[When should a patient with severe acute respiratory distress syndrome (ARDS) be transferred to a specialized hospital?]. / Wann soll ein Patient mit einem schweren akuten Lungenversagen (ARDS) in ein spezialisiertes Zentrum verlegt werden?

The mortality rate for the advanced adult respiratory distress syndrome is still high. Nevertheless there are recent publications showing decreasing incidence and an improving survival rate. This is due to early diagnosis as well as differentiated treatment concepts. The use of special therapy methods including extracorporal gas exchange is only possible at specialized centres. This raises the question as to the right timing of the transfer of those ARDS-patients, whose lungs cannot be cured by the therapy standards practiced locally. In a prospective study, all requests for transfer were noted over a period of 36 months (1992 to 1994) and analyzed by a hospital with a special ward for ARDS. In a total of 469 patients the most prominent predisposing diseases were community-acquired pneumonia (26.3%), followed by multiple trauma (24.4%), the postoperative conditions of systemic inflammatory response syndrome (SIRS) or sepsis (21.3%), bronchopulmonary aspiration (5.8%), and status asthmaticus (2.6%). With a mean preventilation time of 9.5 +/- 9 days and a mean ventilatory peak pressure of 39 +/- 8 cm H2O there was a mean oxygenation index (Horrowitz Index) of 95 (+/- 40) mm Hg. The mean Smith and Gordon Ventilator Score was 82.3 (+/- 12.8) and the mean PIF rate (Benzer Score) 12 (+/- 8.6), 121 out of 469 patients were transferred for further specialized therapy. 75 patients were treated on a conventional basis and 46 patients had to be treated with extracorporal lung assistance (ELA) because conventional treatment failed. The mortality rate was 22.3% altogether, in the group with the conventional treatment 16.0% and 32.6% in the group with ELA. As there are no generally accepted guidelines for the transfer of patients with ARDS to specialized centres, an indication for such a transfer must be established taking into consideration the individual patient history. Very early contact with the specialized centre of choice is recommended.

[Epidemiology, clinical aspects and prognosis of severe progressive community-acquired pneumonia]. / Epidemiologie, Klinik und Prognose schwerstgradiger Verlaufsformen ambulant erworbener Pneumonien.

BACKGROUND: Community-acquired pneumonia can lead to acute lung failure (parapneumonic ARDS) if the course is very severe. The clinical picture reflects a rapidly progressive and potentially fatal respiratory failure. Only occasional cases in which the clinical courses of community-acquired pneumonia lead to acute respiratory failure have been reported so far. The investigation was based on the observation that very severe progressive forms of community-acquired pneumonia are at present one of the most frequent conditions triggering ARDS. PATIENTS AND METHODS: A total of 66 patients of both sexes with an average age of 34 +/- 11 years were included in the retrospective investigation. The patients had been secondarily referred to the center for further treatment. After admission, the further course of the disease was recorded at five defined times (day of admission, 2nd day, 7th day, 14th day and day of spontaneous breathing or day of death). The degree of disturbance of pulmonary function was registered with the scores of Morel and Murray. Further disorders of organ function were evaluated with the MOF score according to Goris, the "Definition Multiple disorder of Organ Function (DeMOF)" and the appraisal of the severity of the systemic inflammatory reaction with the sepsis score according to Elebute & Stoner. RESULTS: The duration of preclinical disease was 6 +/- 4 days and the duration of the pretreatment in the referring hospital was 10 +/- 10 days. A potential primary causative organism (bacteria n = 18, viruses n = 5, "atypical" pathogens n = 6, Candida species n = 4) could be isolated in 50% of the patients. A pre-existing underlying disease was found in 48% of cases. With a total lethality of 31%, this was affected neither by knowledge of the primary causative organism nor by previous diseases. The patients who died did so with improved lung function in a complete clinical picture of multiorgan failure. At the time of admission, 91% of the patients had severe ARDS (Morel III and IV). An improvement of lung function could be demonstrated between the day of admission and the second day of treatment both with the score according to Morel and according to Murray (p < 0.05). For the second day of treatment, a difference could be shown between the patients who survived and those who died (p < 0.05). Owing to the systemic inflammatory reactions, a multiorgan functional disorder was found in 89% of the patients. There were the following findings with regard to the prognostic predictions from the score used: those who died and those who survived could be correctly differentiated with the DeMOF score from the 7th day of treatment and the sepsis from the 7th day of treatment and with the score of Goris from the 14th day of treatment after referral. CONCLUSIONS: The investigation proves that the most severe progressive forms of community-acquired pneumonia also occur both in patients who have previously appeared to be healthy and in younger patients. Despite the use of differentiated treatment measures, these illnesses are subject to a relatively high lethality. The results underscore the need for causal treatment of systemic inflammatory reaction, which is the most important problem in treatment of parapneumonic ARDS.

[Can preoperative lung function diagnosis detect risk of intraoperative pulmonary gas exchange insufficiency in artificial hip replacement with polymethylmethacrylate cement?]. / Lässt die präoperative Lungenfunktionsdiagnostik das Risiko intraoperativer pulmonaler Gasaustauschstörungen in der Hüftendoprothetik mit Polymethylmetacrylat-Zement erkennen?

In a study of 90 patients in whom a hipjoint had been replaced for the first time using polymethylmetacrylate cement, the extent of intraoperative pulmonary gas exchange disorders was established. The effect of a preexisting disorder of lung function was determined. We checked whether an appraisal of the risk patients who are operated on can be assisted by a preoperative analysis of lung function. After preoperative diagnosis of lung function, the arterial blood gases were analysed at defined times during the operation. An intraoperative fall in the partial pressure of oxygen and an increase in carbon dioxide partial pressure in the arterial blood were found in all patients. There were pronounced interindividual differences in the extent of the disorder of pulmonary gas exchange. The degree of severity of the respective acute disorder of lung function did not show any correlation with the pre-existing disorder of pulmonary ventilation. Major hemodynamic changes were not observed. According to the present findings, a definitive statement with regard to the degree of severity of intraoperatively occurring disorders of pulmonary function cannot be expected from a preoperative analysis of pulmonary function.

[Treatment of acute pulmonary infection in a mucoviscidosis patient with extracorporeal lung support]. / Behandlung eines akuten pulmonalen Infektes bei einem Mukoviszidose-Patienten mittels extrakorporaler Lungenunterstützung.

This is a report on a mucoviscidosis patient of 30 years of age suffering from refractory acute failure of pulmonary function during acute exacerbation of an infection with Pseudomonas aeruginosa. To avoid further barotraumatisation of the lungs due to continually increasing artificial respiratory pressure, and to set the lung at rest until subsidence of a concomitant severe bronchial obstruction, we performed modified extracorporal lung assist (ELA). The gas exchange improved rapidly with the help of relevant accompanying measures (including negative liquid balance, administration of antibiotics, etc.) and the pulmonary infection also subsided to a major extent. 26 days after the end of the bypass the patient could be transferred for lung transplantation.

Anti-lipopolysaccharide-immunoglobulin (IgG-anti-LPS) therapy in intensive care patients following surgery from infectious disease.

In 18 intensive care patients the effect of a IgG-Anti-Lipopolysaccharide (Anti-LPS), was investigated in a randomized study following surgery after bacterial infections, mostly peritonitis. Fresh frozen plasma was administered during the first 5 postoperative days, containing either more than 65 micrograms/ml Anti-LPS in the therapy group or less than 12.5 micrograms/ml in the control group. The serum level of Anti-LPS was monitored. Clinical and chemical parameters were recorded to evaluate infectious complications and outcome of the patients. The mortality in the treatment group was not different from the control group with 30% (3 out of 10) and 25% (2 out of 8), respectively. No beneficial effect was observed either from the administration of Anti-LPS or from endogenously produced Anti-LPS on any clinical parameter in our patients.