[Naloxone-induced pulmonary edema. Case report with review of the literature and critical evaluation]. / Naloxoninduziertes Lungenödem. Fallbericht mit Literaturübersicht und kritischer Bewertung.

A case of pulmonary edema after the administration of naloxone for laparoscopic splenectomy is reported. Previous reports of naloxone-induced pulmonary edema are listed and reviewed. The clinical course is compared to other forms of non-cardiogenic pulmonary edema. Uncertainty remains about the underlying pathophysiological process and the true impact of naloxone on the development of pulmonary edema.

S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system.

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery (Deutsche Gesellschaft für Thorax-, Herz- und Gefässchirurgie, DGTHG) and the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess the available monitoring methods with regard to indication, procedures, predication, limits, contraindications and risks for use. The differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilatators, inodilatators and calcium sensitizers and the use of intra-aortic balloon pumps will also be addressed. The guideline has been developed following the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

Perioperative management of patients with cytoreductive surgery for peritoneal carcinomatosis.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important tool in the management of patients with peritoneal malignancies. It is a complex surgical procedure with significant fluid loss during debulking leading to relevant pathophysiological alterations and therefore a challenge for anesthesiologists and critical care physicians. This review summarizes perioperative changes in hemodynamics, oxygen supply, coagulation, hematopoetic parameters and fluid status during cytoreductive surgery and HIPEC and how to deal with these pathophysiological alterations.

Elimination of sevoflurane is reduced in plasma-tight compared to conventional membrane oxygenators.

BACKGROUND AND OBJECTIVE: It has been demonstrated that volatile anaesthetics have cardioprotective properties during open-heart procedures, especially when administered continuously. European Council Directive 93/42/EEC concerning medical devices bans the supplementary incorporation of anaesthetic vaporizers in the bypass circuit. Since the uptake of volatile anaesthetics via diffusion membrane oxygenators is severely reduced, it is hypothesized that clinically relevant concentrations of sevoflurane will remain in the patients' blood following saturation with a volatile agent before start of cardiopulmonary bypass. This study was designed to compare conventional and diffusion membrane oxygenators regarding their in vivo elimination of sevoflurane. METHODS: Twenty patients undergoing elective coronary bypass surgery were randomly allocated to two groups, either using a conventional polypropylene membrane oxygenator or a plasma-tight poly-(4-methyl-1-pentene) membrane oxygenator in a miniaturized extracorporeal circuit. Anaesthesia was maintained with sevoflurane, which was stopped at the start of cardiopulmonary bypass. During cardiopulmonary bypass, sevoflurane concentration was measured in blood and in the exhausted gas from the oxygenator. RESULTS: The elimination of sevoflurane, expressed as the relative blood concentration, was significantly increased in polypropylene membrane oxygenators compared to poly-(4-methyl-1-pentene) membrane oxygenators. This resulted in an approximately threefold higher sevoflurane blood concentration in the poly-(4-methyl-1-pentene) group over the course of cardiopulmonary bypass. CONCLUSIONS: With the incorporation of a poly-(4-methyl-1-pentene) oxygenator in a miniaturized bypass circuit, relevant concentrations of a previously applied volatile agent can be maintained even without further supply throughout cardiopulmonary bypass. This might be an alternative approach to cardioprotection when sevoflurane cannot be administered through cardiopulmonary bypass.

[Guidelines for intensive care in cardiac surgery patients: haemodynamic monitoring and cardio-circulatory treatment guidelines of the German Society for Thoracic and Cardiovascular Surgery and the German Society of Anaesthesiology and Intensive Care Medicine]. / Die intensivmedizinische Versorgung herzchirurgischer Patienten: Hämodynamisches Monitoring und Herz-Kreislauf-Therapie S3-Leitlinie der Deutschen Gesellschaft für Thorax-, Herz- und Gefässchirurgie (DGTHG) und der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI).

Hemodynamic monitoring and adequate volume-therapy, as well as the treatment with positive inotropic drugs and vasopressors, are the basic principles of the postoperative intensive care treatment of patient after cardiothoracic surgery. The goal of these S3 guidelines is to evaluate the recommendations in regard to evidence based medicine and to define therapy goals for monitoring and therapy. In context with the clinical situation the evaluation of the different hemodynamic parameters allows the development of a therapeutic concept and the definition of goal criteria to evaluate the effect of treatment. Up to now there are only guidelines for subareas of postoperative treatment of cardiothoracic surgical patients, like the use of a pulmonary artery catheter or the transesophageal echocardiography. The German Society for Thoracic and Cardiovascular Surgery and the German Society for Anaesthesiology and Intensive Care Medicine made an approach to ensure and improve the quality of the postoperative intensive care medicine after cardiothoracic surgery by the development of S3 consensus-based treatment guidelines. Goal of this guideline is to assess available monitoring methods and their risks as well as the differentiated therapy of volume-replacement, positive inotropic support and vasoactive drugs, the therapy with vasodilators, inodilators and calcium-sensitizers and the use of intra-aortic balloon pumps. The guideline has been developed according to the recommendations for the development of guidelines by the Association of the Scientific Medical Societies in Germany (AWMF). The presented key messages of the guidelines were approved after two consensus meetings under the moderation of the Association of the Scientific Medical Societies in Germany (AWMF).

Assessment of fluid responsiveness in mechanically ventilated cardiac surgical patients.

BACKGROUND AND OBJECTIVE: Accurate assessment of preload responsiveness is an important goal of the clinician to avoid deleterious volume replacement associated with increased morbidity and mortality in mechanically ventilated patients. This study was designed to evaluate the accuracy of simultaneously assessed stroke volume variation and pulse pressure variation using an improved algorithm for pulse contour analysis (PiCCO plus, V 5.2.2), compared to the respiratory changes in transoesophageal echo-derived aortic blood velocity (deltaVpeak), intrathoracic blood volume index, central venous pressure and pulmonary capillary wedge pressure to predict the response of stroke volume index to volume replacement in normoventilated cardiac surgical patients. METHODS: We studied 20 patients undergoing elective coronary artery bypass grafting. After induction of anaesthesia, haemodynamic measurements were performed before and after volume replacement by infusion of 6% hydroxyethyl starch 200/0.5 (7 mL kg(-1) ) with a rate of 1 mL kg(-1) min(-1). RESULTS: Baseline stroke volume variation correlated significantly with changes in stroke volume index (deltaSVI) (r2 = 0.66; P < 0.05) as did baseline pulse pressure variation (r2 = 0.65; P < 0.05), whereas baseline values of deltaVpeak, intrathoracic blood volume index, central venous pressure and pulmonary artery wedge pressure showed no correlation to deltaSVI. Pulse contour analysis underestimated the volume-induced increase in cardiac index measured by transpulmonary thermodilution (P < 0.05). CONCLUSIONS: The results of our study suggest that stroke volume variation and its surrogate pulse pressure variation derived from pulse contour analysis using an improved algorithm can serve as indicators of fluid responsiveness in normoventilated cardiac surgical patients. Whenever changes in systemic vascular resistance are expected, the PiCCO plus system should be recalibrated.

Adequacy of perfusion during hypothermia: regional distribution of cardiopulmonary bypass flow, mixed venous and regional venous oxygen saturation - hypothermia and distribution of flow and oxygen.

BACKGROUND: Hypothermia during CPB is used to reduce metabolic activity, thus protecting organs and tissues. The aim of this study was to investigate the relationship between regional and mixed venous oxygen saturation and distribution of pump flow with respect to hypothermia. METHODS: Twenty-five patients undergoing a Ross procedure were included in a prospective, controlled study. During standard CPB, temperature was reduced stepwise to 28 degrees C. Blood gases (a-stat regimen) were analysed in samples from the inferior (IVC) and the superior vena cava (SVC), arterial and mixed venous blood. Flow was detected separately in the SVC, IVC, arterial, and collecting venous line. Samples were taken, and flows were measured before CPB, during hypothermia, during rewarming, and 30 min after CPB discontinuation. RESULTS: Oxygen saturation in the IVC was lower than in the SVC and in mixed venous blood at all times (max. difference - 17.3 +/- 3.0 % during hypothermia, - 23.8 +/- 2.9 % during rewarming, p < 0.01). There was a statistical correlation of mixed and IVC venous oxygen saturation (r = 0.79, p < 0.001) but not of SVC venous blood. Hypothermia had a major influence on pump flow distribution as backflow from the SVC decreased significantly in favour of IVC flow with increasing degree of hypothermia (increase of flow difference from 1.15 +/- 0.23 l/min to 1.49 +/- 0.36 l/min, p < 0.01). Temperature profiles were similar when detected in aorta, pulmonary artery, tympanum and nasopharygeum, but differed significantly from other sites. CONCLUSIONS: During hypothermic CPB, regional deoxygenation occurs in spite of normal mixed venous saturation. The level of hypothermia has a major impact on bypass flow distribution with cerebral perfusion reduction. Methods of regional oxygenation assessment are needed, and altered strategies during hypothermia have to be taken into consideration.

Assessment of intrathoracic blood volume as an indicator of cardiac preload: single transpulmonary thermodilution technique versus assessment of pressure preload parameters derived from a pulmonary artery catheter.

OBJECTIVE: To analyze the clinical value of a new device (PiCCO) for cardiac output measurement and volume preload parameter assessment, based on transpulmonary thermodilution technique, as an alternative to the pulmonary artery thermodilution technique and assessment of pressure preload parameters derived from the pulmonary artery catheter. DESIGN: Prospective, controlled, clinical study. SETTING: University hospital. PARTICIPANTS: Eighteen patients with ejection fraction >50% undergoing coronary artery bypass graft surgery. INTERVENTIONS: A baseline measurement was performed after induction of anesthesia under clinical steady-state conditions (T1). Hypovolemia, defined as central venous pressure (CVP) <10 mmHg and pulmonary capillary wedge pressure (PCWP) <12 mmHg, was treated by infusion of 6% hydroxyethyl starch 200/0.5 (7 mL/kg). After 10 minutes, a second measurement (T2) was performed. MEASUREMENTS AND MAIN RESULTS: The mean difference (bias) between transpulmonary thermodilution cardiac output and pulmonary artery thermodilution cardiac output did not differ at the 2 sample points. Changes in pressure preload parameters of the pulmonary artery catheter (CVP, PCWP) did not correlate with changes in cardiac output or stroke volume, whereas changes in volume preload parameter intrathoracic blood volume (ITBV) of the PiCCO correlated significantly with changes in cardiac output and stroke volume (r = 0.55, p < 0.05; r = 0.62, p < 0.01). CONCLUSION: These results suggest that increased cardiac preload is more reliably reflected by ITBV than by CVP or PCWP. The assessment of ITBV by the transpulmonary single indicator dilution technique is an interesting alternative to the pressure preload parameters.

[Acute Leriche's syndrome in a patient undergoing coronary artery bypass grafting with extracorporeal circulation]. / Akutes Leriche-Syndrom bei Aorto-Coronarer-Bypass-Operation mit Extrakorporaler Zirculation.

We are reporting a case of an acute thromboembolic obstruction of the aortic bifurcation in a 66-year-old patient undergoing coronary artery bypass grafting with extracorporeal circulation. After declamping of the aorta, the arterial pressure measured in the femoral artery suddenly dropped, whereas the pressure measured in the aortic cannula and in both radial arteries stayed normal. Transoesophageal echocardiography was performed to exclude an acute aortic dissection. While the patient always had a constant sinus rhythm, an angiography following the end of surgery, showed a complete obstruction of the abdominal aorta. Subsequent embolectomy through bifemoral arteriotomies was performed and a histologically fresh embolus (6,5 g in weight) was extracted. Neither the pre- and intraoperative echocardiography, nor the preoperative ventriculography showed signs of an intracardiac thrombus. Insufficient anticoagulation and a lack of inhibitor potential were almost excluded. Considering the histological findings, we assumed that the embolus was formed intraoperatively. Without further complications the patient left our department on the 8th postoperative day.

Training-overtraining: influence of a defined increase in training volume vs training intensity on performance, catecholamines and some metabolic parameters in experienced middle- and long-distance runners.

The influence of an increase in training volume (ITV; February 1989) vs intensity (ITI; February 1990) on performance, catecholamines, energy metabolism and serum lipids was examined in two studies on eight, and nine experienced middle- or long-distance runners; seven participated in both studies. During ITV, mean training volume was doubled from 85.9 km.week-1 (pretrial phase) to 174.6 km within 3 weeks. Some 96%-98% of the training was performed at 67 (SD 8)% of maximal performance. During ITI, speed-endurance, high-speed and interval runs increased within 3 weeks from 9 km.week-1 (pretrial phase) to 22.7 km.week-1 and the total training distance from 61.6 to 84.7 km.week-1. The ITV resulted in stagnation of running velocity at 4 mmol lactate concentration and a decrease in total running distance in the increment test. Heart rate, energy metabolic parameters, nocturnal urinary catecholamine excretion, low density, very low density lipoprotein-cholesterol and triglyceride concentrations decreased significantly; the exercise-related catecholamine plasma concentrations increased at an identical exercise intensity. The ITI produced an improvement in running velocity at 4 mmol lactate concentration and in total running distance in the increment test; heart rate, energy metabolic parameters, nocturnal catecholamine excretion, and serum lipids remained nearly constant, and the exercise-related plasma catecholamine concentrations decreased at an identical exercise intensity. The ITV-related changes in metabolism and catecholamines may have indicated an exhaustion syndrome in the majority of the athletes examined but this hypothesis has to be proven by future experimental studies.