BLUNT TRAUMA INTERCOSTAL LUNG HERNIATION AND DELAYED EXTRA PLEURAL HEMATOMA.

Blunt chest trauma is an important cause of morbidity and mortality in traumatized emergency patients. We report the case of a 74-year-old man who suffered a glenohumeral joint dislocation, trans trochanteric femur fracture, multiple rib fractures, diaphragmatic rupture with chest herniation of the spleen and stomach associated with herniation of the lung through an anterior chest wall defect after blunt trauma. Although immediate surgical repair was performed, he developed a delayed complication of multiple rib fracture in the form of large extrapleural hematoma that had to be surgically removed. Due to massive pulmonary contusion and prolonged pulmonary collapse, we used surfactant to facilitate alveolar opening after evacuation of the hematoma.

[Laparoscopic cholecystectomy in patients with ventriculoperitoneal shunt]. / Laparoskopsko odstranjenje zucnog mjehura u bolesnika s ventrikuloperitonealnim kateterom.

Because of development of laparoscopic surgery and by knowing of its pathophysiological effects on organism, indications for laparoscopic surgery have become more extensive, so this method is today used for therapeutic and diagnostic procedures. Although ventriculoperitoneal shunt is not normally considered a contraindication for laparoscopic surgery, pneumoperitoneum is described as a cause of raised intracranial pressure. Since 1992 when the first laparoscopic cholecystectomy was done at the University Department of Surgery of Sveti Duh Clinical Hospital in Zagreb, three patients with implanted ventriculoperitoneal shunt were managed successfully laparoscopically. In all three patients, there were no complications during and after the surgery. In this paper we present our experience of three cases and short review of the literature.

[Acute compartment syndrome of the muscle in intensive care patients]. / Akutni sindrom tijesnog misicnog odjeljka u bolesnika u jedinici intenzivnog lijecenja.

Acute compartment syndrome of the muscle occurs when elevation of tissue pressure in closed fascial compartments results in muscle and nerve ischemia. Prompt diagnosis and decompression is essential to avoid the devastating local complications with permanent disabilities and systemic even lethal complications. Despite its drawbacks, clinical assessment is still the diagnostic cornerstone of acute compartment syndrome. In critically multisystem injured patients, it often presents silently and clinical examination alone may be insufficient. Intracompartmental pressure measurement is a useful adjunct and can confirm the diagnosis when clinical assessment is difficult. In this article, the etiology, clinical signs, diagnosis and therapy is discussed and underscores the importance of routine surveillance for acute compartment syndrome of muscle.

[Acute compartment syndrome as a complication of prolonged surgery in the Lloyd Davies position]. / Akutni sindrom tijesnog fascijalnog odjeljka donjih ekstremiteta kao komplikacija dugotrajnih kirurskih zahvata u Lloyd Davies polozaju.

Acute compartment syndrome of the muscle is condition in which prolonged increase of tissue pressure in closed unyelding fascial compartments reduces capillary perfusion below a level necessary for tissue viability leading to muscle and nerve ischaemia for few hours. There are wide variety different clinical settings associated with compartment syndrome. Acute lower limb compartment syndrome that occur during and after prolonged surgical procedures in Lloyd Davies position is rare but potentially devastating complication that can lead serious local complications and life threatening situations as, rabdomyolysis, kidney failure and death. In this article we summarize pathophysiology, clinical staging and diagnostic procedures of acute compartment syndrome in Lloyd Davies position. We present female patient developed limb compartment sindrome after surgical procedure which lasted 6,5 hours in the Lloyd Davies position for extensive rectovaginal endometriosis. In this article we rewiev different contributing factors that may predispose to compartment syndrome during Lloyd Davies position and undescore importance of recognise the risk factor and prevent the esthablishment of acute compartment syndrome during and after surgery in the Lloyd Davies position.

[Acute rhabdomyolysis: a case report and literature review]. / Akutna rabdomioliza, prikaz bolesnika i pregled literature.

Acute rhabdomyolysis is a syndrome characterized by the lesion of skeletal muscle resulting in subsequent release of intracellular contents into the circulatory system, which can cause potentially lethal complications. These contents include myoglobin, creatine phosphokinase, potassium, aldolase, lactate dehydrogenase and glutamic-oxaloacetic transaminase. There are numerous causes that can lead to acute rhabdomyolysis and many of patients present with multiple causes. The most common potentially lethal complication of rhabdomyoloysis is acute renal failure. In this article we present a case of a patient that developed clinical signs of acute rhabdomyolysis after consumption of heroin and alcohol. After approximately nine hours of alcohol and heroin induced coma he had acute compartment syndrome of the right arm, and clinical and laboratory signs of acute rhabdomyolysis with acute renal failure as a complication of rhabdomyolysis. Acute rhabdomyolysis developed in the patient as the result of acute compartment syndrome, with direct toxic activity of alcohol and diamorphine. During the period of coma, due to lying in particular position over a long period of time, pressure upon the certain part of the body caused muscle compression and capillary occlusion in fascial compartments, which led to ischemia. Upon pressure relief and beginning of tissue recovery, post ischemic compartment syndrome occurred with subsequent rhabdomyolysis. Getting out of coma the patient started to complain of severe pain in the right arm, which clinically worsened on passive stretching of the limb, with the loss of sensation and weakness. Laboratory findings showed high levels of creatine phosphokinase as the most sensitive marker of muscular damage. The peak of creatine phosphokinase level can be predictive for the development of acute renal failure because myoglobin level may return to normal within 6 hours after muscle injury. The peak of creatine phosphokinase (186.080 U/L; normal range 0-177) was recorded at 12 hours of admission. Other pertinent laboratory results such as urea, creatinine, prothrombin time, alanine aminotransferase and aspartate aminotransferase were also changed significantly. The peak of potassium level before dialysis was 6.8 mmol/L. Emergency fasciotomy of the anterior and posterior compartment syndrome was performed by a team of physicians after clinical examination. The second look debridement was performed at 48 and 72 hours. The plastic surgical procedure was performed 4 weeks later. On admission the patient also had oliguria with dark brown pigment in his urine. Arterial blood gases revealed metabolic and respiratory acidosis. The patient was hypovolemic and IV rehydratation with crystalloids, sodium bicarbonate and mannitol started immediately upon admission. Despite therapy his urine output decreased. Hemodialysis was initiated at serum potassium level of 6.8 mm/L and continued until his urine output returned to normal in three weeks. The patient was discharged from the hospital after six weeks, with normal urine output, without functional abnormality in his upper right limb. Acute rhabdomyolysis should be considered as a possibility in any patient with prolonged imobilization while in coma as well as in any intoxicated patient. Of course, creatine phosphokinase is the most sensitive indicator of muscle injury and the degree of creatine phosphokinase elevation correlates with the amount of muscle injury and disease severity. Other laboratory findings can help identify common complications of rhabdomyolysis such as acute renal failure, metabolic derangements and disseminated intravascular coagulopathy.

[Pathophysiologic effects of CO2-pneumoperitoneum in laparoscopic surgery]. / Patofizioloski ucinci CO2-pneumoperitoneja u laparoskopskoj kirurgiji.

Today, laparoscopic surgery is one of the most important diagnostic and therapeutic tools in general surgery. This minimally invasive procedure requires pneumoperitoneum for adequate visualization and operative manipulation. Carbon dioxide is the most commonly used gas for creating pneumoperitoneum, because of its high diffusibility and rapid rate of absorption and excretion. Certain specific operations that in the past required long hospitalization and were associated with severe postoperative pain and frequent complications are today performed laparoscopically. This minimally invasive technique potentially offers reduced operative time and morbidity, decreased hospital stay and earlier return to normal activities, less pain and less postoperative ileus compared with the traditional open surgical procedures. Because the postoperative benefits are superior to open surgical procedures, laparoscopy is today also used in many high risk patients in advanced age and pre-existent cardiopulmonary and respiratory diseases. However, insufflations of carbon dioxide into the peritoneum may lead to alteration in the acid-base balance, cardiovascular and pulmonary physiology. Although these changes may be well tolerated in healthy patients, in high risk patients they may increase the rate of perioperative complications. Therefore, it is very important that the anesthesiologist thoroughly understands the pathophysiology of carbon dioxide-pneumoperitoneum and treatment of potential complications. In this article, the acid-base balance, cardiovascular and pulmonary changes associated with laparoscopic surgery, and their potential complications and management are discussed based on our experience and literature data.

[Specific anesthetic management in laparoscopic surgery]. / Specificnosti anestezije u laparoskopskoj kirurgiji.

Laparoscopic surgery is a technique by which abdominal surgical treatments are performed in minimally invasive way. Many operations that once required long hospitalization are now being performed with laparoscopic technique. It has significantly reduced postoperative pain and the number of complications, shorter hospital stay, with faster recovery, and more rapid return to normal activities. These are only some of the advantages of laparoscopic surgery. The first laparoscopic cholecystectomy in Croatia was performed on May 14, 1992, at the University Department of Surgery of "Sveti Duh" General Hospital in Zagreb. By the introduction of this method as the "gold standard" in the treatment of cholelithiasis, laparoscopic surgery has been widely accepted, and today, ten years later, has become a recognized and routine surgical method. Because of its particular performance, laparoscopic surgery requires some specific anesthesiologic adjustments. Surgical treatments are usually performed in general endotracheal anesthesia, although regional or local one could be applied too. The choice of anestesiologic technique and anesthetics depends upon preoperative patient's condition, the kind of surgical treatment, anesthesiologist's evaluation, and at last upon the cooperation among patients, anesthesiologist and surgeon. The basic aim of anesthesia is respiratory and hemodynamic patient's stability, and the choice of anesthesiologic technique and anesthesia should enable satisfactory analgesia, amnesia, muscular relaxation, faster recovery and shorter hospital stay.

Prophylactic antiemetics for laparoscopic cholecystectomy: droperidol, metoclopramide, and droperidol plus metoclopramide.

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most significant problems in laparoscopic surgery. The antiemetic effects of metoclopramide and droperidol used alone or in combination for prevention of PONV after laparoscopic cholecystectomy (LC) were assessed in this prospective, double blind, placebo controlled randomized study. PATIENTS AND METHODS: A series of 140 patients, ASA physical status I or II, were included in the study. Patients were randomized to one of the following groups: 1, placebo; 2, metoclopramide 10 mg after the induction of anesthesia and placebo at 12 h postoperatively; 3, droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg at 12 h postoperatively; and 4, droperidol 1.25 mg plus metoclopramide 10 mg after the induction of anesthesia and droperidol 1.25 mg at 12 h postoperatively. Patients were observed for 24 hours for PONV, pain, need for rescue analgesics, and adverse events. RESULTS: Data were analyzed using the Student's t-test and chi-square test, with P < 0.05 considered statistically significant. The mean incidence of PONV was 54% with placebo, 42% with metoclopramide, 14% with two doses of droperidol alone, and 11% with a combination of metoclopramide plus droperidol. The patients receiving a combination of metoclopramide and droperidol had a significantly lower rate of PONV than those administered metoclopramide alone (P < 0.05) or placebo (P < 0.001). Those receiving two-dose droperidol alone also had a significantly lower incidence of PONV compared with metoclopramide (P < 0.05) and placebo (P < 0.001). There was no statistically significant difference between the metoclopramide and placebo groups. Sedation was significantly greater in patients administered droperidol 12 h postoperatively. CONCLUSION: The combination of metoclopramide and droperidol, and two-dose droperidol alone, were found to significantly decrease the incidence of PONV after LC, whereas metoclopramide alone proved inefficient.

[Laparoscopic surgery during pregnancy]. / Laparoskopski kirurski zahvati u trudnoci.

UNLABELLED: With the development oflaparoscopic surgery, number of contraindications has become less and less. At the beginning of laparoscopic surgery pregnancy was considered an absolute contraindication to laparoscopic surgery, because of unknown influence of CO2-pneumoperitoneum on fetus. Over the past few years, in literature there have been several case reports of successful laparoscopic surgery in pregnancy. Since 1992 when the first laparoscopic cholecystectomy was done at the University Department of Surgery of Sveti Duh General Hospital in Zagreb, three pregnant women were managed successfully laparoscopically. Two laparoscopic cholecystectomies, and one laparoscopic appendectomy during pregnancy, were performed. RESULTS: In all three patients, there were no complications during and after surgery. Pregnancies were completed at term spontaneously, delivering healthy children.