Risk factors for multiple organ system failure and death in critically injured patients.

BACKGROUND: This study was undertaken to evaluate the relative importance of factors related to the extent of multiple organ system failure (MOSF) and outcome in critical trauma. METHODS: We performed a retrospective case series analysis of 206 consecutive patients with trauma admitted to a surgical intensive care unit during a 5-year period. Multivariate methods were used to select independent factors related to the MOSF score and subsequent death. RESULTS: Multiple linear regression selected advancing age, prior chronic conditions, malnutrition, injury severity score (ISS), coma on admission, use of H2-receptor antagonists or antacids, number of blood transfusions, and intraabdominal infection as independent factors related to the MOSF score. Multiple logistic regression selected advancing age, chronic disease, ISS, and MOSF score as major predictors of death. CONCLUSIONS: Advancing age, prior chronic disease, malnutrition, coma on admission, and use of H2-receptor antagonists or antacids may impair host defenses of the gastrointestinal tract and predispose to invasive infection, thereby aggravating the severity of existing MOSF. These findings, together with the predominance of Enterobacteriaceae in patients with infection, suggest that bacterial translocation may be important in the late MOSF septic state. Although infection, particularly intraabdominal infection, is a major risk factor for MOSF, a nonspecific host response to critical trauma, as expressed by the ISS and transfusion requirement, and intestinal endotoxin may contribute to the development of the syndrome.

The role of plasma amino acids in hepatic encephalopathy.

The dog with an end-to-side portacaval shunt has a plasma amino acid pattern similar to that in man with chronic liver disease and encephalopathy. When dogs with end-to-side portacaval shunts manifested symptoms of hepatic encephalopathy, superior caval catheters were placed and one of three solutions was infused. Whereas almost all animals given a commercially available synthetic amino acid mixture died, a special mixture formulated to normalize plasma amino acids was associated with 100 percent survival and few neurological symptoms. The results suggest that manipulation and normalization of plasma amino acids in animals with hepatic failure may be efficacious in providing adequate nutrition while minimizing hepatic encephalopathy. Moreover, these experiments may shed some light on the mechanism of human hepatic encephalopathy.

Energy replacement during parenteral nutrition in surgery, sepsis and cancer.

For many years, the increased nutritional requirements of surgical, septic and cancer patients were identified, but no effective therapy existed for averting their negative calorie and nitrogen balance. Parenteral nutrition offered an answer in many of these situations. However, abnormalities in liver function, ventilatory load, hyperglycemia and a disturbed metabolic homeostasis showed that in excessive amounts, glucose can behave as a relatively toxic substance. For cases with increased energy expenditure, new alternatives had to be devised in order to avoid excessive glucose intakes. One obvious possibility in these cases was to refrain from offering more than the basal caloric needs, until the patient had passed the period of acute injury, or other measures had effectively controlled the sepsis or cancer. Other options included the partial substitution of glucose by lipids or amino acids. Preliminary information suggests that this approach could lead to better nutritional outcome and survival rates, but additional studies are required.

Use of a mixture of medium-chain triglycerides and longchain triglycerides versus long-chain triglycerides in critically ill surgical patients: a randomized prospective double-blind study.

Twenty critically-ill surgical patients who needed total parenteral nutrition were randomly enrolled in a double-blind study comparing two intravenous fat emulsions: one containing a mixture of 50% medium-chain triglycerides and 50% long-chain triglycerides and another containing 100% longchain triglycerides. The purpose of this study was to investigate metabolic and biochemical differences between both emulsions with special reference to liver enzymes. After a baseline period of 24 h with only glucose and NaCl infusion, the lipid emulsion was added continuously during 24 h over 5 days. The parenteral nutrition was administered in mixture bags containing amino-acids, glucose and lipids together. Two-thirds of the non-protein calories were administered as glucose 40% and one third as either long-chain triglycerides or a mixture of medium-chain triglycerides and long-chain triglycerides. The total amount of non-protein calories received was the measured energy expenditure during the baseline period plus 10% and was fixed during the study. Plasma substrate concentrations, energy expenditure, and nitrogen balance were determined and arterial blood samples were taken. No toxic effects or complications attributable to one of the two emulsions were observed. There was no significant difference in energy expenditure, nitrogen balance, liver function tests, carnitine, transferrin, pre-albumin, albumin, cholesterol, triglycerides and free fatty acids. The only parameter that showed a different pattern of reaction between the two emulsions was serum bilirubin concentration. In this study no evidence of any advantageous effect of a mixture of medium-chain triglycerides and long-chain triglycerides was seen.

The value of objective measurements to select patients who are malnourished.

Several studies have attempted to define nutritional parameters that can be used to select malnourished hospitalised patients for nutritional support. A combination of objective nutritional parameters was evaluated in a group of 50 patients selected for total parenteral nutrition on clinical grounds only and compared with a control group. This control group consisted of 38 patients who were admitted for elective minor surgical procedures such as varicectomy and hernia repair. On a subset of 18 objective nutritional measurements, discriminant analysis was performed. In the evaluation it was shown that a combination of albumin (ALB), prealbumin (PALB), total lymphocyte count (TLC) and the percentage of ideal weight (PIW) was the most useful combination of nutritional tests in discriminating a chosen malnourished (M) group and a control group who were declared not malnourished (NM). With this combination the patients were correctly classified in 93% with a sensitivity of 93% and a specificity of 94%.

Plasma and parathyroid tumor tissue gastrin and hyperparathyroidism.

Hyperparathyroidism has been associated with an increased incidence of duodenal ulcer, increased acid secretion, and increased plasma gastrin levels. A relationship between these changes, increased serum calcium levels, and the increased incidence of peptic ulceration has been suggested, especially since increased plasma gastrin levels, serum calcium levels, and gastric acid secretion decrease after parathyroidectomy. We have previously suggested that the decrease in plasma gastrin levels after parathyroidectomy may suggest an extragastric source of gastrin, whereas others using immunofluorescent studies have suggested that the parathyroid adenomas themselves might be the source of this gastrin. We prospectively studied in fifteen patients with primary hyperparathyroidism, plasma gastrin and serum calcium levels before and after parathyroidectomy, as well as the gastrin content of parathyroid tumor tissue. The mean basal plasma gastrin level before operation was significantly greater than that of a control group and decreased insignificantly after operation, in contrast to serum calcium levels. No positive correlation could be found between plasma gastrin and serum calcium levels before and after operation. Parathyroid tumor tissue was assayed for gastrin content by radioimmunoassay and no detectable amounts of gastrin could be recovered from any tumor. The results do not support the concept that the extragastric source of gastrin in patients with hyperparathyroidism is the parathyroid adenoma itself.

Characteristics of release of duodenal gastrin.

Duodenal gastrin release in the dog was studied after mucosal antrectomy with intact duodenal innervation, following which basal gastrin levels fell. Acetylcholine at pH 7 but not at pH 1.5 and insulin hypoglycemia but not 2-deoxyglucose release duodenal gastrin. Glycine (pH7), physiologic saline (pH 7), and balloon distention failed to release duodenal gastrin. These findings suggest differences in release characteristics between canine antral and duodenal gastrin, and point out species differences between man and dog in respect to release of duodenal gastrin.

Gastrin and gastric acid secretion in renal failure.

In 10 anephric patients awaiting transplantation, 15 patients with chronic renal failure and 30 patients with acute renal failure, daily basal plasma gastrin levels and basal and stimulated gastric acid secretion were measured. Significant elevated plasma gastrin levels were found in all of the anephric patients and in 50 percent of the patients with acute and 55 percent of those with chronic renal failure. Elevated plasma gastrin levels decreased to normal after kidney transplantation or when kidney function returned to normal in the patients with acute renal failure. Gastric acid secretion studies showed a consistent pattern in all three groups of patients with a low basal acid output, a high basal intragastric pH and a very significant peak acid output, perhaps secondary to elevated plasma gastrin levels due to inadequate renal inactivation of gastrin. This may partly explain the increased incidence of gastrointestinal bleeding and gastritis seen in patients with different degrees of renal failure.

In vitro release of gastrin from isolated perfused antrum.

Gastrin is released from isolated perfused rat antra in a regular fashion by a variety of stimuli, including acetylcholine, glycine, and calcium. Two peaks are seen with the physiologic stimulus, acetylcholine, suggesting perhaps two different antral gastrin populations.

Percutaneous transhepatic drainage and insertion of an endoprosthesis for obstructive jaundice.

As a consequence of the good results with percutaneous transhepatic cholangiography using the Chiba needle, a similar technique was employed for percutaneous transhepatic drainage and insertion of a percutaneous transhepatic endoprostheses. Herein we have described the technique and results of percutaneous transhepatic cholangiography with the Chiba needle in 45 patients and of combined percutaneous transhepatic drainage and insertion of an endoprosthesis in a consecutive group of 69 patients with obstructive jaundice. In the latter group, 50 patients had a malignant lesion. Of these, 38 were subject to continuous drainage, 14 externally and 24 with an endoprosthesis. The percutaneous transhepatic drainage and insertion of an endoprosthesis procedure brings a new dimension to preoperative decompression of the bile ducts and palliative treatment of obstructive jaundice in high-risk patients.

Glutamine-enriched enteral diet increases renal arginine production.

BACKGROUND: Arginine (Arg) is generated in the kidney by the conversion of circulating citrulline. The most important source for circulating citrulline is the metabolism of glutamine (Gln) by the gut. In this study, we investigated the influence of an enteral diet enriched with Gln on renal Arg synthesis in the rat. METHODS: Rats were fed a 12.5% Gln-enriched diet or an isocaloric, isonitrogenous control diet for 14 days. Kidney plasma flow and arterial and renal venous plasma levels of a number of amino acids were measured, and kidney amino acid fluxes were calculated. RESULTS: Compared with the control diet, Gln enrichment resulted in significantly higher arterial plasma levels of circulating citrulline (30%, p < .0001) and Arg (31%, p < .0005). The uptake of circulating citrulline and the subsequent production of Arg by the kidneys were significantly higher in the Gln-enriched group (40% and 38%, respectively) and showed an equimolar relationship in both the control (r = .84, p < .0001) and the Gln-enriched group (r = .83, p < .0001). CONCLUSIONS: The findings indicate that enteral Gln supplementation caused significantly increased arterial plasma levels of Arg as a result of increased renal Arg production from circulating citrulline. Considering the multiple important biologic properties of Arg, the reported beneficial effects of Gln in catabolic states might be explained in part by increased renal Arg production.

TPN catheter sepsis: lack of effect of subcutaneous tunnelling of PVC catheters on sepsis rate.

In an effort to diminish the incidence of catheter related sepsis in total parenteral nutrition, the effect of a 10-cm long subcutaneous tunnel was studied in a prospective randomized manner. This tunnel created a longer anatomical distance between puncture site of the catheter and the subclavian vein. In the control group, a direct puncture technique was employed. Eighty-one catheters (group A) were inserted according to the direct technique, 69 (group B) were tunnelled. Catheter sepsis was defined as an episode of clinical sepsis for which no other cause can be identified and which resolves upon removal of the catheter. No significant differences were noted between the two groups, suggesting that tunnelling of subclavian PVC catheters does not diminish the incidence of catheter related sepsis.

Prevalence and prediction of multiple organ system failure and mortality in acute pancreatitis.

We studied the prevalence of multiple organ system failure (MOSF), the relations between age, pre-existing chronic conditions, local complications, systemic infection, organ system failure, and mortality in patients with acute pancreatitis. During the study period, 267 consecutive patients were admitted to a tertiary hospital with acute pancreatitis. Multivariate analyses were used to identify factors predictive of MOSF occurrence and mortality. Using a previously developed MOSF scoring system at our center, MOSF (> or = 2 organ systems) was found to occur in 63 (24%) of the patients. Cardiovascular, pulmonary, renal, and hepatic failure predominated. Advanced age (> 55 yr) and chronic disease were related to local complications and systemic infection (both, P < .001). Local complications and systemic infection occurred in 68% and 75% of patients, respectively. In multiple logistic regression, advanced age, chronic disease, local complications, and systemic infection independently contributed to the development of MOSF. Overall mortality was 19%. MOSF accounted for 96% of deaths; mortality increased from 1% to 79% in patients without and with MOSF, respectively. In multiple logistic regression, advanced age, chronic disease, local complications, failure of the cardiovascular, renal, hepatic, gastrointestinal, and neurological systems independently contributed to mortality prediction. Advanced age and prior chronic disease may reflect diminished physiological reserve and predispose to local complications, systemic infection, and MOSF. Although local complications and systemic infection are important predisposing factors for MOSF, a host-dependent response to unknown specific or nonspecific factors may have a role in the pathogenesis of the syndrome in 25% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[The prognostic value of cholesterol levels in malnourished patients with esophageal carcinoma]. / Interés pronóstico de los niveles de colesterol en pacientes malnutridos con carcinoma esofágico.

A variety of clinical calculations, including serum cholesterol, have been used as parameters of prognostic value in surgical populations, but there are few studies aimed at patients with esophageal carcinoma. In a set of patients with established esophageal cancer, cholesterol and triglyceride levels were recorded, along with the following parameters: age, sex, body weight, serum albumin, total lymphocytes, and hemoglobin concentration. Manual grip strength was measured, along with delayed cutaneous hypersensitivity response, and the type of surgical treatment was distinguished (palliative versus radical). Total complications and postoperative hospitalisation time are the main indicators used in our study for the surgical results. Patients were divided into two groups: those with serum cholesterol levels over 150 mg/dl (Group I) and those under that figure (Group II). Most nutritional and functional values were lower in Group II patients, for whom the radical surgery rate was also lower, with greater postoperative morbidity. It was concluded that 1): Cholesterol depletion is associated with nutritional and immunological alterations and 2) post-surgical results are poorer in patients with levels below 150 mg/dl.

[Results of therapy combining peritoneal lavage and local application of antibiotics in 250 patients with acute perforating appendicitis]. / Ergebnisse einer kombinierten Behandlung von Lavage der Bauchhöhle und lokal verabreichten Antibiotica bei 250 Patienten mit Appendicitis acuta perforata.

Since 1967, 2480 appendectomies have been performed at the St. Lucas Hospital (Amsterdam) and the St. Annadal Hospital (Maastricht), of which 250 were for perforated appendicitis. A so-called 'combined method' of treatment was used in all these cases: during the operation saline was used to lavage the peritoneal cavity with the patients in the reverse-Trendelenburg position. Antibiotics were left in the peritoneal cavity. No intraperitoneal drainage was performed, but the wound was drained for 5 days. Postoperative treatment consisted of nasogastric suction and parenteral antibiotics for 5 days in combination with anticoagulation. With thus combined approach one death was seen in 250 cases. There were 20 cases of wound infection (8%), 7 pelvic abscesses (2.8%), and 2 retroperitoneal abscesses. No thromboembolic complications were seen because of the use of routine anticoagulation. For 191 patients (77%), total hospitalization was less than 14 days. This method of treatment is compared with recent reports in literature.

[Total parenteral nutrition (TPN) in oncology (author's transl)]. / De rol van "total parenteral nutrition" (TPN) in de oncologie.

The role of TPN in oncology is, in spite of favourable reports, not yet settled. Selected undernourished cancer patients are certainly helped by parenteral nutrition during their course of therapy. Their nutritional status becomes better, their endurance to antineoplastic therapy is enhanced with less complications and more important, their "quality of life" is improved. However, the survival time of the patient is not prolonged. Well designed prospective randomised clinical studies will provide a better insight into this problem. The anorexia of cancer patients might be caused by tumor-induced alterations in the metabolism of the host which might be medically altered by serotonin-antagonists.

24-hour systemic antimicrobial prophylaxis with gentamicin and metronidazole, or metronidazole alone, in elective colorectal surgery after mechanical bowel preparation with mannitol and whole gut irrigation.

In a prospective randomized trial, systemic antimicrobial prophylaxis with metronidazole and gentamicin was compared to the administration of metronidazole alone in elective colorectal surgery. In both groups, an identical mechanical large-bowel preparation was performed. In order to reduce the duration of the whole-gut irrigation, a 10% mannitol solution was administered before the irrigation procedure. Although no serious infections were observed in either group, the incidence of superficial wound infections was relatively high: 19% in the group with metronidazole and gentamicin prophylaxis and 25% in the other group. From all these wounds E. coli was isolated, and no obligate anaerobic bacteria were cultured. This high rate of wound infections is most likely caused by an overgrowth of E. coli after irrigation, due to the residues of mannitol in the colon, which serve as a nutrient for E. coli. It is concluded that mannitol should not be used in the preoperative mechanical preparation of the large bowel before elective colorectal surgery.