The Macedonian Journal of Anaesthesia (MJA) is a peer-reviewed, open-access scientific journal dedicated to the publication of high-quality research in the fields of anaesthesiology, critical care medicine, perioperative medicine, pain management, and related disciplines. The journal aims to promote scientific knowledge, clinical practice, and innovation by providing a platform for clinicians, researchers, and healthcare professionals to disseminate original research, review articles, case reports, and other scholarly contributions. MJA encourages the exchange of knowledge at both national and international levels and supports the advancement of evidence-based medicine and clinical excellence. The journal adheres to internationally recognized ethical and editorial standards, including the recommendations of the International Committee of Medical Journal Editors (ICMJE), Committee on Publication Ethics (COPE), and the EQUATOR Network. All articles are published in English and are freely accessible to ensure wide dissemination of scientific knowledge. The official journal website is available at https://mja.mk
Department of Anaesthesia and Reanimation, University Clinical Center “Mother Teresa”, Skopje, North Macedonia, in collaboration with the Macedonian Society of Anaesthesia (MSA) and Macedonian Society of Critical Care Medicine (MSCCM)
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CT-BASED ANALYSIS OF PULMONARY NEOPLASTIC LESIONS IN PATIENTS WITH EMPHYSEMA: PREVALENCE AND IMAGING CORRELATES — A RETROSPECTIVE STUDY
Objective: Computed tomography (CT) plays a central role in the early detection and characterization of lung neoplasms and allows simultaneous assessment of structural lung diseases such as emphysema. The aim is to determine the prevalence of emphysema in patients with CT-detected pulmonary neoplastic lesions and to evaluate its association with tumor size, morphology, and anatomical distribution. Materials and Methods: This retrospective observational study was conducted at the University Clinic of Pulmonology and Allergology. A total of 1045 thoracic CT examinations performed between August 2025 and January 2026 using a PHILIPS Incisive CT scanner protocol optimized for thoracic imaging were reviewed. One hundred patients with CT-detected lung neoplasms were included. Demographic characteristics, emphysema subtype, tumor features, and associated CT findings were analyzed. Emphysema was assessed visually and classified by subtype. Statistical analysis included chi-square testing, t-tests, Mann–Whitney U tests, ANOVA, and multivariable logistic regression. Results: Lung neoplasms were identified in 9.6% of CT examinations. Emphysema was detected in 48% of patients, predominantly of the centrilobular type. The mean tumor size was 52.4 ± 22.1 mm, with a predominance of the upper lobe and central segment. No statistically significant associations were observed between emphysema and tumor size, morphology, lobar distribution, or segmental localization. Male sex was associated with increased odds of emphysema (OR ≈ 2.4), although the association did not reach statistical significance. The regression model showed limited explanatory power (Pseudo R² = 0.066). Conclusion: Emphysema frequently coexists with lung neoplasms in tertiary clinical practice. However, within the limitations of this retrospective imaging-based study, emphysema was not associated with measurable differences in CT tumor phenotype. Emphysema should be regarded primarily as a background risk substrate rather than a determinant of tumor imaging characteristics.
Copyright (c) 2026 Kristina Dimitrijevikj (Author) https://creativecommons.org/licenses/by/4.0
PERIOPERATIVE ANALGESIC EFFICACY OF THE ERECTOR SPINAE PLANE BLOCK WITHIN A MULTIMODAL ANESTHESIA PROTOCOL FOR OPEN THORACOLUMBAR SPINAL FIXATION SURGERY
Abstract Objective: Open thoracolumbar spinal fixation is associated with severe intraoperative and postoperative pain. Opioids are frequently used for perioperative analgesia in these procedures, but their use is associated with adverse effects, such as postoperative nausea and vomiting, sedation, pruritus, urinary retention, respiratory depression, and delayed recovery. Ultrasound-guided regional techniques, incorporated within a multimodal analgesic strategy, may improve perioperative pain control and reduce opioid requirements. Materials and Methods: This randomized prospective interventional clinical study evaluated the perioperative analgesic effect of bilateral erector spinae plane block (ESPB) as part of multimodal anesthesia compared with opioid-based analgesia in patients undergoing open fixation for thoracic or lumbar vertebral fractures. Seventy patients were randomized into two groups: an opioid group (OG; n=35) and an ESPB with multimodal analgesia group (ESPB+MMA; n=35). Outcomes included intraoperative fentanyl consumption, postoperative tramadol requirements, postoperative Numerical Rating Scale (NRS) pain scores, postoperative nausea and vomiting (PONV), and neurological or psychotomimetic adverse effects. Results: Patients in the ESPB+MMA group required only induction-dose fentanyl, whereas patients in the OG required 500-1200 mcg of fentanyl intraoperatively. Postoperative tramadol was required in only 4 patients (11.4%) in the ESPB+MMA group, compared with all patients in the OG, where total postoperative tramadol consumption ranged from 100 to 1500 mg. Postoperative pain scores were consistently lower in the ESPB+MMA group during the first 48 hours after surgery. PONV occurred in 14.3% of patients in the ESPB+MMA group and 31.4% of patients in the OG. No ESPB-related complications were recorded. Conclusion: The combination of ESPB and multimodal analgesia provided effective perioperative analgesia, markedly reduced opioid consumption, lowered the incidence of PONV, and appeared safe in patients undergoing open thoracolumbar spinal fixation.
Copyright (c) 2026 Aleksandar Dimitrovski, Biljana Kuzmanovska, Natasha Toleska Dimitrovska, Marija Toleska Doneska, Marta Treneva Nicheska, Aleksandra Gavrilovska Brzanov (Author) https://creativecommons.org/licenses/by/4.0
BILATERAL ERECTOR SPINAE PLANE BLOCK IN OPEN SPINAL FIXATION SURGERY: A COMPARATIVE STUDY OF SAFETY AND CLINICAL OUTCOMES
Objective: Open thoracic and lumbar spinal fixation surgery is associated with severe postoperative pain resulting from extensive tissue injury, muscle dissection, periosteal trauma, and instrumentation. Effective postoperative analgesia is essential for early mobilization and functional recovery. Regional anesthesia techniques have become increasingly important components of multimodal analgesic protocols aimed at reducing perioperative opioid exposure and opioid-related adverse effects. The primary objective of this study was to evaluate the safety profile of bilateral erector spinae plane block (ESPB) in patients undergoing open thoracic and lumbar spinal fixation surgery. Secondary objectives included assessment of intraoperative and postoperative opioid requirements, postoperative pain intensity during the first 48 hours, length of hospital stay, postoperative nausea and vomiting. Materials and Methods: We performed a comparative clinical study involving 100 patients scheduled for open thoracic or lumbar spinal fixation surgery. Patients were divided into two groups, each comprising 50 patients. The opioid group (OG) received intermittent fentanyl-based analgesia, whereas the ESPB group (ESPBG) underwent bilateral ultrasound-guided erector spinae plane block with administration of 10 mL of 1% lidocaine and 20 mL of 0.25% bupivacaine on each side. Postoperative pain intensity was assessed using the Numeric Rating Scale (NRS) at 1, 4, 8, 12, 24, 36, and 48 hours after surgery. Statistical analysis included Student’s t-test, Mann–Whitney U test, Pearson chi-square analysis, Cramer’s V coefficient, Friedman ANOVA, and Pearson correlation analysis. Results: Compared with intermittent opioid analgesia, bilateral ESPB was associated with significantly lower fentanyl and tramadol consumption, lower postoperative pain scores, shorter hospital stay, and reduced incidence of postoperative nausea and vomiting. No major block-related complications were observed. Conclusion: Bilateral erector spinae plane block demonstrated a favorable safety profile and significant opioid-sparing effects in patients undergoing spinal fixation surgery. These findings support the incorporation of ESPB into multimodal analgesic protocols and enhanced recovery pathways.
Copyright (c) 2026 Aleksandar Dimitrovski (Author) https://creativecommons.org/licenses/by/4.0
HEMODYNAMIC MONITORING AND GOAL-DIRECTED THERAPY IN MAJOR ABDOMINAL SURGERY: CURRENT CONCEPTS AND FUTURE DIRECTIONS
Objective: Major abdominal surgery is frequently associated with substantial physiological stress, fluid shifts, inflammatory activation, and perioperative hemodynamic instability, all of which may contribute to postoperative organ dysfunction and increased morbidity. Over recent decades, perioperative hemodynamic management has evolved from reliance on static physiological variables toward individualized, physiology-driven optimization strategies. Materials and Methods: This narrative review summarizes current concepts in perioperative hemodynamic monitoring and GDT in major abdominal surgery. The physiological basis of tissue perfusion, preload responsiveness, and cardiovascular optimization is discussed together with the clinical role of static and dynamic monitoring variables, including mean arterial pressure, central venous pressure, lactate, pulse pressure variation, stroke volume variation, and passive leg raising. Contemporary monitoring technologies such as arterial waveform analysis, minimally invasive cardiac output monitoring, and perioperative echocardiography are also reviewed. Discussion: Contemporary perioperative medicine increasingly integrates dynamic hemodynamic monitoring, minimally invasive cardiac output assessment, arterial waveform analysis, ultrasound-based evaluation, and goal-directed therapy (GDT) protocols to optimize tissue perfusion while avoiding both hypovolemia and fluid overload. Current evidence suggests that individualized GDT strategies integrating fluids, vasopressors, and inotropic therapy may reduce postoperative complications, shorten hospital stay, and optimize perioperative outcomes in selected abdominal surgery populations. Emerging technologies including artificial intelligence, predictive analytics, and machine learning-assisted monitoring systems may further transform future perioperative management through precision-based physiological optimization. Conclusion: Current evidence suggests that individualized GDT strategies integrating fluids, vasopressors, and inotropic therapy may reduce postoperative complications, shorten hospital stay, and optimize perioperative outcomes in selected abdominal surgery populations.
Copyright (c) 2026 Haris Sulejmani, Marija Jovanovski Srceva, Nikola Brzanov, Marija Bozinovska, Aleksandra Gavrilovska Brzanov (Author) https://creativecommons.org/licenses/by/4.0
QUESTIONNAIRE-BASED SCREENING FOR PRIMARY HYPEROXALURIA IN HEMODIALYSIS PATIENTS: CLINICAL IMPLICATIONS AND A PRACTICAL PERSPECTIVE
Primary hyperoxaluria (PH) is a rare inherited metabolic disorder that is frequently underrecognized in adult patients, particularly those undergoing chronic hemodialysis. Diagnostic challenges arise from the reduced reliability of biochemical markers in advanced kidney failure, often leading to delayed or missed diagnosis and the development of systemic oxalosis. Recent studies have proposed a simple clinical prediction model based on readily available “red flags” for identifying patients at increased risk of PH1 in dialysis populations. Building on this approach, we propose implementing a questionnaire-based screening strategy adapted for routine clinical use. The potential applicability of this strategy in North Macedonia is further outlined, as a significant proportion of patients receiving kidney replacement therapy have an unknown primary renal disease. Given the existing dialysis care system, systematic screening using a simple questionnaire could be feasibly integrated into clinical practice. Such an approach may facilitate earlier identification of high-risk patients, enable targeted genetic testing, and improve clinical outcomes.
Copyright (c) 2026 Vlatko Karanfilovski, Nikola Gjorgjievski, Pavlina Dzekova Vidimliski (Author) https://creativecommons.org/licenses/by/4.0
ARTIFICIAL INTELLIGENCE AND ROBOTICS IN PEDIATRIC SURGERY: EMERGING CHALLENGES AND OPPORTUNITIES FOR PEDIATRIC ANESTHESIOLOGY
Copyright (c) 2026 Toni Risteski (Author) https://creativecommons.org/licenses/by/4.0
EVALUATION OF RAPID TRAUMA SCORING SYSTEMS FOR PREDICTING IN-HOSPITAL MORTALITY IN POLYTRAUMA PATIENTS ADMITTED TO AN EMERGENCY CENTER
Abstract Objective: Polytrauma remains a major cause of mortality and disability worldwide and requires rapid risk stratification during the early phase of emergency care. Simple physiological trauma scoring systems, such as the New Trauma Score (NTS), Glasgow Coma Scale, Age and Systolic Blood Pressure score (GAP), and Mechanism, Glasgow Coma Scale, Age and Arterial Pressure score (MGAP), may support early triage and prediction of adverse outcomes. This study aimed to evaluate and compare the predictive accuracy of NTS, GAP, and MGAP scores for in-hospital mortality in polytrauma patients admitted to the Emergency Center. Materials and Methods: A single-center retrospective-prospective observational cohort study was conducted at the University Emergency Surgical Center in Skopje from January 2024 to November 2025. A total of 65 polytrauma patients who met the inclusion criteria were analyzed. Demographic characteristics, mechanism of injury, Glasgow Coma Scale (GCS), systolic blood pressure, peripheral oxygen saturation, and in-hospital outcome were recorded at admission. NTS, GAP, and MGAP scores were calculated and compared for their ability to predict in-hospital mortality using receiver operating characteristic (ROC) curve analysis. Results: Among 65 patients, 57 were male and 8 were female. Forty-nine patients survived, while 16 patients died during hospitalization. Mortality was higher among patients aged ≥60 years and among those with lower initial GCS scores. All three scoring systems demonstrated excellent diagnostic accuracy for predicting in-hospital mortality, with area under the curve (AUC) values above 0.90. MGAP showed the highest predictive accuracy (AUC = 0.94), followed by GAP (AUC = 0.93) and NTS (AUC = 0.91). Conclusion: NTS, GAP, and MGAP are simple and rapidly applicable scoring systems with excellent predictive accuracy for in-hospital mortality in polytrauma patients. MGAP showed the highest AUC value in this cohort, likely due to the additional inclusion of injury mechanism. However, because the performance of all three scores was excellent and closely comparable, they may all be considered useful tools for early risk stratification and triage in emergency center settings.
Copyright (c) 2026 Jovana Stanoeva (Author) https://creativecommons.org/licenses/by/4.0
SCIENTIFIC EXCHANGE, PRACTICAL LEARNING, AND PROFESSIONAL DEVELOPMENT: REFLECTIONS FROM THE 47TH INTERNATIONAL MEDICAL STUDENTS’ CONGRESS
Copyright (c) 2026 Matej Jordanoski (Author) https://creativecommons.org/licenses/by/4.0
ILIOPSOAS ABSCESS SECONDARY TO PYELONEPHRITIS WITH SUBSEQUENT UNILATERAL SACROILIITIS PRESENTING AS LOW BACK PAIN IN A YOUNG ADULT: A CASE REPORT
Introduction: Iliopsoas abscess is a rare but potentially life-threatening condition. Secondary iliopsoas abscess following pyelonephritis is rarely reported, and contiguous spread to the sacroiliac joint resulting in sacroiliitis is an uncommon complication. Early detection is crucial, as initial symptoms may mimic low back pain, hip or gluteal discomfort, or genitourinary tract infection, often leading to delayed diagnosis. Case Presentation: We report a case of a young adult who presented with severe low back pain radiating to the right lower extremity. Pyelonephritis was initially diagnosed based on CT imaging and laboratory tests, including blood tests and urinalysis. Almost two months after symptom onset, MRI revealed a unilateral iliopsoas abscess with contiguous involvement of the sacroiliac joint, resulting in secondary sacroiliitis. Methicillin-resistant Staphylococcus aureus (MRSA) was identified as the causative organism. The patient underwent percutaneous core biopsy and culture-guided antimicrobial therapy, leading to complete recovery. Conclusion: This case underscores the importance of considering retroperitoneal and sacroiliac infections in patients with persistent, immobilizing low back pain, even when laboratory abnormalities are transient. Prompt imaging and timely management are essential to prevent morbidity and mortality associated with iliopsoas abscess and secondary sacroiliitis.
Copyright (c) 2026 Tode Vranishkoski, Jasmin Ciriviri, Darko Talevski, Aleksandra Jovanova (Author) https://creativecommons.org/licenses/by/4.0
EFFECTS OF TWO TRANEXAMIC ACID DOSES ON CARDIAC SURGERY-ASSOCIATED ACUTE KIDNEY INJURY IN NON-ANAEMIC PATIENTS UNDERGOING ON-PUMP CARDIAC SURGERY
Objective: Cardiac surgery-associated acute kidney injury is a frequent and clinically significant complication, while the potential impact of tranexamic acid dosing on postoperative renal function remains uncertain. The study aims to compare the incidence of Cardiac surgery-associated acute kidney injury (CSA-AKI) and the stages of AKI between two different doses of Tranexamic acid (TXA) in non-anemic patients undergoing on-pump cardiac surgery; to determine whether the TXA dose is independently associated with CSA-AKI; and to identify predictors of postoperative renal function change and to compare short term renal outcomes in patients with and without CSA-AKI. Materials and Methods: Prospective, randomized study that evaluated the renal safety of low-dose (20 mg/kg) and high-dose (50 mg/kg) TXA in 120 non-anemic patients undergoing on-pump cardiac surgery. Monitored variables were baseline serum creatinine, peak serum creatinine, discharge serum creatinine, creatinine ratio, 24-hour bleeding, and the incidence of transfusion. Results: CSA-AKI occurred in 25% of patients in the low-dose TXA group, and 20% in the high-dose TXA group. Among patients who developed CSA-AKI, AKI stage 1 was the most common severity stage, 66.7% and 75% respectively. The TXA dose was not independently associated with CSA-AKI (OR 1.666, 95% CI 0.599–4.634, p=0.328). Transfusion was an independent predictor associated with higher peak-to-baseline serum creatinine ratio (β = 0.191, 95% CI 0.061–0.322, p=0.004). Patients who developed CSA-AKI had lower estimated glomerular filtration rate (eGFR) at discharge compared to patients without CSA-AKI (48 (40–59) vs 83 (68.5–107.5) mL/min/1.73 m²; Mann–Whitney U test, Z = −5.97, p < 0.001). Conclusion: Within the studied dosing range, the tranexamic acid dose was not independently associated with renal outcomes, suggesting that dosing decisions may prioritize bleeding and transfusion risk rather than renal safety concerns.
Copyright (c) 2026 Aleksandar Radoeshki, Mirjana Shosholcheva, Beti Kostadinovska Jordanoska (Author) https://creativecommons.org/licenses/by/4.0
HEALTH FINANCING SYSTEMS: THE WESTERN BALKANS CASE
Objective: Reforms introduced in the 1990s aimed at sustainability amidst high out-of-pocket costs and low public funding. Over the past three decades, the Western Balkans (WB) countries have undergone profound transformations. The aspiration to join the European Union (EU) strongly shapes health financing policies in the Western Balkans, encouraging reforms focused on equity, efficiency, and financial sustainability. The aim of this paper is to analyze and compare health expenditure levels and financing structures across Western Balkan countries. Materials and Methods: The analysis is based on data from the World Health Organization HFA-DB and the World Bank, supplemented by Health in Action reports for the selected countries. Public health approach has been applied. Results: In 2023, health expenditure ranged from 7% of GDP in Albania to 9.7% in Montenegro. Despite this growth, per capita spending remains substantially below EU levels (US$4,153), with Albania reporting the lowest (US$590) and Montenegro the highest (US$1,147). A common regional challenge is the high reliance on out-of-pocket (OOP) payments, exceeding 30% in most countries and reaching over 40% in Albania and North Macedonia, well above the EU average (14,8%). Conclusion: Health financing systems in the Western Balkans show increasing expenditure but continue to face limited financial protection and persistent inequities. High reliance on out-of-pocket payments and unmet healthcare needs continue to expose populations to financial risk, particularly among lower-income groups. Strengthening public financing, improving risk pooling, and enhancing system efficiency are essential to accelerate progress toward universal health coverage in the region.
Copyright (c) 2026 Hristina Vasilevska, Monika Stojchevska, Fimka Tozija (Author) https://creativecommons.org/licenses/by/4.0
BEYOND MASTITIS: MULTICENTRIC BREAST ABSCESS OF THE RIGHT BREAST DIAGNOSED BY MULTIMODAL IMAGING
Introduction: Breast abscess is a known complication of mastitis, however multicentric involvement in non-lactating patients is uncommon and may closely mimic malignancy, creating a diagnostic challenge and often necessitating advanced imaging. Case Presentation: We report the case of a 28-year-old patient who was referred with a clinical diagnosis of right-sided mastitis following initial surgical evaluation. Ultrasound examination demonstrated a well-defined hypoechoic collection containing dense fluid, associated with a fistulous tract extending toward the para-mammary region, as well as findings suggestive of abscess formation. Given the complexity of the presentation, further evaluation with breast magnetic resonance imaging was performed. MRI revealed multiple multicentric lesions within the right breast, characterized by low signal intensity on T1-weighted images, high signal intensity on T2-weighted images, and peripheral rim enhancement following contrast administration, findings that are consistent with multicentric breast abscesses. No suspicious solid enhancing components were identified. Conclusion: This case highlights the importance of a multimodal imaging approach in the assessment of atypical or extensive breast infections. While ultrasound remains the first-line modality for detection and guidance of intervention, MRI provides superior delineation of disease extent, identification of multicentric involvement, and improved differentiation from malignancy. Accurate imaging interpretation is essential for appropriate clinical management, avoiding unnecessary invasive procedures, and ensuring timely and targeted treatment.
Copyright (c) 2026 Sonja Nikolova (Author) https://creativecommons.org/licenses/by/4.0
MANAGING DUAL PATHOLOGIES: NEPHRECTOMY FOR RENAL CELL CARCINOMA IN A PATIENT WITH SEVERE TRICUSPID VALVE REGURGITATION
Renal cell carcinoma (RCC) is the most prevalent form of kidney cancer. Tricuspid regurgitation is a condition marked by the reverse flow of blood from the right ventricle into the right atrium and necessitates thorough assessment to ascertain its severity and effect on heart function. In this case, we present a 57-years-old male patient with symptomatic renal cell carcinoma and a severe tricuspid valve regurgitation. The performed open nephrectomy went uneventfully. While the patient was successfully and safely managed from an anesthesiology standpoint despite his comorbidities, performing the procedure in a resource-limited setting posed significant challenges. In such environments, the lack of immediate access to advanced hemodynamic monitoring, cardiothoracic surgical support and perioperative cardiac interventions increases the complexity of managing patients with dual pathologies. Ideally, conducting nephrectomy in an operating theater equipped for simultaneous surgical interventions, addressing both the renal pathology and potential worsening of tricuspid valve regurgitation, with a cardiothoracic team on standby, would have provided a safer approach. However, in settings with constrained resources, optimizing intraoperative management, ensuring rigorous hemodynamic monitoring, and coordinating multidisciplinary teams within the available infrastructure become critical for achieving favorable outcomes.
Copyright (c) 2025 https://creativecommons.org/licenses/by/4.0
OBESITY AND POSTOPERATIVE DELIRIUM IN A MIDDLE-AGE SURGICAL PATIEN
The literature for bladder cancer patients outlines the role of malnutrition as one of the key factors for postoperative outcomes, including postoperative delirium (POD). However, there is still a debated question whether obesity has a protective, or etiology role in the process of occurrence of POD. Here, we present a case of a 56-years-old man with obese class 1 admitted to City General Hospital “8th of September”, Skopje, Macedonia, for an elective major surgical procedure, radical cystectomy, presenting with postoperative delirium (POD). Anthropometric measurements (weight, high) and nutrition screening tools (body mass index, NRS-2002) verified his nutrition status. We additionally performed The Confusion Assessment Method and Mini-Mental Status Examination on admission and days 1, 2, 3, and 7 to evaluate signs of POD and his cognition level. Clinical presentation and radiographic imaging confirm the diagnosis of POD. We faced a few challenges writing this case report, including the impact of older age, selection of appropriate and available laboratory markers, examination of how body mass index affects POD, and identification of precipitated factors for POD. We determined that hypoxia could be a key link that connects inflammation, nutrition status, and POD in our patient.
Bardet-Biedl syndrome (BBS) is a genetic and multisystem disease that affects the genitourinary tract, locomotory system, causes eye anomalies, cognitive disorders and characteristic truncal obesity. It is caused by mutations in certain genes, namely: BBS1 to BBS21 gene. The approach to this disease is multidisciplinary. Material and Methods: We present a 3-years-old female child who was referred to the Clinic for Pediatric Surgery due to supernumerary toes on both feet. This is postaxial polydactyly. Intrauterine lobulated kidney structure was observed. The child had problems with her peers and avoids socializing with them. The following examinations were performed: cardiological, ophthalmological and genetic. Genetic examinations confirmed the BBS syndrome. Results: The patient was operated at the clinic for pediatric surgery, the operative and postoperative period were without complications. Conclusion: BBS is a rare autosomal disease that requires timely detection and appropriate multidisciplinary treatment. This allows complications to be reduced and the child to be included in everyday activities.
SEPTIC SHOCK IN POLYTRAUMATIZED PATIENT: A CASE STUDY AND MANAGEMENT CHALLENGES
Septic shock is a life-threatening condition that represents the final stage of sepsis, where infection leads to widespread systemic inflammation, tissue hypoperfusion and multi-organ dysfunction. The management of septic shock becomes even more complicated in polytraumatized patients, where multiple severe injuries often contribute to both the patient’s clinical deterioration and the risk of infection. We present the case of a 55-years-old male with multiple traumatic injuries including thoracic contusion, fractures of the cervical and rib bones and bilateral extremity fractures, who developed severe septic shock during his hospitalization. His medical history included type II diabetes mellitus and chronic gastritis. Upon admission, the patient was intubated and mechanically ventilated, started on broad- spectrum antibiotics, anticoagulants and fluid resuscitation. Initial microbiological tests revealed no pathogens, but by day 10, Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa and Acinetobacter species were identified. Despite aggressive antibiotic therapy, the patient developed worsening sepsis marked by hyperthermia, elevated inflammatory markers and oliguria by day 12. As his condition deteriorated, Cytosorb therapy was initiated on day 13, followed by hemodialysis on day 15 for acute kidney injury. On day 20, blood cultures revealed Vancomycin-resistant Enterococcus (VRE). As the infection evolved, additional pathogens including Klebsiella pneumoniae, Pseudomonas aeruginosa and Candida glabrata, were identified. Antifungal therapy with caspofungin was introduced on day 33. Despite the complexity of multiple infections and resistance patterns, the patient responded to tailored therapy, with negative blood cultures achieved by day 42. This case highlights the challenges in managing septic shock in polytraumatized patients, particularly with the emergence of multidrug-resistant organisms. A multidisciplinary approach, involving timely microbiological testing, antibiotic stewardship and supportive therapies such as Cytosorb and renal replacement was essential for improving patient’s outcome. The case also underscores the importance of vigilant management of fungal infections such as Candida glabrata in critically ill, immunocompromised patients.
UNLOCKING TENSIONS: THE SYNERGY OF POINT OF CARE ULTRASOUND AND FASCIOTOMY
Compartment syndrome is an agonizing state arising from excessive pressure buildup within muscles, hindering blood circulation and depriving nerve and muscle cells of vital oxygen and nutrients. Usually, this condition arises following injury-induced bleeding or swelling. The elevated pressure characteristic of compartment syndrome impedes the circulation of blood, oxygen and essential nutrients to and from the impacted tissues. In some cases, it necessitates immediate surgical intervention to avert lasting damage. Consensus holds that prompt intervention offers the greatest opportunity for full recovery and for averting additional tissue necrosis. Treatment primarily relies on clinical presentation, supported by corroborative measurements of compartmental pressure. A fasciotomy is an emergency procedure used to treat acute compartment syndrome. We describe a scenario involving a 19-years-old male, where in the diagnosis and postoperative outcome was swiftly facilitated by point-of-care ultrasound (POCUS), revealing a substantial thigh hematoma within the anterior compartment with vascular compromise before fasciotomy revealed by color and pulse wave doppler. Using POCUS, restorage of circulation and local hemodynamics after fasciotomy were assured by detecting normal doppler signal of previously involved peripheral arteries. Although POCUS should not serve as the sole method for evaluating potential compartment syndrome, it can significantly contribute as a supplementary tool in the diagnostic process and especially when following up patients where therapeutic actions have been done.
ULTRASOUND GUIDED SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK FOR UPPER LIMB SURGERY IN CARDIOVASCULAR COMPROMISED PATIENT: CASE REPORT
Introduction: We can use the supraclavicular block as a postoperative pain management approach, as an addition to general anesthesia, or as the sole form of anesthesia for upper limb surgery. For upper limb surgery, this block is a fantastic substitute for general anesthesia in patients with pulmonary and cardiac comorbidities. Case Presentation: In order to undergo surgery for a fracture of the proximal portion of his upper arm, a 66-years-old male AA was brought to the Clinic for Orthopedic Diseases in Skopje. The anesthesiologic examination revealed that the patient had diabetes mellitus type II, cardiomyopathy, untreated ischemic heart disease and wheezing and crepitations in the distal portions of his lungs. We planned the open fixation of the fracture for the patient. A supraclavicular brachial plexus block was performed as the most non-invasive procedure for perioperative treatment, taking into consideration the patient's health. The patient's vital indicators were normal and stable during the procedure. After receiving therapy for two days, the postoperative course was uneventful, leading to the patient's discharge. Conclusion: If not addressed earlier, preoperative pulmonary and cardiac comorbidity increases the risk of perioperative and postoperative problems. With no postoperative problems, peripheral nerve block - in our case, supraclavicular brachial plexus block - proved to be a safe option for anesthesia management used for upper limb surgery.
PRE-OPERATIVE ASSESSMENT ON A PATIENT FOR LAPAROSCOPIC CHOLECYSTECTOMY WITH B12 ANEMIA
The pre-operative assessment is an opportunity to identify co-morbidities that may lead to patients’ complications during the anesthesia, surgical or postoperative period. Patients scheduled for elective procedures will generally attend a pre-operative assessment 2-4 weeks before the date of their surgery. A woman at the age of 57 years was admitted to the hospital planned for the elective laparoscopic cholecystectomy. On the preoperative assessment on laboratory analysis, we found presence of anemia with MCV levels above normal and low levels of vitamin B12. She was never treated for anemia before. Peripheral blood smear showed presence of macrocytosis. The patient was put on treatment with intramuscular injections of vitamin B12. The operation was delayed for two months. She was admitted to the hospital after two months of treatment and blood analysis were made that showed Hb levels of 115g/l, hematocrit 35%, MCV was 92. She was operated after she had been hospitalized, and laparoscopic cholecystectomy was made without complications. She was released from hospital two days after surgery. The purpose of a preoperative evaluation is not to “clear” patients for elective surgery, but rather to evaluate, and if necessary, implement measures to prepare higher risk patients for surgery. By diagnosing anemia in the preoperative assessment, we reduced the risk of complications during the surgery and during the postoperative period. Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients.
TWO CASE REPORTS ON THE EFFECT OF SEVOFLURANE EXPOSURE DURATION ON SERUM LEVELS OF NEURON-SPECIFIC ENOLASE (NSE) AND S100 PROTEIN IN CHILDREN
The length of sevoflurane exposure may raise the risk of neuron-specific enolase (NSE) and S100 protein alterations in blood, which might thereafter result in postoperative cognitive dysfunction (POCD). The pathophysiology of POCD caused by the volatile anesthetic sevoflurane has been the subject of extensive research in recent years. This case study looks at preliminary findings about the effects of different sevoflurane anesthetic exposure durations on the levels of S100 protein and NSE in children's blood. Additionally, it looks into how sevoflurane affects children's early cognitive performance following surgery. To detect neurological effects during general anesthesia and ascertain the length of sevoflurane exposure, we employ the particular markers such as S100 protein and NSE. In this case study, we present two pediatric patients who underwent general anesthesia with sevoflurane for different durations. The aim was to observe potential postoperative changes in NSE and S100 protein levels, which are biomarkers associated with neuronal injury and cognitive function. After the surgery, we utilize these levels to assess any cognitive problems. The parents or guardians gave their informed consent.
NON-CARDIAC SURGERY IN CARDIAC PATIENTS: KEY INSIGHTS
The growing elderly population leads to a higher proportion of primarily non-cardiac surgeries being performed on patients with cardiac conditions. This highlights the necessity to review and update protocols for ensuring safe surgery in the patient group mentioned above. The cardiovascular complications are especially prevalent in patients with documented or asymptomatic coronary heart disease, left ventricular (LV) dysfunction, valvular heart disease (VHD) and arrhythmias, particularly when undergoing surgeries that place prolonged strain on the heart and hemodynamics. Preoperative N-terminal fragment of proBNP (NT-proBNP) measurement is the stronger predictor for postoperative complications. We should not initiate beta blockers, alpha-2 agonists, calcium channel blockers and statins, but rather continue them during the preoperative period. The risk of postoperative bleeding should not be the main reason for delaying non-cardiac surgery.
RIGHT VENTRICULAR PERFORMANCE IN MECHANICALLY VENTILATED POLYTRAUMATIZED PATIENTS BASED ON ASSESSMENT OF TRICUSPID ANNULAR PLANE SYSTOLIC EXCURSION AND RIGHT VENTRICULAR FRACTIONAL AREA CHANGE
Even in terms of using lung protective strategies, mechanical ventilation could lead to different types of lung injury with severe consequences over systemic and pulmonary hemodynamics, showing deleterious properties over the right ventricular performance as well. Fifty polytraumatized patients admitted in the ICU were included in this prospective study. They were divided into two groups regarding the need for mechanical ventilation. In all patients we have examined Right heart function by measuring Tricuspid Annular Plane Systolic Excursion (TAPSE) and Fractional Area Change (FAC) 24 hours, 7 and 14 days after admission in the ICU. Statistical analysis was done with calculating the mean value of TAPSE and FAC, as well as with using Mann Whitney U Test. In both groups, mechanically ventilated and spontaneously breathing patients, values for TAPSE were not significantly different at all examination points. The values for FAC were significantly lower in the group of mechanically ventilated patients after 7 and 14 days of mechanical ventilation initiation (U=275; 163,5; 86,5 and z= 0,7; 2,02; 1,96 for p value of 0,47; 0,04 and 0,04 respectively). TAPSE as a surrogate for the assessment of longitudinal systolic function of the right ventricle, has been intact in both groups regardless the usage of mechanical ventilation, but radial systolic function of the right ventricle was significantly lower 7 and 14 days after starting mechanical ventilation. Impairment of the radial systolic function of the right ventricle with preserved longitudinal systolic function was previously reported in patients with high pulmonary pressures and elevated right ventricular afterload. The mechanical ventilation is associated with radial right ventricular systolic dysfunction and with lower values for FAC in mechanically ventilated compared to spontaneously breathing polytraumatized patients.
PREVALENCE AND IDENTIFICATION OF POTENTIAL PREDICTORS ASSOCIATED WITH GESTATIONAL DIABETES MELLITUS IN NORTH MACEDONIA
Introduction: Gestational diabetes mellitus (GDM) is defined as the occurrence of diabetes which is discovered during pregnancy. It is a widespread global condition with many maternal and fetal health risks. Objective: The aim of this study was to identify the prevalence and potential predictors of GDM among a cohort of women from North Macedonia. Patients and Method: A total number of 154 (143) participants were included in the study. The diagnosis of GDM was made using the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria. Patients with known diabetes prior to pregnancy, history of GDM, in vitro fertilization (IVF), multiple gestation and severe medical conditions were excluded from the study. The recorded variables were age, nationality, religion, education, parity, family history of diabetes (FHD), pre-pregnancy body mass index (BMI), weight gain, smoking and oral contraceptive use. The statistical analysis was done calculating exact logistic regression in “R”. Results: Significant predictors: For every one-unit increase in BMI, the odds of developing GDM increased by 8.6% (coefficient=0.086, p=0.026). Women with family history of diabetes had 2.74 times higher odds of developing GDM (coefficient=1.008, p=0.011). The Orthodox participants had significantly lower odds of developing GDM compared to the Muslim ones (coefficient=-2.528, p=0.011). Two prior pregnancies raised the odds to 4.70 times higher compared to no prior pregnancies (coefficient=1.547, p=0.042). Conclusion: The study emphasizes the importance of addressing pre-pregnancy BMI and screening individuals with family history of diabetes. The high prevalence of GDM suggests a need for public health strategies focusing on preconception care, lifestyle interventions and regular screening during pregnancy.
MAPPING THE CURRENT AND FUTURE CLIMATE EXTREMES AND HEALTH THREATS TO VULNERABLE POPULATIONS IN KOSOVO
Introduction: Climate change affects human lives and health in different ways. High temperatures and heat waves are associated with excessive morbidity and mortality, especially among vulnerable categories of the population. In addition to deaths, high temperatures can increase pressure on the healthcare system by increasing emergency room visits, hospitalizations, premature births, causing mental health problems and other negative health outcomes. Infectious diseases that are transmitted through food and water have a high incidence rate and can be exacerbated by climate extremes such as heat waves, floods and droughts. As the climate continues to change, the risks to health systems and facilities including hospitals, clinics and community care centers are increasing, among others reducing the ability of health workers to protect people from a range of climate hazards. Objective: The main objective of the study is to investigate and create an initial database of data and indicators for assessing the risk of climate change on the health of the population and the health system in Kosovo, as a tool to adapt to climate changes and reduce the risks for the population health and healthcare systems and facilities – including hospitals, clinics and community-based care centers. Materials and methods: For conducting the assessment, data, information and publications in the hydrometeorological, health and other relevant sectors, as well as relevant international publications were used. A vulnerability assessment is translated through the definition and analysis of the climate, public health and environmental health profile of Kosovo and the expected climate extremes in future scenarios, the organization and preparedness of the health sector, as well as the research of the current health profile of the population in Kosovo. Results and discussion: the current and future climate profile of Kosovo is analyzed with a focus on the most important climate extremes such as heat waves and floods. Testing the RCP 4.5 and 8.5 future climate scenarios showed an increase in the average annual temperature and number of tropical days on almost the whole territory of the country with a maximum of 40C and a decrease of the precipitation especially in the summer period for more than 30% (in the period 2071-2100) compared to the baseline scenarios. We analyzed the demographic structure and some determinants of health of the population of Kosovo, vulnerable groups such as the elderly, the chronically ill, especially those with cardiorespiratory diseases, people with low incomes and low education, outdoor workers and the homeless, as well as the risk regions in the countries where the highest average temperatures or the highest atmospheric precipitation are registered. There is a particular risk in the northern part of the country, where the older population with low incomes and education is large. Fewer economic opportunities, higher poverty rates, greater distances to health centers and fewer services are available there. These structural factors thus further compromise the existing poor situation in which the aging population, including their long-term care, remains subject to lower quality care in rural and more northern areas. The highest mortality rate is expected to be registered among the most vulnerable population over 65 years of age. Finally, a mapping of the risks of climatic extremes in Kosovo was prepared with indicators for further monitoring and assessment of vulnerability. In conclusion, high temperatures, rainfall and floods are presented as the biggest current and even more future climate and health risks in the area of Kosovo, which will also be a serious threat and burden for the health system.
THE BENEFITS OF ULTRASOUND GUIDED PERIPHERAL NERVE BLOCKS IN ORTHOPEDIC SURGERY
Introduction: Peripheral nerve blocks have an increasingly important role as an anesthetic technique for surgical anesthesia, postoperative analgesia, and fast discharge of patients after surgery involving the upper or lower extremities, alone or in combination with spinal or general anesthesia. Ultrasound guidance has become the most popular for performance of peripheral nerve blocks. Methods: In our retrospective study, we included all patients that were admitted in our hospital for orthopedic procedures on lower and upper extremities who received peripheral nerve block, alone or in combination with spinal or general anesthesia in the last 5 years. Ultrasound guidance was used and local anesthetic Bupivacaine 0.5%. Dexamethasone 4 mg was given intravenously as an adjuvant to peripheral nerve blocks. Results: The total number of patients included in our study was 300, the total number of performed peripheral nerve blocks was 302. 144 (48%) patients were male and 156 (52%) - female. The type of performed blocks was: 164 (54%) femoral, adductor canal blocks 22 (7.28%), 26 supraclavicular (8.60%), 77 interscalene (25.49%), 9 axillar (2.98%), 2 popliteal (0.66%), 1 iPACK and 1 TAP block (0.33%). Peripheral nerve blocks were combined with general or spinal anesthesia or performed as a sole technique for intraoperative analgesia in 17 patients (5.67%). Discussion: In our hospital we performed ultrasound guided peripheral nerve blocks last years in combination with a general, spinal anesthesia or as a sole technic for intraoperative and postoperative analgesia. Our patients were very satisfied with good postoperative pain control, and no serious complications were observed. Conclusion: Ultrasound guided peripheral nerve blocks are good choice for intraoperative anesthesia and postoperative analgesia, especially in older patients and patients with a lot of comorbidities.
CHALLENGES IN ANALGOSEDATION MANAGEMENT IN THE INTENSIVE CARE UNIT
INHALATIONAL ANESTHETICS WITH THEIR PHARMACOKINETIC PROPERTIES
MASS CASUALTY EVENT PREPAREDNESS AND ANESTHESIA MANAGEMENT IN THE EMERGENCY DEPARTMENT AND INTENSIVE CARE UNIT
Mass casualty events whether natural disasters, terrorist attacks, pandemics or large-scale accidents overwhelm healthcare systems, emergency departments and ICUs in minutes. High acuity situations require rapid coordination, strategic resource allocation and seamless inter-disciplinary collaboration. Anesthesiologists are uniquely positioned to play a central role in all phases of the response due to their expertise in airway management, hemodynamic stabilization, pharmacologic sedation and critical care. Their role extends beyond the OR to initial triage, emergency procedural support and ongoing management of ventilated and critically ill patients in the ICU. This article reviews current evidence and operational best practices to examine the role of anesthesiology in mass casualty events preparedness and response. Key areas of focus include disaster planning, ventilator triage, crisis standards of care, sedation protocols and ICU surge capacity. By highlighting the clinical, operational and ethical aspects of anesthesia management in mass casualty events, this article synthesizes current literature and best practices, emphasizing the anesthesiologists’ role in preparedness, immediate response and postoperative care during mass casualty events.
A CRITICAL CARE PERSPECTIVE ON FAMILIAL MEDITERRANEAN FEVER
Familial Mediterranean Fever (FMF) is a rare autosomal recessive autoinflammatory disorder predominantly affecting individuals of Mediterranean origin. FMF is characterized by recurrent febrile episodes and serositis with amyloidosis being its most severe complication, often leading to end-stage renal disease (ESRD). The progression of FMF to amyloidosis is associated with increased morbidity and mortality requiring early diagnosis and effective management. This case report presents a critically ill patient with FMF, amyloidosis and vasculitis-related complications including massive hemorrhage and multi-organ failure. It highlights these complex conditions, the challenges in ICU management and the necessity of a multidisciplinary approach to optimize patients’ outcomes.
MALIGNANT PERIPHERAL NERVE SHEATH TUMOR IN THE RETROPERITONEUM NOT ASSOCIATED WITH THE RENAL OR PERIRENAL PARENCHYMA
The occurrence of an isolated malignant peripheral nerve sheath tumor (MPNST) in the retroperitoneum, unassociated with the kidney capsule, is exceedingly rare, often presenting with an insidious onset of non-specific and misleading symptoms, primarily characterized by lower back pain. We present the case of a patient with a malignant peripheral nerve sheath tumor (MPNST), without neurofibromatosis with nonspecific localization in the retroperitoneum in front of vena cava inferior non associated with the kidney. A 62-years-old male patient was referred due to the presence of an abdominal tumor without accompanying pain. Computed tomography identified a substantial soft tissue retroperitoneal tumor situated anterior to the inferior vena cava. A total resection was performed. The pathological testing verified the existence of a malignant peripheral nerve sheath tumor. The patient received additional treatment through radiotherapy and chemotherapy. This is the inaugural reported case of malignant peripheral nerve sheath tumor in the retroperitoneum without neurofibromatosis, unassociated with renal or perirenal parenchyma. We recommend incorporating malignant peripheral nerve sheath tumor into the differential diagnosis of abdominal masses.