[Intervention-adjusted intraoperative volume substitution--an example of surgical-anesthesiological cooperation]. / Eingriffsadaptierte intraoperative Volumensubstitution--Beispiel chirurgisch-anästhesiologischer Kooperation.

Since 1996 a simple classification of surgical interventions has been used to guarantee adequate intraoperative anesthesiological volume management. Use of this classification, including extension of operation and operative trauma, resulted in 45% less substitution with blood components in comparison to that observed in 1995.

[A comparative study of the effectiveness of 5% human albumin and 10% hydroxyethyl starch (HAES-steril) for correcting hemodynamics and O2 transport in surgical interventions]. / Sravnitel'noe issledovanie éffektivnosti primeneniia pri khirurgicheskikh vmeshatel'stvakh 5% chelovecheskogo al'bumina i 10% gidroksiétil-krakhmala (HAES-steril) po pokazateliam gemodinamiki i transporta O2.

Forty patients subjected to cavitary operations were examined. A high risk of hemodynamic disorders necessitated invasive monitoring; with this aim in view a catheter was inserted for measuring arterial pressure and the Swan-Ganz catheter for measuring the pressure in the pulmonary artery, in which helped monitor the hemodynamics and oxygen transport in the course of hypervolemic hemodilution. Plasma substitutes (one of two) were selected at random. After catheterization of the left radial artery and insertion of the Swan-Ganz catheter in the pulmonary artery through the internal right jugular vein the patients were infused either 5% human albumin or 10% hydroxyethyl starch in a dose of 125 ml every 5 min. The parameters of hemodynamics and oxygen transport were recorded after 500 ml of the solution was infused and the wedge pressure of 18 mm Hg attained. Both agents appreciably improved the mean arterial pressure, central nervous pressure, and wedge pressure. Cardiac index, left ventricular output, and stroke volume increased in both groups, and the pulmonary vascular resistance decreased. Both agents improved oxygen utilization and appreciably decreased hemoglobin level. The positive effect of hydroxyethyl starch on cardiac index, pulmonary vascular resistance, left ventricular output, and oxygen utilization was more expressed; moreover, a lesser dose of this drug was needed than of 5% human albumin (Behringwerke, Marburg, Germany). Loss of plasma caused by surgical intervention was better compensated for with synthetic colloid solutions, such as 10% HAES-steril (Fresinium, Oberurzel, Germany), provided that plasma protein level was at least 3-4 g/dl. The effect of 10% HAES-steril as regards the increase of circulating blood volume is 145%. Due to the hyperoncotic direction of its action it has a positive impact on the hemodynamics and oxygen transport and is needed in lower doses than other colloid solutions.

Use of continuous noninvasive measurement of oxygen consumption in patients with adult respiratory distress syndrome following shock of various etiologies.

OBJECTIVE: To describe the patterns of cardiac index, oxygen delivery (DO2), oxygen consumption (VO2), and oxygen deficit (or excess) and to compare invasive and noninvasive monitoring systems for evaluation of these oxygen transport patterns. DESIGN: Descriptive study of oxygen transport interrelationships throughout critical illness in a consecutive series of surviving and nonsurviving patients with adult respiratory distress syndrome (ARDS). SETTING: University-affiliated city hospital. PATIENTS: A consecutive series of 55 critically ill patients with ARDS after shock of various etiologies. MEASUREMENTS AND RESULTS: Noninvasive VO2 was measured by a continuous, on-line, real-time device developed in our department. Inspired and expired oxygen concentrations were measured using a polarographic oxygen analyzer. Minute ventilation measurements were time integrated over 7-min intervals. Cardiac index, DO2, and VO2 were simultaneously measured invasively by pulmonary artery thermodilution catheters, together with arterial and mixed venous blood gases. There was good agreement (r2 = .60) in VO2 measured by the invasive and noninvasive methods. The estimated oxygen deficit or excess was calculated as the difference between the actual measured VO2 standardized for body temperature pressure saturated and the normative standard VO2 of each patient corrected for temperature and sedation (VO2 need). A total of 317 monitoring days in 55 patients were analyzed; 25 survivors were monitored for a mean of 4.6 +/- 2.9 days and 30 nonsurvivors were monitored for 6.9 +/- 6.6 days. Survivors had significantly higher cardiac index, DO2, and VO2 values. Generally, oxygen excesses were found in the survivors and oxygen deficit was observed in the nonsurvivors. Survivors did not reach a plateau in their DO2-VO2 patterns. In the septic nonsurviving patients and both nonseptic groups by contrast, a plateau was observed in the DO2-VO2 pattern. Surviving septic patients had a critical DO2 of 16 mL/min.kg (700 mL/min.m2) and a critical VO2 of 3.5 mL/min.kg (145 mL/min.m2). CONCLUSIONS: Monitoring of VO2 and DO2 variables is useful for evaluation of tissue oxygenation and titration of therapy in critically ill patients. Noninvasive monitoring of VO2 values are in good agreement with VO2 values calculated from invasive measurements of cardiac index. The increased DO2 and VO2 values are not attributable to mathematical coupling of erroneous cardiac index values.

[Comparative study of the intraoperative effectiveness of 5% human albumin or 10% hydroxyethyl starch (HAES-steril) on hemodynamics and oxygen transport in 40 patients]. / Vergleichende Untersuchung zur intraoperativen Wirksamkeit von 5% Humanalbumin oder 10% Hydroxyäthylstärke (HAES-steril) auf Hämodynamik und Sauerstofftransport bei 40 Patienten.

In 40 patients, whose expected hemodynamic instability during surgery necessitated invasive monitoring (Swan-Ganz catheter) and arterial pressure monitoring the hemodynamic and oxygen transport parameters in conditions of hypervolemic hemodilution were investigated in randomized tests. After insertion of an arterial catheter (arteria radialis) as well as Swan-Ganz pulmonary arterial catheter via the vena jugularis interna, one of the two volume substitutes selected at random was infused in quantities of 125 ml/5 min and the hemodynamic changes were measured after infusion of 500 ml and finally after a wedge pressure of 18 mmHg was reached. Using either solution, the measurements indicated significant increases in mean arterial pressure as well as in central venous pressure (ZVD) and wedge pressure. The cardiac index, left ventricular stroke work index, and stroke output rose consecutively and pulmonary vascular resistance went down in both test groups. In the case of both volume substitutes, there was an improvement in oxygen availability. The hemoglobin content decreased in both groups, though to different degrees in each group. Although the hydroxyethyl starch group registered a greater improvement in the cardiac index, a bigger decrease in pulmonary vascular resistance, a higher rise in the left ventricular stroke work index and a more significant improvement in stroke output, smaller quantities of the volume substitute were required in this group than in the group in which volume substitution was carried out with human albumin 5%.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of hydroxyethyl starch and lactated Ringer's solution on hemodynamics and oxygen transport of critically ill patients in prospective crossover studies.

The cardiopulmonary effects of lactated Ringer's solution (RL) were compared with those of 10% hydroxyethyl starch, hetastarch (HES), given in 44 therapeutic interventions in 15 critically ill patients by crossover design. Each agent was given to each patient at least once; seven patients received each agent twice. Infusions were continued until the wedge pressure (WP) had increased to 16 +/- 2 mm Hg in trauma patients and 18 +/- 2.mm Hg in cardiac patients. HES 10% produced significantly increased cardiac index, left and right ventricular stroke work index, CVP, WP, oxygen delivery, oxygen consumption, and reduced pulmonary vascular resistance index (PVRI). RL increased CVP, WP, and PVRI, but did not significantly improve other hemodynamic or oxygen transport variables.

[Hemodynamic effect of 6% hydroxyethyl starch (HES 200,000/0.62)]. / Hämodynamische Effekte von 6% Hydroxyäthylstärke (HAES 200,000/0.62).

The hemodynamic effects of 6% hydroxyethyl starch (HES) 200,000/0.62 were investigated in 20 patients (7 female, 13 male) who required invasive (Swan-Ganz/radial artery catheter) monitoring during major surgery. In 8 patients infrarenal aneurysmectomy and implantation of a bifurcation prosthesis was carried out, in 10 patients with arteriosclerotic vessel disease a bifurcation prosthesis was implanted, in 1 patient a renal artery aneurysm was repaired, and in another abdominosacral rectum amputation was performed. After induction of general anesthesia with alcuronium 2 mg, fentanyl 0.25-0.5 mg, droperidol 2.5-7.5 mg, thiopental 250-375 mg, succinylcholine 100 mg, and alcuronium 8 mg, the patients were ventilated with an O2-N2O ratio of 1.4:3 and halothane 0.4-0.6 vol%; the left radial artery was cannulated and a Swan-Ganz catheter was introduced percutaneously via the right internal jugular vein. According to clinical needs, repetitive doses of alcuronium, droperidol, and fentanyl were administered. At pulmonary capillary wedge pressures (PCWP) of 8-10 mm Hg arterial and mixed-venous samples were drawn for blood gas analysis and saturations; arterial blood pressure (systolic, diastolic), pulmonary artery pressure (systolic and diastolic), and central venous pressure were measured. Five measurements of cardiac output were carried out with cold saline solution, the highest and lowest values discarded, and the hemodynamic variables calculated based on the average of the remaining three values. All hemodynamic data were measured with the Siemens SIRECUST 400/404 monitoring system. Measurement of injectate temperature was done by on-line thermistor GOULD SP 5045. (ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of colloid volume replacement substances and Ringer's lactate on hemodynamics and oxygen consumption of intensive care patients]. / Die Wirkung von kolloidalen Volumenersatzmitteln und Ringer-Laktat auf Hämodynamik und Sauerstoffverbrauch von Intensivpatienten.

Comparison of the effects of various volume substitutes on hemodynamics and oxygen transport variables in critically ill patients. A computerized monitoring system was used to register the hemodynamic effects of lactated ringers solution, human albumin 5%, human albumin 20%, hydroxyethylstarch 6% (Plasmasteril, Fresenius, Oberursel) and hydroxyethylstarch 10% (HAES-Steril, Fresenius, Oberursel) in 25 patients who required invasive monitoring during ICU treatment. In periods of relative volume deficits as documented by a wedge pressure of 11-13 mm of mercury the various substitutes were administered until the wedge pressure reached 15-17 mm of mercury. Comparison of 221 therapeutic interventions demonstrate: Hemydynamic and oxygen transport variables were improved in all colloid trials whereas lactated ringers solution did not improve the patients cardiopulmonary condition. In contrary pulmonary vascular resistance was significantly increased when Ringer's solution was administered. While all colloids produced improvements in the patients hemodynamic and oxygen transport condition, statistically significant improvements could be demonstrated only during infusion of hes 10%.

Evaluation of prognostic indices based on hemodynamic and oxygen transport variables in shock patients with adult respiratory distress syndrome.

We tested prospectively 30 hypotensive shock patients using a continuous, on-line, real-time hemodynamic and oxygen transport monitoring system with a previously described predictive index, modified for the clinical conditions in our ICU. Continuous monitoring and display of cardiac output and 20 or more derived variables, together with the predictive index, were a feasible and useful approach. Unlike previously documented series of elective postoperative general surgical patients, our series consisted of patients with multiple trauma, myocardial infarction, sepsis, and other medical emergencies as well as postoperative cardiac and general surgical patients, all of whom had respiratory failure (acute respiratory distress syndrome). In addition to these differences, our patients were invariably admitted to the ICU after the nadir of their hypotensive crisis. To compare the continuous recorded values with previous studies that used intermittent measurements, three comparable time intervals were selected; data at these time intervals and the predictions derived from them were in satisfactory agreement with prior studies. Moreover, therapeutic goals based on the median values of survivors of the present series were similar, but not identical, to prior series despite differences in the clinical mix and the later postresuscitation ICU admissions of our series.

Continuous, on-line, real-time measurement of cardiac output and derived cardiorespiratory variables in the critically ill.

A previously reported monitoring system provided continuous direct measurements of oxygen consumption and intravascular pressures. These data were combined with interval measurements of cardiac output and blood oxygen saturations to derive various hemodynamic and oxygen transport variables. This system has now been modified so that cardiac output is measured continuously in real-time.

Microcomputer-assisted monitoring system for measuring and processing cardiorespiratory variables: preliminary results of clinical trials.

A microcomputer-assisted monitoring system was developed for the continuous measuring and processing of cardiorespiratory variables, including: systemic and pulmonary arterial pressures, CVP, minute ventilation, inspired and expired O2 and CO2 concentrations, temperature, and heart rate. The primary data were converted to digital form, processed, displayed on a CRT monitor, and also stored for later evaluation. This system automatically calculated and displayed on-line and in real-time both primary measurements and derived cardiorespiratory variables, including: oxygen consumption, CO2 production, left and right ventricular stroke work, pulmonary venous admixture, and systemic and pulmonary vascular resistances. Printouts of the variables and trend graphs could be obtained for any desired time period. During its development, we tested this monitoring system in 30 critically ill patients, finding that the real-time calculation of cardiorespiratory variables was a great advantage during monitoring and treatment.

[A computer-assisted monitoring system in intensive care units (author's transl)]. / Kontinuierliche Uberwachung kardiopulmonaler Parameter bei Patienten nach schwerem Polytrauma. Mikrocomputergestützte Patientenüberwachungsanlage in der Intensivmedizin.

A microprocessor-based monitoring system is described which is currently being evaluated at out hospital. The microprocessor is capable of processing data from 32 channels from the patient's monitoring system as well as practically unlimited data from manual keyboard entries. At present 20 vital cardiopulmonary parameters are calculated in patients in the shock state (real time calculation).