Association between early postoperative coagulation activation and peri-operative myocardial ischaemia in patients undergoing vascular surgery

We investigated the association of peri-operative myocardial ischaemia with activation of coagulation and endogenous fibrinolysis in patients undergoing vascular surgery. In 50 patients, continuous Holter monitoring was performed to assess peri-operative myocardial ischaemia and 12-lead electrocardiography was recorded preoperatively and 72 h postoperatively to assess myocardial infarction. Serial blood samples were drawn peri-operatively to determine the concentrations of fibrin monomers (for activation of coagulation), D-dimer (for endogenous fibrinolysis) and cardiac troponin T and I. Patients with myocardial ischaemia showed higher concentrations of fibrin monomers at 48 h, and higher concentrations of d-dimer preoperatively and at 24 and 48 h postoperatively. In patients with peri-operative myocardial ischaemia, strong positive correlations were observed between fibrin monomer and D-dimer concentrations at 15 min and 4 h postoperatively, and cardiac troponins at 15 min and at 4, 24, 48 and 72 h postoperatively. Early postoperative activation of coagulation and fibrinolysis is associated with peri-operative myocardial cell damage among patients who are at risk for, or have a history of, coronary artery disease plus peri-operative myocardial ischaemia.

Absorption of D(+)-xylose, cobalamin, and folic acid after autologic-allotopic ileum mucosa transplantation in beagles

BACKGROUND/PURPOSE

Ileum mucosa transplantation in a demucosed colon coat was developed as a new method for small bowel elongation. In an animal model, the authors investigated the absorptive capacity of the transplanted mucosa for D(+)-xylose, cobalamin (vitamin B12), and folic acid.

METHODS

Ileum mucosa was transplanted in a vascularized demucosed segment of transverse colon in 18 beagle dogs. The colon coat-ileum mucosa complex then was integrated in the ileal continuity. Absorptive capacity for D(+)-xylose, cobalamin, and folic acid was measured before and 4 weeks after transplantation. The results were compared and analyzed with the Students' t test for matched pairs. All determined blood values with P values less than.05 were considered to show a significant reduction in the absorptive capacity of the transplanted ileum mucosa.

RESULTS

Fifteen minutes after application there was no significant difference in the absorption of D(+)-Xylose and cobalamin between normal and transplanted ileum mucosa (P >.1). Absorption of folic acid in the transplanted segment was lower but not significant (P <.1). After 30 minutes D(+)-xylose and cobalamin again showed no difference between the absorptive capacity of normal and transplanted ileum mucosa (P >.1), whereas folic acid continued with the tendency toward an impaired absorption (P <.1). However, after 60 minutes, the difference of the absorptive capacity of the transplanted ileum mucosa was significant (P <.05) for folic acid. D(+)-xylose showed a tendency for an impaired uptake (P <.1), whereas absorption of cobalamin did not differ significantly after transplantation (P >.1).

CONCLUSIONS

Experimental autologic-allotopic ileum mucosa transplantation is a feasible new method for small bowel elongation in an animal model. Examination of the absorptive capacity of the transplanted ileum mucosa showed a normal uptake for cobalamin, while there was an impaired absorption of D(+)-xylose and folic acid.

Increased cytokine release by leucocytes in survivors of stroke at young age

BACKGROUND

Enhanced stimulus-induced release of pro-inflammatory cytokines by leucocytes may contribute to the pathogenesis of ischaemic stroke.

DESIGN

We investigated the lipopolysaccharide-induced release of interleukin-1beta (IL-1beta), IL-6, IL-8, and tumour necrosis factor-alpha (TNF-alpha) in whole blood from 20 patients with a history of ischaemic stroke under the age of 50, 20 patients with a history of cervical artery dissection (CAD) and 21 age- and sex-matched healthy control subjects.

RESULTS

Release of IL-8 was higher (P = 0.006) and release of TNF-alpha and IL-6 tended to be higher (P < 0.1) in young stroke patients than in control subjects. No increased release existed in CAD patients. Vascular risk factors or history of infection before stroke did not modify IL-8 production. A common T(250) --> A polymorphism in the IL-8 gene promotor was newly identified but did not correlate with the variability of IL-8 release. The C(260) --> T polymorphism in the gene of the monocytic LPS-receptor CD14--a risk factor for myocardial infarction--was not associated with increased cytokine release.

CONCLUSIONS

We conclude that high inducible release of IL-8--and possibly of TNF-alpha and IL-6--may contribute to the odds of ischaemic stroke in young adults.

[Microbiological and clinical effects of selective bowel decontamination in transthoracic resection of carcinoma of the esophagus and cardia]

INTRODUCTION

Surgical therapy of carcinoma of the esophagus or cardia by transthoracic esophageal resection is associated with a high morbidity in which nosocomial infections have a great importance. This study investigates the influence of prophylactic selective bowel decontamination on the course and results of transthoracic resection of the esophagus.

METHODS

Seventy patients with carcinoma of the esophagus and cardia were included in this prospective and partially randomized study at the University of Heidelberg. Twenty-five patients received prophylactically selective bowel decontamination with tobramycin, polymyxin B and amphotericin B. The treatment course was documented uniformly. In addition, microbiological screening was performed by swab examinations of nose, throat and anus, by urine and blood cultures, and the documentation of results of additional microbiological diagnostic studies.

RESULTS

Bacteriological screening confirmed a reduction in infectious agents and a change of their spectrum in the respiratory and digestive tract without an increase in multiresistant bacteria. Patients who received selective bowel decontamination had a lower infection rate, a shorter artificial respiration period and a shorter intensive care stay without statistically significant differences. The mortality rate was 4% vs 9% in the control group (95% confidence interval -0.172-0.116).

CONCLUSION

This study confirms the feasibility and microbiological effectiveness of selective bowel decontamination in the context of surgical therapy which is associated with a high nosocomial infection rate. The result of the clinical treatment seems slightly more favorable in the treatment group. Decisive are complications caused by surgery which fundamentally determine the clinical course and frequently cause infectious complications. The prophylactic use of selective bowel decontamination may be useful in patients with an increased risk of prolonged ventilation support or colon interposition but it is not to be generally recommended.

[Importance of intraoperative parathormone measurements in primary hyperparathyroidism with 5-gland hyperplasia]

While intraoperative parathormone measurements are mandatory for unilateral operations of primary hyperparathyroidism (pHPT), its value for treatment of parathyroid hyperplasia is regarded as insufficient. We report a case of a pHPT with hyperplasia of five glands, in which only the intraoperative analysis of parathormone detected the remaining fifth hyperparathyroid gland after extirpation of four enlarged parathyroid glands. We describe technical problems involved in the tests available today and how the results of the intraoperative parathormone test need to be interpreted. As several factors can influence the decrease in parathormone concentration, a kinetic analysis may be more accurate in assessing the adequacy of resection. Therefore, intraoperative parathormone measurements are especially useful and important for adequate surgical therapy for pHPT with parathyroid hyperplasia.

Predictive value of serum interleukin-6 and -8 levels in preterm labor or rupture of the membranes

BACKGROUND

The aim of this prospective study was to examine if serum concentrations of cytokines are of value in the identification of patients at risk for preterm delivery.

METHODS

Interleukin- 1beta,2,4,6,8 and tumor necrosis factor alpha were determined between 25 and 37 weeks of gestation in the serum of 72 consecutive patients with preterm labor, 38 patients with preterm rupture of the membranes, and 24 healthy pregnant women as a control group. Material was collected within 18 hours after hospitalization and was immediately centrifuged and shock frozen.

RESULTS

Significantly increased serum levels were found for interleukin-6 and -8 in patients with preterm labor or preterm rupture of the membranes when compared to the control group (p<0.001 and p<0.005, respectively). In patients with preterm rupture of the membranes and interleukin-6 levels above the median of 4.0 pg/ml the delivery occurred significantly earlier than in patients with lower levels (1 versus 5.5 days; p=0.005). Patients of both pathology groups with detectable (>18 pg/ml). Interleukin-8 levels had a shorter pregnancy duration when compared to other patients (p=0.05 for preterm labor and p=0.04 for preterm rupture of the membranes). Interleukin-1beta,2,4, and tumor necrosis factor alpha were not correlated with clinical outcome.

CONCLUSIONS

Increased serum interleukin-6 and -8 levels are associated with a shorter interval between onset of preterm rupture of the membranes and delivery and should therefore be further evaluated for their use in clinical practice.

Effects of restorative proctocolectomy on renal and adrenal function

PURPOSE

Restorative proctocolectomy is a standard procedure in the surgical treatment of ulcerative colitis and familial adenomatous polyposis. The radical removal of the colorectum with construction of an ileostomy often results in high stoma losses. These may lead to changes in the electrolyte and acid-base balance and to alterations in renal and suprarenal gland function.

METHODS

In this study 33 patients who received an ileoanal pouch before and after proctocolectomy were investigated at different time intervals for electrolyte changes, alteration of the acid-base balance, kidney function, and hormonal changes of the suprarenal glands. Measurements were performed before proctocolectomy, ten days after proctocolectomy with ileal pouch-anal anastomosis under protective loop ileostomy, before ileostomy closure, and 6 to 12 months after ileostomy closure. Neither acute renal failure nor other vital complications were observed.

RESULTS

Statistical analysis showed a significant decrease of urine pH to 5.4 +/- 0.22 (before ileostomy closure) and metabolic acidosis (pH 7.32 +/- 0.04; base excess -1.3 +/- 5.6 (before ileostomy closure)). Likewise, we found a decrease in renal clearance to 86 ml/minute (before ileostomy closure) without signs of tubular damage. The most important change during the phase with ileostomy was a functional secondary hyperaldosteronism with aldosterone levels of 63.2 +/- 70.8 ng/dl (before ileostomy closure). In comparison with preoperative levels, there was a ten-fold increase in mineralocorticoid adrenal activity. Additionally, during the period with protective ileostomy, the hepatic synthesis of aldosterone-18-glucuronide was only slightly increased, and the cortisol/cortisone ratio was extremely decreased.

CONCLUSIONS

These results show that restorative proctocolectomy with ileal pouch-anal anastomosis and protective loop ileostomy significantly influences fluid, electrolyte, and acid-base balance. Functional secondary hyperaldosteronism is of central importance for subsequent renal recompensation. Approximately one-half year after ileostomy closure, the endogenous hormones with mineralocorticoid effects returned to normal levels.

[A method for reducing the risk of infection in newborn and premature infants with stomas]

Prematures and neonates with stomas have a high risk of developing sepsis by bacterial translocation, particularly when combined with parenteral nutrition. We studied a group of 35 newborns where split ileo- or jejunostomas were implanted in their first week of life. To prevent the development of a non-used distal bowel and a short bowel syndrome, the proximal bower content was transferred into the aboral stoma via the new continuous extracorporal stool transport (CEST) technique a few days after surgery. By using CEST the sepsis rate was reduced from 9 (without CEST) to only 0.8 cases of sepsis in 1000 days.

Blood cell damage after in vitro irradiation of fresh whole blood with 630 nm laser light

A study on blood cell damage after irradiation of fresh whole blood with 630 nm laser light was carried out in vitro. Various fluence rates of laser light were used with and without cooling of blood. Damage to the blood was assessed by blood cell counts, osmotic fragility measurements and examination of blood films. Exposure of a 1 mm blood layer to 630 nm laser light without cooling led to changes in blood counts first detected at fluence rates of 130 mW/cm2. Changes in osmotic fragility first became evident at 210 mW/cm2. Increasing cell damage with increasing fluence rates was evident in blood films. Using the cooling device changes in whole blood after irradiation first occurred at a fluence rate of 293 mW/cm2. Measurement of the fluence rates at which cell damage begins is important in laser induced fluorescence diagnostics and photodynamic therapy applications in blood or blood products using photosensitizers.

Effects of standard unfractionated and low-molecular-weight heparins on platelets of patients undergoing total hip replacement surgery

For prevention of venous thromboembolism in general and in orthopedic surgery, patients are treated prophylactically with standard unfractionated heparins (SH) or with low-molecular-weight heparins (LMWH). Patients (n = 22) undergoing total hip replacement surgery received either 5,000 IU SH (Heparin-Na) three times per day (n = 10 patients) or LMWH (Fraxiparin) once per day (n = 12 patients). Blood samples using CTAD (citrate, theophylline, adenine, dipyridamole) as anticoagulant were collected perioperatively after the first heparin administration, after the operation, and daily until day 4 postoperatively. After cooling at 4 degrees C blood samples were centrifuged, platelet-rich plasmas (PRPs) prepared, and after platelet counting PRPs were divided into platelet sediments (PS) and platelet-poor plasmas (PPP). Cyclic adenosine monophosphate (cAMP), cyclic guanosine monophosphate (cGMP), serotonin, P-selectin, and laminin were analyzed in PPP and in PS after two freezing/thawing cycles. Platelet serotonin contents and serotonin release did not differ in either heparin group (SH and LMWH). In the LMWH group, 72 h postoperatively the intraplatelet cAMP was significantly (p < 0.01) higher. P-selectin values in PPP and platelet P-selectin release did not vary between the SH and the LMWH group; on the contrary, the platelet P-selectin content increased in the LMWH group 72 and 96 h postoperatively, while in the SH group this parameter showed a small decrease. The differences were significant (p < 0.05). The platelet-bound laminin underwent a slight change 48 and 72 h postoperatively in the LMWH group, but in the SH group the platelet-bound laminin increased permanently and significantly (p < 0.05; p < 0.01) until 72 h postoperatively, but 96 h postoperatively there was a small decline. In the SH group, 24-96 h postoperatively the platelet-bound laminin was significantly (p < 0.05; p < 0.005) augmented, compared with the LMWH group. The higher cAMP and P-selectin contents in the LMWH group suggest that platelets are less impaired by LMWH, and the augmented platelet-bound laminin in the SH group could express the platelet impairment evoked by standard unfractionated heparins.

Pharmacokinetics of a new microemulsion formulation of cyclosporin A (Neoral) in young patients after renal transplantation

Pharmacokinetics of the new galenic formulation of cyclosporin A, Neoral, (Sandoz) was examined in 12 stable young patients after renal transplantation. Six of these patients were tested before and 4 weeks after switching from the standard formulation Sandimmun to Neoral. No significant changes were observed in trough levels, Lmax, Cmax, and AUC0-12 h, but the absorption rate constant (Ka) increased (P = 0.03). Glomerular filtration rate, as assessed by inulin clearance, increased by more than 10% in three patients and decreased in two, and was usually associated with a respective drop and rise in Cmax and AUC0-12 h of cyclosporin A. The large interindividual variability in the response to the conversion to the new formulation points to a need for close monitoring of cyclosporin A trough levels and renal function after switching from Sandimmun to Neoral in this age group in order to avoid nephrotoxicity.

Platelet factor 4 release in patients undergoing cardiopulmonary resuscitation--can reperfusion be impaired by platelet activation?

BACKGROUND

Reperfusion following cardiac arrest is associated with a marked activation of blood coagulation. This seems to be associated with microcirculatory reperfusion disorders. The present study was designed to investigate the possible involvement of platelets in reperfusion injury following cardiac arrest. Plasma levels of platelet factor 4 (PF 4) were used as an indicator for in vivo platelet activation because PF 4 is known to be released from platelets during aggregation.

METHODS

Plasma PF 4 levels (normal range: < 5IU/mL) were measured in 18 patients at predetermined time points during cardiopulmonary resuscitation (CPR). In the case of restoration of spontaneous circulation, additional blood samples were analyzed until seven days after stabilization. The PF 4 levels of four sex-matched volunteers were used as controls.

RESULTS

The median of the maximum individual PF 4 levels measured during CPR was 27.5 IU/mL (range 1.2 to 90 IU/ liter; P < 0.01 versus controls). Compared with PF4 levels in control volunteers (median: 0.35 IU/mL; range 0.2 to 0.6 IU/ liter), PF 4 levels were significantly elevated in patients during CPR and in the early phase until 24 hours after restoration of spontaneous circulation (P < 0.05).

CONCLUSION

A marked increase in PF 4 levels was observed during CPR and in the early phase after cardiac arrest in man. This increase in PF 4 levels has to be viewed as an indicator of platelet activation, which may play a role in the etiology of reperfusion injury and microcirculatory reperfusion disorders occurring after cardiac arrest.

Activation of blood coagulation after cardiac arrest is not balanced adequately by activation of endogenous fibrinolysis

BACKGROUND

Animal studies have demonstrated that hemostatic disorders occurring after cardiac arrest affect outcome. We investigated hemostatic changes during and after cardiopulmonary resuscitation (CPR) in humans.

METHODS AND RESULTS

The prospective study included 23 patients (29 to 86 years) who underwent out-of-hospital CPR for nontraumatic causes. Blood samples were drawn immediately and 15 and 30 minutes after initiation of CPR. In the case of restoration of spontaneous circulation (ROSC; n = 7), additional blood samples were taken immediately, 30 minutes, and 2, 8, 24, 48, and 72 hours after ROSC. A marked activation of blood coagulation was found in all patients. The specific markers of activated blood coagulation and fibrin formation, thrombin-antithrombin complex (TAT; median during CPR, 260 micrograms/L; median after ROSC, 57 micrograms/L; normal range, 1.0 to 4.1 micrograms/L), and fibrin monomers (FM; median during CPR, 34.3 micrograms/mL; median after ROSC, 65.4 micrograms/mL; normal range, 0 to 3.6 micrograms/mL) were markedly increased during and in the early phase after CPR. When patients survived for 48 hours, TAT and FM values returned to the normal range. In most patients, the plasma levels of D-dimer, an indicator of endogenous fibrinolytic activity, were not markedly increased during CPR (median, < 0.25 microgram/mL; normal range, < 0.25 microgram/mL) but increased moderately after ROSC (median, 0.56 microgram/mL). Levels of plasminogen activator inhibitor type 1 (normal range, 0.3 to 3.5 U/mL), a marker for endogenous inhibition of fibrinolytic activity, were moderately increased in most patients (median during CPR, 4.22 U/mL; median after ROSC, 8.08 U/mL).

CONCLUSIONS

Our data clearly demonstrate that there is a marked activation of blood coagulation and fibrin formation after prolonged cardiac arrest and CPR in humans that is not balanced adequately by concomitant activation of endogenous fibrinolysis. These changes may contribute to reperfusion disorders, such as the cerebral "no-reflow" phenomenon, by inducing fibrin deposition and formation of microthrombi.

[Successful use of a heparinoid (danaparoid sodium) for heparin-induced thrombocytopenia type II in aortic valve reoperation]

The 29-year-old, heroin-addicted patient received an aortic valve prosthesis (SJM) 10 years ago because of aortic valve stenosis III. One year after surgical treatment he refused to take Phenprocoumon and thus received no anticoagulation for 9 years. The patient was hospitalized due to cardial decompensation and thrombosis of the aortic valve prosthesis was diagnosed. Under heparinization, he developed heparin-induced thrombocytopenia type II, which disappeared after changing the medication to Danaparoid-Sodium. In order to avoid any further heparin exposure, we also carried out the surgical replacement of the aortic valve prosthesis under anticoagulation with Danaparoid-Sodium.