[Introduction of Prehospital Emergency Ultrasound into an Emergency Medical Service Area]. / Einführung der präklinischen Notfallsonographie in einem ländlichen Notarztdienst-Bereich.

BACKGROUND: Emergency ultrasound as part of the provision of emergency medical services using mobile devices offers great benefits regarding to some important questions related to the management of critically ill and injured patients in the prehospital situation where diagnostic resources are limited. The aim of this study is to determine whether the comprehensive introduction of prehospital emergency ultrasound examinations into a German Emergency Medical Services ("rescue services") area is both feasible and beneficial for patients. METHODS: All emergency physicians at a rural emergency physician base were trained in emergency ultrasound scanning techniques (FAST, FEEL, 14 h of instruction), followed by regular weekly training sessions of approximately 30 min. Over a period of 12 months, prehospital ultrasound examinations performed during emergency physician callouts at this base were documented and analysed. RESULTS: A total of 87 emergency ultrasound examinations were performed during 1343 callouts. Among these, focussed assessment with sonography for trauma (FAST) was performed in 35 patients (40.2%) and focused echocardiography in emergency life support (FEEL) in 41 patients (47.1%). In 11 patients (12.6%), ultrasound scans were performed for other indications (e. g. to rule out urinary tract obstruction in a case of flank pain). One trauma patient's life was saved by the decision to transport him to the nearest hospital and once there directly to the operating room, based on the ultrasound finding of significant free intra-abdominal fluid (ruptured spleen and liver). CONCLUSION: Prehospital emergency ultrasound can be introduced into an emergency medical service area as a diagnostic modality that provides benefits to patients. Emergency physicians have to be specifically trained and to participate in continuous education activities. Especially in rural areas with longer transport routes and journey times, the early diagnosis of for example massive intra-abdominal bleeding is critical for the patient's prognosis.

Comparison of breathing tube connectors during invasive bronchial procedures.

Bronchoscopy and bronchial suctioning during intra-operative artificial ventilation often causes leakage from the ventilation circuit with a decrease in ventilatory parameters and possible workplace contamination with anaesthetic gases. Different connectors have been developed to reduce gas leakage. We evaluated the following connectors : VBM 2 mm, 3 mm and 5 mm, Bodai Suction-Safe, Bodai Bronch-Safe and Bodai Trach-Safe, as well as the BE 105-7, BE 105-8 and SH 7-45. Invasive bronchial instruments (catheters, bronchoscopes and bronchial blockers) with 1.67-7.33 mm diameter were used. Pressure-controlled ventilation was performed on a test lung using a ventilator. Sevoflurane concentration in the room was measured 0.2 and 1.5 m from the connector using a photo-acoustic infrared-spectroscope. The VBM connectors caused the least gas leak and ensured stability of ventilation parameters even at peak pressures when combined with smaller instruments. With instruments > 6 mm, BE 105-7, BE 105-8 and SH 7-45 connectors performed best. The Bodai connectors showed a reduced ability to prevent leakage and to keep ventilatory parameters stable. All connectors, excluding the Bodai Trach-Safe, prevented exposure to anaesthetic gases beyond the current safety recommendations when combined with the fitting instruments. The connectors showed different ranges of tightness, equivalent to different ranges of compatibility with the instruments used.

[Are there pulmonary vascular or respiratory effects of prostaglandin vehicles (ethanol, glycine buffer) after intravenous infusion or inhalation?]. / Verursacht die Infusion oder Inhalation von Prostaglandin-Trägerlösungen (Athanol, Glycin-Puffer) pulmonalvaskuläre oder respiratorische Effekte?

BACKGROUND: Infusion or inhalation of prostaglandins PGE1 and PGI2 is used to reduce vascular resistance. PGE1 and PGI2 are dissolved in ethanol and glycine buffer, respectively. Each vehicle may cause dose-dependent haemodynamic and respiratory side effects. This study was performed to examine the role of low-dose ethanol and glycine buffer as used for the infusion and inhalation of PGE1 and PGI2. METHODS: Two groups of pigs (ethanol and glycine group, n = 9 each) were anaesthetised and ventilated mechanically. Ethanol was given at 0.14 mg/kg/min by infusion and 0.12 mg/kg/min as aerosol, glycine buffer was infused at 3.8 microg/kg/min and inhaled at 3.1 microg/kg/min, respectively. Haemodynamic and respiratory data were recorded before and after application. RESULTS: Neither infusion nor inhalation of ethanol or glycine buffer caused significant changes in systemic and pulmonary haemodynamics, right heart function, oxygenation or ventilation. CONCLUSIONS: The effect of inhaled or intravenously infused PGE1 and PGI2 is not influenced by their preparations containing ethanol or glycine buffer.

[Evaluation of blood and breath alcohol measurement in patients with hepatocellular carcinoma during procedures in intubated patients with percutaneous ethanol instillation]. / Vergleich von Blut- und Atemalkoholkonzentrationen während der perkutanen Athanolinstillationstherapie (PEIT) bei intubierten Patienten mit hepatozellulärem Karzinom.

The accuracy of breath alcohol measurements in intubated patients with assisted ventilation was evaluated. The breath alcohol concentration was measured in 24 patients undergoing percutaneous alcohol injection therapy for hepatocellular carcinoma with Alcotest 7410 med, from Dräger, Germany. The blood ethanol concentrations (BACs) were determined in each blood serum applying the German forensic criteria standard, namely, two alcohol dehydrogenase (ADH) and two gas chromatography (GC) measurements. The blood alcohol concentrations were between 0.07 and 1.51 per thousand in the central venous samples and 0.02-1.66 per thousand in the arterial samples. An excellent correlation between both the venous and arterial blood alcohol concentrations (r2=0.94), as well as between the breath alcohol concentrations and the venous (r2=0.84) or arterial alcohol concentration (r2=0.89), p<0.01 for both parameters was revealed. Determination of breath alcohol concentration using the Alcotest in intubated patients is reliable and reflects the blood alcohol values.

Esomeprazole for the prevention of postoperative nausea and vomiting. A randomized, placebo-controlled trial.

BACKGROUND: Postoperative nausea and vomiting still represents a major problem after surgery. Although risk factors for postoperative nausea and vomiting and procedures to reduce postoperative nausea and vomiting have been described, the incidence of postoperative nausea and vomiting remains high. The aim of the present study was to investigate the potential role of the proton pump inhibitor esomeprazole to reduce postoperative nausea and vomiting after elective surgery. METHODS: In a randomized, double-blind trial, ASA I-III patients at high risk for postoperative nausea and vomiting received esomeprazole tablets 3 x 40 mg or matching placebo the evening before surgery, 2 h preoperatively and 24 h postoperatively. Total intravenous anaesthesia with propofol and remifentanil without nitrous oxide (FiO2 0.5) was used. Patients were interviewed using a standardized postoperative nausea and vomiting questionnaire at discharge from the post-anaesthesia care unit, 6 h and 24 h later. The severity of nausea was estimated on a 0-100 point numerical scale (0 = no nausea, 100 = maximum nausea). RESULTS: The incidence of vomiting was similar in the esomeprazole (n = 45) and the placebo (n = 48) groups (64.4% vs. 60.5%, P > 0.05). The average nausea score was 17.8 with esomeprazole and was 18.7 with placebo (P > 0.05). Only 24.7% of all patients (esomeprazole 24.4%, placebo 25.0%) did not experience any nausea or vomiting. CONCLUSION: There is no evidence that prophylactic esomeprazole reduces the incidence of postoperative nausea and vomiting or the degree of postoperative nausea.

Postoperative nausea and vomiting (PONV) : usefulness of the Apfel-score for identification of high risk patients for PONV.

OBJECTIVE: Postoperative nausea and vomiting (PONV) still represent an important problem in surgery. Treatment and prevention of PONV requires accurate risk stratification. The simplified Apfel-score includes the four factors female gender, no smoking, postoperative use of opioides and previous PONV or motion-sickness in patients' history. Each of these risk factors is supposed to elevate the PONV-incidence about 20%. The aim of the study was to validate this clinical risk assessment score in patients with high risk for PONV. METHODS: In a prospective study 93 patients with high risk preoperative score for PONV (Apfel Score III and IV) were analyzed. Patients and nurses were interviewed using a standardized questionnaire at the time of discharge from the post-anesthesia care unit (PACU) as well as 6 hours and 24 hours after admission to the PACU. General anaesthesia was applied as total intravenous anaesthesia (TIVA) with mivacurium, propofol and remifentanil (no nitrous oxide / FI 02 0.5) RESULTS: In the group with Apfel score III PONV occurred in 59.7% of patients and in the Apfel score group IV in 91.3% of all patients. The incidence of PONV corresponds to the predicted values of 60% for Apfel III and 80% for Apfel IV although the use of TIVA should have reduced the incidence of PONV about 26%. This apparent overestimation could be explained by the frequent questioning of patients and nurses for PONV leading to assessment of very minor symptoms. CONCLUSION: The Apfel-score is a useful and simple tool for stratification of patients with high risk for PONV.

[Assessment of anesthesia methods in ophthalmologic surgery by patients, surgeons, and anesthesiologists]. / Bewertung von Narkoseverfahren in der Ophthalmochirurgie durch Patienten, Operateur und Anästhesisten.

BACKGROUND: The purpose of this study was to evaluate anesthesia methods in ophthalmic surgery in elderly people assessed by patients, surgeon, and anesthesiologist using subjective rating scales. PATIENTS AND METHODS: In a prospective, randomized study we compared in 52 (26 vs 26) elderly patients (ASA II and III, mean age 78.7+/-8.6 years) undergoing a cataract operation the satisfaction perceived by patients, surgeons, and anesthesiologists in relation to anesthesia methods [intravenous anesthesia (TIVA) vs balanced anesthesia (BA)] based on a score from 1=best to 6=worse. RESULTS: Patient satisfaction was better in the TIVA group (1.65) than in the patients treated with BA (2.57), p<0.001. Surgeons perceived no difference (BA 1.15/TIVA 1.07). Anesthesiologists preferred TIVA (TIVA 1.5/BA 3.23), p<0.001. CONCLUSION: In this study patients and anesthesiologists preferred TIVA. There was no difference between TIVA and BA as seen by the surgeon.

[Excessive blood loss after abdominal hysterectomy -- use of recombinant factor VIIa]. / Massive Blutung nach Hysterektomie -- Einsatz von rekombinantem Faktor VIIa.

MEDICAL HISTORY: A 38-yr-old woman suffered from excessive blood loss after elective removal of the uterus because of a leiomyoma. The surgical attempt to stop the bleeding failed. The laboratory evaluation before surgery showed normal coagulation parameters (aPTT 23.4 sec, TPZ > 100 %, platelet count 267 000/microl). DEVELOPMENT: Despite treatment with the plasminogen activator inhibitor Tranexamic Acid (2 x 500 mg) and 10 units of concentrated platelets as well as 31 units of fresh frozen plasma and 31 units of red blood cell concentrates the bleeding continued. Reaching an cumulative blood loss of 15 000 ml the patient developed ventricular fibrillation necessitating cardiac resuscitation including defibrillation and application of epinephrine 7 mg. At this point systolic blood pressure decreased from 90 to 70 mm Hg, the core temperature was 31,9 degrees C. After successful resuscitation (systolic blood-pressure 90 mm Hg after 15 min) the bleeding started again with a blood loss of 2000 ml requiring 3 units of fresh frozen plasma and 3 red cell concentrates Use of recombinant activated Factor VII (r.FVIIa): 6 mg (300 KiU) r.FVIIa have been applied (92 microg/kgKG [4.6 KiE/kg]). Within 10 minutes the bleeding stopped. More transfusions were not necessary. The patient left the intensive care unit 8 days after the operation without neurological deficit. CONCLUSION: The use of recombinant Factor VIIa may stop excessive haemorrhage, even if the cause is unknown.

[Anaesthesia in cataract surgery for elderly people]. / Narkoseverfahren in der Kataraktchirurgie bei geriatrischen Patienten - Patientensicherheit, Aufwachverhalten, Patientenzufriedenheit und Kosten im Vergleich der "Totalen Intravenösen Anästhesie" mit der "Balancierten Anästhesie" -

OBJECTIVE: In the cataract surgery the problems of anaesthesia in ophthalmo-surgery and anaesthesia in elderly people are combined. For this patients we compared intravenous anaesthesia with balanced anaesthesia in cardiac and circulatory side effects (security), patients satisfaction and costs. METHODS: In a prospective, randomised study we compared in 52 (26 vs. 26) elderly patients (ASA II and III, mean age 78.7 +/- 8.6 years) undergoing a cataract operation cardiac and circulatory side effects, recovery time and patients satisfaction with the either type of anaesthesia by a score from 1 = best to 6 = worse and the occurrence of nausea/vomiting (controlled 24 h). The difference in costs were measured by the hospital management. RESULTS: Cardiac and circulatory side effects with hypotonic reactions were similar in both groups (TIVA 18 = 69.2 %/BA 20 = 76.9 %). Hypertonic reactions were mainly seen in BA (Tiva 1.9 %, BA 69.2 %/p < 0,001). There was no problem in the treatment of these side-effects. The frequency of postoperative nausea and vomiting was lower (but not significantly) in the TIVA group (TIVA 8 %/ BA 27 %) than in the BA group (7 and 4). The recovery times were shorter (p < 0.001) in TIVA, those patients were staying 24 (+/- 6.70) minutes in the post operative unit vs. 59 (+/- 28.83) minutes in BA. Patients satisfaction was better in the TIVA-group (1.65) than in the patients treated with BA. In the calculation of costs there was a disadvantage in BA. CONCLUSIONS: This study showed, that in respect of cardiac and respiratory side effects TIVA and BA are safe methods in anaesthesia for elderly people in ophthalmic surgery. Nevertheless, because of shorter recovery-times, lower incidence of hypertonic reactiones, more patients satisfaction and lower costs TIVA had better results in this study. We have to ask for the evaluation of economy in anaesthesia that not only prices of medicaments but the complete costs of the cases have to be calculated.

[Inflammatory syndrome after endovascular implantation of an aortic stent--a comparative study]. / Inflammatorisches Syndrom nach endovaskulären Aortenstentimplantationen--Eine vergleichende Studie.

Immunological changes as described in endovascular aortic aneurysm repair are not yet fully understood. In several studies this reaction (leukocytosis, fever, high CRP levels) is named as a "postimplantation syndrome". In our study we could show that in the first week after endovascular aortic aneurysm surgery complex immunological changes occur. But these changes do not quantitatively differ from those seen in open aortic aneurysm surgery. Fever (38 degrees C) was apparent in almost all patients. White blood cell count rose up to 10.6 (+/- 0.84) G/L during the first days. CRP, one of the acute phase proteins, was elevated with the maximum on postoperative day 2. Only the open operated patients had elevated alpha 1-antitrypsin levels from the second postoperative day on. IL-6 synthesis was increased in both groups, with an elevation in group B until day 8. The coagulation system was impaired, but was most evident in the open aortic aneurysm group. In this study we could show that both operative techniques had comparable immunological changes. During open aneurysm repair the large operative trauma seems to play a central role, whereas endothel activation might be crucial in endovascular operated patients.

CD4+ lymphocyte count in African patients co-infected with HIV and tuberculosis.

The objectives of this study were (a) to compare the CD4+ lymphocyte profiles over time of two groups of patients hospitalized for tuberculosis (TB) treatment [a group of patients with TB only (TB group) and a group dually infected by HIV and TB (HIV/TB group)] and (b) to assess the usefulness of the total lymphocyte count (TLC) as a surrogate of the CD4+ lymphocyte count in the HIV/TB group. A total of 345 patients were enrolled in the study of whom 104 (29.8%) were HIV seropositive (HIV/TB). On admission, the CD4+ lymphocyte counts of the HIV/TB cohort were significantly lower than the TB group with medians of 230 (interquartile range, 90-475) and 630 (500-865), respectively (p < 0.0001). The CD4+ lymphocyte count increased significantly in both cohorts on routine TB treatment. A TLC of 1,300-1,500 cells/mm3 was found to be predictive of a CD4+ lymphocyte count of < or = 200 cells/mm3 both on admission and after 1 month of TB therapy. We conclude from this study that the positive influence of TB therapy on the CD4+ lymphocyte count strongly suggests an additional avenue of influence on the course of HIV infection, whereas the usefulness of the TLC as a surrogate estimation of CD4+ lymphocyte count in HIV/TB patients has important implications for the developing world.