspecte ma/ore3
steno&ele 6tra2eale sau ale roniilor principale7, soluiile de continuitate 6rupturi, fistule7 i corpii strini"
;ordul const n alegerea soluiei optime de intuaie pentru a asigura !entilaia eficient a pacientului pre$ i
intraoperator i e!itarea suprasolicitrii suturilor n perioada postoperatorie"
Recomandrile generale in seama n special de locali&area i gra!itatea le&iunii, dar atitudinea treuie adaptat
particularitilor fiecrui ca& n parte"

.ubglotic pathology of big air!ays fre(uently raises difficulties in the perioperative management for the follo!ing
reasons6 great difference from the routine attitude, difficulties in intubation and/or ventilation, lac1 of eperience
because of the small number of cases, emergency character and lac1 of detailed protocols.
@egarding the anaesthetic management, the pathology of big subglotic air!ays has three important aspects6 tracheal or
main bronchus stenosis, ruptures or fistulas and foreign bodies.
The management relies on the optimal choice for intubation !ith the purpose of assuring efficient ventilation pre$ and
during operation and avoiding ecessive pressure on the sutures postoperatively.
?eneral recommendations refer especially to the localisation and gravity of the lesion, but the attitude has to be
adapted to each particular case.

Anxietatea la pacientul chirurgical
'niety in .urgical Patients
:" S&eder/esi, Ru(andra Copotoiu, ;le(andra Ja&r, Melinda S&ao, :udit Go!acs, Sanda Maria Copotoiu, J" ;&amfirei
Uni!ersitatea de Medicin i Farmacie, %isciplina ;<I, <*rgu Mure, Rom*nia

Ma/oritatea pacienilor care sufer o inter!enie c2irurgical pre&int ntr$o msur diferit team de inter!enia
c2irurgical iBsau aneste&ie"
;n(ietatea repre&int fenomenul de fric e(cesi! care poate determina modificri simptomatice a/ung*nd p*n la
atacul de panic" Ma/oritatea pacienilor pre&int diferite grade de ane(ietate pre i postoperator, a!*nd !aloare
ma(im n dimineaa inter!eniei c2irurgicale" 6+7
#!aluarea gradului de an(ietate al unui pacient se reali&ea& n mod curent cu a/utorul scalei State <rait ;n(ietQ
In!entorQ 6S<;I7" ;ceast scal nsumea& un numr de -, de ntreri legate de fric" %atorit numrului mare de
ntreri i a timpului lung necesar reali&rii acestei metode de e!aluare a an(ietii, s$au de&!oltat i alte scale deri!ate
parial din scala S<;I mai puine elemente cum ar fi F elemente 6BroTn7 sau Fear of SurgerQ Scale 6FSS7" 6+,-7
<emerile principale identificate de ctre di!eri pacieni includ cel mai frec!ent3
h Inter!enia c2irurgical
h %urerea
h %ecesul
h ;neste&ia
h Jipsa de control
h <eama de necunoscut
h Recuperare deficitar
h )ierderea identitii persoanei 6@,C,E7
;u fost identificai di!eri factori care pot influena gradul de fric i an(ietate perioperatorie a pacienilor"
h Factori demografici 6se(, !*rst, status familial, educaie7
h Factori psi2o$sociali 6suport social, capacitate de adaptare7
h #(periene c2irurgicale n antecedente
h Informarea corespun&toare a pacienilor6E,F7
Un studiu efectuat n perioada octomrie -,+- $ aprilie -,+@, totali&*nd un numr de D@ de pacieni, a ncercat s pun
n e!iden principalele cau&e ale an(ietii la pacienii c2irurgicali din cadrul Spitalului Clinic :udeean de Urgen
Mure" Ma/oritatea pacienilor 6FF.7 au declarat faptul c se tem de inter!enia c2irurgical, iar peste /umtate 6F+.7
de aneste&ie" Frica de tre&ire intraoperatorie, deces a a!ut o inciden redus" Ca factor important n determinarea
an(ietii la aceti pacieni a fost oser!at lipsa de informare legat de inter!enia c2irurgical i procedura aneste&ic"
Unii autori 6Ir!ing7 au clasificat an(ietatea n trei trepte n funcie de se!eritate3 uoar, medie i se!er 6gra!7" 6H7
Simptomatologia an(ietii este diferit, cel mai frec!ent e repre&entat de ta2icardie, creterea tensiunii arteriale,
greuri, !rsturi, transpiraii, creterea temperaturii corporeale, 2ipereste&ie, accentuarea sensiilitii auditi!e i
olfacti!e"
Modificrile comportamentale sunt frec!ente i pot fi de la uoar stare de tensiune p*n la atacuri de panic"
h ;n(ietate uoar $ poate aprea atitudinea de a lua n glum inter!enia c2irurgical, pacienii pot n!inui personalul
medical pentru durerile suportate, greu neleg faptul c nu e(ist operaie fr durere" = alt atitudine este cea n care
pacienii !or s par c sunt calmi i rela(ai, nu pre&int tulurri de somn, sunt prea puin preocupai de oala lor i
refu& s contienti&e&e pericolul inter!eniei c2irurgicale" 6H7
h ;n(ietate moderat $ tensiune emoional minim, teama poate fi uor suprimat, deseori pre&int insomnii dar
rspund ine la sedati!ele uoare" Imaginea e(terioar afiat e de calm i linite, uneori ns se poate oser!a faptul c
au un conflict interior" Caut informaii suplimentare despre starea lor" 6H7
h ;n(ietatea se!er $ caut continuu informaii despre oala lor, dar aceste informaii nu i a/ut, deoarece frica este
prea puternic" %eseori caut preocupaii care s le distrag atenia de la frica lor" Greu concep faptul c la sf*rit s$ar
putea ca toate s ai un de&nodm*nt fericit, din cau& c ncearc s supradimensione&e pericolele improaile" 6H7
)entru pre!enirea i tratamentul corect al an(ietii perioperatorii e(cesi!e este necesar n primul r*nd e!aluarea
corect a statusului pacienilor" 6D,A7 ;n(ietatea prea mic nu pregtete suficient pacientul pentru durerea
postoperatorie" ;n(ietatea prea e(agerat poate duce la o 2ipersensilitate la stimuli" ;n(ietatea poate duce la un
necesar crescut de analge&ice, aneste&ice i prelungirea perioadei spitali&rii" 6+,7
%i!erse msuri au fost recomandate pentru reducerea an(ietii e(agerate3
h Informarea pacienilor
h <erapie de rela(are
h <erapie comportamental
h ;cupunctur i presopunctur
h )re&ena aparintorilor
h Medicaie an(iolitic
h Relaia nurs$pacient
h 8i&ita preoperatorie a aneste&istului
h Mu&ic 6@,E,A,+,7
Important este contienti&area n r*ndul personalului medical a pre&enei an(ietii i a potenialului ei noci! la
pacienii c2irurgicali i luarea de msuri corespun&toare acolo unde este necesar"

Most patients !ho undergo surgery eperiences varying degrees the fear of surgery and/or anesthesia.
'niety is ecessive fear phenomenon that can cause various symptomatic manifestations from mild behavioral
disturbances to a panic attac1. +t develops perioperator !ith a 1no!n pea1 at morning at day of surgery. 3"4
The most !idely used method of evaluating aniety stands for the .tate Trait 'niety +nventory 3.T'+4 scale, !hich
consist in t!o %#$item self$report (uestions that attempt to measure the !orry and traits of the patients. This scale is
difficult to use for real life being time$consuming, especially !hen other assessments have to be done as !ell. 's result,
several other evaluation scale !ere developed consisting in fe!er elements 3Bro!n T = (uestions4 or the Aear .urgery
.cale. 3",%4
The most fre(uently ac(uired general fear is represented by6
S .urgical intervention
S Pain
S Death
S 'nesthesia
S *oss of control
S Aear from un1no!n
S Unsuccessful recovery
S *oss of personal identity 39,;,<4
.everal factors !ere observed to play an important role in the developing of the aniety as6
S Demographic factors 3gender, age, familial status, education4
S Psycho$social factors 3social support, accommodation capability4
S Previous surgical interventions
S 'de(uate patient information 3<,=4
' study performed from 5ctober %#"% to 'pril %#"9, enrolling a total of 09 patients attempted to outline the main
causes of aniety in surgical patients at the Mures County Clinical 2mergency ,ospital. Most patients 3==&4 said that
they fear of surgery, and over half 3="&4 of anesthesia. Aear from intra$anesthetic a!a1ening and death !as lo!. 's an
important factor in triggering the aniety in these patients !as the lac1 of information about the surgery and anesthetic
procedures.
+rving classified aniety in three stages according to severity6 lo!, moderate and high. 3D4
The physiological responses in higher grade of the aniety are mostly represented by tachycardia, hypertension, nausea
and vomiting, s!eating, elevated body temperature, hyperesthesia, heightened sense of hearing and smell.
Behavioral dysfunctions may run from a minor emotional tension to a panic attac1.
S *o! aniety $ patient may adopt a jo1ing attitude, they can blame the medical staff for their pain, and they donJt have
the mindset that pain is unavoidable for surgical interventions. 5ther patients displaying calm and relaed position, they
donJt eperience sleeping disorders. Their preoccupation for see1ing information regarding their disease is very lo! and
refuses to accept potential threats during surgery.
S Moderate aniety $ minor emotional tension, the fear can be easily suppressed, fre(uently they present sleeping
disorders, but it usually responds to mild sedatives. They displays out!ard calm, (uite attitude, but sometimes an inner
conflict can be observed in their behavior. The interest they present for their condition is higher.
S ,igh aniety $ they continuously see1ing information about their disease, but these attempts are unsuccessful because
the fear is too high. 5ften they engaging distracting activities to get their mind off of the threats. They hardly ideali-e
that in the end all may could turn out !ell, because they tend to overestimate improbable dangers.3D4
+n order to prevent and treat ecessive aniety in surgical patient crucial point is the correct evaluation of the aniety
status. 30,:4 *o! levels of aniety not prepare the patients ade(uately for the postoperative pain. ,igh level of aniety
can cause hyper sensibility to the stimuli. The high amount of aniety may lead to higher analgesics and anesthetics
re(uirements and may prolong the hospital stay. 3"#4
.everal techni(ues !ere recommended in order to alleviate the ecessive aniety6
S 'ppropriate patient information
S @elaing therapy
S Behavioral therapy
S 'cupuncture or presopuncture
S Permitting family members to be present at several procedures
S 'niolytic medication
S Gurse$patient relationship
S Preoperator visit of anesthesiologist
S Music 39,<,:,"#4
+mportant is the a!areness of medical staff upon the harmful effect of the ecessive aniety in order to treat correctly
!hen is necessary.
@eferences
". 8ohnston M. 'niety in surgical patients. Psychological Medicine ":0#K "#6";<$"<%
%. Bro!n @, Tluc-e1 ', ,enri(ues 8. Q.upport for the @eliability and )alidity of a .i$+tem .tate 'niety .cale Derived Arom
the .tate$Trait 'niety +nventoryR. 8ournal of Gursing Measurement %##:K "D3"46 ":T%0
9. Bajaj '.QPre$operative 'nietyR 'naethesia. <" 3"::=469;;$9;=. 2B.C5. Beb. .eptember %##:.
;. Martine- U. 'ngel 8ournal of Consulting and Clinical Psychology, )ol ;93;4 ":D<K ;9D$;;%.
<. Pritchard M8. P+dentifying and assessing aniety in pre$operative patientsP Gursing .tandard %##:K "K%93<"469<$;#
=. Diri1 ?, >aranci 'G. QPredictors of Pre$ and Postoperational 'niety in 2mergency .urgery PatientsR 8ournal of
psychosomatic @esearch %##9K <<3;469=9$:
D. +rving *8. Psychological .tress6 Psychoanalytic and Behavioral .tudies of .urgical Patients. ,obo1en, G8, U.6 8ohn Biley
d .ons +nc, ":<0
0. 'ugustin P, ,ains ''. 2ffect of Music on 'mbulatory .urgery PatientsZ Preoperative 'niety, '5@G 8ournal "::=
K=93;46D<#, D<9$0
:. Pritchard M8. Managing aniety in the elective surgical patient. Br 8 Gurs %##:K "03D46;"=$:.
"#. 'gar!al ', @anjan @, *a1ra ', >umar M. 'cupressure for prevention of pre$operative aniety6 a prospective,
randomised, placebo controlled study. 'naesthesia %##<K =#3"#46:D0$0"

Tulburri neurocogniti&e postoperatorii
Geurocognitive Disorders 'ssociated !ith .urgery
:udit Go!acs 6+7, J" ;&amfirei 6-7, :" S&eder/esi 6-7
6+7 Institutul de Boli Cardio!asculare i <ransplant, <*rgu Mure, Rom*nia
6-7 Uni!ersitatea de Medicin i Farmacie, <*rgu Mure, Rom*nia

?n perioada postoperatorie, la +E$-E. din pacien'i pot fi oser!ate o serie de modificri ale performan'ei cogniti!e, ca
tulurri de memorie, scderea capacit'ii de concentrare 9i aten'ie, a astrac'iei !i&uospa'iale, care pot afecta calitatea
!ie'ii 9i care au fost denumite declin cogniti! postoperator 6postoperati!e cogniti!e decline $ )=C%7" %isfunc'ia cogniti!
este n general mai accentuat n perioada imediat postoperatorie 6+$H &ile7 9i se ameliorea& sau c2iar dispare dup @$F
luni" Inciden'a )=C% este mai mare la pacien'ii n !*rst, la cei cu afec'iuni renale 9i 2epatice sau cu de&ec2ilire 2idro$
electrolitice 9i acido$a&ice"
%e cele mai multe ori aceste modificri sunt trecute cu !ederea 9i doar un e(amen amnun'it poate rele!a e(isten'a lor"
#(ist o serie de teste pentru e!aluarea strii mentale a unui pacient, dintre care 0Mini Mental State #(amination1,
introdus de Folstein nc din +AHE, este cea mai utili&at, a!*nd n !edere simplitatea testului 9i timpul scurt
6apro(imati! +, minute7 necesar e!alurii" <estul e!aluea& capacitatea de orientare temporo$spa'ial a pacien'ilor,
performan'ele de nregistrare 9i reproducere a informa'iilor, ni!elul de aten'ie 9i capacitatea de calculare, concentrare"
Fi&iopatologia acestor tulurri cogniti!e nu a fost complet elucidat, e(ist mai multe teorii care sugerea& c ar putea
fi !ora de o scdere a acti!it'ii colinergice muscarinice sau o cre9tere a acti!it'ii dopaminergice sau poate c2iar
am*ndou" Lu s$a delimitat p*n n pre&ent nici cau&a e(act a acestor tulurri neurocogniti!e, put*nd fi implica'i
aneste&ia general, perioade de 2ipo(ie 9iBsau 2ipotensiune intraoperatorie, trauma c2irurgical, stresul perioperator,
sindromul inflamator asociat inter!en'iei c2irurgicale sau medica'ia perioperatorie 6inclusi! cea analgetic ma/or7
administrat, e(isten'a unor microemolii, depri!area de somn n perioada postoperatorie" <eoria inflamatorie este
sus'inut de pre&en'a unor mar4eri inflamatori 6IJF, )G#-, )CR7 n lic2idul cefalora2idian n perioada postoperatorie,
studii e(perimentale nu au reu9it s demonstre&e o supresie a neurogene&ei indus de aneste&ice" = alt teorie e(plic
scderea performan'elor cogniti!e prin ni!ele crescute de corti&ol, datorit stresului peroperator, care ar afecta celulele
de la ni!elul 2ipocampului, o
structur responsail pentru memoria de scurt 9i lung durat"
Lu s$a putut implica un tip de aneste&ie n de&!oltarea acestor tulurri cogniti!e, ele fiind raportate at*t dup aneste&ii
generale c*t 9i dup aneste&ii regionale, s$a oser!at n sc2im o inciden' crescut dup inter!en'iile c2irurgicale
ample" S$a oser!at c o acti!itate intelectual sus'inut, ni!elul de educa'ie ridicat scad inciden'a )=C%, posiil
datorit e(isten'ei unei re'ele neuronale de re&er!, care ar putea compensa n ca&ul unor distruc'ii neuronale
moderate"
;!*nd n !edere c nu se cunoa9te nc mecanismul intim de producere a )=C%, nu e(ist nici o terapie specific care ar
putea fi aplicat la pacien'ii cu tulurri cogniti!e postoperatorii" Ceea ce putem s facem n sc2im, este s e!itm
factorii de risc implica'i n de&!oltarea acestei disfunc'ii"

+n the postoperative period, in "<$%<& of patients a number of changes in cognitive performance can be seen, such as
impaired memory, decreased ability to concentrate or focus on something, visuo$spatial abstraction deficit, disorders
that can affect the (uality of life. These changes !ere referred as postoperative cognitive decline 3P5CD4. Cognitive
dysfunction is generally more severe in the immediate postoperative period 3"$D days4 and improves or disappears after
9$= months. The incidence of P5CD is higher in elderly patients, in those !ith liver or 1idney diseases and !ith fluid,
electrolyte and acid$base disorders.
+n most cases these changes are ignored, and only a thorough eamination can reveal their eistence. There are a
number of tests to assess a patientZs mental state, including PMini Mental .tate 2aminationP introduced by Aolstein
since ":D<, !hich is !idely used, given the simplicity and the short time 3about "# minutes4 re(uired for evaluation. The
test assesses the ability of temporo$spatial orientation of patients, the ability of recording and reproducing informations,
the level of attention and concentration.
Pathophysiology of these cognitive disorders has not been fully elucidated, there are several theories that suggest a
decrease in muscarinic cholinergic activity or an increased dopaminergic activity or both. The etiology of these
neurocognitive disorders is not yet determined, but general anesthesia, periods of intraoperative hypoia and / or
hypotension, surgical trauma, perioperative stress, inflammatory syndrome associated !ith surgery, perioperative
medications 3including major analgesics4, eistence of microemboli and sleep deprivation during the postoperative
period may be involved. +nflammatory theory is supported by the presence of inflammatory mar1ers 3+*=, P?2%, PC@4 in
the cerebrospinal fluid in the postoperative period, eperimental studies have failed to demonstrate a suppression of
neurogenesis induced by anesthetics. 'nother theory eplains the decrease in cognitive performance through increased
levels of cortisol caused by perioperative stress, that affect cells in the hippocampus, a structure responsible for short$
and long$term memory.
The type of anesthesia cannot been incriminated in developing these cognitive disorders, because P5CD !as reported
both after general and regional anesthesia, but it !as observed an increased incidence after etensive surgery. +t !as
noted that a sustained intellectual activity, higher level of education decreases the incidence of P5CD, possibly because
of a neural net!or1 bac1up, !hich could compensate in case of moderate neuronal damage.
Because the close mechanism of the development of P5CD is not yet 1no!n, there is no specific therapy that may be
applied to patients !ith postoperative cognitive impairment. Bhat !e can do instead, is to avoid the ris1 factors
involved in the development of this dysfunction.
















































PREZENTRI ORALE
ORAL PRESENTATIONS
Comparaie ntre laringoscopia clasic %i &ideolaringoscopie pri&ind durata intubaiei orotraheale
Comparison bet!een Classic *aryngoscope and )ideolaringoscopy @egarding 5rotracheal +ntubation Time
Ru(andra Copotoiu 6+7, ;le(andra Ja&r 6+7, =rsolQa Benede4 6-7, Ioana G2i'escu 6+7, :" S&eder/esi 6+7,
Sanda Maria Copotoiu 6+7
6+7 Uni!ersitatea de Medicin 9i Farmacie, <*rgu Mure9, Rom*nia
6-7 Spitalul Clinic :ude'ean de Urgen', <*rgu Mure9, Rom*nia

Scopul studiului3 S$a urmrit identificarea e!entualelor diferen'e pri!ind durata intua'iei orotra2eale folosind diferite
dispo&iti!e de !i&uali&are a glotei"
Material 9i metod3 Studiul este unul prospecti!e, oser!a'ional" ;u fost inclu9i +C, de pacien'i supu9i inter!en'iilor
c2irurgicale electi!e 9i de urgen' desf9urate n aneste&ie general n departamentul de c2irurgie general, pe
parcursul lunii feruarie -,+@" %intre aces'ia DC au eneficiat de laringoscopie clasic, -D de !ideolaringoscopul C$Mac,
-- de !ideolaringoscopul <rue!ieT 9i F de dispo&iti!ul Clarus 8ideo SQstem" S$au nregistrat ca 9i !ariaile se(ul,
nl'imea, greutatea, indice de mas corporal, gradul Mallampati, gradul Cormac4, dificultatea !entila'iei pe masc
6grad7, durata !entila'iei manuale, durata intua'iei orotra2eale 9i numrul de tentati!e de !i&uali&are a glotei"
Re&ultate3 ?ntre cele patru loturi de pacien'i nu au e(istat diferen'e semnificati!e n ceea ce pri!e9te datele
demografice, c2iar dac acestea nu au respectat ntotdeauna o distriu'ie gausian" Lu au fost necesare mai mult de
dou tentati!e de !i&uali&are a glotei, c2iar n ca&urile de intua'ie presupus dificil 6pacien'i oe&i, Mallampati i @7 $ D
6A"E-.7 la cei cu laringoscopie clasic, + 6@,EH.7 la cei la care s$a folosit C$Mac 9i C 6+D,+A.7 la cei la care s$a recurs la
<rue!ieT" %urata intua'iei orotra2eale a fost de CD"-Cj@A"DH sec" n ca&ul laringoscopiei clasice, EF"+Ej@C"FE sec"
pentru C$Mac, CH"AEj@H"C@ pentru <rue!ieT 9i @,",,j@-"CD sec" pentru C8S" Lu au fost diferen'e semnificati!e statistic
ntre cele patru metode de aordare 6p ,"+EF+7"
Conclu&ii3 %ispo&iti!ul utili&at pentru intrumentarea orotra2eal poate fi ales n func'ie de complian'a aneste&istului cu
acesta"

'ims6 The purpose of the study !as to identify the possible differences bet!een time of orotracheal intubation using
different glotic visuali-ation devices.
Material and Method6 This is a prospective, observational study. The study included ";# patients, from clinics of general
surgery, subject to elective surgery and emergency surgery re(uiring general anesthesia, during the month of Aebruary
%#"9.
5ut of the total number of patients, 0; !ere intubated by classic laringoscopy, %0 !ith C Mac videolaringoscope, %% !ith
Truevie! videolaringoscope and = !ith Clarus )ideo .ystem.
Be registered as variables6 se, !eight, height, body mass inde, Mallampati grading, Corma1 grading, grading of mas1
ventilation difficulty, duration of manual ventilation, time of orotracheal intubation and number of attempts of glotic
visuali-ation.
@esults6 Go statistical significant values !ere obtained, bet!een the four groups as to demographic data, even though
these groups did not al!ays follo! a ?aussian distribution.
Aor glotic visuali-ation, no more than t!o attempts !ere necessary even in cases assumed to be difficult to intubate
3obese patients, Mallampati g94 $ 0 3:.<%&4, for classic laringoscopy $"39.<D&4, for C$Mac and ; 3"0,":&4 for Truevie!.
5rotracheal intubation time !as ;0,%;h9:,0D seconds for classic laringoscopy, <=,"<h9;,=< seconds for C Mac,
;D,:<h9D,;9 for Truevie! and 9#,##h9%,;0 seconds for Clarus )ideo .ystem.
Go statistic significance !as encountered bet!een the four approaching methods 3p #, "<="4
Conclusions6 The device used for orothracheal instrumentation is to be chosen according to the anesthetistJs compliance.

Miorelaxarea controlat n inter&en-iile laparoscopice
Controlled Miorelaation in *aparoscopic .urgery
<atiana Stratin, M" Galamag2in, S" Colec2i, R" Baltaga, ;" Beli
Centrul Laional etiinifico$)ractic de Medicin Urgent, C2iinu, Repulica Moldo!a

=iecti!e3
+" Compararea duratei de aciune ;tracuriului n <I8; 6<otal intra!enous anestesia7 i <in2; 6<otal in2alatorQ
anest2esia7"
-" =iecti!i&area aciunii ;tracuriului n regim <=F"
@" %eterminarea do&ei optime de ;tracuriu la pacieni supui colecistectomiei laparoscopice" ?n studiul clinic
randomi&at$prospecti! au fost e!aluate @ loturi I$Se!o>;tracuriu ,"EmgB4g, II$)ropofol>;tracuriu ,"EmgB4g, III$
Se!o>;tracuriu ,"@mgB4g, total E, de pacieni supui colecistectomiei laparoscopice" <oi pacienii au fost monitori&ai
cu modul LM< 6%ate($=2meda7 n regim <=F" ; fost e!aluat profun&imea BLM 6locului neuromuscular7 la momentul
inturii, pe parcursul inter!eniei i la momentul e(turii" ; fost e!aluat calitatea BLM, conform scorului de
satisfacie a c2irurgilor i datele !itale al pacientului )pea4, Sp=-, #tC=-"
Re&ultate3 #(ist diferene semnificati!e dintre duratele meninerii BLM single$dose a loturilor S>;,"E 6mediana$
D,min7, S>;,"@ 6mediana$EAmin7 9i )>;,"E 6mediana$H+min7" Se!ofluranul crete durata BLM semnificati! mai mult
dec*t propofolul" ; ,"E menine BLM semnificati! mai mult dec*t ; ,"@" Lu e(ist nici o diferen ntre efectele ;,"E 9i
;,"@ asupra profun&imii BLM" %atele !itale ale pacienilor nu au depit limitele fi&iologice"
Conclu&ii3 durata clinic a ;tracuriului este prelungit n lotul S> ,"E;, Se!ofluranul cre9te durata BLM 6med"$D,
minute7" =iecti!i&area BML permite reducerea do&ei de ;tracuriu p*n la ,"@mgB4g 6med"$EA min7, nea!*nd o
influen asupra calitii BLM" %o&a redus de ;tracuriu ,"@ mgB4g permite scurtarea duratei de 8;), tre&irea rapid a
pacienilor fr pre&ena BLM re&idual" <re&irea rapid a pacientului permite ini'ierea urmtoarei aneste&ii 9i cre9terea
eficacit'ii slii de opera'ie"

5bjectives6
". Comparison of clinical duration of 'tracurium in T+)' and Tinh'.
%. 5bjectivi-ation of clinical duration of 'tracurium in T5A$regime.
9. Determination the optimal do-e of the 'tracuriun for each patient. +n this clinical randomi-ed$prospective study there
!ere 9 groups of patients6 +$.evo7'tracurium #.<mg/1gK ++$.evo 7'tracurium #.9mg/1g and +++$Propofol7'tracuriu #.<
mg/1g, totally <# patients, !hich supported endoscopic colecistectomy. 'll patients !ere monitored !ith GMT$module,
the component of anesthesia machine 3Date$5hmeda4 in T5A$mode. Be evaluated the (uality of GMB 3neuro$muscular
bloc14 at intubation, along the surgery and during etubation. The (uality of the GMB !as also evaluated according to
the surgeonsJ satisfaction scale and patientsJ vital data 3Ppea1, .p5%, 2tC5%4.
@esults6 There are significant differences in the duration of the GMB after singe$dose of 'tracurium in three groups6
.7'#.<mg/1g 3med.$0#min4, .7'#.9mg/1g 3med.$<:min4 and P7'#.<mg/1g 3med.$D"min4. .evoflurane etends
significantly the GMB, more than Propofol does. '#.< etends the GMB significantly longer than '#.9. There are no
difference bet!een '#.< and '#.9 in (uality of the GMB. )ital data didnJt eceed the physiological one.
Conclusions6 Clinical duration of 'tracurium in .7'#.< is the longest one. .evofurane etends the GMB 3med.0# min4.
5bjectivi-ation of the GMB allo!s to reduce the dose of 'tracurium #.9 mg/1g that doesnJt change the (uality of the
GMB, but it reduces the time of )'P, allo!s to a!a1e the patient shortly after the end of the surgery !ith no ris1 of
residual GMB. That also helps to improve the efficacy of the 5@.

'e poate trata hipertermia malign cu ,antrolen expirat!
Case @eport of Malignant ,yperthermia During 'naesthesia $ Can Be Treated !ith 2pired DantroleneC
:" =lk2$BknQaQ, I" )op
Spitalul Municipal, =dor2eiu Secuiesc, Rom*nia

)re&entm ca&ul unui olna! de +A ani, cu greutate de FA 4g, care a suferit o 2ipertermie malign cu e!olu'ie
fulminant" %in antecendentele anestetice de men'ionat c la !*rsta de H ani i s$a efectuat o opera'ie la 0mu9c2ii
g*tului1, informa'ie primit dup accidentul de aneste&ie" )entru premedica'ie a primit +,, mg Maron, +, mg
%iaQepam 9i + mg ;tropin pe cale muscular" S$a fcut induc'ia cu Getalar i"!", pe urm <iopental 9i Succinilcolin 9i I=<
n condi'ii normale" Men'inerea s$a continuat cu 5alotan +. cu amestec L-=3=- cu respira'ie spontan" Ja scurt timp
dup acesta, apar semnele 9i simptomele 2ipertemiei maligne ca rigiditatea muscular, 2ipercaria, ta2ipnea,
ta2icardia, olna!ul de!ine agitat, cianotic generali&at" <ratamentul imediat inclu&*nd ntreruperea agentului trigger, a
rcirii e(terne 9i a %antrolenului e(pirat de A ani, olna!ul a a!ut o e!olu'ie fa!orail" ; a!ut o !indecare total"

5n the "%
th
of 8uly %#"", a healthy ": year old male patient presented for fiation of upper limb injury under general
anaesthesia in the 5dorheiu .ecuiesc District ?eneral ,ospital.
The patient had a previous nec1 surgery in childhood !ithout any complications and no family history of anaesthetic
problems !ere reported.
+ntravenous induction !ith >etalar and Tiopental !as performed, follo!ed by .uccinylcholine administration and
successful endotracheal intubation. Go further muscle relaants had been given and the patient regained his
spontaneous breathing. The anaesthesia !as maintained !ith "& ,alotane in <#& 5%6G%5 miture.
.hortly after the beginning of the procedure, signs and symptoms of malignant hyperthermia, including muscle rigidity,
hypercarbia, tachypnea and tachycardia !ere noted. +mmediate treatment, including discontinuation of the triggering
agent and cooling measures !ere applied. Dantrolene !as given, !hich had been epired for : years. The outcome of
the patient !as good, !ith no postoperative complications.

Administrarea de Rocuroniu dup re&ersia blocului neuromuscular cu 'ugammadex/ 'tudiu de ca(
@ocuronium Use 'fter .ugammade 'dministration for @eversal of Geuromuscular Bloc1ade.
Case @eport
M" )apuric, Carmen Guragata$Balaa, %" %rgulescu, =" Bedreag, #lena Jaura )apuric, G" G2eorg2iu,
C" J" Leamu, ;driana$Magdalena Cioar, %" Sndesc
Spitalul Clinic :udeean de Urgen, <imi9oara, Rom*nia

8om pre&enta un ca& n care am utili&at re!ersia locului neuromuscular 6BLM7 dup administrarea de Rocuronium,
pentru o reinter!en'ie laparoscopic n regim de urgen'" = pacient de EF ani a fost supus unei reinter!en'ii
c2irurgicale laparoscopice n regim de urgen' n scop 2emostatic, dup o colecistectomie laparoscopic" Re!ersia BLM
datorat Rocuroniumului s$a efectuat de fiecare dat cu Sugammade( 6-mgB4gc7 n conformitate cu profun&imea BLM"
Reinter!en'ia a a!ut loc la C ore, utili&*ndu$se +,+E mgB4gc Rocuronium pentru induc'ia aneste&ic" Ja +,E sec", -
rspunsuri <=F, s$a reali&at I=< n condi'ii e(celente" Ja finalul aneste&iei pe pi!ot !olatil re!ersia BLM s$a fcut din nou
cu Sugammade(" Lu s$au oser!at complica'ii postoperatorii de tip respirator" Utili&area Rocuronium dup re!ersia
BLM cu Sugammade( este posiil, n condi'iile unei monitori&ri continue a profun&imii BLM 9i interpretarea corect a
!alorilor nregistrate" ;dministrarea Sugammade( n do&e corecte, corelate cu profun&imea BLM, permite
readministrarea n siguran' a curari&antelor steroidiene"

Be !ill present a case for !hich !e have used the reversal of neuromuscular bloc1ade 3GMB4 after the administration of
@ocuronium, for an emergency laparoscopic reintervention. ' <= year old female patient has undergone emergency
laparoscopic cholecystectomy. The reversal of GMB due to @ocuronium has been performed each time using
.ugammade 3%mg/>g4 according to the GMB depth. The reintervention too1 place after ; hours, using a dose of ","<
mg/ >g @ocuronium for the anesthetic induction. 'fter "#< seconds, % T5A stimulations, 2T+ 3endotracheal intubation4
!as performed under ecellent conditions. 't the end of the volatile anesthesia, the reversal of GMB !as again
performed using .ugammade. There have been no postoperatory respiratory complications. The use of @ocuronium
after the reversal of GMB using .ugammade is possible, under the conditions of continuous monitori-ation of BMB
depth and the correct interpretation of the recorded values. 'dministrating .ugammade using the correct dosage,
corresponding to the GMB deph, allo!s safe readministration of steroidal muscle bloc1ers.

Teste in &itro &ersus teste cutanate %i istoricul de anafilaxie la relaxantele neuro$musculare
+n )itro Tests versus .1in Tests and Positive ,istory of GMB's$+nduced 'naphylais
Cristina )etri9or 6+7, #ri4a Bre&os4i 6+7, Ladia G2erman$Ionic 6+7, Manuela Sfic2i 6-7, Latalia 5agu 6+7
6+7 Uni!ersitatea de Medicin 9i Farmacie 0Iuliu 5a'ieganu1, Clu/$Lapoca, Rom*nia
6-7 Spitalul Clinic :ude'ean de Urgen', Clu/$Lapoca, Rom*nia

)remise3 Rela(antele neuro$musculare 6LMB;s7 sunt cea mai frec!ent cau& de reac'ii anafilactice intraaneste&ice"
%iagnosticul in !itro al anafila(iei induse de LMB;s const n determinarea anticorpilor Ig# specifici 9i a testelor de
acti!are a a&ofilelor 6B;<7"
Metod3 -+ pacien'i cu istoric de reac'ie anafilactic indus de LMB;s au fost testa'i in !i!o 6teste cutanate7 9i in !itro
6B;<9i Ig#7, mpreun cu F- martori fr istoric de reac'ie alergic intraaneste&ic" %eterminarea prin floTcitometriea
mar4erului C%F@ de pe suprafa'a a&ofilelor a fost reali&at prin te2nica FloT-Cast 6Bd2lmann Jaoratories,
STit&erland7" ;nticorpii specifici Ig# au fost determina'i prin radioimundo&are 6RI;7" Co2en Gappa 6G7 inde( a fost utili&at
pentru a staili concordan'a testelor in !itro cu istoricul 9i testele cutanate"
Re&ultate3 Co2en 4 inde( a fost de ,"F@ pentru B;< !ersus istoric 9i de ,"@ pentru Ig#s !ersus istoric" Concordan'a B;< cu
testele cutanate a fost de ,"HC, iar pentru Ig# cu testele cutanate 4 a fost de ,"@H" %oar unul dintre martori a pre&entat
un test B;< po&iti!, iar +@ martori au pre&entat anticorpi Ig# specifici po&iti!i" F dintre ace9tia au primit intraoperator
rela(antul neuro$muscular testat, fr incidente intraaneste&ice"
Conclu&ii3 Inde(ul Co2en G arat corela'ia sustan'ial a B;< cu istoricul 9i testele cutanate, dar e(ist o corela'ie
moderat a anticorpilor Ig# cu istoricul 9i testele cutanate" )re&en'a anticorpilor specifici pentru curare sugerea& c
at*t pre&en'a Ig# specifici, c*t 9i mecanismele celulare sunt necesare pentru declan9area anafila(iei sau c do&area
acestora pre&int re&ultate fals po&iti!e"

Bac1ground6 Geuro$muscular bloc1ing agents 3GMB's4 are the most fre(uent culprit drugs for intraanaesthetic drug
anaphylais. +n vitro diagnostic tests for GMB's$induced anaphylais comprise the detection of drug$specific +g2
antibodies and the basophil activation test 3B'T4.
Material and Method6 %" patients !ith positive history of GMB's$induced anaphylais !ere tested in vivo 3s1in tests4
and in vitro 3B'T and +g24. =% healthy controls !ithout previous intraanaesthetic drug allergy !ere tested as !ell. The
detection of CD=9 mar1er on the surface of the basophils by flo! cytometry !as performed using Alo!%Cast techni(ue
3Bihlmann *aboratories, .!it-erland4. +mmuno$radioassay 3@+'4 !as used to determine drug specific antibodies. The
agreement bet!een in vitro tests versus positive history and s1in tests !as assessed by using Cohen >appa 3>4 inde.
@esults6 Cohen > inde !as #.=9 for B'T versus history and #.9 for +g2 versus history. The concordance bet!een B'T and
s1in tests !as #.D;, !hile for +g2 versus s1in tests, > inde !as #.9D. 5ne of the healthy controls had positive B'T and "9
healthy controls presented positive +g2 for GMB's. Arom these, = received the tested GMB' during anaesthesia !ithout
adverse reactions.
Conclusions6 Cohen > inde indicates a substantial concordance of B'T !ith both the history and the s1in tests, !hile
there is only moderate agreement for +g2 versus s1in tests and history. The eistence of drug specific antibodies in
healthy controls suggests that both specifc +g2 and cellular mechanisms are necessary to induce anaphylais or that +g2
dosing may present false positive results.

+ntraoperative 'naesthesia !ith @opivacaine 'pplied Through 2pidural Cateter for Patients !ith *arge
Urological +nterventions
%" %imitro!, R" Marino!a, M" Ja&aro!, ;" <emel4o!
;le(andro!s4a Uni!ersitQ 5ospital, Sofia, Bulgaria

Bac1ground6 @opivacaine has a lot of advantages li1e6 evaluative dose$dependent effect, minimal and good
differentiated motor bloc1, minimal cardiotoicity, minimal neurotoicity, possibility for prolonged infusion in higher
dosage if needed.
5bjectives6 The target of research is to find the (uality of intraoperative anaesthesia !ith @opivacaine applied through
epidural cateter.
Material and Method6 The patients are separated in % groups. The operative interventions include transperitoneal
nefrectomy, radical prostatectomy and cystectomy. The regular anaesthesia for this 1ind of interventions include
G%5/5% $ <#/<#, +soflurane, Tracrium, Aentanyl. The anaesthesia in the first group is by epidural cateter applied after
intubation and usage of @opivacaine !ith regular anaesthesia. +n this group there are "= patients !ith '.' +++ and +).
There are "= patients in second group that are put under regular anaesthesia for this 1ind of operative interventions
!ithout epidural cateter.
2valuation of results is by accounting of dosage of analgetic, relaant and inhalation anesthetic needed for ade(uate
anaesthesia and by estimating of a!areness by means of monitoring of entropy.
Conclusions6 Be conclude that application of @opivacaine reduces the need of Tracrium, Aentanyl and inhalation
anaesthetics therefore it reduces the toicity of the anaesthesia. +n addition, it ensures a more stabile haemodynamic in
the time of anaesthesia and of !a1ing, continuous postoperative anestheti-ing and lo! percent adverse reactions.
>ey !ords6 @opivacaine, anaesthesia, epidural cateter


2ffects of >etamine on .pectral 2ntropy During .evioflurane 'nesthesia
R" Marino!a, %" %imitro!, ;" <emel4o!, M" Ja&aro!
;le(andro!s4a Uni!ersitQ 5ospital, Sofia, Bulgaria

Bac1ground6 2lectroencephalographic entropy is used to measure the degree of brain hypnosis and anesthesia depth.
T!o parameters are displayed on the monitor6 .2$entropy6 #.0$9%,- 3cortical activity4, @2$entropy6 #.0$;D ,- 3cortical 7
subcortical activity, frontal 2M? activity4. @2$.2 difference is considered predictive for analgesia ade(uacy. >etamine is
an old drug from the anesthetistJs armamentarium and is currently used at a lo! dose to improve perioerative analgesia
by preventing acute opioid tolerance and postoperative hyperalgesia.
5bjectives6 To study the effects of >etamine on spectral entropy during urologic surgery under .evoflurane anesthesia.
Material and Method6 <% patients !ere enrolled in this prospective study. Patients !ere randomi-ed into t!o groups6
group ' 3nE%D4 and group B 3nE%<4. Bhen a stable stage of anesthesia !as achieved, the patients in group ' received
bolus of >etamine #.<mg/1g, the patients in group B received the same volume of saline. Blood pressure 3BP4, heart rate
3,@4, @2$entropy, .2$entropy and @2$.2 inde !ere measured from "# min before 3baseline4 until "< min after >etamine
or saline administration.
@esults6 @2$ and .2$entropy increased significantly in group ', compared !ith group B, from % min until "# min after
>etamine/saline administration. Aor @2$.2 inde significant difference bet!een the t!o groups !as recorded from 0 min
until "< min after >etamine/saline administration. BP, ,@ did not change in either group.
Conclusions6 >etamine administered under .evoflurane anaesthesia causes a significant increase in @2$, .2$ and @2$.2
entropy !ithout modification of the ,@ and BP. This increase is paradoical in that it is associated !ith a deepening level
of hypnosis.
>ey !ords6 22? entropy, >etamine, deep of anesthesia monitoring.

Postoperative Pain @elief in Patients 'fter Total >nee @eplacement !ith Aemoral Perineural Catheter Using
Continuous +nfusion of *ocal 'nesthetic .olution
)etQa I!ano!a, 8iliQan )lati4ano!, MariQa <odoro!a
lSt" Marinal Uni!ersitQ 5ospital, 8arna, Bulgaria

Bac1grounds and 'ims6 Total 1nee arthroplasty often results in severe postoperative pain. +t is a clinical challenge to
achieve ade(uate analgesia in earlier postoperative period. Ultrasound guidance allo!s accurate visuali-ation of nerves
and surrounding structures and can lead to higher success rate of nerve bloc1. The authors present our eperience in
postoperative pain relief using regional techni(ues in patients after total 1nee replacement.
Material and Method6 it is a prospective study of %< patients. Aor postoperative pain relief after total 1nee arthroplasty,
!e performed continuous femoral nerve bloc1. The femoral catheters !ere placed ultrasound guided using Qin planeR
techni(ue after the surgical intervention. 'll of the patients received spinal anesthesia, ecept one$general. Aor the
continuous femoral nerve bloc1 !ere used as local anesthetics *evobupivacaine 3%# patients4 and @opivacaine 3<
patients4. ' bolus of *' 3#,9D<& *evobupivacaine or #,<& @opivacaine4 !as administrated and after that !as started
continuous infusions 3#,"%<& *evobupivacaine or #,%& @opivacaine4. Ten patients became "< ml of bolus solutions and
the others "< patients $ %# ml. The infusions rate of local anesthetic !as =$: ml/h. Pain relief !as assessed by )'., target
values )'.j9. +n "# patients there !ere used stimulating catheter$guided perineural placement.
@esults6 Both *evobupivacaine #."%<& and @opivacaine #.%& provide similar analgesia after total 1nee arthroplasty.
There !ere no differences bet!een the groups 3group !ith *evobupivacaine and group !ith @opivacaine4 in pain score,
motor bloc1 and patientJs satisfaction. The group of patients, !ho had become %# ml as a bolus, had lo!er pain score
and better satisfaction, compared to the group !ith "< ml bolus. 5ur opinion for using stimulating catheter$guided
perineural placement is that these catheters probably provides an increased (uality of continuous femoral perineural
bloc1ade, but !e still do not have a sufficient eperience. Conclusions6 The results sho!ed that U.$guided continuous
femoral nerve bloc1 provides a good (uality analgesia and an ecellent short term side effect profile.


Contribuia seciei A/T/I/ a 'pitalului 0ni&ersitar de 0rgen Militar Central =,r/ Carol ,a&ila> n proiectul
de cercetare internaional ain Out %i n 'tudiul european obser&aional pri&ind durerea cronic
postoperatorie ?"0C'A $ ,ate preliminare
Contribution of the 'nesthesiology and +ntensive Care Department of Central University and 2mergency
Military ,ospital QDr. Carol DavilaR in the +nternational Multicenter @esearch Project Pain 5ut and the
2uropean 5bservational .tudy on Postoperative Chronic Pain 32UCP.P4 $
Preliminary Data
L" 8" <nase, M" %" Jati9, Ioana =prea, %enisa G2inescu, ;" =laru, I" <udorac2e, ;" <udose, <" )duraru,
8" Pa2iu, J" #ne
Spitalul Uni!ersitar de Urgen' Militar Central 0%r" Carol %a!ilal, Bucure9ti, Rom*nia

);IL =U< $ International repre&int un proiect de cercetare interna'ional, multicentric, interdisciplinar, menit s
munt'easc managementul durerii acute n cadrul institu'iilor spitalice9ti" Scopul proiectului este de a cre9te
calitatea tratamentului durerii postoperatorii, prin de&!oltarea 9i !alidarea unui sistem de msurare 9i feedac4 al
calit'ii terapiei durerii, sistem menit s sus'in procesul de luare a deci&iei terapeutice"
)roiectul 9tiin'ific este de&!oltat 9i sus'inut de Spitalul Uni!ersitar din :ena, Germania" #ste primul proiect care
e!aluea& managementul durerii postoperatorii la ni!el european" Corelat proiectului );IL =U< 9i a!*nd drept oiecti!
studierea cronici&rii durerii postoperatorii, este n desf9urare studiul oser!a'ional 0#uropean =ser!ational StudQ on
C2ronic )ost$Surgical )ain1, studiu coordonat de #S; 6#uropean SocietQ of ;naest2esia7, la care spitalul nostru a aderat,
alturi de alte C, de spitale europene" Sec'ia nostr a aderat la proiect n iunie -,++, nrolarea efecti! a pacien'ilor
derul*ndu$se din septemrie -,++" %up o'inerea consim'm*ntului informat, sunt nrola'i n studiu pacien'i afla'i n
&iua + postoperator dup urmtoarele inter!en'ii c2irurgicale3 mastectomie pentru neoplasm de s*n, 2isterectomie,
colectomie, apendicetomie, colecistectomie, cura 2erniei ing2inale, artroscopie de genunc2iU pacien'ii completea& un
c2estionar, acesta urm*nd a fi introdus ntr$o a& de date alturi de anumite date legate de actul operator 9i aneste&ic
pentru fiecare pacient n parte" Ja un inter!al de F luni 9i respecti! +- luni, fiecare pacient rspunde prin e$mail sau
telefon la un nou c2estionar care e!aluea& date legate de poten'iale caractere pri!ind cronici&area durerii
postoperatorii"
Ja data de @+ decemrie -,+-, data nc2eierii nrolrii ca&urilor pentru clinica noastr, din clinic au fost nrola'i -HA de
pacien'i" 8or fi anali&ate, 'in*nd cont de limitele con!enite cu oard$ul de pulicare al studiului, date pri!ind pacien'ii
nrola'i n site$ul sec'iei noastre3 date demografice, intensitatea durerii, interferen'a durerii cu acti!it'ile oi9nuite,
afectarea emo'ional indus de durere, efecte ad!erse ale terapiei analge&ice, percep'ia asupra terapiei durerii
postoperatorii"
?n fiecare an, n #uropa sunt efectuate peste C, de milioane de inter!en'ii c2irurgicale" Cel pu'in /umtate din pacien'ii
supu9i acestor inter!en'ii sufer de durere postoperatorie moderat sau se!er" )re'ul unui management deficitar al
durerii postoperatorii este foarte mare3 durerea nt*r&ie recuperarea postoperatorie, ea cau&ea& suferin' 9i
suprancrcarea c2eltuielilor ser!iciilor de sntate" %omeniul terapiei durerii postoperatorii este caracteri&at de o larg
!ariailitate n ngri/irea terapeutic 9i n re&ultatele acestei ngri/iri, ca 9i n alte domenii medicale"
Sistemul informatic creat prin intermediul proiectului );IL =U< !a ser!i ca model pentru alte domenii ale medicinei n
care se manifest largi !aria'ii ale standardelor de ngri/ire"

P'+G 5UT $ +nternational is an international, multicenter, interdisciplinary research project, designed to improve the
acute pain management !ithin the health care institutions. The project aims to improve the (uality of postoperative
pain therapy by developing and validating a system of measurement and feedbac1 of pain therapy (uality, system
designed to support the therapeutic decision ma1ing.
The scientific project is developed and supported by the University ,ospital of 8ena, ?ermany. +t is the first project
aiming to assess the postoperative pain management at 2uropean level. +n close correlation !ith P'+G 5UT project, a
study coordinated by 2.' 32uropean .ociety of 'naesthesia4, to !hich our hospital has joined together !ith ;# other
2uropean hospitals, is in progress. This is an observational study called P2uropean 5bservational .tudy on Chronic Post$
.urgical PainP and aims to study the postoperative pain chronicity.
5ur department joined the project in 8une %#"", the effective patient recruitment being carried from .eptember %#"".
'fter obtaining their informed consent, patients are enrolled in the trial on postoperative day " after surgery follo!ing
mastectomy for breast cancer, hysterectomy, colectomy, appendectomy, cholecystectomy, inguinal hernia repair, 1nee
arthroscopyK the patients fill in a (uestionnaire, !hich is entered into a database together !ith some data about the
anesthetic and surgery procedure for each patient. 'fter = and "% months, respectively, each patient ans!ers by e$mail
or phone to a ne! (uestionnaire that assesses data on potential characters on chronic postoperative pain.
5n the closing date of cases enrollment to our clinic, December 9", %#"%, a number of %D: patients !ere enrolled in our
department. The follo!ing data on patients enrolled !ill be analy-ed, ta1ing into account the limits agreed !ith the
editorial board of the study6 demographic data, data related to pain intensity, pain interference !ith normal activities,
damage induced by emotional pain, side effects of analgesic therapy, perception of postoperative pain therapy.
2very year, over ;# million surgery cases are performed in 2urope. 't least half of patients undergoing these
interventions suffer from moderate or severe postoperative pain. The price of poor management of postoperative pain is
very great6 pain slo!s the patientJs postoperative recovery, causing much suffering and increasing the health care costs.
's !ell as other medical fields, the postoperative pain therapy is characteri-ed by a !ide variability in therapeutic care
and results of treatment.
The +nformation system created through P'+G 5UT project !ill serve as a model for other areas of medicine !here there
are !ide variations in standards of care.

B+. Monitoring During +ntraoperative Geuromonitoring for Geurosurgery or ,o! to 'void 'nesthesia
'!areness Due to Unusual Circumstances
%" Jic2e!, 8" )lati4ano!
[St" Marina1 Uni!ersitQ 5ospital, %epartment for ;nest2esiologQ m ICM, 8arna, Bulgaria

+ntroduction6 'nesthesia a!areness is a period of time due to general anesthesia !ith presence of luc1 patientJs
unconsciousness. The incidence of anesthesia a!areness persists $ #,%& to ;#& of patients undergoing different types of
surgery. +t is proven that the B+. inde provides correct measurements of levels of the patientJs consciousness under
anesthesia and sedation.
Main goal6 5ur goal is to put on discussion the B+. +nde range for safe general anesthesia for +5GM due to neurosurgery
and also to propose another safety range.
Material and Method6 .even '.' ++ $ '.' +++ patients undergoing fossa crania posterior surgery pro tumor disease !ith
direct nerve stimulation +5GM !ere observed prospectively. ?eneral anesthesia appropriate for direct nerve stimulation
+5GM !as made.
@esults6 +n different stages of the general anesthesia !ith +5GM for tumor fossa posterior !e observe B+. +nde bet!een
%D and =; B+. points. There !ere not found any incidence of anesthesia a!areness in our case series and the posterior
fossa tumors !ere resected totally to subtotally by virtue of +5GM !ith light temporary facial nerve involvement,
preserved hearing and s!allo!.
Conclusion6 Based on the facts, our observations and recently published paper for anesthesia a!areness, !e thin1 that
the bottom level of ;# points B+. +nde for general anesthesia is not al!ays safe. ThatJs !hy !e recommend revision of
and B+. +nde bottom line decreasing at level 9# points. Aurther investigation is needed.

Consim-m1ntul informat n opinia medicilor +i a pacien-ilor
+nformed Consent6 PatientsJ and DoctorsJ 5pinion
#" =leineac, R" Baltaga, Cristina =leineac, S" Colec2i, S" eandru, L" 8aculin
Uni!ersitatea de Stat de Medicin i Farmacie 0Licolae <estemianul, C2i9inu, Repulica Moldo!a

=iecti!ul3 Consimm*ntul informat este un proces de informare care respect dreptul pacientului la autodeterminare"
Studiul a e(aminat calitatea consimm*ntului informat, ce informaie primesc pacienii i ce ar dori s cunoasc despre
riscurile i complicaiile aneste&ice comparati! cu opinia medicilor la acest suiect"
Metode3 ;u fost inter!ie!ai +,, pacieni programai pentru inter!enii c2irurgicale minore i E, medici aneste&iti" S$a
e!aluat opinia acestora pri!ind informarea pacienilor despre complicaiile aneste&ice" ;nali&a statistic s$a efectuat cu
a/utorul distriuiei frec!enelor, n- i testul Fis2er"
Re&ultate3 %ei AC. din pacieni au semnat consimm*ntul informat, doar --. l$au citit nainte de a$l semna" DF. din
medici ar dori s informe&e i HD. din pacieni ar dori s fie informai despre complicaiile aneste&ice foarte frec!ente, p
c,",E" F-. din medici ar dori s informe&e i @F. din pacieni ar dori s fie informai despre complicaiile aneste&ice
moderat frec!ente, p K,",E" EF. din medici ar dori s informe&e i @C. din pacieni ar dori s fie informai despre
complicaiile aneste&ice rare i foarte rare, p K,",E" )entru forma scris de informare au pledat F,. din medici i doar
+H. din pacieni, p K,",,+" <oi medicii inter!ie!ai 6+,,.7, comparati! cu pacienii 6F,.7, susin implicarea rudelor n
procesul de informare, pK,",,+"
Conclu&ii3 ;u fost rele!ate diferite opinii ntre medici i pacieni referitor la informarea pacienilor despre riscurile i
complicaiile aneste&ice specifice"

Bac1ground6 +nformed consent is a process of sharing information that facilitates the individual patientJs right to self$
determination. The study eamined the (uality of patientsJ informed consent, !hat they are told and ho! much
information they desire to 1no! about anesthesia specific ris1s and complications if comparing !ith doctors opinion.
Material and Method6 Patients 3"##4, undergoing minor surgical procedures, and anesthesiologists 3<#4 !ere
intervie!ed to determine their opinion concerning the patientsJ information level about anesthesia complications.
.tatistical analysis !as performed using fre(uency distributions, k% and Aisher eact test.
@esults6 'lthough :;& of patients signed the informed consent, only %%& have read it before signing. Doctors 30=&4
!ould li1e to inform and patients 3D0&4 !ould li1e to be informed about very common and common complications of
anesthesia, p a#.#<. Doctors 3=%&4 !ould li1e to inform and patients 39=&4 !ould li1e to be informed about moderate
and less common complications of anesthesia, p F#.#<. Doctors 3<=&4 !ould li1e to inform and patients 39;&4 !ould li1e
to be informed about rare and very rare complications of anesthesia, p F#.#<. The !ritten format of information !as
preferred by =#& of doctors and "D& of patients, p F#.##". Doctors 3"##&4 and patients 3=#&4 !ant the patientJs
relatives to be involved in the informing process, pF#.##".
Conclusions6 Different opinions bet!een patients and doctors concerning the anesthesia specific ris1s and complications
have been recorded.




Aactors 'ffecting the Blood *oss and ,emotransfusion in ,igh )olume *iver @esection
#" =dissee!a 6-7, I" <a4oro! 6+7, <" Ju4ano!a 6+7, L" 8lado! 6+7, L" )etro! 6-7
6+7 Clinic of 5)B and <ransplant SurgerQ, Sofia, Bulgaria
6-7 MilitarQ Medical ;cademQ, Sofia, Bulgaria

Bleeding in major surgical procedures involving the liver, such as partial liver resection and liver transplantation, occurs
almost inevitably. The amount of blood loss and hemotransfusion has been clearly lin1ed to morbidity and mortality.
'lthough blood loss in patients undergoing liver surgery has decreased substantially during the last decade, ecessive
blood loss can still be a major concern in individual patients. This has led to the introducing and refinement of different
inflo! occlusion techni(ues and further evolution of the surgical technical e(uipment. Maintenance of *o! Central
)enous Pressure 3*C)P4 is !idely accepted li1e one of the most effective strategy for reducing blood lost.
The aim of our study is to investigate the factors correlated !ith blood loss during liver surgery considering the role of
surgeons and anesthesiologists.
Material and Method6 Bet!een 8uly %##; and December %##:, medical and anesthetic records of the patients !ho !ere
admitted to Military Medical 'cademy for resection of more than three liver segments !ere retrospectively and
prospectively revie!ed. Aactors potentially affecting blood loss including patient characteristics, surgical aspects, and
anesthetic aspects in particular C)P !ere analy-ed by regression analysis to eplore the correlation !ith intraoperative
blood loss.
5ne hundred thirty patients !ere included and analy-ed. They !ere divided in t!o groups !ith different protocol of
intraoperative infusion protocol $ liberal strategy during %##; $ %##D and restrictive strategy during %##0 $ %##:.
@esults and Conclusion6 5n multiple regression analysis, the operative time, the intaroperative infusion strategy, volume
status and performed hemotransfusion !ere associated !ith more significant blood loss. The C)P values also had
positive correlation, but in our study !e find that its informativeness is incorrect in liver surgery. +n addition, C)P !as not
the important factor in predicting blood loss.

rotocol de management al coagulrii ba(at pe ROT"M la pacienii cu disecie acut de aort
@5T2M$Based Point$of$Care Coagulation Management in Patients !ith 'cute 'ortic Dissection
%aniela Filipescu, Ioana Marinic, Marilena$;lina )unescu, =" C2ioncel, M" Juc2ian, Simona Marin,
Carmen Manofu
Institutul de Urgen' pentru Boli Cardio!asculare 0)rof" %r" C"C" Iliescul, Bucure9ti, Rom*nia

=iecti!ul studiului3 Scopul studiului este e!aluarea unui protocol, a&at pe tromoelastograma rota'ional 6R=<#M7,
de aordare a tulurrilor de coagulare din c2irurgia disec'iei acute de aort toracic 6%;;7"
Material 9i metode3 Studiul retrospecti! include pacien'ii c2irurgicali cu %;; din -,+-" )rincipalul oiecti! a fost
transfu&ia perioperatorie de produse sanguine allogene 6concentrat eritrocitar C#R, concentrat tromocitar C<,
crioprecipitat C), plasm proaspat congelat ))C7" =iecti!ele secundare au fost3 rata reinter!en'iilor c2irurgicale
pentru 2emosta&, accidentele !asculare cererale isc2emice 6;8C7, insuficien'a renal acut necesit*nd diali&a 6CRR<7,
sepsisul 9i mortalitatea intraspitaliceasc" %atele sunt e(primate ca medii 9i deri!a'ii standard utili&*ndu$se <estul <$
Student 9i c2i ptrat"
Re&ultate3 %in @@ de pacien'i, la +- s$a aplicat protocolul R=<#M 6grupul RG7, restul de -+ au fost ongri/i'i conform
e(perien'ei fiecrui aneste&ist 6grupul UCG7" )acien'ii din RG au necesitat o cantitate semnificati! mai mic de C#R 6F"+j
@"H !s" ++"H j H"EU pI,",@D7 9i C< 6C"Fj -"F in !s" D"D j E",U pI,",C-7" Rata reinter!en'iilor c2irurgicale pentru 2emosta& a
fost semnificati! mai mic on RG3 E 6C+.7 !s" +- pts 6ED.7U pI,",@@" )acien'ii din RG au a!ut o inciden' mai mic de
CRR< NC 6@@.7 !s" A pts 6C- .7U pI,",C-O, sepsis NC 6@@.7 !s" +@ pts 6F-.7U pI,",+-O 9i mortalitate intraspitaliceasc N@
6-E.7 !s" ++ pts 6E-.7U pI,",+CO" )acien'ii din UCG au a!ut mai pu'ine ;8C N@ 6C+.7 !s" E pts 6C+ .7U pI,",,CO"
Conclu&ii3 )rotocolul de management al coagulrii a&at pe R=<#M poate reduce transfu&ia de C#R 9i C< 9i poate
omunt'i e!olu'ia postoperatorie a pacien'ilor cu %;;"

Bac1ground6 The aim of the study !as the evaluation of a @otational Thromboelastometry 3@5T2M4 $ based point$of$
care coagulation management in acute aortic dissection 3''D4 surgery.
Material and Method6 This retrospective study included patients !ith surgery for ''D, during %#"%. The primary
endpoint of this study !as perioperative allogenic blood products use 3pac1ed red blood cells$P@BC, platelet
concentrates$PC, cryoprecipitate$CP, fresh fro-en plasma$AAP4.
The secondary endpoints !ere6 the rate of surgical re$eploration for bleeding, stro1e, renal replacement therapy 3@@T4,
sepsis and in$hospital mortality. Data are epressed as mean h standard deviation 3.D4. Unpaired .tudentZs t$test and
chi$s(uare !ere used.
@esults6 9% patients !ere included. "% pts !ere managed based on @5T2M results 3@5T2M group$@?4 and %" pts
received usual care 3UC?4. @? re(uired significantly lo!er amount of P@BC units 3=."h 9.D vs. "".D h D.<K pE#.#904 and PC
3;.=h %.= in vs. 0.0 h <.#K pE#.#;%4 than UC?. The rate of surgical re$eploration for bleeding !as significantly lo!er in
@?6 < 3;"&4 vs. "% pts 3<0&4K pE#.#99. Patients in @? had a lo!er incidence of @@T H; 399&4 vs. : pts 3;% &4K pE#.#;%I,
sepsis H; 399&4 vs. "9 pts 3=%&4K pE#.#"%I and in$hospital mortality H9 3%<&4 vs. "" pts 3<%&4K pE#.#";I. Patients in the
UC? had a lo!er rate of stro1e H9 3;"&4 vs. < pts 3;" &4K pE#.##;I.
Conclusions6 @5T2M$based point$of$care coagulation management may reduce P@BC and PC transfusion and may
improve clinical outcome in patients !ith ''D surgery. Prospective, controlled studies are needed to confirm these
results.

0tilitatea e&alurii func-iei trombocitare cu Multiplate "lectrode Aggregometr@ n chirurgia cardiac la
pacien-ii cu tratament antiagregant
Utility of 2valuating Platelet Aunction !ith Multiplate 2lectrode 'ggregometry in Cardiac .urgery in Patients
on 'ntiplatelet Therapy
%aniela Filipescu, M" Juc2ian, =ana Constantin, Ioana Marinic, M" etefan, Marilena$;lina )unescu,
Jaura %ima, =" C2ioncel
Institutul de Urgen' pentru Boli Cardio!asculare 0)rof" %r" C"C" Iliescul, Bucure9ti, Rom*nia

Introducere3 =peraiile cardiace cu circulaie e(tracorporal 6C#C7 efectuate la pacieni su tratament antiagregant se
nsoesc de complicaii 2emoragice i e(punere transfu&ional crescute" Funcia tromocitar poate fi apreciat rapid cu
aparate tip Multiplate #lectrode ;ggregometrQ 6M#;7 care cuantific efectul aspirinei 6testul ;S)I7, clopidogrelului
6testul ;%)7 i trominei 6testul <R;)7" Semnificaia acestor teste n perioada perioperatorie nu este nc clarificat"
=iecti!3 #!aluarea impactului tratamentului antiagregant asupra s*ngerriiBtransfu&iei n c2irurgia cardiac cu C#C cu
a/utorul testrii funciei tromocitare cu aparatul M#;"
Material i metod3 ;m anali&at retrospecti! datele oinute pe parcursul anului -,+- la pacieni aduli cu inter!enii
c2irurgicale cardiace aflai su tratament antiagregant, la care determinarea funciei tromocitare cu aparatul M#; a
fost disponiil" S$au urmrit3 !alorile testelor ;S)I, ;%) i <R;), durata opririi preoperatorii a tratamentului
antiagregant i inter!alul p*n la testare, !olumul s*ngerrii, transfu&ia, rata reinter!eniei pentru s*ngerare
postoperatorie" ;nali&a statistic s$a fcut cu testul Student$t" Semnificaia statistic a fost considerat la pK,,,E"
Re&ultate3 Jotul studiat a inclus +A pacieni, dintre care +D su tratament cu aspirin, +F cu dul terapie antiplac2etar
6aspirin i clopidogrel7 i unul doar cu clopidogrel" Ja D pacieni tratamentul antiagregant dual a fost continuat p*n n
momentul operaiei" <rei dintre acetia au pre&entat !alori terapeutice ale testului ;%), - !alori la limita inter!alului
terapeutic iar @ au pre&entat !alori normale ale ;%)" Ja H pacieni clopidogrelul a fost intrerupt preoperator, ntre - i
+, &ile" 8alorile ;%) au fost normali&ate la F din H pacieni, indiferent de numrul de &ile de oprire a tratamentului" C din
H pacieni cu tratament cu clopidogrel oprit preoperator au pre&entat !alori supranormale ale <R;)" %rena/ul
mediastinal n primele -C de ore la pacienii operai su aspirin i clopidogrel a fost asemntor cu cel al pacienilor la
care clopidogrelul fusese oprit sau primiser doar aspirin 6@,@j+,F ml !s" -,HjHD ml !s" -@HjH- ml7" Un singur pacient
a necesitat reinter!enie pentru controlul 2emosta&ei" <ransfu&ia n prima &i postoperator nu a fost diferit ntre cele
trei grupe de pacieni"
Conclu&ii3 )acienii operai su C#C i dul terapie antiagregant nu s*ngerea& mai mult i nu necesit transfu&ie
crescut perioperator" = posiil e(plicaie ar fi faptul c F-. dintre pacieni au !alori suterapeutice ale ;%) i
supranormale ale <R;)" Meninerea !alorilor terapeutice ale ;%) dup ntreruperea tratamentului cu clopidogrel poate
sugera un risc crescut de s*ngerare"

+ntroduction6 Cardiac surgery operations !ith cardiopulmonary bypass 3CPB4 done to patients on antiplatelet therapy are
accompanied by hemorrhagic complications and high transfusion rates. Platelet function can be rapidly assessed !ith
Multiplate 2lectrode 'ggregometry 3M2'4 devices, !hich can (uantify the effect of aspirin 3'.P+$test4, clopidogrel 3'DP$
test4 and thrombin 3T@'P$test4. The meaning of these tests in the perioperative period is yet to be clarified.
5bjective6 2valuating the impact of anti platelet therapy on bleeding/transfusion in cardiac surgery !ith CPB, by testing
platelet function via M2'.
Material and Method6 Be did a retrospective analysis of the data obtained in %#"% in adult patients !ith cardiac
surgical interventions under anti platelet therapy for !hich M2' testing !as available. Be follo!ed6 '.P+, 'DP and T@'P
tests values, the length of preoperative interruption of anti platelet therapy and the interval until testing, bleeding
volume, transfusion, reintervention fre(uency for postoperative bleeds. .tatistical analysis !as done !ith t$.tudent test.
.tatistical significance !as set at pF #,#<.
@esults6 Be studied ": patients, of !hom "0 !ere treated !ith aspirin, "= !ith dual anti platelet therapy 3aspirin and
clopidogrel4 and one !ith clopidogrel only. +n 0 patients dual anti platelet therapy !as continued until surgery. Three of
these had therapeutic values in 'DP test, % had borderline therapeutic values and 9 had normal values in 'DP test. Aor D
patients clopidogrel !as interrupted preoperatively, for % to "# days. 'DP values !ere normali-ed in = of D patients,
regardless of the number of days of interruption. ; of D patients on clopidogrel interrupted treatment had higher values
for T@'P. Thoracic drainage in the first %; hours in patients operated on dual therapy !as similar to that for !hich
clopdiogrel had been stopped or had received aspirin only 39#9 h "#= ml vs. %#D h D0 ml vs. %9D h D% ml4. 5nly one
patient re(uired reintervention for bleeding. Transfusion in the first day postoperatively !as similar amongst the three
groups of patients.
Conclusions6 +n our case series, patients !ho are operated on CPB and receive dual anti platelet therapy donJt bleed
more and donJt have higher transfusion re(uirements perioperatively. 5ne possible eplanation is that =%& of patients
have under therapeutic values for 'DP and higher values for T@'P. Maintaining therapeutic values of 'DP after stopping
clopidogrel treatment suggests a higher ris1 for bleeding.

Cardioprotecia cu 'e&ofluran n chirurgia non$cardiac
Cardioprotection !ith .evoflurane in Gon$Cardiac .urgery
Georgeta RelQ Manolescu, %iana <oma, Mdlina %uu, S" Legoi, %enisa Liu, %" Corneci
Spitalul Uni!ersitar de Urgen 0#lias1, Bucure9ti, Rom*nia

=iecti!3 #!aluarea efectelor cardioprotecti!e ale Se!ofluranului comparati! cu )ropofolul, n c2irurgia non$cardiac, la
pacien'ii cu risc cardiac, prin !aria'ia perioperatorie a troponinei I6<nI7"
Material i metod3 Studiu clinic, prospecti!, cuprinde FD pacien'i, supu9i c2irurgiei adominale" )acien'ii au fost
randomi&a'i n trei loturi, n func'ie de tipul aneste&iei3 lotul ; $ aneste&ie total in2alatorie cu Se!ofluran 68IM;7 $ -C
pacien'i, lotul B $ aneste&ie total intra!enoas cu )ropofol 6<I8;B<CI7 $ -, pacien'i 9i lotul C $ aneste&ie general
alansat cu Se!ofluran $ -C pacien'i" ;u fost monitori&a'i perioperator parametrii 2emodinamici 9i !alorile <nI" S$au
anali&at pre&en'a e!enimentelor cardiace perioperatorii, durata internrii n S<I 9i supra!ie'uirea la + an"
Re&ultate3 )acien'ii cu !*rsta medie de H@ ani au a!ut inciden' semnificati! mai mic a e!enimentelor cardiace
perioperatorii n lotul C comparati! cu lotul ; 9i B6pI ,,,CH7" %urata internrii n terapie intensi! nu a pre&entat
diferen'e ntre loturi" 8aloarea medie a <nI postoperator a fost semnificati! crescut n lotul B, fa' de loturile C 9i ; 6
,,FD j ,,-+ngBml !s" ,,-E j ,,E-ngBml, respecti! ,,- j ,,AA ngBmlU p BBC I,,,@@, p;BB I ,,,-@7" Rata gloal a deceselor
de cau& cardiac la + an nu a pre&entat !aria'ii ntre cele trei loturi 6p c ,,,E7"
Conclu&ii3 ;neste&ia cu Se!ofluran, la pacien'ii cu risc cardiac, n c2irurgia non$cardiac, a fost nso'it de !alori sc&ute
ale <nI postoperator, comparati! cu aneste&ia <I8;B<CI" #!enimentele cardiace perioperatorii au pre&entat inciden'
crescut la pacien'ii cu <I8;B<CI, iar e!aluarea la + an nu a e!iden'iat diferen'e ntre loturi"

5bjective6 Cardioprotective effects evaluation of .evoflurane, comparative !ith Propofol, in non$cardiac surgery, at
patients !ith cardiac ris1, using perioperatory variation of troponin + 3Tn+4.
Material and Method6 The clinical study, !as prospective, and includes =0 patients, undergoing abdominal surgery. The
patients !ere randomi-ed in 9 groups, depending on the anesthesia techni(ue6 group ' $ total inhalatory anesthesia
!ith .evoflurane 3)+M'4 %; patientsK group B $ total intravenous anesthesia 3T+)'$TC+4 %# patientsK group C $ balanced
general anesthesia !ith .evoflurane %; patients.
The haemodinamically parameters !ere monitored and the Troponin + values 3Tn+4. The presence of postoperatory
cardiac events, length of stay in +CU and survival at one year !ere analy-ed.
@esults6 The average age of the patients !as D9 years old. +t !as a lo!er incidence of perioperative cardiac events in
group C, comparing !ith group ' or B 3p E #,#;D4. There !ere no differences among the three groups, regarding length
of stay in +CU.
The average value of postoperatory Tn+, !as significantly increased in group B, comparing !ith groups C and ' 3#,=0 h
#,%"ng/ml vs. #,%< h #,<%ng/ml, respectively #,% h #,:: ng/mlK p B/C E#,#99, p'/B E #,#%94.
Conclusions6 'nesthesia !ith .evofluran, at patients !ith cardiac ris1 in non cardiac surgery, !as postoperatory
accompanied by lo! values of Tn+, comparing !ith T+)'/TC+ anesthesia.
The postoperatory cardiac events, !ere more fre(uent at patients !ith T+)'/TC+ anesthesia.

oate rabdomioli(a s constituie o problem n chirurgia robotic!
M" <udoroiu, M" )opescu, Mdlina Berecel, Gariela %roc
Institutul Clinic Fundeni, Clinica ;<I, Bucure9ti, Rom*nia

C2irurgia rootic este o c2irurgie minim$in!a&i! cu multe a!anta/e do!edite precum un timp mai scurt de recuperare
postoperatorie" Sunt ns c*te!a de&a!anta/e legate de po&i'ia olna!ului pe mas, precum o po&i'ie <rendelenurg
accentuat, pre&en'a pneumoperitoneului 9i durata n general mai lung a inter!en'iilor"
=iecti!ul studiului este stailirea gradului de radomioli& la pacien'ii opera'i rootic 9i compararea re&ultatelor cu
cele o'inute de la un lot martor ce cuprinde pacien'i opera'i prin intermediul c2irurgiei clasice"
Material 9i metod3 %up o'inerea acordului comisiei de etic locale 9i cu respectarea tuturor condi'iilor de un
practic medical, a fost e!aluat prospecti! un lot de @E de pacien'i succesi!i opera'i rootic" ;u fost e(clu9i din lot acei
pacien'i su +D ani 9i cei la care inter!en'iile s$au con!ertit" <o'i pacien'ii au a!ut aneste&ie general alansat cu
FentanQl, Se!ofluran, <racrium" Jotul martor a fost constituit din acelea9i tipuri de inter!en'ii 6re&ec'ii colice, c2irurgie
ginecologic7, dar efectuate clasic prin laparatomie"
;m urmrit e!olu'ia !alorilor creatin 4ina&ei 6C47, ureei, creatininei, potasiului seric n preoperator, la - ore 9i -C ore
postinter!en'ie"
;nali&a statistic a fost efectuat cu a/utorul programului S)SS 68S +A7"
Re&ultate, discu'ii3 Cum era 9i de ateptat, gradul de radomioli& 6C4 la - 9i -C de ore7 se corelea& cu durata
inter!en'iei 6pI,",,E7 9i este mai important n ca&ul c2irurgiei rootice n po&itie <rendelenurg accentuat fa' de
c2irurgia desc2is 6pI,"+@H pt C4 la - ore si pI,"++, pt C4 la F ore7"
)o&i'ia pe mas influen'ea& 9i !alorile de uree care cresc mai mult 6pI,",,- pt uree la -C ore7 n ca&ul n care olna!ul
este n <rendelenurg fa' de antitrendelenurg, proail datorit unei perfu&ii renale mai proaste"
Conclu&ii3 ?n ca&ul c2irurgiei rootice am e!iden'iat e(isten'a radomioli&ei semnificati!e 9i de9i, comunicate n
literatur, noi nu am nregistrat nici un ca& de insuficien' renal acut post procedur rootic n lotul studiat"

Transplant hepatic n sindromul ;oubert/ re(entare de ca(
*iver Transplant for 8oubert .yndrome6 Case @eport and *iterature @evie!
Saina <nsescu, Ro(ana Ciona9u, M" <udoroiu, M" )opescu, Ja!inia :ipa, Gariela %roc
Institutul Clinic Fundeni, Clinica ;<I, Bucure9ti, Rom*nia

Introducere3 Sindromul :ouert este o oal genetic rar descris prima dat n +AFA, n care anomalii specifice de
respira'ie 9i mi9care sunt asociate cu apla&iaB2ipopla&ia !ermisului cereelos 9i cu alte malforma'ii cererale 9i spinale"
)acien'ii pre&int 2ipotonie precoce, urmat de ata(ie, episoade de apnee 9iBsau ta2ipnee, mi9cri oculare anormale,
retard mental" ?n plus pot asocia distrofie retinian, firo& 2epatic, rinic2i polic2istici, de&ec2ilire endocrinologice,
encefalocele 9i polidactilie"
Material 9i metod3 )re&entm ca&ul unei feti'e de H ani la care s$a practicat transplant 2epatic la Institutul Clinic
Fundeni n data de +,",C"-,+@" )articularitatea ca&ului const n faptul c pacienta de&!oltase !arice esofagiene care
necesitaser andare pentru s*ngerare masi!"
Re&ultate3 %urata inter!en'iei c2irurgicale a fost de F2 9i @, minute, pe parcursul creia !entila'ia a fost prolematic,
feti'a pre&ent*nd perioade de desaturare, cu !olume mici 9i presiuni de platou mari" Lu s$au nt*mpinat altfel de
proleme" )acienta a rmas n <erapie Intensi! timp de E &ile, iar dup +E &ile a fost e(ternat din spital" )rotocolul de
imunosupresie a constat din Basili(ima 9i Solu Medrol"
Conclu&ii3 <ransplantul 2epatic este un tratament curati! pentru firo&a 2epatic din cadrul sindromului :ouert" Lu au
fost raportate alte ca&uri de transplant la copiii de !*rst apropiat care sufer de aceast oal"

+ntroduction6 8oubert syndrome is a rare genetic neurodevelopmental disorder, first described in":=:, in !hich specific
breathing and movement abnormalities are associated !ith cerebellar vermis aplasia/hyhoplasia and other brain and
spinal malformations. 'ffected patients manifest early hypotonia follo!ed by ataia, episodic apnea and/or hyperpnea
abnormal eye movements, developmental delay, and intellectual disability. +n addition, retinal dystrophy, hepatic
fibrosis, cystic 1idneys, endocrine abnormalities, encephalocele and polydactyly are seen in some patients.
Matherial and Method6 Be report the case of a D years old girl that under!ent liver transplantation at Aundeni Clinical
+nstitute in "#.#;.%#"9, under general anesthesia. Be mention that she had developed esophageal varices that re(uired
bandation for heavy bleeding.
@esults6 The duration of surgery !as =h and 9# minutes. )entilation in this patient !as very challenging, as she had
periods of desaturation !ith decreased tidal volume and minute volume and high pressures. Go other problems !ere
recorded. .he remained in the +CU < days after the surgery. The immunosupression regimen consisted of Basiliimab and
.olu Medrol. "< days after the surgery the girl is discharged from hospital.
Conclusions6 *iver transplantation is a curative treatment for the hepatic fibrosis occurring in 8oubert syndrome. Go
other cases of liver transplantation !ere noted at children at this age suffering from this disease.

#actori de risc pentru apariia sindromului de reperfu(ie n timpul transplantului hepatic
#caterina Scrltescu, Gariela %roc, %ana <omescu
Institutul Clinic Fundeni, Clinica ;<I, Bucure9ti, Rom*nia

Introducere 9i scopul lucrrii3 ?n timpul transplantului 2epatic, dup declamparea !enei porte 9i reperfu&ia ficatului, se
poate instala o perioad de instailitate 2emodinamic numit sindrom de reperfu&ie care, de9i este de scurt durat,
poate a!ea consecin'e se!ere" Factori predicti!i ai sindromului de reperfu&ie nu au fost complet elucida'i, dar e(ist
numero9i factori de risc ce pri!esc primitorul, donatorul 9i te2nica c2irurgical cu impact asupra inciden'ei 9i se!erit'ii
acestui sindrom" Scopul lucrrii este studiul inciden'ei 9i a factorilor de risc asocia'i sindromului de reperfu&ie ntr$un
grup de pacien'i transplanta'i 2epatic"
Material 9i metod3 @E pacien'i consecuti!i transplanta'i 2epatic au fost inclu9i ntr$un studiu oser!a'ional retrospecti!"
%atele nregistrate au fost3 !*rsta, se(ul, etiologia olii 2epatice, scorurile M#J% 9i C2ild )ug2 pentru primitorii cu ciro&
2epatic, olile asociate, tratamentul cu eta locante pretransplant, lungimea inter!alului a< corectat, durata
inter!en'iei c2irurgicale 9i a fa&ei an2epatice, s*ngerarea intraoperatorie, necesarul de droguri !asoacti!e intraoperator
9i n perioada postoperatorie imediat, durata sta'ionrii pacientului n sec'ia de terapie intensi!" Inter!alul a< a fost
msurat pe electrocardiograma standard n +- deri!a'ii efectuat preoperator 9i a fost corectat pentru frec!en'
cardiac folosind formula Ba&ett" )relucarea statistic a datelor a fost reali&at folosind S)SS Statistics !"+A"+"
Re&ultate 9i discu'ii3 ?n studiul efectuat, criteriile utili&ate pentru definirea sindromului de reperfu&ie au fost a&ate doar
pe modificrile 2emodinamice aprute dup declampare" Sindromul de reperfu&ie a fost diagnosticat c*nd presiunea
arterial medie a sc&ut cu minim @,. fa' de cea de la finalul fa&ei an2epatice cu durata de cel pu'in + minut n
primele E minute de la declampare"
Inciden'a sindromului de reperfu&ie n lotul de studiu a fost de EH"+." ;pari'ia sindromului de reperfu&ie a fost
corelat semnificati! statistic cu !*rsta primitorului 9i cu durata fa&ei an2epatice" %e asemenea, pacien'ii cu sindrom de
reperfu&ie au necesitat o perioad mai lung de internare n sec'ia de terapie intensi! dup transplantul 2epatic" Lu s$
au identificat corela'ii semnificati!e statistic ntre apari'ia sindromului de reperfu&ie 9i etiologia olii 2epatice, scorul
M#J%, !olumul s*ngerrii intraoperatorii sau durata inter!en'iei c2irurgicale" Sindromul de reperfu&ie nu a fost corelat
n studiul efectuat cu pre&en'a factorilor de risc pentru e!enimente cardio!asculare sau cu prelungirea inter!alului a<
corectat"
Conclu&ii3 Reperfu&ia este o perioad critic din timpul transplantului 2epatic asociat cu instailitate 2emodinamic
se!er" Studiul de fa' a artat c durata fa&ei an2epatice 9i !*rsta primitorului pot a!ea un rol n apari'ia sindromului
de reperfu&ie 9i, de asemenea, c sindromul de reperfu&ie din timpul transplantului 2epatic poate a!ea un impact
negati! asupra perioadei postoperatorii precoce" Cunoa9terea factorilor de risc este util pentru identificarea pacien'ilor
care pot de&!olta sindrom de reperfu&ie 9i pentru elaorarea unor strategii eficiente n pre!enirea 9i tratamentul su"

Corelaii ntre balana hidric perioperatorie %i reluarea tran(itului intestinal n chirurgia oncologic
abdominal ma3or/ Re(ultate preliminare
Correlations bet!een Perioperative Bater Balance and @eturn of Bo!el Movements in Major 5ncologic
'bdominal .urgery. Preliminary @esults
;" Caragea 6+7, ;dina Ble/usc 6+7, C" )rista!u 6+7, Ja!inia Bodescu ;mancei 6+7, ;ndreea %umitriu 6+7, %" Rusu 6-7, Ioana
Grigora 6+7
6+7 Uni!ersitatea de Medicin 9i Farmacie 0Gr" <" )opal, Iai, Rom*nia
6-7 Institutul Regional de =ncologie, Iai, Rom*nia

=iecti!3 In!estigarea corela'iei ntre alan'a 2idric perioperatorie 9i reluarea tran&itului intestinal"
Material 9i metod3 Studiu prospecti! oser!a'ional desf9urat n IR= Ia9i ncep*nd cu +",-"-,+@, ce a inclus to'i
pacien'ii consecuti!i complian'i cu criteriile de includereBe(cludere" )arametrii pri!ind ilan'ul 2idric au fost nregistra'i
ca adec!a'iBinadec!a'i3 durata postului pentru lic2ide 6K sau c-27, terapia !olemic intraoperatorie 6K sau c +,mlB4gB27,
ilan'ul 2idric postoperator po&iti! n oricare din primele E &ile postoperator 6K sau c+,,,mlB&i7" Reluarea tran&itului
intestinal a fost consemnat ca precoceBtardi! 6primul flatus la K sau cCD ore postoperator7"
Re&ultate3 ;u fost nrola'i HF pacien'i cu c2irurgie adominal ma/or 62isterectomii totale -H, re&ec'ie de rect +C, de
colon +-, gastrectomii H, 2epatectomii -7" <erapia 2idric intraoperatorie s$a nscris ntre C$-HmlB4gB2 6cu o medie de
+,,HmlB4gB2, !aloare modal DmlB4gB27" Bilan'ul 2idric n &iua + postoperator a fost , la -@ pacien'i 6@,.7 9i a !ariat cu
mai mult sau mai pu'in de +E,,mlB&i la +-6+E.7, respecti! +,6+@.7 pacien'i" Reluarea precoce a tran&itului intestinal
corelea& puternic 6pK,",E7 cu durata postului preoperator 9i cu ilan'ul 2idric postoperator"
Conclu&ii3 Bilan'ul 2idric perioperator influen'ea& n mare msur rapiditatea recuperrii postoperatorii a olna!ului
c2irurgical" #!itarea postului prelungit pentru lic2ide preoperator, terapia !olemic adec!at intraoperatorie 6e!it*nd
at*t 2ipo!olemia, c*t 9i administrarea e(cesi!7 9i men'inerea postoperatorie a unui ilan' 2idric apropiat de &ero
scurtea& durata ileusului postoperator"

?oal6 Correlations bet!een perioperative !ater balance and return of bo!el movements in major oncologic abdominal
surgery.
Material and Method6 Prospective observational study conducted in +@5 +a^i starting !ith ".#%.%#"9 enrolling all
consecutive patients compliant !ith inclusion/eclusion criteria. Parameters regarding !ater balance !ere recorded as
appropriate/inappropriate6 preoperative drin1 fasting 3F or a%h4, intraoperative volume therapy 3F or a "#ml/1g/h4,
positive postoperative !ater balance in any of the first < postoperative days 3F or a"###ml/day4. The return of bo!el
movements 3first flatus4 !as recorded as early/late 3 F or a;0 hours4.
@esults6 D= patients !ith major abdominal surgery 3%D hysterectomies, "; rectal, "% colonic, % hepatic resections, D
gastrectomies4 !ere enrolled. +ntraoperative volume therapy varied bet!een ;$%Dml/1g/h 3average "#,Dml/1g/h, modal
value 0ml/1g/h4. Bater balance in the first postoperative day !as # in %9 patients 39#&4 and varied !ith more or less
than "<##ml/day in "%3"<&4, respective "#3"9&4 patients. 2arly return of bo!el movements strongly correlates 3pF#.#<4
!ith duration of preoperative fasting and !ith postoperative !ater balance.
Conclusions6 Perioperative !ater balance has a major influence on postoperative recovery of the surgical patient.
'voidance of prolonged preoperative fasting, appropriate intraoperative volume therapy 3avoiding both hypovolemia
and ecess administration4 and postoperative !ater balance close to # shortens the duration of postoperative ileus.

Impactul factorului psihologic asupra reaciei de stres n inter&enii ortopedice ma3ore
Psychological +mpact on .tress @eactions in Major 5rthopedic .urgery
Maria Stoica, %aniela Cernea
Spitalul Clinic :udeean de Urgen, Craio!a, Rom*nia

;ordarea laturii psi2ologice a pacientului poate repre&enta, la prima !edere, un suiect desuet n acti!itatea clinic
at*t de aglomerat, n cadrul unui spital de urgen'" %e9i este descris oi9nuit n perioada preoperatorie de ctre
pacien'i, iar pre&en'a 9i intensitatea an(iet'ii pot fi confirmate utili&*nd c2estionare speciale, e!aluarea acesteia nu
este efectuat n mod oi9nuit n spitale" S$a demonstrat c unele inter!en'ii c2irurgicale 6la ni!el toracic, oto$laringian,
cardiac7 au fost asociate cu un ni!el crescut al an(iet'ii"
)rote&area total articular se altur acestor inter!en'iiV Ja teama fa' de inter!en'ia c2irurgical propriu$&is,
aneste&ia 9i discomfortul fa' de mediul spitalicesc, la pacien'ii supu9i endoprote&rii totale la ni!elul memrului inferior
se adaug teama pentru perioada de recuperare" ;9teptrile acestor pacien'i postoperator sunt n general mari, dup o
suferin' de cele mai multe ori de durat 9i, uneori, prost gestionat"
?n pre&ent, de9i studiile e(istente arat o munt'ire cert a func'ionalit'ii 9i o diminuare e!ident a durerii dup
prote&are articular, re&ultatele a9teptate de pacient nu se concreti&ea& ntotdeauna" Caracterele psi2ologice ale
pacien'ilor sunt fr ndoial importante n de&!oltarea durerii cronice postoperatorii3 A din ++ studii stailesc o
legtur ntre an(ietatea preoperatorie i apari'ia acesteia, Bourne gsind un procent de +A. pondere a insatisfac'iei"
Cum reducem riscul psi2ologicV )si2oeduca'ia 9i psi2oterapia cogniti! 9i comportamental sunt instrumente
susceptiile de scdere a riscului durerii cronice" ;nali&a datelor demografice 9i clinice preoperatorii ale pacientului ar
a/uta la pre&icerea an(iet'ii preoperatorii prin configurarea unui profil an(iogen" Sedarea repre&int o solu'ie, cresc*nd
satisfac'ia pacientului n timpul aneste&iei regionale"

'pproaching the psychological patientJs status appears to be, in present, at first sight, an insignificant topic according
!ith busy clinical practice, in a emergency clinical hospital. 2ven if it is mentioned in patient pre$assessment, the
presence and intensity of aniety could be confirmed using special (uestionnaires, its evaluation is not used routinely in
the hospital. +t has been sho!n that some surgical interventions, as thoracic surgeries, 2GT surgeries, cardiac surgeries,
ave been associated !ith a high level of aniety.Does total hip replacement join these interventionsC 't patients
undergoing for total endoprothesis of lo!er limb, there is a fear of surgical procedure, fear of anesthesia, hospital
environment, and !e can add also fear of the recovery period. These patients have usually high epectations
postoperatively, after a long period of distress and an inappropriate management.
2ven if current studies sho!ed an improvement in joint functionality and a obvious decrease in pain scale after total hip
replacement, patientsJ epectations are higher. Psychological status is nevertheless very important in the development
of chronic pain postoperatively. : out of "" studies sho! a relationship bet!een preoperative aniety and its
manifestation, Bourne in one of his studies demonstrated that the percentage of dissatisfaction is ":&.
,o! do !e reduce the ris1 to psychological statusC PatientJs education and cognitive behavioral therapy contribute to
reduce the ris1 of chronic pain. 'naly-ing demographic data and preoperatively patientJs assessment !e could configure
an anious profile. ' solution is to combine sedation !ith regional anesthesia, this increasing patientJs satisfaction.

'unt aneste(ist/ 'unt mul-umit!
+ 'm an 'nesthesiologist. 'm + .atisfiedC
;na Ulinici, I" C2eso!, R" Baltaga
Uni!ersitatea de Stat de Medicin i Farmacie 0Licolae <estemianul, C2iinu, Repulica Moldo!a

Scop3 #!aluarea gradului de satisfac'ie profesional i e(aminarea factorilor cu impact asupra acesteia la aneste&itii din
Repulica Moldo!a"
Material i metod3 Studiu cross$sectional, a&at pe c2estionarea anonim a aneste&itilor"
Re&ultate3 <otal au fost c2estionai -C- de aneste&iti" Rata de participare -F. 6FC7 din numrul celor c2estionai,
rai @ABfemei -E, din care D+. se consider parte a unei ec2ipe multidisciplare" ;neste&itilor le place profesia
deoarece3 ofer ser!icii de calitate 6FH.7, consider profesia o pro!ocare intelectual 6C-.7, interacionea& cu ali
aneste&iti 6-,.7" <otodat, sunt nemulumii de3 remunerare 6F+.7, insuficiena de ec2ipament i medicamente 6E@.7,
politicile naionale de sntate 6@,.7, politicile instituionale 6-H.7, relaiile cu c2irugul 6-H.7" Consider c ser!iciul nu
are un impact negati! asupra familiei FF., iar din totalul de respondeni F,. sunt n general satisfcui de ser!iciu, EA.
nu ar sc2ima profesia"
Conclu&ii3 ?n R"M" aneste&itii raportea& un grad mai mic de satisfacere profesional !s" colegii din rile de&!oltate
6Canada" HE.7" Factorii cu impact asupra satisfaciei aneste&itilor sunt3 retriuia muncii, lipsa te2nicii performante i a
medicaiei calitati!e, opinia pulic" Situaia ar fi redresat prin ameliorarea condiiilor de munc, mrirea retriuiei
muncii, sensiili&area opiniei pulice"

Purpose6 +t is to assess anesthesiologistsJ job satisfaction and to provide impact factors on this issue in the @epublic of
Moldova.
Material and Method6 Cross$sectional study, based on anonymous (uestioning about the level of job satisfaction of the
anesthesiologists from the @epublic of Moldova.
@esults6 ' total of %;% anesthesiologists !ere (uestioned, =; responses !ere received, %=&, men 9:/!omen %:, from
!hich 0"& considered that they are a part of an interdisciplinary team. 'nesthesiologists li1e their job due to6 they
provide high (uality care 3=%&4, intellectual challenge 3;%&4, and interaction !ith other anesthesiologists 3%#&4.
Meantime, they donJt li1e their job because6 small salary 3="&4, lac1 of e(uipment and drugs 3<9&4, national health
policies 39#&4, institutional health policies 3%D&4, interaction !ith surgeon 3%D&4. ==& of the responders donJt thin1 that
job has a negative impact on their family, =# & of responders a overall satisfied !ith job and <:& !ouldnJt change the
job.
Conclusions6 +n the @epublic of Moldova, the anesthesiologistsJ level of job satisfaction is not so high vs. colleagues from
high income settings 3Canada. D<&4. Aactors that influence anesthesiologists job satisfaction6 salary, lac1 of e(uipment
and drugs, public opinion. The things can be improved by6 better !or1ing conditions, increase of the salaries, P@ actions.

@esearch on Are(uency, 2pidemiology and +ntensive Care of the Craniocerebral Trauma in Bulgaria over a
Period of .i Lears
L" )etro!, 8" 8ase!a, R" )opo!
MilitarQ Medical ;cademQ, ;naest2esiologQ and Intensi!e Care %epartment, Sofia, Bulgaria

The authors present results from research on "%"; patients !ith craniocerebral trauma over a period of si years.
Trac1ed injuriesJ causes, incidence, epidemiology and severity in patients !ith severe craniocerebral trauma 3nE9%:4 and
the results of intensive care as !ell.
Material and Method6 Patients !ere divided into groups according to the type of trauma $ isolated severe craniocerebral
trauma 3nE9%:4, severe combined craniocerebral trauma 3nE<#=4, combined severe trauma !ithout head injury 3nE9D:4.
Depending on the approach in monitoring and intensive care patients !ere divided into t!o groups $ standard
monitoring 3?roup ', nE<;04 and those !ith multimodal monitoring 3?roup B $ n E ===4.
+n patients form ?roup B !e monitored intracranial pressure 3+CP4, cerebral perfusion pressure 3PPC4, measured the
velocities in the sylivian artery by using transcranial Doppler 3TCD4, continuous or periodic monitoring .jv5%, calculated
Da$v5% 3arteriovenois oygen difference4, calculated of the a$v difference for oygen 3'$v5%4, glucose, lactate. Be also
calculated cerebral oygen consumption 3CM@5%4 continuous or periodic 22? monitoring. Periodic monitoring of evo1ed
potentials, monitoring of the tissue saturation in the contusion -one 3r.5%4, glycemia continuous and permanent
monitoring, continuous and permanent monitoring glycemic control, scenographic monitoring, according to the
protocol, microbiological monitoring.
?oal6 By the means of multimodal monitoring to develop modern ade(uate model for treatment in patients !ith severe
craniocerebral trauma.
@esults6 The most fre(uent reasons for severe craniocerebral trauma in Bulgaria are traffic accidents 3=0&4, follo!ed by
violence and firearms 3"D&4. )iolence and firearms craniocerebral traumas are a priority for men in age of "0$;<. The
total number of injuries increased to ==& for the si years period, on account of combined trauma !ithout head injury. +n
patients !ith multimodal monitoring !e achieved mortality reduction !ith ""$";& in different trauma types.
Discussion6 5n the base of multimodal monitoring, the current study presents method for comple estimation on
intracranial pressure, cerebral blood flo!, cerebral perfusion pressure, cerebral oygen consumption, cerebral
metabolism in the contet of intensive care in patients !ith isolated and/or combined severe craniocerebral trauma.

Incidena %i etiopatogenia infeciilor de tract respirator n Clinica ATI a 'pitalului Clinic ;udeean de 0rgen Timi%oara
n perioada ianuarie $ decembrie 5E45
The +ncidence and 2thiopathogeny of @espiratory Tract +nfections in +ntensive Care Unit of the Clinical County ,ospital
Timi^oara bet!een 8anuary %#"% and December %#"%
=" Bedreag 6+7, M" )apuric 6+7, %" %rgulescu 6-7, C"J" Leam'u 6-7, Carmen Guragata$Bala9a 6-7, C" I" Macarie 6-7, G"
G2eorg2iu 6+7, C" 5en'ia 6-7, %" Sndesc 6+7
6+7 Uni!ersitatea de Medicin 9i Farmacie 08ictor Bae91, <imi9oara, Rom*nia
6-7 Spitalul Clinic :ude'ean de Urgen', <imi9oara, Rom*nia

?n anul -,++ a fost impelementat n Clinica ;<I a Spitalului Clinic :ude'ean de Urgen' <imi9oara un sistem de raportare
9i monitori&are a infec'iilor intraspitalice9ti, sistem disponiil pe site$ul TTT"raportati"ro" Jucrarea de fa' pre&int
inciden'a 9i etiopatogenia germenilor implica'i n infec'iile de tract respirator n perioada ianuarie $ decemrie -,+-" ;u
fost raportate un numr de H@A culturi po&iti!e la un numr de E@F pacien'i pre&ent*nd infec'ii ale tractului respirator"
?n ordinea frec!en'ei au fost identifica'i urmtorii germeni3 Glesiella sp" 6#" coliBGles sp #SBJ, #" coliBGles sp G)C7 $
+C@ rapoarte 6+A,C.7, ;cinetoacter sp" $ ++A rapoarte 6+F,+.7, )s" aeruginosa $ ++C rapoarte 6+E,C.7, )roteus mirailis
$ ++- rapoarte 6+E,-.7, Stap2" aureus 6MSS;7 $ +,+ rapoarte 6+@,H.7, Stap2" aureus 6MRS;7 $ E@ rapoarte 6H,-.7, #" coli
6#" coliBGles sp #SBJ, #" coliBGles sp G)C7 $ C, rapoarte 6E,C.7, )ro!idencia sp" $ +H rapoarte 6-,@.7, Candida alicans $
A rapoarte 6+,-.7" Sensiilitatea la antiiotice a germenilor a fost urmatoarea3 Glesiella sp"3 Colistin $ +,,.,
Meropenem $ HE,H., Imipenem $ H+,+., Je!oflo(acin $ F,,C., <igecQcline $ ED,E.U ;cinetoacter sp"3 Colistin $ AH,@.,
Rifampin $ FF,H., ;mpicilin$Sulactam $ E,., ;mi4acin $ CF,H., Meropenem $ +C,+., Imipenem $ +-.U )seudomonas
;eruginosa3 ;mi4acin $ +,,., Colistin $ AC,+., <oramQcin $ A-,@., )ipperacilin$<a&oactam $ ED,+., Cefepime $ E@,F.,
Cefta&idime $ E@,+., Imipenem $ E,., Meropenem $ CD,D."

.tarting !ith year %#"", in +ntensive Care Department of Clinical County ,ospital Timi^oara a !eb based system !as
developed for reporting and monitoring the incidence and ethiopathogeny of communitary and nosocomial infections.
This system is available at !!!.raportati.ro. Bet!een 8anuary %#"% and December %#"%, a number of D9: positive
cultures from <9= patients !ith respiratory tract infections !ere reported. .tatistical analisys for these microbiological
results sho!ed the incidence of the follo!ing germs6 >lebsiella sp. 32. coli/>lebs sp 2.B*, 2. coli/>lebs sp >PC4 $ ";9
reports 3":,;&4, 'cinetobacter sp. $ "": rapoarte 3"=,"&4, Ps. aeruginosa $ ""; reports 3"<,;&4, Proteus mirabilis $ ""%
reports 3"<,%&4, .taph. aureus 3M..'4 $ "#" reports 3"9,D&4, .taph. aureus 3M@.'4 $ <9 reports 3D,%&4, 2. coli 32.
coli/>lebs sp 2.B*, 2. coli/>lebs sp >PC4 $ ;# reports 3<,;&4, Providencia sp. $ "D reports 3%,9&4, Candida albicans $ :
reports 3",%&4. 'ntibiotic susceptibility of the multi$drug resistant germs !as6 >lebsiella sp.6 Colistin $ "##&, Meropenem
$ D<,D&, +mipenem $ D","&, *evofloacin $ =#,;&, Tigecycline $ <0,<&K 'cinetobacter sp.6 Colistin $ :D,9&, @ifampin $
==,D&, 'mpicilin$.ulbactam $ <#&, 'mi1acin $ ;=,D&, Tobramycin $ ;<&, Meropenem $ ";,"&, +mipenem $ "%&K
Pseudomonas 'eruginosa6 'mi1acin $ "##&, Colistin $ :;,"&, Tobramycin $ :%,9&, Pipperacilin$Ta-obactam $ <0,"&,
Cefta-idime $ <9,"&, +mipenem $ <#&, Meropenem $ ;0,0&.

Complicaiile utili(rii sistemului .o&alung ?Inter&ention Bung AssistA la pacienii cu AR,' se&er
Complications of Using Govalung .ystem 3+ntervention *ung 'ssist4
C" J" Leamu, %elia Leamu, M" )apuric, %" %rgulescu, =" Bedreag, C" I" Macarie, C" 8asiu,
Carmen Guragata$Balaa, %" Sndesc
Spitalul Clinic :udeean de Urgen, <imi9oara, Rom*nia

Lo!alung 6iJ; Memrane 8entilator7 este un sistem e(tracorporeal arterio$!enos format dintr$o memran special
care re'ine C=- 9i a/ut la munt'irea o(igenrii" #ste o metod nou n tratamentul ;R%S$ului se!er 2ipercapnic,
utili&at pentru prima oar n 'ar n clinica noastr"
Material 9i metod3 Ja un lot de trei pacien'i cu ;R%S se!er 2ipercapnic, seda'i 9i curari&a'i, !entila'i mecanic, s$a
montat sistemul Lo!alung prin punc'ie femural arterio$!enoas prin metoda Seldinger ecog2idat, folosindu$se canule
Lo!aport +@F 9i +E F" Flu(ul sanguin a fost monitori&at cu un sen&or montat pe ramura !enoas a circuituluiU tensiunea
arterial medie fiind sus'inut cu suport !asopresorU toti pacien'ii au primit un olus de 2eparin sodic ini'ial, apoi au
fost trecu'i pe 2eparin continu, cu men'inerea ;)<<$ului n limite terapeutice" Ja un singur ca& s$a nlocuit 2eparina
sodic cu 2eparin frac'ionat 6Cle(ane7, n do&e terapeutice"
Re&ultate3 Ja un pacient a aprut o colmatare precoce a filtrului 6n primele -C de ore7, care a determinat nlocuirea
sistemului" Ja doi pacien'i a aprut un 2ematom arterial ing2inal postpunc'ie la mai mult de 9apte &ile de func'ionare, n
momentul se!ra/ului de pe Lo!alung, n ciuda tratamentului compresi! corect aplicat, 9i a necesitat 2emosta&
c2irurgical" #!olu'ia pacien'ilor a fost fa!orail, cu e(ternarea n condi'ii de siguran'"
Conclu&ii3 Lo!alung este un sistem eficient n tratamentul ;R%S se!er n ciuda complica'iilor aprute" Suprimarea
sistemului Lo!alung treuie efectuat n colaorare cu ec2ipa de C2irurgie 8ascular, pentru o mai un siguran' a
pacien'ilor"
Cu!inte c2eie3 Lo!alungU Lo!aportU colmatareU 2ematom ing2inalU 2eparin"

Govalung 3+*' Membrane )entilator4 is an etracorporeal arterio$venous system, consisting of a special membrane that
retains C5% and helps improve oygenation. +t is a ne! method in the treatment of severe '@D. site hypercapnia, first
used in the country in our clinic.
Material and Method6 +n a batch of three patients !ith severe '@D. hypercapnia, and curari-ants sedated, mechanically
ventilated, Govalung system !as installed by puncture femoral arterio$venous ecoguided .eldinger method using the
tubes Govaport "9A and "< A. Blood flo! !as monitored !ith a sensor mounted on the circuit branch vein, mean blood
pressure !as supported !ith vasopressor support, all patients received an initial bolus of heparin sodium, and then !ere
s!itched to continue heparin maintaining the site 'PTT therapeutic range. +n one case the heparin sodium !as replaced
!ith fractionated heparin 3Cleane4 in therapeutic doses.
@esults6 +n one patient there !as a clogged filter early 3!ithin %; hours4, !hich resulted in the replacement of the
system. T!o patients had a groin hematoma arterial postpunction more than seven days of operation at the time of
!ithdra!al from the Govalung despite treatment properly applied compression, and re(uired surgical hemostasis.
2volution !as favorable for patients !ith safe discharge.
Conclusions6 Govalung is effective in the treatment of severe '@D. despite complications. Govalung suppression system
must be done in collaboration !ith the team of vascular surgery for better patient safety.
>ey !ords6 Govalung, Govaport, !arping, groin hematoma, heparin.

Aplicaii ale utili(rii sistemului .o&alung ?Inter&ention Bung AssistA n managementul insuficienei
respiratorii acuteCAR,'$lui se&er
'pplications of Using Govalung .ystem 3+ntervention *ung 'ssist4 in 'cute *ung Aailure/.evere '@D.
C" J" Leamu, %elia Leamu, M" )apuric, %" %rgulescu, =" Bedreag, C" I" Macarie, C" 8asiu,
Carmen Guragata$Balaa, %" Sndesc
Spitalul Clinic :udeean de Urgen, <imi9oara, Rom*nia

Lo!alung 6iJ; Memrane 8entilator7 este un sistem e(tracorporeal arterio$!enos, [epuratorul e(trapulmonar de C=-1,
format dintr$o memran special care re'ine C=- 9i a/ut la munt'irea o(igenrii" #ste o metod nou n
tratamentul ;R%S$ului se!er 2ipercapnic, utili&at n premier n 'ar n clinica noastr"
Material 9i metod3 Studiu oser!a'ional s$a reali&at pe @ ca&uri clinice internate n Clinica ;<I <imi9oara 6perioada
ianuarie$martie -,+@7, diagnosticate cu insuficien' respiratorie acutB;R%S se!er, cu rapoarte de )a=-BFi=- cuprinse
ntre EE,FF 9i DH,DU dou paciente de se( feminin 9i un pacient de se( masculin, cu !*rste cuprinse ntre -- 9i @@ de ani"
)articularitatea ca&ului3 cele dou paciente erau nsrcinate la care s$a impus opera'ia ce&arian de urgen'" )acien'ii
erau !entila'i mecanic dup protocolul ;R%Snet" Se montea& sistemul arterio$!enos Lo!alung pentru prima dat la noi
n 'ar, n Clinica ;<I <imi9oara, asociat !entila'iei mecanice, a!*nd drept scop ameliorarea clinico$e!oluti! 9i
munt'irea outcome$ului"
Re&ultate3 Mecanismul a fost ine tolerat, dup instalarea Lo!alung s$a putut trece la o !entila'ie mecanic
ultraprotecti!, cu reducerea 8<,Fi=- 9i ulterior la o detuare precoce cu Lo!alung n func'iune" #!olu'ia a fost
fa!orailU to'i pacien'ii au supra!ie'uit"
Conclu&ii3 Lo!alung 6Inter!ention Jung ;ssist7 este o modalitate terapeutic adi'ional cu rol marcant n ameliorarea
parametrilor ga&elor sanguine 6)2, )C=-7 din conte(tul ;R%S$ului se!er 9i implicit cu impact deoseit asupra
supra!ie'uirii"

Govalung 3+*' Membrane )entilator4 is an etracorporeal arterio$venous Petrapulmonary C5% systemP consisting of a
special membrane that retains C5% and helps improve oygenation. +t is a ne! method in the treatment of severe
hypercapnic '@D., used first in the country in our clinic.
Material and Method6 The observational study !as conducted on three clinical cases hospitali-ed in +CU Timi^oara
38anuary $ March %#"94, diagnosed !ith acute respiratory failure/severe '@D. !ith Pa5%/Ai5% ratios bet!een <<.== and
0D.0, t!o female patients and a male patient, aged %% and 99, !ith particularity6 the !omen !ere pregnant
3subse(uently imposed cesarean delivery4. 'rterio$venous system Govalung is put on a patient for the first time in our
country, 'T+ Clinic Timi^oara. Govaport catheters that !ere attached !ere "9A and "< A. +t uses +*' 3Govalung4
associated !ith mechanical ventilation ultraprotective, aiming to improve the clinical course and outcome improvement.
@esults6 The mechanism !as !ell tolerated after installing Govalung could move to a ultraprotective mechanical
ventilation, reducing )T, Ai5% and later to early etubation !ith Govalung still running. 2volution !as favorable, all
patients survived.
Conclusions6 +*' 3Govalung4 is an additional therapeutic modality major role in improving blood gas parameters 3p,,
pC5%4 in the contet of severe '@D. site and thus the impact on survival.
>ey !ords6 Govalung, Govaport, severe '@D., acute respiratory failure.

Faria-ia $'electinei la pacien-ii cu ciro( hepatic +i mane&re in&a(i&e C inter&en-ii chirurgicale interna-i n
'pitalul MAI =rof/ ,/ 2erota>
The )ariation of P$.electin in Cirhotic Patients !ith +nvasive Maneuvres / .urgery 'dmitted in QProf. D.
?erotaR ,ospital
;lida Moise 6+7, Carmen ;rion$Blescu 6+7, Latalia Mincu 6+7, C" <" Guran 6+7, G" Stelea 6+7, <" Bdescu 6+7,
J" Rducan 6+7, ;driana S*rcea 6+7, Felicia Stroe 6-7
6+7 Spital M;I 0)rof" %" Gerota1, Bucure9ti, Rom*nia
6-7 ILS, Bucure9ti, Rom*nia

Scop3 In!estigarea funciei tromocitelor prin )$Selectin la pacienii cu ciro& 2epatic i cu mane!re in!a&i!e admii n
-,,A n spitalul nostru"
Metod3 Un studiu prospecti!, oser!aional cu pacieni admii n spitalul nostru cu ciro& 2epatic, care au a!ut ne!oie
de mane!re in!a&i!e" %up parcurgerea criteriilor de includere pacienii au fost in!estigai conform protocolului de lucru
stailit" Loi am folosit floT$citometria" )roa de s*nge a fost recoltat prin puncie !enoas ferm, atraumatic, fr
garou, cu ac de minimum +FG, pe G@$#%<; ca sustan anticoagulantU transportul imediat la laorator, prelucrarea
proei conform protocolului de determinat )$Selectin" )entru interpretarea statistic s$a creat o a& de date n
Microsoft #(cel -,,@" %atele statistice au fost prelucrate folosind #piInfo soft" %atele e(primate ca medii au fost
comparate cu Studentps t$test 6AE. inter!al de ncredere, pq,",E ni!el de semnircaie7"
Re&ultate3 Cei H, pacieni rmai n studiu, n principal rai, cu !*rsta medie de ED,++>B$++,@C" #(presia )$Selectinei
la pacienii cu ciro& 2epatic i mane!re in!a&i!e e(primat prin prin intensitatea medie a fluorescenei MnI 6>B$ S%7 a
fost ,,EAHA>B$,,HACFD !s -"@A >B$ ,"@,, la control" %up stimularea cu <R;), MnI 6>B$ S%7 a fost H,FEAC>B$@,-CH+D !s
A"DE >B$ @"+DA la control" Corelaia dintre numrul tromocitelor i e(presion )$Selectinei a e!ideniat o relaie po&iti!
puternic n toate grupurile, mai ales la pacien'ii operai"
Conclu&ii3 #(presia )$Selectinei n condiii a&ale, dei mult sc&ut la pacienii cu ciro& 2epatic, crete la !alori medii
relati! apropiate de cele ale grupului martor dup stimularea cu <R;), e(cepie grupul B"

'ims6 To investigate platelet function by P$.electin in patients !ith hepatic cirrhosis !ith invasive maneuvers admitted in
%##: in our hospital.
Material and Method6 ' prospective, observational study, !hich enrolled patients admitted in our hospital !ith hepatic
cirrhosis $ !hich needed an invasive maneuvers associated or not !ith admission in +ntensive Care settings in %##:. 'fter
inclusion criteria, patients !ere investigated according the !or1 protocol. Be used flo!$cytometry. Blood sample for
flo! cytometry $ ta1en by direct atraumatic venous punction !ithout garrot, minimum "=? needle, >9$2DT' as
anticoagulant, !as imediate transport in laboratory, then processed using P$.electine protocol.
Aor statistical interpretation, a database !as created using Microsoft 2cel %##9. .tatistic stratified data processing !as
used 2pi+nfo soft. Data as mean h.D !ere compared using .tudentJs t$test 3:<& confidence interval, level of significance
pl#.#<4.
@esults6 'fter the inclusion criteria, there !ere D# patients, manly male, mean age <0.""7/$"".9;. 2pression of P$
.electin in patients !ith hepatic cirrhosis !ith invasive maneuvers eprimed by mean intensity of fluorescence Mn+ 37/$
.D4 !as #,<:D:7/$#,D:;=0 vs %.9: 7/$ #.9## at control group. 'fter stimulation !ith T@'P, Mn+ 37/$ .D4 !as D,=<:;7/$
9,%;D"0 vs :.0< 7/$ 9."0: at control group. Correlation bet!een number of platelets and epression of P$.electin
revealed strong positive relationship in all groups, stronger in the group !ith surgery. Conclusions6 2pression of P$
.electin in basal conditions, although reduced in patients !ith cirrhosis, increasing to mean values relatively closet o
those of the control group after stimulation !ith T@'P, ecept group !ith liver biopsy.

'indromul <"BB $ O form a preeclampsiei se&ere sau un sindrom nespecific n obstetric!
The ,2**P .yndrome $ ' Aorm of the .evere Preeclampsia or an Unspecific .yndrome of 5bstetricsC
8" Co/ocaru 6+7, 8iorica Copormac 6-7
6+7 Uni!ersitatea de Stat de Medicin i Farmacie 0Licolae <estemianul, C2i9inu, Repulica Moldo!a
6-7 IMS) IMC, C2iinu, Repulica Moldo!a

=iecti!e3 #stimarea factorilor de risc i a complicaiilor sindromului 5#JJ), cu e!aluarea dereglrilor 2emosta&ice i
acido$a&ice"
Material i metod3 ;u fost cercetate EE paciente diagnosticate cu sindromul 5#JJ)" ;u fost studiate datele
anamnestice, clinice 9i paraclinice din carnetele perinatale, fi9ele medicale cu monitori&area3 puls, <;s, <;d, <;m, FCC,
FR, diure& orar"
Re&ultate3 Factori de risc fa!ori&ani3 ostetricali 6primiparitatea, preeclampsia se!er, eclampsia, oala a!orti!
6R)IE,C+@E7, 2emoragiile n na9tere cu 9oc 2emoragic 6R)I-,-FDF77 9i somatici 6asocierea sarcinii cu IR8; 6R)I-,-DAE7,
pielonefrita acut 6R)IE,+C,A7, pneumonia 6R)IF,,HFE77" ?n formele u9oare pre!alea& alcalo&a respiratorie 9i acido&a
metaolic, n cele se!ere$acido& metaolic cu alcalo& respiratorie" Complica'ii3 neurologice 6edem cereral
C-6HF,@FjE,H@.7, sindrom con!ulsi! E6A,,Aj@,DD.77U pulmonare 6;JIB;R%S -F6CH,-HjF,H@.7, tromo& pulmonar
++6-,,,jE,A@.7, pneumonie ilateral A6+F,@FjC,AA.7, atelecta&ii -6@,F@j-,E-.7 9i pleuri&ie @6E,CEj@,,F.77U cardiace
6cardiomiopatie disgra!idic ++6-,,,jE,A@.7, edem pulmonar A6+F,@FjC,AA.7, pericardit e(udati! -6@,F@j-,E-.77U
septice 6endometrit +C6-E,CEjE,DH.7, acese interintestinale H6+-,H@jC,CA.7, peritonit +-6-+,D-jE,EH.7, sepsis
ostetrical +-6-+,D-jE,EH.77U 2emosta&ice 62emoragii intraadominale +E6-H,-HjF,,,.7, 2emoragii uterine
+,6+D,+DjE,-,.7, 2emoragii din plag +C6-E,CEjE,DH.7, aru'ia placentei C6H,-Hj@,E,.7, 2emoragii gastrointestinale
E6A,,Aj@,DD.7, ;8C 2emoragic -6@,F@j-,E-.7, sindromul CI% @,6EC,EEjF,H+.77"
Conclu&ii3 Sindromul 5#JJ) este un sindrom nespecific cu microangiopatie diseminat"
%e!ierile metaolismului acido$a&ic poart caracter polimorf" )erturrile 2emosta&ice s$au manifestat prin
decompensarea ini'ial a mecanismului tromo$parietal, ulterior a mecanismului plasmatic"

The studyJs objective6 2stimating ris1 factors and complications of ,2**P syndrome !ith assessment of acid$base and
hemostasis disorders.
Material and Method6 << investigated patients !ere diagnosed !ith ,2**P syndrome. Bere studied anamnesis, clinical
and laboratory of perinatal records, medical records of the patients. Monitoring included6 heart rate, .BP, DBP, Tam,
ACC, A@, hourly diuresis.
@esults of the study6 @is1 Aactors favoring6 obstetrical 3first pregnancy, severe preeclampsia, eclampsia, abortive disease
3P@E<.;"9<,4, bleeding in hemorrhagic shoc1 birth 3@PE%, :<&4 and somatic 3association of pregnancy !ith a viral or
bacterial infectious pathology 3+@)' 3@PE%.%0:<4, acute pyelonephritis 3@PE<.";#:4, pneumonia 3@PE=.#D=<44. +n mild
forms prevalent respiratory al1alosis and metabolic acidosis, and severe ones $ metabolic acidosis !ith respiratory
al1alosis. Complications6 neurological 3cerebral edema ;%3D=.9=h<.D9&4, convulsions <3:.#:h9.00&44K lung 3'*+ /'@D.
%=3;D.%Dh=.D9&4, pulmonary thrombosis ""3%#.#h<.:9&4, bilateral pneumonia :3"=.9=h;.::&4, atelectasis %39.=9h%,
<%&4 and pleuri-ie 93<.;<h9.#=&44K heart 3cardiomyopathy peripartum "" 3%#.#h<.:9&4, cardiogenic pulmonary edema
:3"=.9=h;.::&4 , eudative pericarditis %39.=9h%.<%&44K septic 3endometritis ";3%<.;<h<.0D&4, interintestinal abscesses,
flegmoane D3"%.D9h;.;:&4 peritonitis "%3%".0%h<.<D&4, obstetric sepsis "%3%".0%h<.<D&4K haemostasis 3abdominal
bleeding "<3%D.%Dh=.##&4, uterine bleeding "#3"0."0h<.%#&4, bleeding from the !ound ";3%<.;<h<.0D&4, abrubtio
placentae ;3D.%Dh9.<#&4, bleeding nose and gums "%3%".0%h<.<D&4, gastrointestinal haemorrhage <3:.#:h9.00&4, acute
hemorrhagic stro1e %39.=9h%.<%&4, D+C syndrome 9#3<;.<<h=.D"&4.
Conclusions6 ,2**P syndrome is a nonspecific syndrome !ith disseminated microangiopathy. Deviations metabolic acid$
base character !earing multiforme. ,emostasis disturbances manifested by initial decompensation thrombo$parietal
mechanism, then the mechanism of plasma.

Prevalence of +mmediate )asovagal @eaction in Blood Donors )isiting Bulgarian Military Blood Ban1
R" )opo!, L" )etro!, 8" 8ase!a
MilitarQ Medical ;cademQ, Sofia, Bulgaria

Bac1ground6 +n order to maintain ade(uate blood supply in the !a1e of increasing demand, ne! blood donors need to
be constantly recruited. 'lthough blood donation is considered safe, there are some inherent ris1s to donors. )oluntary
blood donors normally tolerate blood donation very !ell, but, occasionally adverse donor reactions of variable severity
may occur during or after the end of blood donation.
,aematoma, thrombophlebities and vasovagal reactions 3))@4 are among fe! complications related to blood donation.
' ))@ is a general feeling of discomfort and !ea1ness !ith aniety, di--iness and nausea, !hich may progress to loss of
consciousness. Commonly, there are minor symptoms associated !ith blood donation. ,o!ever, rarely, serious and
severe symptoms li1e loss of consciousness and convulsions or incontinence may occur.
'ccording to the .tandard for surveillance of complications related to blood donation prepared by the +nternational
.ociety of Blood Transfusion and 2uropean ,aemovigilance Get!or1, ))@ are classified as immediate and delayed.
.ymptoms appearing before the donor has left the donation site are termed as immediate ))@ and symptoms
appearing after the donors has left the donation site but !ithin %; h are classified as delayed.
'im6 The recognition and evaluation of so called ))@ during and after !hole blood donation has an operational value for
improving the safety of the donation process. The aim of this study !as to estimate the prevalence of immediate ))@
associated !ith allogeneic !hole blood donations.
Material and Method6 The records of %D;0% allogeneic !hole blood donations !ere assessed for donor reactions. The
rate of ))@ of variable severity !as measured at the collection site. Data regarding the development of only immediate
))@ !as documented. .ymptoms of pallor, s!eating, di--iness and nausea !ithout loss of consciousness !ere referred
as mild reaction and more severe symptoms, such as vomiting and loss of consciousness !ere recorded as moderate
reaction. The donors !ho eperienced convulsions !ere recorded as having had a severe reaction. +n addition to
symptoms, the effect of blood donation on vital parameters li1e pulse rate, blood pressure 3BP4 and respiratory rate !as
also observed. 2vents !ere documented on the blood donation record and captured in a electronic data base.
Demographic and clinical data and development of ))@ in the study participants are presented as descriptive !ith
number and percentages.
@esults6 +mmediate ))@ are easy to observe and do not need follo! up the donors. The present study solicited ))@ from
%D;0% randomly selected !hole blood donors during or !ithin 9# minutes after !hole$blood donation. @esults sho!ed
that overall ;.#0 & of blood donors eperiences immediate systemic complication related to blood donation. The most
common systemic adverse effects !ere mild 39,: &4. +t !as found that moderate adverse reactions !ere #.";& and #.#;
severe. Be then determined the association of age, donation status and collection place !ith the fre(uency of ))@.
,igher reaction rates !ere associated !ith first time donation, donors of younger age and mobile collection place.
Conclusion6 ))@ is the most common type of adverse event related to blood donation. This is the first study conducted in
Bulgaria to estimate the prevalence of immediate ))@ associated !ith blood donation. The incidence of reactions in our
donors is lo!er than in other studies. The possible reason for this is that in the Military Blood Transfusion Center only
physicians are responsible for the selection and care of donors. The presence of trained nurses in the donation room !ho
closely attend the blood donors during and after blood donation play an important role in the preventation of so$called
adverse events. The findings of this study and similar bigger studies across the country !ill serve to identify the
vulnerable groups of population !ho are at increased ris1 of developing ))@ due to blood donation.






Acti&itatea cordonatorului de transplant n 'pitalul Clinic ;ude-ean de 0rgen- Timi+oara
Transplant CoordinatorJs 'ctivity in Clinical County ,ospital Timi^oara
Mi2aela %eac 6+7, Cristina C2iriac 6+7, C" Miu 6+7, C" I" Macarie 6+7, %" Ilincariu 6+7, %" Sndesc 6-7
6+7 Spitalul Clinic :udeean de Urgen, <imi9oara, Rom*nia
6-7 Uni!ersitatea de Medicin i Farmacie 08ictor Bae1, <imioara, Rom*nia

Cea mai important etap a acti!it'ii coordonatorului de transplant este inter!iul cu familia prin care se solicit
acceptul donrii de organe, 'esuturi 9i celule" Inter!iul cu familia este un proces sistematic, a&at pe e!iden'e 9tiin'ifice,
care presupune aordarea familiilor ntr$unul dintre cele mai grele 9i marcante momente din !ia'a lor" ;stfel,
coordonatorul de transplant treuie s fie o persoan cu aptitudini psi2ologice 9i te2nici de comunicare care s i
permit stailirea unei rela'ii cu familia prin folosirea de te2nici narati!e, metafore, lima/ simplu co2erent, ntreri 9i
rspunsuri clare, utili&area comunicrii non$!erale" ?n timpul inter!iului se discut despre moartea cereral, se solicit
consim'm*ntul 9i se e(plic procesul de prele!are 9i transplantare de organe" )entru a pregti inter!iul, coordonatorul
treuie s identifice anterior cau&ele medicale care au condus la deces, istoricul medical, e!olu'ia clinic a pacientului,
precum 9i informa'iile pe care le$a primit familia p*n n acel moment" 8a treui apoi s afle date n legtur cu
structura familiei, cu !i&itele primite 9i rela'ia cu personalul medical"
Ja SC:U <imioara ntre -,+,$-,+- rata de refu& a fost de -E$ @,., cu +C prele!ri n -,+,, +A prele!ri n -,++ i A
prele!ri n -,+-" ?n primul trimestru al anului -,+@ se efectuea& C prele!ri, a!*nd i - refu&uri n oinerea acordului
pentru prele!are" Rata de o'inere a acordului de prele!are depinde n mare msur de gradul de implicare a
coordonatorului n aceast acti!itate i de capacitatea acestuia de a$9i utili&a toate aptitudinile de comunicare 9i
psi2ologice do*ndite"

The most important stage of the activity of the transplantJs coordinator is represented by the intervie! !ith the family,
re(uesting permission to donate organs, tissues and cells. The intervie! is a systematic process based on scientific
evidence that, along !ith the eperience allo!s us to approach the families face to face in one of the hardest moments
of their lives. Thus, the coordinator must be a person !ith psychological s1ills and communication techni(ues that !ill
allo! him to establish a relationship !ith the family by using narrative techni(ues, metaphors, a plain but coherent
language, clear (uestions and ans!ers, also the use of non$verbal communication. Bhile one is tal1ing about brain
death, the consent is re(uired and also the process of procurement and organ transplantation must be eplained. To
prepare for the intervie!, the coordinator must identify the previous medical causes that led to death, medical history,
the patientJs clinical course and the information received so far by the family. +n Timi^oaraJs County ,ospital during
%#"#$%#"% the refusal rate !as %< to 9#&. There had been "; organs and tissues prelevations in %#"#, ": in %#"" and :
in %#"%. +n the first (uarter of the year %#"9, ; organs and tissues prelevations !ere made, together !ith % refusals in
obtaining the consent for the procedure. The rate of the consent obtaining largely depends on the coordinator and his
degree of involvement as much as his ability to use all his communication and psychological s1ills.

Calitatea analge(iei cu "toricoxib &ersus Getoprofen n artroplastia total primar de genunchi
The Nuality of 'nalgesia !ith 2toricoib )ersus >etoprofen in Total Primary >nee 'rthroplasty
Simona Florescu Cionac, ;na Maria Munteanu, %enisa ;nastase
Spital Clinic de =rtopedie Foior, Bucure9ti, Rom*nia

Introducere3 ;cest studiu prospecti! i randomi&at e!aluea& calitatea analge&iei postoperatorii cu #torico(i !ersus
Getoprofen n &iua operaiei i n prima &i postoperator, dup artroplastia total primar de genunc2i"
Material i metod3 )acienii au fost randomi&ai n dou loturi de c*te C, pacieni"
Jotul martor a primit analge&ie postoperatorie ncep*nd de la S8; peste @ cu Getoprofen n do& fi( + f la D ore,
perfalgan n do& fi( + g la D ore i morfin do& de ncrcare ,,+ mgB4g i titrare i"!" p*n la S8; su @" Cei din lotul de
studiu au primit postoperator #torico(i un comprimat de +-, mg precum i )erfalgan i morfin ca i cei din lotul
martor, at*t n &iua operaiei, c*t i n prima &i postoperator" <oi pacienii au primit profila(ie antiemetic cu
=ndansetron" Cei din lotul martor au primit o fiol de Controloc i"!" la prima do& de Getoprofen administrat"
;rtroplastia total primar de genunc2i a fost efectuat su ra2ianeste&ie cu upi!acain ,,E. +,$-,mg" Intraoperator
pacienii au fost sedai cu )ropofol K@ mgB4gBor"
;u fost urmrii urmtorii parametri3 consumul total de morfin n primele -C i CD2 postoperator, efectele secundare i
necesarul de medicaie ad/u!ant i necesarul transfu&ional"
Conclu&ii3 #torico(iul +-, mg p"o" administrat postoperator a redus cantitatea total de morfin folosit comparati! cu
Getoprofenul at*t n &iua operaiei, c*t i n prima &i postoperator, fr creterea necesarului transfu&ional i fr efecte
ad!erse suplimentare n artroplastia de genunc2i"

+ntroduction6 This prospective randomi-ed study evaluates the (uality of postoperative analgesia !ith 2toricoib versus
>etoprofen during the surgery day and in the first postoperative day after the total 1nee arthroplasty.
Material and Method6 The patients have been prospectively randomi-ed in t!o groups, each of one !ith ;# patients.
The control group has received postoperative analgesia beginning !ith .)' over 9 !ith >etoprofen 9# mg/ 0 hours,
Perfalgan " g/ 0 hours and morphine !ith a loading dose #,"mg/1g and intravenous titration until .)' under 9. The
study group has received 2toricoib postoperative, "%# mg p.o., Perfalgan and morphine li1e the control group, for ;0
hours. 'll patients have received anti$emetic prophilay !ith 5ndansetron. The study group also received ;# mg of
Controloc iv.
The primary total 1nee arthroplasty has been performed under spinal anesthesia !ith bupivacaine #,<& "#$%#mg.
Patients have been sedated !ith Propofol F9 mg/1g/hour.
Be monitored the follo!ing parameters6 the amount of consumed morphine in the first %; and ;0 hours postoperative,
the side effects, the adjuvant medication and the transfusion re(uirements.
Conclusions6 2toricoib "%# mg administrated postoperative, reduces the amount of used morphine compared to
>etoprofen both on surgery day and on the first postoperative day !ithout increasing transfusional needs or additional
side effects in total 1nee arthroplasty.
"&aluarea analge(iei cu "toricoxib n artroplastia total primar de genunchi
'ssesment of 'nalgesia !ith 2toricoib 'nalgesia in Total Primary >nee 'rthroplasty
%enisa Mdlina ;nastase, ;na Maria Munteanu, Simona Florescu Cionac
Spitalul Clinic de =rtopedie Foior, Bucure9ti, Rom*nia

Introducere3 Scopul acestui studiu prospecti! randomi&at este de a e!alua eficacitatea analgetic i s*ngerarea
postoperatorie dup administrarea de #torico(i +-, mg pre$ i postoperator dup artroplastia total primar de
genunc2i"
Material i metod3 )acienii au fost randomi&ai n dou loturi de c*te C, pacieni"
Jotul martor a primit analge&ie postoperatorie ncep*nd de la S8; peste @ cu )erfalgan n do& fi( + g la D i Morfin
do& de ncrcare ,,+ mgB4gc i titrare i"!" p*n la S8; su @" Cei din lotul de studiu au primit at*t preoperator c*t i
postoperator un comprimat de +-, mg #torico(i, iar postoperator )erfalgan i morfin ca i cei din lotul martor, at*t n
&iua operaiei, c*t i n prima &i postoperator" <oi pacienii au primit profila(ie antiemetic cu =ndansetron"
;rtroplastia total primar de old a fost efectuat su ra2ianeste&ie cu Bupi!acain ,,E. +,$-,mg n amele loturi"
Intraoperator pacienii au fost sedai cu )ropofol K@mgB4gBor"
#ficacitatea a fost e!aluat prin3 inter!alul de timp de la sf*ritul operaiei p*n la prima do& de analgetic cerut,
consumul total de morfin n primele -C i CD2, efectele secundare i necesarul de medicaie ad/u!ant, necesarul
transfu&ional"
Conclu&ii3 #torico(iul +-, mg p"o" administrat n - do&e, preoperator i postoperator, reduce cantitatea total de
morfin folosit, fr creterea s*ngerrii i fr efecte ad!erse suplimentare n c2irurgia ma/or a genunc2iului"

+ntroduction6 The aim of this study is to evaluate the analgetic effectiveness and postoperative bleeding after the
administration of 2toricoib "%# mg preoperative and postoperative after the total 1nee arthroplasty.
Material and Method6 The patients have been prospective randomi-ed in t!o groups, each one of ;# patients.
The both groups have received postoperative analgesia for .)' over 9 !ith i.v. Perfalgan in fied dose "g every 0 hours
and morphine !ith a loading dose #,"mg/1g and titration until .)' under 9. The study group has received "%# mg
2toricoib pre$ and also postoperatively. Both groups have received Perfalgan and morphine in the first ;0 h. 'll patients
have received anti$emetic prophilay !ith 5ndansetron.
The primary total 1nee arthroplasty has been performed under spinal anesthesia !ith bupivacaine #,<& "#$%#mg. 'll
patients have been sedated !ith Propofol F 9mg/1g/hour.
The effectiveness !as evaluated by6 the time interval from the end of the surgery until the first analgesic dose, the total
amount of consumed morphine in the first %; and ;0 hours postoperative, the side effects and necessary amount of
adjuvant medication and the necessity for transfusion.
Conclusions6 2toricoib "%# mg administrated in t!o doses, preoperative and postoperative, reduces the total amount of
morphine, !ithout any bleeding increase or additional side effects in the major 1nee surgery.

"ficienti(area acti&itii medicului ATI printr$un sistem de telemedicin
5ptimi-ation of the +CU Physician 'ctivity by Telemedicine .ystem
#" <incu 6+7, M" <uriceanu 6-7, ;" Cotrle 6-7, :osep2ine Go2lenerg 6@7
6+7 Spitalul Municipal de Urgen', )aris, Fran'a
6-7 Spitalul Municipal de Urgen', Moineti, Rom*nia
6@7 Institute Mines <elecom, )aris, Fran'a

=iecti!3 #!aluarea eficienti&rii acti!it'ii medicului ;<I n Spitalul Municipal de Urgen' Moine9ti printr$un sistem de
telemedicin"
Material 9i metod3 Studiul prospecti! oser!a'ional efectuat n perioada +E"++"-,+-$+E",-"-,+@ a urmrit
e!enimentele medicale semnalate telefonic de asistentele din <I sau descoperite la accesarea sistemului de
telemedicin de ctre medic"
Re&ultate3 S$au nregistrat -DF e!enimente 6++F 2<;, D- 5<;, -H 5<; 9i tulurri de ritm cardiac, -+ fer, +E com, +F
s*ngerare postoperatorie, A scderea Sp=-7" ?n toate ca&urile a fost necesar accesarea sistemului pentru a transmite
indica'ii diagnostice 9i terapeutice aplicaile imediat, iar n +-D ca&uri a fost necesar deplasarea la spital" ;ccesarea
sistemului de ctre medic a dus la depistarea a altor +H e!enimente, nesemnalate de asistente 6+@ sudeni!elri 9i C
supradeni!elri de segment S<7, toate urmate de indica'ii terapeutice 9i de consult cardiologic, @ fiind nso'ite de
deplasarea la spital"
Conclu&ii3 ;!*nd n !edere c Spitalul Municipal Moine9ti asigur urgen'ele medico$c2irurgicale 9i ostetricale pentru
apro(imati! A,",,, locuitori 9i c dispune de un singur medic ;<I, sistemul de telemedicin a/ut la eficienti&area
acti!it'ii acestuia prin3 capacitatea de e!aluare imediat de la distan' a constantelor monitori&ate n ca&ul
e!enimentelor semnalate, descoperirea precoce a unor e!enimente nesemnalate, recomandarea de msuri terapeutice
imediate 9i e!aluarea necesit'ii deplasrii la spital 9i a gradului de urgen'"

?oal6 2valuation of the activity optimi-ation of +CU physician in Moine^ti 2mergency ,ospital by a telemedicine system.
Material and Method6 Prospective observational study !as performed bet!een "<."".%#"% and "<.#%.%#"9 !hen all
medical events telephonically signaled by +CU nurses or randomly discovered by telemedicine system access !ere
registered.
@esults6 During the study period, %0= events !ere signaled by call 3""= blood hypotension, 0% hypertension, %D
hypertension plus rhythm disturbances, %" fever, "< coma, "= postoperative bleedings, and : decreases in .p5%4. 'll
these events !ere follo!ed by telemedicine system access and therapeutically recommendations. +n "%0 cases the +CU
physician attended the +CU in time. The immediate access of the telemedicine system by the +CU physician resulted in the
discovery of other "D events unnoticed by +CU nurses 3"9 depressions and ; elevation of .T segment4K all follo!ed by
therapeutically recommendations and cardiology consult. +n 9 cases the +CU physician attended immediately the
hospital.
Conclusions6 Ta1ing into account that the Moine^ti 2mergency ,ospital is in charge for all medical, surgical and
obstetrical emergencies in a population of about :#.### inhabitants and that the hospital has a single 'nesthesia and
+ntensive Care physician, the telemedicine system is helpful for the optimi-ation of the +CU physician activity 3the
capacity of remote investigation of monitored parameters in case of telephonically signaled events, by early discovery of
unnoticed events, immediate therapeutically recommendations4.

Autopercepii ale pacienilor pri&ind distresul emoional preoperator
Matilda$Maria ;!ramescu
Institutul Regional de Gastroenterologie 9i 5epatologie 0)rof" %r" =cta!ian Fodor1, Clu/$Lapoca, Rom*nia

Introducere 9i scopul lucrrii3 Jucrarea a a!ut drept scop e!aluarea manifestrilor psi2osomatice ale pacien'ilor n
perioada preoperatorie, precum 9i modalitile de reducere a factorilor de risc inutili"
Material 9i metod3 Jucrarea a fost reali&at pe un nr" de +H, pacien'i supu9i c2irurgiei generale electi!e n cadrul
Institutului Regional de Gastroenterologie 9i 5epatologie [)rof" %r" =cta!ian Fodor1 Clu/$Lapoca" Metoda de cercetare
folosit a fost anc2eta sociologic direct$inter!iul, iar instrumentul folosit$protocolul de inter!iu, cu un numr de -E
ntreri de opinie 9i factuale" )rincipalele teme inter!ie!ate au fost legate de3 temerile legate de opera'ie, acordul scris
pentru opera'ie ca posiil surs de stres, importan'a familiei n influen'area an(iet'ii preoperatorii"
Re&ultate3 Lu s$a oser!at o asociere ntre apartenen'a de gen 9i categoriile de !*rst pri!ind prima reac'ie la aflarea
!e9tii c urmea& o inter!en'ie c2irurgical" Mediul de re&iden', ca 9i conte(t socio$profesional 9i cultural, nu
influen'ea& ma/or reac'ia la au&ul !e9tii c !or fi supu9i unei inter!en'ii c2irurgicale" Li!elul studiilor pacien'ilor se
poate corela cu preocuparea pri!ind posiilele insuccese ale inter!en'iei c2irurgicale" Influen'a familiei este una po&iti!
n general, ea repre&ent*nd un ade!rat generator de stailitate psi2oafecti!" %iscu'ia cu medicul aneste&ist nu
determin o reducere semnificati! a stresului preoperator"
Conclu&ii3 )erioada preoperatorie este marcat de un ni!el de an(ietate crescut al pacien'ilor, at*t pri!ind inter!en'ia
c2irurgical, c*t 9i aneste&ia"
;cest studiu s$a reali&at n cadrul proiectului de masterat )=S%RU F+EHH

Aneste(ia balansat &ersus TIFA $ TCI ?Total IntraFenous Anesthesia$Target Controlled InfusionA la
pacien-ii cu colecistectomie laparoscopic
Balanced 'nesthesia versus T+)' $ TC+ 3Total +ntravenous 'nesthesia$Target Controlled +nfusion4 for Patients
!ith *aparoscopic Cholecystectomy
;nca Cr/eu, Georgeta RelQ Manolescu, %iana <oma, %" Corneci
Spitalul Uni!ersitar de Urgen 0#lias1, Bucure9ti, Rom*nia

Scop3 ;nali&a diferen'elor dintre dous te2nici aneste&ice, aneste&ia generals alansats !ersus <I8;$<CI on c2irurgia
laparoscopics a colecistului"
Material 9i metods3 Studiul s$a desfs9urat on perioada ,+",-$,+",@" -,+@ 9i a inclus un numsr de C, pacien'i care au
primit aneste&ie pentru colecistectomie laparoscopics, randomi&a'i on dous loturi" Jotul ; 6nI-,7 a primit aneste&ie
generals alansats cu Se!oranBFentanQl, iar lotul B 6nI-,7 a primit <I8;$<CI cu )ropofolBRemifentanQl" ;u fost anali&a'i
parametrii 2emodinamici perioperator, timpul de induc'ie 9i tre&ire, e!enimentele ad!erse postoperator 9i costurile"
Re&ultate3 Joturile au fost similare din punct de !edere al !*rstei medii, raportului pe se(e 9i scorului de risc ;S;" ?n lotul
B s$a e!iden'iat o tendin la radicardie 6pI,,,C7 i 2ipotensiune 6pI,,,-7, postinduc'ie care nu s$a men'inut
postoperator" Inciden'a gre'urilor 9i !srssturilor postoperatorii a fost semnificati! mai mics la lotul B 6pI,,,-7, iar
analge&ia cuantificats cu S;8 nu a pre&entat diferen'e ontre loturi" Lu au fost diferen'e semnificati!e on ceea ce pri!e9te
costurile implicate on cele dous te2nici aneste&ice, te2nica <I8;$<CI implictnd costuri de apro(imati! +H@,HF ron, iar
aneste&ia generals alansats u +D+,@A ron"
Conclu&ii3 <e2nica <I8;$<CI asigurs o tre&ire rapids 9i de calitate, fiind recomandats la pacien'ii tineri supu9i unei
inter!en'ii c2irurgicale cu durats medie"

Purpose6 'naly-e differences bet!een t!o anesthetic techni(ues, balanced anesthesia versus T+)'$TC+ for laparoscopic
cholecystectomy.
Material and Method6 The study !as conducted on the period #".#%$#".#9. %#"9 and included a number of ;# patients
!ho received anesthesia for laparoscopic cholecystectomy, randomi-ed bet on t!o lots. ?roup ' 3n E %#4 received
balanced anesthesia !ith .evoran/Aentanyl and group B 3n E %#4 received T+)'$TC+ !ith Propofol/@emifentanyl.
,emodynamic parameters !ere analy-ed perioperative, time induction and a!a1ening, postoperative adverse events
and costs.
@esults6 The groups !ere similar in terms of average age, gender ratio and '.' ris1 score. +n group B sho!ed a tendency
to bradycardia 3p E #.#;4 and hypotension 3p E #.#%4 after induction not maintained postoperatively. The incidence of
P5G) !as significantly lesser in group B 3#.#%4 and analgesia measured !ith )'. did not differ !hile in to!n lots. There
!ere no significant differences regarding costs bet on bet on the t!o anesthetic techni(ues, T+)'$TC+ techni(ue cost
m"D9.D= ron and balanced anesthesia cost m"0".9: ron.
onclusions6 T+)'$TC+ techni(ue ensures a sharp and (uality a!a1ening, as recommended in young patients undergoing
surgery !ith an average time.

Aneste(ia peridural combinat cu aneste(ia general &ersus aneste(ia general la pacienii cu neoplasm
colorectal
Combined 2pidural and ?eneral 'nesthesia versus ?eneral 'nesthesia in Colorectal Cancer Patients
Jia Iulia ;la 6+7, Ioana Gdlean 6+7, Simona ;ng2eloiu 6+7, %" Blag 6+7, <" <at 6+7, Simona Mrgrit 6-7
6+7 Institutul =ncologic 0)rof" %r" I" C2iricu'1, Clu/$Lapoca, Rom*nia
6-7 Uni!ersitatea de Medicin 9i Farmacie 0Iuliu 5a'ieganu1, Catedra ;<I I, Clu/$Lapoca, Rom*nia

Introducere3 Reailitarea rapid postoperatorie dup c2irurgia colorectal este unul dintre de&ideratele c2irurgiei
moderne 9i este influen'at de te2nicile de aneste&ie 9i analge&ie utili&ate"
=iecti!e3 Scopul studiului este de a compara dou metode de aneste&ie 9i analge&ie utili&ate pentru inter!en'iile
c2irurgicale electi!e la pacien'ii cu neoplasm colorectal, 9i de a e!alua efectele fiecreia dintre metode asupra e!olu'iei
postoperatorii, n primele CD de ore"
Material 9i metod3 Studiul prospecti! a fost efectuat pe dou loturi de c*te +D pacien'i cu neoplasm colorectal interna'i
n Institutul =ncologic [)rof" %r" I" C2iricu'1" )rimul lot 6)G7 a eneficiat de aneste&ie general cominat cu peridural,
urmat de analge&ie peridural, iar al doilea lot 6G7 a primit aneste&ie general, urmat de analge&ie i"!"
Re&ultate3 %o&ele de FentanQl administrate intraoperator au fost mai mici pentru lotul )G 6,,+j,,,Emg7 comparati! cu
lotul G 6,,+Ej,,,Amg7" Lecesarul suplimentar de morfin n prima or postoperator a fost mai redus pentru lotul )G
6-,+Fj@,-Hmg7 fa' de lotul G6F,E-j-,D@mg7" <ran&itul intestinal a fost reluat n primele -C de ore la E,. dintre pacien'ii
din lotul )G fa' de nici un pacient din lotul G" ?n primele -C de ore postoperatorii, pacien'ii din lotul )G nu au pre&entat
gre'uri 9i !rsturi comparati! cu lotul G unde acestea au fost pre&ente la @,+H. dintre pacien'i"
Conclu&ii3 ;neste&ia peridural cominat cu aneste&ia general, urmat de analge&ia peridural ofer un control mai
eficient al durerii 9i o recuperare postoperatorie mai rapid"
;c4noTledgement3 Studiu a fost efectuat n cadrul proiectului )=S%RUBF+EHH"

+ntroduction6 @apid postoperative rehabilitation after colorectal surgery is one of the goals of modern surgery and is
influenced by anesthesia and analgesia techni(ues used.
5bjectives6 The aim of this study is to compare t!o different methods of anesthesia and analgesia used for elective
surgery in patients !ith colorectal cancer and to compare postoperative recovery in the first ;0 hours postoperatively.
Material and Method6 The prospective study !as conducted on t!o groups of "0 patients !ith colorectal cancer
admitted in the PProf. Dr. +. Chiricun_P +nstitute. The first group 3P?4 received general anesthesia combined !ith epidural
anesthesia, follo!ed by postoperative epidural analgesia, and the second group 3?4 received general anesthesia
follo!ed by +) multimodal analgesia.
@esults6 The dose of Aentanyl administered intraoperatively !as lo!er for P? group 3#." h #.#< mg4 than in group ?
3#."< h #.#: mg4. 'dditional re(uirement of morphine in the first hour after surgery !as lo!er for P? group 3%."= h 9.%D
mg4 compared to group ? 3=.<% h %.09 mg4. Bo!el movement into the first %; hours !as resumed in <#& of patients in
group P? compared !ith no patients in group ?. Postoperative nausea and vomiting into the first %; postoperative
hours !ere present in 9."D& of patients in group ? compared !ith no patients in group P?.
Conclusions6 ?eneral anesthesia combined !ith epidural anesthesia and analgesia provides a better control of
postoperative pain and a faster recovery compared !ith general anesthesia and +) analgesia.
'c1no!ledgement6 This study !as conducted !ithin the P5.D@U/="<DD project.

Impactul ni&elului de pregtire asupra calitii meninerii aneste(iei/ Corelaii ntre monitori(area
profun(imii aneste(iei %i ni&elul de experien al personalului medical aneste(ic/ Rolul asistentei de
aneste(ie
The +mpact of the *evel of Training on the Nuality of 'nesthesia. Correlations Bet!een the Monitoring of
'nesthesia Depth and the 'nesthesia .taff *evel of 2perience. The @ole of the 'nesthesia Gurse
#ri4a$#ni4o Balla, %aniela Ionescu
Institutul Regional de Gastroenterologie 9i 5epatologie 0)rof" %r" =cta!ian Fodor1, Clu/$Lapoca, Rom*nia

Bac4ground3 Scopul studiului nostru a fost de a anali&a n ce msur aneste&istul re&ident de an IB IIB mpreun cu
asistenta de aneste&ie sunt suficient de instrui'i pentru a putea men'ine o profun&ime adec!at a aneste&iei n asen'a
temporar a aneste&istului senior, 9i de a a!ea o imagine mai corect despre cuno9tin'ele pe care le au re&iden'ii de
aneste&ie despre BIS"
Material 9i metod3 Studiul a inclus +,, de pacien'i interna'i 9i opera'i n Institutul Regional de Gastroenterologie 9i
5epatologie 1)rof" %r" =cta!ian Fodor1, Clu/$ Lapoca, n perioada + feruarie -,+- $ @+ mai -,+-" ;ce9ti pacien'i au fost
ale9i aleator, astfel nc*t s poat fi pus n e!iden', c*t mai fidel, impactul ni!elului de pregtire 9i e(perien'a
personalului medical aneste&ic asupra calit'ii men'inerii aneste&iei"
)rotocolul de studiu a presupus o sec!en de monitori&are BIS intraaneste&ic, n asena unui stimul c2irurgical
puternic, pe o durat de @, minute i la peste @, de minute de la ultima modificare a concentraiei de agent in2alator
iBsau administrare de opioid"
Inter!eniile c2irurgicale au fost toate de c2irurgie adominal pentru a a!ea apro(imati! acelai grad de stimulare
c2irurgical" %up consemnarea datelor n protocolul de studiu s$a cerut medicului re&ident ;<I completareaB rspunsul
la ntreri pe tema profun&imii aneste&iei"
Re&ultate3 8aloarea mediei a indicelui BIS e(primat n !aloare asolut pentru cei +,, de pacien'i este de@AjH cu IC
6@H,CC$ C,,@,7 cu !aloarea minim inregistrat -+ 9i cea ma(im de F,"
Media !alorilor BIS pentru ca&urile asistate de medicii aneste&iti seniori a fost de C,,-@, spre deoseire de media
!alorilor BIS la ca&urile asistate de medicii aneste&iti /uniori 6@H,F,7, pI,"HD" %in totalul de +C re&ideni c2estionai, A
adic FC. au rspuns afirmati! ntrerii, iar E 6@F.7 nu au tiut ce repre&int BIS" %efiniia apro(imati! corect a BIS$
ului a fost dat de ctre @ 6-+.7 medici re&ideni, restul de ++ 6HA.7 au dat o definiie incorect sau nu au tiut definiia
BIS$ului" %in totalul re&idenilor inter!ie!ai C@. 6F re&ideni7 au tiut !alorile normale ale BIS pentru o aneste&ie
suficient de profund, iar EH. 6D re&ideni7 nu au tiut" HA. din medicii re&ideni inter!ie!ai nu au citit studii despre
importana BIS$ului ns, -+. au pre&entat pe scurt un studiu"
Conclu&ii3 ?n studiul nostru !alorile medii ale BIS nu au diferit semnificati! atunci c*nd medicii re&iden'i au rmas singuri
cu pacientul comparati! cu cele nregisrate n ca&ul seniorilor aneste&i9ti" Cu toate acestea semnificati! de mul'i
re&iden'i nu au cunoscut !alorile BIS pentru o profun&ime adec!at a aneste&iei 9i nici detalii legate de monitori&area
BIS" %in acest punct de !edere cursurile dedicate 9i informarea teoretic sunt asolut necesare, cu at*t mai mult cu c*t
aneste&ia insuficient de profund 6aTareness$ul7 c*t 9i cea prea profund pot afecta e!olu'ia postoperatorie pe termen
lung a pacientului"
;c4noTledgement3 Studiul a fost efectuat n cadrul programului )=S%RU$F+EHH"
Referin'e3
+" )rQs Roerts C" ;naest2esia3 ; practical or impractical constructV Br : ;naest2 +ADHU ++3+@C+$+@CE"
-" Flais2on R, Jang #, Seel #" Monitoring t2e ade^uacQ of intra!enous anaest2esia" In3S2ite )F"<e(t ooc4 of
intra!enous anaest2esia, Silliam and Sil4ins, Baltimore, +AAHUECE$EFC"
@" Ionescu %, Berteanu C, Copotoiu S et al" ;neste&ia totala intra!enoas, cap" D" Monitori&area profun&imii aneste&iei,
#d ;cademic )res Clu/$Lapoca -,,HU -F,$-EH"

Bac1ground6 The purpose of our study !as to assess the degree in !hich the "
st
/%
nd
year junior anesthetist and the
anesthesia nurse are able to provide a sufficient depth of anesthesia in the absence of the senior anesthetist and to
obtain a better perspective on the 1no!ledge of the junior anesthetist on B+..
Material and Method6 The study included "## patients admitted in QProf. Dr. 5ctavian AodorR @egional +nstitute of
?astroenterology and ,epatology Cluj$Gapoca bet!een Aebruary "
st
%#"% and May 9"
st
%#"%. The patient !ere selected
randomly, so that !e could emphasi-e as accurate as possible the impact of level of training and anesthetic personnelJs
eperience on the (uality of anesthesia.
The studyJs protocol assumed an intra$anesthetic B+. monitoring se(uence, in the absence of significant surgical stimuli,
over a 9# minutes time frame and after ;< minutes since the last change in the inhalation agentJs concentration and/or
opioid administration.
'll the surgical procedures !ere abdominal in order to provide the same level of surgical stimulation. 'fter the input of
the data in the study protocol, the junior anesthetists !ere as1ed to provide ans!ers regarding the anesthesia depth.
@esults6 The median of the B+.Js absolute value for the "## patients !as 9:hD !ith a C+ 39D,;; T ;#,9#4, !ith the lo!est
recorded value of %" and the highest of =#. The median of the B+. value for the patients !here there !as a senior
attending the surgery !as ;#,%9, as opposed to the median of the junior anesthetist !ich !as 9D.=#, pE#.D0. 5ut of the
"; juniors that ans!ered the (uestionnaire, : 3=;&4 provideded an accurate ans!er, !hile < 39=&4 did not 1no! !hat
B+. !as. ' some!hat accurate deffinition of B+. !as provided by 9 juniors 3%"&4, the other "" 3D:&4 either provided an
inaccurate deffinition or did not 1no! the deffinition of B+.. 5ut of the total responders, ;9& 3= juniors4 1ne! the B+.
correct values for an efficient anesthesia, the other <D& 304 did not. D:& of the intervie!ed juniors did not read studies
about the relevance of B+., %"& of them !ere able to provide a short description of a study.
Conclusions6 *ectures on the subject of anesthesia depth monitoring should become mandatory for both anaesthesia
juniors and nurses.

"fectele acidului tranexamic asupra s1ngerrii postoperatorii n chirurgia cardiac la pacienii coronarieni
operai On ump
2ffects of Traneamic 'cid on Postoperative Bleeding 'fter Coronary 'rtery Bypass ?rafting !ith
Cardiopulmonary Bypass
Melinda Si4lodi 6+7, %aniela Ionescu 6-7, ;ntonela %iana Murean 6+7, Sanda Maria Legruiu 6+7, Stanca Simona ;s&alos
6+7, Juminia #ugenia Slau 6+7, Jucia Geserii 6+7, ;" Wtef 6+7
6+7 Institutul Inimii de Urgen' pentru Boli Cardio!asculare 0Liculae Stncioiu1, %epartamentul ;<I, Clu/$Lapoca,
Rom*nia
6-7 Uni!ersitatea de Medicin 9i Farmacie 0Iuliu 5aieganu1, Clu/$Lapoca, Rom*nia

=iectul studiului3 S*ngerarea i ne!oia de transfu&ii alogene repre&int nc proleme dup Qpass aortocoronarian
6B;C7 cu circula'ie e(tracorporal 6C#C7" ;dministrarea ;cidului trane(amic 6;<7 intraoperator este asociat cu
reducerea 2emoragiei postoperatorii dup B;C"
Material 9i metod3 Studiul retrospecti! 6septemrie -,+- $ feruarie -,+@7 a e!aluat efectele ;< administrat la
pacienii tratai cu aspirin p*n la -C2 nainte de inter!enia c2irurgical programat" %up aproarea Comisiei de
etic, F, pacieni supui B;C cu C#C au fost randomi&a'i n trei grupuri egale 6nI-, 73 grupul + a primit ;< -E mg B 4g
olus i! lent dup inducerea aneste&iei i dup administrarea de protamin, grupul - a primit ;< -E mgB4g olus i! lent
dup protamin i grupul @ de control nu a primit ;<" %rena/ul postoperator a fost e!aluat la F,+-,-C ore" <ransfu&iile de
produse sang!ine au fost nregistrate postoperator p*n la e(ternare" 8alorile 5, 5t, incidena reinter!en'iilor
c2irurgicale postoperatorii pentru controlul 2emosta&ei i durata ederii n unitatea de terapie intensi! 6;<I7 au fost 9i
ele e!aluate"
Re&ultate3 Utili&area intraoperatorie a ;< 6gr"+Ugr" -7 reduce semnificati! s*ngerarea la F2 6p+ K o,oo+7 9i necesarul
postoperator de me si comparati! cu pacien'ii din grupul control" ; e(istat o singur reinter!en'ie control"
Conclu&ii3 ;cidul trane(amic reduce s*ngerarea postoperatorie n B;C cu C#C la pacienii tratai cu aspirin p*n la -C2
anterior inter!eniei c2irurgicale"

Bac1ground6 Bleeding and the need for allogenic transfusions are still problems after coronary artery bypass grafting
3C'B?4 !ith cardiopulmonary bypass 3CPB4. 'dministration of traneamic acid 3T'4 during surgery is associated !ith
reduced postoperative bleeding after C'B?.
Material and Method6 The retrospective study 35ctober %#"% $ Aebruary %#"94 evaluated the effects of T' administered
to patients treated !ith aspirin %; hours before the planned surgery. =# patients undergoing C'B? !ith CPB !ere
randomi-ed into three e(ual groups 3nE%#46 group " received T' %< mg/1g as a slo! bolus injection after anesthesia
induction and after protamine administration, group % received T' %<mg/1g as a slo! bolus injection after protamine
and control group 9 did not receive T'. The postoperative blood loss !as recorded at =, "%, %; hours. Transfusions of
blood products !ere recorded during the !hole hospital stay after surgery. ,b and ,t parameters, the incidence of
postoperative surgical reeplorations for haemostasis control and the duration of stay in the +CU !ere also evaluated.
@esults6 +ntraoperative use of T' 3?r."K ?r.%4 significantly reduces the postoperative blood loss registered after = hours
3p" F o,oo"4.
Conclusions6 T' reduces postoperative bleeding in C'B? !ith CPB in case of patients treated !ith aspirin %; hours before
surgery.

,exameta(ona $ ,o(a unic la inducia aneste(iei generale scade incidena greurilor %i &rsturilor n
chirurgia laparosopic
Deamethasone $ .ingle Dose before +nduction of 'nesthesia Decreases the +ncidence of P5G) in
*aparoscopic .urgery
Ioana Belciu, %aniela G2encea, ;nca Rotaru, %aniela Miru, ;nca 5anganu, Gariela Listor
Spitalul Municipal de Urgen', Moineti, Rom*nia

=iecti!3 Inciden'a gre'urilor 9i !rsturilor n c2irurgia laparoscopic este uneori crescut, put*nd duce la prelungirea
duratei de spitali&are 9i scderea gradului de satisfac'ie a pacientului operat" Studiul urmre9te eficien'a administrrii
do&ei unice de de(ameta&on n induc'ia aneste&iei generale, pentru pre!enirea gre'urilor 9i !rsturilor la pacien'ii
supu9i c2irurgiei laparoscopice"
Material 9i metod3 ;u fost selecta'i +,, de pacien'i cu ;S; I $ II supu9i unor inter!en'ii c2irurgicale laparoscopice
adominale" )acien'ii au fost mpr'i'i aleator n dou grupuri de studiu" Grupul ; de E, pacien'i a primit %e(ameta&on
D mg la induc'ia aneste&iei generale" Grupul B 6placeo7 de E, pacien'i a primit solu'ie salin ,,A." )ostaneste&ic,
pacien'ii au fost supra!eg2ea'i n sec'ia de <erapie Intensi!, urmrindu$se inciden'a episoadelor de gre'uri 9i !rsturi
la inter!al de @, F, +- 9i -C ore"
Re&ultate3 )e durata celor -C 2, grea'a a fost pre&ent la un numr de CBE, 6D.7 din pacien'ii ce au primit
%e(ameta&on 9i la ABE, 6+D.7 din pacien'ii care au primit solu'ie salin ,,A." ?n aceea9i perioad de timp, !oma a
aprut la +BE, 6-.7 pacien'i din grupul ; 9i la CBE, 6D.7 pacien'i din grupul B" %urerea postoperatorie la repaus 9i la
moili&are a fost u9or redus la pacien'ii care au primit %e(ameta&on"
Conclu&ii3 Se consider eficient administrarea preaneste&ic a do&ei unice de D mg %e(ameta&on nu numai din punct
de !edere clinic 6n scderea semnificati! a inciden'ei greturilor 9i !rsturilor7, c*t 9i din punct de !edere economic"

5bjective6 The incidence of P5G) is high after laparoscopic surgery !hich !ould cause the delay in hospital discharge
and decreases the patient satisfaction. The study aims to prove that the administration of single dose Deamethasone
before induction of anesthesia prevents P5G) in patients undergoing laparoscopic surgery. Material and Method6 '
total of one hundred '.' class +$++ patients undergoing laparoscopic surgery !ere randomly divided into % groups of <#
each. ?roup ' received Deamethasone 0 mg and group B received placebo saline #,:&. Postanesthetic, the patients
!ere assessed on +CU for episods of nausea and vomiting at intervals of #$9, =, "% and %; h. @esults6 During the first %; h,
nausea occurred in ;/<# 30&4 patients receiving Deamethasone and :/<# 3"0&4patients receiving placebo saline #,:&.
The pain at rest and the pain on movement !as lo!er in patients !ho received Deamethasone.
Conclusions6 +tJs considered that the administration of preanesthetic single dose of Deamethasone is effective for
clinical reasons 3significant decrease of P5G) incidence4 and for economic considerations.

'trategii de recuperare precoce postoperatorie $ rotocol "RA'/
Rolul asistentului de terapie intensi&
.trategies for 2arly Postoperative @ehabilitation $ 2@'. Protocol. The @ole of the +ntensive Care Gurse
Ionela Ctlina Butu9neac 6+7, ;" C" Bu' 6+7, )aula ;nca Blaga 6+7, Ioana Grigora9 6-7
6+7 Institutul Regional de =ncologie, Iai, Rom*nia
6-7 Uni!ersitatea de Medicin 9i Farmacie 0Gr" <" )opa1, Iai, Rom*nia

=iecti!3 Identificarea parametrilor influen'aili prin acti!itatea asistentei de terapie intensi! pri!ind recuperarea
precoce postoperatorie 9i gradul de implementare actual a acestor parametri"
Material 9i metod3 ;nali& de sugrup n cadrul unui studiu prospecti! oser!a'ional desf9urat n IR= Ia9i ncep*nd cu
+",-"-,+@, ce a nrolat consecuti! to'i pacien'ii complian'i cu criteriile de includereBe(cludere" S$a fcut identificarea
factorilor influen'aili de ctre asistenta de terapie intensi! 9i au fost e(trase date despre ace9tia din a&a de date a
studiului"
Re&ultate3 ;u fost identifica'i factori influen'aili de ctre asistenta de terapie intensi!3 ilan'ul 2idric postoperator,
calitatea analge&iei, cateterul peridural, sonda na&o$gastric postoperatorie, moili&area 9i nutri'ia precoce
postoperatorie" %in cei HF pacien'i inclu9i n a&a de date, gradul de implementare a acestor msuri a !ariat ntre H,D.
6F pacien'i $ analge&ia peridural postoperatorie7 9i AH. 6HC pacien'i $ asen'a sondei na&o$gastrice postoperatorii7"
Conclu&ii3 ;sistenta de terapie intensi! are un rol important n implementarea strategiilor #R;S n perioada
postoperatorie cu scopul de a gri recuperarea pacientului c2irurgical" %atele studiului nostru indic necesitatea
munt'irii aplicrii acestor strategii, mai ales pri!ind calitatea analge&iei, moili&area 9i nutri'ia precoce"

?oal6 +dentification of 2@'. strategies, !hich may be influenced by the intensive care nurse regarding early
postoperative recovery and their level of application.
Material and Method6 .ubgroup analysis part of a prospective observational study conducted in +@5 +a^i starting !ith
".#%.%#"9., !hich enrolled all consecutive patients compliant !ith inclusion/eclusion criteria. The identification of
factors, !hich may be influenced by intensive care nurse !as performed and data !ere etracted from the study
database.
@esults6 +dentified factors, !hich may be influenced by the intensive care nurse, !ere6 !ater and electrolyte balance,
proper postoperative analgesia, epidural catheter, postoperative naso$gastric tube, early postoperative mobili-ation and
nutrition. The implementation !ithin the study group 3D= patients4 varied bet!een D,0& 3= patients $ postoperative
epidural analgesia4 and :D& 3D; patients $ absence of the postoperative naso$gastric tube4.
Conclusions6 The intensive care nurse has an important role in the 2@'. strategies implementation for the postoperative
period in order to enhance the recovery of the surgical patient. The results of our study indicate the need for better
application of these strategies, mainly appropriate postoperative analgesia and early mobili-ation and nutrition.

Rolul asistentei de aneste(ie n implementarea protocolului "RA' n IRO Ia%i/ Anali( de subgrup
The @ole of 'nesthesia Gurse in the +mplementation of 2@'. .trategies. ' .ubgroup 'nalysis
;lina Roma9canu 6+7, Magda Costac2e 6+7, Gariela Melinte 6+7, Maria Ursu 6+7, Ioana Grigora9 6-7
6+7 Institutul Regional de =ncologie, Iai, Rom*nia
6-7 Uni!ersitatea de Medicin 9i Farmacie 0Gr" <" )opa1, Iai, Rom*nia

=iecti!3 Identificarea parametrilor influen'aili prin acti!itatea asistentei de aneste&ie 9i gradul de implementare
actual a acestor parametri"
Material 9i metod3 ;nali& de sugrup n cadrul unui studiu prospecti! oser!a'ional desf9urat n IR= Ia9i ncep*nd cu
+",-"-,+@, ce a nrolat consecuti! to'i pacien'ii complian'i cu criteriile de includereBe(cludere" S$a fcut identificarea
factorilor influen'aili de ctre asistenta de aneste&ie 9i au fost e(trase date despre ace9tia din a&a de date a studiului"
Re&ultate3 ;u fost identifica'i factori influen'aili de ctre asistenta de aneste&ie3 postul preoperator pentru lic2ide 9i
solide, utura dulce preoperatorie, ilan'ul 2idric intraoperator, normotermia intraoperatorie, calitatea analge&iei,
cateterul peridural, sonda na&o$gastric intraoperator" %in cei HF pacien'i inclu9i n a&a de date, gradul de
implementare a acestor msuri a !ariat ntre F,E. 6E pacien'i $ postul pentru solide KD ore7 9i A@. 6H+ pacien'i $
normotermia intraoperatorie7"
Conclu&ii3 ;sistenta de aneste&ie are un rol important n implementarea strategiilor #R;S3 n cadrul ec2ipei de aneste&ie
pentru perioada intraoperatorie, dar 9i pentru instruirea pacientului pri!ind conduita preoperatorie" %atele studiului
nostru arat implementarea e(trem de inegal a unor strategii 9i necesitatea unor politici coerente de promo!are a lor"

?oal6 +dentification of 2@'. strategies, !hich may be influenced by the anesthesia nurse activity and their level of
application.
Material and Method6 .ubgroup analysis part of a prospective observational study conducted in +@5 +a^i starting !ith
".#%.%#"9., !hich enrolled all consecutive patients compliant !ith inclusion/eclusion criteria. The identification of
factors, !hich may be influenced by anesthesia nurse !as performed and data !ere etracted from the study database.
@esults6 +dentified factors, !hich may be influenced by the anesthesia nurse, !ere6 preoperative solid and li(uid food
fasting, preoperative carbohydrate drin1, intraoperative volume therapy, intraoperative normothermia, proper
intraoperative analgesia, epidural catheter, naso$gastric tube. The implementation !ithin the study group 3D= patients4
varied bet!een "=,<& 3< patients $ preoperative solid food fasting less than 0 hours4 and :9& 3D" patients $
intraoperative normothermia4.
Conclusions6 The anesthesia nurse has an important role in the 2@'. strategies implementation, both for the
intraoperative period as a part of the anesthesia team, and for the preoperative period regarding the patient education
for the preoperative conduct. The results of our study indicate the uneven implementation of 2@'. strategies and
mandates for a coordinated educational policies.

Influena meloterapiei asupra unor parametri fi(iologici %i asupra intensitii durerii n perioada
postoperatorie imediat/ 'tudiu pilot
The +nfluence of Melotherapy on .ome Physiological Parameters and on Pain .everity During the +mediate
Postoperative Period. Pilot .tudy
;na Maria )ostu 6+7, Gra&iela Biter 6-7, #lena Bosnceanu 6+7, Licoleta Ionescu 6+7, 8ioleta Sc2ipor 6+7,
Ioana Grigora9 6-7
6+7 Institutul Regional de =ncologie, Iai, Rom*nia
6-7 Uni!ersitatea de Medicin 9i Farmacie 0Gr" <" )opa1, Iai, Rom*nia

=iecti!3 #!aluarea influen'ei stimulrii auditi!e asupra unor parametri fi&iologici 9i asupra intensit'ii durerii n
perioada postoperatorie imediat"
Material 9i metod3 Studiu prospecti! controlat randomi&at desf9urat n IR= Ia9i n perioada +",-$-,",@"-,+@, care a
inclus to'i pacien'ii consecuti!i programa'i pentru inter!en'ii de c2irurgie ma/or oncologic, complian'i cu criteriile de
includereBe(cludere" )acien'ii au fost aloca'i aleator n C grupe3 + $ c9ti cu mu&ic clasic, - $ c9ti cu sunete din natur,
@ $ c9ti pentru i&olarea fonic, C $ fr c9ti" ;plicarea c9tilor s$a fcut pentru @, minute la cel pu'in D ore de la sf*r9itul
inter!en'iei n &iua opera'iei, la un scor al durerii de vC" Lu s$au administrat analgetice n cursul procedurii" )arametrii
nregistra'i nainte de, la sf*r9itul 9i la @, minute dup procedur au fost3 <;, frec!en'a cardiac 9i respiratorie, Sp=- 9i
scorul durerii"
Re&ultate3 D, pacien'i au fost randomi&a'i n grupuri egale" )reprocedural grupurile sunt comparaile din punct de
!edere al constantelor fi&iologice 9i al scorului durerii 6scor mediu grup +,-,@,C3 -,D, -,FE, @,+E respecti! -,D7" Ja sf*r9itul
procedurii se constat !aria'ia nesemnificati! a constantelor fi&iologice n toate grupurile, !aria'ia nesemnificati! a
scorului durerii n grupul control, dar scderea semnificati! 6pK,",E7 a scorului durerii la grupele +,-,@ 6-,+E, -,
respecti! -,E7"
Conclu&ii3 Meloterapia 9i sunetele din natur nu influen'ea& constantele fi&iologice, dar scad semnificati! scorul durerii,
efect c2iar mai pronun'at la @, minute postprocedural"

?oal6 2valuation of auditory stimulation effects on some physiological parameters and on pain severity during the
imediate postoperative period.
Material and Method6 Prospective controlled randomi-ed study in +@5 +a^i bet!een ".#%$%#.#9.%#"9, including all
consecutive patients scheduled for major oncologic surgery compliant !ith inclusion/eclusion criteria. Patients !ere
randomly alocated in ; groups6 " $ headphones !ith classical music, % $ headphones !ith nature sounds, 9 $ headphones
for phonic isolation, ; $ !ithout headphones. The headphones !ere applied for 9# minutes in the day of the surgery at
least 0 hours postoanesthesia at a pain score j;. Go analgetics !ere given during the procedure. The follo!ing
parameters !ere registered before, at the end and at 9# minutes after the procedure6 BP, cardiac and respiratory rate,
.p5% and pain score.
@esults6 0# patients !ere included 3%# in each group4. Before the procedure groups !ere comparable regarding the
physiological parameters and the pain scores 3average pain score group ",%,9,;6 %,0, %,=<, 9,"< respective %,04. 't the
end of the procedure there !ere no significant differences regarding the physiological parameters !ithin all groups,
regarding average pain score !ithin control group, but a significant difference 3pF#.#<4 regarding average pain scores
!ithin groups ",%,9 3%,"<, %, respective %,<4.
Conclusions6 Melotherapy and nature sounds result in no effect on the recorded physiological parameters, but in a
significant decrease in pain scores, a more pronounced effect at 9# minutes postprocedure.

Cercetri de mar*eting educaional pri&ind ne&oia de formare profesional %i speciali(are a asistenilor
medicali n domeniul aneste(ieiD terapiei intensi&e +i a medicinei de urgen
Mar1eting @esearch on the 2ducational and Training Geeds of Gurses .peciali-ing in 'nesthesia, +ntensive
Care and 2mergency Medicine
Felicia 8alerica Rcean 6+7, Ji!ia 8inc&e 6-7, Cristina Bor&an 6-7, %aniela Ionescu 6@7
6+7 Spitalul Clinic de Urgen pentru Copii, Clu/$Lapoca, Rom*nia
6-7 Uni!ersitatea de Medicin 9i Farmacie 0Iuliu 5aieganu1, Catedra de Sntate )ulic 9i Management,
Clu/$Lapoca, Rom*nia
6@7 Uni!ersitatea de Medicin 9i Farmacie 0Iuliu 5aieganu1, Catedra ;"<"I" I, Clu/$Lapoca, Rom*nia

Masteratele profesionale pentru asistenii medicali sunt o ofert educaional curent n SU;, Canada" ?n Uniunea
#uropean aceast ofert s$a de&!oltat odat cu procesul Bologna 9i este nc n curs de de&!oltare n numeroase ri
europene" Uni!ersitatea de Medicin 9i Farmacie 1Iuliu 5aieganu1, Clu/$Lapoca, este prima uni!ersitate din Rom*nia
care a iniiat masterate de tip profesional pentru asistenii medicali liceniai"
;!*nd n !edere ne!oia de personal medical calificat la standarde europene n 'ara noastr, am considerat necesar
testarea opiniei pri!ind oportunitatea nfiinrii i utilitatea practic a masteratelor profesionale pentru asistenii
medicali"
Material i metod3 Ca instrument de lucru am folosit c2estionare originale, cu rspunsuri preformulate, dar i ntreri
desc2ise, aplicate n -,+- la trei categorii de actori implica'i 9i afecta'i de Reforma ser!iciilor de sntate 9i de cea din
sistemul de n!'m*nt rom*nesc3 asisten'i medicali anga/a'i n sec'ii de ;<I i U)UU studen'i de an terminal ai Facult'ii
de ;MJ 9i directori de ngri/iriBasisten'i 9efi de spitale clinice din /udeul Clu/"
%atele au fost prelucrate prin metode matematico$statistice, utili&*nd programul S)SS !ersiunea +"F" %at fiind tipul
datelor nregistrate prin c2estionare 6calitati!e, nominale7 am folosit testul neparametric, Mann$S2itneQ 6U7"
Re&ultate3 +,,. dintre anga/atori, HF,A-. dintre studenii 9i H+,AE. dintre asistenii medicali c2estionai, confirm
utilitatea continurii studiilor post$licen' printr$un masterat profesional"
%in totalul rspunsurilor -,,-F. situea& specialitatea <erapie Intensi! n rangul I, urmat n rangul II de Medicina de
Urgen cu o pondere de +D,AH., iar rangul III, cu o pondere de +@,,D. este deinut de ;neste&ie, ca specialit'i n care
e(ist o ne!oie resim'it de formare profesional"
Conclu&ii3 ;nc2eta de opinie reali&at prin participarea asisten'ilor medicali anga/a'i n sec'ii de ;neste&ie, <erapie
Intensi! 9i Medicin de Urgen', rele! ne!oia resim'it 9i e(primat de nfiin'are a masteratelor profesionale
destinate asisten'ilor medicali licen'ia'i"
<oi directorii de ngri/iri participan'i la studiu au considerat util continuarea studiilor post licen printr$un masterat
profesional, at*t pentru actualii asisteni medicali, c*t i pentru actualii studeni ai Facultii de ;MJ"
Referin'e3
2ttp3BBTTT"aacn"nc2e"eduBeducation$resourcesBmsn$articleB
2ttp3BBTTT"e2esp"frBformationBformations$diplomantesBmaster$sciences$clini^ues$infirmieresB
;c4noTledgement3 ;cest studiu a fost reali&at n cadrul ursei de studii pentru masterat oinut n cadrul proiectului
)=S%RUBDF$+"-$S$F+EHH


Optimi(area administrrii medicaiei n TI prin msuri organi(atorice
5ptimi-ation of Medication 'dministration in +CU by 5rgani-ational Measures
%aniela Boanc 6+7, Jumini'a )opeanu 6+7, Ionela <r*' 6+7, M" Melinte 6+7, Ioana Grigora9 6-7
6+7 Institutul Regional de =ncologie, Iai, Rom*nia
6-7 Uni!ersitatea de Medicin i Farmacie, Ia9i, Rom*nia

=iecti!3 #!aluarea msurilor organi&atorice n <I care duc la optimi&area administrrii medica'iei"
Material 9i metod3 Studiu oser!a'ional, care a dus la identificarea msurilor organi&atorice aplicate n <I din IR= Ia9i ce
duc la optimi&area administrrii medica'iei comparati! cu sistemul u&ual"
Re&ultate3 )rincipalele msuri identificate sunt utili&area de rutin la to'i pacien'ii a infu&omatelor 9i in/ectomatelor,
aparat de medica'ie 9i seruri n fiecare salon 9i pe sec'ie cu apro!i&ionarea ntregii medica'ii recomandate din aceste
surse, ceea ce duce la aplicarea imediat a tratamentului recomandat, fr a a9tepta elierarea medica'iei de la
farmacia spitalului, utili&area condicii electronice de medica'ie"
Conclu&ii3 Msuri organi&atorice simple pot duce la eficienti&area administrrii medica'iei n <I cu un dulu eneficiu3
pentru pacient, care prime9te tratamentul administrat optim 9i fr nt*r&iere 9i pentru asistentul medical, care 9i
organi&ea& mai u9or munca 9i c*9tig timp pentru alte sarcini"

?oal6 2valuation of organi-ational measures in +CU, !hich lead to optimi-ation of drug administration.
Material and Method6 5bservational study, !hich identified the organi-ational measures applied in +CU +@5 +a^i resulting
in optimi-ation of medication administration in comparison !ith the usual system.
@esults6 The main identified measures are6 the routine use infusion pumps and syringes in all patients, medication and
solution stores in each +CU !ard and a central store in +CU 3mini$pharmacy4 !ith immediate drug supply from these
sources, !ithout the delay resulting from hospital pharmacy supply, electronic 3paperless4 drug order.
Conclusions6 .imple organi-ational measures can lead to optimi-ation of medication administration in +CU !ith a double
benefit6 for the patient, !hich receives the recommended treatment in an optimal manner and !ithout delay, and for
the +CU nurse, !hich may easier organi-e the !or1 and save time for other tas1s.

Corela-ia ntre comunicare +i gradul de satisfac-ie al anga3a-ilor dintr$o 'ec-ie de Aneste(ie$Terapie
Intensi&
Correlations bet!een Communication and Personnel .atisfaction in an 'nesthesia and +ntensive Care Unit
Jumini'a )opeanu 6+7, Ro(ana )ostolic 6+7, Iaco #lena 6+7, Ioana Grigora9 6-7
6+7 Institutul Regional de =ncologie, Ia9i, Rom*nia
6-7 Uni!ersitatea de Medicin i Farmacie, Ia9i, Rom*nia

=iecti!3 In!estigarea modului n care comunicarea pe !ertical i pe ori&ontal se reflect n gradul de satisfacie al
anga/ailor dintr$o sectie <I"
Material 9i metod3 Studiu prospecti! oser!a'ional care are la a& rspunsurile anga/ailor Seciei ;<I IR= Ia9i la
C2estionarul de satisfac'ie a anga/atului 6c2estionar reali&at pe a&a indicaiilor C=L;S7, completat de tot personalul din
institut n perioada -A",+$+E",-"-,+@" #!aluarea i interpretarea rspunsurilor a fost fcut centrali&at de Ser!iciul de
Management al Calitii din institut" S$a reali&at distriuia re&ultatelor, anali&a statistic a fiecrei ntreri, n functie
de !*rst, mediul de pro!enien i de studii" S$au corelat rspunsurile la ntrerile pri!ind comunicarea cu cele pri!ind
gradul de satisfacie"
Re&ultate3 EA c2estionare completate de toate categoriile profesionale la ni!elul seciei dintr$un total de HF anga/ai"
Comunicarea pe !ertical a fost considerat corespun&toare de CH responden'i 6HA,F.7, iar cea pe ori&ontal foarte
un de @@ respondeni 6EF.7" Colaorarea pe !ertical generea& rspunsul mul'umit -H 6CE,H.7 i foarte mul'umit la
-D6CH,E.7" Colaorarea pe ori&ontal este apreciat de CH 6HA,F.7 ca fiind gu!ernat de colegialitate"
Conclu&ii3 Comunicarea pe !ertical i pe ori&ontal se reflect po&iti! n gradul ridicat de satisfacie a personalului din
secia noastr" C2estionarul a permis identificarea direciilor de muntire a acti!itii curente, pe a&a rspunsurilor
i a sugestiilor personalului"

?oal6 'ssessment of the influence, !hich vertical and hori-ontal communication has on personnel satisfaction in an
'nesthesia and +ntensive Care Unit.
Material and Method6 Prospective observational study includes the responses of 'nesthesia and +ntensive Care Unit
personnel in @egional +nstitute of 5ncology +a^i to Personnel .atisfaction Nuestionnaire 3relying on C5G'. indications4,
!hich !as completed by all institute personnel bet!een %:.#"$"<.#%.%#"9. The evaluation and interpretation of
responses !as performed by the Nuality Management Unit of +@5 +a^i. 'nalysis of responses ta1ing into account age,
gender, studies !as done. @esponses to (uestions regarding communication !ere analysed in correlation !ith
satisfaction degree.
@esults6 5ut of D=, <: (uestionnaires !ere completed by all 1ind of personnel of 'T+ Unit. The vertical communication
!as considered QsatisfactoryR by ;D responders 3D:,=&4, and the hori-ontal one Qvery goodR by 99 responders 3<=&4. The
vertical collaboration results in the ans!er QsatisfiedR in %D 3;<,D&4 and Qvery satisfiedQ in %0 persons 3;D,<&4. The
hori-ontal collaboration is appreciated by ;D responders 3D:,=&4 as governed by collegiality.
Conclusions6 The vertical and hori-ontal communication results in a high degree of personnel satisfaction in our unit. The
(uestionnaire is helpful in identifying measures !hich should be ta1en in order to improve the current practice relying on
responses and suggestions.

Compliana personalului medical de terapie intensi& la msurile de pre&enire a infeciilor no(ocomiale
?igiena m1inilorA
+ntensive Care Unit Medical Personnel Compliance to Measures Preventing ,ospital$'c(uired +nfections
3,and ,ygiene4
8iorica Ledelcu, Maria Ser2ei, Jiliana Bucur, Ioana %aniela Badea, %aniela Buc, Cristina Florentina Ciuc 6+7, Mi2aela
)odrscu, M" Juc2ian, %aniela Filipescu, %aniela Ionescu
Institutul de Urgen' pentru Boli Cardio!asculare 0)rof" %r" C"C" Iliescu1, Bucure9ti, Rom*nia

Introducere3 Infec'iile no&ocomiale repre&int o amenin'are ma/or asupra siguran'ei pacien'ilor, iar igiena m*inilor
6IM7 constituie cea mai important msur pentru pre!enirea 9i controlul acestor complica'ii"
Scopul studiului este e!aluarea practicii de IM la personalul medical de <erapie Intensi! 6<I7 nainte 9i dup inter!en'ia
de munt'ire a complian'ei"
Material 9i metod3 Studiul oser!a'ional, prospecti!, n dou sec'ii de <I, cu o durat de +- luni, a fost parte a unui
studiu interna'ional multicentric )R=5IBI<" ;u fost reali&ate sesiuni randomi&ate de oser!a'ii asupra
comportamentului de IM" Inter!en'ia a constat n educa'ie$training, monitori&are 9i feedac4"
Re&ultate3 Li!elul a&al al complian'ei a pre&entat ni!eluri diferite n cele - sec'ii 6CA. n ;<I$; 9i FD. n ;<I$B7U
complian'a dup inter!en'ie a crescut n amele sec'ii 6E@. n ;<I$; 9i D,. n ;<I$B7, semnificati! statistic doar pentru
;<I$B 6pI,",,@7" Jegat de categoria profesional, cre9terea a fost semnificati! statistic doar pentru infirmiere
6pI,",@+7" ?n func'ie de metoda de IM, a fost oser!at o cre9tere semnificati! a folosirii solu'iei alcoolice n amele
sec'ii 6pI,",,+ pentru ;<I$; 9i pK,",,,E pentru ;<I$B7" ?n ceea ce pri!e9te complian'a n func'ie de tipul mane!rei,
diferen'e semnificati!e au fost identificate doar la ni!elul sec'iei ;<I$B, pentru indica'iile3 0nainte de ngri/irea
pacientului1 6pI,",,A7, 0nainte de efectuarea unei mane!re aseptice1 6pI,",-+7 9i 0dup contactul cu suprafe'ele din
/urul pacientului1 6pI,",+E7"
Conclu&ii3 Inter!en'ia modific po&iti! rata complian'ei" ;ccesiilitatea crescut, utili&area solu'iilor alcoolice,
monitori&area permanent 9i educa'ia periodic pot duce la munt'irea complian'ei la IM"
;ceast lucrare este reali&at n cadrul proiectului )=S%RU F+EHH"

+ntroduction6 ,ospital$ac(uired infections are a major threat on patient safety and hand hygiene 3,,4 is the most
important measure for preventing and controlling of these complications.
The purpose of this study is to evaluate intensive care unit 3+CU4 medical personnel ,, practice before and after the
intervention for improvement of compliance.
Material and Method6 This prospective, observational study !as carried in t!o +CUs and lasted "% months and !as part
of an international multicenter trial $ P@5,+B+T. The monitoring !as done by random observational sessions on ,,
practice. The intervention consisted in training, monitoring and feedbac1.
@esults6 The base level of compliance !as different in the t!o departments 3;:& in +CU$', =0& in +CU$B4K the post$
intervention compliance !as higher in both +CUs 3<9& vs 0#&4, but !ith statistical significance only for +CU$B 3pE #.##94.
@elated to professional category, the increase !as statistically significant only for auiliary staff 3pE #.#9"4. @egarding
the ,, method, a significant improvement in alcohol solution cleansing !as observed in both +CUs 3pE #.##" for +CU$',
pF #.###< for +CU$B4. 's for compliance by maneuver type, there !ere significant differences only in +CU$B, for the
categories Qbefore patient nursingR 3pE #.##:4, Qbefore doing an aseptic procedureR 3pE #.#%"4 and Rafter contact !ith
surfaces surrounding the patientR 3pE #.#"<4.
Conclusions6 The intervention improved compliance rate. @aised accessibility, using alcoholic solutions, permanent
monitoring and regular staff training can lead to a better ,, compliance.
Gote6 This !or1 !as done in the programme .5P,@D ="<DD.
rofilaxia infec-iilor de cateter &enos central
Prophylais of Central )enous Catheter +nfections
#lena Iaco 6+7, %aniela Boanc 6+7, Jumini'a )opeanu 6+7, Ioana Grigora 6-7
6+7 Institutul Regional de =ncologie, Ia9i, Rom*nia
6-7 Uni!ersitatea de Medicin i Farmacie, Ia9i, Rom*nia

=iecti!3 #!aluarea suiecti! a aplicrii msurilor de profila(ie a infec'iilor de cateter !enos central 6IC8C7 9i e!aluarea
oiecti! a eficien'ei acestora prin numrul de culturi po&iti!e de C8C 9i IC8C"
Material 9i metod3 Studiu retrospecti!, care a inclus date pri!ind C8C 6olna!i cu C8C, &ile de C8C, C8C culti!ate, C8C
po&iti!e, infec'ii de C8C7, e(trase din a&a de date computeri&at a spitalului pri!ind perioada +",H"-,+- $ @+"+-"-,+-"
Concomitent a fost apreciat suiecti! aplicarea politicilor de profila(ie a IC8C" Re&ultate3 %in -H msuri de profila(ie a
IC8C au fost ndeplinite n totalitate +D 9i par'ial alte A" ?n perioada studiat din +-FH pacien'i interna'i n <I +@F au a!ut
C8C cu o medie de F &ile C8CBpacient, FF C8C au fost culti!ate, din care ++ po&iti!e" IC8C 6E ca&uri7 au fost cau&ate de
stafilococi 6@ ca&uri7, Streptoccocus !iridans 6+ ca&7 9i Glesiella pneumonie 6+ ca&7"
Conclu&ii3 ;plicarea par'ial a unor msuri de profila(ie a IC8C a dus la o rat de po&iti!are de +,F+B+,, &ile C8C 9i un
numr de E ca&uri IC8C, re&ultat departe de oiecti!ul nostru 0&ero infec'ii de cateter !enos central1"

?oal6 The subjective evaluation of prophylais strategies of central venous catheter infection 3C)C+4 and the objective
evaluation of their efficiency by the number of positive C)C cultures C)C+.
Material and Method6 @etrospective study including C)C parameters 3number of patients !ith C)C, C)C days, cultured
C)C, positive C)C, C)C+4 etracted from hospital database regarding the period bet!een ".#D.%#"%$9"."%.%#"%.
Concomitantly the subjective evaluation of application of C)C+ prophylais !as performed.
@esults6 5ut of %D strategies of C)C+ prophylais "0 !ere fully and : partially applied. 5ut of "%=D patients admitted to
+CU in the study period, "9= had C)C !ith a mean of =daysC)C/patient, == C)C !ere cultured and "" !ere positive. C)C+
3< cases4 !ere caused by staphyloccoci 39 cases4, .treptoccocus viridans 3" case4 and >lebsiella pneumonia 3" case4.
Conclusions6 The partial completion of some C)C+ prophylais strategies resulted in a positive culture rate of
".="/"##days C)C and a number of < cases C)C+, results !hich are far a!ay from out target6 Q-ero central venous
catheter infectionsR.

#actori de eroare n trasabilitatea probelor biologice
2rror Aactors in the Traceability of Biological .amples
C" Catur 6+7, C" Faraon 6+7, I" Baicanu 6+7, Ioana Grigora9 6-7
6+7 Institutul Regional de =ncologie, Ia9i, Rom*nia
6-7 Uni!ersitatea de Medicin i Farmacie, Ia9i, Rom*nia

=iecti!3 #!aluarea factorilor de eroare n trasailitatea proelor iologice recoltate n <erapie Intensi!" Material 9i
metod3 Studiul identific factorii de eroare n trasailitatea proelor iologice din momentul recoltrii 9i p*n n
momentul inregistrrii la laorator comparati! ntre sistemul u&ual 9i sistemul care utli&ea& codul de are"
Re&ultate3 )rincipalii factori de eroare ai sistemului u&ual sunt notarea incompletBincorect a datelor de identificare a
pacientului pe recipient 9i pe uletinul de solicitare a anali&elor, riscul de erori la pacien'ii cu acela9i nume, scris ili&iil,
deteriorarea etic2etei, erori n cursul copierii datelor de identificare a pacientului sau proei n calculatorul
laoratorului" Sistemul cu cod de are elimin n mare msur ace9ti factori de eroare" Conclu&ii3 Sistemul de cod de
are utili&at n trasailitatea proelor iologice elimin ma/oritatea factorilor de eroare" Rm*ne totu9i pre&ent riscul de
eroare uman"

?oal6 2valuation of error factors in the traceability of biological samples obtained in an +ntensive Care Unit. Material and
Method6 The study identifies error factors in the traceability of biological samples from the moment of harvesting until
the moment of registration in the laboratory computer comparing the usual system !ith the bar code system.
@esults6 The main error factors of the usual system are incomplete/!rong !riting of patient /sample identification data,
error ris1 in case of patients !ith identical names, unreadable hand!riting, tag deterioration, errors during
patient/sample data registration in the laboratory computer. The bar code system eliminates almost all error factors.
Conclusions6 The bar code system results in a better tracealibily of biological samples by elimination of majority of error
factors. The human error still persists.


'elecia de s1nge compatibil la pacienii politransfu(ai/ Importana testrii prin micrometod
.election of Compatible Blood for Poly$Transfused Patients. @ole of the Micromethod in Compatibility Testing
Mi2aela Gaidur 6+7, Jumini'a )opeanu 6+7, Ro(ana Stoica 6+7, Ctlina Manea 6+7, Ioana Grigora 6-7
6+7 Institutul Regional de =ncologie, Ia9i, Rom*nia
6-7 Uni!ersitatea de Medicin i Farmacie, Ia9i, Rom*nia

=iecti!3 #!aluarea metodelor de determinare a compatiilit'ii sanguine cu scopul selectrii unit'ilor de s*nge pentru
pacien'ii politransfu&a'i"
Material 9i metod3 Studiu retrospecti! desf9urat n Institutul Regional de =ncologie Iai pe F luni 6+",H$@+"+-"-,+-7 cu
e(tragerea din a&a de date a Unit'ii de <ransfu&ie Sanguin a numrului de unit'i de s*nge transfu&ate 6US<7, de
pacien'i transfu&a'i 9i de e!enimente transfu&ionale" Metodele de testare a compatiilit'ii au fost3 te2nica de
compatiilitate direct :eanreau 6la -- 9i @Hgrade cu papain7 9i te2nica prin micrometod cu cartele I% 6coloan cu gel
$ test salin, test en&imatic, test Cooms indirect7"
Re&ultate3 S$au identificat +FDH unit'i de s*nge administrate la un numr de CEC pacien'i, dintre care @-@
politransfu&ai 6H+.7" Micrometoda a fost utili&at pentru CD- US<, n ++- ca&uri pentru re&ultate inconcludente la
metoda :eanreau" S$au nregistrat F e!enimente posttransfu&ionale 6frison, fer, erup'ie cutanat, icter7"
Conclu&ii3 Frec!en'a mare a pacien'ilor politransfu&a'i 6H+.7 impune msuri de precau'ie luate pretransfu&ional n
func'ie de patologia pacientului 9i de istoricul transfu&ional al acestuia" Micrometoda de determinare a compatiilit'ii
reali&ea& o selecie a s*ngelui cu fenotip identic 9i este considerat cea mai important component de securitate
pentru depistarea anticorpilor iregulari" ?n acest mod putem pre!eni imuni&area pacien'ilor 9i reducerea reac'iilor
ad!erse 2emolitice transfu&ionale"

?oal6 2valuation of the compatibility testing methods !ith the purpose of selecting compatible blood units for poly$
transfused patients.
Material and Method6 @etrospective study conducted at The @egional +nstitute of 5ncology using the Blood Transfusion
Unit database for a = months period 3".#D$9"."%.%#"%4, from !hich !e etracted the number of transfused blood units
3TBU4, of transfused patients and of transfusion events. The used compatibility testing methods !ere6 8eanbreau direct
compatibility method 3at %% and 9D degrees !ith papain4 and the micromethod using +D cards 3gel column $ saline test,
en-yme test, indirect Coombs test4.
@esults6 "=0D blood units !ere administered to ;<; patients, out of !hich 9%9 !ere repeatedly transfused 3D"&4. The
micromethod !as used for testing ;0% TBU, out of !hich ""% TBU due to inconclusive results of the 8eanbreau method.
There !as a number of = postransfusion events 3shivering, fever, cutaneous eruption, jaundice4.
Conclusions6 The high rate of poly$transfused patients 3D"&4 enforces the strategy to ta1e pretransfusion preventive
measures according to patientJs pathology and blood transfusion history. The micromethod for compatibility testing
enables an optimal selection of compatible blood 3the same phenotype4 and is considered to be the most secure strategy
in the process of blood screening for irregular antibodies, avoiding patient immuni-ation and hemolytic adverse effects.

Asistentul medical $ Coordonator de transplant
Medical Gurse 's Transplant Coordinator
%" Ilincariu 6+7, ;na Bena 6+7, Ro(ana ;!ram 6+7, C" I" Macarie 6+7, Corina Georgescu 6+7, %" %rgulescu 6+7,
%" Sndesc 6-7
6+7 Spitalul Clinic :udeean de Urgen, <imioara, Rom*nia
6-7 Uni!ersitatea de Medicin i Farmacie 08ictor Bae1, <imioara, Rom*nia

#(ist o mare discrepan' ntre numrul mare de pacien'i afla'i pe listele de a9teptare 9i numrul insuficient de organe
disponiile" Lumrul donatorilor este determinat de numero9i factori, unul dintre ace9tia fiind acti!itatea
coordonatorului de transplant" ;pari'ia =MS +-CFB-,+@ aduce clarificrile legislati!e n ceea ce pri!e9te acti!itatea
coordonatorilor de transplant" ;cesta poate fi de profesie asistent medical 9i !a ndeplini urmtoarele atriu'ii3
detectea& 9i identific poten'ialii donatori afla'i n moarte cereralU discut cu familiile acestora n !ederea o'inerii
acordului pri!ind prele!area de organe, 'esuturi 9i celule n scopul transplantriiU !erific completarea corect a
formularului de declarare a mor'ii cererale a donatorului, a fielor de prele!areU contactea& medicul legist n !ederea
o'inerii autori&a'iei medico$legale" ?nainte de apariia =rdinului +-CF, n Rom*nia acti!au - asisteni medicali n aceast
po&iie, actualmente aceasta fiind ocupat de +- asisteni medicali" Ja Spitalul :udeean <imioara n anul -,+, au fost
declarai -- pacieni n moarte cereral cu +C prele!ri efectuate, n anul -,++ din -E pacien'i declara'i n moarte
cereral la +A s$au efectuat prele!ri de organe i esuturi, iar n anul -,+- din +D pacieni doar la nou au fost
efectuate astfel de inter!enii" ;cti!itatea de coordonare este deoseit de comple( 9i necesit o pregtire foarte
atent 9i o de&!oltare a calit'ilor medicale, cuno9tin'elor legislati!e 9i inteligen'ei emo'ionale" Re&ultatul final al
acti!it'ii coordonatorului de transplant depinde de capacitatea sa de a se adapta unor situa'ii deoseite 9i se traduce n
numrul de pacien'i declara'i n moarte cereral de la care se !or efectua prele!ri de organe"

The shortage of organs for transplantation results in a large discrepancy bet!een the large number of patients on the
!aiting lists and the lac1 of available organs. The number of organ donors is determined by many factors, one of them
being the transplant coordinator. 'ppearance of 5M. "%;=/%#"9 brings the legislative clarification regarding the
activity of transplant coordinators. The transplant coordinator can be a medical assistant and he !ill perform the
follo!ing duties6 detecting and identifying potential brain$dead donors, discussing !ith their families to obtain the
agreement on organ, tissues and cells removal for transplantationK verifying the correct completing of the declaration of
brain death donor together !ith the sampling records, contacting the coroner to obtain the Qauthori-ation forensicR.
Before the 5rder "%;=, in @omania, there !ere t!o medical assistants in the position of transplant coordinatorsK this
position is no! occupied by "% medical assistants. +n Timi^oara Clinical 2mergency ,ospital during the period of %#"#,
there !ere %% patients declared brain dead, !ith "; prelevations performed on. 'lso, during %#"", from %< patients
declared brain dead on ": !ere performed prelevations and in %#"% from "0 patients only nine had this intervention
being performed on. Coordination activity is comple and re(uires careful preparation and development of medical
(ualities, 1no!ledge and emotional intelligence. The final result of the activity of transplant coordinator depends on his
capacity to adapt to special circumstances and reflects into the number of patients declared brain dead on !ho organ
prelevations !ill be performed.

Rolul *inetoterapiei n Heaningul de pe &entilator la pacien-ii diagnostica-i cu AR,' de etiologie &iral
?A<4.4A
The @ole of Physical Therapy in Mechanically )entilation Beaning at the Patient Diagnosed !ith )iral
3',"G"4 '@D.
=" Ju4acs, Jorena Jamu, =" Bedreag, M" )apuric, %" Sndesc
Spitalul Clinic :udeean de Urgen, Uni!ersitatea de Medicin i Farmacie 08ictor Bae1, <imi9oara, Rom*nia

Introducere3 Se!ra/ul de pe !entilator al pacientului critic cu ;R%S de etiologie !iral 6;5+L+7 implic, pe l*ng
inter!en'iile terapeutice specifice 6tratamentul cu antiiotice al infeciei respiratorii, di!erse moduri !entilatorii,
tratament patogeneticBsimptomatic7, diferite te2nici de 4inetoterapie respiratorie, asigur*ndu$se o aordare
multimodal"
Scopul lucrrii3 #!aluarea impactului te2nicilor de 4inetoterapie respiratorie asupra se!ra/ului de pe !entilaia mecanic
a pacienilor cu sistemul ino!ator Lo!alung\ 6plm*n artificial7, din Clinica ;"<"I" a Spitalului Clinic :udeean de Urgen
<imioara"
Material 9i metod3 ;u fost selecta'i pacien'ii diagnosticai cu ;R%S de etiologie !iral 6;5+L+7 din Clinica ;<I, intua'i
orotra2eal, !entilai mecanic, a!*nd instalat dispo&iti!ul ino!ator Lo!alung\ la care au fost ndeplinite condi'iile de
ncepere a Teaningului de pe !entilator" S$au aplicat te2nici de 4inetoterapie respiratorie 6tapota/, !ira'ii toracice,
posturri pentru drena/ ron9ic, prone position, posturare n 2amac, posturare n scaun rulant i un alt sistem ino!ator
Coug2 ;ssist7, urmrindu$se eficien'a acestora prin e!aluarea succesului Teaningului 6pacientul rm*ne e(tuat c-C de
ore7"
Re&ultateBConclu&ii3 ;plicarea te2nicilor de 4inetoterapie respiratorie facilitea& Teaningul de pe !entilator, cresc*nd
astfel rata succesului"
Cu!inte c2eie3 !entilaie mecanic, se!ra/, 4inetoterapie, Lo!alung\, Coug2 ;ssist

+ntroduction6 PatientZs !ithdra!al from the mechanical ventilation in critically ill patients !ith '@D. involves, besides
specific therapeutic interventions 3antibiotic treatment of respiratory infections, various ventilatory modes, pathogenetic
treatment/symptomatic4, different respiratory physiotherapy techni(ues, ensuring a multimodal approach.
'im of the study6 2valuation of the respiratory physiotherapy techni(ues impact on !eaning from mechanical ventilation
of patients !ith the innovative Govalung 3artificial lung4 from 'T+ Clinic of the Timi^oara County 2mergency ,ospital.
Material and Method6 Be selected patients diagnosed !ith '@D., viral ethiology 3',"G"4, mechanically ventilated, in
!hich G5)'*UG? device !as used. Be applied techni(ues of respiratory physiotherapy 3beats, vibration chest posture
bronchial drainage, prone position, posture in hammoc1 posture in a !heelchair and other innovative Cough 'ssist4,
pursuing their effectiveness by assessing !eaning success 3patient remain etubateda %; hours4.
@esults and Conclusions6 'pplication of respiratory physiotherapy techni(ues hastens !eaning from the ventilator,
increasing the success rate by 1eeping patients etubated ata %; hours.
>ey!ords6 mechanical ventilation !ithdra!al therapy, Govalung, Cough 'ssist

.ursingul nou nscutului +i sugarului operat %i &entilat mecanic
Gursing Care for the Ge!born and +nfant, 5perated and Mechanically )entilated
Florentina %aniela <urcu, Mariana Ioana Liculici, Rodica Bdei
Spitalul Clinic de Urgen 0Jouis wurcanu1, Clinica de C2irurgie 9i =rtopedie )ediatric, <imioara, Rom*nia

Material 9i metod3 S$a efectuat o anali& retrospecti! pe un lot de -E copii internai n Clinica de C2irurgie i
=rtopedie )ediatric, Compartimentul ;<I din <imioara, n perioada ianuarie -,+- $ ianuarie -,+@" )acienii, cu !*rsta
medie de + lun, au fost supui inter!eniei c2irurgicale pentru urmtoarele afeciuni3 malformaii tu digesti! F,.,
2ernie diafragmatic +F., enterocolit ulceronecrotic D., oclu&ie intestinal D., peritonit neonatal i 2ernie
ing2ino$scrotal C." 8entilaia mecanic 68M7 con!enional s$a aplicat la DD. din ca&uri, la D. s$a impus con!ersia la
5F=8 datorit 2ipo(emiei refractare, iar la C. 5F=8 a fost prima opiune" Manoperele efectuate la pacienii !entilai au
constat n aspiraiiBla!a/ tra2eal, prele!ri acteriologice, aerosoloterapie, 4inetoterapie i te2nici specifice de ngri/ire a
olna!ului c2irurgical"
Re&ultate3 %urata medie a !entilaiei mecanice a fost de F,DD &ile" )acienii care au necesitat suport !entilator
postoperator KCDore au eneficiat de moduri asistate 6SIM8,)S,C);)7" Modurile controlate 6<C)J, )R8C, )C, 8C7 au fost
utili&ate la ca&urile cu !entilaie cAFore" %in E pacieni septici, C au pre&entat infecie pulmonar secundar !entilaiei
mecanice, confirmat prin do!e&i acteriologice i imagistice" Ja - pacieni !entilai n 5F=8 au e(istat complicaii
const*nd n pneumotorace respecti! pneumoperitoneu" %in D pacieni decedai, @ nu au a!ut soluie c2irurgical !iail"
Factorii de risc asociai infeciei pulmonare la pacientul 8M au fost3 malformaii asociate, prematuritate i greutate mic
la natere, reinter!enii datorate complicaiilor aprute, manopere in!a&i!e i mane!re de nursing"
Conclu&ii3 )acientul cu !*rsta su un an, cu afeciune c2irurgical i tare asociate, care necesit 8M este !ulnerail la
infecia pulmonar, fapt care impune creterea standardului profesional al personalului"

5bjective6 The improvement of nursing procedures for infants !ho re(uired surgical intervention and mechanical
ventilation.
Material and Method6 ' retrospective analysis !as conducted on a sample of %< infants hospitali-ed in the Clinic of
Pediatric .urgery and 5rthopedics, the 'T+ Department of Timi^oara, from 8anuary %#"% to 8anuary %#"9. Patients !ith
an average of " month, under!ent surgery for the follo!ing conditions6 =#& digestive tube defects, diaphragmatic
hernia "=&, 0& necroti-ing ulcerative enterocolitis, 0& intestinal obstruction, scrotal inguinal hernia and neonatal
peritonitis ;& each. Conventional mechanical ventilation 3)M4 !as applied in 00& of cases, 0& re(uired conversion to
,A5) due to refractory hypoemia, and for ;& ,A5) !as the first option. Maneuvers performed on ventilated patients
consisted in6 aspiration/tracheal lavage, bacteriological sampling, aerosol therapy, 1inetotherapy and specific care of
surgical patient.
@esults6 The average period of )M !as =.00 days. Patients !ho re(uired postoperative ventilatory support less than ;0
hrs benefited from assisted modes 3.+M),P.,CP'P4. Controlled modes 3TCP*,P@)C,PC,)C4 !ere used in cases !ith
ventilation longer than :=hrs. 5f < septic patients, ; had pulmonary infection secondary to)M, confirmed by
bacteriological and imagistic evidence. T!o patients ventilated in ,A5) had complications consisting of pneumothora
respectively pneumoperitoneum. 5f 0 dead patients, 9 had no viable surgical solution. The ris1 factors associated !ith
lung infection at the mechanically ventilated patients !ere6 associated malformations, prematurity and lo! birth
!eight, reinterventions due to complications, invasive maneuvers and nursing techni(ues.
Conclusions6 Patients up to one year !ith surgical disease and associated disorders re(uiring )M, are vulnerable to
pulmonary infection, so they re(uire an increase in professional standard among medical personal.

Rolul monitori(rii hemodinamice la pacienii cardiaci %i septici n practica asistentului medical
,emodynamic Monitoring @ole of Cardiac and .eptic Patients in the Gurse Practice
Ildi4o S&ao, Maria Magdalena Brsan, ;dela Golea
Spitalul :ude'ean de Urgen' pentru Copii, Unitate de )rimiri Urgen'e, Clu/$Lapoca, Rom*nia

=iecti!ele studiului3 Rolul monitori&rii 2emodinamice n identificarea pacienilor cu risc !ital n conte(te clinice de
patologie cardiac acut i de tip septic n urgen"
Material 9i metod3 )acienii au fost selectai n studiu dintre cei pre&entai n Unitatea de )rimiri Urgene, n perioada
,+ ianuarie$+E martie -,+@, a!*nd patologie cardiacBseptic i criterii clinice de instailitate 2emodinamic" ;u fost
lua'i n studiu un lot de -, pacien'i, la care s$au urmrit parametrii 2emodinamici la pre&entare i n dinamic n prima
or de la pre&entare" ;nali&a datelor s$a reali&at cu programul S)SS -+"," Re&ultate" Re&ultate par'iale, ale cercetrii n
derulare au e!ideniat la lotul de -, pacieni identificai 6+- cu patologie cardiac acut, D cu patologie septic7 !alori ale
indicelui de oc crescut 6peste ,,A7 la pre&entare n procent de EE., cu e!idenierea creterii procentuale n primele -,
de minute 6F,. la E minute, respecti! HE. la -, de minute7" S$au identificat @,. dintre pacieni ca a!*nd indicaie de
intua'ie oro$tra2eal" Monitori&area in!a&i! a presiunii arteriale s$a efectuat la +E." %e asemenea, C,. au a!ut
ne!oie de suport inotrop pentru sus'inerea tensiunii arteriale, iar -E. au pre&entat deit urinar redus 6su ,,E mlB4gB27"
Conclu&ii3 +" Monitori&area 2emodinamic nein!a&i! n practica de urgen a asistentului medical este esen'ial pentru
identificarea pacienilor cu risc !ital ca diagnostic de nursing" -" Recunoa9terea timpurie a modificrilor parametrilor
2emodinamici de deteriorare clinic permite ini'ierea precoce a inter!en'iilor de staili&are i pre!ine instalarea
complicaiilor"

.tudy objectives6 ,emodynamic monitoring role in identifying patients !ith life$threatening ris1 in clinical contets of
acute cardiac and septic pathology in emergency department.
Material and Method6 Patients in the study !ere selected from those admitted to the 2mergency bet!een " 8anuary to
"< March %#"9, !ith cardiac/septic pathology and clinical criteria of hemodynamic instability. %# patients !ere included
in the study, !ho !ere follo!ed hemodynamic parameters at presentation and in dynamic in the first hour after
admission. Data analysis !as performed !ith .P.. %".#. @esults. Partial results, of ongoing research sho!ed in the
group of %# patients identified 3"% !ith acute cardiac pathology, 0 !ith septic pathology4 shoc1 inde values increased
3above #.:4 at presentation in <<&, !ith highlighting the percentage increase in the first %# minutes 3=#& at < minutes
and D<& at %# minutes4. They identified 9#& of patients as having oro$tracheal intubation indication. +nvasive blood
pressure monitoring !as performed at "<&. 'lso, ;#& needed inotropic support for blood pressure maintaining and %<&
had reduced urine output 3less than #.< ml/1g/h4.
Conclusions6 ". Goninvasive hemodynamic monitoring in emergency nurse practice is essential to identify patients !ith
vital ris1 nursing diagnosis. %. 2arly recognition of changes in hemodynamic parameters of clinical deterioration allo!s
early initiation of interventions to stabili-e and prevent the installation of complications.

Anali(a factorilor de risc la pre(entare +i implica-iile adresabilit-ii de urgen- tardi&e n nursingul
pacientului cu IMA
'nalysis of the @is1 Aactors upon .ho!ing up and +mplications of the *ate +.@. 2amination in the Gursing of
the 'M+ Patient
Gariella LagQ 6+7, ;dela Golea 6-7
6+7 Institutul Inimii de Urgen' pentru Boli Cardio!asculare 0Liculae Stncioiu1, Clu/$Lapoca, Rom*nia
6-7 Uni!ersitatea de Medicin i Farmacie 0Iuliu 5aieganu1, Clu/$Lapoca, Rom*nia

=iecti!e3 ;nali&a timpului de la deutul simptomelor p*n la adresare i a pre&enei factorilor de risc la pacien'ii
pre&enta'i n urgen cu talou clinic de infarct miocardic acut 6IM;, implica'iile n aordarea terapeutic $
tromoli&Bconser!atorB)<C;7"
Material 9i metod3 S$au e!aluat +E pacien'i pre&enta'i cu talou clinic de IM; la Institutul Inimii Clu/, n perioada
feruarie$martie -,+@" S$au anali&at factorii de risc cunoscu'i pentru IM;, timpul ntre deutul simptomelor 9i adresarea
n ser!iciul de urgen' al institutului, n func'ie de terapia aordat 9i complica'iile postterapeutice"
Re&ultate3 Ja lotul de +E pacien'i selecta'i n studiu s$a oser!at c3 C,. erau 2ipertensi!i, cu !alori peste +F,BA, la
pre&entare 6C,.7U -,. cunoscu'i cu %P, F,. fumtori, DH. diagnostica'i cu dislipidemie, CH. erau oe&i" <impul mediu
de adresailitate a fost C2U C pacien'i au urmat tratament tromoliticBangioplastie 6K+-27, ++ peste +-2 au urmat
tratament conser!ator" <impul de adresare a artat c rapiditatea cu care se adresea& pacientul la un ser!iciu medical
de specialitate influen'ea& atitudinea terapeutic 9i e!ident prognosticul pacientului" S$a oser!at reperfu&ie
coronarian la -,. dintre pacien'ii pre&enta'i su F2"
Conclu&ii3
+" Factorul de risc identificat a fi n procent ridicat la lotul studiat a fost dislipidemia 6DH.7"
-" <impul mediu de pre&entare crescut ridic o prolem de educa'ie medical 9i nursing la ni!el de medicin de
familieBamulator"
@" Reperfu&ia miocardic, documentat clinic, electrocardiografic 9i en&imatic, a fost semnificati! mai frec!ent n IM;
cu )<C; primar fa' de tromoli&, la cei pre&enta'i su F2"
Studiu efectuat n cadrul proiectului )=S%RU F+EHH"

5bjectives6 'nalysis of duration from the occurrence of symptoms until healing and of the occurrence of the ris1 factors
at emergency patients !ith clinical acute myocardial infarction 3'M+, implications in therapeutic approach $
thrombolysis/conservatory/PTC'4.
Material and Method6 "< patients !ith clinical acute myocardial infarction !ere evaluated at the ,eart +nstitute Cluj,
during Aebruary$March %#"9. The ris1 factors 1no!n for 'M+, the duration bet!een the symptom occurrence and
contacting the +.@. of the institute, depending on the therapy used and post$therapeutic approaches !ere analysed.
@esults6 The follo!ing observations !ere made !ithin the lot of "< patients selected for the study6 ;#& had high blood
pressure, !ith values over "=#/:# upon sho!ing up 3;#&4K %#& 1no!n !ith D`, =#& smo1ers, 0D& diagnosed !ith
dyslipidemia, ;D& obese. The average time for contacting the +.@. !as of ; hoursK ; patients !ere prescribed a
thrombolitic/angioplastic treatment 3F"%h4, "" over "%h !ere prescribed a classical treatment. The contact time
indicated that the (uic1ness in the patient contacting a speciality medical unit influences the therapeutic attitude and
obviously, prognosis. Coronary reperfusion !as noticed at %#& of the patients under =h.
Conclusions6
". The identified ris1 factor present in an increased percentage in the studied lot !as dyslipidemia 30D&4.
%. The average contact time raises an issue of medical training and nursing at the level of the family
physician/ambulatory.
9. Myocardial reperfusion, clinically, electrocardiographically and en-ymatically documented !as significantly more
fre(uent in 'M+ !ith primary PTC', as compared to thrombolisis, at the patients appeared under = h.

Rolul asistentei medicale n administrarea de factori de coagulare/ re(entare de ca(
The @ole of Gurse in 'dministration of Clotting Aactors. Case @eport
;lida Moise, Rodica Co/ocaru, Cristina Moisac, 8iorica Wtefan, Gina Muntele, 8eronica Costac2e,
Carmen ;g2ion, #lisaeta C2irata, #lena G2ergu, Stelua 8artolomei
Spital M;I 0)rof" %" Gerota1, Bucure9ti, Rom*nia

Factorul 8III 6anti2emofilic ;7 liofili&at inter!ine n procesul de coagulare i se administrea& u&ual la pacientul cu
2emofilie tip ; form se!er"
#ficiena tratamentului este asigurat de administrarea conform cu recomandrile medicului 6do&e i timing7,
administrarea fiind efectuat de ctre asistenta medical"
Concentratul de Factor 8III liofili&at conine p*n la C, uniti de factor 8IIIBml"
Ideal este ca preoperator acti!itatea factorului 8III s fie c*t mai aproape de +,,. pentru a fi siguri c aceasta nu scade
intra$operator su @,., procent considerat suficient pentru o 2emosta& intra$operatorie adec!at" <ratamentul se
continu timp de +C$-+ &ile, p*n la cicatri&area plgii"
Respectarea ntocmai a recomandrilor medicale despre modalitate de preparare, do&are, timing sunt e(trem de
importante pentru succesul terapiei"

Aactor )+++ 3antihemofilica '4 interferes !ith coagulation and is usually given to patients !ith severe haemophilia '.
Treatment efficiency is ensured in accordance !ith the doctorZs administration 3dose and timing4, management
performed by the nurse.
Aactor )+++ concentrate po!der contains up to ;# units factor )+++ / ml.
+deally preoperative factor )+++ activity should be as close to "##& to ma1e sure it does not drop belo! 9#& intra$
operative, !hich !as considered sufficient for intra$operative hemostasis appropriate. Treatment is continued for ";$%"
days until !ound healing.
.trict adherence to medical recommendations about the !ay of preparation, dosage, timing are etremely important for
the success of therapy

'igurana utili(rii gastrostomei percutane endoscopice ?"2A la pacienii critici
.afety of Percutaneous 2ndoscopic ?astrectomy 3P2?4 in Critically +ll Patient
Carmen Marin, Florentina ;ng2el, Monica Cupa
Spitalul Clinic de Urgen, Bucureti, Rom*nia

=iecti!e3 )#G este metoda standard pentru administrarea suportului enteral de lung durat, de peste @ sptm*ni, cu
risc sc&ut de mortalitate i moriditate" Scopul studiului a fost s e!alum sigurana utili&rii metodei la pacienii critici"
Material i metod3 )acien'ii cu )#G interna'i pe parcursul unei perioade de -C de luni 6ianuarie -,++$ decemrie -,+-7
au fost e!alua'i retrospecti!, cu nregistrarea urmtoarelor date3 indicaia procedurei, complicaii minore i ma/ore,
durata de utili&are" Montarea )#G$ului s$a fcut n toate situaiile n terapie intensi! de ctre medicul gastroenterolog,
asistat de medicul ;<I i de personalul mediu din secie"
Re&ultate3 ;u fost anali&a'i -E de pacien'i 6+C ra'i, ++ femei7, cu o !*rst medie de ED ani 6limite ntre -+ i HD ani7"
Indica'iile pentru montarea )#G au fost3 status post traumatism cranio$cereral se!er $ +- ca&uri, status post stop
cardio$respirator resuscitat $ E ca&uri, status post accident !ascular cereral $ D ca&uri" )#G a fost montat n medie la +C
&ile de la admisia n terapie intensi! 6limite +, $ -D &ile7" Lu a fost nici un deces legat de procedura de montare" ;u fost
nregistrare @ ca&uri de ostrucie a cateterului, ce au impus scoaterea acestuia" F,. din pacien'i 6+E pacieni7 au fost
e(ternai cu )#G"
Conclu&ii3 )entru ca&urile selec'ionate )#G$ul este o metod sigur 9i eficient de asigurare a aportului enteral de
nutrien'i, u9or de efectuat n terapie intensi!, fr complicaii ma/ore"

Bac1ground and 'im6 P2? is a standard method of choice for long term enteral feeding 3a 9 !ee1s4 !ith lo! morbidity
and mortality. The aim of the study !as to evaluate the safety of P2? use in critically ill patient.
Material and Method6 The patients !ith P2? admitted in +CU during a %;$months period 38anuary %#"" $ December
%#"%4 !ere retrospectively evaluated in terms of procedureZs indication, major and minor complication, durability of
gastrectomy. The entire procedure !as placed in +CU at patientZs, performed by the gastroenterologist, !ith the
assistance of the +CU staff.
@esults6 %< patients 3"; male, "" female4 !ith a median age of <0 years 3range6 %" $ D0 years4 !ere included. P2? !as
performed for coma post severe traumatic brain injury $ "% pts, post cardiac arrest coma $ < cases, post cerebrovascular
accidents $ 0 cases. The procedure !as done bet!een "# to %0 days from +CU admission, median time "; days. Procedure
related$ mortality !as #&. The tube !as removed in 9 patients due to clogging. +n =#& of patients 3"< patients4 the
placement of P2? !as definitive.
Conclusions6 +n selected patients P2? is a safe alternative for enteral nutrition, easy to perform in +CU, !ithout severe
life$threatening complication.

'indromul de hiperstimulare o&arian $ Asistentul ATI pre(ent n linia nt1i de terapie
5varian ,yperstimulation .yndrome $ +ntensive Care Gurse in the Arontline of Care
Ctlina S*ru, Ctlina Wtefania Fier*ntu, Simona Birtum, )etru'a #nescu, J" %ita, %aniela Bandraur,
R" M" %umitrescu
Centrul Medical Unirea, Bucure9ti, Rom*nia

Sindromul de 2iperstimulare o!arian 6S55=7 este o complica'ie rar, iatrogen, dar foarte serioas a stimulrii
o!ariene din cadrul te2nicilor de reproducere asistat, cu moriditate mare 9i uneori c2iar mortalitate, ce implic
paciente tinere, sntoase" Intruc*t utili&area acestor te2nici este n cre9tere, riscul apari'iei acestei patologii de
asemenea cre9teU astfel, tot personalul medical implicat n ingri/ire treuie s cunoasc di!ersele forme de pre&entare,
care pot merge p*n la disfunc'ie organic multipl 9i deces" Sindromul este caracteri&at prin mrirea de !olum a
o!arelor 9i deplasare acut de lic2ide ctre spa'iul e(tra!ascular" Complica'iile S55= includ ascit, 2emoconcentra'ie,
2ipo!olemie, de&ec2ilire electrolitice, stare 2ipercoagulant 6cu risc de tromo& !enoas profund, emolie
pulmonar7, insuficien' renal acut, sindrom de detres respiratorie acut"
)re&entm ca&ul clinic al unei paciente de -A de ani, admis n Spitalul Regina Maria n a +-$a &i dup o procedur de
fertili&are in !itro 9i emriotransfer" )acienta s$a pre&entat cu 2ipotensiune, ta2icardie, dispnee moderat 6satura'ie
perferic n o(igen A, $ A-. n aer atmosferic7, grea', !rsturi, distensie adominal, dureri adominale difu&e 9i
toracice, oligurie" #(amenul ecografic decelea& o!are de dimensiuni crescute 6+- $ +-,E cm7 cu multiple c2isturi,
2idrotora( ilateral 6+- $ +@ cm7, re!rsat pericardic 6D $ A mm7" #(amenele de laorator au rele!ant 2emoconcentra'ie,
2ipoproteinemie, 2ipoaluminemie, 2iperpotasemie, 2iponatremie, citoli& 2epatic, eta$5CG po&iti! 6procedura de
emriotransfer a fost reu9it, pacienta era 9i gra!id7"
?n conclu&ie, suliniem faptul c pentru tratamentul cu succes al acestei categorii de paciente, personalul medical
implicat 6n special asistentul de terapie intensi!7 treuie s fie familiar cu semnele 9i simptomele S55=, s cunoasc
gradele de se!eritate, s recunoasc complica'iile, s 9tie principiile de monitori&are 9i tratament, s urme&e cu stricte'e
protocoalele, procedurile 9i indica'iile primite 9i s complete&e cu mare acurate'e documenta'ia medical"
5varian hyperstimulation syndrome 35,..4 is a rare, but most serious iatrogenic complication of ovarian stimulation for
assisted reproductive technology and other infertility treatments !ith high morbidity and sometimes mortality, mostly in
young healthy patients. The prevalence of therapy employing assisted reproductive technology is increasing. Therefor all
medical staff involved in management must became familiar !ith 5,.. and its myriad clinical presentations, that can
cause multiorgan dysfunction and potentially death. This syndrome is characteri-ed by ovarian enlargement due to
multiple ovarian cysts and an acute fluid shift into the etravascular space. Complications of 5,.. include ascites,
hemoconcentration, hypovolemia, electrolyte imbalances, hypercoagulable state, deep venous thrombosis, pulmonary
embolisms, acute renal failure, acute respiratory distress syndrome.
Be present a case of a patient %: years old, !ho !as admitted in our hospital on the "%
th
day after an in vitro
fertili-ation procedure and embryo$transfer. 't admission, she presented !ith hypotension, tachycardia, moderate
dyspnea !ith :# $ :%& oygenation at room air, nausea, vomiting, abdominal distension, diffuse abdominal and thoracic
pain, oliguria. Ultrasound eams sho!ed big ovaries 3"%$"%,< cm4, important ascites, bilateral hydrothora 3"% $ "9 cm4,
pericardial effusion 30 $ : mm4. *aboratory eams sho!ed haemoconcentration, hypoproteinaemia, hypoalbuminaemia,
hyper1alemia, hyponatremia, hepatic cytolysis, beta$,?C positive 3embryo$ transfer procedure !as a success, she !as
also pregnant4.
+n conclusion, !e emphasi-e that for a successful management, all medical staff involved 3especially intensive care
nurse4 must have appropriate training, be familiar !ith 5,.. symptoms and signs, its various grades of severity 3mild,
moderate, severe, critical4, must 1no! and recogni-e complications, must 1no! principles of treatment and monitoring,
follo! strictly protocols, procedures, indications and 1eep full and very precise documentation.

Atitudinea asistenilor medicali n ce pri&e%te nursingul copiilor %i adolescenilor cu alcoolism acut n
ser&iciile de urgen din )oto%ani
GursesZ 'ttitudes @egarding Gursing of 'lcohol$+ntoicated Patients in Pediatric 'ge in 2mergency .ervice of
Boto^ani
Camelia Caliniuc 6+7, %aniela Ionescu 6-7
6+7 Spital :ude'ean Ma!romati, Boto9ani, Rom*nia
6-7 Uni!ersitatea de Medicin 9i Farmacie 0Iuliu 5a'ieganu1, Clu/$Lapoca, Rom*nia

=iecti!3 Jucrarea 9i propune s aorde&e prolema atitudinii asisten'ilor medicali din ser!iciile de urgen', atunci c*nd
tratea& pacien'i pediatrici cu into(ica'ie alcoolic"
Material 9i metod3 Studiul prospecti!, a!i&at de Comisia de etic, a e!aluat3 atitudinea de satisfac'ieBinsatisfac'ie
personal profesional n ngri/irea pacien'ilor cu into(ica'ie alcoolic acut, atitudinea n fa'a dificult'ii de a ngri/i
ace9ti pacien'i 9i fa' de tratamentul 9i consilierea acestui pacient"
)entru aceasta, s$a utili&at un c2estionar original aplicat asistentilor medicali din sec'ia U)U )ediatrie a Spitalului
Ma!romati din Boto9ani 9i la Ser!iciul :ude'ean ;mulan' Boto9ani, n perioada +E feruarie$+E martie a"c" ;u fost
aplicate un numr de +++ c2estionare asisten'ilor medicali din Urgen' din Boto9ani"
Re&ultate3 Cu toate c asisten'ii medicali tind s trate&e pacien'ii pediatrici cu into(ica'ie alcoolic ca pe oricare al'i
pacien'i 6HF. dintre reponden'i afirm, din moti!e de de&irailitate social, c nu e(ist un disconfort suplimentar n
raport pacien'ii cu alte afec'iuni, 9i numai -C. recunosc acest disconfort7, un procent de HH. declar c cel mai
neplcut aspect n tratarea pacien'ilor cu into(ica'ie acut alcoolic este agresi!itatea !eral, -D. agresi!itatea fi&ic,
@C. sunt deran/a'i de !rsturi, @+. de starea de agita'ie a acestor pacien'i 6ntreare cu rspunsuri multiple, fiecare
repondent a ifat cel pu'in dou tipuri de disconfort7"
Conclu&ii3 Cercetarea a e!iden'iat insatisfac'ia profesional a asisten'ilor medicali n tratarea copiilor 9i adolescen'ilor cu
alcoolism acut n Urgen', 9i au o atitudine negati! n compara'ie cu atitudinea fa' de pacien'ii pediatrici cu alte
diagnostice"
Studiul a fost efectuat n cadrul proiectului )=S%RU DF$+"-$S$F+EHH
'ims6 This purpose of this study is to approach the emergency nursesZ attitudes to!ards alcohol$intoicated patients in
pediatric age.
Material and Method6 This prospective study, approved by the 2thical Commission, evaluated6 attitudes of personal
professional satisfaction and dissatisfaction !hen caring for intoicated patients, attitudes to!ards the difficulty in
caring for alcohol$intoicated patients, attitudes to!ards treatment and counseling of alcohol$intoicated patients.
Be applied an original (uestionnaire to emergency nurses of Department UPU Pediatric of 2mergency Mavromati
,ospital Boto^ani and Boto^ani County 'mbulance .ervice, bet!een "< Aebruary and "< March %#"9. """
(uestionnaires !ere applied to the entire department of emergency nurses of Botosani.
@esults6 'lthough the nurses tend to treat the pediatrics patients !ith alcoholic intoication as any other patients 3D=&
bet!een the respondents assert, from reasons of social desirability that there is no etraordinary discomfort in report
!ith the patients !ith other affections, and only %;& recogni-e this discomfort4, a percentage of DD& state that the
most unpleasant aspect in treating the patients !ith alcoholic acute intoication is the oral aggressiveness, %D& physical
aggressiveness, 9;& are disturbed by vomiting, 9"& by the agitation of these patients 3(uestion !ith multiple ans!ers,
each respondent mar1ed at least t!o types of discomfort4.
Conclusions6 2mergency nurses are fre(uently dissatisfied professionally !hen treating alcohol$intoicated pediatric
patients, and have negative attitudes to!ards this patient population, to!ards pediatric patients !ith dissimilar
diagnosis.
This study !as conducted in the P5.D@U Project 0=$".%$.$="<DD
>ey$!ords6 alcohol$intoicated, pediatric emergency, teenagers, nurse, nursing.















































e-POSTERE
e-POSTERS
"ficacitatea utili(rii combina-iei de Ropi&acain +i Bidocain pentru efectuarea blocului de plex brahial
The 2fficiency of Using *idocaine and @opivacaine 'nesthetic Combination for Performing Brachial Pleus
Bloc1
;le(andra Ja&r, :" S&eder/esi, Sanda Maria Copotoiu, Ru(andra Copotoiu, J" ;&amfirei
Uni!ersitatea de Medicin i Farmacie, %isciplina ;neste&ie 9i <erapie Intensi!, <*rgu Mure, Rom*nia

Scop3 Scopul studiului este e!aluarea eficacit'ii comina'iei aneste&ice de Ropi!acain ,"E. 9i Jidocain ,,E. pentru
efectuarea locurilor de ple( ra2ial, folosind te2nica stimulrii ner!ilor periferici i cea cu g2ida/ ultrasonografic"
Material 9i metod3 Studiu prospecti!, oser!a'ional, care cuprinde pacien'i adul'i, supu9i unor inter!en'ii c2irurgicale
cu indica'ie pentru aneste&ie loco$regional de ple( ra2ial"
S$au nregistrat3 cantitatea de aneste&ic administrat, timpul i calitatea instalrii locului, precum i durata aneste&iei"
Re&ultate3 ?n total au fost @A pacieni 6@ femei i @F rai7 cu !*rsta cuprins ntre +H i FA de ani" Ja -A de pacieni s$a
utili&at te2nica stimulrii ne!ilor periferici 6lotul S<7, iar la +, pacieni te2nica g2ida/ului ecografic 6lotul #C=7"
<impul mediu de efectuare a aneste&iei a fost de +C minute 6jD7, cel de instalare a locului de +A minute 6jF7"
;ccidente intraaneste&ice3 puncia arterial n H ca&uri, iar n C ca&uri aneste&ia a fost insuficient" Bloc motor a fost
e!ideniat n @F ca&uri, n @ ca&uri doar loc sen&orial" Lu au fost oser!ate reac'ii alergice sau alte reac'ii ad!erse"
Cantitatea medie de aneste&ic folosit a fost de @E 6jF7 ml" %urata media a aneste&iei a fost de CDE minute 6j+@E7"
Lu s$au oser!at diferen'e semnficati!e statistic ntre cele dou te2nici pri!ind timpul de efectuare a ple(ului, timpul de
instalare 9i durata aneste&iei"
Conclu&ii3 ;neste&ia loco$regional folosind comina'ia de Ropi!acain 9i Jidocain ofer o aneste&ie de un calitate,
cu instalare rapid i durat lung a locului motor, moti! pentru care recomandm folosirea acestei comina'ii"

'ims6 To evaluate the efficiency of @opivacaine #.<& and *idocaine #.<& anesthetic combination in performing brachial
pleus bloc1, by using peripheral nerve stimulation techni(ue and ultrasound guided method.
Material and Method6 Prospective, observational study !hich included adults, subject to surgery on upper limbs
re(uiring local anesthesia$brachial pleus bloc1.
Processed data6 Nuantity of anesthetic administered, time and (uality of peripheral bloc1 and also total duration of
anesthesia.
@esults6 The study included 9: patients 39 !omen and 9= men4 age bet!een "D and =:.
Aor %: patients peripheral nerve bloc1 !as performed by stimulation and for "# patients ultrasound guided method.
Mean time for performing anesthesia !as "; min 3h04, time of anesthesia installation being ":3h=4. 'ccidents and
incidents during anesthesia6 arterial puncture in D cases and in ; cases insufficient anesthesia.
Be obtained motor bloc1 in 9= patients, in 9 cases only sensory bloc1 !as noticed.
Go allergic or other adverse reactions !ere encountered.
Mean used (uantity of anesthetic !as 9< 3h=4 ml.
Mean anesthesia duration !as ;0<min 3h"9<4.
Go significant differences !ere observed bet!een the t!o techni(ues, regarding time of performing the peripheral
bloc1, installation time or total duration of anesthesia.
Conclusions6 @egional peripheral nerve bloc1 anesthesia, using @opivacaine and *idocaine combination of anesthetic
substances confers a good (uality anesthesia, !ith a short installation time and a long duration of motor bloc1, reasons
for !hich !e recommend this combination of anesthetics.
>ey !ords6 regional anesthesia, @opivacaine, *idocaine, brachial pleus

Aneste(ia loco$regional &ersus aneste(ia general n na+terea prin ce(arian
*oco$@egional 'nesthesia versus ?eneral 'nesthesia in Cesarian Delivery
Ja!inea$Mirela etreang 6+7, %" S" Stnescu 6+7, ;lina$Maria Listor 6+7, 8ioleta Wtefan 6+7, %" Brunc 6+7,
=" Irimescu 6+7, R" Gorceag 6+7, ;lina 8aleria Buciu 6+7, Cristina Mi2aela <iron 6+7, e" 8" Mnic 6-7
6+7 Spitalul de Urgen 0Sf" Ioan cel Lou1, Secia ;neste&ie i <erapie Intensi!, Sucea!a, Rom*nia
6-7 Massac2usetts General 5ospital, Boston, SU;

)e plan mondial s$a nregistrat o cre9tere continu a interesului pentru aneste&ia i analge&ia regional" Ja Spitalul
:ude'ean Sucea!a, p*n n urm cu un an, marea ma/oritate a opera'iilor de ce&arian se efectuau su aneste&ie
general" ?n perioada cuprins ntre ,+",E"-,+-$-D",-"-,+@, situaia s$a sc2imat" %in +@D- operaii de ce&arian, un
numr de E,, 6@F.7 s$au efectuat cu ra2ianeste&ie i restul de DD- 6FC.7 cu aneste&ie general"
=iecti!e3 Compararea eneficiilor intra i postoperatorii ale aneste&iei regionale !ersus aneste&ia general"
Material i metode3 ;u fost un numr de +@D- operaii ce&arian, parturiente cu !*rsta ntre +C$CE ani" S$au luat n
considerare3 pulsul, grimasa, scorul ;pgar al nou$nscutului, durerile n g*t, tusea postoperatorie, infeciile pulmonare,
cefaleea, greuri, !rsturi, necesarul de analge&ice opioide postoperator, costul i durata spitali&rii"
Re&ultate3 ;u fost efectuate un numr de E,, ra2ianeste&ii, din care +E- n operaiile n urgen" Gradul de confort intra
i postoperator pe o scar de la + la +, a fost n medie de A"- la ra2ianeste&ii i H"D la aneste&ia general" ;cesta a fost
corelat cu e(periena aneste&istului i ostetricianului i tipul acului spinal 6)encil$)oint sau auin4e7"
Conclu&ii3 ;legerea tipului de aneste&ie depinde de indicaia operatorie, gradul de urgen 6matern i fetal7, statusul
2emodinamic al parturientei i acceptul pacientei"

Borld!ide there has been a steady gro!th of interest in regional anesthesia and analgesia. +n .uceava County ,ospital,
until last year, the vast majority of caesarean operations !ere carried out under general anesthesia. Bet!een
#".#<.%#"%$%0.#%.%#"9, the situation changed. 5ut of "90% Caesarean operations, a total of <## 39=&4 !ere performed
!ith spinal anesthesia and the remaining 00% 3=;&4 !ith general anesthesia.
5bjectives6 To compare the benefits of intra$and postoperative regional anesthesia versus general anesthesia.
Material and Methods6 ' total of "90% !ere cesarean operations, calving aged bet!een ";$;< years. There !ere
considered6 pulse, grimace, 'pgar score of the ne!born, sore throat, cough, postoperative pulmonary infections,
headache, nausea, vomiting, postoperative opioid analgesic re(uirements, cost and duration of hospitali-ation.
@esults6 There !ere a total of <## spinal efecuate, of !hich "<% in emergency operations. +ntra$and postoperative
comfort level on a scale of " to "# !as an average of :.% in spinal and D.0 in general anesthesia. This !as correlated !ith
the eperience of anesthesist and obstetrician and type spinal needle 3Pencil$Point or Nuin1e4.
Conclusions6 The choice of anesthesia depends on the indication of operative urgency 3maternal and fetal4,
haemodynamic status of calving and patient acceptance.

Aneste(ia pe masc laringian folosind tehnica aneste(iei intra&enoase
The 'dvantage of the Use of *aryngeal Mas1 for Total +ntravenous 'nesthesia
#mx4e ;lmksQ, :" S&eder/esi, Matild Geres&tes, Sanda Maria Copotoiu, J" ;&amfirei, :udit Go!kcs
Uni!ersitatea de Medicin 9i Farmacie, <*rgu Mure9, Rom*nia

=iecti!3 Studierea eficien'ei folosirii m9tii laringiene n cadrul inter!en'iilor c2irurgicale care nu necesit miorela(are,
folosind te2nica aneste&ic <I8;$<CI 6<otal Intra!enous ;nest2esia $ <arget Controlled Infusion7"
Material 9i metod3 Studiu prospecti! inter!en'ional efectuat n cadrul SC:U Mure9, Clinica ;<I I, n perioada
,+"+,"-,++$ ,+",F"-,+-" <e2nica aneste&ic efectuat a fost <I8;$<CI folosind )ropofol 9i SufentanQl, profun&imea
aneste&iei a fost monitori&at cu indicele ispectral 6BIS7"
S$au urmrit refle(ele faringiene la introducerea m9tii, modificrile pulsului, <;, Sp=-, respira'iile, BIS 9i perioada
induc'ieB tre&ire, durata inter!en'iei"
Re&ultate3 Jotul cuprinde -F de pacien'i cu !*rsta ntre +@ 9i D, de ani, +, femei, +F ra'i"
)acien'ii au reac'ionat la introducerea m9tii laringiene prin tuse 6D,.7, moti! pentru care s$a introdus folosirea
Jidocainei ca aneste&ic local, ceea ce a dus la o scdere semnificati! a acestor reac'ii 6@+.7"
<o'i pacien'ii au men'inut respira'ia spontan pe parcursul inter!en'iilor c2irurgicale, A pacien'i 6@C.7 au pre&entat
apnee de scurt durat 6apro(" E minute7, care a necesitat asistare !entilatorie" Lu au fost pacien'i cu scderea Sp=-
su DH." 8alorile BIS au fost men'inute ntre C, 9i F, 6medie E-,DD7 n timpul inter!en'iei, iar la tre&ire a fost peste H,
6medie D,,+A7"
%urata medie a inter!en'iilor a fost de F,,ED minute 6minBma( +,$+-, minute7" <re&irea a fost rapid 9i de un calitate
6medie +@,E minute7"
Conclu&ii3 Folosirea m9tii laringiene mpreun cu te2nica <I8;$<CI asigur o aneste&ie eficient de un calitate cu
men'inerea respira'iei spontane pe parcursul inter!en'iilor 9i tre&ire rapid"
5bjective6 The study of the laryngeal mas1 for surgical interventions !hich not re(uire the administration of
miorelaants, using T+)'$TC+ anesthesia 3Total +ntervenous 'nesthesia $ Target Controlled +nfusion4.
Material and Method6 ' prospective study performed at .C8U Mure^, Department of 'nesthesiology, period of
#"."#.%#""$#".#=.%#"%. The anesthetic techni(ue !as T+)'$TC+, using Propofol and .ufentanyl, !ith hypnosis monitoring
using bispectral inde 3B+.4.
The recorded parameters !ere6 laryngeal reflees at the introduction of the laryngeal mas1, hemodynamic
modifications, oygen saturation, spontaneous breathing, B+., at induction, during anesthesia and at a!a1ening.
@esults6 The number of patients included !as %=, aged bet!een "9 and 0# years old, "# female and "= male. Be
recorded coughing at laryngeal introduction for most of the patients 30#&4, therefore for the further cases the
administration of *idocaine as local anesthetic has been introduced, lead to a significant reduction of these reactions
39"&4.
'll patients !ere on spontaneous breathing during the surgical interventions, : of them 39;&4 presented brief apnea
3approimately < minutes4, !hich made ventilatory assistance necessary. Gone of the patient presented a desaturation
belo! 0D&. B+. values !ere maintained bet!een ;# and =# 3average <%.004 during procedures, and above D# at
a!a1ening 3average 0#.":4.
Mean duration of interventions !as =#.<0 minutes 3min/ma "#$"%# minutes4. The a!a1ening !as fast and high (uality.
Conclusions6 The use of the laryngeal mas1 in combination !ith T+)'$TC+ offers us a safe, efficient and good (uality
anesthesia, !ith maintenance of spontaneous breathing during interventions and (uic1 a!a1ening.


Abordarea aneste(ic prin folosirea TIFA$TCI n ca(ul a trei pacieni cu sindrom 'ippleD propu%i pentru
suprarenalectomie bilateral pentru feocromocitom
'nesthesic 'pproach by Using T+)'$TC+ in Three .ippleJs .yndrome Patients Proposed for Bilateral
.uprarenalectomy to 'ddress Pheochromocytoma
L" 8" <nase, M" %" Jati9, J" #ne, Ioana =prea, Miraela Cipriana Colac, %enisa G2inescu, ;" =laru,
8" %umitra9cu, L" Gu'u, R" )etrescu
Spitalul Uni!ersitar de Urgen' Militar Central 0%r" Carol %a!ila1, Bucure9ti, Rom*nia

%escriem managementul perioperator 9i aordarea aneste&ic a @ pacien'i 6femei apar'in*nd aceleia9i familii7,
diagnosticate cu sindrom de neopla&ie endocrin multipl tip -; 6M#L -;73 feocromocitom ilateral, adenom
paratiroidian 9i carcinom tiroidian medular" Ca&urile pre&entate pot constitui un argument concludent n sus'inerea ideii
conform creia titrarea precis 9i agresi! a )ropofolului 9i Remifentanilului n sistem <CI, e(ercit*nd at*t efecte
depresoare, c*t 9i radicardi&ante de durat foarte scurt, poate repre&enta o alternati! aplicail n ca&ul controlului
2emodinamic pe timpul re&ec'iei suprarenaliene pentru feocromocitom, inter!en'ia constituind ntotdeauna o
pro!ocare pentru aneste&ist"
Inter!en'iile au fost programate, fiind efectuate dup pregtirea atent a pacien'ilor 6%o(a&osin, Car!edilol7"
Monitori&area intraoperatorie a fost comple( 6parametrii !itali standard, alturi de )8C, CI, S88, BIS7" Rata de infu&ie
pentru )ropofol a fost setat pentru atingerea unei Cp de -$-,E ygBml 6Sc2neider7 9i Remifentanilul o concentra'ie de @$
-, ngBml 6Minto7, pentru men'inerea presiunii arteriale sistolice su +E, mm5g 9i a frec!en'ei cardiace su +,, pm"
Un singur ca& a necesitat administrarea unei do&e minime de urapidil 6+E mg7 pentru controlul 2emodinamic n timpul
manipulrii tumorale intraoperatorii" Monitori&area S88 68igileo7 pe parcursul celor @ inter!en'ii s$a do!edit a fi foarte
util n a/ustarea unei reple'ii !olemice adec!ate" Cre9terea ratei de infu&ie a )ropofolului peste @ ygBml nu s$a do!edit
a e(ercita efecte enefice asupra controlului 2emodinamic, spre deoseire de Remifentanil, a crui do&are incremental
a oferit o titrare corect adaptail cerin'elor ca&ului" = concentra'ie minimal a amelor droguri aneste&ice a fost
utili&at dup momentul ala'iei celei de$a doua glande suprarenale n fiecare ca&, g2idat de monitori&area BIS, alturi
de infu&ie continu de Loradrenalin, ini'iat cu ,,,@EygB4cBmin" #!olu'ia postoperatorie a fost fa!orail n toate cele
@ ca&uri"
Regimul aneste&ic ales a permis utili&area minimal a altor sustan'e depresoare u&uale pe parcursul manipulrii
tumorale" ?n ca&ul uneia dintre paciente s$a practicat 9i tiroidectomia total pe parcursul aceleia9i inter!en'ii"
?n conclu&ie, titrarea lieral a )ropofolului 9i a Remifentanilului pentru managementul aneste&ic al re&ec'iei
suprarenaliene ilaterale pentru feocromocitom s$a do!edit a fi simpl, sigur 9i eficient, cu a!anta/e pentru pacien'i"
The paper describes the perioperative management and the anesthetic approach of 9 patients 3!omen from the same
family4 diagnosed !ith multiple endocrine neoplasia syndrome type %' 3M2G %'46 bilateral pheochromocytoma,
medullary thyroid carcinoma and parathyroid adenoma. The cases presented may constitute a conclusive argument in
support of the idea that precise and aggressive titration of propofol and remifentanil in TC+ system, eerting both
depressant and bradicardisant effects of very short duration may be an applicable alternative in hemodynamic control
during resection for suprarenal pheochromocytoma, a very challenging surgical intervention.
+nterventions !ere planned after careful preparation of patients 3Doa-osin, Carvedilol4. +ntraoperative monitoring !as
comple 3standard vital parameters, along !ith P)C, C+, .)), B+.4. The Propofol infusion rate !as set to achieve a Cp of
%$%.< mg / ml 3.chneider4 and @emifentanil concentration of 9$%# Ug / ml 3Minto4 to maintain systolic blood pressure
belo! "<# mm,g and fre(uency heart rate belo! "## bpm. 5ne case re(uired a minimal dose of urapidil 3"< mg4 for
hemodynamic control during the intraoperative tumor manipulation.
The .)) 3)igileo4 monitoring throughout the 9 interventions proved to be very useful in adjusting appropriate volume
repletion. +ncreasing the Propofol infusion rate over 9 Ug/ml !as not found to eert beneficial effects on hemodynamic
control, unli1e @emifentanil, !hose incremental dosage gave a correct titration adapted to the re(uirements of the case.
+n each case a minimum concentration of both anesthetic drugs !as used after ablation of the second suprarenal gland,
guided by B+. monitoring, !ith continuous infusion of norepinephrine, initiated !ith a rate of #.#9< Ug/1c/min. The
postoperative evolution !as favorable in all 9 cases.
The chosen anesthetic regime allo!ed the minimal use of other usual depressor substances during the tumor
manipulation. During the same intervention one of the patients also under!ent a total thyroidectomy.
+n conclusion, the liberal titration of propofol and remifentanil for the anesthetic management of bilateral suprarenal
resection for pheochromocytoma proved to be simple, safe and effective, !ith real benefits for patients.

Managementul perioperator n ca(ul unei paciente cu maladie Fon Iillebrand tip 5) form se&erD
propuse pentru cura chirurgical a unei hernii de disc lombar
Perioperative Management of a Patient !ith .evere )on Billebrand Disease Type %B, Proposed for .urgical
Cure of a ,erniated *umbar Disc
L" 8" <nase 6+7, J" #ne 6+7, M" %" Jati9 6+7, M" Mitric 6+7, Ioana =prea 6+7, ;" Baciu 6+7, ;" =laru 6+7,
Mdlina Ji(andru 6+7, <eodora Weran 6-7, Simona Butoi 6-7
6+7 Spitalul Uni!ersitar de Urgen' Militar Central 0%r" Carol %a!ila1, Bucure9ti, Rom*nia
6-7 Centrul de Medicin ;eronautic 9i Spa'ial, Bucure9ti, Rom*nia

)re&entm ca&ul unei paciente n !*rst de EA de ani, oe& 6BMI@F 4gBm-7 7, polialergic, cunoscut cu maladie !on
Sillerand tip -B, form se!er 6acti!itate cofactor la ristocetin H., acti!itate factor !on Sillerand F!S ;g @D.,
acti!itate F8III CD.7, propuse pentru cura c2irurgical a unei 2ernii de disc lomar la ni!el J@ 6inter!en'ie cu risc
2emoragic important7"
%in antecedentele patologice ale pacientei sunt de men'ionat c*te!a episoade 2emoragice se!ere, sur!enite n conte(t
operator 69i uneori soldate cu 9oc 2emoragic7, p*n n momentul diagnosticului 6tardi!7 al olii, la !*rsta de E, de ani $
n ordine cronologic3 amigdalectomie, apendicectomie, o!arectomie dr", colecistectomie, 2isterectomie total 9i cura
c2irurgical a de!ia'iei de sept na&al"
#!aluarea preoperatorie s$a a(at pe determinarea e(act a profilului coagulrii si al 2emosta&ei, determin*ndu$se
acti!it'ile factorilor de coagulare deficitari men'iona'iU a fost anali&at tromoelastograma 9i au fost asigura'i produ9i
compatiili de s*nge" %at fiind profilul defectului, contraindica'ia la %esmopresin 6n maladia tip -B7, am optat pentru
sustitu'ie cu concentrat mi(t de factor !S 9i F8III 65aemate )7, a!*nd ca target o !aloare a acti!it'ilor men'ionate n
/ur de +,,., pentru momentul operator" ;ctul c2irurgical s$a practicat n condi'ii e(celente, dup administrarea cu D ore
nainte a @ fl 5aemate ) E,,U cu s*ngerare minim 6z-,, ml7 su aneste&ie general alansat, cu aord !enos central
ecog2idat, fr a se impune necesitatea transfu&rii !reunui preparat sang!in" ;dministrarea concentratului mi(t n
perioada postoperatorie, p*n n &iua a H$a, s$a fcut n mod titrat, su monitori&are &ilnic a concentra'iei F8III 9i F!S"
`in*nd cont de riscul tromotic postoperator crescut 6!*rsta, e(ces ponderal, imoili&are, inter!en'ie c2irurgical7,
augmentat de poten'iala apari'ie n conte(tul sustitu'iei a !alorilor supranormale a F8III, din &iua + postoperator a fost
instituit 9i profila(ia antitromotic, folosind #no(aparina C,mgB&i pe toat durata spitali&rii"
#!olu'ia postoperatorie nu a fost gre!at de incidente sau accidente 9i a permis e(ternarea pacientei n siguran', n
&iua a D$a postoperator"
Be present the case of a patient aged <: years, obese 3BM+ 9= 1g/m%44, polyallergic, !ith severe form of type %B on
BillebrandZs disease, 3@istocetin cofactor activity of D&, von Billebrand factor vB 'g 90&, A)+++ activity ;0&4, proposed
for surgical cure of a herniated disc at *9 3intervention !ith significant bleeding ris14.
.ome severe bleeding episodes should be mentioned from the patientZs medical history, !hich occurred during her life in
connection !ith multiple surgery 3and sometimes resulting in hemorrhagic shoc14, until the tardive diagnosis of the
disease, at the age of <# years.
Preoperative assessment focused on determining the eact profile of coagulation and hemostasis, determining the
activities of the mentioned deficient clotting factorsK thus the thromboelastogram has been analy-ed and blood
compatible products !ere ensured. ?iven the defect profile, !hich is contraindication to Desmopressin 3in disease type
%B4, !e opted for substitution !ith factor vB and A)+++ mied concentrate 3,aemate P4, !ith the target value of the
mentioned activities around "##& for the surgical moment. The surgical act !as performed in ecellent conditions, 0
hours after the patient !as given 9 vials ,aemate P <##, !ith minimal bleeding 3o %## ml4, under general balanced
anesthesia, !ith central venous image$guided abord, !ithout a need of any blood product transfusion. Mied
concentrate administration in the postoperative period, by day D, !as done titrately, accordingly daily activities
monitoring.
?iven the increased postoperative thrombotic ris1 3age, over!eight, immobili-ation, surgery4, augmented by the
potential occurring of A)+++ supranormal values in the substitution contet, postoperatively, from day " the
antithrombotic prophylais !ith enoaparin ;#mg/day !as established during entire hospitali-ation.
Postoperative evolution !as not mar1ed by incidents or accidents, allo!ing the safe discharge of the patient on the 0
th
postoperative day.

Terapia durerii postoperatorie cu cateter de infiltrare continu de aneste(ic local $
re(entare de ca(
Postoperative Pain Management !ith Continuous Bound +nfiltratration Therapy $ Case @eport
=rsolQa Benede4 6+7, ;le(andra Ja&r 6+7, Bianca Grigorescu 6-7, #lena Iftenie 6-7, Ru(andra Copotoiu 6+7, M"
G2erg2inescu 6@7, %" )opa 6@7, C" Copotoiu 6@7, Sanda Maria Copotoiu 6+7
6+7 Uni!ersitatea de Medicin 9i Farmacie, %isciplina ;<I, <*rgu Mure9, Rom*nia
6-7 Spitalul Clinic :ude'ean de Urgen', Clinica ;<I, <*rgu Mure9, Rom*nia
6@7 Uni!ersitatea de Medicin 9i Farmacie, %isciplina C2irurgie, <*rgu Mure9, Rom*nia

)acienta BM, n !*rst de E+ de ani, cu antecedente de plag n/ung2iat adominal prin 2eteroagresiune, a fost
internat n Clinica C2irurgie I din <*rgu Mure9 cu diagnosticul3 Suoclu&ie intestinal" #!entra'ie postoperatorie
multilocular multisacular, n perioada -H",- $ ,H",@"-,+@" ?n data de -D",-"-,+@ se practic cura c2irurgical a
e!entra'iei, plastia peretelui adominal cu fire n 0U1 de detensionare 6procedeu Ramire&7, dulu drena/ sucutan" Ja
finalul inter!en'iei c2irurgicale s$a montat cateter de infiltrare continu a plgii operatorie )a/un4 Infiltralong H,, 9i s$a
utili&at Ropi!acain ,,E. cu o rat de infu&ie de E mlBor" S$au completat c2estionarele preoperator, n perioada
imediat postoperatorie, adic prima or dup terminarea opera'iei 9i pe perioada celor CD de ore postoperator" S$au
utili&at c2estionarele de cuantificare a durerii3 Brief )ain In!entorQ, C=MF=R< scale, C2ec4list of Lon!eral )ain
Indicators, Song$Ba4er F;C#S )ain Rating Scale" ;cestea cuantific intensitatea durerii 9i sunt a&ate pe relatrile
pacientului 9i oser!a'iile personalului" Re&ultatele au fost prelucrate n func'ie de recomandrile interna'ionale" ?n
ca&ul n care se considera c analge&ia nu este suficient, s$ar fi recurs la di!ersificarea acesteia"
)articularitatea ca&ului const n lipsa necesarului de analge&ie sistemic" ; fost necesar colaorarea aneste&ico$
c2irurgical" Introducerea, plasarea, fi(area 9i e(tragerea cateterului au fost efectuate de ctre c2irurg" #c2ipa
aneste&ic a condus analge&ia postoperatorie 9i a efectuat inter!iurile" )rin utili&area acestei te2nici, am reu9it
reducerea tratamentului analge&ic sistemic postoperator, astfel reduc*nd 9i efectele secundare"
Cu!inte c2eie3 analge&ie postoperatorie, infiltrare local continu a plgii, Ropi!acain

' <" year old female pacient, BM, !ith a history of abdominal stab !ound !as admitted to the "
st
.urgery Clinic of the
Tprgu Mure^ Clinical County 2mergency ,ospital in the period of %D.#% $ #D.#9.%#"9. The diagnosis of post$incisional
multilocular hernia !as established. .urgery !as performed on the %0
th
of Aebruary %#"9, abdominal !all plasty using
the @amire- techni(ue. ' Pajun1 +nfiltralong D## countinuous !ound infiltration catheter !as introduced at the end of
the surgical intervention. #.<& @opivacaine solution !as used !ith a rate of continuous infusion of <ml/h. The patient
!as (uestioned in the preoperative period, immediate postoperative hour and the net ;0 postoperaive hours about her
pain.
+nternational pain rating scales !ere used6 Brief Pain +nventory, C5MA5@T scale, Chec1list of Gonverbal Pain +ndicators,
Bong$Ba1er A'C2. Pain @ating .cale. These scales measure the pain intensity and are based on self$report,
observational, or physiological data. The results !ere analised according to international re(uirements. +f the local
analgesia !ere to be considered inade(uate, systemic analgesia !ould have been introduced. The particularity of this
case !as the fact that the patient did not need any systemic analgesia. ' strong anesthetic$surgical collaboration is
needed for the use of this techni(ue. The placement, fiation and etraction of the catheter !as performed by the
surgeon, the anesthetic team managed the analgesia and (uestioned the patient. Using this techni(ue !e managed to
reduce the magnitude of postoperative pain treatment, thus reducing the systemic side effects.
>ey!ords6 postoperative analgesia, continuous !ound infiltration, @opivacaine






O posibilitate de tratament n durerea cronic $ rialt ?JiconotidA n administrare intratecal la o pacient
cu ne&ralgie de trigemen/ re(entare de ca(
' Possible Treatment for the Chronic Pain $ Prialt 3`iconotide4 in +ntratechal 'dministration in a Patient !ith
Trigeminal Geuralgia. ' Case .tudy
;" <" Brn&eu, Cristina Brn&eu, Joredana Juca, =" Bedreag
Spitalul Clinic :udeean de Urgen, <imi9oara, Rom*nia

=iecti!ul3 )re&entarea unei sustane noi n terapia durerii"
Piconotidul este repre&entantul unei noi clase de medicamente destinate tratamentului durerii i anume el este un
locant al canalelor de calciu de tip L" ?n administrare intratecal el in2i elierarea de neurotransmitori ai durerii
din neuronii afereni primari i reduce eficient intensitatea acesteia din urm"
)re&entm ca&ul unei paciente cu ne!ralgie de trigemen, cu o e!oluie de patru ani 6-,,A $ -,+@7 la care terapia
anterioar a fost ineficient3 analgetice antiinflamatorii, gaapentin, antidepresi!e triciclice per os i intra!enos urmate
de inter!enie neuroc2irurgical cu intenie de decompresiune a trigemenului" ?n ser!iciul de terapie intensi! s$a
administrat Getamina n perfu&ie intra!enoas, timp de cinci &ile n do&e cresc*nde de la +E, mg la @,, mg cu eficacitate
redus, cu scderea intensitii durerii de la A la D pe o scar de la + la +," ?n continuare
s$a administrat intratecal Piconotid n do&e cresc*nde 6+, -, @ micrograme la inter!ale de CD de ore7 re&ultatul fiind dup
prima do& scderea intensitii de la A la D, dup a doua de la A la H i dup ultima de la D la F cu o durat de CD de ore"
;ceste re&ultate ne fac s credem c implantarea unei pompe de administrare continu a drogului ar putea fi eficient
pe termen lung"
Cu!inte c2eie3 Piconotid, durere cronic, ne!ralgie de trigemen

The goal6 To introduce a ne! drug in the pain management.
`iconotide is the representative of a ne! drug class oriented to the pain treatment and specifically it is a calcium G $
voltage dependent channel bloc1er. 'dministered in an intratechal !ay it inhibits the liberation of neorotransmiters and
effectively reduces the intensity of the pain. Be present the case of a patient !ith trigeminal neuralgia, !ith a four year
long evolution 3%##: $ %#"94 in !hom the previous therapy !as ineffective6 antiinflamatory and analgesic drugs,
gabapentin, triciclic antidepressants given orally and intravenously follo!ed by a neurosurgical procedure !ith a
decompressive goal of the trigeminal nerve. +n the intensive care unit !e made a treatment trial !ith >etamine in
increasing five daily doses from "<# to 9## mg !hich yielded poor results, the pain intensity decreased from : to 0 on a "
to "# scale.
Then !e gave increasing doses of intrathecal -iconotide 3",%,9 microgrames at ;0 hours intervals4. The results !ere a
decrease of the pain intensity from : to 0 after the first dose, from : to D after the second and from 0 to = after the third,
the relief lasting about ;0 hours after each administration. These results made us confident that the subcutaneous
implant of a continuous administration device of the drug may be effective and that it is !orth to try it.
>ey !ords6 `iconotide, chronic pain, trigeminal neuralgia

Inciden-a +i cau(ele contramandrii inter&en-iilor electi&e n Centrul .a-ional Ktiin-ifico$ractic de
Medicin 0rgent
+ncidence and @easons for Cancelation of 2lective .urgery in Gational .cientific and Practic Center of
2mergency Medicine
I" C2eso!, #caterina Scurtu, R" Baltaga
Uni!ersitatea de Stat de Medicin i Farmacie 0Licolae <estemianu1, C2i9inu, Repulica Moldo!a

Scop3 %eterminarea incidenei i cau&elor contramandrii inter!eniilor electi!e n CLe)MU"
Materiale i metode3 ?n perioada noiemrie -,+- $ ianuarie -,+@, au fost supra!eg2eate inter!eniile electi!e n +, sli
de operaii" ;u fost considerate electi!e inter!eniile care au fost trecute n registrul inter!eniilor programate p*n la
orele +F3,,, &iua premergtoare inter!eniei c2irurgicale" Ulterior se documenta cau&a anulrii inter!eniilor
c2irurgicale"
Re&ultate3 Lumrul total de inter!enii electi!e n perioada de referin $ FC,, contramandate $ FF 6+,.7"
Cau&e3 )rogram operator ncrcat @H 6EF.7U ec2ipament insuficient H 6+,.7U refu&ul pacientului F 6A.7U agra!area strii
pacientului C 6F.7U nerespectarea indicaiilor preoperatorii ale aneste&istului @ 6C"E.7U pregtirea insuficient a
pacienilor @ 6C"E.7U sc2imarea tacticii de tratament @ 6C"E.7U alte cau&e @ 6C"E.7" Cel mai frec!ent au fost anulate
inter!eniile din slile de ortopedie i traumatologie @@ 6E,.7"
Conclu&ii3 )rogramul operator !a fi unul realist" #ste necesar eficienti&area managementului spitalicesc
6disponiilitatea de paturi, !entilatoare pe terapie intensi!, instrumente n sala de operaii etc7" Rata inter!eniilor
electi!e contramandate !a fi redus printr$o e!aluare i management eficient preoperatoriu a pacientului 6clinica de
aneste&ie7, muntirea comunicrii c2irurg$aneste&ist"

Purpose6 To determine the incidence and reasons for cancellation of elective surgery in GC.P2M.
Material and Methods6 5ver Govember %#"% $ 8anuary %#"9 the records !ere ta1en over all elective surgeries scheduled
in "# 5@Js. 2lective !as considered surgery that had appeared on the elective surgical operation list before ; p.m. on the
day before the surgery. The reasons for the cancellation !ere documented for the analysis.
@esults6 ' total of =;# elective surgeries !ere scheduled for the study period, out of this number == !ere cancelled
3"#&4.
@easons6 Time constraints 9D 3<=&4K lac1 of e(uipment D 3"#&4K patient self$cancellation = 3:&4K !orsen of patient state
; 3=&4K anesthesiologist recommendations !ere not fulfilled 9 3;.<&4K patient !as not appropriately prepared 9 3;.<&4K
change in treatment strategy 9 3;.<&4, other 9 3;.<&4.
Conclusions6 The operation list should be a realistic one. 2fficiency of hospital management should be improved
3availability of beds and +CU ventilators, e(uipments in 5@Js4. +ncidence of cancellation of elective surgery !ill decrease
by a better preoperative patient management 3anesthesia clinic4, improvement in communication bet!een surgeon and
anesthetist.

'1ngerarea intraoperatorie +i transfu(ia de produ+i de s1nge n transplantul hepatic
+ntraoperative Blood *oss and Blood Products Transfusion in *iver Transplantation. ' @etrospective
5bservational .tudy
%ana <omescu, M" )opescu, Gariela %roc, Saina <nsescu, Simona %ima
Institutul Clinic Fundeni, Bucure9ti, Rom*nia

=iecti!ul acestui studiu a fost de a determina principalii factori de risc ai s*ngerrii masi!e intraoperatorii 6SI=7 i
transfu&iei de produi de s*nge 6)S7"
)acieni i metode3 ;m anali&at retrospecti! HC de pacieni transplantai 2epatic n perioada ianuarie -,+- $ martie
-,+@"
Re&ultate3 %intre pacieni, -D,C. 6nI-+7 au fost transplantai cu fragment 2epatic de la donator !iu, iar H+,F. 6nIE@7 cu
ficat de la donator aflat n moarte cereral" Scorul M#J% 6Model for #nd$Stage Ji!er %isease7 median n momentul
transplantrii a fost de +F 6ntre D$@,7" 8aloarea median a SI= a fost de C,,,ml 6ntre E,,$@,,,,ml7 necesit*nd o
transfu&ie median de )S de F uniti 6ntre +$@E uniti7 concentrat eritrocitar 6C#R7 i +D uniti 6ntre ,$DE uniti7 de
plasm proapt congelat 6))C7" Scorul M#J% nu se corelea& cu SI= 6pI,,+H7 sau transfu&ia de )S 6pI,,CH7" <ransfu&ia
de C#R a fost corelat cu !aloarea B< 6pI,,,,@7 a ILR$ului 6pK,,,,+7 i SI= 6pK,,,,+7" %imensiunile splinei 6pI,,,,+7, B<
6pI,,,,E7, durata inter!eniei c2irurgicale 6pI,,,+D7 i SI= 6pK,,,,+7 au fost identificai ca factori de risc independeni
pentru transfu&ia de ))C" Li!elul ridicat al SI= crete durata !entilaiei mecanice postoperatorii 6pI,,,,-7, durata de
staionare n unitatea de ngri/ire postaneste&ic 6pI,,,-,7 9i incidena complicaiilor neurologice 6pI,,,,+7"
Conclu&ii3 %ei scorul M#J% nu se corelea& cu SI= sau transfu&ia de )S, coagulopatia se!er i !alorile ridicate ale B<
repre&int factori de risc pentru acestea"

5bjective6 *iver transplantation 3*T4 is associated !ith significant operative blood loss. The aim of the present study is
assessing ris1 factors for severe intraoperative blood loss 3+B*4 and massive blood products transfusion 3BPT4.
Patients and Methods6 Be retrospectively analy-ed D; consecutive patients !ho under!ent *T from 8anuary %#"% to
March %#"9. Perioperative data !ere collected from the patients charts.
@esults6 5f all patients, %0,; & 3nE%"4 under!ent living$related *T and D",=& 3nE<94 under!ent deceased donor *T. The
median duration of surgery !as ;<< minutes 3range %<#$0<< minutes4, longer in living related *T 3;<9 min vs. <#0 min,
pE#,#9D4. The median +B* !as ;###ml 3range <##$9####ml4 re(uiring a median BPT of = units 3range "$9< units4 pac1ed
red blood cells 3P@Bc4 and "0 units 3range #$0< units4 Aresh fro-en plasma 3AAP4. 9% patients re(uired cryoprecipitate
transfusion and %# patients re(uired platelet transfusion. +ndependent ris1 factors for massive +B* !ere total bilirubin
levels 3TB4 3pE#,#%4, +G@ 3pF#,##"4, sodium levels 3pE#,#9<4, duration of surgery 3pE#,##;4 and pretransplant platelet
levels 3pE#,#;04. P@Bc transfusion !as associated !ith TB 3pE#,##94, +G@ 3pF#,##"4 and +B* 3pF#,##"4. @is1 factors for
AAP transfusion !ere6 TB 3pE#,##<4, spleen si-e 3pE#,##"4, duration of surgery 3pE#,#"04 and +B* 3pF#,##"4. +B* increased
the need for continuous postoperative mechanical ventilation 3pE#,##%4, length of postanaesthesia care unit stay
3pE#,#%#4 and neurologic complications 3pE#,##"4.
Conclusion6 'lthough high liver disease scores do not correlate !ith +B* and BPT, severe coagulopathy and high bilirubin
levels represent ris1 factors for severe bleeding and transfusion re(uirements.

re(entare de ca( $ TRABI n ostoperator
Case @eport $ T@'*+ in Postoperative
;lida Moise, Carmen ;rion$Balescu, Latalia Mincu, C" <" Guran, G" Stelea, %" Casaalian, %iana Stnescu
Spital M;I 0)rof" %" Gerota1, Bucure9ti, Rom*nia

;dministrarea de s*nge i deri!ai este gre!at de complicaii di!erse" = astfel de complicaie este <R;JI$<ransfusion$
Related ;cute Jung In/urQ"
8 pre&entm ca&ul unui pacient internat cu artroplastie old drept infectat, supurat, fistuli&atU artroplastii old
st*ng, genunc2i drept i st*ngU spondilodiscartro& lomar i 2emofilie ; form se!er la care s$a practicat su ;G$I=<
re!i&ie prote& old drept cu e(tragerea prote&ei infectate, cu dificulti te2nice deoseite i oc 2emoragic, cu montare
de spacer de ciment cu antiiotic" #!oluie dificil, n a ++$a &i postoperator pacientul pre&ent*nd simptome de
insuficien respiratorie acut 2ipo(emic la -$@2 posttransfu&area unei uniti de CM#, cu e!oluie rapid i dramatic,
care necesit suport !entilator pe S$I=< iniial, apoi pe canula de tra2eostom" #!oluia este gra!, marcat de
numeroase complicaii, care au necesitat tratament comple( permanent adaptat e!oluiei, consulturi interdisciplinare i
colaorri cu alte uniti medicale 6Institut Laional de 5ematologie, SMC7" )acientul este deconectat de !entilator
dup -F &ile, se suprim canula de tra2eostom la -C &ile de la montare" )e parcursul internrii a primit +,H ,,,u factor
8III liofili&at, +Hu crioprecipitat, C+u ))C, -EU CM#, L=8=S#8#L, acid trane(amic"
)acientul este transferat ntr$o secie de 2ematologie dup E+ &ile de internare, contient, aferil, C8C n 8:I stg,
ec2ilirat 2emodinamic i respirator 6respir spontan, eficient, orificiu de tra2eostom pe cale de cicatri&are, tuete
eficient7, deglutiie fr dificultate, toleran digesti! un, tran&it intestinal pre&ent, tulurri de sensiilitate i
motilitate la ni!elul memrului inferior st*ng"

'dministration of blood and derivatives is mar1ed by various complications. .uch a complication is T@'*+ $ transfusion$
related acute lung injury.
Be present a patient admitted !ith infected, suppurated, fistulised, right hip arthroplastyK left hip arthroplasty, right
and left 1nee artroplasty, lumbar discopathy and severe haemophilia ' !ho under!ent revision under general
anaesthesia. The infected prosthesis !as removed !ith technical difficulties and hemorrhagic shoc1 and the antibiotic
cement spacer !as applied.
The patient had a difficult evolution, on the eleventh postoperative day !ith acute hypoemic respiratory failure after %$
9 hours after transfusion of one blood unit, !ith fast dramatic evolution, re(uiring ventilator support. Aurther, the
evolution remains severe, mar1ed by complications re(uiring comple treatment permanently adapted !ith patient
evolution, interdisciplinary evaluations and collaborations 3Gational +nstitute of ,ematology4. The patient !as
disconnected from the ventilator after %= daysK the tracheostomy cannula !as removed %; days after insertion. During
hospitali-ation, patient received "#D ###u lyophili-ed factor )+++, "Du cryoprecipitate, ;"u AAP, %<U blood, G5)5.2)2G,
traneamic acid.
'fter <" days, the patient is transferred to the hematology department, conscious, apyretic, !ith C)C into +8), stable
hemodynamic and respiratory 3breathing spontaneously, efficiently, !ith tracheostomy hole almost healed, effective
cough4, s!allo! !ithout difficulty, good digestive tolerance, intestinal transit present, sensitivity and motility
disturbances in the left lo!er limb.


Tulburrile echilibrului acido$ba(ic n chirurgia abdominal asistat robotic
'cid$Base Disorders in @obotic 'ssisted 'bdominal .urgery. ' Prospective .tudy of <% Patients
%ana <omescu, Gariela %roc, Simona %ima, Saina <nsescu, M" )opescu
Institutul Clinic Fundeni, Bucure9ti, Rom*nia

=iecti!ele acestui studiu au fost de a cuantifica se!eritatea de&ec2ilirelor acido$a&ice n c2irurgia adominal asistat
rootic"
)acieni i metode3 ;u fost anali&ai prospecti! E- de pacieni supui unor inter!enii c2irurgicale adominale asistate
rootic n perioada septemrie $ decemrie -,+-" #c2ilirul acido$a&ic, presiunea par'ial a ga&elor sang!ine arteriale i
parametrii !entilatori au fost nregistrai postinducie, apoi la inter!ale de + or"
Re&ultate3 8*rsta medie a grupului de studiu a fost de EA,E ani 6ntre +H 9i D, ani7" %urata medie a inter!eniei
c2irurgicale a fost de -H, minute 6ntre +E, 9i CD, minute7, iar cea a pneumoperitoneului a fost de +D, minute 6ntre
+-, 9i C@, minute7" Ja finalul inter!eniei c2irurgicale -@. 6nI+-7 dintre pacieni a!eau o !aloare a p5KH,@ , D@. 6nI+,7
dintre ei a!*nd o presiune par'ial a C=- n s*ngele arterial 6paC=-7 peste CE mm5g" 8*rsta 6pI,,,E7 i !aloarea p5 la
deutul pneumoperitoneului 6pI,,,@H7 au fost identificai ca factori de risc independeni ai acido&ei la finalul
inter!eniei c2irurgicale" Factorii de risc determinai pentru 2ipercapnie sunt3 !alori mari ale presiunii inspiratorii
6pI,,,-@7 i paC=- 6pI,,,+-7 dup iniierea pneumoperitoneului" <oi pacienii acidotici au necesitat !entilaie
mecanic n unitatea de ngri/ire post$aneste&ic pentru o durat medie de H ore 6ntre F 9i D ore7"
Conclu&ii3 ;cido&a n c2irurgia adominal asistat rootic se datorea& n principal 2ipercapniei 9i poate fi pre&is de o
!aloare ridicat a paC=- dup iniierea pneumoperitoneului" ?n aceste ca&uri acido&a este rapid re!ersiil, pacienii
put*nd fi detuai n siguran dup un inter!al mediu de timp de H ore postoperator"

The primary objective of this study !as to assess the degree of severity of acid$base disorders in robotic$assisted surgery.
Patients and Methods6 Be prospectively enrolled <% patients !ho under!ent robotic assisted surgery from .eptember to
December %#"%. 'cid base status, partial pressure of arterial gases and ventilator parameters !ere recorded at the
beginning of surgery and on an hourly basis.
@esults6 The mean age in our study group !as <:,< years 3range"D$0# years4. Trendelemburg position !as used in =",<&
3nE9%4 of cases. The median duration of surgery !as %D# minutes 3range "<#$;0# minutes4 and that of
pneumoperitoneum !as "0# minutes 3range "%#$;9# minutes4. 't the end of surgery %9& 3nE"%4 had a p,FD,9 and 09&
of them 3nE"#4 had a arterial C5% tension 3paC5%4 above ;< mm,g. 5nly "D& 3nE%4 of acidosis !ere metabolic in
nature. +ndependent ris1 factors for acidosis at the end of surgery !ere6 age 3pE#,#<4 and p, value immediately after
initiation of pneumoperiotoneum 3pE#,#9D4. @is1 factors for hypercapnia !ere6 high inspiratory pressure after
pneumoperitoneum 3pE#,#%94 and high paC5% levels 3pE#,#"%4. 'll acidotic patients re(uired mechanical ventilation in
the post$anaesthesia care unit 3P'CU4 for a median duration of D hours 3range =$0 hours4.
Conclusion6 'cidosis in robotic assisted surgery is mostly due to hypercapnia and can be predicted by the value of paC5%
follo!ing pneumoperitoneum. +n such cases it is rapidly reversible and patients can be safely etubated in the P'CU after
a median of D hours.

"&aluarea modulrii auditi&e a stresului post$operator n chirurgia oncologic ma3or/ 'tudiu pilot
2valuation of 'uditory Modulation of Postoperative .tress in Major 5ncologic .urgery. Pilot .tudy
Ro(ana )ostolic 6+7, Gra&iela Biter 6-7, Ioana Froicu 6-7, %iana Bo/oi 6-7, %iana Maria G*lea 6-7, Iuliana Carmen
;casandrei 6-7, #lena Irina Blan 6-7, #milia )atra9canu 6-7, Ioana Grigora9 6-7
6+7 Institutul Regional de =ncologie, Ia9i, Rom*nia
6-7 Uni!ersitatea de Medicin 9i Farmacie 0Gr" <" )opa1, Ia9i, Rom*nia

=iecti!3 In!estigarea modulrii stresului post$operator prin influen'are auditi!"
Material 9i metod3 Studiu prospecti! controlat randomi&at, inclu&*nd to'i pacien'ii consecuti!i cu c2irurgie oncologic
ma/or, complian'i cu criteriile de includereBe(cludere" )acien'ii au fost inclu9i randomi&at n C grupe3 + $ c9ti cu mu&ic
clasic, - $ c9ti cu sunete din natur, @ $ c9ti numai pentru i&olare fonic, C $ grup control" ?n grupurile +, - 9i @ s$au
aplicat c9tile timp de @, minute la minim D ore post$operator n &iua opera'iei, a!*nd un scor al durerii e!aluat
preprocedur v C 9i fr analgetice intraprocedural" )arametrii urmri'i au fost scorul durerii preprocedur, la sf*r9itul 9i
la @, minute postprocedur, aprecierea suiecti! a ameliorrii durerii e!aluat la @, minute postprocedur pe o scal
de la + 6nici o ameliorare7 la E 6foarte mult7, iar stresul emo'ional a fost e!iden'iat cu a/utorul instrumentului )rofilul
%istresului ;fecti!"
Re&ultate3 <oate grupurile sunt caracteri&ate de un grad nalt de satisfac'ie a terapiei durerii 6C,HEU C,E,U C,-E respecti!
C,@E7, cu diferen'e statistic semnificati!e ntre grupul + 9i grupul control 6pK,,,E7" #!aluarea stresului emo'ional arat
diferen'e semnificati!e ntre toate grupele cu inter!en'ie !ersus control 6scor mediu grupul +,-,@, respecti! grup
control3 @H,+U C,,EEU @D,- respecti! E@,,,, pK,,,E7"
Conclu&ii3 ;cest studiu pilot rele! influen'a componentei auditi!e n ameliorarea intensit'ii durerii 9i n stresul
emo'ional post$operator, i&olarea fonic de mediu a!*nd efecte po&iti!e" Mai mult, modularea po&iti! prin mu&ic
clasic sau sunete din natur ameliorea& profilul emo'ional al pacientului"

?oal6 2valuation of postoperative stress modulation by auditory intervention.
Material and Method6 Prospective controlled radomi-ed study including all consecutive patients !ith major oncologic
surgery, !hich !ere compliant !ith inclusion/eclusion criteria. Patients !ere randomly allocated to ; study groups6 " $
headphones !ith classical music, % $ headphones !ith nature sounds, 9 $ headphones only for auditory isolation, ; $
control group. +n groups ",%,9 the headphones !ere applied for 9# minutes at least 0 hours postanesthesia in the day of
surgery, only if the preprocedural pain score !as j; and !ithout analgetics during the procedure. @egistered parameters
!ere pain score evaluated before, at the end of and at 9# minutes after the procedure, subjective feeling of pain relief,
evaluated at 9# minutes after the procedure on a scale from " 3no improvement4 to < 3very much4 and the emotional
distress !as assessed by 2motional Distress Profile instrument.
@esults6 +n all groups pain relief !as rated very high 3;,D<K ;,<#K ;,%< respective ;,9<4, !ith statistical significant
differences bet!een group " versus control 3pF#,#<4. 2valuation of emotional stress sho!s significant differences in all
interventional groups versus control 3average score6 group ",%,9, respective control6 9D,"K ;#,<<K 90,% respectiv <9,##,
pF#,#<4.
Conclusions6 This pilot study indicates the importance of auditory influence upon pain relief and emotional postoperative
stress, the single phonic isolation having good results. Aurther more auditory stimulation by classical music or nature
sounds results in more effective improvement of emotional distress.

Optimi(area managementului perioperator conform protocolului "RA' n chirurgia oncologic ma3or
abdominal/ Re(ultate preliminare
5ptimi-ation of Perioperative Management 'ccording to 2@'. Protocol in Major 'bdominal 5ncologic
.urgery. Preliminary @esults
Ja!inia Bodescu ;mancei 6+7, C" )rista!u 6+7, ;dina Ble/u9c 6+7, ;" Caragea 6+7, ;ndreea %umitriu 6+7, %" Rusu 6-7, Ioana
Grigora 6+7
6+7 Uni!ersitatea de Medicin 9i Farmacie 0Gr" <" )opa1, Iai, Rom*nia
6-7 Institutul Regional de =ncologie, Iai, Rom*nia

=iecti!e3 #!aluarea gradului de aplicare a strategiilor #R;S 9i corela'ia cu e!olu'ia postoperatorie"
Material 9i metod3 Studiu prospecti! oser!a'ional desf9urat n IR= Ia9i ncep*nd cu +",-"-,+@, care a inclus to'i
pacien'ii consecuti!i complian'i cu criteriile de includereBe(cludere" )arametrii nregistra'i3 durata postului preoperator
pentru solide 9i lic2ide, utura dulce preoperatorie, pregtirea colonului, terapia !olemic intra$ 9i postoperatorie,
2ipotermia intraoperatorie, analge&ia peridural, tuurile de dren, sonda na&o$gastric, analge&ia postoperatorie,
moili&area 9i nutri'ia enteral postoperatorii precoce"
#!olu'ia postoperatorie a fost e!aluat prin reluarea tran&itului pentru ga&e 9i durata spitali&rii"
Complementar au fost nregistrate costurile totale ale spitali&rii"
Re&ultate3 HF pacien'i au fost inclu9i n studiu, la care s$au aplicat ntre -$+, strategii 6mediana fiind E parametri, -,
pacien'i7" )relucrarea statistic demonstrea& o puternic corela'ie ntre numrul de strategii #R;S aplicate 9i reluarea
tran&itului intestinal, durata de spitali&are 9i costuri" Compara'ia dintre aplicarea a @ strategii 6H ca&uri7 9i D strategii 6F
ca&uri7 rele! reluarea tran&itului la KCD ore la + pacient 6+C.7, respecti! F pacien'i 6+,,.7, o durat medie de
spitali&are de +- &ile, respecti! F &ile 9i costuri medii de FH+ER=LBca&, respecti! -AAHR=LBca&"
Conclu&ii3 ;plicarea strategiilor din protocolul #R;S ameliorea& semnificati! recuperarea postoperatorie a pacien'ilor 9i
reduce costurile" Re&ultatele acestui studiu preliminar, care oiecti!ea& practica actual n IR= Ia9i, constituie
argumente solide pentru o mai un implementare a acestor strategii"

?oals6 'ssesment of 2@'. strategies implementation and correlation !ith patient rehabilitation.
Material and Method6 Prospective observational study conducted in +@5 +aqi starting !ith #".#%.%#"9, including all
consecutive patients compliant !ith inclusion/eclusion criteria.
@egistered parameters6 duration of preoperative fluid and solid fasting, carbohydrate preoperative drin1, colon
preparation, intra$ and postoperative volume therapy, intraoperative hipothermia, epidural analgesia, drainage of
abdominal cavity, postoperative analgesia, naso$gastric tube, early postoperative mobili-ation and enteral nutrition.
Postoperative recovery !as assessed by first flatus passage and length of hospital stay 3*5.4. +n addition the total cost of
hospitali-ation !as registered.
@esults6 +n D= enroled patients a number of %$"# strategies !ere applied, a median number of < strategies, being present
in %# patients. The statistical analysis sho!s a strong correlation bet!een the number of applied strategies and the
flatus passage, *5., and costs. The presence of 9 3D cases4 versus 0 3= cases4 strategies resulted in a flatus passage
earlier than ;0 hours in " case 3"; &4 respective = cases 3"##&4, a mean *5. of "% days respective = days !ith an
average cost of =D"< @5G/case respective %::D @5G/case.
Conclusions6 The implementation of 2@'. strategies significantly enhances the postoperative recovery and reduces
dramatically the costs. The preliminary results of the present study enforce a better appliance of 2@'. strategies !ith
the aim to minimi-e hospitali-ation and the financial burden.

Administrarea precoce de Cerebrol@(in n do(e mari a3ut recuperarea neurologic posttraumatic/
re(entare de ca(
Beneficial 2ffects of ,igh Dose Cerebrolysin +mproves @ecovery 'fter Trauma. Case @eport
;nca$Maria )rodea, M" Sa!a, Ioana Ro(ana Codru, Corina Roman$Filip, %oina )atrusel
Spitalul Clinic :udeean de Urgen Siiu, Rom*nia

CererolQsin este un amestec de peptide ce stimulea& mecanismele de neuroprotec'ie i neuroplasticitate, cu eficien
do!edit n tratamentul acut i de neuroailitare posttraumatism craniocereral"
)re&entm ca&ul unui rat, @E ani, internat n spital n urma unui accident prin cdere de la - metri, n pdure, unde a
supra!ie'uit -, ore n condiii de frig e(trem 6$-,grC7" %in prespital s$a practicat intua'ia orotra2eal 9i ncl&irea
e(tern, concomitent cu refacerea !olemiei" ; fost internat n sec'ia ;<I cu 9oc traumatic prin traumatism
craniocereral nc2is, fractur de a&in, fracturi arcuri costale F, H st*nga cu 2emotora( asociat, 2ipotermie moderat
6temperatur central3 @-grC7, com, unde s$au continuat msurile de suport !entilator 6!entila'ie mecanic 9i drena/
pleural st*ng7, suport circulator 6!asopresor, reple'ie !olemic7 9i ncl&ire treptat" Consultul neurologic e!iden'ia&
coma, GCSI@p, pupile egale, intermediare, refle( fotomotor 9i cornean pre&ente, tetraplegie flasc areacti!, refle(e
osteotendinoase aolite gloal, refle( cutanat plantar indiferent, ilateral, iar e(amenul tomograf cereral decelea&
colec'ie 2ematic n cantitate mic n coarnele temporale ale !entriculilor laterali, minim edem cereral difu&" S$a ini'iat
precoce, nc din primele F ore, administrarea continu de CererolQsin n do&e mari F$D fioleB&i, cu ameliorarea
neurologic gradual n urmtoarele - sptm*ni, a fost tratat de ron2opneumonie tardi! asociat !entila'iei
mecanice 9i apoi e(tuat"
; necesitat pe parcursul internrii multiple inter!en'ii pentru le&iunile tegumentare prin degerare de la ni!elul
gamelor, amputarea falangelor distale de la toate memrele" S$a e(ternat dup H sptm*ni de spitali&are fr
complica'ii, cu status neurologic normal, con9tient, cooperant, fr deficite motorii"

Cerebrolysin is a peptides preparation that stimulates the neuroprotective and the neuroplasticity mechanisms, !ith
proven clinical effectiveness in the acute and neuro$recovery treatment after traumatic brain injury.
Be report the case of a 9< years old male, admitted to the hospital after falling from % metres hight, in the !oods, and
surviving %# hours in etreme cold 3$%# degreesC4. The prehospital care included orotracheal intubation, eternal heating
measures and concomitant volemic ressuscitation. ,e !as admitted in the +ntensive Care Unit !ith traumatic shoc1
follo!ed craniocerebral trauma, pelvic fractures, =
th
and D
th
left ribs fractures complicated !ith hemothora, mild
hypothermia 3core temperature 9% degreesC4. +n the unit the ventilatory supportiv measures 3mechanical ventilation, left
pleurostomy4, vassopresor support, volemic ressuscitation and progressive heating continued. The neurological consult
reveals coma, ?C.E9p, intermediate, e(ual pupils, present corneal and pupillary reflees, non$reactive flaccid
tetraplegia, abolished deep tendon responses, indiferent bilateral cutanat plantar response. The computed tomography
sho!ed a small haemorrhage in the temporal hornes of the lateral ventricles, minimal cerebral edema. Be started the
Cerebrolysin therapy early, !ithin the first = hours from admission, in continuous i.v. infusion !ith high doses, =$
0vials/day. The neurological status improved progressively for the net % !ee1s, !as treated for late ventilator
associated pneumonia and etubated.
During hospitali-ation he needed multiple interventions for the frost lessions of the leg s1in, amputations of the distal
phalanges from all the limbs. ,e !as discharged from the hospital after D !ee1s of hospitali-ation !ithout
complications, normal neurological status, conscious, orientated, !ithout motor deficits.

,iagnosticul trombo(elor pulmonare n unitatea de terapie intensi&
Diagnosis of Pulmonary Thrombosis in the +ntensive Care Unit
8" Co/ocaru, =lga Cusnir
Spitalul Clinic Repulican, C2i9inu, Repulica Moldo!a

?n literatur sunt o multitudine de surse 9tiin'ifice despre <#;), ns date clinice, paraclinice referitoare la diagnosticul
clinic al tromo&ei arterei pulmonare lipsesc, e(ist doar date patomorfologice de diferen'iere a acestora"
Scopul3 Stailirea criterilor clinice, paraclinice de diagnostic a tromo&ei pulmonare pentru crearea algoritmului de
terapie intensi! al tromo&elor pulmonare"
Material 9i metode3 %iagnosticul de tromo& pulmonar l$am suspectat la @@ pacien'i, cu !*rsta ntre -D $ H@ ani"
%iagnosticul a fost stailit pe a&a datelor clinice, de laorator 9i e(plorri paraclinice"
Re&ultate3 <) are gene&a de origine local 6pulmonar7, iar <#;) $ cau& e(trapulmonar" Inter!en'ii c2irurgicale dup
care se de&!olt sindromul de compartiment adominal au un poten'ial tromogenetic local pulmonar, specific
tromo&ei pulmonare" Semnele clinice 9i anamne&a au fost anali&ate dup stailirea diagnosticului de <#;)B<) n
ansamlu, terapia intensi! 9i msurile de resuscitare au fost ini'iate la depistarea sindromului respecti!"
Conclu&ii3 <) este un sindrom de CI% local pulmonar, instalat lent cu manifestri clinice silen'ioase, e!idente odat cu
apari'ia le&iunii pulmonare acute de origine secundar" Semnele clinice 9i paraclinice atest decompensarea
mecanismelor pro$ 9i antitromotice, caracteristice sindromului de CI% n fa&ele a!ansate" Sindromul de compartiment
adominal, sindromul de CI%, S%R;, sepsisul, M=%S$ul au un statut de factori predicti!i rele!an'i n de&!oltarea
tromo&ei pulmonare"

Faria-ia numrului de trombocite la pacien-ii cirotici interna-i n 'pitalul MAI =rof/ ,/ 2erota>
)ariations of Platelets in Cirrhotic Patients 'dmitted in M'+ ,ospital QProf. D. ?erotaR
;lida Moise 6+7, Carmen ;rion$Blescu 6+7, Latalia Mincu 6+7, C" <" Guran 6+7, G" Stelea 6+7, %iana Stnescu 6+7, ;driana
S*rcea 6+7, J" Rducan 6+7, <" Bdescu 6+7, Felicia Stroe 6-7
6+7 Spital M;I 0)rof" %" Gerota1, Bucure9ti, Rom*nia
6-7 ILS, Bucure9ti, Rom*nia

Scop3 Identificarea frec!enei i se!eritii cu care apare tromocitopenia la pacienii cu ciro& 2epatic de diferite
etiologii admii n -,,A n spitalul nostru"
Metod i material3 ;m imaginat un studiu prospecti!, oser!aional care a nrolat pacienii admii n spitalul nostru cu
ciro& 2epatic care au a!ut ne!oie de consultul i inter!enia medicului de terapie$intensi!, cu sau fr internare n
secia de ;<I" %up parcurgerea criteriilor de includere pacienii au fost in!estigai conform protocolului de lucru
stailit" )entru interpretarea statistic a re&ultatelor s$a creat o dat de a&e generale n Microsoft #(cel -,,@" %atele
statistice au fost prelucrate folosind #piInfo soft" %atele e(primate ca medii au fost comparate cu Studentps t$test 6AE.
inter!al de ncredere, pq,",E ni!el de semnircaie7"
Re&ultate3 ;u fost ncadrai +H+ pacieni 6-H@ internri7, H+,@C rai, cu !*rsta medie de ED,++IB$++,@C"
<romocitopenia a fost gsit la H,. dintre pacieni, tromocitopenia su +,, (+,@Bml la CF,A., iar tromocitopenia
su E,(+,@Bml la H,@ pacieni" Frec!ena tromocitopeniei la pacieni cu 85C a fost mai mare $ H+,F." ;u primit
transfu&ie de tromocite @ pacieni care au suferit inter!enii c2irurgicale" 8ariaia tromocitelor este mai ine
repre&entat la pacienii care au s*ngerat i se corelea& ine cu mortalitatea" %urata medie de internare a fost de
D,-EjC,+H- &ile, fr legtur cu tromocitopenia"
Conclu&ii3 )acienii cirotici admii n spitalul nostru n -,,A, n principal rai, au pre&entat tromocitopenie ntr$un
procent semnificati! $ H,." <romocitopenia se!er a fost gsit la H,@. dintre pacieni"

Bac1ground and 'ims6 +dentifying the fre(uency and the severity of thrombocytopenia in patients !ith hepatic cirrhosis
admitted in %##: in our hospital.
Methods6 ' prospective, observational study, !hich enrolled patients admitted in our hospital !ith hepatic cirrhosis $
!hich needed an intensive care evaluation, associated or not !ith admission in +ntensive Care settings in %##:. 'fter
inclusion criteria, patients !ere investigated according the !or1 protocol. Aor statistical interpretation of the results, a
generalised database !as created using Microsoft 2cel %##9. .tatistic stratified data processing !as used 2pi+nfo soft.
Data as mean h.D !ere compared using .tudentJs t$test3 :<& confidence interval, level of significance pl#.#<4.
@esults6 'fter the inclusion criteria there !ere "D" patients 3%D9 admissions4 $ male $ D".9;&, mean age <0.""7/$"".9;.
The fre(uency of thrombocytopenia !as D#&, thrombocytopenia under "## "#9/ml had a fre(uency of ;=.:& and
thrombocytopenia under <#"#9/ml !as diagnosed at D,9& of patients. The fre(uency of thrombocytopenia in patients
!ith ),C !as D",= &. 9 patients received thrombocytes transfusion, all of them under!ent surgical procedures. The
variation of platelets is better represented in patients !ith bleeding and is correlated !ell !ith mortality. The mean time
of hospitali-ation !as 0,%<h;,"D% days, !ithout significant differences for levels of thrombocytopenia.
Conclusions6 Cirrhotic patients admitted in our hospital in %##:, mainly men, !ith high consumption of alcohol are
caracteri-ed by the presence of thrombocytopenia in significant percentage $ D#&. .evere thrombocytopenia is found in
a small number of patients $D,9&.



'indrom de hiperstimulare o&arian complicat cu citoli( hepatic marcat
5varian ,yperstimulation .yndrome Complicated !ith Mar1ed ,epatic Cytolysis
Claudia Mi2aela Bu&a9 6+7, =" Bedreag 6-7, C"I" Macarie 6-7, %" %rgulescu 6-7, F" ;" %orneanu 6@7, %" Sndesc 6-7
6+7 Clinica Brol, <imi9oara, Rom*nia
6-7 Spitalul Clinic :ude'ean de Urgen', <imi9oara, Rom*nia
6@7 Clinica )resident, <imi9oara, Rom*nia

Sindromul de 2iperstimulare o!arian este o complica'ie iatrogen, poten'ial se!er a stimulrii o!ariene controlate cu
simptomatologie accentuat 9i durat prelungit n pre&en'a sarcinii"
)re&entm ca&ul pacientei LL, @E ani, supus unui tratament de stimulare o!arian care la ++ &ile de la emriotransfer
se pre&int n clinica noastr cu dureri adominale, gre'uri, u9oar dispnee, oligurie" )araclinic constatm leucocito&,
tromocito&, cre9terea transamina&elor 6+CC U-@D UBJ 7, ascit n cantitate moderat, pleure&ie a&al ilateral"
)acienta se monitori&ea& 2emodinamic, se urmre9te greutatea, diure&a, circumferin'a adominal, lic2idul de ascit 9i
pleure&ia, se administrea& alumin uman -,., antiemetice, 2eparin frac'ionat, solu'ii cristaloide, gluco&a,
tratament de sus'inere a sarcinii cu progesteron intra!aginal" Urmea& re&olu'ia ascitei, dispari'ia gre'urilor,
normali&area diure&ei, !aloarea transamina&elor cre9te progresi! la !alori de F+,U @,A UBJ" ;lte proe 2epatice
modificate3 J%5$ul 9i F;J" Se e(clude 2epatita acut 6;, B, C, #7" Se ntrerupe tratamentul de sus'inere a sarcinii" 8alorile
transamina&elor s$au normali&at n urmtoarele dou sptm*ni" #ste !ora de un sindrom de 2iperstimulare o!arian
form se!er cu remisia citoli&ei 2epatice dup ntreruperea tratamentului cu progesteron"
Cu!inte c2eie3 sindrom de 2iperstimulare o!arian, citoli& 2epatic, progesteron

5varian hyperstimulation syndrome is an iatrogenic complication, potentially severe, of controlled ovarian stimulation,
!ith pronounced symptomatology and prolonged duration during pregnancy. Be present the case of patient GG, 9<
years old, under an ovarian stimulation treatment, !ho, "" days after embryo transfer, comes in our clinic !ith
abdominal pain, nausea, mild dyspnea, oliguria. The paraclinical eamination sho!s leu1ocytosis, thrombocytosis,
elevated transaminases 3";; or %90 U / *4, the presence of moderate ascites 3ultrasound eamination4 and bilateral
basal pleurisy 3chest radiography4. The patient !as hemodynamically monitored, also !ith the monitoring of !eight,
diuresis, and abdominal circumference, the amount of ascites fluid and evolution of pleurisy. ,uman albumin %#& !as
being given, antiemetics, fractionated heparin, crystalloid solutions, glucose, and intravaginal supportive treatment !ith
progesterone. There !as a slo! resolution of ascites, the nausea disappeared, the urine output normali-ed, but the
hepatic transaminases progressively increased, reaching the values of ="# or 9#: U / *. 5ther modified samples !ere
*D, and A'*. ' gastroenterologist specialist !as consulted and an acute hepatitis 3', B, C, 24 !as ecluded. 5ne decided
to stop the pregnancy support treatment. TransaminaseJs levels !ere normali-ed in the net t!o !ee1s. Therefore, it
!as a severe form of ovarian hyperstimulation syndrome in !hich mar1ed hepatic cytolysis remission occurred after
discontinuation of progesterone.
>ey!ords6 ovarian hyperstimulation syndrome, hepatic cytolysis, progesterone


articulariti cliniceD fi(iopatologice n in3uria renal acut consecuti& traumatismelor abdominale
Clinical and Pathophysiological Aeatures in 'cute @enal +njury Aollo!ing 'bdominal Trauma
F" )urcaru, %aniela Cernea, ;lice %rgoescu, M" Lo!ac, ;" Roc9oreanu
Spitalul Clinic :ude'ean de Urgen' Craio!a, Rom*nia

Le$am propus c*te!a oser!a'ii cu pri!ire la particularit'ile clinice 9i fi&iopatologice prin care se manifest in/uria
renal acut n cadrul traumatismelor adominale" ;m a!ut n oser!a'ie @+ de ca&uri de in/urii renale acute dup
traumatisme adominale cu di!erse le&iuni" %intre acestea +- ca&uri au fost n stadiul de insuficien' renal 6failure
dup clasificarea RIFJ#7 ce au necesitat epura'ie e(trarenal, iar +A ca&uri nu au necesitat epura'ie e(trarenal"
Men'ionm c toate ca&urile au suportat di!erse inter!en'ii c2irurgicale" Je&iunile au fost comple(e la ca&urile epurate
e(trarenal3 E ca&uri 2ematoame retroperitoneale plus alte le&iuni 6ruptur de !e&ic, ruptur de rinic2i, splin sau ficat,
contu&ie de pancreas7 de asemenea le&iuni osoase 6fractur de a&in, de femur, de coaste, amputa'ie traumatic a
coapsei drepte7" )eritonite prin perfora'ie de intestin 6C ca&uri7 9i @ ca&uri ruptur de me&enter" Ca particularit'i
fi&iopatologice am remarcat n afar de perturrile renale3 9ocul traumatic, 9ocul 2emoragic, transfu&ii mari de s*nge
conser!at 6cu consecin'ele sistemice7, CI%, radomioli&, elierare de miogloin" ?n plus n paralel cu in/uria renal a
e(istat 9i M=%S n peste E,. din ca&uri" Clinic s$au remarcat3 forme de in/urie renal 2ipercataoliceU alte disfunc'ii
organice 6;R%S, tulurri 2ematologice, tulurri circulatorii7, dificult'i n aplicarea 2emodiali&ei datorit strii
prelungite de 9oc 9i plgilor operatorii recente ce agra!au s*ngerarea" Mortalitatea a dep9it E,. la ca&urile
2emodiali&ate, multe fiind prin complica'ii c2irurgicale"
Ca 9i conclu&ii3 In/uria renal acut n cadrul traumatismelor adominale e!oluea& cu stri de 9oc prelungite 9i M=%S,
pre&int dificult'i terapeutice n aplicarea 2emodiali&ei, au o mortalitate ridicat"

Be set some observations on clinical and pathophysiological signs !hich manifests acute renal injury in abdominal
trauma. + had under observation 9" cases of acute 1idney injury after abdominal trauma injuries. 5f these "% cases !ere
stage renal failure 3failure after @+A*2 classification4 re(uiring etrarenal scrubbers and ": cases re(uiring etrarenal
cleanser. Mention that all cases have supported various surgeries. Comple lesions !ere treated non$renal cases6 < cases
of retroperitoneal hematoma plus other injuries 3ruptured bladder, rupture of 1idney, spleen or liver, pancreatic
contusion4 also bone injuries 3fractures of the pelvis, femur, ribs, traumatic amputation right thigh4. Bo!el perforation
peritonitis 3; cases4 and 9 cases of rupture of the mesentery. 's + noted pathophysiological features besides renal
disturbances6 traumatic shoc1, hemorrhagic shoc1, high blood transfusions preserved 3!ith systemic conse(uences4, D+C,
rhabdomyolysis, myoglobin release. +n addition in parallel !ith renal injury and M5D. has been in over <#& of cases.
Clinic noted6 hypercatabolic forms of renal injury, other organ dysfunction 3'@D., hematologic disorders, circulatory
disorders4, haemodialysis due to difficulties in applying state of shoc1 etralong and recent operators that aggravate
bleeding !ound. Mortality eceeded <#& in haemodialysis cases, many being through surgical complications. 's
conclusions acute 1idney injury in abdominal trauma develops !ith prolonged state of shoc1 and M5D. and has
difficulty in applying haemodialysis therapy, also having a high mortality.

'uportul nutri-ional $ Rol cheie n chirurgia ma3or abdominal
Gutritrion .upport Therapy $ ' >ey @ole in @ecovering 'fter Major 'bdominal .urgery
#lena $ Juminia Stnciulescu, Ioana Grin'escu, Ru(andra ;ndreea Marin
Spitalul Clinic de Urgen Bucureti, Bucureti, Rom*nia

=iecti!3 Scopul acestei lucrri este de a e!idenia importana msurilor de terapie intensi! i
nutriional n c2irurgia ma/or adominal, fistulele digesti!e postoperatorii cu deit mare repre&ent*nd complicaii
gra!e datorit multiplelor consecine"
Material i metod3 )re&entm ca&ul unui pacient n !*rst de F+ de ani diagnosticat cu neoplasm gastric, multiplu
operat n sfera adominal, transferat n stare critic, cu disfuncii organice multiple, n Clinica de ;neste&ie i <erapie
Intensi! a Spitalului Clinic de Urgen Bucureti, a!*nd diagnosticul de sepsis se!er cu punct de plecare adominal,
fistul la ni!elul ontului duodenal, aces sufrenic st*ng, aces su2epatic, status postre&ecie gastric sutotal cu
anastomo& gastro/e/unal" Ja scurt timp de la admisie s$a reinter!enit n urgen, practic*ndu$se e!acuarea aceselor,
splenectomie, la!a/ i drena/ peritoneal multiplu" ?n urma e!alurii statusului nutriional prin metode antropometrice i
paraclinice s$a determinat un risc nutriional crescut, necesit*nd iniierea unei terapii susinute din punct de !edere
nutriional" #!oluia a fost dificil, fiind necesar instituirea suportului !entilator, !asopresor, antiioterapie cu spectru
larg, nutriie mi(t parenteral i enteral"
Re&ultate3 Suportul nutriional a fost introdus precoce i s$a urmrit suprimarea c*t mai rapid a nutriiei parenterale,
ncerc*nd ca necesarul caloric s fie asigurat e(clusi! pe cale enteral pe sond /e/unal, ulterior per os"
Conclu&ii3 Sepsisul gre!at pe un organism cu malnutriie se!er, repre&int cau&a principal de deces"
Managementul nutriional comple(, asociat celorlalte msuri de terapie intensi! a constituit c2eia succesului n acest
ca&"

5bjective6 The paper eplores the importance of the critical care measures and nutrition for patients undergoing major
abdominal surgery. The most significant postoperative complication is represented by the high$flo! digestive fistula
because it may lead to multiple conse(uences.
Material and Methods6 Be report the case of a =" year old male patient diagnosed !ith gastric cancer, !ho !as
operated on several times in the abdominal area. ,e !as transferred in a critical condition to the Bucharest Clinical
2mergency ,ospital $ +ntensive Care Unit, suffering from multiple organ dysfunctions !hich led to the diagnosis of severe
abdominal sepsis, duodenal fistula, left subphrenic abscess, subhepatic abscess, post subtotal gastrectomy !ith
gastrojejunal anastomosis status. 'fter a rather short period of time from the admission into the +CU, the patient had
another emergency surgery in !hich the abscesses !ere evacuated and a splenectomy and a multiple peritoneal
drainage !ere made. 'nthropometric and paraclinical studies established the patientJs high nutritional ris1 status,
evo1ing the need of a nutrition support therapy. There !as a difficult progression in the patientJs health status, thus
needing a mechanical ventilatory support, vasopressor support, broad spectrum antibiotics and mied parenteral and
enteral feeding.
@esults6 Gutrition support !as early introduced, at the same time trying to rapidly suppress parenteral feeding. 't first,
the daily calorie inta1e !as provided only by enetral jejunal feeding and after!ards by oral feeding.
Conclusions6 .evere malnutrition of a septic patient is the main cause of death in these cases. Comple nutritional
management among other critical care measures represented a 1ey to success in this case study.