Biomedical subjects
Publications and source records attributed to R Klose.
After acute hemorrhagic shock in dogs the hemodynamics of hydroxyethyl starch (MW: 40,000) are studied. The experiment shows that this plasma expander has a good efficiency for 3 to 4 hours. The indications of application of this colloidal solution are discussed.
Dogs were bled into haemorrhagic shock. They were then given isovolaemic infusions of dextran 60 and 40 and of hydroxyethyl starch with an average molecular weight of 200,000 and 40,000 respectively with a view of assessing the haemodynamic efficacy of these plasma substitutes. Solutions of high molecular weight hydroxyethyl starch (HES 400) were retained in the circulation for about the same length of time as was dextran 60. HES 40 (molecular weight 40,000) was retained for about 3-4 hours as measured by cardiac output. For normalizing a relative hypovolaemia, e.g. during anaesthesia or in some emergencies, colloidal plasma substitutes which will be retained for only a short time are entirely satisfactory.
The development of new non-irritating thermoplastic endotracheal tubes together with improved nursing techniques have resulted in a considerable reduction in the number of tracheotomies. The choice of method to keep the airways patient depends on various factors and must be made individually. The advantages and disadvantages of naso-tracheal and oro-tracheal intubation and of tracheotomy are reviewed. Some of the risks and complications attendant on long-term naso-tracheal intubation are discussed. Maxillary sinusitis due to obstructed drainage should have X-ray examination without delay and, if necessary, treatment. Suspicious of an open fracture of the base of the skull constitutes a contraindication to nasal intubation. Provided there are no contra-indications and the organs touched by the endotracheal tube (nose, pharynx, larynx) are regularly inspected, nasotracheal intubation can, with careful nursing, be continued for prolonged periods. Tracheotomy is still indicated in some cases.
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Although the successful treatment of critically ill patients often depends on access to the large veins close to the heart, the indications for this procedure should be strictly limited on account of the attendant risks and potential complications. From the large variety of cannulas, catheters and techniques available for this purpose those systems should be chosen that are simple and safe to use. Seldinger's technique is the method of choice for elective puncture under optimum conditions. If the time factor is important, closed complete systems should be employed. Aseptic puncture and nursing technique is essential to prevent the most common late complication-septicaemia. Radiological verification of the siting of the catheter is important. The various access routes to the central veins carry differing success rate and they also vary in respect of the incidence of complications. This should be borne in mind when deciding on a particular technique. On the other hand, the choice also depends on such factors as technical skill of the physician, the quality of nursing and the expected duration of hospital stay. The peripheral veins of the arm are the safest access for the less experienced physician and for short-lasting catheterization; otherwise the internal jugular vein is the preferred site followed by the subclavian vein. Even if the physician prefers a particular access route he should be familiar with all types of technique since critically ill patients are liable to require changes of the catheter. There is no single technique that will cover all contingencies.
After prolonged deliberations guide lines have now been agreed upon regarding the training and examination of nursing personnel for work in recovery and intensive care units. The recommendations, as adopted by the German Hospital Association 16th November 1976, cannot be accepted unreservedly. One of the main objections is that the proposed course of training would lead to excessive specialization at too early a stage. The aim should be to provide training of an interdisciplinary character, including anaesthesia.
Severe art. hypotensions are one of the most frequent complications of epidural anaesthesia. In 62 geriatric patients undergoing transurethral prostatic resection two methods of prophylaxis for hypotension were investigated: 1. 500ml HES before epidural anaesthesia and supine position until operation. 2. Lithotomy position immediately after EDA without plasma substitute. Blood pressure, heart rate and necessity for the application of vasoactive substances show that the lithotomy position immediately after EDA is the statistically better method. The problem of plasma substitutes in transurethral prostatic resection will be discussed.
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Between the years of 1969 and 1974, 68 patients were transferred from our Department of Obstetrics and Gynecology to the Intensive Care Unit. This figure represents 0,5% of all operative cases. 50% were high risk patients, previously under the care of our physicians. 11,8% occurred because of problems arising from latent diseases not previously diagnosed. The main reasons for transfer were septic shock, coagulopathy arising from abruptio placenta, placenta praevia, embolism and pneumonia. Interdepartmental cooperation is indispensable for correct diagnosis and a timely transfer.
A 26-years-old man injected himself intramuscularly with 3.75 gram of demeton methyl in an attempt to commit suicide. After 36 hours severe symptoms of poisoning developed with loss of consciousness and respiratory arrest. As symptomatic treatment failed to improve his condition has given injections of purified serum cholinesterase. This was followed by a rise in the cholin esterase levels and the increased activity was accompanied by a rapid and definite improvement in the clinical findings. The results clearly indicate the usefulness of this method of treatment. Transfusions of fresh blood to counteract the cholin esterase deficiency are inadvisable because of the risks of complications. Substitution therapy with serum cholinesterase must be accompanied by administration of large doses of atropine.
There was no difference between ethrane and halothane in respect of anaesthetic technique, except that on account of its physico-chemical properties induction and recovery was quicker with ethrane. Anaesthesia with this agent is, therefore, more easily controlled. Induction in children was rapid and non-irritating. The marked muscle relaxing effects of the drug carry some risk of impaired gaseous exchange in the spontaneously breathing patient. At higher concentrations ethrane, like all inhalation anaesthetics, is liable to cause respiratory depression. The cardiovascular system remained remarkably unaffected provided induction was slow, i.e. the concentration of ethrane was not too suddenly raised. The blood chemistry appeared to be unaffected, but the electroencephalogram showed certain changes the clinical significance of which has so far not been established.
Continuous electroencephalographic recordings were taken in 25 children who had ethrane-nitrous oxide anaesthesia without a basal anaesthetic. The recordings confirmed the repeatedly reported occurrence of certain abnormal wave patterns distinctive of seizures during ethrane anaesthesia. Although these dysrhythmias were more frequent and more pronounced at higher ethrane concentrations and during hyperventilation, sharp spikes began to appear already at concentrations of 1.0/p.c. without hyperventilation and at moderate depths of anaesthesia. In no case did the usual criteria for assessing depth of anaesthesia provide an indication of over-dosage. Although in the individual case there was a close relationship between the concentration of ethrane in the inhaled mixture and the electroencephalographic changes, the differences between the cases were too great to allow any prediction as to the concentration of ethrane that would bring on the dysrhythmia. Considering that increased cerebral oxygen consumption has been observed to accompany the abnormal wave patterns ethrane is not recommended for use in epileptic children or those with a familial history of epilepsy.
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