Management of candida septicaemia in a regional burn unit

Sepsis due to candida infection is a major cause of mortality and morbidity on our unit. Over a period of 3 years and 4 months, 29 cases of candida septicaemia, diagnosed by blood cultures, were encountered at the burn unit at Augusta Regional Medical Center.

Factors known to predispose to fungal sepsis were present in all cases. All patients had large burns (14–98 per cent total body surface (TBSA) with a mean of 48.3 per cent). All but one patient had at least one central venous line. Respiratory problems requiring ventilator support were present in 24 patients.

Sixteen patients had Candida albicans sepsis, two in association with another fungal sepsis. Candida parapsilosis was encountered in nine patients, one in combination with another species. Four patients had Candida tropicalis.

Amphotericin B was prescribed therapeutically in 25 patients, in seven together with fluconazole. Two patients received fluconazole only and two received no antifungal therapy.

There were eight deaths all attributed to sepsis and all of whom had multiple organ failure. Five of those who died had completed a course of amphotericin B therapy, two were receiving treatment at the time of death, and one patient died before culture data became available. Early and aggressive therapy is advised and amphotericin B appears to be the drug of choice.     

The effect of parenteral nutrition on the healing of abdominal wall wounds and colonic anastomoses in protein-malnourished rats

The effect of postoperative parenteral nutrition on the healing of abdominal wall wounds and colonic anastomoses in protein-malnourished rats was studied. The healing of laparotomy wounds and colonic anastomoses was assessed by bursting pressure measurement on the fifth postoperative day. Compared with control animals on a normal diet (group A), rats on a low-protein diet given postoperative dextrose-saline solution (group B) had significantly lower abdominal wall and colonic anastomotic bursting strengths. The detrimental effects of protein malnutrition could be completely reversed for abdominal wall wounds and partially reversed for colonic anastomoses in rats on a low-protein diet given postoperative parenteral nutrition (group C). Autoradiographic studies showed a marked decrease in the activity of wound fibroblasts that was restored by the administration of postoperative parenteral nutrition. Serum protein measurements showed a closer correlation of colonic anastomotic healing to serum albumin than to serum transferrin values but showed no correlation with abdominal wall wound healing.     

Massive haemorrhage due to rectosigmoid ulcers in a patient with extensive burns.

A 36-year-old white-skinned male was admitted with 45.5 per cent burns, mostly of full skin thickness. Severe rectal bleeding from rectal ulcerations developed on postburn day 12. Various conservative attempts at management failed, and after multiple transfusions, abdominoperineal resection was carried out with eventual complete recovery. Complications during his acute phase included Pseud. aeruginosa sepsis and Clostridium difficile diarrhoea. Extensive skin grafts were required. The cause of the rectal ulcerations is unclear.     

Influence of adenosine on the stimulatory effect of isoprenaline and insulin on myocardial contractility in vivo.

STUDY OBJECTIVE--In vitro investigations have indicated that adenosine can inhibit beta adrenergic stimulated increases in cardiac contractility. The present study was designed to determine the ability of adenosine to inhibit isoprenaline induced increases in contractility in vivo. Adenosine has been reported to exert its inhibitory effects on contractility by inhibiting adenylate cyclase. Thus, adenosine should have no effect on positive inotropic agents that act independently of adenylate cyclase. We therefore assessed the ability of this nucleoside to inhibit the positive inotropic effect of insulin, a hormone that exerts a positive inotropic effect independently of alterations in cyclic AMP. DESIGN--Saline or adenosine (10 mumol.ml-1) was infused into the circumflex artery at 1 ml.min-1 as a background. Isoprenaline (20 or 200 pmol.min-1) was infused into the artery during saline or adenosine infusion. The response to insulin was determined during hyperinsulinaemic euglycaemic clamp. SUBJECTS--16 adult mongrel dogs were anaesthetised with pentobarbitone. Five dogs were used in isoprenaline studies, and 11 dogs in insulin studies. MEASUREMENTS AND MAIN RESULTS--Dogs were instrumented to obtain measurements of mean arterial blood pressure, heart rate, circumflex artery blood flow (Q), instantaneous left ventricular pressure, and posterior left ventricular wall thickness. We used the slope of the end systolic pressure-dimension relationship (Ees) as an index of myocardial contractility, previously shown to reflect changes in myocardial inotropic state independent of influence from afterload and preload. Left ventricular dP/dtmax was derived from left ventricular pressure with respect to time, and Ees was determined from left ventricular pressure and wall thickness. Neither adenosine, isoprenaline, nor insulin alone caused any significant changes in mean arterial pressure or heart rate. Adenosine caused a significant increase in Q. Both left ventricular dP/dtmax and Ees were significantly increased by either insulin or both doses of isoprenaline. Adenosine inhibited the increases in these indices caused by isoprenaline, but not those caused by insulin. CONCLUSIONS--Adenosine is capable of inhibiting the positive inotropic effect of isoprenaline in vivo. The results suggest that adenosine does not inhibit positive inotropic responses that act independently of the stimulation of adenylate cyclase.     

The iron uptake mechanisms of enteropathogenic Escherichia coli: the use of haem and haemoglobin during growth in an iron-limited environment.

The iron uptake mechanisms of enteropathogenic Escherichia coli (EPEC) were examined and compared with those of control E. coli strains. The incidence of aerobactin production was similar (39% and 37% respectively) in the two groups. The quantities of enterochelin produced by aerobactin-negative EPEC and control strains were similar, as were the quantities of enterochelin produced by aerobactin-positive EPEC and control strains. The ability to use haem or haemoglobin as an iron source in an iron-restricted environment was found in 80.4% and 60.8% of EPEC strains respectively, and in 76.6% and 56.6% of control E. coli strains. The ability of E. coli strains to use these compounds was not related to the production of enterochelin or aerobactin or to the production of haemolysins, and may be an important characteristic of bowel organisms. When growing in an iron-limited environment, the iron contained in haemoglobin was used in preference to ovotransferrin-bound iron. During periods of haemoglobin-stimulated growth, the enterochelin uptake system was shown to be fully expressed and may be involved in transport of haemoglobin-derived iron into the cell. Uptake of ovotransferrin-bound iron took place immediately upon exhaustion of haemoglobin-derived iron. The ability to use iron derived from haem compounds represents an alternative iron uptake mechanism for organisms growing in an iron-limited environment and allows greater flexibility during growth in vivo.     

Hematuria in the burned child

Hematuria is a frequent complication in burn patients, but its clinical significance has not been reported. The incidence, etiologies, treatment, and outcome of hematuria in 1,785 burn patients treated from 1964 to 1983, have been reviewed. Ninety-one patients had hematuria (greater than 15 RBC/HPF with unspun urine). There were five main causes: urinary infections (UTI), 50 cases; renal calculi (RC), 14 cases, including 3% and 5% total body surface area burn patients; catheter trauma, 7 cases; renal vein thrombosis (RVT), 5 cases; and acute renal failure (ATN), 4 cases. Ten patients died in the UTI group, five with Candida as the infecting organism. No RC patients died, but two required surgical extraction of their stones. This incidence of RC may be due to large intake of dairy products and antacids and to prolonged immobilization. The catheter trauma group had no deaths and was the youngest group. One RVT patient was diagnosed clinically and successfully treated surgically. The other three were diagnosed at necropsy. The ATN patients all developed renal failure late as part of multiple organ system failure and all died. We conclude hematuria is a serious finding in burn patients and prompt diagnosis of its etiology and treatment are essential for maintaining renal function and patient survival.     

Comparison of hand-sewn and stapled esophagogastric anastomosis after esophageal resection for cancer: a prospective randomized controlled trial.

OBJECTIVE: The objective of this study was to compare the hand-sewn and stapled methods in esophagogastric anastomosis. SUMMARY BACKGROUND DATA: After esophageal resection for cancer, the relative merits of the hand-sewn and the stapled methods of esophagogastric anastomosis, especially regarding leakage and stricture rates, have not adequately been studied. METHODS: A prospective randomized controlled trial was undertaken in 122 patients with squamous cell cancer of the thoracic esophagus who underwent a Lewis-Tanner esophagectomy. Patients were stratified according to esophageal size, based on the diameter of the divided esophagus (< or > or = 30 mm) and then were randomized to have either a hand-sewn or a stapled anastomosis. RESULTS: The mean total operating times (standard error of the mean) when the hand-sewn and the stapled methods were used were 214 (4) minutes and 217 (3.4) minutes, respectively (p = not significant [NS]). The respective in vivo proximal resection margins (standard error of the mean) were 8 (0.4) cm and 7.6 (0.4) cm (p = NS). Leakage rates were 1.6% and 4.9% (p = NS). Excluding hospital deaths, patients with leakage or anastomotic recurrence, and those who received radiation therapy to histologically infiltrated resection margin, anastomotic stricture was found in 5 (9.1%) of 55 patients in the hand-sewn group and 20 (40%) of 50 in the stapler group (p = 0.0003). The difference in stricture rates was significant in small as well as large esophagi. Anastomotic recurrence developed in only one patient in each group. CONCLUSIONS: The authors conclude that both methods were safe, but the stapled technique resulted in more stricture formation.