Cesarean section in a patient with non-compaction cardiomyopathy managed with ECMO.

Isolated ventricular non-compaction is a rare cardiomyopathy associated with left heart failure, severe arrhythmias and thromboembolism. We report about our interdisciplinary strategy in a patient with severe isolated ventricular non-compaction cardiomyopathy scheduled for caesarean section in general anaesthesia. Monitoring included placement of an arterial line, a central venous catheter and a pulmonary artery catheter with pacing option. Small introducer gates were placed in the femoral artery and vein to facilitate quick percutaneous institution of extracorporeal life support via extracorporeal membrane oxygenation in case of acute cardiac failure refractory to medical treatment. Inotropic pharmacological therapy with 3 µg/kg/min dobutamine and 0.25 mg/kg/min milrinone was started before surgery. Induction of general anesthesia and rapid sequence intubation was performed with an analgesic dose of 0.5 mg/kg S ketamine, 0.25 mg/kg etomidate and 5 mg rocoronium followed by 1.5 mg/kg succinylcholine. This regimen provided completely stable hemodynamics in this critical period until delivery of the child and continuation of anaesthesia with continuous infusion of propofol and remifentanyl. The current strategies, particularly the preparation for femoro-femoral extracorporeal membrane oxygenation, may be considered in similar cases with a high risk of acute cardiac decompensation which may be refractory to medical treatment. Anaesthesiologist involved in performing caesarean section in women with complex cardiac disease, should encompass extracorporeal membrane oxygenation standby in management of the perioperative period.

[Postoperative assessment of daily energy expenditure. Comparison of two methods]. / Postoperative bestimmung des täglichen energiebedarfs. Vergleich von zwei methoden.

BACKGROUND: The reference method for determining resting energy expenditure (REE) in clinical nutrition practice is measurement by indirect calorimetry; however, indirect calorimetry has some limitations, is expensive and not widely available. Therefore, the most used methods to estimate the caloric requirements in intensive care patients are predictive equations. The Harris-Benedict equations (HBE) are the most common formulae in the clinical setting. The SenseWear(®) armlet (SWA) is a noninvasive device that monitors skin temperature, heat flux, galvanic skin response and movement. These data as well as anthropometric characteristics are used to calculate REE. The aim of this study was to evaluate the levels of agreement and interchangeability of REE estimated by HBE (EEHBE) and measured by SWA (EESWA) in normometabolic patients after elective bowel resection with laparotomy. Furthermore, postsurgical pain therapy by continuous thoracic epidural anaesthesia (t-PDA) was compared with continuous intravenous pain therapy regarding EESWA in these patients. METHODS: After obtaining approval by the ethics committee and written informed consent 57 patients participated in the study procedures. A total of 50 patients (23 male, 27 female) were finally included in the data analysis because 7 patients did not meet the criterion of > 80% on-body time of the SWA. Additional (a priori) exclusion criteria were metabolic or cardiopulmonary decompensation or postoperative mechanical ventilation. Before induction of general anesthesia 26 patients received a thoracic epidural catheter. Immediately after surgery the SWA was placed on the right upper arm of each patient for 24 h. A continuous pain therapy was started either an epidural application of ropivacain 0.2% and sufentanil or in the other 24 patients an intravenous infusion of metamizol and tramadol. RESULTS AND DISCUSSION: The data showed good agreement between EESWA and EEHBE. The mean on-body time was found to be 22.94±4.77 h. There were no significant differences between EESWA and EEHBE (p>0.05) corresponding to a high Pearson's coefficient of correlation of 0.985. The mean bias (EESWA-EEHBE) was -0.569±0.378 kcal/kgBW/24 h reflecting a minimal systematic underestimation of REE by SWA of -2.9% compared to EEHBE. The Bland-Altman plot shows interchangeability of EESWA and EEHBE. It was noted that 94% of the data points (47 out of 50 patients) were within ±2 SD and the remaining 3 data points were lying close to the 95% interval. The same results (no significant differences between EESWA and EEHBE) were obtained after differentiation of EEHBE into low (<18 kcal/kgBW/24 h, n=9), medium (18-21 kcal/kgBW/24 h, n=30) and high (>21 kcal/kgBW/24 h, n=11) energy ranges. There were no significant differences in EESWA regarding postsurgical pain therapy regimens. CONCLUSIONS: The SWA showed reliable concordance with daily REE estimated by HBE in normometabolic postsurgery patients. This noninvasive, convenient and easy to handle device may be helpful in determining energy requirements as part of metabolic monitoring. Further research is needed to validate the method in patients with severe metabolic disturbances. The energetic requirements of patients with postoperative t-PDA were not different from those with intravenous pain therapy.

[Use of the i-gel laryngeal mask for management of a difficult airway]. / Einsatz der i-gel-Larynxmaske bei schwierigem Atemweg.

The authors report on the airway management during induction of general anaesthesia in a patient with known difficulties with intubation. After failed optimized attempts at direct laryngoscopy ventilation was secured with the new single-use laryngeal mask i-gel. The special construction of the i-gel allowed the fiber optic confirmation of a good view of the glottis and trachea, allowing successful fiber optic-guided intubation of the trachea using a size 6 mm cuffed tracheal tube.

[Semi-invasive cardiac output measurement using a combined transesophageal ultrasound device. Early experiences]. / Semiinvasive Herzzeitvolumenmessung mittels kombiniertem ösophagealen Ultraschallkopf. Erste Erfahrungen.

OBJECTIVE: Measurement of cardiac output (CO) with pulmonary artery catheter (PAC) is currently item of many discussions. We investigated the reliability of results using the noninvasive measurement of aortic blood flow (ABF) (combined Doppler- and M-Mode transesophageal ultrasound, Dynemo 3000, Sometec Inc, Paris, France). METHODS: In 75 patients during cardiac or major abdominal surgery we performed 313 simultaneous measurements of CO and ABF. RESULTS: Placement of ultrasound probe into correct position took less than 2 min. Quality and stability of ultrasound signals were good. The coefficient of correlation between ABF and CO was found to be 0.89 with CO = 0.97 x ABF + 1.1, Bland-Altman-Test positive. CONCLUSION: Results of ABF detected by combined Doppler- and M-Mode-Echography are comparable with results of CO obtained by PAC. Therefore we are convinced that this noninvasive method will find its place in clinical situations of compromised CO.

[Examinations by ocular pressure tonometry]. / Untersuchungen zur Okulopressions-Tonometrie.

A new method has recently been suggested for the determination of the outflow resistance in the anterior chamber angle. In this method the intraocular pressure is set to 45 mmHg for 8 minutes. The intraocular pressure is measured after the removal of the suction cup. Values below 7 mmHg are obtained in healthy subjects. Values above 7 mmHg are thought to be indicative for glaucoma. By setting the intraocular pressure to 45 mmHg for the expression of fluid the authors claim to have brought normalization to tonography. We show here in a series of results that we can reproduce the results which have been published by Ulrich et al. For normalization of a tonographic test we need a pressure rise which effects a uniform expression of volume. According to the knowledge presently generally agreed upon a uniform expression of volume is obtained by increasing the intraocular pressure by a constant factor and not by increasing it to a constant level. In 30 healthy volunteers and in 30 glaucoma patients we have increased the intraocular pressure by the constant factor of 1.8. According to our results the glaucoma patients and the healthy subjects can no longer be differentiated. A better differentiation is possible by the initial intraocular pressure. Thus we have shown that the favorable results by ocular pressure tonometry are mainly due to the intraocular pressure before the test. We feel therefore that ocular pressure tonometry should not be incorporated in our diagnostic armamentarium for glaucoma diagnosis.