Compressional wave velocity measurements on mafic-ultramafic rocks under high aqueous fluid pressure and temperature help to explain low-velocity zones in the lithosphere.

Deep seismic studies have revealed that low-velocity zones mainly occurred in the continental lithosphere at the depth of 100-150 km. Their origin has not been clearly explained yet. The article demonstrates the possible scale of Vp changes in crystalline rocks of different composition. The conclusions were made on the basis of the comprehensive analysis of the experimental data obtained by the authors. The compressional wave velocities in the temperature range from 20 to 800 °C, both in dry conditions (at pressure of 600 MPa) and in the presence of aqueous fluid (at pressure of 300 MPa) were measured. It is shown that the most significant decrease of velocities (by ~ 3 km/s) in the temperature range of 400-700 °C, corresponding to the deep waveguides of the lithospheric mantle, occurs under water pressure in ultramafic rocks enriched by olivine (dunites). Such decrease is due to rock structure changes caused by olivine serpentinization reactions. It is assumed that serpentinization and/or formation of similar hydrous minerals, which are stable in a wide range of PT-conditions in olivine-rich mantle rocks due to the influence of deep fluids, may cause low-velocities zones in the upper mantle at depths of about 100 km.

Microcirculation research in community hospitals - challenges and chances.

Community hospitals provide ideal conditions for large clinical studies because of the high volume of unselected patients admitted every year. With regard to microcirculatory studies, there are still some feasibility problems which are not solved yet. First of all, the lack of reliable automated software to analyze microcirculatory images represents the most important issue. Secondly, hardware aspects still need improvements regarding portability and miniaturization. Finally, to conduct studies of the microcirculation in a community hospital is also always a funding issue. The cost of the measurement device is hereby only one factor. Main cost factor is the personnel.

Relative Blood Volume Monitoring during Renal Replacement Therapy in Critically Ill Patients with Septic Shock: A Preliminary Report.

BACKGROUND: Volume management during renal replacement therapy (RRT) in septic shock is always in the conflict between aggravating hypovolemia by undue ultrafiltration (UF) and insufficient reduction of fluid overload which is associated with adverse outcome. Relative blood volume (RBV) monitoring could be helpful for timely transition from fluid resuscitation to fluid removal. METHODS: Data of RBV were continuously monitored and used for guidance of UF and fluid resuscitation in 21 consecutive patients with severe septic multiple organ failure. RRT was applied with extended daily hemodiafiltration for median 11 h (range 6-23). Changes in RBV were analyzed during the first 4 treatment sessions. RESULTS: During 26 treatments, RBV monitoring revealed an internal volume loss substituted by a median infusion volume of 2.38 l (maximum 8.07 l) per treatment to keep the RBV constant. In the remaining 40 sessions, a median net-UF of 1.00 l (range 0.40-4.40) was achieved. In the first 2 days predominantly substitution was necessary whereas from the third day UF became increasingly possible. The 28-day survival rate was 81%. CONCLUSION: Blood volume monitoring proved to be an easy and feasible tool for safe guidance of fluid management maintaining the balance between UF and vascular refilling. Video Journal Club 'Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=433415

Effects of high volume haemodiafiltration on inflammatory response profile and microcirculation in patients with septic shock.

BACKGROUND: High volumes of haemofiltration are used in septic patients to control systemic inflammation and improve patient outcomes. We aimed to clarify if extended intermittent high volume online haemodiafiltration (HVHDF) influences patient haemodynamics and cytokines profile and/or has effect upon sublingual microcirculation in critically ill septic shock patients. METHODS: Main haemodynamic and clinical variables and concentrations of cytokines were evaluated before and after HVHDF in 19 patients with septic shock requiring renal replacement therapy due to acute kidney injury. Sublingual microcirculation was assessed in 9 patients. RESULTS: The mean (SD) time of HVHDF was 9.4 (1.8) hours. The median convective volume was 123 mL/kg/h. The mean (SD) dose of norepinephrine required to maintain mean arterial pressure at the target range of 70-80 mmHg decreased from 0.40 (0.43) µg/kg/min to 0.28 (0.33) µg/kg/min (p = 0.009). No significant changes in the measured cytokines or microcirculatory parameters were observed before and after HVHDF. CONCLUSIONS: The single-centre study suggests that extended HVHDF results in decrease of norepinephrine requirement in patients with septic shock. Haemodynamic improvement was not associated with decrease in circulating cytokine levels, and sublingual microcirculation was well preserved.

Pharmacokinetics of doripenem during high volume hemodiafiltration in patients with septic shock.

Pharmacokinetics (PK) of doripenem was determined during high volume hemodiafiltration (HVHDF) in patients with septic shock. A single 500 mg dose of doripenem was administered as a 1 hour infusion during HVHDF to 9 patients. Arterial blood samples were collected before and at 30 or 60 minute intervals over 8 hours (12 samples) after study drug administration. Doripenem concentrations were determined by ultrahigh performance liquid chromatography-tandem mass spectrometry. Population PK analysis and Monte Carlo simulation of 1,000 subjects were performed. The median convective volume of HVHDF was 10.3 L/h and urine output during the sampling period was 70 mL. The population mean total doripenem clearance on HVHDF was 6.82 L/h, volume of distribution of central compartment 10.8 L, and of peripheral compartment 12.1 L. Doses of 500 mg every 8 hours resulted in 88.5% probability of attaining the target of 50% time over MIC for bacteria with MIC = 2 µg/mL at 48 hours, when doubling of MIC during that time was assumed. Significant elimination of doripenem occurs during HVHDF. Doses of 500 mg every 8 hours are necessary for treatment of infections caused by susceptible bacteria during extended HVHDF.

Postoperative complications and mortality after major gastrointestinal surgery.

BACKGROUND AND OBJECTIVE: The incidence of postoperative complications and death is low in the general population, but a subgroup of high-risk patients can be identified amongst whom adverse postoperative outcomes occur more frequently. The present study was undertaken to describe the incidence of postoperative complications, length of stay, and mortality after major abdominal surgery for gastrointestinal, hepatobiliary and pancreatic malignancies and to identify the risk factors for impaired outcome. MATERIAL AND METHODS: Data of patients, operated on for gastro-intestinal malignancies during 2009-2010 were retrieved from the clinical database of Tartu University Hospital. Major outcome data included incidence of postoperative complications, hospital-, 30-day, 90-day and 1-year mortality, and length of ICU and hospital stay. High-risk patients were defined as patients with American Society of Anesthesiologists (ASA) physical status ≥3 and revised cardiac risk index (RCRI) ≥3. Multivariate analysis was used to determine the risk factors for postoperative mortality and morbidity. RESULTS: A total of 507 (259 men and 248 women, mean age 68.3±11.3 years) were operated on for gastrointestinal, hepatobiliary, or pancreatic malignancies during 2009 and 2010 in Tartu University Hospital, Department of Surgical Oncology. 25% of the patients were classified as high risk patients. The lengths of intensive care and hospital stay were 4.4±7 and 14.5±10 days, respectively. The rate of postoperative complications was 33.5% in the total cohort, and 44% in high-risk patients. The most common complication was delirium, which occurred in 12.8% of patients. For patients without high risk (ASA130min, and positive fluid balance >1300mL after the 1st postoperative day, were identified as independent risk factors for the development of complications. CONCLUSION: The complication rate after major gastro-intestinal surgery is high. ASA physical status and revised cardiac risk index adequately reflect increased risk for postoperative complications and worse short and long-term outcome.

Physostigmine reverses disturbances of the intestinal microcirculation during experimental endotoxemia.

Intestinal microcirculatory disturbances play an important role in the pathophysiology of sepsis. A neural anti-inflammatory pathway has been suggested as a potential target for therapy that may dampen systemic inflammation. The aim of this study is to investigate the effects of physostigmine, a cholinesterase inhibitor, on the intestinal microcirculation and vascular contractility in experimental endotoxemia. Endotoxemia was induced in Lewis rats by intravenous lipopolysaccharide (LPS) administration. Animals were treated with either physostigmine or saline (control) following LPS challenge. The intestinal microcirculation, including leukocyte-endothelial interaction, functional capillary density (FCD) and non-perfused capillary density (NCD), was examined by intravital microscopy (IVM) 2 hours after LPS administration. The impact of physostigmine on vascular contractility of rat aortic rings was examined by in vitro myography. Physostigmine significantly reduced the number of adhering leukocytes in intestinal submucosal venules (V1 venules: -61%, V3 venules: -36%) of LPS animals. FCD was significantly increased by physostigmine treatment (circular muscle layer: +180%, longitudinal muscle layer: +162%, mucosa: +149%). Low concentrations of physostigmine produced significant contraction of aortic ring preparations, whereas high concentrations produced relaxation. In conclusion, physostigmine treatment significantly improved the intestinal microcirculation in experimental endotoxemia by reducing leukocyte adhesion and increasing FCD.

Estradiol receptors agonists induced effects in rat intestinal microcirculation during sepsis.

The steroid hormone estradiol is suggested to play a protective role in intestinal injury during systemic inflammation (sepsis). Our aim was to determine the effects of specific estradiol receptor (ER-α and ER-ß) agonists on the intestinal microcirculation during experimental sepsis. Male and sham ovariectomized female rats were subjected to sham colon ascendens stent peritonitis (CASP), and they were compared to male and ovariectomized female rats underwent CASP and either estradiol receptor α (ER-α) agonist propyl pyrazole triol (PPT), estradiol receptor ß (ER-ß) agonist diarylpropiolnitrile (DPN), or vehicle treatment. Intravital microscopy was performed, which is sufficiently sensitive to measure changes in the functional capillary density (FCD) as well as the major steps in leukocyte recruitment (rolling and adhesion). The leukocyte extravasations were also quantified by using histological paraffin sections of formalin fixed intestine. We found that either DPN (ER-ß) or PPT (ER-α) significantly reduced (P<0.05) sepsis-induced leukocyte-endothelial interaction (rolling, adherent leukocytes and neutrophil extravasations) and improved the intestinal muscular FCD. [PPT: Female; Leukocyte rolling (n/min): V(3) 3.7±0.7 vs 0.8±0.2, Leukocyte adhesion(n/mm(2)): V(3) 131.3±22.6 vs 57.2±13.5, Neutrophil extravasations (n/10000 µm(2)): 3.1±0.7 vs 6 ±1. Male; Leukocyte adhesion (n/mm(2)): V(1) 154.8±19.2 vs 81.3±11.2, V(3) 115.5±23.1 vs 37.8±12]. [DPN: Female; neutrophil extravasations (n/10000 µm(2)) 3.8±0.6 vs 6 ±1. Male; Leukocyte adhesion (n/mm(2)) V(1) 154.8±19.2 vs 70±10.5, V(3) 115.5±23.1 vs 52.8±9.6].Those results suggest that the observed effects of estradiol receptors on different phases of leukocytes recruitment with the improvement of the functional capillary density could partially explain the previous demonstrated salutary effects of estradiol on the intestinal microcirculation during sepsis. The observed activity of this class of compounds could open up a new avenue of research into the potential treatment of sepsis.

Microcirculation diagnostics and applied studies in circulatory shock - research from the bench to the bedside.

Macrohemodynamic targets such as mean arterial pressure, cardiac output, and mixed or central venous oxygen saturation have been used to guide treatment of patients presenting circulatory shock. However, it has been shown that despite of improvement of macrocirculatory parameters there is persisting microcirculatory dysfunction. The restoration of microvascular perfusion in order to improve oxygenation, prevent tissue hypoxia, and maintain organ function represents the main aim of hemodynamic resuscitation. Therefore, microcirculatory targets may represent the most important endpoints to optimize therapy of circulatory shock.

Extended daily on-line high-volume haemodiafiltration in septic multiple organ failure: a well-tolerated and feasible procedure.

BACKGROUND: The outcome of patients with septic multiple organ failure (MOF) remains poor. There are experimental and clinical data indicating a beneficial effect of high-volume haemofiltration. Delivering high-volume therapy is only cost effective using on-line devices because of high costs for additional solution bags in conventional continuous renal replacement therapy (CRRT). We investigated feasibility and effectiveness of extended daily on-line high-volume haemodiafiltration (HDF) with technically maximum convective volume in patients with septic MOF in a pilot study. METHODS: We included 21 consecutive critically ill patients with septic MOF having a mortality risk >50% (SAPS II >50, APACHE II >25). Renal replacement therapy (RRT) was applied with extended daily HDF for 6-23 h using the AK 200 Ultra S dialysis machine in the ultracontrol pre-dilution mode. Dialysate and substitution fluid were prepared on-line. Patients underwent 289 treatments. RESULTS: The mean convective volume was 17.8 ± 3.7 L/h and 208 ± 66 mL/kg/h, respectively, median treatment time was 10:15 h/day. Seventeen of 21 patients survived 28 days (81%). The 90-day survival rate was 52% (11/21) versus 19% compared to the survival rate predicted by APACHE II (33.6 mean) and SAPS II (68.6 mean) scores. Haemodynamics improved significantly during the treatment procedures. Material costs per treatment amounted to 35 €. CONCLUSIONS: Extended daily on-line HDF using maximum convective volume seems to improve the outcome of septic MOF, especially in the early phase. The investigated mode of treatment proved to be feasible, well tolerated and highly cost effective compared to conventional CRRT. At present, this procedure would be applicable at every ICU facility with nephrological support.

Comparison of arterial pressure cardiac output monitoring with transpulmonary thermodilution in septic patients.

BACKGROUND: The measurement of cardiac output in critically ill patients is complicated by rapid pathophysiological changes. The aim of this study was to compare the recently developed Arterial Pressure Cardiac Output algorithm (APCO) with transpulmonary thermodilution (TDCO). Clinical and hemodynamic parameters were tested for their impact on the measurements. MATERIAL/METHODS: Twenty septic patients were examined. Cardiac output measurements were performed simultaneously on 3 consecutive days. The data were evaluated using regression analysis and the Bland Altman approach. RESULTS: Bland Altman analysis presented a bias of 0.72 L/min and limits of agreement of 2.16 to 3.61 L/min for TDCO vs. APCO. Statistically significant covariables in the regression analysis were systemic vascular resistance (p<0.001), mean arterial pressure (p<0.001), cardiac function index (p=0.01), global end-diastolic index (p=0.02) and stroke volume index (p=0.005). Multiple linear regression analysis showed the residual percentage error decreased from 49.1% to 21.5%. CONCLUSIONS: The APCO algorithm provides a broad range of hemodynamic measurements with a minimally invasive approach and simple access to the patient's hemodynamic state. However, an underestimation at high cardiac output and an overestimation at low cardiac output relative to transpulmonary thermodilution were observed in septic patients. Therefore, the APCO algorithm in its current state cannot be substituted for transpulmonary thermodilution.

Gastrointestinal failure score in critically ill patients: a prospective observational study.

INTRODUCTION: There are no universally accepted diagnostic criteria for gastrointestinal failure in critically ill patients. In the present study we tested whether the occurrence of food intolerance (FI) and intra-abdominal hypertension (IAH), combined in a 5-grade scoring system for assessment of gastrointestinal function (the Gastrointestinal Failure [GIF] score), predicts mortality. The prognostic value of the GIF score alone and in combination with the Sequential Organ Failure Assessment (SOFA) score is evaluated, and the incidence and outcome of gastrointestinal failure is described relative to the GIF score. METHODS: A total of 264 subsequently hospitalized patients, who were mechanically ventilated on admission and stayed in the intensive care unit (ICU) for longer than 24 hours, were prospectively studied. GIF score was documented daily as follows: 0 = normal gastrointestinal function; 1 = enteral feeding with under 50% of calculated needs or no feeding 3 days after abdominal surgery; 2 = FI or IAH; 3 = FI and IAH; and 4 = abdominal compartment syndrome (ACS). Admission parameters and mean GIF and SOFA scores for the first 3 days were used to predict ICU outcome. RESULTS: FI developed in 58.3%, IAH in 27.3%, and both together in 22.7% of patients. The mean GIF score for the first 3 days in the ICU was identified as an independent risk factor for mortality (odds ratio = 3.02, 95% confidence interval = 1.63 to 5.59; P < 0.001). The GIF score integrated into the SOFA score allowed better prediction of ICU mortality than did the SOFA score alone, and was an independent predictor of mortality (odds ratio = 1.49, 95% confidence interval = 1.28 to 1.74; P < 0.001). The development of gastrointestinal failure (FI plus IAH) was associated with significantly higher ICU and 90-day mortality. CONCLUSION: The GIF score is useful for classifying information on the gastrointestinal system. The mean GIF score during the first 3 days in the ICU had high prognostic value for ICU mortality. Development of gastrointestinal failure is associated with significantly impaired outcome.

Primary and secondary intra-abdominal hypertension--different impact on ICU outcome.

OBJECTIVE: To investigate the differences in incidence, time course and outcome of primary versus secondary intra-abdominal hypertension (IAH), and to evaluate IAH as an independent risk factor of mortality in a presumable risk population of critically ill patients. DESIGN: Prospective observational study. SETTING: General intensive care unit of a university hospital. PATIENTS: A total of 257 mechanically ventilated patients at presumable risk for the development of IAH were studied during their ICU stay and followed up for 90-day survival. INTERVENTIONS: Repeated measurements of intra-abdominal pressure (IAP). MEASUREMENTS AND RESULTS: IAP was measured intermittently, via bladder. IAH (sustained or repeated IAP > or = 12 mmHg) developed in 95 patients (37.0%). Primary IAH was observed in 60 and secondary IAH in 35 patients. Patients with secondary IAH demonstrated a significant increase of mean IAP during the first three days (mean DeltaIAP was 2.2 +/- 4.7 mmHg), whilst IAP decreased (mean DeltaIAP -1.1 +/- 3.7 mmHg) in the patients with primary IAH. The patients with IAH had a significantly higher ICU- (37.9 vs. 19.1%; P = 0.001), 28-day (48.4 vs. 27.8%, P = 0.001), and 90-day mortality (53.7 vs. 35.8%, P = 0.004) compared to the patients without the syndrome. Patients with secondary IAH had a significantly higher ICU mortality than patients with primary IAH (P = 0.032). Development of IAH was identified as an independent risk factor for death (OR 2.52; 95% CI 1.23-5.14). CONCLUSIONS: Secondary IAH is less frequent, has a different time course and worse outcome than primary IAH. Development of IAH during ICU period is an independent risk factor for death.

Gastrointestinal failure in intensive care: a retrospective clinical study in three different intensive care units in Germany and Estonia.

BACKGROUND: While gastrointestinal problems are common in ICU patients with multiple organ failure, gastrointestinal failure has not been given the consideration other organ systems receive. The aim of this study was to evaluate the incidence of gastrointestinal failure (GIF), to identify its risk factors, and to determine its association with ICU mortality. METHODS: A retrospective analysis of adult patients (n = 2588) admitted to three different ICUs (two ICUs at the university hospital Charité-Universitätsmedizin Berlin, Germany and one at Tartu University Clinics, Estonia) during the year 2002 was performed. Data recorded in a computerized database were used in Berlin. In Tartu, the data documented in the patients' charts was retrospectively transferred into a similar database. GIF was defined as documented gastrointestinal problems (food intolerance, gastrointestinal haemorrhage, and/or ileus) in the patient data at any period of their ICU stay. ICU mortality, length of stay, and duration of mechanical ventilation were assessed as outcome parameters. RESULTS: GIF was identified in 252 patients (9.7% of all patients). Only 20% of GIF patients were identifiable at admission. GIF was related to significantly higher mortality (43.7% vs. 5.3% in patients without GIF), as well as prolonged length of ICU stay (10 vs. 2 days) and mechanical ventilation (8 vs. 1 day), p < 0.001, respectively. Patients' profile (emergency surgical or medical), APACHE II and SOFA scores and the use of catecholamines at admission were identified as independent risk factors for the development of GIF. Development of GIF during ICU stay was an independent predictor for death. CONCLUSION: Gastrointestinal failure represents a relevant clinical problem accompanied by an increased mortality, longer ICU stay and mechanical ventilation.

Aortic arch thrombosis in a neonate with heterozygous carrier status of factor V Leiden mutation.

Neonatal spontaneous aortic arch thrombosis without an anatomical correlate is an extremely rare disorder of unknown etiology. A 1-day-old newborn was admitted with suspicion of the coarctation of the aorta. Angiography revealed congenital occluding thrombosis of the ascending aorta and the aortic arch. Surgery was considered impossible because of concomitant thrombosis of the inferior vena cava and the right renal vein. Thrombolysis with streptokinase and tissue plasminogen activator was attempted unsuccessfully. Heterozygous carrier status of the factor V Leiden mutation was diagnosed as a single prothrombotic risk factor. Congenital prothrombotic conditions including factor V Leiden carrier status may serve as risk factors for the development of spontaneous aortic arch thrombosis in neonates. In chronic organized thrombi thrombolytic therapy is likely to fail.

Partnership for the heart. German-Estonian health project for the treatment of congenital heart defects in Estonia.

Congenital heart defects (CHD) occur in 8 per 1000 live births. If they remain untreated, 70-80% of these patients die in early childhood. With modern diagnostic and treatment procedures, 90% of these patients reach adulthood. Within 8 years following reunification of Germany, it was possible to improve treatment for CHD in former East Germany to West German standards. Based on the experience gained in this process, a plan for improvement of care of Estonian patients with CHD was developed and implemented in the German-Estonian project, "Partnership for the Heart". The main elements of the project were (1) the training of Estonian physicians in Germany, (2) training courses conducted by German and Estonian specialists in Estonia and (3) use of telemedicine for consultation on a continuous basis. During the project 15 Estonian patients underwent cardiac surgery and/or catheter interventions performed by a joint team of German and Estonian specialists. The infant mortality due to CHD in Estonia fell by 28% during the project period. Key techniques of cardiac surgery are now being employed in Estonia without outside support, indicating the success of the training program and the long-term improvements to cardiac health care in Estonia. The total project costs were 314,252 Euro (euro), which is 50% lower than the estimated cost of treating the 15 patients abroad in Western Europe. The structure of "Partnership for the Heart" and the modified self-sufficiency model of medical care have not only produced results for Estonia but can be taken as a template for future bilateral health projects with other transition countries and for other fields of medical specialisation, and thus might aid a European health policy.

Bioactive oxidized lipids in the plasma of cardiac surgical intensive care patients.

Critical illness is associated with increased oxidative stress that may give rise to the formation of lipid hydroperoxides (LOOH) and various secondary degradation products such as fragmented phosphatidylcholine (FPC) and lipids related to the platelet-activating factor (PAF). Because some oxidized phospholipids are potent proinflammatory agents, we measured the concentration of LOOH, FPC, and PAF-like activity in blood plasma of 36 patients who had undergone cardiac surgery and developed postoperative complications associated with systemic inflammatory response syndrome (SIRS) or multiple organ failure (MOF). These patients were compared to two control groups, namely preoperative patients scheduled for cardiac surgery (n = 13), and postoperative patients without complications (n = 19). Postoperative patents had higher concentrations of LOOH and lower concentrations of FPC than preoperative patients (P < 0.01). However, SIRS and MOF had no significant effect on the concentration of oxidatively modified lipids. This is despite the fact that MOF patients showed evidence of increased lipid peroxidation (7-fold higher ratio of alpha-tocoquinone/alpha-tocopherol compared to control). LOOH correlated positively with the white blood cell count. Postoperative patients had 4-fold higher plasma activities of phospholipase A2 and this activity was further increased in patients with SIRS (P < 0.04). Phospholipase A2 activity correlated negatively with the concentration of FPC. The data suggest that oxidatively modified lipids do not accumulate in patients with SIRS and MOF, perhaps because enhanced peroxidation of lipids is offset by enhanced lipolytic activity.

Myocardial ischemia and cytokine response are associated with subsequent onset of infections after noncardiac surgery.

UNLABELLED: Postoperative myocardial ischemia (POMI) is prevalent among patients after major noncardiac surgery. Surgery, as well as POMI, may modulate the immune system, potentially worsening patient outcome. We sought to investigate the modulation of soluble interleukin (IL)-6 and IL-10 by POMI and its association with increased postoperative infection rates. Two-hundred-three patients undergoing elective major abdominal, vascular, and orthopedic surgery participated in this prospective observational study. Perioperative management was standardized. Hemodynamic variables were kept within 20% of baseline. POMI was assessed by Holter electrocardiography starting at least 8 h before the induction of anesthesia and continued until 96 h after surgery. Twelve-lead electrocardiograms, cardiac enzymes, and immune variables were obtained at the time of admission to the hospital, before surgery, before the induction of anesthesia, after surgery, at the time of admission to the intensive care unit, and 6, 12, 18, 24, 36, 48, 72, 96, 120, 144, and 168 h after surgery. Infections were diagnosed according to the Centers for Disease Control criteria. The incidence of POMI was 27%, and the majority of cases (76%) occurred within the first 24 h after surgery. IL-6 and IL-10 levels significantly increased during surgery but did not differ between the POMI and Non-POMI groups. However, in the subset of patients who developed severe infections or sepsis (n = 47) a median of 3 days (range, 1-8 days) after surgery, the intraoperative increases of IL-6 and IL-10 in the POMI group were, respectively, 3 and 10 times higher compared with the increase in the Non-POMI group. By using a multifactorial analysis in these patients with severe infections, the type of surgical trauma was associated with an increased IL-6 response, whereas the increase in IL-10 was attributed to POMI. These findings suggest that immediate cytokine responses due to POMI and type of surgery might be relevant for the later onset of severe infections and sepsis. IMPLICATIONS: Postoperative myocardial ischemia (POMI) occurred in 27% of patients after major noncardiac surgery. This was associated with an immediate augmented cytokine response in the first 12 h after surgery in patients who developed severe infections or sepsis 3 days later. POMI was associated with an increased interleukin (IL)-10 response, whereas IL-6 was associated with the type of surgery.

Low-dose prostacyclin preserves renal function in high-risk patients after coronary bypass surgery.

OBJECTIVE: Renal failure after bypass is still a threatening problem prolonging hospital care and reducing overall survival. The following pilot study was aimed to analyze whether perioperative low-dose prostacyclin infusion is able to preserve renal function in a selected group of patients who according to a poor cardiac function were stratified as high risk for the development of renal failure after bypass. DESIGN: Prospective randomized study. SETTING: Tertiary care university medical center. PATIENTS: Thirty-four patients scheduled for primary cardiac bypass surgery were included in the study (prostacyclin n = 17, control n = 17). Inclusion criteria were normal renal function before surgery and a cardiac ejection fraction <40%. INTERVENTIONS: Low-dose prostacyclin (2 ng/kg/min) was added to the standard anesthetic protocol. Infusion was started immediately before surgery and was continued for a maximum of 48 MEASUREMENTS AND MAIN RESULTS: Significant differences in the endogenous creatinine clearance were found between the prostacyclin and the control group. Whereas there was a significant drop in the creatinine clearance at 6 hrs after surgery in the control group with a prolonged recovery period, values in the prostacyclin group remained stable. Creatinine clearance before intervention was 100 +/- 22 mL/min in the control group and 91 +/- 22 mL/min in the prostacyclin group, values at 24 hr were 68 +/- 34 mL/min vs. 103 +/- 37 mL/min, respectively (p < .01). Significant findings in favor for the prostacyclin group were also found for urine output and the fractional excretion rate of sodium. CONCLUSION: This first pilot study indicates that low-dose prostacyclin may be of substantial value for preserving renal function in high-risk patients after coronary bypass surgery.