Technical and Clinical Outcome of Low-Milliampere CT Fluoroscopy-Guided Percutaneous Drainage Placement in Abdominal Fluid Collections after Liver Transplantation: A 16-Year Retrospective Analysis of 50 Consecutive Patients.

PURPOSE: Evaluation of the effectiveness of CT-guided drainage (CTD) placement in managing symptomatic postoperative fluid collections in liver transplant patients. The assessment included technical success, clinical outcomes, and the occurrence of complications during the peri-interventional period. METHODS: Analysis spanned the years 2005 to 2020 and involved 91 drain placement sessions in 50 patients using percutaneous transabdominal or transhepatic access. Criteria for technical success (TS) included (a) achieving adequate drainage of the fluid collection and (b) the absence of peri-interventional complications necessitating minor or prolonged hospitalization. Clinical success (CS) was characterized by (a) a reduction or normalization of inflammatory blood parameters within 30 days after CTD placement and (b) the absence of a need for surgical revision within 60 days after the intervention. Inflammatory markers in terms of C-reactive protein (CRP), leukocyte count and interleukin-6, were evaluated. The dose length product (DLP) for various intervention steps was calculated. RESULTS: The TS rate was 93.4%. CS rates were 64.3% for CRP, 77.8% for leukocytes, and 54.5% for interleukin-6. Median time until successful decrease was 5.0 days for CRP and 3.0 days for leukocytes and interleukin-6. Surgical revision was not necessary in 94.0% of the cases. During the second half of the observation period, there was a trend (p = 0.328) towards a lower DLP for the entire intervention procedure (median: years 2013 to 2020: 623.0 mGy·cm vs. years 2005 to 2012: 811.5 mGy·cm). DLP for the CT fluoroscopy component was significantly (p = 0.001) lower in the later period (median: years 2013 to 2020: 31.0 mGy·cm vs. years 2005 to 2012: 80.5 mGy·cm). CONCLUSIONS: The TS rate of CT-guided drainage (CTD) placement was notably high. The CS rate ranged from fair to good. The reduction in radiation exposure over time can be attributed to advancements in CT technology and the growing expertise of interventional radiologists.

Low-Milliampere CT Fluoroscopy-Guided Percutaneous Drainage Placement after Pancreatic Surgery: Technical and Clinical Outcome in 133 Consecutive Patients during a 14-Year Period.

(1) Purpose: To retrospectively assess the technical and clinical outcome of patients with symptomatic postoperative fluid collections after pancreatic surgery, treated with CT-guided drainage (CTD). (2) Methods: 133 eligible patients between 2004 and 2017 were included. We defined technical success as the sufficient drainage of the fluid collection(s) and the absence of peri-interventional complications (minor or major according to SIR criteria). Per definition, clinical success was characterized by normalization of specific blood parameters within 30 days after the intervention or a decrease by at least 50% without requiring additional surgical revision. C-reactive protein (CRP), Leukocytes, Interleukin-6, and Dose length product (DLP) for parts of the intervention were determined. (3) Results: 97.0% of 167 interventions were technically successful. Clinical success was achieved in 87.5% of CRP, in 78.4% of Leukocytes, and in 87.5% of Interleukin-6 assessments. The median of successful decrease was 6 days for CRP, 5 days for Leukocytes, and 2 days for Interleukin-6. No surgical revision was necessary in 93.2%. DLP was significantly lower in the second half of the observation period (total DLP: median 621.5 mGy*cm between 2011-2017 vs. median 944.5 mGy*cm between 2004-2010). (4) Conclusions: Technical success rate of CTD was very high and the clinical success rate was fair to good. Given an elderly and multimorbid patient cohort, CTD can have a temporizing effect in the postoperative period after pancreatic surgery. Reducing the radiation dose over time might reflect developments in CT technology and increased experience of interventional radiologists.

Calorie intake and short-term survival of critically ill patients.

BACKGROUND & AIMS: The association between calorie supply and outcome of critically ill patients is unclear. Results from observational studies contradict findings of randomized studies, and have been questioned because of unrecognized confounding by indication. The present study wanted to re-examine the associations between the daily amount of calorie intake and short-term survival of critically ill patients using several novel statistical approaches. METHODS: 9661 critically ill patients from 451 ICUs were extracted from an international database. We examined associations between survival time and three pragmatic nutritional categories (I: <30% of target, II: 30-70%, III: >70%) reflecting different amounts of total daily calorie intake. We compared hazard ratios for the 30-day risk of dying estimated for different hypothetical nutrition support plans (different categories of daily calorie intake during the first 11 days after ICU admission). To minimize indication bias, we used a lag time between nutrition and outcome, we particularly considered daily amounts of calorie intake, and we adjusted results to the route of calorie supply (enteral, parenteral, oral). RESULTS: 1974 patients (20.4%) died in hospital before day 30. Median of daily artificial calorie intake was 1.0 kcal/kg [IQR 0.0-4.1] in category I, 12.3 kcal/kg [9.4-15.4] in category II, and 23.5 kcal/kg [19.5-27.8] in category III. When compared to a plan providing daily minimal amounts of calories (category I), the adjusted minimal hazard ratios for a delayed (from day 5-11) or an early (from day 1-11) mildly hypocaloric nutrition (category II) were 0.71 (95% confidence interval [CI], 0.54 to 0.94) and 0.56 (95% CI, 0.38 to 0.82), respectively. No substantial hazard change could be detected, when a delayed or an early, near target calorie intake (category III) was compared to an early, mildly hypocaloric nutrition. CONCLUSIONS: Compared to a severely hypocaloric nutrition, a mildly hypocaloric nutrition is associated with a decreased risk of death. In unselected critically ill patients, this risk cannot be reduced further by providing amounts of calories close to the calculated target. STUDY REGISTRATION: ID number ISRCTN17829198, website http://www.isrctn.org.

Long-term changes of patient-reported quality of life after major trauma: The importance of the time elapsed after injury.

BACKGROUND: Numerous studies have identified various risk factors for a poor health-related quality of life (HRQOL) after severe trauma. The relative importance of the time elapsed after injury, however, is unknown and results of clinical studies have been conflicting. METHODS: A cross-sectional study was performed in two trauma centres using data from the German TraumaRegister DGU®, which contained prospectively collected information on the type and severity of the injury, on critical care, and on outcome. To evaluate HRQOL in patients surviving more than 500days after the injury, we used a self-rating instrument, the EQ-5D which contains a visual analogue scale (EQ-VAS), and which allows the calculation of a global outcome indicator, the EQ-D5 index value. Complex statistical models were used to evaluate independent associations between the time elapsed after injury and a poor HRQOL. RESULTS: Of 380 contacted patients, follow-up assessments could be obtained in 168 patients (44.2%) 3.6±1.6 (SD) years after the injury. There was a linear association between the time elapsed after the injury and the% of contacted patients not participating in the study (p=0.013). In participating subjects, average EQ-5D index value was 0.599±0.299, and average EQ-VAS rating 67.8±22.0. A very poor quality of life (EQ-5D index value<0.6, EQ-VAS rating≤50) could be found in 43.5% and 28.0% of the patients, respectively. After adjusting for multiple confounders, the number of days elapsed after injury showed a complex non-linear and independent association with a poor HRQOL (low EQ-5D index value: p=0.027; low EQ-VAS rating: p=0.008). Frequencies of a poor HRQOL reached their minimum about four to five years after the injury and increased thereafter. CONCLUSIONS: There is an independent, U-shaped association between the frequency of extreme values of HRQOL and the time elapsed after injury. Time patterns of HRQOL may be sensitive to increasing rates of attrition since patients with a good outcome are less likely to respond to questionnaires. Time from injury should be incorporated into all future cross sectional studies trying to identify predictors of HRQOL.

TEMPORAL LINKS BETWEEN ENDOTOXIN ACTIVITY LEVELS AND INTERLEUKIN 6 CONCENTRATIONS IN ABDOMINAL SEPSIS.

In severe human peritonitis, the precise pathophysiological importance of endotoxin is controversial. Prognostic and therapeutic studies have yielded conflicting results. The current study wanted to investigate qualitative, quantitative, and temporal associations between blood endotoxin activity (EA) levels and acute inflammatory reactions. We conducted a prospective observational study in 30 patients with intra-abdominal infections who had undergone specific focus therapies (surgical/radiological/pharmaceutical interventions) and who required intensive care therapy. We performed sequential postinterventional measurements of blood EA levels and plasma interleukin 6 (IL-6) concentrations until recurrence or cure. There was no association between daily EA levels and IL-6 concentrations, or daily EA levels and changes in IL-6 concentrations on subsequent days. We found, however, a significant association between EA levels and IL-6 concentrations, when newly changing EA levels were referred to subsequent changes in IL-6 concentrations (P < 0.05). Increasing EA levels were followed by a 90% increase of subsequent IL-6 concentrations during the next 24 to 48 h, whereas decreasing/stable EA levels were associated with slightly decreasing IL-6 concentrations (P < 0.05). Our findings suggest an altered response of the innate immune system because postinterventional EA levels did not vary with concomitant or subsequent inflammatory reactions and because inflammatory responses to newly increasing EA levels were delayed and comparatively small. Still, our results support the concept that endotoxin is a trigger of inflammatory reactions in human peritonitis.

Use of gastric residual volume to guide enteral nutrition in critically ill patients: a brief systematic review of clinical studies.

OBJECTIVE: In critically ill patients, the optimal procedure to monitor upper gastrointestinal function is controversial. Several authors have proposed gastric residual volume (GRV) as a tool to guide enteral nutrition. The aim of this contribution is to briefly discuss corresponding studies. METHODS: We electronically searched MEDLINE, EMBASE, and CINAHL for studies relevant to the subject. RESULTS: Six randomized controlled trials (RCTs) and six prospective observational studies were identified. Each analyzed different thresholds of GRV to guide enteral nutrition and to avoid complications (e.g., vomiting, aspiration, nosocomial pneumonia) in artificially ventilated patients. Due to heterogeneity in outcome measures, patient populations, type and diameter of feeding tubes, and randomization procedures, combination of the results of the six RCTs into a meta-analysis was not appropriate. High-quality RCTs studying medical patients could not demonstrate an association between complication rate and the magnitude of GRV. The only observational study that adjusted results to potential confounders and that studied surgical patients found, however, that the frequency of aspiration increased significantly if a GRV > 200 mL was registered more than once. CONCLUSION: For mechanically ventilated patients with a medical diagnosis at admission to the intensive care unit, monitoring of GRV appears unnecessary to guide nutrition. Surgical patients might profit, however, from a low GRV threshold (200 mL).

In search of the perfect glucose concentration for hospitalized patients: a brief review of the meta-analyses.

In hospitalized patients, the optimal target blood glucose concentration is controversial. Numerous studies have examined clinical use of glucose control in various patient populations. In the present review, we briefly discuss corresponding meta-analyses. We electronically searched MEDLINE, EMBASE and CINAHL for meta-analyses relevant to the subject. Fifteen meta-analyses were identified that analyzed effects of a targeted glucose control. Twelve meta-analyses examined studies performed in critically ill patients. Included studies in this review varied in terms of the type of nutritional support, the efficacy of glucose control, the kind of glucose measurement, clinical end points (hospital or intensive care unit mortality, or 28-, 90- or 180-d mortality, or mortality 30 d after discharge), and the intensity of glucose control (moderate, tight, very tight). Four meta-analyses also including studies with a less stringent glucose control (glucose target <200 mg/dL) showed a beneficial effect on mortality. This effect disappeared when analyzing studies with a tighter glucose control (glucose target <150 mg/dL or <110/120 mg/dL, n = 5), with a very tight glucose control (glucose target <110/120 mg/dL, n = 2), or with a more precise definition of clinical endpoints (28-d mortality, n = 2). Eight meta-analyses showed that, despite the intensity of glucose control, the frequency of hypoglycemic episodes increased. The residual heterogeneity of individual studies incorporated into the various meta-analyses prevents a valid conclusion regarding potential benefits of a specific glucose target. A glucose concentration <200 mg/dL appears preferable.

Nutritional screening for risk prediction in patients scheduled for extra-abdominal surgery.

OBJECTIVE: The Nutritional Risk Screening-2002 (NRS-2000) is currently recommended by the European Society of Parenteral and Enteral Nutrition as a screening tool in hospitalized patients. However, for preoperative risk prediction, the usefulness of this tool is uncertain and may depend on the type of surgical disease. The present study investigated the relative prognostic importance of the NRS-2002 and of established medical and surgical predictors for postoperative complications in patients scheduled for non-abdominal procedures. METHODS: In this prospective observational study, we enrolled 581 patients scheduled for elective non-abdominal surgery. Data were collected on nutritional variables (body mass index, weight loss, and food intake), age, gender, type of surgery, extent of surgery, underlying disease, American Society of Anesthesiologists class, and comorbidity. We also evaluated a modification of the NRS-2002 (ordinal graduation according to <2 or ≥2 points) and the importance of individual parameter values. Relative complication rates were calculated with generalized linear models and cumulative proportional odds models. RESULTS: Forty-four patients (7.6%) sustained at least one postoperative complication. The frequency of this event increased significantly with a higher NRS-2002 score. However, the model that performed the best (sensitivity 81.8%, specificity 78.6%) included the modified NRS-2002 graduation (<2 or ≥2 points) and other factors such as American Society of Anesthesiologists class, the duration of the procedure, and the need for red blood cell transfusion. CONCLUSION: In surgical patients with non-abdominal diseases, a modified NRS-2002 classification may be required to preoperatively identify patients at a high nutritional risk. The NRS-2002 alone is insufficient to precisely predict complications.

Acute prognosis of critically ill patients with secondary peritonitis: the impact of the number of surgical revisions, and of the duration of surgical therapy.

BACKGROUND: Duration of surgical therapy and the number of surgical revisions performed to control the focus may be important prognostic variables. Association of such time-dependent therapies with survival, however, has not yet been studied. METHODS: We analyzed survival times of adult patients (n = 283) who were suffering from secondary peritonitis and associated organ failure. Cox-type additive hazard regression models were used to analyze associations of surgical variables with survival time. RESULTS: Seventy-two patients (25.4%) survived the period of excess mortality after intensive care unit admission. A total of 79.5% of the 283 patients required one or more surgical revisions. Besides the underlying disease and disease severity at intensive care unit admission, there was a nonlinear smoothed association between a poorer outcome and the duration of surgical therapy, and the number of surgical revisions. For the latter, hazard ratios increased sharply between 1 and 5 revisions, and remained largely constant later on. CONCLUSIONS: In critically ill patients with peritonitis, a long therapy and the necessity for a high number of reoperations is related inversely to acute survival.

Albumin synthesis rates are not responsive to hyperglycemic hyperinsulinemia in postoperative patients.

BACKGROUND: Insulin regulates albumin synthesis in vitro and in various experimental models. The current study was undertaken to determine the effects of a physiologic hyperinsulinemia on albumin synthesis in postoperative patients in whom plasma albumin concentrations are decreased. METHODS: Studies were performed in postabsorptive patients after major abdominal operations. Mass spectrometry techniques were used to directly determine the incorporation rate of 1-[(13)C]-leucine into albumin. Consecutive blood samples were taken during a continuous isotope (D-Glc) infusion (0.16 µmol/kg/min). Isotopic enrichments were determined at baseline (period I) and after a 4-hour D-glucose (D-Glc) infusion at currently recommended rates (170 mg/kg/h, n = 10) or after infusion of saline (control group, n = 8) (period II). RESULTS: After D-Glc infusion, plasma insulin concentrations increased significantly (period I, 6.6 ± 1.8 µU/mL; period II, 21.4 ± 2.1 µU/mL; P < .01). In contrast, plasma insulin concentration remained constant in control patients (period I, 3.8 ± 0.9 µU/mL(-1); period II, 5.9 ± 1.1 µU/mL; not significant vs period I, but P < .005 vs the corresponding value at the end of period II in the control group). Hyperinsulinemia was without effect on fractional albumin synthesis (period I, 12.8% ± 1.9%/d; period II, 11.9% ± 1.9%/d; not significant), and synthesis rates corresponded to those measured in controls (period I, 13.0% ± 1.2%/d; period II, 12.1% ± 0.1%/d; not significant vs period I and vs D-Glc infusion). CONCLUSIONS: A standard D-Glc infusion is insufficient to increase albumin synthesis in postoperative patients.

Differential regulation of protein synthesis in hepatic and intestinal tissues by amino acids: studies in patients recovering from major abdominal operations.

BACKGROUND: Currently, it is unknown whether recommended rates of amino acid infusion are sufficient to support hepatic or intestinal protein synthesis specifically after operation. The objective of the study was to determine the effect of a standard parenteral amino acid dose on serum albumin and ileum protein synthetic rates in postabsorptive patients recovering from major abdominal operations. METHODS: Mass spectrometry techniques were used to determine the incorporation rate of 1-[(13)C]-leucine directly into ileum protein and into serum albumin. Consecutive sampling from the same ileum and from blood was performed during continuous isotope infusion (0.16 micromol kg(-1) min(-1)). Isotopic enrichments were determined at baseline (period I) and after a 4-h infusion of amino acids (0.067 g kg(-1) h(-1), n = 8) or after infusion of saline (control group, n = 8) (period II). RESULTS: In controls, protein synthesis in the ileum declined during prolonged isotope infusion (period I: 1.14 +/- 0.13 %/h, period II: 0.47 +/- 0.14 %/h, P < .001). In contrast, during amino acid infusion, protein synthesis in the ileum remained constant (period I: 1.14 +/- 0.17 %/h, period II: 0.89 +/- 0.10 %/h not significant [n.s.] vs period I, but P < .05 vs period II in the control group). Amino acid infusion was without effect when fractional or absolute rates of serum albumin synthesis were studied. CONCLUSION: Currently, the recommended dosages for parenteral amino acid infusion are sufficient to support small-bowel protein synthesis during recovery from major abdominal operation but are ineffective with respect to the formation of new serum albumin.

Dynamics of albumin synthesis after major rectal operation.

BACKGROUND: Major abdominal operations were found to be associated with long-lasting metabolic changes, such as accelerated release of stress hormones and carbohydrate turnover. It is unknown currently whether acute changes of hepatic protein metabolism persist in a similar way. We wanted to determine the long-term dynamics of albumin synthesis and its relationship to whole body protein breakdown and albumin concentration after major rectal operations. METHODS: We used stable isotope tracer techniques to determine albumin synthesis and whole body protein breakdown (rate of appearance of leucine, Ra) in postoperative patients about 1 week after low anterior rectal resection and also during convalescence (about 4 months after operation), and in healthy controls. Consecutive blood sampling was carried out during continuous isotope infusion (1-[(13)C]-leucine, 0.16 micromol/kg min). RESULTS: Serum albumin concentrations were close to the lower normal limit in patients early after operation but were comparable to controls in convalescent patients. Simultaneously, albumin synthesis was increased in the early postoperative phase (0.53 +/- 0.0.5%/h) compared with convalescent patients (0.32 +/- 0.04) and controls (0.28 +/- 0.04) (P < .01 each). A significant inverse correlation could be found between plasma albumin concentration and corresponding rates of albumin synthesis. Early after operation patients showed an increased leucine Ra (3.25 +/- 0.23 micromol/kg min) that was greater than that of convalescent patients (2.37 +/- 0.06 micromol/kg min, P < .05). Leucine Ra in both patient groups were greater than the rates in controls (2.01 +/- 0.07 micromol/kg min, P < .01) Albumin synthesis correlated weakly with whole body protein breakdown rate. CONCLUSIONS: Albumin synthesis and total body protein breakdown are increased after major abdominal operation, but albumin synthesis returns to control values only during convalescence. Hypoalbuminemia after rectal operations may be associated with high rates of albumin synthesis and is, therefore, not necessarily an indicator of insufficient hepatic function or poor nutritional status in that particular situation.