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Background: Since 2011 palliative care has been a compulsory part of the German medical study course (so-called Q13 palliative and pain medicine). Palliative care content does not, however, as often taught, have to focus only on patients in the so-called palliative stages of disease. The aim of this investigation was to encourage a discussion concerning the integration of palliative care aspects into general medical treatment.Methods: For data collection an open discussion of the main topics by experts in palliative medical care was used. The main outcome measures and recommendations included responses regarding current practices related to expert opinions, national and international literature and one case report. The literature search was performed using the databases "PubMed", "Medline" and "Google" (1990-2011).Results: As an important consensus, the following recommendations for optimization of inpatient and outpatient care were: (1) integration of aspects of palliative care into medical curricula of all disciplines, (2) palliative care content should be extended to the general optimization of therapy for all patients, (3) palliative medicine should be part of the everyday medical practice in all disciplines and (4) palliative medicine should not be isolated as "death medicine" or medicine of the dying patient.Conclusions: Palliative care treatment is increasingly becoming integrated into medical education and into medical curricula of all disciplines. Palliative ideas and goals are focussed on patients in the so-called palliative stages of disease. Furthermore, palliative medicine is often described as the medicine of dying patients. As a result of this study it seems to make sense to extend palliative care aspects to all patients and to all patient care. The extent to which such opportunities exist and such health care is economically feasible remains to be the subject of further clinical studies. [ABSTRACT FROM AUTHOR]

Background: At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients.Methods: For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources.Results: As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment.Conclusions: Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive palliative care patients in emergency medical situations are necessary. [ABSTRACT FROM AUTHOR]

Certification is a compulsory element of today's quality management. However, the instruments used for certification have mostly originally been developed for industrial purposes. Even with tried and tested adaptation to hospital structures, transferring these instruments to the medical environment implies partial negligence of outcome quality. This fact is due to the multidimensional structure of medical outcome quality, which cannot be reduced to only one indicator. This review describes the necessity to develop a specific indicator system, which is needed for an objective, reliable and valid system of certification for intensive care units. The second part of the review describes the current efforts which are being undertaken to develop such a certification system for German intensive care units. Until this new system has been validated, certification of intensive care units is of limited value for evaluating the quality of intensive care units in Germany. [ABSTRACT FROM AUTHOR]

Background: Intensive care unit (ICU) patient care bases - among others - upon the staff's assumptions about each patient's subjective preferences and experiences. However, these assumptions may be skewed and thus result in client-professional gaps (cp-gaps), which occur in two subtypes, hyperattention and blind spots to certain burdens. cp-gaps typically reduce quality of care. We investigated whether cp-gaps of either subtype exist in a 36-bed ICU of a university hospital., Methods: Observational study on 82 consecutive patients of a 36-bed university ICU, who voluntarily answered a psychometric questionnaire focusing on patients' experiences during an ICU stay. The questionnaire was reliable and valid (Cronbach's alpha, factor analysis). It consisted of 31 Likert-scaled items, which represented three scales of perception (communicative, intrapersonal, somatic) supplemented by 55 binary items for more specific information. Details of the questionnaire are given in the text. Demographic, educational, and medical data were registered too. Patients reported their subjective ICU experience 2-7 days after ICU discharge. Analogously, 60 staff members (physicians and nurses) reported their assumptions about patients' experiences. After correction for a general bias, group differences indicated cp-gaps., Results: Twelve cp-gaps were found. Hyperattention was found in four communicative and three intrapersonal items. Blind spots appeared in two communicative, two intrapersonal, and one somatic item. The pattern of cp-gap subtypes (hyperattention/blind spots) goes well with self-attributional bias - a model of social interaction., Conclusions: cp-gaps in ICUs can be identified using analogue questionnaires for patients and staff. Both subtypes of cp-gap occur. cp-gaps are substantially influenced by self-attributional bias., (© 2013 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

The accompaniment of people in the face of death offers insights into dimensions which are mostly not seen in ordinary life. These insights also exist in intensive care in German hospitals and are highly relevant in medical decision making. End-of-life decisions in particular often determine medical, cultural and spiritual aspects concerning medical treatment and therapeutic targets and if necessary new therapy targets. The following article especially illuminates cultural aspects and their characteristics in patients at the end of life in the intensive care unit.

Background: Hyperbaric prilocaine 2 % has been available for spinal anesthesia in Germany for 2 years and is characterized by a short duration of action, a lack of postspinal urine retention and a reduction of transient neurological syndromes. However, desirable pharmacological properties are contrasted by higher pharmacological costs compared to hyperbaric bupivacaine 0.5 %., Materials and Methods: This paper deals with a sensitivity analysis for the use of hyperbaric prilocaine 2 % versus hyperbaric bupivacaine 0.5 % in Germany and investigates the financial break-even point up to which time a shorter patient stay in the recovery area compensates for the higher costs for the use of prilocaine 2 % for ambulatory spinal aaesthesia. A sensitivity analysis is an instrument of investment appraisal. It is a model to reduce a complex system with numerous variables to a straightforward calculation by assuming a framework requirement and systematically changing only one or two variables. In this paper additional costs for spinal anesthesia have been neglected, only the time a nurse spends with the patient in the recovery area and the costs for each vial of drug have been taken into account., Results: For the assumption of 75 min time until leaving the recovery area and being discharged after spinal anesthesia with hyperbaric prilocaine 2 % versus 150 min (recovery of motor competence) or 405 min (voiding) with hyperbaric bupivacaine 0.5 % the calculation shows a cost benefit for hyperbaric prilocaine 2 % of EUR 11.64 or EUR 64.76 compared to hyperbaric bupivacaine 0.5 % and EUR 13.32 or EUR 66.44 compared to isobaric bupivacaine 0.5 %. Under the assumption that all patients who have received spinal anesthesia with hyperbaric bupivacaine 0.5 % can be discharged from the recovery area after 150 min, the use of hyperbaric prilocaine 2 % remains more economical as long as the patient is discharged from the recovery area within 130 min. If 405 min recovery time is assumed for hyperbaric bupivacaine 0.5 % the costs compared with hyperbaric prilocaine 2 % will be compensated after 300 min. To be more economical compared to patients with hyperbaric prilocaine 2 % those who received hyperbaric bupivacaine 0.5 % must be discharged from the recovery area within at least 100 min. However, a time of less than 160 min for discharge from the recovery area is not published anywhere in the literature. In summary, the use of hyperbaric prilocaine 2 % for 60 min operation time is cheaper than the use of bupivacaine 0.5 % as long as patients do not stay in the recovery area for longer than 120 min and are discharged from the recovery area., Conclusions: For German framework conditions the use of hyperbaric prilocaine 2 % can provide an economical advantage compared to the use of hyperbaric bupivacaine 0.5 % if staff assignment can be flexible.

Introduction: Neutrophil granulocytes are the first defense line in bacterial infections. However, granulocytes are also responsible for severe local tissue impairment. In order to use donor granulocytes, but at the same time to avoid local side effects, we developed an extracorporeal immune support system. This first-in-man study investigated whether an extracorporeal plasma treatment with a granulocyte bioreactor is tolerable in patients with septic shock. A further intention was to find suitable efficacy end-points for subsequent controlled trials., Methods: The trial was conducted as a prospective uncontrolled clinical phase I/II study with 28-day follow-up at three university hospital intensive care units. Ten consecutive patients (five men, five women, mean age 60.3 ± 13.9 standard deviation (SD) years) with septic shock with mean ICU entrance scores of Acute Physiology and Chronic Health Evaluation (APACHE) II of 29.9 ± 7.2 and of Simplified Acute Physiology Score (SAPS) II of 66.2 ± 19.5 were treated twice within 72 hours for a mean of 342 ± 64 minutes/treatment with an extracorporeal bioreactor containing 1.41 ± 0.43 × 10E10 granulocytes from healthy donors. On average, 9.8 ± 2.3 liters separated plasma were treated by the therapeutic donor cells. Patients were followed up for 28 days., Results: Tolerance and technical safety during treatment, single organ functions pre/post treatment, and hospital survival were monitored. The extracorporeal treatments were well tolerated. During the treatments, the bacterial endotoxin concentration showed significant reduction. Furthermore, noradrenaline dosage could be significantly reduced while mean arterial pressure was stable. Also, C-reactive protein, procalcitonin, and human leukocyte antigen DR (HLA-DR) showed significant improvement. Four patients died in the hospital on days 6, 9, 18 and 40. Six patients could be discharged., Conclusions: The extracorporeal treatment with donor granulocytes appeared to be well tolerated and showed promising efficacy results, encouraging further studies., Trial Registration: ClinicalTrials.gov Identifier: NCT00818597.

The economical pressure on the health system and especially on hospitals is growing rapidly. Hence, economical knowledge for people in medical executive positions becomes imperative. In advanced and forward-looking hospitals controlling is gaining more and more weight, because it takes over a coordinative responsibility. Ideally controlling is navigating the teamwork of managers (CEOs) and medical executives by weighing medical necessities and economical framework. Controlling is contributing to evaluate an optimal efficiency of a hospital in a highly competitive surrounding by providing medical and economical data on a regular basis. A close, open-minded and trusting cooperation between all people, who are involved, is imperative. Hence, controlling in the proper meaning of the word can not flourish in dominant and hierarchic hospital structures., (Georg Thieme Verlag Stuttgart * New York.)

Introduction: Acute lung injury (ALI) is an inflammatory disorder of pulmonary or extrapulmonary origin. We have previously demonstrated that netrin-1 dampens murine ALI, and in an attempt to advance this finding into future clinical practice we evaluated whether netrin-1 would reduce alveolar inflammation during porcine ALI., Methods: This was a controlled in vivo experimental study in pigs. We induced ALI through lipoploysaccharide (LPS) infusion (50 μg/kg) for 2 hours. Following this, we exposed animals to either vehicle, intravenous netrin-1 (netrin-1 i.v.) or inhaled netrin-1 (netrin-1 inh.). Serum samples and bronchoalveolar lavage (BAL) were obtained to determine levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, interleukin-6 and interleukin-8 at baseline and 6 hours following treatment. Myeloperoxidase activity (MPO) and protein levels were determined in the BAL, and tissue samples were obtained for histological evaluation. Finally, animals were scanned with spiral CT., Results: Following LPS infusion, animals developed acute pulmonary injury. Serum levels of TNF-α and IL-6 were significantly reduced in the netrin-1 i.v. group. BAL demonstrated significantly reduced cytokine levels 6 hours post-netrin-1 treatment (TNF-α: vehicle 633 ± 172 pg/ml, netrin-1 i.v. 84 ± 5 pg/ml, netrin-1 inh. 168 ± 74 pg/ml; both P < 0.05). MPO activity and protein content were significantly reduced in BAL samples from netrin-1-treated animals. Histological sections confirmed reduced inflammatory changes in the netrin-1-treated animals. Computed tomography corroborated reduced pulmonary damage in both netrin-1-treated groups., Conclusions: We conclude that treatment with the endogenous anti-inflammatory protein netrin-1 reduces pulmonary inflammation during the initial stages of ALI and should be pursued as a future therapeutic option.

Certification is a compulsory element of today's quality management. However, the instruments used for certification have mostly originally been developed for industrial purposes. Even with tried and tested adaptation to hospital structures, transferring these instruments to the medical environment implies partial negligence of outcome quality. This fact is due to the multidimensional structure of medical outcome quality, which cannot be reduced to only one indicator. This review describes the necessity to develop a specific indicator system, which is needed for an objective, reliable and valid system of certification for intensive care units. The second part of the review describes the current efforts which are being undertaken to develop such a certification system for German intensive care units. Until this new system has been validated, certification of intensive care units is of limited value for evaluating the quality of intensive care units in Germany.

Research interest in epidural anesthesia during sepsis has grown over the past years and studies have tried to determine its mechanisms, which should, theoretically, protect organs and reduce morbidity and mortality. However, different experimental approaches in different animal models have provided conflicting results over whether epidural anesthesia has protective or harmful effects and whether these alter depending on the phase of sepsis, the spread of epidural anesthesia or additional supportive therapies. In the future, more standardized research is necessary to integrate the results of all studies, which have been published.

We describe a case of hiccup in an awakening patient. Since there was no success in stopping the hiccup by deepening anaesthesia with Desflurane, we used Propofol 1.3 mg/kg BW as a short acting i.v. anaesthetic with a fast onset to provide early recovery after eliminating hiccup in the awakening patient. Recommendations for the therapy of hiccup range from breathing exercises to the implantation of a phrenic nerve stimulator. The small number of comparable patients and the lack of controlled studies prevent evidence-based recommendations for therapy. Currently patients profit mostly from the exchange of personal experiences.

Central venous cannulation is essential for management of patients who are critically ill or require major surgery. Based on approximately 90 studies, the use and maintainance of catheters, typical complications, most common puncture sites and techniques were sighted to give an overview over the state-of-the-art concerning central venous catheters.

Background: Over the last 15 years, there has been growing interest in the noble gas xenon as a new inhalational anesthetic. This is due to its favorable pharmacological properties such as short onset and offset, as well as its hemodynamic stability. However, most volatile anesthetics appear to play an important role in the multi-factorial etiology of perioperative liver injury by decreasing liver blood flow with a subsequent reduction of hepatic oxygen supply. However, the effects of the anesthetic gas xenon on hepatic perfusion and oxygenation have not been completely investigated., Methods: Following ethical approval, 18 anesthetized and acutely monitored pigs were randomly assigned to the two following groups: 9 animals received xenon anesthesia in increasing inspiratory concentrations of 0%, 20%, 50%, and 65% in addition to their basic intravenous anesthesia; 9 animals served as a control group. Measurement points for systemic and regional hemodynamic and oxygenation parameters were performed 30 min after changing the xenon concentration., Results: Xenon elicited dose-dependent systemic hemodynamic changes such that the mean arterial pressure did not change, while the heart rate and cardiac output decreased by about 30%, thereby indicating an increase in the systemic vascular resistance. Portal venous blood flow decreased, while hepatic arterial blood flow was unchanged. The oxygen supply of the liver was reduced, but not the rate of indocyanine plasma disappearance from the liver. Furthermore, the increase of liver surface pO2 to systemic hyperoxia was absent, and hepatic lactate uptake was reduced., Conclusion: Xenon, in addition to basic intravenous anesthesia, elicited a decrease in heart rate and cardiac output and an increase in mean arterial pressure. Similar to volatile anesthetics, xenon does reduce portal venous flow and influences hepatic tissue oxygenation. In contrast, hepatic arterial blood flow remains stable in the presence of xenon, and no changes in the hepatic arterial buffer responses were evident. Xenon does affect hepatic perfusion and oxygenation.

What is quality, what is quality management? Who is responsible for quality management in a hospital? Which tools, communication instruments and which instruments for feed back are necessary for institutions to control its tasks in a multi-disciplinary environment? Are there various requirements concerning quality management systems in different hospitals or departments? Which tools of quality management are used in German anaesthesia and intensive care departments? This paper gives an introduction to quality management systems in hospitals and an overview of current models in anaesthesia and intensive care medicine.

In Germany the economical framework of the health system in general and the hospitals in particular has changed dramatically over the last years. The conversion of funding to DRGs has implicated a reduction of budgets. The apportioning of budgets by keys of officially calculating hospitals forces single departments and disciplines to choose financial goals of a hospital as their particular interest and not the financial goals of a department. The calculation of a budget for a department of anaesthesia and/or intensive care medicine is possible from fractions of all DRGs, that have been generated inside a hospital within a period of one year. However, this calculation comprises some problems, because anaesthesia and intensive care medicine are interdisciplinary disciplines, which cannot influence its achievements and its processes solely by its own, but are dependent on efficiency and quality of its partners. Internal cost allocation for improving processes seems not to be sensible in the system of DRGs as long as it is used not only as an instrument of controlling, but also as an instrument of benchmarking.

Background: Increased sympathetic nervous activity which induces vasoconstriction and decreases perfusion may be an underlying mechanism behind the development of perioperative liver damage. This animal study was designed to assess how clonidine-induced systemic sympathicolysis affects liver oxygenation with respect to induced hypotension and vasodilatation under physiological conditions., Methods: Following ethical approval 17 anesthetized and acutely instrumented pigs were randomly assigned to 2 groups. Group 1 consisted of 8 animals receiving intravenous clonidine (2 microg x kg(-1) bolus and 2 microg x kg(-1) x h(-1) for induction of sympathicolysis and group 2 consisted of 9 animals serving as controls. After obtaining baseline values, measurements were repeated 90 and 250 min after starting to reduce systemic sympathetic nervous activity., Results: Clonidine-induced systemic sympathicolysis was associated with decreased mean arterial blood pressure, cardiac output and heart rate. Portal venous and hepatic arterial blood flow, oxygen delivery to the liver, oxygen uptake and liver tissue oxygen partial pressure remained unchanged. The plasma indocyanine green disappearance rate increased., Conclusion: We concluded that despite decreased mean arterial pressure and cardiac output, clonidine-induced systemic sympathicolysis did not affect liver oxygenation or perfusion.

Objective: The aim of this study was to investigate the impact of the water-soluble poly-(ADP)-ribose-polymerase (PARP) inhibitor 5-aminoisoquinolinone (5-AIQ) on liver microcirculation and function after haemorrhagic shock and resuscitation., Design: Controlled, randomized animal study., Setting: University animal care facility and research laboratory., Subject: Male Sprague-Dawley rats were subjected to haemorrhagic shock for 1 h, followed by resuscitation with shed blood and crystalloid solution for a total of 5 h., Interventions: The PARP inhibitor 5-AIQ (3 mg/kg; n=7) or vehicle (n=7) was administered 5 min prior to resuscitation. Sham-operated animals without induction of shock served as controls (n=7)., Measurements and Results: Using intravital fluorescence microscopy hepatic microcirculation was assessed at baseline, end of shock phase as well as 1 h and 5 h after resuscitation. Systemic arterial blood pressure and bile flow were continuously monitored. 5-AIQ treatment attenuated shock/resuscitation-induced increase of intrahepatic leukocyte-endothelial cell interaction with a marked reduction of both sinusoidal leukostasis and venular leukocyte adherence. Moreover, nutritive perfusion was found improved, guaranteeing sufficient oxygen supply to tissue, as indicated by low NADH autofluorescence, which was not different to that in controls. Most notably, excretory liver function reached baseline level over 5 h of reperfusion in 5-AIQ-treated animals., Conclusions: In the present setting of shock/resuscitation in male rats the PARP inhibitor 5-AIQ proved to be very effective in ameliorating compromised liver microcirculation and function. Further research has to confirm that PARP inhibition is a suitable tool in the acute treatment of patients suffering from reduced circulating blood volume and thus microcirculatory organ dysfunction.

Fever is an unspecific symptom of most intensive care patients during their stay on an intensive care unit. The reasons for the increase of body temperature often remain unclear, even extended diagnostic measures are performed. The pathogenetic relevance of fever is commonly underestimated and leads to unreflected treatment of every increase of body temperature above 38 C. But the development of fever in patients is quite often useful and should not be treated with antipyretics. Physical measures like ice packs and surface cooling are only allowed to be used, if the central set point is lower than the actual core body temperature. This gradient can be recognized, when the patient starts to sweat. Principally, the treatment of fever in cardiovascular risk patients, patients with high risk for adverse neurological outcome, pregnant women during the first trimenon and in children with seizures must start with pharmacological interventions,which can be followed by physical measures.

Objective: The aim of this study was to evaluate the impact of intra-aortic balloon pumping (IABP) on the comparison of simultaneous measurements of cardiac output via pulmonary arterial and transpulmonary thermodilution (PiCCO; Pulsion Medical Systems, Munich, Germany)., Design: Prospective., Settings: University research laboratory., Participants: The data were derived from 9 anesthetized (fentanyl, propofol, flunitrazepam, rocuronium) and ventilated pigs., Interventions: A thermodilution catheter was inserted into the pulmonary artery, a PiCCO catheter into the abdominal aorta through the right femoral artery, epicardial atrial pacing wires through a thoracotomy, and a balloon catheter for counterpulsation into the descending thoracic aorta through the left femoral artery. Cardiac output was varied over a wide range by cardiac pacing between 80 and 150/min in steps of 10/min and was measured without and during IABP at an assist frequency of 1:1., Measurements and Main Results: A total of 236 paired cardiac output measurements were carried out in a range of cardiac output between 1.4 to 4.9 L/min. A close correlation was found between transpulmonary and pulmonary arterial thermodilution both without and during IABP (r = 0.94 and 0.93, respectively) and a good agreement of both methods (bias of 0.30 and 0.26 L/min, respectively; precision 0.47 and 0.52 L/min, respectively)., Conclusions: Transpulmonary thermodilution is suitable for cardiac output measurement during IABP. Hence, in critically ill patients with cardiac pump failure, blood flow may be determined as accurately with the less-invasive transpulmonary method as with the traditional pulmonary arterial thermodilution one.

History and Findings: A 41-year-old, obese man with a history of incomplete paraplegia of both legs and chronic venous insufficiency with stasis dermatitis presented with acute respiratory and hyperdynamic hemodynamic failure. He was transferred from another hospital to the department of intensive care medicine for further diagnosis and treatment. A livid coloured, necrotizing-hemorrhagic swelling of the right lower leg was noted., Investigations: Laboratory tests revealed an inflammation probably due to bacterial infection, anemia, acute renal failure, acute hepatic dysfunction, coagulopathy and lactic acidosis, indicating multi-organ failure and septic shock. No focus of sepsis was found at abdominal sonography and exploratory laparotomy. Chest X-Ray and computed tomography revealed bilateral pneumonia. Doppler ultrasonography of both legs showed acute isolated thrombosis of the right posterior tibial vein., Treatment and Course: In addition to a chronic venous ulcer-necrotizing hemorrhagic erysipelas had developed in the right lower leg. A swab taken at surgery and blood cultures grew Streptococcus dysgalactiae ssp. equisimilis (group G streptococci, GGS). Despite intensive care treatment and high dosage penicillin G therapy the patient died two days after admission from septic shock and multi-organ failure., Conclusions: Group G streptococci cause a variety of common and severe infections. Erysipelas is infrequently associated with GGS but, much more often, with group A streptococci (GAS). This unusual and fulminant case emphasizes the importance of considering Streptococcus dysgalactiae as a causative agent in septicemia with multiple predisposing factors and soft-tissue infections.

Background and Objective: Despite the introduction of various less-invasive concepts of cardiac output measurement, pulmonary arterial thermodilution is still the most common measurement technique., Methods: This prospective controlled study was designed to compare different methods of cardiac output measurement simultaneously. Pulmonary arterial thermodilution, transpulmonary thermodilution (PiCCO), trans-oesophageal echo-Doppler probe (HemoSonic) and partial carbon dioxide rebreathing technique (NICO monitor) were evaluated against a peri-aortic transit-time flow-probe as reference method in a clinically relevant animal model. After approval from the Local Ethics Committee on Animal Research, the investigations were conducted in nine anesthetized domestic pigs. Systemic haemodynamics were modulated systematically by the application of catecholamines, caval occlusion and exsanguination. Statistical analysis was performed with Bland-Altman and linear regression., Results: A total of 366 paired cardiac output measurements were carried out at a reference cardiac output between 0.5 and 7 L min(-1). The correlation coefficients for pulmonary arterial and transpulmonary thermodilution against reference were 0.93 and 0.95, for trans-oesophageal Doppler and partial rebreathing technique 0.84 and 0.77. Pulmonary arterial thermodilution and transpulmonary thermodilution showed comparable bias and limits of agreement. Where HemoSonic showed an overestimation of cardiac output at a higher precision, NICO overestimated low and underestimated higher cardiac output values., Conclusions: Our data suggest that pulmonary arterial thermodilution and PiCCO may be interchangeably used for cardiac output measurement even under acute haemodynamic changes. The method described by Bland and Altman demonstrated an overestimation of cardiac output for both thermodilution methods. HemoSonic and NICO offer non-invasive alternatives and complementary monitoring tools in numerous clinical situations. Trend monitoring and haemodynamic optimizing can be applied sufficiently, when absolute measures are judged critically in a clinical context. The use of the NICO system seems to be limited during acute circulatory changes.

Background and Objective: Clonidine, which is used for induction of sympatholysis and prevention or treatment of alcohol withdrawal in anaesthesia and intensive care medicine, may have deleterious effects on intestinal mucosal perfusion. This study was designed to investigate the effects of clonidine on intestinal perfusion and oxygenation., Methods: Following ethical approval 17 anaesthetized, and acutely instrumented pigs were randomly assigned to two groups: eight animals received intravenous clonidine (2 microg kg(-1) bolus and 2 microg kg(-1) h(-1)), nine animals served as a control group. Measurement points for systemic and regional haemodynamic and oxygenation parameters were 135 and 315 min after starting the clonidine application., Results: Clonidine elicited systemic haemodynamic changes (median [25-75th interquartile range]): heart rate (106 [91, 126] to 84 [71, 90] beats min(-1)) cardiac output (147 [123, 193] to 90 [87, 107] mL min(-1) kg(-1)) and mean arterial pressure (77 [72, 93] to 69 [61, 78] mmHg) decreased. Despite systemic haemodynamic changes, the superior mesenteric artery blood flow did not change in the clonidine group. The vascular resistance of the superior mesenteric artery decreased. The small intestinal oxygen supply, the mucosal and the serosal tissue oxygen partial pressure did not change., Conclusions: Systemic sympatholysis induced by intravenously applied clonidine in addition to basic intravenous anaesthesia elicited a decrease in cardiac output and mean arterial pressure. However, regional macrohaemodynamic perfusion was maintained and intestinal oxygenation did not change. Clonidine does not impair intestinal mucosal and serosal oxygenation under physiological conditions.

Background: Xenon is a narcotic gas that might be able to replace volatile anaesthetics or nitrous oxide due to its favourable pharmacological properties, such as providing haemodynamic stability. Intestinal oxygenation is affected by most volatile anaesthetics as a result of cardiodepressive effects. Reducing oxygenation of the gut might be a factor leading to perioperative organ dysfunction. This animal study was designed to assess the effects of xenon on intestinal oxygenation., Methods: After ethical approval, 24 anaesthetized, acutely instrumented pigs were randomly assigned to three groups: nine animals received xenon anaesthesia with inspiratory concentrations of 0, 20, 50 and 65% in addition to their basic i.v. anaesthesia, nine animals served as a study control group, and five animals were used to assess model stability. Measurement of systemic and regional haemodynamic and oxygenation parameters was made 30 min after changing the xenon concentration., Results: Xenon elicited dose-dependent systemic haemodynamic changes: heart rate and cardiac output decreased by 30%, while mean arterial pressure was stable. Superior mesenteric artery blood flow was lower in the xenon group. Vascular resistance of the superior mesenteric artery increased. The small intestinal oxygen supply decreased with increasing xenon concentration; the mucosal tissue oxygen partial pressure decreased but did not reach hypoxic (<5 mm Hg) values. Serosal tissue oxygen partial pressure was maintained., Conclusions: Xenon, in addition to basic i.v. anaesthesia, elicited a decrease in cardiac output and maintained mean arterial pressure. Intestinal oxygenation was maintained, although regional macrohaemodynamic perfusion decreased. Xenon does not impair intestinal oxygenation under physiological conditions.

Cricoid pressure is a simple and effective measure to prevent regurgitation of gastric juice and content. This procedure, which prevents a possible reflux by compression of the oesophagus between the cricoid cartilage and the cervical vertebral bodies, is generally acknowledged in clinical practice, although there is lack of scientific evidence regarding its effect on the outcome of patients at risk of aspiration. However, there is only a rare incidence of complications as long as cricoid pressure is used with exact indication, considering the contraindications and correct performance. Especially important are the optimal force applied on the cricoid and the duration of application. However, there is a lot of evidence in the literature that the knowledge of anaesthetists about the method and technique of cricoid pressure is rather unsatisfactory. Thus, the starting point for improving the efficiency and safety of cricoid pressure seems to be better teaching and training.

With increasing drug abuse of cocaine, the chances are growing that an anaesthetist comes into contact with an acutely intoxicated patient or chronic cocaine user while on call or during his daily routine. In South America chewing coca leaves is daily practise, while in the industrialised world the drug is sniffed, smoked or injected intravenously. Clinically, cocaine is used topically in ENT and ophthalmology due to its local analgesic and strong vasoconstrictive properties. Cocaine has a similar effect on the CNS as amphetamines and produces euphoria and hallucinations. Cocaine acts indirectly on sympathetic stimulation, release of dopamine and inhibition of catecholamine metabolism. It is metabolised in the liver and by serum esterases. Intoxication with cocaine leads to respiratory depression, arrhythmias, ventricular fibrillation and death. If an emergency operation during acute cocaine intoxication is necessary, all sympathomimetic anaesthetic drugs must be avoided. A deep anaesthesia must be provided to reduce the risk of cardiovascular complications. In the literature, anaesthesia is regarded as safe for patients with chronic cocaine misuse after abstinence of 24 hours. This case report shows that, even without acute intoxication, severe cardiovascular problems are possible in patients with chronic cocaine abuse. Hence, we recommend a cocaine-free interval of at least one week before elective surgical procedures.

Remifentanil is an esterase-metabolized ultra-short acting mu-agonist opioid with a rapid clearance. The aim of this study was to determine the efficacy of remifentanil infusion for the short-lasting, but painful, transvaginal puncture for oocyte retrieval. Eighty consenting adult women (ASA I and II) aged 30.5 +/- 5 years and with a body weight of 69.1 +/- 9.1 kg were enrolled in this prospective study. After an oral premedication with 7.5 mg midazolam, all patients received 3 l/min oxygen. Subsequently, the remifentanil infusion was started with a rate of 0.3 microg/kg/min. Remifenanil doses were adjusted as needed for painless puncture and sufficient oxygen saturation in steps of 0.05 microg/kg/min. Dosage requirements, blood pressure, heart rate, oxygen saturation (pulse oxymetry, SaO2) and the level of analgesia were recorded every 3 minutes. Follicular aspiration lasted 11.8 +/- 4.1 min and the time of remifentanil infusion was 18.7 +/- 4.6 min. Dosage requirements of remifentanil were 0.3 microg/kg/min in 48.7% of all patients, but 27.8% needed only 0.25 microg/kg/min and 16.6% needed only 0.2 microg/kg/min. However, 4.2% of patients needed 0.35 microg/kg/min and 2.7% of all cases needed 0.4 microg/kg/min. Vital parameters remained nearly unchanged. Oxygen saturation decreased significantly from 99.2 +/- 0.7% to 98.2 +/- 2.4% after 3 min and to 94.9 +/- 7.2% after 10 min. Nine women showed motoric reactions to puncture. In many cases, the infusion of remifentanil after premedication with midazolam provided a suitable and satisfying anaesthesia for oocyte retrieval. Some patients, however, showed motoric reactions to vaginal puncture, while in other cases significant and clinical relevant decreases in Hb-oxygen saturation occurred. Therefore, we no longer carry out remifentanil infusion for transvaginal oocyte retrieval. We now prefer a remifentanil infusion of 0.2 microg/kg/min and propofol (1 mg/kg initially with intermittent doses of 0.5 mg/kg) combined with assisted ventilation by mask.

Alcaptonuria is a very rare enzymatic disease with a compromised degradation of the amino acids phenylalanine and tyrosine. As a consequence, homogentisic acid accumulates, most of which is cleared by the kidneys. In time, homogentisic acid forms black pigment, which accumulates throughout the body in connective tissue such as cartilage and joints. Apart from superficial discoloration, the most clinical manifestation of the disease is arthropathy, starting in middle age. From the anaesthesiologist's point of view, there is a severe risk of difficult airway because of an advanced stiffness of the cervical spine and a reduced mouth opening in these patients. Due to deformity and stiffness of the spine, difficulties in spinal and epidural anaesthesia must be reckoned with. A further risk for patients with alcaptonuria is cardiac involvement, which occurs later than degenerative changes of the joints. The accumulated pigment most likely adds to the development of degenerative changes of the valve and coronary artery disease and there is an increased risk of developing aneurysms in atherosclerotic altered vessels. Therefore, at the preoperative visit a thorough clinical cardiovascular examination should be performed. Cardiological advice and an examination should be sought from a specialist. For intubation, fibreoptic procedures should be considered. Anaesthetic management and perioperative monitoring are determined by the results of the cardiological examination and the type and extent of the operation.

Alcohol is a socially tolerated drug. Its consumption is associated with several physiological and pharmacological negative side-effects during anaesthesia and intensive care. The impact of chronic and acute alcoholism on perioperative morbidity and mortality and especially on anaesthetic risk are important, due to pharmacological interactions, pathophysiological changes and direct pharmacological interactivities between alcohol and narcotics. In contrast to opioid withdrawal symptoms of alcohol withdrawal are a serious and potentially life-threatening complication and should be avoided or the risk for occurrence must at least be reduced. Patients with a high risk of developing perioperative symptoms of alcohol withdrawal can be detected by laboratory tests and questionnaires. A prophylaxis of withdrawal should be started preoperatively solely with benzodiazepines or in combination with clonidine. Haloperidol is the drug of choice for emerging symptoms of alcohol withdrawal with productive psychosis. To estimate the pharmacological changes during anaesthesia, it is necessary to differentiate whether the patient is an occasional drinker with acute intoxication, a chronic abuser without limitations of hepatic function or a chronic user with insufficiency of the liver. The most important implication for anaesthesia are the choice of a rapid sequence induction to reduce the risk of aspiration and the maintenance of haemodynamic stability and liver perfusion. For the acute alcoholic providing prolonged postoperative surveillance is necessary, for the chronic alcoholic intensive care seems to be mandatory. For regional anaesthesia the indications and limitations are the same as for other patients (cooperativeness, coagulation, consent, etc.).

Perioperative liver injury due to decreased perfusion may be an underlying mechanism behind the development of systemic inflammatory response syndrome. We designed this animal study to assess whether thoracic epidural anesthesia (TEA) impairs liver oxygenation due to induced hypotension. After ethical approval, 19 anesthetized and acutely instrumented pigs were randomly assigned to 3 groups (control and TEA alone versus TEA plus volume loading). Bupivacaine 0.5% 0.75 mL per segment was injected into the epidural space, aiming for a T5 to T12 block. After baseline values were obtained, measurements were repeated 60 and 120 min after epidural injection. TEA was associated with decreased mean arterial blood pressure but no change in total hepatic blood flow. Oxygen delivery to the liver and oxygen uptake remained unchanged. Liver tissue oxygen partial pressure did not decrease. The plasma indocyanine green disappearance rate remained stable. Volume loading before TEA did not relevantly affect total hepatic blood flow; it even decreased oxygen supply to the liver by hemodilution. We conclude that, despite decreased mean arterial blood pressure, TEA did not affect liver oxygenation. There was no clinically relevant effect of volume loading on total hepatic perfusion.

Background: Perioperative intestinal hypoperfusion is a major contributing factor leading to organ dysfunction. It can be caused by stress as a result of surgical manipulation or hypoxia. Additionally, anaesthesia can affect intestinal oxygenation. This animal study was designed to assess the effects of reduced regional sympathetic nervous activity induced by thoracic epidural anaesthesia on intestinal oxygenation., Methods: After ethical approval, 16 anaesthetized and acutely instrumented pigs were randomly assigned to two groups (epidural anaesthesia alone vs epidural anaesthesia plus volume loading). The epidural anaesthesia aimed for a T5-T12 block. Measurements were at baseline and after 1 and 2 h., Results: Epidural anaesthesia was associated with a decrease in mean arterial blood pressure and pronounced mesenteric vasodilatation. Mesenteric blood flow did not change. Intestinal oxygen uptake, mucosal tissue oxygen partial pressure and tissue carbon dioxide partial pressure remained unchanged., Conclusions: Despite marked systemic hypotension, epidural anaesthesia did not affect intestinal oxygenation. There was no benefit obtained from volume loading.

Over the last years several clinical studies have modified the guidelines for preoperative fasting to reduce the risk of pulmonary aspiration. In most western countries the following guidelines are accepted: for clear liquids 2 hours, breast feeding 4 hours, small meals and breast milk substitutes 6 hours, heavy meals 8 hours. Since preoperative smoking is acknowledged as a risk factor, it should be ceased in most clinics 6 hours before induction of anaesthesia, as well. Smoking, however, does not increase the risk of pulmonary aspiration, as is often maintained, but increases the risk of postoperative pulmonary complications. To reduce the risk of perioperative pulmonary complications, cessation of smoking is necessary 8 weeks before operation. Stopping smoking only a few days before operation and anaesthesia even tends to increase the risk of pulmonary complications. Regarding cardiac complications, cessation of smoking 12 hours before anaesthesia is sufficient to reduce the incidence of cardiac ischaemia.

Sneddon's syndrome is a rare combination of generalised livedo reticularis and cerebrovascular accidents. Its clinical presentation varies widely and its aetiology is still not known. 60 to 80% of patients are female. First symptoms of the syndrome are mostly repetitive cerebral strokes, but reduced perfusion of the skin, seen as blue or red-brown mottling, precedes the strokes. The vascular disease is generalised and often accompanied by arteriosclerosis, systemic arterial hypertension, valvular heart disease and the presence of antiphospholipid antibodies. The diagnostic procedures are complicated and have to exclude other autoimmunological diseases. Therapeutic options are anticoagulatory therapy with warfarin, ASS or heparin, reduction of endothelial proliferation with ACE-inhibitors, and improvement of microvascular perfusion with prostaglandine. The increased anaesthesiological risk with these patients is due to the acute risk of thromboembolism and ischaemic cerebral and cardiovascular insults. The anaesthetic management must provide stable perfusion pressures for cerebral and myocardial arteries and avoid increasing risk factors for thromboembolism such as increased blood viscosity or stasis due to improper positioning of the patient. The choice of anaesthetic drugs is dependent on good controllability for haemodynamic stability. The high risk of patients with Sneddon's syndrome justifies a more invasive haemodynamic monitoring and postoperative surveillance on an intensive care unit. This case report describes the anaesthesiological considerations for, and management of, a patient with Sneddon's syndrome who was admitted to hospital for vaginal hysterectomy.

In most developed countries, alcohol is a socially tolerated drug. Nevertheless, its consumption is associated with several negative side-effects during anaesthesia. In surgical patients the prevalence of alcoholism exceeds 20%. Chronic alcoholism and acute alcoholism have an important impact on perioperative morbidity and mortality and especially on anaesthetic risk, due to pharmacological interactions, pathophysiological changes and direct pharmacological interactivities between alcohol and narcotics. Symptoms of alcohol withdrawal are a serious and potentially life-threatening complication and should be avoided or the risk for occurrence should at least be reduced. Patients with a high risk of developing perioperative symptoms of alcohol withdrawal can be detected by laboratory tests and questionnaires. The most important implication for anaesthesia is the choice of a rapid sequence induction to reduce the risk of aspiration and the maintenance of haemodynamic stability and liver perfusion. Maintaining body temperature and providing intensive postoperative surveillance and care are necessary. The indications for regional anaesthesia are the same as for other patients (cooperativeness, coagulation, consent, etc.). In general, awareness of possible interactions can reduce perioperative complications and improve postoperative outcome.

Background: The diagnostic potential of breath analysis has been limited by a lack of knowledge on origin, distribution, and metabolism of the exhaled substances. To overcome this problem, we developed a method to assess trace amounts of hydrocarbons (pentane and isoprene), ketones (acetone), halogenated compounds (isoflurane), and thioethers (dimethyl sulfide) in the blood of humans and animals., Methods: Arterial and venous blood samples were taken from mechanically ventilated patients. Additional blood samples were taken from selected vascular compartments of 19 mechanically ventilated pigs. Volatile substances were concentrated by means of solid-phase microextraction (SPME), separated by gas chromatography, and identified by mass spectrometry., Results: Detection limits were 0.02-0.10 nmol/L. Venous concentrations in pigs were 0.2-1.3 nmol/L for isoprene, 0-0.3 nmol/L for pentane, and 1.2-15.1 nmol/L for dimethyl sulfide. In pigs, substances were not equally distributed among vascular compartments. In humans, median arteriovenous concentration differences were 3.58 nmol/L for isoprene and 1.56 nmol/L for pentane. These values were comparable to pulmonary excretion rates reported in the literature. Acute respiratory distress syndrome (ARDS) patients had lower isoprene concentration differences than patients without ARDS., Conclusions: The SPME method can detect volatile substances in very low concentrations in the blood of humans and animals. Analysis of volatile substances in vascular compartments will enlarge the diagnostic potential of breath analysis.

Recent evidence suggests that the hepatic expression of heme oxygenase-1 (HO-1) may preserve hepatocellular integrity after hemorrhagic shock and resuscitation (HR). Because nitric oxide (NO) has been shown to modulate HO-1 expression in cultured cells in vitro, we determined its potential role in the regulation of HO-1 expression after HR in the rat liver in vivo. HO-1 mRNA and protein were highly induced and HO enzyme activity was higher after HR when compared with time-matched sham controls. Administration of the NO donor, molsidomine (MOL) (3 mg. kg(-1)), during resuscitation attenuated the accumulation of HO-1 mRNA and protein and the rise in HO activity. In addition, MOL prevented the shock-induced increase in DNA binding activity of the transcription factor, activator protein-1 (AP-1), but did not alter the activity of nuclear factor-erythroid 2 related factor (Nrf-2), nuclear transcription factor-kappaB (NF-kappaB), and hypoxia-inducible factor-1 (HIF-1). The suppressing action of MOL was not confined to HO-1, because the hepatic expression of the 70-kd major heat shock protein (HSP) in response to HR was also diminished. Moreover, MOL prevented the HR-induced increase in the serum activity of alanine transaminase (ALT) and alpha-glutathione-S-transferase (alpha-GST) that could otherwise be observed after HR. In contrast, the NO synthase inhibitor, N(omega)-nitro-L-arginine methyl ester (L-NAME) (1 mg.kg(-1)), had either no or only minor effects on the primary experimental endpoints. These findings would be consistent with a reduction of shock-induced liver damage by exogenous NO, which in turn prevents the subsequent activation of injury-sensitive transcription factors, thus attenuating the expression of stress-inducible proteins such as HO-1.

Over the last 20 years there has been increasing interest in the pivotal role of the splanchnic region in the development of SIRS, sepsis and multiple organ failure. One key question is how to monitor and detect in good time regional splanchnic perfusion, oxygenation and impaired function of liver and gut, so as to start appropriate therapeutic measures. This review describes the pathophysiological background of impaired splanchnic perfusion. It focuses on the advantages and risks of methods of monitoring splanchnic perfusion or oxygenation and considers them regarding clinical relevance and usefulness. Special emphasis is laid on gastric tonometry. Despite all the restrictions and the criticism which can be levelled at this method, it remains the only way of monitoring splanchnic perfusion and oxygenation that is currently applicable in clinical routine. The data gained can be useful if clinicians are aware of the weak points of tonometry and consider the data in the overall clinical picture. When this is done, the patient can profit from gastric tonometry and the benefits outweigh the risks.

The rate of uptake of sevoflurane during clinical anaesthesia (1.3 MAC) was measured by computer-controlled injection of liquid anaesthetic into a closed breathing system. The cumulative uptake of sevoflurane was 4.8 ml, 7.4 ml, 9.5 ml and 11.5 ml at 30, 60, 90 and 120 min, respectively. The ratio of inspired to end-expired sevoflurane was greater than similar measurements we have made for desflurane in the past, but the absolute rate of sevoflurane uptake was less than the rate of uptake of desflurane in these cases. The rate of uptake was equivalent to 059e-0.32t + 0.039e-0.036t + 0.105e-0.0034t ml.min-1 liquid sevoflurane. Plasma urea and creatinine measured on the first postoperative day were not significantly different from pre-operative values.

When volatile anaesthetics are used in a closed breathing system it is usually assumed that inflow of anaesthetic to the system matches uptake by the patient. Early laboratory reports on the interactions between sevoflurane and soda lime cast doubt on that assumption. We have measured the loss of sevoflurane, desflurane and isoflurane from a closed breathing system and found no differences of consequences.