Intensive-care management of a patient with HELLP syndrome--case report.

HELLP syndrome belongs to the group of pathological states known as pregnancy-induced hypertension or EPH gestosis. The basic criteria for establishing the diagnosis are as follows: H for hemolysis, EL for elevated liver enzymes and LP for low platelets. A pregnant woman, 38 years of age, multipara (V pregnancy, third delivery) has been admitted to the Clinic of Gynecology and Obstetrics in Novi Sad in 36-37 week gestation complaining of nausea, vomiting, epigastric pain, general weakness, exhaustion as well as symptom of previously diagnosed preeclampsia. Due to signs of fetal distress, the patient has undergone urgent cesarean section, giving birth to a female premature newborn infant. Twenty-four hours after delivery all symptoms and signs HELLP syndrome manifested. Being in a critical state, the patient has been transferred to the Institute of Surgery, Clinic of Anesthesiology and Intensive Care with signs of multiple organ failure. With this case report of a patient with HELLP syndrome, we wished to point to importance of continual intensive clinical follow-up, laboratory monitoring and corresponding therapeutic procedures, and at the same time to this relatively rare syndrome.

[Prolonged apnea after administration of succinylcholine]. / Produzena apneja posle davanja sukcinilholina.

INTRODUCTION: Succinylcholine is a depolarizing muscle relaxant that has been used for five decades in clinical practice. It is decomposed by enzyme acetylcholinesterase, which is synthesized in posed by enzyme acetylcholinesterase, which is synthesized in the liver. This process lasts a few minutes, and is prolonged in the case of hepatic failure of the liver function, in normal pregnancy and puerperium, in persons with lack of this enzyme or genetic anomaly in its composition. CASE REPORT: The patient, a 31 years old woman, was exposed to diagnostic biopsy of endometrium during treatment of primary infertility. She received classic short-term general anaesthesia and 1 mg/kg (50 mg) of succinylcholine. Breathing was completely restored after 90 minutes. Eventually we found out that in previous three anaesthesias she showed the same dysfunction. It was laboratory proven that she had a decrease in contents of acetylcholinesterase in plasma (20 mukat/l). The possibility of genotype investigation does not exist in our country. The patient was introduced in detail with the nature of her disability. DISCUSSION: The activity of enzyme acetylcholinesterase depends on functional state of the liver, as well as the therapy with some drugs (cyclophosphamide, ecothiopate etc.). For the anaesthetic practice the most important is the presence of abnormal acetylcholinesterase. The incidence of recessive homozygotes is 1:1500-1:3000 cases in the total population and the apnea lasts for 1-2 hours, and sometimes even 4-8 hours. Every apnea over 15 minutes requires maximal attention of the anesthesiologist. First it is necessary to eliminate other possible causes of apnea. The therapy is based on oxygenation with 100% O2 blood transfusion or transfusion of fresh frozen plasma or preparation of human acetylcholinesterase. CONCLUSION: The case of the patient with prolonged postsurgical apnea indicates the decisive significance of comprehensive preanaesthetic anamnesis, both in serious surgical and in clinical interventions. Since there is no adequate substitution for succinylcholine, nowadays it is still in use in clinical practice.

[Sedation and analgesia in intensive therapy]. / Sedacija i analgezija u intenzivnoj terapiji.

INTRODUCTION: In the operating room, anaesthetist must provide unconsciousness, analgesia and muscular relaxation. In intensive therapy (IT), the rules are different and not every patient requires sedation, but almost every patient needs analgesia. The patient who is alert, calm and comfortable despite the presence of tubes and cannulas in the nose, mouth, radial artery, central vein, urethra, surgical wounds, pleural space etc. does not need any sedation. However, sedation and analgesia are clinically inseparable. If mechanical ventilation is not well controlled, muscular relaxants must be prescribed. There are a lot of trials in formulating an ideal sedative/analgesic regimen for each individual patient. THE RISKS OF SEDATION AND ANALGESICS: It is not rare that IT patients are oversedated or undersedated. Undersedation is followed by anxiety, pain, hypertension, tachycardia. The most important effect of oversedation is respiratory depression, hypotension, bradycardia, CNS depression, renal dysfunction, immunological depression. SEDATIVES AND HYPNOTICS: Benzodiazepines are among the most widely used drugs in IT. They have sedative, hypnotic, anxyolytic, amnestic, anticonvulsant and myorelaxant effects. Prolonged continuous infusion of benzodiazepines ought to be escaped because of prolonged sedation, accumulation and presence of pharmacologically active metabolites. They have proved to be safe, although they can depress ventilation. Since benzodiazepines are not analgesics, the combined use of an opioid and benzodiazepines is necessary. Many different benzodiazepines are available, but the agents most commonly used in critically ill are: midazolam, diazepam and lorazepam. Midazolam is the most extensively used. PSYCHOTROPIC DRUGS: The most frequently used drugs in the group of the butyrophenones are droperidol and haloperidol. Although these drugs are chemically unrelated to the phenothiazines they have similar actions. ANALGESICS: Opioids have the main place in management of analgesia in IT, especially in patients on mechanical ventilation. In management of postoperative analgesia, epidural route has advantage because less drug is necessary and cardiovascular and respiratory effects are minimal. Morphine is a standard opioid to which all others are compared. Intravenous bolus dose is 1-5 mg (0.1-0.15 mg/kg) or continuous infusion 2-15 mg/h. Hypotensive effect is caused by direct vasodilation and relief of histamine. Morphine has long elimination half-time and there is a danger of acummulation after prolonged administration. Morphine metabolites are pharmacologically active and renally eliminated. Prolonged i.v. infusion needs careful titration because of tolerance. Pethidine is less potent than morphine, usually given as a bolus dose (10 mg) or a continuous i.v. infusion (10-20 mg/h). Other opioid agents used in IT are: fentanil, alfentanil, sufentanil. Non-steroidal anti-inflammatory drugs (NSAID-s) are: aspirin, ibuprofen, ketoprofen, diclofenac, ketorolac. NSAID-s may have an opioid sparing effect and be of particular benefit for the relief of pain from bones and joints. They interfere with the metabolism at the site of the sensory nerve terminals. Several chemicals are released locally in response to tissue injury. Arachidonic acid is produced from damaged cell membranes. One series reactions is mediated by the enzyme cyclo-oxygenase (COX) and results in the formation of prostaglandins, prostacyclins and thromboxane. The cyclo-oxygenase pathway is inhibited by NSAID-s. These analgesics, besides peripherally, also work centrally by mechanisms which are not in connection with COX inhibition. INTRAVENOUS AND INHALED ANAESTHETIC AGENTS: There are two barbiturates in use: thiopentone and pentobarbital. Although the main effect is hypnosis, the most important is anticonvulsant effect. Thiopentone is an agent for cerebral protection. Barbiturates have not achieved popularity in IT because of prolonged elimination and slow recov

[The Institute of Surgery in Novi Sad as a trauma center--10 years' experience]. / Institut za hirurgiju u Novom Sadu kao trauma centar--desetogodisnje iskustvo.

UNLABELLED: Trauma is a surgical disease and a leading cause of death in the population in the age of forties. The Institute for Surgery in Novi Sad (trauma center of the first rank) takes care of all injured people brought to the Institute either directly from the place of accident or from other centers. AIM OF THE STUDY: Retrospective analysis of the injured people treated at the Institute for Surgery in the period 1987-1996. MATERIAL AND METHODS: Multivariate analysis of the traumas from the register of the Institute for Surgery according to the trauma system elements: number of injured individuals, sex and age structure, categorization of injuries, etiology of injuries, distribution of serious injuries by regions, results obtained from the treatment of serious injuries. RESULTS: They show a global representation of all elements involved with injured people: due to moderately serious, serious and critically serious injuries 21.6% of patients were hospitalized; in the age of 29-30 years men with traumas caused on work or in traffic were predominant, while women with injuries caused by falling were predominant in the age of 60-69 years; drastically increased injuries caused by fire-arms in the period 1991-1993 were directly caused by the state of war and these injuries are still numerous; in case of hospitalized patients isolated trauma (80%) was predominant, multiple trauma was under 20% and polytrauma was registered in 5% of patients; after surgical treatment of injuries approximately 17% of patients were indicated for postoperative prolonged treatment and in intensive care unit at the Institute for Surgery; the average mortality of hospitalized patients was 5-7% but with extremely high mortality rate (< 70%) in the group of patients with polytraumas.

[Transplantation of the kidney at the medical school in Novi Sad--3 years' experience of an interdisciplinary transplantation team]. / Transplantacija bubrega na medicinskom fakultetu u Novom Sadu--trogodisnje iskustvo interdisciplinarnog transplantacionog tima.

The interdisciplinary transplant team on Medical faculty--Novi Sad is formed at the beginning of the 1986, and first successfully cadaver binephrectomy was performed in April 1986, and kidneys was transported in Transplant Centre in Belgrade. The first human renal transplantation with cadaveric kidney was performed 20, May 1986, and result was excellent. The first human renal transplantation with living related kidney was performed 27, Sept 1986, and result also was excellent. During the last three years our transplant team performed 32 renal transplantations. cadaveric kidney transplantations - 25 living-related kidney transplantation - 6 kidney autotransplantation - 1 Our Concept and organisation of interdisciplinary transplant team in Medical Faculty--Novi Sad is the very efficacy model of organisation and at the same time the cheapest solution. In this paper we discuss our organization of human renal transplantation, and technique of donor-neprectomy (cadaveric and living-related) and cold perfusion of kidney with Collins solution. Our rules for implantation are shown as the Algorythm. At the end of this paper we present our results, based on three year's experience and list of the members of our interdisciplinary transplant team.