[Documentation in the rescue service. A basis for research and quality assurance]. / Dokumentation im Rettungsdienst. Basis für Forschung und Qualitätssicherung.

Documentation of physician-staffed ambulance runs traditionally focuses on information transfer between the prehospital care provider and the receiving hospital. To use this information as a tool for research and quality assurance programs, the German Interdisciplinary Association of Critical Care Medicine developed in a consensus process a protocol for nationwide use. Protocol development was based on the question of what information can be obtained reliably in the emergency medical service (EMS) environment and what questions should be answered by data analysis. The protocol content was evaluated in several pilot studies and focuses on incidents and interventions that occur with reasonable frequency. It was taken into account that due to this approach, not all information that can possibly be obtained during the ambulance run can be documented. For data collection, the concepts of manual processing versus optical scanning are evaluated. The data analysis can serve as a basic tool for screening structure and process quality of EMS systems on a local as well as a nationwide level. During this process, areas for improvement as well as for clinical research are identified.

[The effect of continuous thoracic peridural anesthesia on the pulmonary function of patients undergoing colon surgery. Results of a randomized study of 116 patients]. / Einfluss der kontinuierlichen thorakalen Periduralanaesthesie auf die Lungenfunktion kolonchirurgischer Patienten. Ergebnisse einer randomisierten Untersuchung an 116 Patienten.

In a prospective randomized clinical investigation, we examined the influence of continuous thoracic epidural analgesia (TEA) on pulmonary function and pathologic chest X-ray findings. METHODS. One hundred sixteen patients having resection and/or anastomosis of the colon participated in this study; 57 were randomly assigned to the epidural group, whereas 59 were given systemic analgesia. Both groups were comparable with regard to ASA classification and pre-existing disease, as well as operative procedures and surgeons. Bupivacaine 0.75% was given to the TEA patients pre- and intraoperatively (epidural catheter T8/9), and postoperatively they received bupivacaine 0.25% continuously by motor pump for 3 days. We aimed to reach an analgesic spread from T5 to L2. In order to maintain sufficient analgesia, we had to increase the dosage from 19.2 mg/h on the evening of the operative day to 22.2 mg on the 3rd postoperative day. However, under these conditions the number of blocked segments decreased from 9.3 postoperatively to 6.6 on the 3rd postoperative day. Balanced anesthesia (isoflurane plus fentanyl) was given to the control group. Postoperatively, these patients received systemic analgesia on request (piritramide i.m., tramadol, or a simple analgesic). Vital capacity and pain score (10-point nominal analog score) were evaluated at 1, 8, 24, 36, 48, 60 and 72 h postoperatively. Blood gas analyses were taken at 1, 8, 24, 48 and 72 h, and chest X-rays were performed on the 1st, 3rd, and 8th postoperative days. Statistically significant results are indicated by "*" (P less than 0.05) and "*" (P less than 0.005) and "***" (P less than 0.001). The standard deviations were shown in cases of statistical significance. RESULTS. There were significantly lower pain scores by 1.0-2.2 points at 1, 8, 24 and 36 h postoperatively in the TEA group. Fourteen patients in group I required adjustments of the postoperative pain treatment regime: 6 had a unilateral epidural block; in 4 the catheter was withdrawn involuntarily. Up to the 2nd postoperative day, patients in the control group received systemic analgesics significantly more often. The vital capacity (percentage of preoperative value) was significantly higher in the TEA group than in the control group after 1 h (58.5% vs 51.7%) and 8 h (63.9% vs 56.7%). From the 1st postoperative day on there was no difference between both groups with regard to arterial blood gases, there was no difference in pCO2 between both groups 1 h postoperatively; it was, however, significantly lower in patients receiving bupivacaine at 8, 24, 48 and 72 h. There was no difference in pO2 at any time. The number of pathologic chest X-ray findings showed no difference between both groups. Looking especially for infiltrates, dystelectasis, atelectasis, and congestion, we also could not demonstrate any difference between the groups. (ABSTRACT TRUNCATED AT 400 WORDS)

Prehospital thrombolysis in acute myocardial infarction.

The benefit and risk of prehospital thrombolysis for acute myocardial infarction (AMI) were evaluated in a double-blind randomized trial. Patients presenting less than 4 hours after symptom onset received 2 million units of urokinase as an intravenous bolus either before (group A, n = 40) or after (group B, n = 38) hospital admission. The mean time interval from onset of symptoms to thrombolytic therapy was 85 +/- 51 minutes in group A and 137 +/- 50 minutes in group B (p less than 0.0005). In 91% of the patients, thrombolytic therapy was administered less than 3 hours after symptom onset. Complication rates during the pre- and in-hospital period were low and did not differ between groups. Three patients died (1 in group A, 2 in group B) from reinfarction 7 to 14 days after admission. Left-sided cardiac catheterization before discharge revealed a patency rate in the infarct-related artery of 61% in group A and 67% in group B (difference not significant). Global left ventricular function and regional wall motion at the infarct site did not differ significantly between group A and B (ejection fraction 51 +/- 10%, n = 28 vs 53 +/- 14%, n = 28; wall motion -2.3 +/- 1.3 vs -2.2 +/- 1.1 standard deviation, respectively). Also, peak creatine kinase did not differ significantly (838 +/- 634 U/liter in group A vs 924 +/- 595 U/liter in group B). Prehospital thrombolysis using a bolus injection of urokinase has a low risk when performed by a trained physician with a mobile care unit. The saving of 45 minutes in the early stage of an acute infarction through prehospital thrombolysis did not appear to be important for salvage of myocardial function.

Epidural analgesia in colonic surgery: results of a randomized prospective study.

Colonic surgery patients were studied to measure: the influence of continuous thoracic epidural analgesia (TEA) on a postoperative pain score, the time till onset of defaecation, blood loss, postoperative temperature elevations, rate of bacterial contamination of wounds and urine, and general surgical complications. Group I patients (n = 57) received general anaesthesia and TEA for the operation, followed by continuous TEA (0.25 per cent bupivacaine) for 72 h. Group II patients (n = 59) received general anaesthesia for the operation, followed by systemic analgesia on request. Significant beneficial effects of TEA in group I were demonstrated by lower pain scores in the first 24 h after surgery and earlier defaecation. However, there were fewer temperature elevations in group II. There was no significant difference between the groups in terms of positive bacteriological cultures, blood loss, need for postoperative mechanical ventilation and complications. However, there was a trend toward a higher rate of rectal anastomotic breakdown, increased blood replacement and intensive care therapy, and longer hospitalization in group I. These results do not suggest any significant beneficial therapeutic effect of continuous TEA in colonic surgery compared with a conventional systemic analgesic regimen. In selected patients (i.e. those with severe pain or those prone to develop postoperative ileus) continuous TEA may be beneficial.

[The thrombolysis treatment of acute myocardial infarct at the site of the emergency. A randomized double-blind study]. / Thrombolyse-Behandlung des akuten Myokardinfarktes am Notfallort. Eine randomisierte Doppelblindstudie.

Two million units of urokinase were administered intravenously as a bolus, either before (group I, n = 40) or after hospital admission (group II, n = 38), to 66 men and 12 women (mean age 55 +/- 8 years) with typical symptoms of acute myocardial infarction of less than 4 hours' duration. Time elapsed between onset of symptoms and urokinase administration averaged 85 +/- 51 min for group I and 137 +/- 50 min for group II (P less than 0.005). The complication rate was low, both during the pre-hospital and the hospital phases, without any significant differences between the two groups. The rate of open infarct vessels (by angiography before discharge from hospital) was 61% for group I and 67% for group II (no significant difference). Global left ventricular function, regional wall motion in the infarct area and maximal creatinekinase values did not significantly differ between the two groups (ejection fraction 51 +/- 10% and 53 +/- 14%, respectively; creatinekinase 838 +/- 634 U/l and 924 +/- 595 U/l, respectively). The data indicate that thrombolytic pre-hospital treatment carried a low risk. The gain of 45 min, however, seems to be of secondary importance in any significant diminution of the acute infarction size.

[Computer-assisted documentation and performance data processing in the intensive care unit. Description of a custom development]. / Computergestützte Dokumentation und Leistungserfassung auf der Intensivstation. Vorstellung einer Eigenentwicklung.

Computer-aided documentation of medical and performance data processing seems to be imperative for every intensive-care unit in the future. It is the rational approach to deal with therapy-related information management as well as organizational and administrative tasks. This custom-made program is based on data collected from 3600 intensive-care patients. It serves 3 objectives: 1. documentation of relevant therapeutic data, 2. information exchange with other departments, 3. thorough analysis of topics related to intensive-care medicine. Based on a microsoft disc operating system, the programme contains not only the data base but also word processing and statistical capacities. Optional choice by menu guarantees easy handling and helps to create a high acceptance.

[Comparative circulatory studies during implantation of total endoprostheses using methylmethacrylate and BDF cement]. / Vergleichende Kreislaufuntersuchungen während Implantation von Totalendoprothesen mit Palacos und BDF-Zement.

In every ten patients undergoing elective surgery for total hip prosthesis methylmethacrylate and BDF cement respectively were used for the implantation of the prosthesis. The results of the haemodynamic investigation demonstrate that improvement of the surgical procedure may reduce the incidence of haemodynamic parameters: After implantation of methylmethacrylate into the femoral shaft the arterial pressure decreased from 95.9 +/- 13 to 86 +/- 11 torr (P less than 0.05); the left ventricular stroke work index dropped from 49.9 +/- 5 to 42.1 +/- 7 g.m/m2 (P less than 0.01). While total peripheral resistance decreased slightly in the methylmethacrylate group, there was a small increase after implantation of BDF cement into the femoral shaft. In both groups, however we found a slight elevation of pulmonary vascular resistance after cement implantation into the femur. The determination of the serum concentration of the cement monomer did not yield any measurable serum concentrations. Heat production by polymerisation of BDF cement (maximum 45.8 +/- 6.5 Centigrade) was much less compared with the temperature which developed during the polymerisation of methylmethacrylate (maximum 63 +/- 16.4 Centigrade); therefore, the safety of clinical application seems to be greater with the new BDF cement.

[Staged lavage therapy in diffuse peritonitis]. / Etappenlavagetherapie bei diffuser Peritonitis.

Sequential lavage is introduced as a new treatment for severe diffuse purulent peritonitis. Following surgical removal of the focus and intraoperative intraabdominal lavage, the sequential lavage technique was applied with length of treatment dependent on the severity of each case. Data from 21 patients were recorded for the study. Subject lethality was 19%. Three patients survived the so-called "incurable triad".

[Haemodynamic measurements during controlled hypotension by nitroglycerin (author's transl)]. / Kreislaufuntersuchungen unter arterieller Hypotension mit Nitroglycerin.

In nine patients undergoing neurosurgical operation for cerebral aneuryms haemodynamic measurements were made before, during and after continuous intravenous administration of Nitroglycerin at a mean dose of 6.5 micrograms/kg . min. Within 15 min of the start of the infusion mean arterial pressure fell from 94.2 +/- 10.5 to 73.4 +/- 11.1 mm Hg. A further decrease of mean arterial pressure even by a substantial raising of the Nitroglycerin dose was not possible. 15 min after the discontinuation of Nitroglycerin administration mean arterial pressure rose to the preinfusion level. The decrease of stroke volume index from 40.8 +/- 9.9 to 31.0 +/- 7.3 ml/m2 was partially compensated by an increase of heart rate from 65.9 +/- 9.6 to 77.7 +/- 19.4 beats/min. Consequently cardiac index fell only slightly from 2.9 +/- 0.6 to 2.5 +/- 0.5 ml/min . m2. The right atrial pressure decreased to 3.3 +/- 2.9 mm Hg, the mean pulmonary arterial pressure to 6.3 +/- 1.9 mm Hg and the pulmonary capillary wedge pressure to 2.3 +/- 2.1 mm Hg. The significant fall of total peripheral resistance to 983 +/- 194 dyn x s/cm5 (p less than 0.05) and the decrease of left ventricular stroke work index to 34.7 +/- 11.5 g . m/m2 contributed to reduce myocardial oxygen consumption. The authors conclude that, because of its effect on blood pressure, it reversibility of action and its absence of adverse side effects Nitroglycerin is a valuable agent for controlled hypotension.

[Effect of metoprolol on the circulation after head trauma. Studies during continuous intravenous administration (author's transl)]. / Kreislaufwirkung von Metoprolol bei Schädel-Hirn-Verletzten. Untersuchungen während kontinuierlicher intravenöser Applikation.

The influence of continuous intravenous administration of metoprolol on heart rate and haemodynamics was tested in ten unconscious patients who, after sustaining a head injury, developed sinus tachycardia due to increased sympathicotonia. In preliminary studies on three patients the effective dosage for heart rate reduction was determined. Following this, seven patients received 0.15 mg/kg . h of metoprolol over 36 hours. Heart rate decreased from an average of 127.5 to 78.8/min, a statistically significant reduction. Stroke volume index significantly rose from an average of 35.5 to 52.3 ml/m2, while other haemodynamic variables were not or only slightly changed. Cardiac index fell (not significantly) from 4.51 to 3.81/min . m2, peripheral vascular resistance rose (not significantly) form 942.4 to 1061.7 dyn . s . cm-5. Arterial and pulmonary artery pressures as well as filling pressures of right and left ventricle and left ventricular work index were not altered. Total oxygen consumption and oxygen extraction rate also remained unchanged. Measurement of metoprolol plasma levels in four patients excluded the possibility of a cumulative effect.

[Gaschromatographic examination of the expired air after anaesthesia with halothane, enflurane and methoxyflurane (author's transl)]. / Vergleichende gaschromatographische Untersuchungen der Exspirationsluft von Patienten nach Narkosen mit Enflurane, Halothane und Methoxyfluran

The concentration of anaesthetic gases in the expired air was studied for up to 17 days in patients who had been anaesthetized with methoxyflurane, enflurane or halothane. The estimation were made by means of gaschromatography. The rate and duration of elimination of the anaesthetic via the lungs depends on the fat stores of the patient (as calculated by the body weight/stature ratio), the length of anaesthesia and the Lutz index (calculated average concentration of the inhaled anaesthetic). The concentration of anaesthetic gases in the expired air fell steeply during the first 12 hours after anaesthetic and then decreased more gradually. The drop in concentration during the first 24 hours was steepest for methoxyflurane, followed by halothane and enflurane in that order. The results are in fair agreement with the rate of metabolization of the three anaesthetic agents. The investigation showed that during the first after anaesthesia appreciable quantities of anaesthetic gases are eliminated via the lungs and, consequently, released into the air of the recovery room.