RESUMEN
INTRODUCTION: Routine EEG is widely used and accessible for post arrest neuroprognostication. Recent studies, using standardised EEG terminology, have proposed highly malignant EEG patterns with promising predictive ability. OBJECTIVES: To validate the performance of standardised routine EEG patterns to predict neurological outcome after cardiac arrest. METHODS: In the prospective multicenter Target Temperature Management trial, comatose cardiac arrest patients were randomised to different temperature levels (950 patients, 36 sites). According to the prospective protocol a routine EEG was performed in patients who remained comatose after the 36 h temperature control intervention. EEGs were retrospectively reviewed blinded to outcome using the standardised American Clinical Neurophysiology Society terminology. Highly malignant, malignant and benign EEG patterns were correlated to poor and good outcome, defined by best achieved Cerebral Performance Category up to 180 days. RESULTS: At 20 sites 207 patients had a routine EEG performed at median 76 h after cardiac arrest. Highly malignant patterns (suppression or burst-suppression with or without discharges) had a high specificity for poor outcome (98%, CI 92-100), but with limited sensitivity (31%, CI 24-39). Our false positive patient had a burst-suppression pattern during ongoing sedation. A benign EEG, i.e. continuous normal-voltage background without malignant features, identified patients with good outcome with 77% (CI 66-86) sensitivity and 80% (CI 73-86) specificity. CONCLUSION: Highly malignant routine EEG after targeted temperature management is a strong predictor of poor outcome. A benign EEG is an important indicator of a good outcome for patients remaining in coma.
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Coma/fisiopatología , Electroencefalografía , Hipotermia Inducida/métodos , Paro Cardíaco Extrahospitalario/terapia , Anciano , Coma/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Monitorización Neurofisiológica/métodos , Paro Cardíaco Extrahospitalario/complicaciones , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , Terminología como AsuntoRESUMEN
BACKGROUND: Admission lactate and lactate clearance are implemented for risk stratification in sepsis and trauma. In out-of-hospital cardiac arrest, results regarding outcome and lactate are conflicting. METHODS: This is a post-hoc analysis of the Target Temperature Management trial in which 950 unconscious patents after out-of-hospital cardiac arrest were randomized to a temperature intervention of 33°C or 36°C. Serial lactate samples during the first 36 hours were collected. Admission lactate, 12-hour lactate, and the clearance of lactate within 12 hours after admission were analyzed and the association with 30-day mortality assessed. RESULTS: Samples from 877 patients were analyzed. In univariate logistic regression analysis, the odds ratio for death by day 30 for each mmol/L was 1.12 (1.08-1.16) for admission lactate, P < .01, 1.21 (1.12-1.31) for 12-hour lactate, P < .01, and 1.003 (1.00-1.01) for each percentage point increase in 12-hour lactate clearance, P = .03. Only admission lactate and 12-hour lactate levels remained significant after adjusting for known predictors of outcome. The area under the receiver operating characteristic curve was 0.65 (0.61-0.69), P < .001, 0.61 (0.57-0.65), P < .001, and 0.53 (0.49-0.57), P = .15 for admission lactate, 12-hour lactate, and 12-hour lactate clearance, respectively. CONCLUSIONS: Admission lactate and 12-hour lactate values were independently associated with 30-day mortality after out-of-hospital cardiac arrest while 12-hour lactate clearance was not. The clinical value of lactate as the sole predictor of outcome after out-of-hospital cardiac arrest is, however, limited.
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Ácido Láctico/metabolismo , Paro Cardíaco Extrahospitalario/metabolismo , Anciano , Femenino , Humanos , Modelos Logísticos , Masculino , Tasa de Depuración Metabólica , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/mortalidadRESUMEN
BACKGROUND AND OBJECTIVES: Traditionally, Denmark has had a high rate of allogeneic red blood cell transfusion caused by a liberal transfusion practice despite the existence of restrictive guidelines. We established a Patient Blood Management programme in a tertiary hospital and report the results of the implementation of evidence-based transfusion practice. MATERIALS AND METHODS: Red blood cell transfusion quality indicators were compared with the evidence-based guideline at hospital and department level. Based on this evaluation, wards were selected for interventions targeting doctors and nurses. The implementation process was monitored by transfusion quality and utilization data over a 3-year period with totally 166 341 admissions in 98 960 mixed, adult medical and surgical patients. RESULTS: At the hospital level, transfusion above the upper guideline limit decreased from 23 to 10% (P < 0·001), and transfusion at or below the restrictive haemoglobin trigger of 7·3 g/dl increased from 7 to 19% (P < 0·001). The percentage of single-unit transfusions increased from 72 to 78% (P < 0·001), and the majority of transfusion rates and volumes decreased significantly. Red cell use decreased with 41% in surgical procedures and 28% in admissions (P < 0·001). CONCLUSION: The intervention was associated with a significant and sustained overall increase in compliance with national guidelines for red blood cell transfusion for non-bleeding patients, and led to significantly fewer patients being exposed to transfusion.
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Transfusión de Eritrocitos , Adulto , Bases de Datos Factuales , Dinamarca , Práctica Clínica Basada en la Evidencia , Femenino , Estudios de Seguimiento , Hemoglobinas/análisis , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Centros de Atención TerciariaRESUMEN
AIM: Survivors of out-of-hospital cardiac arrest (OHCA) may experience psychological distress but the actual prevalence is unknown. The aim of this study was to investigate anxiety and depression within a large cohort of OHCA-survivors. METHODS: OHCA-survivors randomized to targeted temperature of 33 °C or 36 °C within the Target Temperature Management trial (TTM-trial) attended a follow-up after 6 months that included the questionnaire Hospital Anxiety and Depression Scale (HADS). A control group with ST-elevation myocardial infarction (STEMI) completed the same follow-up. Correlations to variables assumed to be associated with anxiety and depression in OHCA-survivors were tested. RESULTS: At follow-up 278 OHCA-survivors and 119 STEMI-controls completed the HADS where 24% of OHCA-survivors (28% in 33 °C group/22% in 36 °C group, p=0.83) and 19% of the STEMI-controls reported symptoms of anxiety (OR 1.32; 95% CI (0.78-2.25), p=0.30). Depressive symptoms were reported by 13% of OHCA-survivors (equal in both intervention groups, p=0.96) and 8% of STEMI-controls (OR 1.76; 95% CI (0.82-3.79), p=0.15). Anxiety and depression among OHCA-survivors correlated to Health-Related Quality-of-Life, and subjectively reported cognitive deterioration by patient or observer. In addition, depression was associated with a poor neurological outcome. CONCLUSION: One fourth of OHCA-survivors reported symptoms of anxiety and/or depression at 6 months which was similar to STEMI-controls and previous normative data. Subjective cognitive problems were associated with an increased risk for psychological distress. Since psychological distress affects long-term prognosis of cardiac patients in general it should be addressed during follow-up of survivors with OHCA due to a cardiac cause. ClinicalTrials.gov NCT01020916/NCT01946932.
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Ansiedad/epidemiología , Depresión/epidemiología , Paro Cardíaco Extrahospitalario/psicología , Sobrevivientes/psicología , Femenino , Humanos , Hipotermia Inducida , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/terapiaRESUMEN
OBJECTIVE AND DESIGN: To elucidate whether platelets differentiate cytokine release following trauma, we prospectively measured three major platelet-derived cytokines in 213 trauma patients on hospital arrival. METHODS: We measured plasma levels of the anti-inflammatory ß-thromboglobulins (ßTGs), transforming growth factor-ß1 (TGFß1) and the pro-inflammatory platelet factor 4 (PF4) cytokines. We also measured soluble glycoprotein VI (sGPVI), procoagulant platelet microparticles (PMPs) and white blood cell (WBC) counts, and evaluated in vitro platelet function in primary and secondary haemostasis by aggregometry and thromboelastometry, respectively. We evaluated associations of each cytokine by multivariate regression including injury severity score (ISS), WBC counts, sGPVI and platelet counts as explanatory variables. RESULTS: Severely injured patients (ISS > 15) had higher levels of ßTGs and TGFß1 (both p < 0.01) but lower levels of PF4 (p = 0.02). GPVI and PMPs levels correlated with TGFß1 and PF4 whereas we found no significant association between cytokine levels and measures of haemostasis. By multivariate regression, a high WBC count was associated with high levels of TGFß1 (p = 0.01) and ßTGs (p < 0.01) but with low levels of PF4 (p = 0.03). CONCLUSION: Severely injured patients had higher levels of ßTGs and TGFß1 but lower levels of the PF4; a high WBC count predicted this anti-inflammatory profile of platelet cytokines.
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Factor Plaquetario 4/sangre , Factor de Crecimiento Transformador beta1/sangre , Heridas y Lesiones/sangre , beta-Tromboglobulina/metabolismo , Adulto , Femenino , Humanos , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Glicoproteínas de Membrana Plaquetaria/metabolismo , Análisis de Regresión , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Heridas y Lesiones/patologíaRESUMEN
BACKGROUND: Severe injury activates the sympathoadrenal, hemostatic and inflammatory systems, but a maladapted response may contribute to a poor outcome. Soluble CD40L is a platelet-derived mediator that links inflammation, hemostasis and vascular dysfunction. OBJECTIVES: To investigate the association between the sCD40L level and tissue injury, shock, coagulopathy and mortality in trauma patients. METHODS: A prospective, observational study of 80 trauma patients admitted to a Level I Trauma Center. Data on demography, biochemistry, Injury Severity Score (ISS) and 30-day mortality were recorded and admission plasma/serum analyzed for sCD40L and biomarkers reflecting sympathoadrenal activation (adrenaline, noradrenaline), tissue/endothelial cell/glycocalyx damage (histone-complexed DNA fragments [hcDNA], Annexin V, thrombomodulin and syndecan-1), coagulation activation/inhibition (PF1.2, TAT-complex, antithrombin, protein C, activated protein C, sEPCR, TFPI, von Willebrand factor [VWF], fibrinogen and factor [F] XIII), fibrinolysis (D-dimer, tissue plasminogen activator [tPA] and plasminogen activator inhibitor-1 [PAI-1]) and inflammation (interleukin-6 [IL-6] and sC5b-9). We compared patients stratified by median sCD40L level and investigated predictive values of sCD40L for mortality. RESULTS: High circulating sCD40L was associated with enhanced tissue and endothelial damage (ISS, hcDNA, Annexin V, syndecan-1 and sTM), shock (pH, standard base excess), sympathoadrenal activation (adrenaline) and coagulopathy evidenced by reduced thrombin generation (PF1.2), hyperfibrinolysis (D-dimer), increased activated partial thromboplastin time (APTT) and inflammation (IL-6) (all P < 0.05). A higher ISS (P = 0.017), adrenaline (P = 0.049) and platelet count (P = 0.012) and lower pH (P =0.002) were associated with higher sCD40L by multivariate linear regression analysis. High circulating sCD40L (odds ratio [OR] 1.84 [95% CI 1.05-3.23], P = 0.034), high age (P = 0.002) and low Glasgow Coma Score (GCS) pre-hospital (P = 0.002) were independent predictors of increased mortality. CONCLUSIONS: High early sCD40L levels in trauma patients reflect tissue injury, shock, coagulopathy and sympathoadrenal activation and predict mortality. As sCD40L has pro-inflammatory activity and activates the endothelium, sCD40L may be involved in trauma-induced endothelial damage and coagulopathy.
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Glándulas Suprarrenales/inervación , Coagulación Sanguínea , Ligando de CD40/sangre , Endotelio Vascular/lesiones , Choque/etiología , Sistema Nervioso Simpático/fisiopatología , Heridas y Lesiones/sangre , Heridas y Lesiones/complicaciones , Adulto , Biomarcadores/sangre , Distribución de Chi-Cuadrado , Dinamarca/epidemiología , Endotelio Vascular/metabolismo , Endotelio Vascular/patología , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Choque/sangre , Choque/mortalidad , Choque/patología , Choque/fisiopatología , Factores de Tiempo , Centros Traumatológicos , Regulación hacia Arriba , Heridas y Lesiones/mortalidad , Heridas y Lesiones/patología , Heridas y Lesiones/fisiopatologíaRESUMEN
BACKGROUND: Therapeutic hypothermia (TH) after cardiac arrest protects from neurological sequels and death and is recommended in guidelines. The Hypothermia Registry was founded to the monitor outcome, performance and complications of TH. METHODS: Data on out-of-hospital cardiac arrest (OHCA) patients admitted to intensive care for TH were registered. Hospital survival and long-term outcome (6-12 months) were documented using the Cerebral Performance Category (CPC) scale, CPC 1-2 representing a good outcome and 3-5 a bad outcome. RESULTS: From October 2004 to October 2008, 986 TH-treated OHCA patients of all causes were included in the registry. Long-term outcome was reported in 975 patients. The median time from arrest to initiation of TH was 90 min (interquartile range, 60-165 min) and time to achieving the target temperature (< or =34 degrees C) was 260 min (178-400 min). Half of the patients underwent coronary angiography and one-third underwent percutaneous coronary intervention (PCI). Higher age, longer time to return of spontaneous circulation, lower Glasgow Coma Scale at admission, unwitnessed arrest and initial rhythm asystole were all predictors of bad outcome, whereas time to initiation of TH and time to reach the goal temperature had no significant association. Bleeding requiring transfusion occurred in 4% of patients, with a significantly higher risk if angiography/PCI was performed (2.8% vs. 6.2%P=0.02). CONCLUSIONS: Half of the patients survived, with >90% having a good neurological function at long-term follow-up. Factors related to the timing of TH had no apparent association to outcome. The incidence of adverse events was acceptable but the risk of bleeding was increased if angiography/PCI was performed.
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Paro Cardíaco/terapia , Hipotermia Inducida , Factores de Edad , Anciano , Angioplastia Coronaria con Balón , Transfusión Sanguínea , Temperatura Corporal/fisiología , Angiografía Coronaria , Cuidados Críticos , Femenino , Escala de Coma de Glasgow , Paro Cardíaco/mortalidad , Hemorragia/epidemiología , Humanos , Hipotermia Inducida/efectos adversos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Valor Predictivo de las Pruebas , Sistema de Registros , Choque Cardiogénico/epidemiología , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND AND AIM: Sudden cardiac arrest survivors suffer from ischaemic brain injury that may lead to poor neurological outcome and death. The reperfusion injury that occurs is associated with damaging biochemical reactions, which are suppressed by mild therapeutic hypothermia (MTH). In several studies MTH has been proven to be safe, with few complications and improved survival, and is recommended by the International Liaison of Committee on Resuscitation. The aim of this paper is to recommend clinical practice guidelines for MTH treatment after cardiac arrest from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI). METHODS: Relevant studies were identified after two consensus meetings of the SSAI Task Force on Therapeutic Hypothermia (SSAITFTH) and via literature search of the Cochrane Central Register of Controlled Trials and Medline. Evidence was assessed and consensus opinion was used when high-grade evidence (Grade of Recommendation, GOR) was unavailable. A management strategy was developed as a consensus from the evidence and the protocols in the participating countries. RESULTS AND CONCLUSION: Although proven beneficial only for patients with initial ventricular fibrillation (GOR A), the SSAITFTH also recommend MTH after restored spontaneous circulation, if active treatment is chosen, in patients with initial pulseless electrical activity and asystole (GOR D). Normal ethical considerations, premorbid status, total anoxia time and general condition should decide whether active treatment is required or not. MTH should be part of a standardized treatment protocol, and initiated as early as possible after indication and treatment have been decided (GOR E). There is insufficient evidence to make definitive recommendations among techniques to induce MTH, and we do not know the optimal target temperature, duration of cooling and rewarming time. New studies are needed to address the question as to how MTH affects, for example, prognostic factors.
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Paro Cardíaco , Hipotermia Inducida/métodos , Resucitación/métodos , Paro Cardíaco/diagnóstico , Humanos , Hipotermia Inducida/efectos adversos , Países Escandinavos y Nórdicos , Factores de TiempoRESUMEN
BACKGROUND: We hypothesized that transoesophageal echocardiography (TOE) performed by the anaesthesiologists would be beneficial for monitoring purposes during paediatric cardiac surgery. We present the results for the first 5 years in 532 consecutive children. METHODS: The probe was successfully inserted in 99% of cases and remained in the oesophagus for 211 min on average (range 10-555 min). RESULTS: Insignificant valve leak, single- or biventricular failure and volume depletion were the most common new findings due to TOE. Changes in inotropic strategy and volume replacement were the most frequent interventions. In 45% of the cases, new information was disclosed and, in a total of 8% of cases, decisive information was provided. Except for tracheal extubation in one child who was uneventfully reintubated, no severe complications were identified. CONCLUSIONS: These data stress the safety and ease of performing TOE in children undergoing cardiac surgery. There is evidence for benefit from TOE findings to potentially enhance the therapeutic basis.
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Anestesia General , Procedimientos Quirúrgicos Cardíacos , Ecocardiografía Transesofágica , Adolescente , Niño , Preescolar , Ecocardiografía Transesofágica/efectos adversos , Femenino , Hemodinámica , Humanos , Lactante , Recién Nacido , Masculino , Monitoreo Intraoperatorio/métodosRESUMEN
Cardiogenic shock following acute myocardial infarction results in the death of most affected individuals. Longitudinal data suggest that in spite of modern pharmacological inotropic support and thrombolytic regimes, survival from cardiogenic shock has not improved during the last several decades. However, recent observational and limited randomized trial data indicate that some of these high risk patients may derive particular benefit from aggressive percutaneous or surgical revascularisation procedures. This review analyses currently available treatment strategies which appear to hold promise for the future.
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Infarto del Miocardio/terapia , Choque Cardiogénico/terapia , Procedimientos Quirúrgicos Cardíacos/métodos , Humanos , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Infarto del Miocardio/cirugía , Pronóstico , Choque Cardiogénico/complicaciones , Choque Cardiogénico/mortalidad , Choque Cardiogénico/cirugía , Tasa de SupervivenciaRESUMEN
Inhaled nitric oxide (iNO) has been extensively used in the treatment of severe hypoxaemic respiratory failure and/or pulmonary hypertension. Although the majority of studies have almost consistently demonstrated a beneficial effect on oxygenation and a reduction in pulmonary artery pressures, none of the randomised trials have reported a reduced mortality using iNO on patients with severe respiratory failure. In neonates with severe respiratory failure and pulmonary hypertension, however, iNO can reduce the need of extracorporal membrane oxygenation. Prior to using iNO on adult patients we suggest other measures to be taken (i.e. optimising ventilator settings, ventilation in prone position).
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Enfermedad Crítica/terapia , Hipertensión Pulmonar/terapia , Óxido Nítrico/administración & dosificación , Insuficiencia Respiratoria/terapia , Administración por Inhalación , Adulto , Enfermedad Crítica/mortalidad , Humanos , Hipertensión Pulmonar/mortalidad , Óxido Nítrico/efectos adversos , Insuficiencia Respiratoria/mortalidad , Terapia RespiratoriaAsunto(s)
Transfusión de Eritrocitos/efectos adversos , Sistema del Grupo Sanguíneo ABO/inmunología , Niño , Transmisión de Enfermedad Infecciosa , Eritroblastosis Fetal/etiología , Eritroblastosis Fetal/inmunología , Enfermedad Injerto contra Huésped/etiología , Hemoglobinas/análisis , Hemólisis/inmunología , Histocompatibilidad , Humanos , Hipersensibilidad/etiología , Tolerancia Inmunológica , Inmunidad , Inmunización , Lactante , Recién Nacido , Isoanticuerpos/inmunología , Neutropenia/inmunología , Síndrome de Dificultad Respiratoria/etiología , Trombocitopenia/inmunologíaRESUMEN
Cytokines are considered to be important mediators in the pathophysiology of sepsis and septic shock. We investigated if continuous arteriovenous haemofiltration (CAVH) could be used to remove excessive amounts of the cytokines tumour necrosis factor-alpha (TNF alpha), interleukin (IL)-1 alpha and IL-6 from peripheral blood in critically ill patients. Nine septic patients with renal failure were treated with CAVH. Ultrafiltrate and plasma were tested for cytokines by ELISA. All patients had detectable TNF alpha and IL-6 plasma levels, ranging from 10-750 pg/ml and 50-4,575 pg/ml, respectively. TNF alpha was removed by the ultrafiltrate with concentrations ranging from 10-1,000 pg/ml. The TNF alpha levels were significantly higher in the ultrafiltrate samples than in the corresponding plasma samples (P < 0.003). IL-6 was undetectable in the ultrafiltrate from five of the patients despite concomitant high plasma levels. IL-1 alpha was detectable in both plasma and ultrafiltrate in four patients. All patients developed multi-organ failure and septic shock and seven died. It is concluded that TNF alpha and IL-1 alpha but not IL-6 can be removed by CAVH in patients with sepsis.
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Soluciones para Diálisis/análisis , Hemofiltración , Interleucina-1/análisis , Interleucina-1/sangre , Interleucina-6/análisis , Interleucina-6/sangre , Insuficiencia Multiorgánica/sangre , Insuficiencia Multiorgánica/terapia , Choque Séptico/sangre , Choque Séptico/terapia , Factor de Necrosis Tumoral alfa/análisis , Lesión Renal Aguda/sangre , Lesión Renal Aguda/terapia , Adulto , Anciano , Enfermedad Crítica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diálisis Renal , Tasa de Supervivencia , UltrafiltraciónRESUMEN
UNLABELLED: Polymorphonuclear neutrophil (PMN) stimulation and degranulation can be mediated by the cytokines and by complement activation. The aim of the present study was to measure TNF alpha, IL-1 alpha, IL-6 and C3d in relation to postoperative increase in lactoferrin and elastase alpha-1-proteinase inhibitor (E alpha-1-PI) levels. Eleven patients undergoing thoracic surgery took part in the study. Blood leucocytes, E alpha-1-PI, lactoferrin and C3d were measured preoperatively, at the end of surgery and postoperatively, at 4 h and on day 1, 2, 3 and 5. TNF alpha, IL-1 alpha and IL-6 were measured preoperatively, at the end of surgery and postoperatively, at 4 h, and on days 1 and 5. The leucocyte count, lactoferrin and E alpha-1-PI levels increased significantly postoperatively (P < 0.01). There was no significant change in C3d values. Plasma IL-6 levels were unchanged in the postoperative period. Plasma TNF alpha and IL-1 alpha were detectable at low levels in only two and four patients, respectively. CONCLUSION: The postoperative increase in blood levels of PMN lactoferrin and E alpha-1-PI complexes observed in the present study was not accompanied by complement activation, or increased blood levels of IL-6.
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Activación de Complemento , Interleucina-6/sangre , Lactoferrina/sangre , Elastasa de Leucocito , Neutrófilos/fisiología , Elastasa Pancreática/análisis , Toracotomía , alfa 1-Antitripsina/análisis , Anciano , Degranulación de la Célula , Complemento C3d/análisis , Femenino , Humanos , Interleucina-1/sangre , Recuento de Leucocitos , Leucocitos/patología , Leucocitos/fisiología , Neoplasias Pulmonares/cirugía , Masculino , Persona de Mediana Edad , Neutrófilos/inmunología , Neutrófilos/patología , Neumonectomía , Factor de Necrosis Tumoral alfa/análisisRESUMEN
Tumour necrosis factor alpha (TNF alpha), interleukin-1 alpha (IL-1 alpha) and IL-6, when released in excess, have been suggested to be important host mediators of the immunoinflammatory response to injury and infections. Corticosteroids suppress this response in vitro. This study was undertaken to investigate if a single dose of methylprednisolone (MP) could modify the cytokine response in patients undergoing lung surgery. Twenty-one patients with lung cancer were allocated randomly to treatment with MP 30 mg/kg i.v. (MP group) or isotonic saline (control group). Patients were anaesthetized with a balanced anaesthesia combined with thoracic epidural anaesthesia. MP or saline was administered immediately before induction of anaesthesia. The cytokines in plasma were measured by ELISA, and blood samples were collected preoperatively, at the end of surgery, 4 h later, and 1 and 5 days postoperatively. All patients had detectable IL-6 in plasma. Compared to preoperative values, plasma IL-6 levels in the MP group increased from 114 pg/ml (12-350 pg/ml) (mean, range) to peak value 146 pg/ml (15-580 pg/ml) on the first postoperative day. In the control group, IL-6 levels increased from 99 pg/ml (17-350 pg/ml) preoperatively to 125 pg/ml (10-300 pg/ml) on the first postoperative day. The increases were not significant. TNF alpha was detectable in only two patients, one from each group. Low levels of IL-1 alpha were demonstrated in three patients in the MP group and in four patients in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)
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Interleucina-1/sangre , Interleucina-6/sangre , Pulmón/cirugía , Metilprednisolona/farmacología , Factor de Necrosis Tumoral alfa/análisis , Anciano , Transfusión Sanguínea , Dextranos/uso terapéutico , Femenino , Humanos , Neoplasias Pulmonares/sangre , Neoplasias Pulmonares/cirugía , Masculino , Metilprednisolona/administración & dosificación , Persona de Mediana Edad , Neumonectomía/métodos , Insuficiencia Respiratoria/etiologíaRESUMEN
A number of interesting applications of plasma elastase/alpha 1-protease inhibitor complexes (ELA-PI) and lactoferrin (LAC) have recently been suggested. However, the clinical utility of these components often seems to be low. This might be improved by minimizing the preanalytical variation, if possible. Therefore, we have evaluated the influence of various aspects of sampling and handling conditions on the results obtained when measuring ELA-PI and LAC. Blood samples from both healthy persons as well as patients, who had undergone laparotomy the day before, were investigated. We confirmed the previous observations of higher concentrations of ELA-PI and LAC in serum compared to plasma. This was more pronounced in patients than in healthy adults. In EDTA-blood the most important change was seen in samples from patients when stored at room temperature. In this situation increases of LAC concentrations of 50% and 100% following 2 and 5 h, respectively were found. This in vitro release of LAC was abolished when samples were stored on ice until centrifugation within 5 h. In contrast, a statistically significant increase in ELA-PI of 10% was observed following storage on ice for 2 h of blood specimens drawn from healthy persons. EDTA-plasma obtained by venous puncture following minimal stasis contained 10% higher concentrations of LAC compared to samples drawn from intravenous catheters, while no difference was observed in the case of ELA-PI. However, in one individual prolonged venous stasis resulted in larger differences of both LAC and ELA-PI. Different centrifugation conditions (1500 vs. 3000 x g; room temperature vs. 4 degrees C) did not influence concentrations of LAC or ELA-PI measured, neither did eating a normal meal nor moderate physical activity (30 min walk). In conclusion, ELA-PI and LAC should be measured in EDTA-plasma. Blood must be drawn by venous puncture applying minimal stasis or from indwelling venous catheters. Samples for measuring LAC must be stored on ice until centrifugation. Separation of plasma from cells should be performed as fast as possible, but storage for up to 5 h can be accepted.
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Lactoferrina/sangre , Elastasa Pancreática/sangre , alfa 1-Antitripsina/análisis , Conservación de la Sangre , Recolección de Muestras de Sangre , Centrifugación , Humanos , Recuento de Leucocitos , Masculino , Valores de Referencia , TemperaturaRESUMEN
An ELISA for neutrophil elastase (ELA) in complex with alpha 1-protease inhibitor (PI) (alpha 1-antitrypsin) was developed in microtitre plates and compared to the ELISA kit from MERCK (2-h version). Recovery of ELA-PI was good in both assays. The detection limits were 4.4 micrograms l-1 and 7.7 micrograms l-1 of the in-house and MERCK assay, respectively, while limits of quantitation were estimated to 7.7 micrograms l-1 (5.5-9.9 micrograms l-1) and 28.9 micrograms l-1 (14.6-44.3 micrograms l-1) for the two assays. Furthermore, as dilution curves of normal plasma were parallel with the calibration curve in the in-house assay over a wide range of dilutions, it is feasible to assay plasma in dilutions of only 1:6, resulting in a limit of quantitation of only 1.1 micrograms l-1. The total analytical coefficient of variation for samples measured in double determinations was 10.5%-12.5% in the in-house assay and 13.9%-14.6% in the MERCK assay. One-hundred-and-eight plasma samples covering a wide range of ELA-PI concentrations were analysed in both assays. A proportional difference between the two methods was detected, the mean ratio (in-house/MERCK) with 95% confidence limits was 1.115 (1.070-1.160). The cause of the difference was probably due to difference calibration of the assays. Until this problem is solved, method specific reference intervals are needed. A reference interval for the in-house method based on plasma samples from 123 healthy adults; median age 36 years (range: 19-65 years) was estimated to 16.5-48.5 micrograms l-1.
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Ensayo de Inmunoadsorción Enzimática , Elastasa Pancreática/sangre , alfa 1-Antitripsina/análisis , Adulto , Anciano , Ácido Edético , Humanos , Elastasa de Leucocito , Persona de Mediana Edad , Plasma/química , Valores de ReferenciaRESUMEN
Degranulation of polymorphonuclear granulocytes following minor surgery and the contributory role of temporary tissue ischaemia in a limb were examined in 22 otherwise healthy patients undergoing elective arthroscopy under general anaesthesia with and without tourniquet. Apart from an increase in lactate levels following tourniquet release there was no difference in complement split product C3d, cortisol, leukocyte or creatinine kinase levels between the two groups. There was a post-operative increase in the plasma E alpha 1-proteinase inhibitor concentration, whereas lactoferrin values decreased 4 h following tourniquet deflation. Anaesthesia and minor surgery are followed by post-operative release of polymorphonuclear neutrophil elastase. This release is not related to complement activation and is apparently unaffected by 50 min of lower limb ischaemia. Anaesthesia and minor surgery do not cause lactoferrin release.
Asunto(s)
Degranulación de la Célula/fisiología , Isquemia/sangre , Articulación de la Rodilla/cirugía , Pierna/irrigación sanguínea , Neutrófilos/fisiología , Torniquetes , Adolescente , Adulto , Anestesia General , Artroscopía , Linfocitos B/patología , Cartílago Articular/cirugía , Femenino , Humanos , Lactatos/sangre , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Neutrófilos/enzimología , Neutrófilos/patología , Elastasa Pancreática/antagonistas & inhibidores , Elastasa Pancreática/sangre , Complicaciones Posoperatorias , Sinovectomía , Factores de Tiempo , alfa 1-Antitripsina/análisisRESUMEN
Degranulation of polymorphonuclear (PMN) granulocytes, complement activation, and the endocrine metabolic response to hysterectomy were compared in two groups of patients receiving either general anaesthesia (GA group) or combined epidural analgesia and general anaesthesia (GAE group). The B-leucocyte and the cortisol responses were attenuated in the GAE group. There was no sign of complement activation. The post-operative rise in elastase-alpha-1-proteinase levels 4 h post-operatively on the first, second and third post-operative days was similar in the two groups. Plasma lactoferrin values were significantly elevated 4 h post-operatively and reached pre-operative values on Day 1 in both groups. Attenuation of the surgical stress response during uncomplicated hysterectomy did not influence the post-operative increase in proteinase activity. Mediators generated at the site of surgical trauma may account for the PMN degranulation observed after major surgery.