[Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]. / Empfehlungen zur extrakorporalen kardiopulmonalen Reanimation (eCPR) : Konsensuspapier der DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI und GRC.

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

[Pretreatment mass casualty incident workflow analysis : Comparison of two level 1 trauma centers]. / Prätherapeutische Ablaufanalyse bei einem Massenanfall von Verletzten : Vergleich von zwei Traumazentren der höchsten Versorgungsstufe.

BACKGROUND: Mass casualty incidents (MCI) have particularly high demands on patient care processes but occur rather rarely in daily hospital routine. Therefore, it is common to use simulations to train staff and to optimize institutional processes. OBJECTIVES: Aim of study was to compare the pre-therapeutic in-house workflow of two differently structured level 1 trauma sites in the case of a simulated mass casualty incident (MCI). MATERIALS AND METHODS: A MCI of 70 patients was simulated by actors in a manner that was as realistic as possible. The on-site triage assigned 7 cases to trauma site A with relatively long in-house distances and 4 patients to an independent trauma site B in which these distances were relatively short. During in-house treatment, time intervals for reaching milestones were measured and compared using the Mann-Whitney U test. RESULTS: As no simultaneous patient arrival occurred, the Patient Distribution Matrix proved to be effective. Site A needed more time (minutes) from admission to endpoints (A: 31.85 ± 7.99; B: 21.62 ± 4.76; p = 0.059). In detail, the time intervals were particularly longer for both patient stay in trauma room (A: 8.46 ± 3.02; B: 2.73 ± 0.78, p < 0.01) and transfer time to the CT room (A: 1.81 ± 0.62; B: 0.06 ± 0.03, p < 0.01). A shorter stay in the CT room did not compensate these effects (A: 8.86 ± 1.84; B: 10.40 ± 2.89, p = 0.571). For both sites, image calculation and distribution were relatively time consuming (17.36 ± 3.05). CONCLUSIONS: Although short in-house distances accelerated pretherapeutic treatment processes significantly, both sites remained clearly within the "golden hour". The strongest potential bottleneck was the time interval until images were available at the endpoints.

[Standardized telephone-assisted instructions on resuscitation by laypersons. Feasibility study using video-assisted quality analysis]. / Standardisierte Telefonanweisungen zur Wiederbelebung durch Laienhelfer. Videogestützte Qualitätsanalyse im Rahmen einer Machbarkeitsstudie.

BACKGROUND: Telephone-assisted instructions for cardiopulmonary resuscitation (T-CPR) are highly recommended by the current European Resuscitation Council (ERC) guidelines for resuscitation 2010. AIM: The aim of this study was to analyze the adherence of laypersons to T-CPR instructions given by dispatchers in a mock scenario. The dispatchers adapted international T-CPR instructions to local requirements. MATERIAL AND METHODS: An emergency "collapse in the office" with subsequent T-CPR was simulated for 10 volunteer, untrained administrative staff, as the only single emergency witness and 4 emergency medical service (EMS) dispatchers. Each volunteer was sent to a "colleague" who simulated a sudden cardiovascular event and collapsed unconscious during the description of symptoms. The local lay responder made an emergency call by landline telephone and was connected to the dispatcher. In the course of the simulation the "victim" was replaced by a CPR manikin. RESULTS: Every participant, i.e. 10 out of 10, assessed the victim, recognized the situation and telephoned for help. On the orders of the dispatchers 9 out of the 10 activated the loudspeaker of the telephone but 4 still continued to use the handset. The instructions for positioning were followed by all 10. Correct positioning of the victim required a median of 33[Symbol: see text]s with an interquartile range (IQR) of 30-39[Symbol: see text]s. Breathing control including instructions lasted a median of 54[Symbol: see text]s (IQR 49-60[Symbol: see text]s). Breathing was assessed by 8 out of 10 but only 2 out of 8 achieved a duration of 10[Symbol: see text]s as recommended by the ERC guidelines for resuscitation 2010. After a median of 202[Symbol: see text]s (IQR 196-241[Symbol: see text]s) chest compressions were started by 9 out of 10 and were performed for a median of 63[Symbol: see text]s (IQR 60-69[Symbol: see text]s). A correct technique was used by 7 but with a low rate of 80 compressions/min (IQR 72-86/min). The instructions for ventilation were understood by 9 out of 10. Mouth-to-mouth resuscitation was performed by 7 participants and technically correct by 5 of them. The ventilation cycle of the 7 active participants lasted for a mean of 25[Symbol: see text]s (IQR 24-30[Symbol: see text]s). The mean total duration of the timeframe analyzed was 340[Symbol: see text]s (IQR 334-368[Symbol: see text]s). CONCLUSION: The results demonstrate that the local T-CPR concept for untrained laypersons is feasible in a mock scenario. No substantial errors were observed for the majority of the untrained responders but the simulation also showed that not every emergency witness implemented the instructions according to the dispatcher's expectations. The T-CPR procedure was also more time-consuming than expected; therefore, every standardized T-CPR concept should be tested for local practicability. In accordance with current studies, the results suggest that the focus should be on compression-only CPR instructions in urban settings. Dispatcher education in T-CPR should incorporate videotaped mock-up scenarios with untrained local laypersons.

[Acupuncture in emergency medicine : results of a case series]. / Akupunktur in der Notfallmedizin : Ergebnisse einer Fallserie.

BACKGROUND: Acupuncture (AP) might be indicated in emergency medicine. This case series was performed to demonstrate the practicability and possible effects of AP in emergency medical services (EMS) as a basis for randomized controlled trials (RCT). SUBJECTS AND METHODS: A total of 60 patients (average age 55.4±23.0 years, 57% female) treated by the EMS received AP if applicable. Main outcome parameter was to rate the symptom alleviating effect of acupuncture treatment on a 4-point scale or by VAS. RESULTS: Of the 60 patients 35 (58%) reported considerable improvement, 15 patients (25%) reported complete relief and 10 patients (17%) reported no changes in the cardinal symptom. The predominant symptoms alleviated by AP were nausea (n=31) and vomiting (n=21). Pericardium 3 and 6 (27%) and Spleen 6 and 9 were the most commonly used AP points. CONCLUSION: This case series demonstrates that AP can alleviate certain symptoms in emergency patients. The results of the study provide data as a basis to perform clinical controlled trials on the effectiveness of AP in emergency medicine.

[Comments on the 2010 guidelines on cardiopulmonary resuscitation of the European Resuscitation Council]. / Kommentar zu den Leitlinien 2010 zur kardiopulmonalen Reanimation des European Resuscitation Council.

ADULTS: Administer chest compressions (minimum 100/min, minimum 5 cm depth) at a ratio of 30:2 with ventilation (tidal volume 500-600 ml, inspiration time 1 s, F(I)O2 if possible 1.0). Avoid any interruptions in chest compressions. After every single defibrillation attempt (initially biphasic 120-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min independent of the ECG rhythm. Tracheal intubation is the optimal method for securing the airway during resuscitation but should be performed only by experienced airway management providers. Laryngoscopy is performed during ongoing chest compressions; interruption of chest compressions for a maximum of 10 s to pass the tube through the vocal cords. Supraglottic airway devices are alternatives to tracheal intubation. Drug administration routes for adults and children: first choice i.v., second choice intraosseous (i.o.). Vasopressors: 1 mg epinephrine every 3-5 min i.v. After the third unsuccessful defibrillation amiodarone (300 mg i.v.), repetition (150 mg) possible. Sodium bicarbonate (50 ml 8.4%) only for excessive hyperkaliemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider aminophylline (5 mg/kgBW). Thrombolysis during spontaneous circulation only for myocardial infarction or massive pulmonary embolism; during on-going cardiopulmonary resuscitation (CPR) only when indications of massive pulmonary embolism. Active compression-decompression (ACD-CPR) and inspiratory threshold valve (ITV-CPR) are not superior to good standard CPR. CHILDREN: Most effective improvement of outcome by prevention of full cardiorespiratory arrest. Basic life support: initially five rescue breaths, followed by chest compressions (100-120/min depth about one third of chest diameter), compression-ventilation ratio 15:2. Foreign body airway obstruction with insufficient cough: alternate back blows and chest compressions (infants), or abdominal compressions (children >1 year). Treatment of potentially reversible causes: ("4 Hs and 4 Ts") hypoxia and hypovolaemia, hypokalaemia and hyperkalaemia, hypothermia, and tension pneumothorax, tamponade, toxic/therapeutic disturbances, thrombosis (coronary/pulmonary). Advanced life support: adrenaline (epinephrine) 10 µg/kgBW i.v. or i.o. every 3-5 min. Defibrillation (4 J/kgBW; monophasic or biphasic) followed by 2 min CPR, then ECG and pulse check. NEWBORNS: Initially inflate the lungs with bag-valve mask ventilation (p(AW) 20-40 cmH2O). If heart rate remains <60/min, start chest compressions (120 chest compressions/min) and ventilation with a ratio 3:1. Maintain normothermia in preterm babies by covering them with foodgrade plastic wrap or similar. POSTRESUSCITATION PHASE: Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32-34°C for 12-24 h (adults) or 24 h (children); slow rewarming (<0.5°C/h)]. Consider percutaneous coronary intervention (PCI) in patients with presumed cardiac ischemia. Prediction of CPR outcome is not possible at the scene, determine neurological outcome <72 h after cardiac arrest with somatosensory evoked potentials, biochemical tests and neurological examination. ACUTE CORONARY SYNDROME: Even if only a weak suspicion of an acute coronary syndrome is present, record a prehospital 12-lead ECG. In parallel to pain therapy, administer aspirin (160-325 mg p.o. or i.v.) and clopidogrel (75-600 mg depending on strategy); in ST-elevation myocardial infarction (STEMI) and planned PCI also prasugrel (60 mg p.o.). Antithrombins, such as heparin (60 IU/kgBW, max. 4000 IU), enoxaparin, bivalirudin or fondaparinux depending on the diagnosis (STEMI or non-STEMI-ACS) and the planned therapeutic strategy. In STEMI define reperfusion strategy depending on duration of symptoms until PCI, age and location of infarction. TRAUMA: In severe hemorrhagic shock, definitive control of bleeding is the most important goal. For successful CPR of trauma patients a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation and excessive ventilation pressure may impair outcome in patients with severe hemorrhagic shock. TRAINING: Any CPR training is better than nothing; simplification of contents and processes is the main aim.

Cerebrospinal s100-B: a potential marker for progressive intracranial hemorrhage in patients with severe traumatic brain injury.

OBJECTIVE: Traumatic brain injury (TBI) is associated with cerebrovascular dysfunction and changes of the blood-brain barrier (BBB) function. Although knowledge about the function of the BBB would be of high interest, non-invasive neurodiagnostic tools are still lacking. In this context it has been shown, that the astrocytic protein S100-B is a significant parameter for neuronal damage. However, there is only poor knowledge about the dynamics of S100-B in cerebrospinal fluid (CSF) and serum of patients with severe TBI. Therefore, the aim of this study was to analyze intrathecal and systemic concentrations of S100-B in patients with severe TBI in correlation to the development of progressive intracranial hemorrhage (PIH) as well as to the CSF/serum albumin ratio (Q subsetalb), as functional parameter of the BBB. PATIENTS AND METHODS: In patients, suffering from severe TBI (GCS =or<8pts) and respectively healthy control patients, albumin for calculating the CSF/serum albumin ratio (Q subsetalb) as well as S100-B protein were analyzed in CSF and serum. Samples were collected immediately after placement of a ventricular catheter and 12h, 24h, 48 h and 72 h after TBI. S100-B was quantified using Elecsys S-100 superset assay (Roche superset Diagnostics; Mannheim, Germany). Volume measurements of focal mass lesions based on CT images taken during the first 72 h after TBI were obtained according to the Cavalieri's Direct Estimator method. RESULTS: 21 TBI-patients and respectively 10 healthy controls were enrolled. In patients exhibiting a mean ICP >15 mmHg (n = 15) CSF levels of S100-B were significantly increased on admission (819 +/- 78 pg/ml) compared to patients with ICP =or<15 mmHg (n = 6, 175 +/- 12 pg/ml) as well as to the control group (n = 10, 0.8 +/- 0.09 pg/ml). In the group with ICP >15 mmHg 8 patients developed PIH A positive correlation was found between CSF S100-B and ICP (r2 = 0.925, p<0.001). Furthermore a positive correlation between serum S100-B and Q subsetalb was found for each sampling point (r superset2 = 0.793, p<0.001). CONCLUSIONS: The cerebrospinal and serum concentration of S100-B in patients with severe TBI was evaluated. Monitoring cerebrospinal S100-B might help to prospectively identify patients with PIH.

[Chest compression without ventilation during basic life support? Confirmation of the validity of the European Resuscitation Council (ERC) guidelines 2005]. / Thoraxkompression ohne Beatmung bei der Laienreanimation? Bestätigung der Gültigkeit der "European Resuscitation Council (ERC) Guidelines 2005".

Basic life support (BLS) refers to maintaining airway patency and supporting breathing and the circulation, without the use of equipment other than infection protection measures. The scientific advisory committee of the American Heart Association (AHA) published recommendations (online-first) on March 31 2008, which promote a call to action for bystanders who are not or not sufficiently trained in cardiopulmonary resuscitation (CPR) and witness an adult out-of-hospital sudden collapse probably of cardiac origin. These bystanders should provide chest compression without ventilation (so-called compression-only CPR). If bystanders were previously trained and thus confident with CPR, they should decide between conventional CPR (chest compression plus ventilation at a ratio of 30:2) and chest compression alone. However, considering current evidence-based medicine and latest scientific data both the European Resuscitation Council (ERC) and the German Resuscitation Council (GRC) do not at present intend to change or supplement the current resuscitation guidelines "Basic life support for adults". Both organisations do not see any need for change or amendments in central European practice and continue to recommend that only those lay rescuers that are not willing or unable to give mouth-to-mouth ventilation should provide CPR solely by uninterrupted chest compressions until professional help arrives. It is also stressed that the training of young people especially teenagers as lay rescuers should be promoted and the establishment of training programs through emergency medical organizations and in schools should be encouraged.

[Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR) : Consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC]. / Empfehlungen zur extrakorporalen kardiopulmonalen Reanimation (eCPR) : Konsensuspapier der DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI und GRC.

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

Effects of hypertonic saline on expression of human polymorphonuclear leukocyte adhesion molecules.

Hypertonic saline prevents vascular adherence of neutrophils and ameliorates ischemic tissue injury. We hypothesized that hypertonic saline attenuates N-formyl-methionyl-leucyl-phenylalanine (fMLP)-stimulated expression of adhesion molecules on human polymorphonuclear leukocytes (PMNLs). fMLP-stimulated up-regulation of beta2-integrins was diminished by hypertonic saline but not by hypertonic choline chloride-, mannitol-, or sucrose-modified Hanks' buffered salt solution. Shedding of L-selectin was decreased by hypertonic saline and choline chloride but not by hypertonic mannitol or sucrose. When the effects of hypertonic sodium chloride- and choline chloride-modified media were compared, neither solution affected fMLP-receptor binding but both equally inhibited fMLP-stimulated increase in intracellular calcium, ionophore A23187, and phorbol myristate acetate (PMA)-stimulated numerical up-regulation of beta2-integrins. Analysis of mitogen-activated protein (MAP) kinases p38 and p44/42 for phosphorylation revealed that hypertonic solutions did not differ in preventing fMLP-stimulated increases in phospho-p38 and phospho-p44/42. Resting PMNLs shrunk by hypertonic saline increased their volume during incubation and further during chemotactic stimulation. Addition of amiloride further enhanced inhibition of up-regulation of beta2-integrins. No fMLP-stimulated volume changes occurred in PMNLs exposed to hypertonic choline chloride, resulting in significant cell shrinkage. Results suggest a sodium-specific inhibitory effect on up-regulation of beta2-integrins of fMLP-stimulated PMNLs, which is unlikely to be caused by alterations of fMLP receptor binding, decrease in cytosolic calcium, attenuation of calcium or protein kinase C-dependent pathways, suppression of p38- or p44/42 MAP kinase-dependent pathways, or cellular ability to increase or decrease volumes.

Buflomedil hydrochloride reduces systemic activation of polymorphonuclear leukocytes during hyperdynamic endotoxemia.

The purpose of the study was to examine the effects of buflomedil hydrochloride (BFL) on the expression of adhesion molecules (beta2-integrins) and oxygen radical production of circulating and emigrated intra-abdominal polymorphonuclear leukocytes (PMNL) in a standardized porcine model of hyperdynamic endotoxemia. A total of 20 anesthetized pigs were randomly assigned to one of the following groups: endotoxin group (endotoxin 5 microg / kg x h, intravenously (i.v.), n = 7), BFL group (BFL (3 mg/kg initial i.v. bolus followed by a continuous infusion (.1 mg / kg x h) and endotoxin 5 microg / kg x h, i.v., n = 7), and control group (NaCl .9%; n = 6). Experiments were terminated at 330 min. Infusion of endotoxin alone resulted in the activation of circulating and emigrated PMNL as evidenced by neutropenia, functional and numerical up-regulation of beta2-integrins, and enhanced oxygen radical production. BFL was able to attenuate functional and numerical up-regulation of beta2-integrins as well as oxygen radical production of circulating and emigrated PMNL. An unexpected decrease in the plasma concentration of BFL during the experiments was associated with an increase in the oxygen radical production of PMNL at the end of the experiments. In addition, BFL attenuated the fall in the intramucosal pH and the increase in plasma concentration of lactate observed in the late phase of endotoxemia. These findings suggest that BFL is able to decrease systemic activation of PMNL and to improve local tissue oxygenation during endotoxemia.

Group A streptococcal toxic shock syndrome with severe necrotizing fasciitis following hysterectomy--a case report.

In the last 10 years an increasing number of cases of group A streptococcal toxic shock syndrome have appeared in various clinical settings. The manifestation of this syndrome includes rapidly progressive multiorgan failure and soft-tissue necrosis. This report presents a case of streptococcal toxic shock syndrome caused by Streptococcus pyogenes with severe necrotizing fasciitis of the abdominal wall following hysterectomy. Aggressive surgical intervention with debridement of all necrotic tissue necessitated resection of the complete abdominal wall (skin, subcutaneous tissue, muscle and peritoneum). The abdominal wall defect was covered with free myocutaneous flaps and split-skin grafts. Optimal treatment, including adequate antibiotic therapy and radical surgical intervention, is an indispensable prerequisite of successful outcome.

Expression of adhesion molecules on circulating PMN during hyperdynamic endotoxemia.

In a porcine model of hyperdynamic endotoxemia, we studied the numerical expression of L-selectin and beta 2-integrins on circulating polymorphonuclear leukocytes (PMN). Functional changes of beta 2-integrins were determined by the adhesion of PMN to C3-coated zymosan particles. Anesthesized pigs received a continuous infusion of Salmonella abortus-equi endotoxin (5 micrograms.kg body wt-1.h-1) for 270 min (endotoxin group; n = 7). A control group received 0.9% NaCl (n = 6). L-selectin had decreased 30 min after the induction of endotoxemia [59.1 +/- 11.9 vs. 91.6 +/- 15.5 relative fluorescence units (RFU) at baseline; P < 0.05], reaching minimal values after 150 min (23.9 +/- 3.9 RFU in endotoxin group vs. 95.2 +/- 30.4 RFU in control group; P < 0.05). PMN adhesion to C3-coated zymosan increased at 30 min (41.3 +/- 9.9% in endotoxin group vs. 2.4 +/- 1.1% in control group; P < 0.05) and remained significantly elevated thereafter. In contrast to the rapid shedding of L-selectin and functional upregulation of beta 2-integrins, the numerical expression of beta 2-integrins remained unchanged until 60 min (44.8 +/- 2.8 vs. 32.2 +/- 1.7 RFU at baseline; P < 0.05); compared with the control group, significantly elevated values were observed 150 min after the start of endotoxin (48.9 +/- 2.4 RFU in endotoxin group vs. 36.5 +/- 2.7 RFU in control group; P < 0.05). We conclude that numerical and functional expressions of beta 2-integrins are dissociated during endotoxemia. Although upregulation of beta 2-integrins might render PMN more adhesive to the vascular endothelium, the presence of activated PMN in the circulation suggests that low expression of L-selectin might impede adhesion.

Microcirculatory therapy in shock.

The normal microvascular perfusion pattern is characterized by temporal and spatial variations of capillary flow. Local driving pressure, arteriolar vasomotion and endothelial cells are key-factors for local regulation of hydraulic resistance and fluid balance between the blood and tissue compartments. In shock, both the central and particularly the local mechanisms controlling microvascular perfusion are impaired. The microvascular perfusion pattern becomes permanently inhomogeneous due to lack of arteriolar vasomotion, changes of flow properties of blood, endothelial cell swelling and blood cell-endothelium interaction. Hence the objectives of primary shock therapy are to reestablish precapillary pressure, arteriolar vasomotion and to open the occluded microvascular pathways in order to reestablish the surface area needed for exchange of nutrients and drainage of waste product. These effects can not be achieved by vasoactive drugs, unless blood volume has been restored and blood fluidity improved by hemodilution. Whereas the necessary hemodilution can be achieved by conventional volume substitutes (colloids, crystalloids) restoration of vasomotion and reopening of narrowed capillaries can be obtained by small volume resuscitation using hyperosmotic/hyperoncotic salt dextran solution. The potential of this new concept for primary resuscitation and treatment of tissue ischemia is presently explored.

A porcine model of hyperdynamic endotoxemia: pattern of respiratory, macrocirculatory, and regional blood flow changes.

Systemic sepsis and multiple organ failure are frequent and often fatal complications after major surgery and trauma. In contrast to the biphasic hemodynamic pattern characteristically seen in patients, most experimental animal models have failed to reproduce the early, hyperdynamic phase of sepsis and endotoxemia. We have designed a standardized model of endotoxemia, which is elicited by continuous IV infusion of Salmonella abortus equi endotoxin in anesthetized juvenile pigs (age 8-12 weeks). The plasma concentration of endotoxin--as evaluated by the LAL test--is significantly elevated within less than half an hour following the start of endotoxin administration and is accompanied by a rapid fall of the leukocyte count in peripheral blood. High cardiac output and low systemic vascular resistance reflect a hypercirculatory state, during which left ventricular filling pressure is maintained by carefully monitored volume substitution (6% dextran 60). In the present investigation, different doses of endotoxin (3.8 and 11.4 micrograms/kg, respectively) were infused intravenously and investigated for their effect on respiratory, macrocirculatory, and regional blood flow alterations. The development of respiratory deterioration depended on the duration of endotoxin administration and on the height of endotoxin plasma levels. In all animals, a high cardiac output was maintained throughout 3.5 hr of endotoxemia. Regional blood flow to the myocardium and liver increased, whereas blood flow to the gastrointestinal tract and the spleen was compromised without difference between both groups. It is concluded that this porcine model should provide the potential for further insight into the early pathophysiological mechanisms involved in the development of multiple organ failure in patients with sepsis and endotoxemia.

Effect of intensive walking exercise on skeletal muscle blood flow in intermittent claudication.

Walking exercise is generally accepted as a valid therapeutic regimen in the treatment of peripheral arterial occlusive disease (PAOD) of Fontaine stage II. In order to quantify the effect of walking exercise and/or drug therapy on regional muscular blood flow, PAOD Fontaine stage II was induced by multiple ligations of the femoral artery and of all side branches in one hindlimb of mongrel dogs; the contralateral extremity served as control. The animals underwent walking exercise with increasing intensities on a treadmill five days per week over one year; one group received 600 mg buflomedil (BF) per day orally in addition. At the end of the training period, the regional blood flow in all skeletal muscles of both hindlimbs was quantified by means of 15 microns radioactively labeled microspheres at resting conditions, after treadmill exercise (ten minutes) with or without preinjection of BF (3 mg/kg body weight) into the abdominal aorta. At resting condition and at the end of treadmill exercise the regional muscular blood flow did not differ significantly between the diseased and control extremity. Supplementary oral treatment with BF over one year had no significant effect; the increase in muscular blood flow during treadmill exercise was not enhanced after intra-aortic injection of BF. Consequently walking exercise has the potential to increase the functional capacity of collaterals in intermittent claudication and to restore blood supply to skeletal muscle.

Pseudocolor display of regional organ blood flow determined by means of the radioactive microsphere technique.

The measurement of regional blood flow (RBF) by means of the radioactive microsphere method yields large sets of raw data. In order to display this large volume of data, we have developed a program which provides the user with a graphical illustration of RBF in different organs (e.g., heart, kidney, brain) using various projections and sections. RBF is visualized by a pseudocolor representation. This set-up enables the user to perform a semiquantitative analysis of RBF and provides a tool for the compact representation of the spatial distribution of RBF values in different parts and layers of the organs being studied. The program runs on a standard microcomputer.

Hypertonic volume therapy: feasibility in the prevention and treatment of multiple organ failure and sepsis.

Small-volume resuscitation by means of bolus infusion of hypertonic saline solutions was first applied for the primary treatment of severe hemorrhagic and traumatic shock and promptly restored central hemodynamics and regional organ blood flow. Mechanisms of action are diverse--i. maintenance of high cardiac output (direct myocardial stimulation; increase in intravascular volume); ii. maintenance of peripheral arterial vasodilation (effect of hyperosmolality; plasma volume effect) and iii. reduction of tissue edema (shifting of tissue water along the osmotic gradient). These mechanisms promote the restoration of the severely impaired microcirculation frequently seen also in sepsis. Hypertonic volume therapy has been the object of several experimental studies of acute hyperdynamic endotoxemia, however, a greater number of clinical studies have to be developed for the better understanding of the positive, and perhaps hazardous, effects of small-volume resuscitation in sepsis and multiple organ failure. The aim of this paper is to review the concepts involving such solutions, and their potential use in treatment of profound hypovolemia and microcirculatory deterioration associated with sepsis and endotoxic shock.