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The importance of circulating blood (BV) and plasma volume (PV) in critically ill patients and physiological research is unchallenged. Recently, Evans blue (EB) [8, 25] and radioactively labelled serum albumin (RIHSA) [20] have mostly been used as tracers for PV determination. However, the disadvantages of radioactive contamination (RIHSA) and dye accumulation (EB), especially in repeated measurements, are obvious. In addition, recent reports show a possible carcinogenic potential for EB [15, 21]. This has prompted us to examine the feasibility of indocyanine green (ICG), a tricarbocyanine dye currently used for cardiac output and liver blood flow measurements, for the determination of PV. The volume of distribution of ICG has been reported to represent PV [5, 26]. METHODS. In 23 healthy volunteers (19 men and 4 women), PV was determined in duplicate (PV1, PV2) with an interval of 30 min. Before injection a tourniquet was put around the arm and a pressure above the systolic arterial pressure was applied for 2 min. During recirculation, ICG (2.5 mg/ml) was administered in a dose of 0.25 mg/kg as a bolus injection over 5 s via an antecubital vein. Blood was drawn from an antecubital vein of the contralateral arm at 1 min intervals. After centrifugation, the optical density (corrected for blank) was read in a densitometer. Third- to ninth-minute plasma samples were used to calculate monoexponential plasma decay curves. The ICG concentration at injection time was achieved by extrapolation. A calibration curve was generated using 5 different known ICG concentrations. PV was calculated from injected ICG dose divided by ICG concentration at injection time. BV and red cell volumes (EV) were derived from measured PV and hematocrit (hct). RESULTS. Between minutes 3 and 9, tracer decay was monoexponential in all but 1 subject. From minute 10 on the plasma decay of ICG represented another, slower compartment (Fig. 1). The plasma half-life of ICG was 3.2 +/- 0.6 min (mean +/- SD). Mean PVs per body weight and body surface area (BSA) were 44 +/- 5 ml/kg and 1662 +/- 176 ml/m2, respectively. Linear regression revealed PV2 = 0.92.PV1 + 226 (r = 0.92) (Fig. 2). The mean percentage of difference (D) was -0.6%, the methodologic error (SD) +/- 5.7% [27]. Linear regression of PV and BSA revealed PV = 1885.BSA -416 (r = 0.71, P less than 0.0001) (Fig. 3). BV and EV estimates (Table 2) obtained from PV and hct showed reproducibility in the range of the PV determination because of excellent reproducibility of hct measurements. DISCUSSION. ICG plasma half-life times in our experiments were comparable to those reported by other authors [18, 19, 24]. Reproducibility of PV determination was good and was well within the limits of other tracer methods (EB, RIHSA) [17, 27]. Using exclusively peripheral veins for ICG injection and blood withdrawal did not seem to affect the accuracy of PV determination. PV estimates obtained by the ICG method showed good agreement with those known from the literature [7, 10, 25]. Our results correspond especially well with the data reported by Hurley [14] obtained from 481 healthy men using different methods (Evans blue, RIHSA, or labelled red cells).

The HELLP-syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), known as a complication during pregnancy, is associated with preeclampsia and may cause subcapsular liver hematomas. In case of hepatic rupture the lives of mother and unborn are threatened. Therefore, an interdisciplinary diagnostic and therapeutic approach is discussed and compared to two examples. The diagnosis of subcapsular liver hematoma must lead to urgent delivery through Cesarean section. Thereafter, the surgeon may decide between observation on an intensive care unit and urgent operation in case of hepatic rupture, without endangering the unborn.

This study evaluates the measurement of oxygen saturation by arterial catheter oximetry and pulse oximetry. The values are compared to values obtained by CO-oximetry. METHODS. In eight patients undergoing cardiac surgery, we determined the oxygen saturation of arterial and mixed-venous blood by CO-oximetry (IL 282, Instrumentation Lab) at prospectively defined points of measurement before, during, and after extracorporeal circulation. At the same points of measurement, saturation readings obtained by arterial catheter oximetry (U425C, Abbott) and pulse oximetry (Siemens/Nellcor) were recorded. RESULTS. The mean saturation values determined by both catheter oximetry and pulse oximetry differed from the mean values obtained by CO-oximetry by less than 1% (= bias). The standard deviations of the readings in relation to readings of CO-oximetry (= precision) were +/- 0.5% to +/- 1.0% for catheter oximetry and +/- 1.0% to +/- 1.3% for pulse oximetry. Furthermore, it was possible to obtain saturation readings in 99%-100% of measurements by catheter oximetry; in contrast, this was possible by pulse oximetry in only 59%-84% of measurements. Low mixed-venous saturation values were not indicated by any of the arterial methods of measurement. CONCLUSIONS. Catheter oximetry was superior to pulse oximetry with regard to both precision of saturation values and reliability to obtain values. Invasiveness and high costs are disadvantages of catheter oximetry, but if reliable and exact measurements are important at any time during surgery or intensive therapy, intra-arterial catheter oximetry is preferable to pulse oximetry.

Serious injuries of the larynx or trachea during tracheal intubation are rare but potentially life-threatening complications. This case report describes the diagnostic procedures and therapeutic management of an intubation-induced tracheal rupture in a young female patient with a musculoskeletal disorder (rigid spine syndrome). Interdisciplinary treatment requires precise documentation of the extent of the injuries, including advanced imaging techniques. Removal of the endotracheal tube prior to accurate diagnosis can result in immediate airway obstruction. Because of the risk of infection, as a rule surgical treatment is indicated.

The induction of dysrhythmias during or after pulmonary artery catheterization is a serious complication in critically ill patients. The following case presentation reports the incidence of life-threatening ventricular tachycardia after catheterisation in a patient known to have Wolff-Parkinson-White (WPW)-Syndrome. The dysrhythmia began during repositioning of the patient 10 h after placement of the catheter. Attempted inversion by administration of Ajmalin was unsuccessful. Removal of the catheter resulted in prompt cessation of the dysrhythmia.

Ovariectomized ewes were immunized against cortisol, oestrogen or progesterone to determine whether steroids of non-ovarian origin occur in sufficient amounts to influence the reproductive system. Ewes immunized against oestrogen (oestrone + oestradiol) had smaller uteri (P less than 0.05) and a lower concentration of oestradiol in uterine tissue (P less than 0.05), while the adrenal gland was heavier (P less than 0.05). In the peripheral plasma of immunized ewes, the concentration of FSH, but not LH, was increased (P less than 0.05). Ewes immunized against cortisol also had smaller uteri (P less than 0.05) and heavier adrenal glands (P less than 0.05), but gonadotrophins and the concentration of oestradiol in the uterus were unaffected. Immunization against progesterone, or injection with synthetic glucocorticoids, did not affect any of the characteristics measured. We conclude that the adrenal gland of the ewes produced sufficient oestrogen or aromatizable androgen to have significant effects on the reproductive system. In contrast, adrenal production of progesterone did not produce detectable biological effects. Immunization against cortisol did affect the reproductive system, but the mechanism of this action could not be determined.

The adult respiratory distress syndrome (ARDS) is the pulmonary manifestation of multiple organ failure. Respiratory distress, alveolar consolidation and hypoxemia refractory to oxygen are the result of uniform and unspecific morphological reactions of the alveolo capillary membrane. The development of ARDS is most commonly associated with risk factors such as sepsis, trauma, shock or pneumonia. A causal therapy for ARDS is not known. Treatment of the underlying disease, maintenance of arterial oxygenation and prevention of secondary complications are the most important therapeutic measures.