Out-of-Hospital Cardiac Arrest in the Eye of the Beholder and Emergency Medical Service.

Purpose: Out-of-hospital cardiac arrest (OHCA) remains a global healthcare problem, with low survival and bystander cardiopulmonary resuscitation (CPR) rates. This study aimed to identify event-related factors in OHCA and their impact on return of spontaneous circulation (ROSC) achievement and maintenance until hospital admission. Patients and Methods: All data were collected from Utstein Resuscitation Registry Template for OHCA from The Institute of Emergency Medicine of Zagreb from January 2012 to August 2022. This cross-sectional research analyzed 2839 Utstein reports, including 2001 male, 836 female, and 8 subjects of unknown gender. The average age was 65.4 ± 16.2 years. Results: The most frequent place of collapse was private residence, and 27% of collapses were unwitnessed. Dispatcher-provided CPR instructions were provided in 39.7% of cases until the arrival of the emergency service team, which showed a very strong effect on bystander-provided CPR, and were followed in 68.4% of cases, while non-instructed bystander CPR was provided in only 7.9% of cases. Bystander CPR is more likely to be provided in public places than in private residences, often with both compression and ventilation. Bystander CPR was also more likely to be provided to men. Cases with bystander CPR, and compressions with ventilation compared to compression only CPR, showed a significantly greater success in maintaining ROSC later in CPR, both with moderate effects. Conclusion: Bystander CPR has been shown to have a significant role in achieving and maintaining ROSC until hospital admission. However, our results showed a location-dependent nature of bystanders' willingness to perform CPR as well as sex disparities in patients receiving CPR. With deficient education in basic life support in Croatia, dispatchers need to insist on and instruct bystander CPR performance.

PERIPHERAL NERVE BLOCKS FOR HIP FRACTURES IN EMERGENCY MEDICINE.

Hip fractures represent a major public health issue with increasing incidence as a population ages. The aim of this review is to describe peripheral nerve block techniques (the fascia iliaca compartment block and the pericapsular nerve group block) as pain management for hip fractures in emergency medicine, and to emphasize their benefits. Hip fractures are extremely painful injuries. The pain itself is unpleasant for patients and if left untreated it can lead to multiple complications during preoperative, operative and postoperative patient management. Pain management for elderly hip fracture patients is often challenging. Non-steroidal anti-inflammatory drugs are not recommended due to their side effects, the increased risk of gastrointestinal bleeding, renal function impairment and platelet aggregation inhibition. Paracetamol alone is often insufficient, and opioids have many potentially harmful side effects, such as delirium development. Peripheral nerve blocks for hip fractures are safe and effective, also in emergency medicine settings. The benefits for patients are greater pain relief, especially during movement, less opioid requirements and decreased incidence of delirium. Regional analgesia should be routinely used in hip fracture pain management.

Stable Gastric Pentadecapeptide BPC 157 Heals Established Vesicovaginal Fistula and Counteracts Stone Formation in Rats.

With the stable gastric pentadecapeptide BPC 157 therapy known to heal various both external and internal rat fistulas, we attempt to approach vesicovaginal fistula, continuous urine leaking through vagina, bladder stones, and a possible therapy solution among rats with well-formed 2 week-fistulas (vaginal/vesical 4 mm large defects) started with delayed therapy. Subsequent control fistula course (the subsequent 1, 2, 4, and 6 weeks) since beginning revealed the failed healing, fistula leaking, adhesions, urinary leaking through vagina, failed epithelization, collagenization, granulation tissue and neovascularization, increased inflammation, and necrosis. Thereby, the later intervals revealed the persistent inability to sustain even minimal volume, vesical, and vaginal defects and stone formation at the end of the experiment (fistula-time day 56). BPC 157 therapy (10 µg/kg, 10 ng/kg, intraperitoneally once time daily or perorally in drinking water until sacrifice) was initiated with a considerable delay (at 2 weeks after fistula formation). Already within 1 week therapy, all BPC 157 regimens stopped urinary leaking through vagina, reversed the otherwise resistant poor healing course to the increased epithelization, collagenization, granulation tissue and neovascularization, decreased inflammation, and decreased necrosis. Thereby, at later intervals, all BPC 157 rats exhibited a five times larger volume that can be sustained before leaking as in healthy, vesical, and vaginal defects completely closed and no stone formation. Thus, macro/microscopic and functional recovery, and counteracted stone formation. Concluding, BPC 157 therapy's beneficial effects resulted in healing and no stone formation, with µg- and ng-regimens, either given daily perorally in drinking water or intraperitoneally.

CORRELATION BETWEEN THE LEVEL OF COLORECTAL ANASTOMOSIS AND ANORECTAL FUNCTION.

Anterior rectal resection is a standard surgical procedure for treating carcinomas of rectum and distal sigmoid colon. In many cases of anterior rectal resection, postoperatively some level of fecal incontinence may occur. The aim of our study was to evaluate the impact of the colorectal anastomosis level on anorectal functional disorder. In our prospective study, the participants were patients diagnosed with carcinoma of rectum or distal sigmoid colon. All patients underwent standard open or laparoscopic anterior rectal resection. Six months after the surgery, the function of anorectum was evaluated in all participants. Finally, 38 patients were analyzed, including 13/38 (34.2%) patients with high rectal anastomosis, 11/38 (28.9%) with mid rectal anastomosis and 14/38 (36.8%) with low rectal anastomosis. Patients with a lower level of anastomosis had a statistically significantly greater number of stools, higher urgency and discrimination impairment, more pronounced solid, liquid and gas incontinence, and greater need for diapers (p<0.05 all). Therefore, patients with lower anastomosis had a statistically significant impairment of their quality of life and higher Wexner score (p<0.001 for both analyses). Our study results suggested reduced neorectal capacity to be the main pathophysiological factor for the development of postoperative anorectal function impairment.

Stress in Gastrointestinal Tract and Stable Gastric Pentadecapeptide BPC 157. Finally, do we have a Solution?

Selye's syndrome produced by diverse nocuous agents and "response to damage as such" means Selye's stress triad in stress coping response to reestablish homeostasis. Logically, from the gastrointestinal tract viewpoint, such organoprotective/healing response implies the angiogenic growth factors that commonly signify the healing. Thereby, the gastric pentadecapeptide BPC 157-organoprotection (huge range of beneficial effects) signifies the Selye's stress concept/stress coping response implemented in and from gastrointestinal tract, and BPC 157 as an integrative mediator that integrates the adaptive bodily response to stress. In clinical trials without side effects, LD1 not achieved, BPC 157 healing in gastrointestinal tract, and particularly the healing of the extragastrointestinal tissues (i.e., skin/tendon/ligament/muscle/bone; nerve; cornea/ brain) were referred throughout its integrative capabilities (i.e., ulcerative colitis/multiple sclerosis model equally counteracted), native in gastrointestinal tract, stability in human gastric juice (and thereby, strong efficacy and applicability), its relevance for dopamine-system function (and thereby, counteracting effects of dopamine-system dysfunction and overfunction, centrally and peripherally (mucosa maintenance); interaction with serotonin- and GABA-system)), afforded cytoprotection/adaptive cytoprotection/organoprotection (and thereby, beneficial effects on gastric and whole intestinal tract lesions and adaptation, wounds and fistulas healing, blood vessels, somatosensory neurons, NSAIDs-side effects (including also pancreas, liver, brain lesions, and blood disturbances, prolonged bleeding, thrombocytopenia, thrombosis)). Further, we combine such gut-brain axis and the NO-system where BPC 157 counteracts complications of either L-NAME application (i.e., various lesions aggravation, hypertension) or Larginine application (i.e., hypotension, prolonged bleeding, thrombocytopenia). Also, BPC 157 particularly affects genes functions (i.e., Fos, c-Jun, Egr-1), all together suggestive for an indicative generalization. Thus, we could suggest gastric pentadecapeptide BPC 157 and BPC 157 induced-organoprotection as integrative mediator that integrates the adaptive bodily response to stress, and thereby practically applied in further therapy and in effective realization of Selye's stress response.

Effects of Diclofenac, L-NAME, L-Arginine, and Pentadecapeptide BPC 157 on Gastrointestinal, Liver, and Brain Lesions, Failed Anastomosis, and Intestinal Adaptation Deterioration in 24 Hour-Short-Bowel Rats.

Stable gastric pentadecapeptide BPC 157 was previously used to ameliorate wound healing following major surgery and counteract diclofenac toxicity. To resolve the increasing early risks following major massive small bowel resectioning surgery, diclofenac combined with nitric oxide (NO) system blockade was used, suggesting therapy with BPC 157 and the nitric oxide synthase (NOS substrate) L-arginine, is efficacious. Immediately after anastomosis creation, short-bowel rats were untreated or administered intraperitoneal diclofenac (12 mg/kg), BPC 157 (10 µg/kg or 10 ng/kg), L-NG-nitroarginine methyl ester (L-NAME, 5 mg/kg), L-arginine (100 mg/kg) alone or combined, and assessed 24 h later. Short-bowel rats exhibited poor anastomosis healing, failed intestine adaptation, and gastrointestinal, liver, and brain lesions, which worsened with diclofenac. This was gradually ameliorated by immediate therapy with BPC 157 and L-arginine. Contrastingly, NOS-blocker L-NAME induced further aggravation and lesions gradually worsened. Specifically, rats with surgery alone exhibited mild stomach/duodenum lesions, considerable liver lesions, and severe cerebral/hippocampal lesions while those also administered diclofenac showed widespread severe lesions in the gastrointestinal tract, liver, cerebellar nuclear/Purkinje cells, and cerebrum/hippocampus. Rats subjected to surgery, diclofenac, and L-NAME exhibited the mentioned lesions, worsening anastomosis, and macro/microscopical necrosis. Thus, rats subjected to surgery alone showed evidence of deterioration. Furtheremore, rats subjected to surgery and administered diclofenac showed worse symptoms, than the rats subjected to surgery alone did. Rats subjected to surgery combined with diclofenac and L-NAME showed the worst deterioration. Rats subjected to surgery exhibited habitual adaptation of the remaining small intestine, which was markedly reversed in rats subjected to surgery and diclofenac, and those with surgery, diclofenac, and L-NAME. BPC 157 completely ameliorated symptoms in massive intestinal resection-, massive intestinal resection plus diclofenac-, and massive intestinal resection plus diclofenac plus L-NAME-treated short bowel rats that presented with cyclooxygenase (COX)-NO-system inhibition. L-arginine ameliorated only L-NAME-induced aggravation of symptoms in rats subjected to massive intestinal resection and administered diclofenac plus L-NAME.

Stable gastric pentadecapeptide BPC 157 heals rectovaginal fistula in rats.

AIM: Rectovaginal fistula is a devastating condition providing more than 99% of patients for surgical treatment. We hypothesized that rectovaginal fistula may be healed by therapy with stable gastric pentadecapeptide BPC 157, in consistence with its initial clinical application and effect on external fistulas. MAIN METHODS: BPC 157 (10µg/kg or 10ng/kg) was given perorally, in drinking water (0.16µg/ml or 0.16ng/ml, 12ml/rat/day) till sacrifice, or alternatively, intraperitoneally, first application at 30min after surgery, last at 24h before sacrifice. Controls simultaneously received an equivolume of saline (5.0ml/kg ip) or water only (12ml/rat/day). The assessment (i.e., rectal and vaginal defect, fistula leakage, defecation through the fistula, adhesions and intestinal obstruction as healing processes) was at day 1, 3, 5, 7, 10, 14 and 21. KEY FINDINGS: Regularly, rectovaginal fistulas exhibited poor healing, with both of the defects persisting, continuous fistula leakage, defecation through the fistula, advanced adhesion formation and intestinal obstruction. By contrast, BPC 157 given perorally or intraperitoneally, in µg- and ng-regimens rapidly improved the whole presentation, with both rectal and vaginal defects simultaneously ameliorated and eventually healed. The maximal instilled volume was continuously raised till the values of healthy rats were achieved, there were no signs of defecation through the fistula. A counteraction of advanced adhesion formation and intestinal obstruction was achieved. Microscopic improvement was along with macroscopic findings. SIGNIFICANCE: BPC 157 effects appear to be suited to induce a full healing of rectovaginal fistulas in rats.

Bilateral synchronous breast cancer.

We report a rare case of synchronous bilateral breast cancer in 79-year-old female patient treated at our hospital. The tumors were discovered one year ago after a complete clinical and radiological (mammography, US) examination with cytopunction of tumor masses. Results came back and showed carcinomas of both breasts. Patient underwent surgical re moval of the both breasts with bilateral axillary lymphadenectomy. Later histological examination confirmed earlier diagnosis of invasive ductal carcinoma in both breasts in a G3 stage. After surgical removal of the tumors patient was also treated with radiotherapy. One year after bilateral mastectomy and axillary lymphadenectomy, clinical and radiological examination that included mammography and ultrasound of breast with tumor marker C15-3 which was 2.8, we did not found recurrence of the tumor.

Blunt trauma of thorax with subclavian and axillary artery lesion--case report.

We report a rare case of blunt trauma of the axillary artery in a 20-year-old man who was injured as a motorcycle rider and received severe body injuries. Injuries included severe trauma of the left lower leg with contusion and extensive soft tissue and bone trauma of these regions with poor general condition and with the presence of clinical signs of traumatic shock. Upon arrival, we found that in addition to earlier clearly visible trauma to the leg, there was a hematoma of the medial side of the left supraclavicular region and the absence of the radial artery pulse with paralysis of the left arm. Given the clinical findings, emergency radiological examination was made to the patient (X-ray, US, CDFI, MSCT-angiography) and we found out that there was trauma of axillary artery with clear signs of thrombosis of extra thoracic part of subclavian artery due to its transition into the axillary artery. After hemodynamic stabilization, above knee amputation of the left leg was performed and emergency exploration of earlier mentioned arteries. Bypass of the damaged arteries with synthetic graft 6 mm in diameter was made. Control MSCT angiography showed normal flow in the arterial tree of the whole left hand and the MRI of the cervical spine and shoulder girdle did not found lesions of the brachial plexus. SSEP demonstrated the absence of pulses on the left hand. Patient on regular check-ups showed normal general condition, with adequate passable graft and pronounced paralysis on the left hand. In the process of rehabilitation physiotherapy was also included. Blunt trauma to the axillary artery is an extremely rare example of trauma of blood vessels which makes only 0.03% of all vascular injuries.

Therapy of umbilical hernia during laparoscopic cholecystectomy.

The aim of this study is to show our experience with umbilical hernia herniorrhaphy and laparoscopic cholecystectomy, both in the same act. During last 10 years we operated 89 patients with cholecystitis and pre-existing umbilical hernia. In 61 of them we performed standard laparoscopic cholecystectomy and additional sutures of abdominal wall, and in 28 patients we performed in the same act laparoscopic cholecystectomy and herniorrhaphy of umbilical hernia. We observed incidence of postoperative herniation, and compared patients recovery after herniorrhaphy combined with laparoscopic cholecystectomy in the same act, and patients after standard laparoscopic cholecystectomy and additional sutures of abdominal wall. Patients, who had in the same time umbilical hernia herniorrhaphy and laparoscopic cholecystectomy, shown better postoperative recovery and lower incidence of postoperative umbilical hernias then patients with standard laparoscopic cholecystectomy and additional abdominal wall sutures.

Preemptive use of diclofenac in combination with ketamine in patients undergoing laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study.

BACKGROUND: To examine the combined preemptive effects of low-dose ketamine, diclofenac, and their combination on postoperative pain in patients undergoing laparoscopic cholecystectomy. METHODS: A total of 80 consecutive patients, American Society of Anesthesiologists physical status I or II, were recruited to the study. Patients were randomized to one of the following groups: group 1 received 100-mL isotonic saline intravenously (i.v.) 20 minutes before the induction of anesthesia and 5-mL isotonic saline i.v. before skin incision as a placebo; group 2 received 100-mL isotonic saline i.v. 20 minutes before the induction of anesthesia and 0.15-mg/kg ketamine diluted in 5-mL isotonic saline i.v. before skin incision; group 3 received diclofenac 1 mg/kg diluted in 100-mL isotonic saline i.v. 20 minutes before the induction of anesthesia and 5-mL isotonic saline i.v. before skin incision; and group 4 received a combination of the same diclofenac sodium and ketamine doses at the same time. Abdominal and shoulder pain intensity was assessed using the visual analog scale and verbal rating scale during 24 hours postoperatively. RESULTS: Patients receiving diclofenac had a significantly lower pain score between 2 and 6 hours after surgery compared with patients receiving placebo. One hour after surgery, patients receiving a combination of diclofenac and ketamine had a significantly lower pain score compared with patients receiving placebo and ketamine alone. Patients from all the 4 study groups required postoperative analgesic; however, the time to diclofenac sodium request was longer in patients receiving a combination of diclofenac and ketamine compared with patients receiving placebo (p<0.001), ketamine (p<0.001), or diclofenac (p=0.03) alone. CONCLUSIONS: The preemptive administration of a combination of low-dose ketamine plus diclofenac sodium improved postoperative analgesia after laparoscopic cholecystectomy, whereas ketamine at a dose of 0.15 mg/kg did not elicit a preemptive analgesic effect.

The effect of spinal versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing peripheral vascular surgery.

The optimal anesthetic technique for peripheral vascular surgery remains controversial. The purpose of this study was to evaluate the effect of spinal versus general anesthesia on postoperative pain, analgesic requirements and postoperative comfort in patients undergoing peripheral vascular surgery. A total of 40 patients scheduled for peripheral vascular surgery were randomly assigned to two groups of 20 patients each to receive general anesthesia (GA) or spinal anesthesia (SA). In GA group, anesthesia was induced using thiopental and fentanyl. Vecuronium was used for muscle relaxation. Anaesthesia was maintained with isoflurane and nitrous oxide. In the SA group, hyperbaric 0.5% bupivacaine was injected into the subarachnoid space. Postoperative pain was assessed for 24 hours by a visual analog scale during three assessment periods: 0-4, 4-12 and 12-24 h as well as analgesic requirements. Patients were also asked to assess their postoperative state as satisfactory or unsatisfactory with regard to the pain, side effects and postoperative nausea and vomiting. Visual analogue scale (VAS) pain score was significantly lower in the group SA compared with group GA. This effect was mainly due to the lower pain score during the first study period. The patients received general anesthesia also reported a significantly higher rate of unsatisfactory postoperative comfort than those receiving spinal anesthesia. We conclude that spinal anesthesia is superior to general anesthesia when considering patients' satisfaction, side effects and early postoperative analgesic management.

Efficacy of antimicrobial triclosan-coated polyglactin 910 (Vicryl* Plus) suture for closure of the abdominal wall after colorectal surgery.

This study compared Triclosan coated polyglactin 910 (Vicryl* Plus) with polyglactin 910 (Vicryl*) on abdominal wall healing in colorectal surgery patients. 184 patients with colorectal cancer were included in the study. In 91, the abdominal wall was closed with the Vicryl* Plus, and in 93 patients with Vicryl*. Demographic characteristics, biochemical inflammatory parameters, wound appearance, length of hospital stay, postoperative wound complications and post-incisional hernia were recorded. In the Vicryl* Plus group there was a shorter hospital stay (13.2 +/- 1.3 days; 21.4 +/- 2.8 respectively). In the Vicryl* Plus group inflammatory parameters decreased to normal within the first week whereas in the Vicryl* group remained increased. In the Vicryl* Plus group four patients had a wound discharge, seven had inflammatory reactions to the skin sutures. One dehiscence was noticed. In the Vicryl* group 12 patients had an SSI, 14 patients had inflammatory reactions to the skin sutures and 7 patients had a wound dehiscence. Closure of the abdominal wall using Vicryl* Plus decreases postoperative wound complications, length of hospital stay and is associated with a more rapid return of inflammatory markers to normal.

[Bile stone ileus with cholecystoduodenal fistula--Bouveret's syndrome]. / Visoki ileus uzrokovan uglavljenim zucnim kamenom u silaznom dvanaesniku kao posljedica kolecistoduodenalne fistule--Bouveretov sindrom.

This is a case report of a 71-year-old man, who presented to emergency department with elevated temperature, vomiting and epigastric pain. Computed tomography of the abdomen revealed a large fistulous tract extending from the gallbladder to the duodenal bulb, as well as a large calculus obstructing the second part of the duodenum. The patient subsequently underwent successful surgical therapy.

[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.

Single incision laparoscopic cholecystectomy--a new advantage of gallbladder surgery.

In this study is demonstrated our experience in single incision laparoscopic cholecystectomy (SILS), compared to standard laparoscopic cholecystectomy. There were 48 single incision laparoscopic cholecystectomies (SILS) performed during one-year period (A group) and results have been compared with a group of 50 patients who underwent standard laparoscopic cholecystectomy (B group). Outcome measures included operative time, need for conversion, complications, additional analgesia for pain control after procedure, hospital stay and cosmetic outcome. The mean operative time was 46 +/- 3.5 min in A group, and 43 +/- 4 min in B patients group. Early postoperative complications were not detected. The mean hospitalization period was 2 days in both groups. Our experience suggests that SILS cholecystectomy can be performed with outcome similar to standard laparoscopic surgery while affording better cosmesis.

[A contribution to surgical treatment of gastric and duodenal ulcer hemorrhage in critically unstable patients]. / Prilog operacijskom lijecenju krvareceg ulkusa zeluca i dvanaesnika u vitalno ugrozenih bolesnika.

UNLABELLED: One of the complications of gastroduodenal ulcer disease is gastrointestinal hemorrhage; it is a cause of a substantial mortality. Standard therapy of gastroduodenal hemorrhage consists of endoscope sclerosation, over sewing or resection. The aim of this study is to analyze our results and methods in treatment of life threatening patients with gastroduodenal hemorrhage. PATIENTS AND METHODS: A series of 47 life treating patients was surgically treated in General Hospital Sveti Duh in Zagreb for gastroduodenal hemorrhage during the period of 10 years and were retrospectively analyzed. Massive gastroduodenal hemorrhage was endoscopically confirmed, and after insufficient endoscopic therapy, surgically treated. For a treatment in 47 patients (which could not survive gastric resection) we used ulcer over sewing in 20 of them combined with gastroduodenal artery (GDA) or left gastric artery (LGA) ligation. RESULTS: Patients which were treated with combination of artery ligation and ulcer oversewing, had better results in stopping gastroduodenal hemorrhage, lower mortality and recidivism when they were compared with group which was treated only with standard ulcer oversewing, without artery ligations. CONCLUSIONS: Combination of artery ligation (LGA or GDA) and ulcer oversewing shows better results in stopping gastroduodenal hemorrhage than standard ulcer suture itself.

Post-intubation long-segment tracheal stenosis of the posterior wall: a case report and review of the literature.

Tracheal stenosis, a well-known complication of endotracheal intubation and artificial ventilation, is most likely to occur in critically ill patients requiring prolonged mechanical ventilation. Although a rare complication, and despite technological improvements and better patient care in intensive care units, tracheal stenosis still constitutes a serious clinical problem which can also develop after a short period of mechanical ventilation. In this article, we present a very rare case report of a patient who developed a long-segment tracheal stenosis localized at the posterior wall after a relatively short period of endotracheal intubation with a high-volume, low-pressure cuffed endotracheal tube, and a review of the literature.

[Effects of pneumoperitoneumon liver function]. / Ucinci pneumoperitoneuma na jetrenu funkciju.

Effects of pneumoperitoneum on liver function during laparoscopic procedures in most patients have no clinical relevance. However, with increasing number and types of surgical procedures the laparoscopic operation is now performed in high-risk patients, including patients with pre-existing liver disease. In these patients laparoscopic procedures may lead to serious complication, including acute liver failure. Because postoperative liver damage induced by pneumoperitoneum has been underestimated, the aim of this article is to review the numerous factors influencing liver damage during laparoscopy and review of therapeutic options for their reduction.

[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.