[Intensive care patients. Determining daily energy expenditure - a comparison of two methods]. / Intensivmedizinische Patienten: Abschätzung des täglichen Energiebedarfs - Vergleich zweier Verfahren.

INTRODUCTION: Using indirect calorimetry (IC), required energy demand may be determined. The SenseWear (SW) armband uses skin temperature, galvanic skin response, heat flux, and a 2-axis accelerometer to estimate daily energy expenditure (EE). The aim of the present study was to evaluate accuracy of the SenseWear measurements in critically ill and ventilated patients. MATERIAL AND METHODS: After approval of the local ethics committee and written informed consent, critically ill and ventilated patients were enrolled. During a 24-h study period EE was continuously measured using the SW armband (standardized position at right upper arm); an IC was performed additionally. Measurement bias (DeltaEE) was calculated as DeltaEE=EE(SW)-EE(IC). Daily energy expenditure of both techniques (IC vs. SW) was compared using regression analysis and the Bland Altman method. The t-Test for paired samples was used for statistical analysis, p<0.05 was considered statistically significant. RESULTS AND DISCUSSION: In total, 23 critically ill and ventilated patients (17 male, 6 female; means: 59.9+/-17.3 years; body mass index 28.0+/-6.3 kg/m(-2)) were investigated. A mean bias of DeltaEE=-565.65+/-1,748.07 kJ (-135.0+/-417.2 kcal) [range: -4,709.56+/-2,224.89 kJ (-1,124 to +531 kcal); p=0.3547] was calculated. Bland-Altman analysis revealed that SW slightly overestimates IC energy expenditure for critically ill patients in the hypo- and normocaloric range [<7,123 kJ/24 h: DeltaEE=+644.42+/-1,038.70 kJ (<1,700 kcal/24 h: DeltaEE=+153.8+/-247.9 kcal); p=0.0838], but significantly underestimated IC values in the hypercaloric range [>10,056 kJ/24 h: DeltaEE=-2,679.09+/-1,698.63 kJ (>2,400 kcal/24 h: DeltaEE=-639.4+/-405.4 kcal); p=0.0098]. CONCLUSIONS: The SenseWear armband is non-invasive, convenient and easy to handle, but has a significant measurement bias in the hypercaloric range. Although IC is still best suited to determining metabolic need in intubated patients, measurements with the SenseWear armband provide significant advantages, e.g. in non-intubated patients, and give a fair estimation of daily energy expenditure when used alone.

[Controlling and reporting in operating room management: analysis of the state of development]. / Controlling und Berichtswesen im OP-Management: Analyse des Entwicklungsstands.

The operating room (OR) is one of the most expensive facilities in most hospitals. The demands on a professional and process-oriented controlling and reporting in the OR are increased due to the increasingly more limited financial margins at the end of the diagnosis related groups (DRG) convergence phase. This study gives an overview of the current situation for cost calculation, controlling and reporting in OR management in German hospitals in 2007. The data from 69 hospitals were evaluated and this represents the largest currently available data pool on this topic.

[The optimization of a medicinal process and the organization of work in an operating-room].

In most hospitals, the operating-room is a most expensive therapeutic subdivision. A clear and understandable concept of organization of the management of a medical process in an operating room should be introduced into all clinics in order to satisfy increasing needs for professional and technological management. Within the framework of a promising management program to optimize a medical process and to organize work in the operating-room, the surgeons are provided with surgical equipment intended for an operating-room in accordance with their assessed needs and with their participation in budgeting, which made it possible to evaluate the efficiency of a medical process and the work of each user of an operating-room.

ECT anesthesia: the lighter the better?

BACKGROUND: Electroconvulsive therapy (ECT) is a most effective treatment for patients with major affective disorders. The influence of anesthetic drugs on seizure "adequacy" or on treatment success has not been systematically investigated. METHODS: A bispectral EEG index score (BIS) was used to identify the depth of anesthesia during ECT. Our study included 22 major depressive episode (MDE) patients expanding to 219 ECTs (05/05-01/06) with no limitations of concurrent medication. RESULTS: Fourteen out of the 22 patients showed full remission. Individual number of ECT sessions needed to reach full remission correlated negatively with mean pre-ECT BIS values (p=0.001). Additionally, using a repeated measurement regression analysis significant correlations were found for pre-ECT BIS versus motor response time, seizure concordance, ictal coherence and peak heart rate. CONCLUSION: The results of our study suggest BIS-levels as a predictor of faster ECT response. Controlling BIS-levels before stimulation may have an additional effect on treatment success.

Efficacy and Safety of the Platelet-Activating Factor Receptor Antagonist BN 52021 (Ginkgolide B) in Patients with Severe Sepsis : A Randomised, Double-Blind, Placebo-Controlled, Multicentre Trial.

OBJECTIVE: To evaluate the efficacy and safety of the natural platelet-activating factor receptor antagonist, BN 52021 (ginkgolide B) in the treatment of patients with severe sepsis related to Gram-negative and mixed bacterial infection. DESIGN AND SETTING: Prospective, randomised, double-blind, placebo-controlled, multicentre study carried out in 13 academic medical intensive care centres in Germany with up to 14 patients per centre. PATIENTS: 88 patients with severe sepsis under standard medical and surgical care: nine patients with pure Gram-positive infection, 79 patients with Gram-negative or mixed bacterial infections (subgroup for which efficacy was to be established). INTERVENTIONS: Patients were randomised to receive either placebo or BN 52021 1.25 mg/kg bodyweight intravenously every 12h over a 4-day period in addition to their standard medical and surgical care. MAIN OUTCOME MEASURES AND RESULTS: The primary efficacy variable was the 28-day all-cause mortality rate. The treatment groups were similar with respect to demographic data and prognostic factors influencing the outcome except for bodyweight and adequacy of antibiotic therapy. Analysis of patients with Gram-negative or mixed bacterial infection, for which efficacy was to be established, resulted in a 28-day all-cause mortality of 42.5% in the placebo group (n = 40; 17 deaths) versus 38.5% in the BN 52021 group (n = 39; 15 deaths). Among all randomised patients, the 28-day all-cause mortality rate was 40.9% in the placebo group (n = 44; 18 deaths) and 38.6% in the BN 52021 group (n = 44; 17 deaths). There were no differences in frequency and severity of adverse events between the two treatment groups. CONCLUSIONS: Four-day administration of BN 52021 failed to demonstrate a statistically significant reduction in mortality in patients with severe sepsis suspected or confirmed to be related to infections other than Gram-positive bacterial infection.

[Virtual reality in ophthalmological education]. / Virtuelle Realitäten für die augenchirurgische Ausbildung.

We present a computer-based medical training workstation for the simulation of intraocular eye surgery. The surgeon manipulates two original instruments inside a mechanical model of the eye. The instrument positions are tracked by CCD cameras and monitored by a PC which renders the scenery using a computer-graphic model of the eye and the instruments. The simulator incorporates a model of the operation table, a mechanical eye, three CCD cameras for the position tracking, the stereo display, and a computer. The three cameras are mounted under the operation table from where they can observe the interior of the mechanical eye. Using small markers the cameras recognize the instruments and the eye. Their position and orientation in space is determined by stereoscopic back projection. The simulation runs with more than 20 frames per second and provides a realistic impression of the surgery. It includes the cold light source which can be moved inside the eye and the shadow of the instruments on the retina which is important for navigational purposes.

Effects of patient-triggered automatic switching between mandatory and supported ventilation in the postoperative weaning period.

OBJECTIVE: To compare two ventilator settings in the postoperative weaning period. Patient-triggered automatic switching between controlled ventilation and supported spontaneous breathing (Automode, AM) was compared to synchronised intermittent mandatory ventilation (SIMV) with stepwise manual adjustment of mandatory frequency according to the breathing activity. DESIGN: Prospective clinical investigation. SETTING: Eighteen-bed intensive care unit in a university hospital. PATIENTS: Forty postoperative patients with healthy lungs who had undergone brain tumour surgery. INTERVENTIONS: Randomisation either to the AM or SIMV weaning procedure after entering the ICU. MEASUREMENTS AND RESULTS: Total weaning time and number of manipulations on the ventilator were observed. Cardiocirculatory and respiratory parameters were measured consecutively at five points during the weaning period. No significant differences were seen for cardiocirculatory parameters, airway pressures and oxygenation between the two groups. There was a trend to shorter weaning times with AM (136 +/- 46 min vs 169 +/- 68 min, n.s.), the average number of manipulations on the ventilator was lower (0.55 +/- 0.69 vs 5.05 +/- 1.19,p < 0.001) and arterial partial pressure of carbon dioxide (PaCO2) levels showed fewer variations in the late phase of the weaning period (39.5 +/- 3.1 vs 38.3 +/- 7.2, p < 0.001 for differences in variance). CONCLUSIONS: Automatic, patient-triggered switching between controlled and supported mode of ventilation can be used for postoperative weaning of neurosurgical patients with healthy lungs. Compared to a SIMV weaning procedure, fewer manipulations on the ventilator are necessary and individual adaptation of ventilation seems to be more accurate.

Autotransfusion during extracorporeal membrane oxygenation.

To reduce allogeneic blood transfusion requirements during extracorporeal membrane oxygenation (ECMO) we evaluated an autotransfusion device which processes and retransfuses erythrocytes of changed ECMO-systems. We studied 10 elective changes of ECMO-systems in 7 patients. Hemoglobin levels, the amount of retransfused autologous blood and of transfused allogeneic packed red blood cell units were documented within 48 h after the system change and compared to the measurements obtained from former ECMO-system changes without using any autotransfusion device. We determined the Horrowitz-index, Interleukin 6, 10, TNF-alpha and endothelin-I concentrations and coagulation parameters during the 48 hours after system change to study the compatibility of this procedure. Allogeneic blood transfusion was reduced from 7 to 2 units of packed red cells using the autotransfusion device. Additionally, no hints of any harmful side effects in these patients was observed.

How reliable is the predictive value of SEP (somatosensory evoked potentials) patterns in severe brain damage with special regard to the bilateral loss of cortical responses?

OBJECTIVE: In patients sustaining severe brain damage (SBD), prediction of later outcome is often very difficult, in particular under conditions of therapeutic management like relaxation and intravenous phenobarbital. Somatosensory evoked potentials (SEP) correlated best with later prognosis and expected neurological deficit. In detail, the primary bilateral loss of cortical responses (BLCR) is regarded to be a reliable marker for poor prognosis. The goal of the following prospective study was to reassess the prognostic value of early serial median nerve SEP recording in severe brain damage in comparison to other neurophysiological, clinical, and neuroradiological parameters and, additionally, to test the hypothesis, that the BLCR-pattern is always associated with a poor prognosis and is never reversible. DESIGN: Prospective study. SETTING: Anaesthesiological hospital intensive care unit. PATIENTS AND PARTICIPANTS: 42 comatose patients with severe brain damage (29 males/13 females), mean age 39.6 +/- 19.3 years, mean initial Glasgow Coma Score (GCS) 6.6 +/- 3.1, investigated by means of median somatosensory evoked potentials (SEP) and brainstem auditory evoked potentials (BAEP) with serial recordings on day 1, 3 to 4, and 8 to 1, and repeated cranial computerized tomography. MEASUREMENTS AND RESULTS: We classified the outcome according to the Glasgow Outcome Scale (GOS). Our data showed a high correlation of initial SEP scores (Spearman correlation coefficient = -0.70) with outcome for both a favorable and an unfavorable prognosis (p = 0.0001). The reliability increased with serial recordings. The SEPs showed superiority to parallel brainstem auditory evoked potentials (Spearman correlation coefficient = -0.50, p = 0.0007), GCS, and standardized neuroradiological criteria. Primary (BLCR) occurred in 16 patients (38%) and implied a fatal prognosis in all adult patients (n = 15, specificity = 93.3%, sensitivity = 59.3%). In contrast, a young child with predominant brainstem hemorrhagic contusions regained consciousness and developed mild to moderate neurological deficit (GOS 3-4) during long-term follow-up of 4 years. This clinical improvement paralleled bilateral asymmetric recovery of cortical SEP responses. CONCLUSIONS: SEP allow an early reliable assessment of both poor and good prognosis in SBD, in particular when applied serially. BLCR does not always imply a fatal diagnosis, as a circumscribed contusional lesion rarely may lead to selective reversible blockage of ascending somatosensory pathways in the brainstem. In contradiction to this lesional etiology, a hypoxia-induced BLCR pattern seems to correlate strictly with a poor prognosis, reflecting a different pathogenesis with diffuse destruction of cortex and thalamocortical pathways.

Octreotide treatment in patients with necrotizing pancreatitis and pulmonary failure.

OBJECTIVE: To determine the efficiency of intravenous infusion of octreotide in the treatment of patients with severe pancreatitis and pulmonary failure. DESIGN: Prospective, case-control study. SETTING: Intensive care unit of a university hospital. PATIENTS: Treatment group: 39 patients with necrotizing pancreatitis were selected for the study. In all, pulmonary failure developed under conservative treatment and surgical intervention had been necessary because of local (abscess, necrosis) or systemic (systemic inflammatory response syndrome) complications. The outcome was prospectively followed up until death or discharge from the hospital. CONTROL GROUP: 54 case-control matched patients with acute necrotizing pancreatitis and pulmonary failure, who had not been treated with octreotide. INTERVENTION: Each patient in the treatment group received 100 micrograms intravenous octreotide three times daily for 10 days, in addition to the standard intensive care therapy. RESULTS: The groups (octreotide group, control group) were highly comparable with regard to age (mean age: 54, 51 years), sex, severity of illness (Acute Physiology and Chronic Health Evaluation II score: 27, 27), etiology of pancreatitis, and pretreatment at the time of admission to the intensive care unit. There was no difference in the development of renal, hepatic, gastrointestinal, hemostatic, neurologic, or local complications. But the frequency of the adult respiratory distress syndrome (18 vs 40%; p < 0.05) and circulatory shock (51 vs 87%; p < 0.05) was significantly lower in the treatment group. Furthermore, mortality was 26% (10 of 39 patients) in the octreotide group and 61% (33 of 54 patients) in the control group (p < 0.01). CONCLUSION: The results of our case-control study showed a beneficial effect of octreotide in patients with severe necrotizing pancreatitis and pulmonary failure. Based on these data, a prospective, double-blind, placebo-controlled study should be performed to evaluate these results.

[Polytrauma and malignant neuroleptic syndrome. Case presentation with diagnostic problems]. / Polytrauma und malignes neuroleptisches Syndrom. Kasuistische Darstellung diagnostischer Probleme.

The neuroleptic malignant syndrome (NMS) is a rare but potentially fatal reaction associated with neuroleptic drugs. The role of an acute reduction in brain dopamine activity in the development of NMS is commonly accepted as underlying pathogenesis. The diagnosis is maintained by the classic findings of extrapyramidal signs, hyperthermia and autonomic dysfunction. Treatment consists primarily of early recognition and discontinuation of triggering drugs. We report on a young patient with an acute paranoid schizophrenia who suffered a severe polytrauma due to a jump from 10 m height initiated by acoustic hallucinations. The patient received haloperidol for psychotic symptoms in a dose of up to 65 mg/d and chlorprothixene. NMS developed during the second week after the polytrauma. Discontinuation of neuroleptic therapy was followed by complete recovery. The report underlines problems of diagnosis due to the ambiguity of the diagnostic criteria of neuroleptic malignant syndrome in the presence of polytrauma.

[Evaluating lung failure and the limits of artificial respiration]. / Beurteilung des Lungenversagens und Grenzen der künstlichen Beatmung.

The treatment and outcome of the respiratory failure decisively depend on its pathophysiological background. Besides simple blood gas analysis the investigation of the respiratory mechanics, interstitial lung water and the monitoring of the pulmonary pressure are necessary for an exact diagnosis. As a scoring method of lung failure the classification by Murray and Morell is most common. In addition to normal volume or pressure controlled artificial ventilation the treatment of lung failure sometimes requires new but accepted modes of ventilation as inversed ratio ventilation, permissive hypercapnea and high frequency ventilation. New methods as negative pressure ventilation, extracorporeal lung ventilation and liquid or partial liquid ventilation are not common yet and should be used only under special conditions. As a supplement of these modes of ventilation the application of prostacyclins, nitric oxide, surfactant and inhibitors of the arachidonic pathway is under clinical investigation. A limitation of the treatment of lung failure should be considered in irreversible multiple organ failure.

[The performance of respirator alarms during simulated critical events in CMV/IPPV artificial respiration]. / Alarmverhalten von Respiratoren bei definiert auslösbaren Störfällen unter CMV/IPPV-Beatmung.

Alarm systems of ventilators enhance detection of possible critical events during artificial ventilation. Due to their significance, in some countries the alarm detection of ventilators is regulated by federal law. Up to now, no recommendations for the adjustment of alarm limits exist and only a few detailed investigations of the accuracy of alarm detection are available. METHODS. The response of four commercially available ventilators (Servoventilator 900C, Siemens, Inc.; Bennett 7200a, Hoyer, Inc.; Veolar, Hamilton, Inc.; EVITA, Dräger, Inc.) to critical events during artificial ventilation of a test lung were evaluated. We measured the alarm time (the time between event creation and alarm response) of ten different simulated critical events including disconnection, differentisized leaks, failure of the gas supply, and obstruction at different places in the artificial airway. DISCUSSION. All respirators were able to recognise severe critical situations such as hose disconnection, failure of gas supply, and total airway obstruction within a short time (< 15 s). The recognition of small airway leaks was more difficult for the ventilators even when the alarm thresholds were close. The alarm detection of the EVITA (software 10.0 or less) under conditions of partial airway obstruction may be a source of risk for the patient as the machine continued supplying inspiration with pressure-limited ventilation even when the pressure threshold was reached.

[Myxedema coma as a rare postoperative complication]. / Das Myxödem-Koma als seltene postoperative Komplikation.

Myxedema coma is characterized by severe lack of thyroid hormones, unconsciousness and serious restriction of vital functions. The mortality rate still ranges between 50 and 80%. In patients with inapparent hypothyroidism myxedema coma occasionally follows surgery, anesthesia or severe infection. A case of myxedema coma following surgery is reported. CASE REPORT. A 46-year-old woman was anesthesized for hip replacement. The intraoperative cardiovascular situation was characterized by hypotension and tachycardia. On the first postoperative day, unexpectedly a cardiac arrest occurred. Resuscitation with high doses of epinephrine was successful. There was no evidence of myocardial infarction, hypoxia and pulmonary embolism as causative factors for cardiac arrest. A pulmonary artery catheter was inserted and showed low cardiac output. Catecholamines and intravascular fluids were administered without hemodynamic improvement. In the next 5 days pneumonia was followed by ARDS and acute renal failure. After successful treatment of these complications the patient remained in deep coma. An intracerebral disease could be excluded by computerized tomography. Evaluation showed low thyroid hormones (T3; T4) and elevated TSH. The diagnosis of a myxedema coma was assumed. After failure of oral therapy with L-thyroxine (0.025-0.05 mg/day) for 10 days, intravenous therapy with 0.5 mg L-thyroxine was performed. Thirty-six hours later the patient regained consciousness, without cardiac complications. The patient progressed uneventfully under oral therapy with 0.1 mg L-thyroxine and was discharged from the hospital 6 weeks later. DISCUSSION. Pathophysiology and symptomatology of a case of postoperative myxedema coma are described (Tables 1-4). In this patient, the following symptoms occurred: low thyroid hormones (T3; T4), elevated TSH, deep coma, decreased ventilatory response to CO2, diminished myocardial contractility under catecholamine stimulation, impaired renal water excretion. After failure of oral substitution of L-thyroxine, intravenous therapy had to be performed in spite of the high risk of further cardiac complications in this patient. This led to complete recovery with normal neuropsychological and cardiopulmonary parameters. CONCLUSION. Myxedema coma is a rare complication in postoperative care, but in cases of inexplicable unconsciousness thyroid failure should be excluded. If myxedema coma is evident, intravenous therapy with L-thyroxine should be performed under the conditions of extended monitoring.

Intelligent alarms reduce anesthesiologist's response time to critical faults.

The proliferation of monitors and alarms in the operating room may lead to increased confusion and misdiagnosis unless the information provided is better organized. Intelligent alarm systems are being developed to organize these alarms, on the assumption that they will shorten the time anesthesiologists need to detect and correct faults. This study compared the human response time (the time between the sounding of an alarm and the resolution of a fault) when anesthesiologists used a conventional alarm system and when they used an intelligent alarm system. In a simulated operating room environment, we asked 20 anesthesiologists to resolve seven breathing circuit faults as quickly as possible. Human response time was 62% faster, decreasing from 45 to 17 s, when the intelligent alarm system was used. The standard deviations in response time were only half as large for the intelligent alarm system. It appears that the computer-based neural network in the intelligent alarm system diagnosed faults more rapidly and consistently than did the anesthesiologists. This study indicates that breathing circuit faults may be more rapidly corrected when the anesthesiologist is guided by intelligent alarms.

[Possibilities of computer use in anesthesia and intensive care medicine]. / Möglichkeiten der Computeranwendung in Anästhesie und Intensivmedizin.

Today anaesthesiologists are on familiar terms with computers. In fact, computer technology has come to stay especially in the monitoring and documentation of measurement data; no new developments in this field are possible without the aid of computers. Computer-monitored respirators, infusion pumps or anaesthetic vaporizers have been developed and tested in practice, but their use is at present still restricted to a small select circle of specialists. However, their routine use can be expected in the very near future. In the fields of training and communication of knowledge, computers are still in the developmental stage. Although so-called "expert systems" are already in use in certain fields of medicine, their application in anaesthesia remains an exception. Progress in this direction does not really depend so much on the availability of suitable computers--they are in fact already in operation. The crux of the problem will be the readiness of anaesthesiologists and anaesthesists to feed the computers with appropriate programmes and to accept computers as partners in their work and in the field of training.

[Transdermal scopolamine (TTS-scopolamine) for the prevention of postoperative nausea and vomiting]. / Transdermales Scopolamin (TTS-Scopolamin) zur Prophylaxe postoperativer Ubelkeit und Erbrechen.

Parenteral scopolamine lost its significance for premedication because of severe side effects, at least in German speaking countries. The drug is now available as a transdermal therapeutic system (TTS-Scopolamine) which provides constant low plasma concentrations for three days, high enough to act as an antiemetic but low enough to be free from severe side effects. In a double blind study against TTS-Placebo TTS-Scopolamine was investigated in 40 patients, undergoing minor gynecological surgery. The anaesthetic procedure was standardized with alfentanil, etomidate, N2O and, if needed, Ethrane, drugs which have a moderate to strong emetic action. The premedication consisted of Flurazepam (evening) and diazepam (morning). The dosages were standardized. TTS-scopolamine was statistically significantly superior to TTS-placebo with respect to the antiemetic action and the judgment by the anaesthetist. Intraoperative complications such as thoracic rigidity and bradycardia were more frequent in the placebo group. There were no severe side effects. TTS-scopolamine can be recommended as an antiemetic for premedication, especially when benzodiazepines are used for the relief of anxiety. It should be administered on the evening before and can be removed one or two days after surgery.

[Use of computer technology in training assistants in the anesthesia department]. / Einsatz von Computertechnologie bei der Ausbildung von Assistenzärzten im Fach Anaesthesie.

The growing importance of computer technology in the fields of medical diagnosis and monitoring cannot be disputed. Few studies, however, have investigated the usefulness of computers in medical education. The following paper presents a teaching program for novice anaesthesists which helps demonstrate the problem of anaesthetizing high risk patients and conveys general guidelines for preoperative diagnosis and intraoperative monitoring. All data registered can be displayed on several video screens simultaneously. A printout of the guidelines is also available. Initial impressions of the program are presented.