Impact of perioperative haemodynamic monitoring on cardiac morbidity after major vascular surgery in low risk patients. A randomised pilot trial.

OBJECTIVE: to evaluate whether perioperative haemodynamic optimisation influences outcome from infrarenal abdominal aortic aneurysm repair. METHODS: a consecutive series of 100 eligible patients were randomised to either haemodynamic optimisation through the use of a pulmonary artery catheter (CI > 3.0 l/min/sqm, PWP > 10 and <18 mmHg, SVR <1450 dyne/sec/cm(-5), DO(2)> 600 ml/min/sqm) or conventional treatment. RESULTS: there were no differences in terms of in-hospital mortality, cardiovascular morbidity, postoperative renal failure or duration of hospital stay between the groups. CONCLUSIONS: in this study perioperative haemodynamic optimisation was not beneficial.

Genotoxicity assessment in aquatic environments under the influence of heavy metals and organic contaminants.

The genotoxicity of river water and sediment including interstitial water was evaluated by microscreen phage-induction and Salmonella/microsome assays. Different processes used to fractionate the sediment sample were compared using solvents with different polarities. The results obtained for mutagenic activity using the Salmonella/microsome test were negative in the water and interstitial water samples analysed using the direct concentration method. The responses in the microscreen phage-induction assay showed the presence of genotoxic or indicative genotoxic activity for at least one water sample of each site analysed using the same concentration method. Similar results were obtained for interstitial water samples, i.e. absence of mutagenic activity in the Salmonella/microsome test and presence of genotoxic activity in the microscreen phage-induction assay. Metal contamination, as evidenced by the concentrations in stream sediments, may also help explain some of these genotoxic results. Stream sediment organic extracts showed frameshift mutagenic activity in the ether extract detected by Salmonella/microsome assay. The concentrates evaluated by microscreen phage-induction assay identified the action of organic compounds in the non-polar, medium polar and polar fractions. Thus, the microscreen phage-induction assay has proven to be a more appropriate methodology than the Salmonella/microsome test to analyse multiple pollutants in this ecosystem where both organic compounds and heavy metals are present.

[The incidence of stress ulcers and the effectiveness of preventive alkalization treatment in patients scheduled for major vascular surgery. Prospective study]. / Incidenza dell'ulcera da stress ed efficacia del trattamento profilattico alcalinizzante in pazienti sottoposti ad interventi di chirurgia aortica maggiore. Studio prospettico.

BACKGROUND: A prospective double blind study has been carried out in order to evaluate the current incidence of stress ulceration and the efficacy of acid-reducing prophylaxis, in patients scheduled for major vascular surgery, without a documented history of ulcer disease or previous upper GI-tract surgery. METHODS: Seventy patients have been randomly assigned to treatment group with ranitidine 50 mg e.v. every six hours or to control group with placebo at the same intervals. Gastric juice has been evaluated for pH and for occult blood by a slide test four times a day and cultured once a day on a suitable ground in the postoperative period. Data have been analyzed on a "treatment efficacy" and not "intention to treat" basis: patients have been considered alkalinized if more than 80% of pH measurement were > 4.5. Patients have been therefore divided into two groups, the "alkaline" one (43 patients) and the "acid" one (27 patients). RESULTS: Twenty-five patients (58.1%) in the alkaline group vs four patients (14.8%) in the acid group, showed positive gastric-juice cultures (p > 0.01). Twenty-three patients in the alkaline group (53.4%) and nine patients in the acid group (33.3%) showed occult gastric bleeding (p = NS). Overall, nine patients (12.8%) had overt gastrointestinal bleeding, four in the alkaline group (9.3%) and five in the acid group (18.5%) (p = NS). Endoscopic evaluation revealed erosive gastropathy in six patients, gastric ulcer in two patients and duodenal ulcer in one. Neither occult nor overt gastrointestinal bleeding did correlate with gastric pH values. On the contrary, the development of overt gastrointestinal bleeding has been positive associated with length of aortic cross-clamping and with postoperative score index. CONCLUSIONS: This observation suggests that factors other than gastric acidity contribute to mucosal damage and bleeding, as intraoperative mesenteric ischemia/hypoperfusion, or oxygen free radicals damage produced during reperfusion of districts below the level of aortic cross-clamping. The results obtained suggest that routinary alkalisation of gastric juice is not warranted in the prevention of gastrointestinal bleeding in major vascular surgical patients.

[Ultrasonography-guided identification of the lumbar epidural space]. / Individuazione ecoguidata dello spazio epidurale lombare.

The study was designed to assess the reliability of sonographic evaluation in the prediction of the depth of the lumbar epidural space. Forty males, scheduled for epidural anesthesia for surgical repair of inguinal hernia, were prospectively studied. Patients were placed in a sitting position and sagittal scanning of the lumbar spine was performed with a 5-MHz transducer over the fourth or fifth interspace in order to identify the deeper hyperechogen interface, which represents the landmark between the ligamentum flavum and the epidural space. Ultrasound depth was measured and transducer removed. A Tuohy needle 18 G was then introduced percutaneously according to the standard technique and a rubber slide placed over it, so that it depth of insertion could be accurately measured. The potential for using ultrasounds for prediction of the distance from skin to epidural space was analyzed using a simple linear regression analysis; p values < 0.05 were considered significant. Mean values of ultrasound depth and needle depth were respectively 51 mm (SD 6.3) and 50.9 mm (SD 6.2); the correlation coefficient was 0.99. Ultrasound scanning of the lumbar spine provides an accurate measurement of the depth of the epidural space, which can facilitate the performance of the epidural anaesthesia and may decrease the complication rate, particularly in those patients in which anatomic landmarks are obscured.

[Clebopride in premedication in ambulatory interventions in general anesthesia]. / La clebopride nella premedicazione degli interventi ambulatoriali in anestesia generale.

The authors examine the antiemetic effects of 1 mg clebopride administered iv after surgery, vs a placebo, by making a double blind randomized study on two groups of 40 women comparable by age and weight. The 2 groups of outpatients, admitted for short gynecological surgery, underwent diagnostic uterine curettage. They were anaesthetized with a cocktail of 2.5 mcg/kg fentanyl and 0.25 mg/kg ketamine, on spontaneous respiration. Nausea, vomiting and the other side effects were evaluated 3-6 hours after surgery. Statistically, clebopride proved more effective than placebo against nausea and vomiting (P ranging between 0.05-0.01), with no relevant side effects.

Comparison of glucose vs. Glucose fat solutions in cancer patients: A controlled crossover study.

The purpose of this investigation was to evaluate in a randomised crossover study the effects on nutritional status of two isonitrogenous-isocaloric regimens of total parenteral nutrition (TPN) in 12 severely cachectic cancer patients. The regimens consisted of (1) G: 50 kcal of glucose.kg(-1).day(-1) + 2g amino-acids.kg(-1).day(-1) (2) GL: 30 kcal glucose and 20 kcal lipids.kg(-1) + 2g amino-acids.kg(-1).day(-1). Regimens G and GL were delivered sequentially for a period of 10 days each. Six patients (Group A) were randomised to receive regimen G first and regimen GL subsequently. In Group B patients the regimens alternated in the opposite way. The following nutritional variables were measured before TPN, after regimen G and after regimen GL: weight, arm circumference, arm muscle circumference, triceps skin fold, serum proteins, serum albumin, cholinesterase, transferrin, pre-albumin, retinol-binding protein, peripheral lymphocytes, cumulative nitrogen balance and mean urinary excretion of creatinine and 3-methylhistidine. The data showed that body weight and retinol-binding protein significantly increased with both G and GL regimens. No difference was found in the remaining variables, not even when comparing regimen G to GL. Increase in retinol-binding protein and in nitrogen balance were significantly better in the first period of treatment than in the second. These results show that the two regimens had a similar impact on the nutritional status of the cachectic cancer patients and choice between a glucose or a glucose-fat TPN should depend mainly on tolerance of the patients, duration and cost of therapy.

Total parenteral nutrition prevents further nutritional deterioration in patients with cancer cachexia.

The effects of total parenteral nutrition (TPN) on some nutritional variables were prospectively investigated in 12 severely cachectic patients with advanced cancer. The following variables were determined before and at 5-day intervals during the 20-day administration of TPN: anthropometric indices (body weight, arm circumference, triceps skinfold, arm muscle circumference, arm muscle area, arm fat area, total body muscle mass); biochemical indices (total protein, albumin, cholinesterase, total iron binding capacity, thyroxin-binding prealbumin, retinol binding protein, urinary 3-methylhistidine and creatinine excretion, nitrogen balance); and peripheral lymphocyte count. TPN was delivered at 49.5 nonprotein kcal/kg-1/day-1 (80% as dextrose and 20% as fat) and amino acids 1.9 g/kg-1/day-1. A significant increase was obtained in body weight, triceps skinfold, arm fat area, and retinol binding protein. All remaining anthropometric and biochemical parameters did not show any significant positive or negative change, although nitrogen balance remained positive. No significant liver toxicity was apparent after the TPN period. It was concluded that although TPN is unable to completely reverse some nutrition-related variables in cachectic patients with cancer, most patients were kept within a normal range and some improved. Therefore, further deterioration of the nutritional state, which is characteristic of this phase of disease, was at least prevented.

"Nutritional" markers as prognostic indicators of postoperative sepsis in cancer patients.

A study was undertaken to identify the nutritional parameters associated with a high risk of postoperative sepsis. The nutritional status of 162 cancer patients subjected to clean or clean-contaminated elective surgery was preoperatively evaluated according to the following parameters: percentage weight loss, arm circumference, triceps skinfold, arm muscle circumference, creatinine-height index, total serum protein, serum albumin, total iron-binding capacity, cholinesterase, peripheral lymphocytes, complement C3-C4 components, and skin tests. Patients were followed postoperatively according to a precise protocol to classify them as infected or noninfected. Postoperative sepsis was present in 40 patients who had significantly different mean values for four nutritional parameters from those of 114 patients with no complications, ie, total serum protein, 6.60 vs 6.99 g/dl, p = 0.008; serum albumin, 3.39 vs 3.66 g/dl, p = 0.001; total iron-binding capacity 301.32 vs 337.17 mmg/dl, p = 0.006; and cholinesterase, 2389.77 vs 2770.10 mU/ml, p = 0.005. Moreover, the relative risk and the attributable risk for these variables were evaluated and the significance was tested by the chi 2 test. By using multiple logistic analysis it appeared that only total serum protein and total iron-binding capacity gave an independent contribution to the risk of postoperative sepsis, while serum albumin disappeared and cholinesterase became non significant when the contribution of the first two variables was accounted for. It was also possible to identify, in a small number of patients, combinations of two variables that were associated with a very high risk of postoperative sepsis.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypocupremia in patients receiving total parenteral nutrition.

Although hypocupremia is a well-known consequence of long-term total parenteral nutrition (TPN), its incidence as well as the duration of TPN necessary to induce it are still unsettled. The purpose of this study is to review the changes in serum copper level in 25 patients receiving TPN for a period longer than 2 wk (mean duration 6 wk) at the Istituto Nazionale Tumori of Milan and to evaluate the possible relationship of cupremia with the basic disease. Main indications for TPN included enterocutaneous fistulas (11 patients), cancer cachexia (10 patients), radiation enteropathy (two patients), and severe postoperative stricture following esophagogastric resection (two patients). Mean value of serum copper at the beginning of the study was 143 micrograms/100 ml (normal value 65-165 micrograms/100 ml), and the regression analysis showed a mean fall of 5.64 micrograms/100 ml/wk. Hypocupremia occurred in four patients (three with intestinal fistulas and one with radiation obstructive enteritis) at 5th, 6th, 9th, and 6th wk of TPN, respectively. No patient with cancer cachexia developed hypocupremia. No patient with hypocupremia had clinical evidence of a copper deficiency syndrome. We conclude that 1) hypocupremia does not occur within the first month of TPN; 2) its incidence is about 16% in patients intravenously fed for period longer than 2 wk; 3) it is more frequent in patients with enterocutaneous fistulas, whereas it never occurs in patients with cancer cachexia, and 4) it is not necessarily associated to a clinicometabolic syndrome of copper deficiency. Finally, the "nutritional" meaning of serum copper should be questioned in cancer patients since it could represent a "tumor marker."

Impact of cancer, type, site, stage and treatment on the nutritional status of patients.

This study analyzed the nutritional status of cancer patients in relation to type and site of origin of the tumor, stage of disease, and previous chemical or radiation therapy. The analysis was performed on 321 patients (280 with cancer and 41 controls). The nutritional parameters included per cent of weight loss, anthropometric indices (arm circumference, triceps skinfold, arm muscle circumference), creatinine-height index, serum protein, albumin, total iron binding capacity and cholinesterase, C3 and C4 components of complement, total peripheral lymphocytes, and skin tests. The statistical comparison between patients with different tumors and controls, between patients with different stages of the same tumor, and between patients treated with or without previous chemical or radiation therapy led to the following conclusions: 1) malnutrition is mainly related to the type and site of origin of the tumor and, in the early stages of disease, is more pronounced in patients with cancer of the esophagus and stomach; 2) except in patients with breast and cervix cancer, malnutrition gets more severe as the disease becomes advanced; 3) chemical or radiation therapy has a variable impact on the nutritional status, but in selected patients it causes a drop in body weight, arm circumference, arm muscle circumference, and peripheral lymphocytes; 4) body weight, cutaneous delayed hypersensitivity and serum albumin are the most commonly altered parameters.

Effect of supportive intravenous hyperalimentation on the nutritional status of cancer patients.

The effect of intravenous hyperalimentation on the nutritional status of 84 cancer patients treated at the Istituto Nazionale Tumori, Milan, has been evaluated. The body weight increased in 78% of patients, mid upper arm circumferance in 93%, triceps skinfold in 73%, mid upper arm-muscle circumference in 73%, creatinine/height index in 30%, serum albumin in 32%, transferrin in 35%, total peripheral lymphocytes in 38%. Lymphocyte blastogenesis increased in 74% of the patients examined and skin tests were converted from negative to positive in about 20% of patients. In addition 8 our of 18 patients responsive to IVH benefited from chemotherapy and/or radiotherapy indicating that the nutritional repletion of the host did not significantly affect the growth of the tumor. These findings support the opinion that neoplastic cachexia may depend partially on malnutrition and can be often reversed by IVH. Moreover, IVH might have an adjunctive role as potentiator of chemotherapy which however must be confirmed by clinical trials.