[A patient with 16 liter blood loss during radical prostatectomy]. / Bolesnik koji je tijekom radikalne prostatektomije izgubio 16 litara krvi.

Radical prostatectomy is the treatment of choice for localized prostate neoplasm. Bleeding is a common problem during this operation. Massive bleeding can occur in case of injury of one of the hypogastric vein branches during lymphadenectomy or transection of the dorsal vein plexus. We present a 67-year-old patient that lost 16 liters of blood during the operation. In order to restitute the lost blood volume and prevent the low cardiac output and hypoxia, the patient was administered crystalloids, colloids, blood and blood derivatives. The patient received epinephrine, norepinephrine and dopamine to maintain mean arterial pressure above 55 mm Hg. After stopping surgical bleeding, stabilization of the coagulation system was achieved and further nonsurgical bleeding prevented by aprotinin and recombinant factor VIla. Timely volume restitution, not only with blood and blood components, was crucial to prevent the consequences of hemorrhagic shock. With pharmacological interventions, by aprotinin and recombinant factor VIIa in particular, we can act prophylactically and therapeutically to stop nonsurgical bleeding. Multimodal therapeutic procedures, promptly administered in massive bleeding, can improve the survival prognosis.

Regional anesthesia for upper extremity surgery--our experience.

Brachial plexus block using axillary approach is a simple and safe method of regional anesthesia often used for elbow, forearm and hand surgery. Different techniques can be used to achieve brachial plexus block. On using perivascular approach to brachial plexus, we neither searched for paresthesia nor used nerve stimulator to identify the correct needle position within the neurovascular sheet. Axillary artery was palpated and a mixture of local anesthetic agents was injected into the neurovascular sheet above and below axillary artery at the site of strongest artery pulsation. The local anesthetic solution comprised equal volumes of lidocaine 2% and bupivacaine 0.5% without adrenaline, in a total volume of 30-40 mL, depending on body mass. This technique is used in more than 150 patients per year at our department. In the present study, 158 patients undergoing upper extremity surgery under brachial plexus block were retrospectively assessed. Successful anesthesia was achieved in 135 (85.0%) patients using brachial plexus block alone, 19 (12.5%) patients required additional medication, two patients required supplementation with intravenous regional anesthesia, and another two patients required general anesthesia. The incidence of successful blocks, latency time of onset, local and systemic complications or allergic skin reactions were investigated. There were no significant complications attributed to the anesthetic technique.

Retrospective study of specific immunotherapy - what should be done in the future.

In this retrospective study, data on 241 atopic patients treated with specific cutaneous immunotherapy during the 1985-2006 period at Allergy Clinic, University Department of Dermatology and Venereology, were reviewed. The following diagnoses were recorded: atopic dermatitis, pure or in combination with allergic rhinitis or allergic bronchitis, or allergic bronchitis and asthma, allergic rhinitis, allergic conjunctivitis, urticaria, and Quincke's edema. The aim was to retrospectively analyze clinical efficacy and laboratory findings in atopic patients undergoing specific immunotherapy. Before specific immunotherapy administration, eosinophil count, immunoglobulins, skin prick test, total IgE (RIST) and specific IgE (IgE UniCAP) were determined. The following allergens were included in specific immunotherapy: Dermatophagoides pteronyssinus, house dust mite (mixed or separately), mixed and single pollens (grass, tree, weed), feather, and animal dander. The most frequent allergens in 241 atopic patients were grass pollen mixture, Dermatophagoides pteronyssinus, ragweed, tree pollen mixture, cocksfoot, birch, animal dander, and feather. Treatment efficacy was demonstrated after 3 years of continuous therapy by clinical evaluation and with the same diagnostic procedure. After several months of therapy, initial clinical improvement was noticed in atopic dermatitis patients as well as in patients with respiratory diseases that were sensitive to airborne allergens. According to literature, specific immunotherapy was used as a treatment option, which may affect the natural course of allergic diseases. It reduces development of asthma in patients with allergic rhinitis and prevents the onset of new sensitizations.

[Anaphylactic reaction as a side-effect of administration of general anesthetics and neuromuscular blocking agents]. / Anafilakticka reakcija kao nuspojava primjene opcih anestetika i misicnih relaksansa.

The incidence of anaphylactic reactions during anesthesia is between 1:5000 and 1:25000 anesthetics. During the IgE-mediated anaphylactic reaction mast cells release proteases such as tryptase, histamine and vasoactive mediators. The release of mediators from the mast cells and basophils is responsible for the immediate clinical manifestations of anaphylaxis. Anaphylactoid reactions can be caused directly by a release of histamine and other mediators from mast cells and basophils and they don't depend on interaction of IgE antibodies with antigen. The most frequent agents that cause anaphylactic and anaphylactoid reactions during anesthesia are neuromuscular blocking agents (among them the highest percent refers to rocuronium and succinylcholine), some general anesthetics, antibiotics, blood and blood products, opioids and latex. Increased tryptase concentration in serum is a marker for systemic mast cell activation. Skin tests (in vivo) are used for verification of specific hypersensitivity to drugs in patients after anaphylactic reaction. In vitro tests prove the presence of specific IgE antibodies for drugs. The plan for the treatment of anaphylactic reactions must be established before the event. Airway maintenance, 100% oxygen administration, intravascular volume expansion and epinephrine are essential to treat the hypotension and hypoxia that result from vasodilatation, increased capillary permeability and bronchospasm. As soon as the diagnosis has been made the adrenalin should be given intravenously 1 to 3 ml of 1:10000 aqueous solution (0.1 mg/ml) over 10 minutes. Prevention is possible with methylprednisolone 125 mg i.v. 1 hour before administering of anesthetics and neuromuscular blocking agents with or without antihistaminic chlorpiramine-chloride 1 amp i.v. few minutes before anesthesia.

Correlation among skin prick test, total and specific IgE UniCAP tests in atopic patients from Zagreb, Croatia.

The correlation of pollen allergens, Dermatophagoides pteronyssinus and animal dender was assessed during a two-year period. Results of skin prick test, total and specific IgE UniCAP tests were compared in atopic patients (AP) with the following diagnoses: atopic dermatitis, allergic rhinitis, allergic conjunctivitis, allergic bronchitis or asthma, allergic urticaria and angioedema. The study included total and specific IgE (in vitro) tests to allergen mixtures (grass, tree, weed) or to single allergens of Dermatophagoides pteronyssinus (Der p), cat and dog fur, feather, etc. Comparison of skin prick test with total and specific IgE UniCAP immunoassay was done in 173 patients, i.e. 107 female and 66 male atopic patients aged 9-76 years. Allergies were most commonly recorded in the 25-35 age group. Total IgE ranged from 8.63 kU/l to >4000 kU/l, with specific IgE ranging from class 1 to class 5. Skin prick test showed high correlation with specific IgE for grass and weed pollen in patients with repiratory allergy (50.28%). Good correlation among all three tests was quite frequently observed. The results suggest that the study should be continued using these three tests in further cases of atopic dermatitis.