[Indications for the insertion of a central venous catheter in emergency situations]. / Indikationen für das Anlegen eines zentralvenösen Katheters in Notfallsituationen.

The use of a central venous catheter (CVC) is associated with numerous complications despite its usefulness. Less experienced personnel have a higher complication rate, however complications are not totally avoidable even for more experienced persons. The complication rate increases under unfavorable working conditions. Therefore, the indication for a CVC even in the emergency situation must be considered very carefully.

An unusual procedure in performing brachial plexus block.

A new surgical treatment of pseudarthrosis humeri needed specific anesthesiological management. The relevant problems for the anesthesiologist were the following: one year prior to the present admission the patient suffered from a polytrauma with contusio cerebri and had, as a result of prolonged intubation during the following period of intensive therapy, an excessive tracheal stenosis in the subglottic area, however without any clinical signs. For these reasons, general anesthesia did not seem to be practicable and the conventional way of blocking the brachial plexus appeared to be somewhat problematic owing to the postoperative scar tissue in the previously surgically treated region. For these reasons an unusual anesthetic management was chosen: the brachial plexus was anesthetized in the subaxillar region by surgical exposure of the neurovascular bundle. We feel, that the surgical exposure of the brachial plexus as described here is a practicable alternative to the common techniques of blocking the brachial plexus in very special situations.

[The clinical application of the "locus of resistance" method for axillary plexus block (author's transl)]. / Klinische Anwendung der "Loss of Resistance"-Methode zur axillären Blockade des Plexus Brachialis.

We describe a new method of axillary brachial plexus block, the principle of which is to verify the position of the needle in the perivascular tissue not by paraesthesia but by the "loss of resistance" measured when penetrating the perivascular sheath. This method has been developed from the well known "loss of resistance" technique used in epidural anaesthesia and has been tested in practice as well as in theory. This technique not only guarantees greater accuracy in locating the perivascular tissue, but also opens the possibility of decreasing the incidence of lesions of nerves and vessels.

Verapamil as a hypotensive agent during neuroleptanaesthesia.

The haemodynamic effects of verapamil were investigated in 11 patients anaesthetized with thiopentone, fentanyl and dehydrobenzperidol. Suxamethonium and pancuronium bromide were used for muscle relaxation. Verapamil 0.07 mg kg-1 given as a single intravenous bolus decreased mean arterial pressure from 108 +/- 18 mm Hg to 84 +/- 20 mm Hg (P less than 0.001) and total peripheral resistance by 29 +/- 10% from 1662 +/- 399 dyne s cm-5 (P less than 0.001) while heart rate and mean pulmonary artery pressure showed only minor changes. The decrease in arterial pressure was caused by reduction in total peripheral resistance while cardiac output was increased.

[The impairment of stress parameters by hip joint close operations and the influence of anaesthesia. Preliminary results of a prospective study (author's transl)]. / Auswirkungen hüftgelenksnaher Operationen auf das Verhalten von Stressparametern und ihre Beeinflussung durch Anästhesie. Vorläufige Ergebnisse einer prospektiven Studie.

A randomized study was done to evaluate operation stress of reconstructive surgical procedures in the pelvic and femoral regions in regional anaesthesia compared to general anaesthesia. Spinal anaesthesia showed more favourable parameters of plasma catecholamines and plasmacortisol. In blood pressure and heart rate there was no significant difference between both anaesthetic groups. According to these (preliminary) results the authors consider spinal anaesthesia a more adequate method of intraoperative anesthesia.

[Cardiac arrest following protamine sulphate administration (author's transl)]. / Akutes Kreislaufversagen nach Protaminsulfatapplikation.

This study presents the case history of a patient who suffered from recurrent pulmonary embolism, despite heparinisation, after a car accident and who died during preparation for caval ligature. We feel that the protamine sulphate given for neutralization of the heparin effect played an important role, since no signs of massive pulmonary embolism were found at autopsy. Protamine sulphate is known to possess a significant cardiovascular depressive action. On the basis of a survey of the literature the possible potentiation of circulatory insufficiency by changed haemodynamics following pulmonary embolism, induction of anaesthesia, and protamine sulphate is discussed. Proposals for improved management of such case are made.

[Inversed ratio ventilation (IRV). Role of the respiratory time ratio in artificial respiration in ARDS]. / Inversed Ratio ventilation (IRV) Die Rolle des Atemzeitverhältuisses in der Veatmung beim ARDS.

Considering the advantages shown by the experiences of Reynolds on prolonged inspiration time it was suggested to study this type of ventilation also in ARDS. We tried the inverse ratio ventilation (IRV) in patients with ARDS and in postoperative cardiac surgical patients. An obvious improvement of gas transfer in the lung is seen and becomes better with increased duration of this type of ventilation. A better filling of various parts of the lung with longer time constants is achieved with prolonged inspiration. An effect similar to PEEP caused by an air trapping mechanism, can be seen with the shortening of expiration time. This air trapping mechanism is followed by autonomous adaption of PEEP for the local situation in various parts of the lung. A higher PEEP in poorly ventilated areas is automatically adjusted with IRV, than in areas with a short time constant (individual PEEP).

[The influence of flunitrazepam on the blood gases during subarachnoid block in geriatric patients (author's transl)]. / Beeinflussung der Blutgaswerte geriatrischer Patienten durch Flunitrazepam während subarachnoidaler Blockade.

Fifty-three geriatric patients under subarachnoid block for orthopaedic surgery received flunitrazepam 0.3-0.4 mg intravenously. Blood gases were checked while breathing room air. This dose caused a significant but small respiratory depression (p less than 0.05). These results confirm other reports on flunitrazepam, but used without spinal anaesthesia. There was no case, however, who needed ventilatory support. Top up doses up to a total of 1 mg caused no further significant changes. We feel that Flunitrazepam is a useful drug for sedation during regional block including poor risk patients.

[History of the early acute R.D.S. and description of a method to improve immediate postmortem fixation of the lung (author's transl)]. / Zur Histologie des Frühstadiums des akuten Lungenversagens und Beschreibung einer Technik der unmittelbar postmortalen Fixierung der Lungen.

A technique for immediate lung fixation on patients who die of ARDS is described. The advantages compared to the selective needle biopsy, the transthoracic circumscript fixation and the lung fixation organ removal are: 1. functional anatomical proportions are kept, 2. Artefact mainly caused by autolysis is avoided, 3. Simple performance and low costs. The results obtained with the described technique are presented. It is demonstrated that the changes in the initial shock phase correlate well with the pattern of its distribution. These changes are not uniform. Therefore we feel that the results with biopsy are somewhat doubtful.

[A comparison of two preoperative medications: responses in sedative, psychic and somatic effects (author's transl)]. / Vergleich zweier Prämedikationsmethoden: Psychische, sedative und somatische Reaktionen.

The influence of two different premedication methods on the psychic reaction of the patient and their somatic-vegetative effect was tested in a controlled double-blind study. 96 patients between the ages of 20 and 40 took part in the study and were divided into two groups. Group 1 (n = 47) received meperidine (Alodan) and promethazine (Phenergan). Group 2 (n = 49) were given thalamonal. All patients underwent a personality test (Cattell 16 PF) a day prior to scheduled surgery. After administration of the respective pre-anaesthetic drugs, three different test methods were applied to determine their subjective state. Simultaneously, independent from the patients, their psychic reactions were determined by the anaesthetist. Premedication 2 effected less calm, i.e. decrease of fear, exhaustion and depression, than premedication 1. The somatic-vegetative region exhibited no significant difference except for increased cardiocirculatory symptoms in group 1. Based on the less favourable psychodynamics in patients who received thalamonal, it is not advised as pre-anaesthetic medication.

[Abolition of hypotension following spinal anaesthesia by dihydroergotamine (DHE) (author's transl)]. / Aufhebung des Blutdruckabfalls bei Spinalanaesthesie durch Dihydroergotamin (DHE).

The conduction block of the preganglionic sympathetic fibres in spina anaesthesia leads to peripheral vasodilation. Such a loss of tone in blood vessels is also pronounced on the venous side. Therefore the effects of intravenously administered DHE (10 microgram/kg i.v.) on 25 healthy patients undergoing spinal anaesthesia were studied. Though all patients were preinfused with 500 ml Ringer there was a sustained decrease in arterial and pulmonary artery pressures (p less than 0.001). However, the heart rate remained unaffected. After DHE the pressure changes were completely reversed whereas heart rate was significantly decreased (p less than 0.001). The effects of DHE can largely be explained by its powerful and selective action on the capacitance vessels in the peripheral circulation. The increased venous return to the heart augments ventricular filling. Perfusion pressure is increased without any concomitant myocardial stimulation. The results indicate that DHE can have a beneficial effect in patients undergoing spinal anaesthesia.

[The continuous perivascular axillary plexus block in hand replantation surgery (author's transl)]. / Die kontinuierliche perivasculäre axilläre Plexus-Blockade bei Replantationen an der Hand.

A modified techniques of axillary plexus block is described which enables prolonged analgesia. The main principle of this techniques is to insert an indwelling canula into the perivascular tissue of the plexus brachialis. A cold local anaesthetic (4 degrees) is injected for controlling the canula site. The indications for this technique are all corrective and reconstructive operations of the upper extremity and the postoperative alleviation of pain. Twenty cases with different indications are discussed in this paper. No allergic, toxic or inflammatory reactions were seen in our patients. They were satisfied with this method of analgesia. The easy application, absence of time limiting factors and suitable intraoperative monitoring are the advantages of the method.

[X-ray control of position of subclavian catheter necessary or not? (author's transl)]. / Ist die angiographische Kontrolle eines Zentralvenekatheters erforderlich?

After subclavian vein cannulation of a 49 year old woman, the catheter was found within the pleural space by a special X-ray-technique. The rare complication stresses the importance of checking the position of a vena cava catheter by X-ray, using radio-opaque dye.

[Administration of glucose 33 p.c. with added high doses of insulin within a scheme of early total parenteral alimentation to patients with shock-related excessive caloric demand (author's transl)]. / Verabreichung hochprozentiger Glucose mit grossen Insulindosen im Rahmen einer frühzeitigen totalen parentalen Ernährung bei Patienten mit schockbedingtem übersteigerten Kalorienbedarf

40 patients, who had been admitted to the ICU in a stage of shock were given glucose 33 p.c. with added high doses of insulin, administered within a scheme of early total parenteral alimentation, along with fat emulsions and aminoacid solutions. It is demonstrated that this type of nutrition is able to improve metabolisation of glucose in a phase of impaired glucose utilisation following shock. The duration of reduced glucose utilisation is 5-10 days during which period increased addition of insulin (24-18 U insulin/50 g glucose) is advisable. After this time the action of endogenous insulin was improved to such an extent that the added insulin could be reduced to 12 U insulin/50 g glucose up to the third week and later (up to 49 days) to 8 U insulin/50 g glucose.