Perioperative risk factors in elective pneumonectomy: the impact of excess fluid balance.

BACKGROUND AND OBJECTIVE: This study was performed to identify risk factors for complications and in-hospital mortality associated with pneumonectomy. METHODS: The influence of fluid balance during anaesthesia was evaluated, taking into account the patient's age, gender and body mass index, smoking habits, history of pulmonary or cardiac disorders, the site of pneumonectomy and duration of anaesthesia. One-hundred-and-seven patients undergoing elective pneumonectomy were included in the study. RESULTS: A total of 31 patients (29%) suffered from one or more postoperative complications, seven (22.4%) of these had severe dysrhythmias, six (19.6%) had pulmonary complications and three (9.3%) had cardiovascular complications. The overall mortality rate was 10.3%. CONCLUSIONS: Based on logistic regression analysis, our data indicate the following risk factors for postoperative complications: positive fluid balance exceeding 4000 mL during anaesthesia (pulmonary complications and mortality), body mass index < 17 or > 25 kg m(-2) (severe dysrhythmias), or history of chronic heart disease (pulmonary complications). Thirteen patients (12.4%) suffered from a fluid balance > 4000 mL during anaesthesia. Regression analysis indicated that fluid balance exceeding 4000 mL was associated with a higher risk of postoperative complications than blood loss exceeding 1000 mL and to be the strongest risk factor for postoperative pulmonary complications and in-hospital mortality. Further trials estimating the effect of restrictive fluid regimens and the use of vasopressors for blood pressure control during anaesthesia must be carried out.

Antibiotic usage in an intensive care unit in a Danish university hospital.

We report a study of antimicrobial use in patients admitted to the Intensive Care Unit (ICU) in a Danish university hospital during the course of 1 year. Of 615 patients admitted, 434 (71%) received antibiotics, 220 (36%) for infections and 222 (36%) for prophylaxis. Therapy for suspected infection accounted for 67% of the total consumption of antibiotics and prophylaxis for 33%. Ampicillin was the drug most frequently used; 43% of the patients treated for infection received this drug. One hundred and thirty-one patients (60%) were treated for suspected lower respiratory tract infection. Relevant microbiological specimens were obtained from 120 (92%) of these patients and a possible pathogen was isolated in 92 patients (77%, 92/120). Staphylococcus aureus and Streptococcus pneumoniae were each isolated in almost a quarter of the patients, and Enterobacteriaceae in 53%. However, many of the pathogens isolated were of no clinical relevance and merely reflected a state of colonization. Most treatments were given during the first few days following admission. Of 220 patients receiving antibiotics for an infection, 87% were treated on day 1, but only 34% (14 of 41) on day 11. The frequent use of laboratory investigations combined with good communication between clinicians and microbiologists probably resulted in rapid cessation of unnecessary therapy. Fifty-two per cent of the antibiotics given for prophylaxis were administered later than the first postoperative day. This study emphasizes the need for consultation between surgeons and clinical microbiologists to supervise postoperative antibiotic use.

[Toxic epidermal necrolysis]. / Toksisk epidermal nekrolyse.

A case of severe toxic epidermal necrolysis is described, stressing the importance of multiorgan system involvement of the disease. A possible pathogenetic mechanism involving tumor necrosis factor is discussed.

Nosocomial pneumonia in an intensive care unit in a Danish university hospital: incidence, mortality and etiology.

We studied the patients admitted to the ICU at a Danish university hospital during 1 year with respect to nosocomial pneumonia (NP). Among 242 patients, who stayed more than 48 h, 23 (10%) developed NP. Patients with NP had significantly higher mortality (43% vs. 19%, p less than 0.05), longer median stay (276 h vs. 99 h, p less than 0.05) and a longer median intubation period (256 h vs. 74 h, p less than 0.05). In the NP group surgical patients were overrepresented as compared to medical patients (74% vs. 45%, p less than 0.05). Thoracotomy, treatment with H-2 blockers and immunosuppression represented significant risk factors. Considering the etiology, Enterobacteriaceae and Pseudomonas aeruginosa constituted 43% of the cases in strong contrast to the low frequency of these pathogens in community-acquired pneumonia. NP in the ICU patient is a resource consuming disease associated with a high mortality (43%), which is related to the frequent severe underlying diseases of these patients.

[Cerebral symptoms in hyponatremia. Treatment and course]. / Cerebrale symptomer ved hyponatriaemi. Behandling og forløb.

Pronounced hyponatraemia results in serious neurological symptoms and the untreated condition is associated with a great mortality. An account is presented of nine hyponatraemic patients (plasma sodium 101-119 mmol/l) without cardiac, renal or hepatic disease who were admitted to a department for intensive care. In all of the patients, consciousness was compromised. Three patients had generalized convulsions and six patients had respiratory involvement which required respirator treatment in two patients. In one patient, the hyponatraemia had developed acutely. The remaining cases had developed chronically. One patient was confused for one month after admission and another patient developed classical central pontine myelinolysis after a latent period of seven days and which required admission for rehabilitation for several months. The remaining patients, including the acute patient, had recovered completely after a few days. The rate of correction for plasma sodium was calculated for the patients. Animal experimental and clinical accounts concerning the pathological physiology and treatment of hyponatraemia are reviewed. It is important to differentiate between acutely and chronically developed hyponatraemia as treatments differ considerably. Severe chronic hyponatraemia should be treated with a rate of correction of plasma sodium of 0.5 mmol/l/hour, and the normal range for plasma sodium should be aimed at after a couple of days. The risk involved in more rapid normalization is development of central pontine myelinolysis with severe neurological sequelae. Hypertonic sodium chloride must only be employed in cases of acutely developed hyponatraemia with convulsions. Acute hyponatraemia may otherwise be corrected with a rate of correction of plasma sodium of 1 mmol/l/hour or more.

[Microbial contamination of tube feeding solutions]. / Mikrobiel kontamination af sondekost.

Forty patients receiving respirator treatment were subdivided at random to receive tube-feeding with either a "home-made" powder product (group 1) or a ready-made sterile standard tube-feeding product: Salvimulsin MCT (group 2). Tube-feeding was administered as a continuous drip infusion and the patients were followed throughout three days, with particular attention to the development of diarrhoea. A series of cultures were taken from the tube-feeding diet, at the beginning and end of an infusion. The volumes were similar in both of the groups and averaged 860 ml on the first day and approximately 1,300 on the second and third days. Significantly greater bacterial contamination was found in the "home-made" tube-feeding diet, particularly with growth of Gram-negative rods. Seven patients (35%) in group 1 and two patients (11.1%) in group 2 developed diarrhoea. This difference is not statistically significant. No correlation was found between hypoalbuminaemia and the development of diarrhoea. It is concluded that powder mixtures and dilution of tube-feeding diets should be avoided on account of the risk of contamination and, similarly, tube-feeding should not be administered for more than 6-8 hours.

Changes in serum electrolyte and atrial natriuretic peptide concentrations, acid-base and haemodynamic status after rapid infusion of isotonic saline and Ringer lactate solution in healthy volunteers.

Opinions differ on the use of isotonic sodium chloride and Ringer lactate solution for extracellular volume depletion. We have compared changes in serum electrolyte concentrations and acid-base and haemodynamic status after rapid infusion of 2 litre of either isotonic sodium chloride or Ringer lactate solution in healthy volunteers. Changes within groups were small and statistically insignificant. Central venous pressure changes were associated with secretion of atrial natriuretic peptide, but this response was delayed.

Preliminary study on treatment of septic shock patients with antilipopolysaccharide IgG from blood donors.

A novel intravenous therapy consisting of polyvalent IgG antibodies to lipopolysaccharide (LPS, endotoxin) obtained from screening of blood donors was used for treatment of patients with profound septic endotoxin shock. Investigation of the anti-LPS IgG pharmacokinetics in the 10 patients revealed time related changes in the plasma concentrations of anti-LPS IgG, endotoxin, tumour necrosis factor (TNF) and the clinical parameters. A decrease in serum concentrations of IgG and IgM antibodies to LPS was observed prior to the immunotherapy as well as in a clinical example of lethal septicemia without anti-LPS immunotherapy. Increasing serum concentrations of anti-LPS IgG during antibody infusion was followed by a decrease in the concentration of endotoxin and TNF. In survivors an IgM and IgG anti-LPS antibody response developed. Using clinical parameters and APACHE II clinical severity scores to measure the clinical condition, a beneficial effect was observed within 24 h corresponding to a decrease in the calculated expected mortality rate from more than 80% to about 50%. Five patients (55%) expired during the study. One patient died in the early septic shock phase. One patient expired due to superimposed hemorrhagic shock. Three immunosuppressed patients died 1-2 weeks after initial recovery, 1 with fungal sepsis and 2 patients due to pseudomonas infection.

Influence of epidural morphine on postoperative pain, endocrine-metabolic, and renal responses to surgery. A controlled study.

In order to assess the analgesic properties of epidural low-dose morphine and its possible influence on the adrenocortical, hyperglycemic, renal, electrolyte and leukocyte responses to surgery and nitrogen excretion, a double-blind randomized study was undertaken in 14 otherwise healthy patients admitted for hysterectomy under halothane, N2O/o2 anesthesia. Before induction of anesthesia, an epidural catheter was introduced into the lumbar epidural space. After induction of anesthesia, either morphine 4 mg in 10 ml saline or 10 ml saline was injected into the epidural space, according to the allocation. Postoperatively, the degree of pain was evaluated by mean of a visual analogue scale (0-10). When pain score exceeded 5 points during the 24 -h trial, either 4 mg morphine in saline or saline was given epidurally. If the pain score did not decrease more than 2 points after an epidural injection, morphine was given parenterally (5 mg i.v. +5 mg i.m.). The results showed that pain scores, duration of pain relief and doses of morphine differed significantly between groups (P less than 0.05). Plasma concentration of cortisol and glucose, plasma-and urine electrolytes, 24-h creatinine and free-water clearances, diuresis, fluid balance, leukocyte count and nitrogen excretion differed insignificantly between groups. In conclusion, epidural low-dose morphine is a superior alternative to conventional postoperative pain treatment because of greater and longer lasting pain relief, without apparent side-effects. The measured endocrine-metabolic and renal response did not differ between groups, indicating that low-dose epidural morphine does not inhibit afferent neurogenic stimuli from the site of surgical trauma.