The gut origin septic states in blunt multiple trauma (ISS = 40) in the ICU

Effects of Different Routes and Forms of Vitamin D Administration on Mesenteric Lymph Node CD4+ T Cell Polarization and Intestinal Injury in Obese Mice Complicated with Polymicrobial Sepsis

This study compared the efficacies of enteral cholecalciferol and/or intravenous (IV) calcitriol administration on mesenteric lymph node (MLN) cluster-of-differentiation-4-positive (CD4+) T cell distribution and intestinal barrier damage in obese mice complicated with sepsis. Mice were fed a high-fat diet for 16 weeks and then sepsis was induced by cecal ligation and puncture (CLP). Mice were divided into the following sepsis groups: without vitamin D (VD) (S); with oral cholecalciferol 1 day before CLP (G); with IV calcitriol 1 h after CLP (V); and with both cholecalciferol before and IV calcitriol after CLP (GV). All mice were sacrificed at 12 or 24 h after CLP. The findings show that the S group had a higher T helper (Th)17 percentage than the VD-treated groups at 12 h after CLP. The V group exhibited a higher Th1 percentage and Th1/Th2 ratio than the other groups at 24 h, whereas the V and GV groups had a lower Th17/regulatory T (Treg) ratio 12 h post-CLP in MLNs. In ileum tissues, the VD-treated groups had higher tight junction protein and cathelicidin levels, and higher mucin gene expression than the S group at 24 h post-CLP. Also, aryl hydrocarbon receptor (AhR) and its associated cytochrome P450 1A1 and interleukin 22 gene expressions were upregulated. In contrast, levels of lipid peroxides and inflammatory mediators in ileum tissues were lower in the groups with VD treatment after CLP. These results suggest that IV calcitriol seemed to have a more-pronounced effect on modulating the homeostasis of Th/Treg subsets in MLNs. Both oral cholecalciferol before and IV calcitriol after CLP promoted cathelicidin secretion, alleviated intestinal inflammation, and ameliorated the epithelial integrity in obese mice complicated with sepsis possibly via VD receptor and AhR signaling pathways.

Pathophysiology in patients with polytrauma

The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.

Magnolol protects against acute gastrointestinal injury in sepsis by down-regulating regulated on activation, normal T-cell expressed and secreted

BACKGROUND

Sepsis is a major medical challenge. Magnolol is an active constituent of Houpu that improves tissue function and exerts strong anti-endotoxin and anti-inflammatory effects, but the mechanism by which it reduces intestinal inflammation in sepsis is yet unclear.

AIM

To assess the protective effect of magnolol on intestinal mucosal epithelial cells in sepsis and elucidate the underlying mechanisms.

METHODS

Enzyme-linked immunosorbent assay was used to measure tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), IL-6, and regulated on activation, normal T-cell expressed and secreted (RANTES) levels in serum and ileal tissue in animal studies. The histopathological changes of the ileal mucosa in different groups were observed under a microscope. Cell Counting Kit-8 and cell permeability assays were used to determine the concentration of drug-containing serum that did not affect the activity of Caco2 cells but inhibited lipopolysaccharide (LPS)-induced decrease in permeability. Immunofluorescence and Western blot assays were used to detect the levels of RANTES, inhibitor of nuclear factor kappa-B kinase β (IKKβ), phosphorylated IKKβ (p-IKKβ), inhibitor of nuclear factor kappa-B kinase α (IκBα), p65, and p-p65 proteins in different groups in vitro.

RESULTS

In rats treated with LPS by intravenous tail injection in the presence or absence of magnolol, magnolol inhibited the expression of proinflammatory cytokines, IL-1β, IL-6, and TNF-α in a dose-dependent manner. In addition, magnolol suppressed the production of RANTES in LPS-stimulated sepsis rats. Moreover, in vitro studies suggested that magnolol inhibited the increase of p65 nucleation, thereby markedly downregulating the production of the phosphorylated form of IKKβ in LPS-treated Caco2 cells. Specifically, magnolol inhibited the translocation of the transcription factor nuclear factor-kappa B (NF-κB) from the cytosol into the nucleus and down-regulated the expression level of the chemokine RANTES in LPS-stimulated Caco2 cells.

CONCLUSION

Magnolol down-regulates RANTES levels by inhibiting the LPS/NF-κB signaling pathways, thereby suppressing IL-1β, IL-6, and TNF-α expression to alleviate the mucosal barrier dysfunction in sepsis.

Selective Digestive Decontamination Attenuates Organ Dysfunction in Critically Ill Burn Patients

OBJECTIVE

To evaluate whether selective decontamination of the digestive tract (SDD) attenuates organ dysfunction in critically ill burn patients.

BACKGROUND

The effect of SDD on the development and progression of organ dysfunction, as an important determinant of mortality in burned patients, is still unknown. We asked whether organ dysfunction is mitigated by treatment with SDD.

METHODS

Patients with burns >20% of total body surface or suspected inhalation injury from a randomized placebo-controlled trial were analyzed to determine the relationship between treatment received (placebo or SDD) and the severity of organ dysfunction as measured by the area under the curve of the Sequential Organ Failure Assessment (SOFA) score (and its individual components) from day 1 to day 7 of admission.

RESULTS

One hundred seven patients (53 in the SDD group and 54 in the placebo group) were included. Survival was significantly higher in SDD-treated patients (48 of 53, 90.6%) than in placebo-treated patients (39 of 54, 72.2%, P = 0.013). Total (P < 0.01) and respiratory (P < 0.01), cardiovascular (P = 0.04) and hematological (not reaching statistical significance, P = 0.07) organ dysfunction was associated with mortality after adjusting for predicted mortality. In multivariate logistic regression, SDD treatment was independently associated with total (P < 0.01), respiratory (P = 0.02), and hematological (P < 0.01) dysfunction over the first week postinjury.

CONCLUSIONS

The beneficial effect of SDD on mortality in critically ill burned patients is accompanied by a reduction in the degree of organ dysfunction. SDD seems to be a valuable therapeutic strategy to prevent organ dysfunction and, more specifically, respiratory and hematological dysfunction in severely ill burn patients.

Nutrition Support in Adult Trauma Patients

Nutrition supplementation is paramount to the care of severely injured patients. Despite its widespread use in trauma patients, many areas of clinical practice remain controversial. The purpose of this paper is to critically review the literature studying the use of enteral vs parenteral nutrition (PN) and to provide the rationale for early enteral nutrition. Additional controversies confronting clinicians are reviewed, including the use of immune-enhancing agents and the optimal site for enteral nutrition delivery (gastric vs small intestinal). Evidence-based recommendations for clinical practice are presented when available.

Shenfu injection alleviates intestine epithelial damage in septic rats

BACKGROUND

Shenfu injection (SFI) promotes tissue microcirculation and oxygen metabolism. We aimed to assess its effects on intestinal epithelial damage in septic rats.

METHODS

Fifty Sprague-Dawley rats were randomly divided into sham operation (Sham), sepsis (cecal ligation and puncture [CLP]), and SFI (low-dose, middle-dose, high-dose) groups (n = 10). For Sham animals, the abdominal cavity was opened and closed. For other groups, severe sepsis was induced by CLP. After surgery, saline (Sham and CLP rats) and SFI (treatment groups) were administered intraperitoneally. Samples were collected 12 hours after injection. Serum tumor necrosis factor α, diamineoxidase, and d-lactate levels and ileal mucosal damage and ultrastructural change, as well as protein and messenger RNA expression of tight junction markers, including Claudin-3 and zonula occludens protein-1 in ileal mucosa's epithelial cells, were assessed. All animal experiments were carried out under aseptic conditions.

RESULTS

Compared with Sham animals, serum tumor necrosis factor α, DAO, and d-lactic acid levels in CLP animals were significantly higher; the ileal mucosal damage was more severe; and the expression levels of tight junction markers were significantly decreased. These indexes were significantly improved in SFI groups, in a concentration-dependent manner, compared with CLP rats. Sham animals displayed orderly arranged ileal mucosal villi, continuous tight junctions between epithelial cells, intact organelles, and microvilli. Compared with CLP animals (with obvious damage in these structures), an overt improvement was observed in SFI groups, especially in the high-dose SFI group, with tight junctions clearly visible between epithelial cells.

CONCLUSIONS

Shenfu injection significantly alleviates intestinal epithelial damage in septic rats, in a dose-dependent manner.

High frequency-low morbidity mechanical complications of tube feeding: a prospective study

Because of preferential use of the enteral route for nutritional support, a prospective study of mechanical complications was done in 109 consecutive patients. One hundred seventy-two nasogastric tubes were placed in 60 patients, 42 esophagostomies in 28 patients, 32 gastrostomies in 22 patients and 9 jejunostomies in 8 patients. Data show that the use of enteral feeding tubes is not without complications. The complications fell into two major categories. There were 15 low frequency mechanical complications, of which four (2 carotid artery blowouts, 1 gastrointestinal perforation, and 1 aspiration) were of high morbidity and 11 of low morbidity. There were 132 high frequency-low morbidity complications with the use of 255 tubes. These consisted mainly of unplanned and untimely removal of feeding tubes with interruption of feedings and necessitating tube replacement. Data indicate that the main problems related to the use of enteral nutrition are not the dramatic complications which create notoriety but those related to the ordinary mechanical complications occurring daily and which command little attention because of their low mortality. These can assume importance because of their high frequency and as such are characterized as high frequency-low morbidity complications.

Energy expenditure in critically ill surgical patients. Comparative analysis of predictive equation and indirect calorimetry

PURPOSE

The aim of this investigation was to compare the resting energy expenditure (REE) calculated by the Harris-Benedict equation (REE HB) with the REE measured by indirect calorimetry (REE IC) in critically ill surgical patients under mechanical ventilation.

METHODS

Thirty patients were included in this work. REE was calculated by the Harris-Benedict equation (REE HB) using real body weight, and it was also measured by indirect calorimetry (REE IC), which was performed for 30 minutes.

RESULTS

REE HB had significant (p < 0.0005) but low correlation (Spearman r = 0.57) with REE IC, with a mean bias of 12 kcal.d-1 and limits of agreement ranging from - 599.7 to 623.7 kcal.d-1 as detected by the Bland-Altman analysis.

CONCLUSION

These findings suggest that REE IC seems to be more appropriate than REE HB for accurate measurement of REE in critically ill surgical patients under mechanical ventilation.

Persistent inflammation and immunosuppression: a common syndrome and new horizon for surgical intensive care

Surgical intensive care unit (ICU) stay of longer than 10 days is often described by the experienced intensivist as a "complicated clinical course" and is frequently attributed to persistent immune dysfunction. "Systemic inflammatory response syndrome" (SIRS) followed by "compensatory anti-inflammatory response syndrome" (CARS) is a conceptual framework to explain the immunologic trajectory that ICU patients with severe sepsis, trauma, or emergency surgery for abdominal infection often traverse, but the causes, mechanisms, and reasons for persistent immune dysfunction remain unexplained. Often involving multiple-organ failure (MOF) and death, improvements in surgical intensive care have altered its incidence, phenotype, and frequency and have increased the number of patients who survive initial sepsis or surgical events and progress to a persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Often observed, but rarely reversible, these patients may survive to transfer to a long-term care facility only to return to the ICU, but rarely to self-sufficiency. We propose that PICS is the dominant pathophysiology and phenotype that has replaced late MOF and prolongs surgical ICU stay, usually with poor outcome. This review details the evolving epidemiology of MOF, the clinical presentation of PICS, and our understanding of how persistent inflammation and immunosuppression define the pathobiology of prolonged intensive care. Therapy for PICS will involve innovative interventions for immune system rebalance and nutritional support to regain physical function and well-being.

Trauma hemorrhagic shock-induced lung injury involves a gut-lymph-induced TLR4 pathway in mice

Background

Injurious non-microbial factors released from the stressed gut during shocked states contribute to the development of acute lung injury (ALI) and multiple organ dysfunction syndrome (MODS). Since Toll-like receptors (TLR) act as sensors of tissue injury as well as microbial invasion and TLR4 signaling occurs in both sepsis and noninfectious models of ischemia/reperfusion (I/R) injury, we hypothesized that factors in the intestinal mesenteric lymph after trauma hemorrhagic shock (T/HS) mediate gut-induced lung injury via TLR4 activation.

Methods/Principal Findings

The concept that factors in T/HS lymph exiting the gut recreates ALI is evidenced by our findings that the infusion of porcine lymph, collected from animals subjected to global T/HS injury, into naïve wildtype (WT) mice induced lung injury. Using C3H/HeJ mice that harbor a TLR4 mutation, we found that TLR4 activation was necessary for the development of T/HS porcine lymph-induced lung injury as determined by Evan's blue dye (EBD) lung permeability and myeloperoxidase (MPO) levels as well as the induction of the injurious pulmonary iNOS response. TRIF and Myd88 deficiency fully and partially attenuated T/HS lymph-induced increases in lung permeability respectively. Additional studies in TLR2 deficient mice showed that TLR2 activation was not involved in the pathology of T/HS lymph-induced lung injury. Lastly, the lymph samples were devoid of bacteria, endotoxin and bacterial DNA and passage of lymph through an endotoxin removal column did not abrogate the ability of T/HS lymph to cause lung injury in naïve mice.

Conclusions/Significance

Our findings suggest that non-microbial factors in the intestinal mesenteric lymph after T/HS are capable of recreating T/HS-induced lung injury via TLR4 activation.

Presidential address: imagination trumps knowledge

Multiple organ failure (MOF) emerged 30 years ago and became our research focus. Over the years, we have proposed a series of cartoons that rallied multidisciplinary translational research teams around common themes to generate "win-win" hypotheses that when tested (right or wrong) have advanced our understanding of MOF. MOF has a bimodal trajectory, and the gut plays a role in both trajectories. Early MOF occurs because of excessive proinflammation (ie, systemic inflammatory response syndrome [SIRS]), and early gut ischemia-reperfusion can amplify SIRS and contribute to the early fulminant SIRS-MOF trajectory. Fortunately, most patients survive early SIRS, but some develop excessive anti-inflammation (ie, compensatory anti-inflammatory response syndrome). The gut also plays a role in this late indolent compensatory anti-inflammatory response syndrome-MOF trajectory. Multiple factors cause progressive gut dysfunction such that the gut (an important immunologic organ) worsens compensatory anti-inflammatory response syndrome and becomes the reservoir for pathogens and toxins that cause late sepsis.

Collection of biological samples in forensic toxicology

Forensic toxicology is the study and practice of the application of toxicology to the purposes of the law. The relevance of any finding is determined, in the first instance, by the nature and integrity of the specimen(s) submitted for analysis. This means that there are several specific challenges to select and collect specimens for ante-mortem and post-mortem toxicology investigation. Post-mortem specimens may be numerous and can endow some special difficulties compared to clinical specimens, namely those resulting from autolytic and putrefactive changes. Storage stability is also an important issue to be considered during the pre-analytic phase, since its consideration should facilitate the assessment of sample quality and the analytical result obtained from that sample. The knowledge on degradation mechanisms and methods to increase storage stability may enable the forensic toxicologist to circumvent possible difficulties. Therefore, advantages and limitations of specimen preservation procedures are thoroughfully discussed in this review. Presently, harmonized protocols for sampling in suspected intoxications would have obvious utility. In the present article an overview is given on sampling procedures for routinely collected specimens as well as on alternative specimens that may provide additional information on the route and timing of exposure to a specific xenobiotic. Last, but not least, a discussion on possible bias that can influence the interpretation of toxicological results is provided. This comprehensive review article is intented as a significant help for forensic toxicologists to accomplish their frequently overwhelming mission.

Gut barrier dysfunction in critically ill surgical patients with abdominal compartment syndrome

OBJECTIVES

This study investigated the effects of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) on gut barrier function in critically ill surgical patients.

METHODS

A prospective observational cohort study on patients with severe acute pancreatitis or abdominal sepsis admitted to an intensive care or high-dependency unit. Intra-abdominal pressure (IAP) and plasma levels of immunoglobulin G (IgG) and IgM antiendotoxin core antibodies (EndoCAb) and procalcitonin (ProCT) were measured serially.

RESULTS

Among 32 recruited patients, 24 (75%) and 8 patients (25%) developed IAH and ACS, respectively. The state of ACS was associated with significant reductions in plasma IgG EndoCAb (P = 0.015) and IgM EndoCAb (P = 0.016) and higher concentrations of plasma ProCT (P = 0.056) compared with absence of ACS. Resolution of IAH and ACS was associated with significant recovery of plasma IgG EndoCAb (P = 0.003 and P = 0.009, respectively) and IgM EndoCAb (P = 0.002 and P = 0.003, respectively) and reduction in plasma ProCT concentration (P = 0.049 and P = 0.019, respectively). Negative correlations were observed between IAP and plasma IgG EndoCAb (P = 0.003) and IgM EndoCAb (P = 0.002).

CONCLUSIONS

Intra-abdominal hypertension and ACS are associated with significantly higher endotoxin exposure and ProCT concentrations, suggestive of gut barrier dysfunction. Resolution of IAH and ACS is associated with evidence for recovery of gut barrier function.

Experimental radiotherapy-induced enteritis: a probiotic interventional study

OBJECTIVE

Acute radiation of the small intestine causes an immediate and potentially reversible effect on the sensitive regenerative epithelium of the intestinal mucosa while markedly altering the overall intestinal ecosystem. The aim of the present study was test a novel probiotic mixture formulation (Microflorana-F) in an experimental model of acute radiation enteritis with particular interest in endotoxinemia and bacterial translocation.

MATERIALS AND METHODS

Male Wistar rats allocated to three groups were fed for 7 days with: (A) a standard balanced diet; (B) a standard diet with the addition of 1 mL t.i.d. of Microflorana-F and (C) the same probiotic but after heat inactivation. Under ketamine anesthesia, abdominal irradiation was performed at a single dose rate of 20 Gy. Sham-radiated healthy rats served as a control (D). Standard food and active/inactive probiotic supplementation schedule was maintained throughout the study period. When they were killed 14 days later a midline laparotomy and a medium sternotomy was carried out. The mesenteric lymph nodes, whole spleen and liver samples as well as blood, the portal vein and bile samples were cultured. Endotoxinemia was also measured.

RESULTS

Early deaths (1 week) occurred mostly in rats fed standard food or inactivated probiotic. The endotoxin level significantly increased in irradiated rats fed standard food and inactivated probiotic while supplementation with the active form of the probiotic mixture significantly improved such parameters (P < 0.05). After radiation injury, mesenteric lymph nodes and portal blood were the samples most frequently yielding bacterial growth. Treatment with only the active form of probiotic significantly reduced the incidence of bacterial contamination in all samples.

CONCLUSIONS

These data suggest that the manipulation of gut ecosystem by biologically effective probiotic preparations might be a worthwhile therapeutic and preventive tool in radiation-induced enteritis.

The introducer technique is the optimal method for placing percutaneous endoscopic gastrostomy tubes in head and neck cancer patients

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes are often placed in head and neck cancer patients to provide nutritional support, but studies have found the complication rates to be higher than other subsets of patients who undergo PEG placement. Complication rates as high as 50% have been reported, with the bulk of these complications being PEG site issues (i.e., cellulitis, abscess, fascitis, and tumor implantation). Because the pull technique has been the primary technique used, the theory is that the transoral tube passage is the source of the complications in these patients. Alternatively, the introducer technique uses a transabdominal approach to place the device, avoiding any tube contamination by upper aerodigestive organisms or tumor cells. At our institution, this technique has been used exclusively for head and neck cancer patients and this article reports our experience.

METHODS

One hundred forty-nine head and neck cancer patients who had a prophylactic PEG tube placed were reviewed from January 1, 1999 to December 31, 2003. The rates of placement success, morbidity, and complications were determined.

RESULTS

Successful placement was achieved in 148 (99%) patients without any PEG-related deaths. Overall, 17 complications (11%) occurred, with only one major complication (0.7%) identified. PEG site infections were uncommon with only five cases (3.4%) and all were mild cellulitis.

CONCLUSIONS

The introducer technique is the safest method for PEG tube placement in head and neck cancer patients. The overall rate of complications is low and PEG site infectious complications are rare. The introducer technique should be the method of choice for PEG tubes in head and neck cancer patients.

[The trauma surgeon's role in intensive care]

Severe injuries in patients of all ages and injuries in elderly multi-morbid subjects are a relevant medical and economic challenge. Optimal care of the polytraumatized patient can be best delivered by physicians specializing both in causal treatment of the injury or underlying disease and in intensive care. For care of critically ill injured patients, trauma surgeons with a certified specialty in intensive care medicine appear best suited. Of course, directing a surgical or trauma intensive care unit has to be full-time. Specialization of trauma surgeons (e.g., in the USA) has resulted in a considerable improvement in outcomes at least partly related to specialized trauma intensive care. Further improvement of trauma care relies on competent and innovative research not only in the fields of general intensive care, e.g., ventilation, but particularly in the complex aspects of the causality of the traumatic disease. An integrative view of the pathobiochemical, pathophysiological, and immunopathological sequelae of severe trauma under consideration of the various surgical and therapeutic strategies is the actual focus of research in surgical critical care medicine. Organ dysfunctions have to be modulated as they develop. Surgeons and trauma surgeons lead worldwide in this field of research. Obviously, competent research in polytrauma care requires competence in polytrauma intensive care.

Comparison of tolerance and change of intragastric pH between early nasogastric and nasojejunal feeding following resection of colorectal cancer

BACKGROUND

Early feeding after injury has been suggested to decrease morbidity and mortality in many studies. Intrajejunal feeding has been preferred over intragastric feeding due to earlier return of peristalsis following laparotomy. Few reports, however, have focused on the tolerance and change in pH inside the stomach after intragastric and intrajejunal feeding. The aim of the present study was the assessment of (1) the postoperative tolerance of intragastric and intrajejunal feeding, and (2) the effect of intragastric and intrajejunal feeding on intragastric pH value.

MATERIALS AND METHODS

From April 1998 to October 2002, 140 patients underwent colon resection for colorectal cancer entered the study. The patients were divided into seven groups of 20 patients each. Group I was kept on NPO for 1 week. Groups II, III, and IV were fed through a nasogastric (NG) tube from the second to the sixth postoperative day (POD) with low residual (Osmolite-HN), high-fat (Pulmocare), and glutamine-containing (AlitraQ) enteral formulas, respectively. Groups V, VI, and VII were fed through a nasojejunal (NJ) tube from the second to the sixth POD with Osmolite-HN, Pulmocare, and AlitraQ, respectively. Feeding started at 500 kcal/500 cm(3)/d. If the patient tolerated the formula well, feeding increased to 1,500 kcal/1,500 cm(3)/d the following day. Intragastric pH was measured preoperatively and then twice daily until the sixth POD.

RESULTS

Poor tolerance occurred in 14 patients (23%) with NG tube feeding and 18 patients (30%) with NJ tube feeding. The pH value of intragastric juice increased significantly once NG feeding started (3.67+/-1.33 on the third POD; 4.28+/-1.26 on the sixth POD). However, the pH value remained low after NJ feeding was started (2.09+/-1.46 on the third POD; 2.14+/-1.49 on the sixth POD).

CONCLUSIONS

This series suggests that (1) the majority of patients can tolerate early feeding well following resection of colorectal cancer, and NJ feeding is not necessarily better tolerated than NG feeding; (2) early NG, but not the NJ feeding, can significantly elevate the intragastric pH value in patients who underwent resection of colorectal cancer. NG may be more effective than NJ feeding in preventing stress-induced gastropathy by elevating the pH value of intragastric juice.

INTRALUMINAL PANCREATIC SERINE PROTEASE ACTIVITY, MUCOSAL PERMEABILITY, AND SHOCK

Shock states are characterized by a pronounced activation of numerous cell types that lead to an acute inflammatory reaction. The exact mechanism by which these inflammatory cells are activated is not known. Numerous studies have implicated the gastrointestinal tract as one of the main sites for the generation of inflammatory mediators and initiation of an acute systemic response. The pancreas is known to secrete powerful digestive enzymes, and we hypothesize that they may play a leading role in the pathogenesis of multiorgan failure after the onset of shock. We carried out a search in PubMed for all relevant studies related to the role of the pancreas in shock. Studies that included information concerning the role of pancreatic enzymes in shock were then summarized. Our article serves to review the current hypotheses on how digestive enzymes produced by the pancreas may play a pivotal role in initiating the systemic inflammatory response. We further hypothesize how these enzymes and/or their products may ultimately contribute to multiorgan failure and death.

Peroxisome proliferator-activated receptor gamma mediates protection against cyclooxygenase-2-induced gut dysfunction in a rodent model of mesenteric ischemia/reperfusion

Cyclooxygenase (COX)-2 has been identified as an important mediator elaborated during ischemia/reperfusion, with pro- and anti-inflammatory properties having been reported. As the role of COX-2 in the small intestine remains unclear, we hypothesized that COX-2 expression would mediate mesenteric ischemia/reperfusion-induced gut injury, inflammation, and impaired transit and that these deleterious effects could be reversed by the selective COX-2 inhibitor, N-[2-(cyclohexyloxy)-4-nitrophenyl] methanesulphanamide (NS-398). Additionally, we sought to determine the role of peroxisome proliferator-activated receptor gamma (PPARgamma) in mediating protection by NS-398 in this model. Rats underwent sham surgery or were pretreated with NS-398 (3, 10, or 30 mg/kg) intraperitoneally 1 h before 60 min of superior mesenteric artery occlusion and 30 min to 6 h of reperfusion. In some experiments, NS-398 (30 mg/kg) was administered postischemia. Ileum was harvested for COX-2 mRNA and protein, PGE2, myeloperoxidase (inflammation), histology (injury), intestinal transit and PPARgamma protein expression, and DNA-binding activity. COX-2 expression and PGE2 production increased after mesenteric ischemia/reperfusion and were associated with gut inflammation, injury, and impaired transit. Inhibition of COX-2 by NS-398 (30 mg/kg, but not 3 or 10 mg/kg) not only reversed the deleterious effects of COX-2, but additionally induced expression and nuclear translocation of PPARgamma. NS-398 given postischemia was equally protective. In conclusion, COX-2 may function as a proinflammatory mediator in a rodent model of mesenteric ischemia/reperfusion. Reversal of gut inflammation, injury, and impaired transit by high-dose NS-398 is associated with PPAR activation, suggesting a potential role for PPAR-gamma in shock-induced gut protection.

Energy expenditure and balance following pediatric intensive care unit admission: a longitudinal study of critically ill children

OBJECTIVE

Longitudinal comparison of prescribed energy, actually administered energy, and energy expenditure (EE) predicted by Schofield's equations to actual EE, as determined by daily indirect calorimetry measurements in critically ill children during the first 7 days following admission.

DESIGN

Observational study.

SETTING

Pediatric intensive care unit, high and medium care wards, in a university hospital.

PATIENTS

Forty-six mechanically ventilated and spontaneously breathing infants and children (0-18 yrs) who were admitted with sepsis or following major abdominal or thoracic surgery or trauma.

INTERVENTIONS

Daily indirect calorimetry measurements and assessment of energy balance.

MEASUREMENTS AND MAIN RESULTS

Energy balance studies were performed for a total of 298 admission days in 13 sepsis, 27 surgery, and 6 trauma patients. Indirect calorimetry measurements were performed on 89% of the days. Mean measured EE was 44.6 +/- 15 kcal/kg.d and equaled predicted EE (44.2 +/- 12 kcal/kg.d; p = .56). Measured EE did not change over time, neither overall nor in diagnostic subgroups. Overall, median (range) administered energy was 31.1 (0-119) kcal/kg.d, which was significantly lower than measured EE (p < .001) and predicted EE (p < .001). Patients were underfed on 60% of days and overfed on 28% of days. Administered energy rose significantly in the course of admission, independently of diagnostic category, and did not differ from prescribed energy (p = .42). Energy intake was significantly higher in sepsis patients than in surgery and trauma patients during the whole course of the study (p < .01). The cumulative energy balance was positive only in sepsis patients. The administration of parenteral feeding was the single significant factor determining energy intake in mixed-effect modeling.

CONCLUSIONS

Measured EE was stable and not significantly different from predicted values over the course of hospitalization. Underfeeding was frequently present and mainly due to prescription and administration of energy amounts inferior to measured EE values in enterally fed patients.

Portal and systemic endotoxemia in abdominal operations: the significance of acute abdomen

Little evidence is available for the implication of bacterial translocation in cases of acute abdomen. Intraoperative endotoxemia in both portal and systemic circulation was studied in 20 surgical patients with acute abdomen and in 36 controls undergoing elective abdominal surgery. Blood was sampled simultaneously from a mesenteric vein immediately after opening the peritoneum and from a peripheral vein. Endotoxin was measured by a colorimetric Limulus amebocyte lysate assay and malondialdehyde (MDA) was measured by the thiobarbiturate assay and passage through a high-performance liquid chromatography (HPLC) system as a marker of the oxidative status. LPS concentrations (mean +/- SE) in portal vein blood from patients with acute abdomen was 5.69 +/- 1.58 and from patients with chronic diseases 1.05 +/- 0.07 EU/ml (P < 0.0001). Respective values for the systemic circulation were 4.98 +/- 1.47 and 1.36 +/- 0.31 EU/ml (P < 0.0001). Concentrations of MDA (mean +/- SE) in portal vein blood from patients with acute abdomen was 11.16 +/- 4.00 and from patients with chronic diseases was 10.56 +/- 2.39 mum (P NS). Positive correlations were observed between endotoxin and MDA in both portal and systemic circulation. These results indicate increased levels of endotoxin in acute abdominal conditions pointing to the gut as the site of origin of the bacterial products.

Burn Injury Exacerbates Hemodynamic and Metabolic Responses in Rats with Polymicrobial Sepsis

The most common and life-threatening complication of severe burn injury is infection, which often results in multiple organ failure (MOF). However, the mechanism of development of MOF after burn injury associated with infection is not fully understood. Our previous studies showed that when polymorphonuclear neutrophils (PMNs) are depleted, burn injury-induced increase in microvascular permeability to albumin is markedly attenuated. Thus, we hypothesized that the combination of burn injury and polymicrobial infection exacerbates PMN activation, increases intestinal microvascular permeability to albumin, and alters hemodynamics and metabolism more than burn injury or infection alone. Sprague-Dawley rats (250-275 g) were divided into four groups. In the burn group, rats were subjected to a 30% TBSA burn injury. In the cecal-ligation puncture (CLP) group, CLP was performed using a 22-gauge needle with one puncture. In burn+CLP group, rats were subjected to CLP immediately after burn procedure. In sham group, rats were subjected to sham procedures. Transient polymicrobial bacteremia and persistent polymicrobial bacteremia were induced in the CLP group and burn+CLP group, respectively. Microvascular permeability, myeloperoxidase, and PMN production of elastase and reactive oxygen species increased in the burn group and CLP group and further increased in the burn+CLP group. Hemodunamic and metabolic alterations on day 1 and 3 after injury correlated with those alterations. Although there was only a low mortality in the burn group and CLP group, there was a high mortality in burn+CLP group (79%). The mechanism of MOF that leads to high mortality in burn injury complicated by infection may involve uncontrolled microvascular damage mediated by PMN activation.

Intestinal permeability is increased in burn patients shortly after injury

There is increasing direct experimental and indirect clinical evidence to indicate that under certain conditions intestinal barrier function may be lost in trauma victims. No direct measurements, however, have been performed in patients to determine whether intestinal permeability is increased shortly after a major thermal injury in the absence of infection. Fifteen hemodynamically stable burn patients with burns on more than 20% of their body surface (39% ± 12%) had their intestinal permeability measured within 24 hours of injury with use of the two nonmetabolizable sugars lactulose and manmtol as permeability markers. Lactulose absorption was fourfold higher in the patients (223 ± 54 μmol) than in the controls (58 ± 77 μmole;p &lt; 0.02), whereas the lactulose/manmtol ratio was threefold higher (5.2 vs 1.7; p &lt; 0.05). Thus intestinal permeability was increased in patients with moderate to major burn injuries shortly after injury. (Surgery 1990;107:411-6).

Gender differences in small intestinal perfusion following trauma hemorrhage: the role of endothelin-1

Although gender differences in intestinal perfusion exist following trauma-hemorrhage (T-H), it remains unknown whether endothelin-1 (ET-1) plays any role in these dimorphic responses. To study this, male, proestrus female (female), and 17 beta-estradiol (E2)-treated male rats underwent midline laparotomy, hemorrhagic shock (blood pressure 40 mmHg, 90 min), and resuscitation (Ringer lactate, 4X shed blood volume, 1 h). Two hours thereafter, intestinal perfusion flow (IPF) was measured using isolated intestinal perfusion. The IPF in sham-operated males was significantly lower than those in other groups and decreased markedly following T-H. In contrast, no significant decrease in IPF was observed in females and E2 males following T-H. The lower IPF in sham-operated males was significantly elevated by ET(A) receptor antagonist (BQ-123) administration and was similar to that seen in sham-operated females. The decreased IPF in males after T-H was also attenuated by BQ-123 administration. The intestinal ET-1 levels in sham-operated males were significantly higher than in other groups. Although plasma and intestinal ET-1 levels increased significantly after T-H in all groups, they were highest in males. Plasma E2 levels in females and E2 males were significantly higher than in males; however, they were not affected by T-H. There was a negative correlation between plasma ET-1 and E2 following T-H. Thus ET-1 appears to play an important role in intestinal perfusion failure following T-H in males. Because E2 can modulate this vasoconstrictor effect of ET-1, these findings may partially explain the previously observed salutary effect of estrogen in improving intestinal perfusion following T-H in males.

Small volume hypertonic resuscitation of circulatory shock

Small volume hypertonic resuscitation is a relatively new conceptual approach to shock therapy. It was originally based on the idea that a relatively large blood volume expansion could be obtained by administering a relatively small volume of fluid, taking advantage of osmosis. It was soon realized that the physiological vasodilator property of hypertonicity was a useful byproduct of small volume resuscitation in that it induced reperfusion of previously ischemic territories, even though such an effect encroached upon the malefic effects of the ischemia-reperfusion process. Subsequent research disclosed a number of previously unsuspected properties of hypertonic resuscitation, amongst them the correction of endothelial and red cell edema with significant consequences in terms of capillary blood flow. A whole set of actions of hypertonicity upon the immune system are being gradually uncovered, but the full implication of these observations with regard to the clinical scenario are still under study. Small volume resuscitation for shock is in current clinical use in some parts of the world, in spite of objections raised concerning its safety under conditions of uncontrolled bleeding. These objections stem mainly from experimental studies, but there are few signs that they may be of real clinical significance. This review attempts to cover the earlier and the more recent developments in this field.

Hypertonic saline prevents inflammation, injury, and impaired intestinal transit after gut ischemia/reperfusion by inducing heme oxygenase 1 enzyme

BACKGROUND

Hypertonic saline (HTS) has been shown to modulate the inflammatory response after shock. We have previously demonstrated that heme oygenase-1 (HO-1) induction is protective against gut dysfunction in models of shock-induced gut ischemia/reperfusion (I/R). We therefore hypothesized that HTS prevents gut inflammation, injury, and impaired transit by inducing HO-1 in a model of gut I/R.

METHODS

Rats underwent 60 minutes of superior mesenteric artery occlusion (SMAO) and then were resuscitated with 4 mL/kg of HTS, an equal volume of lactated Ringer's (LR) solution (4 mL/kg, low volume), or equal salt LR solution (32 mL/kg, high volume) and compared with SMAO alone or shams. A separate group was pretreated with the HO-1 blocker Sn protoporphyrin IX (SNP IX) before SMAO plus HTS. At 6 hours of reperfusion, transit was determined and ileum harvested for HO-1 (anti-inflammatory) and inducible nitric oxide synthase (proinflammatory) immunoreactivity, myeloperoxidase (MPO) activity, and histologic injury. Data are expressed as mean +/- SEM (analysis of variance).

RESULTS

Intestinal transit was severely impaired after SMAO (2.5 +/- 0.1), improved with low- and high-volume LR solution (3.2 +/- 0.2 and 3.1 +/- 0.1, not significant), but returned to sham (4.6 +/- 0.2) with HTS (4.8 +/- 0.2). Pretreatment with SNP abrogated this protective effect. Myeloperoxidase activity was significantly increased by SMAO (SMAO, 2.3 +/- 0.3; sham, 0.4 +/- 0.05), lessened by low- and high-volume LR solution (1.5 +/- 0.3 and 1.7 +/- 0.4), but returned to sham levels with HTS (1.0 +/- 0.01). Activity with SNP IX pretreatment was significantly increased (4.04 +/- 0.8). Mucosal injury followed a similar pattern. Inducible nitric oxide synthase was increased by SMAO and low- and high-volume LR solution (0.8 +/- 0.2, 0.8 +/- 0.03, and 0.8 +/- 0.02, respectively; sham, 0.5 +/- 0.02), but significantly reduced by HTS (0.7 +/- 0.02). HO-1 was induced by SMAO and low- and high-volume LR solution (0.33 +/- 0.02, 0.32 +/- 0.03, and 0.37 +/- 0.4, respectively; sham, 0.0 +/- 0.0), but was further increased with HTS (0.49 +/- 0.04).

CONCLUSION

HTS resuscitation protects against inflammation, injury, and impaired intestinal transit after gut I/R in part by inducing HO-1. This is a novel mechanism of HO-1 protection.

Nutritional support in 111 pediatric intensive care units: a European survey

OBJECTIVE

To study current strategies in nutritional management of pediatric intensive care units (PICUs) in Europe, focusing on energy requirements.

DESIGN AND SETTING

Survey by a 35-item questionnaire sent to representatives of 242 PICUs in 28 countries. Addresses were obtained from national PICU associations and the members' list of the European Society of Pediatric and Neonatal Intensive Care.

PARTICIPANTS

Staff members of 111 European PICUs (46%) from 24 countries.

MEASUREMENTS AND RESULTS

Predominantly physicians were reported to be responsible for nutritional support. In 73% of PICUs a multidisciplinary nutritional team was available. In most PICUs daily energy requirements were estimated using weight, age, predictive equations and correction factors. In 17% of PICUs energy expenditure was regularly measured by indirect calorimetry. Nutritional status was mostly assessed by weight, physical examination, and a wide range of biochemical blood parameters. Approximately 70% of PICUs used dedicated software for nutritional support. A similar percentage of PICUs regarded "nutrition" as a research topic and part of the residents' training program.

CONCLUSIONS

Most European PICUs regard nutritional support as an important aspect of patient care, as shown by the presence of nutritional teams, software, research, and education. However, energy requirements of pediatric intensive care patient were based predominantly on estimations rather than on measurements.

Gender differences in small intestinal endothelial function: inhibitory role of androgens

Although gender differences exist in cardiovascular endothelial function, it remains unclear whether such differences are also seen in small intestinal endothelial function. To determine this, untreated male, age-matched proestrus female, castrated male, and 17beta-estradiol (E2)-treated noncastrated male rats were studied. Dose response curves to ACh and nitroglycerin (NTG) were determined by measuring changes in perfusion pressure by using an isolated small intestinal perfusion model. Endothelium-derived nitric oxide (NO) production/release was indirectly determined by the ability of intact endothelium to suppress serotonin (10(-5) M)-induced perfusion pressure changes. Intestinal tissue levels of NO were also measured. Moreover, plasma levels of androgen and E2 were determined and correlated with ACh (10(-8) M)-induced perfusion pressure reductions. ACh-induced intestinal perfusion pressure reductions in proestrus females, castrated males, and E2-treated noncastrated males were significantly higher than in untreated males. NTG-induced perfusion pressure reductions were not significantly different among groups. Perfusion pressures after administration of serotonin (10(-5) M) and intestinal tissue levels of NO in proestrus females, castrated males, and E2-treated noncastrated males were also significantly higher than in untreated males. Plasma androgen levels in proestrus females, castrated males, and in E2-treated noncastrated males were significantly lower compared with untreated males. There was a positive correlation between plasma androgen and ACh-reduced perfusion pressure; however, E2 levels did not show a similar relationship. Thus androgens appear to play an inhibitory role in small intestinal endothelial function. These properties in male vessels can be modulated by decreasing the level of circulating androgens or by E2 treatment.

Head injury-associated bone fractures induce bacterial translocation: an experimental study

OBJECTIVES

To determine whether long bone fractures cause bacterial translocation and to investigate the effect of concomitant head trauma on this process.

DESIGN

An in vivo animal model.

SETTING

Animal Laboratory, University of Mersin School of Medicine, Mersin, Turkey.

SUBJECTS

Male Sprague-Dawley rats (n = 60).

INTERVENTION

Sixty male Sprague-Dawley rats were divided into five groups: (1). anesthesia only (control group, n = 12); (2). anesthesia and tibia fracture (n = 12); (3). anesthesia, tibia fracture, and femur fracture (n = 12); (4). anesthesia, tibia fracture, femur fracture, and moderate head trauma (n = 12); and (5). moderate head trauma only (n = 12). After 24 hours, mesenteric lymph nodes, liver, spleen, ileum, and systemic blood samples were quantitatively cultured for aerobic organisms.

MAIN OUTCOME MEASUREMENTS

Colony-forming unit per gram for bacteria count.

RESULTS

The incidence of bacterial translocation was higher in groups that had fractures (4/12 in group 2; 5/12 in group 3) than in the control group (2/12); however, this did not reach statistical significance. There was a significant increase in the number of subjects with bacterial translocation in group 4 (9/12) compared with the control group and group 5 (3/12) (P = 0.0123, P = 0.0391).

CONCLUSIONS

Multiple fractures of long bones associated with head injury promote bacterial translocation.

Nutritional support of the critically ill and injured patient

The understanding of the importance of nutrition, particularly in the critically ill patient, is based on the known physiologic consequences of malnutrition. It includes respiratory muscle function, cardiac function, the coagulation cascade balance, electrolyte and hormonal balance, and renal function. Nutrition affects emotional and behavioral responses, functional recovery, and the overall cost of health care. The need to identify and treat the malnourished or potentially malnourished patient is a critical aspect of patient management. Much is known of catabolic and hypermetabolic state caused by trauma and burns. The response to injury needs to be mediated. There is much to learn about the intervention of that response through adjuvant nutritional therapy.

Lactobacilli attenuate bacteremia and endotoxemia associated with severe intra-abdominal infection

BACKGROUND

Systemic administration of antibiotics or selective decontamination is frequently used in the prophylaxis and treatment of infections originating from the gastrointestinal flora. In this study, we wanted to compare the protective effect of enteral administration of lactobacilli to gentamicin against severe intra-abdominal infection.

METHODS

Male Sprague-Dawley rats underwent cecal ligation and puncture (CLP). Rats were pretreated with saline, Lactobacillus R2LC, and gentamicin. Bacterial growth and endotoxin levels in the blood, reticuloendothelial system (RES)-function, and intestinal transit were determined up to 24 hours after CLP.

RESULTS

CLP-provoked bacteremia was significantly reduced by 48% and 55% in lactobacilli- and gentamicin-treated rats, respectively. Notably, CLP-induced endotoxemia was abolished at 12 hours, and reduced by 47% at 24 hours, in rats pretreated with lactobacilli. Gentamicin reduced endotoxin levels provoked by CLP by 86% at 12 hours, but had no effect at 24 hours. Lactobacilli had no effect on the clearance of Escherichia coli (E coli) from the blood, whereas intestinal transit was increased in lactobacilli-treated animals, suggesting that the beneficial effect of Lactobacillus R2LC is not related to an increase of phagocytic capacity but may rather be partly attributable to an enhanced intestinal motility.

CONCLUSION

Enteral administration of Lactobacillus R2LC attenuates bacteremia and endotoxemia associated with intra-abdominal infection in rats.

Bacterial translocation: what it is and what it is not

The reasons our critically ill patients die have been a matter of great interest for many decades, with the hope that if we can identify the mechanisms responsible for death, we might be able to intervene and improve outcome. Over the last 1 to 2 decades, the concept of bacterial translocation-the movement of gut origin microbes across the intact gastrointestinal tract into normally sterile tissues where the organisms may then directly cause infection or incite an inflammatory response that causes tissue injury, organ failure, and death-has grown to the point where it is virtually impossible to make rounds in any intensive care setting without a resident or student blaming some complication or another on bacterial translocation. We will attempt to review the clinically relevant information that supports and refutes the concept of bacterial translocation as a cause of our critically ill patients to exhibit the symptoms and signs of sepsis, develop organ failure, and ultimately die.

Postoperative enteral stimulation by gut feeding improves outcomes in severe acute pancreatitis

OBJECTIVE

We assessed the clinical effectiveness of postoperative enteral stimulation by gut feeding in patients with severe acute pancreatitis (SAP).

METHODS

Medical records of 63 patients who were operated on within the past 4 y due to deterioration of SAP were included in this retrospective study. Patients were stratified in gut feeding (GF; n = 33) and standard therapy (ST; n = 30) groups according to the postoperative therapy provided. The GF group received postoperative standard therapy and enteral stimulation by gut feeding, and the ST group received standard therapy only. The Acute Physiology and Chronic Health Evaluation II score, incidence of the systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), daily calories supply, complication rate, and outcomes were analyzed.

RESULTS

Patient characteristics did not differ between groups when considering age and severity of the disease. All patients underwent similar surgical interventions. SIRS and MODS were observed initially with the same frequency in both groups. Regression of MODS and a lower postoperative complication rate was observed more often in the GF group. Development of early pulmonary complications was observed in 12.1% to 13.3% in both groups, irrespective of the time of surgery. Subsequently, pulmonary complications developed in 15.2% of GF patients compared with 43.3% of ST patients (P <0.05). Acute renal insufficiency developed similarly in 33.3% of the GF patients and in 26.7% of the ST patients within 3 d after admission. Acute renal insufficiency developed later on only in the ST group (26.7%, P <0.05). Wound- and catheter-related septic complications were considerably more frequent in the ST group (30.0%) than in the GF group (9.1%, P <0.05). Intensive care and hospital stays did not differ. Postoperative gut feeding was associated with 6.1% mortality in the GF compared with 26.7% in the ST (P <0.05).

CONCLUSIONS

Enteral stimulation by gut feeding is an effective supplement in the postoperative therapy of patients with SAP.

Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial

OBJECTIVE

To compare the mortality of critically ill patients given either enteral feeding with an immune-enhancing formula or parenteral nutrition (PN). We report the results of a planned interim analysis on patients with severe sepsis which was undertaken earlier than planned once a meta-analysis suggested excess mortality in patients with severe sepsis given enteral immunonutrition.

DESIGN

Randomised multicentre unblinded controlled clinical trial.

SETTING

Thirty-three General Intensive Care Units in Italy.

PATIENTS AND PARTICIPANTS

Among the 237 recruited patients, 39 had severe sepsis or septic shock; 21 of them received PN.

INTERVENTIONS

Eligible patients received either total PN or enteral nutrition, the latter containing extra L-arginine, omega-3 fatty acids, vitamin E, beta carotene, zinc, and selenium.

MEASUREMENTS AND RESULTS

The primary endpoint for the subgroup analysis on patients with severe sepsis was mortality on Intensive Care Unit (ICU). The ICU mortality of patients with severe sepsis given enteral nutrition (EN) was higher than for those given PN (44.4% vs 14.3%; p=0.039). More patients given EN than patients given PN still had severe sepsis when they died (38.9% vs 9.5%, p=0.055). Recruitment of patients with severe sepsis was subsequently stopped.

CONCLUSIONS

Our results show that enteral immunonutrition, compared to PN, may be associated with excess mortality in patients with severe sepsis.

Distributions of ethanol and intubation-related lidocaine in the brain of a trauma patient who was brain dead for about 5 days

A 48-year-old intoxicated man was admitted to a hospital with an acute subarachnoid hemorrhage from a blow to the head following a drinking session. Lidocaine jelly was used to facilitate intubation during cardiopulmonary resuscitation. While his heart resumed beating, he was classified as brain dead and his heart stopped 114 h after admission. His brain was soft and weighed 1.7 kg at autopsy. A small rupture (0.5 by 0.3 cm) of the left vertebral artery and diffuse subarachnoid hemorrhage were observed. Ethanol was detected only in the cerebrum, cerebellum and clotted blood in the superior sagittal sinus at 0.29, 0.15 and 0.12 mg/g, respectively. Lidocaine was also found in these areas at levels of 28, 24 and 7 ng/g, respectively. Significant amounts of ethanol were present in his brain because blood flow stopped after the injury. Smaller amounts of intubation-related lidocaine were probably distributed to the brain by limited cerebral circulation and remained there after circulation ceased. Toxicological analysis of the brain after death was useful for evaluating his state during treatment.