[Ethics and monetary values. Influence of economical aspects on decision-making in intensive care]. / Ethik und Monetik. Einfluss ökonomischer Aspekte auf Entscheidungsprozesse in der Intensivmedizin.

Healthcare expenditure continues to grow and the demand for cost-cutting measures has increased. Critical care medicine is characterized by extremely high expenditure and thus appears to be a suitable candidate for rationing. Based on the hospital address book of Germany, a questionnaire consisting of 25 multiple choice questions was sent out to 1,000 intensive care units (ICU). The questionnaire was focused on obtaining information on whether and how rationing takes place in Germany. A total of 540 questionnaires were returned and analyzed. Only approximately 25% of intensive care units stated that a special budget is available. Approximately 59% answered that therapeutic decisions were never or rarely influenced by economic reasons, but in 9% economics often influenced decisions. Advanced age was not considered to be a reason to limit the use of extremely expensive medication or the use of renal replacement therapy (RRT) in 88% of the answers. Incurable cancer was also no reason to refuse RRT (91%). For 35% of the answers there were no contraindications for admission to intensive care, whereas for 35% an incurable disease was a contraindication, for 10% a non-resuscitation order and for 84% the patients' wishes played a decisive role. Of the intensive care units 67% were convinced that rationing is a matter of fact in ICUs in Germany and 53% were of the opinion that rationing should not occur. Of the answers 43% considered that limiting ICU therapy would be the best when rationing is necessary. Rationing therapy in critical care appears to occur daily in German ICUs. Due to the high costs, intensive care therapy will represent a very important battleground in the inevitable healthcare spending limitations of the future. Rationing cannot be determined exclusively by ICU doctors, thus clear and probably unpopular decisions on this issue are expected to be announced by the politicians.

Nutrition support and treatment of motility disorders in critically ill patients - results of a survey on German intensive care units.

BACKGROUND AND OBJECTIVE: To evaluate the current clinical attitude in enteral nutrition support and motility disorders in adult critically ill patients on German intensive care units. METHODS: A total of 1493 questionnaires, including 25 items on the medical environment, treatment of motility disorders and enteral nutrition, were sent to German intensive care units in September 2005. Responses were collected during a 2-month period. RESULTS: A total of 593 questionnaires were returned (response rate 41%). The intensive care units were mainly led by anaesthesiologists (63%) or internists (17%). Standard nutrition protocols were used in 44%. Feeding was mainly started as a combined enteral-parenteral regimen (70%). Early enteral nutrition was performed in 58% using a volume of 250-500 mL (66%) and increased by 200-400 mL day-1 (55%). It was mainly delivered by gastric tube (76%) via continuous pump systems (72%) with short interruption intervals of <4 h (86%). Enteral nutrition solutions were mainly standard polymeric formulae (86%). Modified solutions for diabetics and those with renal or liver failure were uncommonly used; immunonutrition did not play a role. Prokinetic agents, especially metoclopramide, laxatives and neostigmine, were routinely used (39%). Further therapeutic options in motility dysfunction included purgative enemas (96%), gastrografin (72%) and colon massage (39%). CONCLUSIONS: The concept of early enteral nutrition has been well established and approved in German intensive care units, though the recommendations only meet level C criteria in the current ESPEN guidelines. The current survey may serve for further updates on practical nutrition support in intensive care medicine.

Semi-invasive monitoring of cardiac output by a new device using arterial pressure waveform analysis: a comparison with intermittent pulmonary artery thermodilution in patients undergoing cardiac surgery.

BACKGROUND: Thermodilution technique using a pulmonary artery catheter (PAC) is a widely used method to determine cardiac output (CO). It is increasingly criticized because of its invasiveness and its unclear risk-benefit ratio. Thus, less invasive techniques for measuring CO are highly desirable. We compared a new, semi-invasive device (FloTrac/Vigileo) using arterial pressure waveform analysis for CO measurement in patients undergoing cardiac surgery with bolus thermodilution measurements. METHODS: Forty patients undergoing coronary artery bypass grafting or valve repair were enrolled. A PAC was inserted and routine radial arterial access was used for semi-invasive determination of CO with the Vigileo. CO was measured simultaneously by bolus thermodilution and the Vigileo technique after induction of anaesthesia (T1), before cardiopulmonary bypass (CPB) (T2), after CPB (T3), after sternal closure (T4), on arrival in the intensive care unit (ICU) (T5), and 4 h (T6), 8 h (T7), and 24 h after surgery (T8). CO was indexed to the body surface area (cardiac index, CI). RESULTS: A total of 244 pairs of CI measurements were analysed. Bias and precision (1.96 sd of the bias) were 0.46 litre min(-1) m(-2) and +/- 1.15 litre min(-1) m(-2) (r = 0.53) resulting in an overall percentage error of 46%. Subgroup analysis revealed a percentage error of 51% for data pairs obtained intraoperatively (T1-T4), 42% in ICU (T5-T8), and 56% for values obtained during low CI (T1-T8). CONCLUSIONS: In cardiac surgery patients, CO measured by a new semi-invasive arterial pressure waveform analysis device showed only moderate agreement with intermittent pulmonary artery thermodilution measurement.

Retracted: Do patients profit from physostigmine in recovery from desflurane anaesthesia?

BACKGROUND: Physostigmine is the drug of choice in the central anticholinergic syndrome, but has also been used in post-operative mental derangement secondary to sedatives and volatile anaesthetics. The aim of this double-blind, randomized, prospective study was to determine whether physostigmine alters recovery after desflurane anaesthesia. METHODS: One hundred patients undergoing urologic or surgical procedures were enrolled to receive either NaCl 0.9% (n = 50) or 2 mg of physostigmine (n = 50) at the end of general anaesthesia with propofol, fentanyl, cisatracurium and desflurane. Times to extubation, stating name, birthday and place of residence, and obeying commands such as eye opening and hand squeezing were noted. Haemodynamics, Aldrete and pain scores, the analgesic requirements, and any adverse side-effects were documented until the 1st post-operative day. RESULTS: Demographic, peri-operative data including duration of anaesthesia, surgery and postanaesthetic care unit (PACU) stay, and consumption of anaesthetics were comparable in both groups. No significant difference between the groups was found for extubation time or other emergence parameters. Patients undergoing anaesthesia >150 min showed after receiving physostigmine significantly (P < 0.05) faster spontaneous breathing (2.6 +/- 3.1 vs. placebo 5.0 +/- 4.2 min) and extubation time (6.2 +/- 3.7 vs. placebo 8.8 +/- 5.0 min). Women showed significantly shorter extubation times (5.5 +/- 3.4 min) and eye opening (5.5 +/- 2.6 min) with physostigmine than placebo (7.7 +/- 4.5 and 7.8 +/- 4.0 min). The incidence of post-operative nausea and vomiting (PONV) was significantly higher after physostigmine than placebo, whereas shivering occurred more often after placebo. CONCLUSION: Physostigmine does not alter desflurane-based anaesthesia compared with placebo. An option is to use physostigmine in patients with a duration of anaesthesia >150 min who profit in earlier return to spontaneous breathing and shorter extubation time.

A total balanced volume replacement strategy using a new balanced hydoxyethyl starch preparation (6% HES 130/0.42) in patients undergoing major abdominal surgery.

BACKGROUND AND OBJECTIVE: The kind of fluid for correcting hypovolaemia is still a focus of debate. In a prospective, randomized, controlled and double-blind study in patients undergoing major abdominal surgery, a total balanced volume replacement strategy including a new balanced hydroxyethyl starch (HES) solution was compared with a conventional, non-balanced fluid regimen. METHODS: In Group A (n = 15), a new balanced 6% HES 130/0.42 was given along with a balanced crystalloid solution; in Group B (n = 15), an unbalanced conventional HES 130/0.42 plus an unbalanced crystalloid (saline solution) were administered. Volume was given when mean arterial pressure (MAP) was <65 mmHg and central venous pressure (CVP) minus positive end-expiratoric pressure (PEEP) level was <10 mmHg. Haemodynamics, acid-base status, coagulation (thrombelastography (TEG)) and kidney function (including kidney-specific proteins, N-acetyl-beta-d-glucosaminidase (beta-NAG) and alpha-1-microglobulin) were measured after induction of anaesthesia, at the end of surgery, 5 and 24 h after surgery. RESULTS: Group A received 3533 +/- 1302 mL of HES and 5333 +/- 1063 mL of crystalloids, in Group B, 3866 +/- 1674 mL of HES and 5966 +/- 1202 mL of crystalloids were given. Haemodynamics, laboratory data, TEG data and kidney function were without significant differences between the groups. Cl- concentration and base excess (-5 +/- 2.4 mmol L-1 vs. 0.4 +/- 2.4 mmol L-1) were significantly higher in patients of Group B than of Group A. CONCLUSIONS: A complete balanced volume replacement strategy including a new balanced HES preparation resulted in significantly less derangement in acid-base status compared with a non-balanced volume replacement regimen. The new HES preparation showed no negative effects on coagulation and kidney function.

Insignificant effect of desflurane-fentanyl-thiopental on hepatocellular integrity--a comparison with total intravenous anaesthesia using propofol-remifentanil.

BACKGROUND AND OBJECTIVE: Inhalational anaesthetics have been associated with hepatotoxicity. Even desflurane, with its low solubility in blood and tissues, and its minimal hepatic biotransformation, is known to affect hepatic integrity. The effects of propofol on hepatic function are, however, a matter of controversy. Alpha-glutathione S-transferase (alpha-GST), a sensitive and specific biomarker for hepatic integrity, was measured to assess the influence of total intravenous anaesthesia (TIVA) with propofol vs. anaesthesia with desflurane. METHODS: Forty-two patients scheduled for elective prostatectomy were randomly allocated to receive either desflurane, fentanyl and thiopental (desflurane group) or propofol and remifentanil (TIVA group). Depth of anaesthesia was guided by bispectral index. Plasma concentrations of alpha-GST and aminotransferases were measured before induction of anaesthesia (TO), at the end of surgery (T1), as well as 2 h (T2) and 24 h (T3) postoperatively. Haemodynamic parameters and bispectral index values were documented. RESULTS: alpha-GST increased significantly in the desflurane group from TO (3.0 +/- 2.2 microg L(-1)) to T1 and T2 (5.5 +/- 4.3 and 5.6 +/- 3.7 microg L(-1), respectively), whereas no changes were seen in the TIVA group. alpha-GST values above the normal upper limit (> 7.5 microg L(-1)) were seen in 24% of the patients receiving desflurane. Aminotransferases remained unchanged in both groups throughout the study period. CONCLUSIONS: The use of propofol as part of a TIVA regimen seems to have no influence on hepatocellular function during and after surgery. In contrast, patients receiving desflurane showed a transient slight, but significant, increase of alpha-GST to above the normal upper limit after anaesthesia, although this was without further clinical relevance.

Do we necessarily need local anaesthetics for venous cannulation? A comparison of different cannula sizes.

BACKGROUND AND OBJECTIVE: This randomized, prospective study was performed to evaluate the efficacy of a subcutaneous local anaesthetic infiltration prior to venepuncture using different cannula sizes. METHODS: Three-hundred-and-one patients were included in the study, 150 received mepivacaine 1% (0.25 mL) subcutaneously, 151 were cannulated without local analgesia. Patients were further allocated to one of five cannula size groups (standard wire gauge (G)): 20-, 18-, 17-, 16- and 14-G. They were asked to quantify the pain experienced using a four-point rating scale. RESULTS: In the group without local anaesthetics, 28.8% complained about pain compared to 12% receiving local analgesia. The incidence of pain for 14-G (10%) and 16-G (12.9%) cannulae was significantly reduced in the local analgesia group (P < 0.01) compared to no local analgesia (77.4% and 45.1%). Other cannula sizes showed no difference in pain whether using local analgesia or not. CONCLUSIONS: Patients profit from a subcutaneous infiltration with mepivacaine 1% prior to intravenous cathetherization only when cannulae of size > or = 16-G are inserted.

[ProSeal-laryngeal mask versus endotracheal intubation in patients undergoing gynaecologic laparoscopy]. / Ein Vergleich der ProSeal(R)-Larynxmaske mit der konventionellen endotrachealen Intubation bei Laparoskopien in der Gynäkologie.

BACKGROUND: The aim of this study was to assess the practicality of the ProSeal laryngeal mask (PS-LMA) airway during laparoscopic surgery with capnoperitoneum compared to endotracheal intubation (ET). METHODS: Prospective, randomized study. 104 patients undergoing gynaecologic, laparoscopic surgery were allocated randomly to two groups: 1. ET-group (n = 50). 2. PS-LMA-group (n = 54). Total intravenous anaesthesia was performed by the same anaesthesiologist. MEASUREMENTS: Mean arterial pressure, heart rate, at 4 and circuit pressure at 2 measurement points, and the incidences of coughing and sore throat. Insertion of the ET and the PS-LMA was scored by using a four-point scale. Ease of placing the gastric tube was judged by measuring the number of attempts at insertion and the insertion times. A p-value of < 0.05 was considered as significant. RESULTS: There were no differences between PS-LMA and ET concerning circuit pressure at any measurement point. At the end of anaesthesia, mean arterial pressure (92 +/- 13 vs. 100 +/- 14 mmHg; p < 0.01) and heart rate (66 +/- 13 vs. 76 +/- 14 beats/min; p < 0.01) were lower in the PS-LMA-group compared to the ET-group. At the end of anaesthesia 25 patients of the ET-group coughed but nobody in the PS-LMA-group (p < 0.00001). There was no difference with regard to postoperative sore throat. The insertion of the PS-LMA was easier compared to ET (p < 0.05), but we found no significant difference concerning insertion times. Fewer attempts at insertion of the gastric tube were necessary in the PS-LMA-group than in the ET-group (p < 0.01), whereas insertion times did not differ. CONCLUSION: The PS-LMA is a convenient and practicable approach for anaesthesia in patients undergoing laparoscopic surgery.

[Injection pain secondary to propofol-MCT/LCT and propofol-LCT--comparison of prophylaxis with lidocaine]. / Injektionsschmerz unter Propofol-MCT/LCT und Propofol-LCT - Vergleich einer Prophylaxe mit Lidocain.

OBJECTIVE: Pain on injection is one of the most described side-effects of the intravenous application of propofol. This study was designed to assess the efficacy of lidocaine 40 mg in preventing incidence and severity of injection pain for two different propofol solvents. METHODS: In a double-blind and prospective study 202 patients were enrolled and randomized to 4 different groups: group A receiving 2 ml NaCl 0.9 % and propofol-LCT (Disoprivan; AstraZeneca), group B 40 mg lidocaine and propofol-LCT, group C received 2 ml NaCl 0.9 % and propofol-MCT/LCT (Propofol-Lipuro, B. Braun Melsungen AG) and group D 40 mg lidocaine and propofol-MCT/LCT. According to the protocol, all patients were cannulated with a 18-G venous cannula at the dorsum of the hand and no other medicament was injected before the study drug. Time interval between test agents and propofol application in a dosage of 2 mg/kg was one minute. Severity of pain was evaluated during propofol injection over 30 seconds until loss of consciousness using a 4-point rating scale. RESULTS: The incidence of injection pain did not differ between propofol-LCT and propofol-MCT/LCT (64 % and 53 %). Propofol-MCT/LCT significantly reduced the severity of pain compared to propofol-LCT (p < 0.05). The application of lidocaine resulted in a significant reduction in incidence (Propofol-MCT/LCT: 16 %; Propofol-LCT: 31 %) and severity of injection pain compared to placebo. CONCLUSION: Propofol-MCT/LCT showed a significant advantage compared to propofol-LCT considering the severity of injection pain, but not in reducing the incidence of pain. The use of lidocaine resulted in a significant reduction of incidence and severity of injection pain for both propofol solvents.