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Physicians, nurses and many other allied health professions join in intensive care as a team for the treatment of patients whose vital functions are either endangered or impaired. Apart from continuous monitoring, which represents the smallest common denominator of all types of intensive-care treatment, intensive-care therapy also encompasses continuous treatment and support of failing organ functions and likewise continuous intensive nursing. The complexity of intensive-care medicine is a strong argument against intensive-care becoming a medical specialty of its own. Nevertheless, the coordination of intensive care-medicine by an experienced intensive care physician is of utmost importance. The present situation in intensive-care medicine is characterised by an increasing tension between new and fascinating medical possibilities (such as right and left ventricular assistance device systems, liver support, pharmacologic treatment of sepsis, avoidance of the complications of critical illness) on the one hand, and limited budgets on the other hand. This conflict is reflected by two basic fears within the population: firstly, the fear that not everything medically possible is being done for the patient due to economic reasons, secondly, a fear of futile treatment at the end of life, merely prolonging inevitable death. Accordingly, ethical questions regarding intensive-care are emerging at all levels of the health system.

Objective: To study airway resistance changes induced by placement in lithotomy position under thiopentone and propofol anaesthesia., Design: Prospective, randomised study., Setting: OR of a university hospital., Patients: Consecutive sample of 36 patients without bronchopulmonary disease (ASA 1-2; 18-78 yr.; 45-100 kg) scheduled for elective surgery in lithotomy position under general (mask) anaesthesia; oral premedication with 0.3 mg.kg-1 dipotassium chloroazeptate on the evening before and in the morning of surgery., Interventions: Injection of either 4-6 mg.kg-1 thiopentone or 2-2.5 mg.kg-1 propofol into a fast running peripheral infusion until loss of eyelash reflex. Placement of an oropharyngeal airway and assisted ventilation via anatomic mask until recovery of spontaneous respiration. Oscilloresistometric determination (Siregnost FD 5; Siemens AG, Erlangen) of airway impedance (ROS) before and after placement in lithotomy position., Results: Before positioning ROS was 3.5 +/- 1.3 mbar.l-1.s-1 and 3.7 +/- 1.1 mbar.l-1.s-1 in the propofol and thiopentone group respectively. After positioning ROS was unchanged in the propofol group (3.8 +/- 1.8 mbar.l-1.s-1) and increased to 4.5 +/- 1.5 mbar.l-1.s-1 (p < 0.05) in the thiopentone group., Conclusion: Lithotomy positioning induces an increase in airway impedance under thiopentone but not under propofol anaesthesia.

Objective: To investigate the occurrence of postoperative nausea and vomiting (PONV) in relation to the menstrual cycle in patients anaesthetised with isoflurane and propofol., Methods: 150 patients were randomly allocated to two groups (n = 75). All patients received antiemetic treatment with 20 micrograms/kg droperidol i.v. before induction of anaesthesia. In the isoflurane group, patients were anaesthetised with thiopental, fentanyl, vecuronium, and isoflurane; in the propofol group, with propofol, fentanyl, and vecuronium. Patients were ventilated with nitrous oxide/oxygen in both groups., Results: Under isoflurane-based anaesthesia PONV occurred in 22 (29%) patients, under propofol-based anaesthesia in 4 (5%) patients (p < 0.05). 41 study participants underwent laparoscopy during the first 8 days of the menstrual cycle. 12 (29%) of these patients developed PONV (p < 0.05 vs second and third phase of the menstrual cycle). 10 of these 12 study participants were in the isoflurane group. Postoperative shivering occurred in 38 (51%) patients anaesthetised with isoflurane and in 12 (16%) patients of the propofol group (p < 0.05)., Conclusions: The incidence of PONV is significantly higher when patients undergo laparoscopy during the first 8 days of the menstrual cycle. When compared to isoflurane, propofol results in a significantly lower incidence of PONV and postoperative shivering and a lower occurrence of postoperative pain.

Objectives: To determine the efficacy and safety of intravascular volume augmentation with a hypertonic saline-hyperoncotic HES solution prior to CABG., Design: Randomized, double-blind, clinical trial., Patients: Consecutive sample of 37 patients scheduled for elective CABG; mean age 64.5 (41-80; range) years and weight 74 (51-111) kg., Interventions: Continuous, central-venous infusion of either 250 ml (approx. 3.5 ml/kg) HES (0.9% NaCl/10% hydroxyethyl starch 200.000/0.5) or HT-HES (7.5% NaCl/10% hydroxyethyl starch 200.000/0.5) in 15 minutes, following induction of anesthesia., Measurements and Main Results: Groups were similar with respect to age, weight, and sex. 15 min. after fluid loading, cardiac index, pulmonary artery pressure, and wedge pressure had increased from baseline in both groups (p < 0.05), with a greater increase in the HT-HES-group (p < 0.05). In eight out of 18 patients, who had received HT-HES, transient drops in arterial blood pressure (mean 20% from baseline, range 10-35%) were observed during the first 5 minutes of infusion. Seven of the HT-HES-group patients developed transient left ventricular failure, predominantly 5-20 min. after infusion. No incidence of initial hypotension or LVF was observed in the HES-group., Conclusions: In patients with coronary artery disease, volume augmentation with hypertonic-hyperoncotic solutions may induce transient hypotension and post-infusion hypervolemic left heart failure.

40 adult patients, ASA class I-III, were studied with regard to their arterial oxygen saturation during transportation from the operating room to the recovery room, following ophthalmic surgery under general anaesthesia. Before transportation the patients were breathing oxygen spontaneously for 6 min.; during transportation they were breathing air. The time for the transport from the operating room to the recovery room was between two and eight minutes. Hypoxaemia (SaO2 85-90%) was observed in 18 cases, severe hypoxaemia (SaO2 less than or equal to 85%) in 5 cases.

The halogenated hydrocarbons halothane, enflurane and isoflurane are used extensively. Like every other anaesthetic, these inhaled agents are not devoid of side effects, most of which are undesirable. This review summarises the similarities and differences between the actions of these vapours. Although isoflurane appears to be more advantageous than enflurane and halothane in certain patients, isoflurane is no panacea and the question of which agent to choose still has to be answered for every patient. A note of caution is warranted against the further use of halothane in adults, as halothane offers no advantages when compared to enflurane and isoflurane but carries a higher risk of hepatotoxicity. However, in children halothane remains the halogenated agent of first choice, when anaesthesia is induced via face mask.

Quality of anaesthesia and risk of intoxication are competing principles in IVRA. To evaluate the optimal prilocaine concentration with injection of 40 ml, 300 patients were randomly allocated to receive either a 0.5 (PRI 0.5), 0.75 (PRI 0.5) or a 1.0 (PRI 1.0) per cent solution. Using PRI 0.5, fifteen patients required supplementary fentanyl, with PRI 0.75 one, and with PRI 1.0 two (p less than or equal to 0.05). General anaesthesia proved necessary in three patients of the PRI 0.5 and 0.75 groups, respectively, and in one patient of the PRI 1.0 group (NS). With PRI 1.0 seven patients had subjective signs of intoxication upon tourniquet release, with PRI 0.75 none, and with PRI 0.5 one (p less than or equal to 0.05). Objective symptoms of local anaesthetic toxicity were not observed. The incidence of tourniquet-related pain was 25-30% in all three groups and not related to the prilocaine concentration. In conclusion, with 40 ml injection volume the 0.75% solution of prilocaine offers the optimal relation between incidence of anaesthesia and risk of intoxication.

A new device attachable to the wall rail systems affords tidy handling of cables in the intensive care unit or the operating theatre.

Because of the complex composition of smoke generated during fires and the possible combination of inhalation injury with other pulmonary complications of burns, the clinical course of inhalation injury is variable. Because clinical manifestations may be delayed several hours and furthermore are not specific, fiberoptic bronchoscopy is most appropriate in diagnosing pulmonary injury at the time of admission. Dominating pathological feature is a membraneous tracheobronchitis. Acute airway occlusion with sloughed bronchial mucosa, oedema formation and pulmonary infection are the most common complications. Treatment includes administration of oxygen, use of bronchodilators, and, when necessary, mechanical ventilation. Supplemental oxygen delivered at high concentrations will increase CO elimination and should be administered to all patients until the blood level of carboxyhaemoglobin has been measured.

Haemodynamic changes (cerebral perfusion pressure, cerebral blood flow) and variations of blood gases (especially paCO2) induced by mechanical ventilation, can influence cerebral function. The cerebral response to these changes is modified by the individual pathophysiology of the cranial contents. The cerebral mechanisms of adaptation allow a safe ventilation of a patient without cerebral disorders, provided ventilation is within normal clinical limits. In patients, however, whose mechanisms of adaption are impaired locally or globally, the pathophysiological situation may become grossly changed by variations in the ventilatory pattern. A therapeutical application of this interaction is controlled hyperventilation to lower intracranial pressure. On the other hand, changes in the ventilatory pattern (variation of PEEP-level, variation of minute volume, bronchial toilet) can impair cerebral function critically. As the individual reactions cannot be predicted in this group of patients, monitoring of haemodynamic parameters (MAP, CVP, CO), blood gases, intracranial pressure, and EEG is of utmost importance.

Up to now there are no systematics of respiratory therapy, although those procedures of "conservative" respiratory therapy are well known since the last century. As ventilation will take over a part or the whole work of breathing of a patient this kind of respiratory therapy must be separated from the conservative therapy procedure, which is the focal point of respiratory therapy. This has been demonstrated by an analysis of respiratory therapy made on two different ICU's. From this analysis a system has been developed encompassing the whole range of respiratory therapy.

The accuracy of oxygen flowmeters is a prerequisite for a predictable oxygen therapy. As a flowmeter seems to be of unlimited service life, they are often not serviced regularly. This can result in errors in the actual oxygen flow of as much as 50% of the preset value.