[Optimization of blood gas analysis in intensive care units : Reduction of preanalytical errors and improvement of workflow]. / Optimierung von Blutgasanalysen auf der Intensivstation : Reduzierung präanalytischer Fehler und Verbesserung der zeitlichen Abläufe.

BACKGROUND: Point of care testing with blood gas analysis (BGA) is an important factor for intensive care medicine. Continuous efforts to optimize workflow, improve safety for the staff and avoid preanalytical mistakes are important and should reflect quality management standards. AIM: In a prospective observational study it was investigated whether the implementation of a new system for BGA using labeled syringes and automated processing of the specimens leads to improvements compared to the previously used procedure. MATERIAL AND METHODS: In a 4-week test period the time until receiving the final results of the BGA with the standard method used in the clinical routine (control group) was compared to the results in a second 4-week test period using the new labeled syringes and automated processing of the specimens (intervention group). In addition, preanalytical mistakes with both systems were checked during routine daily use. Finally, it was investigated whether a delay of 10 min between taking and analyzing the blood samples alters the results of the BGA. RESULTS: Preanalytical errors were frequently observed in the control group where non-deaerated samples were recorded in 87.3 % but in the intervention group almost all samples (98.9 %) were correctly deaerated. Insufficient homogenization due to omission of manual pivoting was seen in 83.2 % in the control group and in 89.9 % in the intervention group; however, in the intervention group the samples were homogenized automatically during the further analytical process. Although a survey among the staff revealed a high acceptance of the new system and a subjective improvement of workflow, a measurable gain in time after conversion to the new procedure could not be seen. The mean time needed for a complete analysis process until receiving the final results was 244 s in the intervention group and 201 s in the control group. A 10-min delay between taking and analyzing the blood samples led to a significant and clinically relevant elevation of the values for partial pressure of oxygen (pO2) in both groups compared to the results when analyzing the samples immediately (118.4 vs. 148.6 mmHg in the control group and 115.3 vs. 123.7 mmHg in the intervention group). When using standard syringes the partial pressure of carbon dioxide (pCO2) was significantly lower (40.5 vs. 38.3 mmHg) whereas no alterations were seen when using the labeled syringes. CONCLUSION: The implementation of a new BGA system with labeled syringes and automated processing of the specimens was possible without any difficulties under daily clinical routine conditions in this 10-bed intensive care unit (ICU). A gain of time could not be measured but a reduction in preanalytical errors using the labeled syringes with automated processing was found. Delayed analysis of blood samples can lead to significant changes in pO2 and pCO2 depending on the type of syringe used.

[Placement of a central venous catheter in cases of persistent left superior vena cava]. / Anlage eines zentralen Venenkatheters bei persistierender V. cava superior sinistra.

This article presents a case report on the placement of a central venous catheter (CVC) in a patient with an unknown persistent left superior vena cava (PLSVC). Normally, PLSVCs remain asymptomatic but can be associated with disastrous consequences for the patient during placement of a CVC particularly due to vascular perforation and pulmonary injury. A PLSCV is particularly common in association with congenital heart defects; however, otherwise healthy patients can also be affected. As the presence of a PLSCV is normally unknown special attention must be paid in every patient during placement of a CVC.

[Hemorrhagic shock caused by intraperitoneal hemorrhage after amniocentesis]. / Hämorrhagischer Schock durch intraperitoneale Blutung nach Amniozentese.

This case report its on a haemorrhagic shock developing after amniocentesis during early pregnancy. Initially caused by a lesion of a small subserous artery in the upper uterine fundal wall, the patient consequently developed a protracted haemorrhagic shock that required emergency treatment and surgery. Thirteen days later fetal death was diagnosed by ultrasonographic examination, apparently caused by an abnormality of the umbilical cord without any connection with the previous complication.

[Spontaneous malignant transformation of extra-abdominal fibromatosis to fibrosarcoma]. / Die spontane maligne Transformation einer extraabdominalen Fibromatose in ein Fibrosarkom.

The desmoid tumour with infiltrative and destructive growth tendencies, is a rare benign alteration of the connective tissue from musculo-aponeurotic structures and fascial sheaths. The exact pathogenesis is unknown, however trauma (surgery), genetic (Gardener's Syndrome) or hormonal factors (pregnancy) have been implicated. A spontaneous malignant transformation of a desmoid (extra-abdominal fibromatosis) to a fibrosarcoma is a rarity. Only one case is recorded in the literature. We report on the second case in international literature and describe the coherence to an endocrine factor (pregnancy), the high recurrence rate and the difficulty of therapy with regard to the risk of late malignant transformation.

Inhibition of brain macrophage/microglial respiratory chain enzyme activity in experimental autoimmune encephalomyelitis of the Lewis rat.

We measured the activities of five respiratory chain enzymes in brain macrophages/microglial cells from Lewis rats with experimental autoimmune encephalomyelitis (EAE) and found a significant reduction of the activity of nicotinamide adenine dinucleotide-dehydrogenase (NADH-DH), succinate cytochrome c reductase (SCCR) and succinate dehydrogenase (SDH) when compared with age-matched healthy control animals. The inhibition of NADH-DH (complex I) was specific for EAE, while we also found a reduction of SCCR and SDH activities (complex II) in newborn rats and adjuvant-immunised rats. Activities of NADH cytochrome c reductase (NCCR) and cytochrome c oxidase (COX) were not significantly changed. These observations demonstrate an impairment of brain macrophage/microglial respiratory chain function in central nervous system inflammation.

Experience with leuprorelin acetate depot in the treatment of fibroids: a German multicentre study.

Between October 1988 and October 1990 in a noncomparative multicentre study, 114 patients were treated for uterine fibroids with the gonadotrophin-releasing hormone (Gn-RH) agonist, leuprorelin acetate depot. The mean age of the women was 33 years and 55.3% of them had a history of infertility. After confirmation of the diagnosis by ultrasound and/or operation, treatment began between day 1 and 3 of the cycle with leuprorelin acetate depot 3.75 mg subcutaneously. Therapy was carried out for a total of 6 months with one injection every 4 weeks. Treatment was paralleled by measurements of endocrine and metabolic parameters, estimation of myoma and uterine size by ultrasound and self-reporting of the patients of drug-related complaints. Four of the 114 women did not complete the whole treatment, two of them because of general side effects, one because of carcinophobia and unsatisfactory regression of the myoma and the last one for unspecified reasons. During treatment, a mean reduction of the uterine volume of about 67% was observed, in conjunction with shrinkage of the myoma in 92.1% of cases (mean decrease of 56% of the fibroids) with a large interindividual difference. Maximal diminution of uterine and fibroid size had been nearly completely reached within the first 12 weeks of therapy. After 4 weeks of the Gn-RH agonist depot most of the patients had achieved postmenopausal status, which continued throughout the remaining 20 weeks of treatment. In accordance with this finding, the majority of general side effects was due to the hypo-oestrogenic endocrine status. Liver and lipid metabolism was almost unaffected, although increasing calcium and alkaline phosphatase serum levels as well as an increased urinary calcium/creatinine ratio demonstrated an increased metabolic turnover of the bone. Haemoglobin concentrations, however, increased in those cases with fibroid-related anaemia. Thus the slow-release form of leuprorelin acetate is an adjunct to myomectomy especially in those women in whom family planning is not yet completed.

[Intrauterine cerebral hemorrhage as a cause of hydrocephalus]. / Intrauterine Hirnblutung als Ursache eines Hydrocephalus.

Intracranial haemorrhages in before-term children and risk newborn are a well-known problem, hydrocephalus being one of the possible posthaemorrhagic complications. In most cases intrapartal and postpartal complications will be responsible for the occurrence of haemorrhages. However, in this regard it is difficult to assess the ranking of individual factors such as acidosis, birth trauma, postpartal care and infusion therapy or postpartal complications. The following case report concerns a rare case of prepartal intraventricular bleeding resulting in hydrocephalus in an otherwise uneventful pregnancy course. Whereas in the 32nd pregnancy week both the cerebral ventricular system and the dimensions of the head had been normal, development of hydrocephalus was discovered at random in the 36th week during a screening procedure.

Squamous cell carcinoma antigen for monitoring cervical cancer.

The tumour-associated antigen was determined in the plasma of patients with squamous cell carcinoma (SCC) of the uterine cervix by radioimmunoassay. Setting a limit of 2 ng/ml, levels were abnormal in 13.4% of healthy controls, in 14% of patients with carcinoma in situ and in 62% of patients with invasive cervical SCC. The incidence of elevated SCC antigen levels and the absolute antigen plasma concentration were dependent upon the tumour load, increasing significantly with advanced stage disease. Abnormal SCC antigen values in operable cervical cancer declined to normal within one week after radical hysterectomy with pelvic lymphadenectomy. In cases of radiotherapy antigen values took 4-6 weeks after the start of treatment to return to normal. The success of both treatment modalities was announced by an early rise in the SCC antigen in the initial phase of therapy, followed by normalisation. After successful primary treatment and a complete remission during further follow-up SCC antigen in plasma was only increased in 3.8% of the cases. Retrospective evaluations in ten patients with progressive disease showed the reappearance of abnormal SCC titers and further increase preceeding the clinically detectable relapse or progression, with a median interval of 8 weeks. The present study indicates that SCC antigen determination is not useful for the early diagnosis of cervical cancer, but it is a potential means for monitoring the efficacy of individual anticancer therapy of SCC of the uterine cervix and for detecting recurrent disease.

[Acute phase proteins (C-reactive protein, orosomucoid, haptoglobin)--specific markers in the diagnosis of inflammatory adnexal diseases]. / Akute-Phase-Proteine (C-reaktives Protein, Orosomucoid, Haptoglobin)--Spezifische Marker bei der Diagnostik entzündlicher Adnex-erkrankungen.

The group of patients discussed here comprises 51 women admitted to hospital with diagnosed adnexitis. Twenty-seven patients whose diagnosis was confirmed by the correlation of pathologic laboratory parameters with examination findings or by laparoscopy or laparatomy were defined as adnexitis-positive. Apart from clinical examination findings, the evaluation analysis also included blood sedimentation rate, leukocytes and body temperature, as well as the acute-phase proteins C-reactive protein, orosomucoid, and haptoglobin. It was found that both clinical examination findings and normal laboratory parameters, as they have been set up to the present in normal clinical routine, were only partially useful in the diagnosis of an inflammatory adnexal lesion. Ultrasonic examination findings resulted in unequivocally positive or negative findings in roughly one-half of the cases. In contrast, the 27 inpatients receiving treatment for adnexitis had pathologically increased levels of C-reactive protein. In all 24 cases in which an inflammatory adnexal lesion was ruled out, a normal concentration (less than 0.6 mg/dl) of the same protein was found. Similarly good results were arrived at in the analysis of orosomucoid and haptoglobin. By means of follow-up controls of the acute-phase proteins, as opposed to measurement of BSR and leukocyte count, the success of treatment could also be determined unequivocally. For routine clinical procedures analysis of the inflammation marker C-reactive protein seems to be sufficient, since no additional information about the inflammatory lesion was obtained by assay of the other acute-phase proteins.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tubal pregnancy: recent aspects of diagnosis and treatment]. / Tubargravidität: Aktuelle Aspekte in Diagnostik und Therapie.

The histories of 139 patients who received treatment for tubal pregnancy between January 1975 and December 1981 in our department were reviewed. 12% of the patients had a prior contralateral tubal pregnancy. The commonest clinical finding was metrorrhagia in 84% of the cases. The HCG in the urine was positive in 68% of the cases with the clinical routine methods used up to date. The beta HCG in the blood showed an atypical trophoblastic process in all cases. The tubal pregnancy was diagnosed by ultrasonography in 19% of the cases and suspected in 54% of the cases. Aspiration of the pouch of Douglas verified the diagnosis in 79% of the cases. Laparoscopy confirmed the diagnosis in every case. Laparoscopy was especially required when the symptoms were unclear or when the aspiration of the pouch of Douglas showed negative or dubious results. 85 patients had a salpingectomy, 50 patients had a conservative operation of the tube. Laparoscopy was done in 34 patients who had a conservative tubal operation. In 79% of the patients an intact tubal wall made a conservative operation possible. 51 women desired further child-bearing by written questionnaire. After salpingectomy and normal contralateral fallopian tube at operation, 25 patients showed further desire for child-bearing. 18 cases delivered infants, three cases had abortions, and one case had a recurrent ectopic pregnancy. Following conservative operations 24 patients desired further children. 11 patients had intrauterine pregnancies, one of them an abortion. Five patients had a recurrent ectopic pregnancy.

Concentration of placental protein 10 (PP10) in maternal serum and amniotic fluid throughout normal gestation and in pregnancy complicated by fetal growth retardation.

PP10, a new placental glycoprotein, was studied by a specific and sensitive double-antibody radioimmunoassay in maternal serum and other body fluids throughout pregnancy. The mean value of serum PP10 in healthy nonpregnant individuals was approximately 10 microU/l. During normal pregnancy it rose to 3,500 microU/l. The rate of rise was obtained from 78 normal pregnancies with 279 single assay values from weeks 6-40. The shape of the curve resembled that for other placental proteins (HPL, SP1). PP10 levels in amniotic fluid were measured in 145 samples from weeks 13-55 of normal pregnancies and at term. The mean concentration was 500 microU/l until week 18 and then rose slowly. Cord blood contained only trace amounts. PP10 was not found in maternal urine. The concentration in maternal serum and amniotic fluid was higher in twin pregnancies than in singleton pregnancies. In 46 cases with low birth weights the PP10 levels in maternal serum were significantly lower than normal. Simultaneous measurements of PP10 and E3, HPL and SP1 were made in 17 individual follow-up's. PP10 was comparable with E3 and appeared to be better than HPL and SP1 in predicting intrauterine fetal growth retardation.

[Operative correction of a urogenital malformation with persistent cloaca]. / Operative Korrektur einer urogenitalen Missbildung mit persistierender Kloake.

A case of malformation of the urogenital system with a persistent urogenital sinus and a cloaca is reported. There was unilateral agenesis of the kidney, megaureter and a double ureter with an ureteral orifice into the vagina and the clitoris. There was a double uterus and vagina with an orifice into the terminal gut. The patient had chronic recurrent urinary tract infections which required a colostomy during childhood. The operation largely restored a normal urogenital area and a functional anus.

Radioimmunoassay of SP1 (pregnancy-specific beta1-glycoprotein) in maternal blood and in amniotic fluid normal and pathologic pregnancies.

Sp1, the pregnancy-specific beta 1-glycoprotein, was studied in normal and pathologic pregnancies. We developed a highly specific and sensitive double-antibody-radioimmunoassay by radioiodination of purified placental SP1. This RIA allowed the estimation of SP1 concentrations as low as 2 ng/ml. In a collective of 227 women with normal pregnancies we established the normal distribution curve in maternal plasma from the fifth week of gestation to term. The median value rose steadily from 3 microgram/ml in the 8th week to 140 microgram/ml in the 36th week when a plateau was formed. In more than 400 patients with pregnancies complicated by a variety of pathologic disorders the SP1 levels were controlled by either single assays or serial estimations throughout pregnancy and were compared with the normal distribution range. SP1 was also determined in about 200 samples of amniotic fluid gained by amniocentesis and during parturition of normal pregnant women from the 13th gestational week until term. The normal range was established up to the 20th w.o.p. The concentrations rose from below 0.2 microgram/ml in early pregnancy to 3 microgram/ml and generally amounted to approximately 1% of the respective serum value. Pathologic cases with diverse chromosomal anomalies, Rh-incompatibility, anencephaly, hydramnios and other abnormal conditions were examined. From these only twin-pregnancies with slightly elevated levels and cases with fetal trisomies with reduced SP1 concentrations showed aberrations from the normal distribution. The estimation of serum concentrations in mothers with diabetes or Rh-incompatibility were not significantly different from the normal collective. In diabetes a characteristic course of the follow-up curves was observed. Abortion in early pregnancy was frequently but not always indicated by reduced SP1 values. Threatened abortion with subsequent continuation of pregnancy exhibited SP1 values scattered within the normal range. Since the radioimmunological determination of SP1 is possible in the early stage of gestation (from week 8) it may serve as a useful tool for prediction at times when the determination of placental lactogen is not yet possible. In pregnancies with "small-for-date babies" the correlation between SP1 in maternal plasma and fetal growth retardation was reflected in a pronounced tendency to low SP1 levels. Serial determinations of SP1 in the serum of women with EPH-gestosis were compared with the corresponding HPL determinations and showed the equality of SP1 concerning the assessment of the placental function.