[Polytrauma with tension pneumothorax with inserted chest tube]. / Polytrauma mit Spannungspneumothorax bei liegender Thoraxdrainage.

The authors report a case of a 25-year-old woman with a polytrauma, caused by a free fall of 12 metres in suicidal intention. Following endotracheal intubation and mechanical ventilation by an emergency physician at the scene, the patient was delivered to the emergency room of an university hospital. An ultrasonic check of the abdomen revealed free fluid in the abdominal cavity, and a rupture of liver and spleen was suspected. Since breath sounds over the right lung were diminished, a chest tube was inserted immediately in the fifth intercostal space in the anterior axillary line. About 300 millilitres of blood were drained by the tube. Shortly thereafter, a laparotomy was performed, where spleen and liver rupture were confirmed and treated. After 60 minutes, the patient developed severe hypotension coupled with ventricular tachycardia and fibrillation, and resuscitation measures had to be initiated. Since breath sounds over the right lung were missing, a tension pneumothorax was suspected and a thoracotomy performed immediately. While huge amounts of air and blood were emerging from the thoracic cavity, a rupture of the right mainstem bronchus as well as of the right pulmonary artery and vena subclavia was identified. The chest tube was found dislocated into the subcutaneous tissue. Despite of open heart compression, application of adrenaline and noradrenaline and substitution of packed red blood cells and of crystalloid and colloid solutions, all resuscitation measures failed so that the patient died shortly after on the operation table. This case illustrates first the difficulties of an adequate thoracic trauma management, particularly, when clinical symptoms are discrete, second the problems of the insertion and control of a chest tube, and third risks associated with wrong position or secondary dislocation which may include - as in our case - "masking" of severe injury patterns and delay of life-saving measures such as an immediate thoracotomy. In order to improve prognosis of patients with poly-/thoracic trauma, establishment of spiral-CT in emergency centres, routine bronchoscopy and safe handling of chest tubes may be helpful.

Mediators of complement-independent granulocyte activation during haemodialysis: role of calcium, prostaglandins and leukotrienes.

Granulocyte activation during haemodialysis using cuprophane membrane is mediated by complement-derived anaphylatoxins C3a and C5a. However, neutrophil degranulation induced by modified cellulosic membranes or synthetic membranes does not correlate with C3a or C5a concentrations. Incubation and recirculation experiments were performed to find out which messengers trigger neutrophil degranulation during blood contact with different membrane materials. During in vitro haemodialysis for 2 hours, PMMA and cuprophane induced pronounced degranulation of neutrophils. With PMMA this was associated with increased thromboxane B2 but low C3a levels, while with cuprophane membrane, marked complement activation but only little thromboxane B2 release was observed. Indomethacin (10 microM) nullified all thromboxane B2 response but could not influence elastase release, indicating that cyclo-oxygenase products are not involved in neutrophil degranulation under these conditions. During incubation of blood with dialysis membranes, inhibition of lipoxygenase by esculetin or of phospholipase A2 by hydrocortisone also had no effect on neutrophil degranulation. One messenger involved in granulocyte activation might be free cytosolic calcium. Application of different calcium channel blockers (verapamil, diltiazem, or nitrendipine) did not influence neutrophil degranulation in incubation experiments, in PMMA or cuprophane membranes. In contrast, chelation of plasmatic calcium by sodium citrate or EDTA blunted elastase release induced by these membranes. This study indicates that calcium is a key mediator required for neutrophil degranulation in complement-activating and non-complement-activating dialysis membranes, while activation of the prostaglandin or leukotriene cascade are not required.

Induction of rat alpha 2-macroglobulin in vivo and in hepatocyte primary cultures: synergistic action of glucocorticoids and a Kupffer cell-derived factor.

Turpentine injection into rats elicits enhanced secretion of acute phase proteins including alpha 2-macroglobulin (alpha 2M). Hypophysectomized rats, however, do not respond in this way unless dexamethasone is given together with turpentine. On the other hand, dexamethasone injection alone did not result in an induction of alpha 2M synthesis. When a medium of Kupffer cell cultures was added to hepatocytes, a dose-dependent stimulation of alpha 2M synthesis of up to 4-fold after 10-12 h was observed. However, the presence of low concentrations (10(-9)M) of dexamethasone was essential for the stimulatory effect. We conclude that the acute phase induction of alpha 2M in hepatocytes requires the synergistic action of glucocorticoids and a non-dialysable factor secreted by Kupffer cells.

Synthesis of prostanoids and cyclic nucleotides by phagocytosing rat Kupffer cells.

Rat Kupffer cells in monolayer culture were allowed to phagocytose unopsonized zymosan granules. They responded with a strongly stimulated synthesis and release of prostanoids, mainly the immunologically determined prostaglandins PGE2 and PGF2 alpha. The same response could be obtained by treatment with the calcium ionophore A23187. The effects of the ionophore and the zymosan particles were of the same magnitude but not additive. The rapid uptake of Ca2+ after contact with phagocytosable material recently described by us [(1983) Eur. J. Biochem. 131, 539-543] appears to mediate the enhanced prostaglandin synthesis. That response was suppressed not only by indomethacin but also by trifluoperazine which does not inhibit Ca2+ entry in the Kupffer cells. Similar effects by R24571 and 4-bromophenacyl bromide support the participation of calcium-calmodulin and of phospholipase A2. The calcium channel blocker Verapamil did not influence the zymosan-provoked production of prostaglandin PGE2 nor were any indications obtained for a feedback inhibition by PGE1 or PGE2. Contact with zymosan resulted in a rapid but transient rise of the intracellular levels of cAMP and cGMP: 10 nM indomethacin completely blocked the increase of both cyclic nucleotides while trifluoperazine elicited different responses in the cAMP and cGMP levels. The stimulated release of prostaglandin E2 was inhibited in a dose-dependent manner by nordihydroguaiaretic acid, an inhibitor of 5-lipoxygenase and by FPL 55712, known as a receptor antagonist for some leukotrienes. This suggests a regulatory role for its metabolites on prostaglandin synthesis.

Calmodulin content and activity of Ca2+-ATPase and phospholipase A2 in rat Kupffer cells.

A protein resembling calmodulin was isolated from non-parenchymal and parenchymal cells of rat liver by affinity chromatography. The biological activity of the purified protein was assessed by the bovine brain cAMP phosphodiesterase assay. A highly sensitive radioimmunoassay as well as the cAMP phosphodiesterase method were employed to determine the calmodulin content of crude extracts from monolayer cultures of rat Kupffer cells and hepatocytes. An ATP-dependent, calmodulin-enhanced calcium transport was demonstrated in a membrane fraction of the non-parenchymal cells. Phospholipase A2 activity specific for 2-arachidonoyl phosphatide and with a pH optimum of 8.1 was measured in homogenized Kupffer cells; it was stimulated by agents previously shown to enhance prostaglandin synthesis in Kupffer cells, e.g. zymosan particles and lipopolysaccharide isolated from Salmonella minnesota. The increase in activity was completely prevented by pretreatment with or simultaneous addition of R 24571, a known calmodulin antagonist. However, if this inhibitor or calmodulin was added to the cell-free extract phospholipase A2 activity was not influenced. Phospholipase A1 activity could be detected at pH 5 only, showing a slight decrease in the homogenate of stimulated macrophages. Acyltransferase activity was high but independent of treatment of the Kupffer cells.

[Perioperative therapy in juvenile pheochromocytoma]. / Die perioperative Therapie beim kindlichen Phäochromozytom.

The article reports on the paediatric-anaesthesiological treatment of 6 phaeochromocytomas in 5 children who were 8 to 16 years of age. Therapeutic recommendations for the perioperative medication of infantile phaeochromocytoma patients are involved. The therapeutic aim of this study was the management of the effects of phaeochromocytoma before and after extirpation of the tumour, the effect of the phaeochromocytoma being of an alpha-adrenergic and beta-adrenergic cardiovascular nature and transmitted by catecholamines. Preoperative stabilization of blood pressure by means of the alpha-blocker phenoxybenzamine and a subsequent intraoperative, controlled reduction of blood pressure by means of sodium nitroprusside were found to be an effective, safe and easily appreciated therapeutic concept for the perioperative care of paediatric phaeochromocytoma patients. Considerable individual differences in dose an duration of the necessary preoperative phenoxybenzamine administration rendered ward control of therapy recommendable. The risk of complete alpha-sympathicolysis by additive drug effects during premedication and induction of anaesthesia, had to be taken into consideration for conducting phenoxybenzamine therapy. Additional administration of the beta-blocker pindolol successfully controlled the intraoperatively manifested tachycardial heart rhythm phases without provoking any complicating arrhythmias. During the entire perioperative treatment of the patients it is mandatory to ensure sufficient substitution of intravascular volume to prevent hypotensive complications. Our patients did not need any cardiac and sympathicomimetic drugs as postoperative administration. None of the patients had any perioperative complications worth mentioning.