The computer program PEDINFUS permits the fast and simple definition of the individual nutrient amounts and infusion volumes in accordance with age, weight and possible metabolic complications for children up to 18 years. All components needed for total parenteral nutrition are taken into account. The conditions necessary for the optimal satisfaction of the individual needs of each patient by means of combined solutions have thus been created.
Definite suspensions of malignant cells from three human tumor cells lines (bladder, prostate and renal cell carcinom) were passed through a cell saver (Althin Mediplast) and a leucozyte removal filter (PALL RC 100) under standard conditions. The examination of the solutions did not detect any malignant cells at all. If investigations with malignant cells in the blood will confirm these results, the use of intraoperative autotransfusion in urological tumor surgery would be possible.
Medium-chain triglycerides are generally assumed to be metabolized independently of carnitine. The effects of infusing medium-chain triglycerides on plasma concentrations of carnitine derivatives and beta-hydroxybutyrate was studied in four healthy male adults. Glucose and amino acids were infused alone for three hours, then continued for another 5.5 hours together with a lipid emulsion containing only long-chain triglycerides or a mixture of medium-chain and long-chain triglycerides (50:50; w/w). During the fat-free infusion, the concentration of free carnitine rose, while the level of acylcarnitines decreased. Infusion of the mixed emulsion over 5.5 hours reduced free carnitine to lower values (32.4 +/- 4.7 mumols/L) than long-chain triglycerides infusion (44.4 +/- 2.7 mumols/L). By contrast, the plasma concentrations of short-chain acylcarnitines (12.1 +/- 3.3 vs. 5.4 +/- 1.9 mumols/L; p less than 0.01) and of beta-hydroxybutyrate (93 +/- 32 vs. 47 +/- 14 mumols/L; p less than 0.01) became significantly higher with the mixed emulsion than with long-chain triglycerides. These findings suggest that oxidation of medium-chain fatty acids is to some extent carnitine-dependent, whether or not transport into mitochondria is carnitine-mediated.
Strides made in the past several decades have greatly enhanced patients' quality of life particularly that of cancer patients, who often have to receive continuous infusion therapy. Research efforts that resulted in the development and use of the long-line central indwelling silicone elastomeric catheter, new methods for problem management, and the design and use of portable infusion pumps for administration of investigational and other chemotherapeutic agents have made it possible to deliver safe care to these patients on an ambulatory basis. These new programs made it imperative that patients who received such care would have audio, not just verbal and written information to assist them in carrying out procedures for these programs. Patient education programs, and particularly the ones at M. D. Anderson Cancer Center have produced many teaching and information aids. These programs are a credit to the pioneering spirit and trust of patients who came to M. D. Anderson in those early days. I can remember well when all of us were trying and working together on these programs. This spirit continues today.
The use of hypocaloric parenteral nutrition (HPN) is very common in surgical medicine because it allows for a standardized peripheral venous supply of nutrients. HPN causes very little stress to the posttraumatically labile carbohydrate metabolism-this applies to the use of glucose as well as to sugar substitutes: For example, mean glucose concentrations in serum on glucose administration of 2-3 g/kg/day are between 5.5 and 8.4 mmol/l. The mean dose of amino acids of 1.0-1.2 g/kg/day commonly used in HPN leads to a 50-67% improvement in the N-balance compared to an exclusive water/electrolyte supply or the administration of 2 g of carbohydrates per kg and day. Even a high caloric nutritional therapy leads to no significantly improved N-balances on the first posttraumatic days. HPN is recommended after major surgery and severe trauma in order to better estimate the individual metabolic reaction to nutritional supply prior to any consumption-orientated parenteral nutrition. HPN is also important as an adjunct to early-phase enteral nutrition. Its value after moderate surgical interventions is questionable because studies have yet to confirm HPN's clinical efficacy. HPN should not be used after minor surgery or brief periods of fasting. A possible, but as yet uncertified indication for HPN is the longer-term nutrition of very obese patients.
Anaesthesiology and transfusion medicine are presented as two specialties in medicine which have many common interests and mutual bonds. They both are young developments with similar historical stages during the last centuries and fulminant final progresses within the last decades. In a state of the art review transfusion medicine is described as a new specialty whose complexity, its nowadays accepted facets, the goals and topics are clearly understood. The anaesthesiologist as the clinician with the greatest proximity to blood transfusion should know about transfusion medicine not only theoretical basic science, but also practical clinical work. It is necessary for anaesthetists to know about immunology, haemoglobin levels, blood coagulation and the haemodynamics of circulation, some of these facets being already well known to him from everyday work in the O.R. and at the ICU. The anaesthetist must furthermore be familiar with bed side pretransfusion testing, autologous blood transfusion, the indications for an appropriate use of the different blood components and the danger of adverse effects of blood transfusion. A clear and safe use of blood during surgery and in the intensive care medicine must be the final goal for anaesthesiologists wanting to fulfill their tasks properly.
O2-uptake was measured continuously in 18 polytraumatized and 21 long-term ventilated patients. All patients were on assisted ventilation with sufficient sedation and analgesia. O2-uptake was measured every minute, the values were recorded over 24 h and the mean O2-uptake/min was calculated. At the same time, the O2-uptake of the last 15 min of every hour was measured separately (e.g. 7.45-8.00, 8.45-9.00, etc.). The mean O2-uptake/min measured continuously was compared and correlated with the mean O2-uptake per day, calculated on the basis of each of the short-term measurements.There were only slight differences between the mean values of the two procedures: In the group of long-term ventilated patients the mean O2-uptake was found to be 364 ml/min in continuous measurements and 363 ml/min in short-term measurements. This O2-uptake corresponded to an energy expenditure of 2360 kcal/day. The mean correlation coefficient was 0.89 (range: 0.79-0.96). If O2-uptake was measured over 2 periods of 15 min each, e.g. in the late morning and in the afternoon, the mean correlation coefficient improved to 0.94 and the standard deviation was reduced. Comparable results were obtained in the group of polytraumatized patients. This study shows that under certain preconditions short-term measurements of O2-uptake of 2 x 15 min allow sufficiently reliable predictions of the daily O2-uptake and energy expenditure in severely traumatized or critically ill patients.
Important criteria for assessing a cell separator are thrombocyte yield, separation efficiency, and purity of the thrombocyte concentrates. Based on a Multicentric Counting Study, in which 12 centers participated, we conclude that it is very difficult to compare the results of the various centers in regard to the separation efficiency. This is especially true for the comparison of different separation procedures. In Marburg we compared three different cell separators of the newest generation: COBE Spectra (n = 71), Fresenius AS-104 (n greater than 1100) and Fenwal CS-3000 TNX (n = 79). The COBE Spectra exhibited the best separation efficiency with the lowest leukocyte contamination (thrombocytes 4.3 x 10(11) (72.2%), leukocytes 0.5 x 10(7)) on the condition that the ACD-blood ratio did not differ more than -15% from the required algorithm. In order to reduce the risk to the donor, the system correspondingly reduces the donor's blood flow, resulting in a longer donation time (on the average 89-100 min). When the ACD ratio was reduced further, a considerable number of spontaneous and sometimes irreversible platelet aggregation occurred, increasing the risk of shortened survival through reduced platelet function. The AS-104 and the modified CS-3000 (TNX) had similar separation efficiencies (approx. 60%). While the platelet concentrates (PC) of the AS-104 almost reached the purity of that from the COBE Spectra, the leukocyte contamination of the CS-3000 PC's was still about four times as high. Other results published show that morphology, in-vitro function and in-vivo survival of thrombocytes collected with the AS-104 are significantly better than those from the CS-3000.(ABSTRACT TRUNCATED AT 250 WORDS)
The concentrations of anti-A and anti-B IgM and IgG antibodies have been studied in the serum of a patient with blood group AB who received a type A donor liver. A newly developed ABO-ELISA was used for this purpose and the values were compared to hemagglutination titers. During the postoperative study period over 8 weeks, the anti-A and anti-B levels showed a higher fluctuation than was measured in preoperative samples. Thus, in this AB-type patient, anti-A IgM varied 10-fold, anti-A IgG 20-fold and anti-B IgG 16-fold. Peak values corresponded to rejection episodes. Immunoactivation in the patient was further documented by the presence of abnormally high levels of soluble interleukin-2 receptors (slL-2R) in serum samples. The study shows that monitoring of anti-A/B antibodies may represent a further criterion to follow-up transplanted patients during the critical postoperative graft acceptance period.
In six renally insufficient children and adolescents (age: 8-21 years) on hemodialysis the effect of L-carnitine supplementation at two dose levels (10 mg/kg/d vs. 100 mg/kg/d) on parameters of lipid metabolism was investigated. L-Carnitine substitution was carried out over four weeks per dose level. Under this regime a significant increase of the serum carnitine concentration occurred together with a decrease in the AC/FC-ratio (x: 1.59 to x:0.83). During the same period a significant decrease in serum triglyceride levels as well as an increase in serum HDL-cholesterol were observed. An inverse correlation (r = -0.63; p less than 0.0008) was found between HDL-cholesterol and the AC/FC-ratio. L-carnitine supplementation and its increasing effect on HDL-cholesterol in patients with renal insufficiency may be considered as antiatherogenic.
115 patients with bone marrow aplasia/hypoplasia received a total of 567 transfusions of fresh HLA-selected platelet concentrates at random from the AS-104 and CS-3000 and, whenever possible, from both separators using the same donor. By daily platelet counting pre and up to seven days post transfusion, the posttransfusional increments per 10(11) platelets transfused were calculated. Fresh platelets collected from the AS-104 showed comparable in vivo recovery at the first day post transfusion but significant better survival compared to those from the CS-3000. This is in line with in vitro studies published before, where we already reported on better in vitro function and morphology. Increased platelet yields and improval of the platelet survival of the PC's from the AS-104 should result in prolonged transfusion intervals.When additionally evaluating a limited number of PC's from the AS-104 stored in teflon bags up to five days before transfusion (n = 12), we did not get favorable results compared to PC's from the CS-3000 stored in polyolefine bags. As this seemed to be due to the geometry of the bags, it was consequently changed in the meantime.
The major risk factor associated with repeated platelet transfusions is alloimmunization. Its management represents one of the greatest remaining clinical and research challenges in the field of platelet transfusion therapy. This is particularly true because current approaches to the treatment of leukemias and various solid tumors are now focussed on the administration of intensive, repetitive courses of postremission chemotherapy necessitating successful platelet support for a prolonged time. Moreover, once alloimmunization has supervened and histocompatible donors cannot be identified there are no proven approaches for the management of bleeding complications in thrombocytopenic patients. Thus, any practical means by which the rate or the speed of alloimmunization could be minimized would be of considerable clinical importance.
After abdominal surgery there is a postoperative small bowel ileus. We evaluate whether the duration of the small bowel ileus is depending on the kind of surgery or not. Over a needle catheter jejunostomy a 3-tip transducer was placed into the distal jejunum. At the end of the operations a pressure detector was connected to measure the intraluminal pressure continuously over five days. Group A consisted of three patients undergoing explorative laparotomy because of inoperable gastric cardia cancer, and group B of eight patients who underwent gastrectomy. In none of the patients a normal empty stomach motility pattern, determined by the activity of a migrating myoelectric complex (MMC) was detectable. In group A the normal MMC-activity returned after 24 +/- 4.5 h and in group B after 82 +/- 25 h. Therefore the duration of the loss of the interdigestive myoelectric complex appeared to be dependent upon the type of surgery.
Leukocyte poor platelet concentrates (PC), containing less than 10 leukocytes, prepared from buffycoats can be stored in normal PVC bags for 7 days at 22°C without deterioration of the pH. We assumed that a low number of leukocytes present in the PC, is a critical factor to maintain the pH. To test this hypothesis increasing amounts of leukocytes were added to four groups of three PC with comparable plasma volumes (mean 58.6 ± 0.8 (SD) ml) and platelet concentrations (1.01 ± 0.04×109 /ml). Group I had a leukocyte concentration of 0.14±0.048×106 /ml, group II 1.96±0.09×106 /ml, group III 5.53±0.98×106 /ml, and group IV 13.0±0.93×106 /ml. The PC were stored in normal PVC bags for 7 days at 22°C. Measurements in vitro were performed at day 0, 2, 5 and 7. The initial mean pH value was 7.12±0.02 (SD) for all PC and dropped to 6.89, 6.85, 6.77 and 6.61 for group I to IV respectively, at day 7. A significant correlation (Spearman rank test) between low pH values and high leukocytes was found. The same significant positive correlation was observed between high leukocyte concentrations and high glucose consumption and high lactate production and LDH release during storage. These results show that the amount of leukocytes in PC has a significant contribution to the detrimental effect on pH during platelet storage. It is therefore important to prepare PC with a leukocyte count lower than 10 . Moreover the risk of alloimmunisation against HLA antigens will be diminished.
A newly developed filter-system (PL 100) for the removal of leukocytes from platelet concentrates was tested. It removes contaminating leukocytes by 99.7 +/- 0.6%. The platelet loss was calculated as 25.7 +/- 9.5%. The filtration process does not influence the filtered platelets; plasma-electrolytes, LDH-concentrations, platelet aggregation curves and serotonin-release remain constant. In addition, platelet ultrastructure is not influenced by the filtration. In spite of the high platelet loss, the tested filter-system seems to be a suitable alternative to the conventional methods for the removal of contaminating leukocytes from platelet concentrates.
Medium-chain triglycerides are generally assumed to be metabolized independently of carnitine. The effects of infusing medium-chain triglycerides on plasma concentrations of carnitine derivatives and beta-hydroxybutyrate were studied in four healthy male adults. Glucose and amino acids were infused alone for 3 h, then continued for another 5.5 h together with a lipid emulsion containing only long-chain triglycerides or a 50:50% (wt/wt) mixture of medium-chain and long-chain triglycerides. During the fat-free infusion, the concentration of free carnitine rose, whereas the level of acylcarnitines decreased. Infusion of the mixed emulsion over 5.5 h reduced free carnitine to lower values (32.4 +/- 4.7 mumols/l) than long-chain triglycerides infusion (44.4 +/- 2.7 mumol/l). By contrast, the plasma concentrations of short-chain acylcarnitine (12.1 +/- 3.3 vs. 5.4 +/- 1.9 mumols/l; P less than 0.01) and of beta-hydroxybutyrate (93 +/- 32 vs. 47 +/- 14 mumols/l; P less than 0.01) became significantly higher with the mixed emulsion than with long-chain triglycerides. This suggests that intravenous medium-chain triglycerides are not metabolized independently of carnitine. Carnitine may play an important role in removing acyl and acetyl groups from mitochondria and in restoring the intramitochondrial CoA level. Fat substrates are converted into compounds that might be utilized by tissues that do not normally oxidize fatty acids, creating an interorgan energy cycle.
In addition to measuring the routine blood coagulation parameters (Quick, PTT, TT, AT III, Fibrinogen, PLT), the Thrombin-Antithrombin III Complex (TAT) Test was performed preoperatively on 20 patients treated because of nodular goiter in the euthyreoid state and ten patients with symptomatic cholecystolithiasis. While there were no changes in the routine blood coagulation parameters, significant alterations of the TAT occurred in both patient groups. This indicates that TAT makes operation-induced activation of the blood coagulation system, which is impossible by just measuring the routine blood coagulation parameters alone, detectable.
The central venous catheter, on the one hand, and the peripheral venous cannula, on the other hand, are available as fundamental access possibilities for parenteral nutrition. While the implantation of a central venous catheter is technically tiresome and subject to a complication rate up to 5%, the peripheral venous cannulization, in general, does not represent any technical problem. However, in case of peripheral venous access, due to the local venous compatibility, not only the duration of application is generally limited to 4-6 days, but the feeding of nutritious substances as such (excepting fat emulsions) is restricted, too. This means a limitation of the applicability in temporary and acute phases of a disease, as well as its application as a supplementary therapy in the event of oral or enteral nutrition. The advantage of the central venous parenteral nutrition refers to the possibility of a long-term high-doses, and thus to a complete parenteral, nutritional therapy. It is, however, subject to an aggravating rate of thrombotic (0.5-5%) and septic complication (3-6%), so that the indication and duration of application should be looked upon very closely and critically. The low-risk alternatives of a peripheral venous parenteral nutrition should be observed more closely.
Application of carbohydrates in pediatric infusion therapy has recently been limited to glucose and xylitol. Fructose and sorbitol, which formerly had been used widely as energy sources in parenteral nutrition, have meanwhile been banned in order to prevent fatal complications in patients with undiscovered hereditary disturbances in fructose metabolism. The aim of this review is to focus the attention on potential side effects and limitations of glucose administration in pediatric infusion therapy. With special regard to total parenteral nutrition in preterm infants, sufficient glucose conversion to N-acetylneuraminic acid and other carbohydrate building blocks of glycoproteins and gangliosides is to be placed in question. This might have consequences for normal brain development and can be considered a challenge for future research work in this field.
