[Anesthesia in concomitant bronchopulmonary diseases]

The goal of any anaesthesiologist delivering anaesthesia to patients with pre-existing lung disease has to be the prevention of intra- and postoperative complications. Changes in gas exchange imposed by anaesthesia and surgery can cause dangerous disturbances in oxygen transport and in acid-base balance. Uptake and elimination of volatile and gaseous anaesthetics depend upon normal respiratory function. Any marked impairment can considerably modify the kinetics of these processes.

[The need for a specific postoperative, total parenteral nutrition therapy after various intra-abdominal procedures]

119 metabolically healthy surgical patients, who had to undergo elective intraabdominal surgery, were separated into upper -- cholecystectomy, gastric resection -- and lower -- colonic and sigma surgery -- intraabdominal procedures and divided into 8 groups with different infusion regimes. During the early postoperative period patients with upper abdominal surgery had significantly higher postoperative enzyme changes compared with patients with lower abdominal surgery. Patients with cholecystectomy had the significantly highest postoperative enzyme changes. On postoperative day 6 the enzyme changes showed a significant dependence from the duration of total parenteral nutrition, the chosen calorie-nitrogen-ratio, and the chosen energy substrate, xylitol or glucose. We could show a significant negative correlation between the extent of the stimulation of hepatic lipid synthesis and the protein parameters. Of all chosen infusion regimens xylitol in a dose of 0.11 g/kg BW X h together with the high amino acid infusion rate of 1.76 g/kg BW X day had the most favourable effect on the extent of stimulation of hepatic lipid synthesis, the late postoperative enzyme changes and the synthesis rate of visceral proteins. This study could demonstrate, that different intraabdominal surgical procedures need a more specific nutritional therapy.

[Comparison of xylose and glucose as energy sources in hypocaloric, postoperative parenteral nutrition]

After a 5 day preoperative preparing period 24 metabolically healthy patients, who had to undergo gastric resection, were fed postoperatively by hypocaloric total parenteral nutrition for a 5 day period. Group I (n = 13) received 0,11 g Xylitol/kg BW X h; Group II (n = 11) received 0,11 g Glucose/kg BW X h; Both groups received 1,71 g L-crystalline amino acids/kg BW X day. During the whole postoperative period group II had significantly higher serum Glucose and Insulin levels. Due to the high postoperative Insulin concentration in group II. Free Fatty Acids, Acetate, beta-Hydroxybutyrate and Branched Chained Amino Acids were significantly lower. The augmented release of Muscle Amino Acids and the covering of a part of the energy expenditure by increased Fatty Acid oxidation in group I led to a higher postoperative synthesis rate of visceral proteins. From postoperative day 3 on Transferrin and from postoperative day 6 on Albumin and Total Protein were significantly higher in group I. This study could demonstrate, that due to its special role in the intermediary metabolism during the postoperative period Xylitol leads to a significantly higher regeneration rate of visceral proteins compared to Glucose during total parenteral nutrition.

Vergleich von Xylit und Glukose als Energieträger im Rahmen der hypokalorischen postoperativen parenteralen Ernährungstherapie

24 stoffwechselgesunde Patienten, die sich einer Magenoperation unterziehen muβten, wurden nach einer 5tägigen präoperativen Vorbereitungszeit 5 Tage lang postoperativ hypokalorisch total parenteral ernährt. Kollektiv l (n = 13) erhielt 011 gXylit/kg KG•Std.; Kollektiv II (n = 11) erhielt 0,11 g Glukose/kg KG•Std. Beide Kollektive erhielten 1,71 g L-kristalline Aminosäuren/kg KG × die. Während der gesamten postoperativen Phase konnten bei Kollektiv II signifikant höhere Glukose- und Insulinspiegel im Serum gemessen werden. Der postoperativ stark erhöhte Insulinspiegel bei Kollektiv II führte zu signifikant niedrigeren Werten an freien Fettsäuren, Acetat, β-Hydroxybutyrat- und verzweigtkettigen Arninosäuren. Die erhöhte Freisetzung muskulärer Arninosäuren, sowie die Deckung eines Teiles des energetischen Bedarfes durch eine gesteigerte Fettoxidation bei Kollektiv I, führte zu einer verstärkten Synthese viszeraler Proteine. Das Transferrin lag vom 3., das Albumin und das Gesamteiweiβ vom 6. postoperativen Tag an signifikant höher bei Kollektiv I. Diese Untersuchung konnte zeigen, daβ Xylit aufgrund seiner besonderen Bedeutung für den Intermediärstoffwechsel in der postoperativen Phase bei der Regeneration viszeraler Proteine der Glukose als Energieträger überlegen ist.

[Differences in postoperative metabolism after pre- and postoperative beginning of total parenteral nutrition]

In this study we intended to investigate the influence of a 24-h-preoperative total parenteral nutrition (TPN) therapy--10 surgical patients, group 1--compared with the postoperative beginning of TPN--9 surgical patients, group 2--on the postoperative metabolism. Most probably due to preoperatively depleted glycogen storages in G 2, the urinary carbohydrate losses declined more rapidly postoperatively compared with G 1. 45 mMol/l of sodium did not cover the postoperative requirements of G 1. Although we administered 90 mMol/l of potassium/24 h, several patients of G 1 needed an additional substitution. No additional phosphate substitution was necessary in either group. Except for a slight positive balance on the operation day, fluid balance was well balanced on all the other days in G 1. From postoperative day 2 on, G 2 developed a deficit of free water. It could be demonstrated very clear in this study that the postoperative fluid and electrolyte requirements are strongly influenced even by a short-term preoperative fasting period.

[Postoperative metabolism--differences between pre- and postoperative start of total parenteral nutrition (author's transl)]

We investigated the postoperative metabolism of patients undergoing gastric operation by beginning total parenteral nutrition pre- (group 1) and postoperatively (group 2). A third group remained fasting until 3 h after the surgical intervention. Because of the high serum glucose concentrations and the high glucose losses in the 24-h-urine on the operation day in group 1 and 2 only the basic glucose requirement (150--250 mg/24h) should be given in the early postoperative period. The low blood glucose concentration in group 3 and the elevated lactate values in group 2 underline this recommendation. Compared with group 2 and 3 group 1 had low free fatty acid concentrations of 250 muVal/l because of the continuous pre-, intra-, and postoperative infusion. Compared with normal metabolic conditions the free fatty acids don't seem to have the same insulinantagonising effect in the posttraumatic state. The fall of cholesterol after the surgical trauma reached its maximum after 12--15 h and amounted to about 40mg% in the first two groups. Albumin and total protein fell continuously in group 1 and 2. The electrophoresis in group 1 showed a rise of alpha 1-, and alpha 2-globulin to more than double the initial value, the beta-globulin showed only slight changes, the gamma-globulin dropped only slightly up to the 4th postoperative day. As a sign of an augmented catabolism the serum urea concentration rose during the postoperative state. Group 1 and 2 had a favourable nitrogen balance. The postoperative bilirubin rise could be held lower in group 1 compared to group 2.

[Differences in postoperative metabolism in reference to pre- and postoperative initiation of total parenteral nutrition. I]

We investigated the postoperative metabolism of patients undergoing gastric resection by beginning total parenteral nutrition pre- (group 1) and postoperatively (group 2). A third group remained fasting until 3 h after the surgical intervention. Because of the high serum glucose concentrations and the high glucose losses in the 24-h urine on the operation day in group 1 and 2 only the base glucose requirement (150--250 g/24/h) should be given in the early postoperative period. The low blood glucose concentration in group 3 and the elevated lactate values in group 2 underline this recommandation. Compared with group 2 and 3, group 1 had low free fatty acid concentrations of 250 micronVal/l because of the continuous pre-, intra-, and postoperative infusion. Compared with normal metabolic conditions, the free fatty acids do not seem to have the same insulin-antagonizing effect in the posttraumatic state. The fall of cholesterol after the surgical trauma reached its maximum after 12--15 h and amounted to about 40 mg% in the first two groups. Albumin and total protein fell continuously in group 1 and 2. The electrophoresis in group 1 showed a rise of alpha 1- and alpha 2-globulin to more than double the initial value, the beta-globulin showed only slight changes, the gamma-globulin dropped only slightly up to the 4th postoperative day. As a sign of an augmented catabolism the serum urea concentration rose during the postoperative state. Group 1 and 2 had a favourable nitrogen balance. The postoperative bilirubin rise could be held lower in group 1 compared to group 2.

[Weaning a patient from the respirator (author's transl)]

Weaning a patient from the respirator should be started as early as possible. The right time when to stope artificial ventilation is determined by certain criteria. Pathological processes which might interfere with the weaning process should be corrected beforehand. Incipient septicaemia, peritonitis, circulatory instability and a marked postoperative or posttraumatic rise in intracranial pressure are extrapulmonary contraindications for weaning. Apart from conventional weaning, continuous positive airway pressure ventilation and intermittent mandatory ventilation are discussed.

[Haemodynamic changes during artificial ventilation with and without positive end-expiratory pressure in respiratory insufficiency (author's transl)]

Artificial ventilation with positive end-expiratory pressure (PEEP) affects the haemodynamic function of the various organs differently. Depending on intravascular volume, myocardial contractility and the pulmonary vasculature PEEP ventilation may result in a reduced cardiac output. By increasing the circulating blood volume the cardiovascular changes induced by PEEP can be minimized. When PEEP ventilation is stopped symptoms of hypervolaemia may appear. The effects of PEEP ventilation on the brain, liver, mesenterial circulation and kidney manifest themselves in a rise of intracranial pressure, reduced portal bloodflow, increased mesenteric vascular resistance and redistribution of the intrarenal blood flow respectively.

[Biochemistry of free amino acids in the stratum corneum of human epidermis. I. The reaction of arginase (author's transl)]

The human horny layer contains insoluble arginase, which is tied to keratinic cells, with an activity of about 1 mU/cm2 skinsurface. About 50 p.c. of arginase is inhibited by water soluble substances of horny layer or by using soaps and syndets. By washing the skinsurface with water the activity increases. Presumable the horny layer arginase has a function in the urea production of sweat.

Cellular distribution and clearance of aerosolized dipalmitoyl lecithin

Wistar-Lewis rats were anesthetized anc connected to a 3-MHz nebulizer which aerosolized 250 muCi l-alpha-1-palmitoyl-2palmitoyl-[9-10-3H]phosphatidylcholine ([3H]DPL) for 3 min. Appleton frozen-section autoradiographs showed greater than 4 times background radioactivity in approximately 30% of alveoli at 1 min and 2 h after aerosol. As tritium content in the lung decreased, it increased in liver, spleen, kidney, blood, and urine. Percentage of radioactivity from [3H]phosphatidylcholine in the liver declined with time, while [3H]phosphatidylethanolamine doubled between 2 and 12 h. One minute postaerosol 2,500 +/- 500 (SE) type I cells/mm3 lung and 2,500 +/- 750 type II cells/mm3 lung had greater than 20 times background radioactivity; 2 h later only 950 +/- 250 type I cells/-m3 lung still had levels of radioactivity greater than 20 times background while 3,150 +/- 600 type II cells/mm3 lumg now had this level of 3HIDPL. Corresponding numbers of alveolar macrophages were 450 +/- 250 1 min postaerosol and 1,100 +/- 200 after 2 h. Aerosolized DPL as a synthetic surfactant is hampered by significantly faster clearance from the alveolar surface as compared with normal in vivo DPL.