Impact of cumulative fluid balance on the pharmacokinetics of extended infusion meropenem in critically ill patients with sepsis.

BACKGROUND: Meropenem dosing for septic critically patients is difficult due to pathophysiological changes associated with sepsis as well as supportive symptomatic therapies. A prospective single-center study assessed whether fluid retention alters meropenem pharmacokinetics and the achievement of the pharmacokinetic/pharmacodynamic (PK/PD) targets for efficacy. METHODS: Twenty-five septic ICU patients (19 m, 6f) aged 32-86 years with the mean APACHE II score of 20.2 (range 11-33), suffering mainly from perioperative intra-abdominal or respiratory infections and septic shock (n = 18), were investigated over three days after the start of extended 3-h i.v. infusions of meropenem q8h. Urinary creatinine clearance (CLcr) and cumulative fluid balance (CFB) were measured daily. Plasma meropenem was measured, and Bayesian estimates of PK parameters were calculated. RESULTS: Eleven patients (9 with peritonitis) were classified as fluid overload (FO) based on a positive day 1 CFB of more than 10% body weight. Compared to NoFO patients (n = 14, 11 with pneumonia), the FO patients had a lower meropenem clearance (CLme 8.5 ± 3.2 vs 11.5 ± 3.5 L/h), higher volume of distribution (V1 14.9 ± 3.5 vs 13.5 ± 4.1 L) and longer half-life (t1/2 1.4 ± 0.63 vs 0.92 ± 0.54 h) (p < 0.05). Over three days, the CFB of the FO patients decreased (11.7 ± 3.3 vs 6.7 ± 4.3 L, p < 0.05) and the PK parameters reached the values comparable with NoFO patients (CLme 12.4 ± 3.8 vs 11.5 ± 2.0 L/h, V1 13.7 ± 2.0 vs 14.0 ± 5.1 L, t1/2 0.81 ± 0.23 vs 0.87 ± 0.40 h). The CLcr and Cockroft-Gault CLcr were stable in time and comparable. The correlation with CLme was weak to moderate (CLcr, day 3 CGCLcr) or absent (day 1 and 2 CGCLcr). Dosing with 2 g meropenem q8h ensured adequate concentrations to treat infections with sensitive pathogens (MIC 2 mg/L). The proportion of pre-dose concentrations exceeding the MIC 8 mg/L and the fraction time with a target-exceeding concentration were higher in the FO group (day 1-3 f Cmin > MIC: 67 vs 27%, p < 0.001; day 1%f T > MIC: 79 ± 17 vs 58 ± 17, p < 0.05). CONCLUSIONS: These findings emphasize the importance of TDM and a cautious approach to augmented maintenance dosing of meropenem to patients with FO infected with less susceptible pathogens, if guided by population covariate relationships between CLme and creatinine clearance.

Methodology for the Implementation of Internal Standard to Laser-Induced Breakdown Spectroscopy Analysis of Soft Tissues.

The improving performance of the laser-induced breakdown spectroscopy (LIBS) triggered its utilization in the challenging topic of soft tissue analysis. Alterations of elemental content within soft tissues are commonly assessed and provide further insights in biological research. However, the laser ablation of soft tissues is a complex issue and demands a priori optimization, which is not straightforward in respect to a typical LIBS experiment. Here, we focus on implementing an internal standard into the LIBS elemental analysis of soft tissue samples. We achieve this by extending routine methodology for optimization of soft tissues analysis with a standard spiking method. This step enables a robust optimization procedure of LIBS experimental settings. Considering the implementation of LIBS analysis to the histological routine, we avoid further alterations of the tissue structure. Therefore, we propose a unique methodology of sample preparation, analysis, and subsequent data treatment, which enables the comparison of signal response from heterogenous matrix for different LIBS parameters. Additionally, a brief step-by-step process of optimization to achieve the highest signal-to-noise ratio (SNR) is described. The quality of laser-tissue interaction is investigated on the basis of the zinc signal response, while selected experimental parameters (e.g., defocus, gate delay, laser energy, and ambient atmosphere) are systematically modified.

Use of autologous platelet-rich plasma in healing skin graft donor sites.

OBJECTIVE: To demonstrate that the use of platelet-rich plasma (PRP) enhances both the quality of healing and the time required for wound healing at a skin graft donor site. METHODS: Patients who had dermo-epidermal skin grafts taken from the thigh area were included in a prospective, randomised clinical study. PRP was applied to one donor site and then covered with Vaseline-impregnated, open-weave gauze and gauze, while the contralateral donor site on the other thigh served as a control and was covered with the open-weave gauze and gauze without PRP. RESULTS: A total of 24 patients took part in the study, of which three developed infections and were thus removed from the study. Use of PRP reduced the wound healing time of the dermo-epidermal graft donor sites by a mean 17.8% and median 18 days. On average, the treated donor sites healed in 14.9 days compared with 18.4 days for the control group. The median was 14 days compared with 18 days in the control group (p=0.026). In one patient, healing was slower on the side where PRP was applied. In 20 patients, healing of the donor site was accelerated where PRP was applied. CONCLUSION: The study demonstrated a beneficial effect of PRP, as healing time was shortened. Using PRP to heal wounds could be beneficial for patients for whom commonly available wound healing therapies have failed, as well as for high-risk patient groups for whom problematic wound healing may be expected.

Quality of Life after Reconstructive Surgery for Intestinal Fistulas.

BACKGROUND: This retrospective clinical study would like to objectively denote a quality of life of persons afflicted by an abdominal catastrophe and managed by an extensive surgery can be almost as well conformable as those of healthy people in a similar age group. METHODS: A set of eighteen patients who were successfully surgically treated and cured enjoyed a relatively good convalescence after their surgery and returned to a satisfactory standard of life from the point of view of organ function and psychosomatic state. Statistical analysis of the data collected over a period of 1 to 6 years after this complex therapy using special questionnaire for QOL assessment SF-36 was performed. RESULTS: Almost half of the patients evaluated their state similarly to the rest of the population of comparable age and general health status. The remainder of the patients declared significantly worse evaluations in the majority of the observed domains of the questionnaire. CONCLUSION: Therapy of these patients was and must be complex: it included preparation for surgery at a special metabolic internal site, careful diagnostics of the digestive tract state, suitable surgery and good quality care after the surgery.

Modern methods for vancomycin determination in biological fluids by methods based on high-performance liquid chromatography--A review.

Vancomycin is a glycopeptide antibiotic used in the therapy of severe bacterial infection. The monitoring of vancomycin levels is recommended because of its narrow therapeutic index and toxicity. This measurement is especially appropriate in patients with unstable renal functions, who receive high doses of vancomycin or present serious bacterial infections accompanied by important sequestration of liquids when it could be difficult to achieve the optimal therapeutic dose. Most of the methods for vancomycin determination in routine practice are immunoassays. However, chromatography-based techniques in combination with UV or mass spectrometry detection provide results with greater accuracy and precision also in complicated biological matrices. This review provides a detailed overview of modern approaches for the chromatographic separation of vancomycin in various biological samples and useful sample preparation procedures for vancomycin determination in various biological fluids.

Imaging the elemental distribution within human malignant melanomas using Laser-Induced Breakdown Spectroscopy.

The diagnosis of malignant melanoma, often an inconspicuous but highly aggressive tumor, is most commonly done by histological examination, while additional diagnostic methods on the level of elements and molecules are constantly being developed. Several studies confirmed differences in the chemical composition of healthy and tumor tissue. Our study presents the potential of the LIBS (Laser-Induced-Breakdown Spectroscopy) technique as a diagnostic tool in malignant melanoma (MM) based on the quantitative changes in elemental composition in cancerous tissue. Our patient group included 17 samples of various types of malignant melanoma and one sample of healthy skin tissue as a control. To achieve a clear perception of results, we have selected two biogenic elements (calcium and magnesium), which showed a dissimilar distribution in cancerous tissue from its healthy surroundings. Moreover, we observed indications of different concentrations of these elements in different subtypes of malignant melanoma, a hypothesis that requires confirmation in a more extensive sample set. The information provided by the LIBS Imaging method could potentially be helpful not only in the diagnostics of tumor tissue but also be beneficial in broadening the knowledge about the tumor itself.

Can early postoperative parenteral nutrition have some impact on postoperative inflammatory response intensity?

BACKGROUND AND AIMS: Enhanced recovery after surgery (ERAS) is currently the modern perioperative method of care for improvement of post-surgery patient condition and for minimising various postoperative complications. A question of some negative impact of early postoperative parenteral nutrition on postoperative inflammatory response intensity has not clear-cut answer yet. This pilot project was focused on the possible influence of early parenteral nutrition on the intensity of inflammatory postoperative response to operating trauma in surgical patients. Elected as a model of these conditions were patients with colorectal cancer undergoing major surgery. PATIENTS AND METHODS: 45 patients (of whom 39 were analysed finally) operated for cancer of the large bowel were enrolled into the clinical, prospective, randomized, blinded, and monocentric trial - reference number 201811 S09P of the Ethics committee, University Hospital Hradec Kralove, Czech Republic. Patients were divided into two subgroups according to the type of nutrition: subgroup A - supplemented only with 10% glucose for supported mineral carrier; and subgroup B - supplemented with total parenteral nutrition. Samples of blood and urine were examined immediately after surgery, and on the first, second, and fourth days postoperatively. The inflammatory reaction was monitored by the serum or/and urine concentration of neopterin, tryptophan, and kynurenine, and their urinary ratios with creatinine. The results were analysed by multivariate analysis, and p-values ≤ 0.05 were considered statistically significant. RESULTS: The final total of 39 patients comprised 20 from subgroup A and 19 from subgroup B. The intensity of the inflammatory response detected by the selected inflammatory markers (serum and urine concentrations of neopterin, kynurenine, tryptophan, their serum ratios, and their urinary ratios to creatinine) did not demonstrate statistically significant differences after early administration of the two alternative types of parenteral nutrition. CONCLUSIONS: The results of the study demonstrated the same or a very similar impact on the intensity of postoperative inflammatory response, regardless of whether the patient received intravenous administration of a small simple sugar infusion or total parenteral nutrition during early postoperative care.

Various surgical techniques for the repair of injured vas deferens in rat experiments.

OBJECTIVE: The aim of this study was to evaluate whether the different vasovasostomy techniques can be performed using only the operating loupe in a rat model. The secondary aims were to evaluate the patency rate and inflammation of the vas deferens (VD) after contusion and the different vasovasostomy repair techniques. METHODS: A total of 40 male rats were divided into 4 groups based on the type of surgery: 1. contusion of the VD; 2. cutting of the VD and vasovasostomy with absorbable sutures; 3. cutting and joining of the VD using absorbable sutures with an intraluminally situated lead fibre; and 4. cutting and joining of the VD using non-absorbable sutures with an intraluminally situated lead fibre. Ninety days after the surgery the VD was resected, patency and histopathological signs of inflammation in the VD were evaluated. RESULTS: All vasovasostomy techniques were successfully performed in all animals using only the operating loupe. The patency rate was 100% in the subgroup with contusion. Differences in the patency rates were found among the subgroups with vasovasostomy (P=0.007). The patency rate was higher in the subgroup that underwent group 3. Compared with vasovasostomies, contusion was associated with lower rates of inflammation (P=0.02) and severe inflammation (P=0.003). No differences were found among the subgroups of vasovasostomy techniques. CONCLUSION: Contusion of the VD was not related to impairment in terms of patency. Vasovasostomy with an intraluminally situated lead fibre resulted in the highest patency rate among the standard vasovasostomy techniques.

Effect of short-term administration of lipid emulsion on endothelial glycocalyx integrity in ICU patients - A microvascular and biochemical pilot study.

BACKGROUND: Endothelial glycocalyx (EG) is a carbohydrate-rich vascular lining of the apical surface of endothelial cells. It has been proved to have an essential role in vascular homeostasis. Lipid emulsions as part of parenteral nutrition (PN) are widely used in patients in the setting of critical care and perioperative medicine. Due to their structure, lipids may potentially interact with EG. The aim of the study was to evaluate the effect of lipid emulsion on EG. OBJECTIVE: To assess the influence of lipid emulsion on EG integrity in ICU patients using a videomicroscopic and biochemical methods. METHODS: Patients in surgical ICU after major abdominal surgery or cardio surgery and in general ICU were assessed for eligibility for this pilot observational study in University Hospital. The study was performed during the first day of adding lipids as a part of their PN. The patients were given the SMOFlipid 20% for 6 hours in prescribed dose of approx. 1 g/kg of body weight. EG integrity was measured indirectly by automated sublingual videomicroscopy calculating a parameter PBR which describes the amount of lateral deviation of red blood cells from the central column and by levels of syndecan-1 and syndecan-4 in plasma as EG degradational products. Measurements were performed before lipid administration (T0) and 30 minutes after (T6) the infusion of lipid emulsion was completed. The statistical analysis was performed at the level of significance p < 0.05, data are expressed as mean ± standard deviation (SD) and for PBR as median and interquartile range (IQR). RESULTS: Fifteen patients were studied, from them 9 included in final analysis. PBR (expressed in µm) increased after the lipid infusion with no statistical significance (T0 = 2.10; 1.97-2.33 vs. 2.28; 2.11-2.45, p = 0.13). At T6 both syndecans showed statistically significant decrease in their particular levels. Syndecan-1 at T0 = 2580±1013 ng/l, resp. at T6 = 2365±1077 ng/l, p = 0.02; syndecan-4 at T0 = 134±29 ng/l, resp. at T6 = 123±43 ng/l, p = 0.04. CONCLUSION: In our study, we showed that six hours long SMOFlipid 20% infusion had no detrimental effect on the EG integrity as assessed by PBR value and by syndecan-1 and syndecan-4 plasmatic levels. Observed decrease of syndecans shortly after lipid infusion allows us to hypothesize even possibly protecting effect of lipids on EG.

Covariate determinants of effective dosing regimens for time-dependent beta-lactam antibiotics for critically ill patients.

AIMS: Critically ill patients undergoing aggressive fluid resuscitation and treated empirically with hydrosoluble time-dependent beta-lactam antibiotics are at risk for sub-therapeutic plasma concentrations. The aim of this study was to assess the impact of two covariates - creatinine clearance (Clcr) and cumulative fluid balance (CFB) on pharmacokinetics/pharmacodynamics (PK/PD) target attainment within a week of treatment with meropenem (ME) or piperacillin/tazobactam (PIP/TZB). METHODS: In this prospective observational pharmacokinetic (PK) study, 18 critically ill patients admitted to a surgical Intensive Care Unit (ICU) were enrolled. The primary PK/PD target was free antibiotic concentrations above MIC at 100% of the dosing interval (100%fT>MIC) to obtain maximum bactericidal activity. Drug concentration was measured using liquid chromatography-tandem mass spectrometry. RESULTS: The treatment of both 8 septic patients with IV extended ME dosing 2 g/3 h q8 h and 10 polytraumatized patients with IV intermittent PIP/TZB dosing 4.0/0.5 g q8 h was monitored. 8/18 patients (44%) manifested augmented renal clearence (ARC) where Clcr ≥130 mL/min/1.73 m2. Maximum changes were reported on days 2-3: the median positive CFB followed by the large median volume of distribution: Vdme=70.3 L (41.9-101.5), Vdpip = 46.8 L (39.7-60.0). 100%fTme>MIC was achieved in all patients on ME (aged ≥60 years), and only in two patients (non-ARC, aged ≥65 years) out of 10 on PIP/TZB. A mixed model analysis revealed positive relationship of CFBpip with Vdpip (P=0.021). CONCLUSION: Assuming that the positive correlation between CFB and Vd exists for piperacillin in the setting of the pathological state, then CFB should predict Vdpip across subjects at each and every time point.

The effect of three different surgical techniques for colon anastomosis on regional postoperative microperfusion: Laser Doppler Flowmetry study in pigs.

BACKGROUND: The optimal surgical approach to reconnecting bowel ends safely after resection is of great importance. OBJECTIVES: This project is focused on assessment of the perianastomotic microcirculation quality in the short postoperative period when using three different anastomosis techniques in experimental animal. METHODS: The experimental study involved 27 young female domestic pigs divided into three subgroups of 9 animals according to each surgical method of anastomosis construction in the sigmoid colon region: by manual suture, by stapler, or by gluing. Blood microcirculation in the anastomosis region was monitored using Laser Doppler Flowmetry (LDF). Anastomosis healing was evaluated by macroscopic and histological examination. RESULTS: Evaluation of the microcirculation in the anastomosis region showed the smallest decrease in perfusion values in animals reconstructed by suturing (Δ= -38.01%). A significantly more profound drop was observed postoperatively after stapling or gluing (Δ= -52.42% and Δ= -59.53%, respectively). All performed anastomoses healed without any signs of tissue and function pathology. CONCLUSIONS: Sewing, stapling, and gluing techniques for bowel anastomosis each have a different effect on regional microcirculation during 120 min. postoperatively. Nevertheless, the final results of anastomosis healing were found without of any pathology in all experimental animals managed by above mentioned anastomotic techniques.

Simple and rapid quantification of vancomycin in serum, urine and peritoneal/pleural effusion via UHPLC-MS/MS applicable to personalized antibiotic dosing research.

Management of the therapy of life-threatening bacterial infection is extremely based on an optimal antibiotic treatment. Achieving the correct vancomycin dosage in blood and target tissues can be complicated in special situations, e.g., where large fluid sequestration and/or acute renal failure occur. A UHPLC-MS/MS method operating in electrospray (ESI) positive ion mode was applied for the determination of vancomycin in serum, urine and peritoneal/pleural effusion. Sample pretreatment was composed of dilution and simple protein precipitation where only a small volume (50µL) of serum, urine or peritoneal/pleural effusion was required. The separation of vancomycin was performed on a Meteoric Core C18 BIO column (100×4.6mm, 2.7µm) by gradient elution with 0.1% formic acid in water and acetonitrile. The total time of analysis was 4.5min. The method was found to be linear in the range of 2-60µM (or 0.5-10µM) for serum, 0.27-10µM (or 2-60µM) for peritoneal/pleural effusion and 25-300µM for urine, which was adequate for the determination of vancomycin in patient samples. The intra- and inter-day precision was below 8% RSD, and accuracy was from 89 to 104%. The UHPLC/MS-MS method offers a fast and reliable approach to determine vancomycin concentrations in three different human body fluid samples (serum, urine and peritoneal/pleural effusion) with a simple sample pretreatment that was the same for all selected specimens. This method should be applicable to large sample series in clinical (pharmacokinetic/pharmacodynamic) studies.

A pilot study on pharmacokinetic/pharmacodynamic target attainment in critically ill patients receiving piperacillin/tazobactam.

BACKGROUND: In critically ill patients, multi-trauma and intensive therapy can influence the pharmacokinetics (PK) and pharmacodynamics (PD) of antibiotics with time-dependent bacterial killing. Consequently, PK/PD targets (%fT>MIC) - crucial for antimicrobial effects -may not be attained. METHODS: Two patients admitted to the surgical ICU of the University Hospital in Hradec Králove for multiple-trauma were given piperacillin/tazobactam by 1-hour IV infusion 4/0.5 g every 8h. PK variables: total and renal clearance (CLtot, CLR), volume of distribution (Vd), and elimination half-life (T1/2) were calculated, followed by glomerular filtration rate (MDRD) and cumulative fluid balance (CFB-total fluid volume based on 24-h registered fluid intake minus output). The PK/PD target attainment (100%fT>MIC) was defined as free (f) piperacillin plasma concentrations that remain, during the entire dosing interval (T), above the minimum inhibitory concentration (100%fT>MIC) within days 4-8 (when CFB culminates and disappears). Piperacillin concentrations were determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and corrected for unbound fraction (22%). RESULTS: CFB culminated over days 2-5 reaching 15-30 L and was associated with a large Vd (29-42 L). While MDRD in patient 1 was low (0.3-0.4 mL s⁻¹ 1.7 m⁻²), that of patient 2 was increasing (> 3.1 mL s⁻¹ 1.7 m⁻²), which was associated with augmented CLR. In patient 2, the fT reached only 62, 52, and 44% on days 4, 6, and 8, respectively. In patient 1, the %fT was much higher, attaining values four to fivefold greater than that targeted. CONCLUSIONS: Critically ill patients are at risk of drug under- or overdosing without dose up-titration with regard to covariate effects and individual drug pharmacokinetics.

Dynamics of antioxidants in patients with acute pancreatitis and in patients operated for colorectal cancer: a clinical study.

OBJECTIVES: This clinical study compared the dynamics of antioxidants levels in patients with acute pancreatitis (AP), patients operated for colorectal cancer (CA), and healthy control subjects. METHODS: This prospective descriptive study enrolled 21 AP and 14 CA patients and 17 healthy controls. Blood was collected from AP patients on days 1, 5, and 9 and from CA patients before surgery and on days 1, 5, and 9 after surgery. We measured concentrations of selenium in plasma, red blood cells (RBCs), and big-toe nails, vitamin A (retinol) in serum, alpha-tocopherol in serum and in RBCs, vitamin C in serum, concentration ratio of 9,11- and 10,12-octadecanoic acids to linoleic acid in RBC membrane, activity of superoxide dismutase, and glutathione peroxidase in RBCs. RESULTS: Plasma concentrations of selenium, vitamin A, and vitamin C were significantly lower in AP and CA patients than in healthy controls over the monitored period (P < 0.05). Patients with severe AP had a significantly lower concentration of selenium in RBCs than did healthy controls and CA patients (P < 0.05). The concentration of selenium in toe nails of AP patients was significantly lower than that in CA patients and healthy controls (P < 0.001). The marker of increased reactive oxygen species activity the ratio of 9,11- and 10,12-octadecanoic acids to linoleic acid in RBCs was significantly higher in AP and CA patients than in healthy controls (P < 0.05). CONCLUSIONS: Low levels of measured antioxidants and increased activity of reactive oxygen species occurred during the course of AP. These findings applied in particular to patients who had severe AP. Levels of measured antioxidants seemed to be similar in AP and CA patients except for lower levels of selenium in toe nails in AP patients and lower selenium concentrations in RBCs in patients with severe AP.

Markers of Perioperative Bowel Complications in Colorectal Surgery Patients.

Colorectal cancer is a clinical condition whose treatment often involves intestinal resection. Such treatment frequently results in two major gastrointestinal complications after surgery: anastomotic leakage and prolonged ileus. Anastomotic leakage is a serious complication which, more often than not, is diagnosed late; to date, C-reactive protein is the only available diagnostic marker. A monocentric, prospective, open case-control study was performed in patients (n = 117) undergoing colorectal surgery. Intestinal fatty acid binding protein (i-FABP), citrulline, D-lactate, exhaled hydrogen, Escherichia coli genomic DNA, and ischemia modified albumin (IMA) were determined preoperatively, postoperatively, and on the following four consecutive days. Bacterial DNA was not detected in any sample, and i-FABP and D-lactate lacked any distinct potential to detect postoperative bowel complications. Exhaled breath hydrogen content showed unacceptably low sensitivity. However, citrulline turned out to be a specific marker for prolonged ileus on postoperative days 3-4. Using a cut-off value of 20 µmol/L, a sensitivity and specificity of ~75% was achieved on postoperative day 4. IMA was found to be an efficient predictor of anastomosis leak by calculating the difference between preoperative and postoperative values. This test had 100% sensitivity and 80% specificity and 100% negative and 20% positive predictive value.

Differential effects of intravenous anesthetics on hepatosplanchnic microcirculation in rats: sidestream dark-field imaging study.

This study aimed to investigate the effects of intravenous anesthetics on hepatosplanchnic microcirculation in laparotomized mechanically ventilated rats using Sidestream Dark-field (SDF) imaging. Thirty male Wistar rats were divided into 5 groups (n = 6 each). All rats were initially anesthetized with 60 mg/kg pentobarbital (i.p.) for instrumentation. This was followed by either ketamine, propofol, thiopental, midazolam or saline+fentanyl (iv bolus over 5 min and then maintenance over 90 min). SDF imaging of the liver and distal ileum microcirculation was performed at the baseline and at t = 5, 35, 65 and 95 min. In propofol group there was increase of functional sinusoidal density (FSD) following induction (+25%, P < 0.05) and maintenance at t = 95 min (+10.3%, P < 0.05), in ketamine and midazolam group decrease of FSD was observed after induction (-20.4%, P < 0.05; -10.1%, P < 0.05) and during maintenance at t = 65 min (-11.6%, P < 0.05; -11.4%, P < 0.05) when compared to baseline. Following induction with propofol functional capillary density (FCD) of ileal longitudinal muscle layer increased (+10.6%, P < 0.05) and returned to baseline values during maintenance. Ketamine and midazolam decreased FCD of longitudinal layer after induction (-24.6%, P < 0.05; -21.1%, P < 0.05) and remained decreased during maintenance at t = 95 min (-10.8%, P < 0.05; -15.5%, P < 0.05). In thiopental and control group, changes in microcirculatory parameters were not significant throughout the study. In conclusion, intravenous anesthetics affect the hepatosplanchnic microcirculation differentially, propofol has shown protective effect on the liver and intestinal microcirculation.

Mechanical ileus caused by a tablet of tralgit SR 100 stuck in a stenotic rectum affected by carcinoma: case report and literature survey.

A patient with an advanced carcinoma in the recto-sigmoideum was taken for urgent operation because of abdominal pain, significant distension of colon, clinical symptoms and radiological proofs of ileus. The cause of the complete obstruction of the proximal rectum which was significantly narrowed by a tumour was one tablet of Tralgit SR 100, which had been administered to the patient for 4 weeks after osteosynthesis of the right femur neck following fracture. According to the radiologist between 45 and 50 tablets of the medicament had been found in the digestive tract. The mechanical ileus was solved by operation according to Hartmann. This case has two aspects: 1) surgical--mechanical ileus resulting from a rare set of circumstances, and 2) pharmacological and metabolic--disorder of medicament absorption in the digestive tract. The cause of maldigestion (disorder of absorption) of the Tralgit tablets is further investigated.

The impact and safety of preoperative oral or intravenous carbohydrate administration versus fasting in colorectal surgery--a randomized controlled trial.

BACKGROUND AND AIMS: Increasing evidence suggests that preoperative fasting, as was the clinical practice for many decades, might be associated with untoward consequences and that a standardized preoperative intake of nutrients might be advantageous; this is a component of the enhanced recovery after surgery (ERAS) concept. Thus, in a randomized controlled trial we compared preoperative fasting with preoperative preparation with either oral or intravenous intake of carbohydrates, minerals and water. Biochemical, psychosomatic, echocardiographic and muscle-power parameters were assessed in surgical patients with colorectal diseases during the short-term perioperative period. We also assessed the safety of peroral intake shortly before surgery. METHODS: A total of 221 elective colorectal surgery patients in this bicentric, randomized, prospective and blinded clinical trial were divided into three groups: A - patients fasting from midnight (control group); B - patients supported preoperatively by glucose, magnesium and potassium administered intravenously; C - patients supported preoperatively by oral consumption of a specifically composed solution (potion). RESULTS: The general perioperative clinical status of patients in groups C and B was significantly better than those in group A. Psychosomatic conditions postoperatively were found to be best in group C (P < 0.029). The rise in the index of insulin resistance (QUICKI) from the preoperative to the postoperative state was significant in group A (P < 0.05). The systolic and diastolic function of the left ventricle improved postoperatively in group C vs. group A (P < 0.04), and the ejection fraction was also significantly higher postoperatively in group C vs. group A (P < 0.03). The gastric residual volume was 5 ml and the pH of stomach juice was 3.5-5 in all groups without statistically significant difference. No difference was found in the length of hospital stay or the rate of complications. CONCLUSIONS: Preoperative fasting does not confer any benefit or advantage for surgical patients. In contrast, consumption of an appropriate potion composed of water, minerals and carbohydrates offers some protection against surgical trauma in terms of metabolic status, cardiac function and psychosomatic status. Peroral intake shortly before surgery did not increase gastric residual volume and was not associated with any risk.