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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.

Single-injection paravertebral block offers adequate unilateral analgesia for thoracic and upper abdominal surgery. This technique is easy to learn but there is a risk, albeit low, of pleural puncture. The aim of the study was to determine whether sonographic measurements of the distances from the skin to the transverse process and to the parietal pleura are useful for calculating the required depth of needle insertion. Before puncture of the paravertebral space, the distances from the skin to the transverse process and to the parietal pleura were measured by sonography. The deviation of the needle from the horizontal plane was measured and an angle correction for the insertion depth was calculated. Twenty-two women undergoing elective unilateral breast surgery were studied. Sonographic visualization of the transverse process and the parietal pleura and measurement of their distances from the skin was successful in all women. Puncture of the paravertebral space failed in one obese woman. There was a very close correlation between needle insertion depth from the skin to the transverse process and the distance measured by ultrasound if angle correction was used (adjusted r2=0.95). Similarly, there was excellent correlation between the angle-corrected ultrasound distance from the skin to the parietal pleura and the distance from the skin to the paravertebral space (adjusted r2=0.92).

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