[Data management in an ICU: Experiences with ICM (Intensive Care Manager)]. / EDV im rauen Alltag der Intensivstation: Erfahrungsbericht über die Einführung des "Intensive Care Manager" (ICM, Dräger Medical, Lübeck).

OBJECTIVE: Experience with implementation and operation of a patient data management system on an intensive care unit. METHODS: Patient data management system "Intensive Care Manager" (ICM, Dräger Medical). Anaesthesiologic ICU (surgical patients only) of an academic teaching hospital. RESULTS: ICM was installed without problems and is used in routine patient treatment. The system is running reliably, availability was 99.87 % during the last 8 months. CONCLUSION: Documentation has become better and more detailed with comparable time spent. More secondary diagnoses have been recorded since ICM was implemented. Special "views" related to organ systems allow to monitor organ dysfunction more easily and facilitate treatment decisions. Review of textual information needs to be further optimised. Writing of medical reports is ideally supported by ICM. Using ICM is advantageous for doctors, nurses and patients.

Respiratory depression under long-term sedation with sufentanil, midazolam and clonidine has no clinical significance.

OBJECTIVE: Assessment of respiratory depression caused by long-term sedation with sufentanil, midazolam and clonidine. DESIGN: Retrospective assessment using data from a patient data management system. SETTING: University hospital anaesthesiological ICU. PATIENTS: Three hundred ninety-five surgical and trauma patients with an ICU stay of more than 48 h. INTERVENTION: None. MEASUREMENTS AND RESULTS: Arterial blood partial pressure of carbon dioxide (PCO2) was evaluated during mechanically assisted spontaneous ventilation (continuous positive airway pressure, synchronised intermittent mandatory ventilation, mandatory minute ventilation, bilevel positive airway pressure). Continuous sedation with sufentanil, midazolam or clonidine or a combination of those drugs was administered to achieve a Ramsay score between 2 and 4. Spontaneously breathing patients without continuous sedation and patients on controlled mechanical ventilation (and sedation) served as control groups. Mean arterial PCO2 from spontaneously breathing patients without continuous sedation was 39.5 +/- 7.3 torr compared with 42.7 +/- 6.8 torr under sufentanil (median 0.44 microg x kg(-1) x h(-1), 98 % of observations between 0.1 and 2.1 microg x kg(-1) x h(-1)), 41.5 +/- 6.1 torr under sufentanil (median 0.90 microg x kg(-1) x h(-1) (0.1-2.8)) plus midazolam (median 45 microg x kg(-1) x h(-1) (7-170)) and 39.8 +/- 5.6 torr under a combination of sufentanil (median 1.15 microg x kg(-1) x h(-1) (0.2-3.6)), midazolam (median 45 microg x kg(-1) x h(-1) (11-216)) and clonidine (median 1.3 microg x kg(-1) x h(-1) (0.2-2.5)). Mean arterial PCO2 from patients on controlled mechanical ventilation was 39.9 +/- 6.1 torr. CONCLUSION: Patients under continuous sedation with sufentanil exhibit a statistically significant rise in arterial PCO2, however this respiratory depression is only slight and has no clinical significance. Mechanically assisted spontaneous ventilation modes can safely be used under continuous sedation with sufentanil, midazolam or clonidine.

[Ratings and complications with minimally invasive percutaneous tracheotomy]. / Stellenwert und Komplikationen der minimalinvasiven perkutanen Tracheotomieverfahren.

Indication, timing and technique of tracheostomy in intensive care medicine have changed significantly during the last decade. Benefits and risks of percutaneous dilatational tracheostomy are reviewed in the current literature. Typical complications are misplacement of the tracheal cannula, injury to the trachea, trachealstenosis, rupture of the cuff-ballon and death. The results of a questionnaire about the use, timing and complications of percutaneous dilatational tracheostomy at 651 German intensive care units are presented. In Germany tracheostomy is performed within 20 days in 75% of patients on mechanical ventilation, following the recommendation of the Consensus Conference on Artificial Airways in Patients Receiving Mechanical Ventilation from 1989. Percutaneous dilatational tracheostomy in Germany is performed following the methods described by Ciaglia in 58% of intensive care units, Griggs in 35% and Fantoni in 7%.

[Level concept of analgesic dosing in intensive care medicine with sufentanil]. / Stufenkonzept zur Analgosedierung in der Intensivmedizin mit Sufentanil.

OBJECTIVE: The efficacy of a 3-level regimen of analgesia and sedation was investigated in a clinical setting. Level 1 consisted of continuous administration of sufentanil, in level 2 continuous administration of midazolam and level 3 continuous administration of midazolam and clonidine was added according to patients' needs. METHODS: Sufentanil at 1 microgram/kg/h was given initially. Later it was adjusted to patients' requirements in accordance with the Ramsay score (group 1). Long-term intubated patients received in addition midazolam 0.05 mg/kg/h (group 2). If needed, clonidine 1 microgram/kg/h was added (group 3). Mean drug requirements were investigated during controlled ventilation and during assisted ventilation with spontaneous breathing > 25% of total minute ventilation. In group 1 arterial paCO2 was measured to estimate drug-induced respiratory depression. Values given are median and ranges. RESULTS: With the 3-level-regimen of analgesia and sedation a Ramsay score of 2-3 was achieved in all intensive-care patients. In group 1 (n = 109; 36.7%) paCO2 values were similar at all times. Patients on controlled ventilation needed sufentanil 0.6 (0.075-2.5) microgram/kg/h, on assisted ventilation 0.4 (0.05-2.5) microgram/kg/h. Patients of group 2 (n = 113; 38.1%) had on controlled ventilation a higher requirement of sufentanil 1.2 (0.09-2.7) micrograms/kg/h, in addition Midazolam 0.05 (0.002-0.56) mg/kg/h was given. On assisted ventilation with spontaneous breathing > 25% sufentanil 0.9 (0.05-2.6) microgram/kg/h plus midazolam 0.04 (0.002-0.38) mg/kg/h was sufficient. Group 3 (n = 75; 25.2%) had on controlled ventilation a higher requirement of sufentanil with 1.5 (0.09-4.0) micrograms/kg/h and midazolam 0.05 (0.005-0.52) mg/kg/h, in addition clonidine 1.1 (0.12-2.88) micrograms/kg/h was given. On assisted ventilation with spontaneous breathing > 25% requirement of sufentanil with 1.1 (0.15-2.6) micrograms/kg/h and of midazolam with 0.05 (0.002-0.22) mg/kg/h was slightly lower, whereas more clonidine was needed with 1.3 (0.12-2.88) micrograms/kg/h. CONCLUSION: Continuous infusion of sufentanil only for analgesia and sedation is suitable for intensive-care patients with a short stay in the ICU. Respiratory depression during spontaneous breathing is not significant. The supplementary administration of midazolam and clonidine according to the presented regimen was shown to be of advantage for patients with a longer stay in ICU.

[Intracranial pressure monitoring in patients with severe craniocerebral injury]. / Hirndruck-Monitoring bei Patienten mit schwerem Schädel-Hirn-Trauma.

After severe head injury intracranial pressure (ICP) must be measured continuously for management to assess and maintain the cerebral perfusion. Therefore in our hospital epidural transducers are used. To prove the efficiency of this method in a 12-month period the clinical courses of 23 patients with intracranial pressure transducers were analysed retrospectively. Eighteen patients survived, 5 of them without residuals, 13 with residuals and 2 remained in coma. In 14 patients secondary rises of intracranial pressure were observed between days 3 and 6 post injury. The mean ICP value of the survivors revealed 25 mm Hg. whereas the expired showed 60 mm Hg. In 17 patients the measurements were considered as reliable, 6 measurements were not reliable, which included 1 of the 5 patients who died. One transduce was displaced, another one showed a hemorrhage at the drill hole. There was no infection.

[Indications and technique of percutaneous dilatation tracheotomy for intensive care patients]. / Indikation und Technik der perkutanen Dilatationstracheotomie für den Intensivpatienten.

OBJECTIVE: Since the different techniques of percutaneous dilatational tracheotomy were introduced they have attracted particular attention in the intensive care setting. We present here a modification of the technique first described by Ciaglia in 1985. Objective of this study was to evaluate the frequency of complications of this modification in comparison with published data. METHODS: 151 dilatational tracheotomies were performed on 141 patients of an anaesthesiologic intensive care unit. Ciaglia originally presented an approach between the cricoid cartilage and the first tracheal cartilage. We found it preferable to insert the cannula between the 2nd and 3rd tracheal cartilage after blunt dissection of the pretracheal tissues. The Dilators of Cook Critical Care Ltd. were used in this study. RESULTS: With 151 tracheotomies only 11 complications were noted: pneumothorax (1), bleeding (2), mucosal lesion of the trachea (2), others (6). None of these complications was considered to be serious. There was no tracheotomy-related death. Tracheotomy was performed within 11.5 min (range 5 to 23 min). The duration of artificial ventilation following tracheotomy was 21.1 days (range 1 to 142 days). CONCLUSION: The presented modification of dilatational tracheotomy is a safe and effective technique which can be performed on the intensive care unit. Compared with conventional tracheotomy the new method is quickly done and will be an integral part of intensive care treatment.

Colliding shock lens as an intracavity Q-switch element.

We show how a varifocal pulsed gas lens, the colliding shock lens, can be used as an intracavity element to Q switch a ruby laser. By placement of the shock lens in tandem with a second lens, a giant pulse is obtained. The second lens may be a conventional glass lens or a continuous-wave gas lens.

Postoperative pulmonary complications in patients with esophageal cancer.

There are recent reports on postoperative pulmonary complications in patients with esophageal cancer who were treated preoperatively with chemotherapy and irradiation. The Hamburg Esophageal Study Group is currently undertaking a prospective randomized study to evaluate the efficacy of preoperative treatment. Postoperative pulmonary complications and mortality in these patients with either a combined preoperative treatment (group 1, n = 11) or chemotherapy alone (group 2, n = 9) are evaluated in the present paper. Complete remission of the tumor was found more often in group 1 (54.6%) than in group 2 (22.2%). However, postoperatively the patients of group 1 developed adult respiratory distress syndrome (ARDS; 54.6%) more frequently than in group 2 (11.1%), and all patients with ARDS died. Thus, although the combined preoperative treatment is more effective in tumor remission, it is associated with a higher respiratory failure and postoperative mortality. Therefore, the preoperative regime has now been changed by the study group. Since after the clinical manifestation of ARDS no causative clinical therapy is available up to now, attention must be focused on the prevention of respiratory failure.