Administration of omega-3 fatty acid may reduce mortality, antibiotic use, and length of hospital stay in different diseases. Effects and effect sizes related to fish oil doses are diagnosis dependent. In view of the lack of substantial study literature concerning diagnosis-related nutritional single-substrate intervention in the critically ill, the present data can be used in formulating hypotheses and may serve as reference doses for randomized, controlled studies, which may, for instance, confirm the value of omega-3 fatty acid in the adjunctive therapy of peritonitis and abdominal sepsis.

SummaryRopivacaine 1% 40 ml was mistakenly injected as part of an axillary plexus block in an 84-year-old woman. After 15 min the patient complained of dizziness and drowsiness and developed a generalised tonic-clonic seizure followed by an asystolic cardiac arrest. After 10 min of unsuccessful cardiopulmonary resuscitation, a bolus of 100 ml of Intralipid 20% (2 ml.kg )1 ) was administered followed by a continuous infusion of 10 ml.min )1 . After a total dose of 200 ml of Intralipid 20%had been given spontaneous electrical activity and cardiac output was restored. The patient recovered completely. We believe the cardiovascular collapse was secondary to ropivacaine absorption following the accidental overdose. This case shows that lipid infusion may have a beneficial role in cases of local anaesthetic toxicity when conventional resuscitation has been unsuccessful. Lipid infusion has been evaluated in several animal models as a treatment for local anaesthetic-induced cardiovascular collapse [1,2]. Although this method might offer a possible therapeutic alternative for treatment of local anaesthetic intoxication [3][4][5] there are no reports of successful human use to date. We report an 84-year-old patient who was successfully resuscitated from cardiovascular collapse after axillary plexus blockade with ropivacaine by use of a lipid infusion. Case reportAn 84-year-old, ASA III, 50-kg woman presented for surgery on a Dupuytren contracture under brachial plexus block. Her medical history included a mild form of Morgagni-Adams-Stokes syndrome, left bundle branch block, and grade II mitral and tricuspid valve regurgitation. The patient was premedicated with midazolam 7.5 mg orally 30 min prior to start of anaesthesia. After placement of routine monitoring and peripheral venous access, an axillary brachial plexus block was performed using a 22-G insulated needle and peripheral nerve stimulation. Nerves were located at three sites corresponding with the ulnar, median and radial nerves. Due to a misunderstanding between the anaesthesiologist and the nurse anaesthetist a total of 40 ml of 1% (instead of 0.5%) ropivacaine was injected after repeated negative aspiration tests. After 15 min the patient complained of dizziness and drowsiness, lost consciousness and had a generalised tonic-clonic seizure. Her heart rate increased to 120 beats.min )1 but blood pressure remained unchanged.The patient was immediately ventilated by mask with oxygen 100% and thiopental 150 mg was given intravenously to stop seizure activity. About 2 min later, the patient developed ventricular extrasystoles followed by severe bradycardia and asystole. Cardiopulmonary resuscitation was started. The patient was given 1-mg increments of epinephrine (total 3 mg), which did not restore cardiovascular activity. An arterial line and central venous line were placed. The patient remained asystolic.

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Key words: omega-3 fatty acid; fish oil; soybean oil; immunonutrition; inflammation; acute-phase response; parenteral nutritionEpidemiologic studies have indicated that high intake of saturated fat and/or animal fat increases the risk of colon and breast cancers. 1 Further laboratory experiments showed reduced risk of colon carcinogenesis after omega-3 PUFA supplementation. In a phase II clinical trial of patients with colonic polyps, dietary FO supplements inhibited cell proliferation. Mechanisms accounting for the antitumour effects in animal models are reduced levels of PGE 2 and inducible NO synthase as well as increased lipid peroxidation or translation inhibition and subsequent cell-cycle arrest. 2 In patients with advanced cancer, weight loss is a major cause of morbidity and mortality. While it is possible to increase energy and protein intake on the enteral or parenteral route, this appears to have little impact on patients' progressive weight loss. 3 Clinical studies in the last few years have provided evidence for beneficial effects of FO administration in cancer cachexia 4 and during radioand chemotherapy. 5 Omega-3 EPA is capable of downregulating the production and action of a number of mediators of cachexia, e.g., IL-1, IL-6, TNF-␣ and proteolysis-inducing factor. 6,7 However, SO (omega-6) emulsions appear to impede tumoricidal activity compared to EPA. 8 Beyond the beneficial effects of long-term intake of omega-3 PUFA in cancer patients, we likewise observed rapid-onset effects in previous experimental studies. Compared to SO emulsion, we found decreased inflammatory pulmonary vascular response in isolated rabbit lungs after omega-3 PUFA infusion. 9 Lung edema formation was blunted because proinflammatory 4-series leukotrienes were shifted to less inflammatory 5-series leukotrienes and, consequently, pulmonary vascular resistance and permeability were reduced. 9 These rapid effects of omega-3 PUFA were confirmed in patients with acute respiratory distress syndrome, showing improved pulmonary function within a few days on an omega-3 fatty acid-enriched diet. 10 The background of these beneficial effects was reduced release of proinflammatory AA derivatives. 11 Following major abdominal nonliver surgery, increases in ALAT were observed and correlated with ultrastructural damage of the liver. 12 In the postoperative course after major abdominal surgery, intact liver function is crucial not only for energy balance (glucose and lactate metabolism) but also for providing several humoral factors, which induce, support and ultimately terminate regenerative mechanisms. This APR of the liver sets off immediately after the (surgical) trauma and upregulates coagulation factors and proteinase inhibitors for wound healing and complement components and opsonins (e.g., CRP) for early bactericidal activity at the site of trauma. 13

A 91-yr-old man (57 kg, 156 cm, ASA III) received an infraclavicular brachial plexus block for surgery of bursitis of the olecranon. Twenty minutes after infraclavicular injection of 30 mL of mepivacaine 1% (Scandicain) and 5 min after supplementation of 10 mL of prilocaine 1% (Xylonest) using an axillary approach, the patient complained of agitation and dizziness and became unresponsive to verbal commands. In addition, supraventricular extrasystole with bigeminy occurred. Local anesthetic toxicity was suspected and a dose of 200 mL of a 20% lipid emulsion was infused. Symptoms of central nervous system and cardiac toxicity disappeared within 5 and 15 min after the first lipid injection, respectively. Plasma concentrations of local anesthetics were determined before, 20, and 40 min after lipid infusion and were 4.08, 2.30, and 1.73 microg/mL for mepivacaine and 0.92, 0.35, and 0.24 microg/mL for prilocaine. These concentrations are below previously reported thresholds of toxicity above 5 microg/mL for both local anesthetics. Signs of toxicity resolved and the patient underwent the scheduled surgical procedure uneventfully under brachial plexus blockade.