Money well spent: a comparison of hospital operating margin for laparoscopic and open colectomies.

BACKGROUND: Cost analysis after laparoscopic colectomy has been examined, although reports evaluating the effects of laparoscopy on hospital operating margin are lacking. We compared several cost/revenue measures, including hospital operating margin, between open and laparoscopic colectomies at an academic center. METHODS: Our cost-accounting database was queried for laparoscopic partial (LPC) and total colectomies (LTC), and open partial (OPC) and total colectomies (OTC) to analyze net revenue, total costs, and total hospital operating margin over a 4-year period. Laparoscopic and open colectomy cases were compared, with mean operating margin as the primary outcome. RESULTS: From July, 2002 through May, 2006, 842 patients were included for analysis with 138 undergoing laparoscopic colectomy. Net revenue was higher in the LTC group compared with open (US dollars 30,300 vs US dollars 26,800 [P = .02]), and lower in the LPC group (US dollars 15,300 vs US dollars 21,300 open [P < .0001]). Total costs were reduced in both the LPC and LTC groups compared with open [US dollars 11,700 vs US dollars 17,600 [P < .0001] and US dollars 18,000 vs US dollars 19,400 [P = .0019], respectively). LPC resulted in a similar HOM (US dollars 3,602) compared with OPC (US dollars 3,647; P = .35). LTC resulted in a higher HOM (US dollars 12,300) compared with OTC (US dollars 7,400; P = .02). CONCLUSIONS: LTC generates a significantly higher hospital operating margin than an OTC, although the margins are similar for LPC and OPC.

Transport properties of alveolar epithelium measured by molecular hetastarch absorption in isolated rat lungs.

To evaluate the transport properties of the alveolar epithelium, we instilled hetastarch (Het; 6%, 10 ml, 1 - 1 x 10(4) kDa) into the trachea of isolated rat lungs and then measured the molecular distribution of Het that entered the lung perfusate from the air space over 6 h. Het transport was driven by either diffusion or an oncotic gradient. Perfusate Het had a unique, bimodal molecular weight distribution, consisting of a narrow low-molecular-weight peak at 10-15 kDa (range, 5-46 kDa) and a broad high-molecular-weight band (range 46-2,000 kDa; highest at 288 kDa). We modeled the low-molecular-weight transport as (passive) restricted diffusion or osmotic flow through a small-pore system and the high-molecular-weight transport as passive transport through a large-pore system. The equivalent small-pore radius was 5.0 nm, with a distribution of 150 pores per alveolus. The equivalent large-pore radius was 17.0 nm, with a distribution of one pore per seven alveoli. The small-pore fluid conductivity (2 x 10(-5) ml. h(-1). cm(-2). mmHg(-1)) was 10-fold larger than that of the large-pore conductivity.

Results of multiple diagnostic tests for Mycobacterium avium subsp. paratuberculosis in patients with inflammatory bowel disease and in controls.

Mycobacterium avium subsp. paratuberculosis has been incriminated as a cause of Crohn's disease (CD); however, studies to date have been relatively small and generally only used a single diagnostic assay. The objective of the study was to reexamine the association of M. avium subsp. paratuberculosis and CD using multiple diagnostic tests. Five methods were used to detect M. avium subsp. paratuberculosis infections in 439 inflammatory bowel disease (IBD) patients and 324 control subjects in the United States and Denmark. Most assays were adaptations of diagnostic tests for this infection performed routinely on animals. PCR for IS900, a genetic element unique to M. avium subsp. paratuberculosis, was positive significantly more often on resected bowel and lymph node tissues from CD patients (19.0%) and ulcerative colitis (UC) patients (26.2%) than from controls (6. 3%) (P < 0.05). Positive IS900 PCR results occurred more often in U. S. than in Danish IBD patients, 32.0 versus 13.3% (P = 0.025). The majority of Danish patients were bacillus Calmette-Guérin (Mycobacterium bovis BCG) vaccinated (CD, 77.5%; UC, 86.6%; controls, 83.0%) whereas none of the U.S. patients with IBD and only 2% of U. S. controls were vaccinated. Among Danish IBD patients, positive PCR findings were four times more common among subjects who were not BCG vaccinated (33.3%) than among BCG vaccinates (8.8%, P = 0.02). Culture of the same tissues tested by PCR using modified BACTEC 12B medium failed to grow M. avium subsp. paratuberculosis from patients or controls. U.S. CD patients had the highest serological evidence (enzyme-linked immunosorbent assay [ELISA] for serum antibodies) of M. avium subsp. paratuberculosis infection (20.7% of patients positive) which was higher than for all UC patients studied (6.1%) or healthy controls (3.8%, P < 0.005). Among Danish patients alone, however, no significant differences in rates of ELISA-positive results among CD, UC, or control patients were found. For 181 study subjects, both IS900 PCR and ELISA were performed. Although 11 were ELISA positive and 36 were PCR positive, in no instance was a patient positive by both tests, suggesting that these states are mutually exclusive. Evaluation of cytokine-mediated immune responses of IBD patients was complicated by the influence of immunosuppressive therapy given most IBD patients. Gamma interferon (IFN-gamma) release by peripheral blood leukocytes after M. avium purified protein derivative PPD antigen stimulation showed significantly lower responses in CD patients than in UC patients or controls in both U.S. (by ex vivo assay) and Danish (by in vitro assay) populations (P < 0.05). Interleukin-5 responses were not different among CD, UC, or control groups. Collectively, the PCR, ELISA, and IFN-gamma tests for M. avium subsp. paratuberculosis together with the unexpected observation that BCG vaccination influenced M. avium subsp. paratuberculosis detection, lead us to conclude that M. avium subsp. paratuberculosis, or some similarly fastidious mycobacterial species, infects at least a subset of IBD patients. Whether the infection is primary (causal) or secondary, it may contribute to the etiopathogenesis of IBD.

Acellular hemoglobin solution enters compressed lung capillaries more readily than red blood cells.

High lung inflation pressures compress alveolar septal capillaries, impede red cell transit, and interfere with oxygenation. However, recently introduced acellular hemoglobin solutions may enter compressed lung capillaries more easily than red blood cells. To test this hypothesis, we perfused isolated rat lungs with fluorescently labeled diaspirin cross-linked hemoglobin (DCLHb; 10%) and/ or autologous red cells (hematocrit, 20). Septal capillaries were compressed by setting lung inflation pressure above vascular pressures (zone 1). Examination by confocal microscopy showed that DCLHb was distributed throughout alveolar septa. Furthermore, this distribution was not affected by adding red blood cells to the perfusate. We estimated the maximum acellular hemoglobin mass within septa to be equivalent to that of 15 red blood cells. By comparison, we found an average of 2.7 +/- 4.6 red cells per septum in zone 1. These values increased to 30.4 +/- 25.8 and 50.4 +/- 22.1 cells per septum in zones 2 and 3, respectively. We conclude that perfusion in zone 1 with a 10% acellular hemoglobin solution may increase the hemoglobin concentration per septum up to fivefold compared with red cell perfusion.

CD52 mRNA is modulated by androgens and temperature in epididymal cell cultures.

Cultured rat epididymal tissue explants formed >90% pure, adherent growing epithelial cell monolayers. Despite their flattened and apparently androgen receptor-negative phenotype, these cells for a short period kept characteristics of the epididymal duct epithelium, i.e., expression of the tissue-specific marker CD52 and responsiveness of its mRNA toward temperature elevation and androgen withdrawal. When cells were grown on permeable supports at 33 degrees C, androgen supplementation or withdrawal specifically modulated the levels as well as the length of the CD52 mRNA. Elevation of the culture temperature to a quasi abdominal milieu of 37 degrees C selectively reduced the CD52 mRNA levels under all culture conditions. This reduction was not affected by the presence of androgens and was not accompanied by changes in length, suggesting that the modulation of CD52 mRNA in epididymal cells by androgens and by temperature is synergic, but may involve different molecular mechanisms. CD52 mRNA levels, however, were not stable in the primary cultures but decreased rapidly to undetectable levels after 4-5 days at all culture conditions. GAPDH mRNA levels, on the other hand, were stable throughout the culture period.

Pulmonary capillary sieving of hetastarch is not altered by LPS-induced sepsis.

BACKGROUND: Gram-negative lipopolysaccharide (LPS) has been demonstrated to increase pulmonary capillary permeability as judged by the increased flow of protein-rich lymph from the lungs of sheep infused with LPS. This finding suggests that LPS-injured pulmonary capillaries might be less restrictive than uninjured capillaries to the filtration of large hetastarch molecules. Hetastarch has a broad molecular mass spectrum (35-1,500 kilodaltons (kDa)), and one way to test the restrictiveness of pulmonary capillaries is to measure the size of the largest hetastarch molecules that cross the microvascular barrier and enter the lymph. To evaluate the effects of LPS, we compared hetastarch molecular distributions in the lung lymph of normal and LPS-injured sheep. METHODS: Adult sheep (38.2 +/- 0.8 kg) were surgically prepared for the collection of lung lymph, with study initiation after a 5- to 7-day recovery period. Hetastarch (6%) was infused (10 mL/kg) 24 hours before study to allow for stabilization of the hetastarch molecular distribution. On the day of study, LPS (Escherichia coli lipopolysaccharide, 2 microg/kg; n = 6) was infused, and plasma and lymph samples were collected for 12 hours. An additional group of animals not infused with LPS (n = 6) served as controls. Hetastarch molecular distributions in plasma and lymph were measured by using high performance size exclusion chromatography. RESULTS: In control sheep, the largest hetastarch molecules in lymph averaged 861 +/- 18 kDa (mean +/- SEM) (plasma, 1,065 +/- 18 kDa). In LPS-treated sheep, the largest hetastarch molecules in lymph averaged 845 +/- 19 kDa (not significant vs. normal) (plasma, 1,025 +/- 14 kDa). Hetastarch concentrations in plasma and lung lymph of normal sheep, respectively, were 0.61 +/- 0.05% and 0.34 +/- 0.07%. In LPS-treated sheep, hetastarch concentrations in plasma and lymph were 0.56 +/- 0.08 (not significant vs. normal) and 0.29 +/- 0.07, respectively (p < or = 0.05). Lymph concentrations were lower after LPS because of increased lymph flows (19.9 +/- 5.4 mL/30 min, compared with 3.6 +/- 0.8 mL/30 min in normal sheep). CONCLUSION: Our results suggest that LPS does not alter the diameter of the largest pores perforating the walls of pulmonary capillaries. Rather, the number of these pores in the capillary wall appears to be increased. This increase would explain why lymph flows rise after LPS with little change in the lymph protein concentration. Our results are also consistent with a filtration model in which capillaries are assumed to be perforated by small pores (protein reflection coefficient = 1) as well as large pores (protein reflection coefficient = 0).

Formal swallowing evaluation and therapy after traumatic brain injury improves dysphagia outcomes.

BACKGROUND: The incidence of swallowing dysfunction after brain injury is unknown. The efficacy of dysphagia therapy is also unknown. We reviewed our experience to define the incidence of swallowing dysfunction and efficacy of therapeutic intervention. METHODS: Patients with brain injury sustained between January of 1996 and December of 1997 were reviewed. All were screened with trials of oral intake. Abnormal findings were confirmed with a videofluoroscopic swallow study. Standard therapies included diet, posture, and behavior modifications. RESULTS: A total of 47 patients were evaluated. Bedside evaluations were normal in 14 patients, 2 patients had overt aspiration and underwent gastrostomy, and 31 patients were referred for a videofluoroscopic swallow study (66%). The videofluoroscopic swallow study was abnormal in 22 of 31 patients (71%). Of these, 4 additional patients required gastrostomy, 13 patients had laryngeal penetration or minor aspiration responsive to dysphagia therapy and were fed. Five other patients had silent aspiration and were fed by means of nasogastric tube; these five patients responded to dysphagia therapy and were able to resume oral intake. CONCLUSION: Dysphagia is common after severe head injury. With formal swallowing service intervention, aspiration is avoided. Therapeutic interventions can be used to restore oral intake.

Structures of the van der Waals Isomers of Halosulfuric Acids: Microwave Spectra of HX-SO3 (X = F, Cl, Br).

The complexes of SO3 with HF, HCl, and HBr have been studied by microwave spectroscopy. In all three systems, the halogen atom approaches the SO3 on or near its C3 axis, and the vibrationally averaged structure is that of a symmetric top. The S-X bond lengths are 2.655(10), 3.1328(57), and 3.2339(85) Å for the HF, HCl, and HBr complexes, respectively, and in all three systems the out-of-plane distortion of the SO3 is negligible. In HF-SO3, the hydrogen points away from the SO3 and hyperfine structure in the DF complex gives an average angle of 47.7 degrees with respect to the vibrationally averaged C3 axis of the complex. In the HCl and HBr complexes, however, the HX unit is nearly parallel to the SO3 plane. In HCl-SO3, the HCl forms a 72.8 degrees angle with the average C3 axis of the complex, with the proton tilting slightly toward the SO3. In HBr-SO3, the average orientation of the HBr is 73.0 degrees off the symmetry axis of the complex, but the direction of the tilt (toward or away from the SO3) is not determined. Although the hydrogen halides react with SO3 in bulk to produce halosulfuric acids, these gas-phase complexes are much like weakly bound dimers. Copyright 1998 Academic Press.

Fungal sacral osteomyelitis as the initial presentation of Crohn's disease of the small bowel: report of a case.

We report a unique case of Candida albicans sacral osteomyelitis in a 48 year-old female with previously undiagnosed Crohn's disease. The patient was ill for one year with fatigue, weakness, and a 60-lb weight loss. At the time of presentation, she developed chills, fever, right lower quadrant abdominal pain, and right knee pain. Physical examination was significant for a palpable right lower quadrant abdominal mass. A computed tomographic scan of the abdomen and pelvis identified a large right-sided retroperitoneal mass, severe right hydronephrosis, and air within the right sacrum. Findings at laparotomy included small-bowel changes consistent with Crohn's disease, a multiloculated retroperitoneal abscess, and evidence of sacral osteomyelitis. A right hemicolectomy with sacral debridement and placement of presacral drains was performed. Bone cultures from the sacrum demonstrated a predominance of C. albicans, in addition to coliforms and enterococcus. The patient was placed on amphotericin B and intravenous antibiotics. Because serial computed tomographic scans of her pelvis demonstrated progression of her pelvic osteomyelitis to include the sacrum, right ilium, right acetabulum, and right femoral head, a repeat debridement with resection of the right femoral head was performed. After 12 months of follow-up, she was doing well without medications and had no constitutional symptoms or radiographic evidence of disease progression. This report illustrates a unique case of Crohn's disease presenting as sacral osteomyelitis secondary to small-bowel fistulization. Aggressive multidisciplinary surgical and medical management were the key to the successful management of this difficult case.

Traumatic asphyxia following stadium crowd surge: stadium factors affecting outcome.

BACKGROUND: Stadium crowd surges frequently occur following major athletic events. A recent crowd surge injured more than 80 persons by trampling and/or crushing. This incident was reviewed to identify injury patterns consistent with crush-related injury. In addition, the incident was reviewed to determine which stadium policy and design factors may have potentiated this event. METHODS: A recent crowd surge occurred following a college football game. This resulted in 86 people being transported to the University of Wisconsin and other area hospitals. All charts were reviewed to evaluate patient outcomes. The stadium was examined as were security system video tapes to evaluate stadium factors that contributed to this event. Current policies were obtained through the university sports administration. RESULTS: Of 86 patients transported for evaluation of stadium-related injuries, 10 were treated for traumatic asphyxia. Other injuries requiring hospital admission included musculo-skeletal trauma in two patients and one grade II liver injury. Six others were admitted overnight for observation. Several stadium factors were identified that contributed to the event, and appropriate changes in crowd control policies and stadium design were instated to prevent recurrence. CONCLUSIONS: This report details the largest single report of traumatic asphyxia second to the England Hillsborough disaster. Several stadium factors were identified that resulted in crush-related injury. Cooperative review and modification of stadium policies and design may prevent such events in the future.

Filtration of diaspirin crosslinked hemoglobin into lung and soft tissue lymph.

Diaspirin crosslinked hemoglobin (DCHb) is a new blood substitute manufactured from human blood. To evaluate its microvascular filtration properties, we infused DCLHb into unanesthetized sheep (10%, 20 ml/kg) and measured the flow and composition of lung and soft tissue lymph. For comparison, we also infused human serum albumin (HSA; 10%, 20 ml/kg). DCLHb raised systemic and pulmonary arterial pressures from baseline values of 83 +/- 7 and 13 +/- 2 mm Hg, respectively, to peak values of 113 +/- 9 and 26 +/- 3 mm Hg (p < 0.05 versus baseline). These increases were significantly greater than those associated with HSA, which raised systemic and pulmonary arterial pressures from baseline values of 86 +/- 4 and 13 +/- 2 mm Hg, respectively, to peak values of 97 +/- 3 and 21 +/- 7 mm Hg (p <= 0.05 versus baseline and versus DCLHb). These differences reflect the known pressor properties of DCLHb. Accordingly, DCLHb raised lung and soft tissue lymph flows to peak values of 12.2 +/- 3.8 and 1.6 +/- 0.7 ml/30 min, respectively, while HSA raised lung and soft tissue lymph flows to peak values of 7.5 +/- 4.8 and 4.6 +/- 1.9 ml/30 min, respectively (p <= 0.05 versus DCLHb). The half-times of DCLHb equilibration from plasma into lung and soft tissue lymph of 1. 0 +/- 0.3 and 2.1 +/- 1.1 h, respectively, were significantly faster than HSA equilibration half-times of 3.1 +/- 0.2 and 3.8 +/- 0.9 h. Filtration differences between DCLHb and HSA appear to be due to the pressor properties DCLHb.

Physiologic evaluation and surgical management of failed ileoanal pouch.

BACKGROUND: Following proctocolectomy and ileal pouch-anal anastomosis, a small percentage of patients will have poor functional results attributable to pouchitis or anastomotic or septic complications. Additionally, functional failures can occur secondary to limited pouch capacity and compliance. We present five such patients managed with operative conversion to W-ileal pouch-anal anastomosis and examined physiologic parameters important for improving functional results. METHODS: Five female patients (mean age, 30 (range, 24-39) years) with poorly functioning J-ileal pouch-anal anastomoses were referred for evaluation with symptoms of high stool frequency and incontinence problems. Three had severe nocturnal incontinence, and the remaining two patients experienced minor nocturnal incontinence. Preoperative and postoperative evaluation included barium pouch studies, flexible sigmoidoscopy, anal manometry, evacuation volume, and pouch compliance. Pouch-to-anal pressure gradients were calculated. To improve reservoir capacity and compliance, all five patients underwent conversion to W-ileal pouch-anal anastomoses. RESULTS: Twenty-four hour and nocturnal stool frequencies decreased from 13.8+/-1.7 and 3+/-1.3 to 5.8+/-0.3 and 0.3+/-0.2 postconversion (P < 0.05). Mean pouch evacuation volume increased from 83+/-27 to 290+/-29 ml postoperatively (P < 0.05). Pouch compliance increased from 2.7+/-0.5 mmHg/ml to 7.7+/-0.6 mmHg/ml postconversion (P < 0.05). Improvement in postconversion stool frequency correlated with an increase in pouch evacuation volume (r=-0.87). All patients reported improved day and nocturnal continence, despite no significant change between preoperative and postoperative anal manometric pressures. Improved continence correlated with a significant widening of the pouch-to-anal pressure gradients, which increased from 5 to 25 mmHg at 150 ml following pouch conversion. CONCLUSIONS: Poorly functioning ileal reservoirs secondary to limited capacity and compliance can be successfully managed with conversion to W-ileal pouch-anal anastomosis. The increased pouch capacity is associated with improvement in compliance and widening of the pouch-to-anal pressure gradients, providing excellent functional results.

Computed tomographic angiography with three-dimensional reconstruction in patients with complex diverticular disease and portal hypertension: report of a case.

We report a case of a patient with portal hypertension secondary to alcoholic cirrhosis (Child's Class C) who initially presented with a colovaginal fistula secondary to acute sigmoid diverticulitis. The patient had a prior history of hepatic cirrhosis with ascites, coagulopathy, and portal hypertension. Computed tomography of the abdomen and pelvis demonstrated a large diverticular phlegmon and ascites. Computed tomographic angiography demonstrated a large left anterior abdominal wall varix in the region of the anticipated sigmoid resection. Three-dimensional reconstruction of the computed tomographic angiography further delineated the path of this large varix, confirming the increased risk from surgical intervention. Following initial conservative treatment with intravenous antibiotics, parenteral nutrition, and percutaneous abscess drainage, a transjugular intrahepatic portosystemic shunt procedure was performed to decompress the portal system varices. A repeat computed tomographic scan with three-dimensional reconstruction confirmed decompression of the varix. A successful sigmoid resection was subsequently performed. Preoperative computed tomographic angiography with three-dimensional reconstruction is a useful adjunct in planning the operative strategy in patients with complex intraabdominal pathology and collateral portovenous flow secondary to portal hypertension.

[Tumor necrosis factor-alpha (TNF-alpha) gene polymorphism in surgical intensive care patients with SIRS]. / Tumornekrosefaktor-alpha (TNF-alpha) Gen-Polymorphismus bei chirurgischen Intensivpatienten mit SIRS.

Biallelic polymorphism in the promotor region of the TNF-alpha gene have been associated with variation in TNF-alpha production. We determined the TNFA polymorphism (position--308) and related these data to plasma cytokine levels of TNF alpha, IL6, IL6R and IL8 in patients with SIRS and sepsis. Although there seems to be a different cytokine secretion pattern for both allelic groups (TNFA1 and TNFA2), a clear risk group could not be determined. It still remains unclear whether there is a genetic factor that influences the development of sepsis and multi organ failure.

Pneumocystis carinii pneumonia postrestorative proctocolectomy for ulcerative colitis: a role for perioperative prophylaxis in the cyclosporine era? Report of a case and review of the literature.

PURPOSE: Medical management of severe ulcerative colitis has used cyclosporine with increasing frequency as an adjuvant to systemic steroids and mercaptopurine. However, the effects of combined management with cyclosporine and prednisone may lead to significant immune compromise and adversely affect operative morbidity in the event urgent surgery is required. METHODS: A case is reported of a 43-year-old white male who presented with severe ulcerative colitis. The patient had been initially treated with prednisone and cyclosporine for six weeks before surgical intervention. The intractability of his ulcerative colitis caused the patient to present to surgery, where he underwent restorative proctocolectomy. RESULTS: On initial presentation, the patient manifested systemic signs of severe ulcerative colitis with hypoalbuminemia, anemia, and weight loss, despite continuous prednisone and cyclosporine management. Before surgical intervention, a chest x-ray and the patient's respiratory status were normal. A total abdominal colectomy with ileal pouch reconstruction and temporary loop ileostomy were performed without incident. On the fifth postoperative day, the patient developed respiratory failure, which was subsequently diagnosed as Pneumocystis carinii pneumonia. Although ventilator support and both aggressive medical and surgical management eventually resulted in successful outcome, significant perioperative morbidity occurred. CONCLUSIONS: In the era of aggressive medical management for ulcerative colitis with both steroids and cyclosporine, the complications of immunosuppression may be significant, including opportunistic pneumonia. Prophylaxis against P. carinii pneumonia with sulfa antibiotics should be considered, especially in patients for whom proctocolectomy is a potential end point.

Neoplasia in ileal pouch mucosa after total proctocolectomy for juvenile polyposis: report of a case.

PURPOSE: Patients treated with restorative proctocolectomy for familial adenomatous polyposis or ulcerative colitis occasionally develop disease in the ileal pouch similar to that originally present in the colon. We investigated the possibility of analogous involvement in the ileal pouch of juvenile polyposis patients. METHODS: Endoscopic surveillance for neoplasia throughout the gastrointestinal tract was performed, with retrieval of all polypectomy specimens for histologic classification using the criteria of Morson. RESULTS: Multiple large juvenile polyps were found in the ileal pouch of one patient less than 10 years after restorative proctocolectomy for hereditary juvenile polyposis. The pouch was much more severely affected than the proximal ileum, small intestine, or stomach. Although most polyps had a completely benign histologic appearance, three had moderate to severe dysplasia. DISCUSSION: Mucosal changes induced by bacteria or stasis of luminal contents may promote manifestation in the ileal pouch of the disease phenotype usually more evident in the colon. Patients with severe or generalized juvenile polyposis should be considered for periodic endoscopic surveillance of the ileal pouch beginning several years after restorative proctocolectomy.

Molecular distribution of hetastarch in plasma and lung lymph of unanesthetized sheep.

We used high performance size exclusion chromatography (HPSEC) to measure concentrations and molecular masses of hetastarch (Het) in plasma and lung lymph of unanesthetized sheep. Our goal was to assess the osmotic effectiveness of Het in the pulmonary circulation as judged by its exclusion from lung lymph. Sheep (n = 5) received 35 ml/kg of Het (6%) over 90 min. At the end of the infusion, Het concentrations in plasma reached a peak value of 2.9 +/- 0.1% (mean +/- SD). Lymph concentrations reached a peak value of 1.3 +/- 0.3% at 4.5 h. Het molecular masses in plasma averaged 650 +/- 36 kD at 90 min, but ranged from 31 to 2,942 +/- 187 kD. Masses in lung lymph averaged 373 +/- 71 kD, and ranged from 19 +/- 2 to 1,693 +/- 514 kD (p < or = 0.05 vs. plasma). Het contributed 6.7 +/- 1.5 mm Hg to the plasma macromolecular osmotic pressure, and 3.7 +/- 1.8 mm Hg to the lymph osmotic pressure. Despite the fact that Het has the largest molecular mass of any of the current macromolecular plasma volume expanders, we found that it filtered readily into lymph, raising the lymph osmotic pressure. These findings suggest that the rationale for the osmotic performance of such solutions may need to be reconsidered.

Resuscitation from hemorrhagic shock with diaspirin cross-linked hemoglobin, blood, or hetastarch.

BACKGROUND: An oxygen-transporting hemoglobin solution should be more effective than a nonhemoglobin solution for resuscitation from hemorrhagic shock. A way to evaluate this effectiveness is to determine whether a hemoglobin solution can reverse the base deficit accumulated during hemorrhage at a faster rate than a nonhemoglobin solution. Using this criterion, we compared the resuscitative powers of autologous blood, hetastarch (Het), and diaspirin cross-linked hemoglobin (DCLHb). METHODS: Fifteen sedated, spontaneously breathing sheep (37.5 +/- 10.2 kg) were bled until base deficits fell to -5 to -10 mEq/L, and plasma lactate concentrations rose to 6 to 9 mg/L. The animals were resuscitated with autologous blood (n = 5), Het (n = 5), or DCLHb (n = 5) (3.5-4.0 mL/kg every 15 minutes) until base deficits returned to prehemorrhage baseline. RESULTS: Exsanguination to target base deficits required removal of an average of 41.4 +/- 5.5 mL blood/kg (estimated total blood volume, 80 mL/kg). Resuscitation required 18 +/- 3, 38 +/- 2 (different from blood), and 35 +/- 1 (different from blood) mL/kg of autologous blood, Het and DCLHb, respectively, over periods of 78 +/- 8, 163 +/- 10 (different from blood), and 129 +/- 9 minutes (different from blood and different from Het (p < or = 0.05)). Based on regression analysis, autologous blood, Het, and DCLHb corrected the base deficit at rates of, respectively, 0.074 (different from Het (p < or = 0.05)), 0.016, and 0.056 (different from Het (P < or = 0.05)) mEq/L/min. CONCLUSIONS: Based on the rate of base deficit correction and the volume of solution required, autologous blood was the most effective resuscitation solution. However, DCLHb was more effective than Het. DCLHb may be an attractive alternative to blood for resuscitation from hemorrhagic shock.

Lung lymph oncotic pressure may not modulate pulmonary vascular filtration in sheep.

We tested the hypothesis that plasma oncotic pressure alone, not the plasma-to-lymph oncotic pressure difference, modulates pulmonary transvascular fluid filtration. To do this we measured lung lymph flow after raising left atrial pressure (by inflating a balloon) in sheep that were receiving a continuous (32 h) infusion of dextran 40. For comparison, we also raised left atrial pressure elevation, plasma oncotic pressures in dextran and control sheep, respectively, were 39.5 +/- 4.5 and 17.7 +/- 2.2 mm Hg; plasma-to-lymph oncotic pressure gradients, respectively, were 4.4 +/- 0.6 and 4.4 +/- 0.6 mm Hg. Left atrial pressure elevation during dextran infusion increased lung lymph flow by a factor of 2.4 +/- 0.4, compared with a factor of 4.2 +/- 2.3 in control sheep. Thus, left atrial pressure elevation increased lymph flow less in dextran-treated animals than in control animals, even though the plasma-to-lymph oncotic pressure gradients were equal. This suggests that plasma oncotic pressure alone may be a more important determinant of pulmonary transvascular fluid filtration than the plasma-to-lymph oncotic pressure difference.

Safety of a low-dosage Filgrastim (rhG-CSF) treatment in non-neutropenic surgical intensive care patients with an inflammatory process.

OBJECTIVE: To evaluate the effect and safety of a low dose Filgrastim treatment in surgical intensive care patients. DESIGN: Prospective, clinical study. SETTING: Surgical intensive care unit (ICU) in a university hospital. PATIENTS: Ten patients with the systemic inflammatory response syndrome (SIRS) and ten patients with sepsis were included in the study. INTERVENTIONS: Filgrastim was given intravenously at 1.0 microgram/kg for 3 days, followed by 0.5 microgram/kg for 4 days. MEASUREMENTS AND RESULTS: Filgrastim treatment increased leukocyte counts and plasma levels of G-CSF. Cytokine levels (IL-6 and IL-8) decreased in the first 3 days of treatment. None of the SIRS patients developed sepsis or multiple organ failure and none of the patients died. In the sepsis group four patients died. No adverse side effects were observed, especially no attenuation of lung injury. CONCLUSIONS: Low-dosage Filgrastim treatment in ICU patients is safe. Whether the observed changes of the inflammatory response can be attributed to Filgrastim has to be clarified in further randomized trials.