Contamination of central venous catheters. The skin insertion wound is a major source of contamination.

In a prospective controlled trial we compared the rates of catheter-tip contamination in central venous catheters inserted with or without skin contact. The study was designed so that each patient was their own control. All patients had a single-lumen central venous catheter and a Swan-Gantz sheet inserted through the skin. A Swan-Gantz catheter was inserted and retracted through the sheet thus avoiding contact with skin or subcutaneous tissue. Catheter-tip cultures were performed on removal of catheters. Thirty-three Swan-Gantz catheters were cultured and all were sterile. In the corresponding 33 sheets 16 (48.6%) yielded bacterial growth. Four of the sheets showed growth of more than 15 cfu. In the 26 single-lumen catheters, eight (30.8%) catheter-tips grew bacteria, and four of them had more than 15 colonies. The study supports the theory that the skin-insertion wound is a major source of catheter-contamination.

Immediate and prolonged effects of pre- versus postoperative epidural analgesia with bupivacaine and morphine on pain at rest and during mobilisation after total knee arthroplasty.

Thirty-two patients scheduled for total knee arthroplasty were randomized to receive an identical epidural blockade initiated 30 min before surgical incision (N = 16), or at closure of the surgical wound (N = 16). Before induction of general anaesthesia the epidural catheter was tested with bupivacaine 7.5 mg.ml-1, 2 ml. General anaesthesia was induced with thiopentone, pancuronium or atracurium, and fentanyl 0.1-0.3 mg, and maintained with N2O/O2 and enflurane. The epidural regimen consisted of a bolus of 16 ml of bupivacaine 7.5 mg.ml-1 plus morphine 2 mg, and continuous infusion of bupivacaine 1.25 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1 for the first 24 h, and bupivacaine 0.625 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1, for the next 24 h after operation. Additional morphine 2.5-5 mg was administered i.v. or i.m. for the first 24 h postoperatively, and ketobemidone or morphine 5-10 mg orally or rectally from 24 h to 7 d postoperatively, on request. Paracetamol 1000 mg every 8 h was administered from 48 h to 7 days postoperatively. No significant differences were observed in request for additional opioids, or in pain scores at rest or during mobilisation of the operated limb, during or after cessation of the epidural regimen. These results do not suggest timing of analgesia with a conventional, continuous epidural regimen to be of major clinical importance in patients undergoing total knee arthroplasty.

Contamination of central venous catheters: use of infusion-lines does not increase catheter-contamination.

In a prospective controlled trial we compared the rates of intraluminal contamination between the two lumens of a double-lumen central venous catheter. One lumen was used for repeat infusions and injections, and the other was permanently connected to a slow infusion of 0.9% NaCl. The study was designed so that the patient was his own control. Twenty-eight catheters were examined and comparison with catheter-tip cultures was performed in 24. Intraluminal culture was performed 67-77 h after insertion of the catheter and catheter-tip culture was performed on removal of the catheter. The contamination rate from catheter-tips was 20.8%, which is acceptable compared with other studies. There was only one positive intraluminal culture in each group (3.6%), and thus no correlation was found between contamination rate and the number of times the infusion-line had been interrupted for use. As for catheter-tip contamination, we found no correlation between infusion of blood-products or parenteral nutrition and contamination rates.

Myocardial ischaemia and spinal analgesia in patients with angina pectoris.

We have studied prospectively myocardial ischaemic events by Holter monitoring of ST-segment depression in patients with angina pectoris given spinal analgesia for minor surgery compared with a reference day of normal daily activities. Monitoring was undertaken continuously for 24 h on both days, starting just before anaesthesia on the day of surgery. On the reference day, seven of 14 patients had 27 ischaemic events with mean max ST-depression of 0.15 mV and total duration of 143 min, compared with 10 of 14 patients with 70 ischaemic events with mean max ST-depression of 0.22 mV and total duration of 1078 min (P < 0.01 for all). On the day of surgery, the first ischaemic event occurred a mean 338 min (range 75-480 min) after spinal analgesia, and the duration of all first events was 480 min. On this day, the first ischaemic event was associated with increased heart rate (103 beat min-1 (range 66-131 beat min-1) compared with 92 (60-122) beat min-1 during all events (P = 0.011)). In patients with angina pectoris, myocardial ischaemia did not occur immediately after the onset of spinal analgesia, but several hours later, corresponding to the cessation of block. This could be explained by increased cardiac pre- and afterload, probably further aggravated by the volume load.

Postoperative pulmonary complications and lung function in high-risk patients: a comparison of three physiotherapy regimens after upper abdominal surgery in general anesthesia.

The effect of three postoperative regimens of respiratory therapy on pulmonary complications and lung function was compared in high-risk patients. Fifty-one patients were randomized to: 1) conventional chest physiotherapy alone (PHYS), 2) chest physiotherapy and positive expiratory pressure (PEP), or 3) chest physiotherapy with both positive expiratory pressure and inspiratory resistance (RMT). Treatments were given twice daily by a physiotherapist and self-administered. The incidence of postoperative pulmonary complications (PPC) was respectively, 71%, 76% and 65% in the PHYS-, PEP- and RMT-groups. The incidence of PPC requiring treatment with antibiotic, bronchodilator or supplementary oxygen according to the existing clinical practice was 47%, 47% and 29%. The incidence of atelectasis was 65%, 64% and 60% and of pneumonia 29%, 35% and 6%. There was no difference between the groups, except for a tendency to a lower frequency of pneumonia in the RMT-group. Postoperatively forced vital capacity (FVC) decreased to mean 54%, forced expired volume in 1 s to 48% and functional residual capacity to 76% of preoperative values. Arterial oxygen tension (PaO2) declined to mean 8.1 kPa and arterial saturation (SaO2) to 89%. There was no difference between the groups except for FVC, PaO2 and SaO2 (P = 0.008, P = 0.008 and P = 0.002), which showed the least decrease in the RMT-group. None of the regimens could be considered as satisfactory concerning the prevention of PPC, but RMT seemed to be the most efficient. Insufficient self-administration of treatment was probably one of the causes of the overall high incidence of PPC in this study.

Treatment of pancreatic pain with interpleural bupivacaine: an open trial.

This study comprised 12 patients admitted for interpleural catheter treatment of chronic pancreatic pain. After the insertion of a left-sided interpleural catheter, 20 ml of bupivacaine 0.5% plain was given, followed by top-ups of 10-20 ml bupivacaine 0.5% as needed. Catheters were left in situ for 12-30 h. Immediate pain relief was achieved in all patients. Five patients had only a single blockade offering pain relief for a median of 33 days. One patient suffering from pancreatic carcinoma remained pain-free until death 45 days later. Seven patients returned for a second blockade after a median of 10 days. After this second blockade long-lasting pain relief was achieved in three patients for 70, 105 and 145 days. Two patients experienced pain relief lasting 11-14 days, while in two patients only a short-lived effect was observed, 3-8 days. Unimportant pneumothorax occurred in one patient. No cardiovascular or respiratory side-effects were recorded. We consider interpleural blockade an alternative worth further investigations in the future in the treatment of patients suffering from chronic pancreatic pain.

[Use of controlled hyperventilation in the treatment of comatose patients with cranial injuries]. / Anvendelse af kontrolleret hyperventilation i behandlingen af komatøse patienter med kranietraume.

Controlled hyperventilation is a recognized method by which it is possible to reduce the intracerebral blood volume and thus the intracranial pressure (ICP). In the review, the physiological conditions involved in the regulation of ICP are illustrated, particularly in connection with acute cranial traumata and effect of controlled hyperventilation in these situations is discussed. Controlled hyperventilation is recommended in the hyperacute phase for all patients with cranial trauma prolonged impairment of consciousness (Glasgow Coma Scale less than 7 for more than 30 minutes) and other clinical evidence of expanding space-occupying intracranial process. Prolonged hyperventilation is recommended for younger patients as these have most frequently hyperaemia and retained CO2 reactivity and for patients with predominantly cortical lesions as assessed by CT scanning. Caution in the employment of hyperventilation is advised in elderly patients, severely traumatized patients and late in the course of cerebral trauma.

Solitary fibroepithelial polyp of the renal pelvis.

An unusual case of benign fibroepithelial polyp of the renal pelvis in a patient past middle age is presented. Peroperative frozen section microscopy should be done to prevent nephroureterectomy. The therapy was local excision. The postoperative course was uneventful.

Prognostic value of human placental lactogen (HPL) in an unselected obstetrical population.

A prospective study on the value of routine HPL determination as a supplement to clinical antenatal care is presented. The HPL values in the apparently normal pregnant women were not known to the clinicians. The material comprised 1 660 pregnancies and deliveries, in 87% of which at least one HPL value was available. The results are expressed as the ability of a low HPL value to predict the birth of a distressed infant and/or an infant of low birth weight, a normal HPL value the birth of a non-distressed infant and/or an infant of normal birth weight. Moreover, the results show has many of the distressed infants and infants of low birth weight were born to mothers with low HPL values. Like a number of other authors, we found that HPL screening increases the prognostic reliability in pregnancies with complications. On the other hand, its value in normal pregnancies could not be confirmed.