Branislava Stefanović

D-dimer in acute pancreatitis: a new approach for an early assessment of organ failure.

Objectives: Studies on the clinical value of parameters of hemostasis in predicting pancreatitis-associated complications are still scarce. The aim of this prospective study was to identify the useful hemostatic markers for accurate determination of the subsequent development of organ failure (OF) during the very early course of acute pancreatitis (AP). Methods: In 91 consecutive primarily admitted patients with AP, prothrombin time, activated partial thromboplastin time, fibrinogen, antithrombin III, protein C, plasminogen activator inhibitor 1, d-dimer, and plasminogen were measured in plasma within the first 24 hours of admission and 24 hours thereafter. Two study groups comprising 24 patients with OF and 67 patients without OF were compared. Results: Levels of prothrombin time, fibrinogen, and d-dimer on admission were significantly different between the OF and non-OF groups, and all these parameters plus antithrombin III were significantly different 24 hours later. A d-dimer value of 414.00 &mgr;g/L on admission was the best cutoff value in predicting the development of OF with sensitivity, specificity, and positive and negative predictive values of 90%, 89%, 75%, and 96%, respectively. Conclusions: Measurement of plasma levels of d-dimer on the admission is an accurate method for the identification of patients who will develop OF in the further course of AP.Abbreviations: AP - acute pancreatitis, PT - prothrombin time, APTT - activated partial thromboplastin time, AT III - antithrombin III, PAI-1 - plasminogen activator inhibitor 1, ROC - receiver operating characteristic, AUC - area under the curve

Elevated Serum Protein S100B and Neuron Specific Enolase Values as Predictors of Early Neurological Outcome after Traumatic Brain Injury

Summary Background: The objective of our study was to determine the serum concentrations of protein S100B and neuron specific enolase (NSE) as well as their ability and accuracy in the prediction of early neurological outcome after a traumatic brain injury. Methods: A total of 130 polytraumatized patients with the associated traumatic brain injuries were included in this prospective cohort study. Serum protein S100B and NSE levels were measured at 6, 24, 48 and 72 hours after the injury. Early neurological outcome was scored by Glasgow Outcome Scale (GOS) on day 14 after the brain injury. Results: The protein S100B concentrations were maximal at 6 hours after the injury, which was followed by an abrupt fall, and subsequently slower release in the following two days with continual and significantly increased values (p<0.0001) in patients with poor outcome. Secondary increase in protein S100B at 72 hours was recorded in patients with lethal outcome (GOS 1). Dynamics of NSE changes was characterized by a secondary increase in concentrations at 72 hours after the injury in patients with poor outcome. Conclusion: Both markers have good predictive ability for poor neurological outcome, although NSE provides better discriminative potential at 72 hours after the brain injury, while protein S100B has better discriminative potential for mortality prediction.

Influence of Syrgical Trauma on Nitric Oxide and Nitrotyrosine Serum Levels in Patients Undergoing Laparoscopic or Conventional Cholecystectomy

Summary Background: Oxidative stress represents tissue damage caused by reactive forms of oxygen and nitrogen due to the inability of antioxidant mechanisms to reduce reactive forms into more stable ones. The aim of the study was to evaluate the influence of surgical trauma on nitric oxide (NO) and nitrotyrosine (NT) values in patients undergoing conventional and laparoscopic cholecystectomy. Methods: A prospective study included sixty patients from the Department of Emergency Surgery, Clinical Centre of Serbia who were operated for gallstone related chronic cholecystitis. All the patients enrolled in the study underwent cholecystectomy; the first group was operated conventionally (30 patients - control group), while the second group was operated laparoscopically (30 patients - treatment group). Results: There were no statistically significant differences in the values of NO and its postoperative changes in both groups, the conventionally operated group (p=0.943) and the laparoscopically operated group (p=0.393). We found an increase in NT values 24 hours postoperatively (p=0.000) in the conventionally operated patients, while in the group operated laparoscopically we didn’t find statistically significant changes in the values of NT (conventionally operated group (p=0.943) and laparoscopically operated group (p=0.393)). Conclusions: In our study, we found a significant increase in NT values 24 hours postoperatively in conventionally operated patients i.e. the control group, vs. the treatment group. Further randomized studies are needed for a better understanding of the impact of surgical trauma on oxidative stress response.

Coagulopathy in trauma

Trauma is still a leading cause of morbidity and mortality in the contemporary community, particularly in population younger than 40 years of age. Recent studies have offered new knowledge on the central role of coagulopathy in traumatized people. Massive hemorrhage is a cause of death in severely traumatized people in 40% of cases, and the control of bleeding is a special challenge in the developed and verified coagulopathy. After severe trauma, massive hemorrhage is very often the consequence of associated surgical and coagulopathic bleeding. Massive blood loss diminishes the capacity of coagulation system, resulting in coagulopathy even in patients whose hemostasis before the injury has been within physiological limits.

Veštačka stimulacija nervus-a frenikus-a nakon povrede

The phrenic nerve is a nerve that originates in the neck (C3-C5) and passes down between the lung and heart to reach the diaphragm. It controls the diaphragm which is the primary muscle involved in breathing. Injuries of the phrenic nerve can occur after trauma such as falls, blunt trauma, after penetrating injuries or in car accidents, iatrogenic nerve injury during surgery in the neck and chest. Phrenic nerve pacing (PNP), or “diaphragm pacing”, is the application of rhythmic electrical impulses to the diaphragm, resulting in respiration for patients who would be otherwise dependent on a mechanical ventilator. Phrenic nerve stimulators are indicated for selected patients with partial or complete respiratory insufficiency” and “can be only effective if the patient has an intact phrenic nerve and diaphragm, which means in patients with spinal cord injuries, central sleep apnea and in patients with lesion of central nervous system. In contrast, trauma below C2 usually does not allow pacing, because the cell bodies of the phrenic nerves are damaged. This kind of treatment can lead to a significant improvement in the quality of life of ventilator-dependent quadriplegic individuals. It can improve pulmonary function and reduce the incidence of pulmonary infections. In addition, it improves quality of speech and olfaction which leads to much better quality of life and higher rates of social participation. We would like to demonstrate a case of a nineteen years old patient that was admitted to the ER department in Clinical Center of Serbia as an emergency case with penetrating wound injury after a gunshot wound to the neck. Data from the literature, which have been also confirmed with our individual experience suggest that the phrenic nerve pacing begins in cases that there is no recovery of nerve not earlier than three and no later than six months after the injury when the results are the most appropriate. Most patients with diaphragmatic pacemakers continue to need tracheostomies and mechanical ventilators as a back-up to their pacemakers. It is important to note that diaphragmatic pace makers only improve inspiratory function and do not target expiratory functions such as coughing and clearing secretions. Finally, the extremely high cost of the device itself, with modest results of the implementation of the device, gives a basis to observe it with great criticism, especially in countries with lower economic status.

Injuries of the pancreas

Background: In spite of significant progress in diagnostics and surgery for pancreatic injuries in the last few decades, there have still been professional controversies about its management. Aim: Retrospective analysis of patients with pancreatic injuries, treated at the Clinic for Urgent Surgery of the Emergency Center, Clinical Center of Serbia (2003-2013), highlighting the relevant diagnostic and therapeutical aspects of the pancreatic injuries, present dilemmas, as well as review of post-operative complications and mortality. Methods: Statistical analysis. Results: In the abovementioned period, 60 patients with pancreatic injuries were treated. More than 50% of patients were managed by lesion suture and drainage. A total percentage of complications was 32.6% and an overall mortality was 18%. Conclusion: Management of pancreatic injuries might present a serious professional problem, even if managed by qualified and experienced teams in highly specialized (“high volume”) centers.

[Myocardial dysfunction in septic shock--a case report].

INTRODUCTION Sepsis is characterized by generalized inflammatory response induced by infection. The incidence of myocardial dysfunction in sepsis is unknown as well as its impact on survival, independently other organ system dysfunction. CASE REPORT A female patient, age 36, with clinical signs of septic shock was admitted to the Intensive Care Unit. After initial therapy of septic shock, patient was still haemodynamically unstable. Transthoracic echocardiography showed left ventricular dysfunction (EF = 20%), with mitral regurgitation 2-3+, tricuspid regurgitation 3+, and estimated systolic right ventricular pressure of 53 mm Hg. Inotropic drug, dobutamine, was initiated, which led to significant improvement of hemodynamic parameters. Eight days after the initiation of therapy the clinical improvement was observed and the control transthoracic echocardiography was performed. It showed the improvement in left ventricular size and function, with EF of 57%, and reduced mitral regurgitation to 2+, and tricuspid regurgitation to 1+. DISCUSSION A hyperdynamic state is typically present in sepsis. Myocardial dysfunction in sepsis is characterized by decreased ejection fraction, ventricular dilatation and impaired contractile response to volume loading. Cardiac output can be measured using pulmonary artery catheter, transthoracic and transoesophageal echocardiography, or by pulse contour analysis. In this patient, myocardial dysfunction was detected by echocardiography, which helped in clinical decision making to administer inotropic agent. The recovery of myocardial function was also confirmed by echocardiography. CONCLUSION Echocardiography can be used in septic patient for diagnosis of myocardial dysfunction, decision making, follow-up of the response to inotropic therapy, and detection of the complete recovery of cardiac function.