Biomedical subjects
H A Bruining
Publications and source records attributed to H A Bruining.
Role of selective decontamination in surgery.
Aspects of selective decontamination as an antibiotic prophylaxis in general surgery are discussed with respect to the respiratory tract and wound infection. The high rate of nosocomial infection encountered in surgical patients, who experience up to 71 per cent of all such infection, is considered. The infection rate increases to 70-80 per cent after 1 week in the surgical intensive care unit, while the infection-related mortality rate rises to up to 60 per cent. The endogenous origin of nosocomial infection suggests the importance of maintaining colonization resistance to prevent colonization with Gram-negative micro-organisms, especially using selective decontamination which eliminates potentially pathogenic micro-organisms while leaving colonization resistance intact. Selective decontamination has proved effective in decreasing infection rates by 50-80 per cent, and is especially successful in respiratory tract infection. Possible adverse effects and future indications for selective decontamination are discussed.
In vivo NADH and Pd-porphyrin video fluori-/phosphorimetry.
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A simple device to inject indicator gas for wash-out tests during mechanical ventilation.
OBJECTIVE: To evaluate a simple device which injects a constant fraction of indicator gas to the inspiratory mixture for performing multi-breath wash-out tests during controlled ventilation. DESIGN: the technique in which the indicator gas is injected at the mouth of the patient (post-mix) is compared with the technique where the indicator gas is administered in the bellows of the ventilator (pre-mix). SETTING: Surgical Intensive Care Unit of a University Hospital. PATIENTS: 10 post-operative mechanically ventilated patients. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: 3 wash-out tests with the post-mix and 3 wash-out tests with the pre-mix method were performed within an hour on every patient. The calculated mean end expiratory lung volume (EEV) was 1.91 +/- 0.871 with the post-mix technique and 1.89 +/- 0.881 with the pre-mix technique. There was a good agreement with a mean difference of -1.9 +/- 6.5% in the calculated EEV values by the two different techniques. CONCLUSION: The described injector is an affordable device, is easy to assemble and can be incorporated in most electronically regulated ventilators to perform multi-breath indicator gas wash-out tests for pulmonary monitoring at the bed side of ICU patients.
The advantages of pylorus-preserving pancreatoduodenectomy in malignant disease of the pancreas and periampullary region.
The aim of this study was to establish whether the pylorus-preserving pancreatoduodenectomy (PPPD) is a safe and radical procedure in malignant disease of the head of the pancreas and periampullary region, without increased morbidity and mortality rates compared with the standard Whipple's procedure. During the period 1984 to 1990, a Whipple's procedure (n = 44) or PPPD (n = 47) was performed in 91 patient. In-hospital mortality rates were 2% after PPPD and 5% after Whipple's procedure. Median duration of the resection procedure and median blood loss in the PPPD group were 210 minutes and 1800 mL, respectively. After Whipple's procedure, these figures were 255 minutes and 2500 mL, both significantly different (p less than 0.01) as compared with PPPD. No difference was found during follow-up with respect to days of gastric suctioning, start of liquid diet, normal diet, complaints of ulcer disease, postoperative complications, recurrence of disease, and survival. In all patients, curative resection was performed with comparable TNM (tumor, nodes, metastases) staging. The number of tumor-containing duodenal or gastric resection margins did not differ in both groups of patients (two patients after PPPD, two patients after Whipple's procedure). Hospital stay was significantly (p = 0.02) shorter after PPPD; median 14 days, compared with median 18 days after Whipple's procedure. The advantage of the PPPD is that it is an easier and less time-consuming operation, with less blood loss, a shorter hospital stay, and better weight gain (p = 0.02) during follow-up. In conclusion, PPPD is a safe and radical procedure for cancer in the head of the pancreas or periampullary region, with the same survival and appearance of locoregional recurrence and distant metastases as after standard Whipple's resection.
Primary hyperparathyroidism: pathology, flow cytometric DNA analysis, and surgical treatment.
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Optical spectroscopic imaging for non-invasive evaluation of tissue oxygenation.
Altered rates of oxygen delivery and uptake between and possibly within different organs occur during critical illness. The mechanisms governing this heterogeneity are as yet not fully understood and techniques directed at being able to map the course of oxygen to the mitochondria to produce ATP, the main molecule needed to drive energy requiring processes in the cell, would give valuable information about the mechanisms underlying organ dysfunction during disease. Oxidative phosphorylation occurring in the mitochondria is the main site for the production of ATP in mammalian cells. Metabolic substrates, ADP and Pi, and O2 are the ingredients needed to produce ATP. Due to the central role of oxidative phosphorylation in the metabolism of the cell, much attention has been directed at developing non-invasive techniques to measure intermediates of the oxidative phosphorylation in tissue as an indication of the metabolic state of tissue. One such method enables mapping the distribution of tissue hypoxia by use of a fluorescence technique based on the measurements reduced nicotine amide dinucleotide (NADH). NADH is situated at the high-energy side of the respiratory chain and during tissue hypoxia accumulates in concentration because less NADH is oxidized to NAD+. Excitation of NADH by 366 nm light produces, unlike NAD+, fluorescence at 460 nm light. Previously, however, producing images of NADH fluorescence distribution in tissue has been limited to saline perfused in vitro models. We recently undertook to develop an NADH videoflurometer sensitive enough to NADH fluorescence in vivo (Ince C, Bruining HA (1991) Optical Spectroscopy for the measurement of tissue hypoxia.(ABSTRACT TRUNCATED AT 250 WORDS)
Independent oxygen uptake and oxygen delivery in septic and postoperative patients.
Previous studies reporting pathologic oxygen supply dependency calculated VO2 as CO x C(a-v)O2. We investigated whether pathologic oxygen supply dependency exists in septic and postoperative patients if VO2 and DO2 are assessed independently. In septic patients, VO2 was 164 +/- 31 and DO2 was 633 +/- 209 ml/min/m2. The slope (b) of the VO2-DO2 regression line VO2 = b x DO2 + a ranged from -0.10 to 0.08 (mean, 0.02 +/- 0.01, p less than 0.05) and was statistically significant in two patients (b = 0.05 and b = 0.08, p less than 0.05). In postoperative patients VO2 was 136 +/- 19 and DO2 was 481 +/- 160 ml/min/m2; b ranged from -0.07 to 0.09 (mean, 0.04 +/- 0.01, p less than 0.001) and was statistically significant in one patient (b = 0.09, p less than 0.01). The lack of a close relationship between independently measured VO2 and DO2 may indicate that septic and postoperative patients in stable hemodynamic condition have no pathologic oxygen supply dependency. Analysis of the VO2-DO2 relationship may not be useful to guide therapy or predict outcome.
Primary hyperparathyroidism due to solitary adenoma. A comparative multicentre study of early and long-term results of different surgical regimens.
Surgical regimens for treatment of solitary parathyroid adenoma were compared in a multicentre study in five departments of surgery in the United States and Europe. Three hundred and twenty-five patients fulfilled the inclusion criteria. Eight years after the operation 272 patients (84%) were available for follow-up investigation. Severe postoperative hypocalcaemia (less than 2.00 mmol) was significantly more common after bilateral than unilateral exploration (p less than 0.001), and in women (p less than 0.01). Neither age nor preoperative serum calcium concentration was related to the severity of postoperative hypocalcaemia. At follow-up, 96% of the patients who had had unilateral, and 89% of those who had had Bilateral exploration had remained normocalcaemic without further treatment. Of the patients who had had incisional biopsies of normal glands 8% had hypercalcaemia and 8% had hypocalcaemia. Of patients operated on without a biopsy being taken or who had had one whole normal gland removed 1% were hypercalcaemic and 4% were hypocalcaemic. Early and late hypocalcaemia are reduced by atraumatic handling of the normal parathyroid gland without increasing the risk of persistent or recurrent hypercalcaemia.
Fournier's gangrene: the need for early recognition and radical surgical débridement.
Fournier's gangrene, a specific form of necrotizing fasciitis, predominantly affects the male genitals, perineum and perianal region. Most frequently Fournier's gangrene is caused by the synergistic action of aerobic and anaerobic microorganisms and leads to early septicaemia with a high mortality. The case histories of three patients with Fournier's gangrene are presented to illustrate the importance of early recognition and radical surgical débridement as essential objectives for therapeutic success. In the first patient, who died of Fournier's gangrene after a vasectomy, appropriate therapy was significantly delayed due to late recognition of the condition. The second patient presented with a rapidly progressive fasciitis secondary to a perianal abscess; immediate excision of all necrotic tissue was successfully performed. The third patient developed gangrene from an urogenital infectious focus, which was primarily treated by insufficient incisional and drainage therapy. Only after radical débridement his general condition rapidly improved.
[Surgical treatment of traumatic rupture of the thoracic aorta].
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Selective decontamination to reduce gram-negative colonisation and infections after oesophageal resection.
181 patients undergoing resection of the oesophagus for carcinoma were randomised to receive selective decontamination (test group) or conventional perioperative antibiotic prophylaxis (controls). 114 patients were finally included in the study: 12 of 56 test patients had 18 infections, whereas 32 of 58 controls acquired 51 infections. Colonisation with aerobic gram-negative microorganisms, and the number of postoperative respiratory tract infections were significantly lower in the test patients. The postoperative therapeutic use of antibiotics was significantly lower in the test group. No endogenous infections were caused by gram-negative bacilli in the test group. Selective decontamination reduces colonisation with gram-negative bacilli and postoperative infections after resection of the oesophagus.
Effects of selective decontamination on gram-negative colonisation, infections and development of bacterial resistance in esophageal resection.
Patients undergoing an esophageal resection because of carcinoma are at risk of developing postoperative respiratory tract infections. These patients were studied with respect to preceding colonisation with gram-negative bacilli and the effect of selective decontamination (SD) in decreasing this phenomenon, thereby reducing gram-negative infections. We randomised prospectively 114 patients into a test group receiving SD-medication (n = 56) and a control group receiving conventional prophylaxis. Postoperatively, all patients were admitted to the intensive care unit and mechanically ventilated. The preoperative administration of SD-medication resulted in adequate decontamination within 3-4 days in most patients, and SD could prevent gram-negative colonisation and infections effectively. Discontinuation of SD showed gram-negative (re-)colonisation, and resulted in 12 infections in 4 patients having late complications. This indicates that prolonged use in these patients might be beneficial. This new antibiotic prophylaxis proved effective, without causing an increase in bacterial resistance.
Design and validation of an indicator gas injector for multiple gas washout tests in mechanically ventilated patients.
A device to produce a stepwise indicator gas fraction variation to initiate a washout test in mechanically ventilated patients is described. The device, which can be used in conjunction with the commonly used Siemens-Elema series 900 ventilators, is based on simple, off-the-shelf technology. It features the simultaneous use of two indicator gases (so that the influence of diffusion processes in the gas exchange to the patient can be measured) and maintains a nearly constant FIO2 during a washout procedure. With this indicator gas injector, the transition time of the indicator gas fraction at the beginning of a washout proved to be short enough to detect ventilation inhomogeneity by visual inspection of the washout curves. Functional residual capacity measurements using this device are presented on a test lung with known volume, on healthy volunteers, and on critically ill patients.
Characterization of adrenal autonomy in Cushing's syndrome: a comparison between in vivo and in vitro responsiveness of the adrenal gland.
We measured cortisol and precursor steroid production in response to ACTH, cholera toxin, and forskolin by the dispersed adrenocortical cells prepared from the adrenal glands of 10 patients with different forms of Cushing's syndrome. The cells prepared from the hyperplastic adrenal glands from 4 patients with Cushing's disease responded in a dose-dependent manner to ACTH, cholera toxin, and forskolin. The adrenal cells prepared from 4 encapsulated adrenal adenomas showed no (n = 2), a lowered (n = 1), or a clear (n = 1) response of cortisol release to ACTH. The cells prepared from the adrenal glands of 1 patient with dysplastic micronodular adrenal glands showed a limited response to ACTH, while the cells from an adrenocortical carcinoma, which secreted very little cortisol per cell, were unresponsive to ACTH, cholera toxin, and forskolin. The reaction of the dispersed adrenal cells from these 10 patients to ACTH, cholera toxin, and forskolin showed a close correlation (P less than 0.001 in all instances). This suggests that the defect in autonomous glands is not located at the level of the ACTH receptor, but, rather, involves the adenylate cyclase complex as a whole or its coupling to cAMP-dependent protein kinase. The release into the medium of the cortisol precursors deoxycortisol, 17-hydroxyprogesterone, and progesterone showed that the four autonomous nodules were characterized by a significantly higher deoxycortisol/cortisol ratio in the medium (P less than 0.01), suggesting a relative blockade of 11 beta-hydroxylase in these adrenal adenomas. This was further substantiated in cells from several adrenals by a significant increase in the release of these precursors in response to ACTH in the absence of a cortisol response. We conclude the following. 1) Adrenal adenoma formation in patients with Cushing's syndrome is accompanied by a parallel decrease in the stimulation of the release of steroid hormones in response to ACTH, cholera toxin, and forskolin. This points to a defect in the adenoma cells beyond the ACTH receptor. 2) Adrenal adenoma formation in patients with Cushing's syndrome is accompanied by a relative blockade of 11 beta-hydroxylase activity. 3) By comparing the preoperative dynamic tests of the pituitary-adrenal axis, the plasma ACTH concentration, the morphology of the adrenal glands, and their in vitro responsiveness, a gradual transition from pituitary to (partial) adrenal autonomy could be recognized in several patients.
Parallel in vivo and in vitro detection of functional somatostatin receptors in human endocrine pancreatic tumors: consequences with regard to diagnosis, localization, and therapy.
The effects of octreotide in vivo and in vitro on hormone release, in vivo [123I]Tyr3-octreotide scanning, and in vitro [125I]Tyr3-octreotide autoradiography were compared in five patients with endocrine pancreatic tumors. [123I]Tyr3-octreotide scanning localized the primary tumor and/or previously unknown metastases in four of the five patients. The patient with a negative scan had an insulinoma that did not respond to octreotide in vivo. No Tyr3-octreotide-binding sites were subsequently found at autoradiography of the tumor, whereas somatostatin-14 receptors were present at a high density. In parallel, culture studies with the cells prepared from this adenoma showed that insulin release was not affected by octreotide, while both somatostatin-14 and -28 significantly suppressed hormone release. Culture studies of the tumor cells from two gastrinomas showed a dose-dependent inhibition of gastrin release by octreotide. Octreotide exerted direct antiproliferative effects in one of these gastrinomas, which had been shown to be rapidly growing in vivo. Both gastrinomas had specific somatostatin receptors, as measured by in vitro receptor autoradiography. Somatostatin release by the cultured somatostatinoma cells from one of these patients was suppressed by octreotide. In conclusion, 1) the [123I]Tyr3-octreotide scanning procedure is valuable in the localization of primary endocrine pancreatic tumors as well their often clinically not yet recognized metastases; 2) the in vitro detection of somatostatin receptors in those tumors that were also visualized in vivo after injection of [123I] Tyr3-octreotide indicates that the ligand binding to the tumor in vivo indeed represents binding to specific somatostatin receptors; and 3) the parallel between the presence of somatostatin receptors on tumors and in in vivo and in vitro effects of octreotide on hormonal release from these tumors indicate that a positive scan predicts a good suppressive effect of octreotide on hormonal hypersecretion by these tumors.
Oxygen delivery and oxygen uptake in postoperative and septic patients.
Pathologic dependency of VO2 on DO2 has been reported in postoperative and septic patients. We studied the influence of an artifact due to calculation of VO2 from CO and AV content difference. In 13 postoperative and seven septic patients, the relationships between DO2 and cVO2 and between DO2 and mVO2 were analyzed by linear regression. In ten patients, cVO2 and DO2 were significantly correlated, but in only two of these patients mVO2 also correlated with DO2. In two patients, there was a significant correlation between mVO2 and DO2. The main contribution to the correlation and to the slope of the regression line between cVO2 and DO2 may be due to mathematic coupling of cVO2 and DO2. With cVO2, erroneous conclusions concerning the VO2-DO2 relationship may be drawn. In four patients, DO2 and mVO2 were significantly related, reflecting either physiologic coupling or pathologic supply dependency of VO2.