since none was given during dialysis. For technical reasons 35-40 minutes elapsed from the time parenteral feeding was stopped until dialysis was established.On the 13th day after admission, when dialysis had been in progress for some 50 minutes, she complained of drowsiness and rapidly became comatose. On that day 20 U soluble insulin had been added/I parenteral fluid, this amount having been calculated from her previous blood glucose concentrations and insulin requirements. Unlike on previous occasions, however, the infusion had been allowed to continue until dialysis was established.A capillary blood sample was taken and glucose concentration determined with Dextrostix (Miles Laboratories Ltd, Slough); this gave a negative result. Simultaneously a venous blood sample was sent to the emergency biochemistry laboratory, and the plasma glucose concentration was reported as < 1 mmol/l (18 mg/100 ml). She responded rapidly to a 50 ml intravenous bolus of 50% dextrose and suffered no permanent ill effect from the hypoglycaemic episode. Six weeks later she was discharged home having recovered full gastrointestinal and renal function but with residual paraplegia. DiscussionAddition of insulin to intravenous feeding solutions is established practice in many centres1 when stress from trauma or sepsis causes reduced use of exogenously supplied carbohydrate. Experience has shown that because the insulin is delivered as an additive to the hypertonic dextrose hypoglycaemia is not a problem even if the infusion is stopped abruptly.2 In the case reported, however, dialysis was already in progress when the infusion was stopped and the patient then had both a mildly raised blood glucose concentration owing to the infusion of 25% glucose and an appreciable blood concentration of exogenously supplied insulin. The solution used for dialysis contained no glucose and so a shift of glucose occurred across the semi-permeable membrane from the blood to the dialysate, resulting in a rapid reduction in the blood glucose concentration. The exogenous insulin, having too great a molecular size to cross the membrane, remained in the patient's circulation to reduce the blood glucose concentration further to critical hypoglycaemic levels.If the infusion is stopped 30-45 minutes before dialysis is started blood glucose and insulin concentrations are allowed to fall naturally and simultaneously so that even if dialysis subsequently depresses the blood glucose concentration there is insufficient residual exogenous insulin, with its physiological half life of 20-30 minutes,3 to have a pronounced hypoglycaemic effect.This case prompted us to make changes in our management of such patients, and we have not subsequently encountered this hypoglycaemic complication. the incidence of joint sepsis confirmed at reoperation within the next one to four years was about half that of patients who had had the operation in a conventionally ventilated room at the same hospital. When whole-body exhaust-ventilated suits had been worn by the operating team in a thea...

No abstract

(1987) Ultraclean air and antibiotics for prevention of postoperative infection: A multicenter study of 8,052 joint replacement operations, Acta Orthopaedica Scandinavica, 58:1, 4-13,

Operating in ultraclean air and the prophylactic use of antibiotics have been found to reduce the incidence of joint sepsis confirmed at re-operation, after total hip or knee-joint replacement. The reduction was about 2-fold when operations were done in ultraclean air, 4.5-fold when body-exhaust suits also were worn, and about 3- to 4-fold when antibiotics had been given prophylactically. The effects of ultraclean air and antibiotics were additive. Wound sepsis recognized during post-operative hospital stay was, however, reduced by these measures only when it had been classed as major wound sepsis. This was reported after 2.3% of operations done without antibiotic cover in conventionally ventilated operating rooms. Joint sepsis was much more frequent after wound infection and especially after major wound sepsis, although most cases of joint sepsis were not preceded by recognized wound sepsis. This was particularly noticeable after major wound sepsis associated with Staphylococcus aureus; after 37 such infections the same species was subsequently found in the septic joint of 11 patients. The sources of wound colonization with Staph. aureus, when this was not followed by joint sepsis, appeared to differ widely from those where joint sepsis occurred later. Operating-room sources could be found for most of the latter and the risk of infection appeared to be similar with respect to any carrier in the operating room whether a member of the operating team or the patient. For wound colonization that was not followed by joint sepsis, operating-room sources could only be inferred for fewer than half and of these more than one half appeared to be related to strains carried by the patient at the time of operation. During the follow-up period, which averaged about 2 1/4 years with a maximum of four years, there were, in addition to the 86 instances of deep joint sepsis confirmed at re-operation, 85 instances in which sepsis in the joint was suspected during this period but was not confirmed, because re-operation on the joint was not done. The incidence of suspected joint sepsis was, like that of confirmed joint sepsis, less after operations done in ultraclean air: 1/2.5, or with prophylactic antibiotics, 1/2.3 Although re-operation was more frequent on the knee-joint than on the hip, and pain after the initial operation was more frequent after knee operations, there was no evidence that this was the result of any increased risk of infection.(ABSTRACT TRUNCATED AT 400 WORDS)