Glucocorticoids dose-dependently increase plasma levels of granulocyte colony stimulating factor in man.

Glucocorticoids increase neutrophil counts by decreasing the margination of neutrophils and mobilizing neutrophils from the bone marrow pool. The mechanisms for these effects however are not fully elucidated, but it has been demonstrated that dexamethasone enhances release of colony stimulating factor (G-CSF) in-vitro. We therefore hypothesized, that dexamethasone may increase plasma levels of G-CSF. A double blind, randomized, placebo-controlled, three-way cross-over trial was conducted in nine healthy men. Every subject received four identical infusions of saline, 0.04 mg/kg or 1.0 mg/kg dexamethasone during three observation periods of 48 hours each. The low dose of dexamethasone increased G-CSF levels from a baseline of 15.5 ng/L (CI: 10.6-20.4) by 240% (CI: 115-366%) at 24 hours. The high dexamethasone dose increased G-CSF levels from a baseline of 12.3 ng/L (CI: 9.7-14.9) by 871% (CI: 592-1149%) at 24 hours (p=0.008 for all comparisons). No further increase was observed at 48 hours but the effect was less pronounced (p<0.008 and p=0.08 for the high and the low dose of dexamethasone, respectively). Granulocyte-macrophage-CSF (GM-CSF) levels were below the assay's detection limit of 0.36 ng/L in all subjects. In conclusion, dexamethasone dose dependently increases G-CSF levels in healthy men, an effect which may account for some of its effects on neutrophils.

Acetaminophen has greater antipyretic efficacy than aspirin in endotoxemia: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To compare the antipyretic efficacy of aspirin and acetaminophen (INN, paracetamol) in 30 male volunteers with the use of endotoxin (lipopolysaccharide) to elicit a standardized febrile response. METHODS: A randomized, double-blind, placebo-controlled trial was conducted in parallel groups. Subjects received an intravenous endotoxin bolus of 4 ng/kg after premedication with either placebo, 1000 mg aspirin, or 1000 mg acetaminophen by mouth. RESULTS: Peak body temperatures were 38.5 degrees C +/- 0.2 degrees C in the placebo group, 37.6 degrees C +/- 0.2 degrees C in the acetaminophen group (P = .001 versus placebo), and 38.6 degrees C +/- 0.2 degrees C in the subjects treated with aspirin (P = .001 versus acetaminophen; P = .570 versus placebo) at 4 hours after lipopolysaccharide infusion. Subjective symptom scores for chills and perception of fever were higher in the placebo group than in the acetaminophen group (chills, 2.5 +/- 0.3 versus 1.0 +/- 0.2, P = .009 and fever, 2.5 +/- 0.2 versus 2.0 +/- 0.2, P = .021). Tumor necrosis factor-alpha, interleukin-6, and interleukin-8 levels rose by several orders of magnitude (P < .001 versus baseline in all groups), without significant intergroup differences. CONCLUSIONS: Acetaminophen was the superior antipyretic drug in endotoxemia compared with aspirin. Treatment with acetaminophen ameliorates subjective symptoms induced by endotoxemia without compromising the humoral response of a subject to endotoxin. This observation has clinical interest and may also help to improve the lipopolysaccharide model, which can be used to test anti-inflammatory and anticoagulatory drugs.

Effects of heparin and aspirin on circulating P-selectin, E-selectin and von Willebrand Factor levels in healthy men.

As thrombin stimulates P-selectin expression on platelets and its release into plasma, we hypothesized that enhancing antithrombin activity by unfractionated heparin (UFH) could decrease plasma levels of circulating (c)P-selectin, (c)E-selectin, and von Willebrand Factor (vWF). Hence the effect of UFH and aspirin were examined on these activation markers in healthy volunteers. UFH decreased cP-selectin levels by -10% (CI: -16 - (-4%); P = 0.005) at 24 h, but did not change levels of vWF-Ag. In contrast, aspirin did not affect cP-selectin levels but decreased vWF-Ag levels by -12% (CI: -18 - (-7%); P = 0.005) at 24 h. Neither drug affected cE-selectin levels. Thus, UFH decreases cP-selectin levels, which may reflect decreased platelet activation in vivo. An increase in cP-selectin under UFH therapy should alert the clinician to look for platelet destruction.

Partial inhibition of nitric oxide synthase primes the stimulated pathway of vWF-secretion in man.

Increased release of von Willebrand factor (vWF) has been linked to the pathogenesis of atherosclerosis. For this complex disease, impairment of endothelium-derived, nitric oxide production and impaired vascular relaxation has also been reported. Since endothelially produced nitric oxide (NO) is known to inhibit secretion of the Weibel-Palade bodies in animals, we hypothesized that NO could mitigate vWF secretion. In a randomized, placebo controlled cross-over trial, eight male volunteers received N-monomethyl-L-arginine (LNMMA) to block endothelial NO production or placebo, and vWF release was stimulated by infusing desmopressin in three cumulative doses (0.05, 0.15, 0.4 microg/kg) in both periods. At a threshold dose of 0.l5 microg/kg desmopressin, concomitant partial blockade of NO production resulted in 20% higher levels of vWF (P<0.04). However, maximal vWF release after 0.4 microg/kg desmopressin was unaffected by L-NMMA (Delta7% between periods, P=0.88). These data show the dampening effect of NO production on vWF release in response to threshold concentrations of secretagogues. This may in part explain the higher vWF levels in cardiovascular diseases associated with impaired endothelial NO generation.

Plasma levels of activated factor VII decrease during the menstrual cycle.

Men have an increased cardiovascular risk as compared to women, which is largely ascribed to the cardioprotective effects of female sex steroids. We hypothesised that this may be reflected by differences in the activation status of the coagulation system. Hence the aim of this study was to compare plasma levels of activated factor VII (FVIIa) in men and women, and to study the influence of the menstrual cycle on FVIIa levels. In a prospective study we investigated 20 healthy young women and 20 men. Men had significantly higher levels of activated factor VII (60 mU/ml, CI: 52 to 67) than women during all phases of the menstrual cycle. In women FVIIa was higher during the follicular phase (41 mU/ml, CI: 33 to 50) than during midcycle (34 mU/ml, CI: 24 to 45; p = 0.022 vs. follicular phase) and during the luteal phase (33 mU/ml, CI: 24 to 42; p = 0.006 vs. follicular phase). Prothrombin fragment (F1 + 2) levels decreased from 0.86 nmol/l (CI: 0.51-1.21) by -23% (-39% to -8%; p = 0.011) during midcycle and by -25% (CI: -51% to 1%; p = 0.023) during the luteal phase. These data support the contention that plasma levels of FVIIa, a key enzyme of the coagulation cascade, may be down-regulated by endogenously produced female sex hormones during the menstrual cycle. This may at least partially explain the marked gender differences found in FVIIa.

Effects of endotoxemia on thrombopoiesis in men.

BACKGROUND: Febrile conditions are often associated with increased platelet turnover and refractoriness to platelet transfusions, although several pyrogenic cytokines enhance thrombopoiesis. This study aimed to characterize the effects of experimental human endotoxemia on platelet turnover and thrombopoiesis. METHODS: Endotoxin (4 ng/kg) was infused into 30 healthy men to study the regulation of thrombopoiesis in systemic human inflammation. Platelet counts, plasma thrombopoietin (TPO) and glycocalicin levels, and reticulated platelets (RP) were measured to evaluate the effect of acute endotoxemia on thrombopoiesis. Ten subjects received pretreatment with 1000 mg aspirin po. to evaluate possible effects of aspirin on platelet turnover, and ten subjects received paracetamol to control for effects of antipyresis. RESULTS: Platelet counts dropped by about 15% (p <0.001) one hour after LPS infusion, began to recover at 24 h, and exceeded baseline values by 81% (CI: 5-12; p <0.001 ) at 7 days after LPS iv. Reticulated platelet counts increased from 1.62% (CI: 1.24-2.0) to a maximum of 2.39% (CI: 1.81-2.98; p = 0.003) at 6 h. TPO levels increased from baseline values of 10 A.U/ml (CI: 8.8-11.2) to 15.5 A.U/ml (CI: 13.6-17.3) at 24 h (p <0.001), whereas plasma glycocalicin was not changed (p >0.05). The number of circulating platelet-neutrophil aggregates increased more than 100% at 6 h (p <0.001). Neither aspirin nor paracetamol affected changes in any of the parameters measured. CONCLUSION: Low grade endotoxemia induces a rapid fall of platelet counts, which is followed by an early increase in reticulated platelets and TPO levels but not of glycocalicin levels. Finally peripheral platelet counts increase several days after LPS infusion.

Murine recombinant GM-CSF-driven rat bone marrow cell differentiation and factors suppressing cell proliferation.

Rat or mouse bone marrow cells (BMC) cultured for one week with a crude mouse L929 cell supernatant or with purified colony stimulating factor type 1 (CSF-1) differentiate into an essentially pure population of macrophages (M phi). Surprisingly, 90 to 95% of the cells obtained by culturing rat BMC for seven days with recombinant murine granulocyte-macrophage CSF (rmGM-CSF), regardless of concentrations, were classified as M phi. The majority of the remaining cells were granulocytes. This effect is in contrast to that on mouse BMC cultures, where the percentage of granulocytes increased with higher concentrations of rmGM-CSF. The proliferative capacity of rat BMC was demonstrated by colony formation in soft-agar, enumerating total cell number in liquid cultures or measuring 3H-thymidine uptake. A crude L929 cell supernatant and rmGM-CSF induced cell proliferation in a dose-dependent manner. Maximal DNA-synthesis was observed on the fifth day of incubation when BMC were cultured at a density of greater than or equal to 1 x 10(5) cells/well. In cultures initiated with lower cell density, prolonged DNA synthesis was observed. Thereafter, the rate of proliferation declined rapidly. Simultaneous incubation of BMC with GM-CSF and indomethacin led to increased levels of DNA synthesis, suggesting that prostaglandins may suppress cell proliferation. Furthermore, the CSF-induced BMC proliferation was dose dependently inhibited by dexamethasone and 1,25-dihydroxy-vitamin D3 as well as by interferon-gamma and tumor necrosis factor-alpha. The suppressive effect of both cytokines could be abrogated by the addition of the respective anticytokine antibodies.

The acute respiratory distress syndrome: definitions, severity and clinical outcome. An analysis of 101 clinical investigations.

OBJECTIVE: To determine possible changes in outcome from acute respiratory distress syndrome (ARDS) and to compare severity of lung injury and methods of treatment from 1967 to 1994. DATA SOURCES: Computerized (Medline, Current Contents) and manual (Cumulated Index Medicus) literature search using the key word and/or title ARDS. STUDY SELECTION: Only clinical studies published as full papers reporting data on both patient mortality (survival) and oxygenation index (PaO2/FIO2) were included. Single case reports, abstracts, reviews and editorials were excluded from evaluation. DATA EXTRACTION: Relevant data were extracted in duplicate, followed by quality checks on approximately 80% of data extracted. DATA SYNTHESIS: 101 papers reporting on 3264 patients were included: 48 studies (2207 patients) were performed in the USA, 43 studies (742 patients) in Europe and 10 studies (315 patients) elsewhere. Mortality reported in these studies was 53 +/- 22% (mean +/- SD), with no apparent trend towards a higher survival (1994: 22 studies, mortality 51 +/- 19%). The mean PaO2/FIO2 ratio remained unchanged throughout the observation period (118 +/- 47 mmHg). No correlation could be established between outcome and PaO2/FIO2 or lung injury score. Patients who underwent pressure-limited ventilation had a significantly lower mortality (35 +/- 20%) than patients on volume-cycled ventilation (54 +/- 22%) or patients for whom there was no precise information on ventilatory support (59 +/- 19%). Significantly lower PaO2/FIO2 ratios (61 +/- 17 mmHg) were observed in patients prior to extracorporeal lung assist, together with mortality rates in the range of those for conventionally treated patients (55 +/- 22%). CONCLUSIONS: The mortality of ARDS patients remained constant throughout the period studied. Therefore, the standard for outcome in ARDS should be a mortality in the 50% range. Neither PaO2/FIO2 ratio nor lung injury score was a reliable predictor for outcome in ARDS. Patients might benefit from pressure-limited ventilatory support, as well as extracorporeal lung assist. Since crucial data were missing in most clinical studies, thus preventing direct comparison, we emphasize the importance of using standardized definitions and study entry criteria.

Jugular venous bulb oxygen saturation depends on blood pressure during cardiopulmonary bypass.

BACKGROUND: Central nervous system dysfunction after cardiopulmonary bypass is frequent and can be caused by inadequate cerebral perfusion and oxygenation. METHODS: To test the effectiveness of cerebral autoregulation during cardiopulmonary bypass, we induced changes in the cerebral perfusion pressure by administering phenylephrine during moderate (29 degrees C) hypothermia. Using the Fick principle, we calculated relative changes in cerebral blood flow from changes in the jugular venous bulb oxygen saturation. RESULTS: Increasing the cerebral perfusion pressure (from 47 +/- 8.2 to 93 +/- 16 mm Hg) induced increases in the jugular venous bulb oxygen saturation by 4.9% and a calculated increase in the cerebral blood flow by 19.9%, strongly suggesting impaired cerebral autoregulation. CONCLUSIONS: Because cerebral autoregulation is impaired during cardiopulmonary bypass, phenylephrine is effective in increasing the cerebral blood flow and may contribute to the prevention of postoperative neurologic dysfunction, especially in patients who have a low jugular venous bulb oxygen saturation.

Effects of nitroglycerin and sodium nitroprusside on endexpiratory concentrations of nitric oxide in healthy humans.

The cellular origin of nitric oxide (NO) in exhaled air of healthy humans is unknown. It is currently not known, whether changes in NO concentrations that originate from pulmonary vessels, can be detected as changes in exhaled NO. Thus, we have studied the effects of increased intravascular NO generation on endexpiratory NO-levels. Twenty-four young healthy volunteers received nitroglycerin (GTN), sodium nitroprusside (SNP) or placebo i.v. in a randomized, double blind cross-over trial. Diastolic blood pressure decreased from 59 mmHg (95% confidence interval: 56-62) during placebo to 48 mmHg (CI: 45-51) and to 48 mmHg (CI: 45-50) after infusions of GTN and SNP, respectively. Heart rate increased from 69 (CI: 65-73) during placebo to 78 (CI: 72-84) and to 84 (CI: 77-92) after infusions of GTN and SNP, respectively (p<0.01 for all comparisons). However, no increase in exhaled NO was detected: endexpiratory NO-concentrations averaged 6.1 ppb (CI: 4.9-7.4), 5.7 ppb (CI: 4.4-7.0) and 6.4 ppb (CI: 5.3-7.6) under placebo, GTN and SNP infusions, respectively (Friedman ANOVA p=0.328). NO release from within the pulmonary vasculature does not significantly contribute to endexpiratory NO concentrations in non-intubated healthy humans suggesting that such NO measurements quantify NO production mainly from non-vascular pulmonary cells.

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.

Local anaesthesia versus general anaesthesia for cardioverter-defibrillator implantation.

AIMS: Cardioverter-defibrillators are conventionally implanted under general anaesthesia. However, implantation under conscious sedation is being increasingly used. It has been shown that cardioverter-defibrillators can be implanted in a more pacemaker-like approach: under local anaesthesia for the surgical procedure, and with mild sedation for defibrillation threshold testing only. The aim of the present study was to compare local and general anaesthesia in defibrillation threshold testing and implantation of cardioverter-defibrillators. METHODS AND RESULTS: Forty patients were assigned to two groups: in the first 20 consecutive patients the cardioverter-defibrillator was implanted under general anaesthesia (GA), and in the subsequent 20 patients under local anaesthesia (LA). There was no significant difference between the two groups in regard of age, body weight, underlying disease, left ventricular ejection fraction, and NYHA classification. The defibrillation threshold was 13.7 +/- 5.5 J under local anaesthesia versus 10.7 +/- 4.7 J under general anaesthesia (n.s.). For defibrillation threshold testing 7.9 +/- 3.6 shocks had to be applied in patients under general anaesthesia versus 6.2 +/- 1.3 shocks under local anaesthesia (n.s.). Mean heart rate, arterial oxygen saturation and mean arterial blood pressure remained stable throughout defibrillation threshold testing, irrespective of the type of anaesthesia used. The duration of the surgical procedure was 62 +/- 16 min under GA and 60 +/- 14 min under LA (n.s.), however, the entire implantation procedure was significantly longer in patients under general anaesthesia than in those under local anaesthesia (124 +/- 24 min and 97 +/- 22 min, respectively, p < 0.005). There were no complications in either group and the procedure was well tolerated. With the use of local anaesthesia the cost of anaesthesia were reduced by 72%. CONCLUSION: Local anaesthesia in combination with mild sedation is as safe and well tolerated as general anaesthesia in cardioverter-defibrillator implantation. Lidocaine used for local anaesthesia does not adversely affect the defibrillation threshold. Device implantation in a pacemaker-like approach results in a significant reduction in total procedure time and costs, and facilitates scheduling of the procedure.

[Difference between gastric mucosal pCO2 and arterio-intramucosal pCO2 during orthotopic liver transplantation]. / Magenmukosa-pCO2 und arterio-intramukosale pCO2-Differenz während orthotoper Lebertransplantation.

Tonometry is a clinically accepted method to monitor blood flow of the splanchnic region, which is of particular interest in orthotopic liver transplantation (OLT). We investigated the hemodynamic changes and the tonometrically registered perioperative course of the difference between gastric mucosal pCO2 (prCO2) and arterial mucosal CO2 (CO2 gap) in 23 patients undergoing OLT without veno-venous bypass. Gastric mucosal pH (pHi) was additionally calculated. Despite significant changes in systemic hemodynamics during the anhepatic stage and after reperfusion and a significant drop in pHi during anhepacy, the difference between prCO2 and CO2 was constant. These contrasting findings of tonometry, i.e. solely a drop in pHi is, in our opinion, a consequence of the poor metabolic capacity of the liver in the perioperative OLT period, which influenced the calculation of the pHi with the Henderson-Hasselbalch equation. We conclude that, due to methodical problems, calculated pHi is not a reliable indicator of splanchnic blood flow and oxygenation during OLT. We therefore suggest that the prCO2 and the CO2 gap be used to monitor the splanchnic region. These parameters, obtained perioperatively, do not indicate a further reduction in splanchnic oxygenation despite profound changes in systemic hemodynamics during OLT without veno-venous bypass.

Malposition of central venous catheters. Incidence, management and preventive practices.

INTRODUCTION: Proper placement is an essential prerequisite for the use of central venous catheters. Our study was undertaken to determine the incidence of aberrant locations dependent on different anatomic approaches for various types of central venous catheters and to elucidate failures and pitfalls of preventive practices. METHODS: 2580 percutaneously inserted lines (including 538 tunneled devices and 112 implantable Port-A-Caths) introduced by Seldinger's technique were reviewed for inadvertent malpositioning. RESULTS: Primary misplacement was evident on 47 occasions (1.82%), 38 times into large venous tributaries of the superior vena cava. 3 aberrant locations involved a persistent left superior vena cava, two catheters were placed into minor intrathoracic veins and in 3 patients inadvertent arterial cannulation occurred. The frequency of malpositioning was related to the anatomic approach and the catheter type used, but not to the physician's experience. Respective incidences were 4.12% for the left internal jugular access, but were lower for the right internal jugular (1.1%) and the right (1.01%) and left (0.89%) supraclavicular approach. Misplacement was more frequent with soft silicone catheters (2.53%) than with semi-rigid catheters (0.79%). All malpositions but one were detected on chest X-ray. DISCUSSION: Our data suggest that the incidence of catheter malposition depends on the site of insertion, the type of material used, but not on the experience of the physician who inserted the catheter. Scrupulous use of preventive practices reduces the frequency of malpositioned catheters, but physicians must keep in mind potential pitfalls. Injection of radioopaque contrast medium into the catheter during control chest X-ray should be done even with opaque catheters.

Coagulation Day 2010: an Austrian survey on the routine of thromboprophylaxis in intensive care.

PURPOSE: Venous thromboembolism (VTE) is a common but often overlooked life-threatening complication of critical illness. The aim of this cross-sectional survey was to assess current practice of thromboprophylaxis as well as adherence to international guidelines. METHODS: After ethics committee approval, all intensive care units in Austrian hospitals treating adult patients were invited to participate in this web-based survey. Anonymized data on each patient treated at the participating intensive care units on Coagulation Day 2010 were collected using an electronic case report form. Risk assessment, choice and monitoring of anticoagulants, means of mechanical prophylaxis, and demographic data were recorded. RESULTS: Data from 325 critically ill patients were collected. Patients had a median of four risk factors for thrombosis and 6 % suffered from VTE. Of the 325 patients, 80 % received low molecular weight heparins subcutaneously, 10 % received unfractionated heparin intravenously, 1 % received alternative anticoagulants and 9 % received no pharmacological prophylaxis. Mechanical prophylaxis was used in 49 % with a predominant use of graduated compression stockings. In 39 % a combination of pharmacological and mechanical prophylaxis was applied and 5 % received no prophylaxis at all. Overall guideline adherence was 40 % on Coagulation Day 2010. CONCLUSION: Current practice of thromboprophylaxis is predominantly based on the administration of low molecular weight heparins prescribed at rather arbitrary doses without a discernible relationship to drug monitoring, thromboembolic risk factors, vasopressor use or fluid balance. The use of mechanical prophylaxis, evaluation of risk scores and overall guideline adherence must be further encouraged by education, training and communication.

[Preoperative evaluation of the bleeding history. Recommendations of the working group on perioperative coagulation of the Austrian Society for Anaesthesia, Resuscitation and Intensive Care]. / Präoperative Blutungsanamnese. Empfehlungen der Arbeitsgruppe perioperative Gerinnung der Osterreichischen Gesellschaft für Anästhesiologie, Reanimation und Intensivmedizin.

Unexpected bleeding in the perioperative period is largely caused by impaired inherited or drug-induced primary haemostasis. Standard tests for plasma coagulation are predominantly employed to gauge the risk of bleeding. In accordance with several reports the subcommittee for perioperative coagulation (AGPG) of the Austrian Society of Anaesthesia, Resuscitation and Intensive Care (OGARI) recommends the use of a standardised questionnaire to detect an increased risk of bleeding. Accordingly, healthy patients of the American Society of Anesthesiologists (ASA) grades I and II without any suspicion of impaired haemostasis who are scheduled for procedures without expected transfusion requirements, need no standard tests for coagulation. In all other patients (including patients taking medication affecting coagulation, or patients who are unable to provide adequate information) platelet count, platelet function, aPTT, PT, and fibrinogen levels should be assessed.

[Locoregional anesthesia and coagulation inhibitors. Recommendations of the Task Force on Perioperative Coagulation of the Austrian Society for Anesthesiology and Intensive Care Medicine]. / Lokoregionalanästhesien unter gerinnungshemmender Medikation. Empfehlungen der Arbeitsgruppe Perioperative Gerinnung (AGPG) der Osterreichischen Gesellschaft für Anästhesiologie und Intensivmedizin (OGARI).

More efficacious anticoagulant and antiplatelet agents have been introduced in vascular medicine and in the prevention of perioperative venous thromboembolisms. Patient management should be guided by familiarity with the pharmacology of coagulation-altering drugs and by consensus statements. The present paper reviews recommendations from the Austrian Task Force for Perioperative Coagulation which are based on thorough evaluation of the available pharmacological information and case reports. The consensus statement focuses on neuraxial and peripheral techniques and is designed to encourage safe and quality patient care.

A new device for blind oral intubation in routine and difficult airway management.

41 patients (ASA I-II) were intubated using a new device for blind oral intubation (Augustine Guide). A group of 33 consecutive patients (Mallampati I and II), was studied for routine intubation. Another group of eight patients (Mallampati III and IV) was selected to study the guide in difficult airway management. Intubation was successful in 31 of the 33 normal patients (two patients required a second attempt), and in seven of the eight patients in the difficult intubation group (three patients with two attempts). In the remaining three patients intubation had to be performed by direct laryngoscopy. One patient (Mallampati IV), was intubated by the Augustine guide after three unsuccessful attempts by direct laryngoscopy. The Augustine Guide proved to be helpful to intubating patients with an anterior larynx and receding mandible. However, blind oral intubation attempts required a median duration of 65 s (range 35-90 s). Patients with a low Mallampati score did not benefit from the new device.

Inhalation of nitric oxide as a life-saving therapy in a patient after pulmonary embolectomy.

We describe a 54-yr-old man with cardiogenic shock caused by acute right heart failure after pulmonary embolectomy. Inhalation of nitric oxide led to immediate improvement in respiratory and haemodynamic variables. Inhaled nitric oxide can be used to reduce acute right heart failure until conventional therapy can provide successful haemodynamic stability.

Systemic blood pressure and cerebral blood flow velocity during carotid surgery.

BACKGROUND: To evaluate the effect of mean arterial blood pressure (MAP) on cerebral perfusion during carotid surgery, we investigated blood flow velocity in the middle cerebral (Vs,mca) using transcranial Doppler ultrasonography (TCD). METHODS: During carotid crossclamping, treatment included either phenylephrine-induced hypertension without shunting (Group XC; n = 11) or insertion of a shunt (Group S; n = 12). RESULTS: Increasing MAP in Group XC before crossclamping (81 + /-13 mmHg to 107 +/- 12 mmHg) caused an increase of Vs,mca (59 +/- 17 cm/s to 75 +/- 20 cm/s; p < 0.001). During crossclamping without a shunt, Vs,mca was not dependent on MAP, and was reduced (mean 47 +/- 24 cm/s) in relation to preclamp values. In Group S, Vs,mca was always dependent on MAP and the preclamp velocity was maintained (before shunt: 75 +/- 26 cm/sec; during shunt: 79 +/- 30 cm/sec). CONCLUSIONS: Although we found an impaired cerebral autoregulation, Vs,mca was independent of MAP during carotid crossclamping. Thus, TCD measurements have to be interpreted with caution during crossclamping, and the effect of induced hypertension has to be confirmed with more invasive measures of cerebral blood flow.