Search

Byline: B. KremzEar (1), A. SEpec-Marn (1), L. Kompan (1), O. CerovicA' (1) Keywords: Key words Patients with multiple injuries; Oxygen transport; SvO2 Abstract: Objective: To determine whether maintaining normal levels of mixed venous oxygen saturation (SvO.sub.2) in patients with multiple injuries is more relevant to survival than maintaining above-normal levels of oxygen transport. Design: Non-randomised, retrospective control study over a 38-month period. Setting: Multidisciplinary intensive care unit in a university hospital. Patients: 40 patients with multiple injuries divided in to group A (23 patients) and group B (17 patients). Interventions: In group A patients, we maintained normal SvO.sub.2 by manipulation of oxygen transport variables oxygen delivery (DO.sub.2) was increased only if SvO.sub.2 decreased or the dobutamine test was positive. In group B patients, DO.sub.2 was routinely maintained at above-normal levels by aggressive use of fluids and dobutamine. Measurements and results: In group A we measured SvO.sub.2 continuously and performed the dobutamine test. Oxygen transport-related variables were recorded every 12h in the first 5 days after injury in both groups, as well as lactate concentrations. Survival was significantly greater in group A than in group B (p&lt 0.01). Multiple organ failure was less frequent in group A than in group B (p&lt 0.01). The average DO.sub.2 in group A was significantly lower than in group B from day 2 onwards (p&lt 0.05--0.01). Average values of DO.sub.2 of 605--688ml/min per m.sup.2 were required to maintain normal SvO.sub.2 and aerobic metabolism in group A 10 patients required dobutamine 2.5--5ug/kg per min. The average DO.sub.2 in group B was 622ml/min per m.sup.2 on day 1 and then it increased to 835ml/min per m.sup.2 on day 5 after trauma. Conclusions: Our results indicate that for patients with multiple injuries maintaining normal SvO.sub.2 values and increasing DO.sub.2 only if required are more relevant for survival than routine maintenance of above-normal oxygen transport values. Author Affiliation: (1) University Medical Centre, Institute of Anaesthesiology, ZaloEska 7, 1000 Ljubljana, Slovenia FAX: +386 (61) 1337262 Article note: Received: 4 March 1996 Accepted: 28 September 1996

Purpose: The aim of the current study was to determine the incorporation of cis (c) 9, trans (t) 11-conjugated linoleic acid (CLA) and t10, c12-CLA into porcine erythrocytes-both isomers were supplemented in equal proportions., Methods: The study group consisted of 16 piglets randomly assigned into experimental and control group. For the period of 5 weeks, the piglets from the experimental group were receiving a 1.2% CLA supplement while the controls were supplemented with the same amount of sunflower oil. For the remaining 7 weeks, the piglets were fed without a supplement. Blood samples to evaluate incorporation of CLA into erythrocyte membranes were taken from all animals on weekly basis., Results: Compared to t10, c12-CLA isomer, proportion of c9, t11-CLA isomer in the membrane of erythrocytes was higher for the whole time of the study period. After 4 weeks of feeding, it approaches the plateau. The peak value for both isomers was measured at the end of week 5, with a value of 3.24 g c9, t11-CLA/100 g of fatty acids and a 1.09 g t10, c12-CLA/100 g of fatty acids (p < 0.0001). After cessation of supplementation, the proportion of both isomers gradually decreased to be almost completely washed out-in 7 weeks., Conclusions: During supplementation with equivalent amounts of CLA isomers, their proportion in membranes of porcine erythrocytes increases with time, with higher proportion of c9, t11-CLA. CLA isomers probably differently incorporate into different cell membranes at different species which could explain its various biological functions.

Background & Aims: Enteral glutamine may have protective effects on gut function and reduce metabolic stress in patients receiving radiochemotherapy. The aim of our study was to evaluate its influence in patients with rectal cancer undergoing preoperative radiochemotherapy., Methods: We performed a randomized double blind, placebo controlled pilot study in 33 patients. 30 g of glutamine, average dose 0.41 g/kg (SD = 0.07) g/kg/day was administered orally in three doses per day for five weeks during preoperative radiochemotherapy of rectal cancer. 30 g of maltodextrin was given as placebo. Body weight was measured and NRS 2002 screening was performed before and after treatment. Bowel function was evaluated by stool consistency and frequency. Plasma levels of inflammatory parameters and hormones were measured., Results: There was no difference between groups in frequency and severity of diarrhoea during radiochemotherapy (p = 0.5 and p = 0.39 respectively), insulin levels significantly increased in both groups, IL-6 only in glutamine group., Conclusion: Results of this small pilot study in rectal cancer patients receiving preoperative radiochemotherapy, showed that ingestion of larger quantities of glutamine given more often as previously reported did not diminish the incidence and severity of diarrhoea and did not affect inflammatory and metabolic activity compared to the placebo treatment with maltodextrin., (Copyright © 2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Preoperative bowel cleaning for elective colorectal surgery is a routine procedure. Synbiotics (probiotics plus prebiotics) are known for their beneficial effects on gut immune function and maintenance of the gut barrier. The main purpose of this study was to replace preoperative mechanical bowel cleaning with synbiotics and to assess the systemic inflammatory response and clinical outcome in patients undergoing colorectal surgery., Patients and Methods: A prospective double-blind randomized placebo-controlled trial was conducted in 68 patients. The first group of 20 patients received synbiotics, the second group of 28 patients prebiotics and heat-deactivated probiotics, and the third (control) group of 20 patients mechanical bowel cleaning prior to the operation., Results: Significantly higher values of interleukin 6 (IL-6) were detected 72 h after the operation in the synbiotic group (P = 0.025), as well as an increase of fibrinogen at 24 h postoperatively (P = 0.030). No statistical differences were found in leukocytes count, C-reactive protein or the lymphocyte/granulocyte ratio. There were no differences in postoperative complications between the groups. Mean hospital stay was 9.2 days in the prebiotic group, 9.5 days in the control group, and 10.95 days in the synbiotic group., Conclusions: Preoperative administration of prebiotics in elective colorectal surgery appears to have the same protective effect in preventing a postoperative inflammatory response as mechanical bowel cleaning. Further prospective studies are needed to verify the effects of synbiotics.

Rationale: Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs., Objectives: To record the prevalence, characteristics, and risk factors for conflicts in ICUs., Methods: One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries)., Measurements and Main Results: Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings., Conclusions: Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

Background: Conjugated linoleic acid (CLA) has diverse influences on the immune response in different experimental models. In the present study we investigated the effect of CLA feeding on inflammatory and immune responses in a piglet model. We studied the duration of this effect and possible detrimental effects of CLA feeding. After 12 weeks of CLA and control supplementation and washout, animals were sacrificed and parenchymal organs were histologically examined., Results: In activated peripheral mononuclear cells interferon-gamma was significantly (p = 0.008) lower in the CLA group by the end of the feeding period. This effect disappeared as soon as supplementation was stopped. No differences were found in the tumour necrosis factor-alpha, interleukin-10 production, serum immunoglobulin-G levels and fat infiltration of the liver, except that fat storage cell infiltration was significantly (p < 0.04) higher in the CLA-fed group. The effect of time for interferon-gamma, interleukin-10 and immunoglobulin-G levels was statistically significant., Conclusion: At the end of the feeding period the interferon-gamma response was depressed. However, the maturation of the piglet immune system in our young pig model probably outweighs the impact of CLA feeding on the immune response, even though liver fat storage cell infiltration, which plays an important role in liver regeneration, increased during CLA feeding of the piglets.

Background: Since the hepatosplanchnic region plays a central role in development of multiple-organ failure and infections in critically ill trauma patients, this study focuses on the influence of glutamine, peptide, and synbiotics on intestinal permeability and clinical outcome., Methods: One hundred thirteen multiple injured patients were prospectively randomized into 4 groups: group A, glutamine; B, fermentable fiber; C, peptide diet; and D, standard enteral formula with fibers combined with Synbiotic 2000 (Synbiotic 2000 Forte; Medifarm, Sweden), a formula containing live lactobacilli and specific bioactive fibers. Intestinal permeability was evaluated by measuring lactulose-mannitol excretion ratio on days 2, 4, and 7., Results: No differences in days of mechanical ventilation, intensive care unit stay, or multiple-organ failure scores were found between the patient groups. A total of 51 infections, including 38 pneumonia, were observed, with only 5 infections and 4 pneumonias in group D, which was significantly less than combined infections (p = .003) and pneumonias (p = .03) in groups A, B, and C. Intestinal permeability decreased only in group D, from 0.148 (0.056-0.240) on day 4 to 0.061 (0.040-0.099) on day 7; (p < .05). In group A, the lactulose-mannitol excretion ratio increased significantly (p < .02) from 0.050 (0.013-0.116) on day 2 to 0.159 (0.088-0.311) on day 7. The total gastric retention volume in 7 days was 1150 (785-2395) mL in group D, which was significantly more than the 410 (382-1062) mL in group A (p < .02), and 620 (337-1190) mL in group C (p < .03)., Conclusions: Patients supplemented with synbiotics did better than the others, with lower intestinal permeability and fewer infections.

In experimental settings, the increased intestinal permeability (IP) following severe trauma is associated with increased serum concentrations of cytokines. Multiply injured patients are susceptible to the development of multiple organ failure (MOF). The aim of this study was to determine if altered IP after trauma was associated with upregulation of cytokines and if cytokines and IP influenced the development of MOF. In 30 multiply injured patients, IP was measured on days 2 and 4 after injury using the lactulose-mannitol (L-M) test, and the levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and IL-8 were determined simultaneously. The L-M ratio increased significantly from 0.049 (0.017-0.133) on day 2 to 0.150 (0.059-0.339) on day 4 (p < 0.02) On day 4, a significant correlation was also found between the L-M ratio and IL-6 (r = 0.43, p < 0.03). The IL-6 level on days 2 and 4 was significantly (p < 0.01 and p < 0.03, respectively) higher in MOF patients than in those without MOF, as was the TNF-alpha level on day 4 significantly higher (p < 0.04) in MOF patients. IP increases following multiple trauma, and on day 4 it correlates with the IL-6 level. However, in patients who develop MOF only cytokines are invariably increased, with IL-6 alone being significantly increased on both measurements in these patients.

Objective: To determine the effects of extended experimental hepatic blood flow occlusion (ie, portal triad clamping [PTC]) in dogs by measuring acid-base status and plasma lactate concentrations in arterial, mixed venous, and portal blood and evaluating the relationship between metabolic and concurrent hemodynamic changes., Animals: 6 healthy Beagles., Procedure: During anesthesia with isoflurane, cardiac output and arterial blood pressure were measured. Arterial, mixed venous, and portal blood samples were collected simultaneously for blood gas analyses and plasma lactate measurements before PTC and at 8-minute intervals thereafter., Results: PTC resulted in severe hemodynamic and metabolic alterations. Eight minutes after PTC, significant decreases in cardiac index from a baseline value of 3.40 +/- 0.27 to 1.54 +/- 0.26 L/min/m2 and in mean arterial blood pressure from a baseline value of 74 +/- 6 to 43 +/- 6 mm Hg were recorded. After PTC, results indicative of lactic acidosis were found in portal blood at 16 minutes, in mixed venous at 32 minutes, and in arterial blood at 48 minutes. Significant differences in measured variables were also found between arterial and portal blood samples, between mixed venous and portal blood samples, and between arterial and mixed venous blood samples after PTC, compared with differences at baseline., Conclusions and Clinical Relevance: Analysis of mixed venous blood is preferable to analysis of arterial blood in the assessment of metabolic derangement. In a clinical setting, occluded portal blood is released to the systemic circulation, and the degree of reperfusion injury may depend on the metabolic status of pooled portal blood.

Objective: To find out if there was a relationship between increased intestinal permeability and the development of multiple organ failure (MOF) after multiple injuries, we correlated the extent of injury and MOF with intestinal permeability on the second and fourth day after injury., Design: Prospective open study., Setting: University hospital, Slovenia., Patients: 29 multiply injured patients, injury severity score (ISS) over 25, admitted shocked., Intervention: Intestinal permeability measured by giving lactulose and mannitol solution enterally on days 2 and 4., Main Outcome Measures: The lactulose: mannitol ratio calculated from the urinary portion of the probe molecules. ISS and the acute physiology and chronic health evaluation (APACHE II) calculated on admission., Results: The median lactulose: mannitol ratio for five volunteers was 0.014 (range 0.008-0.017) and that for 29 patients was 0.03 (0.01-0.1). On day 2 it was 0.03 (0.02-0.1), on day 4 0.02 (0.01-0.2). The ratio calculated on day 2 correlated with average and late MOF scores (r = 0.41 R2 = 0.1681, p <0.03 and r = 0.38, R2 = 0.1444, p <0.04) and that measured on day 4 correlated with overall, early, and late MOF scores (r = 0.47, R2 = 0.2209, p <0.01; r = 0.51, R2 = 0.2601, p <0.005; r = 0.39, R = 0.1512, p <0.04). No correlation was found between ISS, transport time, shock index, APACHE II, and days in intensive care., Conclusions: Even if intestinal permeability is invariably increased after injury, it seems to have some predictive value for MOF in multiply injured patients because it correlates with its development.

This study evaluated the cost of sequential treatment with once-daily ofloxacin or twice-daily ciprofloxacin in 474 hospitalised patients in different countries. The patients were treated intravenously for at least 3 days, then orally for 7 to 10 days or for 3 days beyond the disappearance of infection-related symptoms. The overall clinical cure rate (86.8% with ofloxacin and 89.6% with ciprofloxacin) and the overall bacteriological response rate (89.9 and 89.0%, respectively) were similar, and a cost-minimisation analysis was conducted. The acquisition costs for ofloxacin and ciprofloxacin in Greece, Israel, Slovenia and Turkey were used and converted to Deutschmarks (DM), and the costs of administration were analysed for each hospital. The different cost categories for oral and intravenous (IV) treatment (e.g. antimicrobial acquisition, drug monitoring, drug delivery costs) were used to identify any differences. The total costs per patient varied between the countries involved, but were higher for ciprofloxacin (ofloxacin: DM239 to DM724; ciprofloxacin: DM540 to DM976). In a sensitivity analysis using identical daily acquisition costs for the 2 fluoroquinolones, the total cost of treatment was higher for ciprofloxacin, as a result of the lower cost of administration of ofloxacin in the once-daily regimen. Continuing IV therapy would be approximately 50% more expensive than switching to oral administration; however, whenever possible, both drugs can be switched from IV to oral treatment.

Objective: To determine whether maintaining normal levels of mixed venous oxygen saturation (SvO2) in patients with multiple injuries is more relevant to survival than maintaining above-normal levels of oxygen transport., Design: Non-randomised, retrospective control study over a 38-month period., Setting: Multidisciplinary intensive care unit in a university hospital., Patients: 40 patients with multiple injuries divided in to group A (23 patients) and group B (17 patients)., Interventions: In group A patients, we maintained normal SvO2 by manipulation of oxygen transport variables: oxygen delivery (DO2) was increased only if SvO2 decreased or the dobutamine test was positive. In group B patients, DO2 was routinely maintained at above-normal levels by aggressive use of fluids and dobutamine., Measurements and Results: In group A we measured SvO2 continuously and performed the dobutamine test. Oxygen transport-related variables were recorded every 12 h in the first 5 days after injury in both groups, as well as lactate concentrations. Survival was significantly greater in group A than in group B (p < 0.01). Multiple organ failure was less frequent in group A than in group B (p < 0.01). The average DO2 in group A was significantly lower than in group B from day 2 onwards (p < 0.05-0.01). Average values of DO2 of 605-688 ml/ min per m2 were required to maintain normal SvO2 and aerobic metabolism in group A; 10 patients required dobutamine 2.5-5 micrograms/kg per min. The average DO2 in group B was 622 ml/ min per m2 on day 1 and then it increased to 835 ml/min per m2 on day 5 after trauma., Conclusions: Our results indicate that for patients with multiple injuries maintaining normal SvO2 values and increasing DO2 only if required are more relevant for survival than routine maintenance of above-normal oxygen transport values.