[Nosocomial pneumonias. The effect of selective intestinal and ventricular decontamination in respirator-treated intensive care patients]. / Nosokomielle pneumonier. Effekten af selektiv dekontaminering af tarm og ventrikel hos respiratorbehandlede intensivpatienter.

Nosocomial infections, especially pneumonias, are a common problem in Intensive Care Units (ICU) and are a major cause of morbidity and mortality. During the past ten years a new regime, selective decontamination of the digestive tract (SDD) has been introduced to prevent these infections which are often preceded by colonization with aerobic potentially pathogenic microorganisms. Topical antibiotics are applied both orally and by nasogastric tube to prevent secondary endogeneous infections with Gram-negative enteric rods, Staphylococcus aureus and yeasts, in combination with parenteral antibiotics for the treatment of early primarily exogeneous and endogeneous infections. The effect of SDD on morbidity and mortality has been studied in many papers which are very conflicting and their results are difficult to interpret. This article reviews 11 published randomized trials of SDD in ICU among intubated and artificially ventilated adult patients aged more than 15 years. Of the eleven available controlled studies, eight showed a significant reduction of nosocomial pneumonias among patients who received selective decontamination. Only two studies demonstrated a reduction in infection related mortality rates.

[Hypertrophic tonsils, upper airway obstruction and cardiac complications. A combined otological, medical and anesthesiological problem]. / Hypertrofiske tonsiller, øvre luftvejsobstruktion og kardiale komplikationer. Et kombineret otologisk, medicinsk og anoestesiologisk problem.

Hypoventilation in children with hypertrophied tonsils can cause hypoxemia, hypercarbia, acidosis and pulmonary vasoconstriction resulting in cardiac arrhythmias or cor pulmonale. In addition, cerebral symptoms such as day-time hypersomnia or even seizures may be present. Early recognition of hypertrophied tonsils is necessary to avoid development of severe cardiac symptoms. If cardiac incompensation is present, medical treatment is advocated prior to tonsillectomy. Anaesthesia for tonsillectomy in these children is associated with special considerations. Preoperative sedation should be excluded, and inhalational induction with O2 and Halothane is recommended. On induction a difficult intubation should be expected.

[Acute adult respiratory distress syndrome (ARDS) in a patient with amitriptyline poisoning]. / Akut lungeparenkymsvigt (ARDS) hos en amitriptylinforgiftet patient.

A case of "adult respiratory distress syndrome" after amitriptyline overdosage is reported. Amitriptyline is rapidly absorbed from the intestinal tract and the drug is concentrated in the tissues, particularly the brain, heart and lungs. It is suggested that in large quantities it may inhibit surfactant production and thus cause the clinical picture described. The ventilatory treatments are discussed. It seems that inversed ratio ventilation (IRV) has something to offer, avoiding the use of high oxygen fractions in inspired air and high peak airway pressures. Our patient improved with IRV.

Plasma fibronectin concentration in normal pregnancy and pre-eclampsia.

Plasma fibronectin concentration was determined by electroimmunoassay in 111 normal pregnant women and in 23 pregnant with evidence of pre-eclampsia. The plasma fibronectin concentration during the period of normal pregnancy showed a significant increase. In mild or severe pre-eclampsia patients, the plasma fibronectin concentration was significantly higher than that measured at normal 38-41 weeks of gestation. The present findings suggest that measurement of plasma fibronectin might be of diagnostic value in pre-eclampsia.

CBF and CMRO2 during craniotomy for small supratentorial cerebral tumours in enflurane anaesthesia. A dose-response study.

In 14 patients with supratentorial cerebral tumours with midline shift less than or equal to 10 mm, cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO2) were measured twice on the contralateral side of the craniotomy, using a modification of the Kety & Schmidt method. For induction of anaesthesia, thiopental, fentanyl and pancuronium were used. The anaesthesia was maintained with enflurane 1% in nitrous oxide 67%. Moderate hypocapnia to a level averaging 4.3 kPa was achieved. The patients were divided into two groups. In Group 1 (n = 7), 1% enflurane was used throughout the anaesthesia, and CBF and CMRO2 measured about 70 min after induction averaged 30.1 ml 100 g-1 min-1 and 1.98 ml O2 100 g-1 min-1, respectively. During the second CBF study 1 h later, CBF and CMRO2 were unchanged (P greater than 0.05). In Group 2 (n = 7), the inspiratory enflurane concentration was increased from 1 to 2% after the first CBF measurement. In this group a significant decrease in CMRO2 was observed, while CBF was unchanged. In six patients EEG was recorded simultaneously with the CBF measurements. In patients subjected to increasing enflurane concentration (Group 2), a suppression in the EEG activity was observed without spike waves. It is concluded that enflurane induces a dose-related decrease in CMRO2 and suppression in the EEG activity, whereas CBF was unchanged.

Effect of Pseudomonas aeruginosa proteases on human leukocyte phagocytosis and bactericidal activity.

The effect of Pseudomonas aeruginosa alkaline protease (AP) and elastase (Ela) on neutrophil phagocytosis and bactericidal activity was examined. It was found that both proteases reduced the phagocytic activity of the leukocytes against P. aeruginosa, whereas they had little effect on the phagocytosis of S. aureus. AP and Ela at concentration of up to 250 micrograms per ml (much higher than the levels detectable under in vivo conditions) did not interfere with the bactericidal activity of the leukocytes against both test organisms. Inhibition of phagocytosis by AP and Ela without effect on the bactericidal activity suggests that the P. aeruginosa proteases most probably exert their effect on the cell surface perhaps by proteolytic cleavage of the cell receptors which are necessary for phagocytosis.

Opsonic activity of serum in the acute phase of meningitis.

The present study was designed to determine the opsonic activity of serum obtained from meningitis patients in the acute stage of their illness. This study was part of a Danish multicentre prospective study on various aspects of meningitis for a 12-month period. The opsonic activity of serum was determined by a phagocytosis and a chemiluminescence assay using human peripheral blood polymorphonuclear leukocytes. The mean chemiluminescence and phagocytosis indices determined in the sera of 58 patients suffering from various forms of bacterial or non-bacterial meningitis did not differ significantly from that of control sera. Although sera of 4 patients with pneumococcal, 3 with meningococcal, and 1 with streptococcal meningitis exhibited lower opsonic activity than the control sera in the chemiluminescence assay, their values in the phagocytosis assay were similar to control value. It is concluded that serum opsonic activity in meningitis patients is normal and similar to that of healthy individuals.

Phagocytosis and bactericidal activity of human leucocytes under influence of antimalarial drugs.

The phagocytic and bactericidal activity of human peripheral blood leucocytes under the influence of commonly used antimalarial drugs was studied. The following drugs were used: chloroquine diphosphate, quinine HCl, mefloquine HCl, proguanil HCl, cycloguanil, pyrimethamine and tetracycline HCl. It was found that leucocytes treated with mefloquine, proguanil and cycloguanil at concentrations higher than 0.5 mg/litre showed reduced phagocytic activity against Staphylococcus aureus. None of the other drugs tested had any inhibitory effect on phagocytosis. The bactericidal ability of the leucocytes was not affected by any of the drugs. It is concluded that none of the commonly used antimalarial drugs, at concentrations obtainable in malaria prophylaxis and therapy, have any undesirable effect on the bactericidal activity of human leucocytes.

Fibronectin in tears following surgical trauma to the eye.

The concentration of the high molecular glycoprotein fibronectin (FN) was measured by an enzyme-linked immunoadsorbent technique (ELISA) in tears of 25 patients before and after cataract extraction. Both native and degraded FN was measured. The median concentration of FN in tears before surgery was 0.28 mg/l (range: 0.1-3.8 mg/l) and 0.18 mg/l (range: 0.1-1.95 mg/l for degraded and native FN, respectively. The time course of the median values of both types of FN during the post-operative observation period described a biphasic curve with peaks at the second and fifth day following operation. On the twelfth day the concentration of degraded and native FN had almost reached pre-operative levels. The variation in the post-operative FN concentration proved statistically significant. The biological significance of the changes in FN level in the post-operative period is not obvious; the first peak may be explained by a spill-over from plasma, and the second peak may reflect FN production from fibroblasts in the granulation tissue of the corneoscleral cicatrix.

Plasma antithrombin III concentration in patients on regular haemodialysis treatment.

Plasma concentration of antithrombin III (AT III) was measured by both immunological and functional assays before, during and after treatment with haemodialysis in 42 patients with chronic renal failure on regular long-term haemodialysis. Intravenous heparin administration during the haemodialysis session was found not to induce a consumption of the circulating AT III.

Respiratory depression after epidural morphine in the postoperative period. Influence of posture.

Twelve females scheduled for elective lower abdominal surgery received 4 mg of morphine by lumbar epidural injection for postoperative pain relief. The patients were divided into two groups nursed postoperatively in a supine or 45 degree elevated position, respectively. Mouth occlusion pressure during CO2 stimulation was used for the determination of respiratory depression, following epidural morphine. No significant difference in occlusion pressure was found between the two groups. Within the groups a significant reduction of the occlusion pressure was found when compared with the value obtained immediately before the administration of epidural morphine. However, compared with the value obtained the day before surgery, no significant reduction of the occlusion pressure was observed. It is concluded that the 45 degree elevated position does not protect against the occurrence of respiratory depression following epidural morphine.

Plasma fibronectin concentrations in patients with severe burn injury.

Plasma fibronectin concentrations were measured in 33 patients with major burn injury. Changes in plasma fibronectin concentration were related to the day of burn injury, surgery and to the development of sepsis. Within 24 hours of the burn injury and surgical treatment, a decrease of the plasma fibronectin concentration was observed, which returned to normal values within 72 hours. A decrease in the plasma fibronectin concentration was observed as sepsis developed, while recovery from septicaemia was associated with plasma fibronectin concentration returning to normal values.

Opsonic activity of fibronectin in the phagocytosis of Staphylococcus aureus by polymorphonuclear leukocytes.

The effect of the opsonic activity of human purified fibronectin on phagocytosis of Staphylococcus aureus by human polymorphonuclear leukocytes was investigated. After opsonization with fibronectin there was a significant increase in the rate of phagocytosis of four out of six Staphylococcus aureus strains. Both attachment to and ingestion by leukocytes was affected, as revealed by lysostaphin treatment. Incubation of leukocytes with fibronectin prior to phagocytosis did not enhance the phagocytosis of Staphylococcus aureus. This shows that the observed enhancement of phagocytosis was dependent on the binding of fibronectin to Staphylococcus aureus. The ability of fibronectin to opsonize different strains of Staphylococcus aureus varied with the strain. A variation was also observed in fibronectin-induced phagocytosis by leukocytes from different donors.

Plasma and urine fibronectin concentration in kidney-transplanted patients.

Plasma and urine fibronectin concentration was determined by electroimmunoassay and ELISA-method in patients who received renal transplantation. The plasma fibronectin concentration decreased both after the transplantation, in relation to the acute rejection of the graft, and in the relation to immunosuppressive therapy. Urine fibronectin excretion increased in relation to the kidney transplantation and acute rejection of the graft. In association with improved kidney function, the urine fibronectin excretion decreased. It is suggested that it might be of clinical importance to determine the excretion of fibronectin into the urine in patients undergoing kidney transplantation.

Plasma fibronectin concentration in patients admitted to intensive care unit.

The plasma fibronectin level was determined by immunoelectrophoresis in patients under intensive care. The decrease in plasma fibronectin concentration was most pronounced in patients with sepsis and DIC. Survival of these patients was related to the extent of decrease of the plasma fibronectin concentration. Burn injury and the associated surgical treatment were followed by a decrease in fibronectin concentration which then normalized in 24-48 h after the burn injury. It is concluded that serial determinations of plasma fibronectin are essential for studying the relation of a low plasma fibronectin with the clinical condition.

Plasma fibronectin concentration in patients with chronic renal failure and treated with haemodialysis.

By quantitative electroimmunoassay the plasma fibronectin concentration was determined in 42 patients with chronic renal failure and treated with haemodialysis. The plasma fibronectin concentration was significantly reduced, independent of the haemodialysis, compared to a control group. Delayed wound healing seen in patients with chronic renal failure might be a result of the reduced plasma fibronectin.