[Dilated coronary sinus. A preoperative transesophageal echocardiographic diagnosis]. / Koronarsinusdilatation.Eine präoperative transösophageale echokardiographische Diagnose.

A 36-year old woman was presented to our hospital with congenital ventricular septal defect and one-vessel coronary artery disease (75% proximal left main coronary artery) for CABG and repair of the VSD. After induction, a transesophageal echocardiographic (TEE) baseline examination was performed, showing a severely dilated coronary sinus (CS) measuring approximately 3 cm (abnormal >1 cm). We suggested a persistent left superior vena cava (PLSVC) draining into the CS. PLSVC is a common venous congenital anomaly, with a reported incidence of 0.5% in general population and in 3-5 % of patients with congenital heart defect. Injection of echo-contrast solution in a left arm vein, visualizing microbubbles passing through the PLSVC into the CS confirmed our suspicion. The diagnosis of a PLSVC and dilated CS is a contraindication for retrograde cardioplegia because of the loss of cardioplegia into the PLSVC resulting in a inadequate myocardial protection. It may be difficult to pass a pulmonary artery catheter (PAC) through a left internal or left subclavian vein and it may be associated with arrhythmias. A chest radiograph shows the anomalous course of the PAC along the left heart.

[Spontaneous bacterial peritonitis without ascites]. / Spontane bakterielle Peritonitis ohne Aszites.

A 34-year-old woman with acute pain in the lower abdomen and a history of non-A-non-B-hepatitis underwent laparotomy. A diffuse light redness of the small bowel without ascites was the only abnormal finding. An appendectomy was performed. The patient deteriorated into a sepsis during the next 60 hours. Relaparotomy established acute diffuse peritonitis with ascites and without any apparent intra-abdominal source of infection. Tracheal, blood, and intraperitoneal cultures of both procedures grew group A streptococci and proved a haematogenous spread of the infection. The sepsis was successfully treated with antibiotics and peritoneal lavage. The course of the infection and the findings are discussed and the case is interpreted as a spontaneous bacterial peritonitis without ascites.

Use of continuous noninvasive measurement of oxygen consumption in patients with adult respiratory distress syndrome following shock of various etiologies.

OBJECTIVE: To describe the patterns of cardiac index, oxygen delivery (DO2), oxygen consumption (VO2), and oxygen deficit (or excess) and to compare invasive and noninvasive monitoring systems for evaluation of these oxygen transport patterns. DESIGN: Descriptive study of oxygen transport interrelationships throughout critical illness in a consecutive series of surviving and nonsurviving patients with adult respiratory distress syndrome (ARDS). SETTING: University-affiliated city hospital. PATIENTS: A consecutive series of 55 critically ill patients with ARDS after shock of various etiologies. MEASUREMENTS AND RESULTS: Noninvasive VO2 was measured by a continuous, on-line, real-time device developed in our department. Inspired and expired oxygen concentrations were measured using a polarographic oxygen analyzer. Minute ventilation measurements were time integrated over 7-min intervals. Cardiac index, DO2, and VO2 were simultaneously measured invasively by pulmonary artery thermodilution catheters, together with arterial and mixed venous blood gases. There was good agreement (r2 = .60) in VO2 measured by the invasive and noninvasive methods. The estimated oxygen deficit or excess was calculated as the difference between the actual measured VO2 standardized for body temperature pressure saturated and the normative standard VO2 of each patient corrected for temperature and sedation (VO2 need). A total of 317 monitoring days in 55 patients were analyzed; 25 survivors were monitored for a mean of 4.6 +/- 2.9 days and 30 nonsurvivors were monitored for 6.9 +/- 6.6 days. Survivors had significantly higher cardiac index, DO2, and VO2 values. Generally, oxygen excesses were found in the survivors and oxygen deficit was observed in the nonsurvivors. Survivors did not reach a plateau in their DO2-VO2 patterns. In the septic nonsurviving patients and both nonseptic groups by contrast, a plateau was observed in the DO2-VO2 pattern. Surviving septic patients had a critical DO2 of 16 mL/min.kg (700 mL/min.m2) and a critical VO2 of 3.5 mL/min.kg (145 mL/min.m2). CONCLUSIONS: Monitoring of VO2 and DO2 variables is useful for evaluation of tissue oxygenation and titration of therapy in critically ill patients. Noninvasive monitoring of VO2 values are in good agreement with VO2 values calculated from invasive measurements of cardiac index. The increased DO2 and VO2 values are not attributable to mathematical coupling of erroneous cardiac index values.

Comparison of hydroxyethyl starch and lactated Ringer's solution on hemodynamics and oxygen transport of critically ill patients in prospective crossover studies.

The cardiopulmonary effects of lactated Ringer's solution (RL) were compared with those of 10% hydroxyethyl starch, hetastarch (HES), given in 44 therapeutic interventions in 15 critically ill patients by crossover design. Each agent was given to each patient at least once; seven patients received each agent twice. Infusions were continued until the wedge pressure (WP) had increased to 16 +/- 2 mm Hg in trauma patients and 18 +/- 2.mm Hg in cardiac patients. HES 10% produced significantly increased cardiac index, left and right ventricular stroke work index, CVP, WP, oxygen delivery, oxygen consumption, and reduced pulmonary vascular resistance index (PVRI). RL increased CVP, WP, and PVRI, but did not significantly improve other hemodynamic or oxygen transport variables.

[Effect of colloid volume replacement substances and Ringer's lactate on hemodynamics and oxygen consumption of intensive care patients]. / Die Wirkung von kolloidalen Volumenersatzmitteln und Ringer-Laktat auf Hämodynamik und Sauerstoffverbrauch von Intensivpatienten.

Comparison of the effects of various volume substitutes on hemodynamics and oxygen transport variables in critically ill patients. A computerized monitoring system was used to register the hemodynamic effects of lactated ringers solution, human albumin 5%, human albumin 20%, hydroxyethylstarch 6% (Plasmasteril, Fresenius, Oberursel) and hydroxyethylstarch 10% (HAES-Steril, Fresenius, Oberursel) in 25 patients who required invasive monitoring during ICU treatment. In periods of relative volume deficits as documented by a wedge pressure of 11-13 mm of mercury the various substitutes were administered until the wedge pressure reached 15-17 mm of mercury. Comparison of 221 therapeutic interventions demonstrate: Hemydynamic and oxygen transport variables were improved in all colloid trials whereas lactated ringers solution did not improve the patients cardiopulmonary condition. In contrary pulmonary vascular resistance was significantly increased when Ringer's solution was administered. While all colloids produced improvements in the patients hemodynamic and oxygen transport condition, statistically significant improvements could be demonstrated only during infusion of hes 10%.

[A computer-assisted monitoring system in intensive care units (author's transl)]. / Kontinuierliche Uberwachung kardiopulmonaler Parameter bei Patienten nach schwerem Polytrauma. Mikrocomputergestützte Patientenüberwachungsanlage in der Intensivmedizin.

A microprocessor-based monitoring system is described which is currently being evaluated at out hospital. The microprocessor is capable of processing data from 32 channels from the patient's monitoring system as well as practically unlimited data from manual keyboard entries. At present 20 vital cardiopulmonary parameters are calculated in patients in the shock state (real time calculation).