[Nasotracheal intubation with laryngeal mask and fiber bronchoscope]. / Nasotracheale Intubation mittels Larynxmaske und Fiberbronchoskop (NILB).

An alternative way to the usual mode of nasotracheal intubation is described. 50 patients had to be intubated nasotracheally for surgical procedures. After induction of anaesthesia and insertion of the laryngeal mask a fiberoptic bronchoscope was nasally inserted during sufficient breathing. After view of the laryngeal mask, it was taken out and a tube via fiberoptic bronchoscope was placed endotracheally. Way and avoidance of complications by this method are described.

[Acute respiratory distress syndrome of the adult (ARDS) and artificial respiration--results in surgical intensive care patients]. / Akutes Atemnotsyndrom des Erwachsenen (ARDS) und Beatmung--Ergebnisse bei operativen Intensivpatienten.

A prospective clinical trial was performed in an operative intensive care unit to examine the incidence and outcome of patients with adult respiratory distress syndrome (ARDS) and the outcome of intensive care patients on mechanical ventilation and the incidence of barotrauma and pulmonary infection. 161 mechanically ventilated patients showed an overall mortality of 19.9%. The mortality rate in the ARDS patients was 11 of 26. Most of these patients with ARDS died from multiorgan failure. Pulmonary infection was the most frequently registrated complication of mechanical ventilation. We conclude from these data that --according to the literature the outcome of surgical ICU patients on mechanical ventilation with and without ARDS is more favourable than that of medical ICU patients; --the interpretation of therapeutic results and of epidemiological data in ARDS patients is possible only by providing exact and detailed criteria; these should include compliance data; --evaluation of present ARDS therapy by comparison to previous data, even when the same criteria are applied, e.g. ECMO-criteria, may fail as the outcome of conventional therapeutic measurements - mechanical ventilation - may have improved. A controlled randomised trial might be more suitable for evaluation of alternative therapy in ARDS.

Assessment of contractility changes in humans by transoesophageal echocardiography: the peak-systolic pressure end-systolic diameter relationship (PSPESDRS).

The peak-systolic pressure end-systolic diameter relationship (PSPESDRS) was determined in ten healthy subjects under general anaesthesia by using the radial artery pressure tracing (peak-systolic pressure) and transoesophageal 2d-and m-mode echocardiography (left ventricular diameters) without blocking of autonomic reflexes. Left ventricular load was changed by injection of a single intravenous dose of 0.2 mg nitroglycerin (NTG). Linear regression analysis showed a close linear relationship during the pressure decrease between peak-systolic pressures and end-systolic diameters. During infusion of dobutamine 5 micrograms/kg/min there was also a close linear relationship during pressure decrease with increased slope and unchanged Do (D0 = diameter at theoretical pressure zero). Values taken during pressure returning to control level were shifted leftward indicating transient increased contractility. We conclude, that the PSPESDRS can reliably be measured in humans without autonomic blockade during the decrease of arterial pressure after NTG, where reflex changes in inotropy are not yet present. This relationship increases in slope with dobutamine, reflecting the increased contractile state.

[Comparative echocardiographic studies on the negative inotropic effect of halothane, enflurane and isoflurane]. / Vergleichende echokardiographische Untersuchungen zur negativen Inotropie von Halothan, Enfluran und Isofluran.

Using the afterload-independent end-systolic pressure-dimension-relationship a study was performed in order to investigate whether there are differences in the negative inotropic effects of halothane, enflurane and isoflurane at 1 MAC in 70% N2O. 30 patients of ASA-groups I and II were studied. Using transoesophageal 2d- and m-mode echocardiography the end-systolic-pressure-dimension-relationship was established and the slope (parameter of contractility) determined. The slope decreased significantly (paired Wilcoxon-test 2 alpha less than 0.01) with halothane (68.5/46.5 mmHg/cm), enflurane (56/48 mm Hg/cm) and isoflurane (63/35 mmHg/cm). There is no difference between the three groups (Kruskal-Wallis-test 2 alpha greater than 0.05). The negative inotropic effects of halothane, enflurane and isoflurane at 1 MAC in 70% N2O are the same. The vasodilation caused by isoflurane enables better pump function compared to halothane and enflurane, but may cause severe hypotension. We conclude that for cardiac risk patients isoflurane has no outstanding advantages in comparison to halothane and enflurane.

[Aortofemoral bifurcation bypass--effect of the anesthesia procedure (NLA, thoracic continuous catheter peridural anesthesia) on circulation, respiration and metabolism. Intraoperative circulatory reactions]. / Aortofemoraler Bifurkationsbypass--Der Einfluss des Anaesthesieverfahrens (NLA, thorakale kontinuierliche Katheterperiduralanaesthesie) auf Kreislauf, Atmung und Stoffwechsel. Intraoperatives Kreislaufverhalten.

51 patients who were selected for aorto-bifemoral bypass operation (infrarenal aortic aneurysm, iliac or iliofemoral occlusive disease) were randomized into two groups. 26 patients were operated on under neuroleptanaesthesia and 25 patients had a continuous thoracic epidural, which was supplemented with a light general anaesthesia during the operation. All patients were optimally volume loaded prior to surgery. The most marked haemodynamic alterations (tachycardia, arterial hypertension, increase of cardiac index, left ventricular stroke work index and cardiac minute work) were provoked by eventration of the gut. In the epidural group, these changes were attenuated and in contrast to the neuroleptanaesthesia group, there were a few patients who had a serious fall in blood pressure. These reactions were regularly accompanied by a generalized flush which led to the hypothesis that they were caused by the release of intestinal hormones, reactive peptides and neurotransmitters, from the mechanically irritated gut. Clamping of the aorta was relatively uneventful. Heart rate and cardiac index decreased in both groups but mean arterial pressure and pulmonary capillary wedge pressure remained stable. Systemic vascular resistance increased slightly in the neuroleptanaesthesia, but not in the epidural group. Declamping was followed by significant but transient falls in systemic vascular resistance and arterial pressure in both groups, despite sufficient volume loading before opening the clamp. In the neuroleptanaesthesia group these changes spontaneously returned to normal; in the epidural group 6 patients received vasopressors or positive inotropic drugs. These results indicate the following: Epidural anaesthesia prevents hypertension and tachycardia and lowers cardiac minute work. Eventration of the gut, acute blood losses and declamping of the aorta may be critical situations, which can lead to profound hypotension. Under neuroleptanaesthesia eventration of the gut is followed by tachycardia and hypertension whereas blood losses and declamping are not as critical as when an epidural is used. Only experienced anaesthetists should use epidural anaesthesia for aortic surgery. An intensive monitoring of haemodynamic function during this form of anaesthesia is mandatory.

[Aortofemoral bifurcation bypass--effect of anesthesia procedure (NLA, thoracic continuous catheter peridural anesthesia) on circulation, respiration and metabolism. Hemodynamic changes caused by peridural anesthesia and anesthesia induction]. / Aortofemoraler Bifurkationsbypass--der Einfluss des Anaesthesieverfahrens (NLA, thorakale kontinuierliche Katheterperiduralanaesthesie) auf Kreislauf, Atmung und Stoffwechsel.

UNLABELLED: In 50 patients scheduled for infrarenal aortic bypass surgery the cardiovascular effects of two anaesthetic regimes were investigated prior to surgery. A Swan-Ganz-catheter was used for haemodynamic measurements. These patients, having been randomized into two groups, were optimally volume loaded (PCWP 10 mmHg) before anaesthesia. In 24 patients a thoracic epidural was induced with 12-15 ml 0.25% plain bupivacaine. When segmental anaesthesia had extended from T4/5 to L1/2 general anaesthesia was additionally applied (flunitrazepam 1.5-2 mg, pancuronium bromide 0.1 mg/kg). In 26 patients neuroleptanaesthesia was induced (droperidol 0.1-0.2 mg/kg, fentanyl 0.01 mg/kg, pancuronium bromide 0.1 mg/kg, and thiopentone 100-150 mg. Haemodynamic measurements were made before injection into the epidural catheter, after complete spread of anaesthesia, before commencing general anaesthesia and 10-15 min thereafter. RESULTS: Neither of the two procedures were associated with severe haemodynamic alterations. In the epidural group HR fell slightly during latency of complete spread and increased to the same extend following general anaesthesia. The epidural caused MAP (104 to 88 mmHg), mean PAP (20 to 14 mmHg), PCWP (10 to 7.5 mmHg), and RAP (4.5 to 2.5 mmHg) to decrease moderately but no further changes were effected by the subsequent general anaesthesia. SVR and PVR were not influenced by either epidural or by general anaesthesia. CI (3.6 to 3.41 . min-1 . m-2), LVSWI (67 to 52 p . m-1), and cardiac minute work index (55 to 40 J . min-1 . m-2) decreased during latency of complete spread but were no further influenced by general anaesthesia. The haemodynamic changes of neuroleptanaesthesia were almost identical to those of the combined epidural-general anaesthesia. For the operation which followed, a continuous infusion of 0.125 per cent plain bupivacaine (0.25 ml/kg X h) via epidural catheter (in combination with N2O/O2-anaesthesia) was sufficient for complete analgesia in the epidural group. These findings lead to the conclusion that a small bolus volume and a low concentration of bupivacaine result in good anaesthesia while avoiding serious haemodynamic alterations.

[Influence of specimen withdrawal on the results of chemical analyses of blood, plasma and serum in patients with stable or centralized circulation (author's transl)]. / Einfluss der Materialgewinnung auf Klinisch-Chemische Parameter in Blut, Plasma und Serum bei Patienten mit stabilem und zentralisiertem Kreislauf.

The influence of circulatory conditions, point of blood withdrawal (arterial, central or peripheral venous) and the plasma-serum relation on 29 clinical chemical and hematological parameters were studied with 22 polytraumatized patients. The conditions studied significantly affect the results, and must be taken into consideration in evaluating the results and their comparison to reference values. This is especially important for the determination of the catalytic activities of creatine kinase, aspartate and alanine aminotransferases, and alkaline phosphatase in centralized-circulatory patients, for the total protein the electrophoretic fractions and analyses of blood gas as a function of the point of blood withdrawal, and for the total protein, gamma-globulins and potassium when plasma is analysed instead of serum.

[Artificial ventilation with the servo-ventilator 900 (author's transl)]. / Künstliche Beatmung mit dem Servo-Ventilator 900

The use of artificial ventilation in the treatment of seriously ill or severely injured patients demands extensive knowledge on the part of the physician of the physiological and pathological effects of ventilation. In addition, it is required that the manufacturers develop ventilators able to meet there special demands. During the last two years the Servo-Ventilator 900 has been in use in our intensive care unit. During this period we were very impressed by its versatile applicability. The use of this apparatus however more than ever before requires the knowledge of breathing mechanisms and their pathophysiological consequences. The various flow- and breathing-rate-patterns combined with the exact electronic control of the respiratory make possible subtle adjustments--to the required ventilation pattern.

Use of limulus assay to compare the biological activity of peptidoglycan and endotoxin.

The gelation of a lysate prepared from the amebocytes of Limulus polyphemus, the horseshoe crab, has been used to detect endotoxin-like material in clinical studies and in "in vitro" experiments. The investigation of blood samples from 54 hospitalized patients suspected of having endotoxemia, revealed a positive limulus test in 14. Infections due to gram-positive organisms were not associated with positive assays. These results were in agreement with the observation that living gram-positive microorganisms - in contrast to gram-negative bacteria - did not initiate lysate gelation when studied "in vitro". Only very high concentrations of peptidoglycan, isolated from the cell walls of various gram-positive bacteria, induced the reaction. Therefore, these findings support the view, that the limulus test is relatively specific for the detection of gram-negative bacterial endotoxin and endotoxemia.

[The effect of 6% hydroxyethyl starch, 45% dextran 60 and 5.5% oxy-poly-gelatine on blood volume and circulation in human volunteers (author's transl)]. / Wirkung von 6% iger Hydroxyäthylstärke, 4, 5% igem Dextran 60 und 5, 5% iger oxypolygelatine auf Blutvolumen und Kreislauf bei Versuchspersonen

Studies in 30 volunteers showed that the volume increasing effect of a 2.5% Oxypolygelatine-solution is rather short (90 to 240 min), whereas the volume effect of a 4.5% Dextran 60 solution remained stable over a period of 240 min hydroxethyl-starch solution 6% caused a distinct increase in blood volume after a period of 90 min and of 240 min in five volunteers, while the blood volume of the other volunteers remained rather constant. The parameters we measured provide no explanation for this effect.