[Anaesthesiological experience and factoid public information - effects, interactions and possible strategies for perioperative stress reduction]. / Vorinformationen und Vorerfahrungen - ihre Auswirkung, Interaktionen und Prävention.

BACKGROUND: Preoperative stress influences perioperative complications. Their severity is influenced by advanced information and previous experience. This study evaluates the emotional effects of these factors. METHODS: In a prospective observational study we documented existing anaesthesiological pre-information and previous experience of 461 patients (255 w/206 m) individually. In addition, we recorded the affective emotional condition of each patient before and after the premedication visit via a visual analogue scale (VAS) and a test of current stress (KAB). RESULTS: 248 patients had previous anaesthesiological pre-information. Of those 61 were of a negative nature. These patients showed a significantly higher level of stress and anxiety compared to those with positive information. 41 of 388 patients reported bad experiences with increased anxiety and stress. The premedication visits caused a significant attenuation of the overall stress level in patients with negative experience/information. CONCLUSION: During the individual premedication visit, patients should be asked directly about negative pre-information and perioperative experience. Thus the conversation can be customised to the individual stress factors and show empathy as well. Independent of any medical intervention, this approach can be an effective contribution to stress reduction.

[Carotid surgery in regional anesthesia--anesthesiological, neurological and surgical aspects]. / Die Chirurgie der A. carotis in Regionalanästhesie--anästhesiologische, neurologische, chirurgische und ökonomische Aspekte.

Surgery of the carotid artery is justified only if it is performed with low complication rates. The essential advantages of regional anesthesia in comparison to general anesthesia are a secure neuromonitoring, hemodynamic stability and prolonged analgesia. Regional anesthesia for carotid surgery, which is described methodically in this paper, needs only a minor expenditure. Our own data show that patients with a contralateral occlusion of the internal carotid artery and patients with a high risk for surgery (ASA IV) are at a high risk for neurological events during carotid crossclamping. Consequences of regional anesthesia on the surgical procedure are to ignore. The question, whether economic advantages exist for regional anesthesia, cannot yet be answered.

Comparison of Solvent/Detergent-Inactivated Plasma and Fresh Frozen Plasma under Routine Clinical Conditions.

Background: Reduced levels of protein S (PS) and alpha(2)-antiplasmin alpha(2)-AP) in solvent/detergent virus-inactivated plasma (S/D-VIP) might induce an imbalance of plasma coagulation factors and inhibitors in patients transfused. We investigated 40 patients (23 fresh frozen plasma (FFP), 17 S/D-VIP, random distribution by a list calculated by statisticians) who suffered from dilution coagulopathy, liver disease, disseminated intravascular coagulation (DIC), polytrauma or were connected to extracorporeal circulation. Study Design and Methods: The following markers of activated coagulation (MAC) were measured: Prothrombin fragment F1+2 (F1+2), fibrin monomers (FM), D-dimers (DD), thrombin-antithrombin (TAT) and plasmin-antiplasmin (PAP) complexes as well as fibrinogen degradation products (FgDP), and additionally antithrombin III (antithrombin), protein C (PC), PS and alpha(2)-AP. Blood was taken only just before and 1 h after the first plasma replacement (2 units). No additional blood products were transfused before the second blood withdrawal. Pre- and posttransfusion (pre/post) values of all parameters measured were compared within the same group and between both groups. Statistical evaluation of the data was done by Wilcoxon's paired test for data in the same plasma group and by the test of Mann and Whitney for data comparison between both plasma groups. Results: Average pretransfusion values of all inhibitors for both plasma groups were in the same range and increased after transfusion, except for PS in both groups. Whereas the pre/post values did not differ significantly in the FFP group, antithrombin (p = 0.02), PC (p = 0.0005), and alpha(2)-AP (p = 0.02) showed a significantly higher increase in the S/D-VIP group. Considering the pre/post differences between both plasma groups, there were no significant differences. The same was true for MAC measured pre- and posttransfusion. Conclusion: Data showed no significant difference between both plasma groups, indicating that S/D-VIP plasma behaves as FFP under the study conditions employed. Copyright 2000 S. Karger GmbH, Freiburg

[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.

[Knowledge-based diagnosis and therapeutic recommendations with fuzzy-set theory methods in patients with acute lung failure (ARDS)]. / Wissensbasierte Diagnostik und Therapieempfehlung mit Methoden der Fuzzy-Set-Theorie bei Patienten mit akutem Lungenversagen (ARDS).

OBJECTIVE: Since the treatment of patients with severe ARDS using the extracorporal lung assist (ECLA) methods remains a cost intensive and speculative procedure, a knowledge based computer system should be created and evaluated in order to support clinical decisions. METHODS: The model was based on the fuzzy set theory and therefore able to give decisions between yes and no, that means that a criterion could also be fulfilled to 35% or 80% for example. The development of this computer program consists of two steps: first, the entry criteria for the ECLA therapy were established within a framework of an international evaluation of clinical data from 3 centres (Berlin, Marburg, Vienna). Here, inherent vagueness, uncertainty of the occurrence and limited availability of medical data are to be considered to establish a useful tool. Secondly, this was done by grouping and weighting of parameters by the system and the status of each patient or patient group was assigned by the percentage of fulfillment of the criterion. RESULTS: By using a mixed sample of patients from these three centres, the fulfillment of entry criteria according either to definitions of Berlin or to definition of Marburg was different (68% versus 36%). Other differences (36% vs. 22% and 68% vs. 60%) were found between the fuzzy based score and the crisp score which represents the usually performed method. CONCLUSIONS: This now preevaluated minimal data set to describe severe ARDS patients based on the fuzzy set theory may be useful to evaluate patients for ECLA therapy or for another controlled ARDS-therapy.

[Radiation exposure during thoracic radiography at the intensive care unit. Dose accumulation and risk of radiation-induced cancer in long-term therapy]. / Strahlenexposition durch Röntgenthoraxaufnahmen auf der Intensivstation. Dosiskumulation und Strahlenkrebsrisiko bei Langzeittherapie.

PURPOSE: Assessment of the additional morbidity risk due to repeated bedside chest radiography according to ICRP 60 during intensive care. MATERIAL AND METHODS: Ventral surface doses were recorded by thermoluminescence dosimetry in 2 man and 7 women, mean age 36 +/- 12 years, mean height 169 +/- 5 cm, mean weight 74 +/- 8 kg, receiving long-term ventilation therapy due to Adult Respiratory Distress Syndrome (ARDS). RESULTS: From 18 to 126 days duration of therapy 9 patients received a total of 348 bedside chest radiographs, mean 39 +/- 22 radiographs per patient. 217 chest radiographs yielded 217 surface doses and 217 gonadal doses. Patient's mean surface dose varies between at least 0.31 +/- 0.12 mGy and at most 0.56 +/- 0.09 mGy. The surface dose representing gonadal exposure is less than 0.03 mGy per exposure. The mean effective dose is about 0.15 mSv per exposure. The cumulative effective dose Heff ranges between 2.49 mSv and 14.09 mSv, thus estimating the additional individual cancer risk ranges between 0.01% and 0.07%. CONCLUSION: In comparison with the decreased prognosis of severely ill long-term ventilated patients the additional morbidity risk due to chest radiographs is a negligible quantity.

The spatial distribution of pulmonary lesions in severe ARDS. An autopsy study of 35 cases.

The present study was undertaken in order to describe the local distribution and temporal course of pulmonary lesions in severe ARDS. We investigated a total of 35 patients (22 females), ranging in age from 2 to 51 years, who suffered from ARDS III and IV and were treated by extracorporeal CO2 removal and low frequency positive pressure ventilation (ECCO2-R). The extent of acute and chronic diffuse alveolar damage was assessed on histologic gross sections in the ventral, central and dorsal zone of the upper and lower lobes. The lesions showed a characteristic uniform distribution. Areas with chronic DAD were predominantly situated in the ventral portions of the upper lobes. Acute DAD predominated in the dorsal and basal areas of the lung. The extent of acute and chronic DAD was virtually independent of the duration of disease. Hemorrhage occurred at the interface zone between chronic and acute DAD and made up a significant volume portion of the lung tissue, ranging between 8% (lower lobes) and 42% (upper lobes). We conclude that the progression of acute DAD to chronic DAD is mainly determined by local factors (hydrodynamic and hydrostatic forces, intraalveolar pressure) that differ within the lung, whereas the duration of disease plays a minor role. Parenchymal hemorrhage occurs at the interface between areas of acute and chronic DAD and may therefore primarily be due to an increased susceptibility of the pulmonary parenchyma to mechanical stress.

[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.

["Treatment of total atelectasis of the left lung in severe ARDS with side-separated ventilation and surfactant administration"]. / "Behandlung einer Totalatelektase der linken Lunge bei schwerem ARDS mit seitengetrennter Beatmung und Surfactant-Applikation."

Severe thoracic trauma is always an important risk factor for the development of acute pulmonary failure. The course is often complicated by barotrauma or volutrauma. We report on a 48-year-old patient who was transferred to us nine days after a bicycle accident because of a severe disturbance of gas exchange and atelectasis of the left lung refractory to therapy. The left lung could not be ventilated even after separate artificial ventilation on each side with positive end expiratory pressure. After administration of surfactant (50 mg Exosurf per kg body weight) and continued separate artificial ventilation on each side, there was a complete re-expansion of the left lung with an increase of the arterial pO2 value from 65 mm Hg to 416 mm Hg with a FIO2 of 1,0 and a decrease of the intrapulmonary venous admixture from 34% to 12% within a few hours. The extravascular pulmonary fluid was unaffected by the administration of surfactant (200 ml solution). The administration of surfactant preparations may be a new therapeutic approach in treatment of ARDS patients.

[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.

[Pulmonary function one year after extracorporeal lung assist. A long-term follow-up of patients with acute adult respiratory distress syndrome]. / Lungenfunktion ein Jahr nach extrakorporalem Lungenersatz (ELA). Langzeitverlauf von Patienten mit schwerstem ARDS.

This retrospective follow-up studied lung function and reconvalescence in 38 young patients without primary lung disease, who suffered from severe ARDS and survived by means of extracorporeal lung assist (ELA) treatment. Over a period of 3, 6, 9 and 12-20 months dynamic and static lung volumes and the results of X-ray and CT scan of the thorax were studied. Within the third and sixth month the forced vital capacity, FEV1, and arterial blood gases reached the lower range of normal values. Obvious relative emphysema RV/TLC was observed at the time of discharge from hospital and during the first four months. This was found to reverse during the following months. After a period of 12-20 months all patients had an abnormal diffusion capacity (TLCO) but with normal transfer coefficients (TLCO/VA). Even though ARDS did not induce obstructive changes, the diminished diffusion capacity and the slightly reduced expiratory peak flow in 25-75% of FVC (FEF 25-75) indicates slight changes in the small airways. Following up the X-ray and CT results we found extraordinary morphological restitution. Spiroergometry results showed a normal cardiopulmonary pattern for untrained individuals. 36 of the 38 patients were integrated in normal working and social life within 12-20 months.

[Acute respiratory failure--support of gas exchange using extracorporeal or implanted oxygenators--present status and future development]. / Akutes Lungenversagen--Unterstützung des Gasaustausches mittels extrakorporaler oder implantierter Oxygenatoren--Gegenwärtiger Stand und zukünftige Entwicklung.

In acute respiratory failure gas exchange can be supported or even maintained in an "alternative" way to mechanical ventilation using extracorporeal techniques (extracorporeal membrane oxygenation ECMO, extracorporeal CO2-removal ECCO2R), or intravenacaval oxygenators (IVOX). These techniques, which are currently in use in neonatology, pediatrics, and adult intensive care medicine, or techniques at present in clinical evaluation (IVOX), are reviewed with their indications, contraindications, differences, problems, worldwide results, and possible future applications.

[Determinations by indirect calorimetry need not be expensive and technically complicated. A new measurement system and its validation]. / Die Bestimmung der indirekten Kalorimetrie muss nicht teuer und technisch aufwendig sein. Ein neues Messsystem und seine Validierung.

Presentation of a newly conceived measuring instrument to determine the energy expenditure of critically ill patients at the bedside by means of indirect calorimetry. The special advantages of the measuring instruments are easy handling, little maintenance and very low working expenses and prime costs. The accuracy of measurement is considerable nd is comparable with that of other measuring methods, as has been established by an extensive validation.

[The measurement of extravascular lung water--significant in the follow-up of ARDS?]. / Messung des extravaskulären Lungenwassers--sinnvoll zur Verlaufsbeobachtung des ARDS?

In 40 adult patients suffering from severe ARDS stage III and IV (Morel) we examined the course of the extravascular lung water (EVLW) measured by the double indicator dilution method with 858 single measurements, during mechanical ventilation with PEEP, or extracorporeal CO2 elimination (ECCO2 R). No correlation could be found between EVLW and the values of alveolar arterial oxygen difference (AaDO2) and intrapulmonary right-left shunt (Qs/Qt) or haemodynamic values such as CVP, PCWP, mean pulmonary arterial pressure, or the 24 h fluid balance. It was, therefore, not possible to estimate a prognostic trend based on a single measurement of EVLW. However, the course EVLW was more appropriate to perceive the prognostic trend of ARDS because a rapid decrease of very high EVLW was correlated with a decrease of AaDO2 (r = 0.87); whereas lethal ARDS (fibrosis) was associated with moderately increased, unchanged EVLW. However, during the ECCO2-R treatment the repeated estimation of EVLW and AaDO2 is a useful tool to assess recovery because other parameters such as Qs/Qt and chest computer tomography during long-term bypass are very difficult or impossible to employ for this purpose. A change of EVLW with increasing PEEP level could not be found. The reproducibility of 858 EVLW values was excellent with a coefficient of variation of 4.9 +/- 3.5%.

Marburger concept for computer-aided acquisition, processing and documentation of patient data in the intensive care unit.

The authors report on their experience with the computer-aided acquisition, processing and documentation of patient data in an intensive care unit. The goal of an effective data and information collection system in the intensive care unit is to make therapy, and the patients respond to it, recognizable and understandable through the clear and complete representation of the patients conditions. The focal point of the data documentation is the medical record. In the implementation of a computer-aided data documentation and processing system the application of one central PC is unpractical. Each bed will be equipped with its own PC, and all the individual PCs will be connected to one central PC, which functions as server, and to connected to another PC in the doctors room. The data will be managed in a powerful database-management-system and be stored on an optical-disk. The development of an effective man/machine interface is especially important. In addition we can promote the user acceptance in other ways, so as to ensure a concrete benefit for each user group.

[Personal experiences with extracorporeal CO2 elimination in patients with severe ARDS--a current review]. / Unsere Erfahrungen mit der extrakorporalen CO2-Elimination bei Patienten mit schwerem ARDS--eine aktuelle Ubersicht.

The method of extracorporeal CO2 elimination (ECCO2-R) as described by Luiciano Gattinoni and Theodor Kolobow is compared with earlier extra corporeal methods such as extracorporeal membrane oxygenation. The physiological fundamentals of the method, as well as indications and contraindications are explained. - The results of more than 100 patients treated worldwide are discussed together with the present problems of the method. In cases of severe ARDS stage IV, ECCO2-R definitely reduces mortality.

[Adult respiratory distress syndrome in legionella pneumonia--successful treatment with extracorporeal CO2 elimination procedures]. / ARDS bei Legionellen-Pneumonie--erfolgreiche Behandlung mit dem extrakorporalen CO2-Eliminationsverfahren.

We report on successful treatment of an 46-year-old patient with ARDS (Adult Respiratory Distress Syndrome), caused by legionella-pneumophilia-pneumonia. The treatment with conventional artifical mechanical ventilation had failed. The new method of extracorporeal CO2-Elimination and low frequency positive pressure ventilation (ECCO2-R-LFPPV), introduced by L. Gattinoni (2) was in that case of severest ARDS very helpful. Supported by antimicrobial therapy with Erythromycin and Rifampicin the lung function could be improved to "restitutio ad integrum". Changes in chest radiographs, clinical parameters of ventilation, gas exchange and haemodynamics as well as the results of sequential pulmonary studies are demonstrated and discussed.

Regression of cardiac hypertrophy: morphometric and biochemical studies in rat heart after swimming training.

There is currently little information about the morphological changes of the myocardium accompanying the reversal of cardiac hypertrophy. In this study the hypothesis was tested that myocardial alterations induced by exercise will regress within a short interval after the end of training. Rat hearts were examined using morphometric and biochemical methods at the end of a 9-week period of endurance training and also 7, 10 and 14 days after its termination. At the end of the training period the heart weight had increased by 65% but the weight ratio of the right and left ventricular wall remained unchanged. A decline in the DNA content by 27% as well as a decrease in the volume density of the interstitial space by 14% and in the number of interstitial cell nuclei by 32% against controls, are explained by a 30% increase in the width of myofibres. The capillary density was reduced by 22% but the volume density of capillaries remained nearly constant as a result of widening of the capillary diameter by 27%. The surface density of capillaries was diminished by 10%. Ultrastructurally an increase in the ratio of mitochondrial to myofibrillar volume density was observed in the myocytes of hypertrophied hearts as compared to controls (0.54 and 0.63, respectively). Fourteen days after termination of training, 80% of the increment in heart weight had regressed. At this time the width of the myofibres and the volume density of the interstitial space had nearly normalized, while the capillary to fibre ratio had significantly increased. The ratio of mitochondrial and myofibrillar volume density became nearly normal, and a confluence of intermyofibrillar mitochondria resulted in significantly longer organelles. The increased DNA content 10 days after the training, as compared to controls, is attributable to the genesis of non-myocardial cells during the hypertrophic growth and their persistence during regression. The study has shown that cardiac hypertrophy induced by physical training nearly completely regresses within 14 days after termination of conditioning. The increased capillary to fibre ratio indicates neoformation of transversely oriented capillary branches in hypertrophy which particularly becomes apparent in two-dimensional estimation in the regression period. In comparison with myofibres, regression of capillaries seems to be delayed. The decline of heart weight and a significantly diminished RNA content during the regression of hypertrophy suggest that reduced synthesis is responsible for the decrease in heart weight.