Colonoscopic laxative instillation for the fecal-loaded colon: a case series

Context: Postoperative, critically ill, and elderly patients often have fecal loading or impaction. In a few such patients, disimpaction of fecalomas and colon cleansing are difficult. Bowel obstruction, megacolon, lower gastrointestinal bleeding, and gut perforation are complications that may ensue. Oral laxatives or enemas may only be partially effective. Surgical intervention may be needed for salvage or to treat complications. Series and Design: Fourteen hospitalized cases with defecation disorder due to fecal loading of the colon were enrolled for retrospective analysis. Colonoscopic instillation of mannitol and/or lactulose was undertaken as an intervention when the use of oral laxatives was either ineffective or unfeasible, and enema had yielded poor results. Results: Ten patients had satisfactory outcomes for fecal clearance, whereas four patients with poor or incomplete responses underwent repeat interventions or surgery. No significant complications were encountered due to this therapy. Conclusion: Colonoscopic instillation of mannitol or lactulose in fecal-loaded critically ill patients results in a safe and satisfactory fecal clearance. (AU)

Comparison of half-molar sodium lactate and mannitol to treat brain edema in severe traumatic brain injury: A systematic review / 中华创伤杂志(英文版)

PURPOSE@#Hypertonic fluids such as mannitol and half-molar sodium lactate are given to treat intracranial hypertension in patients with severe traumatic brain injury (TBI). In this study, sodium lactate was compared to mannitol in patients with TBI to investigate the efficacy in reducing intracranial pressure (ICP).@*METHODS@#This study was a systematic review with literature research on articles published in any year in the databases of PubMed, ScienceDirect, Asian Journal of Neurosurgery, and Cochrane Central Register of Controlled Trials. The keywords were "half-molar sodium lactate", "mannitol", "cerebral edema or brain swelling", and "severe traumatic brain injury". The inclusion criteria were (1) studies published in English, (2) randomized control trials or retrospective/prospective studies on TBI patients, and (3) therapies including half-molar sodium lactate and mannitol and (4) sufficient data such as mean difference (MD) and risk ratio (RR). Data analysis was conducted using Review Manager 5.3.@*RESULTS@#From 1499 studies, a total of 8 studies were eligible. Mannitol group reduced ICP of 0.65 times (MD 0.65; p = 0.64) and improved cerebral perfusion pressure of 0.61 times (MD 0.61; p = 0.88), better than the half-molar group of sodium lactate. But the half-molar group of sodium lactate maintained the mean arterial pressure level of 0.86 times, better than the mannitol group (MD 0.86; p = 0.09).@*CONCLUSION@#Half-molar sodium lactate is as effective as mannitol in reducing ICP in the early phase of brain injury, superior over mannitol in an extended period. It is able to prevent intracranial hypertension and give better brain tissue perfusion as well as more stable hemodynamics. Blood osmolarity is a concern as it increases serum sodium.

Comparative analysis of myocardial protection with htk solution and hypothermic hyperkalemic blood solution in the correction of acyanogenic congenital cardiopathies - a randomized study

Abstract Objective: The goal of the present study was to compare the myocardial protection obtained with histidine-tryptophan-ketoglutarate (HTK) cardioplegic solution (Custodiol®) and with intermittent hypothermic blood solution. Methods: Two homogenous groups of 25 children with acyanotic congenital heart disease who underwent total correction with mean aortic clamping time of 60 minutes were evaluated in this randomized study. Troponin and creatine kinase-MB curves, vasoactive-inotropic score, and left ventricular function were obtained by echocardiogram in each group. The values were correlated and presented through graphs and tables after adequate statistical treatment. Results: It was observed that values of all the studied variables varied over time, but there was no difference between the groups. Conclusion: We conclude that in patients with acyanotic congenital cardiopathies submitted to total surgical correction, mean aortic clamping time around one hour, and cardiopulmonary bypass with moderate hypothermia, the HTK crystalloid cardioplegic solution offers the same myocardial protection as the cold-blood hyperkalemic cardioplegic solution analyzed, according to the variables considered in our study model.

Histidine-tryptophan-ketoglutarate solution decreases mortality and morbidity in high-risk patients with severe pulmonary arterial hypertension associated with complex congenital heart disease: an 11-year experience from a single institution

Cardioplegic reperfusion during a long term ischemic period interrupts cardiac surgery and also increases cellular edema due to repeated solution administration. We reviewed the clinical experiences on myocardial protection of a single perfusion with histidine-tryptophan-ketoglutarate (HTK) for high-risk patients with severe pulmonary arterial hypertension associated with complex congenital heart disease. This retrospective study included 101 high-risk patients undergoing arterial switch operation between March 2001 and July 2012. We divided the cohort into two groups: HTK group, myocardial protection was carried out with one single perfusion with HTK solution; and St group, myocardial protection with conventional St. Thomas' crystalloid cardioplegic solution. The duration of cardiopulmonary bypass did not differ between the two groups. The mortality, morbidity, ICU stay, post-operative hospitalization time, and number of transfusions in HTK group were lower than those in St group (P<0.05). Univariate and multivariate analysis showed that HTK is a statistically significant independent predictor of decreased early mortality and morbidity (P<0.05). In conclusion, HTK solution seems to be an effective and safe alternative to St. Thomas' solution for cardioplegic reperfusion in high-risk patients with complex congenital heart disease.

Freeze-drying of ampicillin solid lipid nanoparticles using mannitol as cryoprotectant

abstract Solid lipid nanoparticles (SLNs) are interesting colloidal drug-delivery systems, since they have all the advantages of the lipid and polymeric nanoparticles. Freeze-drying is a widely used process for improving the stability of SLNs. Cryoprotectants have been used to decrease SLN aggregations during freeze-drying. In this study Ampicillin was chosen to be loaded in a cholesterol carrier with nano size range. To support the stability of SLNs, freeze-drying was done using mannitol. Particle size, drug release profile and antibacterial effects were studied after freeze-drying in comparison with primary SLNs. Preparations with 5% mannitol showed the least particle size enlargement. The average particle size was 150 and 187 nm before and after freeze-drying, respectively. Freeze-drying did not affect the release profile of drug loaded nanopartilces. Also our study showed that lyophilization did not change the antimicrobial effect of ampicillin SLNs. DSC analysis showed probability of chemical interaction between ampicillin and cholesterol.

resumo Nanoparticulas lipídicas sólidas (NLSs) são sistemas coloidais de liberação interessantes, uma vez que reúnem todas as vantagens de nanopartículas lipídicas e poliméricas. A liofilização é um processo amplamente utilizado para melhorar a estabilidade das NLSs e os crioprotetores têm sido usados para diminuir a agregação destas durante esse processo. Neste estudo, a ampicilina foi escolhida para ser encapsulada em um carreador de colesterol de escala nanométrica. Para manter a estabilidade das NLSs, a liofilização foi realizada utilizando-se manitol. O tamanho de partícula, o perfil de liberação do fármaco e os efeitos antibacterianos foram estudados após a liofilização em comparação com a NLSs primária. De acordo com os resultados, as preparações que contêm 5% de manitol mostraram o menor aumento do tamanho de partícula. Os resultados de tamanhos médio foram de 150 e 187 nm antes e depois da liofilização, respectivamente. O perfil de liberação prolongada, bem como o efeito antimicrobiano da ampicilina NLSs não foram alterados após a liofilização. A análise por DSC evidenciou provável interação entre a ampicilina e o colesterol.

Mannitol versus hypertonic saline for brain relaxation in patients undergoing craniotomy

BACKGROUND: Patients with brain tumour usually suffer from increased pressure in the skull due to swelling of brain tissue. A swollen brain renders surgical removal of the brain tumour difficult. To ease surgical tumour removal, measures are taken to reduce brain swelling, often referred to as brain relaxation. Brain relaxation can be achieved with intravenous fluids such as mannitol or hypertonic saline. This review was conducted to find out which of the two fluids may have a greater impact on brain relaxation. OBJECTIVES: To compare the effects of mannitol versus those of hypertonic saline on intraoperative brain relaxation in patients undergoing craniotomy. METHODS: Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 10), Medline via Ovid SP (1966 to October 2013) and Embase via Ovid SP (1980 to October 2013). We also searched specific websites, such as www.indmed.nic.in, www.cochrane-sadcct.org and www.Clinicaltrials.gov. Selection criteria: We included randomized controlled trials (RCTs) that compared the use of hypertonic saline versus mannitol for brain relaxation. We also included studies in which any other method used for intraoperative brain relaxation was compared with mannitol or hypertonic saline. Primary outcomes were longest follow-up mortality, Glasgow Outcome Scale score at three months and any adverse events related to mannitol or hypertonic saline. Secondary outcomes were intraoperative brain relaxation, intensive care unit (ICU) stay, hospital stay and quality of life. Data collection and analysis: We used standardized methods for conducting a systematic review, as described by the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. All analyses were made on an intention-to-treat basis. We used a fixed-effect ...

Surgical treatment of chronic aortoiliac occlusion / Tratamento cirúrgico da oclusão crônica aorto-ilíaca

Chronic aortoiliac occlusion (CAIO) is a significant cause of lower limb ischemia and is often found in young patients who smoke. OBJECTIVE: To review recent results achieved treating CAIO patients with open surgery. METHODS: From November 2011 to April 2014, 21 patients with CAIO were treated at the Santa Casa de Misericórdia, Porto Alegre, Brazil. Demographic data, comorbidities, clinical presentation and surgical results were analyzed. RESULTS: Eleven women and ten men were treated with direct aortic bypass (DAB; n=18) or with extra-anatomic bypass (EAD; n=3). Mean age was 53.7 ± 7.3 years (range: 43-79 years) and all patients smoked. Thirteen patients (62%) had critical ischemia. Six of the patients treated with DAB (33.4%) also required additional revascularization (3 renal and 3 femoropopliteal procedures). Perioperative mortality was zero. Four patients (22.2%) suffered transitory renal dysfunction, but only one patient (5.6%) required hemodialysis. Median follow-up time was 17 months (range: 2-29 months) and there was just one late death, from ischemic heart disease, 7 months after the surgery on the abdominal aorta. CONCLUSIONS: Aortic reconstruction is a safe method for treating patients with CAIO, with low perioperative morbidity and mortality rates...

A oclusão crônica aorto-ilíaca (OCAI) é uma importante causa de isquemia dos membros inferiores e é frequentemente encontrada em pacientes jovens e tabagistas. OBJETIVO: Revisar os resultados recentes da cirurgia aberta em pacientes com OCAI. MÉTODOS: Entre novembro de 2011 e abril de 2014, 21 pacientes com OCAI foram tratados na Santa Casa de Misericórdia de Porto Alegre. Foram analisados dados demográficos, comorbidades, apresentação clínica e resultados cirúrgicos. RESULTADOS: Onze mulheres e dez homens foram tratados com derivação aórtica direta (DAD; n=18) ou com derivação extra-anatômica (DEA; n=3). A média de idade foi 53,7 ± 7,3 anos (variação 43-79 anos), sendo todos os pacientes tabagistas. Treze pacientes (62%) apresentavam isquemia crítica. Dos pacientes submetidos à DAD, seis (33,4%) necessitaram de revascularização associada (3 renais e 3 fêmoro-poplíteas). A mortalidade perioperatória foi nula. Quatro pacientes (22,2%) desenvolveram disfunção renal transitória, mas apenas um paciente (5,6%) necessitou de hemodiálise. O tempo mediano de seguimento foi de 17 meses (variação 2-29 meses), havendo apenas um óbito tardio, por cardiopatia isquêmica, sete meses após a cirurgia da aorta abdominal. CONCLUSÃO: A reconstrução aórtica é um método seguro para o tratamento de pacientes com OCAI, com baixas taxas de morbidade e mortalidade perioperatórias...

Cerebelite aguda com herniação tonsilar: relato de caso / Acute cerebellitis with tonsillar herniation: a case report

A cerebelite aguda é uma síndrome inflamatória rara frequentemente caracterizada por rápida disfunção cerebelar. Neste estudo relatamos os achados de imagem do caso de uma criança com cerebelite aguda, herniação tonsilar e hidrocefalia hipertensiva. O agente etiológico não foi descoberto. O tratamento foi conservador, com manitol e corticoide. A análise evolutiva por imagem demonstrou resolução do quadro clínico sem sequelas.

Acute cerebellitis is a rare inflammatory syndrome frequently characterized by fast onset of cerebellar dysfunction. The present case report describes imaging findings in a child with acute cerebellitis, tonsillar herniation and hypertensive hydrocephalus. The etiologic agent has not been determined. A conservative management was adopted, with corticoid and diuretic drugs. Imaging follow-up demonstrated resolution of the clinical condition with no sequela.

Basal ganglia involvement in herpes simplex encephalitis.

Herpes simplex encephalitis (HSE) is a leading cause of sporadic, nonepidemic viral encephalitis in children and adults. We report a very rare case of HSE with involvement of bilateral thalamus, putamen, upper pons and midbrain, with development of extrapyramidal symptoms which responded to corticosteroid therapy. A 15-mth-old female baby admitted with complaint of fever for 5 days and generalised tonic clonic seizure 10 hours before admission. On clinical examination patient was drowsy, temperature was 39.4 oC and vitals were stable with signs of increased intracranial tension. There were no signs of meningeal irritation. Patient gradually become unconscious in the next few hours and pupils were constricted bilaterally with development of atonia in all four limbs and neck muscles. Doll’s eye phenomenon was absent.

Estudo comparativo entre manitol e polietilenoglicol no preparo intestinal para colonoscopia / Manitol versus polyethylene glycol in bowel preparation for colonoscopy

OBJETIVOS: O estudo visa comparar o preparo intestinal para colonoscopia com manitol a 10 por cento, com o uso de polietilenoglicol (PEG). Levou-se em conta o custo de cada preparo, tolerabilidade, eficácia, e alterações bioquímicas causadas pela administração. MÉTODOS: Desenvolveu-se um ensaio clínico randomizado, duplo-cego, unicêntrico. Pacientes que já haviam feito o exame foram excluídos. Fez-se a dosagem de hematócrito, sódio, potássio e cloretos antes e depois do preparo. Escalas de sintomatologia e eficácia foram utilizadas. O custo foi calculado pelo volume médio necessário para obter-se evacuação com líquido claro sem resíduos. RESULTADOS: Foi necessário um litro a mais de solução de PEG para o preparo. Apesar disso, a tolerabilidade desta solução foi melhor. Na avaliação do colonoscopista sobre a qualidade do preparo, o manitol obteve vantagem. Não houveram alterações bioquímicas significativas, e o custo foi comparável. CONCLUSÃO: O manitol, apesar de parecer provocar mais sintomatologia nos pacientes, é mais eficaz na limpeza do cólon. Apesar de não ter seu uso endossado pelos últimos consensos internacionais, mostra-se seguro e eficaz. O PEG torna-se de custo vantajoso quando comprado pelo paciente, porém o manitol é mais barato em ambiente hospitalar.

OBJECTIVES: The present study aims to analyze bowel preparation for colonoscopy with mannitol compared to polyethylene glycol (PEG). Variables were the cost of preparation, patient acceptance, efficacy, and biochemical imbalances due to the use. METHODS: A randomized, double-blind, unicentric clinical trial was designed. Patients already submitted to colonoscopies were excluded. Haematocrit, sodium, potassium, and chloride were evaluated before and after the administration. Symptom and efficacy scores were determined, and the cost was calculated by the average volume of solution necessary to produce a clear-liquid passage. RESULTS: It took one liter more of PEG solution to obtain an acceptable preparation. Yet, the compliance to that medication was better. The evaluation of quality by the endoscopist was superior in the mannitol group. Biochemical alterations were not significant, and a comparable cost was observed. CONCLUSION: Mannitol, despite causing more symptoms in patients, is more effective to clean the bowel lumen. Recent international consensus statements do not endorse the use of manitol, but it proves to be safe and efficient. PEG becomes cost-effective when bought over-the-counter by patients, but in hospital environment, mannitol is less expensive.

Management of intracranial hypertension.

Raised intracranial pressure (ICP) is a life threatening condition that is common to many neurological and non-neurological illnesses. Unless recognized and treated early it may cause secondary brain injury due to reduced cerebral perfusion pressure (CPP), and progress to brain herniation and death. Management of raised ICP includes care of airway, ventilation and oxygenation, adequate sedation and analgesia, neutral neck position, head end elevation by 200 -300, and short-term hyperventilation (to achieve PCO2 32- 35 mm Hg) and hyperosmolar therapy (mannitol or hypertonic saline) in critically raised ICP. Barbiturate coma, moderate hypothermia and surgical decompression may be helpful in refractory cases. Therapies aimed directly at keeping ICP <20 mmHg have resulted in improved survival and neurological outcome. Emerging evidence suggests that cerebral perfusion pressure targeted therapy may offer better outcome than ICP targeted therapies.

Isoniazid Toxicity Presenting As Status Epilepticus and Severe Metabolic Acidosis.

Isoniazid (INH) is an integral component of treatment of tuberculosis. An acute overdose is potentially fatal and is characterized by the clinical triad of repetitive seizures unresponsive to the usual anticonvulsants, metabolic acidosis with a high anion gap and coma. The diagnosis of INH overdose should be considered in any patient who presents to emergency medical services (EMS) with the triad. We report a patient presenting with multiple generalised tonic clonic (GTC) convulsions with severe metabolic acidosis as a manifestation of INH toxicity. ©

Bilateral anterior cerebral artery infarction following viper bite.

The viper is one of India’s most commonly encountered poisonous snakes and envenomation following viper bite usually leads to consumption coagulopathy. Clinical manifestations most frequently include external and internal bleeding. In the setting of viper envenomation, large-vessel thrombosis is a very rare occurrence. Also, bilateral anterior cerebral artery infarction, when unrelated to anatomical abnormalities, subarachnoid haemorrhage, surgery or trauma, itself is an exceedingly rare event. We report a case of a 24-year-old previously healthy man who presented with bilateral anterior cerebral artery infarction following a viper bite. We also present hypotheses that may explain this unusual occurrence. ©

Posterior circulation stroke in a young male following snake bite.

Neurological deficits can occur following snake bite. It is usually due to intracerebral haemorrhage or subarachnoid bleed as a result of depletion of clotting factors. A healthy 14-years-old male developed bilateral ptosis and altered sensorium within 3 hours of snake bite. CT Brain revealed bilateral cerebellar and right occipital infarction with mass effect. Clotting time and bleeding time were normal. The possible mechanism for infarction in this patient is discussed.

Comparison of colon-cleansing methods in preparation for colonoscopy - Comparative efficacy of solutions of mannitol, sodium picosulfate and monobasic and dibasic sodium phosphates / Estudo comparativo entre as soluções de manitol, picossulfato de sódio e fosfato monobásico e dibásico de sódio no preparo de cólon para colonoscopia

PURPOSE: Colonoscopy plays an essential role in the therapeutic and diagnostic approach in various colonic pathologies, the aim of the present study was to compare three solutions and their efficacy for the bowel preparation in adult patients submitted to elective colonoscopy. METHODS: Sixty patients were randomly divided into three groups of 20 each. Each group was submitted to a bowel preparation with one of the following solutions: 10 percent manitol, sodium picosulphate or sodium phosphate. The parameters evaluated were: taste, tolerance, associated side effects and quality of cleansing. Postural blood pressure and pulse rate as well as serum sodium, potassium, calcium and phosphate were compared. RESULTS: Sodium phosphate and 10 percent manitol solutions provided superior results in terms of colon cleansing compared to sodium picosulphate solution. All serum electrolytes evaluated were significantly altered in the three groups, without important clinical signs. DISCUSSION: High levels of serum phosphate were the most striking alteration in patients prepared with sodium phosphate solution, again with no clinical signs. Variations related to blood pressure and pulse rate suggested contraction of intravascular volume, with no clinical effects. CONCLUSION: Sodium phosphate and 10 percent manitol solutions are equivalent in providing good quality colon cleansing, with no significant side effects that could compromise the procedure.

INTRODUÇÃO: A colonoscopia é exame fundamental na avaliação das doenças do cólon e na abordagem terapêutica de determinado grupo de patologias. O preparo intestinal é obrigatório para a realização das colonoscopias eletivas, e a qualidade encontra-se relacionada ao sucesso do procedimento. Comparou-se três soluções para limpeza anterógrada do cólon em pacientes adultos, submetidos à colonoscopia. METODOS: Sessenta pacientes foram distribuídos em três grupos de vinte. Cada grupo realizou o preparo do cólon com uma das três soluções estudadas: manitol a 10 por cento (MN), picossulfato sódico (PS) e fosfato monobásico e dibásico de sódio (NaP). O sabor, a tolerância, os efeitos colaterais, os custos e a qualidade de limpeza do preparo foram avaliados. Frequência cardíaca e pressão arterial sistêmica foram analisados. Variações dos eletrólitos foram dosados antes e após o preparo. RESULTADOS: Os resultados foram semelhantes em relação aos efeitos colaterais. O sabor da solução de NaP não chegou a comprometer a sua aceitação. DISCUSSÃO: Soluções de NaP e MN proporcionaram resultados superiores tanto em qualidade de limpeza colônica, como em relação aos custos, quando comparadas à solução de PS. CONCLUSÃO: Comparados os três, os eletrólitos avaliados apresentaram diferenças significativas, sendo a hiperfosfatemia dos pacientes com a solução de NaP, a mais importante.

Grave prognosis on spontaneous intracerebral haemorrhage: GP on STAGE score.

BACKGROUND AND OBJECTIVE: Spontaneous intracerebral haemorrhage (ICH) is more common in Asia than in western countries, and has a high mortality rate. A simple prognostic score for predicting grave prognosis of ICH is lacking. Our objective was to develop a simple and reliable score for most physicians. MATERIAL AND METHOD: ICH patients from seven Asian countries were enrolled between May 2000 and April 2002 for a prospective study. Clinical features such as headache and vomiting, vascular risk factors, Glasgow coma scale (GCS), body temperature (BT), blood pressure on arrival, location and size of haematoma, intraventricular haemorrhage (IVH), hydrocephalus, need for surgical treatment, medical treatment, length of hospital stay and other complications were analyzed to determine the outcome using a modified Rankin scale (MRS). Grave prognosis (defined as MRS of 5-6) was judged on the discharge date. RESULTS: 995 patients, mean age 59.5 +/- 14.3 years were analyzed, after exclusion of incomplete data in 87 patients. 402 patients (40.4%) were in the grave prognosis group (MRS 5-6). Univariable analysis and then multivariable analysis showed only four statistically significant predictors for grave outcome of ICH. They were fever (BT > or = 37.8 degrees c), low GCS, large haematoma and IVH. The grave prognosis on spontaneous intracerebral haemorrhage (GP on STAGE) score was derived from these four factors using a multiple logistic model. CONCLUSION: A simple and pragmatic prognostic score for ICH outcome has been developed with high sensitivity (82%) and specificity (82%). Furthermore, it can be administered by most general practitioners. Validation in other populations is now required.

Adjuvant therapy in cerebral malaria.

Cerebral malaria is the most common cause of non-traumatic encephalopathy in the world. The mainstay of therapy is either quinine or artemisinin, both of which are effective antimalarials. The clinical picture of cerebral malaria may persist or even become worse in spite of the clearance of parasites from blood. The death rate is unacceptably high even with effective antimalarials in tertiary care hospitals. The mortality increases in presence of multi organ failure (renal failure, jaundice, respiratory distress, severe anaemia, lactic acidosis, etc.). The pathogenesis of cerebral malaria is multifactorial and includes clogging, sequestration, rosette formation, release of cytokines, cerebral oedema, increased intracranial hypertension, etc. Attempts are made to use adjuvant therapy which will act through alternate mechanisms and address one or more of the pathogenetic processes. In this review, we have discussed the role of corticosteroids, pentoxifylline, desferrioxamine, mannitol and newer agents in the treatment of cerebral malaria. Though the literature on adjuvant therapy in cerebral malaria is large enough, there are a number of shortcomings in the clinical trials, many being open and non randomized or of very small sample size. Further research is of utmost importance through large multicentric, double-blind controlled trials to show the efficacy of any of these drugs.