[Lipid infusion in multiple trauma intensive care patients in the early phase of treatment]. / Fettinfusion bei polytraumatisierten Intensivpatienten in der Frühphase der Behandlung.

OBJECTIVES: To study the metabolic effects of a high-dose fat infusion application in the early phase of total parenteral nutrition (TPN) after major trauma. DESIGN: Prospective study in male patients after major trauma. SETTING: Intensive care unit of the University Clinic. PATIENTS: 21 male, mechanically ventilated patients after major trauma. INTERVENTIONS: Infusion of Elolipid 20% (Fa. Leopold, Graz, Austria), starting on the 3rd day after ICU admission (0.075 g/kg body weight/h) in 8 h. The dose was increased on the 5th day (0.125 g/kg BW/h) and on the 7th day (0.15 g/kg BW/h). RESULTS: There was a pathologic rise in serum triglycerides on days 3, 5 and 7 during the infusion period. A serious diabetic metabolic state was shown on the 3rd day. No significant changes in urea production rate could be demonstrated after the high-dose fat infusion. CONCLUSIONS: The reason for the decreased fat elimination in patients after major trauma after high-dose fat infusion (8 h) remains unclear (fat clearance or fat oxidation failure). Therefore the fat infusion should be started after normalization of the blood glucose level. Thus the fat infusion should be given continuously over 24 h to avoid serious metabolic complications.

Long-term administration of pancuronium and pipecuronium in the intensive care unit.

This study was performed to determine the optimum dose of pancuronium (n = 30) and pipecuronium (n = 30) under continuous sedation and analgesia in the intensive care unit (ICU). This was an open clinical investigation in 60 critically ill patients with head injury, multiple trauma (in some complicated with sepsis and multi-organ failure), requiring neuromuscular block for ventilation for at least 48 h. Emphasis was placed on the neuromuscular monitoring with a peripheral nerve stimulator and adequate sedation and analgesia. Satisfactory block was achieved in all cases with an average dose of 3 mg/h with either compound. None of the patients experienced prolonged paralysis, muscle weakness, or other neuromuscular dysfunctions in the postventilatory period. We suggest that adequate use of sedative hypnotics and opioids plus neuromuscular monitoring allowed us to optimize the dose of muscle relaxants according to the need of individual patients.

A study of neurotransmitters in human inner ear. Preservation of human temporal bone and value of organ donation for inner ear research.

Twenty-nine human temporal bones (TBs) from 3 different groups of patients were used to investigate an effective preservation method of the inner ear and to study the suitability of TBs from organ donors for human inner ear research. Inner ears were fixed by perilymphatic perfusion and immersion fixation. Choline acetyltransferase (ChAT) and gamma-aminobutyric acid (GABA) activities were detected either by an indirect immunostaining method or by the peroxidase-anti-peroxidase (PAP) technique. The results show that the cytoarchitecture of the sensory epithelia is excellently preserved in specimens fixed within 2 h after death. ChAT- and GABA-immunoreactivities were revealed in the efferent nerve endings and fibers of the cochlea. Morphological preservation of the sensory epithelia was also good in specimens fixed within 5 h after death. However, inner ear sensory epithelia of organ donors that had died from head trauma and were in the definite brain death state for at least 7 1/2 h were severely damaged and showed cellular debris due to autolysis, although they were fixed within 2 1/2 h after death. The mechanisms underlying this damage of the sensory epithelia are discussed.

[Hypertriglyceridemia and acute pancreatitis]. / Hypertriglyzeridämie und akute Pankreatitis.

Data of 26 patients suffering from severe pancreatitis, who were treated at the anesthesiologic intensive care unit during the years 1991 and 1992, were evaluated with respect to etiologic factors, especially hypertriglyceridemia, stage of the disease and clinical outcome. Hypertriglyceridemia was found in 13 cases (11 men, 2 women, mean age 42 +/- 9 years) with values between 330 mg/dl and 4000 mg/dl. Lipid electrophoresis revealed a pattern typical for type IV hyperlipidemia. Insulin dependent diabetes was present in 4 patients and 5 reported about an unusual high alcohol intake preceding pancreatitis. Beside surgical approaches, including drainage and lavage, and basic intensive care treatment plasmapheresis was performed in 8 patients with hypertriglyceridemia. 5 patients with pancreatitis and hypertriglyceridemia died out of multiorganic failure, and so the mortality rate was 38%. The group of patients with pancreatitis caused by cholelithiasis or chronic alcohol consumption showed a mortality rate of 46%. The poor outcome of pancreatitis associated with hypertriglyceridemia demonstrates the importance of the treatment of hypertriglyceridemia in order to prevent the development of pancreatitis. The determination of plasma triglyceride values should belong to the routine diagnostic procedures in acute pancreatitis.

Multiple organ failure after mitral valve repair with intravascular hemolysis and its recovery due to mitral valve replacement.

We present a patient with evidence of severe intravascular hemolysis after mitral valve repair, an established method for the surgical treatment of mitral valve disease to avoid prosthesis related complications. The coincidence of this uncommon complication with hemodynamic instability due to pre-existing myocardial dysfunction and Gram-negative pneumonia promoted the development of simultaneous dysfunction of liver, kidney and the cardio-respiratory system. Elimination of the source of hemolysis by re-operation with mitral valve replacement on the ninth postoperative day allowed prompt recovery from severe organ dysfunction. Free hemoglobin may have perpetuated progressive organ failure in our patient.