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PURPOSE: There are no evidence-based guidelines for volume replacement during surgical procedures such as laparoscopic cholecystectomy. However, the administration of a restrictive volume of crystalloids could be more cost-effective and safe. This trial aimed to determine the effectiveness and safety of a restrictive regimen of crystalloids in patients during laparoscopic cholecystectomy by analyzing its cost-effectiveness and 1-year morbidity rate. PATIENTS AND METHODS: In this randomized, prospective study, patients were assigned to one of three groups based on the volume of fluid administered: the restrictive group received 1 mL/kg/hr, the low liberal group received 5 mL/kg/hr, and the high liberal group received 15 mL/kg/hr of Ringer's solution intraoperatively. There were 40 patients in each group. Each patient's hemodynamic parameters and laboratory values (arterial blood gas and lactate levels) were measured together with their consumption of crystalloids, volatile anesthetics, and analgesics. RESULTS: Analysis of the hemodynamic and laboratory parameters revealed no signs of global hypoperfusion in any of the groups analyzed. There was no significant difference in the duration of surgery and anesthesia, but the consumption of crystalloids, volatile anesthetics, and opioids was significantly lower in the restrictive group, compared with the low and high liberal groups. Although there was no significant difference in the 1-year morbidity among the groups, heart failure was observed in one patient in the high liberal group in the early postoperative period. CONCLUSION: Restrictive fluid therapy during laparoscopic cholecystectomy is justified, safe, and more cost-effective than other options.

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BACKGROUND: The endothelial glycocalyx is located on the luminal side of blood vessels and maintains vessel integrity. This study analysed how various dosages of infusion affected the secretion of atrial natriuretic peptide (ANP) and potential glycocalyx damage in patients undergoing laparoscopic cholecystectomy. We hypothesised that the liberal administration of Ringer's solution during the operation can cause iatrogenic hypervolemia with releasing of ANP and glycocalyx damage. METHODS: The study included 90 patients with American Society of Anesthesiologists' (ASA) class I and II, in good cardiopulmonary health, who were assigned to one of three groups: Restrictive group, which received 1 mL/kg/hr intraoperatively and six hours postoperatively; Low liberal group, which received 5 mL/kg/hr of Ringer's solution intraoperatively and six hours postoperatively and High liberal group, which received 15 mL/kg/hr intraoperatively and 10 mL/kg/hr six hours postoperatively. We measured patients' concentrations of glycocalyx constituents, ANP, markers of kidney and liver function, C-reactive protein (CRP), and albumine at three time points. We also measured noinvasive hemodynamics, the correlation between ANP secretion and the concentration of glycocalyx components. RESULTS: We found a significantly higher concentrations of hyaluronic acid and syndecan-1 and more ANP secretion in the High liberal group than in the other groups. We also observed a positive correlation between ANP secretion and glycocalyx constituent concentration. Markers of kidney and liver function were normal, suggesting preservation of splanchnic perfusion and global hemodynamics. CONCLUSIONS: Measuring the endothelial glycocalyx constituents in circulating blood could be a marker of intraoperative volume overload during laparoscopic operations.

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BACKGROUND: Proximal femoral fractures are a major public health problem because of the increasing proportion of elderly individuals in the general population. The mode of choice for anaesthesia in surgical treatment of these fractures is still debated in terms of better postoperative outcome. The aim of our study was to compare the effect of general over spinal anaesthesia on mortality in proximal femoral fracture surgery. PATIENTS AND METHODS: This study was a retrospective analysis of 115 patients aged at least 70 years who underwent surgery for proximal femoral fracture. The survey was conducted from 1 January to 31 December 2015 at the General Hospital Karlovac, Croatia. Patients were divided into two groups: group 1 - general anaesthesia and group 2 - spinal anaesthesia. The primary outcome measure was the effect of mode of anaesthesia, general versus spinal, on mortality within 30 days, six months and one year after surgery. RESULTS: General anaesthesia (EndoTracheal Anaesthesia) was administered in 77 patients (67%; group I - ETA) and spinal anaesthesia in 38 patients (33%; group 2 - SPIN). Both groups had more female than male patients: 69 patients (89.6%) in the ETA group and 32 patients (84.2%) in the SPIN group were female. The mean age in the ETA group was 82.91 years and in the SPIN group was 80.18 years. ASA II status was more common in patients in the SPIN group (25 patients [65.8%]). The average time from hospitalisation to surgery was 53.44 hours in the ETA group and 53.33 hours in the SPIN group. There was no significant difference between groups in the number of comorbidities, or intraoperative and postoperative complications. There was no statistically significant difference in mortality between the groups. Mortality after surgery in the ETA and SPIN groups, respectively, was as follows: 10.4% and 10.5% at 30 days, 23.4% and 15.8% at six months, and 32.5% and 31.6% at one year. CONCLUSION: The results indicate that the mode of anaesthesia (general vs spinal) has no effect on postoperative mortality, and that the mode of anaesthesia should be applied on an individual basis in correlation with associated comorbidities.

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The aim of the study was to show the role of tools in the evaluation of chronic pain (CP) in general practitioner (GP) everyday clinical practice. The study was done by analyzing electronic database of the first visits of 1090 CP patients referred to the Pain Clinic of the Karlovac General Hospital, Karlovac, Croatia, by their GPs. All patient records were analyzed according to the cause of CP, strongest pain a week before the examination, quality of sleep, and the Patients' Global Impression of Change scale. All statistical analyses were done using the IBM SPSS Statistics version 19.0.0.1 (www.spss.com). CP predominantly occurs in older age group. Patients with musculoskeletal pain accounted for the highest percentage (n = 316; 29%), followed by those with neuropathic pain (n = 253; 23.20%) and those with low back pain (n = 225; 20.60%). The mean pain intensity rating scale score was 8.3 ± 1.8 a week before the examination and the mean quality of sleep score was 6.8 ± 1.9. Moderate and severe sleep quality disorder was significantly present in patients over 65 years of age (p = 0.007), patients with musculoskeletal and neuropathic pain, back pain, and those having rated Patients' Global Impression of Change scale as worsening (p = 0.001). The severity of pain and poor quality of sleep are the leading causes of deterioration of the Patients' Global Impression of Change scale in patients suffering from musculoskeletal and neuropathic pain. In order to treat CP comprehensively, it is important for GPs to evaluate the outcomes of clinical treatment using tools for CP assessment.

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The aim of our study was to evaluate the pro- and anti-inflammatory cytokine response during acute pancreatitis and its predictive value on severity of disease. A hospital-based prospective clinical study was conducted. Twenty patients with acute pancreatitis were enrolled during a 12-month period. Plasma concentrations of TNF-α, IL-1ß, IL-6, and IL-10 were determined at days 1, 2, 3, 6, and 9. The patient population was analyzed by type of acute pancreatitis. Severity was defined according to the Atlanta criteria for assessing severity of acute pancreatitis. Clinical variables were recorded to patients classified in one of two groups: severe acute pancreatitis (SAP group) and mild acute pancreatitis (MILD group). Patients with SAP had significantly higher average levels of IL-6 compared to the MILD group patients (539.2 pg/L vs. 23.4 pg/L, p < 0.0001). Also, the values of IL-10 were significantly higher in patients with SAP (242.4 pg/L vs. 8.1 pg/L, p = 0.003). The values of TNF-α were not significantly different in both groups. The value of IL-6 and IL-10 showed a positive correlation (r = 0.7964, p < 0.0001). Although a relatively small sample of patients was used, we can conclude that the determination of the value of IL-6 and IL-10 can help in the clinical assessment of disease severity.

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Aggressive large volume resuscitation is obligatory to achieve necessary tissue oxygenation. An adequate venous preload normalizes global hemodynamics and avoids multiorgan failure (MOF) and death in patients with multiple injuries. Large volume resuscitation is associated with complications in minimally monitored patients. A properly guided resuscitation procedure will finally prevent MOF and patient death. Transpulmonary thermodilution technique and gastric tonometry are used in venous preload monitoring, calculating volumetric hemodynamic variables and estimating splanchnic perfusion as well. We present a 24-year-old man with multiple injuries resuscitated with large volume infusions and monitored by transpulmonary thermodilution technique and gastric tonometry. It is very important to monitor regional hemodynamics that enables clinician to maintain the required relations between global and regional hemodynamics. It prevents the development of MOF and patient death.

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