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In 1994, external quality assurance in anaesthesia according to the German Society of Anaesthesiology and Intensive Care (DGAI) was obligatory introduced in Hamburg. Since 1992 in a pilot project and since 1994 compulsory nearly 500,000 anaesthesias were documented by 39 institutions with a standard data set issued by the DGAI and transferred to the project office of the Association for Quality Assurance (EQS) Hamburg. Comparative statistics of these data were produced at the project office. In the controlling committee and in meetings of the project participants the contents, policy and results of the project were critically analyzed and adjustments initiated whenever necessary. With an incidence of 14.1% of all anaesthesias with special occurrences (AVB), the results are in the same range compared to most other studies. To evaluate the concept of documentation the predictory power of single and combined risk assessments for the incidence of particular AVBs in elective anaesthesias were compared to the predictory power of ASA-Classification in order to reduce the parameters that had to be collected. This should lead to a positive influence on the quality of documentation. Besides one exception, no superior prediction power for AVB incidence could be demonstrated for any special risk assessment as compared with the ASA-classification. This is also true for the AVBs which are associated with high lethality. Thus, the documentation of risk factors in the core data set as predictors can be abandoned without major loss of information. The participants consider the project to be a useful support for internal improvement projects. Besides the reduction of the amount of data in quality assurance to get a core of particularly meaningful parameters the classification of the surgical procedure by the ICPM- or OPS 301-Code should be integrated into the core data set of the DGAI. It would lead to an increase in acceptance of the method and thus to an increase in the validity of its results and valuations.

Objective: The analysis of result variation in quality benchmarking projects in anaesthesia showed that ASA classification was often the most relevant parameter in distinction of risk groups. Thus the parallel description of the risk level of a patient both with the ASA classification and with particular risk parameters was examined critically. The hypothesis was tested that the documentation of both parameter groups in the running quality benchmarking projects does not lead to relevant information gain. As a pragmatic consequence we see the possibility to reduce the core dataset with significant reduction of the documentation workload., Methods: With machine readable protocols or online computer documentation nearly all anaesthesias in hospitals in Hamburg were documented with the DGAI core data set and transferred to the project office of EQS Hamburg since 1992. We compared the predictory power of single and combined risk assessments for the incidence of particular AVBs (grade 3 to 5) in elective anaesthesias with that of ASA-classification., Results: In 257,878 elective anaesthesias AVBs were documented in 14.5% of cases. Besides one exception no superior prediction power for AVB incidence could be demonstrated for any special risk assessment as compared with the ASA-classification. This is also true for the AVBs decompensated cardiac insufficiency, myocardial infarction, pulmonary embolism and cardiac arrest which are associated with high lethality., Conclusion: We assume that the documentation of risk factors in the core data set as predictors can be abandoned without major loss of information. This would be a first step towards reduction of the amount of data in quality assurance to get a core of especially meaningful parameters. It would lead to an increase in acceptance of the method and thus to an increase in the validity of its results.

Purpose: Since 1992 421,851 anaesthesias were documented by 39 institutes with a standard dataset issued by the German Society of Anaesthesiology and Intensive Care (DGAI). The project was run by the Association for Quality Assurance (EQS) in Hamburg. Some results of the evaluation of this datapool are presented questioning the feasibility of the project to support improvement processes within the participating institutions and which adjustments should be done considering these experiences., Methods: Data from machine-readable protocols and documentation software representing all anaesthesia cases were recorded since 1992 in a pilot project and since 1994 compulsory with a standard dataset issued by the DGAI. Comparing statistics of these data was produced at the EQS project office. In the steering committee and in meetings of the project participants the contents, policy and results of the project office. In the steering committee and in meetings of the project were critically analysed and adjustments initiated whenever necessary. Validity of data and feasibility of the method used was also questioned on the background of comparable studies., Results: With an incidence of 14.1% of all anaesthesias with special occurrences (AVB) the results are in the same range if compared with most other studies. However, documentation of data is not complete. This is assumed to be due to the large size of the dataset with 112 items and the additional workload associated with it. Nevertheless the participants mostly consider the project to be a very useful support for internal improvement projects., Conclusion: The project method used so far is not mature yet. The data set must be streamlined and rendered more concise, quality indicators should be defined and tested, and the availability of statistically proven limits of tolerance should be the immediate aims in the further development of the project.

Objective and Study Design: In 115 cases of submersion the initial findings of the rescue team, the patients status in the emergency room and the course of clinical treatment were analyzed retrospectively., Results: Submersion accidents happened preferably in February, March and in the summertime from May to August. Most of the accidents took place in public waters or public baths (85.2%). Children below 10 years of age were involved in 34.8% of the submersion accidents. 57 patients were near drowned and 58 patients were drowned. The prognosis of patients with detectable heartbeat at the site of the accident depends on the primary pulmonary lesion. If respiratory insufficiency is recognized early and treated aggressively by intubation and mechanical ventilation with PEEP, these patients have an excellent prognosis. Only one patient with detectable heartbeat died, typically, after delayed treatment of respiratory failure. 55 patients recovered completely; one patient was suffering from a lesion of the n. medianus. Contrariwise, the prognosis of patients without detectable heartbeat is mainly determined by the consequences of hypoxaemia and is, overall, poor. Though resuscitation succeeds in 50% of submersion victims, only one out of four successfully resuscitated patients survived with little or no neurologic damage. Severe hypothermia may improve the prognosis of submersion victims., Conclusion: Thus, there are no useful parameters that would accurately predict the individual course of a submersion victim.

Objective: To determine how isoflurance affects the longitudinal distribution of pulmonary vascular resistance and pulmonary gas exchange during Escherichia coli bacteremia., Design: Prospective, controlled study with open-label assignment of animals to two groups., Setting: Laboratory., Subjects: Goehingen minipigs., Interventions: Induction of acute respiratory failure by a 4-hr infusion of live E. coli bacteria in 12 animals; six animals anesthetized with methohexital/piritramide; six animals anesthetized with isoflurane. The control group consisted of four animals that received the same surgical procedure, but no E. coli infusion. Two animals were anesthetized with methohexital/piritramide and two with isoflurane, respectively., Measurements and Main Results: Cardiac output and pressures were measured by means of an arterial catheter, Swan-Ganz catheter, and a left atrial catheter. Effective pulmonary capillary pressure was evaluated graphically from a pulmonary artery occlusion pressure decay. Arterial-alveolar PO2 ratio was calculated to evaluate pulmonary function. Measurements were performed before and after 1, 2, and 3.5 hrs of E. coli infusion. Statistical significance was tested with analysis of variance (ANOVA). E. coli infusion caused hypodynamic shock, an increase in pre- and postcapillary pulmonary vascular resistance and respiratory failure. Postcapillary pressure gradient and effective pulmonary capillary pressure were lower in the isoflurane-group. Methohexital-anesthetized animals developed pulmonary dysfunction after 1 hr of bacteremia, whereas isoflurane-anesthetized animals developed pulmonary dysfunction after 3.5 hrs of E. coli infusion (significantly different, ANOVA, p < .05). There were no significant changes in the sham group., Conclusions: Isoflurane is a pulmonary venodilator. During lethal E. coli infusion, it ameliorates the increase in pulmonary capillary pressure and preserves pulmonary function until vascular permeability increases.

Objective: To evaluate the influences of site of measurement, respiratory rate, and tidal volume on end-tidal PCO2 measurement in children ventilated with a non-rebreathing system., Setting: Paediatric surgical patients of a university hospital., Patients: Thirty-one children scheduled for major abdominal or urogenital surgery; weight varying between 2.2 and 9.8 kg., Interventions and Methods: During a relative steady-state situation, end-tidal carbon dioxide partial pressure (PetCO2) was measured at the proximal and distal ends of the endotracheal tube by a sidestream analyser (Datex, Normocap) and between the proximal end of the tube and the Y-piece of the ventilator by a mainstream analyser (Hewlett Packard, HP14265A). PetCO2 was corrected for water vapor and calculated as partial pressure at a barometric pressure of 760 mmHg. At the same time, capillary blood was taken for blood gas analysis. The capillary-end-tidal PCO2 gradient [dPCO2(cap-et)] was computed to compare the three capnometric methods. Statistical analysis was performed with the Friedmann test. Correlations were calculated by means of the least-square fitting method and significance of the correlation was checked with the F-test., Results: dPCO2 (cap-et) did not differ significantly in children with more than 6 kg body weight. In patients less than 6 kg, however, the three capnometric methods revealed significantly different dPCO2 (cap-et) values (P less than 0.01): dPCO2 (cap-et) was 3.0 +/- 4.7 mmHg at the distal end of the endotracheal tube, 5.8 +/- 4.6 mmHg at the proximal end, and 8.7 +/- 4.6 mmHg between the proximal sidestream connector and the Y-piece of the ventilator. There was no correlation between tidal volume and dPCO2 (cap-et) (Fig. 1), however, a significant relation was found between respiratory rate and dPCO2 (cap-et) (Fig. 2) and between respiratory rate and the PCO2 difference between the distal and proximal ends of the endotracheal tube (Fig. 3)., Conclusions: Even in a non-rebreathing system, capnometry is influenced by the site of measurement. In small children with body weight below 6 kg, analysis of an endotracheal sample may provide the best PetCO2 values. In our opinion, dPCO2 (cap-et) in the present investigation was not caused by rebreathing or by pendelluft (a significant correlation between dPCO2 (cap-et) and tidal volume would then have been expected), but was mainly due to ventilation-perfusion mismatch. This may result from high respiratory rates causing inadequate ventilation of lung regions with long time-constants.

Pulmonary hypertension, systemic vasodilation and the supply dependency of oxygen uptake are the major problems associated with sepsis. Thus, the goal of haemodynamic therapy in septic patients is an increase in cardiac output large enough to permit adequate tissue oxygenation. The purpose of this study was to establish whether the additional use of the phosphodiesterase inhibitor amrinone is useful in hypodynamic septic patients with inadequate tissue perfusion. Nine patients who had developed the clinical signs of sepsis (temperature greater than 38.5 degrees C, leukocytosis greater than 15,000/mm3, thrombopenia less than 100,000/mm3 or a drop in platelet count greater than 30%, cardiovascular shock) were given amrinone 30 micrograms.kg-1.min-1 for one hour. All patients showed mixed venous oxygen saturations below 70% and oxygen extraction rates above 30%, despite maximum catecholamine therapy. Haemodynamic parameters were measured with the help of a pulmonary artery catheter. Statistical significance was checked using the Wilcoxon signed-ranks test. During amrinone application cardiac index increased significantly from 4.6.1.81.min-1.m-2 to 5.6 +/- 1.81.min-1.m-2 (p less than 0.01), while central venous pressure was kept constant by volume supply. Mean pulmonary artery pressure remained nearly unchanged, whereas mean arterial pressure dropped significantly from 91 +/- 13 mmHg to 75 +/- 8 mmHg (p less than 0.01). The oxygen supply rose during administration of amrinone by an average of 17%, which led to a rise in oxygen uptake. Independence of oxygen uptake from oxygen supply, however, could not be attained. In septic patients, amrinone increases cardiac output via pulmonary vasodilation. However, pronounced systemic vasodilation lowers arterial blood pressure, enhancing the risk of myocardial ischaemia.

We examined the perioperative course of 1013 patients who had undergone coronary surgery between 1984 and 1987, to identify preoperative examination findings which are suitable as risk indicators in coronary surgery. The features we paid attention to were: anamnestic data, parameters of coronary disease, haemodynamic parameters and accompanying illnesses. We considered a perioperative course as complicated when systolic blood pressure dropped to 80 mmHg or less for longer than 15 min, when reconnection to the heart-lung-machine was necessary, when an intra-aortal balloon counterpulsation was required, when the patient had to have mechanical ventilation for longer than 24 h, when resuscitation took place, or when the patient died in the hospital. The Chi-square test was used for statistical analysis. Very good risk indicators (p less than 0.001) were: age greater than 60 y, resuscitation history, more than two bypass grafts, SvO2 70%, ejection fraction less than 50% and cardiac index less than 2.5 l/min*m2. Good risk indicators (p less than 0.001) were: functional capacity less than 50 watts, more than one previous myocardial infarction and LVEDP greater than 20 mmHg. LCA-stenosis, arterial hypertension with diastolic blood pressure values above 100 mmHg, and obstructive airway disease were identified as suitable risk indicators (p less than 0.05). The following findings were combined with significantly increased mortality: female sex, age over 60 years, two or more previous myocardial infarctions, history of resuscitation, mixed venous oxygen saturation below 70% and the need for three or more bypass grafts for complete revascularisation.

Objective: To determine whether pulmonary artery occlusion pressure (PAOP) accurately reflects left atrial pressure (LAP) in acute pulmonary failure., Design: Sham-controlled laboratory investigation on Goettingen minipigs., Interventions: Induction of acute respiratory failure by a 4-hr infusion of live Escherichia coli bacteria in 11 animals; two animals served as the control group. Anesthesia was obtained with methohexital/piritramide and pancuronium bromide., Measurements and Main Results: Cardiac output and pressures were measured by means of femoral artery, pulmonary artery, and left atrial catheters. Arterial-alveolar Po2 ratio was calculated to evaluate pulmonary function. Measurements were obtained before and after 1 and 2 hr of the E. coli infusion. Statistical significance was tested with analysis of variance. E. coli infusion caused the hypodynamic shock and respiratory failure. The PAOP-LAP gradient was -0.3 +/- 1.6 mm Hg before bacteremia and increased significantly (p less than .001) to 2.9 +/- 1.8 and 3.4 +/- 2.0 mm Hg after 1 and 2 hr of bacteremia, respectively. No significant changes occurred in the sham group., Conclusions: A PAOP-LAP gradient may develop during acute respiratory failure. Therefore, pulmonary venous vascular resistance may be underestimated if its determination is based on PAOP. An increase in bronchial to pulmonary blood flow and pulmonary venoconstriction are discussed as hypothetical causes of a PAOP-LAP gradient during acute respiratory failure.

In 9 Goettingen minipigs we studied the effect of E. coli bacteremia on effective pulmonary capillary pressure and the longitudinal distribution of pulmonary vascular resistance. Precapillary pressure gradient (dPa) was calculated as the difference between mean pulmonary artery pressure (MPP) and effective pulmonary capillary pressure (Pc) (dPa = MPP-Pc), postcapillary pressure gradient (dPv) as the difference between Pc and left atrial pressure (dPv = Pc-LAP). The disturbance of pulmonary gas exchange was quantified by the AaDO2 quotient 1-PaO2/PAO2. Live E. coli infusion resulted in hypodynamic circulatory failure. Cardiac index fell from 3.7 +/- 0.81 . min-1.m-2 to 2.2 +/- 0.71 .min-1.m-2 after bacteremia lasting for 3.5 h. Simultaneously venous pulmonary vascular resistance rose from 25% of total pulmonary vascular resistance before to 32% after 3.5 h bacteremia, thus raising Pc from 11 mmHg to 16 mmHg. The degree of respiratory insufficiency was correlated with changes of MPP, dPa and dPv: 1-PaO2/PAO2 = 0.2 + 0.035.dPv (r = 0.829). Our results show, that the longitudinal distribution of pulmonary vascular resistance changes during septicemia, thus raising Pc. This may be an important factor in the genesis of septic pulmonary failure.

Prehospital emergency patients, especially with polytrauma and/or severe head injury need sedation for intubation and transportation. The use of relaxant drugs is dangerous under these circumstances. The "ideal drug" for this indication should not have any harmful effects on respiration, circulation, intracranial pressure, and should facilitate intubation. Short action without cumulation is desirable to make an early neurological diagnosis possible. Althesin was studied in our rescue service (ambulance and helicopter) in 133 cases (trauma n = 91, neurologic n = 18, cardiologic n = 12, intoxication n = 12), Althesin facilitated intubation in 129 cases, and was generally sufficient for sedation. Negative side effects were not seen provided althesin was correctly used. The necessity of the preceding use of an antihistaminic drug is emphasized. Althesin should not be used in patients suffering from severe cardiac disease because of its possible negative influence on cardiocirculatory function.

Hirudin causes a rapid inhibition of blood coagulation as shown by in vitro and in vivo experiments in the dog. The substance appears to be a rather specific antithrombin. Its inhibitory action is linearly dose related and therefore easy to control and reproduce. Side effects can be expected to be abolished after further purification of the substance.

Conventional methods for the replacement of nasotracheal tubes are often dangerous. The interruption of respiration while replacing the nasotracheal airway may cause severe hypoxia. We developed a technique which shortens the time of apnoe to a few seconds. A 16F nasogastric tube is connected to a simple jet ventilation device driven by 100% oxygen. The nasotracheal tube is disconnected from the respirator and its cuff deflated. While performing jet ventilation (inspiration time 1.5 sec, frequency 12/min., pressure 1.5-2 bar) the nasogastric tube is threaded into the nasotracheal tube until the tip lies inside its distal end. The old endotracheal tube can now be retracted over the nasogastric tube under continuous jet ventilation. The nasogastric tube need only be disconnected from the jet ventilator for a few seconds while the old endotracheal tube is replaced for a new one. Now the new endotracheal tube is guided into the trachea by the nasogastic tube while jet ventilation is continued. We used this technique 19 times without any complications. We found the method safe and simple, giving sufficient ventilation in all patients, provided that contraindications and precautions are observed.

Twenty-six anesthesized mongrel dogs were subjected to a standardized traumatic hemorrhagic shock. Compared with the control group prophylactic treatment with high doses of methylprednisolone reduced functional and histologic alterations of the lung. Methylprednisolone in combination with heparin pretreatment prevents microthrombi but produces more alveolar bleeding.

The significance of pulmonary pressure-flow relation and its correlation to alveolar dead space and histological lesions of the lung were evaluated in ten mongrel dogs, which were subjected to standardized bone trauma and hemorrhagic hypotension at 40 mm Hg for 3h. These results were compared with those of 5 control dogs without trauma and shock. Two different pressure-flow curves were obtained by consecutive measurements of cardiac output and mean pulmonary artery pressure during stepwise arterial hemorrhage and reinfusion. In each experiment, the difference between the two curves at CO of 100 ml/kg min was obtained and represents an increase in pulmonary artery pressure (delta MPP). This increase in pulmonary artery pressure is flow-independent and, therefore, can be used as a quantitative indicator of pulmonary vasoconstriction or vascular obstruction. Severity of shock (uptake) as well as grade of early histological lesions of the lung (microthrombi, edema, hemorrhage) and increased alveolar dead space after reinfusion were associated with a more pronounced shift of the pulmonary pressure-flow curve. In severe experimental shock, therefore, a consistent pattern of pulmonary hemodynamics, lung histology, and respiratory function was demonstrated by the pulmonary pressure-flow relation. This approach permits estimation of the effects of therapeutic interventions and may be suitable for assessing postshock pulmonary impairment.

Time and accuracy required for diagnosis are two of the most important factors in medical microbiology. Computer-assisted diagnosis is one tool to overcome these problems. The software of such systems, much more than the hardware, is of utmost importance and both have to fulfill several items. 1) High flexibility and integration within the already existing working schemes of the laboratory. 2) Terminals in every laboratory. 3) High speed of calculation. 4) Online data transfer from automated instruments. 5) External terminals on intensive care units. 6) Epidemiological and etiopathological investigations have to be possible at any time. In the laboratory the burden of simple, repeating tasks is diminished, inquiries can be made in a minute and precise information about the epidemiological situation can be gained within a few hours. Thus, calculated antimicrobial therapy depending on the incidence of certain pathogens in given specimens in different departments is possible. In the case of fast-growing bacteria, preliminary reports, including susceptibility testing available within the first 24 h, are possible and will be of great help to the clinician in monitoring the calculated antimicrobial regimen. External terminals will allow continuous flow of data from the laboratory to wards and vice versa.

Three cases of severe carbon monoxide poisoning are described presenting with deep coma, generalised extensor spasms and myoclonia as symptoms of acute midbrain syndrome. Despite this poor prognosis all patients survived without essential neurological impairment. This favourable outcome is thought to be due to the administration of thiopentone for the amelioration of hypoxic brain damage in dosages commonly employed in anaesthesia.

Twenty mongrel dogs are subjected to a standardized traumatic hemorrhagic shock. After reinfusion of the dogs' own blood the animals are continuously observed for the 72 hr. Deterioration of general hemodynamics and activation of intravascular coagulation is more pronounced in the nonsurviving animals. Correspondingly, histologic alterations particularly of the liver and intestine are more marked in the nonsurvivors. Increase of partial thromboplastin time and long-lasting increase of the prothrombin time (Quick) appear to be early signs of a fatal prognosis.

Between the end of 1979 and the beginning of 1984, the authors served as anaesthetists for Red Cross missions in surgical field hospitals on the Thai-Cambodian and the Afghan-Pakistan borders, in Lebanon, and in Indonesia. A total of 3665 civilian emergency patients were anaesthetised. 643 were operated on under local anaesthesia; 639, under regional anaesthesia, in most cases spinal anaesthesia. In spite of principal preference for local and regional anaesthetic techniques, 65% of the patients (2383 patients) were managed under general anaesthesia, which was maintained with halothane in 947 cases and ketamine in 1345 cases. 877 general anaesthesias with ketamine were performed with spontaneous breathing of ambient air; endotracheal anaesthesia was necessary in 1238 patients. In spite of the high risk for the patients and of the operative interventions and in the light of the simple and sometimes even primitive working conditions, no anaesthesia-related fatalities occurred. Postoperative lethality was 2%. In all cases, the duties of the anaesthesist involved more than performance of anaesthesia, which was sometimes assigned to paramedics. Other duties included preoperative examination, postoperative intensive care, consultation services in nonsurgical emergency cases, resuscitation, and training of local assistants.

The clinical efficacy and safety of a new pseudomonas hyperimmune globulin for intravenous administration were examined in 30 patients in a prospective randomized study. Although the statistical evaluation of the measurable parameters did not show relevant differences between the therapy group (n = 15) and the controls (n = 15), the clinical course of the disease was markedly better in patients treated with hyperimmune globulin. In the control group, three patients died from Pseudomonas aeruginosa infections, but none in the therapy group. The preparation was very well tolerated.

A severe shock is produced in 18 mongrel dogs by standardized bone trauma and haemorrhagic shock. Impairment of microcirculation is demonstrated by acidosis, reduced oxygen uptake and disseminated intravascular coagulation (DIC). Further, a specific increase in pulmonary vascular resistance--independent of the reduction in blood flow--is evoked, concomitantly with the occurrence of microthrombi, oedema and haemorrhage in lung tissue. Pretreatment with heparin inhibits disseminated intravascular coagulation and reduces impairment of microcirculation and the consecutive damage of intestinal organs. However increase of pulmonary vascular resistance is unchanged and pulmonary haemorrhage is pronounced. Therefore heparin pretreatment enhances pulmonary histologic impairment after trauma and haemorrhagic shock.

The value of successful cardiopulmonary resuscitation (CPR) must be considered in the light of late outcome of survivors, including the neurological situation as well as the subsequent quality of life. We followed up the fates of 168 patients (pts) primary successfully resuscitated by rescue helicopter and mobile intensive care unit of the rescue centre at the military hospital of Hamburg and admitted to emergency hospitals after heart action became stabilised. 130 pts died during hospitalisation and 38 pts (7.9% of 480 resuscitation attempts total) were discharged from hospital. 32 of them had no essential neurologic damage. Within the next 3 years after discharge from hospital 15 of the 38 survivors died (3-year-survival rate: 4.8% of all attempts of CPR or 60% of survivors). 4 of the 6 survivors with persistent cerebral damage died within 6 months after discharge from hospital. Interviews (n = 28) with survivors or their relatives provided information on social situation, physical and psychical condition after CPR as well as recollection of CPR. 29% (n = 8) became incapacitated for work after CPR. 68% considered meaning of life unchanged, 25% as limited and for 7% the incident had a positive effect concerning their outlook on life. 18% (n = 5) suffered from depressions after CPR. Reductions of physical efficiency (64%), of memory (68%) and of concentration capacity (61%) were realised. The majority of survivors did not remember anything, neither experiences of intubation nor of external cardiac massage. Only one patient thought he remembered the incident and reported about "blows on the chest". 89% considered resuscitation to be a sensible and important provision.(ABSTRACT TRUNCATED AT 250 WORDS)

Logistic reasons gave rise to construction, production and application of an external fixation made of the wood of the rubber-tree (ficus elastica) during the treatment of Cambodian war-injured patients at the field hospital of Khao I Dang. Round pieces of wood 1.5 cm respectively 2 cm in diameter, with drill-holes (diameter 3.2 mm) for the "Steinmann"-nails were planed from well-seasoned planks of the Jang-tree. For the treatment of 25 open fractures - the wooden fixation proved to be the best solution.

For respiratory monitoring of spontaneously breathing patients in the operation theatre, recovery room and intensive care ward a gauze attached on the nose may be used successfully. This continuous optical and practically cost-free aid has proved to be valuable in such cases when electronic monitoring is not available.

The clinical efficacy and safety of a new pseudomonas hyperimmune globulin for intravenous administration were examined in 30 patients in a prospective randomized study. Although the statistical evaluation of the measurable parameters did not show relevant differences between the therapy group (n = 15) and the controls (n = 15), the clinical course of the disease was markedly better in patients treated with hyperimmune globulin. In the control group, three patients died from Pseudomonas aeruginosa infections, but none in the therapy group. The preparation was very well tolerated.

Extracorporeal circulation (ECC), with its shock-like pulmonary perfusion, leads to pathomorphologic and functional pulmonary changes, the postperfusion syndrome. This study investigated the effects of different types of ventilation during ECC on postoperative pulmonary function and the resulting pulmonary blood gas changes. METHOD. Thirty patients scheduled for aortocoronary bypass surgery were studied. Patients with pre-operative left ventricular end-diastolic pressures exceeding 15 mmHg or signs of right ventricular failure, pulmonary hypertension, or pre-existing pulmonary disease were excluded. The patients were randomly assigned to one of the following three groups: Group 1 (n = 10): static pulmonary inflation during ECC, PEEP 5-10 cm H2O, F1O2 1.0; Group 2 (n = 10): low-frequency ventilation during ECC, rate 10/min, PEEP 5 cm 5H2O, F1O2 1.0; Group 3 (n = 10): medium-frequency ventilation during ECC, rate 120/min, PEEP 5 cm 5H2O, F1O2 1.0. The measurements were made under relative steady-state conditions before the start of surgery and postoperatively after an equilibrium phase of at least 15 min. During ECC using a bubble oxygenator (Bentley BOS 10 S) in moderate hypothermia, blood was aspirated from the pulmonary artery during inflation of the wedge balloon and blood gases were analyzed. Postoperative changes in pulmonary function were evaluated by venous admixture (QVA/Qt); changes in pulmonary vascular resistance after ECC were determined using the pulmonary pressure-flow relationship. RESULTS. In group 1, QVA/Qt rose significantly from 9.6 +/- 2.9% preoperatively to 13.6 +/- 3.5% postoperatively (P less than 0.05, t-test for paired samples). In groups 2 and 3, postoperative QVA/Qt was significantly lower than preoperative QVA/Qt (P less than 0.05; group 2: preoperative 11.9 +/- 3.5%, postoperative 8.1 +/- 2.6%; group 3: preoperative 11.9 +/- 3.0%, postoperative 7.8 +/- 3.2%; Fig. 1). The postoperative pulmonary pressure-flow relationship changed similarly in all three groups (Fig. 2). During ECC, blood aspirated from the pulmonary artery during inflation of the wedge balloon was fully oxygenated with a hematocrit approximating that of arterial blood. In ventilated patients, pO2 during ECC was higher in pulmonary arterial blood than in arterial blood. Pulmonary ventilation during ECC did not lead to pulmonary arterial alkalosis. CONCLUSIONS. Pulmonary ventilation during ECC can prevent a post-operative increase in venous admixture. ECC-related pulmonary vascular changes were not affected by ventilation. Middle-frequency ventilation offers no advantage over low-frequency ventilation during ECC, except that the operating field is more quiet.

26 mongrel dogs are subjected to a standardized bone trauma followed by a hypotonic hemorrhagic shock. Compared with a control and heparin group prophylactic treatment with Dipyridamol and Acetylsalicylic Acid decreases pulmonary vascular resistance significantly. After an initial period of hyperocagulability secondary fibrinolysis develops. The decrease of the fibrinogen level and the fall of total platelet count after trauma and hemorrhage can partly be prevented by the application of heparin, likewise the development of pulmonary microthrombosis. Histological examination shows a markedly diminished pulmonary microthrombosis.

480 preclinical cardiopulmonary resuscitations performed at the Emergency Center of the Federal Military Hospital in Hamburg were analysed. The late success was 7.9%, i.e., 38 patients were released after initially successful resuscitation and subsequent clinical treatment. Prognostic parameters indicating late success were deduced from the data. The age of the patients, call times, and organisational course do not influence the survival rate. For this reason resuscitation should be attempted in every patient, even in those with longer transport times, and if resuscitation proves unsuccessful, the measures should be discontinued at the site. Patients with multiple injuries or craniocerebral trauma, who require resuscitation, and patients with asystole, who are older than 70 years of age, do not survive. Even in young patients, the prognosis for asystole is extremely poor. Although the prognosis for patients with ventricular fibrillation is better, we are of the opinion that the success rate of preclinical cardiopulmonary resuscitations can be improved by systematic use of antiarrhythmics; metaproterenol sulfate should no longer be administered. The prognosis of resuscitated patients with contracted pupils and gasping breath and of patients with severe tachycardia is relatively good. Cardiac arrest after drowning carries best prognosis: 4 of 7 patients survived.

Pulmonary complications are among the key factors responsible for the postoperative morbidity and mortality after esophagectomy. The thoracotomy by itself as well as the duration of the operation do not seem to increase the frequency of pulmonary complications. Preoperative poor respiratory function and especially a high perioperative blood loss significantly increase the risk for postoperative pneumonia. The postoperative pulmonary risk after esophagectomy seems to be closely correlated to the AaDO2 quotient in the early postoperative period.

This investigation is based on 140 autopsy protocols of unsuccessful resuscitation procedures (Resuscitation Center of the Army Hospital, Hamburg); injections and closed-chest cardiac massage had been performed in every case. - Most of the patients had collapsed because of cardiac shock; patients with thoracic or abdominal injury were excluded from this study. In individual cases only, the following severe complications originated from the resuscitation procedures: fracture of a chest vertebra, serial fractures of ribs resulting in an unstable thorax, bilateral haemothorax, tension pneumothorax, rupture of kidney and of spleen (but not of liver). In one case the lesions caused by the resuscitation measures must be considered as responsible for the lethal outcome. Fractures of ribs and/or sternum were found in 45.9% of all cases, the frequency increasing with age. The number of fractured ribs ranged up to 16, mainly 3-8 ribs were fractured. Fractures of rib No. 1 and 8-12 were very rare. The fractures were located between the parasternal and axillary lines.--In a comparative study the site of rib fractures after heavy blunt thoracic injuries was preferably found in the dorsal region.

A 71 year-old woman was admitted for transurethral resection of bladder carcinoma. The procedure was performed under spinal anaesthesia with mepivacaine 4% hyperbaric. The procedure was carried out without any technical problems. Despite appropriate positioning the patients spinal anaesthesia spread slowly cephalad. 60 minutes after injection of the local anaesthetic aphonia and respiratory insufficiency occurred. The patient was intubated and controlled ventilation was started. 4 hours later the tube could be removed again. 6.5 hours after performing the block no residual block could be detected. The authors discuss the aetiology of this rare complication. It is recommended to keep all patients under continuous anaesthesiologic supervision where the spread of spinal anaesthesia is not definitely declining.