Pulmonary embolism and myocardial hypoxia during extracorporeal membrane oxygenation.

The treatment of a newborn with severe meconium aspiration by venoarterial extracorporeal membrane oxygenation (ECMO) was complicated by myocardial hypoxia with a marked decrease of myocardial contractility. The onset of the cardiac hypoxia was related to a pulmonary artery embolus. The origin of the embolus was a deep femoral vein thrombosis, caused by a central vein catheter, which was inserted 1 day before ECMO by venous cutdown. The possible pathophysiology of myocardial hypoxia in this patient is discussed, especially with regard to myocardial perfusion, supporting the hypothesis of coronary perfusion occuring with blood from the left ventricle and not from the arterial cannula in the aorta.

A comparison of sevoflurane with halothane in outpatient adenotomy in children with mild upper respiratory tract infections.

STUDY OBJECTIVE: To investigate the efficacy and safety of sevoflurane compared with halothane in pediatric outpatient ear-nose-throat (ENT) surgery during the induction, maintenance, emergence, and recovery of anesthesia. DESIGN: Prospective, randomized, comparative, open-label study. SETTING: ENT operating room and postoperative recovery room at a university medical center. PATIENTS: 41 ASA status I and II children between the ages of 2 to 10 years, with mild upper respiratory tract infection (URI). INTERVENTIONS: Induction and maintenance of anesthesia with either sevoflurane or halothane for outpatient adenotomy, otomicroscopy, and myringotomy. MEASUREMENTS AND MAIN RESULTS: Induction (means +/- SEM) was significantly shorter in the sevoflurane group (2.6 +/- 0.2 minutes) than in the halothane group (3.2 +/- 0.2 minutes). There was no difference between the two groups with regard to complications that occurred during the induction and maintenance period. The time to emergence and recovery was significantly shorter with sevoflurane than with halothane (means +/- SEM; time to extubation 9.9 +/- 0.98 minutes vs. 13.4 +/- 1.06 minutes, time to eye opening 12.9 +/- 1.6 minutes vs. 24.5 +/- 1.8 minutes, command response time 20.7 +/- 2.5 minutes vs. 36.4 +/- 2.8 minutes). No difference in the incidence of complications during emergence and recovery was found. Evaluation of recovery as assessed by a modified Aldrete score showed that children who had received sevoflurane reached higher scores in the first 30 minutes following the discontinuation of the anesthetic. The Pain/Discomfort Scale demonstrated a difference in the sevoflurane group, with more children being agitated and restless. CONCLUSION: Sevoflurane provides a safe and rapid anesthetic induction with no differences in complications during the induction, maintenance, and emergence period. With sevoflurane, the time of emergence and recovery was significantly shorter. The characteristics of sevoflurane as evaluated in the present study make it a suitable anesthetic in pediatric outpatient surgery even in the presence of mild URI.

[Extracorporeal membrane oxygenation of the newborn infant--an example of interdisciplinary project management]. / Extrakorporale Membranoxigenierung des Neugeborenen--ein Beispiel für interdisziplinäres Projektmanagement.

In the last three years an interdisciplinary ECMO (extracorporeal membrane oxygenation) team has been set up at the Free University of Berlin in the Steglitz clinic. With this form of management, newborns only a few hours or days old who present with pulmonary failure can temporarily be managed with extracorporeal oxygenation until normal lung function is restored. The set up of this ECMO team, starting with experimental training in animal models, to the bedside clinical use is discussed. The following presentation of the first four cases managed here with ECMO aims to clarify the problems which may be encountered as well as amplifying its use as a life-saving measure.

Safe and normothermic massive transfusions by modification of an infusion warming and pressure device.

A fluid-warming pressure infusion device (H-500/H25i, Level 1) was modified to meet the demands for safe, normothermic, and effective massive transfusions. By incorporating an autoventing 40 microns filter (Pall AV-SP), which was originally manufactured for use in an extracorporal circulation, the risk of accidental air embolism can be eliminated. Feasibility and efficiency of this model were tested in ten patients. The mean volume transfused and infused (packed red cells and colloids) was 6750 mL (SD +/- 2519) during a mean period of acute volume resuscitation of 55 minutes (SD +/- 30). Calculated flow rates averaged 140 mL/min, which were sufficient to stabilize all but one patient. This patient subsequently died because of uncontrollable surgical bleeding. Body temperature remained stable with a minimal mean drop of -0.3 degrees C. Supplying the Level 1 warming and pressure device with a Pall AV-SP filter allows for safe, effective, and demand-adapted massive transfusions in a large number of trauma patients at a reasonable cost.

The influence of lung injury due to mechanical ventilation on the initiation of ECMO.

Before the entry criteria for extracorporeal membrane oxygenation (ECMO) are met, newborns may require aggressive mechanical ventilation which may result in lung injury. The question arises whether the presence of a pneumothorax in these infants plays a role in the prognosis. Of the 21 newborns transferred to our hospital for ECMO, 8 were treated with ECMO. 9 of the 21 newborns developed a pneumothorax with conventional ventilation and 6 of these 9 newborns subsequently required ECMO. Infants who developed a pneumothorax but did not meet ECMO criteria and remained in the oxygenation index (OI) range between 25 and 40 for more than 2 days had a poorer prognosis. If adequate oxygenation cannot be attained with acceptable mechanical ventilation and a more aggressive ventilation results in a pneumothorax, ECMO should be considered even if the oxygenation index is below 40.

[A device for patient-controlled intranasal analgesia (PCINA).]. / Ein neues Gerät zur patientenkontrollierten intranasalen Analgesie.

INTRODUCTION: It has been demonstrated that intranasal opioid titration has a rapid onset of action and can provide satisfactory management of postoperative pain [10, 12, 14]. In these studies the intranasal titration was carried out by the investigator. Self-administration of an opioid intranasally by patients requires a spray bottle with safety precautions of an equivalent standard to those offered by an intravenous PCA device. We describe a device for patient-controlled intranasal analgesia (PCINA) that meets these safety requirements. METHODS: The Baxter PCA on demand system consists of a mechanically driven infusor, a flow restrictor, and a patient control module for bolus administration. The flow restrictor provides a flow rate of 5 ml/h or 2 ml/h. This Baxter intravenous PCA system has been subjected to a slight modification to adapt it for PCINA. The patient control module has a bolus volume of 0.5 ml and in this modification it is attached, instead of to an intravenous line, to a narrow, 26-gauge plastic cannula with the needle tip removed (Fig. 1). To check the accuracy of the volume delivered, three PCINA devices with a flow rate of 5 ml/h (filling time of 6 min for the 0.5-ml bolus volume) and three PCINA devices with a flow rate of 2 ml/h (filling time of 15 min for the 0.5-ml bolus volume) were examined at defined time intervals. The PCINA devices were filled with distilled water and the volume demanded was immediately determined by means of a high-precision scale. Three determinations of the volumes delivered were performed. In an initial unblinded pilot observation in five orthopaedic patients, PCINA (for a 4-h period) was compared with the conventionally prescribed pain medication (for a subsequent 5-h period). For intranasal opioid administration, fentanyl (1 ml=0.05 mg) was used. At every evaluation point, pain intensity was evaluated with the aid of a 101-point numerical rating scale (0 = no pain, 100 = worst pain possible). At the end of both examination periods (PCINA/conventionally prescribed pain medication), overall patient satisfaction with the method of pain management experienced was evaluated (graded: very good, good, satisfactory, bad, very bad, not acceptable). RESULTS: The volumes delivered from the three PCINA devices with a flow rate of 5 ml/h (PCINA device 6') and from the three PCINA devices with a flow rate of 2 ml/h (PCINA device 15') are presented in Fig. 4. The subjective pain intensities measured with the 101-point numerical rating scale are demonstrated in Fig. 5. The patients used 0.28+/-0.097 mg fentanyl (0.15-0.45 mg) during the 4-h period of PCINA. No patients had any difficulty using the PCINA device. No technical problems arose with any of the devices. No patient complained of intranasal pain or burning during or after nasal administration. At the end of the study overall patient satisfaction with PCINA was judged as very good (2 patients), good 2 patients) or satisfactory (1 patient). The relief obtained with the customarily prescribed pain medication was judged as satisfactory (1 patient) or bad (4 patients). CONCLUSION: We conclude that the PCINA device presented fulfils the PCA device safety requirements. The bolus volume delivered by the device is precise and follows the manufacturer's specifications for flow rate and bolus volume. Initial.

[The value and limits of endorectal sonography in the preoperative stage classification of rectal cancer]. / Wert und Grenzen der endorektalen Sonographie in der präoperativen Stadieneinteilung des Rektumkarzinoms.

The article deals with the valuation of endorectal and abdominal sonography in preoperative staging of rectal carcinoma. Data processing of 40 patients suffering from tumours of the rectum examined rectoscopically, by biopsy and via sonography showed that endorectal sonography can achieve preoperative staging (T) with a sensitivity of 89%, a specificity of 100%, a positive predictive value of 89% and a negative predictive value of 100%, the overall accuracy being 81%. Identification of pararectal adenopathies can be performed with a sensitivity of 16% and a specificity of 100%. Liver metastases were determined with a sensitivity and specificity of 100%. Hence, endorectal sonography is a valuable method for preoperative staging of carcinoma of the rectum.

[Cystic echinococcosis of the liver--problems of ultrasound diagnosis]. / Die zystische Echinokokkose der Leber--Probleme der Ultraschalldiagnostik.

The authors examined 100 patients with a total of 119 cysts of the liver. The diagnosis was subsequently confirmed via scintigraphy, radiology and laparotomy. This paper reports on a sonographic analysis of cystic echinococcosis of the liver, its sonographically demonstrable types, structures and complications and their differential diagnosis. In 58% of the cases the classical aspect of cystic echinococcosis was seen (Type A). 22.7% of the cases pointed toward a sediment within the cyst (Type B). 8.4% of the cysts were septated (Type C), whereas 6.7% had daughter cysts (Type D). However, only 4.2% of the cysts were important for differential diagnosis, since they had to be set off against other space-occupying growths on account of their solid tumorous structure.