[Organ donation]. / Organspende.

For patients with end-stage organ disease transplantation of human organs is a well-established therapy, and in most cases it is the only life-saving one. But the lack of available organs is a big problem. The legal basis in Germany is the transplantation law (TPG). According to this law, every ventilated patient with diagnosed brain death is a potential organ donor. However, brain death may lead to strong reactions in the patient's cardiovascular system as well as disturbances in thermoregulation, water and electrolyte balance, and the endocrine and haemostatic systems. Thus, protecting the organs of the organ donor and, furthermore, caring for his or her relatives are great challenges for every physician and nurse in the intensive care unit.

[Heparin-induced thrombocytopenia]. / Heparininduzierte Thrombozytopenie.

Heparins are in widespread use as anticoagulants for the prophylaxis and therapy of thromboembolisms. A dangerous side-effect is heparin-induced thrombocytopenia type II (HIT type II) with the paradox of thromboembolic venous and arterial vascular occlusions. HIT type II is an immunological disease which results in activation of platelets and plasma coagulation. The main symptom is an acute onset of thrombocytopenia with a fall in thrombocytes to less than 50% of the initial value with or without newly arising thromboembolic complications between days 5 and 14 after the start of heparin therapy. Surgery patients are more often affected by subclinical antibody formation as well as by symptomatic HIT type II than clinical patients. In this review we will discuss the difficult diagnosis and the differential diagnosis with special emphasis on postoperative intensive care patients, as well as preventive measures and management on occurrence of HIT type II and associated thrombotic complications.

Hydrolysis of mixed lipid emulsions containing medium-chain and long-chain triacylglycerol with lipoprotein lipase in plasma-like medium.

We explored the effects of plasma-like conditions on hydrolysis of medium-chain triglyceride (MCT) and long-chain triglyceride (LCT) emulsions at different mixing ratios and the effect of the physical method of mixing on lipoprotein lipase hydrolysis of mixed emulsions in vitro. Mixed emulsions with two different mixing ratios, 50% MCTs with 50% LCTs and 70% MCTs with 30% LCTs by weight, were studied. Emulsions containing both MCT and LCT oils blended in the same emulsion particle were compared with mixtures of separate pure MCT emulsion particles and pure LCT particles. MCT hydrolysis was always greater than LCT hydrolysis. In a plasma-free tris(hydroxymethyl)aminomethane-albumin buffer at pH 8.5, the physical method of mixing had substantial effects on hydrolysis; blended emulsions of MCTs and LCTs were hydrolyzed better than separate mixes of pure MCT and pure LCT particles, ie, more total free fatty acids were released. In plasma-free systems, there were no differences in rates of hydrolysis of LCTs or MCTs (as individual triglycerides) between the two different mixing ratios of 50:50 and 70:30. However, the presence of plasma markedly diminished the differences in hydrolysis between blended vs separately mixed emulsions at pH 7.4. Also, in plasma-like incubation buffer, the rates of hydrolysis of MCTs and LCTs in emulsions with 50:50 or 70:30 MCT to LCT ratios reflected the respective amounts of MCT and LCTs in the emulsions.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical tolerance and metabolism of a fat emulsion containing carnitine and gamma-linolenic acid.

The purpose of the present study was to study the metabolism and evaluate the tolerance of a new fat emulsion, which is rich in gamma-linolenic acid and has been supplemented with carnitine. 24 adult male volunteers participated in an open, randomised, crossover study where half of the subjects were given Intralipid 20% (IL) on day one followed by administration of the supplemented fat emulsion (FE) on day two, the other half being treated in the reverse order. Both fat emulsions were first administered as a bolus dose of 0.10 g triglycerides per kg BW (an intravenous fat tolerance test) followed 40 min later by a continuous intravenous infusion during 4 h at a rate of 0.21 g triglycerides per min. The plasma fractional elimination rate, k(2)-value, was lower for FE than for IL (4.6 +/- 1.8 vs 5.3 +/- 1.6% per min, P < 0.05, mean +/- SD). Infusion of FE, as distinct from IL administration, was accompanied by a marked increase in serum gamma-linolenic acid concentration (239 +/- 133 vs 0 +/- 11 mumol/l, P < 0.05). No differences between FE and IL were discernible regarding the serum concentrations of dihomo-gamma linolenic acid (C 20: 3omega6), arachidonic acid (C 20: 4omega6), adrenic acid (C 22: 4omega6) or docosapentanaenoic acid (C 22: 5omega6). Leucocyte chemotaxis and random migration increased, 0.5 +/- 0.3 arb. units (P < 0.01) and 0.2 +/- 0.2 arb. units (P < 0.05), during infusion of FE but no such effect was noted during IL administration. No effect of the fat emulsion composition and carnitine was detected on phagocytosis and oxidative metabolism of neutrophil leucocytes. In conclusion, the new fat emulsion containing a relatively high proportion of gammalinolenic acid and supplemented with carnitine was found to be well tolerated although it was eliminated from plasma at a 13% slower rate. The supplemented fat emulsion had a moderate stimulatory effect on leukocyte chemotaxis.

Effect of medium- and long-chain triglyceride infusion on lipoprotein and hepatic lipase in healthy subjects.

Plasma lipolytic activity and hydrolysis of intravenous fat were studied in six healthy subjects during infusion of a long-chain triglyceride (LCT) fat emulsion (Intralipid 20%) or of a medium-chain triglyceride (MCT)/LCT emulsion (Lipofundin MCT 20%). The fat emulsions were infused continuously at a rate of 0.17 g triglyceride kg-1 body weight (BW)h-1 for 6 h in random order at 7-day intervals. A continuous infusion of glucose (0.18 g kg-1 BW h-1) was administered for a period of 7 h and was started 1 h before the lipid infusion. Infusions of both types of fat increased plasma triglyceride (TG), free fatty acid (FFA) and lipoprotein lipase (LPL) levels and steady-state values were present during the 3rd to 5th h of infusion. MCT/LCT infusion resulted in higher plasma levels at steady-state of TG (3.63 +/- 0.45 [SEM] vs 2.73 +/- 0.45 mmol l-1; P less than 0.05), FFA (1.05 +/- 0.08 vs 0.54 +/- 0.04 mmol l-1; P less than 0.01) and LPL (4.6 +/- 0.6 vs 2.6 +/- 0.5 mU ml-1; P less than 0.05) in comparison with LCT administration. There was a positive correlation between plasma LPL activity and TG concentration (r = 0.77; P less than 0.001) when data for the two infusions were combined. Although the same amount of fat was infused on a weight basis, the molar infusion rate was 40% higher with MCT/LCT than with LCT infusion, due to differences in molecular weights (634 vs 885 Da).(ABSTRACT TRUNCATED AT 250 WORDS)

Supplemental immunoglobulin (ivIgG) treatment in 163 patients with sepsis and septic shock--an observational study as a prerequisite for placebo-controlled clinical trials.

In a multicenter observational study of 163 medical and surgical patients with a total of 173 episodes of sepsis or septic shock (Elebute sepsis score: 19.0 +/- 0.5), the effects of supplemental i.v. immunoglobulin (i.v. IG) treatment (unmodified polyvalent IgG pH 4.25, n = 123; for Pseudomonas sepsis, n = 50, Pseudomonas IgG) on multiple organ failure (MOF) were investigated by means of APACHE II score changes (pretreatment: 23.7 +/- 0.6). In 44% of the cases ("responders"), a prompt improvement in APACHE II score (defined as decrease greater than or equal to 4) was evident from day 0 to day 4 after onset of therapy, thus being in close time relationship to the i.v. IG administration. This improvement, associated with a better prognosis (mortality 24% vs. 55%), was found in all subgroups, most importantly the following: polyvalent IgG vs. Pseudomonas IgG treatment; medical vs. surgical patients; moderate vs. severe MOF; and gram-positive vs. gram-negative septicemia. In a small-sized second comparative nonrandomized control group (n = 27, antibiotic treatment alone) of septic patients (Elebute: 14.7 +/- 1.0) with similar MOF severity (APACHE II: 23.6 +/- 1.4), the response rate (30%) was, though not statistically significant, lower by one-third. The optimal baseline score ranges for patient inclusion into future placebo-controlled randomized i.v. IG trials were found to be 20-35 for the APACHE II score and 12-27 for the Elebute score.

[Side effects and complications of parenteral nutrition]. / Nebenwirkungen und Komplikationen der parenteralen Ernährung.

Despite increasing advances in total parenteral nutrition, a lot of partly serious side effects have been seen. This includes among other things the lactic acidosis after high amounts of carbohydrates or the deficiency and excessive expenditure respectively, of thiamine in carbohydrate metabolism. Metabolic changes in bone system, especially with long term parenteral nutrition are reported by american groups. Cholestasis is often caused by intravenous feeding. In patients with malnutrition a carefully balanced supply of calories and phosphate should be offered. Without misuse of TPN, the rate of complications is very low.

[Clinical studies with fat emulsions containing LCT and MCT]. / Klinische Untersuchungen mit LCT- und MCT-haltigen Fettemulsionen.

In an effort to supply energy carriers with a high utilization rate specifically in parenteral nutrition during postaggression metabolism, fat emulsions were developed containing long- and medium-chained triglycerides in a 1:1 ratio. The special advantage of the medium-chained fatty acids is, among other things, their low rate of accumulation and high oxidation rate in the organism. Using a graduated schedule, intensive-care patients who were being parenterally fed exclusively were administered either an MCT/LCT mixture or an LCT emulsion alone as a bolus injection and later continuously. Among other things, the behavior of the triglyceride concentrate and the individual fatty acids in serum and of individual lipid fractions, as well as the effect on various parameters of carbohydrate and fat metabolism, were measured. In addition, the oxidation rate of an MCT/LCT emulsion labelled with 13C was measured. The results of the comparative lipid studies were compared. The expected result-that the oxidation rate of medium-chained triglycerides exceeds that of long-chained triglycerides-was confirmed. It was surprising that the median oxidation rate with a continuous fat supply within a complete nutrition program was only 32 +/- 6.8%. Why some patients showed higher triglyceride levels with the MCT/LCT emulsion than with the supply of LCT alone is still unclear. It remains to be investigated whether the rapid splitting of medium-chained triglycerides leads to a temporary loss of activity of the lipoprotein lipase accompanied by a rise in triglycerides in serum. More research will be necessary before we know what role MCT/LCT emulsions will play in future. Such an emulsion would possibly be suitable in severely injured patients, whereby the MCT portion could preferentially supply the organism with energy carriers and the long-chained triglycerides structural components.

[Current status of parenteral feeding with fat emulsions. Clinical experiences with infected patients]. / Aktueller Stand der parenteralen Ernährung mit Fettemulsionen. Klinische Erfahrungen mit septischen Patienten.

In sepsis the utilization of endogenous and administered fuel sources is sometimes impaired. The precise origin of this metabolic failure is currently unknown. In long term and severe septic processes an increased peripheral energy deficit appears accompanied by a drastically augmented muscle protein catabolism. Branched chain amino acids released by this protein breakdown, at least temporarily, meet the energy needs of the muscles. Ketone bodies as energy source for the muscle are not available because their production is diminished in sepsis. The question of whether or not fat emulsions can be administered to septic patients still remains unanswered, although some recent investigations have demonstrated that fat is utilized and oxidized by septic patients. Results from our patients indicate that a marked reduction of cholesterin ester quotient, an increase of total and VLDL triglycerides and a severe reduction of HLDL Cholesterin are particularly characteristic changes in lipid metabolism during sepsis. The proportional decrease of the linoleic acid levels in cholesterol esters of plasma observed in septic patients was even more pronounced followed severe injury. Together with others we believe that parenteral fat application is not contraindicated in sepsis. The decision to infuse fat emulsions depends more on the metabolic situation of a patient than on a specific diagnosis; in other words, a sufficient peripheral oxygen supply, the level of the serum triglycerides and the reaction of the blood glucose concentration to an intravenously administered fat emulsion are, among others, the decisive factors.