A fatal case of AIDS-defining meningoencephalitis by C. neoformans, sensitive to antifungal therapy.

Cryptococcus neoformans is the most common cause of life threatening meningoencephalitis in HIV-infected patients. Diagnosis is based on tests for cryptoccocal antigen in serum and cerebrospinal fluid, and on culture of the organism. We present a case of AIDS-related cryptococcal meningoencephalitis unresponsive to antifungal combination therapy, despite of evidence of fungal susceptibility in vitro. Significant decreases in cryptococcal antigen titers in serum and cerebrospinal fluid did not correlate with progress in disease and fatal outcome.

[Bilateral monitoring of cerebral oxygen saturation in aortic arch surgery]. / Bilaterales Monitoring der zerebralen Sauerstoffsättigung in der Aortenbogen-Chirurgie.

Cerebral ischemia with consecutive neurological damage is a typical complication in aortic arch surgery. Therefore, intraoperative neuromonitoring is of increasing interest. This paper describes the role of bilateral near-infrared-spectroscopy (NIRS) in detecting cerebral ischemia. In the case of a patient with acute aortic dissection (Daily, type A), an unexpected sudden reduction of perfusion of the right carotid artery could easily be detected with the help of two instruments INVOS 3100A. The decrease in the saturation values from 74% to 54% correlated well with the drop of blood pressure in the right radial artery. Clamping of the aorta with interruption of the blood flow into the innominate artery through the false lumen was the reason for the low cerebral perfusion. After repositioning the aortic clamp NIRS in combination with invasive blood pressure monitoring sufficiently allowed to control the further course of cerebral perfusion. The NIRS is a non-invasive, easy to handle, and easy to interpret method for intraoperative monitoring of the neurological status. Therefore in our opinion it has got some relevant advantages in contrast to other neuromonitoring methods in aortic arch surgery.

Intrapericardial pheochromocytoma.

Pheochromocytoma are catecholamine-secreting tumors occurring in less than 1% of the hypertensive population. Even though more sensitive methods have facilitated the diagnosis of intrathoracic paragangliomas they still remain extremely rare. This study reports a patient with a cardiac pheochromocytoma in whom the tumor was located on the outside of the roof of the left atrium and involved the left main coronary artery. Due to this anatomy the resection of the tumor required a cardio-pulmonary bypass and transsection of the pulmonary artery. The postoperative course was uneventful and the patient could be discharged without significant hypertension.

[Noninvasive monitoring of cerebral oxygen saturation after severe craniocerebral trauma in a Jehovah's witness]. / Nicht-invasives Monitoring der zerebralen Sauerstoffsättigung nach schwerem Schädel-Hirn-Trauma eines Zeugen Jehovahs.

Patients with severe head injury run a high risk of developing secondary cerebral defects. Various methods have so far been described which vary in their continuity, invasiveness and technical aspects for the early detection and treatment of complications. Within this group of patients Jehovah's witnesses pose a particular problem due to their restriction concerning therapeutical possibilities. That may mean an additional danger to the cerebral O2-delivery. This case report highlights on the value of continuous, non-invasive cerebral O2-saturation measurement and its combination with the fiberoptical monitoring of mixed venous O2-saturation. It has been possible to recognize episodes of imbalance between O2-delivery and its demand owing to a variety of causes. Other measured parameters were unable to reliably detect the development of critical complications. Further latrogenic loss of blood by laboratory tests was significantly reduced. Despite partially insufficient circulation and anemia with a hemoglobin value of 49 g/l we were able to discharge the patient from ICU without recognizable neurological sequelae.

[Ventilation via a transnasally placed pharyngeal tube. Comparison with mask ventilation]. / Ventilation über einen transnasal im Pharynx plazierten Tubus. Vergleich mit der Maskenbeatmung.

OBJECTIVE: The present prospective study was designed to investigate the respiratory function during ventilation via a tube inserted through the nose into the pharynx. Results were compared with respiratory parameters measured during conventional mask ventilation in the same patients. METHODS: 20 ASA physical status I-II patients were studied after approval by the local Ethics Committee. Anaesthesia was induced with alfentanil 15 micrograms/kg and propofol 2.5-3.0 mg/kg and maintained with propofol, 12-15 mg/kg/h. Patients were ventilated via a facemask with oxygen and a tidal volume of approximately 8ml/kg (measurement A). After insertion of a tube (I.D. 7.0-7.5 mm) through the nostril into the pharynx ventilation was repeated in the same manner (measurement B). To secure airway seal a second person closed the patient's mouth and exerted cricoid pressure. Following neuromuscular blockade with suxamethonium (1.5 mg/kg) respiratory parameters were measured again (C). Measurements included pulse oximetry and side stream spirometry with continuous collection of the following data: airway pressure, inspired and expired tidal volume, dynamic compliance, expired volume in one second, inspiratory and expiratory oxygen and carbon dioxide concentration. Pressure-volume and flow-volume loops were displayed continuously. RESULTS: Ventilation via facial mask or via pharyngeal tube with and without relaxation showed normal endtidal FECO2. The mean values were 4.5 +/- 0.7%, 4.8 +/- 0.4% and 4.6 +/- 0.7%, respectively. Mean oxygen saturation exceeded 98% in each period. Leakage during mask ventilation was 59.3 +/- 65.5 mL and decreased to 40.5 +/- 62.1 mL with the pharyngeal tube, whereas relaxation resulted in a significant increase to 92.3 75.0 mL. Compliance (Cdyn) and expired volume in one second (V 1.0) did not change significantly during the entire period of measurement. CONCLUSION: The use of a pharyngeally placed tube proved adequate compared to conventional mask ventilation in 20 patients without underlying airway disease.

[Positioning the central venous catheter using intra-atrial ECG]. / Die Positionierung des zentral-venösen Katheters mit Hilfe des intraatrialen EKG.

In a small study (n = 9) central venous catheters were positioned in front of the right atrium using ECG. ECG was registered using a soft J-wire inside of the catheter. Big vessels were cannulated and in all cases cannulation was successful. ECG and x-ray control showed good agreement.