Rainer J. Litz

Omega-3 fatty acids improve the diagnosis-related clinical outcome.

Objective:Supplementation of clinical nutrition with omega-3 fatty acid in fish oil exerts immune-modulating and organ-protective effects, even after short-term application. The aim of this study was to evaluate dose-dependent effects of parenteral supplementation of a 10% fish oil emulsion (Omegaven, Fresenius-Kabi, Bad Homburg, Germany) on diagnosis- and organ failure–related outcome. Design:Prospective, open label, multiple-center trial. Patients and Methods:A total of 661 patients from 82 German hospitals receiving total parenteral nutrition for ≥3 days were enrolled in this study. The sample included 255 patients after major abdominal surgery, 276 with peritonitis and abdominal sepsis, 16 with nonabdominal sepsis, 59 after multiple trauma, 18 with severe head injury, and 37 with other diagnoses. The primary study end point was survival; secondary end points were length of hospital stay and use of antibiotics with respect to the primary diagnosis and the extent of organ failure. Multiple quasi-linear and logistic regression models were used for calculating diagnosis-related fish oil doses associated with best outcome. Results:The patients enrolled in this survey were (mean ± sd) 62.8 ± 16.5 yrs old, with a body mass index of 25.1 ± 4.2 and Simplified Acute Physiology Score (SAPS) II score of 32.2 ± 13.6. Length of hospital stay was 29.1 ± 18.7 days (12.5 ± 14.8 days in the intensive care unit). Total parenteral nutrition, including fish oil (mean, 0.11 g·kg−1·day−1), was administered for 8.7 ± 7.5 days and lowered hospital mortality as predicted by Simplified Acute Physiology Score II from 18.9% (95% confidence interval, 17.4–20.4%) to 12.0% (p < .001). The fish oil dose·kg−1·day−1 did correlate with beneficial outcome (intensive care unit stay, hospital stay, mortality). Fish oil had the most favorable effects on survival, infection rates, and length of stay when administered in doses between 0.1 and 0.2 g·kg−1·day−1. Lower antibiotic demand by 26% was observed when doses of 0.15–0.2 g·kg−1·day−1 were infused as compared with doses of <0.05 g·kg−1·day−1. After peritonitis and abdominal sepsis, multiple quasi-linear regression models revealed a fish oil dose for minimizing intensive care unit stay of 0.23 g·kg−1·day−1 and an inverse linear relationship between dosage and intensive care unit stay in major abdominal surgery. Conclusion:Administration of omega-3 fatty acid may reduce mortality, antibiotic use, and length of hospital stay in different diseases. Effects and effect sizes related to fish oil doses are diagnosis dependent. In view of the lack of substantial study literature concerning diagnosis-related nutritional single-substrate intervention in the critically ill, the present data can be used in formulating hypotheses and may serve as reference doses for randomized, controlled studies, which may, for instance, confirm the value of omega-3 fatty acid in the adjunctive therapy of peritonitis and abdominal sepsis.

Reversal of Central Nervous System and Cardiac Toxicity After Local Anesthetic Intoxication by Lipid Emulsion Injection

A 91-yr-old man (57 kg, 156 cm, ASA III) received an infraclavicular brachial plexus block for surgery of bursitis of the olecranon. Twenty minutes after infraclavicular injection of 30 mL of mepivacaine 1% (Scandicain) and 5 min after supplementation of 10 mL of prilocaine 1% (Xylonest) using an axillary approach, the patient complained of agitation and dizziness and became unresponsive to verbal commands. In addition, supraventricular extrasystole with bigeminy occurred. Local anesthetic toxicity was suspected and a dose of 200 mL of a 20% lipid emulsion was infused. Symptoms of central nervous system and cardiac toxicity disappeared within 5 and 15 min after the first lipid injection, respectively. Plasma concentrations of local anesthetics were determined before, 20, and 40 min after lipid infusion and were 4.08, 2.30, and 1.73 microg/mL for mepivacaine and 0.92, 0.35, and 0.24 microg/mL for prilocaine. These concentrations are below previously reported thresholds of toxicity above 5 microg/mL for both local anesthetics. Signs of toxicity resolved and the patient underwent the scheduled surgical procedure uneventfully under brachial plexus blockade.

Omega-3 fatty acids improve liver and pancreas function in postoperative cancer patients.

Epidemiologic studies have indicated that high intake of saturated fat and/or animal fat increases the risk of colon and breast cancer. Omega‐3 PUFAs in fish oil (FO) can inhibit the growth of human cancer cells in vitro and in vivo. These effects are related to the uptake of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) into the cellular substrate pool and their competitive metabolism with arachidonic acid (AA) at the cyclooxygenase and 5‐lipoxygenase levels. The metabolites of EPA and DHA have less inflammatory and immunosuppressant potency than the substances derived from AA. Based on previous experimental data, we hypothesized that FO supplementation after major abdominal cancer surgery would improve hepatic and pancreatic function. Ours was a prospective, randomized, double‐blinded clinical trial on 44 patients undergoing elective major abdominal surgery, randomly assigned to receive total parenteral nutrition (TPN) supplemented with either soybean oil (SO 1.0 g/kg body weight daily, n = 20) for 5 days or a combination of FO and SO (FO 0.2 + SO 0.8 g/kg body weight daily, n = 24). Compared to pure SO supplementation in the postoperative period, FO significantly reduced ASAT [0.8 ± 0.1 vs. 0.5 ± 0.1 mmol/(l · sec)], ALAT [0.9 ± 0.1 vs. 0.6 ± 0.1 mmol/(l · sec)], bilirubin (16.1 ± 5.3 vs. 6.9 ± 0.6 mmol/l), LDH (7.7 ± 0.4 vs. 6.7 ± 0.4 mmol/(l · sec) and lipase (0.6 ± 0.1 vs. 0.4 ± 0.1 μmol/(l · sec) in the postoperative course. Moreover, patients with increased risk of sepsis (IL‐6/IL‐10 ratio >8) showed a tendency to shorter ICU stay (18 hr) under omega‐3 PUFA treatment. Weight loss as encountered after the SO emulsion of 1.1 ± 2.2 kg was absent in the FO group. After major abdominal tumor surgery, FO supplementation improved liver and pancreas function, which might have contributed to the faster recovery of patients.

Comparison of the American Society of Anesthesiologists Physical Status classification with the Charlson score as predictors of survival after radical prostatectomy

OBJECTIVES To compare the American Society of Anesthesiologists Physical Status (ASA) classification with the Charlson score in the radical prostatectomy setting. The ASA classification is a widely accepted way to evaluate perioperative risk. At present, the Charlson score is probably the most frequently used comorbidity measure to predict long-term survival after radical prostatectomy. METHODS A total of 444 consecutive patients were enrolled in this study. The ASA classification was obtained from the anesthesia chart, and the Charlson score was assigned based on conditions noted during the preoperative cardiopulmonary risk assessment or mentioned on the discharge document. Kaplan-Meier time-event curves and Mantel-Haenszel hazard ratios were estimated for comorbid (noncancer) and overall survival. RESULTS After a mean follow-up of 5.9 years, both classifications were able to predict comorbid and overall survival in dose-response patterns. The ASA classification was superior in terms of a clearer discrimination of the survival curves (lower P values, higher hazard ratios). Both classifications identified a high-risk group (ASA 3 and Charlson score 2 or more), but only the ASA classification sufficiently defined a low-risk group (ASA 1). CONCLUSIONS In experienced hands, the ASA classification is a promising tool to improve the classification of prognostic comorbidity in the radical prostatectomy setting and may be used as an alternative to the Charlson score.

Spinal Epidural Hematoma after Spinal Anesthesia in a Patient Treated with Clopidogrel and Enoxaparin

VON Willebrand’s Disease (vWD) is the most common inherited bleeding disorder in humans with an estimated incidence as high as 2–3% in the general population. Characterized by abnormal platelet interactions with the subendothelium or other platelets, the disease is caused by changes in the multimeric glycoprotein, von Willebrand’s Factor (vWF). Types 1 and 3 vWD are associated with relative or absolute quantitative defects in the protein, respectively. Type 1 vWD accounts for 70% of all cases and is likely to temporally improve in parturients as a result of an increase in vWF and factor VIII with pregnancy. Type 2 vWD has qualitative abnormalities and comprises 20–30% of all vWD diagnoses. A unique subtype, type 2B, accounts for less than 20% of all type 2 vWD and is characterized by an increased affinity of vWF for platelet glycoprotein Ib, resulting in spontaneous binding and clearance of both vWF and platelets. This feature allows type 2B, unlike most other vWD variants, to be exacerbated by pregnancy and to exhibit a poor or worsening response to desmopressin (DDAVP; Aventis, Bridgewater, NJ). We present the management of a parturient with type 2B vWD who had severe thrombocytopenia during the peripartum period.

Misplacement of a psoas compartment catheter in the subarachnoid space

Background and Objectives: This case report describes an unusual cause of misplacement of an indwelling catheter in the subarachnoid space after primary psoas compartment block in a patient undergoing total knee arthroplasty. Case Report: A 67-year-old woman presenting for total knee joint replacement received a combination of continuous psoas compartment block and sciatic nerve block. Neurostimulation and additional ultrasound guidance were used for identification of the lumbar plexus. After elicitation of a quadriceps motor response, a negative aspiration test, and an uneventful test dose, 20 mL ropivacaine 0.375% and 20 mL mepivacaine 1% were injected. Despite difficult ultrasound conditions because of intestinal air, local anesthetic spread was observed paravertebrally at the medial border of the psoas muscle as usual. A catheter was then advanced 7 cm through the insulated directional puncture needle. An additional sciatic nerve block was performed by using Labats approach. Ten minutes after injection unilateral sensory block was noted and surgery was started. After uneventful surgery, bilateral sensory block to the T4 level and complete motor block in both lower limbs was detected. A second aspiration test was negative, and an epidural block was suspected. For verification of the catheter tip location, a computed tomography scan with contrast dye was performed revealing catheter placement in the subarachnoid space. The catheter was removed and showed a kink about 7 cm from the tip. After regression of the neuraxial block, lumbar plexus block persisted for another 2 hours. Conclusion: An additional test dose via the catheter is recommended if the indwelling catheter is inserted after injection of the local anesthetics through the puncture needle. If epidural anesthesia occurs, an x-ray of the catheter is advisable because negative aspiration via catheter does not rule out subarachnoid catheter location.

Spinal-epidural hematoma following epidural anesthesia in the presence of antiplatelet and heparin therapy.

ANTIPLATELET drugs are widely used in various categories of patients 1 ; therefore, knowledge of their impact on coagulation is important for the patients perioperative care. The American Society of Regional Anesthesia and Pain Medicine does not consider antiplatelet drugs, by themselves, as risk factors for the development of spinal hematoma in patients having neuraxial blocks, but concurrent use of other medications that affect clotting mechanisms may increase the risk of bleeding complications. 2,3 We report a case of an epidural hematoma in a patient to whom low-molecular-weight heparin (LMWH) was administered perioperatively as prophylaxis against development of venous thromboembolism and who additionally had taken oral ibuprofen for pain relief on her own.

Combined anesthesia with epidural catheter. A retrospective analysis of the perioperative course in patients ungoing radical prostatectomy

ZusamenfassungPatienten, die sich einer radikalen Prostatektomie (rPE) einschließlich retroperitonealer Lymphadenektomie (rLA) unterziehen, haben aufgrund ihres Alters und ihrer Begleiterkrankungen ein erhöhtes perioperativen Risiko. Ziel dieser Untersuchung war es, den intra- und postoperativen Verlauf der standardisierten Operation rPE+rLA unter verschiedenen Anästhesieregimen zu analysieren.Krankenakten von 433 Patienten, die sich zwischen 1994 und 1999 in unserer Einrichtung einer rPE+rLA unterzogen, wurden retrospektiv ausgewertet. Die Patienten wurden nach dem durchgeführten Anästhesieverfahren eingeteilt:1. Allgemeinanästhesie (AA),2. Kombination lumbale Epiduralanästhesie (LEA)+AA,3. thorakale Epiduralanästhesie (TEA)+AA.Für die intra- und postoperative Katheteranalgesie wurden Bupivacain 0,25% oder Ropivacain 0,2%, 8–12 ml/h verwendet. Die Allgemeinanästhesie wurde als balancierte Anästhesie durchgeführt.Diese retrospektive Erhebung zeigt unter epiduraler Analgesie, gemessen an Tachykardien und hypertensiven Episoden, eine reduzierte intra- und postoperative Stressantwort, kürzere Extubationszeiten, früheres Wiedereinsetzen der gastrointestinalen Motilität ([h] AA: 50,6±11,1/ LEA: 39,3±13,6/ TEA:33,8±13,0), tendenziell selteneres Erbrechen und eine um einen Tag verkürzte Krankenhausverweildauer ([d] AA: 12,4±5,8/ LEA: 11,1±3,1/ TEA: 11,5±3,8). Dabei war unter TEA die Dauer der Anästhesiepräsenz im OP-Bereich vergleichbar mit AA ([min] AA: 222,9±43,5/ LEA: 238,2±41,8/ TEA: 227,0±46,2), und der Wachstationsaufenthalt verkürzt. Daneben war unter TEA die Anzahl der auffälligen postoperativen Thoraxröntgenbefunde reduziert. Zum Erreichen einer der TEA vergleichbaren Analgesie mussten unter LEA häufiger sensomotorische Blockaden, saO2-Abfälle und tendenziell eine höhere Anzahl kardialer Komplikationen in Kauf genommen werden.Gemessen an den von uns erhobenen Parametern stellt damit die Kombination einer Allgemeinanästhesie, insbesondere mit thorakaler Epiduralanalgesie ein sicheres und auch betriebswirtschaftlich effizientes anästhesiologisches Vorgehen bei radikalen Prostatektomien dar.AbstractPatients requiring radical prostatectomy (rPE), including retroperitoneal lymphadenectomy are often aged and have coexisting cardiopulmonary diseases, increasing the risk of perioperative complications. The aim of the present study was to evaluate our perioperative anaesthesiologic regimen over the last five years, in terms of safety and patients comfort.Records of 433 patients who underwent rPE between 1994 and 1999 in our hospital were retrospectively reviewed. Patients were divided in those who received:1. general anaesthesia (GA) alone,2. a combination of lumbar epidural anaesthesia (LEA)+GA or,3. thoracic epidural anaesthesia (TEA)+GA.General anaesthesia was performed as balanced anaesthesia, and epidural administered local anaesthetics were bupivacaine 0.25% or ropivacaine 0.2%, 8–12 ml/h.In terms of intra- and postoperative numbers of tachycardic and hypertensive episodes, a reduced stress response was observed under epidural anaesthesia (EA). Moreover, the weaning duration was shorter under EA and onset of gastrointestinal motility was found earlier ([h] GA: 50.6±11.1/ LEA: 39.3±13.6/ TEA:33.8±13.0). Furthermore, a trend to rarer phases of postoperative vomiting and a significant decrease of in hospital stay of about one day ([d] GA: 12.4±5.8/ LEA: 11.1±3.1/ TEA: 11.5±3.8) was observed. The duration of personnel binding in the OR did not differ significantly between GA and TEA ([min] GA: 222.9±43.5/ LEA: 238.2±41.8/ TEA: 227.0±46.2), but ICU stay was shortened under TEA. Besides this, TEA reduced the number of pathologic postoperative thorax-x-rays. Senso-motor blockades, decreases of SaO2 and cardiac complications were experienced more frequent under LEA as compared with TEA.Combination of GA and EA, especially TEA, appears to improve perioperative care of patients undergoing rPE, in terms of patients safety and comfort.

Renal Responses to Desflurane and Isoflurane in Patients with Renal Insufficiency

Background The most consistent risk factor for postoperative renal failure is poor preoperative renal function. Desflurane is not contraindicated in patients with renal disease, but the data regarding its effects on renal function in these patients are sparse. Methods Only patients with preexisting renal disease were recruited into the study. In 51 adults undergoing elective surgery, general anesthesia was maintained using randomly desflurane or isoflurane according to a standardized protocol. Creatinine, creatinine clearance, and blood urea nitrogen were measured pre- and postoperatively. Results The administered amounts of the inhaled anesthetic agents were 1.8 ± 2.1 minimum alveolar concentration hours (mean ± SD) of isoflurane (24 patients) and 2.2 ± 1.8 minimum alveolar concentration hours of desflurane (27 patients), respectively. No deterioration in renal parameters was noted when comparing the pre- and postoperative values between the groups and within the groups over time. Conclusion General anesthesia with desflurane or isoflurane did not aggravate renal impairment in patients with preexisting renal insufficiency.

Detailed analysis of Charlson comorbidity score as predictor of mortality after radical prostatectomy.

OBJECTIVES To investigate the prognostic significance of the individual conditions contributing to the Charlson comorbidity score in patients selected for radical prostatectomy. METHODS A total of 1910 consecutive patients who underwent radical prostatectomy from 1992 to 2004 were studied. The Charlson score and its contributing single conditions were analyzed, and the patients were stratified into 3 age groups. Comorbid (noncancer), competing (nonprostate cancer), and overall mortality were used as the study endpoints. Mantel-Haenszel hazard ratios and Kaplan-Meier survival curves were calculated. Comparisons were made using the log-rank test. RESULTS Eleven comorbid conditions were significant predictors of any type of mortality in the different age groups. Eight conditions (congestive heart failure, peripheral vascular disease, cerebrovascular disease, diabetes, hemiplegia, moderate or severe renal disease, diabetes with end organ damage, moderate or severe liver disease, and metastatic solid tumor) were significant predictors of overall mortality. Two conditions (moderate or severe renal disease and metastatic solid tumor) were significant predictors of overall mortality in patients <63 years old. Five conditions (myocardial infarction, congestive heart failure, hemiplegia, moderate or severe renal disease, and diabetes with end organ damage) were significant predictors in patients aged 63-69 years, and 3 (peripheral vascular disease, cerebrovascular disease, and moderate or severe liver disease) were significant in patients aged >or=70 years. CONCLUSIONS In patients selected for radical prostatectomy, the Charlson score can also predict the mortality risk in those >70 years of age. The selection for good risks alters, however, the prognostic weight of the individual comorbid diseases in this age group.