World journal of surgery
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Catheter-related bloodstream infections (CBIs) rank among the most frequent and potentially lethal nosocomial infections. Intravascular devices become contaminated on the outer surface during nonaseptic insertion or maintenance of the catheter exit site or endoluminally during hub manipulation. CBI is heralded by spiking fever, malaise and rigors and should be promptly diagnosed to prevent endocarditis and septic metastasis. ⋯ Prevention strategies should aim at avoiding extra- and endoluminal contamination and should be based on three main pillars: maximal aseptic barriers at insertion, appropriate site maintenance, and junctional (hub) care and protection. Treatment includes catheter withdrawal and appropriate antibiotic coverage. For long-term cuffed catheters, local treatment with intraluminal administration of antibiotics is effective and can save a significant number of catheters, particularly those colonized by coagulase-negative staphylococci.
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The critically ill patient exhibits a well defined endocrine and metabolic adaptive response to stressor agents, characterized by incremented resting energy expenditure (hypermetabolism, which is believed to signify increased energy requirements), accelerated whole-body proteolysis (hypercatabolism), and lipolysis. These phenomena occur in the acute stage, which is also characterized by hyperglycemia, typically accompanied by a hyperdynamic cardiovascular reaction manifested by high cardiac output, increased oxygen consumption, high body temperature, and decrease peripheral vascular resistance. High provisions of glucose-derived calories tend to accentuate these reactions and increase the degree of hyperglycemia. ⋯ In contrast, our hypocaloric-hyperproteic approach has resulted in a more physiologic clinical course and considerable reduction in cost. The infusion of high glucose loads, such as those used in hypercaloric TPN, does not seem to suppress the excessive endogenous production of glucose but instead markedly exacerbates the hyperglycemia of the postinjury and acute stress condition. We believe that the hypocaloric-hyperproteic regimen we utilize during the first few days of the stress situation is more in accordance with the inflammatory and hormonal mediator climate of the initial stages of the flow phase and thus appears to be beneficial vis-à-vis the hypercaloric loads that many use as routine metabolic support in critically ill patients.
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World journal of surgery · May 1999
Prospective evaluation of selective defunctioning stoma for low anterior resection with total mesorectal excision.
Low anterior resection with total mesorectal excision for rectal carcinoma is associated with a high anastomotic leakage rate, and the effectiveness of a defunctioning stoma in preventing anastomotic leakage remains controversial. In this study a policy of selective defunctioning stoma for stapled colorectal anastomosis after low anterior resection with total mesorectal excision in 148 consecutive patients was evaluated prospectively. A defunctioning stoma was performed in 61 patients (41%) considered at high risk of anastomotic leakage. ⋯ Closure of the stoma was associated with no mortality, a morbidity rate of 8.7%, and a median hospital stay of 6. 0 days. In conclusion, a defunctioning stoma is effective in preventing clinical anastomotic leakage after low anterior resection with total mesorectal excision. The relatively high incidence of leakage in the low risk group indicates the difficulty of predicting anastomotic leakage and hence the need for more liberal use of a defunctioning stoma especially in male patients.