Comparison of the effect of two dose schedules of oral omeprazole with oral ranitidine on gastric aspirate pH and volume in patients undergoing elective surgery

We have compared gastric aspirate pH and volume at induction of anaesthesia in 222 patients who had received either omeprazole or ranitidine before elective operations. Omeprazole was given orally either as 40 mg on the evening before and 40 mg on the morning of surgery or as 80 mg on the morning of surgery. Ranitidine 150 mg was given orally on the evening before surgery and 2 h before anaesthesia. Treatment success was defined as aspirate pH > or = 2.5 and volume < 25 ml at induction of anaesthesia. Treatment was successful in 84% (95% confidence interval (CI) 73-91%) of patients in the omeprazole 40 + 40 mg group, 84% (95% CI 73-91%) in the ranitidine group and 73% (95% CI 61-83%) in the omeprazole 80 mg group. There were no statistically significant differences between the groups. Twelve patients in the omeprazole 80 mg group had gastric pH < 2.5 and four had volume > 25 ml. Only three patients had a gastric pH < 2.5 in the omeprazole 40 + 40 mg group and none had volume > 25 ml, which compared well with the ranitidine group. Omeprazole, given as 40 mg in the evening and 40 mg on the morning of operation, has a potential role for use in patients at risk for aspiration during general anaesthesia.     

Effects of oral rabeprazole on oesophageal and gastric pH in patients with gastro-oesophageal reflux disease

BACKGROUND: This study examined the dose-response effects of the new proton-pump inhibitor rabeprazole on oesophageal and gastric pH in patients with gastro-oesophageal reflux disease. METHODS: This study had a single-centre, double-blind, randomized, two-way crossover design. Twenty patients were treated for two 7-day periods separated by a 7-10-day washout period. Patients were randomly assigned to receive either 20 mg of rabeprazole once daily during the first treatment period and 40 mg once daily during the second treatment period, or 40 mg during the first treatment period and 20 mg during the second treatment period. The primary efficacy variable was oesophageal acid exposure determined by 24-hour ambulatory pH monitoring. Acid-reflux time was defined as the percentage of time over 24 h that oesophageal pH was < 4. A dosage was considered effective if reflux time was reduced to < 6%, a number which has been our internal laboratory reference. RESULTS: Both rabeprazole 20 mg and 40 mg, given once daily, normalized reflux time, with decreases of 79% and 92% in acid exposure by day 7. Both dosages also decreased the mean total number of reflux episodes and the number of episodes lasting > 5 min, with no significant differences between dosages for any reflux parameter. Mean gastric pH increased with 20 mg from 1.86 at baseline to 3.71 on day 1 and 4.17 on day 7. Rabeprazole 40 mg once daily increased gastric pH from 2.01 to 4.37 on day 1, and to 4.65 on day 7. Safety analyses revealed no significant acute side-effects for either dosage. CONCLUSIONS: Pathological oesophageal acid exposure was normalized with both 20 mg and 40 mg dosages of rabeprazole, and the effects of these two doses did not differ. Rabeprazole was well-tolerated in this short-term study.     

Immunonutrition in gastric cancer surgical patients

The aim of this study was to evaluate the potential advantages of perioperative versus postoperative administration of an enteral immune-enhancing diet on host defense and protein metabolism. Thirty subjects, candidates for gastrectomy for cancer, were randomly allocated into two groups. The first group (n = 15) received an enteral formula enriched with arginine, omega-3 fatty acids, and RNA 7 d before and 7 d after surgery; the second group (n = 15) received the same diet but only 7 d after surgery. Postoperative immune and inflammatory responses were investigated by phagocytosis ability of polymorphonuclear cells, interleukin-2 receptors (IL-2R), lymphocyte subsets, interleukin-6 (IL-6), and delayed hypersensitivity response (DHR). Prealbumin (PA), retinol binding protein, albumin, and transferrin were determined as protein synthesis indicators. Perioperative immunonutrition prevented the early postoperative impairment of phagocytosis, DHR, total number of lymphocytes, and CD4/CD8 ratio (P < 0.05 versus postoperative group). The IL-2R levels were significantly higher in the perioperative group (P < 0.05 versus postoperative on postoperative day [POD] 4 and 8). Perioperative group also showed lower levels of IL-6 (P < 0.05 versus postoperative on POD 1, 4, and 8) and higher levels of PA (P = 0.04 versus postoperative on POD 8). The perioperative administration of immunonutrition ameliorated the host defense mechanisms, controlled the inflammatory response, and improved the synthesis of short half-life constitutive proteins.     

The pharmacokinetics of acetyl starch as a plasma volume expander in patients undergoing elective surgery

Acetyl starch (ACS) is a new synthetic colloid solution for plasma volume expansion and is now undergoing phase 2 clinical trials. We compared the pharmacokinetics of ACS with those of hydroxyethyl starch (HES) in 32 patients (ASA physical status I and II) undergoing elective surgery. In this randomized, double-blind trial, patients received either 15 mL/kg ACS 6% (average molecular weight [Mw] 200,000/molar substitution [MS] 0.5) or HES 6% (Mw 200,000/MS 0.5) i.v. up to a maximal dose of 1000 mL. Plasma colloid concentrations were measured by repetitive arterial blood sampling over 24.5 h. Plasma colloid concentrations were detected using a high-pressure liquid chromatography controlled enzymatic test. Standard pharmacokinetics were calculated, including initial half-life (t(1/2init)), i.e., the time required for a 50% decline of the maximal plasma colloid concentration at the end of drug infusion. Whereas HES was eliminated by second-order kinetics, ACS followed first-order characteristics. In the first hours after i.v. administration, t(1/2init) and clearances were similar in both groups. However, the terminal half-life of HES was significantly longer than that of ACS (9.29 +/- 1.43 h vs 4.37 +/- 1.06 h). After 16.5 and 24.5 h, ACS showed significantly lower plasma concentrations than HES, which indicates that the final degradation of ACS by esterases and amylase was significantly more rapid. ACS might be an alternative plasma volume expander, which avoids the accumulation of persisting macromolecules. Implications: We studied the pharmacokinetics of acetyl starch, a newly developed colloid solution for plasma volume substitution, compared with hydroxyethyl starch in 32 surgical patients undergoing elective major general surgical procedures. In contrast to hydroxyethyl starch, this new agent undergoes rapid and nearly complete enzymatic degradation.     

Implementation of guidelines for preoperative laboratory investigations in patients scheduled to undergo elective surgery

OBJECTIVE: To assess the impact on preoperative laboratory investigations in elective surgery after the implementation of guidelines for ordering such tests. DESIGN: A retrospective chart audit. SETTING: A university teaching hospital. PATIENTS: The charts of 903 patients who underwent an elective surgical procedure from each surgical specialty except cardiovascular and thoracic. INTERVENTIONS: Implementation of guidelines for preoperative laboratory investigations. MAIN OUTCOME MEASURES: Impact on the preoperative use of laboratory investigations after implementation of the guidelines as well as patient morbidity and mortality. RESULTS: The mean number of preoperative laboratory investigations done per patient decreased from 4.65 before implementation of the guidelines to 4.18 after (p < 0.001). There was no apparent adverse impact on patient morbidity or mortality. CONCLUSION: Implementation of guidelines for preoperative laboratory investigations for elective surgery resulted in a reduction in the number of tests without adverse impact on patient morbidity or mortality.     

Deconjugation ability of bacteria isolated from the jejunal fluid of patients with progressive systemic sclerosis and its gastric pH

BACKGROUND/AIMS: Our goal was to demonstrate the role of bacteria in altered bile acid metabolism, which overgrow in the upper small intestine of patients with progressive systemic sclerosis. We identified the bacterial species, isolated from the jejunal fluid obtained from patients with progressive systemic sclerosis, who had previously shown an increase in 14CO2, specific activity on breath test, and normal controls. After which, we investigated the deconjugation ability of the isolated bacteria and the relationship between 14CO2, specific activity and gastric pH. METHODOLOGY: Bile acid breath tests were performed on 12 patients, and 19 normal controls using 5 microCi of oral glycine-1-(14)C-labeled glycocholate. Jejunal fluid was aspirated through a double lumen-tube with a rubber cover on the tip. Deconjugation ability was examined by thin-layer chromatography using conjugated bile acids in ox gall. RESULTS: The following species were identified in jejunal fluid samples obtained from patients: Bacteroides vulgatus, Eubacterium lentum, enterococcus, Lactobacillus bifidus, Escherichia (E) coli, Aerobacter (A) aerogenes. Except for E. coli and A. aerogenes, these species were capable of hydrolyzing conjugated bile acids in ox gall. The administration of chloramphenicol (1 g orally per day for 14 days in divided doses) significantly reduced the 14CO2, specific activity (p<0.05) in the patients with progressive systemic sclerosis. On the other hand, nineteen healthy control subjects demonstrated no increase in CO2 excretion, and 16 of the 19 had no bacteria isolated from jejunal fluid. The remaining healthy man showed an overgrowth of E. coli and Pseudomonas (P) aeruginosa, but the E. coli and P. aeruginosa did not have the ability of deconjugation. CO2 specific activity of expired breath samples in the patients with progressive systemic sclerosis was correlated with gastric pH (n=12, r=0.588, p<0.05). CONCLUSIONS: Our results demonstrated that some of the bacterial species that overgrow in the upper small intestine of patients with progressive systemic sclerosis can deconjugate bile acids, and that a shift to neutral pH in gastric juice, may promote the bacterial overgrowth related to their impaired peristaltic activity.     

The effects of prostacyclin on gastric intramucosal pH in patients with septic shock

OBJECTIVE: To investigate whether infusing prostacyclin (PGI2) in patients with septic shock improves splanchnic oxygenation as assessed by gastric intramucosal pH (pHi). DESIGN: Interventional clinical study. SETTING: Surgical ICU in a university hospital. PATIENTS: 16 consecutive patients with septic shock according to the criteria of the ACCP/SCCM consensus conference all requiring norepinephrine to maintain arterial blood pressure. INTERVENTIONS: All patients received PGI2 (10 ng/kg x min) after no further increase in oxygen delivery could be obtained by volume expansion, red cell transfusion and dobutamine infusion. The results were compared with those before and after conventional resuscitation. The patients received continuous PGI2 infusion for 33-32 days. MEASUREMENTS AND RESULTS: O2 uptake was measured directly in the respiratory gases, pHi was determined by tonometry. Baseline O2 delivery, O2 uptake and pHi were 466 +/- 122 ml/min.m2, 158 +/- 38 ml/min.m2, and 7.29 +/- 0.09, respectively. While O2 uptake remained unchanged, infusing PGI2 increased O2 delivery (from 610 +/- 140 to 682 +/- 155 ml/min.m2, p < 0.01) and pHi (from 7.32 +/- 0.09 to 7.38 +/- 0.08, p < 0.001) beyond the values obtained by conventional resuscitation. While 9 of 11 patients with final pHi > 7.35 survived, all patients with final pHi < 7.35 died (p < 0.01). CONCLUSIONS: Infusing PGI2 in patients with septic shock increases pHi probably by enhancing blood flow to the splanchnic bed and thereby improves splanchnic oxygenation even when conventional resuscitation goals have been achieved.     

The role of echocardiography in preoperative diagnosis of cardiac risk in patients before non-cardiac surgical interventions

Echocardiography is a noninvasive method for cardiac evaluation. A review of the current literature shows that the routine use of echocardiography for assessing perioperative cardiac risk in patients undergoing noncardiac surgery can not be supported. Only patients with suspected relevant heart valve diseases, acute heart failure, cardiomyopathy or condition after heart or heart-lung transplantation may benefit from preoperative echocardiography. In patients with suspected or proven coronary artery disease stress echocardiography offers the most relevant additional information for the anaesthesiologist. However, because of the high financial and personal implications it should be reserved to those patients who are not able to perform a normal stress test. Besides in patients in whom transthoracic echocardiography doesn't offer sufficient information or is not possible transesophageal echocardiography plays only a minor role in preoperative cardiac evaluation.     

Correlation between preoperative mouth opening and surgical outcome after arthroscopic lysis and lavage in patients with disc displacement without reduction

PURPOSE: This study was designed to evaluate the efficacy of arthroscopic lysis and lavage for patients with limited mouth opening. The relationship between preoperative mouth opening and the surgical outcome was determined. METHOD: Fourteen patients with 16 internally deranged joints were treated by arthroscopic lysis and lavage. All had received 10.4 (7 to 19) months of nonsurgical treatment before arthroscopy. The preoperative magnetic resonance images showed anterior disc displacement without reduction in all treated joints. RESULTS: Twelve of the 14 patients (86%) showed good reduction in pain and improved range of jaw movement on average follow-up of 28.5 (13 to 66) months. Two patients showed no improvement after arthroscopy and required open surgical procedures. The preoperative mouth opening of the successful group averaged 29.4 (22 to 35) mm, whereas the two failed cases had 10- and 19-mm openings, respectively (P < .05). CONCLUSION: Persistent limitation of mouth opening of more than 22 mm after nonsurgical treatment has a good prognosis when treated by arthroscopic lysis and lavage. However, those with greater limitation should probably have earlier surgical intervention.     

Measurement of extracellular fluid volume in patients on maintenance hemodialysis

Angiosarcoma of the breast, a rare tumor with very poor prognosis and insidious early manifestations, frequently is far advanced when first detected clinically. The clinical and pathologic changes in two women with primary, unilateral angiosarcoma of the breast are reviewed and the results are compared with 46 cases already published in the literature. Both patients were middle aged with symptoms for approximately 6 months prior to operation. Both frozen section reports were benign and only called malignant on permanent section. Microscopically the tumors were composed of varying sized, tortuous, elongated vascular channels. The operation varied--a modified radical and a simple mastectomy--and both patients are free from disease 4 and 2 years following operation. It is considered that, in view of the proclivity of this tumor for hematogenous metastases, an axillary dissection may not be justified.     

Food intake after gastrectomy for gastric carcinoma: the role of a gastric reservoir

Patients with carcinoma of the stomach who underwent curative resection were randomized to total gastrectomy (n = 49), total gastrectomy and an S-shaped gastric substitute (n = 28) or subtotal gastrectomy (n = 12); all had a Roux-en-Y reconstruction. The gastric substitute and gastric remnant allowed a volume of 400-500 ml to be installed without increments in basal pressures. The corresponding volume in the Roux limb was 100 ml. Energy intake was approximately 120 kJ/kg preoperative weight per day 3 months after operation, and then remained constant. Patients who had subtotal gastrectomy ate less (91.7 kJ/kg preoperative weight) 3 months after operation, but thereafter increased their intake. Patients allocated to have a gastric pouch or subtotal gastrectomy complained more frequently of adverse postprandial symptoms (P < 0.03) as a major cause of reduced calorie intake. The construction of a gastric reservoir did not improve nutritional adaptation after surgery for gastric carcinoma.     

Comparison of gastric mucosal pH and clinical judgement in critically ill patients

OBJECTIVES: To compare gastric tonometry (pHi) with estimates of pHi in ill injured patients, and to correlate pHi with haemodynamic variables. DESIGN: Prospective, non-interventional study. SETTING: ICU of Level I trauma centre, USA. MAIN OUTCOME MEASURES: 154 gastric tonometry measurements were compared with physicians' estimates of adequacy of resuscitation. Resuscitation was categorised as inadequate (pHi < 7.35) or adequate (pHi> or = 7.35). Measured and estimated pHi were also compared with oxygen delivery, oxygen consumption, cardiac index, mixed venous O2 saturation, and critical illness scores. RESULTS: Estimated pHi was often higher than measured pHi in the judgement of all four surgical intensive care physicians. Measured pHi correlated positively with mixed venous O2 tension (r = 0.21). There were significant negative correlations between measured pHi and both oxygen delivery (r = -0.25) and oxygen consumption (r = 0.28). Estimated pHi correlated positively with mean arterial pressure (r = 0.21) and hospital day (r = 0.26); it correlated negatively with pulmonary arterial elastance (r = -0.35). CONCLUSION: Experienced intensive care physicians tended to overestimate visceral perfusion, which suggests that gastric tonometry adds useful information over and above routine haemodynamic indices. Arterial blood pressure and mixed venous oxygen saturation correlated better with measured pHi than with other indices of perfusion.     

Endotoxemia after elective surgery for abdominal aortic aneurysm and the effect of early oral feeding

BACKGROUND: Endotoxemia after major vascular surgery has been suggested to be caused by the passage of bacterial endotoxins through the gut. Early enteral feeding has been reported to prevent bacterial translocation. Therefore, we investigated the incidence of endotoxemia in 12 patients with normal liver function after elective surgery for abdominal aortic aneurysm. METHODS: Blood samples were taken from the brachial vein of each patient before surgery, 1 day after surgery, and 3 days after surgery. The endotoxin concentration was measured using a chromogenic endotoxin-specific assay. RESULTS: The endotoxin concentration was significantly higher one day after surgery (2.15+/-1.36 pg/ml) than that before surgery (1.27+/-1.00 pg/mL), (p<0.05). The mean endotoxin concentration in the patients after early oral feeding (0.74+/-0.74 pg/ml) was significantly lower than that in the patients who could not eat (1.58+/-0.48 pg/ml). CONCLUSIONS: A low concentration of systemic endotoxins can be observed after surgery for abdominal aortic aneurysm, and early oral feeding prevented this elevation.     

Measurement of extracellular fluid volume and blood volume in sheep

Methods are described for the simultaneous measurement of extracellular fluid volume (ECFV) and plasma volume (PV) in sheep using dilution of 82Br (as sodium bromide) and 131I-labelled ovine gamma globulin. Following injection of 82Br (100 micronCi), equilibrium in blood was reached after 3 h at which time only 4% of the injected dose was in rumen water. The ECFV was measured as the mean of the 2- and 3-h bromide space after correction for the relative water content of plasma, the Gibbs-Donnan factor and the loss of 82Br into red blood cells. 131I-labelled ovine gamma globulin (20 micronCi) was injected after the 3-h 82 Br space was obtained and blood samples were taken at 10, 20, 30 and 40 min. In 16 determinations in 11 sheep (25-47 kg body weight) the mean (+/- s.e.m.) ECFV was 9112 +/- 289 ml (or 245 +/- 9 ml/kg). The mean PV for 16 observations in 11 sheep measured together with ECFV was 1597 +/- 62 ml (or 42-8 +/- 1-8 ml/kg). Although there was no relationship between body weight and PV there was a significant correlation between ECFV and body weight and also significant negative correlations between body weight and ECFV or PV when these were expressed as a function of body weight. The variation in ECFV measured on four occasions over 7-10 days in four sheep was 3-5% (range 2-6-4-6%). For PV measured in two animals on two consecutive days at the same time as ECFV the coefficient of variation was 1-5 and 2-1%. Acute sodium depletion (250-670 mmol) by parotid duct cannulation in three sheep resulted in a fall in ECFV which would account for only 15-20% of the sodium deficit. The remainder is presumably derived from ruminal sodium stores.     

Risk factors for major thromboembolism and bleeding tendency after elective general surgical operations. The Fragmin Multicentre Study Group

OBJECTIVE: To elucidate those factors that contribute to the risk of major postoperative thromboembolism and perioperative bleeding tendency. DESIGN: Retrospective multiple logistic regression analysis. SETTING: 7 Scandinavian hospitals (6 Swedish and 1 Norwegian). SUBJECTS: 2070 patients undergoing elective major abdominal surgery. INTERVENTIONS: Patients were randomised to receive 2500 or 5000 XaI units of low molecular weight heparin daily. MAIN OUTCOME MEASURES: Major thromboembolism (proximal deep vein thrombosis confirmed by phlebography or necropsy, or pulmonary embolism confirmed by scintigraphy or necropsy, or both). Bleeding tendency (bleeding complications which were not explained by local haemorrhagic lesions or by coexisting disease). RESULTS: Previous thromboembolism, leg fracture or arthroplasty, present leg ulcer or malignant disease, operating time longer than 150 minutes, preoperative transfusion of 2 or more units, and preoperative hospital stay of 6 days or more (but not age, body weight, or varicose veins) were independent predictors for major postoperative thromboembolism. The risk was significantly increased with an increasing number of such risk factors. The risk of developing a diffuse bleeding complication was dependent on the dose of low molecular weight heparin, particularly in patients without risk factors. CONCLUSIONS: The use of a narrow definition of thromboembolism lead to a pattern of risk factors which was partly different from that found in previous studies, which were usually based on diagnosis with the 125I-fibrinogen uptake test.     

Escape from deficits in sodium intake after thalamic lesions as a function of preoperative experience.

Saline and water intakes in response to treatments with a natriuretic agent and a mineralocorticoid were studied in intact Sprague-Dawley male rats and in rats with lesions centered in the taste relay of the thalamus. Intact Ss responded to the treatments by increasing both saline and water intake. Ss with thalamic lesions that had never drunk saline prior to induction of the lesions generally did not increase their saline intake in response to the treatments but showed normal increases in water intake. In contrast, Ss with thalamic lesions that had drunk saline prior to induction of the lesions showed normal increases in both saline and water intake. Preoperative experience of sodium need did not protect Ss against the lesion-induced deficit. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Postoperative recurrent ulcer after gastric resection--results of surgical treatment]

Within a 10-year period, 50 patients with postoperative ulcer recurrence after gastric resection were treated; 31 of these had one, 8 two, 5 three and 6 four previous gastric operations. Ulcer recurrence was attributed to surgery-related causes in 78% of the cases; excessively large gastric remnant 56%, anastomotic stenosis 18%, loop problems 4%. Some 22% of the patients had causes independent of previous surgery: abuse of non-steroidal antirheumatics (NSAR) 10%, hyperacidity of normal gastric remnant 6%, Zollinger-Ellison-Syndrome 6%. The most important co-factor of ulcer genesis was chronic abuse of NSAR (38% of the total series). The interval between onset of complaints of ulcer disease and the last ulcer-dependent operation amounted on average to 13.8 (0.5-36) years. The definitive treatment of recurrent ulceration was surgery in 34 cases-indicated by ulcer complications (73.5%) or failure of medical therapy (26.5%)-and conservative treatment in 16 cases. Surgery comprised 21 re-resections, 7 thoracic truncal vagotomies 4 total gastrectomies 1 Whipple procedure and 1 enucleation of gastrinoma (hospital mortality 0%). During the follow-up period (median 7.1 years, follow-up rate 96%), the cumulative ulcer re-recurrence rate was 57% for the conservatively treated group and 17.6% for the patients treated by surgery (p < 0.05). In none of the eight patients who died during long-term follow-up was the cause of death ulcer-related.     

The pharmacokinetics of methimazole in pregnant patients after oral administration of carbimazole

1 A high performance liquid chromatographic (HPLC) method was used to study the pharmacokinetics of methimazole after oral administration of carbimazole to women in various stages of pregnancy. 2 In one patient it was possible to conduct the study in the first and third timesters: there was an appreciable increase in the apparent clearance of methimazole. 3 Based on the assumption of complete absorption and hydrolysis of carbimazole to methimazole the mean apparent clearance was found to be significantly higher in pregnant patients receiving 10 mg carbimazole than in non-pregnant patients receiving the same dose.     

Early and late complications after surgical gastric resection for peptic ulcer

For evaluating early and late complications after partial gastrectomy in gastric and duodenal ulcer, performed in 1976-92 years, was investigated 585 patients. The surgery was carry out mutables Rydygier and Billroth-2 methods. The smallest complications early and late found after the operations Finney-Haberer and Billroth-2 with Braun anastomosis and vagotomy.