Faculty of Medicine

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    BILATERAL TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK FOR TREATMENT OF CHRONIC ABDOMINAL WALL PAIN: A CASE REPORT
    (Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, 2022-11)
    Toleska, Marija
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    Dimitrovski, Aleksandar
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    Transversus abdominis plane (TAP) block is a regional anesthesia technique where the local anesthetic is injected into the interfascial plane between the internal oblique and transversus abdominis muscle. This block is mainly used for treatment of acute pain following abdominal surgery. Persistent postsurgical pain (PPSP) or chronic postsurgical pain (CPSP) is pain that persists at least three months after surgery, which was not present before surgery, or which had different characteristics or increased intensity from preoperative pain. It is localized near the surgical site or a referred area, and other possible causes for the pain had been excluded (cancer recurrence or infection). This pain can lead to functional limitation and psychological trauma in patients. By presenting our case report we would like to describe the effect of TAP block on CPSP in a female patient who had previously undergone many abdominal surgeries.
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    PSYCHOLOGICAL AND SOCIAL INFLUENCE OF IDIOPATHIC SCOLIOSIS ON ADOLESCENTS AND THEIR CAREGIVERS
    (Department of Anaesthesia and Reanimation, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, R.N. Macedonia, 2024-05)
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    Dimitrovski, Aleksandar
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    Andonovska, Spasovska Nadica
    Adolescent idiopathic scoliosis (AIS) is a lateral curvature of the spine greater than 10° in children aged 10-18 years. The deformity may progress severely during adolescent development and if the curve is greater than 45°, an operative treatment should be considered. This condition is accompanied by cosmetic deformity and dissatisfaction of adolescents with their own body image, which results in changes in their mental health and lifestyle. In addition, family functioning and the emergence of parental anxiety and depression may be affected after a child is diagnosed with a chronic health condition. Objective: Recognition of mental health disorders in the patients and their parents in order to take appropriate measures that would improve the outcome of AIS treatment. Method: Research was performed, using available databases, including PubMed and Google Scholar, to capture relevant research published covering AIS. Results: Adolescents with scoliosis may show a less positive outlook on life, suffer from lower self-esteem, and have difficulty relating to peers. However, there is conflicting evidence whether the different stages of treatment, such as observation, bracing or surgery, affect the longterm psychological effect of scoliosis. Parents’ depression and anxiety were closely related to their children’s depression and anxiety. The parents face challenges such as acquiring adequate knowledge about scoliosis, participating in decisions about the type of treatment and managing their child undergoing invasive spine surgery. Conclusion: Psychosocial support is a key component in promoting better outcomes in adolescents as they cope with the challenges associated with idiopathic scoliosis. Providing parents with adequate information and resources on how to support their child can alleviate some of the emotional burden they experience.
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    Practicing opioid-free anesthesia for laparoscopic cholecystectomy opioid-free anesthesia
    (Centre for Evaluation in Education and Science (CEON/CEES), 2019)
    Toleska, Marija
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    Dimitrovski, Aleksandar
    Opioid free anesthesia (OFA) is an anesthesiological technique, which uses non-opioid analgesics, such as paracetamol, dexamethasone, lidocaine, ketamine, and magnesium sulfate instead of opioids. In this case, the report about patient who after previous surgeries experienced opioid side effects is followed by a narrative review; we present the OFA method for laparoscopic cholecystectomy. Case report: We present a case of a 55-year-old woman with a history of controlled hypertension and asthma, planned for laparoscopic cholecystectomy. Previously she underwent two surgical interventions; bilateral radical mastectomy performed separately with a three year gap. Both anesthesias were complicated, postoperatively with nausea, vomiting, dizziness, and respiratory depression. Based on the previous postoperative complications, we hypothesized that nausea, vomiting, dizziness, and respiratory depression were caused by opioids, and we decided to perform OFA. Before the induction the patient received dexamethasone 8 mg and paracetamol 1 gr intravenously, followed by induction with midazolam 3 mg, lidocaine hydrochloride 78 mg, propofol 160 mg, ketamine hydrochloride 39 mg and rocuronium bromide 60 mg. After tracheal intubation, continuous intravenous infusion with lidocaine hydrochloride 2 mg/kg/hr and magnesium sulfate 1.5 gr/hr was started. Anesthesia was maintained by using sevoflurane MAC 0.7–1. At the end of the surgery, 2.5 gr of metamizole was given intravenously. Postoperative recovery was uneventful. Conclusion: In our patient, OFA eliminated opioid-related side effects (nausea, vomiting, dizziness, and shortness of breath), and provided satisfying postoperative analgesia.
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    EFFECT OF BILATERAL ERECTOR SPINAE PLANE (ESP) BLOCK ON PAIN AFTER LAPAROSCOPIC VENTRAL HERNIA REPAIR: A CASE SERIES
    (Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, 2023)
    Toleska, Marija
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    Dimitrovski, Aleksandar
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    Trposka, Angela
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    Panoska Avramovska, Aleksandra
    Laparoscopic ventral hernia repair (LVHR) operations are followed by moderate postoperative pain, shorter recovery periods and less surgical complications such as seroma, hemorrhage, intestinal injury, mesh infection and recurrence. Pain after LVHR sometimes can be severe and last more than one week up to one month. Erector spinae plane (ESP) block is inter-fascial plane block and performed bilaterally can provide a good visceral and somatic analgesia for various abdominal surgeries. We describe five cases of laparoscopic ventral hernia repair who received bilateral ESP block prior to induction to general anesthesia and its effective analgesic effect was seen in the intra- and postoperative period. Our results showed that bilateral ESP block performed before the induction to general anesthesia provided a good analgesia and low opioid consumption in the intraoperative period, low pain scores in the first 48 hours and no need of rescue analgesia after laparoscopic ventral hernia repair surgery.
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    Anaesthesia for pilonidal sinus surgery in a patient with Dilated cardiomyopathy. A case report
    (Wolters Kluwer, 2020-06)
    Trposka, Angela
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    Toleska, Marija
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    Stojkovska, Ana
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    Background: Dilated cardiomyopathy (DCMP), is a myocardial disease of varied causes characterized by dilatation of one or both the ventricles, impaired myocardial contractility, decreased cardiac output and increased ventricular filling pressures [1].These patients are often at a risk of dysrhythmias or sudden cardiac death.
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    Opioid sparing effect of transversus abdominis plane (TAP) block in open ventral hernia repair: case series
    (Wolters Kluwer, 2022-06)
    Toleska, Marija
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    Dimitrovski, Aleksandar
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    Trposka, Angela
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    Background: Open ventral hernia repair surgery is characterised with pain that arises from skin, muscles of the anterior abdominal wall and parietal peritoneum. Transversus abdominis plane (TAP) block can be suitable for these operations and can lower usage of opioids during surgery and in the postoperative period. Case report: We represent five patients, all ASA classification 2, scheduled for open ventral hernia repair surgery. After induction to standard general anesthesia with 2 mg midazolam, 100 µgr fentanyl, propofol 2 mg/kg, and rocuronium bromide 0.6 mg/kg, ultrasoundguided TAP block was performed with 20 ml 0.25% bupivacaine + 4 mg dexamethasone on both sides before surgical midline incision. Anesthesia was maintained with sevoflurane 0.7-1 MAC. Pain was measured first 48 hours after surgery with numeric rating score (NRS) from 1 to 10, where for NRS 4-6/10 1 gr metamizol was given, and for NRS 7-10/10 1 mg/kg tramadol was administered. Opioid consumption during surgery and in the postoperative period was measured too. The first three patients have pain 22 hours after surgery with NRS 4/10, other two patients have pain 25 hours after surgery with NRS 6/10 and all received 1 gr metamizol. Next complaint was 34 and 46 hours after surgery in all patients with NRS 4-5/10 and 1 gr metamizol was given. Total opioid consumption during surgery in all patients was 150 µgr fentanyl and none of the patients received opioids in the postoperative period. Discussion: Pain in open ventral hernia repair operations is from somatic origin and can lead to high pain scores in the postoperative period, bigger opioid consumption and prolonged stay in hospital.1 Bilateral TAP block is ideal for treatment of somatic pain and given together with dexamethasone can prolong analgesia in first 48 hours after surgery. References: 1. Zhang D, Zhou C, Wei D, Ge L, Li Q. Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials. PLOS ONE 14(1): e0209646. https://doi.org/10.1371/journal.pone.0209646 Learning points: TAP block given with steroids before surgical incision achieves prolonged analgesia during and after surgery, minimise opioid consumption and better pain control.