[Acute obstruction of an anesthetic gas evacuation system. Ventilation with a Servo Ventilator 900D]. / Akute Obstruktion einer Narkosegasentsorgung. Beatmung mit einem Servo Ventilator 900D.

During aorto-coronary bypass surgery acute expiratory airway obstruction occurred in two patients during controlled ventilation with a Servo D ventilator (Siemens Elema) in combination with a Servo EVAC 180 gas evacuation system. In this system expiratory volume passes from the ventilator to the reservoir bag. Distension of the bag will open the valve to the receiving unit by vertical dislocation of the valve spring. The mechanism relies on free mobility of the valve spring within the reservoir bag. We observed an increase in mean expiratory and inspiratory airway pressure above 40 mmHg due to blockage of the expiratory gas outlet by external lateral dislocation of the valve spring. In conclusion, while free mobility of the valve spring within the hanging Evac bag has to be ascertained at all times for safe application of the EVAC 180 system, the manufacturer should provide some appropriate mechanical shelter around the bag.

Role of phospholipase A in multiorgan failure with special reference to ARDS and acute renal failure (ARF).

In 150 patients admitted to an ICU phospholipase A serum activity was measured daily. The correlation between the increase of phospholipase A serum activity and the severity of adult respiratory distress syndrome (ARDS) and the incidence of acute renal failure (ARF), two important target systems in multiple organ failure (MOF) syndrome was studied as well as the efficacy of a treatment with phospholipase A inhibitors (methylprednisolone and dexamethasone). The results of this study show that there exists a statistically significant correlation between the increase of phospholipase A activity and the incidence of multiple organ failure. Inhibitory treatment ameliorates the organ function for a short time without any change of long-term outcome. The results could not clarify whether the rise of the mother enzyme of the arachidonic acid metabolism is only an epiphenomenon of multiple organ failure or the causative agent itself.

[Experiences with therapeutic whole-body hyperthermia]. / Erfahrungen mit der Ganzkörperhyperthermie.

Therapeutic whole body hyperthermia (WBH) as an additional therapy in the treatment of cancer has been known for a long time and is beginning to attain acceptance. In a clinical study 28 patients were treated 70 times with WBH at a core temperature of 41.8 degrees C. Hyperthermia was induced and maintained with an extracorporal circuit (ECC). Patients were anaesthesized with nitrous oxygen, enflurane and fentanyl. Therefore artificial ventilation was mandatory. Invasive monitoring was used to control vital functions. The effect of WBH includes a rise in cardiac output and heart rate as well as a decrease in total vascular resistance and mean arterial pressure. Pulmonary function almost remains constant. A raised oxygen consumption is compensated by a rise of oxygen availability. In consequence of an augmented perspiratio insensibilis and the ECC, close observation of fluid and electrolyte balance is necessary. According to our experience the small number of complications and problems allows the treatment with WBH even of patients with a high risk of anaesthesia.

[Extracorporeally induced whole-body hyperthermia in conventionally incurable malignant tumor patients]. / Extraskorporal induzierte Ganzkörperhyperthermie bei konventionell inkurablen Malignompatienten.

Whole body hyperthermia was produced in 14 patients with conventionally incurable malignant disease. The technique consisted of arteriovenous shunting involving extracorporeal circulation with heat exchange during general anaesthesia. A temperature of 41.8 degrees C was maintained for periods of 6 hours. After achieving hyperthermic temperatures treatment was enlarged by administration of 5-fluorouracil (1000 mg) in patients with colorectal carcinoma and by dacarazine (200 mg/m2) in patients with malignant melanoma. In 5 out 6 patients with stage IV colorectal carcinoma stabilisation of the disease was seen for an average of 10 months. In contrast, progression of the disease was seen in patients with malignant melanoma and mean survival was only 5 months. These preliminary results in a small number of patients indicate that 1. induction and maintenance of whole body hyperthermia is clinically possible, 2. technical requirements are considerable, however feasible, 3. different tumours react differently to treatment.

[The problem of the difficult intubation]. / Zur Problematik der schwierigen Intubation.

Endotracheal intubation has become widespread routine in modern anaesthesiology and intensive care. Nevertheless, there are still patients in whom endotracheal intubation fails or is hampered by anatomical malformations. In these cases "conventional" attempts at intubation are not only time-consuming but also involve considerable risk for the patient, including total failure. Moreover these techniques (e.g., blind nasal) require a highly skilled performer as well as a good deal of luck. Under such circumstances, fiberoptic endotracheal intubation is the method of choice. This technique is easy to perform even by untrained persons, achieves a high rate of success and nearly totally lacks special hazards. The practical points of the procedure are outlined and possible problems discussed, which, however, are rare.

[Ketamine--a suitable agent for emergency situations (author's transl)]. / Stellenwert von Ketamin in der Notfallsituation.

Various surgical procedures have been performed using ketamine alone (Group I) or ketamine-relaxant-air anaesthesia (Group II). In all patients we observed a significant rise in systolic and diastolic blood pressure and pulse rate. The intraoperative values showed a tendency to return to normal. Ten minutes after injection 2 mg/kg body-weight i.v., ketamine caused a significant reduction in arterial PO2 and oxygen saturation as well as a significant rise in arterial PCO2, though these changes were of no clinical importance. In both groups the intraoperative values were normal as compared to the preoperative level. In all cases base excess reflecting the metabolic side of blood gas analysis was within normal range. Based on our findings we recommend the use of ketamine as a sole anesthetic agent for IPPB ventilated as well as spontaneously breathing patients in disaster situations.

[Anaesthesia problems in massive transfusion (author's transl)]. / Narkoseprobleme bei der Massivtransfusion.

It is essential for adequate anaesthesia during massive transfusion to avoid further shift of the oxygen dissociation curve to the left by hyperventilating the patient, by not rewarming the cold blood and by an overenthusiastic correction of an eventually arising metabolic acidosis. The occurrence of coagulation disorders during massive transfusion has been overestimated in the past and is a poor basis for "blind" substitution. The additional use of blood microfilters and caustious attitude towards the use of crystalloid solutions e.g. Ringer lactate, are indispensable measures for counteracting impending pulmonary insufficiency. The avoidance of surfactant irritating inhalation anesthetics such as halothane or methoxyflurane seems advisable. In this context the use of adequate PEEP plays an important role. Circulatory stability is guaranteed by using ketamine or fentanyl for general anaesthesia and analgesia, and by the use of pancuronium for relaxation.