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We describe a patient with severe preeclampsia and postpartum complications in whom we investigated a panel of autoimmune reactions. Case Report: A 27-year-old primigravida was referred at 37 weeks' gestation because of severe preeclampsia. A cesarean section was performed. Postpartum the patient developed severe cardiac dysfunction, thrombocytopenia, eclamptic seizures, and blindness. Immunohistochemical studies of the placenta showed marked deposition of terminal C5b-9 complement complex in intervillous fibrin and in intravillous stroma. Conclusion: The generation of C5b-9 complement complex may be involved in the pathogenesis ofpreeclampsia-eclampsia.

Untersuchungen zur Haufigkeit, Relevanz und Versorgung praklinischer psychiatrischer Notfalle beschreiben bislang lediglich Teilaspekte. Ziel der Untersuchung war die umfassende Darstellung psychiatrischer Notfalle nach Haufigkeit, Diagnose und Therapie. Hierzu wurden die Notarztprotokolle eines norddeutschen Landkreises ausgewertet und parallel Notarzte und Rettungsdienstmitarbeiter hinsichtlich Haufigkeit, Wertigkeit und Umgang mit psychiatrischen Notfallsituationen mittels eines validierten Fragebogens befragt. Danach stellen psychiatrische Notfalle mit 9,2% die dritthaufigste Einsatzursache dar, den grosten Anteil nahmen dabei Suchterkrankungen (70%) ein. Suizidalitat lag bei ca. 33% vor. Eine spezifische Therapie psychiatrischer Erkrankungen findet so gut wie nie statt. Bei der Befragung hielten sowohl Notarzte wie Rettungssanitater psychiatrische Kenntnisse fur wichtig, schatzten die eigenen Kenntnisse aber als nur gering ein. Bei der Beantwortung 5 typischer Notfallsituationen wurde von den Notarzten in 71% die richtige Diagnose (Rettungsdienstmitarbeiter: 39%) und in 32% die richtige Therapie (Rettungsdienstmitarbeiter: 14%) angegeben. Die Fortbildungsbereitschaft war hoch und wurde signifikant wichtiger von Notarzten mit langerer Diensterfahrung beurteilt. Praklinische psychiatrische Notfalle sind haufig und stellen das behandelnde Personal vor grose Anforderungen. Eine ausreichende Ausbildung findet bislang nicht statt. Gefordert sind Fortbildungsprogramme zu Diagnostik und Therapie psychiatrischer Notfalle. Die Motivation zur Teilnahme ist hoch.

Eighty patients undergoing major abdominal surgery using remifentanil-based anaesthesia were randomly allocated in a double-blind manner to receive an intravenous bolus of fentanyl, buprenorphine, morphine or piritramide 20 min before the end of surgery. A reduced dose was administered postoperatively when patients reported moderate pain. Subsequent analgesia was provided by patient-controlled analgesia (PCA). The mean time from the end of anaesthesia to spontaneous respiration was 9 +/- 5 min. At first pain assessment, 63% of patients reported no or mild pain; 80% of patients required the second opioid bolus, those receiving piritramide needed the bolus significantly later than patients receiving buprenorphine or fentanyl. First PCA requirement also occurred significantly later in the piritramide group. This technique provided effective postoperative pain relief and transition to routine PCA and did not compromise recovery.

Fragestellung: Psychiatrische Notfalle stellen die dritthaufigste Einsatzursache fur Notarzte dar, bei untergeordneter Rolle wahrend der Notarztausbildung. Bei aktiv tatigen Notarzten sollen die Relevanz von und Belastung durch psychiatrische Notfalle erfragt, deren personliche Kenntnisse bezuglich der Diagnostik und Therapie evaluiert und der Fortbildungsbedarf bzw. die Fortbildungsbereitschaft bemessen werden. Methodik:Uber einen Fragebogen wurden von 222 Notarzten folgende Angaben erhoben: demographische Daten, Haufigkeit psychiatrischer Notfalle, Belastung durch diese, personliche Kenntnisse, Fortbildungsbedarf und Fortbildungsbereitschaft. Anschliesend sollten psychiatrische Notfallsituationen diagnostisch und therapeutisch beurteilt werden. Ergebnisse: 183 Manner/37 Frauen/2 ohne Angabe des Geschlechts (78,8% Klinikarzte, 20,1% Niedergelassene), durchschnittliches Alter 40,1±6,7 Jahren, Notarzttatigkeit seit 9,6±5,1 Jahren, gaben die Haufigkeit psychiatrischer Notfalle mit 9,4% an. Die personlichen Kenntnisse schatzten 12,7% als gut ein, 14,2% fuhlten sich uberfordert. 73% sehen Fortbildungsbedarf, erfahrene Notarzte signifikant mehr. Fallbeispiele: korrekte Diagnose 65%, korrekte Therapie 33%, richtige stationare Einweisung 74%. Schlusfolgerung: Psychiatrische Notfalle sind haufig im Notarztdienst, eigene Kenntnisse werden von Notarzten uberwiegend als nicht ausreichend eingestuft. Fortbildungsbedarf und -bereitschaft hierzu sind hoch und steigen mit zunehmender Erfahrung.

Documentation of physician-staffed ambulance runs traditionally focuses on information transfer between the prehospital care provider and the receiving hospital. To use this information as a tool for research and quality assurance programs, the German Interdisciplinary Association of Critical Care Medicine developed in a consensus process a protocol for nationwide use. Protocol development was based on the question of what information can be obtained reliably in the emergency medical service (EMS) environment and what questions should be answered by data analysis. The protocol content was evaluated in several pilot studies and focuses on incidents and interventions that occur with reasonable frequency. It was taken into account that due to this approach, not all information that can possibly be obtained during the ambulance run can be documented. For data collection, the concepts of manual processing versus optical scanning are evaluated. The data analysis can serve as a basic tool for screening structure and process quality of EMS systems on a local as well as a nationwide level. During this process, areas for improvement as well as for clinical research are identified.

Colonic surgery patients were studied to measure: the influence of continuous thoracic epidural analgesia (TEA) on a postoperative pain score, the time till onset of defaecation, blood loss, postoperative temperature elevations, rate of bacterial contamination of wounds and urine, and general surgical complications. Group I patients (n = 57) received general anaesthesia and TEA for the operation, followed by continuous TEA (0·25 per cent bupivacaine) for 72 h. Group IIpatients (n = 59) received general anaesthesia for the operation, followed by systemic analgesia on request. Significant beneficial effects of TEA in group I were demonstrated by lower pain scores in the first 24 h after surgery and earlier defaecation. However, there were fewer temperature elevations in group II. There was no significant difference between the groups in terms of positive bacteriological cultures, blood loss, need for postoperative mechanical ventilation and complications. However, there was a trend toward a higher rate of rectal anastomotic breakdown, increased blood replacement and intensive care therapy, and longer hospitalization in group I. These results do not suggest any significant beneficial therapeutic effect of continuous TEA in colonic surgery compared with a conventional systemic analgesic regimen. In selected patients (i.e. those with severe pain or those prone to develop postoperative ileus) continuous TEA may be beneficial.

To determine the epidemiological and clinical significance of invasive fungal infections in non-neutropenic patients in intensive care who stay longer than 10 days on the intensive care unit (ICU).Prospective epidemiological multicenter study over a period of 11 months, based on strict clinical, bacteriological, serological and histological criteria.Six surgical and two medical ICUs units in five university and two municipal hospitals.435 non-neutropenic patients from medical and surgical ICUs with an ICU stay of more than 10 days.A new occurrence of invasive mycosis (3 sepsis/4 peritonitis/1 disseminated candidiasis), corresponding to the protocol conditions with onset after day 10 in the ICU, was detectable in 2.0% (95% confidence interval 0.85 to 3.8%) of the 409 patients who could be assessed. Candida species were identified as an infection-relevant pathogen in all cases. The most important risk factor for the development of an invasive mycosis was the onset of peritonitis by the day 11 in the ICU (odds ratio 11.3; p = 0.003). A fungal colonization was detected in 64% of patients (Candida species 56%, Aspergillus 4%, and other fungi). Six of 8 patients with an invasive mycosis died on the ICU; ICU mortality in patients with fungal colonization was 31% and in noncolonized patients 26%. Serological tests were not helpful clinically. The sensitivity was 88% for the Candida HAT (haemagglutination test) (threshold titer1:160), 100% for the Candida IFT (immunofluorescence test) (threshold titer1:80), and 50% for the Candida Antigen Test (Candtec Ramco, threshold titeror = 1:8), and the specificity was 26, 6, and 73%, respectively. The specificity for the Aspergillus HAT (threshold titer1:10) was 29%.Invasive mycoses are rare in non-neutropenic ICU patients, even after a longer stay in the intensive care unit; fungal colonization, on the other hand, is frequently detectable. The mortality of invasive mycosis--even with systemic antimycotic therapy--was high; the mortality in patients with fungal colonization was not significantly increased compared to that in noncolonized patients. The serological test procedures, Candida HAT, Candida IFT, and the Candida Ramco Antigen Test, had a low specificity and were not helpful in diagnosing relevant invasive mycosis.

The implementation of an experienced pre-hospital care emergency physician as an on the-scene medical command officer (MCO) within the emergency medical service (EMS) is an essential prerequisite to guarantee qualified medical supervision during mass-casuality incidents (MCI). The MCO has four basic functions. Within the administration of the EMS system, he is responsible for the medical aspects of strategic planning for the MCI response. During the MCI the MCO is responsible for the overall assessment of the situation, triage, and supervision of medical treatment by physician and non-physician providers. Aside from extensive personal experience in pre-hospital care, the MCO needs special training to be qualified for this position. State EMS laws provide the legal basis for the MCO within the EMS system.

Documentation of physician-staffed ambulance runs traditionally focuses on information transfer between the prehospital care provider and the receiving hospital. To use this information as a tool for research and quality assurance programs, the German Interdisciplinary Association of Critical Care Medicine developed in a consensus process a protocol for nationwide use. Protocol development was based on the question of what information can be obtained reliably in the emergency medical service (EMS) environment and what questions should be answered by data analysis. The protocol content was evaluated in several pilot studies and focuses on incidents and interventions that occur with reasonable frequency. It was taken into account that due to this approach, not all information that can possibly be obtained during the ambulance run can be documented. For data collection, the concepts of manual processing versus optical scanning are evaluated. The data analysis can serve as a basic tool for screening structure and process quality of EMS systems on a local as well as a nationwide level. During this process, areas for improvement as well as for clinical research are identified.

The preliminary results of a multicenter study designed to determine the utility of the processed EEG in combination with heart rate and blood pressure for estimating anesthetic depth are reported. The study is planned to include 1,000 ASA I, II, and III patients undergoing surgery with at least a 60-minute duration of anesthesia. The preliminary results indicate that the use of EEG and clinical signs may provide better control of anesthetic depth. The study design provides ideal conditions for determining whether spectral edge frequency is a useful criterion for management of routine general anesthesia in a typical clinical environment.

Die grose Bedeutung, die heute der Luftrettung Verletzter und Kranker im Katastrophenfall zukommt, wurde bereits mehrere Hundert Jahre vorausgesehen, bevor der Traum vom Fliegen Wirklichkeit wurde.

Objective: To determine the epidemiological and clinical significance of invasive fungal infections in non-neutropenic patients in intensive care who stay longer than 10 days on the intensive care unit (ICU). Design: Prospective epidemiological multicenter study over a period of 11 months, based on strict clinical, bacteriological, serological and histological criteria. Setting: Six surgical and two medical ICUs units in five university and two municipal hospitals. Patients: 435 non-neutropenic patients from medical and surgical ICUs with an ICU stay of more than 10 days. Measurements and main results: A new occurrence of invasive mycosis (3 sepsis/ 4 peritonitis/ 1 disseminated candidiasis), corresponding to the protocol conditions with onset after day 10 in the ICU, was detectable in 2.0 % (95 % confidence interval 0.85 to 3.8 %) of the 409 patients who could be assessed. Candida species were identified as an infection-relevant pathogen in all cases. The most important risk factor for the development of an invasive mycosis was the onset of peritonitis by the day 11 in the ICU (odds ratio 11.3; p = 0.003). A fungal colonization was detected in 64 % of patients (Candida species 56 %, Aspergillus 4 %, and other fungi). Six of 8 patients with an invasive mycosis died on the ICU; ICU mortality in patients with fungal colonization was 31 % and in noncolonized patients 26 %. Serological tests were not helpful clinically. The sensitivity was 88 % for the Candida HAT (haemagglutination test) (threshold titer > 1:160), 100 % for the Candida IFT (immunofluorescence test) (threshold titer > 1:80), and 50 % for the Candida Antigen Test (Candtec Ramco, threshold titer ≥ 1:8), and the specificity was 26, 6, and 73 %, respectively. The specificity for the Aspergillus HAT (threshold titer > 1:10) was 29 %. Conclusions: Invasive mycoses are rare in non-neutropenic ICU patients, even after a longer stay in the intensive care unit; fungal colonization, on the other hand, is frequently detectable. The mortality of invasive mycosis – even with systemic antimycotic therapy- was high; the mortality in patients with fungal colonization was not significantly increased compared to that in noncolonized patients. The serological test procedures, Candida HAT, Candida IFT, and the Candida Ramco Antigen Test, had a low specificity and were not helpful in diagnosing relevant invasive mycosis.