[Effect of Nutriflex 48 on the plasma amino acid pattern in surgical intensive care patients with infection]. / Einfluss von Nutriflex 48 auf das Plasmaaminosäuren-Muster chirurgischer Intensivpatienten mit Sepsis.

Nutriflex 48 (48 g amino acids and 1250 nonprotein kcal/l), containing 20% branched chain amino acids, was infused in a dose of 2000 ml per day over a period of 14 days to 8 surgical intensive care patients with sepsis and concomitant liver dysfunction. Cumulative nitrogen balance was negative on each day of investigation, as aspected in those patients. The amino acid patterns in plasma showed increased concentrations of methionin, while the concentration of branched chain amino acids remained in the normal range until the end of the study. The concentration of plasma ammonium was always normal. These results seem to indicate that in septic patients a total parenteral nutrition with conventional amino acid solutions containing normal concentrations of branched chain amino acids, is possible. The results of the present study show that the necessity of parenteral nutrition in septic patients with highly branched chain amino acids can not be supported.

[Patient monitoring]. / Patientenüberwachung.

The main problems of monitoring patients on prolonged artificial respiration are discussed. These are: uninterrupted technical control of the respirator and of its clinical effects; continuous observation of the functioning of tubes, vaporizers and nebulizers; adequate tracheobronchial clearance and breathing therapy is absolutely compulsory. Intensive care units are classified into three categories according to their monitoring and surveillance capacities. The minimum, which corresponds to category I, should be performed by every intensive care unit. Category III includes additional computerized intensive care. The most important parameter for monitoring pulmonary function is blood gas analysis, which has been improved by the introduction of continuous arterial pO2 registration. Haemodynamic control serves for detection of arrhythmias and changes in pump function. The determination of pulmonary shunt flow (Qs/Qt) and of the ratio of dead space to tidal volume (VD/VT) impart information on the overall function of both systems (category II). A nomogram to simplify the calculation of pulmonary shunt is proposed which aggregates the factors contributing most to pulmonary shunt in acute respiratory failure. Its results deviate less than 1% from the calculated values if PCO2 ranges between 32 and 52 mm Hg and the error does not exceed 1.5 per cent with a PCO2 up to 82 mm Hg, unless it is combined with a very low Hb and high mixed venous saturation.

[Antibiotic therapy of infections in patients under surgical intensive care, in particular with mezlocillin (author's transl)]. / Antibiotika-Behandlung von Infektionen bei chirurgischen Intensivpflege-Patienten-speziell mit Mezlocillin.

Twenty-two patients from our surgical intensive care ward were, after unsuccessful treatment outside, treated with a combination of antibiotics including 6-[(R)-2-[3-methylsulfonyl-2-oxo-imidazolidine-1-carboxamido]-2-phenyl-acetamido]-penicillanic acid sodium salt (mezlocillin, Baypen) as a beta-lactam antibiotic. The infection was cured in 16 and improved in 2 patients. Three cases of infection with Serratia did not respond to treatment and antibacterial efficacy was unassessable in another case. Four patients died of shock lung (2), pulmonary embolism (1) or Candida-induced septicaemia (1) after cure of the infection. The daily dose of mezlocillin was 3 x 5 g, given as an i.v. short-term infusion. Diarrhoea (1) and petechiae (1) were observed as side effects probably attributable to mezlocillin. In none of the patients was a discontinuation of treatment necessary. Owing to its broad spectrum of action (covering both gram-positive and gram-negative microorganisms and anaerobes) and its consistently strong molar action, mezlocillin is well suited as a beta-lactam combination component for intensive care patients. At the end of this study in vitro resistant strains appeared. Therefore mezlocillin with its very valuable properties should be given only to critically selected cases.

[Problems in prolonged artificial respiration. A review]. / Problematik der Langzeitbeatmung - eine Ubersicht.

For about twenty years, the method for prolonged artificial respiration was an imitation of spontaneous breathing pattern. New pathophysiological informations about acute respiratory failure showed that a technique which is widely different in frequency, cycle, and tidal volume is more suitable for the fast and safe restauration of spontaneous breathing. Especially the determination of pulmonary shunt flow (QS/Qt), and of the ratio of dead space to tidal volume (VD/VT) have completed our knowledge. In the management of patients with prolonged artificial ventilation, the calculation of shunt flow allows an evaluation of therapeutic procedures. This was the reason to present a nomogram, which simplifies the determination of pulmonary shunt and to discuss an easy, non-invasive method to at least estimate its amount.

[Anaesthesia with flunitrazepam (rohypnol) and fentanyl for geriatric patients (author's transl)]. / Die Anaesthesie mit Rohypnol (Flunitrazepam) und Fentanyl beim geriatrischen Patienten

Favorable clinic experiences with an anaesthetic involving rohypnol (flunitrazepam) and fentanyl led to an investigation of the haemodynamic effect of this procedure in a group of 9 geriatric patients, aged from 86 to 95 years. Anaesthesia was induced with 0.5 mg rohypnol and 0.1 to 0.2 mg fentanyl depending on the narcotic effect of rohypnol, intubation was performed under relaxation with suxamethonium and long term relaxation was achieved with pancuronium. The patients were normoventilated with nitrous oxide/oxygen. The individual values of the changes in cardiac output and total peripheral resistance showed a great variation. There was a significant correlation between the relative changes in mean arterial pressure and total peripheral resistance (r = 0.69, p less than 0.05) but no correlation between mean arterial pressure and cardiac output (r = 0.09). This indicates that the pronounced drop in arterial pressure which occurred in 4 patients can be explained by a decrease in total peripheral resistance. Careful dosage of the drugs, in particular of fentanyl, and knowledge of adequate measures to treat a decrease in blood pressure if it occurs, appears to be a prerequisite for the use of this type of anaesthesia in poor risk patients.

[Effect of volume substitution with dextran on the haemodynamics under enflurane anaesthesia in geriatric patients (author's transl)]. / Die Auswirkungen einer Volumenrestitution mit Dextran-Ringerlaktat auf den kreislaufdepressorischen Effekt von Ethrane bei geriatrischen Patienten

The haemodynamic effect of enflurane has been examined in two groups of geriatric patients, one with and the other without preanaesthetic administration of 15 mg/kg of 1,8% dextran in lactated Ringer's solution. All the patients have been immobilized for 2 to 3 days before they were operated for an orthopaedic procedure. The administration of the colloidal solution led only to minor cardiovascular alterations: a rise of central venous pressure by 6 +/- 1 (+/- S.E.M.) cm H2O, an increase of mean arterial pressure by 6 +/- 2%, an increase of cardiac output by 10 +/- 4%. Heart rate decreased by 5 +/- 4% and total peripheral resistance by 12 +/- 5%. The cardiovascular depressant effect of enflurance was markedly attenuated by the preanaesthetic volume administration. Mean arterial pressure decreased during anaesthesia by only 16 +/- 3%, as compared with a decrease of 25 +/- 7% in the control group, cardiac output remained virtually unchanged (-3 +/- 9% vs. -37 +/- 5% in the controls) and total peripheral resistance decreased not significantly by 10 +/- 12%, while it rose in the controls by 20 +/- 8%. These findings support the hypothesis that the particular sensitivity of geriatric patients towards the depressant effects of anaesthetics is at least partially due to a compensated hypovolaemia which occurs as a physiological adaptation to immbolization. Enflurane appears as a suitable anaesthetic for geriatric patients, if proper measures for preanaesthetic volume substitution are taken.

A nomogram to obtain pulmonary shuntflow (Qs/Qt).

A nomogram to simplify the determination of pulmonary shunt is presented. It is based on Leigh's et al. shunt-equation (1969). The nomogram aggregates the factors which contribute most to the pulmonary shunt in acute respiratory failure. Arterial and venous oxygen saturation, Hb content, arterial oxygen tension and barometric pressure do influence strongly the result of calculated shuntflow. For the factors with little importance in the calculation (vapor pressure, mixed venous oxygen tension, alveolar-CO2 tension), international mean values are used. The shunt determined with the nomogram deviates less than 1% from the calculated values, if the range of PCO2 is between 32 and 52 mm Hg and the error does not exceed 1,5% with a PCO2 up to 82 mm Hg unless it is combined with a very low Hb and a high mixed venous saturation. By the nomogram the effect of the different parameters on the shunt can be very well illustrated. Especially mistakes in determination of the mixed venous saturation and of arterial O2 tension result in errors. Too high saturation values in mixed venous blood occur in distally located catheters due to pulmonary capillary admixtures. This contamination can be easily detected if the relationship between PVO2 and PACO2 is examined. The other source of error lies in the technical problems of PO2 determination in high ranges and is caused by escape of O2 into the PO2-electrode and O2-consumption of the blood. The end effect which the factors of O2 escape have on the accuracy of PO2 determination in high ranges is demonstrated with blood samples which have been equilibrated with different gas mixtures at different temperatures and had their PO2 measured at regular intervals. The error in PaO2 measurement can be reduced if blood-gas analyses are performed immediately or on cooled samples.

[Effect of ethrane on the circulatory parameters of geriatric patients (author's transl)]. / Wirkung von Ethrane auf die Kreislaufgrössen geriatrischer Patienten

The cardiovascular effects of enflurane in geriatric patients have been compared with the effects of this anaesthetic agent in a group of young patients. The degree of cardiovascular depression in geriatric patients was much greater than in the young patients despite the smaller inspired concentration of enflurane necessary to produce a similar depth of anaesthesia. In comparison with halothane and neuroleptanaesthesia, enflurane produced the greatest decrease in cardiac output. The mean arterial pressure, however, was quite well maintained due to a simultaneous increase in total peripheral resistance.