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PubMed1999

Liquid ventilation.

Research on using liquid ventilation to provide artificial respiration in mammals has been ongoing since the 1960s. The development of inert perfluorocarbon (PFC) liquids with high oxygen and carbon dioxide solubility has made gas exchange with liquid ventilation possible. In 1991 the technique of partial liquid ventilation was introduced where PFC are instilled into the lungs whilst continuing with conventional mechanical ventilation. Partial liquid ventilation has been shown to improve gas exchange and lung function with decreased secondary lung injury, in animal models of acute lung injury and surfactant deficiency. It has been used in uncontrolled trials in preterm neonates, and preliminary results are available from a randomized controlled trial of partial liquid ventilation in paediatric acute respiratory distress syndrome. Perfluorocarbons can also be used to deliver drugs to the lungs, to lavage inflammatory exudate and debris from the lungs, and as an intrapulmonary X-ray contrast medium. Many questions about partial liquid ventilation remain unanswered particularly with regard to the dose of PFC required, its ideal method of administration and the long-term effects. Partial liquid ventilation promises to be an exciting new therapy for infants and children with a variety of respiratory problems. The technique requires ongoing research and experimentation.

Acute Disease↗
PubMed2003

Visual receptive field properties of neurons in the caudate nucleus.

Visual single-unit activity was recorded in the caudate nucleus of halothane-anaesthetized, immobilized, artificially respirated cats. Visually sensitive neurons were found in the dorsolateral part of the caudate body. A majority of the units responded optimally to small spot-like stimuli moving with velocities between 30 and 120 degrees /s. The receptive field of these units is large: it covers a major part of both the contra- and ipsilateral visual hemifields. No signs of retinotopy were observed. Most of the neurons display directional selectivity and are narrowly tuned to the direction of the moving stimulus. These physiological properties are consistent with recent morphological results that reveal multiple connections of the caudate nucleus with the superior colliculus through tecto-extrageniculo-thalamic pathways in the mammalian brain.

Anesthesia↗
PubMed2002

Anaesthesia for thoracoscopic surgery.

The surgical requirement for thoracoscopy is a good view of the contents of the thorax. This is achieved by capitalizing on natural consequences and the skills of anaesthesiologists to produce a pneumothorax and collapse the ipsilateral lung--a process that is commonly enhanced by insufflating carbon dioxide. Insufflating CO2 to actively promote lung collapse creates the dynamics of a tension pneumothorax. Complications are clinically insignificant if CO2 is used judiciously. There is a body of experience using ordinary endotracheal tubes and two-lung ventilation. Techniques of one-lung ventilation are more widely reported. All the factors known to contribute to the significant increase in shunt fraction associated with one-lung ventilation apply. The manoeuvre of collapsing a lung is no longer regarded as benign. Chemical attempts to produce a reversible post-pneumonectomy pulmonary circulation have not been shown to be an improvement. Post-operative pain can be severe. The mechanism is not defined but it differs from that associated with thoracotomy. Epidural analgesia and opioids may be required. Chronic pain syndromes have been described as complications.

Anesthesia↗
PubMed2003

Thoracoscopic lobectomy for prenatally diagnosed lung lesions.

PURPOSE: The aim of this report is to assess the technique and outcome of thoracoscopic lobectomy for asymptomatic prenatally diagnosed lung lesions. METHODS: From June 1999 to March 2002, 14 consecutive asymptomatic patients with a prenatal diagnosis of congenital cystic adenomatoid malformation or pulmonary sequestration, ages 3 to 15 months, underwent postnatal thoracoscopic lobectomy. Single-lung ventilation and controlled pneumothorax with low pressure (4 torr) and low flow (1.0 L/min) were used in all. Follow-up ranged from 4 to 35 months. RESULTS: All procedures were completed successfully using 3 ports. Rather than using stapling devices or clips, pulmonary vessels were sealed and the fissure completed (when necessary) with the Ligasure thermal energy device. Eleven lesions were on the left (10 lower lobe), and 3 were in the right lower lobe. The mean operating time was 110 minutes. The average hospital stay was 38 hours. There were no intraoperative or postoperative complications. CONCLUSIONS: This is the first report of a completely thoracoscopic technique for pulmonary lobectomy in small children. Thoracoscopic lobectomy is a relatively quick and safe procedure, and the cosmetic result is excellent. Early resection obviates the risk of infection in these lesions.

Bronchopulmonary Sequestration↗
PubMed1999

[Rudolf Eisenmenger's biomotor--predecessor of active compression-decompression cardiopulmonary resuscitation].

Lerman mentioned in 1994 Eisenmenger's Biomotor as a precursor of Active Compression-Decompression Cardiopulmonary Resuscitation (ACD-CPR). We attempted to find additional information. We checked Medline 1966-1998, Quarterly Cumulative Index 1916-1926, Quarterly Cumulative Index Medicus 1927-1950 for publications of Eisenmenger and the secondary literature thereof. Rudolf Eisenmenger (1871-1946) published in 1903 a "Device for Artificial Respiration" consisting of an air-tight thoraco-abdominal shield and a foot-operated bellows for generation of alternating pressure and vacuum on the abdomen and lower thorax. He proposed use of the device for patients in cardiopulmonary arrest caused by drowning or intoxication. The device was patented and in 1904 made commercially available. In 1911 he published a successful resuscitation with his device after one hour of "Vacuum and Pressure Massage of the Abdomen" in a case of attempted suicide by hanging. The foot-operated bellows was replaced by an electromotor (hence "Biomotor") in 1924. Experiments on dogs in cardiac arrest were published in 1929. With the methods available not only "normal" tidal volumes and blood pressure, but also carbon dioxide exhalation and transport of intravenous dye to all parts of the body were shown. In 1939 an eight part series was published, describing use of the device as a respirator in several hospitals. Eisenmenger was the first to propose ACD-CPR, to build a device to perform ACD-CPR and to use it successfully in a patient. Furthermore, he was the first to propose the "cardiac pump theory" and the first to recognize the connection of carbon dioxide exhalation, cardiac output and prognosis of cardiac arrest.

Anesthesia↗
PubMedDate not supplied

[Significance of uterine contractions for adaptation of the newborn infant before cesarean section].

UNLABELLED: There are quite a few publications on the influence of labour on the adaptation of neonates after elective cesarean sections. Many authors recommend the induction of labor prior to the cesarean section. They found that this improves the adaptation of the infants. MATERIAL AND METHOD: All cesarean sections between 1991 and 1996 are recorded. Mature neonates (> 36 weeks of pregnancy) were evaluated separately from premature infants (< 36 weeks of pregnancy). As target-parameters we chose 1. the condition of the neonates (characterized by the Apgar-Score, the pH of the umbilical cord artery, and the requirement of artificial respiration). 2. the necessity of transfer to the neonatologic intensive care unit. Concerning these parameters, the immature neonates (> 36 weeks of pregnancy) were evaluated separately from the mature infants (< 36 weeks of pregnancy). In the latter group we finally evaluated the data of those who were not delivered by a cesarean section because of intrauterine fetal distress. RESULTS: The adaptation of the premature neonates was so closely related to the gestational age that all the other variables were of no statistically significant influence. Thus also the factor "labour" was of no influence. The results in the group of the mature infants were completely different. Between week 36 und 42 of pregnancy the gestational age was of no influence on the adaptation of the neonates. Statistically noticeable however was the influence of preoperative labour: The adaptation of infants delivered by cesarean-section after labour was remarkably worse than the adaptation of those who were delivered without labour prior to the operation. This statement is also correct when one rules out those infants who were delivered by a so called emergency cesarean section. When evaluating the group of neonates in which the cesarean section was not performed because of intrauterine fetal distress we could find no influence of preoperative labour on the adaptation of the infants. All other variables examined (e.g. maternal age, parity, duration of labour, method of anaesthesia, twin-pregnancy) were no factors of influence on the adaptation of the babies. CONCLUSION: From our results we cannot support the recommendation to induce labour prior to any elective cesarean section by infusion of oxytocin or to wait for the spontaneous onset of labour. There ist no reason to change our policy to perform an elective cesarean section as near as possible to term before the onset of labour.

Adaptation, Physiological↗
PubMed2006

[Post-lobectomy bronchopleural fistula -- a challenge for postoperative intensive care].

Bronchopleural fistula (BPF) and bronchial stump insufficiency (BSI) after lobectomies and pneumonectomies are dreaded complications with incidences of up to 12 % and a mortality rate of up to 51 %. Apart from the basic illness causes include complications like aspiration-pneumonia and ARDS, formation of empyema as well as histories of sepsis. Corticoid treatments, old age, diabetes mellitus, previous irradiation as well as post-operative mechanical ventilation (barotrauma) are often counted among contributing causes. Suturing the bronchus and reinforcement by tissue are still the methods of choice, but they are often counter-indicated in high-risk patients. Endoscopic treatments with partial lung occlusions, e. g. by insertion of spongiosa, coils, and/or fibrin glue have been described. However, they require the respective area to be probable. With only one third the rate of success is quite unsatisfactory. The retro-graded instillation of inflammatory-selerotizing substances, like doxycycline, via a chest tube leads to a pleurodesis caused by adhesion of the remaining lung parenchyma to the thoracic wall and a reduction in size of the residual pleural space. In an 82-year old female patient a BPF of the second upper lobe bronchus was detected after a middle lobe resection for abscess and post-radiation ulcer following a mastectomy for carcinoma. The leakage was detected on bronchoscopy by retro-graded instillation via the chest tube of methylene-blue solution into the thoracic cavity. After administering the water-soluble contrast agent amidotrizoic acid in a similar manner a CT confirmed the diagnosis. As the bronchial segment concerned could not be entered selectively, preservation of the right lung lobe's residual ventilation by endoscopic-occlusion procedures was ruled out. Employing a strictly conservative therapy (spontaneous ventilation, retro-graded doxycycline instillations) complete healing with a fully ventilated lower lobe could be achieved over a period of 78 days. BPF as well as residual intro-thoracic cavities after lobectomies pose a serious problem. Using methylene blue for a retro-graded demonstration of BPF during bronchoscopy presents a feasible and cost-efficient diagnostic method. A strictly applied conservative therapy including short-time low-pressure artificial respiration as well as obliteration by fibrous tissue of the thoracic cavity using doxycycline is a feasible procedure for inoperable high-risk patients.

Aged, 80 and over↗
PubMed1992

[Effect of anesthesia and operation on essential immune functions].

Study of the references listed leaves no doubt that essential specific and unspecific immune functions are more or less strongly influenced by a wide variety of anaesthetics. In clinically employed concentrations these negative effects are rapidly and completely reversible. No clinically relevant adverse actions on the immune system have ever been identified in short-term anaesthesia with any substance, not even with the thiobarbiturates although these are known to be highly inhibitory. However, matters are entirely different in respect of highly dosed long-term sedation. In such cases, it may occur with e.g. thiobarbiturates or diazepam that in the course of days or weeks concentrations are attained in the tissue which may lead us to expect in vivo quite considerable suppression of both unspecific and antigen-specific cellular immune mechanisms. This expectation, which is first of all based on in-vitro results, has been indirectly supported by a clinical study in patients suffering from craniocerebral trauma who received artificial respiration and in whom an association was seen between thiopental administration and the incidence of bacterial pneumonias. Over and above this, however, the preoperative condition of the patient and of course mainly the operation as such with its associated stress reaction will cause direct and indirect changes in the immune system (Fig. 4). Trauma and anaesthesia exert not only a direct action, but act as inhibitors or stimulators of important immune functions chiefly by modulating the stress response. We are still unaware as to whether and to what extent the prognosis of the individual patient is actually adversely affected by the combined action of these factors. Many findings, however, seem to point to an essential role played by both the surgical trauma and the stress response it induces, as well as by the pre-operative immune status of the patient, in the occurrence of subsequent infectious complications (Fig. 4).

Anesthesia, General↗
PubMed1991

[Psychological changes in intensive care patients with acute Guillain-Barré syndrome--psychoanalytic aspects of loss of communication and adjustment].

Ten patients who had been hospitalized with acute Guillain-Barré-syndrome (GBS) were monitored during their course of treatment and were asked in short intervals through semi-structured interviews how they experienced their illness. States of anxiety were especially evident at the initial phase of the disease, during the dissemination and maximum intensity of paralysis. In contrast, depressive symptoms were primarily noticeable during the phase of remission. As a rule, the degree of anxiety correlated in intensity and duration with the degree of severity of the neurological deficit. Five patients experienced a temporary derealization, among those, three patients showed productive-psychotic symptoms (optical and acoustical hallucinations, delusional reactions). Frequently, dreams were reported, which were associated with elementary experiences of anxiety and in part took on an overwhelming realistic character. Finally, the psychic changes are interpreted in context with the extreme condition of the disease which does not only signify a situation of forced dependence and regression for the patient but also results in--through loss of mobility and communication (cranial nerve dysfunction, artificial respiration)--a fundamental change in the perception of reality.

Adaptation, Psychological↗
PubMed1985

Tracheal resection--state of the art.

Sleeve resection of the trachea and reconstruction by end-to-end anastomosis is seen as the method of choice in the treatment of short and long stenoses of the trachea following long-term artificial respiration and tumors. The experience with tracheal resection in 73 patients operated upon at 2 different thoracic units is analyzed. Postintubation was the main indication for operation in 63% of the patient population. The 30-day postoperative mortality rate was 8% with a total mortality of 19%. A satisfactory functional result was attained in 73% of the patients operated upon including those with malignant tumors. Restenoses occurred in 6 of the 73 patients who underwent surgery. Different approaches to tracheal resection were chosen in the 2 clinics and the possibility of mobilizing the larynx was used in a different way. A preference for resorbable material was noted regardless of the operative technique and has prevented restenosis. The diagnostic procedures considered mandatory, the indications for surgery and the various operative techniques are discussed.

Humans↗
PubMed1989

Repetitive intercostal nerve block via catheter for postoperative pain relief after thoracotomy.

After anterolateral thoracotomy, before incision closure, indwelling plastic catheters were inserted percutaneously under digital and/or visual control into the intercostal space of access and the two neighbouring ones. Initially, we injected 25 mg of bupivacaine through each catheter (to a total of 75 mg), and subsequently - on the patients demand - another 15 to 25 mg per catheter. To date, 25 patients received repetitive intercostal nerve blocks by this method (ICB-group). We compared their personal and perioperative data with those of another 30 patients, receiving opiates systemically after major thoracic surgery (SA-group). Multiple blood samples from the ICB-group were analyzed by gaschromatography for bupivacaine concentration-time-profiles. In 19 of 25 patients (76%) the bupivacaine-injections provided sufficient analgesia, 6 patients required additional analgesics. The duration of general anaesthesia (ICB: 174 min vs. SA: 136 min) and the operation time (ICB: 103 min vs. SA: 94 min) were not statistically different in both groups. The periods of intensive care therapy (ICB: 0.7 d vs. SA: 1.2 d), artificial respiration (ICB: 11.2 h vs. SA: 21.6 h) and hospital stay (ICB: 12.1 d vs. SA: 14.2 d) were shorter for the ICB-group. Atelectasis (ICB: 20% vs. SA: 37%) and pneumonia (ICB: 0 vs. SA: 13%) were observed less frequently than in the control group, whereas tachyarrhythmia occurred in 6 of 25 ICB-patients compared to 4 of 30 SA-patients. Nevertheless, none of these parameters reached statistical significance (p less than 0.05). Maximum bupivacaine levels of 0.65 +/- 0.21 micrograms/ml were found after 29 +/- 12 min of intercostal application.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

[Severe HELLP syndrome with temporary kidney and lung failure].

This report is on a severe case fo a HELLP-syndrome (H haemolysis, EL elevated liver enzymes, and LP low platelets). A 32-year old gravida developed severe preeclampsia with epigastric pain at 33 weeks' gestation. During a few hours post partum she showed disseminated intravascular coagulation (DIC) and required intensive care. The severe HELLP-syndrome was combined with a fast increasing acute respiratory distress syndrome (ARDS) and acute oligo-anuric renal failure. She was treated in the intensive-care unit for several days with artificial respiration, 10 acute haemodialyses, 4 plasma exchanges with fresh-frozen plasma and many blood and platelet transfusions. An early Caesarean section and treatment in the intensive care unit managed to turn the otherwise complicated progression of the disease. It is pointed out that plasma exchange with fresh-frozen plasma is a rarely employed treatment.

Acute Kidney Injury↗
PubMed1997

[Effect of endoscopic surgery techniques in children on ventilation].

The purpose of our study was to show the effects of laparoscopic procedures on the ventilation of children. We measured an increase of ventilation pressures (Pmax, Ppfat and Pmean) of 28, 35 and 48% respectively. petCO2 rose from 35 to 41 +/- 2 mmHg. There was no loss of body temperature in any child. Laparoscopic procedures as seen here for appendectomy or diagnostic exploration in children of 13.5 kg body weight or more caused no problems that were clinically evident. The increase of ventilation pressure could be attenuated by choosing the parameters of ventilation (e.g. flow, I:E ratio) in such a way that Pmax does not exceed 20 mbar. Alternatively, pressure-controlled ventilation may be used, adjusting petCO2 by ventilation frequency. In any case there must be a strict control of all possible side effects of laparoscopy, such as cutaneous emphysema or pneumothorax.

Anesthesia, General↗
PubMed1997

[Therapeutic problems in tetanus--presented via a case report].

This is the case presentation of a forty-year old female patient, who had incurred a tetanus infection as a result of intravenous drug abuse. Clostridium tetani could be detected repeatedly in abscesses caused by injections. The patient had to be put on continuous relaxation, sedation and artificial respiration for 42 days. Besides the usual intensive care regimen, a high-dose antitoxin therapy was initiated. The areas of abscesses had to be eradicated surgically several times. With the exception of a thrombus of the vena cava superior (without haemodynamic consequences) and a pneumonia, the further course was without any other serious complications. After seven months of hospitalisation the patient could be dismissed at "restitutio ad integrum". The known immunosuppressive effect of a high dosed tetanus antitoxin therapy could be confirmed by the patient's antitoxin titre course. Repeated active immunisation attempts to produce a sufficient endogenous antitoxin titre failed. The existing therapeutic uncertainties regarding the dosage of the tetanus antitoxin therapy, the titre control and the proper antibiotic treatment are described.

Adult↗
PubMed1996

[Anesthesiologic management of ankle joint osteosynthesis in the 35th week of pregnancy in a patient with Charcot-Marie-Tooth syndrome].

We describe the case of an extremely overweight woman in her 35 th week of pregnancy with a manifest Charcot-Marie-Tooth syndrome (CMT), on whom a tibial fracture was operated under general anaesthesia. Anaesthesia was induced with thiopental, droperidol, fentanyl and maintained with nitrous oxide and isoflurane. Atracurium was administered as a muscle relaxant agent. Depolarizing muscle relaxants have not been used because of a significantly increased risk of hyperkalemia. The immediate intubation using the principle of a so-called "priming dose" was within normal limits. CMT syndrome is a very rare hereditary autosomal dominant degenerative disease of the peripheral nervous system. The main site of manifestation is the peroneus muscle. In case of affection of the respiratory muscular system, which acutely can occur postoperatively even without any suspicious findings in the preoperatively performed lung function tests, an insufficiency of the respiratory tract is predominant and may require a postoperative intensive care with a prolonged artificial respiration. With the application of non-depolarizing muscle relaxants significant prolongations of the half-life period have occasionally been observed. Therefore we recommend the monitoring of the neuromuscular blockade perioperatively using the train-of-four ratio. An extraordinary progression of the disease frequently occurs during pregnancy.

Adult↗
PubMed1994

[Modification of ventilation and length of stay of traumatized intensive care patients by quality and duration of preclinical management].

AIM: The study aimed at detecting relations between the quality and duration of prehospital care in the case of traumatic patients and the duration of artificial respiration and ICU stay times. DESIGN: 94 traumatic patients, admitted to the intensive care unit, were subdivided into groups according to the type of trauma. The mean time of prehospital care, injury severity score, the Apache II at the admission to the clinic and the discharge to the ICU, intraoperative replacement of blood and clinical care times were calculated. RESULT: In the group of all patients, times of the ICU-stay were correlated to the ISS and the Apache II of the hospital admission. In the group with multiple fractures, a positive correlation to the prehospital care times was found. DISCUSSION: Quality and duration of the prehospital care were identified as factors, influencing the time of the ICU stay. Optimizing these factors will be helpful in respect of economic considerations.

APACHE↗
PubMed1994

[Inner ear blood flow with betahistine--an animal experiment study].

The influence of the drug Betahistin on the cochlear blood flow (CBF) was checked on 15 guinea pigs (6 controls) (Charles River, BFA 350-450 g) by means of the hydrogen clearance method. The hydrogen clearance measurements were carried out under alpha-chloralose-ethylurethane anaesthesia, artificial respiration with simultaneous control of the electrocardiogram, arterial blood pressure and body temperature. The actual arterial pH-value was checked hourly. Indirect measurement of CBF was carried out in the perilymphatic space (basal turn) before and after intravenous application of Betahistin (vena jugularis externa) (dosage: 0.11 mg/kg/min). The mean arterial blood pressure remained within the 10% range during the experiments. Under Betahistin-treatment the CBF showed an significant increase (p = 0.05). Despite this favourable pharmacological efficiency of Betahistin it must be pointed out that the general application of vasoactive drugs, especially of vasodilative drugs, in the treatment of postulated inner ear blood flow disturbances is presently controversial.

Animals↗
PubMed1989

Suppression of cerebrospinal fluid (CSF) production by a Na+/K+ pump inhibitor extracted from human cerebrospinal fluid.

A low molecular weight compound (about 600 daltons) extracted from human cerebrospinal fluid, and sensitive to proteolytic enzymes, has been shown to mimic the specific inhibitory effects of cardiac glycosides on the Na+/K+ pump of erythrocytes. The compound, which was labelled CSF-inhibitor (CSF-I) and reconstituted in artificial rabbit CSF, was used to study its effects on the rate of CSF formation in rabbits. Three groups of adult New Zealand white rabbits of either sex, anesthetized with ketamine and xylazine, and artificially respired were subjected to ventriculocisternal perfusions. Baseline rates of CSF formation were obtained during the first 2 hours of perfusion when plain rabbit CSF was used as the perfusate. Thereafter, the animals were perfused for an additional 2 to 3 hours with either plain rabbits CSF (controls), rabbit CSF containing 10(-6) M ouabain (group 2) or CSF-I (group 3). The rate of CSF formation in control animals was observed to gradually decline with time (about 7.5% in 4 hours). The addition of ouabain to the perfusate caused an abrupt and marked 43% decline in the rate of formation while the addition of CSF-I resulted in a 57% decline. These results suggest that the peptide CSF-I which is present in human CSF may act as an endogenous regulator of CSF production.

Animals↗