RESUMEN
Oxidative stress and inflammation generate edema in burns. The aim of our study was to assess effect of N-acetylcysteine (NAC) on oxidative stress, inflammation, fluid requirement, multiple organ dysfunction (MOD) score and vasoactive drug requirement. In this study 15 patients were on standard therapy, whereas for other 15 patients NAC was supplemented. Blood samples were taken on admission and on the next five consecutive mornings. Levels of malondialdehyde, protein sulfhydril (PSH) groups, reduced gluthation (GSH), activity of myeloperoxidase, catalase and superoxide dismutase enzymes and induced free radical generating capacity were measured as well as concentrations of TNF-α, IL-6, IL-8, and IL-10. MOD score, use of vasopressor agents and fluid utilisation were recorded daily. NAC treatment increased GSH level on days 4-5 (p<0.05) and PSH level on days 2-6 (p<0.05) compared to controls. Plasma IL-6 was lower on days 4-5 (p<0.05), IL-8 on days 4-6 (p<0.05) and IL-10 on days 4-6 (p<0.05) in NAC group. NAC group received less catecholamines than controls (p<0.01) from day 4 without significant differences in MOD score. NAC treatment is associated with a diminished oxidative stress reflected in preserved antioxidant levels, lower inflammation mirrored in lower interleukin levels and less vasopressor requirement.
Asunto(s)
Acetilcisteína/uso terapéutico , Quemaduras/tratamiento farmacológico , Citocinas/metabolismo , Depuradores de Radicales Libres/uso terapéutico , Estrés Oxidativo/efectos de los fármacos , Síndrome de Respuesta Inflamatoria Sistémica/tratamiento farmacológico , Adulto , Anciano , Antioxidantes/metabolismo , Biomarcadores/metabolismo , Quemaduras/metabolismo , Catalasa/metabolismo , Femenino , Glutatión/metabolismo , Humanos , Recuento de Leucocitos , Masculino , Malondialdehído/metabolismo , Persona de Mediana Edad , Insuficiencia Multiorgánica/metabolismo , Peroxidasa/metabolismo , Estudios Prospectivos , Superóxido Dismutasa/metabolismo , Síndrome de Respuesta Inflamatoria Sistémica/metabolismoRESUMEN
BACKGROUND: Esophageal cancer is a major cause of morbidity and mortality, but despite continuing research, few effective therapies have been identified. In recent years, surgical resection following chemoradiotherapy has been associated with improved survival in several clinical models. AIM: In a prospective, observational study, we evaluated the direct effects of chemoradiotherapy on postoperative mortality, morbidity, and inflammatory response in patients following esophagectomy. METHODS: The study cohort was divided into two groups: the first group received preoperative chemoradiotherapy, while the second group had surgical intervention without prior treatment. Nutritional status was evaluated for the members of both patient groups at various time points. RESULTS: Preoperative chemoradiotherapy did not influence morbidity or organ function, and the postoperative inflammatory response did not show immunosuppressive side effects directly after surgery. CONCLUSION: Preoperative chemoradiotherapy does not improve postoperative organ function, inflammatory response or nutritional status in the patients. These findings may help to improve outcome in patients with esophageal cancer in the future.
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Neoplasias Esofágicas/terapia , Adulto , Anciano , Quimioradioterapia , Estudios de Cohortes , Terapia Combinada , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/fisiopatología , Esofagectomía , Femenino , Humanos , Mediadores de Inflamación/sangre , Masculino , Persona de Mediana Edad , Estado Nutricional , Periodo Preoperatorio , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: There is a need for a procedure-specific means of assessment of clinical performance in anaesthesia. The aim of this study was to devise a tool for assessing the performance of spinal anaesthesia, which has both content and construct validity. METHODS: The clinical assessment tool was generated using a focus group discussion of practicing anaesthetists. The tool comprised three components: a checklist of 11 pre-defined errors, two time intervals and a six-item global rating scale (GRS). Thirty-one anaesthetists at three different levels of experience underwent testing using the clinical assessment tool: novice (n=10), intermediate (n=10) and expert (n=11). RESULTS: The error checklist and GRS scores but not the time intervals were significantly different between the three groups (P<0.005). CONCLUSION: The error checklist and GRS form the basis for a procedure-specific assessment tool for spinal anaesthesia.
Asunto(s)
Anestesia Raquidea , Anestesiología/educación , Competencia Clínica , Evaluación Educacional/métodos , HumanosRESUMEN
Oxidative stress and inflammatory processes generate edema in burns. Treatment of consequent hypovolemia is a challenge. The aim of study was to assess if glutathione pro-drug N-acetylcysteine (NAC) can influence inflammation and fluid requirement. We also aimed to compare organ functions scores and vasoactive drug requirement. This prospective randomised study involved 28 patients with burn injury affecting more than 20% of body surface area. Fourteen patients were on standard therapy, whereas for other 14 patients NAC was supplemented. Blood samples were taken on admission and on the next five consecutive mornings. Leukocyte surface marker expressions were determined, multiple organ function scores, use of vasopressor agents and fluid requirements were recorded daily. Expression of CD11a (p < 0.05), CD18 (p < 0.05) and CD97 (p < 0.01) on the granulocytes were significantly lower in the NAC treated group, similarly to lymphocyte CD 49d (p < 0.05) and monocyte CD 49d (p < 0.01) and CD 97 (p < 0.05) expression. No significant difference was found in the fluid requirement between groups but patients the NAC group required less vasopressor and inotropic drugs from day 4. NAC treatment is associated with a less pronounced inflammation reflected in lower CD marker expression and vasopressor requirement.
Asunto(s)
Acetilcisteína/uso terapéutico , Antígenos CD/metabolismo , Antioxidantes/uso terapéutico , Quemaduras/tratamiento farmacológico , Leucocitos/efectos de los fármacos , Estrés Oxidativo/efectos de los fármacos , Acetilcisteína/farmacología , Anciano , Antioxidantes/farmacología , Biomarcadores/metabolismo , Quemaduras/sangre , Quemaduras/fisiopatología , Femenino , Citometría de Flujo , Humanos , Leucocitos/metabolismo , Masculino , Persona de Mediana Edad , Insuficiencia Multiorgánica/fisiopatología , Estudios ProspectivosRESUMEN
Sepsis and multiple organ failure remain the leading cause of mortality and morbidity in burns. The aim of our study was to analyse the predictive value of extravascular lung water index (EVLWI) in the development of severe septic complications and mortality. The records of 28 patients with total burned surface area >20% were analysed (EVLWI, procalcitonin (PCT), intrathoracic blood volume index (ITBVI), positive end-expiratory pressure (PEEP), Baltimore Sepsis Scale (BaSS)). Diagnosis of infection (day 0) was based on consensus conference of the American Burn Association. EVLWI correlated with PCT (r=0.597), and PEEP (r=0.501) on day 0 and with BaSS (r=0.524) and MODS (r=0.513) from day 1. EVLWI was elevated (p<0.05) from one day before diagnosis of infection, PCT was higher (p<0.05) from day 0 only. ROC analysis for EVLWI on day -1 and for PCT on day 0 showed similar areas under curve (0.760; 0.766). EVLWI >9 ml kg(-1) on day -1 predicted sepsis (89% sensitivity, 72% specificity). After antibiotic treatment EVLWI remained high in non-survivors, decreased in survivors, whereas PCT decreased in both groups. Our data suggest that EVLWI is an early warning sign of developing infection and its continuous elevation can predict poor prognosis in burns.
Asunto(s)
Quemaduras/complicaciones , Agua Pulmonar Extravascular , Sepsis/diagnóstico , Adulto , Calcitonina/sangre , Péptido Relacionado con Gen de Calcitonina , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Precursores de Proteínas/sangre , Estudios Retrospectivos , Sensibilidad y Especificidad , Sepsis/etiologíaRESUMEN
BACKGROUND: Annual data collection is obligatory in Hungary for every department in the fields of anaesthesia and intensive care. A new, web-based data-reporting system was introduced in Hungary in 2003. The present paper summarizes experience from the first 5 yr of its operation. METHODS: The Information Technology Working Group of Hungarian Society of Anaesthesia and Intensive Care developed a data collection system, which was Internet-based, provided web surface for every accredited department, and used the integration of international code systems. The analysis mode summarized the data automatically at loco-regional, national, or both levels. In 2008, a questionnaire was sent to the users in order to evaluate the usefulness of, and user satisfaction with, the web-based system. RESULTS: The examples of anaesthetic and intensive therapy workload activities reflect the status of the discipline in Hungary. There have been no significant changes in the total number of anaesthesias per year in the past 5 yr, except that the number of combined general and regional anaesthesias has been elevated by more than 30%. The physicians' workload has increased by 13.2% in relation to the total number of anaesthetic procedures per physician per year. In this field, our data have verified that the number of physicians has decreased in Hungary. On the basis of the opinion of the users, the web-based data collection system has increased the effectiveness and accuracy of annual data collection. CONCLUSIONS: The developed web-based system is an effective tool for data collection. Its usefulness was also borne out by its users on the basis of experience from the first 5 yr.
Asunto(s)
Anestesiología/estadística & datos numéricos , Cuidados Críticos/estadística & datos numéricos , Internet , Informática Médica/métodos , Adulto , Anciano , Anestesia/métodos , Anestesia/estadística & datos numéricos , Anestesiología/organización & administración , Cuidados Críticos/organización & administración , Investigación sobre Servicios de Salud/métodos , Humanos , Hungría , Auditoría Médica/métodos , Persona de Mediana Edad , Recursos Humanos , Carga de TrabajoRESUMEN
INTRODUCTION: Trends and the prognostic value of cytokine responses to severe burns have not been fully examined in humans. Therefore, the aim of this study was to determine the time course and prognostic value of pro- and anti-inflammatory cytokines in the immediate post-burn period. PATIENTS AND METHODS: Blood samples were taken for measuring IL-1 beta, IL-6, IL-8, IL-10, IL-12p70 and TNF-alpha concentrations from patients with more than 20% burned surface area on admission and on 5 consecutive days. Development of sepsis was assessed using standard criteria twice a day. RESULTS: IL-12p70 remained under assay detection levels in the study period. IL-1 beta and TNF-alpha could be detected in stimulated blood samples with higher levels in survivors (n=21). IL-6 on days 4-5 and IL-8 on days 4-6 in non-stimulated plasma showed significant elevation in non-survivors (n=18) whereas in stimulated blood its levels did not differ significantly. IL-10 levels were significantly higher in non-survivors during the study period in non-stimulated, and except day 6 in stimulated blood. Using the cut-off level of 14 pg ml(-1) for IL-10 predicted ICU mortality with 85.4% sensitivity and 84.2% specificity on admission. CONCLUSION: Early anti-inflammatory excess had a bad prognosis for patients suffering from severe burns.
Asunto(s)
Quemaduras/sangre , Interleucina-10/sangre , Adulto , Anciano , Área Bajo la Curva , Femenino , Humanos , Interleucinas/sangre , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Sepsis/epidemiología , Sobrevivientes , Factores de Tiempo , Factor de Necrosis Tumoral alfa/sangreRESUMEN
UNLABELLED: Glutamine is the most abundant amino-acid in the extra- and intracellular compartments of the human body, which accounts for over 50% of its free amino-acid content. Utilization of glutamine peptides is explicitly useful, resulting in a decrease in the number of postoperative infectious complications, period of hospitalization, and therapeutic costs. This article aims to study the effects of glutamine on systemic inflammatory response, morbidity, and mortality after esophagectomy. A prospective, randomized, double-blind, and controlled trial was used. Following sealed-envelope block randomization, the patients were divided into two groups. Members of the glutamine group (group G) received glutamine (Dipeptiven, Fresenius) as continuous infusion for 6 hours at 0.5 g/kg for 3 days prior to, and 7 days following surgery; while patients of the control group were given placebo. We examined 30 patients in group G, and 25 patients as controls. In both patient groups, the levels of total protein, albumin, pre-albumin, retinol binding protein, transferrin, transferring-saturation, C-reactive protein, procalcitonin, lymphocte, Interleukin-6, Interleukin-8, tumor necrosis factor alpha, and serum lactate were determined prior to surgery (t(0)), directly after surgery (t(u)), following surgery on day 1 (t(1)), day 2 (t(2)), and day 7 (t(7)). For statistical analysis Mann-Whitney U test and chi-square test were used. There was no significant difference between the two groups regarding age, male/female ratio, and SAPS II scores. Intensive care unit morbidity and mortality was similar in both groups (group G: 24 survivors/6 nonsurvivors; CONTROL: 17 survivors/8 nonsurvivors; P= 0.607). Daily Multiple Organ Dysfunction Score did not differ significantly between the two groups. The observed inflammatory markers followed the pattern we described without significant difference. Based on our study, the glutamine supplementation that we used had no influence on morbidity, mortality, or postoperative inflammatory response after esophagectomy.
Asunto(s)
Esofagectomía/métodos , Glutamina/uso terapéutico , Complicaciones Posoperatorias/prevención & control , Síndrome de Respuesta Inflamatoria Sistémica/prevención & control , Adulto , Anciano , Proteínas Sanguíneas/análisis , Proteína C-Reactiva/análisis , Calcitonina/sangre , Péptido Relacionado con Gen de Calcitonina , Método Doble Ciego , Femenino , Estudios de Seguimiento , Glutamina/administración & dosificación , Glicoproteínas/sangre , Humanos , Interleucina-6/sangre , Interleucina-8/sangre , Ácido Láctico/sangre , Recuento de Linfocitos , Masculino , Persona de Mediana Edad , Placebos , Prealbúmina/análisis , Premedicación , Estudios Prospectivos , Precursores de Proteínas/sangre , Proteínas de Unión al Retinol/análisis , Albúmina Sérica/análisis , Tasa de Supervivencia , Transferrina/análisis , Factor de Necrosis Tumoral alfa/sangreRESUMEN
BACKGROUND: Patients with stroke are more susceptible to infections, suggesting possible deficiencies of early immune responses, particularly of leucocytes. AIMS: To serially examine leucocyte antisedimentation rate (LAR), a simple test to detect activation of leucocytes, and correlate it with S100beta, procalcitonin and outcome in patients with acute ischaemic events. METHODS: Venous blood samples were taken from 61 healthy volunteers and 49 patients with acute ischaemic events (acute ischaemic stroke (AIS), n = 38; transient ischaemic attack (TIA), n = 11) within 6 hours, at 24 and 72 hours after onset of symptoms. RESULTS: LAR was significantly higher in acute ischaemic events compared to controls within 6 hours after onset of stroke regardless of post-stroke infections. In addition, the increase of LAR was delayed and attenuated in TIA in contrast to AIS. A deficiency in early increase of LAR was associated with post-stroke infections and a poor outcome, measured by the Glasgow Outcome Scale in AIS. There was a positive correlation between LAR and S100beta at 72 hours after the onset of ischaemic stroke. Increased levels of S100beta at 24 and 72 hours after stroke were associated with poor outcome. CONCLUSIONS: An early activation of leucocytes indicated by an increase of LAR is characteristic of acute ischaemic cerebrovascular events. A delayed and ameliorated leucocyte activation represented by LAR is characteristic of TIA in contrast to stroke. Deficient early activation predisposes to post-stroke infections related to poor outcome. In addition, the extent of tissue injury correlates with the magnitude of innate immune responses.
Asunto(s)
Leucocitos/inmunología , Infecciones Oportunistas/complicaciones , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/inmunología , Biomarcadores/sangre , Isquemia Encefálica/complicaciones , Isquemia Encefálica/inmunología , Humanos , Inmunidad Celular , Ataque Isquémico Transitorio/complicaciones , Ataque Isquémico Transitorio/inmunología , Activación Neutrófila/inmunología , Infecciones Oportunistas/inmunología , Pronóstico , Estudios Prospectivos , Subunidad beta de la Proteína de Unión al Calcio S100/sangreRESUMEN
AIMS: We evaluated the possibility that repeated ischemic preconditioning or N-acetylcysteine (NAC) could prevent ischemia-reperfusion injury as determined by indocyanine green plasma disappearance rate (ICG-PDR) or has favorable hemodynamic effects during reperfusion in an in vivo canine liver model. METHODS: Under general anesthesia, 3 groups of mongrel dogs (n = 5 per group) were subjected to (1) 60-min hepatic ischemia, (2) same ischemia preceded by intravenous administration of 150 mg kg(-1) NAC, and (3) three episodes of IPC (10-min ischemia followed by 10-min reperfusion) prior to same ischemia. Hepatic reperfusion was maintained for a further 180 min, with hemodynamic and hepatic function parameters monitored throughout. RESULTS: Plasma disappearance rate of indocyanine green and serum levels of aspartate transferase and alanine transferase showed no significant differences between groups. Although liver injury was obvious, reflected by hemodynamic, blood gas, and liver function tests, NAC and IPC failed to prevent decay in hepatic function in this canine model. CONCLUSION: The results do not support the hypothesis that short-term use of NAC and IPC is beneficial in hepatic surgery.
Asunto(s)
Acetilcisteína/farmacología , Precondicionamiento Isquémico/métodos , Hepatopatías/metabolismo , Hepatopatías/prevención & control , Daño por Reperfusión/metabolismo , Daño por Reperfusión/prevención & control , Alanina Transaminasa/sangre , Animales , Aspartato Aminotransferasas/sangre , Colorantes/farmacocinética , Modelos Animales de Enfermedad , Perros , Verde de Indocianina/farmacocinéticaRESUMEN
BACKGROUND: A number of target points have been used for fluid replacement in severely burned patients. The aim of our prospective randomized study was to compare the effect of two different types of fluid resuscitation regimes on the multiple organ dysfunction score (MODS) and central venous oxygen saturation (ScvO(2)) in the first 3 days after injury. METHODS: Twenty-four patients admitted to the critical care unit of a university hospital with the presence of burn injury affecting more than 15% of the body surface area and in-hospital fluid resuscitation started within 3 h after burn injury were included. Patients were randomized into two groups. Fluid resuscitation was guided by the hourly urine output (HUO Group, n=12) or by the intrathoracic blood volume index (ITBVI Group, n=12). Invasive transpulmonary hemodynamic measurements utilizing pulse contour analysis with a single dilution technique and continuous ScvO(2) measurements were performed in both groups. RESULTS: The mean ScvO(2) was significantly lower in the HUO Group than in the ITBVI Group (P=0.024) for the first 24 h. MODS was significantly higher in the HUO Group than in the ITBVI group 48 h (P=0.024) and 72 h after injury (P=0.014). The two main outcome parameters, i.e., MODS calculated at 48 and 72 h after injury and ScvO(2) were negatively correlated on day 1 (r=-0.684, P=0.004, r=-0.677, P=0.003). There were no statistical differences in clinical outcome parameters. CONCLUSION: Our data suggest that ITBVI may be a better target parameter than HOU in the fluid resuscitation of severely burned patients after injury.
Asunto(s)
Volumen Sanguíneo/efectos de los fármacos , Quemaduras/terapia , Fluidoterapia/métodos , Insuficiencia Multiorgánica/sangre , Oxígeno/sangre , Adulto , Anciano , Quemaduras/sangre , Quemaduras/orina , Protocolos Clínicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/estadística & datos numéricos , Termodilución/métodos , Resultado del TratamientoRESUMEN
Increased blood viscosity has not been associated with mortality risk in coronary heart disease (CHD). We aimed to investigate the predictive power of hematocrit per blood viscosity (Hct/BV) ratio as a marker of rheological oxygen carrying capacity of the blood to assess mortality risk of CHD. Elective coronary angiography was performed and CHD was proved in 109 patients in 1996 and 1997. In 78 cases (72%) complete follow up information was obtained in February 2006. During the follow up time (mean 8.9 years) 10 patients died due to cardiac cause (group C). Two patients died due to non-cardiac cause and 66 were still alive at the end of the follow up period (group NC, n=68). Mean hematocrit per blood viscosity (Hct/BV) ratio was significantly lower in group C comparing to NC (87+/-5; 93+/-9 Pa(-1)s(-1), SD, respectively, p=0.022). Other factors (body mass index, serum cholesterol, fibrinogen, hematocrit, plasma and blood viscosity, cardiac index, left ventricular ejection fraction) provided no statistical differences. Kaplan-Meier survival analysis showed only the impact of fibrinogen and Hct/BV ratio on cardiac mortality (p=0.029 and 0.009, respectively). Receiver operating characteristic curves proved only Hct/BV ratio to be able to differentiate between groups (area under curve: 0.716, p=0.028). Hct/BV ratio showed significant negative correlation with the frequency of hospital admissions (r=-0.377, p=0.03). Low Hct/BV ratio can be regarded as a risk factor of cardiac death in CHD.
Asunto(s)
Viscosidad Sanguínea , Enfermedad Coronaria/diagnóstico , Enfermedad Coronaria/mortalidad , Hematócrito , Causas de Muerte , Femenino , Fibrinógeno/análisis , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Curva ROC , Factores de Riesgo , Análisis de Supervivencia , Tasa de SupervivenciaRESUMEN
Plasma fibrinogen concentration, plasma and whole blood viscosity (WBV) are independent risk factors of coronary artery disease (CAD). Fibrinogen seems to be a relatively stronger risk factor for women than for men, but men are more endangered by higher hematocrit (Hct) and WBV than women are. We have previously reported that a theoretically optimal Hct value can be determined using Hct/WBV ratio in healthy subjects, hyperlipidemic and Raynaud's disease patients. Our aim was to examine whether Hct/WBV ratio is differently correlated with Hct in men and women with proven CAD. In a retrospective study we analysed the hemorheological data of 162 CAD outpatients (107 men and 55 women). Coronary angiography, echocardiography and impedance cardiography were performed. Hemorheological parameters (Hct, fibrinogen level, plasma viscosity, WBV), blood picture, serum lipid concentrations were determined and Hct/WBV ratio was calculated. Mean ages of male and female patients were similar (54.9 and 55.4 years, respectively), but men had significantly higher coronary angiography score than women. Mean left ventricular ejection fraction, stroke volume index and cardiac index showed no significant differences in men and women. Similarly, lipid concentrations, fibrinogen levels and plasma viscosities demonstrated no statistical differences. However, Hct, WBV and Hct/WBV ratios were significantly higher in male than in female patients (p < 0.00001; p < 0.00001 and p < 0.005, respectively). The most striking gender difference was found in the correlation between Hct/WBV ratio and cardiac index. Men older than 56 years showed negative, women positive correlation (r = -0.485, p = 0.01; r = 0.468, p = 0.006, respectively). This study demonstrates that Hct/WBV ratio as a rheological oxygen carrying capacity parameter is positively correlated with the cardiac index as it can be expected. However, the correlation is negative in elder men indicating an unhealthy relation between hemodynamic and hemorheologic parameters.
Asunto(s)
Viscosidad Sanguínea/fisiología , Enfermedad de la Arteria Coronaria/sangre , Fibrinógeno/análisis , Hematócrito , Hemorreología , Volumen Sistólico/fisiología , Anciano , Estudios de Cohortes , Femenino , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores SexualesRESUMEN
Cardiac complications are the leading cause of peri-operative morbidity and mortality of patients undergoing vascular surgery. This high incidence of cardiac complications is related to the presence of underlying coronary artery disease. The optimal treatment strategy for these high-risk patients, including the use of pre-operative coronary revascularization for the purpose of improving peri-operative and long-term cardiac outcomes, has been controversial for several decades. Recently, the results of the Coronary Artery Revascularization Prophylaxis (CARP) trial showed that in the short term there is no reduction in the number of post-operative myocardial infarctions, deaths or length of stay in the hospital, or in long-term outcomes in patients who underwent pre-operative coronary revascularization compared with patients who received optimized medical therapy. In this review, we summarize the role of pre-operative revascularization before elective vascular surgery using current evidence from the CARP trial and of those from published studies.
Asunto(s)
Revascularización Miocárdica , Procedimientos Quirúrgicos Vasculares , Procedimientos Quirúrgicos Electivos , Humanos , Complicaciones Intraoperatorias/prevención & control , Infarto del Miocardio/etiología , Complicaciones Posoperatorias/prevención & control , Factores de Riesgo , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
Cardiac complications are the major cause of perioperative morbidity and mortality of patients undergoing non-cardiac surgery. This is related to the frequent presence of underlying coronary artery disease. In the last few decades, attention has focused on preoperative cardiac risk assessment that may help to identify patients at increased cardiac risk for whom cardioprotective medication and, when indicated, coronary revascularization may improve perioperative outcome. On the other hand, less attention was given to the role of anaesthesia and monitoring techniques in the cardiac risk management of high-risk patients undergoing non-cardiac surgery. The aim of this review was to summarize the current evidence from published studies on the effect of the type of anaesthesia and monitoring techniques on perioperative cardiac outcome in non-cardiac surgery.
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Anestesia/métodos , Enfermedades Cardiovasculares/prevención & control , Monitoreo Intraoperatorio/métodos , Atención Perioperativa , Anestesia/efectos adversos , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/patología , Humanos , Factores de Riesgo , Gestión de RiesgosRESUMEN
Leukocyte function tests are suitable for monitoring the severity of chronic inflammatory and acute infectious diseases. The tests usually require time consuming leukocyte separation techniques while the original character of leukocytes can substantially alter. In contrast, we noted that gravity sedimentation properties of leukocytes is simple to measure and it also reflects non-specific inflammatory reactions of leukocytes. Our novel test is named leukocyte antisedimentation rate (LAR) which is measured by leukocyte counting in the upper (U) and lower (L) half of the sedimentation blood column after one-hour gravity sedimentation of the whole blood. The formula LAR=100.(U-L)/(U+L) is used to calculate the percentage of leukocytes crosses the middle line of sedimentation blood column upward during one-hour sedimentation (normal range<15%, inter-assay coefficient of variation<5%). In this study we found that in vitro pre-treatment of septic patients' blood samples with protamine, lidocaine and prednisolone decreased leukocyte antisedimentation rate in a concentration dependent manner without effecting erythrocyte sedimentation rate. Leukocyte adherence was measured by the retention rate of leukocytes in a nylon fibre column. There was a significant positive correlation between leukocyte antisedimentation rate and leukocyte adherence (p<0.01), hematocrit (p<0.05), erythrocyte sedimentation rate (p<0.05) when blood samples of 35 healthy individuals were analysed. We concluded that leukocyte antisedimentation rate in septic patients is significantly elevated comparing to healthy controls and as a bedside test it can reflect leukocyte involvement in infections. In vitro protamine, lidocaine and prednisolone pre-treatment of septic patients' blood samples indicates that leukocyte antisedimentation process is partially independent from the ongoing erythrocyte sedimentation.
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Sedimentación Sanguínea , Leucocitos/fisiología , Adulto , Anestésicos Locales/farmacología , Antiinflamatorios/farmacología , Adhesión Celular/efectos de los fármacos , Separación Celular/métodos , Femenino , Antagonistas de Heparina/farmacología , Humanos , Leucocitos/efectos de los fármacos , Lidocaína/farmacología , Masculino , Persona de Mediana Edad , Prednisolona/farmacología , Protaminas/farmacologíaRESUMEN
BACKGROUND: Early detection of blood stream infection can be lifesaving, but the results of blood cultures are not usually available before 24 hours after blood sampling. An earlier indication would lead to the initiation of immediate and adequate antibiotic treatment with obvious advantages for the patient. OBJECTIVE: To evaluate the ability of leucocyte count, serum procalcitonin (PCT) concentration, erythrocyte sedimentation rate (ESR), and leucocyte antisedimentation rate (LAR) in predicting the blood culture results in critical care patients. METHODS: 39 consecutive patients with their first febrile episode were investigated prospectively. LAR was determined as the percentage of leucocytes crossing the midline of a blood column upward during one hour of gravity sedimentation. The relevance of the different variables was estimated by likelihood ratio tests and area under receiver operating characteristic curves (AUC). RESULTS: 23 patients had positive blood culture results and 16 negative. LAR was significantly higher in bacteraemic patients than in non-bacteraemic patients (p = 0.001), but leucocyte count, ESR and PCT level failed to show significant differences. Leucocyte count, PCT, and ESR yielded low discriminative values with the AUCs of 0.66, 0.64, and 0.52, respectively. LAR provided a likelihood ratio of 3.6 and an AUC of 0.80 (95% confidence interval, 0.64 to 0.95) (p = 0.002). CONCLUSIONS: The simple LAR test can predict blood culture results and support urgent treatment decisions in critical care patients in their first febrile episode.
Asunto(s)
Bacteriemia/diagnóstico , Cuidados Críticos , Fiebre/microbiología , Leucocitos/patología , Adulto , Anciano , Área Bajo la Curva , Bacteriemia/sangre , Sedimentación Sanguínea , Calcitonina/sangre , Péptido Relacionado con Gen de Calcitonina , Movimiento Celular , Femenino , Fiebre/sangre , Humanos , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Precursores de Proteínas/sangre , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Large-scale epidemiological studies have demonstrated that both anaemia and polycytaemia are independent cardiovascular risk factors. This was substantiated by the Framingham study, which demonstrated a U-shaped relation between haemoglobin concentration and mortality. It was previously noted that delineating the corresponding haematocrit/blood viscosity ratios in the function of haematocrit provided a distribution of an inverted U-shaped curve. The peak appeared physiologically important because it denotes a healthy balance between a relatively high oxygen binding capacity and a moderately low blood viscosity. It was the aim of this study to examine the mathematical relationship between the haematocrit and haematocrit/blood viscosity ratio. MATERIALS AND METHODS: In a retrospective study, the haemorheological data of 32 healthy controls, 52 outpatients with hyperlipidaemia and 120 outpatients with Raynaud's disease were analyzed. Whole blood viscosity was measured with Hevimet 40 capillary viscometer at 37.0 degrees C and at shear rates of 10 s(-1), 90 s(-1) and 200 s(-1). RESULTS: Haematocrit/blood viscosity ratios in the function of haematocrit values showed a Gaussian association in the healthy subjects, hyperlipidaemic and Raynaud's disease outpatient groups. Peak values (i.e. the rheologically optimal haematocrit) were shear-rate and group dependent and were found at 44.3%, 43.5% and 38.3% in controls, hyperlipidaemic and Raynaud's disease patients, respectively, at a shear rate of 90 s(-1). CONCLUSIONS: This is one of the first reports in which a theoretically optimal haematocrit value was determined using the haematocrit/blood viscosity ratio. Further studies are needed to examine the potential clinical usefulness of this approach.
Asunto(s)
Viscosidad Sanguínea/fisiología , Eritrocitos/fisiología , Hematócrito/métodos , Adolescente , Adulto , Anciano , Femenino , Humanos , Hiperlipidemias/fisiopatología , Masculino , Persona de Mediana Edad , Distribución Normal , Enfermedad de Raynaud/fisiopatología , Estudios RetrospectivosRESUMEN
Whole blood gravity sedimentation technique can be modified for studying leukocyte sedimentation properties. Previously, we demonstrated that the displacement rate of leukocytes was associated with activation of leukocytes during traditional gravity sedimentation of the whole blood. The plasma flow as well as the difference between the specific gravity of leukocytes and plasma propel the leukocytes upward in the sedimentation tube while the erythrocyte aggregates are descending. The leukocyte ascension rate can be described as the increment of leukocyte concentration in the upper half section of the blood column after one-hour sedimentation. The aim of the present study was to characterize the ascending and non-ascending leukocytes using a flow cytometric technique. Venous blood samples were taken from 8 healthy controls and 8 septic patients after major thoracic or abdominal surgical procedures. The upper and lower halves sections of venous blood column were separately removed from the sedimentation tube after one hour gravity sedimentation. Using flow cytometry, the leukocyte subsets were identified by their CD45 density and side scatter parameters followed by characterization of their cellular size and cytoplasmic granularity. The size indices of septic patients' ascending polymorphonuclear leukocytes (PMNs) were significantly lower than that of the non-ascending ones (253 +/- 22 versus 387 +/- 12 (SEM), p < 0.002) or the ascending PMN fraction taken from healthy individuals (382 +/- 28, p < 0.005). Septic patients' ascending PMNs presented significantly lower cytoplasmic granularity indices compared to non-ascending (447 +/- 23 versus 538 +/- 18, p < 0.05) or healthy ascending PMNs (539 +/- 20, p < 0.05). The cellular size and cytoplasmic granularity indices of heavy and light monocytes as well as lymphocytes were similar in both groups. It can be assumed that venous blood samples of septic patients contain significantly smaller PMNs with less cytoplasmic granularity than healthy control cells.