Cost containment through L-alanyl-L-glutamine supplemented total parenteral nutrition after major abdominal surgery: a prospective randomized double-blind controlled study.

BACKGROUND & AIMS: Glutamine is recognized as a conditionally essential amino acid. Recent studies indicate that glutamine-containing total parenteral nutrition improves nitrogen economy, enhances gastrointestinal and immune functions and shortens hospital stay. METHODS: Thirty-seven patients (19 w and 18 m; age 61. 4+/-10.4 years; BMI 23.7+/-2.8 kg/m(2)) following major abdominal surgery receiving an isonitrogenous isoenergetic TPN with or without alanyl-glutamine supplementation (0.5 g/kg BW/day), were evaluated in a double-blind, randomized, controlled trial over a five-day period by measuring nitrogen balance, selected biochemical parameters and length of hospital stay. RESULTS: Supplemental alanyl-glutamine improved the overall mean (-3.5+/-1.6 vs. -5.5+/-1. 4 g N;P<0.05) and cumulative nitrogen balance (-14.1+/-9.1 vs. -21.7+/-11.4 g N;P<0.05) compared with the isonitrogenous, isoenergetic standard regimen. Alanyl-glutamine normalized plasma glutamine concentration and reduced the length of hospital stay (12.8+/-2.6 vs. 17.5+/-6.4 days;P<0.05). CONCLUSIONS: The results of the study confirm that supplementation with synthetic alanyl-glutamine dipeptide is associated with cost containment due to shortened hospitalization and improved nitrogen economy.

Success rate of unilateral spinal anesthesia is dependent on injection flow.

BACKGROUND AND OBJECTIVES: The dependence of unilateral spinal anesthesia on injection flow is controversial. We hypothesized that it is possible to achieve strictly unilateral sympathetic block (as assessed by temperature measurements of the limbs) and unilateral sensory and motor block, respectively, during spinal anesthesia by a slow and steady injection of a hyperbaric local anesthetic solution. METHODS: Forty-four patients (American Society of Anesthesiologists [ASA] physical status I-III) undergoing surgery of one lower extremity were randomly assigned to one of two groups. Dependent on the patients' height, 1.4 to 1.7 mL hyperbaric bupivacaine 0.5% was injected manually with the patient in the lateral decubitus position, which was maintained for 30 minutes after injection. Injection flow was approximately 0.5 mL/min in group I ("air-buffered" injections performed by 4 mL air between the local anesthetic and the syringe's plunger, n = 25) and approximately 7.5 mL/min in group II ("conventional" injections, n = 19). Sympathetic block was defined as a temperature increase of more than 0.5 degrees C at the foot. Any reduction in the ability to move the hip, knee, or ankle as well as loss of temperature discrimination and/or pinprick even in one dermatome on the nondependent side was considered as a bilateral block. RESULTS: Before surgery, significant differences (P < .05) were observed for unilateral motor paralysis (92% in group I v 68.4% in group II), unilateral sensory block (48.0% v 10.5%), and unilateral sympathetic block (72% v 42.1%). Strictly unilateral spinal anesthesia was found to be significantly more frequent in group I (40% v 5.3%). Significant hemodynamic differences between the groups were not detected. CONCLUSIONS: For hyperbaric spinal anesthesia, the injection flow is an important factor in achieving unilateral sympathetic block. A slow injection proves useful to restrict spinal anesthesia to the side of surgery.

Pretreatment technique for fast intubation with vecuronium: intubation conditions and unwanted effects.

In eighty patients 15 micrograms kg-1 of vecuronium was given 3 minutes before induction of anesthesia and 50 micrograms kg-1 was given at the time of induction. The trachea was intubated 60 seconds after the second dose. A wide spread of twitch depression was found. The 80 patients were divided into 4 groups retrospectively with respect to the degree of neuromuscular blockade during intubation. Tracheal intubation was performed when the mean twitch depression was 48.8 +/- 11.8 (SD)% and the conditions were satisfactory in 89% of the cases. Intubating conditions were different significantly between the four sub-groups (p less than 0.01). Ptosis occurred in 77 patients, diplopia in 13 patients and dyspnea in 2 patients between the first injection of vecuronium and induction of anesthesia. The administration of vecuronium in divided doses gives satisfactory intubating conditions in the majority of the patients, but close observation between the priming dose and the induction of anesthesia is mandatory. The method is not considered suitable for obese and is probably not indicated in severely ill patients.

Percutaneous venous cannulation and central venous line placement by means of ultrasonography and ultrasonic Doppler.

Ultrasonography is being increasingly used in the field of anesthesiology. One major indication is visualization of central venous vessels, in particular the internal jugular vein before and during cannulation by means of ultrasonography or ultrasonic Doppler. This should facilitate puncture with a higher rate of successful cannulations and decreased rate of complications related to needle probing during catheterization attempts. Furthermore, by using ultrasonography central venous catheters can be located in the vessels. The picture quality of various central venous catheters currently used in anesthesia and intensive care does not show any noticeable difference.

Improved PCO2 measurement in six standard blood gas analysers using a phosphate-buffered solution for gastric tonometry.

The measurement of gastric intramucosal pH serves as a non-invasive technique for early detection of gastrointestinal ischaemia in critically ill patients. The method is based on the determination of the partial pressure of carbon dioxide in a 0.9% saline solution using a standard blood gas analyser. However, the use of standard blood gas analysers leads to an underestimation of carbon dioxide partial pressure in saline. Instrumental biases of six blood gas analysers were investigated using either a saline or a phosphate-buffered solution. Both test solutions were equilibrated with five defined carbon dioxide concentrations. Each blood gas analyser underestimated this defined partial pressure of carbon dioxide with a bias between -3.7% and -57.5% if saline was used. The phosphate-buffered solution considerably improved instrumental precision, resulting in biases between +2.7% and -17.6% Thus, a phosphate-buffered solution increases the accuracy of gastric intramucosal pH measurement.

[Assessing nutritional status]. / Erfassung des Ernährungszustandes.

Malnutrition is associated with a delayed recovery from illness and an increased rate of complications. Heart failure, respiratory diseases, impaired immune function and postoperative wound healing are influenced by the nutritional status. Nutritional assessment includes patients history, physical examination, anthropometric measurements, laboratory dates and changes of immunocompetence. Anthropometric assessment, like skinfold and muscle area measurements, is not an extremely accurate method predicting nutritional status of an individual patient. Multifactorial influence on the concentration of the serum proteins, albumine, transferrin and retinolbinding protein caused a wide range of normal values. Therefore the validity and sensitivity of these parameters to assess nutritional status are diminished for the individual patient. The concentration of serum albumin seems to be of some value as a marker for nutritional status. The influence of malnutrition on immunity is complex. There are no sensitive markers available to assess the influence of malnutrition on the immuno competence of an individual patient for the clinical routine. Malnutrition may be assessed and the resulting clinical complications may be predicted by calculating a prognostic nutritional index, which include several nutritional parameters.

[Intraoperative anaphylactic shock due to a latex allergy]. / Intraoperativer anaphylaktischer Schock aufgrund einer Latexallergie.

Delayed hypersensitivity to rubber chemicals is well known, but there has been an increasing number of reports of immediate-type hypersensitivity due to latex causing contact urticaria, angioedema, bronchial asthma, and anaphylactic shock in adults. We report a 10-year-old boy who developed anaphylactic shock during surgery due to surgical gloves containing latex. The patient was atopic and had a history of neurodermatitis and localized angioedema on exposure to rubber. There had been two previous uneventful surgical procedures. Thirty-five minutes after induction of anesthesia and 5 min after laparotomy for appendectomy there was an acute onset of increased airway pressure, oxygen desaturation, and profound hypotension. The circulation and gas exchange stabilized after treatment with oxygen, intravenous fluids, epinephrine, H1 and H2 blockers, aminophylline, and methylprednisolone. A positive skin test and RAST revealed a latex allergy. Latex can cause life-threatening allergic reactions in patients with a history of rubber allergy or frequent exposure to latex products.

IgE-mediated hypersensitivity to latex in childhood.

A total of 267 children scheduled to receive anesthesia during a surgical, neurosurgical, or orthopedic intervention were investigated. IgE antibodies against latex were detected in serum samples of 6.4% (17/267 children) of the patients. The most important difference between sensitized and nonsensitized children was the number of surgical interventions in the past. The median of surgical interventions was 1.0 in the nonsensitized group of children and 3.0 in the sensitized group. Only 0.9% of the children with up to two surgical interventions and 34.1% with three or more procedures were sensitized to latex. Only one of the sensitized children developed intraoperative anaphylaxis during intervention after our investigation. We conclude that children with a history of three or more surgical interventions have a high risk of sensitization to latex proteins. Nevertheless, the predictive value of IgE antibodies against latex for development of anaphylaxis during anesthesia seems to be low.

Postoperative alpha 2-adrenergic stimulation attenuates protein catabolism.

The metabolic effects of continuous intravenous (IV) application of the alpha 2 agonist clonidine were evaluated by assessment of nitrogen economy and postaggression endocrine patterns. Twenty-four patients undergoing abdominothoracic esophageal cancer resection were studied. Thirteen of these patients with alcohol abuse were treated postoperatively with IV clonidine for prevention of alcohol withdrawal syndrome. Eleven patients who were not treated with clonidine served as controls. All patients were treated in a standardized manner in regard to surgical technique, balanced anesthesia, and postoperative intensive care treatment, including thoracic epidural analgesia with bupivacaine and fentanyl. Isonitrogenous and isocaloric nutrition was comparable in all patients. A significantly improved cumulated 6-day nitrogen balance was found in clonidine-treated patients (-1.5 +/- 4.9 g nitrogen) compared to the control group (-17.6 +/- 4.2 g nitrogen) (P < 0.05). The main reason for improved nitrogen economy may be clonidine-induced growth hormone (GH) release. The pattern of insulin-like growth factor I (IGF-I) and insulin-like growth factor binding protein 3 (IGFBP-3) concentrations could support this hypothesis.

Strategies to reduce the need for peri-operative blood transfusion.

Therapeutic regimens involving the transfusion of blood components are a matter of debate, not only with regard to patients' safety, but also with regard to cost-effectiveness. The following different measures to reduce the use of blood components and their efficacy are discussed: autologous transfusion, including predonation, isovolaemic haemodilution and peri-operative retransfusion; toleration of a lower haematocrit; and measures to reduce blood loss. In particular, a combination of these methods may be most effective at reducing transfusion needs.

Gastric tonometry: precision and reliability are improved by a phosphate buffered solution.

OBJECTIVE: To compare a phosphate buffered solution with normal saline as tonometric fluid in intramucosal PCO2 measurement in humans. DESIGN: Prospective, unblinded comparison. SETTING: Postsurgical critical care unit of a university hospital. PATIENTS: Six septic patients. INTERVENTIONS: Two tonometric probes were positioned in the gastric lumen in each patient. One tube was used for conventional tonometry (saline-filled balloon), while phosphate buffered solution was instilled into the second tube. MEASUREMENTS AND MAIN RESULTS: PCO2 was determined with three blood gas analyzers (ABL 2 [Radiometer, Copenhagen, Denmark], Corning 288 [Ciba Corning Diagnostics GmbH, Neuss, Germany], and StatProfile 9 Plus [Nova Biomedical, Waltham, MA]). Eight parallel PCO2 measurements per patient were evaluated, yielding a total of 48 measurements with each tonometric solution. Intrainstrumental comparison of the PCO2 determinations demonstrated an increase of 12.3 +/- 9.9% for ABL 2, 3.10 +/- 12.9% for Ciba Corning 288, and 101.2 +/- 31.5% for StatProfile 9 Plus with the phosphate buffered solution. The PCO2 values were decreased by the following amounts when the three instruments were compared, using the saline method: 14.2 +/- 8.2% (Ciba Corning 288 vs. ABL 2); 40.7 +/- 9.9% (StatProfile 9 Plus vs. ABL 2); and 30.9 +/- 9.35% (StatProfile 9 Plus vs. Ciba Corning 288). The difference in PCO2 determination, resulting from the different instrument designs, were significant between the three blood gas analyzers (p<.001). In addition, the variance of the intramucosal PCO2 values was significant between blood gas analyzers (p<.001) with normal saline as tonometric solution, but not with phosphate buffered solution. The coefficients of determination between PCO2 values in saline and phosphate buffered solution were r2=.85 for ABL 2, r2=.81 for Ciba Corning 288, and r2=.74 for StatProfile 9 Plus. When all 48 PCO2 values were analyzed, the interinstrumental coefficients of determination within a method for saline (and for phosphate buffered solution in parenthesis) were:r2=.83 (.92) between ABL 2 and Ciba Corning 288, r2=.72 (.92) between ABL 2 and StatProfile 9 Plus, and r2=.81 (.98) between Ciba Corning 288 and StatProfile 9 Plus. CONCLUSIONS: A considerable instrumental bias in PCO2 analysis is observed when saline is used as tonometric fluid in gastric tonometry, thus preventing a reliable determination of intramucosal pH. The present in vivo data show that the accuracy and reliability of intramucosal pH measurement can be improved by the use of phosphate buffered solution as tonometric fluid.

[Safety and tolerance of a new dipeptide-containing amino acid solution DP-Gln 20 versus a conventional amino acid solution Vamin 18EF in patients after elective colon surgery]. / Sicherheit und Verträglichkeit der neuen dipeptidhaltigen Aminosäurelösung DP-Gln 20 versus einer konventionellen Aminosäurelösung Vamin 18EF bei Patienten nach elektiver Kolonchirurgie.

OBJECTIVE AND METHODS: Recent studies have demonstrated the important role of glutamine in postoperative metabolism. Using dipeptide-containing amino acid solutions it is possible to enhance glutamine supply. Safety and tolerance of DP-Gln 20 (gly-gln, gly-tyr) and Vamin 18EF were investigated in an open, prospective, randomised study. 16 patients received isonitrogenous parenteral nutrition over 4 days. RESULTS: There was no difference in clinical and biochemical patterns between both groups. Complications and adverse events due to the infused amino acid solutions were not observed.

[Glucose-xylitol 35% (1:1) versus glucose 40%. Effectiveness and metabolic effects after major surgery]. / Glukose-Xylit 35% (1:1) versus Glukose 40%. Effektivität und metabolische Auswirkungen nach grossen operativen Eingriffen.

Injury and stress are accompanied by a characteristic hormonal response and altered energy utilisation. Hyperglycaemia and negative nitrogen (N) balance are the leading symptoms of the metabolic changes in the post-operative state. In a prospective, randomised study the efficacy and metabolic effects of glucose-xylitol (GX) 35% (1:1) versus glucose (G) 40% were investigated in patients undergoing major surgery. METHOD. Twenty-four patients undergoing abdomino-thoracic oesophageal cancer surgery were treated in a standardised manner. Total parenteral nutrition was administered over 6 days (kg body wt.-1/day): day of surgery 1-1.25 g carbohydrate (CH); 1st postoperative day (POD) 1.5 g CH, 1 g amino acids (AA); 2nd POD 3 g CH, 1.5 g AA, 1.0 g fat; from 3rd POD 3 g CH, 1.5 g AA, 1.5 g fat (CH GX35% (n = 12) or G40% (n = 12), AA Intrafusin 15%, fat Intralipid 20%). Daily and cumulative N balances, blood-G profiles, blood chemistry, and physical parameters were determined. Glucagon and insulin profiles, CH losses, and oxalic acid secretion were measured. RESULTS. Both groups were comparable for age, body mass index, clinical and physical parameters, and blood chemistry. Mean cumulative N balances after 6 days were -12.0 +/- 16.3 g N for GX35% and -5.6 +/- 19.4 g N for G40% (n.s.; Wilcoxon, P < 0.05). Blood G was similar for both groups with values ranging from 130 to 240 mg/dl on the day of surgery and below 150 mg/dl on the consecutive days. In each group 1 patient needed additional insulin therapy. Glucagon and insulin levels did not show a significant difference between the groups. CONCLUSION. No difference in tolerance and efficacy of nutritional support by GX versus G at a dose of 3 g.kg body wt.-1.d in oesophagectomised patients could be observed. Similar blood G profiles were in accordance with comparable glucagon and insulin levels. Because of the high standard deviations of N balances, differences in efficacy could not be proven. A significantly lower level of pseudocholinesterase (PCHE) for G40% on day 7 might indicate enhanced hepatic protein synthesis in the GX group.

[Experiences with a new fat emulsion in surgical intensive care medicine]. / Erfahrungen mit einer neuen Fettemulsion in der operativen Intensivmedizin.

As far as energy availability is concerned, it is advantageous to give lipid emulsions to severely catabolic patients, in comparison to lipid-free TPN. It is important to administer essential fatty acids, especially linoleic and linolenic acid, which play a major part in synthesis of membrane phospholipids and prostaglandin metabolism. Lipid emulsions with linoleic acid content and high linoleic-linolenic ratio might be of great value in posttraumatic situations, where the need for linoleic acid might be increased up to 50 g/day. We have examined the safety of a new lipid emulsion with a linoleic-linolenic acid ratio of 16:1 in 14 severely catabolic surgical ICU patients. As a result, neither liver enzyme elevation nor allergic reactions occurred. The limited elevation of triglycerides under lipid infusion and the rapid fall of these values to normal levels account for the satisfactory utilization of the examined lipid emulsion in critically ill patients.

Effect of parenteral glutamine peptide supplements on muscle glutamine loss and nitrogen balance after major surgery.

Twelve patients admitted for elective resection of carcinoma of colon or rectum were allocated at random to experimental and control groups (six in each) and received a total parenteral nutrition regimen providing 230 mg N/kg and 166 KJ/kg daily over the first 5 postoperative days. In the experimental group the parenteral fluid was supplemented with a synthetic glutamine-containing dipeptide, L-alanyl-L-glutamine (54 mg peptide-N/kg per day) and the control group received corresponding amounts of alanine-N and glycine-N. On each postoperative day nitrogen balance was better in the experimental group; mean daily nitrogen balance with alanyl-glutamine was -1.5 (SE 0.4) g N/day and with the control solution -3.6 (0.2) g N/day. The cumulative nitrogen balances on the fifth postoperative day were -7.1 (2.2) and -18.1 (1.7) g N, respectively. With the peptide-containing solution intramuscular glutamine concentration remained close to the preoperative value whereas with the control solution it decreased from 19.7 (SE 0.9) to 12.0 (0.6) mmol/l intracellular water.

[Protein oriented peripheral venous nutrition following surgical trauma]. / Eiweissorientierte peripher-venöse Ernährung nach operativem Trauma.

In the postoperative state, hypercaloric parenteral nutrition is not indicated in every patient where enteral nutrition is not feasible. Low caloric protein oriented peripheral venous parenteral feeding might be an alternative nutritional regimen in moderate catabolic postoperative states. In a prospective study, 18 females received a completed nutritional solution during 4 days postoperatively following major colon surgery. The solution contained 80 g Sorbitol, 40 g Xylitol, 70 g amino acids and electrolytes (700 kcal/day). A slightly negative nitrogen balance with daily losses of about 4 g of N were observed. Routine biochemical data did not change compared to preoperative values. Plasma free amino acid homeostasis has been maintained so that conditions for optimal utilisation of the infused nutrients were given. No general side effects could be observed. This protein oriented nutritional solution may be recommended for hypocaloric peripheral venous nutrition in moderate catabolic states.

Acute pain management: analysis, implications and consequences after prospective experience with 6349 surgical patients.

An acute pain service (APS) was set up to improve pain management after operation. We attempted to reduce the length of stay in the intensive care unit (ICU) of patients undergoing major surgery and to improve their homeostasis and rehabilitation using a multimodal approach (pain relief, stress reduction, early extubation). Patient-controlled epidural analgesia (PCEA) was a keystone of this approach. If PCEA was not applicable, patients received patient-controlled intravenous analgesia (PCIA) instead. Brachial plexus blockade (BPB) was used for surgery of the upper limbs. A computer based documentation system was used to help evaluate prospectively (a) the quality of analgesia, (b) adverse effects and risks of the special pain management techniques, and (c) cost-effectiveness. Patients receiving PCEA (n = 5.602) received a patient-titrated continuous infusion into the epidural space of either bupivacaine 0.175% or ropivacaine 0.2%, with 1 microg sufentanil mL(-1) added, followed by patient-controlled boluses of 2 mL (lockout time 20 min). For patients receiving PCIA (n = 634) an initial bolus of 7.5-15 mg piritramide was given, and the subsequent bolus was 2 mg (lockout time 10 min). A continuous infusion of bupivacaine 0.25% was administered to patients receiving BPB (n = 113). The dose was titrated to a dynamic visual analogue scale (VAS) scores < 40. The mean treatment periods were: BPB = 4.33 days, PCEA = 5.6 days, PCIA = 5.0 days. In the case of PCEA, the quality of pain relief, vigilance and satisfaction were superior compared with the PCIA method, which resulted in greater sedation and nausea. Although personal supervision was higher for the PCEA-treated patients, cost analysis revealed final savings of Euro 91,620 for the year 1998 obviating the need for an ICU stay totalling 433 days. Provided that PCEA is part of a fast-track protocol employing early tracheal extubation and optimal perioperative management, the associated initial higher costs will be recouped by the benefits to patients of better pain relief after surgery and fewer days subsequently spent in the ITU.

A new method for continuous intramucosal PCO2 measurement in the gastrointestinal tract.

Gastric tonometry has been introduced for the early detection of impaired splanchnic perfusion by determination of the intramucosal PCO2. However, due to methodological problems, i.e., instability of CO2 in water, to assess the exact intramucosal PCO2 with the nasogastric tonometer is unreliable. The present in vitro and in vivo study examines a new fiberoptic PCO2 sensor for the continuous determination of the intramucosal PCO2 and compares these data with that of conventional tonometry. In an in vitro experiment the fiberoptic PCO2 sensor was used to determine the PCO2 of water and humidified air with predefined CO2 values. In both media, predefined CO2 values (35, 42, 49 mm Hg) could be assessed exactly after 9 min of equilibration with a maximum deviation less than 3.5%. In contrast, the values obtained by conventional tonometry showed larger differences. In in vivo experiments on six pigs PCO2 differences were induced by ventilatory changes to validate the fiberoptic PCO2 sensor. Under anesthesia a laparotomy was performed, the ileum punctured, and the fiberoptic PCO2 sensor introduced into the ileal lumen. Arterial PCO2 (PaCO2), mesenteric venous PCO2 (PmvCO2), and intramucosal PCO2, (PiCO2) were determined during normoventilation, hypoventilation, and hyperventilation. During hypoventilation the PiCO2 increased from 53.8 +/- 2.0 mm Hg (PaCO2 = 39.8 +/- 1.4 mm Hg, PmvCO2 = 48.7 +/- 2.7 mm Hg) to 66.5 +/- 4.9 mm Hg (PaCO2 = 52.7 +/- 3.1 mm Hg, PmvCO2 = 62.4 +/- 5.7 mm Hg). With hyperventilation the PiCO2 decreased to 46.8 +/- 2.5 mm Hg (PaCO2 = 29.8 +/- 1.8 mm Hg, PmvCO2 = 41.8 +/- 2.7 mm Hg). The coefficient of correlation (r2) between PiCO2 and PaCO2 was 0.82, and between PiCO2 and PmvCO2 0.94. The fiberoptic PCO2 sensor can determine PiCO2 in a precise and reliable manner, and can continuously record fast intraluminar changes of CO2 in the ileum that were caused by ventilatory changes. The fiberoptic PCO2 sensor is the only method that reliably monitors PiCO2 in the gastrointestinal tract. By the direct measurement of PCO2 the methodological problems associated with the conventional nasogastric tonometry are abolished.