[Optimized analgesic sedation techniques for ESWL]. / Optimiertes Analgosedierungs-Verfahren zur ESWL-Behandlung.

Analgo-sedation for ESWL treatment has been associated with a variety of problems. Minimal invasiveness of this technique should combine with haemodynamic stability as well as with adequate oxygenation. Patient acceptance has to be considered as another important aspect. Our study demonstrates the effectiveness of an analgosedative regimen with regard to these aspects. 50 ASA I-III patients scheduled for ESWL treatment were randomly allocated to receive either no premedication (n = 25) or chlorazepam as oral premedication (n = 25). The analgosedative technique was identical in both groups, consisting of atropine 0.25 mg, droperidol 5 mg (2.5 mg, if body weight less than 60 kg), and alfentanil 10 micrograms/kg intravenously. If necessary, repeated boluses of alfentanil 5 micrograms/kg were administered up to a maximum of 2 mg. Heart rates, arterial blood pressures, and peripheral oxygen saturation were measured during treatment. Post-treatment, patients were interviewed to assess the quality of analgesia. The results showed that our analgo-sedative regimen is suitable for ASA I-III patients. Stable heamodynamic conditions and adequate oxygenation were achieved in all patients. Patient acceptance was good. Patients with anxiolytic premedication benefited in terms of reduction in blood pressure and heart rate. The study also showed that anaesthesiologists may underestimate the pain intensity experienced and assessed by the patient.

[Continuous intragastric pH measurement in intensive care patients treated with ranitidine and tube feeding]. / Kontinuierliche intragastrale pH-Wert-Messung bei Intensivepatienten unter Ranitidin- und Sondenkostgabe.

We studied 22 critically ill patients on long-term mechanical ventilation using continuous intragastric pH monitoring with an antimony electrode. Intragastric pH profiles were established for the duration of mechanical ventilation (mean: 7 days). The aim of our study was to achieve a gastric pH between 3.0 and 4.5 utilizing the H2-receptor antagonist ranitidine and nasogastric feeding with Nutricomp F. Patients were divided into three groups which were given (A) ranitidine boluses, (B) continuous ranitidine infusions, or (C) continuous ranitidine infusions together with enteral nutrition via the nasogastric tube. In group B we were able to obtain a pH value between 3.0 and 4.5 only in 11.6% of the observation period. With ranitidine boluses, there were even less measurements (9.3%) in the "optimal" pH range. The combination of continuous ranitidine application together with enteral alimentation made our attempts slightly more successful (20.0%). This failure to achieve the desired pH range encourages airway colonisation and nosocomial pneumonia at gastric pH greater than 4.5. At pH less than 3.0 there is a significantly higher incidence of acute stress ulcerations. Other therapeutic regimens e.g. the application of pirenzepine and sucralfate offer adequate protection of the gastric mucosa without raising the pH level.

[Contamination of respirators in long-term ventilation]. / Kontamination von Beatmungsgeräten bei Langzeitbeatmung.

The role of artificial ventilation as an exogenous source of nosocomial pneumonia in long-term ventilated patients is well established. Hence, decontamination of respirators after use is inevitable, although this procedure is costly and time-consuming. The purpose of the study was to prove the efficacy of bacterial filters (Ultipor BB 50, Pall Ltd., Dreieich) in preventing microbial contamination of respirators during long-term ventilation. We investigated the impact of the patient tracheal flora on different parts of the ventilation system. A total of 30 patients included 9 patients treated with an aminoglycoside intratracheally and whose ventilators were equipped with breathing system filters, 10 patients treated with the aminoglycoside intratracheally and without filters, and finally 11 patients without antibiotic prophylaxis and without filters. 1495 samples were taken from different parts of the ventilation circuit. The data obtained suggest that there is no significant influence on the contamination rate of the ventilators by application of bacterial filters or intratracheal aminoglycoside. The use of the breathing system filters to protect the ventilator from microbial contamination, therefore, seems to be unnecessary.

Serum aluminium levels of intensive care patients treated with two different antacids for prevention of stress ulceration.

We studied the serum aluminum levels of 30 intensive care patients receiving six daily doses of magaldrate (Riopan) or aluminium hydroxide (Trigastril). In both groups we found a significant rise of the serum aluminium concentration (p less than 0.01) following administration of the antacid solutions. Examination on day 9 and 15 the magaldrate group showed significantly (p less than 0.05) lower aluminium levels than the aluminium hydroxide group. An increase up to the critical serum aluminium level of 100 ng/ml occurred in none of the patients that all had normal or slightly impaired renal function. Therefore routine measurements of serum aluminium levels in patients without renal impairment are not considered necessary following antacid therapy. However, we recommend the use of antacids with an aluminium absorption rate as low as possible.

[TUR syndrome as a late postoperative complication. Case report]. / TUR-Syndrom als postoperative Spätkomplikation. Fallbericht.

A 81-year-old patient developed a TUR-syndrome gradually one and half an hour after termination of TURP. Surgery was complicated by perforation of the bladder dome at the end of TURP. Due to extravasation of the perioperative irrigating fluid intraperitoneally and intravascular resorption a TUR-syndrome became apparent. Early diagnosis and rapid initiation of appropriate intensive care resulted in a benign postoperative course and the patient attained full recovery.

[Adsorption of insulin to the Perfusor systems]. / Adsorption von Insulin an Perfusor-Systeme.

Using radioimmunoassay determination we examined the recovery rate of 100 units of regular insulin that had been added to 50 ml. of a carrier solution in a plastic Perfusor syringe. We measured the recovery rate with sodium chloride 0.9% as carrier and after adding albumin (10 g./l.) and gelatine (6 g./l. resp. 12 g./l.). An initial insulin loss of 26% (with albumin) to 37% (with gelatine) was followed by only a small loss (less than 9%) during the next 24 hours. We conclude from our results that it is unnecessary to add substances with high molecular weight in order to reduce insulin adsorption to Perfusor systems.

[No indications for barbiturate therapy following complete cerebral ischemia. A comment on "cerebroprotection" by barbiturates following cardiovascular arrest]. / Keine Indikation zur Barbiturattherapie nach kompletter zerebraler Ischämie. Eine Bemerkung zur "Zerebroprotektion" durch Barbiturate nach Herzkreislaufstillstand.

Cardiac arrest is followed by complete cerebral ischemia, which is characterized by delayed hypoperfusion and transient hypermetabolism. Brain metabolism depressant drugs, such as barbiturates, were suggested to improve neuronal outcome. The hypothesis of a cerebroprotective effect of barbiturates remained nevertheless controversial. In order to define the utility of large doses of thiopentone, the effect of thiopentone on carbohydrate and energy metabolism of 1-year old Wistar rats was investigated in an experimental model of complete reversible ischemia followed by a recovery period. No beneficial effect of high-dose thiopentone could be demonstrated by means of changes in the carbohydrate metabolism and the energyrich compounds. There were no differences between the treated group and the spontaneous recovery group. These results are mainly confirmed by other investigators. In contrast to focal ischemia and hypoxemia beneficial effects of barbiturates can not be demonstrated after complete cerebral ischemia in experimental studies and in clinical studies as well. In conclusion there is no indication for high-dose barbiturate therapy after cardiac arrest and successfull resuscitation.

[High-dose thiopental infusion in cerebral dysfunction following extracorporeal circulation]. / Hochdosierte Thiopentalinfusion bei zerebraler Dysfunktion nach extrakorporalem Kreislauf.

Thiopentone (thp) infusion was administered to 33 patients with cerebral dysfunction or convulsions out of 2986 patients operated on via extracorporeal circulation because of valvular disease, coronary insufficiency, septum defects and intrathoracic aortic aneurysms. If phenytoin, diazepam and clonazepam proved ineffective, thp 10-15 mg/kg was injected slowly, followed by infusion of 2-4 mg/kg/h for 0.5-5 days. 9 patients died. 18 survivors had a good recovery, 6 were moderately disabled. In the survivors embolisation of particulate matter prevailed as a cause of cerebral dysfunction while in nonsurvivors prolonged pre- and postoperative hypotension was the main cause, with one patient suffering a hemispheric infarction. The amelioration of convulsions and psychosyndromes in the survivors is compatible with the known anticonvulsive effect of thp and its alleged influence on cerebral focal ischaemia. However, in protracted cerebral hypoperfusion as a cause of cerebral dysfunction no protection can be expected from thp. The known effects of barbiturates do not justify the use of these substances for the purpose of cerebral protection.

[Pericardial tamponade: a rare but severe complication of a vena cava catheter. Case report]. / Herzbeuteltamponade: Eine seltene aber schwerwiegende Komplikation eines Cava-Katheters. Ein Fallbericht.

A case of catheter-induced cardiac tamponade followed by successfully treated cardiac arrest is reported in a 5-month old infant with oesophageal atresia. The complication occurred after a delay of 16 h following catheter placement and was diagnosed by ultra-sound technique. Treatment consisted of direct pericardial puncture. Cardiac tamponade is an unusual, but potentially fatal complication and is always due to incorrect catheter tip position.