Development of effective prophylaxis against intraoperative carcinoid crisis.

STUDY OBJECTIVE: The prophylactic use of a preoperative, intraoperative, and postoperative high-dose continuous octreotide acetate infusion was evaluated for its ability to minimize the incidence of carcinoid crises during neuroendocrine tumor (NET) cytoreductive surgeries. DESIGN: A retrospective study was approved by the institutional review boards at Ochsner Medical Center-Kenner and Louisiana State University Health Sciences Center. SETTING: Ochsner Medical Center-Kenner operating room and multispecialty NET clinic. PATIENTS: One hundred fifty consecutive patients who underwent a total of 179 cytoreductive surgeries for stage IV, small bowel NETs. INTERVENTIONS: All patients received a 500-µg/h infusion of octreotide acetate preoperatively, intraoperatively, and postoperatively. MEASUREMENTS: Anesthesia and surgical records were reviewed. Carcinoid crisis was defined as a systolic blood pressure of less than 80mm Hg for greater than 10minutes. Patients who experienced intraoperative hypertension or hypotension, profound tachycardia, or a "crisis" according to the operative note were also reviewed. MAIN RESULTS: One hundred sixty-nine (169/179; 94%) patients had normal anesthesia courses. The medical records of 10 patients were further investigated for a potential intraoperative crisis using the aforementioned criteria. Upon review, 6 patients were determined to have had a crisis. The final incidence of intraoperative crisis was 3.4% (6/179). CONCLUSIONS: A continuous high-dose infusion of octreotide acetate intraoperatively minimizes the incidence of carcinoid crisis. We believe that the low cost and excellent safety profile of octreotide warrant the use of this therapy during extensive surgical procedures for midgut and foregut NETs.

Enterobacter sakazakii in the mouths of stroke patients and its association with aspiration pneumonia.

BACKGROUND: Previous studies by our group have identified a high prevalence of Gram-negative bacilli in the mouths of stroke patients. Eradication of such organisms by selective decontamination of the digestive tract (SDD) has not previously been studied. Enterobacter sakazakii is a rarely found organism that has previously been identified as a cause of neonatal meningitis and sepsis but that has rarely been reported as a pathogen in older people. The purpose of this study was to look specifically for E. sakazakii in the mouths of stroke patients and to correlate its isolation with response to SDD gel and the presence of clinical complications such as pneumonia. METHODS: Following an acute stroke, 203 patients were recruited for the study and received placebo or SDD in a 50:50 ratio. Oral swabs were obtained on nine separate occasions and E. sakazakii was cultured from them. Clinical data were prospectively collected and analysed. RESULTS: E. sakazakii was identified in 7 of 203 patients. The organism was almost exclusively removed by SDD gel, but in those patients in whom an abnormal swallow was present, pneumonia was found in two of the four cases. CONCLUSION: E. sakazakii may colonise the mouths of acute stroke patients. Since SDD gel is not routinely administered to such patients, this organism may be implicated in patients who subsequently develop aspiration pneumonia.