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Hintergrund: Krankenhausinterne Leit- bzw. Richtlinien sind im Rahmen des „Antibiotic Stewardship“ (ABS) ein wichtiger Baustein zur Steuerung der antiinfektiven Therapie. Wir untersuchten, ob ein Leitfaden die Verordnungspraxis beeinflusst. Methoden: Am Universitatsklinikum Halle (Saale) wurde ein Leitfaden fur die empirische antimikrobielle Therapie und mikrobiologische Diagnostik eingefuhrt. Wichtigste Ziele waren eine Reduktion des Verbrauchs von Drittgenerationscephalosporinen und Fluorchinolonen, eine Verringerung des Selektionsdrucks fur Enterokokken und multiresistente gramnegative Erreger sowie eine Abnahme der Clostridium difficile-Infektionen. Zudem wurde angestrebt, die mikrobiologische Probenentnahmefrequenz als Basis fur verbesserte Deeskalationstherapien zu optimieren. 12 Monate nach Einfuhrung des Leitfadens wurden Veranderungen des Antibiotikaverbrauchs, der Erreger- und Resistenzstatistik sowie der Blutkulturentnahmefrequenz untersucht. Ergebnisse: Der Verbrauch an Drittgenerationscephalosporinen (-18,6 %) und Fluorchinolonen (-9,8 %) war rucklaufig, bei jedoch gleichzeitigem Anstieg des Verbrauchs von Breitspektrum- und Intermediarspektrum-Penicillinen (+ 23,8 % bzw. + 37 %) sowie von Carbapenemen (+ 11,9 %). Das Gesamtvolumen verschriebener Antiinfektiva blieb unverandert. Die Zahl der Enterokokken-Isolate (-18,3 %) sowie der Clostridium difficile-Infektionen war deutlich rucklaufig (-26,3 %). Gramnegative Erreger, insbesondere ESBL-Bildner, wurden im Rahmen ausgeweiteter Screening-Untersuchungen haufiger nachgewiesen. Die Rate an Blutkulturen/1000 Patiententage blieb unbeeinflusst. Folgerung: Hausinterne Richtlinien fur die antiinfektive Therapie erscheinen als ein geeignetes Instrument, um das Verordnungsverhalten und den Selektionsdruck fur einzelne Erregergruppen zu steuern. Der Gesamtverbrauch an Antiinfektiva lies sich dadurch in unserer Untersuchung nicht nennenswert beeinflussen.

Severe infections play an important role in the emergency department (ED) and early risk stratification is essential. We compared the prognostic value of APACHE II, SOFA, and MEDS scores, and the biomarkers C-reactive protein (CRP), procalcitonin (PCT), and interleukin 6 (IL-6). We performed a prospective observational study. Patients aged 18 years or older with a severe infection, from whom blood cultures were taken, were included. Two hundred and eleven patients were included. The 30-day mortality rate was 8.5%. All scores and biomarkers showed significant area under the curve (AUC) values of receiver operating characteristic curve analysis for death within 30 days: 0.801 for APACHE II, 0.785 for MEDS, 0.708 for SOFA, 0.693 for CRP, 0.651 for PCT, and 0.716 for IL-6. For treatment in an ICU and need for mechanical ventilation, these parameters had significant AUC values, too. For renal replacement therapy, only APACHE II, SOFA, and PCT showed significant AUC values. According to the trend observed, the AUC values were highest for the APACHE II score. All investigated parameters have a predictive value in patients with an infection in the ED. According to the trend observed, the APACHE II score seems to have the best discriminative power. Use of the APACHE II score already at the time of admission to the ED may be useful for stratifying patients at risk for ICU treatment, thereby using the same score in the ED and the ICU.

For elderly patients specific medical problems, such as the consequences of aging organs, comorbidities or geriatric syndromes must be considered in the intensive care treatment of acute diseases. Under these circumstances special instruments for geriatric assessment are particularly useful. Up to now geriatrics and intensive care medicine have made complementary contributions in the treatment of severely ill elderly patients. A closer interdisciplinary cooperation of the two disciplines could be of substantial beneficial value in the care of the sick and elderly to overcome the many open questions and pressing problems.

Sepsis in the early stage is a common disease in emergency medicine, and rapid diagnosis is essential. Our aim was to compare pathogen diagnosis using blood cultures (BC) and the multiplex polymerase chain reaction (PCR) test.Methods. At total of 211 patients admitted to the multidisciplinary emergency department of our university hospital between 2006 and 2009 with suspected severe infection from any origin were studied. Blood samples for BC (aerobic and anaerobic) and multiplex PCR were taken for identification of infectious microorganisms immediately after hospital admission. Results of the BC and PCR correlated with procalcitonin concentration (PCT) and clinical diagnosis of sepsis (≥2 positive SIRS criteria) as well as with severity of disease at admission and with clinical outcome measures.Results of the BC were available in 200 patients (94.8%) and PCR were available in 119 patients (56.3%), respectively. In total, 87 BC (43.5%) were positive and identified 94 pathogens. In 45 positive PCRs, 47 pathogens (37.8%) were found. Identical results were obtained in 81.4%. In addition, BC identified 9 Gram-positive and 3 Gram-negative bacteria, while PCR added 5 Gram-negative pathogens. Coagulase-negative staphylococci were detected in blood cultures only (n=20, 21.3%), whereas PCR identified significantly more Gram-negative bacteria than BC. In patients with positive PCR results, the PCT level was significantly higher than in patients with negative PCR (15.0±23.3 vs. 8.8±32.8 ng/ml, p0.001). This difference was not observed for BC (10.6±25.7 vs. 11.6±44.9 ng/ml, p=0.075). The APACHE II score correlated with PCR (19.2±9.1 vs. 15.8±8.9, p0.05) and was also higher in positive BC (18.7±8.7 vs. 14.4±8.0, p0.01). Positive PCR and BC were correlated with negative clinical outcomes (e.g., transfer to ICU, mechanical ventilation, renal replacement therapy, death).In patients admitted with suspected severe infection, a high percentage of positive BC and PCR were observed. Positive findings in the PCR correlate with elevated levels of PCT and high APACHE II scores.

Historisch hat sich die Personalbedarfskalkulation in der Anasthesie von Anhaltszahlen die anhand der Arbeitsplatzmethode entwickelt wurden, hin zur Leistungsmethode (XX-Zeit) entwickelt. Die DRG-Erlose resultieren aus einer Durchschnittskalkulation von Kosten, die aus einer ubertragenen Personalbedarfskalkulation anhand der Leistungsmethode resultieren. Unter DRG-Bedingungen ist im Gegensatz zum Selbstkostendeckungsprinzip eine sehr viel starkere Prozessorientierung erforderlich. Diese Prozessorientierung erfordert auch bei der Personalbedarfskalkulation eine primare Orientierung an der Betriebsorganisation mit Differenzierung zwischen saalbezogenen und nicht-saalbezogenen anasthesiologischen Leistungen. Erst in einem zweiten Schritt wird die in einer festgelegten Betriebsorganisation erbrachte Leistung auf ihre Effizienz uberpruft und ggf. optimiert. Wie fur das Gesamtklinikum gilt auch fur die Anasthesieabteilungen, dass DRG-Erlose und tatsachliche Kosten in Einklang zu bringen sind.

In-house guidelines are an essential tool of antibiotic stewardship (ABS) programs to guide antimicrobial therapy. We studied the effect of in-house guidelines adapted to the local pathogen and resistance epidemiology on prescribing behavior.At the University Hospital Halle (Saale) guidelines for the antimicrobial therapy and essential microbiological diagnostics were introduced. Main objectives were reducing the use of third generation cephalosporines and fluoroquinolones, decreasing selection pressure for enterococci and multidrug-resistant Gram-negative bacteria, minimizing Clostridium difficile infections (CDI), and improving microbiological diagnostics to enhance de-escalation strategies. 12 months thereafter a comparison of antibiotic consumption, pathogen and resistance statistics and use of blood cultures was performed.There was a decrease of third-generation cephalosporines (-18.6%) and fluoroquinolones (-9.8%), while consumption of broad- and intermediate-spectrum penicillins (+23.8% and +37%) as well as carbapenems (+11.9%) increased. The total volume of prescribed anti-infectives remained unchanged. The number of enterococcal isolates (-18.3%) and CDI (-26.3%) decreased considerably. Gram-negatives, particulary ESBL-producing Enterobacteriaceae, were detected more frequently due to an expanded screening program. The rate of blood cultures/1000 patient-days was unaffected.In-house guidelines for the empiric antiinfective therapy appear to be suitable to influence the prescribing behavior and the selection pressure on individual pathogen groups. The total volume of antibiotic prescriptions was not affected in this study.

Ziel der Arbeit: Die Abteilung Anaesthesiologie und Operative Intensivmedizin der Justus-Liebig-Universitat Giessen hat sich 1994 fur den Aufbau eines Anasthesie-Informations-Management-Systems (AIMS) entschieden, um die bisherige manuelle Papierdokumentation abzulosen. Einzelne Aspekte und Ergebnisse dieses Datenpools sollen mit der Fragestellung vorgestellt werden, wie das System in seiner jetzigen Form geeignet ist, die Qualitatsdokumentation nach den Vorgaben der Deutschen Gesellschaft fur Anasthesiologie und Intensivmedizin (DGAI) zu gewahrleisten.

For elderly patients specific medical problems, such as the consequences of aging organs, comorbidities or geriatric syndromes must be considered in the intensive care treatment of acute diseases. Under these circumstances special instruments for geriatric assessment are particularly useful. Up to now geriatrics and intensive care medicine have made complementary contributions in the treatment of severely ill elderly patients. A closer interdisciplinary cooperation of the two disciplines could be of substantial beneficial value in the care of the sick and elderly to overcome the many open questions and pressing problems.

Im Rahmen der praoperativen Abklarung von Patienten mit einem Bauchaortenaneurysma gilt es vor allem, eine Herzerkrankung zu erkennen und deren Schweregrad richtig zu deuten bzw. praoperativ zu behandeln. Folgende kardiale Erkrankungen sind beim Patienten mit Bauchaortenaneurysmen zu berucksichtigen: koronare Herzkrankheit, Herzinsuffizienz, Herzklappenfehler, Herzrhythmusstomngen, arterielle Hypertonie. Erst nach deren Abklarung kann Narkose und Operation durchgefuhrt werden. Hier mussen vor allem drei Fragen individuell fur den jeweiligen Patienten entschieden werden: Pulmonalarterienkatheter ja oder nein, Legen eines Peridualkatheters perioperativ und – fruhzeitige Extubation oder Nachbeatmung?

Historically, calculation of staffing requirements for anesthesia has developed from index numbers derived from the workplace method to the service performance method (XX time). The DRG revenues result from an average calculation of costs that results from an assumed calculation of staffing requirements based on the service performance method. In contrast to the principle of full cost coverage, a much stronger process orientation is needed under the conditions of the DRG system. When calculating personnel needs this process orientation also requires that it be oriented to the organization by differentiating between theater-related and non-theater-related anesthesiological services. In a second step the services rendered in a specified organization are then assessed for efficiency and if necessary optimized. Just as it applies to the whole clinical center, in departments of anesthesiology DRG revenues should be brought in line with the actual costs.

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.

In 1994 the Department of Anaesthesiology and Intensive Care Medicine of the Justus Liebig University of Giessen decided to implement an Anaesthesia Information Management System (AIMS) to replace the previous hand-written documentation on paper. From 1997 until the end of 1998 the data sets of 41,393 anaesthesia procedures were recorded with the help of computers and imported into a data bank. Individual aspects and results of this data pool are presented under the aspect of how the system in its present form is able to guarantee documentation of quality according to the requirements of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI).Since 1997 information on all anaesthesia procedures has been documented "online" with the anaesthesia documentation software NarkoData 4 (ProLogic GmbH, Erkrath). The data sets have been stored in a relational data bank (Oracle Corporation) and statistically processed with the help of the SQL-based program Voyant (Brossco Systems, Espoo, Finland). As an example of two adverse perioperative events (AVB) we compared incidences of "hypotension" and "nausea/vomiting", recorded by staff members into the AIMS, with the incidence of comparable events that were recorded with the help of online data during anaesthesia procedures, such as blood pressure and drug application. Since 1998 data recording has been revised constantly in department meetings; advanced training has been given. The results have been analysed critically.In 1997 the incidence of adverse perioperative events entered manually into the system was 3.6% (grade III and higher 0.9%) and increased during 1998 to 22.2% (grade III and higher 1.9%). The frequency of anaesthesia procedures with manually documented AVBs was significantly below the incidence (determined with the help of online data) of comparable events: "hypotension" (1.8% vs. 8.5%) and "nausea/vomiting" (4.9% vs. 8.3%).The current documentation of AVBs in almost any hospital is incomplete. In contrast to the hand-written procedure, the AIMS provides recorded data for evaluation and guarantees more detailed and complete quality documentation. In addition, the effort needed for documentation is reduced. Whether these data sets really describe and measure quality or not has to be evaluated. In addition it has to be considered whether different requirements (such as automatic AVB recognition for an AIMS) are advantageous for quality documentation regarding the data raster and the AVB recognition, with respect to different documentation procedures.

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.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.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.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.

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.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.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.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.

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.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.Thus, there are no useful parameters that would accurately predict the individual course of a submersion victim.

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.Paediatric surgical patients of a university hospital.Thirty-one children scheduled for major abdominal or urogenital surgery; weight varying between 2.2 and 9.8 kg.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.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).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.

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.

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.

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.

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.

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 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.

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)

Die Berechnung des Pulmonalarterienwiderstands nach dem Ohmschen Gesetz ist unzulassig, da folgende Voraussetzungen nicht erfullt sind: Hagen-Poiseuille-Gesetz, laminarer Flow, homogene Newton-Flussigkeit intravasal und konstant offenes, rigides Gefassystem (Versprille 1984). Daruber hinaus hat die Lungenstrombahn sehr elastische Gefaseigenschaften, so das eine erhebliche Flussteigerung ohne kritische Druckerhohung moglich ist und eine Abnahme des Flusses zu einer passiven Nachregulierung der Gefase fuhrt. Damit sind PVR-Werte stark vom Herzzeitvolumen abhangig, und berechnete Widerstandswerte erlauben wegen der nicht linearen Druck-Flus-Beziehung prinzipiell nicht die Beurteilung einer Widerstandssteigerung (Borst et al. 1957; Leinberger et al. 1975). Ohne diese Probleme kann der pulmonale Gefaswiderstand jedoch anhand pulmonaler Druck-Flus-Kurven beurteilt werden.

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.

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.

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.

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.

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.

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.

Aus den Veranderungen des Saure-Basen-Haushalts in Hypothermie und den Veranderungen in einer Blutprobe bei Abkuhlung unter geschlossenen Bedingungen (McNicol 1967) wird vermutet, das die Korrektur von pH und pCO2 auf Korpertemperatur mit Hilfe von Korrekturfaktoren nicht sinnvoll ist. Dagegen spricht insbesondere, das die CO2-Loslichkeit und die Dissoziationskonstanten je nach Temperatur unterschiedlich sind und die meisten linearen Korrekturkoeffizienten nur fur einen kleinen Temperaturbereich gelten.

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.

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.

Intrapulmonale Rechts-Links-Shunts und die daraus folgende arterielle Hypoxamie sind Zeichen der manifesten respiratorischen Insuffizienz. Ein erhohter pulmonaler Stromungswiderstand wird schon fruhzeitig im Verlauf experimenteller und klinischer Schockzustande beobachtet.

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.