Telemetric monitoring of tracheal pressure after tracheal occlusion for treatment of severe congenital diaphragmatic hernia.

INTRODUCTION: Prenatal tracheal occlusion using endoscopic techniques obstructs the normal egress of lung fluid during pulmonary development and stimulates lung growth in cases of congenital diaphragmatic hernia (CDH). Although FETO might be an effective strategy for treatment of CDH, the mechanism especially due to the supposed increasing transpulmonary pressure is unknown. OBJECTIVE: The purpose of this study was to monitor the pressure below the attached balloon in the fetal lamb telemetrically. METHODS: Four time-dated pregnant Merino ewes underwent fetal and maternal surgery. A special prepared silicone catheter was placed below the epiglottis by laryngoscopy on day 110 or 140 of gestation. The tracheal pressure below the fixed catheter could be monitored telemetrically using the Data Sciences TA11-PA-C40 pressure device. Hundred and twenty measurement points were recorded over a period of 2 min. RESULTS: A maximum of lung pressure rate was found immediately after implantation (23.7 +/- 4.6 mm Hg). During the first hour, the pressure decreased to an average value of 16.9 mmHg. About 70 h after the block, this value decreased to a minimum level of 8.3 +/- 0.4 mmHg. CONCLUSION: Decreasing pressure variation might indicate that lung growth has stopped and that the ideal point of time to remove the balloon is achieved. Increasing pressure has to be related to the morphometric analysis of the lung's structural development and maturation, comparing the efficacy of FETO in preventing or reversing pulmonary hypoplasia. Further investigation of continuous telemetric monitoring of tracheal pressure in the fetal lamb is required.

Evaluation of the development of lung hypoplasia in the premature lamb.

BACKGROUND: The death rate from human diaphragmatic hernia (CDH) ranges from 50 to 80%, mainly due to the associated lung hypoplasia. To prevent these irreversible pathological and physical defects, the question of intrauterine surgical intervention arises. The histological changes of the lung tissue after inducement of a diaphragmatic hernia were examined. Of special interest was the time elapsing until the development of lung hypoplasia. METHODS: A model of intrauterine inducement of diaphragmatic hernia was established using five fetal lambs to study consecutive pulmonary hypoplasia. Inducement of a diaphragmatic hernia was undertaken between 105 and 108 days' gestation. Lung tissue was examined histologically on postoperative days 8, 17, 21, 22, and 25 after inducement of the defect. RESULTS: On postoperative days 8, 17, and 21, no signs of pulmonary hypoplasia were found on histological examination. A pulmonary hypoplasia was found in two fetuses (on the 22nd and 25th postoperative day). The pathological and anatomical examination of a unilateral pulmonary hypoplasia after a short period of time shows that the artificially created diaphragmatic defect is a good model for producing a congenital diaphragmatic hernia. DISCUSSION: The severity of the pulmonary hypoplasia is related to the duration of lung compression by the herniated organs. The time elapsing until the development of lung hypoplasia is shorter than expected. Tracheal occlusion seems to be an effective strategy for treatment of the defect CDH, but the best technique for achieving occlusion, and particularly the ideal point in time to carry out "Fetendo," are unknown. Further research into this congenital illness is required in order to treat it.

[Plasma cholinesterase variations as a result of prolonged neuromuscular blockade. Review and problems encountered in two cases of prolonged neuromuscular blockade after muscle relaxation with succinylcholine as compared to mivacurium]. / Plasmacholinesterasevarianten als Ursache prolongierter neuromuskulärer Blockaden. Ubersicht und Problemdarstellung anhand zweier Fallberichte prolongierter neuromuskulärer Blockaden nach Muskelrelaxation mit Succinylbischolin bzw. Mivacurium.

Succinylcholine and mivacurium are degraded more slowly in patients with a qualitatively or quantitatively reduced plasma cholinesterase and are therefore known for inducing a prolonged postoperative apnea. Perioperative laboratory screening even including plasma cholinesterase activity testing will not prevent this due to a possible aberration only in the qualitative cholinesterase activity. This is illustrated by introducing two cases reports of prolonged apnea after administration of mivacurium or succinylcholine. The pathophysiology of plasma cholinesterase is reviewed including genetically determined variants and the degradation pathways of mivacurium and succinylcholine. Only extensive laboratory chemical tests are sufficient to prevent this possible complication. Due to the rare incidence there is no evidence for recommending these laboratory investigations in all patients. Once prolonged apnea occurs following the administration of mivacurium or succinylcholine the best choice is ongoing ventilation combined with a sufficient sedation.

ARDS in fulminant ornithosis and treatment with extracorporeal lung assist.

We report a 47-year-old male patient with fulminant ornithosis who developed severe respiratory failure leading to acute respiratory distress syndrome (ARDS) complicated by gastrointestinal, neurological and renal symptoms. ARDS was successfully treated by extracorporeal lung assist. As leukocytosis is typically absent in ornithosis, C-reactive protein, interleukin 6 and procalcitonin were used as infection parameters in order to monitor clinical development. The English-language literature on severe cases of ornithosis requiring respiratory support over the past 30 years is reviewed.

Comparison of Solvent/Detergent-Inactivated Plasma and Fresh Frozen Plasma under Routine Clinical Conditions.

Background: Reduced levels of protein S (PS) and alpha(2)-antiplasmin alpha(2)-AP) in solvent/detergent virus-inactivated plasma (S/D-VIP) might induce an imbalance of plasma coagulation factors and inhibitors in patients transfused. We investigated 40 patients (23 fresh frozen plasma (FFP), 17 S/D-VIP, random distribution by a list calculated by statisticians) who suffered from dilution coagulopathy, liver disease, disseminated intravascular coagulation (DIC), polytrauma or were connected to extracorporeal circulation. Study Design and Methods: The following markers of activated coagulation (MAC) were measured: Prothrombin fragment F1+2 (F1+2), fibrin monomers (FM), D-dimers (DD), thrombin-antithrombin (TAT) and plasmin-antiplasmin (PAP) complexes as well as fibrinogen degradation products (FgDP), and additionally antithrombin III (antithrombin), protein C (PC), PS and alpha(2)-AP. Blood was taken only just before and 1 h after the first plasma replacement (2 units). No additional blood products were transfused before the second blood withdrawal. Pre- and posttransfusion (pre/post) values of all parameters measured were compared within the same group and between both groups. Statistical evaluation of the data was done by Wilcoxon's paired test for data in the same plasma group and by the test of Mann and Whitney for data comparison between both plasma groups. Results: Average pretransfusion values of all inhibitors for both plasma groups were in the same range and increased after transfusion, except for PS in both groups. Whereas the pre/post values did not differ significantly in the FFP group, antithrombin (p = 0.02), PC (p = 0.0005), and alpha(2)-AP (p = 0.02) showed a significantly higher increase in the S/D-VIP group. Considering the pre/post differences between both plasma groups, there were no significant differences. The same was true for MAC measured pre- and posttransfusion. Conclusion: Data showed no significant difference between both plasma groups, indicating that S/D-VIP plasma behaves as FFP under the study conditions employed. Copyright 2000 S. Karger GmbH, Freiburg

[Intra- and postoperative airway management of tracheal carina ruptures from bilateral endobronchial intubation]. / Intra- und postoperatives Airway-Management karinanaher Trachealrupturen über bilaterale endobronchiale Intubation.

OBJECTIVE: Carina near tracheal ruptures following blunt chest trauma or endotracheal intubation are rare, but lifethreatening events. Both early diagnosis by fibreoptic bronchoscopy and immediate surgical treatment are essential. There is no uniform recommendation for airway-management concerning the tube. Standard tracheal- and double-lumen tubes position the cuff at the site of the injury and tracheostomy tubes are too short to protect the lesion from positive airway pressure. We discuss the causes, diagnosis, and treatment of tracheal ruptures, reviewing the recent literature. METHODS: We analysed data from three female patients who sustained carina near tracheal ruptures. They underwent selective endobronchial intubation with two tubes, both under fibreoptic control. Following the surgical repair the tubes were then introduced via tracheostomy. Because of severe respiratory failure (aspiration pneumonia, mediastinitis, status asthmaicus, ARDS) independent lung ventilation was performed for 9-14 days. Obviously the fixation of the tubes is most essential and their correct position was confirmed by daily fibreoptic or radiologic control. Then a single tracheostomy tube was inserted. RESULTS: The patients respiratory functions improved and they were discharged from ICU after 21-36 days, breathing spontaneously with closed tracheostoma. No long-term complications were noted. CONCLUSION: Maintaining the safety procedures the bilateral endobronchial intubation is an important and successful method in carina near tracheal rupture, perioperatively and for long-term ventilation.

[When should a patient with severe acute respiratory distress syndrome (ARDS) be transferred to a specialized hospital?]. / Wann soll ein Patient mit einem schweren akuten Lungenversagen (ARDS) in ein spezialisiertes Zentrum verlegt werden?

The mortality rate for the advanced adult respiratory distress syndrome is still high. Nevertheless there are recent publications showing decreasing incidence and an improving survival rate. This is due to early diagnosis as well as differentiated treatment concepts. The use of special therapy methods including extracorporal gas exchange is only possible at specialized centres. This raises the question as to the right timing of the transfer of those ARDS-patients, whose lungs cannot be cured by the therapy standards practiced locally. In a prospective study, all requests for transfer were noted over a period of 36 months (1992 to 1994) and analyzed by a hospital with a special ward for ARDS. In a total of 469 patients the most prominent predisposing diseases were community-acquired pneumonia (26.3%), followed by multiple trauma (24.4%), the postoperative conditions of systemic inflammatory response syndrome (SIRS) or sepsis (21.3%), bronchopulmonary aspiration (5.8%), and status asthmaticus (2.6%). With a mean preventilation time of 9.5 +/- 9 days and a mean ventilatory peak pressure of 39 +/- 8 cm H2O there was a mean oxygenation index (Horrowitz Index) of 95 (+/- 40) mm Hg. The mean Smith and Gordon Ventilator Score was 82.3 (+/- 12.8) and the mean PIF rate (Benzer Score) 12 (+/- 8.6), 121 out of 469 patients were transferred for further specialized therapy. 75 patients were treated on a conventional basis and 46 patients had to be treated with extracorporal lung assistance (ELA) because conventional treatment failed. The mortality rate was 22.3% altogether, in the group with the conventional treatment 16.0% and 32.6% in the group with ELA. As there are no generally accepted guidelines for the transfer of patients with ARDS to specialized centres, an indication for such a transfer must be established taking into consideration the individual patient history. Very early contact with the specialized centre of choice is recommended.

[Rett's syndrome: pathophysiology and anesthesiological implications]. / Das Rett-Syndrom: Pathophysiologie und anästhesiologische Implikationen, dargestellt anhand eines Fallbeispiels.

Rett's syndrome is a neurodevelopmental disorder which is caused by a mutation on the x-chromosome; thus, it only affects the female sex. After seemingly normal postnatal development affected girls lose already acquired mental, motoric and social skills. The last stage of the syndrome is characterized by microcephaly, severe mental retardation, spastic paraparesis, epilepsia, respiratory dysrhythmia, neurogenic scoliosis, abnormal joint alignment and muscle contractures. Rett's syndrome is probably the leading cause for progressive mental retardation in girls, but still it is relatively unknown. This paper describes Rett syndrome and its pathophysiology. The following case report discusses special anesthesiological implications due to the immature cardiorespiratory system and describes a coagulation disorder following treatment with valproic acid.

[Epidemiology, clinical aspects and prognosis of severe progressive community-acquired pneumonia]. / Epidemiologie, Klinik und Prognose schwerstgradiger Verlaufsformen ambulant erworbener Pneumonien.

BACKGROUND: Community-acquired pneumonia can lead to acute lung failure (parapneumonic ARDS) if the course is very severe. The clinical picture reflects a rapidly progressive and potentially fatal respiratory failure. Only occasional cases in which the clinical courses of community-acquired pneumonia lead to acute respiratory failure have been reported so far. The investigation was based on the observation that very severe progressive forms of community-acquired pneumonia are at present one of the most frequent conditions triggering ARDS. PATIENTS AND METHODS: A total of 66 patients of both sexes with an average age of 34 +/- 11 years were included in the retrospective investigation. The patients had been secondarily referred to the center for further treatment. After admission, the further course of the disease was recorded at five defined times (day of admission, 2nd day, 7th day, 14th day and day of spontaneous breathing or day of death). The degree of disturbance of pulmonary function was registered with the scores of Morel and Murray. Further disorders of organ function were evaluated with the MOF score according to Goris, the "Definition Multiple disorder of Organ Function (DeMOF)" and the appraisal of the severity of the systemic inflammatory reaction with the sepsis score according to Elebute & Stoner. RESULTS: The duration of preclinical disease was 6 +/- 4 days and the duration of the pretreatment in the referring hospital was 10 +/- 10 days. A potential primary causative organism (bacteria n = 18, viruses n = 5, "atypical" pathogens n = 6, Candida species n = 4) could be isolated in 50% of the patients. A pre-existing underlying disease was found in 48% of cases. With a total lethality of 31%, this was affected neither by knowledge of the primary causative organism nor by previous diseases. The patients who died did so with improved lung function in a complete clinical picture of multiorgan failure. At the time of admission, 91% of the patients had severe ARDS (Morel III and IV). An improvement of lung function could be demonstrated between the day of admission and the second day of treatment both with the score according to Morel and according to Murray (p < 0.05). For the second day of treatment, a difference could be shown between the patients who survived and those who died (p < 0.05). Owing to the systemic inflammatory reactions, a multiorgan functional disorder was found in 89% of the patients. There were the following findings with regard to the prognostic predictions from the score used: those who died and those who survived could be correctly differentiated with the DeMOF score from the 7th day of treatment and the sepsis from the 7th day of treatment and with the score of Goris from the 14th day of treatment after referral. CONCLUSIONS: The investigation proves that the most severe progressive forms of community-acquired pneumonia also occur both in patients who have previously appeared to be healthy and in younger patients. Despite the use of differentiated treatment measures, these illnesses are subject to a relatively high lethality. The results underscore the need for causal treatment of systemic inflammatory reaction, which is the most important problem in treatment of parapneumonic ARDS.

Elimination of drugs by the new polyamide hemofilter FH77H during various in vitro conditions.

BACKGROUND/AIMS: Multiple organ failure alters the dosage of drugs during hemofiltration. To separate factors, we utilized in vitro hemofiltration to investigate different blood flows, protein concentrations and intracellular drug partition with the FH77H polyamide membrane. METHODS: One liter of warm heparinized fresh human blood was hemofiltrated in two series: (1) with digoxin, netilmycin, phenobarbital, ceftriaxone and teicoplanin, and (2) with amikacin, theophylline, ceftazidim, phenytoin and vancomycin and, in addition, with cell-free fresh frozen plasma. RESULTS: The increased volumes of distribution of aminoglycosides and theophylline were a combined result of partition into cells and adsorption into the filter membrane. The deviations of drug sieving from predicted values were due to different affinities of the drugs on whole blood binding sites. CONCLUSION: The in vitro composition of drugs and blood improved the detection of factors that influence drug elimination during hemofiltration. The FH77H polyamide hemofilter facilitates more precise predictions of drug dosages by low adsorption rates to the membrane.

["Treatment of total atelectasis of the left lung in severe ARDS with side-separated ventilation and surfactant administration"]. / "Behandlung einer Totalatelektase der linken Lunge bei schwerem ARDS mit seitengetrennter Beatmung und Surfactant-Applikation."

Severe thoracic trauma is always an important risk factor for the development of acute pulmonary failure. The course is often complicated by barotrauma or volutrauma. We report on a 48-year-old patient who was transferred to us nine days after a bicycle accident because of a severe disturbance of gas exchange and atelectasis of the left lung refractory to therapy. The left lung could not be ventilated even after separate artificial ventilation on each side with positive end expiratory pressure. After administration of surfactant (50 mg Exosurf per kg body weight) and continued separate artificial ventilation on each side, there was a complete re-expansion of the left lung with an increase of the arterial pO2 value from 65 mm Hg to 416 mm Hg with a FIO2 of 1,0 and a decrease of the intrapulmonary venous admixture from 34% to 12% within a few hours. The extravascular pulmonary fluid was unaffected by the administration of surfactant (200 ml solution). The administration of surfactant preparations may be a new therapeutic approach in treatment of ARDS patients.

[Can preoperative lung function diagnosis detect risk of intraoperative pulmonary gas exchange insufficiency in artificial hip replacement with polymethylmethacrylate cement?]. / Lässt die präoperative Lungenfunktionsdiagnostik das Risiko intraoperativer pulmonaler Gasaustauschstörungen in der Hüftendoprothetik mit Polymethylmetacrylat-Zement erkennen?

In a study of 90 patients in whom a hipjoint had been replaced for the first time using polymethylmetacrylate cement, the extent of intraoperative pulmonary gas exchange disorders was established. The effect of a preexisting disorder of lung function was determined. We checked whether an appraisal of the risk patients who are operated on can be assisted by a preoperative analysis of lung function. After preoperative diagnosis of lung function, the arterial blood gases were analysed at defined times during the operation. An intraoperative fall in the partial pressure of oxygen and an increase in carbon dioxide partial pressure in the arterial blood were found in all patients. There were pronounced interindividual differences in the extent of the disorder of pulmonary gas exchange. The degree of severity of the respective acute disorder of lung function did not show any correlation with the pre-existing disorder of pulmonary ventilation. Major hemodynamic changes were not observed. According to the present findings, a definitive statement with regard to the degree of severity of intraoperatively occurring disorders of pulmonary function cannot be expected from a preoperative analysis of pulmonary function.

[Treatment of acute pulmonary infection in a mucoviscidosis patient with extracorporeal lung support]. / Behandlung eines akuten pulmonalen Infektes bei einem Mukoviszidose-Patienten mittels extrakorporaler Lungenunterstützung.

This is a report on a mucoviscidosis patient of 30 years of age suffering from refractory acute failure of pulmonary function during acute exacerbation of an infection with Pseudomonas aeruginosa. To avoid further barotraumatisation of the lungs due to continually increasing artificial respiratory pressure, and to set the lung at rest until subsidence of a concomitant severe bronchial obstruction, we performed modified extracorporal lung assist (ELA). The gas exchange improved rapidly with the help of relevant accompanying measures (including negative liquid balance, administration of antibiotics, etc.) and the pulmonary infection also subsided to a major extent. 26 days after the end of the bypass the patient could be transferred for lung transplantation.

[Determinations by indirect calorimetry need not be expensive and technically complicated. A new measurement system and its validation]. / Die Bestimmung der indirekten Kalorimetrie muss nicht teuer und technisch aufwendig sein. Ein neues Messsystem und seine Validierung.

Presentation of a newly conceived measuring instrument to determine the energy expenditure of critically ill patients at the bedside by means of indirect calorimetry. The special advantages of the measuring instruments are easy handling, little maintenance and very low working expenses and prime costs. The accuracy of measurement is considerable nd is comparable with that of other measuring methods, as has been established by an extensive validation.