[Pathophysiological aspects of severe acute pancreatitis-associated lung injury].

Acute pancreatitis is an inflammatory process which occurs in severe form in 20% of all patients, out of whom 15%-25% will die. The incidence of severe acute pancreatitis-associated lung injury (APALI) varies from 15% to 55% and its severity varies from mild hypoxemia to acute respiratory distress syndrome (ARDS). Acute lung injury (ALI) and ARDS are the most significant manifestations of extra abdominal dysfunctions in severe acute pancreatitis with mortality rate as high as 60% in the first week of the onset of illness. Different pathophysiological mechanisms of severe acute pancreatitis-associated lung injury have been described. The role of enzymes, adhesion molecules, neutrophils, fibronectin and various inflammatory mediators has been emphasized. Mechanism of the acute lung injury associated with the acute pancreatitis is very complex and has not been clear yet. There is no specific therapeutic procedure and mortality rate is very high. Therefore, further studies are necessary to address this acute and growing problem in intensive medicine.

[New strategies in multiple organ dysfunction syndrome therapy for sepsis].

Despite more than 20 years of extensive research, sepsis and/or trauma induced multiple organ dysfunction syndrome (MODS) remain the chief cause of death in intensive care units, with mortality rates between 30% and 80%. Early goal-directed therapy (EGDT), use of drotrecogin alfa (activated), tight control of hyperglycaemia, and adrenal replacement therapy (low doses of corticosteroids), all constitute new treatment strategies. In future, a combination of therapies should be individually adjusted for each patient.

[Importance of determination of proinflammatory cytokines in the blood of polytraumatized patients with sepsis]. / Znacaj odredivanja proinflamatornih citokina u serumu politraumatizovanih bolesnika sa sepsom.

Severe sepsis and trauma complicated with multiple organ dysfunction syndrome (MODS) are among the leading causes of death in intensive therapy units, with mortality rate exceeding 50%. The outcome is not determined only by infection or trauma, but also by the intensity of immuno-inflammatory response, which is essential for host defence, but if uncontrolled leads to MODS. Pro-inflammatory cytokines (tumor necrosis factor-alpha--TNF-alpha, IL-1, IL-8, IL-12, IFN-gamma, etc.) represent a part of this immuno-inflammatory response to an insult. The results of the clinical investigation of correlation between pro-inflammatory cytokines (IL-8, IL-12, TNF-alpha, IFN-gamma), the outcome (survivors, non-survivors), and the severity (systemic inflammatory response syndrome--SIRS--less severe, and MODS--more severe) in polytraumatised patients with sepsis are presented in this paper. Mean values of IL-8 were 1.3-fold higher in non-survivors (p<0.05), and 60-fold higher in MODS group (p<0.01). Mean values of IL-12 were 1.6-fold higher in survivors (p<0.01), while the values between SIRS and MODS group did not differ significantly; mean values of TNF-alpha were 3-fold higher in survivors (p<0.05), and 46-fold higher in MODS group (p<0.01). Mean values of IFN-gamma did not differ significantly between the two groups regarding the outcome and severity. The obtained results indicated that IL-8 was a reliable predictor of lethal outcome and MODS (p<0.01), IL-12 a reliable predictor of survival (p<0.05), and TNF-alpha a reliable predictor of survival (p<0.05) and MODS (p<0.01).

[Pheochromocytoma as a challenge for the anesthesiologist]. / Feohromocitom kao izazov za anesteziologa.

INTRODUCTION: Pheochromocytoma is a tumour of adrenal chromaffin tissue which produces extreme amounts of catecholamines, and leads to significant haemodynamic disturbances. The anaesthesiologist has an important role in diagnostic procedures of pheochromocytoma (physical examination, biochemical analyses, pharmacological tests, tomographic, scintigraphic, and genetic examinations), and is included in the preparation of the patient for surgery, maintenance of anaesthesia during operation, and postoperative intensive care. RESULTS: We reviewed 268 patients with adrenal tumours, who were operated on in the Military Medicaf Academy in Belgrade over the period 1974-2002. In 93 (34.7%) patients pheocromocytoma was confirmed. Unilateral localization of tumours was noted in 75 patients (80.6%)), bilateral in 3 patients (3.2%), ectopic in 7 patients (7.5%), and multiple in 3 patients (3.2%). Malignancy was observed in 3 cases (3.2%), and recidivation in 2 cases (2.2%). The most frequent surgical approach was intercostal--by Turner Warvick (72.4%). During a retrospective analysis of complications in perioperative period, we found 3 cases (1.1%) of cardiac arrest, with lethal outcome in one patient (0.4%). In two patients (0.8%) we noted significant intraoperative bleeding (lesion of v.cavae and aortae). In five cases (2.0%) we recorded accidental pleural unilateral lesion, splenectomy in one patient (0.4%), and wound infection in 3 cases (1.1%). DISCUSSION: Pheochromocytoma is a rare disease but it is followed by numerous, significant, and very dangerous haemodynamic disturbances. This is the reason for necessity of a multidisciplinary approach in diagnostic procedures and treatment of the disease. Endocrinologists, anaesthesiologists, and surgeons must cooperate at the same time, and only then we can achieve a timely diagnostic, adequate preoperative preparation of the patient, surgical extirpation of tumours, and intensive postoperative care. Our retrospective study shows successful treatment of 268 patients with adrenal tumours and 93 patients with pheochromocytomas. CONCLUSION: Pheochromocytoma is a disease with high mortality rate. Surgical extirpation of tumour is the only way for a successful treatment. This tumour is a great challenge for anaesthesiologists, because of numerous disturbances of vital parameters in perioperative period. Low mortality rate in our study (0.4% in all patients, and 1.07% in patients with pheochromocytoma) is the result of an adequate perioperative treatment of our patients. Treatment of this tumour needs hospitalisation in greater clinical centres with adequate personnel and equipment.