[Treatment reduction in intensive care. "Allowing the patient to die" by conscious withdrawal of medical procedures]. / Therapiereduktion in der Intensivmedizin. "Sterben zulassen" durch bewusste Begrenzung medizinischer Möglichkeiten.

The conversion of an "attempt to treat" to "prolongation of dying" represents an important problem in modern intensive care. If the actual or presumed will of the patient is unknown, the physician has to decide about the extent of treatment in a paternalistic manner. In these difficult decisions the physician has to consider prognosis, and certainty of prognosis and has to carefully balance between the right to live and the right to die. This decision about the extent of therapy is a very personal medical activity and can be taken off the physician's shoulders by nobody. Consultation with other physicians involved, relatives, nurses and clergy, however, is mandatory, as a joint decision should be sought. If the situation is hopeless and further medical interventions are futile, then allowing the patient to die by therapy reductions is not only a possibility but a mandatory act of humanity. In that case it does not matter whether new treatment modalities are abandoned or whether already instituted medical measures are withdrawn. In clinical practice, however, the "fine tuning" of therapy reduction has to be tailored to the individual case and largely depends on prognostic certainty.

Repeated administration of recombinant human insulin-like growth factor-I in patients after gastric surgery. Effect on metabolic and hormonal patterns.

OBJECTIVE: The primary objective of this investigation was to evaluate the anticatabolic effects of repeated subcutaneous administration of recombinant human insulin-like growth factor-I (rhlGF-I) in patients after gastric surgery. SUMMARY BACKGROUND DATA: The anabolic and protein-sparing effects of growth hormone are primarily mediated by IGF-I. Malnutrition and catabolic states result in increasing blood levels of growth hormone and decreasing levels of IGF-I. Experimental data showed that exogenous IGF-I could attenuate or reverse catabolism. METHODS: After giving their written informed consent, 38 male and female patients undergoing gastrectomy (age 40-75 years, body mass index 17-30 kg/m2) were treated with 80 micrograms/kg body weight rhlGF-I or placebo in a prospective, randomized, double-blind study for 5 consecutive days. Patients received a standardized total parenteral nutritional regimen with 3 g/kg body weight glucose and 0.1 g/kg body weight nitrogen. Nitrogen balance and 3-methylhistidine excretion were measured daily. Hormone profiles (IGF-I, IGFBP1, IGFBP3, cortisol, insulin, glucagon, triiodothyronine [T3], levothyroxine [T4], and thyroxine-binding globulin) were taken.

[Glucose-xylitol 35% (1:1) versus glucose 40%. Effectiveness and metabolic effects after major surgery]. / Glukose-Xylit 35% (1:1) versus Glukose 40%. Effektivität und metabolische Auswirkungen nach grossen operativen Eingriffen.

Injury and stress are accompanied by a characteristic hormonal response and altered energy utilisation. Hyperglycaemia and negative nitrogen (N) balance are the leading symptoms of the metabolic changes in the post-operative state. In a prospective, randomised study the efficacy and metabolic effects of glucose-xylitol (GX) 35% (1:1) versus glucose (G) 40% were investigated in patients undergoing major surgery. METHOD. Twenty-four patients undergoing abdomino-thoracic oesophageal cancer surgery were treated in a standardised manner. Total parenteral nutrition was administered over 6 days (kg body wt.-1/day): day of surgery 1-1.25 g carbohydrate (CH); 1st postoperative day (POD) 1.5 g CH, 1 g amino acids (AA); 2nd POD 3 g CH, 1.5 g AA, 1.0 g fat; from 3rd POD 3 g CH, 1.5 g AA, 1.5 g fat (CH GX35% (n = 12) or G40% (n = 12), AA Intrafusin 15%, fat Intralipid 20%). Daily and cumulative N balances, blood-G profiles, blood chemistry, and physical parameters were determined. Glucagon and insulin profiles, CH losses, and oxalic acid secretion were measured. RESULTS. Both groups were comparable for age, body mass index, clinical and physical parameters, and blood chemistry. Mean cumulative N balances after 6 days were -12.0 +/- 16.3 g N for GX35% and -5.6 +/- 19.4 g N for G40% (n.s.; Wilcoxon, P < 0.05). Blood G was similar for both groups with values ranging from 130 to 240 mg/dl on the day of surgery and below 150 mg/dl on the consecutive days. In each group 1 patient needed additional insulin therapy. Glucagon and insulin levels did not show a significant difference between the groups. CONCLUSION. No difference in tolerance and efficacy of nutritional support by GX versus G at a dose of 3 g.kg body wt.-1.d in oesophagectomised patients could be observed. Similar blood G profiles were in accordance with comparable glucagon and insulin levels. Because of the high standard deviations of N balances, differences in efficacy could not be proven. A significantly lower level of pseudocholinesterase (PCHE) for G40% on day 7 might indicate enhanced hepatic protein synthesis in the GX group.

[Safety and tolerance of a new dipeptide-containing amino acid solution DP-Gln 20 versus a conventional amino acid solution Vamin 18EF in patients after elective colon surgery]. / Sicherheit und Verträglichkeit der neuen dipeptidhaltigen Aminosäurelösung DP-Gln 20 versus einer konventionellen Aminosäurelösung Vamin 18EF bei Patienten nach elektiver Kolonchirurgie.

OBJECTIVE AND METHODS: Recent studies have demonstrated the important role of glutamine in postoperative metabolism. Using dipeptide-containing amino acid solutions it is possible to enhance glutamine supply. Safety and tolerance of DP-Gln 20 (gly-gln, gly-tyr) and Vamin 18EF were investigated in an open, prospective, randomised study. 16 patients received isonitrogenous parenteral nutrition over 4 days. RESULTS: There was no difference in clinical and biochemical patterns between both groups. Complications and adverse events due to the infused amino acid solutions were not observed.

[Autologous blood donation and isovolemic hemodilution--indications and practical implementation]. / Eigenblutspende und isovolämische Hämodilution--Indikationen und praktische Durchführung.

OBJECTIVE: The state of the art of autologous blood transfusion is described with special emphasis on safety aspects, indications and medicolegal implications. DATA SOURCES AND SELECTION CRITERIA: Literature was retrieved using the MEDLINE literature database. Medical and legal expert opinions on autologous blood transfusion programmes are presented as well as the actual German jurisdiction. Guidelines for autologous predeposit and haemodilution used in the University of Münster are described. RESULTS: In the past decade all forms of autologous transfusions gained increasing influence in haemotherapy due to the ongoing discussion on the safety of blood products. The German Federal Court has demanded that whenever homologous perioperative transfusion is considered likely, patients have to be offered autologous predeposit. Legal conditions for autologous programmes directed by anaesthetists not specialised in transfusion medicine are described. Whole-blood predeposit should be limited to two autologous units. In cases with minor blood loss, isovolaemic haemodilution may be performed instead of autologous predeposit. However, autologous transfusions have their specific risks that are either related to the patient or to the procedure of autologous predeposit, e.g., clerical error, contamination of blood products and technical faults. Standard procedures of the University of Münster to ensure low-risk autologous transfusion are presented. They consist in adequate handling and proper identification, testing of donor for virus infection markers, bacterial culture from blood products and a list of contraindications: anaemia, unstable angina, myocardial infarction within 3 months, decompensated heart insufficiency, aortic valve stenosis with angina, and cases with infection and fever. CONCLUSION: The risks related with autologous transfusion should be lower compared to homologous transfusions. Well-defined standards concerning indications and techniques are required to reach this goal.

Continuous spinal anesthesia: mechanical and technical problems of catheter placement.

BACKGROUND AND OBJECTIVE: Although continuous spinal anesthesia with microcatheters has a number of advantages, there are also some drawbacks: technical problems in advancing the catheter, the possibility of traumatizing neural structures, the development of cauda equina syndrome, and maldistribution of the local anesthetic. METHODS: Spinaloscopy was performed with a 2-mm-diameter endoscope in fresh cadavers to visualize the fate of the catheters, as well as the distribution of the local anesthetic administered through these fine-bore catheters. Midline and paramedian approach achieved an easy insertion of the 28-gauge catheter as long as the 22-gauge needle was not advanced too far into the subarachnoid space, thereby making it impossible for the catheter to bend at the anterior wall of the dura mater. RESULTS: Injection of methylene blue-colored hyperbaric local anesthetic through the catheter revealed an inhomogenous distribution with pooling in the caudal segments. After the catheter tip leaves the needle, the catheter should be advanced only 2-3 cm to avoid coiling, possible damage of the nerve roots, or malpositioning in preformed pouches. CONCLUSION: To take advantage of continuous spinal anesthesia, a meticulous technique is required.

Mechanical ventilation in the prone position for acute respiratory failure after cardiac surgery.

Ten patients with acute respiratory failure (ARF) after coronary artery bypass grafting were studied during conventional mechanical ventilation in the supine and in the prone position. Impaired gas exchange was defined as an inspired oxygen fraction (FIO2) greater than 0.5 to maintain an arterial oxygen tension (PaO2) > or = 70 mmHg, an alveolar-arterial PaO2 gradient (PA-aO2) > 200 mmHg and a venous admixture (QVA/QT) > 15% during mechanical ventilation with a tidal volume (VT) = 10 to 12 mL/kg, frequency (f) = 10 to 15 VT/min, inspiratory-expiratory (I:E) ratio = 0.5, and positive end-expiratory pressure (PEEP) of 5 to 7.5 cm H2O. In the supine position, systemic and pulmonary hemodynamics were in the normal range, but oxygenation was severely impaired. In all patients thoracic computed tomography scans were obtained and revealed crest-shaped bilateral densities in the dependent lung regions. FIO2 of 0.67 +/- 0.22 was required to maintain a PaO2 greater than 70 mmHg during mechanical ventilation in the supine position. Under these conditions PA-aO2 and QVA/QT were 362 +/- 153 mmHg and 32.5 +/- 8.3%, respectively. CO2 elimination was not severely affected. The patients were turned into the prone position after an average of 30.6 +/- 5.4 hours postoperatively and ventilated with unchanged VT, f, PEEP, and inspiratory-expiratory ratio for 26.7 +/- 11.7 hours (range, 10 to 42 hours). A second cardiopulmonary status was obtained within 2 to 5 hours of ventilation in the prone position.(ABSTRACT TRUNCATED AT 250 WORDS)