[Central neurological complication of an interscalene plexus catheter]. / Zentralneurologische Komplikation einer interskalenären Plexuskatheteranlage.

A 78-year-old patient received an interscalene plexus catheter for perioperative pain therapy during implantation of an inverse shoulder prothesis. After stimulation-assisted puncture under sonographic control, 25 ml of local anesthetic (LA) were first administered and then the catheter was placed using the through the needle technique. Immediately after the administration of another 5 ml of local anesthetic via the inserted catheter, the patient showed symptoms of total spinal anesthesia, so that she had to be intubated and ventilated. The following computed tomographic diagnostics of the neck revealed an intrathecal misalignment of the plexus catheter, the tip of which was lying dorsal to the vertebral artery at the level of the 5/6 cervical vertebrae. The catheter could then be removed without any problems and there were no neurological sequelae. The use of ultrasound with clear identification of the nerve roots C5-C7 and the surrounding structures provides additional security when installing an intrascalene catheter. The spread of the LA should be traceable at all times using ultrasound and should otherwise be immediately terminated. Furthermore, a strict adherence to the needle position while inserting the catheter without manipulation of the needle depth is necessary. The first injection of the catheter has to be performed under controlled conditions, preferably connected to surveillance monitors with neurological monitoring of the awake patient and control of vital signs with direct access to the emergency equipment.

Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study]. / Implementierung anästhesiologischer Qualitätsindikatoren in Deutschland : Eine prospektive, nationale, multizentrische Qualitätssteigerungsstudie German version.

BACKGROUND: In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals. OBJECTIVE: This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals. MATERIAL AND METHODS: This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation. RESULTS: The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources. CONCLUSION: In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

Use of a novel vessel-sealing device for peripheral lung biopsy and lung lobectomy in a cadaveric model.

OBJECTIVE: To evaluate the Caiman vessel-sealing device for peripheral lung biopsy and total lung lobectomy in cadaveric canine lung lobes. MATERIAL AND METHODS: Twelve lung lobes were randomly assigned to peripheral lung biopsy (n=6) or total lung lobectomy (n=6) with the 12-mm Caiman vessel-sealing device. Lungs were connected to a ventilator set at 10 breaths per minute with an initial pressure of 5 cm H2 O during the procedure. The lungs were submerged in water for leak testing and the pressure increased until leakage occurred. RESULTS: Mean airway pressure at which leakage occurred was 39.17 ±13.20 cm H2 O for peripheral lung biopsies and 38.33 ±13.67 cm H2 O for total lung lobectomies. None of the samples leaked below 25 cm H2 O, which is well above the physiologic airway pressure. Histologically, the largest bronchial diameter at the sealed area was 8.84 mm and the extent of collateral damage was approximately 2.7 mm in all specimens. CLINICAL SIGNIFICANCE: The Caiman vessel-sealing device was successfully used for peripheral lung biopsy and total lung lobectomy in cadaveric canine lung lobes. All sealed lung lobes tolerated supra-physiologic airway pressure, displayed minimal collateral damage, and were of good diagnostic quality. Further experimental studies are needed to evaluate the clinical safety of the device for peripheral lung biopsy or total lung lobectomy.

Vasomotion of mice mesenteric arteries during low oxygen levels.

BACKGROUND: Ischemia of intestinal organs is a main cause of complications in surgical intensive care patients. Changes in the tonus of arteries contributing to vascular resistance play an important role in the determination of blood flow and thus oxygen supply of various abdominal organs. It is generally acknowledged that hypoxia itself is able to alter arterial tonus and thus blood flow. METHODS: The present study compared the effects of various degrees of hypoxia on second-order mesenteric arteries from male C57BL/6J mice. After vessel isolation and preparation, we assessed vessel diameter using an arteriograph perfusion chamber. Investigating mechanisms promoting hypoxia-induced vasodilatation, we performed experiments in Ca2+-containing and Ca2+-free solutions, and furthermore, Ca2+-influx was inhibited by NiCl2, eNOS-/--, and TASK1-/--mice were investigated too. RESULTS: Mild hypoxia 14.4% O2 induced, in 50% of mesenteric artery segments from wild-type (wt) mice, a vasodilatation; severe hypoxia recruited further segments responding with vasodilatation reaching 80% under anoxia. However, the extension of dilatation of luminal arterial diameter reduced from 1.96% ± 0.55 at 14.4% O2 to 0.68% ± 0.13 under anoxia. Arteries exposed to hypoxia in Ca2+-free solution responded to lower oxygen levels with increasing degree of vasodilatation (0.85% ± 0.19 at 14.4% O2 vs. 1.53% ± 0.42 at 2.7% O2). Inhibition of voltage-gated Ca2+-influx using NiCl2 completely diminished hypoxia-induced vasodilatation. Instead, all arterial segments investigated constricted. Furthermore, we did not observe altered hypoxia-induced vasomotion in eNOS-/-- or TASK1-/- mice compared to wt animals. CONCLUSIONS: The present study demonstrated that hypoxic vasodilatation in mice mesenteric arteries is mediated by a NO-independent mechanism. In this experimental setting, we found evidence for Ca2+-mediated activation of ion channels causing hypoxic vasodilatation.

STED microscopy visualizes energy deposition of single ions in a solid-state detector beyond diffraction limit.

Fluorescent nuclear track detectors (FNTDs) allow for visualization of single-particle traversal in clinical ion beams. The point spread function of the confocal readout has so far hindered a more detailed characterization of the track spots-the ion's characteristic signature left in the FNTD. Here we report on the readout of the FNTD by optical nanoscopy, namely stimulated emission depletion microscopy. It was firstly possible to visualize the track spots of carbon ions and protons beyond the diffraction limit of conventional light microscopy with a resolving power of approximately 80 nm (confocal: 320 nm). A clear discrimination of the spatial width, defined by the full width half maximum of track spots from particles (proton and carbon ions), with a linear energy transfer (LET) ranging from approximately 2-1016 keV µm-1 was possible. Results suggest that the width depends on LET but not on particle charge within the uncertainties. A discrimination of particle type by width thus does not seem possible (as well as with confocal microscopy). The increased resolution, however, could allow for refined determination of the cross-sectional area facing substantial energy deposition. This work could pave the way towards development of optical nanoscopy-based analysis of radiation-induced cellular response using cell-fluorescent ion track hybrid detectors.

Impact of unsuspected subsegmental pulmonary embolism in ICU patients.

BACKGROUND: Critically ill patients in intensive-care units are at high risk for pulmonary embolism (PE). As a result of modern multi-detector computed tomographic angiography (MDCT) increased visualization of peripheral pulmonary arteries, isolated subsegmental pulmonary embolisms (ISSPE) are increasingly being detected. AIM: The aim of this study was to investigate the rate, impact on treatment, and outcome of unsuspected ISSPE in critically ill patients receiving MDCT. The secondary aim was to investigate the potential impact of contrast media-induced nephropathy (CIN) in our cohort. METHODS: We conducted a retrospective single-centre analysis on critically ill adult patients treated between January 2009 and December 2012 who underwent a contrast-enhanced chest MDCT. We excluded patients with clinical suspicion of PE/ISSPE prior to CT and patients with MDCT confirmed central PE. Clinical findings, laboratory parameters, and outcome data were recorded. RESULTS: We identified 240 ICU patients not suspected for PE receiving MDCT. A total of 12 Patients (5%) showed unexpected ISSPE representing increased 24 h mortality (16.7 vs. 3.5%; p = 0.026) compared to non-ISPPE/non-PE patients. A 30-days mortality did not differ between the groups (33.3 vs. 33.8%; p = 0.53). Highest mean creatinine serum level in our cohort (n = 240) was found before MDCT with a significant decrease to day 5 (1.4 ± 1.1 vs. 1.1 ± 0.9 mg/dl: p < 0.0001) after contrast media administration. CONCLUSION: Critically ill patients are at relevant risk for ISSPE. ISSPE was associated with a poor 24 h outcome. In addition, in our cohort, contrast media application was not associated with increased serum creatinine.

Intravenous immunoglobulin in necrotizing fasciitis - A case report and review of recent literature.

INTRODUCTION: Necrotizing fasciitis (NF) is an inflammatory disease of the soft tissue, which causes local tissue destruction and can lead to lethal septic shock. The therapy consists of early surgical treatment of the septic focus and an accompanying broad spectrum antibiotic therapy. Recent literature considers the additional use of immunoglobulin therapy in severe soft skin and tissue infections. PRESENTATION OF CASE: In this report, we describe the case of a 33-year-old male patient treated at a university hospital intensive care unit because of an NF of his left leg. The patient rapidly developed a complicated septic disease after a minor superficial trauma. Despite intense microbiological diagnosis, no causative pathogens were identified. After non-responding to established broad anti-infective treatment, the patient received intravenous immunoglobulin, that rapidly improved his clinical condition. DISCUSSION: NF represents a disease processes, which is characterized by fulminant, widespread necrosis of soft tissue, systemic toxicity, and high mortality (>30%). Beside the surgical debridement and broad spectrum antibiotic therapy IVIg therapy might be an additional option in the treatment of NF. But the current literature supporting the use of IVIG in NF is largely based on retrospective or case-controlled studies, and only small randomized trials. CONCLUSION: The demonstrated case suggests that IVIg treatment of patients with NF can be considered in case of hemodynamic unstable, critically ill patients. Although randomized controlled trials are missing, some patients might benefit from diminishing hyperinflammation by immunoglobins.

Stimulation of duodenal biopsies and whole blood from dogs with food-responsive chronic enteropathy and healthy dogs with Toll-like receptor ligands and probiotic Enterococcus faecium.

The composition of the microbiome plays a significant role in the pathogenesis of inflammatory bowel disease (IBD) in humans and chronic enteropathies (CE) in dogs. The administration of probiotic micro-organisms is one way of modulating the microbiome, but experiments elucidating mechanisms of action of probiotics in the intestine of healthy and CE dogs are lacking. The aim of our study was to investigate the effects of different Toll-like receptor (TLR) ligands and Enterococcus faecium (EF) on ex vivo cultured duodenal samples and whole blood (WB) from dogs with food-responsive chronic enteropathy (FRE) when compared to healthy dogs. Biopsy stimulation was performed in 17 FRE and 11 healthy dogs; WB stimulation was performed in 16 FRE and 16 healthy dogs. Expression of TLR2, 4, 5 and 9, IL-17A, IL-22, IFNy, TNFα, IL-4, IL-10, TGFß and PPARy was determined in biopsies by quantitative polymerase chain reaction (PCR). In addition, production of TNFα, IL-10, IFNy and IL-17A protein in WB and biopsy supernatants was assessed by ELISA. Treatment with individual TLR ligands or EF induced a variety of changes in the expression of different TLRs and cytokines, but not necessarily a consistent change with a single stimulating agent. Even though cytokine protein could not be detected in supernatants from ex vivo stimulated biopsies, we found TNFα protein responses in blood to be opposite of the transcriptional responses seen in the biopsies. Stimulation of canine duodenal biopsies with TLR ligands can potentially induce anti-inflammatory gene expression, especially in healthy tissue, whereas the effects of EF were limited.

Lethal cervical abscess following bisphosphonate related osteonecrosis of the jaw.

CONTEXT: Bisphosphonates are common drugs used in the management of bone metabolic diseases. Because of their recently increased use, their adverse effects, especially bisphosphonate-related osteonecrosis of the jaw (BRONJ), are monitored more frequently. BRONJ is a critical challenge in craniofacial surgery and is difficult to treat. Its occurrence is either spontaneous or follows dentoalveolar surgery. Typical complications of BRONJ are painful exposed bone, pathological fractures, extra-oral fistula, and local infections. OBJECTIVE: The aim of this paper is to report a rare case of bacterial embolism in the internal jugular vein after a BRONJ-induced submandibular abscess resulting in bacterial sepsis, multi-organ failure syndrome, and death. CASE ILLUSTRATION: A 59-year-old female patient developed severe BRONJ (stage II) with recurrent abscesses after oral osteoporosis therapy with alendronic acid. A subsequent submandibular abscess led to bacterial embolism of the left internal jugular vein, causing sepsis and death. DISCUSSION: Prevention, early detection and management of BRONJ remain a crucial challenge in craniofacial clinical practice. Despite several therapeutic approaches described in the current literature, none have undergone bedside application. CONCLUSION: Considering this report of death after recurrent abscesses following BRONJ, the use of bisphosphonates should be carefully monitored in order to prevent such severe complications.

[Awake ECMO therapy in airway stenosis. Bronchoscopic treatment using laser resection]. / Wach-ECMO-Therapie bei Atemwegsstenose. Bronchoskopische Behandlung mithilfe der Laserresektion.

This article presents the case of a 62-year-old patient with cancer in the left upper pulmonary lobe who underwent lobe resection with postoperative respiratory insufficiency. The right upper lobe had already been resected 5 years earlier because of an adenocarcinoma. Prior to the present surgery a computed tomography scan detected a narrow stenosis at the former resection site; however, both pulmonary lobes beyond this stenosis appeared to be sufficiently ventilated. After resection of the left upper lobe attempted extubation was unsuccessful due to insufficient global gas exchange as the stenosis prevented ventilation of the right lung. Bronchoscopy provided evidence of a normal diameter of the bronchus behind the stenosis so both lobes were to be recruited after possible correction of this section. A veno-venous extracorporeal membrane oxygenation device (ECMO) was established as bridging therapy to attain normal gas exchange. As the patient showed no muscle weakness and was cooperative, extubation was performed and spontaneous breathing occurred without any support while still under ECMO treatment. The stenosis was reduced by bronchoscopic laser resection within seven consecutive sessions. Each of these surgeries was conducted with the patient under general anesthesia with oral intubation and jet ventilation in combination with the ECMO. The patient was extubated after each treatment session and weaned from ECMO after the final resection within 2 days. This case demonstrates the use of ECMO in combination with surgical procedures in a spontaneously breathing patient as a causal therapy and option for selected patients to prevent complications from long-term ventilation.

Effects of echinocandin preparations on adult rat ventricular cardiomyocytes. Preliminary results of an in vitro study.

BACKGROUND: Candida infections represent a relevant risk for patients in intensive care units resulting in increased mortality. Echinocandins have become the agents of choice for early and specific antifungal treatment in critically ill patients. Due to cardiac effects following echinocandin administration seen in intensive care unit (ICU) patients the in vitro effects of echinocandins and fluconazole on isolated cardiomyocytes of the rat were examined. AIM: The study was designed to investigate a possible impact of echinocandins and fluconazole in clinically relevant concentrations on the in vitro contractile responsiveness and shape of isolated rat cardiomyocytes. MATERIAL AND METHODS: Ventricular cardiomyocytes were isolated from Lewis rats. Cardiomyocytes were cultured in the presence of all licensed echinocandin preparations and fluconazole at concentrations of 0 (control), 0.1, 1, 3.3, 10, 33 and 100 µg/ml for 90 min. Cells were stimulated by biphasic electrical stimuli and contractile responsiveness was measured as shortening amplitude. Additionally, the ratio of rod-shaped to round cells was determined. RESULTS: Anidulafungin concentrations of 3.3 and 10 µg/ml caused a significant increase in contractile responsiveness, caspofungin showed a significant decrease at 10 µg/ml and micafungin concentrations of 3.3-33 µg/ml led to a significant increase in cell shortening. Measurement was not possible at 33 µg/ml for anidulafungin and caspofungin and at 100 µg/ml for all echinocandins due to a majority of round-shaped, non-contracting cardiomyocytes. Fluconazole showed no significant effect on cell shortening at all concentrations tested. For the three echinocandins the ratio of round-shaped, non-contracting versus rod-shaped normal contracting cardiomyocytes increased in a dose-dependent manner. CONCLUSIONS: Echinocandins impact the in vitro contractility of isolated cardiomyocytes of rats. This observation could be of great interest in the context of antifungal treatment.

Co-occurrence of an intraventricular meningioma and cholesterol granuloma of the choroid plexus in a cat.

A 12-year-old domestic shorthair cat was presented with neurologic signs localized to the forebrain. Magnetic resonance imaging (MRI) of the brain revealed a space occupying lesion within the third and the lateral ventricles. The lesion had areas of disparate signal characteristics and exerted a mass effect on the surrounding parenchyma and ventricular system. The histologic examination identified the co-existence of two intraventricular masses: a meningioma and a choroid plexus cholesterol granuloma.

Cardiac effects of echinocandin preparations - three case reports.

WHAT IS KNOWN AND OBJECTIVE: Echinocandins are antifungal agents, routinely used in invasive candida infections in critically ill patients. Their excellent anticandidal activity and their low frequency of reported adverse events and drug interactions make them first-line guideline treatments of candidiasis especially in intensive care units (ICU). We report on three ICU patients who developed cardiac insufficiency and hemodynamic instability during administration of loading doses of an echinocandin. CASE SUMMARY: Three ICU patients showed a substantial drop in their cardiac index or a deterioration of the mean arterial pressure following start of echinocandin administration. The patients were 75 years (female), 71 years (male) and 66 years (male) old. One patient received caspofungin, and two patients received anidulafungin as empirical antifungal treatment for severe sepsis. WHAT IS NEW AND CONCLUSION: Our cases suggest that the observed cardiac impairment could be associated with echinocandin administration. Therefore, we recommend close hemodynamic monitoring of critically ill patients receiving echinocandins.

Flow cytometric detection of Mycobacterium avium subsp. paratuberculosis-specific antibodies in experimentally infected and naturally exposed calves.

A desirable test to diagnose infections with Mycobacterium avium subsp. paratuberculosis facilitates identification of infected cattle prior to the state of M. avium subsp. paratuberculosis shedding. This study aimed at adjusting a flow cytometry (FC)-based assay, using intact M. avium subsp. paratuberculosis bacteria as the antigen, for diagnosis of M. avium subsp. paratuberculosis infections in calves. Serum samples were collected from experimentally infected (n = 12) and naturally exposed (n = 32) calves. Samples from five calves from positive dams were analyzed to determine the dynamics of maternal antibodies. Samples from adult cattle with defined infection status served as the standard (18 M. avium subsp. paratuberculosis shedders, 22 M. avium subsp. paratuberculosis free). After preadsorption with Mycobacterium phlei, sera were incubated with M. avium subsp. paratuberculosis and M. avium subsp. avium bacterial suspensions, respectively, followed by the separate detection of bovine IgG, IgG1, IgG2, and IgM attached to the bacterial surface. M. avium subsp. paratuberculosis-specific sample/positive (S/P) ratios were compared to enzyme-linked immunosorbent assay (ELISA) S/P ratios. In adult cattle, the FC assay for IgG1 had a sensitivity of 78% at a specificity of 100%. Maternally acquired antibodies could be detected in calves up to 121 days of life. While all but two sera taken at day 100 ± 10 postnatum from naturally exposed calves tested negative, elevated S/P ratios (IgG and IgG1) became detectable from 44 and 46 weeks postinoculation onwards in two calves infected experimentally. Even with the optimized FC assay, M. avium subsp. paratuberculosis-specific antibodies can only occasionally be detected in infected calves less than 12 months of age. The failure to detect such antibodies apparently reflects the distinct immunobiology of M. avium subsp. paratuberculosis infections rather than methodological constraints.

[Near-infrared spectroscopy in sepsis therapy : predictor of a low central venous oxygen saturation]. / Nahinfrarotspektroskopie in der sepsistherapie : prädiktor für eine erniedrigte zentralvenöse sauerstoffsättigung.

BACKGROUND: Early goal-directed hemodynamic optimization has become a cornerstone of sepsis therapy. One major defined goal is to achieve adequate central venous oxygen saturation (SO(2)). This study aimed to investigate the correlation between central venous SO(2) and frontal cerebral near-infrared spectroscopy (NIRS) measurement in patients with severe sepsis and septic shock. The NIRS method provides non-invasive measurement of regional oxygen saturation (rSO(2)) in tissues approximately 2 cm below the optical NIRS sensors which depends on arterial, capillary and venous blood. Thus this system gives site-specific real-time data about the balance of oxygen supply and demand. METHODS: This was a secondary analysis from a prospective study of surgical intensive care (ICU) patients in the early phase of severe sepsis or septic shock. Bilateral cerebral rSO(2), central venous SO(2), arterial oxygen saturation (S(a)O(2)) and other surrogate parameters of oxygen supply, such as hemoglobin, partial pressure of oxygen and oxygen content in arterial blood were recorded. RESULTS: A total of 16 ICU patients (4 women, median age 65.5 years) were included in the study. As sepsis focus an intra-abdominal infection was detected in 62.5 % of patients, severe pneumonia was determined in 31.3 % and skin and soft tissue infections were recognized in 12.5 %. At study inclusion 50 % of patients had septic shock, the median sequential organ failure assessment (SOFA) score was 10.2 (interquartile range 5.25-8.75) and the median acute physiology and chronic health evaluation II (APACHE II) score was 26 (range 23.25-29.75). Mortality at day 28 was 37.5 %. Minimum rSO(2) (median 58) and right-sided rSO(2) (median 58) values showed a significant correlation in the analysis of receiver operating characteristics (area under the curve 0.844, p= 0.045). A central venous SO(2)< 70 % was indicated by rSO(2)< 56.5 with sensitivity and specificity of 75 % and 100 %, respectively. CONCLUSIONS: Cerebral NIRS could provide a fast and easily available side effect-free monitoring that could be used in addition to established procedures for goal-directed treatment in the early phase of sepsis. Further studies should be made in a larger population to verify the correlation found and to investigate the impact of NIRS-directed resuscitation treatment in early sepsis.

Pyruvate: immunonutritional effects on neutrophil intracellular amino or alpha-keto acid profiles and reactive oxygen species production.

For the first time the immunonutritional role of pyruvate on neutrophils (PMN), free α-keto and amino acid profiles, important reactive oxygen species (ROS) produced [superoxide anion (O(2) (-)), hydrogen peroxide (H(2)O(2))] as well as released myeloperoxidase (MPO) acitivity has been investigated. Exogenous pyruvate significantly increased PMN pyruvate, α-ketoglutarate, asparagine, glutamine, aspartate, glutamate, arginine, citrulline, alanine, glycine and serine in a dose as well as duration of exposure dependent manner. Moreover, increases in O(2) (-) formation, H(2)O(2)-generation and MPO acitivity in parallel with intracellular pyruvate changes have also been detected. Regarding the interesting findings presented here we believe, that pyruvate fulfils considerably the criteria for a potent immunonutritional molecule in the regulation of the PMN dynamic α-keto and amino acid pools. Moreover it also plays an important role in parallel modulation of the granulocyte-dependent innate immune regulation. Although further research is necessary to clarify pyruvate's sole therapeutical role in critically ill patients' immunonutrition, the first scientific successes seem to be very promising.