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The influence of pentoxifylline on human polymorphonuclear granulocyte (PMN) respiratory burst activity (RBA) was studied in 23 patients fulfilling the established criteria of sepsis and in 10 healthy donors. Pentoxifylline (PTX) was administered (5 mg/kg) by intravenous infusion in 13 septic patients over a period of 180 min. The control group consisted of 10 patients with septic syndrome who received an infusion of physiological saline. For determination of RBA, 10 mL of blood was drawn at respective time intervals before, during, and after treatment with PTX or a placebo. RBA measurements were performed using a chemiluminescence assay after stimulation of PMN with formyl-methionyl-leucyl-phenylalanine (FMLP), phorbol-myristate-acetate, and opsonized zymosan, respectively. RBA measurements of each patient were performed in replicate samples. CL was measured for 1 h at respective time intervals (1, 3, 5, 8, 10, 15 min etc.). RBA of PMN of septic patients was compared with RBA of PMN of healthy donors and patients receiving PTX were compared with controls. Our results demonstrate that PMN of patients with sepsis had an increased oxidative response compared with healthy donors. We found that PTX administered intravenously was able to reduce this reactivity. RBA was significantly decreased during PTX infusion when PMN were stimulated with FMLP and phorbol-myristate-acetate, compared with the control group. No significant decrease was observed when PMN were stimulated with opsonized zymosan. These data suggest that PTX may be a valuable drug in septic state.

To investigate the frequency and extent of spontaneous changes (“events”) in continuously measured mixed venous oxygen saturation (SvO2) in septic patients and to determine whether attention to individual event-frequency offers additional information for patient management.

In addition to the invasive haemodynamic monitoring procedures, an on-line assessement of cardiac performance by means of transoesophageal echocardiography might have a certain role in small volume resuscitation of patients with acute respiratory failure or Adult Respiratory Distress Syndome (ARDS). The goal of this investigation was therefore to determine the effects of a hypertonic hyperoncotic solution, hypertonic hydoxyethl-starch (HHES), (HHESHES 200.0000.6-0.66; 60 g I-1; Leopold, Graz; Austria combined with NaCl 75 g I-1) on haemodynamics and cardiac performance using the transoesophageal hocardiography. After institutional approval we investigated 23 patients suffering from septic ARDS after trauma or major surgery during four periods of resuscitation. Phase Icontrol values after infusion of 20 ml kg-1crystalloid solution, phase II50 hypertonic hydroxyethyl-starch solution (2 ml kg-1), phase IIIat the end of HHES (4 ml kg-1), IV30 min after the end of HHES. Before HHES-infusion, all patients showed arterial hypotension with mean arterial pressures of 64±2 mmHg. The infusion of 2 ml kg-1HHES resulted in a significant increase of systemic and pulmonary arterial pressures over the study period. A significant improvement in cardiac output was associated with increasing stroke volumes, oxygen delivery and oxygen consumption (see Tables 1 and 2). Small volume resuscitation also resulted in significant increases of endsystolic and endiastolic left ventricular areas and the corresponding calculated wall stress (Figs 1-3). We conclude from our preliminary data that when using HHES, only modest fluid resuscitation was sufficient to restore adaequate preload and oxygen delivery in patients with sepsis-related acute respiratory failure.

The activity of the sympathetic nervous system during the course of severe closed head injury has been evaluated in 15 patients by measuring plasma levels of epinephrine and norepinephrine. With the onset of the transition stage from midbrain syndrome to the apallic syndrome the plasma levels mainly of norepinephrine started to increase and remained high during the further course of the disease. During the remission from the apallic syndrome the elevated norepinephrine levels started to decline. The data indicate that a longlasting overactivity of the sympathetic nervous system is a characteristic feature in the course of severe head injury.

Abstract

Summary Plasma levels of adrenaline, noradrenaline and octopamine were estimated by a radioenzymatic method in nine cirrhotic outpatients with encephalopathy and in ten patients with hepatic coma (coma grade III–IV). In the cirrhotic outpatients normal as well as elevated plasma levels of noradrenaline were found. Octopamine could not be detected in the plasma of these patients as well as of ten healthy volunteers. Elevated noradrenaline levels were present in all patients with hepatic coma. Plasma noradrenaline remained elevated or even further increased during the course of hepatic coma, whereas adrenaline was elevated less frequently. In eight of the ten patients with hepatic coma octopamine was again not detectable in plasma. Only in two patients high levels of octopamine up to 59.5 ng/ml could be found in addition to increased noradrenaline concentrations. The infusion of the branched chain amino acid L-valine had no influence on the plasma level of either noradrenaline or octopamine.

The activity of dopamine ß-hydroxylase in plasma was studied in 10 patients with various diseases accompanied by a prolonged overactivity of the sympathetic nervous system. Eight of these patients were suffering from head injury, one from tetanus and one from multiple injuries complicated by fat embolism syndrome. Plasma noradrenaline and adrenaline levels were measured concomitantly by a radioenzymatic method. It could be demonstrated that sustained increases of noradrenaline and/or adrenaline levels, which were present for several days or even weeks, were associated with a gradual decline of dopamine ß-hydroxylase activity. The decrease of dopamine ß-hydroxylase activity was more pronounced in those patients with especially high plasma catecholamine levels. In 3 patients only 13–16% of the initial dopamine ß-hydroxylase activity remained after an increase in the activity of the sympathetic nervous system lasting 3–4 weeks. In one of these 3 patients it could be shown that the dopamine ß-hydroxylase activity and the noradrenaline and adrenaline levels in plasma returned to the initial levels after complete recovery. An initial increase followed by a decline was present in these patients with the highest increases in adrenaline levels. The decline in dopamine ß-hydroxylase activity was not due to an increase in endogenous inhibitors, since the activity of a known amount of dopamine ß-hydroxylase was not reduced by adding it to a plasma in which the dopamine ß-hydroxylase activity was decreased.

Within the last decade extracorporeal lung assist has been recommended for the treatment of acute respiratory distress syndrome. However, this recommandation was challenged by several recent clinical studies and reviews. The goal of our analysis was therefore to investigate data on outcome and severity of gas exchange disturbance published from patients treated with ECLA. These data were compared to a historical control group consisting of ARDS patients treated conventionally. Computerized (MEDLINE 1967-95) literature search using the keywords ARDS, ECLA, ECMO, ECCO2R and HUMAN was performed. Only clinical studies published as full papers reporting data on both, patients mortality and oxygenation index (PaO2/FiO2) were included. Overall mean mortality reported was 53±22% in 17 studies (419 patients), with no apparent trend towards a higher survival within the last decade with a mean PaO2/FIO2(14 papers; 61±17 mmHg). However, mean mortality rates of ARDS patients requiring ECLA was 52.3% and 44.9% if patients undergoing ECMO were excluded (3 papers). Therefore the mortality of these patients with severe lung injury was in the range of patients treated conventionally. Patient outcome observed in our analysis is in accordance with the mortality rates from the European ECLA centres published recently (49% in 1993). Therefore, we conclude that the mean mortality rate of patients suffering from severe ARDS treated with ECLA is in the 50% range and does not differ significantly from those of patients treated conventionally, despite significantly poorer pulmonary function.

The plasma levels of adrenaline and noradrenaline were determined by a radioenzymatic method in 6 severely burned patients during the course of treatment and during the surgical procedures. The mean level of noradrenaline of all patients was 0.83±0.48 ng/ml during the first week of treatment, 0.62±0.40 ng/ml during the 2nd week and 0.61±0.42 ng/ml during the 3rd week. The corresponding levels of adrenaline were 0.23±0.20 ng/ml, 0.13±0.08 and 0.08±0.04 ng/ml, respectively. — These levels of catecholamines were lower than those reported in literature. However the surgical treatment provoked a considerable increase of especially noradrenaline intra-as well as postoperatively. This increase was most pronounced during the first operation performed within the 3rd and 13th day after the thermal injury and was independent of the anaesthetic agent used. — The data indicate that adequate infusion, intensive care, warm environment (30–32 °C) and early surgical treatment are important factors in the treatment of burn patients. Additionally warm environment during operation and short operation time are considered to be beneficial.

There is little experience of anaesthesia for patients with Huntington's chorea. These patients have an increased risk of intraoperative complications such as pulmonary aspiration. We present the successful anaesthetic management of a 17-yr-old patient suffering from Huntington's chorea requiring urgent appendectomy. After rapid-sequence induction with thiopental 400 mg and succinylcholine 100 mg, anaesthesia was maintained with sevoflurane. For maintenance of neuromuscular blockade mivacurium 10 mg was administered and repeated 15 min later. Except for a short episode of postoperative shivering, the perioperative course was uneventful. Sevoflurane and mivacurium were used safely and effectively in this patient.