The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial.

BACKGROUND: Cervical plexus block is frequently associated with unsatisfactory sensory blockade. In this randomized, double-blind, placebo-controlled trial, we examined whether the addition of fentanyl to local anesthetics improves the quality of cervical plexus block in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-seven consecutive adult patients scheduled for elective CEA were randomized to receive either fentanyl 1 mL (50 microg) or saline placebo 1 mL in a mixture of 10 mL bupivacaine 0.5% and 4 mL lidocaine 2% for deep cervical plexus block. Superficial cervical plexus block was performed using a mixture of 10 mL bupivacaine 0.5% and 5 mL lidocaine 2%. Pain was assessed using the verbal rating scale (0-10; 0 = no pain, 10 = worst pain imaginable), and propofol in 20-mg IV bolus doses was given to patients reporting verbal rating scale >3 during the procedure. Rescue medication consumption during surgery and analgesia requirements over the next 24 hours, as well as onset of sensory blockade, were recorded. A P value <0.05 was regarded as statistically significant. RESULTS: Fewer patients in the fentanyl group (4 of 38, 10.5%) required propofol compared with the placebo group (26 of 39, 66.7%; P < 0.001). In comparison with the placebo group, the fentanyl group consumed less propofol (median 0 [0-60] vs 60 [0-160] mg, respectively; P < 0.001), required postoperative analgesia less frequently (22 of 38 patients, 57.9% vs 35 of 39 patients, 89.7%, respectively; P = 0.002), and requested the first analgesic after surgery later (median 5.8 [1.9-15.6] vs 3.1 [1.0-11.7] hours, respectively; P < 0.001), whereas the onset time of sensory blockade was similar in both groups (median 12 [9-18] vs 15 [9-18] minutes, respectively; P = 0.18). CONCLUSIONS: The addition of fentanyl to local anesthetics improved the quality and prolonged the duration of cervical plexus block in patients undergoing CEA.

Management of right ventricular myxoma diagnosed at full-term pregnancy.

BACKGROUND: The diagnosis of cardiac myxoma in a woman at term pregnancy is extremely rare. Prompt surgical removal of the tumor is generally advised because of the high risk of potentially fatal complications. On the other hand, cardiac surgery during pregnancy is a delicate procedure which carries a significantly increased maternal risk when performed at or immediately after delivery. CASE REPORT: A previously healthy 23-year-old woman at 38 weeks' gestation was diagnosed with myxoma in the right ventricle on the basis of clinical and echocardiographic examination. The patient went into labor while awaiting urgent Cesarean section. Severe right heart failure developed which completely resolved after delivery of a healthy baby. After balancing the risks of uncontrolled uterine bleeding associated with cardiopulmonary bypass against those of thromboembolism and valvular obstruction associated with the presence of myxoma itself, emergency cardiac surgery was rejected. The tumor was successfully removed five days after Cesarean section and the patient recovered uneventfully. CONCLUSIONS: Cesarean section should be done as soon as possible. Considering the increased maternal morbidity and mortality when delivery is immediately followed by cardiopulmonary bypass, urgent cardiac surgery may be more reasonable than an emergency one for a patient who is clinically stable and at low risk of thromboembolism.

Emergence delirium in children: many questions, few answers.

The introduction of a new generation of inhaled anesthetics into pediatric clinical practice has been associated with a greater incidence of ED, a short-lived, but troublesome clinical phenomenon of uncertain etiology. A variety of anesthesia-, surgery-, patient-, and adjunct medication-related factors have been suggested to play a potential role in the development of such an event. Restless behavior upon emergence causes not only discomfort to the child, but also makes the caregivers and parents feel unhappy with the quality of recovery from anesthesia. Although the severity of agitation varies, it often requires additional nursing care, as well as treatment with analgesics or sedatives, which may delay discharge from hospital. To reduce the incidence of this adverse event, it is advisable to identify children at risk and take preventive measures, such as reducing preoperative anxiety, removing postoperative pain, and providing a quiet, stress-free environment for postanesthesia recovery. More clinical trials are needed to elucidate the cause as well as provide effective treatment.

Diagnosis and treatment of carotid body paraganglioma: 21 years of experience at a clinical center of Serbia.

BACKGROUND: The carotid body paraganglioma (chemodectoma) is a relatively rare neoplasm of obscure origin. These are usually benign and commonly present as asymptomatic cervical mass. PATIENTS AND METHODS: Records of 12 patients (9 female and 3 male) with carotid body tumors treated between 1982 and 2003, treated at our center were retrospectively reviewed. Data on classification, clinical presentation, and surgical treatment were extracted from the case records. Surgical complications and treatment outcome were noted and survival was calculated by actuarial method. The literature on carotid body paraganglioma was reviewed. RESULTS: The average age of the patients was 52 years (range 30-78 years). Eight of these cases presented as a large asymptomatic non-tender neck mass, and two each presented with dysphagia, and hoarseness of voice. As per Shamblin classification seven of tumors were type II and 5 were types III. In 7 cases subadventitial tumor excision was performed, while in 5 associated resection of both external and internal carotid arteries was carried out. The artery was repaired by end-to-end anastomosis in one case, with Dacron graft in one case, and with saphenous vein graft in 3 cases. There was no operative mortality. After a mean follow-up of 6.2 years (range 6 months to 20 years), there were no signs of tumor recurrence in any of the cases. CONCLUSIONS: Surgical excision is the treatment of choice for carotid body paragangliomas although radiation therapy is an option for patients who are not ideal candidates for surgery. For the tumors that are in intimate contact with carotid arteries, the treatment by vascular surgeon is recommended.

[Hybrid procedure in the treatment of thoracoabdominal aortic aneurysms: case report].

INTRODUCTION: Treatment of thoracoabdominal aortic aneurysms is a major problem in vascular surgery. Conventional open repair is associated with significant rates of mortality and morbidity and therefore, there is a need for better solutions. One of them is a hybrid procedure that includes visceral debranching. This paper presents the first such case performed in Serbia, with a brief overview on all published procedures worldwide. CASE OUTLINE: A 57-year-old woman was admitted to the hospital because of thoracoabdominal aneurysms type V by Crawford-Safi classifications. Because of the significant comorbidities it was concluded that conventional treatment would bear unacceptably high perioperative risk, and that the possible alternative could be the hybrid procedure in two stages. In the first stage aortobiliacal reconstruction with bifurcated Dacron graft (16 x 8 mm) and visceral debranching with hand made tailored branched graft was done. In the second act, the thoracoabdominal aneurysm was excluded with implantation of the endovascular Valiant stent graft, 34 x 150 mm (Medtronic, Santa Rosa, CA). Control MSCT angiography showed a proper visceral branch patency and positioning of the stent graft without endoleaks. Nine months after the procedure the patient was symptom-free, with no aneurysm, diameter change and no graft-related complication. All visceral branches were patent. CONCLUSION: So far about 500 cases of visceral debranching have been published with the aim of treating thoracoabdominal aneurysms, and still we have no valid guidelines concerning this method. However, in carefully selected high-risk patients this is an excellent alternative to open surgery of thoracoabdominal aneurysms.

Cervical plexus block versus general anesthesia in carotid surgery: single center experience.

INTRODUCTION: Carotid endarterectomy may be performed under general (GA) or regional anesthesia (RA). The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing carotid surgery. MATERIAL AND METHODS: This prospective study included 1098 consecutive patients operated on between 2003 and 2009 (773 underwent cervical plexus block and 325 underwent general anesthesia). RESULTS: There were 6 deaths, 3 (0.9%) after GA and 3 (0.4%) after RA (p = 0.272). Neurological complication rates were not significantly different (GA 2.1% vs. RA 1.1%, p = 0.212). Incidence of myocardial infarction was similar (GA 0.31% vs. LA 0.39%, p = 0.840). Shunt placement rate was the same in both groups, 11.1%. Total operating time and carotid clamping time were significantly shorter in RA patients (RA: 92 min vs. GA: 106 min; p < 0.001 and RA: 18 min vs. GA: 19 min; p = 0.040). There was no significant difference in number of reinterventions (RA: 1.0% vs. GA: 0.6%; p = 0.504). Pulmonary complications were common in the GA group (RA: 0 vs. GA 0.9%; p = 0.007). Time to first postoperative analgesic was significantly shorter in the GA group (RA: 226 min vs. GA: 139 min; p < 0.001). CONCLUSIONS: Type of anesthesia does not affect the outcome of surgical treatment of carotid disease. However, it should be stressed that fewer respiratory complications, later requirement for first postoperative analgesic, and an awake patient who can continue oral therapy early after surgery, give priority to regional techniques of anesthesia.

Some technical considerations of open thoracoabdominal aortic aneurysm repair in a transition country.

A variety of operative approaches and protective adjuncts have been used in thoracoabdominal aneurysm (TAA) repair to minimize the major complications of perioperative death and spinal cord ischemia. There is no consensus with respect to the optimal approach. We present 118 surgically treated patients over a 10-year period. The present study reviews our experience as a transition country (Serbia) in the treatment and problems we have encountered during open operative treatment of TAAs. Between 1999 and 2009, the authors reviewed 118 consecutive patients who underwent thoracoabdominal aortic resection using a variety of spinal cord protection. Clinical data collected prospectively were analyzed retrospectively. The purpose of the current study was to review the results of a large series of TAA repairs and to present some technical considerations and complications of open TAA repair. There were seven operative deaths (5.9%): two in the setting of ruptured TAAs, three myocardial infarctions and two due to hemorrhage. All 30 (25.4%) postoperative deaths occurred during the initial hospitalization. Postoperative complications included paraplegia in 11 patients (9.3%); renal failure in eight patients (6.8%), with four patients (3.4%) requiring hemodialysis; pulmonary complications in 75 patients (63.5%); bleeding requiring reoperation in two patients (1.7%) and coagulopathic hemorrhage in five patients (4.2%); cardiac complications in six patients (5.1%); stroke in five patients (4.2%); wound dehiscence in six patients (5.1%); and subdural hemorrhage in one patient (0.87%). Open TAA repair intrinsically has substantial complications, of which spinal cord ischemia and renal failure are the most devastating, despite major progress in our understanding of the pathophysiology and operative strategy. Our current review of data clearly proves that the surgical repair of TAAs remains a challenge even in the 21st century, especially in a country in transition.

Intraoperative cell salvage versus allogeneic transfusion during abdominal aortic surgery: clinical and financial outcomes.

The objective of this study was to assess the clinical and financial outcomes of intraoperative cell salvage (ICS) during abdominal aortic surgery. In this study, 90 patients were operated on with the use of ICS (group 1, prospective) and 90 patients without ICS (group 2, historical control). According to the type of operation, the patients were subdivided into three consecutive 30-patient subgroups (1, aortoiliac occlusive disease [AOD]; 2, elective abdominal aortic aneurysm [AAA]; or 3, ruptured abdominal aortic aneurysm [RAAA]). Transfusion requirements and postoperative complications were recorded. The total amounts of perioperatively transfused allogeneic blood were higher in all patient subgroups that underwent surgery without ICS (p = .0032). In the ICS group, 50% of AOD patients and 60% of elective AAA patients received no allogeneic transfusions. There were no significant differences in the incidence of postoperative complications in any group examined. ICS significantly reduced the necessity for allogeneic transfusions during abdominal aortic surgery. ICS use was most valuable in urgent situations with high blood losses, such as RAAA, for which only small amounts of allogeneic blood were initially available. In patients with more than 3 units of autologous blood reinfused, this method was cost effective.

[Recombinant activated factor VII in the treatment of intractable non-surgical bleeding following major vascular procedures].

INTRODUCTION: A recombinant form of activated factor VII (rFVIIa) is a haemostatic drug that is approved for use in haemophiliacs with antibodies to factor VIII or factor IX. Most recent studies and clinical experience have shown that rFVIIa (NovoSeven, Novo Nordisk A/S, Denmark) gives extreme haemostatic effect in patients with severe "non-haemophilic" bleeding produced after trauma and major surgery. OBJECTIVE: We present our preliminary experience of the use of rFVIIa in vascular surgery when conventional haemostatic measures are inadequate. METHOD: There were 32 patients divided into five groups: Group I--14 patients with ruptured abdominal aortic aneurysms; Group II--10 patients with thoracoabdominal aortic aneurysms; Group III--5 patients with retroperitoneal tumours involving great abdominal vessels; Group IV--2 patients with portal hypertension and Group V--one patient with iatrogenic injury of brachial artery and vein during fibrinolytic treatment, because of myocardial infarction. RESULTS: Clinical improvement was detected following treatment in 29 patients. Bleeding was successfully controlled as evidenced by improved haemodynamic parameters and decreased inotropic and transfusion requirements. CONCLUSION: In vascular patients more liberal use of rFVlla is limited, because no randomized controlled trial has proved its efficacy and safety in such patients; while also keeping in mind that the price of a 4.8 mg of rFVIIa is $4080. We recommend the use of rFVIIa in vascular surgery only during and after operative treatment of thoracoabdominal aortic aneurysms, ruptured abdominal aortic aneurysms, retroperitoneal tumours involving the aorta and/or inferior vena cava, as well as portal hypertension, when non-surgical massive uncontrolled bleeding are present.

[Treatment of traumatic rupture of the thoracic aorta].

INTRODUCTION: Interest for traumatic thoracic aorta rupture stems from the fact that its number continually increases, and it can be rapidly lethal. OBJECTIVE: The aim of this study is to present early and long term results as well as experiences of our team in surgical treatment of traumatic thoracic aorta rupture. METHOD: Our retrospective study includes 12 patients with traumatic thoracic aorta rupture treated between 1985 and 2007.There were 10 male and two female patients of average age 30.75 years (18-74). RESULTS: In six cases, primary diagnosis was established during the first seven days days after trauma, while in 6 more than one month later. In 11 cases, classical open surgical procedure was performed, while endovascular treatment was used in one patient. Three (25%) patients died, while two (16.6%) had paraplegia. Nine patinets (75%) were trated without complications, and are in good condition after a mean follow-up period of 9.7 years (from one month to 22 years). CONCLUSION: Surgical treatment requires spinal cord protection to prevent paraplegia, using cardiopulmonary by-pass (three of our cases) or external heparin-bonded shunts (five of our cases). Cardiopulmonary by-pass is followed with lower incidence of paraplegia, however it is not such a good solution for patients with polytrauma because of haemorrhage. The endovascular repair is a safe and feasible procedure in the acute phase, especilly because of traumatic shock and polytrauma which contributes to higher mortality rate after open surgery. On the other hand, in chronic postrauamatic aortic rupture, open surgical treatment is connected with a lower mortality rate and good long-term results. There have been no published data about long-term results of endovascular treatment in the chronic phase.

[Surgical treatment of abdominal tumours closely related to major blood vessels].

INTRODUCTION: Radical operative treatment of abdominal tumours closely related to major blood vessels often demands complex vascular procedures. OBJECTIVE: The aim of this paper was to present elementary principles and results of the complex procedures, based on 46 patients operated on at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, from January 1999 to July 2006. METHOD: Primary localisation of the tumour was the kidney in 14 patients, the suprarenal gland in 2, the retroperitoneum in 23 and the testis in 7 patients. Histologically, the most frequent were the following: renal carcinoma in 14 patients, teratoma in 7, liposarcoma in 5, fibrosarcoma and lymphoma in 3 patients. The tumour compressed abdominal aorta occurred in 3 cases, vena cava inferior in 5 and both the abdominal aorta and vena cava inferior in 11 cases. In 4 cases the tumour infiltrated the abdominal aorta, in 11 the vena cava inferior and in 8 both of them. In two patients, the tumour compressed the vena cava inferior and infiltrated the aorta; in two patients the aorta was compressed and the vena cava was infiltrated. In three cases only the exploration was performed due to multiple abdominal organ infiltration. The ex tempore biopsy showed the type of tumour in which the radical surgical treatment did not improve the prognosis. In 20 cases of tumour compression, subadventitional excision was performed. In 23 cases of infiltration, the tumour excision and vascular reconstruction had to be performed. Intraoperative blood cell saving and autotransfusion were applied in 27 patients. RESULTS: The lethal outcome happened in 3 (6.5%) patients during hospitalization. In other patients all reconstructed blood vessels were patent during the postoperative hospitalization period. CONCLUSION: Treatment of the abdominal tumours closely related to major blood vessels must be interdisciplinary, considering diagnostics, operability estimation and additional measures. Tumour reduction cannot improve long term prognosis, and has no major impact on life quality. There have been not many papers that analyse the long term results after such complex operations proving their appropriateness.

Pain associated with carotid artery surgery performed under carotid plexus block: preemptive analgesic effect of ketorolac.

Carotid artery surgery (CAS) performed under cervical plexus block is frequently associated with significant intra- and postoperative pain. To evaluate whether preoperative administration of ketorolac may improve analgesia in this type of surgery, 80 patients scheduled for CAS under cervical plexus block were randomly allocated to receive intravenously either 30 mg of ketorolac or placebo 30 minutes before surgery. Verbal rating scale pain scores during surgery and 3 and 6 hours after surgery, the number of patients requiring additional analgesia, and the total analgesic consumption both during and within 6 hours after surgery were significantly lower, whereas the time to first postoperative analgesia was significantly shorter in the ketorolac group than in the control group. The results of this prospective, randomized, double-blind study show that a single 30 mg dose of ketorolac administered intravenously 30 minutes before surgery reduces intraoperative pain and preempts postoperative pain in patients undergoing CAS under carotid plexus block.

Ruptured abdominal aortic aneurysms: factors influencing early survival.

In this study we aimed to define relevant prognostic predictors for the outcome of surgical treatment of ruptured abdominal aortic aneurysms. The study included 406 consecutive patients treated between January 1991 and December 2003. There were 337 (83%) male and 69 (17%) female patients aged 67 +/- 7.5 years. Fourteen (3.5%) patients had aortocaval fistula whereas 4 (0.98%) had primary aortorenteric fistula caused by aneurysm rupture into the inferior vena cava or duodenum. Reconstruction included interposition of a tube graft (215-53%), aortobiiliac bypass (134-33%), and aortobifemoral bypass (58-14.3%). Findings on admission that significantly correlated with both intraoperative (13.5%) and total operative mortality (48.3%) were systolic blood pressure <95 mmHg, low diuresis, unconsciousness, cardiac arrest, leukocytes >14 x 10(9)/L, hematocrit <0.29%, hemoglobin <100 g/L, urea> 11 mmol/L, and creatinine >180 micromol/L. Intraoperative determinants of increased mortality were aortic cross-clamping time >47 min, duration of surgery >200 min, intraoperative blood loss >3500 mL, diuresis <400 mL, arterial systolic pressure <97.5 mmHg, and the need for aortobifemoral bypass. Respiratory complications and multisystem organ failure were significantly associated with lethal outcome in the postoperative period. Surgical treatment of ruptured abdominal aortic aneurysm was life-saving in 51.7% of patients. Variables significantly associated with mortality were unconsciousness, low systolic blood pressure, cardiac arrest, low diuresis, high urea and creatinine levels, signs of blood loss, and the need for aortobifemoral reconstruction. Short aortic cross-clamping and the total operation time, low intraoperative blood loss, and well-controlled diuresis and arterial pressure during surgery have improved survival. Therapeutic efforts should concentrate on intraoperative factors that are possible to correct, leading to better survival of these patients.

[Effect of infusion of hypertonic-hyperoncotic solution on cardiovascular function in surgery of the abdominal aorta during the perioperative period].

INTRODUCTION: When blood flow is decreased, as in prolonged hypovolaemia and hypotension, or in the course of transversal clamping of the aorta during aortic reconstruction, nutritive tissue perfusion can also fall below the critical level. AIM: The objective of this study was to analyse the effects of hypertonic-hyperoncotic solution on cardiovascular function during reconstruction of the abdominal aorta. METHOD: This prospective randomised study included 40 patients. All patients underwent surgery of the abdominal aorta under general endotracheal anaesthesia. Based on the type of solution infused from the time of clamping to the moment of the removal of the transversal aortic clamp, the patients were divided into two groups of 20. The study group was infused with a small volume of hypertonic-hyperoncotic solution, while the controls were administered infusions of isotonic solution. Patients with a preoperative creatinine level over 130 micromol L(-1) and an ejection fraction of less than 40% were excluded from the study. RESULTS: Cardiac output increased from 5.67 +/- 2.95 to 7.05 +/- 3.39 L min(-1) in the study group, in comparison to the controls, where it increased from 4.98 +/- 2.06 to 5.99 +/- 3.02 L min(-1) (p = 0.004). Central venous pressure increased from 8.75 +/- 3.67 to 9.30 +/- 2.77 mm Hg in the study group, in comparison to the controls, where the values decreased from 6.84 +/- 2.73 to 6.45 +/- 2.50 mm Hg (p = 0.022). Diastolic pulmonary artery pressure increased from 15.92 +/- 5.61 to 16.65 +/- 6.53 mm Hg in the study group, in comparison to the controls, where it decreased from 12.65 +/- 4.28 to 11.85 +/- 3.91 mm Hg (p = 0.021). The amount of given crystalloids 24 hours after the removal of the aortic clamp totalled 2562.5 +/- 485.82 mL in the study group, versus 3350 +/- 727.29 mL in the control group (p = 0.000). The amount of given human albumins 24 hours after the removal of the aortic clamp totalled 30 +/- 49.74 mL in the study group versus 100 +/- 4.34 mL in the control group (p = 0.001). CONCLUSION Haemodynamic stability of patients and adequate organ perfusion during surgery are achieved through the infusion of hypertonic-hyperoncotic solution, which maintains optimal values of: cardiac output, mixed venous oxygen saturation, and delivery of oxygen, while reducing alveolo-arterial oxygen difference. The balance of fluids, 24 hours after the removal of the aortic clamp, was maintained with the aid of hypertonic-hyperoncotic solution, while isotonic solution produced an excess of over 1000 mL of fluid in the control patients. Hypertonic-hyperoncotic solution increases cardiac output considerably more than does isotonic solution, and its application significantly reduces the accumulation of crystalloid solutions and human albumins.

[Renal protection during surgical procedures on the infrarenal aorta]. / Zastita bubrega tokom hirurskih intervencija na infrarenalnoj aorti.

INTRODUCTION: Despite the progress in surgical and anaesthetic management, decreased renal function is still observed after abdominal infrarenal aortic surgery and remains an important problem in postoperative period. Although data regarding the efficacy of perioperative renal protection are conflicting, it is widely believed that renal protection before aortic cross-clamping is beneficial and therefore is commonly used. The aim of this study was to evaluate the impact of renal protection in patients undergoing elective infrarenal aortic surgery (1ARS). PATIENTS AND METHODS: We have prospectively studied 80 patients undergoing elective infrarenal aortic surgery from October 1996 to May 1998 in the Clinical Centre of Serbia, because of aorto-occlusive disease or aortic aneurysm. Patients were excluded from the study for three reasons: prior renal dysfunction, suprarenal aortic cross-clamping and ruptured aortic aneurysm. We have randomized the patients in two groups: without renal protection--group A (n = 40) and with renal protection--group B (n = 40). Preanaesthetic medication consisted of midazolam (5 mg i.m.). Anaesthesia was induced with etomidat 0.3 mg/kg, fentanyl 0.05-0.1 mg and succinil-holin Img/kg. Ventilation was controlled using 50% of nitrous oxyde and oxygen. Supplemental anaesthesia consisted of isoflurane and fentanyl, in order to maintain the mean arterial pressure and heart rate +/- 20% regarding preoperative values. In all patients two peripheral vein and radial artery catheters were cannulated before anaesthesia. Central venous catheter and Foley urinary bladder catheter were inserted after the induction of anaesthesia. Two-lead electrocardiograms were recorded. All patients in group B were given intravenously mannitol (0.3 g/kg) before aortic cross-clamping (ACC). After aortic cross-clamping, these patients received furosemide (20-40 mg) or dopamine (1-3 micrograms/kg/min) to the end of surgery (Table 1). In 8 time points (preoperatively, after induction, during ACC, 2 and 8 hours after ACC, on day 1, 2 and 3 postoperatively) haemodynamic parameters (mean arterial and central venous pressure), volume load, urinary output, creatinine and free-water clearance, serum electrolytes, BUN, creatinine, plasma and urine osmolality and ACC time were analyzed in each patient. Renal complications were classified as transient or persistent. Transient renal dysfunction was defined as a greater rise than 20% rise in peak serum creatinine level over baseline serum creatinine level, with a peak of at least 168 mumol/L. Persistent renal insufficiency was defined as a greater rise than 20% rise in discharge serum creatinine level over baseline serum creatinine level, with a peak of at least 168 mumol/L. Moreover, renal insufficiency was defined as a free-water clearance greater than -15 ml/h. Aortic cross-clamping time was defined as a period in which the proximal inflow was occluded. The results were expressed as means +/- SD. Statistical difference detected with Student's t-test, with p < 0.05 being considered significant. RESULTS: Patients in groups A and B were similar regarding the age (64.32 vs. 62.00), sex (males 35, females vs. males 34, females 6) and preoperative diseases. (Tab. 2) No difference was found between groups regarding any of the parameters (BUN, serum creatinine, electrolytes, volume load, creatinine and free-water clearance, haemodynamic parameters, plasma and urine osmolality). Urinary output was higher in group B during and 2 hours after ACC. (Graph 1.) ACC time was similar in two groups (24.1 min vs 24.5 min). (Graph. 2) Only one patient in group B revealed transitory renal insufficiency, not requiring special treatment. These data indicate that renal protection did not influence renal function. Short ACC time may have impact on the obtained results. Our results suggest that renal protection should not be considered as mandatory for elective infrarenal aortic surgery. Because of the short ACC time observed in this study (in comparison to other studies), further studies of renal protection in patients with longer ACC time are needed.

[Effect of preoperative factors on survival in patients with ruptured aneurysms of the abdominal aorta]. / Uticaj preoperacionih parametara na prezivljavanje bolesnika sa rupturom aneurizme abdominalne aorte.

Between 1991-2001 total number of 1058 patients was operated at the Institute of Cardiovascular Diseases of Serbian Clinical Centre due to abdominal aortic aneurysm. Of this number, 288 patients underwent urgent surgical treatment because of ruptured abdominal aortic aneurysm. The aim of this retrospective study was to show results of the early outcome of the surgical treatment of patients with ruptured abdominal aortic aneurysm, and to define relevant preoperative factors that influenced their survival. There were 83% male and 17% female patients in the study, mean aged 67 years. Intrahospital mortality that included intraoperative and postoperative deaths was 53.7%. Therefore, 46.3% patients survived surgical treatment and were released from hospital. Intraoperative mortality was 13.5%. Statistics showed that the gender and the age did not have any influence on mortality of our patients, as well as their co morbid conditions (p > 0.05). Clinical parameters at admission in hospital such as state of consciousness, systolic blood pressure, cardiac arrest and diuresis significantly influenced the outcome of treatment, as well as laboratory findings such as levels of hematocrit, hemoglobin, white blood cells, urea and creatinin (p < 0.05; p < 0.01). Ruptured abdominal aortic aneurysm still remains one of the most dramatic surgical states with very high mortality reported. We assume that important preoperative factors that influence the outcome of surgical treatment can be defined, but there is no single parameter which can certainly predict the lethal outcome after surgery. Also, the presence of co morbid conditions does not significantly influence the outcome of treatment in these patients. Therefore, urgent operation should not be withheld in most of the patients with ruptured abdominal aortic aneurysm.

[Successful revascularization of the kidney--3 case reports]. / Revaskularizacija bubrega--prikaz tri bolesnika.

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

Ruptured abdominal aortic aneurysm. Predictors of survival in 229 consecutive surgical patients.

BACKGROUND AND PURPOSE: A ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality. The aim of the present study was to define relevant prognostic predictors for the outcome of surgical treatment. PATIENTS AND METHODS: This study included 229 subsequent patients (83% males, 17% females, age 67.0 +/- 7.5 years) with a ruptured abdominal aortic aneurysm. Before surgery, all patients underwent clinical examination, ultrasonography was performed in 78.6% (mean aneurysm diameter 73 mm, range 40-100 mm), computed tomography (CT) scan in 16.2%, magnetic resonance imaging (MRI) in 0.9%, and angiography in 12.6% of patients. The aneurysm was infrarenal in 74%, juxtarenal in 12.3%, suprarenal in 6.8%, and thoracoabdominal in 6.8% of patients. Types of rupture were retroperitoneal (65%), intraperitoneal (26.8%), chronic (3.8%), rupture into vena cava inferior (3.2%), and into duodenum (0.6%). Reconstruction included interposition of Dacron graft (53%), aortobiiliac bypass (32.8%), and aortobifemoral bypass (14.2%). RESULTS: Findings on admission that significantly correlated with both intraoperative (13.5%) and total intrahospital mortality (53.7%) were: systolic blood pressure < 95 mmHg, low diuresis, unconsciousness, cardiac arrest, leukocytes > 14 x 10(9)/l, hematocrit < 0.29%, hemoglobin < 100 g/l, urea > 11 mmol/l, and creatinine > 180 micro mol/l. Intraoperative determinants of increased mortality were: aortic cross-clamping time > 47 min, duration of surgery > 200 min, intraoperative blood loss > 3,500 ml, diuresis < 400 ml, arterial systolic pressure < 97.5 mmHg, and the need for aortobifemoral bypass. Respiratory complications and multisystem organ failure were associated with a lethal outcome in the postoperative period. CONCLUSION: Surgical treatment of ruptured abdominal aortic aneurysm was life-saving in 46.3% of patients. Hypotension, low diuresis, high urea and creatinine levels, signs of blood loss, unconsciousness, cardiac arrest, and the need for aortobifemoral reconstruction predicted poor outcome. Short aortic cross-clamping and total operation time, low intraoperative blood loss, and well-controlled diuresis and arterial pressure during surgery have improved survival.