[Implementation of modern operating room management -- experiences made at an university hospital]. / Implementierung eines OP-Statuts -- Erfahrungen unter den Bedingungen einer Universitätsklinik.

Caused by structural changes in health care the general need for cost control is evident for all hospitals. As operating room is one of the most cost-intensive sectors in a hospital, optimisation of workflow processes in this area is of particular interest for health care providers. While modern operating room management is established in several clinics yet, others are less prepared for economic challenges. Therefore, the operating room statute of the Charité university hospital useful for other hospitals to develop an own concept is presented. In addition, experiences made with implementation of new management structures are described and results obtained over the last 5 years are reported. Whereas the total number of operation procedures increased by 15 %, the operating room utilization increased more markedly in terms of time and cases. Summarizing the results, central operating room management has been proved to be an effective tool to increase the efficiency of workflow processes in the operating room.

Limitations of score-based daily outcome predictions in the individual intensive care patient. An example of the RIAHDH algorithm.

OBJECTIVE: The nature of score-based predictions is probabilistic, and their accuracy depends on the reliability and validity of the applied system. As an example, the present study investigates the accuracy of the RIP-algorithm (RIP = Riyadh Intensive Care Program) based on daily APACHE II scores, and compares it with published results of that algorithm from other investigators. DESIGN: Prospective observational study and review of the literature. PATIENTS AND METHODS: 1,986 consecutive admissions of 1,808 patients to a surgical intensive care unit were documented. Daily changes of score values were used to derive a risk of death estimation. Sensitivity and the rate of false predictions were calculated for score-based predictions. Health status one year after discharge was assessed in survivors predicted to die. RESULTS: Daily application of the algorithm identified 109 situations leading to death predictions in 56 patients. Five of these patients were discharged alive from the hospital (positive predictive value 91%). One year later 3 of these patients were still alive. The algorithm identified 51 of the non-survivors (sensitivity 19%), 110 died in the ICU without prediction. Altogether 270 patients died during their hospital stay. Among the 6 independent validation studies, similar results were found, but differences occurred due to the problematic assessment of consciousness. CONCLUSIONS: Sequential assessment of scores in intensive care could identify high risk patients, but with some degree of uncertainty. Therefore, the scores should only be used by those familiar with their limitations and risks.

[Clinical results with the "open lung concept"]. / Klinische Ergebnisse bei der Anwendung des "Open-Lung-Konzepts".

Elements of the "open lung concept" are being increasingly included in clinical ventilatory strategies. Despite encouraging experimental investigations to date, relatively few studies exist that examine the clinical application of the complete concept. The aim of this study was to prove that with effective recruitment maneuvers and titrated PEEP levels this concept is applicable in clinical settings. We sought to determine if it was possible to achieve a significant improvement in oxygenation and also to examine what side-effects resulted. Twenty consecutive patients who had had an acute lung injury (ALI) for less than 72 hours, with an oxygenation index (P/F-Ratio = quotient from arterial partial pressure of oxygen [PaO2] and the inspiratory fraction of oxygen [FiO2]) of less than 200 torr, and with a PEEP > or = 10 cmH2O were treated using a recruitment manoeuvre (RM). A PEEP was titrated to keep the lung open, and the patients were kept under pressure-controlled ventilation. The P/F-Ratio increased while using a recruitment pressure of 66 +/- 13 cmH2O from 137 +/- 41 to 381 +/- 150 torr (p < 0.001). The titrated PEEP which kept the lung open after recruitment was 17 +/- 3 cmH2O. One patient developed a pneumothorax. The dose of norepinephrine was increased in ten patients from 0.24 +/- 0.12 to 0.31 +/- 0.1 microgram/kg/min. Due to elevated liver enzymes within the first 48 hours, titrated PEEP had to be decreased in three patients. The clinical application of the "open lung concept" demonstrated a quick and effective improvement in oxygenation in many patients. Side-effects in some patients limited the use of high PEEP levels.

Outcome analysis of 189 consecutive cancer patients referred to the intensive care unit as emergencies during a 2-year period.

The referral of critically ill cancer patients to an intensive care unit (ICU) is a matter of controversial debate. This study was conducted by an interdisciplinary clinical group to evaluate the outcome of ICU treatment in cancer patients according to their characteristics at the time of referral. A retrospective analysis was used to identify relevant subgroups among 189 consecutive cancer patients referred as emergencies to one of four ICUs during a 2-year period. Reasons for ICU referral were pneumonia (29.6%), sepsis (27.0%), fungal infection (11.1%), another infection (9.5%), gastrointestinal emergency (16.9%), treatment-related organ toxicity (6.9%), or other, non-infectious complications (43.9%). Vasopressor support was required in 50.3%, mechanical ventilation in 49.7%, and haemodialysis/-filtration in 26.5% of the patients. Overall, 41.3% died during ICU treatment, 12.2% died after transfer from ICU to a non-ICU ward, and 35.4% were discharged alive. Sepsis, mechanical ventilation, vasopressor support, renal replacement therapy and neutropenia were independent risk factors for fatal outcome, but no single risk factor unequivocally predicted death. All patients with fungal infection who required vasopressor support and either had sepsis (n=13) or needed mechanical ventilation (n=14) died during ICU treatment, while all non-septic patients. who did not require mechanical ventilation, were younger than 74 years of age and had a non-infectious underlying complication (n=29), survived. This analysis may help to early identify relevant subgroups of cancer patients with different prognoses under ICU treatment. A prospective study to confirm the predictive usefulness of this approach is needed. Cancer patients should not be excluded from referral to the intensive care unit in an emergency solely due to their underlying malignant disease or a single unfavourable prognostic factor.

[The effect of dopexamine and iloprost on plasma disappearance rate of indocyanine green in patients in septic shock]. / Einfluss von Dopexamin und Iloprost auf die Plasma-Disappearance-Rate von Indozyaningrün bei Patienten im septischen Schock.

OBJECTIVES: To evaluate the effect of dopexamine and iloprost on the plasma disappearance rate (PDR) of indocyanine green (ICG) in patients in septic shock in a prospective clinical trial. METHODS: In 40 consecutive patients in septic shock, a femoral arterial fiberoptic catheter (COLD system) and a gastrotonometric probe were placed. Patients received either dopexamine infusion (0.5 microgram/kg body weight/min) or iloprost (1 ng/kg body weight/min) for 24 h i.v. PDR, intramucosal pH of stomach wall (pHi), cardiac index (HI) and intrathoracic blood volume (ITBV) were determined before, 1, 6, and 24 h after dopexamine or iloprost infusion and 1 h after end of infusion. RESULTS: PDR was significantly increased 24 h after starting dopexamine infusion from 12.2 +/- 1.8%/min to 17.8 +/- 2.2%/min (+45.9%) and 1 h after the end of infusion PDR decreased to baseline values. PDR increased to 16.4 +/- 2.1%/min, 1 h after starting iloprost infusion and increased to a maximum value of 18.6 +/- 2.2%/min (+33.8%, p < 0.05) 24 h after start of infusion compared to the baseline (13.9 +/- 1.7%/min). After the end of infusion PDR decreased to baseline values. Baseline values of pHi were in normal ranges in all groups and there was no change during the observation period. Cardiac index and ITBV were stable during the study. Dosage of norepinephrine could be reduced by dopexamine infusion. CONCLUSIONS: Dopexamine and iloprost have a positive effect on the plasma disappearance rate of ICG and therefore have a protective effect on splanchnic perfusion and liver function, respectively.

[Experimental results of using the "open lung concept"]. / Experimentelle Ergebnisse zur Anwendung des "Open-Lung-Konzepts".

Several elements of the "open lung concept", like ventilation with small tidal volumes, were incorporated into various ventilatory strategies. Our study demonstrates how the whole concept can be applied in an animal model using a standardized protocol with the following possible results. Eighteen pigs weighing between 30 and 45 kg were anaesthetized, tracheotomized and ventilated. Acute lung injury was induced by surfactant washout. Blood gases were monitored via a continuous arterial sensor system (Trendcare system). After washout, the ventilatory pattern of the American "ARDS Network study" was applied (PEEP = 9 cmH2O, volume controlled mode with a tidal volume of 6 ml/kg body weight and a respiratory rate of 25 breaths per minute). Afterwards, the opening pressure and the pressure at which the lung collapses were titrated. Both levels were used as the basis for adjusting the recruitment pressure and PEEP, which was necessary to keep the lung open. The respiratory rate was chosen in such a way that at a low intrapulmonary pressure difference between inspiration and expiration as well as normocapnia was reached. After induction of an acute lung injury by surfactant washout, the oxygenation index (OI) dropped from 556 +/- 54 to 176 +/- 89 mmHg. In the "ARDS Network" mode, OI increased to 285 +/- 49 mmHg. After alveolar recruitment with a peak pressure of 53 +/- 7 cmH2O and application of a median PEEP of 17 +/- 3 cmH2O, oxygenation returned close to baseline. A pCO2 of 33 +/- 4 mmHg resulted after using a respiratory rate of 39 breaths per minute. The median tidal volume was 8 ml/kg body weight. Despite a short arterial systolic blood pressure drop of 23 +/- 11 mmHg during recruitment, no significant difference was detectable afterwards compared to the baseline. Using low tidal volumes alone, complete reopening was not achieved in an experimentally induced acute lung injury. After recruitment manoeuvres, it was possible to reopen the lung and keep it open by application of a sufficient PEEP.

Effects of the stable prostacyclin analogue iloprost on the plasma disappearance rate of indocyanine green in human septic shock.

OBJECTIVES: To evaluate the effect of the stable prostacyclin analogue iloprost on the plasma disappearance rate of indocyanine green (PDR) in patients with septic shock. DESIGN AND SETTING: A prospective clinical study in a university hospital intensive care unit. PATIENTS AND INTERVENTIONS: 20 patients in septic shock. Patients received iloprost infusion (1 ng/kg per minute) for 24 h. MEASUREMENTS AND RESULTS: PDR was determined by a femoral arterial fiberoptic catheter before, 1, 6, and 24 h after start and 1 h after end of iloprost infusion. PDR increased significantly 24 h after start of iloprost infusion (baseline: 13.9 +/- 1.7% vs. 18.6 +/- 2.2%/min) and decreased 1 h after end of infusion (13.7 +/- 1.7%/min; p < 0.002). There was no change in pHi, cardiac index, mean arterial pressure, heart rate, central venous pressure, or intrathoracic blood volume index. CONCLUSION: Administration of the stable prostacyclin analogue iloprost significantly increases PDR, indicating improvement in liver function.

[Contribution of Berlin clinics and especially the Charité to the development of modern anesthesia in Germany]. / Der Beitrag der Berliner Kliniken und speziell der Charité zur Entwicklung der modernen Anästhesie in Deutschland.

Soon after announcement of the first American ether anesthesias in 1846 one started to anesthetize with ether in Europe. The first ether anesthesia in Germany took place on January 24th, 1947, and was given by Johann Ferdinand Heyfelder in Erlangen. Two weeks later the first ether anesthesia in Berlin was given on February 6th, 1847, by the orthopaedic surgeon Heimann-Wolff Berend. On February 12th, 1847, the surgeon Johann Friedrich Dieffenbach used ether to anesthetize a patient in the Berlin university hospital. Still in 1847 he published his book "The Ether against Pain" which used to be the standard textbook of anesthesia in Germany for many years to come. On February 15th, 1847, Johann Christian Jüngken operated his first patient under ether anesthesia in the surgical department of the Charité hospital assisted by Rudolf Virchow. Since then several famous Berlin surgeons influenced the development of modern anesthesia until the middle of the 20th century. The nitrous oxide bottle was introduced into practice by the Barth company in cooperation with the dentist Carl Sauer and Kurt Schimmelbusch introduced his mask for ether anesthesia. Carl Ludwig Schleich reported at the German congress of surgery in 1894 about his first experience with infiltration anesthesia. Spinal anesthesia developed by August Bier in Kiel was improved during his time in Berlin.

[Otto J"ungling--the first "specialist in anesthesiology" in Berlin]. / Otto Jüngling--der erste "Facharzt für Anaesthesiologie" in Berlin.

Compared to English-speaking countries, anaesthesiology in Germany developed into an independent field relatively late. German doctors were sent abroad to other European countries to learn modern anaesthetic techniques. At the beginning of the fifties, colleagues from East Germany had increasing problems to travel abroad. Otto Jüngling, who specialised in anaesthesiology in Vienna under Otto Mayrhofer, came with a work permit to the small town of Quedlinburg in the Harz mountains in November 1952. One year later, in September 1953, he went to Berlin to set up a new department of anaesthesiology at Friedrichshain Hospital. After recognition of his speciality by the Austrian General Medical Council in Linz, Otto Jüngling became the first specialist for anaesthesiology to practise in Berlin. Scientifically he worked on the development of new anaesthetics and anaesthetic machines. A transportable suction unit was one of his excellent ideas. Furthermore, he rendered outstanding services to the training of anaesthesists in Berlin. Otto Jüngling resigned in February 1959 due to unsatisfactory cooperation with public authorities and went back to Austria were he lives today as a pensioner.

[Candida antigen and antibody kinetics during antifungal therapy in non-neutropenic intensive care patients]. / Candida-Antigen- und -Antikörper-Kinetik unter antimykotischer Therapie bei nicht-neutropenischen Intensivpatienten.

The present study aimed at determining Candida antigen and antibody kinetics during antifungal therapy. 115 non-neutropenic patients with a stay of more than 5 days in an interdisciplinary intensive care unit during a period of 2 years were reviewed. Routinely measured Candida antigen and antibody titers were evaluated at the beginning and during antifungal therapy. In 67 patients serological data were evaluable in defined time slots. Under fluconazole therapy (FT) the median of Candida antigen (Ramco) was 1:4 and did not change significantly. Candida antibody level increased from 1:80 to 1:320. Initial titers between FT and amphotericin B/5-fluorocytosine therapy (AT) showed a significant difference. During AT antigen titers decreased from 1:8 to 1:4 while antibody titers kept constant at a level of 1:160.

[FRC measurement in intensive care patients. A definition of standards]. / FRC-Messung bei beatmeten Intensivpatienten. Eine Standortbestimmung.

Determination of Functional Residual Capacity (FRC) can be performed through washout methods, indicator gas dilution or bodyplethysmography. Some of these techniques have been adapted for use in intensive care patients whilst being mechanically ventilated. However, most measurement setups are bulky, cumbersome to use and their running costs are high. Hence FRC measurement has not become a routine method in intensive care although it offers considerable advantages in the management of ventilated patients such as the determination of "best PEEP", the detection of progressive alveolar collapse in the course of acute lung injury and during weaning from mechanical ventilation. Up to now most efforts to improve and simplify FRC measurement were made at the expense of accuracy. An ideal method ought to be accurate, easy to handle and cost-effective. It should supply not only FRC data but also information about intrapulmonary gas distribution and dead space. These demands can be met using modern data acquisition software. The pros and cons of all methods available for FRC measurement are discussed in view of their suitability for intensive care patients. A conventional nitrogen washout using emission spectroscopy for measurement of nitrogen concentration gives satisfying exact values for the determination of the parameters mentioned above. The measurement error can be lowered under 5% by special corrections for flow and nitrogen signal (delay and rise times, changes of gas viscosity). For flow measurement a normal pneumotachograph can be used. Using a laptop computer for data acquisition the bed-side monitor fulfills most of the demands in intensive care. It is then also possible to measure indices of intrapulmonary gas distribution such as Alveolar Mixing Efficiency and Lung Clearance Index.

Parenteral selenium supplementation in critically ill patients--effects on antioxidant metabolism.

Decreased plasma selenium (Se) levels are common in critically ill patients. Oxidative stress is regarded as one possible cause of the Se deficiency. We investigated in 20 critically ill patients with decreased plasma selenium concentrations the antioxidant metabolism during parenteral selenium supplementation (week 1: 2 x 500 micrograms; week 2:1 x 500 micrograms, week 3:3 x 100 micrograms sodium selenite). As marker of oxidative stress we measured the plasma malondialdehyde levels on days 0, 1, 3, 7, 14, and 21. The content of reduced and oxidized glutathione as well as the leucocyte activity marker elastase were estimated on the same days. Initial plasma Se levels were considerably decreased (0.44 +/- 0.1 mumol/l, mean +/- SEM). After one day of supplementation Se concentrations were in the reference range. Plasma malondialdehyde levels and the ratio of oxidized and reduced glutathione were initially elevated and decreased beginning on day 3 of supplementation. The mean elastase level was 113 +/- 10 micrograms/l on day 0. On day 3 elastase values decreased significantly (85 +/- 13 micrograms/l, p < 0.05; day 21, 19 +/- 7 micrograms/l, p < 0.001). Antioxidant metabolism showed significant changes beginning after 72 hours of therapy. This latency may be explained with the induction of the enzyme glutathione peroxidase. The lowered plasma Se concentrations measured in the critically ill patients and the significant effects on antioxidant metabolism during supplementation emphasized the importance of selenium administration in these patients.

Interferon gamma-1b in the treatment of compensatory anti-inflammatory response syndrome. A new approach: proof of principle.

BACKGROUND: Immunoparalysis is defined as a decrease in the level of HLA-DR expression on monocytes during the course of sepsis. OBJECTIVE: To evaluate whether interferon gamma-1b has an immunoregulatory effect in patients with immunoparalysis during the compensatory anti-inflammatory response syndrome. METHODS: Of the patients admitted consecutively to the intensive care unit for the management of sepsis, 10 received interferon gamma-1b, 100 micrograms per 0.5 mL, after confirmation of HLA-DR expression of less than 30% on 2 consecutive days. The therapy was continued until HLA-DR expression remained more than 50% for 3 days. RESULTS: Interferon gamma-1b therapy resulted in the recovery of diminished levels of HLA-DR expression on monocytes. Of the 10 patients, 8 responded to treatment within 1 day. On the first day of interferon gamma-1b therapy, HLA-DR expression increased from mean (+/- SEM) pretreatment levels of 27% +/- 6% to 62% +/- 8% (P < .01) and remained high during the 28-day study period in 8 patients. The therapy was given to 2 patients a second time when HLA-DR expression on monocytes was less than 30%. The recovery of monocytic HLA-DR expression levels after administration of interferon gamma-1b was associated with restitution of monocytic function, reflected by a significant increase of plasma interleukin-6 (P < .05) and tumor necrosis factor alpha (P < .05) levels in 9 patients. CONCLUSIONS: This study shows that HLA-DR expression is a good marker of compensatory anti-inflammatory response syndrome. It also shows that interferon gamma-1b not only restored the levels of HLA-DR expression but also reestablished the ability of monocytes to secrete the cytokines interleukin-6 and tumor necrosis factor alpha.

[Effect of selenium administration on various laboratory parameters of patients at risk for sepsis syndrome]. / Einfluss einer Selensubstitution auf verschiedene Laborparameter bei sepsisgefährdeten Patienten.

BACKGROUND: Low selenium plasma levels were often measured in ICU patients with polytrauma, major surgery or various severe diseases. Activation of selenium-dependent functions of the antioxidant metabolism and the immune system is suggested to be causally. METHODS: In a prospective randomized clinical trial including 24 critically ill patients we investigated the plasma levels of selenium, malondialdehyde, glutathione, elastase, fT3, fT4, TSH, IL-2R, IL-6 and IL-8 with and without parenteral selenium supplementation for 3 weeks (study design: week 1: twice 500 micrograms daily, week 2: once 500 micrograms, week 3: three times 100 micrograms sodium selenite). RESULTS: Following 24 hours of supplementation selenium plasma levels were normalized. Malondialdehyde level decreased in the therapy group significantly beginning at day 3. In the control group we observed increased malondialdehyde values, a disturbed glutathione metabolism and an elevated elastase activity. fT3-values were diminished at day 0 in all patients. In the therapy group we measured a gradual fT3 restoration. In the control group a reactive TSH increase was observed. Selenium supplementation did not lead to an excessive stimulation of IL-2R, IL-6 or IL-8. CONCLUSIONS: 1. Rapid normalization of selenium plasma levels can be achieved with the applied selenium dosage. 2. Parameters of radical metabolism are significantly reduced following selenium administration. 3. T3 synthesis correlates closely with the selenium levels. 4. Excessive stimulation of the immune system does not appear in the applied dosage.

[The limits of intensive care medicine]. / Grenzen der Intensivmedizin.

Over the last 30 years intensive care medicine has undergone drastic changes not only because of changes in patient population but also because of the progress in medical technology. Given that resources are finite and limited medical and socio-ethical principles should be applied for the distribution and withdrawal of these resources. Scoring systems can not only assist in this decision making process but also provide criteria for the termination of treatment in intensive care. Whilst in intensive care patients should be scored every day to identify as early as possible those patients who are going to die and those who are going to survive in order to use intensive care resources efficiently. After discharge from intensive care quality of life should be an important factor to assess intensive care performance.

Immunodepression following neurosurgical procedures.

OBJECTIVE: To determine the influence of a selective, sterile central nervous system surgery on immune reactivity, particularly whether a decrease of monocytic human leukocyte antigen-DR expression, indicating immunodepression, occurs after neurosurgery and if this measurement is useful for identification of patients with a high risk of infection. DESIGN: Prospective study. SETTING: Department of neurosurgery and intensive care unit in a university hospital. PATIENTS AND INTERVENTIONS: Blood samples were obtained from 46 patients at least once during the first 3 days after undergoing sterile central nervous system surgery. Fourteen of these patients developed infectious complications as defined by clinical and microbiological criteria. In ten of 46 patients, paired samples of blood and cerebrospinal fluid were collected from a ventricle drain at the following times: 1 day before surgery; several times on the day of surgery; and every day after surgery for at least 6 days. MEASUREMENTS AND MAIN RESULTS: Monocytic human leukocyte antigen-DR expression, as measured by flow cytometry on days 1 through 3 after surgery in 46 patients, was lower in 14 patients who developed infection after neurosurgery (p < .0001). In all ten closely monitored patients, monocytic human leukocyte antigen-DR expression decreased temporarily after surgery. Of these patients, only one patient showed a persistent and considerably decreased monocytic human leukocyte antigen-DR expression. This patient was the only patient in this subgroup who developed sepsis syndrome. In order to assess whether the monocytic human leukocyte antigen-DR decrease was associated with a preceding inflammatory response, local and systemic concentrations of interleukin (IL)-1 beta, IL-6, IL-8, tumor necrosis factor-alpha, and interferon-gamma were measured in this subgroup. These cytokines were not detectable in plasma during the first days after surgery. In contrast, considerable increases of IL-6 and IL-8 concentrations were detectable in cerebrospinal fluid within hours after surgery. CONCLUSIONS: A decrease of monocytic human leukocyte antigen-DR expression occurs after neurosurgery and is associated with a preceding, strong, intracranial (but not systemic) inflammatory response. A very low monocytic human leukocyte antigen-DR expression (< 30% positive monocytes) suggests the possibility of infection. Measurement of monocytic human leukocyte antigen-DR expression could help to detect patients with a high risk of infection after neurosurgery. Our results suggest that even sterile central nervous system surgery may contribute to general immunodepression. The local intracranial inflammatory response may be involved in this process.