Influence of positive end-expiratory pressure on right and left ventricular performance assessed by Doppler two-dimensional echocardiography.

The advent of modern Doppler two-dimensional ultrasound technology has overcome the need of invasive measurements of several important cardiac parameters. It allows estimation of preload, contractility, and afterload. Positive end-expiratory pressure (PEEP) is associated with a reduction in cardiac output. The responsible mechanisms are controversial. To evaluate the cardiovascular responses to PEEP, we employed different Doppler hemodynamic indices for the first time, combined with conventional two-dimensional echocardiography. Twenty-one healthy, young, and unsedated volunteers were admitted to the study. Under spontaneous respiration, PEEP level was increased stepwise (0, 5, 7.5, 10, 12.5 cm H2O). At each PEEP level, the following right and left ventricular parameters were assessed with Doppler two-dimensional echocardiography: two-dimensional variables: end-diastolic volume indices (EDVI), ejection fraction (EF), and left ventricular afterload-LaPlace relation (combined with cuff systolic pressure); Doppler variables: cardiac index (CI) (combined with two-dimensional measure of valve area), maximum velocity (Vmax), time velocity integral (TVI), acceleration time (AT), deceleration time (DT), deceleration rate (DR), ratio of early to atrial peak (E/A), ratio of isovolumic contraction time to ejection time (IVCT/ET), and maximum blood acceleration (dv/dt) in aorta and main pulmonary artery. Increasing PEEP resulted in a proportional decrease in biventricular EDVI. Moreover, PEEP application is also causing a drop of CI, which is determined from a decrease in Vmax and TVI, while EF, IVCT/ET, dv/dt, Doppler trans-atrioventricular parameters, and afterload stay in normal ranges. Employing Doppler hemodynamic indices for the first time in this study setting clearly supports data that the drop in EDVI and CI during PEEP is caused by reduction in ventricular filling due to decreased venous return. Using the Doppler parameters IVCT/ET and dv/dt, changes in myocardial contractility, as well as changes in afterload (LaPlace relation) can be ruled out.

[The value of thoracic and abdominal computed tomography with intensive care patients]. / Wertigkeit der thorakalen und abdominellen Computertomographie bei Intensivpatienten.

We evaluated in a retrospective study the therapeutic relevance of thoracic and abdominal CT examinations on 157 intensive-care patients with previously inconclusive radiological examinations. Indications for CT were sepsis (n = 105), rarely a decrease in haematocrit (n = 30), multiorgan failure (n = 16) or suspected aortic aneurysm (n = 6). In 83.4% of examinations CT detected clinically relevant features, in 44.3% positive CT studies resulted in invasive therapy within 72 hours and therefore changed patient management decisively. Our results justify the use of CT, enabling if necessary an on-target intervention, the advantages outweighing the inherent risks if the patient is exposed to the relatively small risk of being temporarily removed from the intensive-care unit for immediate invasive treatment.

Prehospital emergency medicine services in Europe: structure and equipment.

In order to get an update on prehospital emergency medicine practice all over Europe we submitted questionnaires with a total of 61 questions concerning prehospital emergency medicine in Europe, to 123 European members of the World Association of Emergency and Disaster Medicine (WAEDM). Sixty (49%) questionnaires were returned. One up to seven questionnaires from 22 European countries were analysed: 37 (62%) from urban and 23 (38%) suburban or rural areas; 12 being from former Eastern European countries. Sixteen of the questions--those concerning rescue systems and equipment--are analysed and presented in this paper. A fleet of ambulance cars staffed with paramedics/nurses based at the emergency organization is the most frequently used system in 59% (10/17) of the countries. The same percentage claims to have a ground-based coverage of its area of 80-100%. Airborne coverage between 80-100% and below 60% of the areas is given in the same percentage of 35% (6/17). Physicians are frequently involved in prehospital emergency care in the Eastern European Countries, France, Germany, Italy, Belgium and Turkey, rarely in Switzerland, Denmark, the United Kingdom, Greece, Ireland and Finland, never in the Netherlands and Sweden. In more than 50%, a combination of national, regional and local organizations provide emergency care, which results in large differences of standards. We discovered remarkable differences which could be overcome by enhanced co-ordination and information exchange provided by the European Society for Emergency Medicine, WAEDM, the European Red Cross or the European Academy of Anaesthesiologists.

[Concomitant perforated ulcer and acute myocardial infarct--a diagnostic challenge in emergency medicine]. / Gleichzeitiges Auftreten von Ulkusperforation und akutem Myokardinfarkt--eine diagnostische Herausforderung in der Notfallmedizin.

Clinical differentiation between acute myocardial infarction and peptic ulcer perforation may sometimes be difficult. We report on a sixty-five year-old patient who presented at the Emergency Department with upper abdominal pain and local tenderness suggestive of acute perforation of a gastric ulcer. However, the initial electrocardiogram (ECG) showed acute inferior wall myocardial infarction. Although abdominal pain is a major symptom of acute inferior wall myocardial infarction the history of gastritis and abdominal findings on admission of our patient required further exploration. The first plain abdominal radiograph was inconspicuous, therefore we performed a gastroscopy, which showed a prepyloric gastric ulcer. The second plain abdominal radiograph revealed air in the peritoneal cavity as sign of perforation. Echocardiography, ECG and the increase of heart enzymes confirmed acute inferior wall infarction. After successful surgical treatment of the perforated ulcer the patient recovered and progressed satisfactorily at the intensive care unit. He was discharged after three weeks and remains in good health. This case shows that rapid diagnosis and good interdisciplinary therapeutic management prevented a fatal outcome of acute myocardial infarction and concomitant gastric ulcer perforation in an elderly patient.

Postoperative hemodynamic and thermoregulatory consequences of intraoperative core hypothermia.

STUDY OBJECTIVE: To evaluate the postoperative hemodynamic and thermoregulatory consequences of intraoperative core hypothermia. DESIGN: Prospective, randomized clinical trial. SETTING: Operating room and postanesthesia care unit of a university hospital. PATIENTS: 74 healthy, ASA status I, II, and III patients (average age 58 yrs) undergoing elective colon surgery. INTERVENTIONS: Patients were randomly assigned to be kept normothermic or approximately 2.5 degrees C hypothermic during surgery. Anesthesia was maintained with isoflurane, nitrous oxide, and fentanyl. Postoperatively, surgical pain was treated with patient-controlled analgesia (PCA) opioid. MEASUREMENTS AND MAIN RESULTS: An observer blinded to group assignment and core temperatures evaluated shivering, thermal comfort, surgical pain, heart rates (HRs), and blood pressures (BPs) during the first six postoperative hours. Morphometric characteristics, oxygen saturation, fluid balance, PCA-administered opioid, and visual analog pain scores were comparable in the two groups. Hypothermic patients felt uncomfortably cold during recovery, and their postoperative core temperatures remained significantly less than in the normothermic patients for more than four hours. Peripheral vasoconstriction and shivering were common in the hypothermic patients but rare in those kept normothermic. HRs and BPs were comparable in the two groups. CONCLUSIONS: These data confirm that the effects of intraoperative hypothermia on postoperative HR and BP are modest in relatively young, generally healthy patients. In contrast, intraoperative hypothermia caused substantial postoperative thermal discomfort, and full recovery from hypothermia required many hours. Delayed return to care normothermia apparently resulted largely from postoperative thermoregulatory impairment.

[Coverage of pressure sores with free flaps]. / Dekubitalulkusdeckung durch mikrochirurgische Lappenplastiken.

INTRODUCTION: The coverage of recurrent pressure sores with unstable scar in the surrounding tissue is still an unsolved problem in the literature. Local and regional transfer of tissue often does not meet the requirements of the tissue deficit. Especially in recurrent pressure sores, the adjacent skin has already been consumed due to multiple surgeries. As a good alternative, the microsurgical transfer of flaps offers viable tissue to cover even large pressure sores. METHODS: We performed a total of six free flaps in five patients who suffered from intractable pressure sores in the hip region. The age of the patients was between 41 and 63 years. The defect size varied between 6 x 6 cm and 25 x 30 cm. Two combined myocutaneous scapula-latissimus dorsi, two myocutaneous latissimus dorsi, one anteromedial thigh, and one rectus femoris flap were used to cover the defects. RESULTS: The average follow-up time was 29 months. Flaps provided stable coverage in four of five patients at 12-month follow-up. There was one subtotal flap necrosis that was subsequently treated with split-thickness skin grafting. CONCLUSION: In this series of five patients with six free flaps, we were able to show that the microsurgical transfer of tissue is a valuable option in the treatment of difficult pressure sores. Even in older and debilitated patients, this method is a good alternative to conventional local flaps.

[Endoscopically-assisted latissimus dorsi muscle harvest in a young child]. / Endoskopisch-assistierte Hebung der M. latissimus dorsi-Lappenplastik beim Kleinkind.

Free tissue transplantation is nowadays regarded as an established method in reconstructive surgery - even in infants. Adequate diameters of vessels for microsurgical anastomosis have been shown in numerous studies. Especially the latissimus dorsi muscle seems to be ideal as a standard flap in this age group. The main disadvantage of this muscle flap lies in its donor-site morbidity with the risk of scar contracture and limitation of shoulder movement. A possible solution to this problem is the endoscopically-assisted harvest of this muscle. A three-year old boy sustained a subtotal amputation of his right heel with consecutive necrosis of soft-tissue. After debridement, a latissimus dorsi-muscle flap was transplanted to cover the defect. The flap was harvested endoscopically-assisted through a single, 2 cm long incision in the left axilla. Healing of the flap was uneventful. At 30 months follow-up the patient showed stable conditions at the right heel without limitations of movement and a hardly visible scar in the left axilla without any noticable growing impairment. Free microvascular muscle-flaps are the treatment of choice in infants with extensive traumatic defects. With the use of minimally invasive operation techniques it is possible to significantly reduce donor-site morbidity and increase therapeutic success even in the youngest patients.

[Report of the consensus workshop on microsurgical training at the 32nd annual meeting of the german-speaking group for microsurgery of the peripheral nerves and vessels in Basel 2010]. / Bericht zum Workshop und Consensusmeeting zur Mikrochirurgischen Ausbildung an der 32ten Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) 2010 in Basel.

After the foundation of a trinational task force to develop quality criteria for a training and educational system in microsurgery at the annual conference of the German-speaking group for microsurgery of the nerves and vessels (DAM) in Erlangen 2009, at the 2010 conference in Basel, a modular educational system was approved and criteria for a basic course were discussed. Before the next annual conference in 2011 these aspects should be clarified and defined in a spring meet-ing.

[Microsurgical training - report on the consensus workshop of the 31st annual meeting of the German-language group for microsurgery of the peripheral nerves and vessels 2009 in Erlangen]. / Mikrochirurgische Aus- und Weiterbildung - Bericht des Consensus-Workshops im Rahmen der 31. Jahrestagung der Deutschsprachigen Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefässe 2009 in Erlangen.

Based on the increasing importance of microsurgical procedures in the field of plastic and hand surgery, as well as in other related fields, a consensus workshop was held during the 31st annual meeting of the German-language working group for microsurgery of the nerves and vessels (DAM). The current state of microsurgical training and possible ways of optimisation were discussed. Furthermore, a trinational task force was established in order to develop quality criteria for a future certification of microsurgical training centres under the auspices of the DAM.

Comparison of the effectiveness of gene therapy with vascular endothelial growth factor or shock wave therapy to reduce ischaemic necrosis in an epigastric skin flap model in rats.

The effect of gene therapy with adenovirus-mediated (Ad) vascular endothelial growth factor (VEGF) was compared to that of shock wave (SW) therapy on skin flap survival in a rat model, using the epigastric skin flap, based solely on the right inferior epigastric vessels. Thirty male Sprague-Dawley rats were randomly divided into three groups (SW-group, Ad-VEGF-group, and Control-group) of 10 rats each. Immediately after surgery, the SW-group was administered 2500 impulses at 0.15mJ/mm(2), in the Ad-VEGF-group injections were made to the subdermal space whereas the Control-group received no treatment. Flap viability was evaluated on day 7 after the operation. Standardised digital pictures of the flaps were taken and transferred to the computer, and necrotic zones relative to total flap surface area were measured and expressed as percentages. Overall, significantly smaller areas of necrotic zones were noted in the SW-group and the Ad-VEGF-group compared with the Control-group (SW-group: median 2.23% (range: 0-5.1) versus Control-group: median 17.4% (range: 11.8-22.8) (p<0.05); Ad-VEGF-group: median 9.25% (range: 7.6-11.9) versus Control-group: median 17.4% (range: 11.8-22.8) (p<0.05)). Furthermore, in the SW-group, areas of necrotic zones were significantly smaller than in Ad-VEGF-group (SW-group: median 2.23% (range: 0-5.1) versus Ad-VEGF-group: median 9.25% (range: 7.6-11.9) (p<0.05)). We conclude that treatment with SW enhances epigastric skin flap survival significantly more than Ad-VEGF treatment and also represents a feasible and cost effective technique to improve blood supply in ischaemic tissue.

A new variant of mastocytosis: report of three cases clinicopathologically mimicking histiocytic and vasculitic disorders.

Cutaneous mastocytosis (CM) or urticaria pigmentosa is characterized by abnormal proliferation and accumulation of mast cells. Clinically, CM usually presents as symmetrically distributed red-brown macules or papules that develop weals, erythema and often pruritus on stroking (Darier's sign). The histological hallmark of the disease is an increase in oval to spindle-shaped mast cells in the dermis located around blood vessels and skin appendages. We describe three patients with a new clinicopathological type of CM, which clinically mimics a histiocytic disorder and histologically mimics leucocytoclastic vasculitis (LV). Three infants (two boys and one girl) developed generalized reddish-yellow-brown macules of 3-10 cm with occasional scaling and crusting on the trunk and extremities without further symptoms or organ involvement except variable itching. Histology revealed diffuse and dense dermal infiltrates of eosinophils, neutrophils and nuclear debris with perivascular accentuation, imitating LV. This infiltrate masked large epithelioid cells, positive for macrophage markers, which by special histochemical stains for metachromatic granules turned out to be mast cells. This is the first report of this new variant of CM, which may cause considerable diagnostic difficulties both clinically and histopathologically.

Extracorporal shock wave may enhance skin flap survival in an animal model.

Several methods have been used in an attempt to increase blood supply and tissue perfusion in ischemic tissues. The authors investigated the effect of extracorporal shock wave (ESW) treatment on compromised skin flaps. For this purpose, the epigastric skin flap model in rats, based solely on the right inferior epigastric vessels was used. Twenty male Sprague-Dawley rats were divided into two groups (ESW-group, Control group) of 10 rats each. The ESW-group was administered 2500 impulses at 0.15 mJ/mm(2) immediately after surgery, whereas, the control group received no treatment. Flap viability was evaluated on day 7 after the operation. Standardised digital pictures of the flaps were taken and transferred to the computer, and necrotic zones relative to total flap surface area were measured and expressed as percentages. Overall, there was a significant reduction in the surface area of the necrotic zones of the flaps in the ESW group compared to the control group (ESW group: 2.2+/-1.9% versus control: 17.4+/-4.4% (p < 0.01). In this study, the authors demonstrated that treatment with ESW enhanced epigastric skin flap survival, as confirmed by the significant reduction of necrotic flap zones. ESW treatment seems to represent a feasible and cost effective method to improve blood supply in ischemic tissue.

Bed-side infection screening of ICU patients using gram stained smears.

Bronchial, abdominal or pleural aspirates (n = 364) collected from 165 ICU patients were both cultivated and evaluated microscopically using Gram stained smears, and the results were compared: 331 aspirates (91%) were classified correctly. Fungi were confirmed in all cases (21/21, sensitivity and specificity 100%). Gram-negative findings (n = 66) had a specificity of 97% (2/66 reclassified as Gram positive by culture): 21/85 Gram-negative cultures were overlooked by the Gram method (sensitivity 75%). Of 106 Gram-positive results, culture was negative in 10/106 and 7/106 were diagnosed as Gram-negative (specificity 84%). Sensitivity was 98% (only 2/91 not detected by the Gram technique). In 171 cases, no organisms were seen; specificity was 92% (Gram-negative bacteria cultivated in 14/171). Sensitivity was 94% (10/167 misdiagnosed as Gram-positive). Gram diagnoses were available 63 +/- 14 h prior to the culture test results. Treatment decisions based upon the Gram results were correct in 90% (326/364). It is concluded that Gram stained smears are a valuable tool for bed-side infection screening in ICU patients.

Transoesophageal echocardiographic assessment of mitral and aortic valve function during cardiopulmonary resuscitation.

There has been controversy over whether forward blood flow during closed-chest cardiopulmonary resuscitation (CPR) is generated by a general increase in intrathoracic pressure (chest-pump theory) or by creating atrioventricular gradients that close the mitral valve and open the aortic valve during thoracic compression (cardiac pump theory). The crucial issue is the position of the mitral valve during the downstroke of chest movement. Questions remain over the actual mechanics of mitral and aortic valve function. This report describes an intraoperative cardiac arrest followed by CPR during which routinely instituted two-dimensional transoesophageal Doppler echocardiography enabled study of the motion of the valves of the left heart and the transmitral blood flow.

Pharmacodynamics, pharmacokinetics, and intubation conditions after priming with three different doses of vecuronium.

The effects of three different priming doses of vecuronium on pharmacokinetics, pharmacodynamics, and endotracheal intubation conditions were investigated. Forty-two patients were studied in two parts. In each part, 21 patients were allocated into three groups (n = 7/group) receiving 10, 15, or 20 micrograms/kg vecuronium as a priming dose, followed by a 50- micrograms/kg intubating dose 6 min later. In Part I, Train-of-Four (TOF) ratios and serum concentrations after priming were measured every minute up to the sixth minute. Onset time [from injection of the intubating dose to maximum depression of the first twitch (T1)], clinical duration (T1 return from maximum block to 25% of control), and recovery index (T1 recovery from 25% to 75% of control) were calculated and serum concentrations were determined up to 6 h after injection of the intubating dose. In Part II, the intubating dose was injected 4 min after priming, onset time was determined, and intubation conditions were scored. TOF ratio was significantly lower after priming with 20 micrograms/kg at the fifth and sixth minutes (0.59 +/- 0.29 and 0.56 +/- 0.32; mean +/- 1 SD) compared with the first minute (0.95 +/- 0.1). Recovery index was significantly increased after priming with 20 micrograms/kg (13.2 +/- 6.6 min, P < 0.05) compared with 10 micrograms/kg (9.2 +/- 4.8 min) and 15 micrograms/kg (6.7 +/- 1.5 min). Between groups no differences in onset time, clinical duration, and pharmacokinetic variables were found. In Part II, onset time and intubating scores showed no significant differences between the groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Behavior of hemodynamics and catecholamines in patients undergoing excision of pheochromocytoma]. / Verhalten von Hämodynamik und Katecholaminen bei Phäochromozytomexstirpationen.

In order to investigate the relation between catecholamine output and haemodynamics, 13 patients aged between 16 and 62 years, who were operated for active pheochromocytoma, were investigated. Patients had general anesthesia employing muscle relaxants, artificial ventilation with nitrous oxide/oxygen and predominantly intravenous analgetics. Before surgery 9 patients had increased norepinephrine blood levels and only 6 patients increased epinephrine levels. Intraoperatively an increase in pulse rate and blood pressure was found, although alpha- and beta-blockers were employed. At this time there was a massively increased level of epinephrine and norepinephrine, both however decreasing at the conclusion of surgery going along with a normalisation of cardial parameters. Comparing norepinephrine to cardiovascular parameters, the best correlation could be found between norepinephrine and mean arterial pressure, followed by total catecholamines and mean arterial pressure. Heart rate showed a smaller correlation coefficient to norepinephrine, followed by norepinephrine and total peripheral resistance. It is concluded that invasive haemodynamic monitoring helps to differentiate between haemodynamic disturbances and to improve the cardiovascular management, although direct relations between blood catecholamine levels and circular vascular parameters could not be found.

The threshold for thermoregulatory vasoconstriction during nitrous oxide/isoflurane anesthesia is lower in elderly than in young patients.

BACKGROUND: Thermoregulatory vasoconstriction minimizes further core hypothermia during anesthesia. Elderly patients become more hypothermic during surgery than do younger patients, and take longer to rewarm postoperatively. These data indicate that perianesthetic thermoregulatory responses may be especially impaired in the elderly. Accordingly, the authors tested the hypothesis that the thermoregulatory threshold for vasoconstriction during nitrous oxide/isoflurane anesthesia is reduced more in elderly than in young patients. METHODS: The authors studied 12 young patients aged 30-50 yr and 12 elderly patients aged 60-80 yr. All were undergoing major orthopedic or open abdominal surgery. Anesthesia was induced with thiopental and fentanyl, and maintained only with nitrous oxide (70%) and isoflurane (0.6-0.8%). Core temperature was measured in the distal esophagus. Fingertip vasoconstriction was evaluated using forearm minus fingertip, skin-temperature gradients. A gradient of 4 degrees C identified significant vasoconstriction, and the core temperature triggering vasoconstriction identified the thermoregulatory threshold. RESULTS: The vasoconstriction threshold was significantly less in the elderly patients (33.9 +/- 0.6 degree C) than in the younger ones (35.1 +/- 0.3 degrees C) (P < 0.01). The gender distribution, weight, and height of the elderly and young patients did not differ significantly. The end-tidal isoflurane concentration at the time of vasoconstriction did not differ significantly in the two groups. CONCLUSIONS: These data indicate that thermoregulatory responses in the elderly are initiated at temperatures approximately 1.2 degrees C less than that in younger patients. Thus, it is likely that elderly surgical patients become more hypothermic than do younger patients, at least in part, because they fail to trigger protective thermoregulatory responses.

Catheter-induced thrombus in the superior vena cava diagnosed by transesophageal echocardiography.

BACKGROUND: To present the role of transesophageal echocardiography (TEE) in the diagnosis and management of catheter-related superior vena cava thrombosis. CASE HISTORY: A 42-year-old woman with severe Crohn's disease presented with septic shock and pulmonary embolism three weeks after emergency laparotomy and ileocolic resection for small-bowel perforation with peritonitis. Cardiopulmonary evaluation with ECG, pulmonary artery catheter and TEE demonstrated no evidence of acute myocardial ischemia or ventricular dysfunction; hemodynamic indices were consistent with severe sepsis. TEE revealed a large sheathing thrombus surrounding a central venous catheter used for parenteral nutrition. A spiral CT scan of the chest confirmed multiple peripheral pulmonary emboli. Treatment consisted of systemic anticoagulation and antibiotics. To avoid further pulmonary embolism, the central venous catheter was not removed until six days later under TEE monitoring, which revealed that the thrombus was firmly adherent to the superior vena cava. The patient made an uneventful recovery and was discharged from hospital on long-term anticoagulant therapy. CONCLUSION: In a case of catheter-induced superior vena cava thrombosis with septicemia and pulmonary embolism, bedside TEE was very helpful to make the correct diagnosis early, assess thrombus size during anticoagulation, and monitor cardiac performance and thrombus disposition during central venous catheter removal.

[Revision of diffuse peritonitis: planned versus on demand]. / Revision bei diffuser Peritonitis: geplant v. on-demand.

Planned and "on-demand' reoperations are well-established concepts in the management of severe diffuse peritonitis. Both concepts were applied at our surgical department and reviewed with regard to specific complications and lethality. In the period between 1 January 1989 and 31 May 1994, 62 patients with the diagnosis of diffuse peritonitis underwent operative treatment at our surgical department. The mean age of the 29 female and 33 male patients was 58.2 years (range 17-93 years). The origin of peritonitis was the stomach in 8.1%, duodenum in 16.1%, small intestine in 12.9%, large intestine in 41.9% and the pancreas in 16.1%. Among these 62 patients, 15 were reoperated upon according to plan and 47 were reoperated upon on demand. The intraoperatively gained Mannheim peritonitis index and the Apache II score were similar in both groups. The average number of reoperations was five in the group of planned revisions and three in the group of on-demand revisions. Also lethality was similar in both groups. Regarding lethality, only the age of the patient (P < 0.03) and the preoperative Apache II score (P < 0.01) reached statistical significance. As expected, eradication of the infectious source was the precondition of survival regardless of the type of reoperation. Regarding our results, we conclude that planned or on-demand reoperations lead to similar results in the treatment of diffuse peritonitis. The crucial point for success is that elimination of the infection source take place as soon as possible.