[Treatment of carbon monoxide poisoning in Germany : A retrospective single center analysis]. / Behandlung von Kohlenmonoxidvergiftungen in Deutschland : Eine retrospektive Single-Center-Analyse.

BACKGROUND: The symptoms of acute carbon monoxide (CO) poisoning are unspecific, ranging from headaches to unconsciousness and death. In addition to acute symptoms, delayed severe neurological sequelae may occur. While a total of 440 deaths by CO poisoning were registered in Germany in 1999, a total of 594 patients died (0.73 per 100,000 inhabitants) in 2014 and in 2015 the number even increased to 648 deaths. A national database on clinical symptoms, course of illness or quality of care concerning CO poisoning does not yet exist. METHODS: The treatment data of patients admitted to the Hyperbaric Emergency Centre Wiesbaden (HEC) from 2013 to 2017 with CO poisoning formed the basis of the study. This was a comparative evaluation of patient demographics, poisoning sources, symptom spectrum, course of treatment and time intervals registered on the preclinical and clinical levels. RESULTS: From 2013 to 2017 a total of 476 patients (282 men and 194 women) with an average non-invasively measured CO-Hb of 15% (Q0.25 = 7.6%, Q0.75 = 22.3%) were treated with hyperbaric oxygen. Heaters (n = 131), charcoal barbecues (n = 93), fires (n = 90), hookahs (n = 78) and combustion engines (n = 37) were the most frequent CO sources identified. Headaches, vertigo, nausea and syncope were the most prevalent symptoms. A median of 91 min (Q0.25 = 53 min; Q0.75 = 147 min) passed between first medical contact and BGA-validated diagnosis. In total, 151 patients were transferred directly to the HEC, whereas 325 patients were secondarily transferred. The delay in this subgroup took 183 min (median Q0.25 = 138 min; Q0.75 = 248 min). After receiving the first hyperbaric treatment, 80% were free of symptoms. Remaining symptoms included headache (10%), fatigue (8%), vertigo (5%) and nausea (3%) and 45 patients terminated further treatment. Of the patients 417 received a second hyperbaric treatment and 370 patients were treated 3 times. After the third treatment, 89% were free of symptoms and 5% still reported headaches, 3% vertigo and 2% fatigue. In total, 6 patients died and 430 patients were symptom-free after treatment. CONCLUSION: Commonly known sources (fire, charcoal grills) aside, many poisonings by smoking a hookah were observed. This study highlights the importance of considering CO poisoning as a differential diagnosis when encountering patients, especially of younger age, with non-specific neurological symptoms, as well as the importance of early initiation of treatment. A direct correlation between CO-Hb values (whether measured noninvasively or by invasive BGA) and the initial symptoms could not be demonstrated. In total, substantial time expired between the diagnosis and start of treatment of patients transported to a primary care hospital compared to those transported directly to the HEC. Although analysis showed adequate treatment with oxygen in the preclinical interval, administration of oxygen during primary hospital stay showed room for improvement. Introducing a national CO poisoning register and uniform treatment guidelines could improve in-house clinical processes. Multicenter studies are needed to close the gaps identified in the quality of care in Germany.

[Diagnosis and treatment of diving accidents. New German guidelines for diving accidents 2014-2017]. / Diagnostik und Behandlung von Tauchunfällen: Neue "Leitlinie Tauchun2014-2017".

In 2015 the German Society for Diving and Hyperbaric Medicine (GTÜM) and the Swiss Underwater and Hyperbaric Medical Society (SUHMS) published the updated guidelines on diving accidents 2014-2017. These multidisciplinary guidelines were developed within a structured consensus process by members of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), the Sports Divers Association (VDST), the Naval Medical Institute (SchiffMedInst), the Social Accident Insurance Institution for the Building Trade (BG BAU), the Association of Hyperbaric Treatment Centers (VDD) and the Society of Occupational and Environmental Medicine (DGAUM). This consensus-based guidelines project (development grade S2k) with a representative group of developers was conducted by the Association of Scientific Medical Societies in Germany. It provides information and instructions according to up to date evidence to all divers and other lay persons for first aid recommendations to physician first responders and emergency physicians as well as paramedics and all physicians at therapeutic hyperbaric chambers for the diagnostics and treatment of diving accidents. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose and the following key action statements: on-site 100% oxygen first aid treatment, still patient positioning and fluid administration are recommended. Hyperbaric oxygen (HBO) recompression remains unchanged the established treatment in severe cases with no therapeutic alternatives. The basic treatment scheme recommended for diving accidents is hyperbaric oxygenation at 280 kPa. For quality management purposes there is a need in the future for a nationwide register of hyperbaric therapy.

[Clinical quality measurement in anaesthesia from routine data. Examples of appendectomy and resection of the colon]. / Anästhesiologische Ergebnisqualität aus Routinedaten. Beispiele der Appendektomie und der Dickdarmresektion.

BACKGROUND: There is no nationwide evaluation of the quality of anaesthesia in Germany. Thus, the aim of this study was to perform analyses using administrative routine data relating to this topic. METHODS: Nationwide hospital claims data of patients insured with the local healthcare insurance fund (AOK) in the year 2007 were analyzed. Indicators from International Statistical Classification of Diseases and Related Health Problems-10, German modification (ICD-10-GM) diagnosis codes for possible anaesthesia complications were selected. RESULTS: Based on the present data, it was not possible to validate indicators which can be applied to detect the quality of anaesthesia. CONCLUSIONS: Administrative data seem to be an appropriated basis for measurement of quality of outcome in anaesthesiology. Further investigations should be performed to include the diagnosis present on admission. Moreover, there is a need for comparing routine data to the standardized data set, known as the "core data set anaesthesia".

[Case report: fatal diving-accident. Or: accident while diving?]. / Tödlicher Tauchunfall. Oder: Unfall während des Tauchens mit Todesfolge?

This example of a fatal diving accident shows how challenging such cases can be in pre-hospital and clinical care. There is no common mechanism in diving fatalities and more than one group of disorders coming along with decompression sickness. Diving medicine is not an element of medical education, which results in insecurity and hampers adequate therapy of diving incidents. This is aggravated by an insufficient availability of hyperbaric chambers in Germany.

Safety of glucose-containing solutions during accidental hyperinfusion in piglets.

BACKGROUND: Errors in fluid management can lead to significant morbidity in children. We conducted an experimental animal study to determine the margin of safety in accidental hyperinfusion of different glucose and electrolyte containing solutions. METHODS: Fifteen piglets [bodyweight 12.1 (sd 2.0) kg] were randomly assigned to receive either 100 ml kg⁻¹ of balanced electrolyte solution with glucose 1% (BS-G1), hypotonic electrolyte solution with glucose 5% (HE-G5), or glucose 40% solution (G40) over 1 h. Blood electrolytes, glucose, and osmolality and intracranial pressure (ICP) were measured before, during, and after fluid administration. RESULTS: Hyperinfusion of BS-G1 led to moderate hyperglycaemia [baseline 3.4 (sd 1.3) mmol litre⁻¹, study end 12.6 (1.8) mmol litre⁻¹], but no other relevant pathophysiological alterations. Hyperinfusion of HE-G5 produced marked hyperglycaemia [baseline 3.9 (1.2) mmol litre⁻¹, study end 48.6 (4.3) mmol litre⁻¹, P < 0.05] and hyponatraemia [baseline 136.4 (1.3) mmol litre(-1), study end 119.6 (2.1) mmol litre⁻¹, P < 0.05], whereas osmolality remained stable during the course of the study. Hyperinfusion of G40 induced acute hyperglycaemic/hyperosmolar decompensation with an extreme decrease in serum electrolytes [e.g. sodium baseline 138 (1.1) mmol litre⁻¹, 30 min 87.8 (6.4) mmol litre⁻¹, P < 0.01], leading to cardiac arrest after infusion of 50-75 ml kg⁻¹. ICP remained within a physiological range in all groups. CONCLUSIONS: In an animal model of accidental hyperinfusion, BS-G1 showed the widest margin of safety and can therefore be expected to enhance patient safety in perioperative fluid management in children; HE-G5 proved significantly less safe; and G40 was found to be outright hazardous.

Mycophenolic acid inhibits PMA-induced activation of the neutrophil respiratory burst.

Mycophenolate mofetil (MMF) is commonly used in immunosuppressive regimens for solid organ transplantation. There is evidence that the hydrolyzed active agent mycophenolic acid (MPA) causes the endothelial depletion of intracellular guanosine 5'-triphosphate (GTP) levels. This depletion may cause inactivation of nicotinamide adenine dinucleotide phosphate oxidase. The purpose of the present study was to examine the impact of MPA on the neutrophil respiratory burst and phagocytic activity using flow cytometry. In whole blood of healthy volunteers, 2 different doses of MPA (1 and 10 mumol/L) did not alter hydrogen peroxide production of neutrophils induced by receptor-dependent activators. In contrast, MPA inhibits the protein kinase C (PKC)-mediated hydrogen peroxide production by phorbol 12-myristate 13-acetate (PMA) in a time-dependent manner (negative: 21.17 +/- 1.64 vs. 120 min: 14.46 +/- 1.28 mean fluorescence intensity, incubation with 1 mumol/L MPA). In conclusion, our results corroborated that the neutrophil respiratory burst activity of healthy volunteers, induced by either formyl-methionyl-leucylphenylalanine (fMLP), priming with tumor necrosis factor alpha followed by fMLP or Escherichia coli and neutrophil phagocytic capacity, were not significantly affected after MPA treatment. We also could demonstrate that the hydrogen peroxide production of neutrophils decreased in response to the PKC activator PMA in a time-dependent manner.

[Assessment of anesthesia methods in ophthalmologic surgery by patients, surgeons, and anesthesiologists]. / Bewertung von Narkoseverfahren in der Ophthalmochirurgie durch Patienten, Operateur und Anästhesisten.

BACKGROUND: The purpose of this study was to evaluate anesthesia methods in ophthalmic surgery in elderly people assessed by patients, surgeon, and anesthesiologist using subjective rating scales. PATIENTS AND METHODS: In a prospective, randomized study we compared in 52 (26 vs 26) elderly patients (ASA II and III, mean age 78.7+/-8.6 years) undergoing a cataract operation the satisfaction perceived by patients, surgeons, and anesthesiologists in relation to anesthesia methods [intravenous anesthesia (TIVA) vs balanced anesthesia (BA)] based on a score from 1=best to 6=worse. RESULTS: Patient satisfaction was better in the TIVA group (1.65) than in the patients treated with BA (2.57), p<0.001. Surgeons perceived no difference (BA 1.15/TIVA 1.07). Anesthesiologists preferred TIVA (TIVA 1.5/BA 3.23), p<0.001. CONCLUSION: In this study patients and anesthesiologists preferred TIVA. There was no difference between TIVA and BA as seen by the surgeon.

Reduction of catheter-related infections in neutropenic patients: a prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter.

Antiseptic coating of intravascular catheters may be an effective means of decreasing catheter-related colonization and subsequent infection. The purpose of this study was to assess the efficacy of chlorhexidine and silver sulfadiazine (CH-SS)-impregnated central venous catheters (CVCs) to prevent catheter-related colonization and infection in patients with hematological malignancies who were subjected to intensive chemotherapy and suffered from severe and sustained neutropenia. Proven CVC-related bloodstream infection (BSI) was defined as the isolation of the same species from peripheral blood culture and CVC tip (Maki technique). This randomized, prospective clinical trial was carried out in 106 patients and compared catheter-related colonization and BSI using a CH-SS-impregnated CVC (n=51) to a control arm using a standard uncoated triple-lumen CVC (n=55). Patients were treated for acute leukemia (n=89), non-Hodgkin's lymphoma (n=10), and multiple myeloma (n=7). Study groups were balanced regarding to age, sex, underlying diseases, insertion site, and duration of neutropenia. The CVCs were in situ a mean of 14.3+/-8.2 days (mean+/-SD) in the study group versus 16.6+/-9.7 days in the control arm. Catheter-related colonization was observed less frequently in the study group (five vs nine patients; p=0.035). CVC-related BSI were significantly less frequent in the study group (one vs eight patients; p=0.02). In summary, in patients with severe neutropenia, CH-SS-impregnated CVCs yield a significant antibacterial effect resulting in a significantly lower rate of catheter-related colonization as well as CVC-related BSI.

[Excessive blood loss after abdominal hysterectomy -- use of recombinant factor VIIa]. / Massive Blutung nach Hysterektomie -- Einsatz von rekombinantem Faktor VIIa.

MEDICAL HISTORY: A 38-yr-old woman suffered from excessive blood loss after elective removal of the uterus because of a leiomyoma. The surgical attempt to stop the bleeding failed. The laboratory evaluation before surgery showed normal coagulation parameters (aPTT 23.4 sec, TPZ > 100 %, platelet count 267 000/microl). DEVELOPMENT: Despite treatment with the plasminogen activator inhibitor Tranexamic Acid (2 x 500 mg) and 10 units of concentrated platelets as well as 31 units of fresh frozen plasma and 31 units of red blood cell concentrates the bleeding continued. Reaching an cumulative blood loss of 15 000 ml the patient developed ventricular fibrillation necessitating cardiac resuscitation including defibrillation and application of epinephrine 7 mg. At this point systolic blood pressure decreased from 90 to 70 mm Hg, the core temperature was 31,9 degrees C. After successful resuscitation (systolic blood-pressure 90 mm Hg after 15 min) the bleeding started again with a blood loss of 2000 ml requiring 3 units of fresh frozen plasma and 3 red cell concentrates Use of recombinant activated Factor VII (r.FVIIa): 6 mg (300 KiU) r.FVIIa have been applied (92 microg/kgKG [4.6 KiE/kg]). Within 10 minutes the bleeding stopped. More transfusions were not necessary. The patient left the intensive care unit 8 days after the operation without neurological deficit. CONCLUSION: The use of recombinant Factor VIIa may stop excessive haemorrhage, even if the cause is unknown.

Impact of tobacco smoking on platelet function in apheresis products in vitro.

BACKGROUND AND OBJECTIVES: The aim of this study was to analyse the platelet function, over a 5-day time-period, of apheresis-derived platelet concentrates obtained from smokers and non-smokers. MATERIALS AND METHODS: Smoker and non-smoker plateletpheresis products were investigated on days 1, 3 and 5 of storage. Receptor expression (as evaluated by flow cytometry) and the platelet aggregation response were measured. RESULTS: There was only a slight loss of platelet function in apheresis products from smokers compared to non-smokers. CONCLUSIONS: Smoking does not significantly change the quality of platelet preparations. The current practice, of not to exclude smokers from platelet donation, can be continued.

Differential platelet receptor expression following hydroxyethyl starch infusion in thrombocytopaenic orthotopic liver transplantation recipients.

BACKGROUND AND OBJECTIVE: Platelet function abnormalities influence the haemostatic defect in patients with liver failure. Patients after orthotopic liver transplantation present thrombocytopaenia associated with bleeding problems, which may be aggravated by the interaction of hydroxyethyl starches with platelets. METHODS: From 12 patients after liver transplantation venous blood samples (3 mL) were taken before, 20 and 120 min after infusion of hydroxyethyl starch of medium molecular weight (200 kDa/0.5) 6% 10 mL kg(-1) over a period of 30 min. Surface expression of glycoprotein IIb/IIIa and P-selectin were quantified by flow cytometry as well as the percentage of platelet-leucocyte complexes. RESULTS: A significant decrease of P-selectin expression following administration of hydroxyethyl starch after 120 min (89.1 +/- 4.2%, P = 0.029) and a corresponding significant reduction in the formation of platelet-monocyte complexes (81.1 +/- 7.8%, P = 0.001) were observed. There was no alteration in the glycoprotein IIb/IIIa expression after hydroxyethyl starch infusion. CONCLUSIONS: Infusion of hydroxyethyl starch 200 kDa/0.5 in clinically relevant doses does not alter glycoprotein IIb/IIIa expression in thrombocytopaenic patients with pre-existing platelet dysfunction after orthotopic liver transplantation. Accordingly, infusion of hydroxyethyl starch may have a beneficial effect on microvascular graft perfusion through the resulting haemodilution and reduced P-selectin expression with subsequent reduced leucocyte-platelet complexes and endothelial adhesion.

Lack of toxic side effects in neutrophils following hyperbaric oxygen.

Conflicting data have been reported about the impact of repeated HBO2 exposure on the production of superoxide radicals during the neutrophil respiratory burst (RB) and on phagocytosis. In this study we wanted to see if exposure to hyperoxia would affect human neutrophil RB and phagocytosis. Short- and long-term effects after single or repetitive HBO2 exposure of 2.5 atmospheres absolute over a period of 90 min were studied in 40 healthy volunteers. The RB was measured by the intracellular oxidation of dihydrorhodamine after induction by Escherichia coli (E. coli), or priming with recombinant tumour necrosis factor alpha (TNF-alpha), followed by N-formyl-methionyl-leucyl-phenylalanine (fMLP) stimulation. The phagocytic activity was determined by the intake of FITC-labelled opsonized E. coli. No differences could be found between RB and phagocytic activity before and after HBO2 therapy, regardless of short- or long-term exposure. These findings indicate that exposure to hyperoxia does not impair these two important functions of the human innate host defense.

[Effects of Repetitive Exposure to Hyperbaric Oxygen (HBO) on Leukocyte Function]. / Einfluss der hyperbaren Sauerstofftherapie auf die Funktion humaner Leukozyten.

OBJECTIVE: Despite favourable clinical data on the successful use of hyperbaric oxygen (HBO), only limited investigations have been carried out to date regarding the influence of hyperoxia on leukocyte function. In a murine model, CD4+ T-cell population remained unchanged after repeated HBO exposure, however CD8+ cells were found to be increased. The aim of this study was to investigate whether repetitive exposure to hyperoxia would affect human monocyte and lymphocyte function. METHODS: Methods: After Ethics Committee approval the effects of elevated partial oxygen pressure were studied in the course of a ten-day HBO therapy (2.5 atmospheres absolute over a daily period of 90 min). Monocytes and lymphocytes of 30 patients with acute hearing loss were determined by flow cytometry before, throughout and after HBO therapy using monoclonal antibodies to CD3, CD4, CD8, CD14, CD25, CD45 and HLA-DR. Statistical analysis was made by ANOVA (analysis of variance). RESULTS: The relative percentage of CD3+, CD4+, CD8+, CD25+, CD14+, and HLA-DR+ cells remained unchanged during the course of and after HBO therapy. CONCLUSIONS: We conclude that repetitive exposure to hyperoxia does not influence human monocyte and lymphocyte functions in contrast to experimental data.

Effects of colloidal resuscitation fluids on the neutrophil respiratory burst.

BACKGROUND: Experimental studies have revealed that gelatin and HES produce increased neutrophil respiratory burst activity. It was investigated whether 3-percent gelatin (MW 35,000) and three types of 6-percent HES (MW 70,000; degree of substitution, 0.5; 200,000/0.5; 450,000/0.7) preparations can influence superoxide anion production during respiratory burst under clinical conditions. STUDY DESIGN AND METHODS: Blood samples were obtained from 40 patients before and 1 hour after the infusion, before anesthesia and surgical treatment. After stimulation with bacteria (Escherichia coli), the respiratory burst was measured by oxidation of nonfluorescent dihydrorhodamine 123 to the fluorescent rhodamine 123 by the use of flow cytometry. RESULTS: Respiratory burst activity decreased significantly (p = 0.004) from the baseline (60.0 +/- 6.5%) to 1 hour after the administration of the low-molecular-weight HES preparation (55.0 +/- 6.8%). No significant differences in respiratory burst activity could be found after the administration of gelatin or medium-molecular-weight or high- molecular-weight HES solution. CONCLUSION: The investigated administration of gelatin and medium- and high-molecular-weight HES preparations did not influence respiratory burst activity under clinical conditions. However, the neutrophil respiratory burst was impaired after the administration of low-molecular-weight HES. Neutrophil respiratory burst activity may vary according to the type of colloidal plasma substitutes administered.

[A new microglossary for biopsy pathology]. / Ein neues Mikroglossar für die Biopsiepathologie.

The documentation of surgical biopsy reports involves the ordering, processing and retrieval of their informative content. Large amounts of data require computerization, which in turn demands a hierarchical code for optimal exploitation. The best coded nomenclature at present is the Systematized Nomenclature of Medicine (SNOMED), which was developed from the Systematized Nomenclature of Pathology (1965) after a 10-year trial and systematic evaluation. This system is based on the principle of facet classification and was conceived especially for computerized data processing. A microglossary is a strict subset of diagnostic terms for one particular field, which has been chosen from the entire set of medical terms available. The microglossary for computerized processing of biopsy data, which is currently being developed at the Department of Pathology of Graz University, is presented in this paper.