The effect of peri-operative dexmedetomidine on the incidence of postoperative delirium in cardiac and non-cardiac surgical patients: a randomised, double-blind placebo-controlled trial

Delirium occurs commonly following major non-cardiac and cardiac surgery and is associated with: postoperative mortality; postoperative neurocognitive dysfunction; increased length of hospital stay; and major postoperative complications and morbidity. The aim of this study was to investigate the effect of peri-operative administration of dexmedetomidine on the incidence of postoperative delirium in non-cardiac and cardiac surgical patients. In this randomised, double-blind placebo-controlled trial we included 63 patients aged ≥ 60 years undergoing major open abdominal surgery or coronary artery bypass graft surgery with cardiopulmonary bypass. The primary outcome was the incidence of postoperative delirium, as screened for with the Confusion Assessment Method. Delirium assessment was performed twice daily until postoperative day 5, at the time of discharge from hospital or until postoperative day 14. We found that dexmedetomidine was associated with a reduced incidence of postoperative delirium within the first 5 postoperative days, 43.8% vs. 17.9%, p = 0.038. Severity of delirium, screened with the Intensive Care Delirium Screening Checklist, was comparable in both groups, with a mean maximum score of 1.54 vs. 1.68, p = 0.767. No patients in the dexmedetomidine group died while five (15.6%) patients in the placebo group died, p = 0.029. For patients aged ≥ 60 years undergoing major cardiac or non-cardiac surgery, we conclude that the peri-operative administration of dexmedetomidine is associated with a lower incidence of postoperative delirium.

Impact of brief prewarming on anesthesia-related core-temperature drop, hemodynamics, microperfusion and postoperative ventilation in cytoreductive surgery of ovarian cancer: a randomized trial

Background

General (GA)- and epidural-anesthesia may cause a drop in body-core-temperature (BCT_drop), and hypothermia, which may alter tissue oxygenation (StO₂) and microperfusion after cytoreductive surgery for ovarian cancer. Cell metabolism of subcutaneous fat- or skeletal muscle cells, measured in microdialysis, may be affected. We hypothesized that forced-air prewarming during epidural catheter placement and induction of GA maintains normothermia and improves microperfusion.

Methods

After ethics approval 47 women scheduled for cytoreductive surgery were prospectively enrolled. Women in the study group were treated with a prewarming of 43 °C during epidural catheter placement. BCT (Spot on®, 3 M) was measured before (T₁), after induction of GA (T₂) at 15 min (T₃) after start of surgery, and until 2 h after ICU admission (T_ICU2h). Primary endpoint was BCT_drop between T₁ and T₂. Microperfusion-, hemodynamic- and clinical outcomes were defined as secondary outcomes. Statistical analysis used the Mann-Whitney-U- and non-parametric-longitudinal tests.

Results

BCT_drop was 0.35 °C with prewarming and 0.9 °C without prewarming (p < 0.005) and BCT remained higher over the observation period (ΔT₄ = 0.9 °C up to ΔT₇ = 0.95 °C, p < 0.001). No significant differences in hemodynamic parameters, transfusion, arterial lactate and dCO₂ were measured. In microdialysis the ethanol ratio was temporarily, but not significantly, reduced after prewarming. Lactate, glucose and glycerol after PW tended to be more constant over the entire period. Postoperatively, six women without prewarming, but none after prewarming were mechanical ventilated (p < 0.001).

Conclusion

Prewarming at 43 °C reduces the BCT_drop and maintains normothermia without impeding the perioperative routine patient flow. Microdialysis indicate better preserved parameters of microperfusion.

Trial registration

ClinicalTrials.gov; ID: NCT02364219; Date of registration: 18-febr-2015.

Risk factors for 30-day complications after cancer surgery in geriatric patients: a secondary analysis

BACKGROUND

The aim was to analyse the association between severity of complications up to 30 days after surgery and pre-operative nutritional and physical performance parameters.

METHODS

The participants were a subsample of the previously published PERATECS study (ClinicalTrials.gov: NCT01278537) and included 517 onco-geriatric patients aged ≥ 65 years, undergoing thoracoabdominal, gynaecological, or urological surgery. Post-operative complications were classified according to the Clavien Classification System (CCS). Independent risk factors related to the severity of complications, defined as major complications (CCS IIIa-V) and graded complications (CCS grade 0-V), were analysed using logistic and ordinal regression, respectively.

RESULTS

In total, 132 patients suffered major post-operative complications. The development of major post-operative complications was independently associated with body mass index (BMI) < 20 kg/m² , hypoalbuminaemia (< 30 g/l), longer duration of surgery, and specific tumour sites (upper gastrointestinal, gynaecological, colorectal) (all P < 0.05). Higher-grade complications were predicted by Timed Up and Go (TUG) > 20 s, hypoalbuminaemia (< 30 g/l), higher American Society of Anesthesiologists (ASA) status III-IV, longer duration of surgery (> 165 min), and specific tumour sites (upper gastrointestinal, gynaecological) (all P < 0.05). Mini Nutritional Assessment (MNA) scores and weight loss were not independent risk factors for the severity of complications.

CONCLUSIONS

Nutritional and physical performance risk factors that predicted the severity of complications differed between major and higher-grade post-operative complications, but hypoalbuminaemia independently predicted both. The results support the need for pre-operative risk screening. Due to the explorative nature of the study, further research is required in larger cohorts to corroborate these findings.

No convincing association between post-operative delirium and post-operative cognitive dysfunction: a secondary analysis

BACKGROUND

Post-operative delirium and post-operative cognitive dysfunction (POCD) are both common but it has not been clarified how closely they are associated. We aimed to assess the possible relationship in a secondary analysis of data from the 'Surgery Depth of anaesthesia and Cognitive outcome'- study.

METHODS

We included patients aged ≥ 60 years undergoing non-cardiac surgery planned for longer than 60 min. Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders IV criteria in the post-anaesthesia care unit (PACU) as well as within the first week after surgery. Cognitive function was assessed with a neuropsychological test battery. Multivariable analysis of POCD was performed with consideration of predisposing and precipitating factors.

RESULTS

Of 1277 randomized patients, 850 (66.6%) had complete data. Delirium was found in 270 patients (32.9% of 850). We detected POCD in 162 (20.9% of 776) at 1 week and in 52 (9.4% of 553) at 3 months. In multivariable analysis (n = 808), delirium had no overall effect on POCD (P = 0.30). Patients with no delirium in PACU but with postoperative delirium within 7 days had an increased risk of POCD at 3 months (OR = 2.56 (95%-confidence interval: 1.07-6.16), P = 0.035). No significant association was found for the other subgroups.

CONCLUSIONS

There is no clear evidence that postoperative delirium is independently associated with POCD up to 3 months.

Obesity in regional anesthesia--a risk factor for peripheral catheter-related infections

BACKGROUND

Obesity is believed to increase the risk of surgical site infections and possibly increase the risk of catheter-related infections in regional anesthesia. We, therefore, analyzed the influence of obesity on catheter-related infections defined within a national registry for regional anesthesia.

METHODS

The German Network for Regional Anesthesia database with 25 participating clinical centers was analyzed between 2007 and 2012. Exactly, 28,249 cases (13,239 peripheral nerve and 15,010 neuraxial blocks) of patients ≥ 14 years were grouped in I: underweight (BMI 13.2-18.49 kg/m(2) , n = 597), II: normal weight (BMI 18.5-24.9 kg/m(2) , n = 9272), III: overweight (BMI 25.0-29.9 kg/m(2) , n = 10,632), and IV: obese (BMI 30.0-70.3 kg/m(2) , n = 7,744). The analysis focused on peripheral and neuraxial catheter-related infections. Differences between the groups were tested with non-parametric ANOVA and chi-square (P < 0.05). Binary logistic regression was used to compare obese, overweight, or underweight patients with normal weight patients. Odds ratios (OR and 95% confidence interval) were calculated and adjusted for potential confounders.

RESULTS

Confounders with significant influence on the risk for catheter-related infections were gender, age, ASA score, diabetes, preoperative infection, multiple skin puncture, and prolonged catheter use. The incidence (normal weight: 2.1%, obese: 3.6%; P < 0.001) and the risk of peripheral catheter-related infection was increased in obese compared to normal weight patients [adjusted OR: 1.69 (1.25-2.28); P < 0.001]. In neuraxial sites, the incidence of catheter-related infections differed significantly between normal weight and obese patients (normal weight: 3.2%, obese: 2.3%; P = 0.01), whereas the risk was comparable [adjusted OR: 0.95 (0.71-1.28); P = 0.92].

CONCLUSION

This retrospective cohort study suggests that obesity is an independent risk factor for peripheral, but not neuraxial, catheter-related infections.

Preoperative depression and hospital length of stay in surgical patients

BACKGROUND

The association of depression and hospital length of stay (LOS) has rarely been examined in surgical patients outside of cardiovascular surgery. This study investigates whether clinically significant preoperative depression shows an independent association with LOS in patients from various surgical fields after adjusting for age, gender and important somatic factors.

METHODS

A total of 2624 surgical patients were included in this prospective observational study. Data were collected before the preoperative anesthesiological examination within a computer-assisted psychosocial self-assessment including screening for depression (Center for Epidemiologic Studies Depression Scale, CES-D). Data on peri- and postoperative somatic parameters were obtained from the electronic patient management system of the hospital six months after the preoperative assessment.

RESULTS

LOS of patients with clinically significant depression (N.=296; median: 5 days, interquartile range: 3-8 days) was longer than LOS of patients without depression (N.=2328; median: 4 days, interquartile range: 2-6 days) (P<0.001). A multivariate logistic regression model with the binary dependent variable 'above versus below or equal to the median LOS' revealed that the significant association between depression and LOS persisted (OR: 1.822 [95% CI 1.360-2.441], P<0.001) when simultaneously including the covariates age, gender, ASA classification, Charlson Comorbidity Index, surgical field and POSSUM operative severity rating.

CONCLUSION

Data suggest that the association of depression and LOS is independent of the impact of age, gender, surgical field, preoperative physical health, severity of medical comorbidity and extent of surgical procedure. Integration of depression therapy into routine care of surgical patients might be an option to improve outcomes.

Incidence and Risk Factors for Cognitive Dysfunction in Patients with Severe Systemic Disease

OBJECTIVE: To determine the relevance of surgery and other causative factors to the incidence of postoperative cognitive dysfunction (POCD) in patients with severe systemic disease. METHODS: This observational study included 107 noncardiac surgical patients and 26 nonsurgical control subjects, all of whom had an American Society of Anesthesiologists physical classification status of 3. Cognitive assessment was performed preoperatively and 7 days postoperatively, or with a 7-day interval for the control group. POCD was calculated as a combined Z-score. Mini Mental State Examination (MMSE) was used to exclude patients with pre-existing cognitive deficit (MMSE score ≥ 23). Surgical and other factors including duration of surgery/anaesthesia and length of stay in the intensive care unit (ICU) were recorded. RESULTS: After 7 days, POCD was found in 40/107 (37.4%) surgical patients compared with 4/26 (15.4%) nonsurgical controls. Preoperative MMSE score, duration of surgery/anaesthesia, and length of stay in the ICU and hospital were associated with POCD. Logistic regression analysis revealed that preoperative MMSE score was an independent predictor of POCD. CONCLUSION: Lower baseline MMSE score was the only independent predictor for POCD in patients with severe systemic disease.

Strategies for diagnosis and treatment of iatrogenic tracheal ruptures

BACKGROUND

Management of tracheal ruptures in critically ill patients is challenging. Conservative treatment has been described, but in mechanically ventilated patients with distal tracheal ruptures surgical repair might be inevitable. Strategies for diagnosis and treatment of tracheal ruptures and handling of mechanical ventilation remain to be clarified. Our aim was to comprise a structured diagnostic and treatment protocol for patients suspicious of tracheal injury, including detailed principles of mechanical ventilation and specific indications for conservative or surgical treatment.

METHODS

Patients with tracheal ruptures were compared in accordance to the need of mechanical ventilation and to indication for surgical repair. In patients suffering from tracheal ruptures affecting the whole tracheal wall and with protrusion of mediastinal structures into the lumen surgery was indicated. We compared ventilatory, hemodynamic and clinical parameters between the different patient groups. We report our structured approach in diagnostics and treatment of tracheal ruptures and place special emphasis on respiratory management.

RESULTS

Seventeen patients with tracheal rupture were identified. In 8 patients surgical repair was performed 1.8±1.5 days after diagnosis. Previous to surgery, ventilation parameters improved significantly: plateau pressure decreased, percentage of assisted spontaneous breathing increased and compliance improved. Conservative treatment was successful in long-term ventilated patients (13.7±8 days) even when suffering from distal lesions.

CONCLUSION

Invasiveness of mechanical ventilation and obstruction of tracheal lumen might indicate conservative or surgical treatment strategies in long-term ventilated patients suffering from iatrogenic tracheal rupture. Indications for surgical repair remain to be further clarified.

Documented Intraoperative Hypotension According to the Three Most Common Definitions Does Not Match the Application of Antihypotensive Medication

This observational study investigated which of the three most common definitions of intraoperative hypotension (IOH), reported in a published systematic literature review, were associated best with anaesthetists' administration of antihypo-tensive medication (AHM). IOH and AHM use in anaesthetic procedures in a mixed surgical population ( n = 2350) were also reviewed. The definitions were: arterial systolic blood pressure (SBP) < 100 mmHg or a fall in SBP of > 30% of the preoperative SBP baseline; arterial SBP < 80 mmHg; a fall in SBP of > 20% of the preoperative SBP. Accuracy of predicting AHM using these three definitions was 67%, 54% and 65%, respectively. Prediction by a new fourth definition, using an optimal threshold of minimal SBP falling to < 92 mmHg or by > 24% of preoperative baseline, was 68% accurate. In multivariate logistic analysis, age, volatile versus intravenous anaesthetics, medical history of arterial hypertension and all four definitions of IOH were associated with intraoperative AHM, however IOH was not associated with postoperative in-patient stay. The three original definitions correlated poorly with the anaesthetist's judgement about applying AHM. Anaesthetists make complex decisions regarding the relevance of IOH, considering various perioperative factors in addition to SBP. Age, physical status and duration and type of surgery showed better correlations with postoperative in-patient stay than IOH.

Adherence to Guideline-Based Standard Operating Procedures in Pre-Hospital Emergency Patients with Chronic Obstructive Pulmonary Disease

This study investigated improvements in pre-hospital care for patients with acute exacerbated chronic obstructive pulmonary disease (aeCOPD) achieved by using a standard operating procedure (SOP). An SOP for pre-hospital treatment of patients with aeCOPD was designed based on valid national guidelines. A total of 1000 Emergency Medical Service patient care reports were analysed prospectively: 500 before and 500 after introduction of the SOP. Overall guideline adherence was 34.6% before and 53.8% after introduction of the SOP; this increase was not statistically significant. After SOP introduction, the administration of β2-mimetics by inhalative, intravenous and subcutaneous routes increased significantly. The level of knowledge of the national guidelines was rated at 67% by emergency physicians during self-assessment, but was only 33% when physicians were asked specific questions during interview. Introducing the SOP for patients with aeCOPD did not significantly improve adherence to valid national guidelines, but did help to improve specific elements of therapy.

Risk factors for inadequate emergence after anesthesia: emergence delirium and hypoactive emergence

AIM

Inadequate emergence after anesthesia in the adult patient may be distinguished by the patients' activity level into two subtypes: emergence delirium and hypoactive emergence. The aim of this study was to determine the incidence of inadequate emergence in its different forms, to identify causative factors and to examine the possible influence on postoperative length of stay in the recovery room and in the hospital.

METHODS

In this prospective observational study, 1868 non-intubated adult patients who had been admitted to the recovery room were analyzed. Inadequate emergence was classified in its different forms according to the Richmond agitation and sedation scale (RASS) 10 minutes after admission to the recovery room. Emergence delirium was defined as a RASS score >or=+1, and hypoactive emergence was defined as a RASS score <or=-2.

RESULTS

Of the 1,868 patients, 153 (8.2%) displayed symptoms of inadequate emergence: 93 patients (5.0%) screened positive for emergence delirium, and 60 patients (3.2%) showed hypoactive emergence. Significant risk factors for emergence delirium were premedication with benzodiazepines, induction of anesthesia with etomidate, younger as well as older age (age below 40 years and over 64 years), higher postoperative pain scores (NRS 6-10) and musculoskeletal surgery. Risk factors for hypoactive emergence were younger age, long duration of surgery and intraabdominal surgery. Patients with hypoactive emergence had a significantly increased length of stay in the hospital.

CONCLUSION

Inadequate emergence after anesthesia is a frequent complication. Preventable risk factors for emergence delirium were induction of anesthesia with etomidate, premedication with benzodiazepines and higher postoperative pain scores. Hypoactive emergence was less frequent than emergence delirium and was associated with a longer postoperative hospital stay.

Documentation of Post-operative Nausea and Vomiting in Routine Clinical Practice

This study investigated the quality of documentation of post-operative nausea and vomiting (PONV) by comparing incidences collected by a research team with those reported routinely by nursing personnel. A total of 560 patients passing through an interdisciplinary recovery room were included in the study. The overall recorded incidence of PONV over 24 h was 30.7%, which was in agreement with the predicted value of 32% calculated using incidences from published randomized controlled trials. Out of the total number of 86 cases of PONV in the recovery room only 36 (42%) were detected by nursing staff. Similarly, out of the total number of 129 cases of PONV on the ward over 24 h, only 37 (29%) were recognized by nursing staff during routine care. In conclusion, PONV in routine clinical care is likely to be under-reported. To use PONV as a valid quality measure, patients need to be actively asked about nausea and vomiting at frequent intervals in a standardized fashion. A considerable proportion of patients experience PONV after discharge from the recovery room, so the assessment of PONV should cover at least 24 h post-operatively

Improving the detection of illicit substance use in preoperative anesthesiological assessment

AIM

Illicit substance use (ISU) is a worldwide burden, and its prevalence in surgical patients has not been well investigated. Co-consumption of legal substances, such as alcohol and tobacco, complicates the perioperative management and is frequently underestimated during routine preoperative assessment. The aim of this study was to compare the anesthesiologists' detection rate of ISU during routine preoperative assessment with a computerized self-assessment questionnaire.

METHODS

In total, 2,938 patients were included in this study. Prior to preoperative assessment, patients were asked to complete a computer-based questionnaire that addressed ISU, alcohol use disorder (AUDIT), nicotine use (Fagerström) and socio-economic variables (education, income, employment, partnership and size of household). Medical records were reviewed, and the anesthesiologists' detection of ISU was compared to the patients' self-reported ISU.

RESULTS

Seven point five percent of patients reported ISU within the previous twelve months. ISU was highest in the age group between 18 and 30 years (26.4%; P<0.01). Patients reporting ISU were more often men than women (P<0.01), smokers (P<0.01) and tested positive for alcohol use disorder (P<0.01). Anesthesiologists detected ISU in one in 43 patients, whereas the computerized self-assessment reported it in one in 13 patients. The detection was best in the subgroup self-reporting frequent ISU (P<0.01).

CONCLUSIONS

Anesthesiologists underestimate the prevalence of ISU. Computer-based self-assessment increases the detection of ISU in preoperative assessment and may decrease perioperative risk. More strategies to improve the detection of ISU as well as brief interventions for ISU are required in preoperative assessment clinics.

Effects of remifentanil and fentanyl on the cell-mediated immune response in patients undergoing elective coronary artery bypass graft surgery

This prospective randomized pilot study compared the influence of fentanyl-based versus remifentanil-based anaesthesia on cytokine responses and expression of the suppressor of cytokine signalling (SOCS)-3 gene following coronary artery bypass graft surgery. Forty patients were assigned to receive anaesthesia with either intravenous remifentanil (0.3 - 0.6 microg/kg per min; n = 20) or intravenous fentanyl (5 - 10 microg/kg per h; n = 20). Levels of interleukin (IL)-6, IL-10, tumour necrosis factor-alpha and interferon-gamma (IFN-gamma) and the expression of SOCS-3 were measured pre- and post-operatively. The data from 33 of the patients were analysed. The IFN-gamma/IL-10 ratio after concanavalin A stimulation in whole blood cells on post-operative day 1 and SOCS-3 gene expression on post-operative day 2 were significantly lower in the remifentanil group than in the fentanyl group. The time in the intensive care unit was also significantly lower in the remifentanil group. These findings suggest that remifentanil can attenuate the exaggerated inflammatory response that occurs after cardiac surgery with cardiopulmonary bypass. Further clinical trials are required to define the influence of choice of intra-operative opioid on post-operative outcome.

Impact of combined C1 esterase inhibitor/coagulation factor XIII or N-acetylcysteine/tirilazad mesylate administration on leucocyte adherence and cytokine release in experimental endotoxaemia

We determined the effects of combinations of C1 esterase inhibitor (C1-INH) with factor XIII and of N-acetylcysteine (NAC) with tirilazad mesylate (TM) during lipo-polysaccharide (LPS)-induced endotoxaemia in rats. Forty Wistar rats were divided into four groups: the control (CON) group received no LPS; the LPS, C1-INH + factor XIII and NAC + TM groups received endotoxin infusions (5 mg/kg per h). After 30 min of endotoxaemia, 100 U/kg C1-INH + 50 U/kg factor XIII was administered to the C1-INH + factor XIII group, and 150 mg/kg NAC + 10 mg/kg TM was administered in the NAC + TM group. Administration of C1-INH + factor XIII and NAC + TM both resulted in reduced leucocyte adherence and reduced levels of interleukin-1beta (IL-1beta). The LPS-induced increase in IL-6 levels was amplified by both drug combinations. There was no significant effect on mesenteric plasma extravasation. In conclusion, the administration of C1-INH + factor XIII and NAC + TM reduced endothelial leucocyte adherence and IL-1beta plasma levels, but increased IL-6 levels.

Comparison of three scores to screen for delirium in the recovery room

BACKGROUND

Delirium is often seen in the recovery room and is a predictor for postoperative delirium on the ward. However, monitoring to detect delirium in the recovery room as a basic prerequisite for early intervention is rarely used. The aim of this study was to identify a valid and easy-to-use test for early screening of delirium in the recovery room.

METHODS

One hundred and fifty-four adult patients admitted to the recovery room during regular working hours were included. A screening assessment for delirium was performed in the recovery room by a trained research team at the time when the patient was judged to be 'ready for discharge'. Delirium monitoring was performed with the Confusion Assessment Method (CAM), the Delirium Detection Score (DDS), and the Nursing Delirium Screening Scale (Nu-DESC). The Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria were used as the gold standard.

RESULTS

Delirium in the recovery room was seen in 21 patients (14%) with the DSM-IV criteria, in 11 patients (7%) with the CAM, in four patients (3%) with the DDS, and in 37 patients (24%) with the Nu-DESC. Sensitivity and specificity were 0.43 and 0.98 for the CAM, 0.14 and 0.99 for the DDS, and 0.95 and 0.87 for the Nu-DESC, respectively.

CONCLUSIONS

All scores used were very specific, but the CAM and the DDS were less sensitive compared with the gold standard. Overall, the Nu-DESC was the most sensitive test in the recovery room to detect delirium.

Influence of vaccination and surgery on HLA-DR expression in patients with upper aerodigestive tract cancer

Major surgery is associated with an increased risk of post-operative immunosuppression and infections. We investigated the influence of influenza vaccination on cell-mediated immune responses in cancer patients undergoing either surgical or conservative therapy. Forty patients with an upper aerodigestive tract tumour were allocated to either a surgical or non-surgical treatment course. Patients within each group were randomized to the vaccination or non-vaccination group. Vaccination was performed twice before surgery or conservative treatment. Human leucocyte antigen receptor (HLA-DR) expression on monocytes was analysed by flow cytometry. In the surgical patients, HLA-DR expression on day 1 after surgery decreased in both the vaccinated and non-vaccinated groups. Vaccinated non-surgical patients showed significantly increased HLA-DR expression levels compared with the non-vaccinated patients. This pilot study demonstrated that vaccination increased monocyte HLA-DR expression in conservatively-treated cancer patients whereas surgery abrogated this response. Vaccination before surgery, therefore, might not help to maintain immune reactivity after surgery.

[Central induction area. Reduction of non-operative time without additional costs]

BACKGROUND

Induction areas (IA) can lead to more efficient operating sessions through shortening the changeover time between patients. To date IAs have always required additional staff members, whose cost was only partly covered by improvements in productivity. The objective of this project was to demonstrate that a reduction in non-operative time through a newly introduced induction area can be achieved without a need for extra personnel.

METHODS

Non-operative time in 5,963 ENT, orthopedic and cardiac surgical patients from 8 operating theatres were studied for 1 year before and 1 year after the introduction of an induction area. The non-operative time was defined as the time between the end of surgical procedures in one operation and the start of surgical procedures in the next, within regular working hours. Through reallocation of anesthetic nursing and medical staff it was possible to introduce the induction area without increasing staff numbers.

RESULTS

Non-operative time was significantly reduced from 20 min (range 10-30 min) to 14 min (5-25 min). Subgroup analysis showed significant reductions in all specialities: from 10 min (2.5-20 min) to 5 min (0-20 min) in 1,240 cardiac surgical patients, 25 min (20-35 min) to 15 min (5-25 min) in 2,433 ENT patients and 20 min (10-30 min) to 10 min (0-20 min) in 2,290 orthopedic patients. There were no critical incidents attributable to patient handover.

DISCUSSION AND CONCLUSIONS

An induction area can be established and can reduce non-operative time and improve operation theatre throughput without the need for extra personnel. The efficiency of these measures will be increased when the relevant surgical organizational measures are taken to adjust to the faster anesthesiology workflow. The induction area does not lead to a higher rate of critical incidents. To what extent the induction area can be used for structured training of doctors and nurses, remains to be investigated.

Effects of N-acetylcysteine and tirilazad mesylate on intestinal functional capillary density, leukocyte adherence, mesenteric plasma extravasation and cytokine levels in experimental endotoxemia in rats

INTRODUCTION

The study's objective was to determine the effects of the administration of N-acetylcysteine (NAC) and of tirilazad mesylate (TM) on intestinal functional capillary density, mesenteric plasma extravasation, leukocyte adherence and on cytokine release during experimental endotoxemia in rats.

METHODS

In a prospective, randomized, controlled animal study, 80 male Wistar rats were examined in 2 test series. Both series were divided into 4 groups. Group 1 served as control group (CON group). Group 2 (LPS group), group 3 (NAC group) and group 4 (TM group) received endotoxin infusions (10 mg/kg over 2 h). In NAC group 150 mg/kg body weight NAC was administered after the first 30 minutes of endotoxemia intravenously. In TM group, 10 mg/kg body weight TM was administered after the first 30 minutes of endotoxemia intravenously. Animals of the series 1 underwent studies of leukocyte adherence on submucosal venular endothelium of the small bowel wall and intestinal functional capillary density (FCD) in the intestinal mucosa and the circular as well as the longitudinal muscle layer by intravital fluorescence microscopy (IVM). Plasma levels of interleukin 1beta (IL-1beta), interferone gamma (IFN-gamma) and soluble intercellular adhesion molecule1 (s-ICAM 1) as well as white blood cell count (WBC) were estimated. In the animals of the series 2 mesenteric plasma extravasation was determined by IVM and plasma levels of tumor necrosis factor alpha (TNF-alpha), IL-4, IL-6, IL-10 and malondialdehyde (MDA) were estimated.

RESULTS

After LPS administration, FCD in the villi intestinales was unchanged and in the longitudinal muscularis layer it was increased. There was no effect of NAC or TM administration on FCD.Although the plasma extravasation was not significantly influenced by LPS administration, TM administration resulted in a lower plasma extravasation in the TM group compared to the other groups. After endotoxin challenge, the firmly adherence of leukocytes to vascular endothelium as a parameter of leukocyte activation in endotoxemia was increased but NAC or TM administration had no influence on leukocyte adherence. The plasma levels of IL-1beta, IL-6, IL-10, TNF-alpha, IFN-gamma and sICAM-1 were increased in the endotoxemic groups (LPS group, NAC group and TM group) and the WBC was decreased compared to controls. IL-4 levels were unchanged during observation period. Plasma MDA levels were not influenced by LPS administration compared to controls. The administration of NAC resulted in lower sICAM-1 and MDA levels compared to the LPS group. The IL-1beta, IL-6, IL-10, TNF-alpha and IFN-gamma plasma levels were not influenced by NAC or TM administration.

CONCLUSIONS

In this posttreatment sepsis model in rats, NAC administration resulted in lower sICAM-1 and MDA levels compared to the LPS treated animals. TM administration reduced the plasma extravasation in this model.

Trauma patients' desire for autonomy in medical decision making is impaired by smoking and hazardous alcohol consumption--a bi-national study

This cross-sectional investigation studied the association between substance use and patients' desire for autonomy in medical decision making (MDM) in two trauma settings. A total of 102 patients (age 42.7 +/- 17.4 years, 70.6% male) admitted to an orthopaedic service in Warsaw, Poland, and 1009 injured patients (age 34.6 +/- 12.8 years, 62.3% male) treated in an emergency department in Berlin, Germany, were enrolled. Patients' desire for autonomy in MDM was evaluated with the Decision Making Preference Scale of the Autonomy Preference Index. Substance use (hazardous alcohol consumption and/or tobacco use) and educational level were measured. Linear regression techniques were used to determine the association between substance use and desire for autonomy in MDM. Substance use was found to be independently associated with a reduced desire by the patient for autonomy in medical decision making. No differences in patients' desire for autonomy were observed between the study sites. Empowerment strategies that encourage smokers or patients with hazardous alcohol consumption to participate in MDM may increase the effectiveness of health promotion and injury prevention efforts in this population.

Hyperactive delirium and blood glucose control in critically ill patients

Delirium is a common complication of critically ill patients and is often associated with metabolic disorders. One of the most frequent metabolic disorders in intensive care unit (ICU) patients is hyperglycaemia. The aim of this retrospective study of 196 adult ICU patients was to determine if there is an association between hyperactive delirium and blood glucose levels in ICU patients. Hyperactive delirium was diagnosed using the delirium detection score. Blood glucose levels were monitored by blood gas analysis every 4 h. Hyperactive delirium was detected in 55 (28%) patients. Delirious patients showed significantly higher blood glucose levels than non-delirious patients Higher overall complication rates, length of ventilation, ICU stay and mortality rates were seen in the delirium group. In a multivariate analysis, glucose level, alcohol abuse, APACHE II score, complication by hospital-acquired pneumonia and a diagnosis of polytrauma on-admission all significantly influenced the appearance of delirium.

Propofol increased the interleukin-6 to interleukin-10 ratio more than isoflurane after surgery in long-term alcoholic patients

This study investigated the effect of an anaesthetic regimen on the immune response in 40 long-term alcoholic patients undergoing surgery. Patients were randomly allocated to receive either propofol or isoflurane during surgery. Plasma cytokines interleukin (IL)-6 and IL-10 were measured at defined times and rates of post-operative infections were documented. The IL-6/IL-10 ratio significantly increased with propofol compared with isoflurane on day 1 after surgery and the IL-10 level significantly increased with isoflurane on day 1 after surgery. The overall post-operative infection rate was significantly higher in isoflurane-treated patients. Our findings indicate that propofol anaesthesia might be the more favourable regimen, with the IL-6/IL-10 ratio indicating an attenuation of the immune imbalance after surgery in long-term alcoholic patients. These results support the undertaking of a properly powered clinical trial to determine if propofol anaesthesia can reduce the postoperative infection rate in this special patient population.

Preferences for shared decision making in chronic pain patients compared with patients during a premedication visit

BACKGROUND

There is some evidence that patients' outcomes improve if they are involved in shared decision making (SDM). A chronic pain clinic or premedication visit could be adequate settings for the implementation of SDM. So far, the patients' preference for involvement in decision making and their desire for information have not been tested in anesthesiological settings.

METHODS

A group of chronic pain patients was compared with a group of patients in the premedication visit with respect to SDM, the desire for information and perceived involvement in care. The autonomy preference index (API, measuring preference for involvement and desire for information) and the perceived involvement in care scale (PICS, measuring patients' perception of easier involvement by doctors and information exchange) were administered.

RESULTS

In total, 190 chronic pain patients and 151 patients of premedication were included in this study. Patient of the premedication visit had significantly higher SDM scores. Desire for information was high, but there were no differences between groups. Younger patients [B (estimate) =- 0.3; 95% CI (-0.4) - (-0.1)], women (B = 10.9; 95% CI 6.3-15.4) and patients with higher educational level (B = 10.1; 95% CI 5.6-14.6) had more desire for SDM. PICS scores were basically influenced by groups: chronic pain patients felt more facilitated by doctors [B =- 0.185; 95% CI (-0.4) - (-0.1)] and had more information exchange [B =- 19.5; 95% CI (-15.8) - (-2.4)] than patients in the premedication visit.

CONCLUSION

In both anesthesiological settings, the desire for information was high, but patients in the premedication visit had higher SDM scores, especially young female patients with higher educational level. Real patient-physician interaction showed that premedication patients felt less involved by doctors and had less information exchange compared with the chronic pain patients. Therefore, premedication visits should be focussed more on adequate information exchange and involvement of the patient in the shared decision making process.

Stellenwert von inhaliertem Stickstoffmonoxid bei der Behandlung des schweren akuten Lungenversagens

Acute respiratory distress syndrome (ARDS) is characterized by perfusion in favor of non-ventilated areas of the lungs as the main cause of intrapulmonary right-to-left shunt and hypoxemia. Therapeutic interventions to selectively influence pulmonary perfusion in ARDS became possible with the introduction of inhaled nitric oxide (iNO), which provided a way not only to reduce pulmonary hypertension, but also to acutely improve ventilation-perfusion mismatch, and thus to treat severe hypoxemia. Clinical studies in ARDS demonstrated that the combination of iNO with other interventions, such as positive end-expiratory pressure (PEEP) and prone positioning, yielded beneficial and additive effects on arterial oxygenation. Although randomized controlled trials of this concept have up to now failed to show an improved outcome, iNO is a valuable option for the treatment of severe refractory hypoxemia in ARDS patients.

Pr�operative Nahrungskarenz

In Germany the predominant standard of preoperative care for elective surgery is fasting after midnight, with the aim of reducing the risk of pulmonary aspiration. However, for the past several years the scientific evidence supporting such a practice has been challenged. Experimental and clinical studies prove a reliable gastric emptying within 2 h suggesting that, particularly for limited intake of clear fluids up to 2 h preoperatively, there would be no increased risk for the patient. In addition, the general incidence of pulmonary aspiration during general anaesthesia (before induction, during surgery and during recovery) is extremely low, has a good prognosis and is more a consequence of insufficient airway protection and/or inadequate anaesthetic depth rather than due to the patient's fasting state. Therefore, primarily to decrease perioperative discomfort for patients, several national anaesthesia societies have changed their guidelines for preoperative fasting. They recommend a more liberal policy regarding per os intake of both liquid and solid food, with consideration of certain conditions and contraindications. The following article reviews the literature and gives an overview of the scientific background on which the national guidelines are based. The intention of this review is to propose recommendations for preoperative fasting regarding clear fluids for Germany as well.

Beta-carbolines in chronic alcoholics following trauma

In our society every second polytraumatized patient is a chronic alcoholic. A patient's alcohol-related history is often unavailable and laboratory markers are not sensitive or specific enough to detect alcohol-dependent patients who are at risk of developing alcohol withdrawal syndrome (AWS) during their post-traumatic intensive care unit (ICU) stay. Previously, it has been found that plasma levels of norharman are elevated in chronic alcoholics. We investigated whether beta-carbolines, i.e. harman and norharman levels, could identify chronic alcoholics following trauma and whether possible changes during ICU stay could serve as a predictor of deterioration of clinical status. Sixty polytraumatized patients were transferred to the ICU following admission to the emergency room and subsequent surgery. Chronic alcoholics were included only if they met the DSM-III-R and ICD-10 criteria for alcohol dependence or chronic alcohol abuse/harmful use and their daily ethanol intake was > or =60 g. Harman and norharman levels were assayed on admission and on days 2, 4, 7 and 14 in the ICU. Harman and norharman levels were determined by high pressure liquid chromatography. Elevated norharman levels were found in chronic alcoholics (n = 35) on admission to the hospital and remained significantly elevated during their ICU stay. The area under the curves (AUC) showed that norharman was comparable to carbohydrate-deficient transferrin (CDT) and superior to conventional laboratory markers in detecting chronic alcoholics. Seventeen chronic alcoholics developed AWS; 16 of these patients experienced hallucinations or delirium. Norharman levels were significantly increased on days 2 and 4 in the ICU in patients who developed AWS compared with those who did not. An increase in norharman levels preceded hallucinations or delirium with a median period of approximately 3 days. The findings that elevated norharman levels are found in chronic alcoholics, that the AUC was in the range of CDT on admission and that norharman levels remained elevated during the ICU stay, support the view that norharman is a specific marker for alcoholism in traumatized patients. Since norharman levels increased prior to the onset of hallucinations and delirium it seems reasonable to investigate further the potential role of norharman as a possible substance which triggers AWS.

Preoperative evaluation of chronic alcoholics assessed for surgery of the upper digestive tract

BACKGROUND

Alcoholics are at risk of developing major complications in the postoperative period. Adequate prophylactic treatment, as well as preoperative abstinence, can significantly decrease the rate of complications. However, the preoperative diagnosis of alcoholism is difficult to establish. The purpose of this study was to assess whether three preoperative visits, an alcohol-related questionnaire (CAGE), and the laboratory markers carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) would increase the rate of detection of chronic alcoholics.

METHODS

The study included the Departments of ENT, Facial and Maxillofacial Surgery, and General Surgery of a university hospital; 705 male patients were assessed for tumor surgery of the upper digestive tract and were allocated to 5 different groups. All patients were seen three times, and five different strategies were used to detect chronic alcoholics. The gold standard was the diagnosis of alcohol misuse made by an experienced (blinded) investigator according to the DSM-III-R. The main outcome measurements were the detection rates of the different test strategies.

RESULTS

By clinical routine alone, only 16% were detected during the first visit and 34% after three visits. If the CAGE questionnaire was added, sensitivity increased to 64%. The further addition of GGT or CDT led to 80 and 85% detections, respectively. A combination of all tests had a sensitivity of 91%.

CONCLUSIONS

To detect more alcoholic patients at risk for major complications, patients should be seen more often, and additional diagnostic tools such as the CAGE, CDT, and GGT should be used before surgery.

Suppression of interleukin-6 to interleukin-10 ratio in chronic alcoholics: association with postoperative infections

OBJECTIVE

To investigate the interleukin-6 (IL-6) to interleukin-10 (IL-10) ratio and levels of sE-selectin in patients undergoing elective surgery of the upper digestive tract and to define the differences in the perioperative immune response between chronic alcoholic and non-alcoholic patients.

DESIGN

Prospective pilot study.

SETTING

Single center, interdisciplinary intensive care unit (ICU) at a university hospital.

MEASUREMENT AND MAIN RESULTS

The study compared chronic alcoholics ( n=25) and non-alcoholics ( n=20) before and after surgery for resection of upper digestive tract tumors. White blood cell counts, C-reactive protein and circulating levels of sE-selectin, the pro-inflammatory cytokine IL-6 and the inhibitory cytokine IL-10, were obtained at hospital admission, preoperatively, postoperatively at ICU admission and 2 and 4 days later. Rates of postoperative infectious complications including pneumonia and sepsis were determined. sE-selectin only differed between chronic alcoholics and non-alcoholics preoperatively. Compared to non-alcoholics, chronic alcoholic patients showed a fourfold increase in circulating levels of IL-10 ( p<0.01) and a suppression of the IL-6/IL-10 ratio ( p=0.001) immediately after surgery. Coincident with the immune alterations, chronic alcoholics had a prolonged ICU stay ( p<0.01) and a threefold increased rate of wound infections ( p<0.05) and pneumonia ( p<0.01). Lower IL-6/IL-10 ratios were associated with increased rates of infectious complications ( p<0.05).

CONCLUSION

Chronic alcoholics had decreased IL-6/IL-10 ratios at ICU admission and increased rates of infectious complications in the postoperative ICU course. This may indicate immediate postoperative immune suppression before the onset of infections and may help to identify chronic alcoholic patients at risk.

Effects of alcohol on the heart

Some evidence suggests that light to moderate alcohol consumption protects against cardiovascular diseases. However, this cardioprotective effect of alcohol consumption in adults is absent at the population level. Approximately 20 to 30% of patients admitted to a hospital are alcohol abusers. In medical practice, it is essential that patients' levels of consumption are known because of the many adverse effects that might result in the course of routine care. Ethanol damage to the heart is evident if alcohol consumption exceeds 90 to 100 g/d. Heavy ethanol consumption leads to increased risk for sudden cardiac death and cardiac arrhythmias. In patients with coronary heart disease, alcohol use was associated with increased mortality. An early response to drinking was an increased ventricular wall thickness to diameter ratio, possibly proceeding with continuous drinking to alcoholic cardiomyopathy, which had a worse outcome compared with idiopathic dilative cardiomyopathy if drinking was not stopped or at least reduced (< 60 g/d). In the ICU, patients with chronic alcoholism have more cardiac complications postoperatively. These complications probably are caused by biventricular dysfunction, particularly with the occurrence of severe infections or septic shock, events that are three to four times more frequent among chronic alcoholics than occasional drinkers or nondrinkers. To prevent further complications from drinking and for long-term management of drinking, patients with alcohol abuse and heart failure should be treated in brief intervention and follow-up programs. Prognosis is good even in patients with New York Heart Association class IV heart failure caused by cardiomyopathy if complete abstinence is accomplished. Noncompliance to smoking and alcohol restrictions, which are amenable to change, dramatically increases the risk for hospital readmissions among patients with heart failure.

Enoximone in contrast to dobutamine improves hepatosplanchnic function in fluid-optimized septic shock patients

OBJECTIVE

To investigate the impact of dobutamine and enoximone on hepatosplanchnic perfusion and function in fluid-optimized septic patients.

DESIGN

Prospective, randomized, double-blinded interventional study.

SETTING

Intensive care unit of a university hospital.

PATIENTS

Forty-eight septic shock patients were examined within 12 hrs after onset of septic shock. Patients were conventionally resuscitated, achieving an optimal pulmonary artery occlusion pressure at which the left ventricular stroke work was on the maximal plateau. Liver blood flow was estimated by venous suprahepatic catheterization using the continuous indocyanine green infusion technique. Microsomal liver function was assessed by the plasma appearance of monoethylglycinexylidide, and release of hepatic tumor necrosis factor-alpha (TNF-alpha) was measured to estimate the severity of hepatic ischemia-reperfusion syndrome.

INTERVENTIONS

Patients were randomly treated with dobutamine or enoximone. Within the first 10 hrs after baseline measurements, the dosage was increased until no further increase in the left ventricular stroke work index occurred. Then, positive inotropes were kept constant throughout the study.

MEASUREMENTS AND MAIN RESULTS

Measurements were performed at baseline and after 12 and 48 hrs after baseline measurements. Cardiac index, systemic oxygen delivery, systemic oxygen consumption, and liver blood flow increased significantly in both groups during treatment (p <.01) without a significant difference between groups. Fractional liver blood flow (liver blood flow/cardiac index) did not change in the enoximone group and showed a significant but only minor (median, 10%) decrease in the dobutamine group (p <.05 after 12 hrs and p <.01 after 48 hrs vs. baseline). After 12 hrs of enoximone treatment, monoethylglycinexylidide kinetics and hepatosplanchnic oxygen consumption demonstrated a significant increase (p <.05). The release of hepatic TNF-alpha after 12 hrs of dobutamine treatment was twice as high (p <.05) as during enoximone.

CONCLUSION

The increase in hepatosplanchnic oxygen consumption, together with an increased lignocaine metabolism and decreased release of hepatic TNF-alpha, indicates improved hepatosplanchnic function and antiinflammatory properties after 12 hrs of enoximone treatment. Therefore, if the inflammatory response should be attenuated in high-risk patients, administration of enoximone in fluid-optimized septic shock patients may be favorable compared with dobutamine.

Renal replacement therapy: physical properties of hollow fibers influence efficiency

INTRODUCTION

Physical properties of filters for continous renal replacement therapy have a great impact on biocompatibility. According to Poiseuille's law, a filter with more and shorter hollow fibers should offer a decreased pressure drop and, therefore, lower transmembrane pressure (TMP). The aim of this study was to study the effect of a new filter configuration in terms of TMP and clotting compared with the standard configuration.

METHODS

In a prospective randomized cross-over study 2 polysulphone hollow fiber hemofilters, one handmade, which differed only in length and number of hollow fibers were compared. In each group 12 filters were investigated during continous venovenous hemofiltration in patients with acute renal failure due to septic shock. Pressures were measured every 3 hours and running time until filter clotting was documented. Mediators before and after the filter, at the end of treatment and in filtrate were assessed.

RESULTS

The standard filter with longer hollow fibers had significantly lower TMPs (106 vs. 194 mmHg, p=0.02) and longer running times (1276 vs. 851 min, p=0.04). There were no differences in hematocrit, total protein, cellular and plasmatic coagulation or blood temperature. No significant elimination of mediators was shown.

CONCLUSION

In contrast to our expectations, the filter with the longer hollow fibers had a better performance, as it ran longer and had lower TMP This may be due to slower blood flow leading to an increase in blood viscosity in a filter with a larger cross section.

Downward movement of syringe pumps reduces syringe output

We studied how lowering a syringe pump and changing the outflow pressure could affect syringe pump output. We experimentally reduced the height of three different syringe pump systems by 80 cm (adult setting) or 130 cm (neonatal setting), as can happen clinically, using five flow rates. We measured the time of backward flow, no flow and the total time without flow. An exponential negative correlation was present between infusion rate and time without flow (r2=0.809 to 0.972, P<0.01). Minimum flow rates of 4.4 and 2.6 ml h(-1) respectively were calculated to give 60 and 120 s without infusion. The compliance of the different syringe pumps and their infusion systems was linearly correlated with the effective time without infusion (r2=0.863, P<0.05). We conclude that the height of the syringe pumps should not be changed during transportation. If vertical movement of the syringe pump is necessary, the drugs should be diluted so that the flow rate is at least 5 ml h(-1).

Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery

Thoracic epidural anesthesia (TEA) combined with general anesthesia (GA) as well as total-IV anesthesia (TIVA) are both established anesthetic managements for thoracic surgery. We compared them with respect to hypoxic pulmonary vasoconstriction, shunt fraction and oxygenation during one-lung ventilation. Fifty patients, ASA physical status II-III undergoing pulmonary resection were randomly allocated to two groups. In the TIVA group, anesthesia was maintained with propofol and fentanyl. In the TEA group, anesthesia was maintained with TEA (bupivacaine 0.5%) combined with low-dose concentration 0.3-0.5 vol% of isoflurane (end-tidal). Changing from two-lung ventilation to one-lung ventilation caused a significant increase in cardiac output (CO) in the TIVA group, whereas no change was observed in the TEA group. One-lung ventilation caused significant increases in shunt fraction in both groups which was associated per definition with a significant decrease in PaO(2) in both groups but PaO(2) remained significantly increased in the TEA group (P < 0.05). We conclude that both anesthetic regimens are safe intraoperatively. However, TEA in combination with GA did not impair arterial oxygenation to the same extent as TIVA, which might be a result of the changes in CO. Therefore, patients with preexisting cardiopulmonary disease and impaired oxygenation before one-lung ventilation might benefit from TEA combined with GA.

IMPLICATIONS

Fifty patients underwent lung surgery through the opened chest wall requiring ventilation of only one lung. Patients were randomly assigned to receive either general anesthesia alone or in combination with regional anesthesia via a catheter in the back. Oxygen content in the blood and blood pressure was better maintained in the group receiving the combination of general with regional anesthesia.

Increased endothelial injury in septic patients with coronary artery disease

STUDY OBJECTIVE

Recently, it was proposed that soluble intercellular adhesion molecule (sICAM)-1 plasma levels may allow subgroup identification of patients at risk for cardiovascular complications during sepsis. However, the impact of preexisting coronary artery disease (CAD) on these results has not yet been tested. The aim of this study was to investigate whether plasma levels of adhesion molecules, nitric oxide, and cytokines differ between septic patients with or without preexisting CAD.

DESIGN

Prospective study.

SETTING

Surgical ICU.

PATIENTS

Forty-four septic patients, 24 of whom met the criteria of CAD.

MEASUREMENT

Hemodynamic measurements were performed and blood samples were taken within 12 h after onset of sepsis (early sepsis) and again 72 h thereafter (late sepsis). Soluble adhesion molecules and cytokines were determined using commercially available enzyme-linked immunosorbent assay kits, cyclic guanosinomonophosphate (cGMP) by competitive radioimmunoassay, and nitrite/nitrate photometrically by Griess reaction.

RESULTS

In CAD patients, sICAM-1 (p < 0.02) was significantly elevated in early and late sepsis, whereas soluble endothelial-linked adhesion molecule (sE-selectin; p < 0.01) and cGMP (p < 0.03) were only increased in late sepsis. Oxygen consumption did not significantly differ between groups. Oxygen delivery and mixed venous oxygen saturation during early and late sepsis were significantly diminished and the oxygen extraction ratio significantly increased in the CAD group (p < 0.05).

CONCLUSIONS

Increased endothelial injury may be indicated by the elevated levels of sICAM-1, sE-selectin, and cGMP in septic patients with preexisting CAD. These parameters, however, failed to serve as predictors for unknown CAD or chances for survival in early sepsis.

The value of immune modulating parameters in predicting the progression from peritonitis to septic shock

Intra-abdominal infection is one of the major causes of septic shock and multiple organ failure. To date, what causes the disease's progression remains unclear and therefore the relevance of immune modulating therapies remains speculative. The primary outcome measure of this study was to investigate immune modulating mediators at the onset of peritonitis before the development of subsequent septic shock. The secondary outcome measure was to investigate the usefulness of these immune parameters in predicting progression from peritonitis to septic shock. Fifty-eight peritonitis patients were included in this study: 14 patients subsequently developed septic shock. All patients were examined on "diagnosis of peritonitis" (<4 h within establishment of diagnosis), during "early septic shock" (<12 h following the onset of septic shock), and once again during "late septic shock" (within 72-98 h following the onset of septic shock). The immune modulating parameters tumor necrosis factor-alpha (TNF-alpha), the soluble TNF-alpha receptors I and II (sTNF-alpha RI and sTNF-alpha RII), interleukines (IL) -1beta, -6, -8, and -10, and the adhesions molecules endothelial-leukocyte-adhesion-molecule (E-Selectin), intercellular-adhesion-molecule-1 (ICAM-1), and vascular-adhesion-molecule-1 (VCAM-1), in addition to nitrate and nitrite, were determined. In the peritonitis group with subsequent septic shock, TNF-alpha, sTNF-alpha RI + RII IL-1beta, IL-8, IL-10, and nitrate were significantly increased before the onset of septic shock. TNF-alpha had an area under the receiver operating characteristics curve (AUC) of 0.84 and was reliable in predicting the progression from peritonitis to septic shock. The AUC of the other immune modulating parameters, despite being significantly elevated, ranged from 0.71 to 0.76. The AUC of the conventional laboratory markers such as leukocytes and C-reactive protein ranged from 0.64 to 0.68. In peritonitis that progressed to septic shock, an early immune response had already occurred before the onset of septic shock. The progression was best predicted by TNF-alpha. Therefore, mediator therapy might be considered in high-risk peritonitis patients who show an exaggerated immune response before the progression to septic shock.

Alcohol withdrawal in the surgical patient: prevention and treatment

In the literature on AWS, there is repeated emphasis on performing a thorough preanesthesia assessment in patients with suspected chronic alcohol use. Because these patients are difficult to diagnose and to treat in surgical settings if complications arise, a multimodal approach is highly recommended (86). Ideally, AWS should be prevented by adequate prophylaxis. If AWS develops after surgery or trauma, immediate therapy is required. The symptoms of AWS can be controlled using the combination of a benzodiazepine (in Europe, also chlormethiazole) with haloperidol or clonidine. The drug regimens must be individualized and symptom-oriented to treat hallucinations and autonomic signs. Dosages are generally larger than those in detoxification units. Other approaches to modulate the neuroendocrine-immune axis in patients with an increased risk of postoperative infectious complications look promising but await controlled trials.

The urinary ratio of 5-hydroxytryptophol to 5-hydroxyindole-3-acetic acid in surgical patients with chronic alcohol misuse

The urinary ratio of 5-hydroxytryptophol to 5-hydroxyindole-3-acetic acid was reported to be elevated for a period of up to 22 h following acute alcohol ingestion. Therefore, the ratio could detect continuous alcohol consumption, in what was considered to be a high-risk surgical group, on the evening prior to surgery. The aim of this study was to determine the preoperative ratio of 5-hydroxytryptophol to 5-hydroxyindole-3-acetic acid in patients with continuous preoperative alcohol misuse. Forty-two patients participated in this institutionally approved study, once their written informed consent had been obtained. Chronic alcoholics were defined by meeting the criteria of the Diagnostic and Statistical Manual of Mental Disorders criteria and an ethanol consumption > or =60 g/day. The urine samples were taken preoperatively and determined by means of gas chromatography-mass spectrometry and high performance liquid chromatography. The urinary ratio of 5-hydroxytryptophol to 5-hydroxyindole-3-acetic acid was significantly increased in chronic alcoholics. The ICU stay of these patients was significantly prolonged due to an increased incidence of pneumonia and sepsis. Five chronic alcoholics died, whereas no deaths occurred in the nonalcoholic group (p = 0.05). As the measurement of the urinary ratio of 5-hydroxy-tryptophol to 5-hydroxyindole-3-acetic acid could detect alcohol consumption immediately prior to operation, this marker could assist the carbohydrate-deficient transferrin in screening for patients with high-level dependency; these patients were considered to be at a high risk of developing intercurrent complications.

Tryptophan metabolism in alcoholism. Tryptophan but not excitatory amino acid availability to the brain is increased before the appearance of the alcohol-withdrawal syndrome in men

Tryptophan (Trp) metabolism and disposition and excitatory and other amino acid concentrations were determined in alcohol-dependent subjects in relation to the alcohol-withdrawal syndrome (AWS). Parameters were examined in 12 alcohol-dependent male subjects, undergoing elective upper digestive tract tumour resection, and 12 age-, gender-, and medication-matched controls on three occasions: pre-operatively, post-operatively, and immediately before (i.e. within 24 h of) the appearance of the AWS. No significant differences were observed between controls and alcoholic subjects on the first or second of these occasions. On the third occasion, within 24 h of the appearance of the AWS, alcoholics showed a dramatic elevation (117%) in free serum Trp concentration and a consequent increase (111%) in the ratio of [free Trp]/[competing amino acids], which is an accurate predictor of Trp entry into the brain. Increases were also observed on this third occasion in concentrations of total Trp (49%), cortisol (123%), and norharman (137%). Concentrations of glutamate, glycine, aspartate, serine, and taurine did not differ significantly within or between the control and alcohol-dependent groups of subjects on any of the three occasions. The possible significance of the Trp and related metabolic changes in relation to the behavioural features of the AWS is discussed.

Elevated carbohydrate-deficient transferrin predicts prolonged intensive care unit stay in traumatized men

Carbohydrate-deficient transferrin (CDT) is reported to have a higher specificity in alcoholism than conventional markers. As the morbidity and mortality rates amongst chronic alcoholics are raised following trauma, the objective was to investigate if CDT could be used to predict prolonged intensive care unit (ICU) stay and an increased morbidity in patients with multiple injuries admitted to the ICU. In this prospective double-blind study, 66 traumatized male patients were transferred to the ICU following admission via the emergency room and operative management. Blood samples for CDT determination were taken upon admission to the emergency room, the ICU and on days 2 and 4 following admission. The patients were allocated a priori to two groups: high CDT group (CDT >20 U/l on admission to the emergency room) and low CDT group (CDT < or = 20 U/l). CDT values were determined by microanion-exchange chromatography and radioimmunoassay. Thirty-six patients had an elevated CDT value on admission to the emergency room. The high CDT group had a significantly prolonged ICU stay (median high CDT group: 13 davs; median low CDT group: 5 days). Major intercurrent complications, such as alcohol-withdrawal syndrome, tracheobronchitis, pneumonia, pancreatitis, sepsis, and congestive heart failure, were significantly increased in the high CDT group. The increased risk of pneumonia in the high CDT group may be related to the significantly increased period of mechanical ventilation. As high CDT values were associated with an increased risk of intercurrent complications and a prolonged ICU stay, it seems reasonable to use CDT as a marker in intensifying research work into preventing alcoholism-associated complications.

Alcoholism and carcinoma change the intracellular pH and activate platelet Na+/H+-exchange in men

The occurrence of carcinoma in chronic alcoholics exceeds that of the general population. Cytoplasmic alkalinization, due to the influence of different factors on the transmembrane Na+/H+ exchange (NHE), has been put forward as a triggering event in cell growth and division. In accordance with these findings, the carcinogenic potential of NHE deficient cell types is reported to be diminished. The aim of this study was to investigate whether the intracellular pH and the NHE activity is altered in chronic alcoholics. Seventy-two Caucasian males were assigned to one of four groups: non-alcoholics without carcinoma, chronic alcoholics without carcinoma, non-alcoholics with carcinoma and chronic alcoholics with carcinoma. Alcoholism was diagnosed according to DSM-III-R. The groups did not differ in relation to basic patient characteristics, such as age and blood pressure. Intracellular calcium, pH and NHE in platelets were determined by spectrofluorometry before and after thrombin stimulation. In chronic alcoholics with carcinoma, the intracellular pH was significantly more alkaline and the NHE activity was elevated. In contrast, a decrease in intracellular pH associated with an increased activity of NHE and a more acidic set point was found in chronic alcoholics without carcinoma. Basal and thrombin stimulated intracellular Ca2+ did not differ between groups except in chronic alcoholics with carcinoma in whom a thrombin-induced increase of Ca2+ due to liberation of Ca2+ from intracellular stores was demonstrated. In chronic alcoholics with carcinoma, cytoplasmic alkalinization was observed and this may be an indication of an increase in cell proliferation. The possibility that the increased incidence of carcinomas in chronic alcoholics is related to the increased activity of NHE and whether this may be prevented by NHE inhibitors requires further investigation.

Epinephrine impairs splanchnic perfusion in septic shock

OBJECTIVE

To assess the effects of epinephrine on splanchnic perfusion and splanchnic oxygen uptake in patients with septic shock.

DESIGN

Prospective, controlled trial.

SETTING

University hospital intensive care unit (ICU).

PATIENTS

Eight patients with septic shock, according to the criteria of the 1992 American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference, requiring treatment with vasopressors.

INTERVENTIONS

We compared in crossover design a 2-hr infusion of epinephrine with dobutamine plus norepinephrine in eight ICU patients with septic shock. Systemic and splanchnic hemodynamics and oxygen transport were measured before and during treatment with epinephrine.

MEASUREMENTS AND MAIN RESULTS

There was essentially no effect of epinephrine on the global parameters, except for increased lactate concentrations. There were marked effects on the regional variables; epinephrine caused lower splanchnic flow and oxygen uptake, lower mucosal pH, and higher hepatic vein lactate.

CONCLUSION

We conclude that undesirable splanchnic effects on patients in whom that region is particularly fragile should be considered when using epinephrine for septic shock treatment.

Intensive care unit stay is prolonged in chronic alcoholic men following tumor resection of the upper digestive tract

BACKGROUND

The prevalence of chronic alcohol misuse in patients with oral, pharyngeal, laryngeal or esophageal carcinomas exceeds 60%. No data is available, to our knowledge, on the morbidity and mortality of chronic alcoholics in surgical intensive care units (ICU) following tumor resection. We investigated whether the subsequent ICU stay in chronic alcoholics following tumor resection was prolonged and whether the incidence of pneumonia and sepsis was increased.

METHODS

213 patients with carcinomas of the upper digestive tract were evaluated regarding their drinking habits. Chronic alcoholics met either the DSM-III-R criteria for alcohol abuse or dependence. Conventional laboratory markers and serum carbohydrate-deficient transferrin were determined preoperatively. Major intercurrent complications during ICU stay such as an alcohol withdrawal syndrome, pneumonia and sepsis as well as the frequency of death were documented.

RESULTS

Patients did not differ significantly between groups regarding age or APACHE score on admission to the ICU.121 patients were diagnosed as being chronic alcoholics, 39 as being social drinkers and 61 as being non-alcoholics. In chronic alcoholics the frequency of death was significantly increased. Due to the increased incidence of pneumonia and sepsis the ICU stay was significantly prolonged in chronic alcoholics by approximately 8 days.

CONCLUSIONS

The increased mortality and morbidity rate demonstrates that chronic alcoholics undergoing major tumor surgery have to be considered as high-risk patients during their postoperative ICU stay. Further studies are required with respect to the immuno-competence of chronic alcoholics and the prevention of alcohol withdrawal syndrome, pneumonia and sepsis in these patients.

Intercurrent complications in chronic alcoholic men admitted to the intensive care unit following trauma

OBJECTIVE

A chronic alcoholic group following trauma was investigated to determine whether their ICU stay was longer than that of a non-alcoholic group and whether their intercurrent complication rate was increased.

DESIGN

Prospective study.

SETTING

An intensive care unit.

PATIENTS

A total of 102 polytraumatized patients were transferred to the ICU after admission to the emergency room and after surgical treatment. Of these patients 69 were chronic alcoholics and 33 were allocated to the non-alcoholic group. The chronic-alcoholic group. met the DSM-III-R and ICD-10 criteria for alcohol dependence or chronic alcohol abuse/harmful use. The daily ethanol intake in these patients was > or = 60 g. Diagnostic indicators included an alcoholism-related questionnaire (CAGE), conventional laboratory markers and carbohydrate-deficient transferrin.

MEASUREMENT AND RESULTS

Major intercurrent complications such as alcohol withdrawal syndrome (AWS), pneumonia, cardiac complications and bleeding disorders were documented and defined according to internationally accepted criteria. Patients did not differ significantly between groups regarding age, TRISS and APACHE score on admission. The rate of major intercurrent complications was 196% in the chronic alcoholic vs 70% in the non-alcoholic group (p = 0.0001). Because of the increased intercurrent complication rate, the ICU stay was significantly prolonged in the chronic-alcoholic group by a median period of 9 days.

CONCLUSIONS

Chronic alcoholics are reported to have an increased risk of morbidity and mortality. However, to our knowledge, nothing is known about the morbidity and mortality of chronic alcoholics in intensive care units following trauma. Since chronic alcoholics in the ICU develop more major complications with a significantly prolonged ICU stay following trauma than non-alcoholics, it seems reasonable to intensify research to identify chronic alcoholics and to prevent alcohol-related complications.

Therapy of alcohol withdrawal syndrome in intensive care unit patients following trauma: results of a prospective, randomized trial

OBJECTIVES

To assess the effect of three different alcohol withdrawal therapy regimens in traumatized chronic alcoholic patients with respect to the duration of mechanical ventilation and the frequency of pneumonia and cardiac disorders during their intensive care unit (ICU) stay.

DESIGN

A prospective, randomized, blinded, controlled clinical trial.

SETTING

A university hospital ICU.

PATIENTS

Multiple-injured alcohol-dependent patients (n=180) transferred to the ICU after admission to the emergency room and operative management. A total of 180 patients were included in the study; however, 21 patients were excluded from the study after assignment.

INTERVENTIONS

Patients who developed actual alcohol withdrawal syndrome were randomized to one of the following treatment regimens: flunitrazepam/clonidine (n=54); chlormethiazole/haloperidol (n=50); or flunitrazepam/haloperidol (n=55). The need for administration of medication was determined, using a validated measure of the severity of alcohol withdrawal (Revised Clinical Institute Withdrawal Assessment for Alcohol Scale).

MEASUREMENTS AND MAIN RESULTS

The duration of mechanical ventilation and major intercurrent complications, such as pneumonia, sepsis, cardiac disorders, bleeding disorders, and death, were documented. Patients did not differ significantly between groups regarding age, Revised Trauma and Injury Severity Score and Acute Physiology and Chronic Health Evaluation II score on admission. In all except four patients in the flunitrazepam/clonidine group, who continued to hallucinate, the Revised Clinical Institute Withdrawal Assessment for Alcohol Scale decreased to <20 after initiation of therapy. ICU stay did not significantly differ between groups (p=.1669). However, mechanical ventilation was significantly prolonged in the chlormethiazole/haloperidol group (p=.0315) due to an increased frequency of pneumonia (p=.0414). Cardiac complications were significantly (p=.0047) increased in the flunitrazepam/clonidine group.

CONCLUSIONS

There was some advantage in the flunitrazepam/clonidine regimen with respect to pneumonia and the necessity for mechanical ventilation. However, four (7%) patients had to be excluded from the study due to ongoing hallucinations during therapy. Also, cardiac complications were increased in this group. Thus, flunitrazepam/haloperidol should be preferred in patients with cardiac or pulmonary risk. Further studies are required to determine which therapy should be considered.

Prophylaxis of alcohol withdrawal syndrome in alcohol-dependent patients admitted to the intensive care unit after tumour resection

Prophylaxis of alcohol withdrawal syndrome (AWS) in alcohol-dependent patients shortens the duration of stay in the intensive care unit (ICU). The objective of this study was to assess the effect of four different prophylactic regimens on the duration of ICU stay, prevention of AWS and rate of major intercurrent complications in alcohol-dependent patients admitted to the ICU after tumour resection. A total of 197 alcohol-dependent patients, diagnosed by the Diagnostic and Statistical Manual of Mental Disorders (third revised edition) with a daily ethanol intake of 60 g, were allocated randomly to one of the following regimens which were commenced on admission to the ICU: flunitrazepam-clonidine, chlormethiazole-haloperidol, flunitrazepam-haloperidol or ethanol. The duration of ICU stay, prevention of AWS, incidence of tracheobronchitis and major intercurrent complications such as pneumonia, sepsis, cardiac disorders, bleeding disorders and death were documented. On admission, patients did not differ significantly in age, APACHE II and multiple organ failure scores. ICU stay, incidence of AWS, severity of AWS (revised clinical institute withdrawal assessment for alcohol scale > 20) and major intercurrent complication rate did not differ significantly between groups. Although there was no advantage in any of the four regimens with respect to the primary outcome measures, pulmonary and cardiac patients were not included in the study. Patients in the chlormethiazole-haloperidol group had a significantly increased incidence of tracheobronchitis (P = 0.0023), probably because of an increased incidence of hypersecretion.

Relevance of carbohydrate-deficient transferrin as a predictor of alcoholism in intensive care patients following trauma

Every second traumatized patient is a chronic alcoholic. Chronic alcoholics are at risk due to an increased morbidity and mortality. Reliable and precise diagnostic methods for detecting alcoholism are mandatory to prevent posttraumatic complications by adequate prophylaxis. The patient's history, however, is often not reliable, and conventional laboratory markers are not sensitive or specific enough. The aim of this study was to investigate whether carbohydrate-deficient transferrin (CDT) is a sensitive and specific marker to detect alcoholism in traumatized patients. One hundred and five male traumatized patients or their relatives gave their written informed consent to participate in this institutionally approved study. All patients were transferred to the intensive care unit after admission to the emergency room, followed by surgical treatment. Diagnostics included an alcoholism-related questionnaire, conventional laboratory markers (mean corpuscular volume, gamma-glutamyltransferase, aspartate aminotransferase, and alanine aminotransferase), and CDT sampling (microanion-exchange chromatography, turbidimetry, and radioimmunoassay, respectively). Only patients in whom a reliable history could be obtained were included. Alcoholism was diagnosed if the patients met the Diagnostic and Statistical Manual of Mental Disorders criteria for chronic alcohol abuse or dependence. The administration of fluids before CDT sampling was carefully documented. Patients did not differ significantly regarding age, Trauma and Injury Severity Score, and Acute Physiology and Chronic Health Evaluation score. The sensitivity of the CDT research kit was 70% and of the commercially available kit CDTect was 65%. Early sampling in the emergency room and before administration of large volumes of fluid increased the sensitivity to 83% for the CDT research kit and 74% for CDTect, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)