Mortality in patients with severe COVID-19 who underwent tracheostomy due to prolonged mechanical ventilation

BACKGROUND

The usefulness of tracheostomy has been questioned in patients with COVID-19 and prolonged invasive mechanical ventilation (IMV).

AIM

To compare the 90-day mortality rate of patients who underwent a tracheostomy due prolonged IMV with those that did not receive this procedure.

MATERIAL AND METHODS

We studied a historical cohort of 92 patients with COVID-19 and prolonged IMV (> 10 days). The primary outcome was the 90-day mortality rate. Secondary outcomes included days on IMV, hospital/intensive care unit (ICU) length of stay, frequency of nosocomial infections, and thrombotic complications demonstrated by images. A logistic regression was performed to adjust the effect of tracheostomy by SOFA score and days on IMV.

RESULTS

Forty six patients aged 54 to 66 years (72% males) underwent tracheostomy. They had a median of two comorbidities, and received the procedure after a median of 20.5 days on IMV (interquartile range: 17-26). 90-day mortality was lower in patients who were tracheostomized than in the control group (6.5% vs. 32.6%, p-value < 0.01). However, after controlling for confounding factors, no differences were found in mortality between both groups (relative risk = 0.303, p-value = 0.233). Healthcare-associated infections and hospital/ICU length of stay were higher in patients with tracheostomy than in controls. Thrombotic complications occurred in 42.4% of the patients, without differences between both groups. No cases of COVID-19 were registered in the healthcare personnel who performed tracheostomies.

CONCLUSIONS

In patients with COVID-19 undergoing prolonged IMV, performing a tracheostomy is not associated with excess mortality, and it is a safe procedure for healthcare personnel.

Fiber optic bronchoscopy-assisted percutaneous tracheostomy: a decade of experience at a university hospital

Objective

To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation.

Methods

Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates.

Results

The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma.

Conclusion

Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using a standardized procedure.

Effects of dexmedetomidine and esmolol on systemic hemodynamics and exogenous lactate clearance in early experimental septic shock

BACKGROUND

Persistent hyperlactatemia during septic shock is multifactorial. Hypoperfusion-related anaerobic production and adrenergic-driven aerobic generation together with impaired lactate clearance have been implicated. An excessive adrenergic response could contribute to persistent hyperlactatemia and adrenergic modulation might be beneficial. We assessed the effects of dexmedetomidine and esmolol on hemodynamics, lactate generation, and exogenous lactate clearance during endotoxin-induced septic shock.

METHODS

Eighteen anesthetized and mechanically ventilated sheep were subjected to a multimodal hemodynamic/perfusion assessment including hepatic and portal vein catheterizations, total hepatic blood flow, and muscle microdialysis. After monitoring, all received a bolus and continuous infusion of endotoxin. After 1 h they were volume resuscitated, and then randomized to endotoxin-control, endotoxin-dexmedetomidine (sequential doses of 0.5 and 1.0 μg/k/h) or endotoxin-esmolol (titrated to decrease basal heart rate by 20 %) groups. Samples were taken at four time points, and exogenous lactate clearance using an intravenous administration of sodium L-lactate (1 mmol/kg) was performed at the end of the experiments.

RESULTS

Dexmedetomidine and esmolol were hemodynamically well tolerated. The dexmedetomidine group exhibited lower epinephrine levels, but no difference in muscle lactate. Despite progressive hypotension in all groups, both dexmedetomidine and esmolol were associated with lower arterial and portal vein lactate levels. Exogenous lactate clearance was significantly higher in the dexmedetomidine and esmolol groups.

CONCLUSIONS

Dexmedetomidine and esmolol were associated with lower arterial and portal lactate levels, and less impairment of exogenous lactate clearance in a model of septic shock. The use of dexmedetomidine and esmolol appears to be associated with beneficial effects on gut lactate generation and lactate clearance and exhibits no negative impact on systemic hemodynamics.

[Physician's adherence to medical indications for invasive procedures in the critical care unit of a university hospital]

INTRODUCTION

Physicians' adherence to pre-established criteria for the indication and/or maintenance of invasive devices is a weak point in infection control programs. Fulfillment of the recommendations for preventing infections associated with invasive devices is essential to reduce their risk.

OBJECTIVE

To assess the adherence of physicians to the standardized criteria for indication of central venous catheter (CVC) and permanent urinary catheter (PUC) and to the application of supervision guidelines.

METHODS

During a period of 7 months, residents of the Critical Patient Unit monitored the adherence to criteria for indication of CVC and PUC recorded in patients' medical records. This information was compared with current regulations to assess compliance.

RESULTS

Between April and September 2009, 2078 supervision guidelines were applied. Invasive devices were identified in 47.7%. 10.4% of CVCs and 19.2% of PUCs did not meet criteria for installation and / or maintenance at the time of monitoring.

CONCLUSIONS

Adherence of our medical staff to criteria for installation and /or maintenance of CVC and CUP should be improved. Monitoring can be efficiently performed by residents and could reduce infections associated with invasive procedures.

Impairment of exogenous lactate clearance in experimental hyperdynamic septic shock is not related to total liver hypoperfusion

Introduction

Although the prognostic value of persistent hyperlactatemia in septic shock is unequivocal, its physiological determinants are controversial. Particularly, the role of impaired hepatic clearance has been underestimated and is only considered relevant in patients with liver ischemia or cirrhosis. Our objectives were to establish whether endotoxemia impairs whole body net lactate clearance, and to explore a potential role for total liver hypoperfusion during the early phase of septic shock.

Methods

After anesthesia, 12 sheep were subjected to hemodynamic/perfusion monitoring including hepatic and portal catheterization, and a hepatic ultrasound flow probe. After stabilization (point A), sheep were alternatively assigned to lipopolysaccharide (LPS) (5 mcg/kg bolus followed by 4 mcg/kg/h) or sham for a three-hour study period. After 60 minutes of shock, animals were fluid resuscitated to normalize mean arterial pressure. Repeated series of measurements were performed immediately after fluid resuscitation (point B), and one (point C) and two hours later (point D). Monitoring included systemic and regional hemodynamics, blood gases and lactate measurements, and ex-vivo hepatic mitochondrial respiration at point D. Parallel exogenous lactate and sorbitol clearances were performed at points B and D. Both groups included an intravenous bolus followed by serial blood sampling to draw a curve using the least squares method.

Results

Significant hyperlactatemia was already present in LPS as compared to sham animals at point B (4.7 (3.1 to 6.7) versus 1.8 (1.5 to 3.7) mmol/L), increasing to 10.2 (7.8 to 12.3) mmol/L at point D. A significant increase in portal and hepatic lactate levels in LPS animals was also observed. No within-group difference in hepatic DO₂, VO₂ or O₂ extraction, total hepatic blood flow (point D: 915 (773 to 1,046) versus 655 (593 to 1,175) ml/min), mitochondrial respiration, liver enzymes or sorbitol clearance was found. However, there was a highly significant decrease in lactate clearance in LPS animals (point B: 46 (30 to 180) versus 1,212 (743 to 2,116) ml/min, P <0.01; point D: 113 (65 to 322) versus 944 (363 to 1,235) ml/min, P <0.01).

Conclusions

Endotoxemia induces an early and severe impairment in lactate clearance that is not related to total liver hypoperfusion.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0928-3) contains supplementary material, which is available to authorized users.

When to stop septic shock resuscitation: clues from a dynamic perfusion monitoring

Background

The decision of when to stop septic shock resuscitation is a critical but yet a relatively unexplored aspect of care. This is especially relevant since the risks of over-resuscitation with fluid overload or inotropes have been highlighted in recent years. A recent guideline has proposed normalization of central venous oxygen saturation and/or lactate as therapeutic end-points, assuming that these variables are equivalent or interchangeable. However, since the physiological determinants of both are totally different, it is legitimate to challenge the rationale of this proposal. We designed this study to gain more insights into the most appropriate resuscitation goal from a dynamic point of view. Our objective was to compare the normalization rates of these and other potential perfusion-related targets in a cohort of septic shock survivors.

Methods

We designed a prospective, observational clinical study. One hundred and four septic shock patients with hyperlactatemia were included and followed until hospital discharge. The 84 hospital-survivors were kept for final analysis. A multimodal perfusion assessment was performed at baseline, 2, 6, and 24 h of ICU treatment.

Results

Some variables such as central venous oxygen saturation, central venous-arterial pCO₂ gradient, and capillary refill time were already normal in more than 70% of survivors at 6 h. Lactate presented a much slower normalization rate decreasing significantly at 6 h compared to that of baseline (4.0 [3.0 to 4.9] vs. 2.7 [2.2 to 3.9] mmol/L; p < 0.01) but with only 52% of patients achieving normality at 24 h. Sublingual microcirculatory variables exhibited the slowest recovery rate with persistent derangements still present in almost 80% of patients at 24 h.

Conclusions

Perfusion-related variables exhibit very different normalization rates in septic shock survivors, most of them exhibiting a biphasic response with an initial rapid improvement, followed by a much slower trend thereafter. This fact should be taken into account to determine the most appropriate criteria to stop resuscitation opportunely and avoid the risk of over-resuscitation.

Central venous saturation in septic shock: co-oximetry vs gasometry

OBJECTIVES

Central venous oxygen saturation calculated by gasometry (Gaso-Scvo2) is more available than central venous oxygen saturation measured by co-oximetry (Co-oxy-Scvo2) in environments with less resources and underdeveloped countries. Therefore, we aimed to determine the agreement between Co-oxy-Scvo2 and Gaso-Scvo2 and between central venous oxygen tension measured by gasometry (Gaso-Pcvo2) and Co-oxy-Scvo2, respectively.

DESIGN AND SETTINGS

This is a prospective study in a university hospital's intensive care unit.

PATIENTS

Sixteen patients were studied during the first 48 hours after diagnosis of septic shock. All patients were intubated, connected to mechanical ventilation, and resuscitated according to the standards of care.

MEASUREMENTS AND RESULTS

One hundred eleven pairs of central venous blood measurements were analyzed both by conventional gasometry and co-oximetry. Bland and Altman analysis between Co-oxy-Scvo2 and Gaso-Scvo2 showed lack of agreement (1.7 [-10.7, +14.2]). A Gaso-Scvo2 less than 70% had a positive predictive value of 63% in relation to Co-oxy-Scvo2, and its negative predictive value was 90% with 20% false-positives and 5% false-negatives. The area under the receiver operator characteristic curve of Gaso-Pcvo2 to discriminate a Co-oxy-Scvo2 greater than or equal to 70% was 0.87 (confidence interval, 0.80-0.93), and the best cut-off point was a Gaso-Pcvo2 more than 40 mm Hg, (sensitivity, 75%; specificity, 93%).

CONCLUSIONS

The reliability of Gaso-Scvo2 determination during the resuscitation phase of septic shock is not acceptable. There is a good agreement between a Gaso-Pcvo2 more than 40 mm Hg and a Co-oxy-Scvo2 greater than or equal to 70%. Our results suggest that given these limitations, Gaso-Scvo2 results should be interpreted with caution, helped by Gaso-Pcvo2 measurements and in context with other perfusion parameters.

Near-infrared spectroscopy StO2 monitoring to assess the therapeutic effect of drotrecogin alfa (activated) on microcirculation in patients with severe sepsis or septic shock

Background

Sepsis is a leading cause of death despite appropriate management. There is increasing evidence that microcirculatory alterations might persist independently from macrohemodynamic improvement and are related to clinical evolution. Future efforts need to be directed towards microperfusion monitoring and treatment. This study explored the utility of thenar muscle oxygen saturation (StO₂) and its changes during a transient vascular occlusion test (VOT) to measure the microcirculatory response to drotrecogin alfa (activated) (DrotAA) in septic patients.

Methods

A prospective, observational study was performed in three general intensive care units at three university hospitals. We studied 58 patients with recent onset of severe sepsis or septic shock and at least two organ dysfunctions. Thirty-two patients were treated with DrotAA and 26 were not treated because of formal contraindication. StO₂ was monitored using near-infrared spectroscopy (NIRS), and VOT was performed to obtain deoxygenation (DeOx) and reoxygenation (ReOx) slopes. Measurements were obtained before DrotAA was started and were repeated daily for a 96-hour period.

Results

Patients’ characteristics, outcome, severity, and baseline values of StO₂, DeOx, and ReOx did not differ between groups. Treated patients significantly improved DeOx and ReOx values over time, whereas control patients did not. In treated patients, ReOx improvements were correlated to norepinephrine dose reductions. Early clinical response (SOFA improvement after 48 hours of treatment) was not associated to changes in VOT-derived slopes. In the treated group, the relative improvement of DeOx within 48 hours was able to predict mortality (AUC 0.91, p < 0.01).

Conclusions

In patients with severe sepsis or septic shock, DrotAA infusion was associated with improvement in regional tissue oxygenation. The degree of DeOx amelioration after 2 days in treated patients predicted mortality with high sensitivity and specificity. Thus, StO₂ derived variables might be useful to evaluate the microcirculatory response to treatment of septic shock.

Comparison of two different generations of "NIRS" devices and transducers in healthy volunteers and ICU patients

The purpose of this study is to compare Near Infrared Spectroscopy (NIRS) thenar eminence parameters obtained with 2 different devices from the same manufacturer (InSpectra Models 325 and 650, Hutchinson Tech, Min USA), and 2 different probes (15 vs. 25 mm spacing), in healthy volunteers (HV) and ICU patients. Prospective, observational study in ICU setting. Simultaneous, cross over NIRS inter-device comparison and comparison between different probes (25 vs. 15 mm spacing) were done at baseline and during vascular occlusion tests (VOTs). Forty patients (19 septic shock, 21 trauma), and 29 HV were included. NIRS inter-device comparison showed similar baseline StO(2) values in HV and patients. The VOT result were significantly different for minimal StO(2) value reached during VOT (StO(2min)) (intraclass concordance coefficient (ICC) = 0.18), the occlusion slope (ICC = 0.16) and the reperfusion slope (StO(2reperf)) (ICC = 0.26). The probe comparison was also significantly different for VOT parameters (StO(2min) (ICC = 0.43), occlusion (ICC = 0.50) and StO(2reperf) (ICC = 0.48). The low concordance, poor agreement and large bias (ICC and Bland & Altman) observed, were related both to the device used and the probe spacing. StO(2) data obtained with NIRS model 650 and 15 mm probe differ from values obtained with the previous device (325 and probe spacing 25 or 15 mm). This difference is not related to the population tested, but to the device and probe spacing. As a consequence, despite similar trends for variations between HV and patients during VOT, threshold and predictive values for outcome should be revisited with the new device before the acceptance for routine clinical use.

Organizing pneumonia in patients with severe respiratory failure due to novel A (H1N1) influenza

The authors describe two cases that developed organizing pneumonia (OP) associated with novel influenza A(H1N1) virus. These patients were admitted to intensive care unit (ICU) because of severe respiratory failure. After initial clinical improvement, both patients worsened their condition during their second week of ICU stay, presenting fever, increasing in inflammatory parameters and worsening in oxygen exchange and respiratory mechanics. Chest x-rays and computed tomographies showed an increment on lung infiltrates, given by areas of consolidation and ground glass opacification. Although broad-spectrum antibiotics were administered, patients showed no improvement. All cultures, including bronchoalveolar lavage samples, were negative. In both cases, an open lung biopsy was performed, and histopathological examination of the specimen was compatible with OP. Both patients were successfully treated with high-dose corticoids. The aim of this report is to alert about the possibility of OP associated with novel influenza virus in patients with severe respiratory failure.

Short communication: effect of storage and preservation on total bacterial counts determined by automated flow cytometry in bulk tank goat milk

This study was designed to evaluate the effects of different storage conditions on total bacterial count (TBC) determinations made in goat bulk tank milk using an automated flow cytometry method. The storage conditions tested were storage temperature (refrigeration at 4 and 10 degrees C or freezing at -20 degrees C), the use of a preservative (no preservative, NP; azidiol, AZ; or bronopol, BR), and the age of the milk samples for each analytical condition (storage times at 4 degrees C: from 0 h to 5 d for NP; and from 0 h to 22 d for AZ and BR; storage times at 10 degrees C: from 24 h to 2 d for NP and from 24 h to 22 for AZ and BR; storage times at -20 degrees C: from 24 h to 22 d for NP, AZ, and BR). Significant effects on individual bacterial count (IBC) variation were shown by the bulk tank milk sample, preservative, storage temperature, interaction preservative x storage temperature, and milk age within the interaction preservative x storage temperature. In preserved samples, the highest IBC were obtained for AZ and the lowest counts were obtained in samples preserved with BR. Because of the variation in IBC recorded in BR-preserved samples, we recommend that BR should not be used for TBC determinations using the automated flow cytometry method. The NP samples stored at 4 and 10 degrees C showed significantly higher IBC at 24 h postcollection, also invalidating these analytical conditions for TBC analyses. The practical implications of our findings are that goat milk samples preserved with AZ and stored at 10 or 4 degrees C are appropriate for TBC by the BactoScan flow cytometry method for up to 24 h and 11 d postcollection, respectively.

Detection limits of four antimicrobial residue screening tests for beta-lactams in goat's milk

This study was conducted to compare the detection limits (DL) of several antibiotic residue screening tests with the maximum residue limits (MRL) authorized by the EU according to the guidance for the standardized evaluation of microbial inhibitor tests of the International Dairy Federation. Composite antibiotic-free milk samples from 30 primiparous Murciano-Granadina goats in good health condition were used to prepare test samples spiked with different concentrations of each antimicrobial. In total, 5,760 analytical determinations of 10 beta-lactam antibiotics (penicillin-G, ampicillin, amoxicillin, cloxacillin, oxacillin, dicloxacillin, cefadroxyl, cefalexin, cefoperazone, and cefuroxime) were performed using 4 antibiotic residue screening tests: the brilliant black reduction test BRT AiM (AiM-Analytik in Milch Produktions-und Vertriebs GmbH, München, Germany), Delvotest MCS (DSM Food Specialties, Delft, the Netherlands), Eclipse 100 (ZEU-Inmunotec SL, Zaragoza, Spain), and the Copan Milk Test (CMT; Copan Italia SpA, Brescia, Italy). For each method, we estimated the detection limits of the antimicrobial agents using a logistic regression model. Using the CMT and Delvotest on samples spiked with the 8 antibiotics for which MRL were available, DL were at or below the MRL. The BRT test provided DL at or below the MRL for all of the agents except cefalexin, whereas the Eclipse 100 method failed to detect 4 antibiotics (ampicillin, amoxicillin, cloxacillin, and cefoperazone) at MRL or below. Logistic regression-determined levels of agreement were highest for the CMT method (98.6 to 100%) and lowest for Eclipse 100 (66.3 to 100%). In general, agreement levels indicated good correlation between observed results and those predicted by logistic regression. The lowest b values (closely related to test sensitivity) were recorded for the cephalosporins (0.074 to 0.430) and highest for penicillin G, ampicillin, and amoxicillin (11.270 to 11.504). Delvotest and CMT best fulfilled IDF criteria for the ideal test for detecting antibiotic residues in milk.

Is thenar tissue hemoglobin oxygen saturation in septic shock related to macrohemodynamic variables and outcome?

INTRODUCTION

The study objectives were to evaluate septic shock-induced alterations in skeletal muscle hemoglobin oxygenation saturation (StO2) using near-infrared spectroscopy (NIRS) and forearm skin blood flow velocity using laser Doppler (LD) to determine the relationship of macroperfusion and microperfusion parameters, and to test the relationship of the worst NIRS parameters during the first 24 hours of shock with 28-day prognosis.

METHODS

A prospective, observational study was performed in a 21-bed university hospital surgical intensive care unit. Forty-three septic shock patients with at least another organ failure underwent a 3-minute, upper arm (brachial artery) vascular occlusion test (VOT). Microperfusion parameters (thenar eminence StO2 and forearm LD skin blood flow) were collected on days 1, 2 and 3, before (baseline StO2 and LD values) and during the 3-minute VOT with calculation of occlusion and reperfusion slopes for StO2 and LD. Daily Sequential Organ Failure Assessment (SOFA) score, macrohemodynamic parameters (systolic arterial blood pressure, cardiac output (pulmonary artery catheter or transesophageal Doppler), mixed venous oxygen saturation (pulmonary artery or superior vena cava catheter)) and metabolic parameters (pH, base excess, lactate) were determined.

RESULTS

Baseline StO2 (82% (75 to 88) vs. 89% (85 to 92), P = 0.04) and reperfusion slope (2.79%/second (1.75 to 4.32) vs. 9.35%/second (8.32 to 11.57), P < 0.0001) were lower in septic shock patients than in healthy volunteers. StO2 reperfusion slope correlated with occlusion slope (P < 0.0001), cardiac output (P = 0.01) and LD reperfusion slope (P = 0.08), and negatively with lactate level (P = 0.04). The worst StO2 reperfusion slope during the first day of shock was lower in nonsurvivors than in survivors (P = 0.003) and improved significantly the predictive value of Simplified Acute Physiology Score II and SOFA scores.

CONCLUSIONS

The alteration of StO2 reperfusion slope in septic shock patients compared with healthy volunteers was related with macrohemodynamic, microhemodynamic and metabolic parameters. The addition of the worst value of the day 1 StO2 reperfusion slope improved the outcome prediction of Simplified Acute Physiology Score II and SOFA scores.

Evaluation of the MilkoScan FT 6000 Milk Analyzer for Determining the Freezing Point of Goat's Milk Under Different Analytical Conditions

The aim of this research was to evaluate the Milko-Scan FT 6000 (Foss Electric, Hillerød, Denmark) for determining the freezing point (FP) of goat's milk under different analytical conditions. The FP was determined in duplicate in 1,800 milk aliquots obtained from 45 bulk tank milk samples from 10 Murciano-Granadina goat herds, using the MilkoScan method and a reference thermistor cryoscopy method (Advanced Instrument Inc., Norwood, MA). Five different preservation strategies--no preservative, preservation with azidiol (0.006 or 0.018 g of sodium azide/100 mL), and preservation with bronopol (0.020 or 0.040 g/100 mL)--were then used to preserve the milk. For each preservation strategy, 8 different amounts of water were added (0, 1, 2, 3, 4, 5, 6, or 7% total volume). The results obtained with each method under these 40 analytical conditions were examined by comparison of means, comparison of the standard deviations of repeatability (s(r) and its relative value s(r)%), and a regression analysis. Under most analytical conditions, the FP was recorded as lower by the MilkoScan method, with a mean difference of 1.5 m degrees C compared with the reference method. Both methods showed similar repeatabilities (the overall s(r)% was 0.22% for the MilkoScan method and 0.20% for the reference method). In comparisons of the 2 methods, the highest regression coefficients were obtained with aliquots containing >3% added water. The best regression coefficients (0.85 to 1.02) were obtained for milk samples preserved with bronopol at 0.020 g/100 mL. These results allow the MilkoScan method to be used with goat's milk for screening purposes. The factors of added water, preservative, analytical method, lactose concentration, and the effect of the bulk tank milk sample within each lactose group contributed significantly to the observed variation in FP. For practical purposes, either of the bronopol concentrations could be used when determining the FP of goat's milk with the methods tested. However, the increase in the concentration of sodium azide in the azidiol formula contributed to an important reduction in the FP recorded. Thus, the type and concentration of preservative should be taken into account when interpreting FP values.

Influence of Storage and Preservation on Fossomatic Cell Count and Composition of Goat Milk

This study was designed to evaluate the effects of different test conditions on the somatic cell count (SCC) and composition of goat milk. To this end, 3600 tests were performed on 1800 aliquots taken from 40 goat milk samples using a combined instrument set-up based on flow cytometry for SCC and Fourier transform infrared analysis for fat, total protein, lactose, total solids, and freezing point determinations. The conditions tested were storage temperature (refrigeration and freezing), use of a preservative [no preservative (NP), azidiol (AZ), and bronopol (BR)], and age of the milk samples at each storage temperature (24 h to 42 d at refrigeration temperature and 21 to 105 d at freezing temperature). Significant effects on logSCC variation were shown by the storage temperature, the preservation treatment, the interaction of storage temperature x preservation treatment, and milk age within the interaction of storage temperature x preservative. Highest counts were recorded in the BR-preserved milk samples (logSCC = 5.877), and lowest counts were recorded in milk samples preserved using AZ (logSCC = 5.803). The use of frozen/thawed samples led to a significantly decreased logSCC for the treatments AZ and NP; the logSCC was not modified when BR-preserved frozen/thawed samples were analyzed. During storage, variations in the SCC observed for BR-preserved samples stored at refrigeration temperature for up to 25 d and at freezing temperature for all times tested were always < 10%. The preservation treatment was the main factor affecting the milk composition variables examined. Highest values of most variables were obtained in the BR-preserved samples, and the lowest values were obtained in the AZ-preserved samples. The freezing point was lower in the preserved samples than in the NP samples. The levels of milk constituents recorded in the BR-preserved samples were independent of both the storage temperature and age of milk sample. Our findings indicate that the freezing point of goat milk must be interpreted according to the preservative used.

Effect of Clinical Contagious Agalactia on the Bulk Tank Milk Somatic Cell Count in Murciano-Granadina Goat Herds

From 19 herds of Murciano-Granadina goats, weekly bulk tank somatic cell count (BTSCC) were performed from October to April, and suspicious milk (n = 182), synovial fluid, and ocular swabs (n = 15) from diseased goats were processed for mycoplasma isolation and identification. Also BTSCC from 65 herds were determined (n = 2693). A mixed model procedure was used to establish the effect of the herd and the lactation month on the BTSCC. Monthly rolling values were calculated for each herd using data collected over the preceding 3 complete months, and 4 different BTSCC thresholds were considered: 1,750,000, 1,500,000, 1,000,000, and 750,000 cells/mL. The mean log BTSCC for the 7-mo study period was 5.89 +/- 0.28 for herds without mycoplasma detection from clinical cases, 5.91 +/- 0.31 for mycoplasma-infected herds without clinical contagious agalactia (CA), and 6.47 +/- 0.32 for the herd with clinical CA. The posthoc tests revealed that only the herd that suffered a clinical CA outbreak showed counts that were significantly higher. No significant differences were found for BTSCC between herds not showing clinical episodes of CA, regardless of whether the mycoplasma had been isolated or not. The 1,750,000-cells/mL threshold would only be surpassed by a few herds with serious mastitis problems (clinical outbreak of CA for example). Seventy percent of the goat herds studied were in compliance with the proposed European Union legal limit of 1,500,000 cells/mL for goat milk.

Effect of freezing goat milk samples on recovery of intramammary bacterial pathogens

With the aim of evaluating the effect of freezing goat milk samples on recovery of intramammary pathogens, 1200 milk samples from udder halves with subclinical intramammary infection were studied. Samples (20 ml) were frozen at -20 and at -80 degrees C. Thawing was carried out at room temperature at 7, 14, 21, 28, 58, 118, 178, 236 and 730 days after collection and bacteriological analyses were carried out to determine the number of colony forming units/ml (CFU/ml). Mixed model statistical analysis showed that bacterial group, temperature of storage, interaction of bacterial group and temperature of storage and the interaction of bacterial group, time and temperature of storage were statistically significant effects. For coagulase negative staphylococci (CNS), least squares means of log CFU/ml recovered at -20 and -80 degrees C were not different. Nevertheless, for Gram negative bacilli (GNB) a significant decrease was detected in samples frozen at -20 vs. -80 degrees C. At both temperatures and at different times of storage, significant increases were detected between log CFU/ml of CNS and values on day zero. At -20 degrees C, a significant decrease in GNB recovery was detected between freezing days zero and 730. This difference was not detected when goat milk samples infected by GNB were frozen at -80 degrees C. The results show that frozen milk samples can be useful in goat subclinical mastitis control programs.

Daily delivery of dietary nitrogen to the periphery is stable in rats adapted to increased protein intake

Dietary nitrogen was traced in rats adapted to a 50% protein diet and given a meal containing 1.50 g (15)N-labeled protein (HP-50 group). This group was compared with rats usually consuming a 14% protein diet and fed a meal containing either 0.42 g (AP-14 group) or 1.50 g (AP-50 group) of (15)N-labeled protein. In the HP group, the muscle nonprotein nitrogen pool was doubled when compared with the AP group. The main adaptation was the enhancement of dietary nitrogen transferred to urea (2.2 +/- 0.5 vs. 1.3 +/- 0.1 mmol N/100 g body wt in the HP-50 and AP-50 groups, respectively). All amino acids reaching the periphery except arginine and the branched-chain amino acids were depressed. Consequently, dietary nitrogen incorporation into muscle protein was paradoxically reduced in the HP-50 group, whereas more dietary nitrogen was accumulated in the free nitrogen pool. These results underline the important role played by splanchnic catabolism in adaptation to a high-protein diet, in contrast to muscle tissue. Digestive kinetics and splanchnic anabolism participate to a lesser extent in the regulation processes.

Postprandial modulation of dietary and whole-body nitrogen utilization by carbohydrates in humans

BACKGROUND

Sucrose exerts a sparing effect on whole-body protein metabolism, mainly during the absorptive phase.

OBJECTIVE

We aimed to characterize the acute postprandial effect of addition of sucrose on deamination of dietary and endogenous nitrogen, with particular consideration being given to the effects of bioavailability.

DESIGN

Twenty-one subjects equipped with ileal tubes ingested (15)N-labeled soy protein combined with [(13)C]glycine, with (n = 10) or without (n = 11) sucrose. Dietary and endogenous ileal flow of nitrogen were determined from the ileal effluents. The kinetics of dietary amino acid transfer to the blood were characterized by (13)CO(2) enrichment in breath and (15)N enrichment in plasma amino acids. Deamination of dietary and endogenous amino acid was determined from body urea, urinary nitrogen, and (15)N enrichment.

RESULTS

(13)CO(2) recovery in breath and (15)N plasma amino acid enrichments were highly correlated (R:(2) >/= 0.95, P: < 0.001, for both meals) and markedly delayed by sucrose (half-(13)CO(2) recovery: 274 min compared with 167 min), whereas exogenous and endogenous ileal nitrogen kinetics and balances remained unchanged. Addition of sucrose halved the early (0-2 h) deamination peak of dietary nitrogen and reduced endogenous nitrogen oxidation over the first 4 h. Both were reduced by 18-24% over the 8-h period after the meal.

CONCLUSIONS

Without changing the nitrogen absorptive balance, sucrose markedly affected the bioavailability profile, which is governed by gastric emptying. Endogenous and dietary nitrogen were not spared in the same way and over the same periods, showing that the metabolism of endogenous and dietary nitrogen may be affected differently by nutritional modulation, even if the effects are of a similar magnitude over the entire postprandial period.

Nutritional value of [15N]-soy protein isolate assessed from ileal digestibility and postprandial protein utilization in humans

The purpose of this work was to assess the true oro-ileal digestibility, and to concurrently quantify the deamination of absorbed dietary nitrogen to examine the postprandial nutritional value of a soy protein isolate (SPI) in humans. To assess bioavailability and bioutilization of SPI, 10 healthy volunteers ingested 30 g of SPI, intrinsically and uniformly [15N]-labeled, added with 100 g of sucrose and water up to a final volume of 500 mL. True ileal digestibility was assessed by the [15N]-dilution method for 8 h by means of a naso-intestinal intubation technique. To describe and quantify exogenous nitrogen deamination for the same time period, urine and plasma samples were collected. True oro-ileal digestibility of SPI nitrogen was 91%. The amount of absorbed SPI amino acids used for nonoxidative disposal, i.e., postprandial biological value, was 86% 8 h after meal ingestion. Hence, net postprandial protein utilization of SPI was 78%. Compared to previous data that were assessed under the same condition in humans, the nutritional value of SPI is 92% of that in milk protein concentrate.

Net postprandial utilization of [15N]-labeled milk protein nitrogen is influenced by diet composition in humans

The aim of this study was to follow the fate of dietary nitrogen to assess the postprandial utilization of purified milk protein and to determine the acute influence of energy nutrients. For this purpose, a [15N]-labeling dietary protein approach was used. Twenty-five subjects swallowed an ileal tube and ingested [15 N]-milk protein alone or supplemented with either milk fat or sucrose. The absorption and postprandial deamination of dietary protein was monitored for 8 h. Sucrose delayed the absorption of protein longer than fat, but the ileal digestibility did not differ among groups (94.5-94.8%). Sucrose, but not fat, significantly reduced the postprandial transfer of [15N]-milk nitrogen to urea. Consequently, the net postprandial protein utilization (NPPU) of milk protein calculated 8 h after meal ingestion was 80% when ingested either alone or supplemented with fat and was significantly greater with sucrose (NPPU = 85%). This study shows that energy nutrients do not affect the nitrogen absorption but modify the metabolic utilization of dietary protein in the phase of nitrogen gain. Our method provides information concerning the deamination kinetics of dietary amino acids and further allows the detection of differences of dietary protein utilization in acute conditions. The diet composition should be carefully considered, and protein quality must be determined under optimal conditions of utilization.

Assessment of net postprandial protein utilization of 15N-labelled milk nitrogen in human subjects

The nutritional quality of milk proteins, evaluated both in terms of digestibility and postprandial oxidation and retention in human subjects, was investigated in this study. Five healthy adult volunteers were given 480 ml 15N-labelled milk (i.e. 190 mmol N). 15N was subsequently determined at the ileal level, using a naso-intestinal intubation technique, as well as at the faecal level. Plasma and urine were sampled for 8 h after meal ingestion. Dietary exogenous N recovered at the terminal ileum after 8 h reached 8.6 (SE 0.8) mmol while the amount collected in the faeces was 6.5 (SE 0.7) mmol after 5 d. The true ileal and faecal digestibilities were 95.5 (SE 0.4)% and 96.6 (SE 0.4)% respectively. The appearance of [15N]amino acids in the plasma was rapid and prolonged. The measurement of 15N in the body urea pool and in the N excreted in the urine allowed us to calculate the deamination occurring after [15N]milk protein absorption. The net postprandial protein utilization (i.e. NPPU = (Nabsorbed-Ndeaminated)/Ningested), calculated as an index of protein quality 8 h after milk ingestion, was 81.0 (SE 1.9)%. Our data confirm that milk protein has a high oro-ileal digestibility in man and demonstrate that milk protein has a high NPPU, an index corresponding to a period in which the dietary protein retention is maximal.

[15N]-labeled pea flour protein nitrogen exhibits good ileal digestibility and postprandial retention in humans

The aim of the present study was to evaluate postprandial absorption of pea protein as well as exogenous nitrogen retention in humans. For this purpose, after fasting overnight, seven healthy adults (4 males and 3 females) ingested [15N]-labeled pea protein (195 mmol N). Ileal effluents were collected for 8 h at 30-min intervals using a nasointestinal intubation technique. Urine and plasma samples were collected for 24 h. The [15N]-enrichment was determined in the intestinal samples, in the plasma amino acids and urea as well as in the urinary urea and ammonia fractions. The true gastroileal absorption of pea protein was 89.4 +/- 1.1%. This absorption was correlated with a significant increase (P < 0.05) in [15N]-enrichment in the plasma amino acids and in the nitrogen incorporated into the body urea pool for 1 h following pea ingestion. The enrichment remained significantly higher than the basal values in these pools 24 h after pea ingestion. The recovery of total urinary exogenous nitrogen after 22 h was 31.1 +/- 9.3 mmol N. Moreover, the kinetics of [15N]-labeled pea amino acids deamination reached a plateau of 39 mmol. Under these conditions, pea nitrogen retention represented 78% of the absorbed dietary nitrogen in healthy humans. The present results demonstrate the good true nitrogen digestibility and retention of pea protein in humans.

Whole-body protein turnover in humans fed a soy protein-rich vegetable diet

OBJECTIVES

This study was designed to compare the whole-body protein turnover in humans after the ingestion of a soy protein-rich vegetable diet with that of a control group fed a western animal protein-rich diet.

SUBJECTS

Twelve male volunteers were divided into two groups of six subjects who were given for two weeks either a 85% vegetable protein diet (diet VP) or a control western animal protein-rich diet (diet AP).

INTERVENTIONS

Whole-body protein turnover was estimated at the end of the two-week controlled diet period using the [15N]-glycine end-product method. Nitrogen flux rates were determined in the fed state (1.3 g protein/kg) over a 9 h period after the dose of [15N]-glycine was given.

RESULTS

After the 9 h of the test, the urinary ammonia excretion was significantly higher in the group receiving the diet AP than that in the group receiving the diet VP (P < 0.05). In contrast, there was no significant difference for both total nitrogen and urea nitrogen excretions. Both the protein synthesis and the protein breakdown were similar in both groups. In the same way, the net protein deposition measured in the fed state during 9 h was similar for both diets at 0.07 g/kg/h.

CONCLUSIONS

Young adults fed 1.3 g/kg/d of either meat or vegetable protein-rich diet for two weeks did not show a different protein turnover.

Fasting and postprandial polyamine concentrations in the human digestive lumen

Polyamines are essential to cellular proliferation and differentiation. The gastrointestinal tract could represent a major source of polyamines in the body; however, there is little information regarding the presence of polyamines in the human intestinal chyme, and the source of these intraluminal polyamines remains unclear. The aims of our study were to determine the concentrations and flow rates of polyamines in the human intestinal lumen and to estimate the contribution from food to these concentrations. Polyamine concentrations and flow rates were determined after 12 h of fasting in jejunal (n = 25) and ileal (n = 9) effluents collected by the slow-marker perfusion technique. Kinetic studies were performed after water ingestion (no polyamines) in the jejunum (n = 6) and ileum (n = 5) and in the jejunum after a yogurt test meal (polyamine content: 2.8 mumol putrescine, 2.1 mumol cadaverine, 2.1 mumol spermidine, and 1.9 mumol spermine; n = 9). There were significant polyamine concentrations in the lumen of the human gut during the fasting state, suggesting endogenous secretion. Higher polyamine concentrations were observed in the jejunum than in the ileum (P < 0.05), suggesting proximal absorption. Kinetic studies showed a 25% transitory increase in the jejunal putrescine flow rate after ingestion of the yogurt test meal, suggesting that dietary polyamines are fully absorbed.

The gastro-ileal digestion of 15N-labelled pea nitrogen in adult humans

The aim of the present study was to determine the gastro-ileal behaviour of pea protein in humans. For this purpose, twelve healthy volunteers were intubated with an intestinal tube located either in the jejunum (n 5) or in the ileum (n 7). After fasting overnight, they ingested 195 mmol N of [15N]pea. Intestinal samples were collected for 6 h in the jejunum and for 8 h in the ileum. Before meal ingestion the basal liquid flow rate (ml/min) was 2.01 (SD 0.31) in the jejunum and 2.02 (SD 0.33) in the ileum. After meal ingestion the liquid phase of the meal peaked in the 40-60 min period in the jejunum and in the 150-180 min period in the ileum. The jejuno-ileal transit time of the liquid phase of the meal was 102 min. The basal flow rate of endogenous N (mmol N/min) was 0.22 (SD 0.15) in the jejunum and 0.16 (SD 0.10) in the ileum. The endogenous N flow rate peaked significantly (P < 0.05) in the jejunum in the 40-60 min period whereas no stimulation of endogenous N could be detected in the ileum after meal ingestion. A significantly increased (P < 0.05) concentration of exogenous N was detected in the jejunum during the 20-320 min period and during the 90-480 min period in the ileum. The overall true gastro-ileal absorption of pea N was 89.4 (SD 1.1)% with 69 (SD 14)% absorbed between the stomach and the proximal jejunum and 20.4% between the proximal jejunum and the terminal ileum. The percentage of ethanol-insoluble fraction (PN) in the exogenous N at the terminal ileum increased significantly (P < 0.05) to 75% after 360 min. These results suggest that heat-treated pea protein has a digestibility close to that of animal protein.

A 15N-leucine-dilution method to measure endogenous contribution to luminal nitrogen in the human upper jejunum

OBJECTIVE

This study was done to investigate whether an intraveinous infusion of 15N-leucine was accurate to differentiate between endogenous and exogenous nitrogen in the human jejunum after meal ingestion.

SUBJECTS

Four healthy human volunteers equipped with an upper jejunal tube.

INTERVENTIONS

The jejunal effluents were collected both under fasting conditions and after ingestion of 300g of yoghurt. The nitrogen, amino acid composition and 15N-leucine enrichment were determined in the digesta.

RESULTS

During fasting, the jejunal flow rates (mmol/h) of both total nitrogen and amino acids were stable (6.9 +/- 2.7 and 1.88 +/- 0.79, respectively). After yoghurt ingestion, the flow rate of total nitrogen increased to 28.6 +/- 5.8mmol/h at 2h. The 15N-leucine enrichment in plasma reached a plateau at 4.3 mole % excess after one hour and did not vary significantly after meal ingestion. The 15N-leucine enrichment of the endogenous secretion (Ee) in the jejunum was fitted by the equation: Ee = 2.18[1 - 2.05 x exp( - 0.42 x t)]. After yoghurt ingestion, the enrichment in jejunal secretions decreased during the first 80 min. The endogenous nitrogen, calculated from the 15N-enrichment, significantly increased from 20 to 40min after meal ingestion compared to the basal value (P < 0.05). The estimation of the exogenous nitrogen and amino acid yield 300min after yoghurt ingestion indicated that 62 +/- 30% of the exogenous nitrogen and 75 +/- 12% of the amino acids were absorbed in the upper jejunum.

CONCLUSIONS

The 15N-leucine-dilution method appears to be a convenient method to differentiate between the exogenous and endogenous contributions to nitrogen fluxes in the intestinal digesta of humans. It can be used in association with dietary protein labelling or in substitution when no labelled dietary proteins are available to compare the digestion as well as the absorption of meals at different levels of the intestine.

Gastrojejunal kinetics and the digestion of [15N]beta-lactoglobulin and casein in humans: the influence of the nature and quantity of the protein

The evolution and luminal effects of different quantities of casein and beta-lactoglobulin were investigated in the upper jejunum of 35 volunteers who ingested 400 mL water with either beta-lactoglobulin or casein in either low or high doses (72.6 mmol N, Lbetalg; 71.7 mmol N, LCas; 368.2 mmol N, Hbetalg; 386.8 mmol N, HCas). The flow rate of the liquid effluents as well as the nitrogen movements were measured and the exogenous ([15N]) and endogenous nitrogen fractions analyzed in the upper jejunum after milk protein ingestion. The basal jejunal liquid flow rate (mL/min) was 3.88+/-1.84 and peaked in the 0-20 min period for water (9.92+/-3.72) and Lbetalg (7.27+/-3.08) and during the 20-40 min period for LCas (5.69+/-2.49), HCas (6.32+/-1.85), and Hbetalg (6.11+/-2.31). One hour after water, LCas, Lbetalg, Hbetalg, and HCas ingestion, 100%, 95%, 85%, 71%, but only 38% of the liquid phase of the meal were passed through the jejunum, respectively. The flow rate of the endogenous nitrogen was 12.93+/-5.22 mmol N/h before meal ingestion; remained unchanged after water, LCas or Hbetalg ingestion; but increased significantly (P<0.05) after Lbetalg and HCas ingestion. The net disappearance of exogenous nitrogen in the upper jejunum 240 min after HCas, Lbetalg, LCas and Hbetalg ingestion was 82.6+/-9.5%, 61.6+/-9.6%, 58.4+/-14.7%, and 44.7%+/-24.4%, respectively. The exogenous fraction of protein nitrogen recovered in the upper intestinal lumen represented 43.3% of the ingested Hbetalg nitrogen, but only 4.9% of the ingested HCas nitrogen. In conclusion, casein and beta-lactoglobulin present differences in both the intestinal kinetics of amino acid delivery and in the nature of the products in the intestinal lumen. These differences have to be taken into account from both nutritional and physiologic points of view for the utilization of these proteins in humans.

Exogenous and endogenous nitrogen flow rates and level of protein hydrolysis in the human jejunum after [15N]milk and [15N]yoghurt ingestion

Milk and yoghurt proteins were 15N-labelled in order to measure the flow rate of exogenous N during digestion in the human intestine. After fasting overnight, sixteen healthy volunteers, each with a naso-jejunal tube, ingested either [15N]milk (n 7) or [15N]yoghurt (n 9). Jejunal samples were collected every 20 min for 4 h. A significant stimulation of endogenous N secretion was observed during the 20-60 min period after yoghurt ingestion and the 20-40 min period after milk ingestion. The endogenous N flows over a 4 h period did not differ between the groups (44.3(SEM 6.5) mmol for milk and 63.5(SEM 5.9) mmol for yoghurt). The flow rates of exogenous N indicated a delayed gastric emptying of the yoghurt N compared with N from milk. The jejunal non-protein N (NPN) flow rate increased significantly after milk and yoghurt ingestion due to an increase in the exogenous NPN flow rate. The NPN fraction of exogenous N ranged between 40 and 80%. The net gastro-jejunal absorption of exogenous N did not differ significantly between milk (56.7(SEM 8.5)%) and yoghurt (50.9(SEM 7)%). The high level of exogenous N hydrolysis is in accordance with the good digestibility of milk products. Fermentation modifies only the gastric emptying rate of N and does not affect the level of diet hydrolysis, the endogenous N stimulation or the digestibility rate.

Metabolism of enterostatin in rat intestine, brain membranes, and serum: differential involvement of proline-specific peptidases

The degradation of enterostatin (VPDPR), a potent inhibitor of food intake, by intestinal brush-border membranes, brain membranes, and rat serum has been investigated in the presence of specific inhibitors. Hydrolysis by intestinal membranes was found to be 10 and 100 times faster than in serum and brain membranes, respectively. Enterostatin hydrolysis by intestinal and brain membranes involves the removal of C-terminal arginine by carboxypeptidase P, leading to the production of des-Arg-enterostatin, and the splitting of the Pro2-Asp3 bond by dipeptidyl aminopeptidase IV (DPP IV). A small amount of the potent anorectic peptide Pro2-Asp3-Pro4 was released during hydrolysis of des-Arg-enterostatin by brain membranes and rat serum. In rat serum, enterostatin degradation was mainly due to DPP IV.

[Premedication with clonidine in the neurosurgical patient: sedation, anesthetic requirements and hemodynamic perfusion]

OBJECTIVES

To analyze the effect of premedication with clonidine on postoperative sedation, anesthetic requirements and hemodynamic repercussions in patients undergoing craniotomy due to supratentorial intracranial pathology.

PATIENTS AND METHODS

Twenty ASA I/II patients in a double-blind prospective study were assigned randomly to receive lorazepam (0.03 mg/kg/po, n = 10) or clonidine (0.005 mg/kg/po, n = 10) the night before and 90 minutes before surgery. Arterial pressure and heart rate were monitored continuously during and immediately after surgery (first 24 hours). Anesthetic induction was achieved with thiopental (maximum 6 mg/kg) and maintained with O2/N2O and an infusion of alfentanyl (1 microgram/kg/min). Hemodynamic response to surgical stimulus was treated with additional boluses of alfentanyl up to a maximum dose of 0.1 mg/kg and with an increase in infusion dosage to 2 micrograms/kg/min. When these were ineffective, isoflurane was given. All patients were extubated in the operating room.

RESULTS

No differences in level of sedation were found between the two groups. The infusion dose and total amount of alfentanyl given were smaller for patients treated with clonidine (0.8 +/- 0.04 vs 0.6 +/- 0.01 microgram/kg/min and 22.4 +/- 5.3 vs 17.5 +/- 4.9 mg, respectively) (p < 0.05). No differences were found in isoflurane requirements (5/5 vs 2/8). Mean arterial pressure and heart rate were lower with clonidine from 3 minutes after intubation until the patient's arrival in the recovery room (p < 0.05), with marked bradycardia (49 +/- 5 vs 73 +/- 7 bpm) (p < 0.05) upon intubation.

CONCLUSIONS

Premedication of neurosurgical patients with clonidine offers no advantages over lorazepam with respect to sedation. Nevertheless, clonidine may offer advantages with respect to the amount of alfentanyl required and attenuation of perioperative adrenergic response.

Cardiomyopathy and phaeochromocytoma

A case is presented of phaeochromocytoma with catecholamine-induced cardiomyopathy. The difficulties in the management when left ventricular failure occurred are reported and the importance of monitoring pulmonary artery pressure during the anaesthetic procedure is stressed.

Acute pulmonary oedema due to lithium intoxication

We present a case of acute lithium ion intoxication in which the main clinical feature was respiratory failure secondary to pulmonary oedema possibly due to myocardial depression, associated with profound stupor. The initial lithium ion concentrations were 3.15 mmol/l in plasma and 27.6 mmol/l in urine. Under symptomatic treatment with oxygen, digitalis and diuretics, both the pulmonary and the neurological disorders reverted gradually, in parallel with the decreasing plasma lithium ion concentrations.