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A continuous insulin infusion and glucose control during surgery improves white cell function in diabetic patients and may increase resistance to infection after surgery.

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Background:In order to determine the type and incidence of pulmonary complications associated with the placement of narrow-bore enteral feeding tubes we conducted a prospective, descriptive study in the multidisciplinary intensive care unit (ICU) of a university hospital. All patients that had narrow-bore enteral feeding tubes inserted over a 2-year period (1993-1995) were included. The study required no clinical interventions.Results:Seven hundred and forty feeding tubes were inserted during the study period. In 14 cases (2%), the feeding tube was inserted into the tracheopulmonary system. Five patients (0.7%) suffered a major complication, including two (0.3%) who died from complications directly related to the feeding tube placement. All patients had altered consciousness and 13 of the 14 had endotracheal tubes in place. Malposition of the feeding tube was not predictable from clinical signs and auscultation, but was detectable by chest roentgenogram.Conclusions:Inadvertent insertion of enteral feeding tubes into the tracheopulmonary system during placement is associated with significant morbidity and mortality. Clinical signs at the time of insertion are not useful in identifying feeding tubes which are malpositioned. In the ICU patient, a chest roentgenogram is required after all feeding tube insertions prior to the initiation of enteral feeding. In the high-risk patient, alternatives to blind feeding tube insertion should be considered.

Diabetic patients are at increased risk of wound infection after major surgery, but the effect of perioperative glucose control on postoperative wound infection rates after surgery is uncertain. We tested the effect of an insulin infusion on perioperative neutrophil function in diabetic patients scheduled for coronary artery bypass surgery. Participants (n ϭ 26) were randomly allocated to receive either aggressive insulin therapy (AIT) or standard insulin therapy (SIT) during surgery. Blood was drawn for neutrophil testing before surgery, 1 h after the completion of cardiopulmonary bypass, and on the first postoperative day. Neutrophil phagocytic activity decreased to 75% of baseline activity in the AIT group and to 47% of baseline activity in the SIT group (P Ͻ 0.05 between groups). No important differences in neutrophil antibody-dependent cell cytotoxicity were found. This study documents a potentially beneficial effect of continuous insulin therapy in diabetic patients who require major surgery. Implications: A continuous insulin infusion and glucose control during surgery improves white cell function in diabetic patients and may increase resistance to infection after surgery.

In this prospective, randomized, double-blinded, and placebo-controlled trial, we identify an effective postoperative analgesic approach in total knee replacement surgery. Intrathecal morphine (250 microg) combined with clonidine (25 or 75 microg) provided superior analgesia compared with intrathecal morphine alone.

Objective-There is continuing controversy regarding the effect of glucocorticoids on a systemic inflammatory process. Based on a model of glucocorticoid action that includes both pro-and antiinflammatory effects, we used the human experimental endotoxemia model to test the hypothesis that a transient elevation of plasma cortisol to stress-associated levels would enhance a subsequent (delayed) systemic inflammatory response to bacterial endotoxin. Design-Prospective, randomized, double-blind, placebo-controlled clinical investigation.Setting-Academic medical center. Subjects-Thirty-six healthy human volunteers.Interventions-Participants were randomized to receive a 6-hr intravenous infusion of saline (control), an intermediate dose of cortisol (Cort80; 6.3 mg/hr/70 kg), or a high dose of cortisol (Cort160; 12.6 mg/hr/70 kg) on day 1. On day 2, participants received an intravenous injection of 2 ng/kg Escherichia coli endotoxin followed by serial measurements of plasma cytokine concentrations.Measurements and Main Results-Baseline participant characteristics and cortisol and cytokine concentrations were similar in all three groups. The plasma cortisol response to endotoxemia on day 2 was similar in all three groups. The interleukin-6 response to endotoxemia was significantly increased in the Cort80 Group compared with the control Group (p = .004), whereas the interleukin-10 response was significantly suppressed (p = .034). Corresponding results for the Cort160 Group were not significantly different from control Group values.Conclusions-In this study, transient elevation of in vivo cortisol concentrations to levels that are observed during major systemic stress enhanced a subsequent, delayed in vivo inflammatory response to endotoxin. This appeared to be a dose-dependent effect that was more prominent at intermediate concentrations of cortisol than at higher concentrations of cortisol. Glucocorticoids (GCs) have been widely used to suppress inflammation since 1949 when Hench et al first described the anti-inflammatory effect of GCs in humans (1). Over the ensuing 50 years, most GC research focused on the anti-inflammatory and immune-suppressive properties of GCs, whereas comparatively little research examined the stimulatory properties of GCs that were, in fact, widely acknowledged before 1949 (2-4). More recently, investigators have again examined the stimulatory effects of GCs on inflammatory processes (5). Recent work has shown that GCs induce increased expression of receptors for inflammatory cytokines, including interleukin (IL)-1 (6), IL-2 (7), IL-4 (8), IL-6 (9), IL-7 (10) and interferon-γ (11) as well as granulocyte-macrophage colony-stimulating factor (12). GCs also stimulate effector cell functions, including phagocytosis by monocytes (13) and neutrophils (14), proliferative responses of T-cells (7) and macrophages (15), and tissue inflammatory responses to injury (16). NIH Public AccessTo account for both suppressive and stimulatory effects of GCs on inflammatory processes, a model of GC action ...

IV insulin, as used in this study, had effects on blood glucose only after cardiac surgery, when it was associated with an increased neutrophil count and a greater total capacity of peripheral blood neutrophils to ingest foreign particles.