Mid-Term Results of Fenestrated Endovascular Repair after Prior Open Aortic Reconstruction

This study aims to assess the mid-term results of fenestrated endovascular aneurysm repair (FEVAR) for the treatment of proximal aortic pathology after previous open surgical repair (OSR). All patients with a previous history of OSR of an abdominal aortic aneurysm undergoing a FEVAR procedure between October 2010 and November 2021 were included. The endpoints of the study were technical success, mortality, target vessel patency and reinterventions during follow-up. Thirty-five patients (34 male, mean age 72.9 ± 7 years) were included. The median interval from the primary surgery to the FEVAR procedure was 136 months (range 47–261). The indication for treatment was a para-anastomotic aneurysm in 18 (51%) patients and a true aneurysm due to progression of disease in 17 (49%) patients. Technical success was achieved in 33 (94%) patients. There was one (3%) early death due to postoperative bleeding from a renal artery. Estimated survival at 12, 24 and 36 months was 89.1% ± 6%, 84.4% ± 7.3% and 84.4% ± 7.3%, respectively. There was no aneurysm-related mortality. One (3%) target vessel occluded during follow-up and three (9%) patients underwent late reinterventions. In conclusion, FEVAR is a safe and effective alternative for the endovascular treatment of para-anastomotic aneurysms/pseudoaneurysms after OSR showing high technical success, low mortality and morbidity, and good mid-term outcomes.

Glycemia Influences on Glucose Metabolism in Sepsis During Hyperinsulinemic Clamp

BACKGROUND

We investigated glucose metabolism in septic patients during hyperglycemic clamps and compared the different levels of insulinemia and glycemia.

METHODS

In 10 non-diabetic stable septic patients on mechanical ventilation with baseline glycemia >6 mmol/L and continuous insulin infusion, 3 steps of hyperinsulinemic clamp were performed after 8 hours without caloric intake. In step 1, the targets were insulinemia of 250 mIU/L and glycemia of 5 mmol/L; in step 2, insulinemia of 250 mIU/L and glycemia of 10 mmol/L; in step 3, insulinemia of 1250 mIU/L and glycemia of 5 mmol/L. Glucose uptake was calculated as the amount of glucose per time needed to maintain the target level of glycemia. Glucose oxidation was calculated from indirect calorimetry and urinary nitrogen losses. Values are provided as means +/- SD. A two-way analysis of variance and Scheffe's method were used for statistical analysis and p < .05 was considered significant.

RESULTS

At step 1, glucose uptake was lower than at step 2 (3.8 +/- 2.48 mg/kg/min and 7.9 +/- 3.45 mg/kg/min, respectively; p < .001). Glucose oxidation was also lower at step 1 (2.6 +/- 0.98 and 4.2 +/- 1.85 mg/kg/min, respectively; p < .01). Glucose storage was low at step 1 (0.7 +/- 1.39) and increased at step 2 (3.5 +/- 2.18; p < .05). In step 3, glucose uptake was 7.0 +/- 2.1, oxidation was 3.6 +/- 1.37, and storage was 2.9 +/- 2.79. There was no significant difference in all these parameters between steps 2 and 3. Energy expenditure between steps 1, 2 and 3 did not change (2294 + 307.42, 2334 + 341.53, and 2342 + 426.67 kcal/day, respectively). Alanine in plasma dropped significantly (p < .05): 10 mmol/L (311 +/- 55.88 mmol/L) at glycemia compared with 5 mmol/L (390 +/- 76 micromol/L) at insulinemia 250 mIU/L. It did not differ significantly from the values obtained at glycemia 5 mmol/L and insulinemia 1250 mIU/L (348 +/- 70.68 mmol/L). Even if the level of cytokines in sepsis was higher, there was no correlation between the insulin level in plasma (250 and 1250 mIU/L), glycemia (5 and 10 mmol/L) and cytokine level (IL-1beta, IL-2, IL-6, IL-8 and TNFalpha).

CONCLUSION

At insulinemia 250 mIU/L, a glucose level of 10 mmol/L seems to increase glucose uptake, oxidation, and storage compared with glycemia 5 mmol/L. This glucose uptake and oxidation at glycemia 10 mmol/L is comparable with the effect of extremely high insulinemia (1250 mIU/L) clamped at glycemia 5 mmol/L. A higher level of blood glucose or a high level of insulinemia significantly increases glucose uptake but not energy expenditure.

ESPEN Guidelines on Enteral Nutrition: Adult Renal Failure

Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where normal food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in nephrology patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. Because of the nutritional impact of renal diseases, EN is widely used in nephrology practice. Patients with acute renal failure (ARF) and critical illness are characterized by a highly catabolic state and need depurative techniques inducing massive nutrient loss. EN by TF is the preferred route for nutritional support in these patients. EN by means of ONS is the preferred way of refeeding for depleted conservatively treated chronic renal failure patients and dialysis patients. Undernutrition is an independent factor of survival in dialysis patients. ONS was shown to improve nutritional status in this setting. An increase in survival has been recently reported when nutritional status was improved by ONS.

Influence of insulin on glucose metabolism and energy expenditure in septic patients

Introduction

It is recognized that administration of insulin with glucose decreases catabolic response in sepsis. The aim of the present study was to compare the effects of two levels of insulinaemia on glucose metabolism and energy expenditure in septic patients and volunteers.

Methods

Glucose uptake, oxidation and storage, and energy expenditure were measured, using indirect calorimetry, in 20 stable septic patients and 10 volunteers in a two-step hyperinsulinaemic (serum insulin levels 250 and 1250 mIU/l), euglycaemic (blood glucose concentration 5 mmol/l) clamp. Differences between steps of the clamp (from serum insulin 1250 to 250 mIU/l) for all parameters were calculated for each individual, and compared between septic patients and volunteers using the Wilcoxon nonpaired test.

Results

Differences in glucose uptake and storage were significantly less in septic patients. The differences in glucose oxidation between the groups were not statistically significant. Baseline energy expenditure was significantly higher in septic patients, and there was no significant increase in either step of the clamp in this group; when comparing the two groups, the differences between steps were significantly greater in volunteers.

Conclusion

A hyperdynamic state of sepsis leads to a decrease in glucose uptake and storage in comparison with healthy volunteers. An increase in insulinaemia leads to an increase in all parameters of glucose metabolism, but the increases in glucose uptake and storage are significantly lower in septic patients. A high level of insulinaemia in sepsis increases glucose uptake and oxidation significantly, but not energy expenditure, in comparison with volunteers.

No reduction in the sufentanil requirement of elderly patients undergoing ventilatory support in the medical intensive care unit

The aim of the study was to test the hypothesis that the requirement of sufentanil is reduced in elderly patients when the opiate is primarily used to facilitate mechanical ventilation in a medical intensive care unit. A further aim was to study whether elderly patients developed withdrawal symptoms after discontinuing prolonged sufentanil administration. We have studied prospectively two groups of patients requiring mechanical ventilation for more than 96 h; group 1 age < 60 years (n = 316 or 68%) and group 2 age > 70 years (n = 150 or 32%). In all patients sufentanil and midazolam were administered continuously in order to facilitate ventilatory support. After an initial intravenous bolus injection of sufentanil 3.0-8.0 micrograms kg-1, the dosage was adjusted to the patients needs (0.75-1.0 microgram-1 kg-1 h) using a modified Ramsey score by accepting between 3b and 4a as the end point. The amount of sufentanil administered and side effects were recorded at 24-h intervals. Seventy-two hours following the start of sedation with sufentanil/midazolam the dose of sufentanil required for sedation increased significantly (P < 0.05) in both groups when compared with the first 24 h. There was no statistical difference between the two groups in sufentanil requirement at any time during the study. This suggests that tachyphylaxis develops to a similar degree in patients in both age groups. In addition, weaning in the elderly was characterized by a similar degree of withdrawal-like symptoms suggesting that independent of age, there are similar receptor related reactions once the opiate is withdrawn.

Nutritional care of pancreatitis and its complications

This article reviews the current literary data on the role of conservative supportive treatment for acute pancreatitis, with special emphasis on parenteral and enteral nutrition. Despite the fact that the indications for both methods have been discussed, defined and widely accepted in recent years, enteral nutrition is currently the focus of recent clinical investigations for use in acute pancreatitis.

Comparison of oxygen cost of breathing with pressure-support ventilation and biphasic intermittent positive airway pressure ventilation

OBJECTIVE

To assess the oxygen cost of breathing with either pressure-support ventilation (PSV) or biphasic intermittent positive airway pressure ventilation (BIPAP).

DESIGN

Prospective, randomized, crossover study.

SETTING

Medical intensive care unit of a university hospital.

PATIENTS

Twenty clinically stable and spontaneously breathing patients after long-term mechanical ventilation.

INTERVENTIONS

Patients were randomized to start on either PSV or BIPAP, and measurements were performed after an adaptation period of 30 mins. Immediately after, the ventilatory mode was changed and after another 30-min adaptation period, the same measurements were performed.

MEASUREMENTS AND MAIN RESULTS

Indirect calorimetry was performed during each ventilatory mode for a period of 30 mins. Oxygen consumption, energy expenditure, CO2 production, and respiratory quotient did not differ significantly between the two ventilatory modes, regardless of the patients' randomization. There were no statistically significant differences with regard to respiratory rate, minute volume, and blood gas analysis. All patients tolerated both ventilatory modes without any signs of discomfort.

CONCLUSIONS

Pressure support ventilation and BIPAP are both used for weaning patients gradually from the ventilator. BIPAP may be advantageous in patients not breathing sufficiently with PSV, since no patient effort is necessary with use of this ventilatory mode.

Influence of pentoxifylline on cytokine levels and inflammatory parameters in septic shock

OBJECTIVE

To evaluate the influence of pentoxifylline (PTX), a phosphodiesterase inhibitor, on cytokines and inflammatory proteins in patients suffering from septic shock.

DESIGN

Prospective study comparing a therapy group to a matched control group.

SETTING

Medical intensive care unit at a university hospital.

PATIENTS

Twenty four patients fulfilling the criteria of septic shock were included in this study. Twelve patients received PTX (therapy group) and 12 patients matched for diagnosis, age and gender served as the control group.

INTERVENTIONS

Pentoxifylline at 1 mg/kg per hour over 24 h in the therapy group.

MEASUREMENTS AND RESULTS

Cytokine levels [tumor necrosis factor-alpha (TNF)], soluble TNF receptor [TNF-R], and interleukin-6 [IL-6] and inflammatory proteins [C-reactive protein, alpha-1-antitrypsin (AAT), fibronectin, and haptoglobin], as well as hemodynamic parameters and the APACHE III score were evaluated before initiation of therapy and 24 h-later. After 24 h, TNF levels were significantly lower in the therapy group (p = 0.013), while IL-6 levels were significantly higher in the therapy group (p = 0.030). Within the 24 h TNF declined significantly in the therapy group (p = 0.006), while IL-6 showed a significant increase (p = 0.043). AAT and the APACHE III score tended to differ significantly after 24 h between the groups [AAT levels higher in the therapy group (p = 0.05), APACHE III score lower (p = 0.05)]. In the therapy group, the systemic vascular resistance index was significantly higher after 24 h (p = 0.0026) whereas the cardiac index declined (p = 0.035).

CONCLUSIONS

PTX does influence TNF levels in septic shock patients. Nevertheless, inhibiting a single mediator in severe septic shock cannot stop the inflammatory overreaction.

Emergency intubation with the Combitube in two cases of difficult airway management

The airway was managed successfully in two cases of difficult intubation using the Combitube, a new device for emergency intubation, which combines the functions of an oesophageal obturator airway and a conventional endotracheal airway. One patient could not be intubated due to lockjaw; in the other patient, the vocal cords could not be seen because of continued vomiting. The cases illustrate the benefit of the Combitube during emergency intubation for different problems and its effectiveness as an alternative to traditional intubation techniques.

[Bronchiolitis obliterans organizing pneumonia with acute respiratory insufficiency]

A 22-year-old woman was hospitalized because of fever of 39 degrees C and increasing dyspnoea. The chest radiograph demonstrated coarse confluent opacities bilaterally. Despite antibiotic treatment the condition deteriorated acutely after 2 days. All efforts to find an infectious agent, including immunological tests, were unsuccessful. Artificial ventilation became necessary because of increasing respiratory failure with an arterial oxygen partial pressure of 56 mm Hg, CO2 of 41 mm Hg and a respiratory rate of 60/min. Histological examination of a transthoracic lung biopsy revealed bronchiolitis obliterans organizing pneumonia, which was treated with prednisolone. The initial dose was 500 mg/d, gradually reduced to 12.5 mg/d over 2 weeks. The clinical and radiological findings improved markedly after 2 days and the patient discharged herself after 3 weeks and there was no follow-up.