[Severe respiratory insufficiency as manifestation of a pulmonary metastasized Ewing's sarcoma]. / Schwerste Atemnot als Manifestation eines pulmonal metastasierten Ewing-Sarkoms.

A previously unknown tumor led to respiratory failure due to pulmonary metastasis in a young male. The shortness of breath began gradually and then rapidly progressed within 2 weeks. With the cause of respiratory failure still unclear, extracorporeal membrane oxygenation (ECMO) treatment was initiated to gain time for the definitive diagnosis. After the exclusion of infectious lung diseases the diagnosis could be made by a biopsy. Surprisingly, a Ewing's sarcoma was diagnosed and chemotherapy was initiated. This led to tumor regression within about 3 weeks, so that the patient could be successfully weaned from ECMO treatment.

[Blockade of the distal sciatic nerve in the supine position with a newly developed ultrasound probe holder]. / Distale Ischiadikusblockade in Rückenlage mittels neu entwickelter Ultraschallsondenselbsthalterung.

Sonographically controlled blockade of the distal sciatic nerve is usually performed by placing the ultrasound probe on the dorsal side of the thigh. This requires positioning maneuvers (prone or side positioning) of the patient as well as additional assistance. In order to avoid these positioning maneuvers, a positioning aid with integrated ultrasound probe holder has been developed and its practicability was examined on patients with lower limb surgery. The sonographically controlled block of the sciatic nerve was performed with the patient under general anesthesia and in a supine position with the help of the new positioning aid with an integrated ultrasound probe holder. A total of >100 patients were treated, who underwent elective lower leg, ankle or foot surgery with a continuous blockade of the distal sciatic nerve using catheters for postoperative analgesia. The advantages are easy performance, hands-free needle movement and catheter placement. The disadvantages might be the need for in-plane catheter placement and a fixed ultrasound angle.

Cumulative changes in weight but not fluid volume balances reflect fluid accumulation in ICU patients.

BACKGROUND: The cumulative fluid balance of critically ill patients seems to be an outcome-relevant variable. However, there are no validated data for their reliability calculated for longer (> 5 days) periods of time. METHODS: All ICU patients ≥ 18 years, with an ICU stay ≥ 5 days and a body weight ≤ 195 kg were evaluated from 1 January 2013 to 31 December 2013. Daily standardized weighing was performed using bed-integrated scales simultaneously with the daily 24-h fluid balance. Simultaneously, a fluid balance without and with insensible perspiration (10 ml/kg/day) was calculated for each 24 h. Primary endpoint: difference between cumulative fluid balance and body weight changes at the day of transfer to the normal ward or the day of death in the ICU, respectively, in each patient. All data are presented as medians with interquartile ranges (IQR) with 25 and 75 percentiles (IQR/25/75) unless otherwise noted. RESULTS: One hundred and six critically ill patients were evaluated; 82 survivors and 24 nonsurvivors. Cumulative 24-h fluid balances rose continuously while body weight decreased over time. Correction of cumulative fluid balances for insensible perspiration (10 ml/kg/day) also did not match with body weight changes. Only survivors had a significant loss in body weight -1.8 (27.5/-6.1/1.0) kg. CONCLUSIONS: Assuming that changes in body weight reflect changes in whole body water content cumulative daily fluid volume balances without or with correction for insensible water loss are not useful for estimating cumulative fluid balance of ICU patients. Survivors but not nonsurvivors had a significant loss of weight over time.

[Methohexital for analgosedation of ventilated intensive care patients : prospective nonrandomized single center observational study on incidence of delirium]. / Methohexital zur Analgosedierung bei beatmeten Intensivpatienten : Prospektive nichtrandomisierte "Single-center"-Observationsstudie zur Delirinzidenz.

BACKGROUND: Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) as a potentially reversible disturbance of consciousness and a change of cognition caused by a medical condition, drug intoxication, or medication side effect. Delirium affects up to 80 % of intensive care unit (ICU) patients and is associated with increased morbidity and mortality. One risk factor for development of delirium in ventilated intensive care unit patients is sedation. The German S3 guidelines on "Analgesie, Sedierung und Delirmanagement in der Intensivmedizin" (analgesia, sedation and delirium management in intensive care medicine) of the DGAI (German Society for Anesthesiology and Intensive Care Medicine) and the DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine) recommend midazolam and propofol for sedation, although both drugs are associated with a high incidence of delirium. AIM: Within the framework of this study the question arose whether the barbiturate methohexital could be associated with a lower incidence of delirium in comparison to midazolam or propofol in analgosedated and ventilated ICU patients. MATERIAL AND METHODS: This was a prospective nonrandomized observational cohort study in a mixed medical surgical intensive care unit. Patients ventilated within 72 h after admittance were consecutively allocated to either propofol/remifentanil versus methohexital/remifentanil (expected ventilation duration ≤ 7 days) or midazolam/fentanyl versus methohexital/fentanyl (expected ventilation duration > 7 days) by the attending senior consultant anesthetist at the time of admission and/or intubation. Primary endpoint was delirium at any time during the ICU stay. Delirium was checked every 8 h by ICU nurses using the intensive care delirium screening checklist (ICDSC), with delirium defined as ICDSC ≥ 4 points. Before evaluation of the ICDSC the Richmond agitation sedation scale (RASS) score and the visual analogue scale for pain (VAS target ≤ 4) were measured. To assure reliable evaluation of the ICDSC, the RASS score of the patient at the time of evaluation had to be ≥ - 2. Assuming an incidence of delirium in the midazolam group of 70 % and in the methohexital group of 35 %, 16 patients were needed each in the midazolam/fentanyl and the methohexital/fentanyl cohorts (p = 0.05, ß = 0.1). Assuming an incidence of delirium in the propofol group of 50 % and in the methohexital group again of 35 %, 94 patients were needed in the propofol/remifentanil and methohexital/remifentanil groups, respectively (p = 0.05, ß = 0.1). RESULTS: A total of 222 patients were evaluated, 34 in the methohexital vs. midazolam group and 188 in the methohexital vs. propofol group. Out of 16 patients sedated with midazolam, 15 developed delirium (94 %) in contrast to only 5 out of 18 patients sedated with methohexital (28 %). Thus compared to midazolam the sedation with methohexital reduced the incidence of delirium by 66 % (p < 0.001) corresponding to a number needed to treat (NNT) of 1.5. Out of 94 patients in the propofol/remifentanil group, 64 developed delirium (68 %) in contrast to only 23 out of 94 in the methohexital/remifentanil group (24 %). Thus compared to propofol the sedation with methohexital reduced the incidence of delirium by 44 % (p < 0.001), corresponding to an NNT of 2.5. CONCLUSION: Sedation with methohexital compared to midazolam or propofol reduced the incidence of delirium by more than 50 % in ventilated ICU patients.

[Successful treatment of extreme metabolic acidosis and profound hypothermia]. / Erfolgreiche Behandlung einer extremen metabolischen Acidose mit ausgeprägter Hypothermie.

A case of extreme metabolic acidosis (pH 6.6) and severe hypothermia (27.3 degrees C) is reported. The patient's anamnesis and medical examination led to the assumption of ketoacidosis. Pronounced ketoacidosis is not unusual in juvenile diabetics type 1 and the incidence in Europe is reported to be between 15 and 70% for all type 1 diabetics. The case describes the targeted therapy of controlled re-warming to avoid neurological damage.

Fentanyl-induced cough does not depend on injection speed: a randomized study.

BACKGROUND: The aim of the study was to investigate whether the incidence of cough after intravenous fentanyl depends on the speed of injection. METHODS: With ethics committee approval, 476 ASA class I-III nonsmoking patients free of bronchial hyperreactivity and respiratory tract infection undergoing general anaesthesia for elective surgery were randomized to either 1.5 microg/kg fentanyl injected over 2, 5 or 10 s or placebo (saline) via a peripheral intravenous cannula. The primary endpoint was the incidence of cough within 5 min after completion of injection. RESULTS: The study was terminated for futility after enrollment of 476 patients because an interim analysis yielded an incidence of cough of 3%, 3% and 6% in the three fentanyl groups, respectively, and of 2% in the placebo group, with no difference between groups (P=0.374, chi(2) test for cough between fentanyl and placebo groups). CONCLUSIONS: Under the conditions of our study, the incidence of cough after 1.5 microg/kg fentanyl injected intravenously over 2, 5 or 10 s was between 3% and 6%, unrelated to the speed of injection and not different from placebo.

Successful treatment of massive pulmonary embolism with recombinant tissue type plasminogen activator (rt-PA) in a pregnant woman with intact gravidity and preterm labour.

We report a patient with massive pulmonary embolism and circulatory shock during pregnancy (31st gestational week) and preterm labour who has been successfully treated with recombinant tissue type plasminogen activator. Thrombolysis was performed using 10 mg.h-1 over 4 h followed by 2 mg.h-1 for 1 h 30 min resulting in complete resolution of cardio-respiratory symptoms. Except for slight bleeding from one puncture site no complications occurred. At 48 h after the end of thrombolytic therapy the patient was delivered spontaneously of a male preterm healthy infant. The relevance of this new thrombolytic agent in the treatment of massive life-threatening pulmonary embolism during pregnancy is discussed.

Extracorporeal CO2-removal with a heparin coated artificial lung.

Treatment of severe acute respiratory failure with extracorporeal gas exchange necessitating near complete systemic anticoagulation requires a delicate balance to be maintained between disseminated intravascular coagulation and hemorrhagic complications. The present study describes our first experience using a heparin coated extracorporeal artificial lung and circuitry during clinical extracorporeal CO2 removal. In spite of a partial thromboplastin time and activated clotting time within or close to the normal range, neither laboratory evidence for disseminated intravascular coagulation induced by the extracorporeal circuit nor thrombi in the pulmonary vasculature were found. Scanning electron microscopy of the heparin coated hollow fiber gas exchanger demonstrated only minor deposits on the surface. Use of a heparin coated artificial lung may enhance the margin of safety of extracorporeal gas exchange and ultimately broaden its indications.

Observations on animal and human health during the outbreak of Mycobacterium bovis in game farm wapiti in Alberta.

This report describes and discusses the history, clinical, pathologic, epidemiologic, and human health aspects of an outbreak of Mycobacterium bovis infection in domestic wapiti in Alberta between 1990 and 1993, shortly after legislative changes allowing game farming. The extent and seriousness of the outbreak of M. bovis in wapiti in Alberta was not fully known at its onset. The clinical findings in the first recognized infected wapiti are presented and the postmortem records for the herd in which the animal resided are summarized. Epidemiologic findings from the subsequent field investigation are reviewed, the results of recognition and investigation of human exposure are updated, and recommendations for reduction of human exposure are presented.

Safety and feasibility of nasopharyngeal evaporative cooling in the emergency department setting in survivors of cardiac arrest.

AIM: Mild therapeutic hypothermia improves survival and neurologic recovery in primary comatose survivors of cardiac arrest. Cooling effectivity, safety and feasibility of nasopharyngeal cooling with the RhinoChill device (BeneChill Inc., San Diego, USA) were determined for induction of therapeutic hypothermia. METHODS: Eleven emergency departments and intensive care units participated in this multi-centre, single-arm descriptive study. Eighty-four patients after successful resuscitation from cardiac arrest were cooled with nasopharyngeal delivery of an evaporative coolant for 1h. Subsequently, temperature was controlled with systemic cooling at 33 degrees C. Cooling rates, adverse events and neurologic outcome at hospital discharge using cerebral performance categories (CPC; CPC 1=normal to CPC 5=dead) were documented. Temperatures are presented as median and the range from the first to the third quartile. RESULTS: Nasopharyngeal cooling for 1h reduced tympanic temperature by median 2.3 (1.6; 3.0) degrees C, core temperature by 1.1 (0.7; 1.5) degrees C. Nasal discoloration occurred during the procedure in 10 (12%) patients, resolved in 9, and was persistent in 1 (1%). Epistaxis was observed in 2 (2%) patients. Periorbital gas emphysema occurred in 1 (1%) patient and resolved spontaneously. Thirty-four of 84 patients (40%) patients survived, 26/34 with favorable neurological outcome (CPC of 1-2) at discharge. CONCLUSIONS: Nasopharyngeal evaporative cooling used for 1h in primary cardiac arrest survivors is feasible and safe at flow rates of 40-50L/min in a hospital setting.

[Mobile single-pass batch hemodialysis system in intensive care medicine. Reduction of costs and workload in renal replacement therapy]. / Mobiles Single-pass-batch-Hämodialyse-System in der Intensivmedizin. Reduktion von Kosten und Arbeitsbelastung in der Nierenersatztherapie.

This paper describes the introduction of a single-pass batch hemodialysis system for renal replacement therapy in a 14 bed intensive care unit. The goals were to reduce the workload of intensive care unit physicians using an alternative and simpler method compared to continuous veno-venous hemodiafiltration (CVVHDF) and to reduce the costs of hemofiltrate solutions (80,650 EUR per year in our clinic in 2005). We describe and evaluate the process of implementation of the system as well as the achieved and prospective savings. We conclude that a close cooperation of all participants (physicians, nurses, economists, technicians) of a hospital can achieve substantial benefits for patients and employees as well as reduce the economic burden of a hospital.

[Successful resuscitation of a patient with hyperkalemic cardiac arrest by emergency hemodiafiltration]. / Erfolgreiche Reanimation einer Patientin mit hyperkaliämischem Herzstillstand durch notfallmässige Hämodiafiltration.

The combination of spironolactone with an ACE inhibitor for patients with heart failure may cause severe hyperkalemia. We report the case of a female patient, who developed hyperkalemic (11.4 mmol/l) cardiac arrest probably induced by combined spironolactone and ACE-inhibitor therapy. She was treated successfully by hemodiafiltration under on-going resuscitation which resulted in restoration of spontaneous circulation within 30 min of starting CPR. She was discharged 2 weeks later without any residual neurological effects.

[Are peripheral nerve blocks of the leg (femoralis in combination with anterior sciatic blockade) as sole anaesthetic technique an alternative to epidural anaesthesia]. / Ist die periphere Nervenblockade des Beines (Femoralis- in Kombination mit anteriorer Ischiadikusblockade) als alleinige Anästhesietechnik eine Alternative zur Periduralanästhesie für arthroskopische Eingriffe am Kniegelenk?

OBJECTIVE: We compared peripheral nerve blocks (PNB, femoral nerve block together with anterior sciatic nerve block) as sole anaesthetic with epidural anaesthesia (EA) in a randomised study in patients undergoing elective arthroscopic knee surgery with respect to patient satisfaction and time required to perform each procedure. METHODS: 99 ASA class I-III patients were randomised to either PNB (20 ml bupivacaine 0.5 % + 60 ml prilocaine 1 %) or EA (12 - 20 ml bupivacaine 0.5 %). ENDPOINTS: patient satisfaction with the anaesthetic evaluated by a questionnaire 3 months after the operation, anaesthesia and surgical times, need for additional analgesics and the modified Aldrete-score (global assessment of postanaesthetic condition) at admission in the postanaesthesia care unit. RESULTS: Significantly more patients in the PNB compared to the EA group needed intravenous opioid supplementation (10 vs. 3, p = 0.040). While the patients in the PNB group had a significantly higher modified Aldrete score (9.3 +/- 0.7 vs. 8.8 +/- 0.9, p = 0.0009), assessment (0 = worst, 10 = best) of the induction of PNB or EA respectively, was significantly better rated in the EA compared to PNB group (8.7 +/- 2.1 vs. 6.7 +/- 2.6, p = 0.0024). Assuming that the willingness to undergo the same anaesthetic again reflect overall satisfaction with the procedure satisfaction in both groups was high: 25/26 (PNB) and 27/28 (EA) would have preferred their regional blockade (p = 0.95). CONCLUSION: Patients in the PNB and EA group both were satisfied with their anaesthetic procedure. While there are obviously differences in favour of the EA, PNB is an alternative in the case of contraindication or patient rejection to EA.

[A factorial trial of six interventions for the prevention of postoperative nausea and vomiting]. / Eine faktorielle Studie von 6 Interventionen zur Vermeidung von Ubelkeit und Erbrechen nach Narkosen Ergebnisse des "International Multicenter Protocol to assess the single and combined benefits of antiemetic strategies in a controlled clinical trial of a 2x2x2x2x2x2 factorial design" (IMPACT).

BACKGROUND: Untreated, one third of patients who undergo surgery will have postoperative nausea and vomiting. Although many trials have been conducted, the relative benefits of prophylactic antiemetic interventions given alone or in combination remain unknown. METHODS: In a randomized, controlled trial of factorial design, 5,199 patients at high risk for postoperative nausea and vomiting were randomly assigned to 1 of 64 possible combinations of 6 prophylactic interventions: 1) 4 mg of ondansetron or no ondansetron; 2) 4 mg of dexamethasone or no dexamethasone; 3) 1.25 mg of droperidol or no droperidol; 4) propofol or a volatile anesthetic; 5) nitrogen or nitrous oxide; 6) remifentanil or fentanyl. The primary aim parameter was nausea and vomiting within 24 h after surgery, which was evaluated blindly. RESULTS: Ondansetron, dexamethasone, and droperidol each reduced the risk of postoperative nausea and vomiting by about 26%, propofol reduced the risk by 19%, and nitrogen by 12%. The risk reduction with both of these agents (i.e., total intravenous anesthesia) was thus similar to that observed with each of the antiemetics alone. All the interventions acted independently of each other and independently of the patients' baseline risk. Consequently, the relative risks associated with the combined interventions could be estimated by multiplying the relative risks associated with each intervention. However, absolute risk reduction was a critical function of patients' baseline risk. CONCLUSIONS: Because antiemetic interventions are similarly effective and act independently, the safest or least expensive should be used first. Prophylaxis is rarely warranted in low-risk patients, moderate-risk patients may benefit from a single intervention, and multiple interventions should be reserved for high-risk patients.

[Comparative study of the modification of blood, blood coagulation, cardiovascular circulation by 3% modified, fluid gelatins and 6% low-molecular weight hydroxyethyl starch]. / Vergleichende Untersuchung zur Beeinflussung von Blut, Blutgerinnung, Herz und Kreislauf durch 3%ige modifizierte, flüssige Gelatine und 6%ige niedermolekulare Hydroxyäthylstärke.

A randomized, comparative study with 3% modified fluid gelatine and 6% low molecular hydroxyethylstarch has been made on 87 patients of an intensive care unit. Both plasma substitutes were well compatible to the patients. The erythrocyte sedimentation rate was accelerated significantly by both plasma substitutes. This effect was at a maximum after 24 h and in the gelatine group it was percental about three times stronger, referred to the base line level in this group. In the hydroxyethylstarch group after 12 h the thrombocyte cell number decreased about 10.3%, referred to the base line, in the gelatine group the decrease was only 1.5% at the same time. At the chemical parameters there were no more differences between the two substitutes. Both plasma substitutes showed a mean effect of 4 h on plasma volume, referred to the changes of central venous pressure. The gelatine substitute showed a significant rise in blood pressure after end of infusion, the hydroxyethylstarch substitute did not. Both substitutes showed a rise in diuresis with a delay of 1 h. There were no differences between both solutions in the diuretic effect after infusion.

[Incidence and predisposing factors of persistent backache after lumbar catheter epidural anesthesia in a non-obstetrical settingø]. / Inzidenz und prädisponierende Faktoren persistierender Rückenschmerzen nach lumbaler Katheterperiduralanästhesie im nichtgeburtshilflichen Bereich.

OBJECTIVE: To determine the incidence of long term backache after lumbar epidural anesthesia with catheter (EPA) in the non-obstetrical setting. DESIGN: Prospective 1-year follow-up study. PATIENTS: All patients scheduled for elective arthroscopical surgery of the knee performed under EPA (n = 195). INTERVENTIONS: A first questionnaire was sent to each patient three months after the operation. To chose patients reporting persistent backache after three months, a second questionnaire was sent one year after the operation. MEASUREMENTS: Back pain before, within 5 days and at the time of the inquiry, i.e., three months and one year after EPA as well as patient satisfaction with the regional anesthetic. Statistic: contingency tables with Fisher's exact test (for categorical variables) and an unpaired t-Test (for continuous variables), p < 0.01 after adjustment for multiple testing (Bonferroni's method). MAIN RESULTS: Response rate was 67%. Before EPA 23 patients (17.5%) complained of back pain. The short term incidence of back pain (i.e, within 5 days after EPA) was 24 out of 131 patients (18.3%) and not associated with pre-epidural back pain (p = 0.036, n.s.). 15 out of 131 patients (11.5%) reported persistent back pain after three months, 13 of them had complained of back pain before EPA (p < 0.0001). Thus, the incidence of new back pain 3 months after EPA was only 1.5%. 7 of the 15 patients returned the second questionnaire: 6 reported still persistent back pain, and all had complained of back pain before EPA. Age, height, weight, sex, duration of anesthesia and operation were not associated with long term back pain. Despite persistent back pain after three months 10 out of 15 patients would opt again for EPA. CONCLUSION: The incidence of long term backache after EPA in the non-obstetrical setting is 11.5% and almost exclusively associated with pre-existing back pain. Biometrical factors seem to play no role. In patients with pre-existing back pain satisfaction with the anesthetic procedure might be improved by improving informed consent.

Persistent back pain after spinal anaesthesia in the non-obstetric setting: incidence and predisposing factors.

We determined the incidence of persistent back pain (PBP) after non-obstetrical spinal anaesthesia (SPA) and investigated factors predisposing to such pain in a prospective 1 yr follow-up study in 245 patients undergoing elective general or trauma surgery (218 patients undergoing single SPA, 27 undergoing two to six SPAs). All patients received a first questionnaire 3 months after the last SPA, and those reporting PBP after 3 months were sent a second questionnaire I year after the operation. Variables were PBP before and within 5 days, at 3 months and I year after SPA, patient satisfaction with SPA, patient characteristics and technical data. Statistical analysis was by contingency tables with Fisher's exact test and an unpaired t-test with logistic regression (P < 0.001 after Bonferroni correction was taken as significant). The response rate in patients who had a single SPA was 56% (122/218). Twenty-three of these 122 patients (18.9%) complained of back pain before SPA compared with 12/122 (10.7%, P = 0.0015) within 5 days after SPA. After 3 months, 15/122 patients (12.3%) reported PBP with 14 complaining of PBP before SPA (P < 0.0001), corresponding to an incidence of new PBP of 1/122 (0.8%). Multiple logistic regression revealed that pre-existing back pain was the only variable associated with PBP after 3 months (P < 0.0001). Patient characteristics and technical factors were not associated with PBP. Nine of the 15 patients with PBP after 3 months returned the second questionnaire: four still reported PBP (three of these had suffered from PBP before SPA). Despite PBP after 3 months, 13/15 patients said they would opt for SPA again. The response rate and results in patients who had had multiple SPAs were similiar to those who had had a single SPA.

[Perioperative diagnosis of acute myocardial ischemia]. / Perioperative Diagnostik akuter Myokardischämien.

The prevalence of coronary artery disease substantially affects both cardiac and noncardiac surgery. Assuming that biometric data reported from North America are representative for Germany, the following incidences can be estimated: around 1 million out of 8 million patients operated upon each year will suffer from coronary artery disease, and 15,000 of these patients will have a perioperative myocardial infarction. Since a close relationship has been shown between pre-, intra-, and postoperative myocardial ischaemia and postoperative cardiac morbidity and mortality, early diagnosis and therapy of acute perioperative myocardial ischaemia is warranted. The purpose of this review is to weigh critically the various methods for diagnosis of myocardial ischaemia in view of their practicability and cost/benefit relationship in the perioperative setting. The symptoms of angina pectoris are unreliable in the perioperative period, since patients are premedicated preoperatively, without symptoms during anaesthesia, and usually receive analgesics postoperatively. Intraoperative detection of myocardial ischaemia focuses on standard electrocardiography (ECG) with on-line registration of the ST-segment in two leads (usually leads II and V5) and automatic analysis of ST-segment deviation, achieving a sensitivity of 80% in the detection of myocardial ischaemia. Measurement of regional wall motion abnormalities with trans-esophageal echocardiography (TEE) is a more sensitive method of myocardial ischaemia detection compared to ECG. However, several reasons preclude the broader application of this method in the perioperative phase: (1) it lacks validation by an accepted and independent gold standard; (2) there is a wide spectrum of false-positive findings (considerable interindividual variations in left ventricular contraction, bundle branch blocks, hypertension, hypervolemia); (3) changes in the inferior and apical segments of the left ventricle cannot be detected by single-plane TOE. Detection in these segments might be achieved with biplane echocardiography, but few data on this improved technique are presently available; (4) the method is semi-invasive and might be not applicable during periods with a high incidence of myocardial ischaemia, e.g., intubation, the end of anaesthesia, and extubation; (5) anaesthetists seldom fulfil standard guidelines in echocardiography training; and (6) the method is expensive, which also limits its broader application. Cardiokymography, a noninvasive technique, allows analog representation of anterior wall motion.(ABSTRACT TRUNCATED AT 400 WORDS)

[Recombinant tissue-type plasminogen activator for the emergency treatment of perioperative life-threatening pulmonary embolism (stage IV). Results in 7 patients]. / Rekombinanter Gewebeplasminogenaktivator (rt-PA) zur Notfallbehandlung der perioperativen lebensbedrohlichen Lungenembolie (Stadium IV). Ergebnisse bei sieben Patienten.

We report a series of seven patients (age: 43-77 years, preoperative American Society of Anesthesiologists (ASA) physical status II-III) with perioperative, life-threatening pulmonary embolism and severe cardiogenic shock treated with recombinant tissue type plasminogen activator (rt-PA). Diagnosis was established by ECG (n = 7), arterial blood gas analysis (n = 7), massive elevation of mean pulmonary arterial pressure (MPAP: 40 +/- 6 mmHg SD, n = 7), echocardiography (n = 3), increased arterial/end-tidal CO2 difference (30 +/- 16 mmHg, n = 3), and pulmonary angiography (n = 4). All patients had to be ventilated, six with an FIO2 of 1.0. To achieve a mean arterial pressure of above 60 mmHg all patients received norepinephrine 0.4 +/- 0.2 microgram.kg-1.min-1 in combination with dopamine 11 +/- 5 micrograms.kg-1.min-1 (n = 6), epinephrine 0.13 +/- 0.04 microgram.kg-1.min-1 (n = 5) or dobutamine 14 +/- 6 micrograms.kg-1.min-1 (n = 3). In addition, six of seven patients had to be resuscitated by external chest compression (duration of resuscitation: 5 to 40 min) prior to or during the thrombolytic therapy. The dosages of rt-PA ranged from 10 to 150 mg, and the duration of administration up to 31 h. Six patients survived neurologically intact. In these six patients MPAP had decreased from 41 +/- 6 mmHg to 33 +/- 6 mmHg (P less than 0.05, Wilcoxon rank test) 2 h after the start of thrombolytic therapy, with concomitant reduction of vasopressor and inotropic support.(ABSTRACT TRUNCATED AT 250 WORDS)