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Can selective digestive decontamination avoid the endotoxemia and cytokine activation promoted by cardiopulmonary
A E Martinez-Pellús1, P Merino, M Bru
1Intensive Care Unit, University Hospital Virgen de la Arrixaca, Alicante, Spain.
Objective:
To evaluate the effect of selective digestive decontamination on endotoxemia and cytokine activation during the ischemic phase of cardiopulmonary bypass surgery.
Design:
Prospective, open, randomized, controlled trial.
Setting:
Two multidisciplinary intensive care units in tertiary care hospitals.
Patients:
Eighty consecutive patients randomly allocated to two groups: selective digestive decontamination (group 1, n = 40) and controls (group 2, n = 40).
Interventions:
Preoperative administration of oral antibiotics (polymyxin E, tobramycin, and amphotericin B) vs. untreated controls.
Measurements And Main Results:
Assessment of decontamination by bacteriologic evaluation of rectal swabs (colony-forming units [cfu]/mL) were made in each group, along with circulating endotoxin, tumor necrosis factor and interleukin-6 (IL-6) determinations before surgery, during ischemic and reperfusion phases of bypass, and at 4 hrs and at 24 hrs after surgery. Group 1 patients showed that rectal bacteria decreased ten-fold after treatment for 24 hrs, thousand-fold after 48 hrs, and registered 0 cfu/mL after digestive decontamination was administered for > 72 hrs. Endotoxin and IL-6 assays showed significantly lower values in this latter group vs. those circulating concentrations of control patients. On the other hand, both endotoxin and IL-6 concentrations correlated positively with the duration of surgical ischemia.
Conclusions:
Selective digestive decontamination reduces the gut content of enterobacteria, with complete elimination after 3 days of treatment. This fact could explain the lower endotoxin and cytokine concentrations found in the blood samples of patients who had been fully decontaminated. Duration of aortic cross-clamping is an important factor in generating endotoxemia and in the activation of cytokines.