Anasthesie, Intensivtherapie, Notfallmedizin最新文献

100 thoracic surgery patients were intubated by means of a left-hand Broncho-Cath PVC Double-Lumen Tube (DLT) and 10 further patients with a right-hand tube. In 76 of the 100 left-hand DLT's safe conventional placement of the tube was successful, oriented exclusively by auscultation findings and positive pressure respiration. However, fibre-optic control showed that only 44 of these tubes were correctly positioned (57.1%). 25 DLT's were too high and 24 too low, whereas the right main bronchus had been intubated in 6 cases. 1 DLT was endoscopically correctly placed although the positioning of the tube had been considered unsatisfactory during conventional examination. Only 2 right-hand DLT's fulfilled the conventional and endoscopic criteria for correct placement of the tube. All malpositionings could be corrected via fibre optics. Recurrent tube dislocations occurred both after lateral repositioning of the patients (so that they were now lying sideways) (27.3% of all patients) and intraoperatively (24.6% of all patients). Besides, intraoperative obstructions of the tube/bronchus lumen due to blood/coagulates (49.1% of the patients) and/or secretion (46.4% of the patients) could be demonstrated and eliminated by endoscopy. Fibre bronchoscopy proved to be a decisive help to reduce the possibilities of complications associated with the use of the Broncho-Cath PVC-DLT in thoracic surgery.

A prospective clinical trial was performed in an operative intensive care unit to examine the incidence and outcome of patients with adult respiratory distress syndrome (ARDS) and the outcome of intensive care patients on mechanical ventilation and the incidence of barotrauma and pulmonary infection. 161 mechanically ventilated patients showed an overall mortality of 19.9%. The mortality rate in the ARDS patients was 11 of 26. Most of these patients with ARDS died from multiorgan failure. Pulmonary infection was the most frequently registrated complication of mechanical ventilation. We conclude from these data that --according to the literature the outcome of surgical ICU patients on mechanical ventilation with and without ARDS is more favourable than that of medical ICU patients; --the interpretation of therapeutic results and of epidemiological data in ARDS patients is possible only by providing exact and detailed criteria; these should include compliance data; --evaluation of present ARDS therapy by comparison to previous data, even when the same criteria are applied, e.g. ECMO-criteria, may fail as the outcome of conventional therapeutic measurements - mechanical ventilation - may have improved. A controlled randomised trial might be more suitable for evaluation of alternative therapy in ARDS.

We investigated in vitro the influence of flunitrazepam concentrations ranged between 10 and 140 ng/ml on immunological parameters by using the rosette-inhibition-test and the lymphocyte-transformation-test. After addition of 30 ng/ml flunitrazepam, which is in accordance with a threshold concentration of 1 mg flunitrazepam after intravenous injection, we saw a significant decrease of the positive cells in the rosette-inhibition-test. In higher concentrations no significant changes could be observed. By the lymphocyte-transformation-test no significant evidence of immunodepression could be demonstrated in concentration usually achieved during anaesthesia or possibly after long term application in intensive care unit, independent of the used mitogenes. Thus, flunitrazepam demonstrates no immunosuppressive effect in concentrations achieved during anaesthesia or in intensive care unit as could be observed by tests of cellular immune competence. However, one has to take into consideration that only parts of the immunesystem could be examined with these tests and in vivo-investigations have to verify these results.

Recovery of motor and mental functions we investigated in 60 patients at different age ranges (Group 1: 20 young patients between 20 and 35 years; Group 2: 20 middle-aged patients between 40 and 55 years) after nitrous oxide-oxygen anaesthesia in combination with enflurane of 1.3 MAC for lumbar nucleotomy. The following parameters were investigated before and up to 80 minutes after anaesthesia: simple and discriminating motor activities, the vigilance and the short and long term memory. In simple motor actions we noticed no significant differences between the three groups. By examination of discriminating motor activity, the functional capacity of Group 3 was significantly reduced in comparison to Groups 1 and 2. Nevertheless the efficiency in Group 2 was also decreased in comparison to Group 1. The postoperative vigilance was especially impaired in the elderly patients. Only 50% of the old patients were able to satisfy the asked requirements 60 minutes after extubation. The vigilance in Group 2 showed a better improvement compared to the elderly patients but was in comparison to the young patients significantly decreased. The long term memory of the old patients pointed out a considerable reduction after this kind of anaesthesia. While no distinct differences could be found between Group 1 and 2 40 minutes after extubation, a significant difference could be observed between Group 1 and 3 even after 60 minutes. The short term memory of the elderly and the middle-aged patients was considerably reduced 60 minutes after extubation.(ABSTRACT TRUNCATED AT 250 WORDS)

The method of extracorporeal CO2 elimination (ECCO2-R) as described by Luiciano Gattinoni and Theodor Kolobow is compared with earlier extra corporeal methods such as extracorporeal membrane oxygenation. The physiological fundamentals of the method, as well as indications and contraindications are explained. - The results of more than 100 patients treated worldwide are discussed together with the present problems of the method. In cases of severe ARDS stage IV, ECCO2-R definitely reduces mortality.

The basics of the acute management of severe diving accidents are outlined by means of 25 patients (20 patients presented with decompression sickness, 5 suffered from a barotrauma of the lungs with consecutive air embolism) treated at our facilities. Contrary to widespread notion, disturbed vital functions have to be treated by intensive care measures, prior to the definite recompression therapy. These are: (1) Treatment of generalized or localized tissue hypoxia secondary to bubble-generation; (2) puncture of a (valvular-) pneumothorax after a pulmonary barotrauma; (3) haemodynamic stabilization when cardiac or spinal shock is present; (4) improvement of the rheological situation. When vital functions are unstable or endangered, these patients must not be transported in a monoplace chamber. This type of chamber does not leave any access to the patient in case of a deteriorating status. Since the severe diving accident mostly turns out to be a problem of intensive care medicine in close combination with the recompression therapy, the continuous integration of the recompression protocol with a comprehensive intensive care therapy is considered crucial.

Prior to cannulation of the dorsalis pedis artery the collateral circulation through the plantar arch should be examined to evaluate the consequence of an occlusion of this artery. Since the performance of the Allen's test is impossible for assessment of the plantar arch, another suitable technique has to be chosen. We selected the photoelectric plethysmography. Toe pulses were recorded with photoelectric plethysmography in 20 neurosurgical patients. The pulse amplitudes were measured before and during successive compression of the dorsalis pedis and the posterior tibial artery. Obvious decrease or absence of the pulse wave during compression of the dorsalis pedis artery is indicating an inadequate collateral circulation and cannulation of this artery seems not to be safe. In our study this occurred in 4 of 32 examined feet (12.5 percent). The photoelectric plethysmography has proved to be a simple and accurate means for assessment of collateral circulation.

The aim of this study was to demonstrate the clear relations between psychological and physiological parameters determined in intensive care patients. For this purpose, heart rate, salivary-cortisol secretion and blood pressure were measured as physiological stress indicators; psychological parameters were covered by examining the patients' way of coping, that is to contrast emotional with rational coping. By comparison, the equivalent parameters were determined in a group of healthy patients. When comparing both groups, we found a higher salivary-cortisol secretion and an increased heart rate in the group of intensive care patients, with the circadian rhythm of the cortisol-secretion remaining almost stable. When examining the patients' group according to the way of coping, we found a higher activation of the sympathetic nervous system in those patients who coped with their situation emotionally than in those who faced their problems rationally. The level of physiological excitation significantly decreased after the patients had been transferred from the ICU to the normal ward. The increased physiological excitation of ICU patients serves to release energies that help them to cope with their situation and can likewise be associated with emotional reactions such as being extremely watchful and in a state of mobilization as well as feeling particularly helpless. The extent of physiological irritation is modified by the way of intrapsychical coping.

Various morphological studies indicate that the microcirculation plays a vital role in the development of ARDS. The significance of the structural and functional integrity of the endothelium for normal pulmonary function is supported by cell biological data. Biochemical studies in bronchoalveolar lavage and blood from ARDS-patients, coupled with studies in animals and endothelial cell cultures support the role of a variety of mediators such as complement factors, products of the coagulation cascade and fibrinolytic system, enzymes, endotoxins and metabolites of arachidonic acid. Of particular importance is the interaction between neutrophilic granulocytes and the endothelium, although the individual components of this interaction and the relationship between cellular and humoral factors remain unclear. Furthermore, the literature shows that it is still uncertain, how the data obtained from studies in vivo and in vitro can be applied to ARDS in humans. Future research in this field must come to terms with the cell biology and pathobiology of the pulmonary endothelium, a hitherto neglected aspect. In addition, studies are essential to investigate possible additive or synergistic effects of mediators on inflammatory and endothelial cells. Finally, the role of more recently discovered inflammatory mediators and modulators in the pathogenesis of ARDS requires clarification.