Acute Respiratory Failure I. Morophology and Pathophysiology

Acute Respiratory Failure 147 I, Morphology and Pathophysiology

1 3 DESIGN OF ALVEOLO-CAPILLARY SYSTEM: GAS AND FLUID EX- IMPACT OF MECHANICAL FORCES ON GAS EXCHANGING CHANGE BARRIERS. E.R. Weibel, Department of Anatomy, STRUCTURES. H. Bachofen, Department of Medicine, University of Berne, Berne, Switzerland University of Berne, Berne, Switzerland. The design of the alveolar septum displays a number of Efficent gas exchange in the lung requires a features that favor the maintenance of a dry air-blood short diffusion distance between alveolar air barrier in the interest of gas exchange. Whereas gas ex- and capillary blood over a wide contact area. To change occurs in relation to a 2-compartment model - al- this aim the tissue mass of lung parenchyma is veolar air space and capillary blood space separated by extremely reduced: the capillary bed is covered the tissue barrier - the control of fluid movements is by a thin tissue membrane and supported by a understood on the basis a 3-compartment model, with the flimsy connective tissue network. Obviously, cellular sheets of epithelium and endothelium separating these delicate structures are easily deformable, three fluid spaces: plasma, interstitium, and alveolar and the dimensions of structural elements im- lining layer. The capillary endothelial cell lining is portant for gas exchange, i.e. the alveolar continuous, but the intercellular junctions are leaky, surface area, the thickness of the blood-gas allowing smaller solutes to be easily exchanged between barrier, and the capillary volume are profoundly plasma and interstitial fluid. In contrast, the alveolar affected by the interaction of four mechanical epithelium is made of a mosaic of squamous type I cells forces: i) tissue forces; 2) the microvascular and cuboidal type II cells; the epithelial intercellular pressure; 3) the alveolar pressure; and 4) the junctions are tight, preventing simple solute exchange surfaces forces. Within the lung volume range between interstitium and alveolar lining layer. In the of normal breathing the surface forces have a interest of optimizing barrier structure for gas exchange strong impact on the free surface area, since the type I cells are of vast expanse, highly complex in alveolar walls appear to be negligible mechani- their architecture. As a consequence they are very vul- cal components except as platforms for surface nerable and their repair upon damage is difficult. Rege- tension. Compared with fluid filled lungs normal neration of alveolar epithelium must occur from type II air filled lungs reveal a reduced free alveolar cells as stem cells. An important question is how the al- surface area by folding of the alveolar septa veolar septum prevents fluid from accumulating in the beneath the surface lining layer. Abnormally tissue space. It appears that the compliance of the al- increased surface forces further reduce the veolar septal interstitium is restricted by design: (I) by surface area. The peripheral airspaces become eliminating an actual interstitial space on large parts unusually wide, and are separated by bulky of the surface due to fusion of epithelial and endothe- tissue masses of piled-up septa of "collapsed" alveoli. Among other features these structure- lial Oasement membranes; (2) by the myofibroblasts in the actual interstitial space. Moreover, any fluid accumula- function relations may explain impaired gas diffusion, increased right-to-left shunts, and ting in the septum is rapidly drained away towards the increased alveolar dead spaces in lung diseases juxtaalveo]ar fluid sumps and lymphatics. affecting the properties of alveolar surface lining layers only.

MORPHOLOGY IN ARDS CONSIDERING STRUCTURE- PATHOGENETIC FACTORS OF INCREASED CAPILLARY PERMEABILITY FUNCTION RELATIONS. M. Bachofen, Department of IN ARDS. M. LAMY, M. BRAUN, C. DEBY, G. DEBY-DUPONT, J. Anesthesiology, University of Berne, Berne, DUCHATEAU, M. HAAS, J. VAN ERCK (Universities of Li6ge Switzerland. and Brussels, Belgium). The acute stage of ARDS is characterized by an The pulmonary edema of the ARDS is due-to loss of interstitial and alveolar edema due to focal integrity of pulmonary capillary walls. ARDS complicates alveolo-capillary barrier destruction regardless pulmonary and systemic infections, hypoperfusion states, of whether the primary action site of the nox- inhalation of toxic gases including oxygen, aspiration of ious stimulus may have been alveolar space or damaging liquids, intravascular coagulation or embolism, capillary lumen. While epithelial lesions can platelet and leukocyte aggregation, immunopathies and easily be visualized endothelial defects are allergic reactions, and hypoxia, all of which may lead sparse although occasional large amounts of red directly or indirectly to endothelial cell damage. Many blood cells and fibrin strands in the subendo" humoral factors are involved (in vitro and in vivo animal thelial and interstitial space are strong evi- studies, very few human studies) : activated complement dence of temporary capillary leaks. Different fractions, prostanoids, leukotrienes, proteases, peptides cell repair mechanisms, a fast one for the endo- and coagulation and fibrinolysis products. We have thelium and a time consuming two stage repair studied complement activation, thromboxane and process for the type I epithelial cells, account prostacycline metabolites (TX% and 6-oxo-PGF I ), for this observation. The thickening of alveolar and immunoreactive and enzymatlcally active thypsin in septa by proliferation of type II epithelial plasma from 50 ARDS patients. Abnormal C~ consumption cells and an accumulation of cells and fibers in (as measured by C3a/C~ ratio) and elevated plasma the interstitial space, intraalveolar fibrosis, Cm -like activity ~as~measured by a leukocyte changes in extraalveolar vessels and structural a~regation assay) were associated with, respectively, 84 rearrangements of peripheral air spaces are % and 86 % of cases of ARDS. Both tests were more distinctive features of the subaeute stage of sensitive indicators of complement consumption than the disease. Its duration does not necessarily assays of total hemolytic complement activity (CH50) or correlate with the severity of structural altera- total C3. Sequential samples on both sides of the tions. Cases of severe functional impairment may pulmonary circulation showed initial pulmonary clearance go along with extremely reduced capillary volumes followed by liberation of C~ -like activity. Abnormal and a very low oxygen diffusion capacity as esti- TXBe plasmatic values were ~und in 58 % of ARDS mated by morphometry. Rapid improvement of gas patients, during consecutive days of evolution; values up exchanging and ventilatory lung function may re- to 8000 pg/ml were measured. Trypsin values were enhanced flect a partial restoration of the geometry of (> 70 ng/ml) in 87 % of ARDS patients, particularly in peripheral airspaces rather than a reversion of septic cases; repetitive high trypsine values correlated fibrotic lesions. with high mortality rate. Our data confirm the participation of the complement-leukocyte cascade in the increased pulmonary capillary permeability of ARDS. II. Experimental Studies

BDLE OF ELASTASE AND GRANULOCYTES IN EXPERIMENTAL POSTTRAUMATZC ULTRASTRUCTURAL CHANGES AND THE MODELS OF ARDS. ROLE OF GRANULOCYTES IN THE LUNGS, LIVER AND H.Burchardi, T.Stokke, I.Hensel, W.H.H~rl I, G.Schlag 2, _ SKELETAL MUSCLE, G. Schlag, H. Redl, Ludwig Zentrum Anaesthesiologie, Universit~t G~ttingen, West- Boltzmann Institute of experimental Traumatology, Germany, (I WTirzburg, 2 Wien). Vienna, Austria Selective sequestration of polymorphonuclear neutrophils The posttraumatic-hypovolemic shock results in (PMNs) in the lung seems to play a central role in early pulmonary changes which predominantly affect the ARDS. Sequestered PMNs m~y damage lung tissue either di- cellular and subcellular levels. Morphologically rectly or by releasing mediators such as lysosomal pro- 2 distinct stages are present, the "lung in teases (f.e. elastase). We studied the possible role of shock" within the first hour and the "shock lung PMNs and of elastase on lung function by infusing elas- syndrome" which manifest itself after 24 to 48 h. tase in normal and in agranulocytic minipigs. The early stage "lung in shock" is characterized METHODS: Among 16 minipigs studied (anaesthetized and ven- by a multitude of changes in the microvascular tilated) 4 were pretreated with dimethylmyleran which de- system: massive leukostasis, polymorphonuclear pleted granulocytes ccmioletely. 3 pigs without pretreat- granulocyte (PMN) degranulation, and endothelial ment or elastase infusion for control. Elastase was in- cell swelling. The purpose of the study was to fused (330 U/kg-h) continously for 3-4 hours in the elas- compare the ultrastructural findings of the lung, tase and in the agranulocytic group. ~itiple determina- liver and skeletal muscle with respect to the tions of cardio-respiratory functions were repeated in granulocytes (PMN) and the endothelial cell da- short intervalls before and during the treatment. Finally, mage. In many phases, the endothelial cells are morphological studies were performed. considerably swollen in the lung and skeletal RESULTS: The control group revealed steady state condi- muscle. tions during the whole experiment. However, elastase But whereas many polymorphonuclear granulocytes caused typical effects beth in the normal as well as in present in the alveolar capillaries of the lung, the agranulocytic pigs: I/anediately after onset of elas- only a few isolated granulocytes are seen in the tase pulm.art.pressure (PAP) increased but only temporar- vessels of the skeletal muscle tissue. ily. Oxygenation (AaD02) deteriorated after one hour when Leucostasis in the lung was also confirmed quan- PAP again had returned to baseline. Pulm. diffusing capa- titatively using llIIn-oxine labeled PMN; in the city decreased slightly. In the non-pretreated pigs elas- liver it was present to a much lesser extent, tase infusion caused a significant sequestration of PFi~s while there were no changes versus the pre-shock in the lung. But, as the effects on lung function were period in skeletal muscle. nearly identical in the normal as well as in the agranu- The granulocytes might be responsible for the on- locytic group, this could primarily be an elastase effect set of lung damage after shock, acting on the independent of the presence of PMNs in the lung. endothelial cells (reactive oxygen species). One CONCLUSION: Elastase, released by PMNs sequestered in the needs to consider other causes of analogues in lung, may (interacting with other systems?) play a role striated muscle (hypoxia?) . in early ARDS. Elastase itself seems to induce pulmonary P~ sequestration by neurophil activation.

HYPOXIC PULMONARY VASOCONSTRICTION IN PATHOLOGICAL CONDITIONS. M.K.Sykes, Nuffield Department of Anaesthetics, Radcliffe Infirmary,. Oxford, 0X2 6HE, United Kingdom.

The pulmonary circulation is a low pressure, low resistance system which accommodates the marked increases of cardiac output associated with exercise by recruitment and distension of the pulmonary vaseulature. The required distribution of perfusion is governed primarily by the relationship between alveolar, pulmonary arterial and left atrial pressures, blood flow being least in the non-dependent zones and maximal in its dependent zones, whatever the body position. Regional blood flow is reduced by a reduction in regional lung volume (which narrows the extra-alveolar vessels) and by regional underventilation (which leads to a reduction in alveolar P02 and increases in alveolar Pco2). The reduction in regional flow from hypoxic pulmonary vasoconstriction (HPV) isprimarily governed by alveolar P02. However, in collapsed regions of lung the mixed venous P02 determines vascular tone. HPV is, therefore,accentuated when cardiac output is reduced and decreased when output is increased. This may account for the well known direct relationship between shunt and cardiac output. An increase in shunt may also Occur when HPV is inhibited by drugs, raised pulmonary artery or left atrial pressure or hypothermia, or when drugs cause vasoconstriction in the oxygenated areas of lung. III. Pulmonary Circulation and Right Heart Performance 149

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PHYSIOLOGY OF PULMONARY CIRCULATION AND RIGHT LV FUI~CTION DURING HECHA[~ICAL VEI~TILATION. J.L. HEART PERFORMANCE. A.Versprille, Deptm. of pul- Robotham, University of Texas Health Science Center at monary diseases, Erasmus University, Rotterdam, San Antonio, San Antonio, Texas. The Netherlands. Conventional wisdom suggests that the dominant hemody- The cyclic changes in heart performance during namic factor during IPPV is the inspiratory reduction artificial ventilation have to be ascribed to in systemic venous return and hence a secondary reduc- mechanisms with short time constants because tion in LV output. The purpose of this paper is to they occur and recover within the period of a question this simplistic approach to analysis of the LV ventilatory cycle. Therefore, nervous and humo- during IPPV in critically ill patients. Under patholo- ral control as well as cardiac contractility gic conditions, (e.g. congestive failure) other factors changes are rejected as mechanisms explaining will theoretically become increasingly important based the cyclic events. on a physiologic analysis of IPPV. Guyton's theory, that venous return (Qv) is controlled by central venous pressure (Pcv), also Variables to be examined which have been found to influ- counts for the cyclic events during artificial ence LV performance during IPPV include: a) inspiratory ventilation. Pcv is mainly dependent on intra- expiratory variation in RV and LV stroke volume b) in- thoracic pressure (Pth), although a decrease of fluence of respiratory rate (from I0 breaths per minute Pcv,tm (transmural) occurs during insufflation: to I0 per second) and the influence of the I-E ratio the decrease in venous return due to the in- c) changes in pulmonary vascular volume, e.g. hypovole- crease in Pcv causes a decrease in filling pres- mia or pulmonary edema d) end expiratory lung volume, sure i.e. preload. Also transmural pulmonary ar- i.e. PEEP e) changes in tidal volume and its effects tery pressure (Ppa,tm) decreases during insuf- boLi~ on pulmonary vascular volume and mechanical com- flation when PEEP is below about 6 cmH20. This pression of the heart by the lung f) changes in heart fall in afterload might contribute to the de- volume on mechanical heart-lung interaction g) the increase in RV-filling pressure. Above a PEEP of creases in inspiratory pleural pressure acting to 6 cmH20, Ppa,tm at peak insufflation increases effectively reduce LV afterload h) respiratory changes progressively, when PEEP increases, undoubtedly in abdominal pressure which may influence not only due to a progressive obstruction of the pulmona- venous return but also LV afterload and regional dis- ry circulation. The fall in venous return to the tribution of cardiac output i) regional changes in LV left ventricle (LV) can be ascribed to the fall geometry produced by IPPV with and without PEEP, and j) in RV-output. The time delay can be explained by the influence variation in right heart volume during a squeezing effect on the pulmonary circulation the respiratory cycle on LV performance. during early insufflation. Plved,tm fell during late insufflation and early expiration concomi- From analysis of the above, it is concluded that under tantly with the fall in pulmonary venous return. pathologic conditions, multiple factors other than This fall also caused a fall in transmural aor- changes in systemic venous return may significantly tic pressure. Cardiac compression and ventricu- affect LV performance during IPPV. It is hypothesized lar interdependence were rejected as mechanisms that when better understood, IPPV may be able to assist controlling heart action during artificial ven- LV performance in critically compromised patients. tilation.

EFFECTS OF PEEP ON RIGHT VENTRICULAR FUNCTION IN ARDS PATIENTS. J.F. Dhainaut,'J.Y. Devaux, B. Schlemmer, O. Salmon, V. Fouresti@, A. Carli et J.F. Monsallier. Departments of Intensive Care and Nuclear Medicine. Hop. Cochin. F 75674 PARIS C@dex 14. To identify the mechanisms responsible for decreased right ventricular (RV) performance during mechanical ventilation with high levels of PEEP in ARDS pts and the effects of mormali- zing cardiac output by volume expansion (VE), we studied I0 such pts. RV volumes (EDV-ESV) were calculated by both thermodilution and radionuclide studies at O, 15, 20, 25 cm H2 0 PEEP and after VE. While heart rate remained unchanged, stroke ~olume (SV~ gradually fell with PEEP from 40 ~ 2 TO 31 3 ml/M2 at 25 cm H2 0 PEEP and returned to prePEEP values af~_rVE. PEEP O 25 25+VE EDV 85 ~ 5 64 ~ 8 ~ 85 ~ 4 ESV 45 ~ 5 33 ~ 7 ~ 44 ~ 9 EF .47 ~ ~4 .49 ~ O5 .48 ~.05 ESPt 28 ~ 5 31 ~ 5 37 ~ 7 ~

EF= ejection fraction, ESPt = transmural end- systolic pressure, 0p < . O1 PEEP o vs 25

Conclusions : In ARDS pts, PEEP decreases RVSV by imposed limitation on EDV (due to increased intrathoracic pressure) despite a higher after load. RV contractility tends to increase (left ward shift of the RVESPt-V relationship) probably due to increased catecholamine levels. After VE, SV returns to prePEEP values in relation to increased preload and sustained increase in contractility. IV. New Trends in Therapy

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NEW METHODS FOR ASSESSING GAS EXCHANGE. F. LEMAIRE, HOpi- HIGH FREQUENCY VENTILATION(HFV) :UPDATE ON INDI- tal Henri Mender, F - 94010 CRETEIL C~dex. CATIONS AND TECHNIQUES.H.Benzer,M.Baum,St,Duma, The oxygen method (Berggreen, 1942) is routinely W.Koller,N.Mutz,G.Pauser, Klinik fdr Anaesthesie used in the ICU to evaluate venous admixture. However, va- u. Allgem. Intensivmed.,Universitit Wien,Austria lues obtained by this method may vary according to the Since the introduction of High Frequency Jet Ve~ inspired FiO 2. New methods have emerged to provide relia- tilation(HFJV) (f=1,5-SHz,V~VD)other HFV systems ble assessment of gas exchange. The Krypton m 83 scinti- has been designed. In High Frequency Pulsation gra~ can be used to evaluate the distribution of regional (HFP) better elimination of CO o is managed by VA/Q. This short lived isotope, highly soluble in gas and transversely flowing current o[ fresh gas and liquid phase, provides scintigrams of ventilation and eer- in using a circle with CO2-absorber(f=5-9Hz), fusion when inhaled and in.fuse.d intravenously. The two V~V_).In Forced Diffusion Ventilation(FDV) 2jet scans can be compared and VA/Q ratio can be evaluated zo- nozzles are located at the distal end of the tube ne by zone. This method best used when regional altera- (f=upto25HZ,VT=1O-3oml).In the field of High Fr~ tions of ventilation and/or perfusion are suspected (pul- quency Oscillation(HFO) we developed the so cal- monary embolism, emphysema, unilateral pneumonia) and eva- led Pneumatic BFO(f=up to 12Hz). Indications for luate the role of changes in body position on gas exchan- HFV are based upon our clinical experiences in ge. 137 patients: 1.Postoperative ventilation in car- The six inert gas method, proposed by W~gner et diac patients (n=45). Gasexchange could be main- Evans in 1974, assesses the abnormalities in VA/Q distri- tained well during controlled ventilation and bution, irrespective of their topography. The high sensi- the weaning period. Conteraction to hemodynamics tivity of this method is its major advantage, since the depends on f,I/E-ratio and primary pressure. use of highly, insoluble gas (SF6, ethane) can detect zo- 2.Intraoperative application of HFV (lung surge- nes with VA/Q ratios of lower than 0,01. The infusion of ry) (n=36) is favourable (extensive resting po- the most soluble gas (acetone, ether) provides a measure- sition of the lungs, reduced gas loss through ment of dead space. Additionally, this method is not de- pleural leakage).3.Intensive care patients(n=56). pendent on Fi% and oxygen diffusion. It can be applied In ARDS better PaD 2 in comparison to conventio- to patients wi~h mechanical ventilation in the Icu, with- nal ventilation could be established in using out changing the FiO 2. So far, this method has been main- high frequencies( 5Hz) long I/E ratio and high ly directed at evaluating the effect of mechanical venti- primary pressure. Bronchopleural fistulae were lation, with and without PEEP, anesthesia, decubitus, pul- managed with FDV(Iow VT) , the combination with monary edema, ARDS. However, technical difficulties requi- IPPV faciliated CO 2 elzmination. In normal lung re highly specialized laboratory, and prevent its routine function low frequencies (I,5-5Hz) short I/E- use. The method offers a sophisticated aooroach for un- ratio and low primary pressure (1,5-2 bar) derstanding the complex VA/Q relationshi.o in lung disease. achieved satisfactory gas exchange with low Pairway" In patients with brain damage we observed a arop in intracranial pressure. HFP acts as a advantageous method of augmented ventilation (flail chest) and is a suitable method for breathing therapy.

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DIFFERENTIAL VENTILATION 151 BILATERAL LUNG DISEASE. G. HIGH FREQUENCY OSCILLATION: EFFECTS ON Hedenstierna, Dept. of Clinical Physiology, Huddinge Hos- LUNG MECHANICS AND CARDIAC FUNCTION. J. pital, Stockholm, Sweden Armengol, R.L. Jones, E.G. King. Hospital de Anaesthesia and acute respiratory failure impede vnetila- Sant Pau, Barcelona, Spain and University Lion of dependent luna units and perfusion of non-depen- Hospital, Edmonton, Canada. dent ones, creating considerable ventilation-perfusion (V/Q) mismatch. General PEEP can improve V/Q but it can- We studied the effects of high frequency not restore it to normal. To imarove matching, ventila- oscillatory ventilation (HFOV) on gas tion must be distributed in proportion to regional blood exchange, hemodynamics and basic pulmonary flow. This can be accomplished by I) placing the subject mechanics in dogs with normal and stiff in the lateral position, 2) ventilating each lung in pro- lungs. In a group of 9 healthy animals, HFOV portion to its blood flow (differential ventilation) and maintained normal gas exchange but cardiac 3) applying PEEP solely to the dependent lung to ensure output decreased and pulmonary and peripheral even distribution of inspired gas within that lung (se- resistances rose. In another group of 5 lective PEEP). Differential ventilation with equal dis- dogs, HFOV was found to increase functional tribution of the tidal volume between the lun~d a se- residual capacity (FRC), mean airway and lective PEEP of I0 cm H~O to the deoendent lung resulted pleural pressures. This effect was more in equal distribution o~ perfusion between the lunqs in accentuated at high oscillatory ana~tized lung-healthy subjects, suggesting "optimum" frequencies. The FRC was measured over a 16 ~/Q matching. Using this ventilator setting as a rule of minute period and found to increase around thumb in patients with acute, severe, bilateral lung dis- 60% during the first minute, after which it ease, arterial oxygen tension was impr~an average remained stable. The effects of HFOV were of 45% compared with that during general PEEP, with no also studied in 8 other dogs which were first reduction in cardiac output. It is concluded that differ- lavaged with saline to remove some surfactant ential ventilation with selective PEEP can offer consider- and produce stiff and unstable lungs. HFOV able improvement in gas exchange in acute, bilateral produced a higher FRC than positive end- lung disease. expiratory pressure even though mean airway Table Cardiac output (QT), venous admixture (Q~/QT), ar- pressures were similar. In these animals ~I oxygen tension (Pa09) and oxygen availabiTity A-aD02 gradients were lower during HFOV but (02avail) in 8 patients wi~h acute bilateral lung disease C02" elimination was somewhat decreased. We conclude that although HFOV can achieve gas Supine Supine Left lateral Left lateral exchange in normal and stiff lungs, the Gen. ~ 50:50 + cardiovascular function may be impaired, ZEEP PEEP IO 50:50 SeI.PEEP I0 probably due to its effect on lung volumes. QT I/min 6.1 5.1 6.0 6.5 Q~/QT % 32 30 24 22 P~O~'kPa 9.5 10.5 11.4 14.5 O~a~ail__ ml/l 970 940 1040 1080 m: equal distribution of ventilation between the lungs. 151

INDICATIONS FOR EXTRACORPOREAL CO 2 REMOVAL L.Gattinoni Istituto di Anestesia e Rianimazione, Univez- sit& di Milano, Milano, Italia Extracorporeal CO 2 removal (ECCO2R) with low frequency positive pressure ventilation (LFPPV) has been introduced in clinical practice in 1979. Most of the experience with this technique has been gained in Milano (22 pts) even tought few other ptsrecently underwent LFPPV-ECC0_R in West Germany, U.S.A. and Australia. All t~e pts had severe ARDS of various etiology: politrauma, viral and bacterial pneumonia, fat embolism and septic, toxic shock lung. The relatively small number of patients does not allow to suggest any indication on etiological basis, even tought an higher rate of success has been reached in some etiological group (Shock lung, fat embolism, virus and bacterial pneumonia). To date the entry criteria are based on functional data: i) blood gases values under defined ventilatory conditions, as proposed in the American extracorporeal membrane lung oxygenation study; 2) total s~atic lung compliance lower than 30 ml cmH 0- , when measured at 10 ml kg- I lung inflact~on. These criteria still entail a mortality rate close to 100% with conventional treatment. Controindications to the treatment remain systemic degenerative diseases, severe head injury and pulmonary active bleeding (including hemothorax). Cardiovascular Intensive Care I. Acute Arrhythmias

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EXPERIMENTAL ELECTROPHYSIOLOGICAL BASIS OF #/IIIHYTH- DETECTION AND DOCUMENTATION OF ARRHYTHMIAS - R. Ritz, MIAS IN ISCHEMIC HEART DISEASE H.Antoni,Physioleg. Intensive Care Unit, Dep. Internal ~ed.,University of Basle Inst. Univ. of Freiburg i.Br., Eermann Herder Str. 7 The computerized arrhYthmia-monitoring system allows i) D 7800 Freiburg i.Br. recognition of ectopic beats, for a potentially prophylac- Cardiac arrhythmias accompanying ischemic heart dis- tic treatment, 2) instantaneous alerting to the first oc- ease include disturbances of impulse formation ( de- currence of life-threatening arrhythmias, including docu- pressed or enhanced automaticity) as well as of im- mentation of the preceding rhythm, 3) detection of a need pulse conduction (block of conduction, reentry). The for special procedures, e.g. pacemaker, by announcing even primary causes of these disturbances are the decrea- short periods of "omitted beats" (sick sinus), and 4) check- ses of the ionic gradients (K,Na,Ca) due to the lack ing of therapeutic management, e.g. testing of antiarrhyth- of energy supply and specific effects of acidosis or mic drugs in chronic coronary heart disease or pacemaker of metabolites due to inappropriate perfusion. function. Depression of the regularautomaticity as well as of In patients with acute coronary heart disease the value of impulse conduction is favoured by the decrease of the antiarrhythmic treatment of the so-called "warning '! ventri- KU,Na-,and Ca-gradients and by acidosis. Ectopic fo- cular ectopic beats to prevent ventricular tachycardia or cal activity is enhanced by the release of sympathe- fibrillation is still questionable. As long as such ar- tic transmitters and by injury currents occuring in rhythmias are treated routinely in most coronary care units, the border zone of an acute myocardial infarction. worldwide, the reliable detection of ectopic beats is ~oreover 9 acidosis favours the development of ectopic essential. The conservative methods of continuous ECG ob- focal activity by inducing early af~crdepolarizations servation on a scope of up to eight patients at a time is in Purkinje fibres. no longer a justifiable task for well trained and highly The production of reentry requires shortening of the skilled CCU personnel, for two reasons: l) Even persons waves of excitation either by accelerated repolariza- specialized in rhythm recognition miss up to 60% of ectopic tion or by slewing of the propagation of impulses or beats during more or less continuous observation of an ECG by both. The slowing of impulse conduction might be display screen. 2)ECG reading is a typical taskforthecomputer. due to the generation of slow responses in depola- An investigation of the specificity and sensitivity of our rized fibres exposed to sympathetic stimulation. arrhythmia-monitoring system (EP 78220) still revealed a Moreover, an appropriate delay of conduction may also considerable number of false-positive alarms, disturbing the result from the electrotonic spread of excitation nursing staff unnecessarily, but ahighsensitivityofmore across damaged inexcitable tissue. A non-homogeneous than 90% in the detection of ectopic beats (n=10.400) re- state of excitability of the heart forms another presents an increased level of security for the patients. condition indispensible for reentry because it en- Histographical presentation of the trend of the arrhyth- ables unidirectional conduction to take place. Non- mias facilitates the overview, while TV display in all homogeneous excitability is normally encountered rooms of the CCU and the proven reliability of the system during the early phase of recovery in the cardiac ex- give the nursing staff more freedom in patient care. Our citatory cycle (vulnerable period) and is strongly nurses would now certainly not like to have to live with- increased by frequent extrasystoles. out the system.

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CLINICAL PHARMACOLOGYOF ANTIARRHYTMICDRUGS. F. Follath. ANTIARRHYTHMIC PROPHYLAXIS IN ACUTE MYOCARDIAL INFARCTION Division of Clinical Pharmacology, Oepartment of Medicine, K.I. Lie, Department of Cardiology & Clinical Physiology, University Hospital, Basel, Sw~zerland. Wilhelmina Gasthuis, Amsterdam, the Netherlands An exact knowledge of the pharmacodynamic and pharmacokinetic properties of antiarrhytmic agents is essential for Many antiarrhythmic drugs have been studied on their their optimum use in intensive care patients. The electro- efficacy in preventing primary ventricular fibrillation physiological mechanisms of action, as well as possible in acute myocardial infarction, but only lidocaine given effects on sinoatrial,atrioventricular or intraventricu- in rather high dosages has been shown to be effective in one randomized controlled study. In view of the rather lar conduction, myocardial contractility and peripheral high incidence of side effects this latter study and the resistance should be taken into account when a particular equal mortality rates in both groups, prophylactic anti- drug is selected to treat acute ventricular or supraven- arrhythmic treatment in all patients admitted to the CCU tricular arrhytmias.A further decisive factor for thera- because of acute myocardial infarction is questionnable. peutic success is the choice of an adequate dosage regimen However, recent uncontrolled observations on lidocaine Potentially effective drugs may fail because the therapeu- have indicated a very low incidence of primary ventricu- tic serum drug levels are not reached and/or maintained lar fibrillation and one case controlled study showed a during a dosage interval.Drug elimination rate in acutely lower hospital mortality in lidocaine treated patients. ill patients is often altered by cardiac,hepatic and re- Moreover 20% of untreated patients will develop recur- nal failure or by interacting drugs administered simulta- rent attacks of ventricular fibrillation which may lead neously. Individualization of antiarrhytmic drug dosage to extension of infarction and higher mortality rates. is therefore necessary to obtain maximum benefit and to Other studies have suggested that effective lidocaine avoid unwanted side-effects. This task can be facilita- prophylaxis during 48 hours can be achieved with an ted by serum drug concentration monitoring. Rapid and acceptable incidence of minor side effects and a low reliable techniques for measuring lidocaine, procainamide, toxicity provided that the following measures are under- quinidine and disopyramide concentrations are now availa- taken: I. adequate loading dosages of 200 mg given in 10-20 ble. The practicability and utility of this approach will minutes, be illustrated by data on lidocaine treatment in patients 2. continuous administration using automatic infusion with ventricular arrhythmias following myocardial infar- pumps in dosages averaging 3 mg/minute, ction. 3. carefull monitoring of side effects and abrupt dis- continuing when they supervene, 4. reducing dosages by at least 50% in shock, heart failure or hepatocellular disease. It may be concluded that prophylactic antiarrhythmic treatment with lidocaine is preferable than placebo, provided that adequate measures are undertaken. II. Massive Pulmonary Embolism ]53

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MASSIVE PULMONARY EMBOLISM : DIAGNOSTIC ASPECTS. P.Even, MASSIVE PULMONARY EMBOLISM - FIBRINOLYSIS D.Safran, G.Dennewald, M.Stern, P.Reynaud, H.Sors.H~pital INDICATIONS AND LIMITS. G.A.H. Miller, Laennec, 75007 Paris, France. Cardiac Department, Brompton Hospital, 500 patients with pulmonary embolism (PE) were studied by Fulham Road, London. SW3 6HP heart catheterization, perfusion lung scan (PS) and angi~ graphy (PA) and some by ventilation scan (VS) or digitali- Fibrinolysis is not indicated in minor embolism zed substraction angiography ; 40% had massive PE (> 60% where there is no haemodynamic disturbance vascular obstruction-Miller index). In spite of new soph~ and is ineffective in chronic thromboembolism. sticated investigation methods the initial diagnosis re- Its use is limited to acute massive embolism mained desperately erratic and delayed (I-90 days) with (with or without shock) when it is the an eqal number (60%) of false positives or false negati- treatment of choice. In such patients ves eliciting dramatic consequences : recurrent PE and un- accelerated resolution has been demonstrated due and hazardous anticoagulation or surgery. The main (as compared with anticoagulant therapy) erro~were : a) in non-massive PE, acute or chronic lung in a number of studies. Improved survival diseases (pneumonias, atelectasis, cancer, asthma, pleu- has not been demonstrated and would require risy) b) in massive PE, heart, abdominal, septic or ner- larger studies than have been practicable. vous diseases (myocardial infarction, cardiac tamponade, Fibrinolysis is contraindicated when there is dissecting aneurysm, hypovolaemic or septic shocks, acute an increased risk of bleeding or where peritonitis, liver or sub-phrenic abcesses, acute chole- haemorrhage would have a high risk. cystitis or pancreatitis, stroke). To improve the diagno- Fibrinolysis may be contraindicated in sis performance we have reexamined the sensitivity and supra-massive embolism where only embolectomy specificity of clinical and laboratory findings rather provides rapid enough reversal of the their frequency order. We propose the following state- haemodynamic disturbance. Fibrinolysis ments : I) always think to PE but never accept it without becomes less effective when the duration of proof, 2) there is no benign PE but only benign first embolism extends beyond 48 hours. Bleeding PE, 3) there is no unic massive and lethal PE but only complications are no more common than with multirecurrent PE, 4) a suspected PE has to be urgently anticoagulant therapy. Whatever the initial proved or disproved and energically treated whatever its treatment there is little if any late mortality importance, 5) the decreasing order of specifity is : PA or morbidity in survivors of massive embolism (to affirm) = PS (to eliminate) > Chest X-ray >> phlebi- who received energetic treatment. tis, associated symptoms (pain + dyspnea + hemoptysis), etiology, EKG, hemodynamics, >> isolated sympto~ , blood gas, enzymes, lung scan (to affirm): 6) VS gives rarely more information than PS, 7) recurrency has to be proved by PA and not by PS, 8) PA has to be performed as freque~ tly as possible to establish the diagnosis, specify the site and size of the clots and control the venous ilio- caval axis.

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ACUTE RIGHT HEART FAILURE IN MASSIVE PULMONARY TROMBENDARTERECTOMY OF THE PULMONARY ARTERY IN CHRC- EMBOLISM. A. Bloch, O. Guinand, H6pital de la NIC PULMONARY EMBOLISM WITH PULMONARY HYPERTENSION Tour, Meyrin-Geneva, Switzerland. AND COR PULMONALE.V.0.BjSrk,L.Bengtsson,A.Hclmgren. Massive pulmonary embolism (MPE), obstructing Dept.cf Thoracic Surgery, Karolinska hospital,Stock- more than 50% of the pulmonary circulation, holm, Sweden. leads to an increase in pulmonary artery (PA) Chronic pulmonary embolism with pulmonary hyperten- resistance, PA pressure and right ventricular sion and cot pulmcnale can,after intense functional (RV) work. This will lead to acute RV failure and anatomic investigation,be treated succesfully (acute cor pulmonale) and decrease of pulmonary with TEA of the pulmonary artery. Perfusion scinti- flow and cardiac output. gram is for screening a simple and informative procedure.Pulmonary angiogram is accurate for anatomi- Echocardiography has revealed several abnormali- cal localisation,and angiogram of the bronchial art- ties in patients with MPE. I) Dilatation of the eries important to assure a ~ell functioning perif- PA and right ventricle. The size of the PA ap- eral circulation of the pulmonary vessels. Heart pears to correlate well with the mean PA pressu- catheterization is necessary to evaluate the degree re. 2) Decrease of the left ventricular dimen~o~ of pulmonary hypertension,which is the most important Additional inspiratory decrease in left heart prognostic variable for succesful surgery, the better volume may lead to failure of aortic valve ope- prognosis the lower pressure. The cases of three ning and therefore to paradoxical pulse. 3) Ab- young women with chronic pulmonary embolism with sys- normally high ratio of right/left ventricular tolic pulmonary pressure of three different levels enddiastolic diameter. This index correlates about 25,80 and125 mm Hg respectively were all oper- well with the angiographic severity of the embo- ated with TEA at clinic of Thoracic surgery,Karolinska lic obstruction in patients without prior cardio hospital,Stockholm,with results corresponding to pre- pulmonary disease. 4) Abnormal (paradoxical) dia- operative pulmonary pressure. The importance of early stolic motion of the intervenhricular septum. 5) diagnosis before severe pulmonary hypertension has Abnormal motion of mitral or tricuspid valve. developed is stressed and the value of adequate diag- Echocardiographic association of a large right nostic methods is illustrated. Operation is to be done with cardio-pulmonary by pass stand by. With proper ventricle, a small left ventricle and a parado- investigation and treatment in cooperation with sur- xical motion of the septum is very common in MPE geons,cardiologists,physiologists and radiologists and allows to explain the physical findings. the prognosis f~ chronic ~ulmonary embolism with Dyspnea, tachypnea and tachycardia are usually pulmonary hypertension and cot pulmonale encouraging present in MPE. Other findings may indicate acu- for many patients,where although optimal pharmacolog- te cor pulmonale: accentuation of the pulmonic ical treatment,pr0gressive heart and pulmonary in- closing sound, RV diastolic gallop, elevated ju- competence develops. gular venous pressure with large A waves. These abnormal signs and symptoms Will progressively disappear with the spontaneous or therapeutical removal of pulmonary embolic obstruction. III. Aortic Dissection

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AORTIC DISSECTION - CLASSIFICATION AND DIAGNOS- ACUTE AORTIC DISSECTION: SURGICAL MANAGEMENT TIC PROCEDURES. F.G.M. ROSS, E.R. Davies, Bris- AND RESULTS. Tom Treasure and R.K.Firmin, The tol Royal InfJrmary, Bristol BS2 8HW, England. Middlesex and The London Chest Hospitals.

The universally accepted classification of We use the classification suggested by Dissecting Aortic Aneurysms defined by De Bakey Shumway~s group in whic~ all dissections et al (1965) will be described and two others involving the ascending aorta are TYPE A end mentioned. The role of diagnostic imaging me- those confined to the descending aorta are thods, particularly radiology, ultrasound and termed TYPE B. We have reviewed a series of 24 computed tomography in determining the presence cases (17 men and 7 women) where the catheter of a dissecting aneurysm of the aorta and in diagnosis was aortic dissection: 19 TYPE A and demonstrating its site and extent, including 5 TYPE B. Surgical correction was attempted in involvement of branches of the aorta, will be 17 and 2 cases with a hospital mortality of 24% discussed and illustrated. A review of 15 Gases and 50% respectively. These small numbers are of surgically treated dissecting aortic aneu- in general agreement with published series. We rysms will be presented. have therefore adopted the following policy. Reference: De Bakey et al (1965). Surgical Ma- Acute TYPE A dissections are managed nagement of Dissecting Aneurysm Of the Aorta . surgically and operation is performed as soon J. Thorac. Cardiovasc. Surg. 4_99, 130 ~ 149. as possible. Medical management carries a mortality of 80-90% with death being due to rupture into the pericardium, coronary artery occlusion or severe aortic regurgitation. Surgery reduces this to the region of 25-35%. Preoperative hypotensive measures are considered to be important and the operation should be kept to the minimum consistent with repairing the ascending aorta and associated lesions. TYPE B dissections have a mortality of around 30% whether managed medically or surgically with spinal cord complications an additional operative hazard. TYPE B are therefore managed medically. We use CT scanning as an indicator of continuing enlargement of the aneurysm and ~ resort to surgery in that sub-group.

AORTIC DISSECTION: NATURAL COURSE AND MEDICAL MANAGEMENT. P.C. Baumann, Medical Intensive Therapy Unit, University Hospital, CH-8091 Zurich, Switzerland The mortality of aortic dissection is very high and the death rate is approximately 83% one month from date of onset, if the course is not altered by treatment (I). The prognosis is influenced by the localization of the dissection. Without surgical treatment it is extremely poor in patients with proximal dissections (type A or I/II by the DeBakey classification) with early rupture into the pericardium being the main cause of death. Me- dical management alone should not be considered unless there are serious contraindications to surgery. Patients with distal dissections (type B or III) should be treated medically in the acute phase, if there are no major complications such as bleeding, obstruction of major arteries or continuing enlargement and pain. If there is no hypotension medical therapy usually consists of a peripheral vasodilator (e.g. sodium nitroprusside) to lower blood pressure in combination with a beta-adrenergic blocking agent to reduce myocardial contractile force. Blood pressure is kept as low as possible. A diuretic and medications for pain and sedation may be added. From 1975 to 1982 123 patients with acute aortic dissections (80 type A, 43 type B) were admitted to our Medical Intensive Therapy Unit. Therapy in the acute phase was purely medical in 64% with type A and in 79% with type B. Death rate within 4 weeks was 84% (A) and 29% (B). Death rate in those who were operated in the acute phase was 34% (A) and 56% (B). Ref.: (I) Anagnostopoulos C.E. et al. Am J Cardiol 1972; 30: 263-73. Nursing in Intensive Cam 155 L Formation

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RECRUTMENT OF PERSONNEL FOR I.C.U.E. Staub, Bern. PROBLEHS OF A TRAINING UNIT. M. HOESS, This report concerns our experience in the I.C.U. in the UNIVERSITAETSSPITAL ZUERICH, 8092 ZUERICH Inselspital in Bern. In an I.C.U. recognized for specia- I would like to indicate the problems and trends lized education some regulations exist concerning the mi- of developement: nimum number of nurses, as well as the ratio between nur- I. Overstrain by the increase of dangerously ill ses in training and I.C.U. staff. We could only achieve patients, 2. Physical and psychical strain on satisfactory results after greatly increasing the number the nursing staff, 3. Increasing technicalisati- of trained nurses. The change from one I.C.U. to another on of the intensive care is a great problem not only for trained I.C.U. nurses but To point I: The nurses starting their intensive even more so for I.C.U. student nurses, who have to comp- care training are often unable to cope with the lete their education in a second unit. Since unfortunate- hi3h demands in supervision. The only answer to ly supply is less than demand, departing I.C.U. nurses these problems is a thorough and gradual intro- with "capacity certificates"often must be replaced by un- duction. I would like to consider in detail the trained nurses in the I.C.U.The number of candidates for introductory concept of the UniversitMtsspital I.C.U. training courses is sufficient to satisty demand, Z~rich. but not enough to allow a selection of highly capable I. To point 2: In the future the shift work will confront us with serious problems. It has to be C.U. nurses. possible to find specific solutions for special units. The continuous monitoring requires a ma- PRACTICAL EDUCATION OF NURSES J. Grosgurin-Robert, Soins ximum of concentration and sen~of responsibili- Intensifs de Medecine, Gen~ve. ty. The daily confrontation with other peoples A group of head.nurses working in ten different size destiny must not turn into ones own fate. The swiss hospit~sdevelopped a programme to achieve common constant confrontation with live and death re- practical goals which could be inserted into the educative quires stzong personalities. programm of intensive care nurses. This programme will To point 3: The technical developement has to be be presented. critically observed by the staff since a conti- nuos supervision and control of the equipment means security for the patient. Technology is only ment to serve as an aid to do the daily work. 1~e should open our intensive care units to the public so that critical persons too may get an insight of the security described by patients who have been in an intensive care unit. To ~ive the whole staff the possibility to take part in the developements, direc~ves if necessary definition of position, should be worked out. 0nly he who accepts the challenge can look forward to the future.

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FORMATION THEORIQUE DES INFIRMIERES ET INFIRMIERS EN SOINS STAFFING AND EDUCATION OF NURSES IN OXFORD.C.E. Church INTENSIFS ET REANIMATION.Ch. Baechto]d,Zurich SRN.DipN(LON)Nursing Officer ITU/CCU John Radcliffe Hos- Afin de pouvoir am@liorer et unifier sur le plan national pital, Oxford, England. la formation en soins intensifs et r~animation, l'Associa- The Intensive Therapy Unit (ITU) in Oxford is classed as tion suisse des infirmi@res et infirmiers (ASl)en colla- a general Unit for there is a separate Coronary Care Unit boration avec des m~decins repr~sentant 5 Soci~t~s m~dica- and paediatric ITU. The ITU is set up with 8 beds, 2 les (soci@t~s suisses d'anesth6siologie et de r~animation, of which are high dependancy and medically the Unit is de chirurgie, de m@decine interne, de m~decine intensive run by anaesthetists. There is a small commitment to car- et de p@diatrie) ont ~labor@ un r~glement et un programme dio-thoracic surgery, otherwise general medicine,surgery, de formation qui entra en vigueur le ler janvier 1973. Une trauma and renal cases are admitted. To cover these 8beds Commission pour la formation en soins intensifs et r@ani- there is a total of 47 trained nurses plus 2 Student nur- mation fut nomm@e. Elle comprend I0 membres : 5 infirmi~- ses in basic training; for a period of 1 month, and post res repr6sentant I'ASI et 5 m@decins repr@sentant chaqUe basic course nurses.These are people undertaking National soci~t@ m@dicale sus-mentionn6e. En outre, sont revus r@- recognised Courses in various specialities; Intensive Care, guli~rement: la reconnaissance et contr61e des centres Accident and Emergency Nursing and Anaesthetic Nursing. de formation, d~signation des experts aux examens, ~tude There are 6 ITU Course members, of which we have a mini- de proposition concernant un changement du r~glement. Les mum of 2 and maximum of 6 at anyone time.The other 2 Cour- modifications propos@es par la Commission sont @tudi@es ses never send more than 2 members each at anyone time. par les 5 Soci6t~s m6dicales concern~es et par I'ASI. Le A part from these various other people from different a- r~glement d6finit : les conditions d'admission, le but, reas come for a period of orientation ie Renal Course, la dur6e, le d@roulement et le programme de la formation theatre assistant trainees.Of the 47 permanent team, 6 th~orique et pratique, les examens finaux. L'infirmi@re are Sisters, 31 are Staff Nurses (3 yr.general training) ayant achev@ sa formation avec succ~s obtient le certi- and I0 Enrolled Nurses (2 yr.general training). The Unit ficat de capacit@ en soins intensifs et r6animation. is covered with two-eight hr. shifts overlapping during the day and an I1 hr night.There is a minimum of 8 nurses per shift plus basic and post basic learners.The average lenght of stay of staff is about 7 month,that means a continual recruitment programme, stepped up just before the Summer as this is when the main drop occurs 70% of the permanent team hold a nationally recognised ITU nursing certificate, the other 30% are made up of people with little or noexperience in this speciality, consequently the teaching input has to be high, and the overlap period in the afternoon is an ideal time to do lectures.Education of all staff not only Course members and learners, but experienced staff must be an ongoing process to train and maintain motivation.All staff, commen- 156

cing employment undergo a 3 day general hospital orientation.Staff within the Unit then work with experienced members of staff for the first two weeks and have lectureson basic monitoring and ventilating equipment technique. Fol- lowing this,those staff programme involving lectures and clinical teaching on basic ITU knowledge and skills ie Ca- re of Ventilated patient, from both staff nurses and Sis- ters. Intravenous additives and arterial line assessments are taken by all staff before they are able to administer drugs or take blood specimens from arterial lines.Staff are predominantly trained by the bedside with one to one teaching which is ideal for gauging knowledge and adapti- bility of the learner. Impromptu lectures are given by all staff including Doctors, depending on work load on the Unit.Available each day are lectures for staff to attend; general hospital sessions,lectures from all dis- ciplines specifically for ITU nurses,XRay conferences; to short talks given by the staff nurses themselves. The nationally recognised ITU Course is run in Oxford and whilst they have a clinical tutor attached to the Cour- se,the Sisters are very much involved in teaching members, and all Course lectures are open for all Unit staff to attend. The Health Authority periodically run Courses mainly for Sisters to extend their managerial skills ie Art of Assessing, Interviewing Skills and every 6 months all staff are seen, to be given career guidance and counsel- ling, so they and their seniors are aware of their progress, capabilities,new avenues to be explored,and where they are going in the future.

II. Dotation en Personnel

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PATIENT CATEGORIES IN INTENSIVE CARE: THE SYSTEM USED IN SEVERITY INDEXES (S.I.) IN INTENSIVE CARE UNITS (ICU) SWITZERLAND. F. Trembley, Soins Intensifs de Chirurgie, Jean-Roger LE GALL -HENRI MONDOR HOSPITAL-CRETEIL-FRANCE Gen~ve. Recent advances in medical technology have increased our In 1976 guidelines for categorizing intensive care patients ability to treat many illnesses included those involving and staffing requirement, were issued by the Swiss Society previously fatal physiologic probl~ms. New questions have of Intensive Care Medecine.The patients are divided into 3 come about when to use an how to determine value of these main categories,according to the equipment required for new developments. A classification of patients based upon therapeutic intervention.The guidelines do not eliminate the acute severity of their illness would be very helpful completely the problem of allocation of patients to diffe- not to predict survival for individual patients, but to rent categories;this varies between l.C.U's.Once the cate- provide a precise estimate of risk of death for groups of gory is established a simple formula is used to determine acutely ill patients and, perhaps, a precise estimate of the staffing required. the staff requirements. Two methods can be used to built a S.I~ : the discrimi- CRITERIA FOR NURSING STAFF REQUIREMENTS IN THE I.C.U. nant analysis and the subjective methods. In all cases F.Trembley, Soins~Intensifs de Chirurgie, Gen~ve. the SI will be used by other hospitals only if it has re- Since no satisfactory rules exist on how to staff adequa- liability, Validity criteria, data requirements, mathema- tly an I.C.U.,a group of nurses and physicians was created tical consistency. in order to attempt to establish objective criteria for For ICU patients special SI are currently used, such as staffing the I.C.U.For that purpose a protocol was created coronary prognosis index, or the indexes for burns. Seve- to produce data concerning the time involved in different ral general SI for all patients have been proposed such as. the complication impact index, the condition index score, nursing care procedures,administration and education. but rarely employed. Only two indexes till now are used PROBLEMS AND SPECIFICITY OF AN INTENSIVE CARE UNIT IN A by several hospitals in several countries : the TISS sys- REGIONAL HOSPITAL.F.Payot R.H.,H6pial R#gional,2900 Por- tem and the APACHE. rentruy, Switzerland. The TISS system (therapeutic investigation scoring sys- The organization and topography of an I.C.U. in a Regional tem) of D. CULLEN is not strictly speaking, a S.I. Hospital are presented. The following problems are consi- Nevertheless it can be used for a same technologic level as an out come prediction for groups of patients. dered :-Guidance for the team,-personal responsability of The APACHE (Acute Physiologic and chronic health evalua nurses facing emergencies,-difficulties in recruiting staff tion) has been proposed by W.A. KNAUS and others : it is nurses for remote and non-urban areas. reliable, valid and has been used to compare different NURSING CARE PROBLEMS IN PATIENTS TREATED BY LAPAROTOMY ICU in USA as well as in a french US comparison. Further L.Douchamps-F.Turc-P.Meier- S~ins Intensifs de Chirurgie, research should be directed at mathematical and statis- Gen~ve. tical techniques to maximize the amount of observation Presentation of a patient treated with laparostomy for se- that can be obtained from a lesser data set, veral weeks and the specific problems, their implications on nursing care. Aims, actions,evaluation of the treatment. 157

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QUANTIFICATION OF INTENSIVE CARE : NURSING NURSES' MOTIVATIONS FOR PAPTICIPATING IN CRITICAL CARE REQUIREMENTS AND DIAGNOSTIC CRITERIA. A MULTI- CONTINUING EDUCATION. J.A. Bennett, M. Cree~an, A. O'Connor CENTER TRIAL. Long Island College Hospital, Brooklyn, New York, U.S.A. F.C.MGIIer, H.Bergmann, K.Steinbereithner, The study was undertaken to identify dimensions or motiva- Depts.of Anesthesiology General Hospital tional orientations, that underlie nurses' participation in M6dling, General Hospital Linz and University a critical care continuing education nrogram (CE). ~.~ile Clinics of Anesthesia and Intensive Care,Vienna, the need for continuing education in the health professions Austria. is generally accepted, the value of legally mandating specific numbers of hours of CE has been debated, with few In a multieenter study intensive care nursing states adopting such requirements. The increasing invest- requirements of 10 different Austrian ICUs have ment of health care dollars in nursing CE requires a con- been evaluated using the scoring systems of tinuing evaluation of the objectives of these programs and CULLEN ( TISS ) and of HUDSON. their impact on patient care. Previous research, viewin~ The average TISS points per patient are in the participation as motivated behavior rather than a phenome- range between 5,3 ( poison center Vienna ) and non in itself, identified motivational dimensions of adults 30,4 ( Rudolfspitai Vienna, Operative ICU ),the participating in education programs as goal-oriented, acti- HUDSON points are ranging from 24,7 to 125,2 vity-oriented, or learning-oriented. Subsequent research respectively. Altogether a mean of 187,8 has identified other motivational orientations. It was patient days per ICU has been assessed. hypothesized that critical care nurses would differ in mo- Calcu]ations of nurse/patient ratios depending tivational orientation from the general nursin~ nopulation on the average TISS points have been done for due to a DerceDtion of greater or quicker obsolesence and each ICU taking into account the general wor- therefore a greater need for more frequent or even continu- king conditions for nurses in Austria. ous updating. The study sampled participants in a two day HUDSON/TISS ratios lie between 3,67 and 9,48 critical care symposium sponsored by a professional organi- possibly giving some hints as to the adequacy zation which focused on both clinical content and personal/ of the number of ICU personnel. professional development. 93 questionnaires (32% of the Finally the TISS-situation of each ICU has been participants) were returned. The Education Participation studied in detail as well as the TISS number Scale is a self report instrument in which learners rate for the different diagnoses and their changes the influence of 56 motivating factors in their decision in the course of the disease. to participate in a CE program. Varimax orthogonal rota- In conclusion it can be stated that wide quan- tion was used to analyze responses, findin~ eight factors titative differences in the intensity of inten- meaningful. Chronbach's alpha method was used to determine sive care and in the patient material exist internal consistency and Pearson product moment correlation even within the same type of ICU. To assess was used to analyze relationships of factors to demographic real nurse requirements of any ICU quantitative variables. While the orientations identified indicate that data including well known score systems are participation is primarily for professional reasons, job absolutely necessary thus presenting hard data competence and credentials acquisition did not "load." No which cannot be overlooked by the hospital correlations with personal data characteristics were identi- administration. fied. Subsequent study is currently in progress to afford extended data with emphasis on critical care clinical foci. Research and Training in Intensive Care Medicine A. Formation and Teaching in Intensive Care Medicine

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FORMATION ANDTEACHING IN INTENSIVE CARE MEDICINE - AN TEACHING AND QUALIFICATION IN "INTENSIVE CARE" IN FRANCE INTRODUCTION. K. Steinbereithner, Boltzmann-Inst. of Exp. (J. UOTIN) Anaesthesiology & Research in Intensive Care Medicine, Service de R~animation HSpital Edouard-Herriot, Lyon/France University Hospital, Vienna, Austria The term "Intensive Care" usually stands for the Though the interdisciplinary character as well as the practice of active medicine in the Department of Surgery, fact that Intensive Care Medicine (ICM) eventually might Medicine or Speciality. The name "Critical Care" (or require full time engagement become evident more and Reanimation"b in France, defines similar medical practice more, besides Australia the formation of a (sub)specialty usually performed in a Department set up to receive a more has only been decided upon in outlines in the USA (4), acute or polyvalent pathology. In reality, there exists first certification not to be awaited before July 1984 a confusion between the vernacular and the facts : (5). In most other countries (cf. subsequent discussions) "Cardiac critical care", "Hematological critical care", there are still but negotiations if any; Austria did in- "Surgical critical care"... This ambiguity persists in clude ICM obligatory into the 4 yrs postgraduate scheme the teaching and the professional training conditions. "Medical Critical Care" (R~animationMedicale Polyvalent~ for anaesthetists by Sept. 1981. - A similar discomposure is a subject taught far a period of three years in cer- is to be observed as to core curriculum (necessary know- tain Universities, although not leading to a Notional ledge and skills, not to speak of attitude and experien- Degree. Anesthesiology is one of the great specialities ce), special training in emergency (and disaster) medi- which provides intensive core and/or critical care. It is cine, and to prior qualification. Concerning time of recognized by the University. There are three years of training a rising tendency cannot be ignored: Programs of training at the end of which o degree in "Anesthesiology- more than 1 yr's duration were offered in 38% for 198o Crifical Care" is obtained. This recovery is mostly compared to 66% of all USA fellowships in 1982 (2,3). - employed in traumatology or post-surgery, and often poly- We (i) have tried to develop a "step by step" training volent. scheme adapted to individual needs reaching from introduction tc training~pecialists. According to scattered The qualification for "Medical Critical Care" may experiences "basal" training does improve general in- be obtained without the specialized exams if the Univer- hospital acute care substantially. As ICU nurses are sity Hospital residency boards'are passed and tWO years trained now largely on a 1-2 yrs basis unsupervised me- in the approved departments falfilled. Anesthesiology - dical activities or appointments in ICM without equiva- Critical Care residents may obtain on equivalency of the lent special training are hardly justifiable by today. National Degree in "Anesthesiology - Critical Care" and are qualified in Medical Critical Care after three I) Bergmann H, Steinbereithner K, in press semesters in the approved Departments of Anesthesiology 2) Greenbaum DM, Holbrook PR, Crit Care Med 8 (198o) 693 and four semesters in Critical Care and Intensive Care 3) Greenbaum DM, Holbrook PR, Crit Care Med io (1982) 347 Departments. 4) Grenvik A, Leonard JL et al, Crit Care Med 9 (1981)117 5) SCCM Newsletter Dec 1982 Thus there is major discrepancy between the theoretical and clinical qualification of recovery experts. From 1984 a reform will allow specialists to undergo more homogeneous training.

33 B 33 C Big

WHO SHOULD PRACTISE INTENSIVE CARE MEDICINE? Hillman KM, THE INTEGRATED SYSTEM O~ TEACHING, TRAINING ICU, Charing Cross Hospital, London, UK. AND CONTINUING EDUCATION IN INTENSIVE CARE MEDICINE IN THE GEPJ~AN DEMOCRATIC REPUBLIC Intensive Care Medicine is a specialty which encompasses M.Meyer, Chair of Anaesthssiology/Intensive the acute aspects of everyon e else's specialty. The ex- Care Medicine, Academy of Postgraduate Medi- pertise necessary to treat critically ill patients comes cal Education of the GDR, Berlin, GDR from adequate training of the doctors and constant expos- Anaesthesiology/Intensive Care Medicine is one ure to the patients' problems. Anaesthetists, Physicians of 32 specialities licensed in the GDR. The and Surgeons are not specifically trained in Intensive medical curriculum at the universities sched- Care Medicine, and because they are specialists in other ules this field in the first, fourth and fifth branches of medicine cannot spend most of their time car- year of studies in which the first year is gi- ing for seriously ill patients. Thus one either becomes ven to an interdisciplinary lecture series on proficient in one's parent specialty (Anaesthetics, Med- "Emergency Situations" and ',~irst Aid". The icine, Surgery) or in Intensive Care Medicine. Intensive fourth and fifth year is reserved for lectu- Care Medicine has become too complicated and demanding to res, seminars and practical courses of 30h re, be treated as a hobby. It is a specialty requiring cer and 45 hrs per year, respectively. The body tain Anaesthetic knowledge and skills, such as applied of knowledge in Intensive Care Medicine forms physiology, rapid reaction to problems, ability to per- a substantial part of the State Examination form a wide range of invasive procedures and familiarity in Medicine. with monitoring and support equipment. It also requires For quality reasons the postgraduate training certain Medical knowledge and skills, such as a broad in amy speciality follows nationwide standards. knowledge of conventional medicine, and the ability to The standard for this speciality were worked interpret diagnostic data. However, further specialised out in close cooperation between the Chair of knowledge about bacteriology, radiology, surgery, resus- Anaesthesiology/Intensive Care Medicine of the citation, and administration is required. More important- Academy of Postgraduate Medical Education, and ly, knowledge of acute organ failure and multlorgan fai- the Society of Amaesthesiology and Intensive lure is essential for an Intensive Care Physician. This Therapy of the GDR. All these standards are is poorly understood by most conventional physicians and subject to final approval by the Ministry of anaesthetists. Furthermore, the specialist Intenslvist Health. must ideally be familiar with research principles and current journals, as much of Intensive Care Medicine is The training takes place in departments and being defined now. It doesnlt matter who practises Inten- hospitals which are especially appointed for sive Care Medicine (other than a committee); as long as that purpose, and the period of training is he or she devotes most of their clinical time to working 4 years for all specialities. Certification as a specialist is only achievable by passing in an Intensive Care Unit. a final examination before the Board of Exa- miners of the Academy. After qualification a system of continuing education follows to keep the level high during all the professional life. 159

33 D 33 E

"]IqTENSIVIST" : TOWARDS A RECYXINIZ~3 SPECIALITY SHOULD INTENSIVE CARE MEDECINE BE AN INDEPENDENT SPECIALTY? J.P.Gardaz,P.M.Suter,Department d'Anesthi@siblogie,H6pital JL.Vincent, Department of Intensive Care, Eramne Hospital, Cantonal Universitaire,GenOve. Free University of Brussels, Belgium. The structures of intensive care medecine(ICM)vary widely Intensive care was born frc~ several specialities, inclu- from country to country.ln France,Japan and South Africa, ding internal medicine, anesthesiology, surgery and pedia- for example,there are university departmen~of critical trics. The will of these primary specialties to keep care medecine headed by full professors in ICM.It has be- critically ill patients within their own deparhaent has come a primary speciality of its own in Spain and Austra- impeded the development of multidisciplinary intensive lia.The United States has opted for a subspecialty in cri- care units. These specialities have also feared that tical care medicine rather than a primary discipline,whe- recognition of intensive care medicine as a distinct entity would anloutate their own cfml0etence. Hcm~ver, a reas others countries like the United Kingdom,Switzerland multidisciplinary approach to an unique "intensive care" do not recognize ICM officially. These differences encoun- improves both conprehension and management of critical trered in the academic and medical structures reveal the states. The introduction of large autoncmous departments complexity of the problem. Intensive care medecine is a of intensive care has been facilitated by the construction "multidisciplinary"endavour crossing traditional depart- of new hospitals. Nevertheless, critical should be better mental an speciality lines and it is conceivable to create defined throughout the world. Responsabilities in inten- autonomous departments of multidisciplinary ICM runned by sive care, coronary care, neonatology and even emergency primary specialits in intensive therapy.Although we reco- medicine can be very different not only from town to gnize that there is a need for special knowledge and skills town but even scmetimes frcm hospital to hospital within on the part of those providing patient care in intensive the same to~n. care units,we do not support the specialty of"intensivist" In our 31-bed medico-surgical department, internists, as primary specialty for the following reasons:First ICM anesthesiologists and surgeons who are in rotation repre- physicians should have a solid training in Internal Medi- sent 8 of the 16 manbers of the medical staff. They are cine and Anesthesia(or Pediatrics for pediatric ICM)before eager to spend this training period and very concerned training and practicing ICM.Second, at the present time about Instruction in our discipline. Each patient has there is no specific training programme,no uniform career one "intensivist" directly responsible for his care, in good relationship with consultants and primary physician. structure nor academic future ensured in the majority of Specialization in intensive care medicine is rendered countries of Western Europe. Furthermore intensive care essential by the coniolexlty of ccmlorehension and manage- medicine as primary specialty can be hazardous,because, ment of critical illnesses more than by purely technical outside intensive care units,there is no professional al- aspects of their care. We suggest specialty in intensive ternative for intensivists who whish or have to change care medicine to be recognized to those who have had a their medical activity at a later time.This point is of two year period of training in a deparlxnent of intensive particular importance because good ICM needs dynamism, care, after full training in one of the primary special- fresh ideas and a great physical and psychological commi- ties. tment, factors found usually in greater quantity in people at 30 than at 60 years of age.

B. Research in Intensive Care Medicine 33 F 33 H

RESEARCH IN INTENSIVE CARE MEDICINE - SOME CURRENT PRO- LINKING CLINICAL PROBLEMS TO RESEARCH: Hillman KM, ICU BLEMS. K. Steinbereithner, Boltzmann-Inst. of Exp. Anaes- Charing Cross Hospital, London, UK. thesiology & Research in Intensive Care Medicine, Univer- sity Hospital, Vienna,Austria Much of our current knowledge and clinical practice in Intensive Care is based on animal experiments and conven- In Intensive Care Medicine (ICM), a rather young branch tional medical principles and may not be relevant to of medical sciences, almost day b~ day sets of problems treating critically ill patients. As an Intensive Care are encountered, some of them "shouting with urgency" for specialist, I have tried to document the three most com- rapid answers. Systematic research efforts in this field, mon important problems I face each day; on the basis that however, are not yet taken for granted. A cumulative sur- this is where our research should have priority. My first vey for 198o/$2 comparing 3 leading anaesthesiological is getting enough money to run the ICU, and being able to (A: Anesthesiology, BJA, Anaesthesist) with the same num- justify to my colleagues and the community that my treat- ber of Intensive Care periodicals (I: Critical Care Medi- ment makes a difference and that the difference is worth- cine, Intensive Care Medicine, Intensivmedizin) revealed while. Because this is one of the hardest areas to define a striking difference in research activities: 64.9% of and from which to gather meaningful results, it does not papers in (A) vs. only 31.4% in (1) were devoted to mean that we should not collectively attempt it. It is scientific investigations (studies related to morbidity, imPortant now and crucial for the future. My second epidemiology, assessment of economic and personnel requi- problem is how to assess, treat and predict outcome rements not being taken into consideration). In our own after cerebral damage - from whatever cause. I often feel institution 56.8% of ICM-papers referred to research pro- I am working without hard facts or guidelines, and too grams. - Besides that a wide scatter in intensity of in- often with"personal experience" and instincts. The third terest is to be seen: Subjects like cardiovascular and/or major problem I have in clinical practice, and not neces- pulmonary pathophysiology etc. covering 45% of all publi- sarily the least important, is how to prevent or treat cations are opposed to poorly if not insufficiently (<1%) septicaemia. I feel current recipes temPorarily improve treated topics like e.g. renal function or immunology. - the "numbers" but do not substantially affect outcome. In order to enhance interest and to overcome the above- Our research should be linked to our clinical challenges. mentioned gaps being eventually also detrimental to ICU- ICUs treat a small number of patients and we have little patients organisational (access to experimental depart- control over the type of admission. The patients often ments, research programs (i), and computing facilities; have complicated multiorgan diseases. To answer the ques- provision of biomedical and laboratory technicians wor- tions I have posed we need large numbers of patients, king IN the ICU etc.) as well as other motivating measu- changing only one variable, and Using controls. To res (editorial policy of journals, improvement in career achieve this we need multi-centre; national and interna- structures etc.) should be promoted. tional controlled trials. Furthermore we should all i) Greenbaum DM, Crit Care Med 8 (198o) 69o collect the same information about our patients; preferably on common computerised record-keeping systems. This would expedite our research and give us meaningful comparisons on cost, outcome, workload and prognostic information. 160

33 1 33 J

INVESTIGATION IN INTENSIVE CARE MEDICINE RAOIONUCLIDE TECHNI@UES IN THE OETECTION AND EVALUATION OF J.L.VINCENT, Department of Intensive Care, Erasme Hospital, PATIENTS WITH ACUTE MYOCARDIAL INFARCTION. A. Righetti, Free University of Brussels, Belgium. Centre de C~rdiologie, H~pitel Cantonal Universitaire, Gen6ve, Suisse In the intensive care unit, both the large variety of Tracer techniques such thallium-2Ol [TI-201] and techne- critical illnesses and the availability of sophisticated tium-BBm pyrephosphate {To-PYP] myeoardlal imaging and ra- material and motivated personal foster clinical investigation. Spectrum of research activities is very broad, going dionuclide ventrieulography (RNV] are increasingly used to from cardiovascular, respiratory or metabolic studies to evaluate patients (pts) with acute myocardial infarctdoe search for technical developments, establishment of (ANI). These techniques are non invasive and may be appli- prognostic indexes or discussion of ethical problems. ed to critically ill pts at the bedside without apprecia- Studies can focus on gross clinical abnormalities as well ble extra risk or discomfort. as on precise cellular or biochemical mechanics underlying Approximately 80 percent of the pts with transmural or non- pathologic states. Multidisciplinary approach to intensive transmural AMI can be detected by Tc-PYP if the imaging is care and collaboration with specialists in basic research performed 24 to 72 hrs aTter the onset of the symptoms. should be encouraged to improve the quality of the investi- Tc-PYP has been utilized in localizing the site and deter gation. Systematic collection of datais essential to yield mining the extent of AMI. The "doughnut" pattern is asso- comprehensive clinical studies. Some forms of treatment, ciated with a large incidence of subsequent congestive such as fluid challenge or PEEP administration, should be heart failure and death. standardized. In our department, a minimum daily set of T1-201 performed within 24 hours of AMI has been useful laboratory data is defined, including arterial lactate for recognizing, localizing and roughly sizing areas of concentration, colloid osmotic pressure and urine osmola- infarction and surrounding ischemia, The extent of TI-201 rity. A simple, mobile cart has been designed to perform defect in an initial image may have important value, For routine hemodynamic studies at intervals in patients with separating high-risk and low-risk subgroups of hemodynami- invasive monitoring. cally stable pts with AMI. Clinical practice raises questions that need an experimen- Short and long term prognosis after ANI appears to be de- tal support to be answered. Clinical investigation in the intensive care unit should be closely linked to an animal termined essentially by residue] ventricular function. laboratory. Difficulties in the development of reproducible RNV provides the means for assessing the evolutionary experimental models of acute organ failure should be changes in regional performance after AMI. In pts with challenging rather than dissuasive. We have set up a dog complicated AMI and cardiogenic shock a combination of T1- laboratory for hemodynamic studies of acute states, for 201 and RNV should be considered to identify those with which fonding has been essentially supplied by external massive LV damage from those with residual ischemia or support, in a spirit of positive collaboration between right ventricular damage. Ouantitative evaluation of re- the private industry and the university. gional LV motion after pharmacologic or surgical treatment is pts with AMI may provide useful information regarding the efficacy of a variety of interventions.

Acute Renal Failure

34 36

PATHOPHYSIOLOGY OF ACUTE RENAL FAILURE. K.Thurau, EARLY DIAGNOSIS OF ACUTE RENAL FAILURE. Department of Physiology, University of Munich, Munich, FRG H. Favre, B. Ody, Departments of medicine and radiology, In order to reprocess the chemic'al composition of body Hopital cantonal universitaire, Geneva, Switzerland. fluids, the kidneys deliver a large volume of filtrate from The causes of acute renal failure (ARE) have to be early plasma to the tubular epithelium, which then forms the final recognized in order to put the patients into one of the 3 urine by selective reabsorption of filtered water and substan- following categories : prerenal, renal or postrensl. The ces and the secretion of substances from the blood into the two first situations could be separeted on the basis of urine. Both processes, filtration and reahsorption/secretion, several urinary indices among which the most efficient are powered by different energy sources, filtration by myo- is the fractional sodium excretion (FeNs). This parameter cardial metabolism and reabsorption by tubular cellular meta- classifies correctly 99 % of the patients. FeNa allowed, bolism. Normally, the large reabsorptive capacity of the tu- in our personal series, an early diagnosis of prerenai or bules allows the kidney to deliver 100-150 ml fihrate/min to renal ARF in 50 patients at the time where serum creati- the tubules which have inherent discriminatory activities in nine was rising from 120 + 30 to 250 + 50 umol/1. Limita- the selection of filtered constituents for reabsorption or ex- tions to this index concern mostly patients with non- cretion. This high turn-over of extracellular fluid serves the oliguric ARF associated with salt retaining states. Some important function in the kidney of continuously reprocessing of these patients could be considered as prerenal while the plasma. It contains an inherent danger - that of severe they are actually renal. In these peculiar setting, fluid loss if the tubular reabsorptive mechanism should fail measurements of enzymuria could provide an accurate due to nephrotoxins or renal hypoxia. There is evidence that diagnosis.Radiologieal investigations have to be done in the primary site of action of nephrotoxins and hypoxia is lo- all patients in whom an obstruction of the upper cated in the tubular cells. The pathobiochemistry of the kid- urinary tract is suspected or could not be ruled out. ney in acute failure includes defects in the membrane-bound Nowadays, the method of choice to demonstrate pyelocali- properties for fluid reabsorption, such as changes in permea- ceal dilatation is sonographic examination. Its bility and active salt transports. These initial cellular defects specificity and sensitivity is very high. Rare false may produce secondary phenomena such as activation of the positive results are due to a very recent obstruction or tubulo-glomerular feedback, the intrarenal renin angiotensin to large calculi whereas false positive are due to prior system, a fall in GFR, tubular occlusion, vascular constriction dilatations or to constitutive large cavities without etc. The foremost "secondary phenomenon" appears to depend obstruction:at the time of ARF. critically on the type of renal insult, its severity and time In cases of dilatation, sonography must be completed by course. intravenous (antero or retrograde) ureteropyelography to A rational treatment of acute renal failure, aimed at determine the nature and the location of the obstruction. treating the causes rather than the symptoms, should restore Conclusions. Use of FeNs and sonography provides an early the disturbed celIuIar functions. Since, at present, there is no diagnosis of the causes of ARF and permits the choice of specific cellular treatment known, dialysis and careful fluid the appropriate therapy which prevents a further and metabolic balance constitute the only possibility of sup- degradation of renal function and may change the outcome porting the patient until spontaneous healing occurs. of the patients. Exceptional causes of ARF such as acute glomerulonsphritis or vascular obstruction need a different approach based on clinical ground. 161

Therapeutic modalities in acute renal failure J.P. Wauters, Division of Nephrology, University Hospital, Lausanne, Switzerland. The classical treatment of acute renal failure (ARF) i.e. peritoneal dialysis or hemodialysis once uremic symptoms appear, has now been largely replaced by a more aggressive and individualized therapeutic approach.The importance of an adequate caloric and protein intake has been better understood. At least 35 Kcal/kg and 0.5 gr/kg of protein should be given daily. There- fore the management of fluid and electrolyte balance is not always possible by conservative means. It is presently admitted that once oliguric ARF is established there is no further reason for diuretic or mannitol administration. Among the substitutive therapies, peritoneal dialysis became easier through the experience gained with the CAPD technique. Hemodia- lysis can now be performed with the use of bicarbonate in dialysate,sequential ultrafiltration and/or volumetricaly monitored ultrafiltration during dialysis. Other substitutive therapies have been proposed : I) hemofiltration can be usefull when cardio-vascular insta- bility precludes the use of conventional dialysis; 2) plasmapheresis by centrifugation or filtration techniques has been recommended when ARF is due to acute intoxications by poisons which are largely bound to proteins; 3) spontaneous femoral arterio-venous hemofiltration appears as an easily applicable bedside technique allowing to overcome simultaneously the fluid balance and uremic problems, without the continuous need for dialysis equipment and staff. Despite those advances, the complication rate during ARF remains high and is still responsible for the persistently high mortality.

Pediatric Intensive Care

38 39.1

PERSISTANCE OF THE FETAL CIRCULATION. D. ~ULIN, Soins In ASSESSEMEMT OF NEONATAL RISK FOR RDS BY PULMONARY COMPLIANCE IN AM tensifs P~diatriques, Clin. Univ. Saint-Luc (U.C.L.), iO EXPERIMENTAL MODEL. M. Solca, T. Kolobow, R. Funagalli, P. Arosio, A. Avenue Hippocrate, B-1200 Bruxelles. In 1969, Gersony, Duc and Sinclair reported the fatal out Pesenti, L, Gattinoni. Ist. Anestesiologla e Rianimazione, Universit~ come of two term neonates who had severe hypoxemia within Milano, Italy, and Lab. Technical Development, NIH, Bethesda MD, USA. the first 24 hours of life. Carefull investigations and Fetal lambs are widely regarded as a useful experimental model of post-mortem examination had failed to demonstrate any un- human RDS. We studied 115 animals between 125 and 134 days gestation derlying abnormalities. In order to explain these obser- (tern 147-150 days) to determine the optimal pulmonary nanagement for vations, the authors suggested that a suprasystemic pul- RDS prevention. In 70 cases we performed a cesarean section, exposed monary vascular resistance may have create a right to left shunt through the foramen ovale and/or the ductus arterio the head of the fetus, and intubated the trachea, leaving the fetus sus and therefore decreased dramatically the pulmonary still connected to the nether through the intact umbilical cord and perfusion. This hypothesis was thereafter applied to va- placenta. The lungs were inflated to a pressure of 35 cm H 0 for 5 2 rious situations of neonatal cardiopulmonary distress secs for 3 times; we then measured the total compliance injecting with severe hypoxemia and where no cardiac defect could known quantity of gas in the lungs and recording the resulting be detected. Different conditions have been demonstrated pressure. Thereafter 32 animals were immediately delivered and to participate in increasing the pulmonary vascular resis tance I. increased blood viscosity 2. inadequate develop- treated with state oF the art ventilatory care, while 38 underwent ment of the pulmonary vascular bed 3. pulmonary vasocon- apneic oxygenation while still on placenta, until total conpllance -i-i striction and 4. extrinsic or intrinsic pulmonary vascu- exceeded 0.5 ml (cm M20) kg . Overall mortality rate was 0.31, lar obstruction. At birth, the term neonate has function- totally for RDS, and was not different between treatment groups. nally closed fetal shunts ; he also has very reactive and Survivors had a total co| markedly hi~her than non-survivors mu$culated pulmonary vessels. This makes him particularly - -1 (0.28 ~ 0.11 vs. 0.12 ~ O.Ok ml (cn H20) kg , P < 0.001): this prone to develop persistent fetal circulation, even more so as pulmonary vascular smooth muscle can be further hy- suggested a key role of pulmonary nechanlcs in insurgence and pertrophied by chronic hypoxemla or premature ductal clo- severity of RDS in premature fetuses. ~e were then able to dellneate sure during fetal life. In assessing the neonates who pre a descriminant value of total compliance between the two groups: -i -I 2 sent severe hypoxemia resistant to optimal oxygen therapy~ 0.205 ml (c~ H20) kg (~., 37.14, P~O.O01; predictive index 87%). echocardiography seems to be the most appropriate proce- It carries a ~ error of 1.7% and a ~ error of 25%: in our study dure. It helps i. to rule out a structural cardiac defect 2. to objectivate concomitant cardiac dysfnnction and 3. none of the non-survlvors had a higher compliance, and only 19% of to document pulmonary hypertension, pulmonary hypoperfu- survivors had a lower value. Thls implies that we can predict within sion and/or right to left shunt. Therapy should first try 2% of error which animal is at great risk for developlng RDS, and to suppress any factors favoring pulmonary vasoconstric~ subsequent death, with a very simple and safe procedure: inflation of tion. If inefficient it may be completed by the earefull the lungs and measurement of total compliance. use of vasodilator drugs and/or respiratory alkalosis. 162

39.2 39.4

MECHANICAL VENTILATION OF IDIOPATHIC RESPIRATORY DISTRESS INHIBITION OF INTRALIPiD R AND OXIDANTS INDUCED SYNDROME (IRDS) OF THE NEWBORN INFANT WITH OPTIMAL PEEP PULMONARY VASOCONSTRICTION BY NIFEDIPINE. DETERMINED BY PRESSURE-VOLUME (P/V) CURVES OF THE TOTAL H.Stopfkuchen, J.C.Maggi, M.C.R0gers and RESPIRATORY SYSTEM. J.C. MATHE (1)~.~CHEVALIER (1), D. Schranz. Universit~tskinderklinik Mainz and C. GAULTIER (2), J. COSTIL (1). (i) Service de R6anima- Dept. of Anesthesiology and Critical Care tion Polyvalente et d'H@modialyse P@diatriques, (2) Medicine, Johns Hopkins Medical Institutions, Laboraloire Central d'Explorations fonctionnelles. HOpi- Baltimore MD tal Trousseau 26 Avenue du Dr.A. Netter 75012 PARIS Oxidants and unsaturated lipids cause a mar- 30 newborn infants (mean geststional age : 3~ weeks (28 - ked pulmonary vasoconstriction which can be 40), mean birth weight 2100 grams (1300-3500) with IRDS blocked by Indbmethacin and is correlated with (mean O? alveolo arterial difference : 500 torr (293-643) the presence of Thromboxane in the effluent were tr@ated with mechanical ventilation with optimal PEEP perfusate (Crit Care Med Io (3):29o,1982). In determined by P/V curves of total respiratory system. 37 order to evaluate the effect of nifedipine on P/V curves were performed by slow constant thoracic in- pulmonary hypertension induced by infusion of flow according to a previously described method. (J.C. oxidants and lipids, we carried out the present MATHE Int. Care Med. 1982 - 8 - 246 Abst). The mean opti- experiment, using isolated rabbit lungs ventila- mal PEEP were 9.25 + 3.2 cm H20 (4 - 17). ted with 5% CO 2 in room air and perfused st Optimal PEEP were applied before H48 in 23 patients and 50 ml/min with Krebs Hensleit buffer in a non- after H48 in 7 patients. Mean exposure to Fi02 > 0.4. recirculating manner. were signifiantly reduced in the first group (32.1 + 18.1 Pulmonary hypertension was induced in 12 hours (5-84) vs 128.4 + ~5.2 hours (60-]92) p < O.OOI). rabbits by infusing 69 mM tertiary butyl hydro- 5 pneumothorax were observed and no bronehodysplasia. 2 peroxide t-Bu00H (mean ~Ppa = 13.41 torr ~ 3.52 imtraventricular hemorrhages (IVH) and 1 periventricular SE) or a lo% Intralipid a infusion (mean Ppa = hemorrhage were investigated by means of 18 cranial ultra 13.66 3.13 SE). While reaching a plateau in sonography and 3 venfiricular punctures. 5 patients died the pulmonary artery pressure and still infusing (2 IVH, i nosocomial infection). the pressor drug, Nifedipine 2o ~g/kg were given. The mechanical ventilation with optimal PEEP in IRDS is Significant decreases in pulmonary artery pres- a method well toIerated which reduces exposure to Fi02 sure (mean Ppa 7.54 i 1.33 SE) were noted re- > 0.4. and provides a successfull treatment for the gardless of the challenge. most severely impaired patients. Results were evaluated by analysis of variance which showed a significant inhibitory effect by Nifedlpine of the vasoconstriction caused by both agents (p< o.ool). We conclude that Nifedipine can inhibit pulmonary vasoconstriction induced by oxidants.

39.3 40

HANDLING AND RELIABILITY OF THE TRANSCLTfANEOUS PCO~ HIGH FREQU~qCY VI~NTILATIC~ (HFV) IN PEDIATRICS. DJ.Bohn, (TcPco2) IN THE NEONATAL ~SIVE CARE. HU.BUCHER z The Hospital for sick children, Toronto, Canada. G.DUC, D.W~I'IT/qSCHWILER, A.HUCH, R.HUCH, Divisions of Since the introduction ofpositive pressure ventilation Neonatology and Perinatal Physiology, Univ. of Z[irich, into clinical medicine, the parameters used in mechanical Switzerland. ventilation tended to mimic those seen in normal respira- In the ~ measurements, the electrode must have a tion. While in most instances this proves to be an effec- relatively ~igh core tenloerature (44-45UC) in order to tive method of managing respiratory failure, there are achieve a sufficient hyperaemia and it has to be changed still many patients with severe parenchymal lung disease to different places every 2 to 4 hours. Some good experi- who have a hypoxemia, refractory to any manipulation of ences with lower temperatures for tcPcO2-measurements the respirator. (changing I:E ratio, wave forms, end have been reported (i) which allow for a long-time moni- expiratory pressure). With the introduction of HFV, a new toring without the risk of skin burns 6 We have examined era has opened up in ventilator management of patients how different tesperatures (41 and 44 C) influence the with severe respiratory disease. High frequency positive calibration stability, the repreductibility, the response pressure ventilation (HFPPV) includes all ventilators that time and the correlation to the Pco 2 in blood samples. can cycle at rates between 60 and 120 (facility available The measurements were carried out on premature infants on some modern conventional mechanical ventilators). High in serve-controlled incubators. We used two industrial frequency jet ventilation (HFJV) includes a group of prototypes (Draeger and Radic~eter) which were calibrated ventilators that use a high pressure gas source ventila- at 40 and at 80 Torr, fixed simultaneously on the thorax ting at voltages at or below dead space at rates up to and conloared values with the Pco 2 in capillary or arterial 5 HZ. High frequency oscillation (HFO) uses rates of blood sanloles. Except for the expected slower response 1-40 Hz. generated by high frequency sine wave. These t//ne there was no disadvantage at 41UC. With both temloera- technic have features and characteristics which are unique tures the tcPco 2 was largely increased for both prototypes but the theory is essentially the same : patients may be ccnloared to the Pce2 in blood samples. There were stri- ventilated at volumes substantially less than dead space, kingly large interi~dividual differences. This makes a with lower mean airway pressures than seen with conventio- general inset built compensation difficult. nal ventilation. There are now nt~nerous studies in the literature to show that both HFJV and HFO are extremly (i) Continuous Transcutaneous Blood Gas Monitoring II, efficient in terms of CO 2 elimination with low mean air- edited by R.HUCH, A.HUCH, Marcel DEKKER, London, New York, way pressures. However, in order for this technique to in press. make a transition fram a physiological curiosity to a therapeutic advance, it requires that it can be shown to iuprove patients with severe respiratory diseases (refractory hypoxemia secondary to either alveolar or interstitial lung disease). As oxygen transfer occurs during both inspiration and expiration, ,the major problem remains to open alveoli and keep them open throughout the respiratory- cycle. HFV is an efficient way to achieving gas exchange in both normal and diseased lungs. 163

Preliminary results fram its use in hyaline membrane CONGENITAL LARYNGEAL ANOMALIES - P. Narcy, Y. Manae'h, disease and ARDS are encouraging, but a large multi- S. Bobin. Service O.R.L. - HSpital Bretonneau - 75.877 centre trial is necessary to prove its advantages over Paris C~dex 18 - France. conventional ventilation in these diseases. There is no Congenital laryngeal anomalies are a Frequent etiology doubt that it is a major advance in the treating of of upper airway obstruction in new-horns and ins and brcncho-pleural fisulae, and in laryngeal and tracheal must be well known by all physicians who care For neo- surgery where substantially lower moan airway pressures ngtes. The clinical picture is usually a combination of are of undoubted benefit. The proponents of HFV also strider, obstructive dyspnea, dysphonia, and swallowing advocate its use in thoracic and neurosurgical proce- disorders. But less typical features are possiblep such dures where a motionless operating field would be of as apnea, cyanotic attaks, bradycardia or cardiac arrest. great assistance to the surgeon. This presentation is a retrospective study on g80 new Before widespread introduction into clinical practices, borns and infants with congenital laryngeal anomalies several major mechanical and safety features have to be seen at our pediatric otolaryngology department from ironed out. Htwnidification is a problem ~n to all 6 Is, 1974 to 5 31th 1982. types of high frequency ventilation. The ht~nidification The diagnosis was : idiopathic congenital laryngeal systems currently in use are not entirely satisfactory, strider (laryngom~lacia) in 348 cases (51 ~), 15 % of but there does not seem to have been a problem with witch were severe, with respiratory distress and/or Fee- mucociliary clearance in htmlan studies. The second major ding difficulties ; laryngeal paralysis in 161 cases problem is that of patient safety. The very high gas (24 ~), among witch 56 were bilateral and 105 unilateral; flow used in both HFO and HFJV can lead to a rapid laryngeal incoordination in 23 cases ; laryngeal stenosis buildup of pressure within the lung if the gas outflow in 79 cases (12 %), among witch there were 58 subglottic beeches obstructed. A rapidly responsive blc~off system stenosis, 18 webs and 3 atresias ; subglottic hemangioma needs to be incorporated to relieve the pressure within in 45 cases ; ary-epiglottic and hypoglossal cysts in 15 the system, if the gas exit beccn~s occluded. cases ; laryngo-esophageal cleft in 8 cases and bifid HFV stands on the verge of beccming a major advance in epiglottis in one case. respiratory care. A well controlled study is urgently For each o~e os these anomalies, clinical features, ra- needed before it can be clearly demonstrated that it is diologic evaluation, endoscopic findings and treatment superior to conventional ventilation in patients with are reviewed. severe lung disease. HFV will never replace conventional ventilation as the standard form of ventilator, but the day is probably not too far off when every ICU will have one or two high frequency ventilators to cope with patients With severe parenchymal lung disease. Respiratory Infections in the Pediatric ICU

42.1 42.3

BACTERIOLOGICAL DIAGNOSIS OF PNEUMONIA IN CHILDREN WITH RAPID DIAGNOSIS OF RESPIRATORY SYNCYTIAL VIRUS INFECTION BY IMMUNOFLUO- MECHANICAL VENTILATION. J. Costil, J.C. Maths, C. Ssfran RESCENCE IN CHILDHOOD. P. Blanchard, A.Goudeeu, J.Drucker, R.Thompson, J.Y. Chevalier, M. Menoret. Service de R6snimstion p4- Y.Lebranchu, B.Grenier, F.Gold, J.Laugier. Hopital Enfants de Cloche- distrique - HOpital Trousseau, 26 Rue du Dr. Arnold rifle. Laboratoire de Virologie. CHU, 37000 TOURS. NeCtar 75571 Paris Cedex 12 - France. Nasopharyngeal specimens were collected from december 1981 to march Specific etiological diagnosis of pneumonia in children 1982 in 85 hospitalized children (2 weeks to 22 months old, 45 under with endotracheal tubes is often difficult since upper 3 months) with lower respiratory illness to study respiratory syncytial as colonization with multiple organisms is frequent. (RS) virus antigen by an indirect immunofluorescence technic (IFI). 59 children incubated or tracheostomized, aged 1 day to Collected by_nasopharyngeal aspiration, the specimens were flushed lO years, and having X-ray evidence of pulmonary infil- with phosphate-buffered saline 1,5 ml, then centrifuged at 1500 rpm for trate were studied ~ith the technique of uncontaminated ten minutes three times. The cellular pellet was used to prepare peripheral airway samples (UPAS) described by E.B. smears, which were air dried and fixed in acetone for ten minutes. The Matthew (Grit Csre Red 1977 ; 5 : 76 - 81). 41UPAS slides were stained with anti RS antibody (Wellcome), then with anti- were performed,no complication was observed. 29 UPAS immunoglobulin fluorescent conjugate (Wellcome). A slide was conside- showed no growth though one pathogen was recovered from red positive when several epithelial ceils showed a granulous cytoplas- 17 trachea] samples. In 28 patients pulmonary course mic fluorescence. Result could be obtainable 6 to 12 hours later. was fsvourable without antibiotic therapy. In i patient Thirteen children with no respiratory illness were used as a control false negative UPAS was observed. In 12 UPAS pure cul- group ; all samples were negative. 37 of 59 samples of children with ture of a single organism was obtained, in 8 cases th e wheezing associated respiratory infection were positive . Among lO psthogene recovered from tracheal samples was identiesl, children with bronchitis without wheezing, 5 were also positive. Three in 2 cases it was different, in 2 cases tracheal sam- children had evldenced apneas of whom two had positive specimens. ples were sterile. The organism's role in producinq Overall RS antigen was found in 44 out of 72 children (61%) suffering pneumonia was confirmed by its isolation in 4 patients of lower respiratory illness. A correlation with levels of total and from blood or empyema fluid. UPAS in children is s anti RS virus immunoglobulins present in serum and in secretions is single, safe and reliable technique. It shows that most under investigation. pulmonary infiltrates in children with endstrseheal This study demonstrate that RS detection using IFI is a convenient ra- tubes have not a bacteriological etiology and do not pid diagnostic test to precise the etiology of infant viral respiratory need antibiotic therapy. Positive UPA5 gives s spe- illness and to decrease antibiotics prescriptions. We have now extended cific etiological diagnosis ; however its interpreta- this approach as a rapid diagnosis technic of RS and others potential tion is more difficult when trseheal pathogen is iden- viral agents of respiratory illness in children. tical.

42.2 42.4

DIAGNOSIS OF PULMONARY INFECTIONS IN AN P.I.C.A : ADULT RESPIRATORY DISTRESS SYNDROME (ARDS) AND COMPARISON BETWEEN BACTERIAL TRACHEAL AND POST- INFECTIONS. J. Pfenninger, University Childrens MORTEM SPECIMEN Hospital, Berne, Switzerland S.Marchand, E.Borderon, J.C.Borderon, M.C.Grangeponte F.Gold, J.Laugier * The ARDS is a complex sequela of shock, trauma, HSpital G. de Clocheville, 49 Bd B4ranger sepsis, near drowning and many other insults. 37 044 TOURS CEDEX In a series of 20 children suffering from ARD~, The bacterial quantification is difficu!t in small selected on strict criteria, 7 had a septic samples. The comparison between cultural characters process most often of intraabdominal origin l of tracheal secretions and pulmonary biopsy may be an leading to ARDS. 8 children of the whole series reliable approach for the diagnosis of the pulmonary died. The cause of death consisted most often infection. This study included 22 neonates and in an unresolved basic medical und surgical infants who died from different diseases. They had problem, complicated by multiple organ failure been intubated few hours to 57 days. The tracheal and septicemia. Thus, septicemia plays a major secretions were collected for culture twice a week ; role in the genesis and mortality of ARDS. the last sample collected on the day of death. Pulmo- The third aspect of ARDS and infections are the nary tissue specimens were obtained by needle punctu- bronchopneumonias. The main reason for frequent re immediately after death. Pathology has been known bronchopulmonary infections lies in by-passing for cases. All positive cultures on the day of 19/22 natural defence mechanisms by prolonged naso- death were monobacterial. - 12 pulmonary culture were tracheal incubation, exposing the lower air- negative ; among them, 7 patients had no bacteria in ways and lungs to exogenous and endogenous their tracheal secretions and one germ was found in microorganisms. In our series these were most 5 patients. In these 12 cases, no histologic sign of often Pseudomonas, Klebsiella and Enterobacter. infection has been reported. - 10 pulmonary culture were positive ; among them, in 7 cases the same bacte The infections complications of ARDS can be mi- ria was found in tracheal secretions (with 5 times, nimized by using strict aseptic techniques, mo- histological signs of pulmonary infection] and in 3 nitoring of the bacterial flora of the patient cases a different germ was isolated. The bacteriolo- and the ICU, and a carefully selecte~ antibio- gical concordance between pulmonary tissue specimens tic treatment, if indicated. Attention should and tracheal secretions was present 14 times. In 8 also be paid to adequate nutritional support cases no concordance was observed. This study allows which may help to improve the host defence to conclude that : - absence of germ in tracheal mechanisms. secretions is a favorable factor, statistically lik- *Pfenninger J. et al.: Adult respiratory ked with an absence of pulmonary infection ; - pre- distress syndrome in children. J. Pediatr. sence of germ should be followed by clinical, biolo- i01: 352, 1982 gical and radiological investigation looking for an pulmenary infection. Their absence with presence of a germ correspond to a colonlsation of the tracheal tube. 165

42.5 42.7

ACUTE PNEUMONITIS WITH RESPIRATORY DISTRESS CAUSED SCORING SYSTEMS IN PEDIATRIC INTENSIVE CARE - F. BEAUFILS BY CLAMYDIA TRACHOMATIS IN INFANTS LESS THAN TWO D. AZEMA-S. CHANTEREAU-J.C MERCIER-Y.BOMPARD - PARIS MONTHS OF AGE. 3 patients classification systems developped for adult G.KRIM, B.RISBOURG, CI.HERBAUT, G.0LEWNICZAK, population since 10 years has been tried for pediatric 0JWEMBONYAMA, M.CHENTOUF. patients. I) The Clinical Classification System CCS (I), Department of Pediatrics (Intensive Care Unit) a bedside assessment of patient stability and care needs Hospital Amiens, France. dividing the patients in 4 classes of severity. II) The Severity Score (2) a weighted sum of 36 physiological mea- Four infants less than two months of age were admit- surements obtained from the patient's clinical record. We ted in the Pediatric Intensive Care Uni~ with severe will propose a simplified score with only 14 variables. impairment of general condition and respiratory III) The Therapeutic Intervention Scorin~ System TISS (I) distress, caused by CHLAMYDIA TRACHOMATIS (C.T) consisting in 84 interventions ranging 0-4 points. pneumonitis. Diagnosis could be quickly achieved by The following informations can be obtained by collec- a specific micro-immunofluorescent method. Three ting these dat~ : infants required assisted ventilation but in all a) Classification of the patients and identification of cases the treatment with erythromycin terminated inappropriate admissions in the ICU. shedding of C.T. b) Evaluation of results and comparison between diffe- Since the course of the illness is usually conside- rent institutions, which otherwise, would be difficult be- red to be mild, it is of interest to be aware of cause of heterogenous diagnosis and severity of illness : this aspect of natally acquired C.T. infection. almost all the deaths are among patients class IV. In the i~ture, multicenter collaborative studies Should also ta-- KEY WORDS : Chlamydia trachomatis, newborn infant; ke into account the organ system requiring the most atten- pneumonitis, respiratory distress tion - respiratory, cardiovascular, etc... c) a gaide for the decision of discharge by daily evaluation of TISS (3). d) evaluation of nurse patient ratio in the ICU, and definition of medical staff. For example : class IV patients require a I/I nurse/patient ratio. e) definition of the number of beds needed in a country from a Correct classification of patients who should be admitted in ICU. All this aspects will be illustrated and discussed with personal data and with data from adult and pediatric literature (4,5). References : I) Cullen D.J st al. Crit. Care Med. 1974,2, 57. 2) Knaus W.A et al. Crit. Care Med. 1981, 9, 591. 3) Keene A.R et al. Crit. Care Med. 1983, 11, I. 4) Rc- thstein P. etal. Crit. Care Med. 1982, 10, 34. 5) Yeh T.S etal. Crit. Care Med. 1982, 10, 497.

42.6

TREATMENT OF NOSOCOMIAL RESPIRATORY INFECTION IN THE MECHANICALLY VENTILATED CHILD. A.BAROIS, B.ESTOURNET, J.BATAILLE. Service de R~animation Infantile, HSpital R.Poincar~ 92 380 GARCHES FRANCE.

In this report we study 130 mechanically ventilated children observed during 1982. All had bacteriological tracheal or uncontaminated peripheral airways samples, weekly in acute, or monthly in chronic diseases. Among these children : -75 were intubated ; 21 younger than I year (mean age 4,6 ~ 2,5 months~ 54 older than I year (mean age 6,8 ! 4,8 years) -55 were tra~heostomised : 7 younger than I year (mean age 6,3 I 2,9 mQnths) and 48 older than I year (mean age 11,7 - 6,5 years). Results are the same in the two groups of age. Among intubated children, we only treated 12 original pulmonary infections (Haemophilus 6, Pneumococcus 2, Staphylococcus 4) and 2 nosocomial infections (Staphylococcus). The airways of infants are usually colonized with a variety of Gram - organisms (Serratia, Pseudomonas Klebsiella, Acinetobacter) we only treated them by preventing retention of pulmonary secretions. Among tracheostcmised patients 6 had alternate antibiotics treatment for bronchopulmonary dysplasia. All these children have chronic diseases (neurological or pulmonary) and are ventilated all year long. During 1982, we treated 13 children for Staphylococ- cus, 6 for Pneumocoocus and 18 for Haemophilus. Conclusion : Adequate humidification of inspired gases, regular position changes, chest physiotherapy and frequent tracheal suctioning often avoid antibiotic treatment during mechanical ventilation. We only treat Gram + organisms and hemophilus. These infections often occur on an epidemic way. Parenteral Nutrition in Intensive Care I. Principles of Nutrition in the Critically III Patient

43 45

METABOLIC AND HORMONAL CHANGES IN THE CRITICALLY ILL. CATABOLISM & NITROGEN SPARING IN THE CRITICALLY ILL STONER, H.B. MEDICAL RESEARCH COUNCIL TRAUMA UNIT, PATIENT . Herbert R. Freund, Department of Surgery, MANCHESTER UNIVERSITY, MANCHESTER M13 9PT. ENGLAND. Hebrew University - Hadassah Medical School, Jerusalem, Patients who have suffered severe injuries and those with Israel. active sepsis occurring as a complication of either The severly injured or septic critically ill patient accidental trauma or of surgical operation show many sufferes a major catabolic insult leading to increased similar metabolic features. In these patients, for proteolysis and nitrogen loss, accompanied by a modified instance, the distribution of metabolic subs~rates in the carbohydrate and fat metabolism. This special metabolic plasma and tissues is altered. The changes in the set-up of the critically ill patient dictates a modified carbohydrate and lipid substrates are clearest after nutritional support regime: accidental trauma but similar changes occur in sepsis, i. Decrease calorie / nitrogen ratio. although the pattern is more variable. Basically, the 2. Do not supply calories in excess of need. stores of both carbohydrate and fat are mobilized so that 3. Increase part of fat in total caloric intake. it might seem that these patients have a choice of fuel 4. Increase amino acid intake. oxidation. In fact, these very ill patients oxidize 5. Increase amount of branched chain amino acids in total predomlnently fat. This occurs even when they are presented amino acid intake. with extra glucose during parenteral feeding. T~mechanism 6. Decrease fluid load. of this metabolic effect is not understood but it may be 7. Apply metabolic monitoring if possible. related to those in the endocrine system following trauma and sepsis. There are widespread changes in endocrine function in these patients. Starting with the activation of the adrenal medullary-sympathetic nervous system to give an increased catechelam]nergic effect, there arechangesin thevasopressin, growth hormone, ACTH, cortisol and Tnsulin concentrations in the plasma. The variations in the last two are particularly complex and, again, these are best seen after accidenta] trauma. Given the initial role of the adrenal medulla and sympathetic nervous system in the mobilisation of the stores of carbohydrate and fat the subsequent changes in cortisol and insulin maybe importantindetermining the metabolic features of this group of patients. The presence of insulin resistance after both injury and sepsis may be particularly significant. There is growing evidence that the decrease in tissue sensitivity to insulin is due to a post-receptor block and this may be important both in deciding the fuel oxidized by these patients and for the abnormal protein metabolism wiaich is also present.

44 46

ENERGY REQUIRIK,~/~TS AND ITS SUPPLY NUTRITIONAL ASPECTS IN SEPTIC CONDITIONS. M.D. D.Schwander, HSpital Cantonal, CH-1700 Fribourg. Yvon A. CARP~NTIER, H6pital Saint-Pierre, Universit@ The most important metabolic variations typical Libre de Bruxelles, Brussels (Belgium). of a septic ill patient are as follow: glucid related metabolic perturbations, increase of Accurate measurements of energy expenditure can be body metabolism and rise of oxygen consumption, performed in man by direct or indirect calorimetry. The increase of protein catabolism and ureogenesis. values obs by such measurements are very often These changes are the outcome of centrally con- below those found in the classical literature. In the trolled neuroendocrine incidents. They mobilize absence of precise measure/rents, the energy expenditure in fact an excess of endogenous substrates. of various types of patients is usually overestimated. These three kinds of disturbances escort in fact every trauma or important stress, but for the Hypercaloric parenteral nutrition with high glucose septic patient, they are characterized by their intake can induce severe metabolic coniolications in persistence and by the fact that unhappily most critically ill patients : hyperglycaemia due to insulin of the time, zhe evolution turn co be an uncon- resistence, hyperosmolarity, essential fatty acid trolable multiple organ failure whose mortality deficiency, but also respiratory distress due to high is very high. CO 2 production and increased incidence of liver Before infusing the necessary substrates to dysfunction. spare the essential proteins for a good body function, one must try first to suppress or in- During the hypermetabolic phase of critically ill hibit the condition who maintains the s~ress and patients, endogenous and exogenous fat appear to be a it's catabolic reaction what means ~o control preferential fuel for - at least - some tissues. the patient milieu, his adaption to stress and the pathological conditions responsable or whor- Adjusting the total calorie intake to the patients sening stress and infection. energy expenditure and introducing exogenous lipids in The treatment must aim to perfuse and bring the TPN regimen significantly decreases the incidence enough calories to cover the needs without cau- and the magnitude of metabolic side-effects. sing suplementary work to the body by means of lipogenesis, glucogenogenesis and ureogenesis in ~articulary for the failing liver. In practice mos~ of the times one can only infuse a minimum of 125 to 150 g of glucose, i00 to 500 ml of 10% Intral~pid and i0 ~o 20 g nitrogen as a rich in branchchained aminoacids solution. Only repeated calorimetric measurements will allow co quantify the metabolic monitoring and to document the global metabolic care. II. Parenteral Nutrition in Acute Organ Failure 167

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PARENTAL NUTRITION IN ACUTELLY ILL DIABETIC PATIENTS. II.PARENTERAL NUTRITION IN ACUTE ORGAN FAILURE. G. Kleinberger; Ist Dept. Internal Medicine, Univ. of MULTIPLE ORGAN FAILURE. E.R. Schmitz, Institut Vienna, Austria. fur An~sthesiologie der Ludwig Maximilians-Uni- versit~t M~nchen, FRG Diet plays an important role in the treatment of diabetes Since the possibilities of a combined, subtle mellitus and should be considered when parenteral nutri- cardiopulmonary, renal, and nutritional support tion is used. A complete nutrition solution with a calorie are at the disposal of the intensive care units, content consisting of 44% carbohydrate, 17% l-amino acids the failure of multiple organs (MOF) has been and 39% fat is recommended. In uncontrolled diabetes mel- identified not only as a disturbed function of litus parenteral nutrition should be started after water some organs but as a syndrome-like entity with and electrolyte imbalances is corrected and blood glucose an expected mortality of more than 50%. Charac- level is decreased below I0 mmol/l and beta-hydroxy buty- terized by its progressive nature MOF may end in rate below 3 mmol/l. This can be obtained by a low dose insulin regime and rehydratation with a glucosefree elec- a complex reduction of nearly all organ func- trolyte solution with 90 mmol sodium, 60 mmol chloride, tions with an at last untreatable cardiopulmona- 25 mmol potassium, 10 mmol phosphate, 0.5 mmol calcium, ry insufficiency. The controlling factors in MOF are not well understood. Neuronal, hormonal, and 1.5 mmol mangesium and 43 mmol malate within 1000 ml H20 and an infusion volume adjusted to the value of the cen- other influences change the metabolic state and -as for the nutritional aspect in a wider sense tral venous pressure. of the word-one general conclusion can be drawn: Total parenteral nutrition of acutelly ill diabetic pain MOF cells, tissues, and organs are more or tients containing 2.9 g carbohydrates, 1.1 g l-amino less unable to provide energy and protein syn- acids and 1.1 g fat with a caloriecontent of 26 kcal (110 kJ)/kg KG/d has been under current investigation. thesis in as sufficient amounts as they are nee- The results showed that the blood glucose level is main- ded and exactly there, where they should be tained well by a continuous intravenous insulin dosage of used. From a practical point of view organ fai- 3 + 0.6 IU and no deviation of osmolality and serum lac- lure in intensive care units is connected with tate occured. The blood gas analysis remained unchanged. modalities of nutrition in different ways: it is The triglycerides concentration was 0.8 + 0.12 mmol/l at a fact, that an incomplete nutrition or a state the beginning and reached a steady state-of 1.3 + 0.26 of malnutrition always means a risk for an addi- mmol/l. The beta-hydroxy butyrate concentration ~howed a tional organ failure. It is evident too, that a transient increase from 0.6 + 0.05 tO 0.9 + 0.22 mmol/l failing organ troubles the metabolic homeostasis and afterwards decreased to the normal range. The intra- so, that a normal "classical" nutrition is dan- venous infusion of a standard amino acid mixture caused gerous. Therefore nutrition therapy in MOF means no derangement of the plasma amino acid concentration to find a way between the necessity of avoiding during adequate supply of insulin. Therefore it can be symptoms of malnutrition by substituting enough concluded that insulin treated patients with diabetes substrates and between the knowledge, that this mellitus do not need a special amino acid mixture. may lead to metabolic disturbances followed by a worsening of the state of illness.

ACUTE RENAL FAILURE (AF). P. FHrst, Inst, for Biological Chemistry and Nutrition, Univ. of Hohenheim, Stuttgart. A major contributing factor to the high mortality observed in AF is the net breakdown of body cell mass. Nutritional therapy in AF is thus, mandatory. Modern principles imply frequent dialysis or ultrafiltration as early as possible after the patient has become definitely oliguric, thus allowing an adequate nutritional supply by the parenteral route. Energy should be provided as much as any intensive care patient, i.e. 10.5-12.5 MS/day or considerably more, if the patient has a marked hypermetabolism as for instance in severe burns. At least 200 g should be provided as carbohydrate in order to decrease glueoneogenesis of keto- acids. To cover the increased energy requirements the use of fat emulsions are of special value since they provide the patient with a high amount of energy in a low volume of fluid. Fat emulsion should, however, not be given unless the need of carbohydrates is satisfied. Parenteral administration of amino acids should be given to all patients with AF of more than 2-3 days duration who cannot take protein by mouth. The administration should not start until the uremic state is controlled by adequate dialysis. The optimal proportion between essential amino acids and non-essential amino acids with a daily amount of 30-60 g is to emphasize. Electrolytes and water soluble vitamins should be provided as for any intensive care patients. Patients in whom the problems are restricted primarily to the kidneys usually survive the acute phase, if adequately dialysed, even when the renal function has not returned. There is yet no conclusive evidence existing that the use of parenteral nutrition in AF will increase survival when associated with sepsis or other severe organ failure.There are reports, though anecdotic, that vigorous nutritional therapy with glucose, insuline, fat and amino acids combined with frequent dialysis or ultrafiltration therapy promote survival even in high-risk patients. Certainly, it is justified to make every efforts to prevent these patients from starvation and internal canibalism. Metabolic Disorders in Intensive Care

51 52 Bis

PROTEIN WASTING IN THE CRITICALLY ILL: PATI~OGENESIS AND THE EUTHYROID SICK SYNDROME A.G. Bffrger CLINICAL IMPLICATIONS. U. Keller, Department of Internal Thyroid Research Unit, Geneva, Switzerland Medicine, University Hospital, CH-4031 Easel, Switzerland Among the known iodothyronines only T3 is nowadays collsi- The classical view of protein wasting in severe illness as dered to be biologically relevant, Contrary to general developped by Cuthbertson in the 1930ies has been that pro- belief, T3 is not a secretory product of the thyroid, tein breakdown results from substrate mobilisation to cov- it is mainly produced by monodeiodination in the liver, er energy demands. Today we have more detailed explana- kidneys and brain. It is now well established that tiormfor the pathogenesis of disturbed protein dynamics in in illness this pathway is blocked while the inactive catabolic states. The general view is that negative nitro- pathway of T4 degradation via rT3 remains intact. Hence gen balance in moderate trauma results from diminished in disease serum T3 can be as low as in severe hypothy- protein synthesis without major increase in protein break- roidism and serum T4 values can also be markedly redu- down; adequate nutrition may restore in part the impair- ced. Clinically it is however easy to exclude primary ment of protein synthesis. In contrast, severe trauma is hypothyroidism (but not secondary hypothyroidism) by a associated with accelerated protein breakdown out of pro- serum TSH measurement which will remain normal even if portion to energy requirements. Protein synthesis may be both, serum T3 and T4 are markedly decreased, the low enhanced provided that adequate nutrition is supplied. serum T3 and total and free T4 levels being therefore diagnostically useless. Are these hormonal changes The overall metabolic alterations in severe catabolic adequate adaptations to the sick state or do they indi- states are enhanced protein breakdown, ongoing fat oxi- cate a partial deficiency in thyroid hormones ? The dation, relative inhibition of glucose oxidation, and majority of indices favor the hypothesis of an adequate failure to increase hepaticproduction of ketone bodies as adaptation : kinetic studies have shown that the low alternative fuel. This maladaptation is, at least in part, serum T4 levels are in part explained by an increased explained by elevated stress hormones, such as glucocorti- metabolic clearance rate, the production rate being coids and epinephrine. They result in enhanced protein only moderatly reduced. The effect on the target breakdown and fat mobilisation, they induce insulin resis- tissues have been studied in the model of the starving tance and thus hyperinsulinemia. Results are presented de- rat : there is evidence for a partial resistance to T3 monstrating inhibition of hepatic ketogenesis by insulin; with nuclear receptors clearly decreased which is not glucose utilization may be impaired due to elevated free typical for hypothyroidism. However in rats with renal fatty acid levels. insufficiency T3 can have some beneficial effects on enzymes. Therapeutic measures include avoidance of stress, catabolic hormones and administration of insulin as a potent an- A definite answer to the question raised will therefore ticatabolic agent. In addition, adapted nutrition should have to awaide a better understanding of thyroid hormone action. cover the altered requirements of carbohydrates, fat and amino acids.

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HYPOTHYROIDISM IN THE CRITICALLY ILL - PART OF THE DISEASE METABOLIC TREATMENT OF CARDIOVASCULAR FAILURE: OR EPIPHENOMENON? P.R. Bratusch-Marrain, I. Medizinische A REASSESSMENT OF THE INSULIN CONCEPT. Universit~tsklinik, Vienna, Austria M. J. ELLIOTT, F.R.C.S., FREEMAN HOSPITAL, Systematic evaluation of endocrine systems during critical HIGH HEATON, NEWCASTLE-UPON-TYNE, U.K. non-endocrine illness is severely hampered by the hetero- geneity of diseases and the variety of applied treatments. Insulin has been used in the treatment of heart failure Yet,interpretation of endocrine function tests in severely almost since its discovery. Such intervention has ill patients may be mandatory to uncover underlying or ac- always been controversial. Insulin therapy has, of companying endocrine disorders. course, been combined with glucose and pomassium as In the present study the impact of non-thyroidal disease GIK) ro prevent hypoglycaemia and hypokalaemia. Such upon the pituitary-thyroid axis was evaluated. Out of 335 combination has led, pari passu, no difficulties in consecutive patients admitted to an intensive care unit defining the exact mode of action of the therapy since 20 patients suffering from severe non-endocrine diseases each constituent has potentially beneficial effects in (septicaemia, fulminant hepatic and renal failure, acute the failing heart. Sporadic reporrs of clinical pancreatitis, polytrauma, cerebral haemorrhage) were found benefit from the use cf GIK led to therapeutic trials to have serum total thyroxine (TT4) levels in the hypo- of the treatment in a wide variety of clinical thyroid range (below 4~g/dl). Serum concentrations of TT4 situations - ranging from its use after myDcardial (2.3~O.2~g/dl), triiodothyronine (TT3, O.23+O.O3ng/ml), infarction no its use before open-heart surgery. and thyroxine binding globuline (iS.5~l.3~g/ml) were re- Unfortunately, highly varied doses of G, I ~nd K have duced, but were above normal for reverse T3 (0.43+0.06 ng/ been used, and it is not surprlslng that clinical ml). The response of TSH secretion to iv TRR was Tound to results have been equivocal. Further, the responses be either normal, lowered or absent. Primary hypothyroid- sought by the various workers have also differed ism was excluded, as no enhanced TSH response was observed markedly, ranging from suppresslon of dysrhythmias to in any case. Although decreased TT4 levels may be due to increased cardiac output. Few reports exls[ which increased thyroid hormone degradation it appears that as- relate dose to response, yet it is exactly this sociated impaired TSH responsiveness to TRH may result information which is needed by the clinician planning from illness-related inhibition of pituitary TSH release. therapy. There is, however, a noticeable trend in Even though free T4 serum levels may also be decreased in recent reports ~o increase the doses of insulin used, some of the patients at the summit of their illness, the and results appear encouraging, particularly after metabolic response to thyroid hormone deficiency is to be myocardial infarction and in relation ~o myocardial expected with considerable delay. failure following open-heart surgery. In the latter Although the finding of decreased thyroid hormone levels case enormous bolus doses of insulin have been employed. is not rare in intensive care patients, it represents an index of poor prognosis. Differentiation between this This presentation reassesses the evidence for the use "low-T4 syndrome" and true hypothyroidism depends essenti- of insulin in myocardial failure, discusses the ally on clinical symptoms and course of disease. If there logistics of its use, and emphasises the need for the is no clinical evidence of hypothyroidism, thyroid hormone establish/tent of a dose:response relationship. substitution may not only lack a rational basis, but due to their cardiotropic action could also endanger some of these patients. 169

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BEDSIDE MEASUREMENTS OF RQ - METHODS AND WATER AND ELECTROLYTE BALANCE DURING MECHANICAL VE~TILA - THERAPEUTIC IMPLICATIONS. J.Eckart,Augsburg,FRG TION.P.IL Suter, H6pital cantonal universitaire, Gen6ve Handling of water and electrolytes results under physiolo- Indirect calorimetry is the method in use today for gical circumstances from neural, humoral, cardiovascu- providing data on total energy expenditure and on the lar and renal mechanisms. Mechanical ventilation interfe- amount and composition of the oxidized fuel. The meta- res with several of these regulatory circles, causing ge- bolic rate can he calculated by multiplying oxygen up- nerally water and sodium retention(1). The changes are mo- take by the oxygen caloric equivalent corresponding to the RQ. The respiratory quotient is the ratio of the re marked when positive end-expiratory pressure(PEEP) is volume of carbon dioxide produced to the volume of oxygen applied, and in most studies PEEP was used to amplify the consumed over a given interval of time. Whereas fats underlying mechanisms. The following factors are involved: and carbohydrates are completely oxidized,proteins are l)Increased intrathoracic pressures elevates central ve- not. Each gram of urinary nitrogen signifies a respira- nous pressure, decreases venous return and cardiac output. tory exchange of 4.7 liters CO2 and 5.9 liters 0 2 . 2) Renal function is impaired by changes in intrarenal per- Using this figures we can calculate the nonprotein RQ. fusion(2) leading to water and salt retention.3) Antidiu- This ratio indicates the relative amounts of fat and retic hormone secretion is increased during both short(5) carbohydrate katabolized. For measuring metabolic rate and long term positive pressure ventilation(4).4) Plasma traditional techniques - Douglas-bag technique, closed- renin activity and plasma aldosterone are increased(6). circuit spirometry have been replaced by automated ~1ost of these mechanisms are more important during cont- systems - Beckman Metabolic Measurement Cart, Canopy- rolled or intermittent mandatory ventilation than during Spirometer-Computer System (Kinney et al), Engstr~m spontaneous breathing with positive airway pressure(8).The Metabolic Computer - usable for mechanically ventilated application of dopamine or dopamine with dobutamine impro- and spontaneously breathing patients. By means of in- ves water and sodium excretion in ventilated patients(3,7). direct calorimetry and calculations of nonprotein RQ It is not clear if water retention during mechanical ven- new insights were gained in recent years into the meta- tilation is part of an adaptive mechanism to the decreased bolism and nourishment of critically ill patients. It could be demonstrated for instance that administration cardiac filling or simply due to a dysregulation of the of large glucose load to hypermetabolic patients does mentionned circulatory and neurohumoral factors. not totally suppress the net fat oxidation as it does References: in depleted patients and that excess carbohydrate in- l)Sladen,Laver,Pontoppidan,N Engl J lied 279:448,1968 take maybe a critical factor in weaning of a patient 2)Priebe,Heyman,Hedley-Whyte;J appl Phys 50:543,1981 with mechanical ventilatory support. By using the same 3)Hemmer,Suter; Anesthesiology 50:399,1979 technique other authors have shown that after an oral 4)Hemmer,Viquerat~Suter,Vallotton;Anesth 52:395,1980 glucose tolerance test lipid oxidation rates were 5)Kumar,Pontoppidan,Baratz,Laver;Anesth 40:215,1974 completely different in maturity-onset and in juvenile- 6)Annat,Viale,Bui Xuan,Hadj Aissa,Benzoni,Vincent,Gharib, type diabetics. Motin;Anesthesiology 58:136,1983 7)Brandl,Pasch,Kamp,Grimm;Int Care Med 8:69,1982 8)Steinhoff,Falke,Schwarzhoff,lnt Care r~ed 8:69:1982 Early Management of the Trauma Patient

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PRIMARY FLUID LOSS AND REPLACEMENT THERAPY CHEST TRAUHA AND SURGICAL TREATEHEtIT K. Me6mer, Dept.Exp. Surgery, University of Hei- W. Glinz, Surgical C]inlc B, University Hospital delberg/FRG Hospital, ZUrich.

Primary fluid loss in trauma patients means Apart of intercostal tube drainage, which is first of all loss of both red blood cells and the basic therapeutic procedure in all severe their colloidal suspension fluid. Depending upon chest injuries, operative intervention is severity and duration of hypovolemia, hypovole- seldom necessary in blunt thoracic trauma. We mia-induced activation of the sympathetic ner- performed thoracotomy in 8% of such hospi- vous system and deterioration of the fluidity of talized patients. There are clearly defined in- blood, the microvascular perfusion becomes im- dications for surgery: Hassive and persistent paired with the final result of tissue hypoxia bleeding, acute cardiac tamponade, rupture of and depletion of the extravascular fluid com- trachea, bronchi, aorta, supraaortic branches, and diaphragm. partments. The length of time, a trauma patient Operative stabilization of the chest wall has remained hypovolemic is critical for survi- should be considered in exceptional cases. Hany val due to promotion of multiorgan failure with duration of hypovolemia and shock, respectively. restricting factors are involved in such an operation, and in many cases it is just not Primary therapy should replace the colloidal necessary. fluid actually lost. The aim of initial volume Conditions are similar in the case of penetra- substitution, however, is not only to restore ting injuries. Here too, th0racotomy is recirculating volume and central haemodynamics but served for precisely defined indications. Many to counteract at the same time the secondary im- cases can be treated by conservative management~ pairment of the microcirculation. By virtue of which does not mean being inactive. Immediate their oncotic power and capacity to retain wa- thorac0t0my~ however, is the keyt0 success in ter within the circulation, red cell free all penetrating heart injuries,and this applies colloid solutions should preferably be used for particularly to situations that are apparently primary volume replacement in trauma patients. hopeless. From the artificial colloids, Dextran 70 is con- Th0raeotomy was performed in #9 out of 155 sidered most suitable due to its long lasting penetrating thoracic injuries (#8% of which volume and blood fluidity improving effect. were gunshot wounds). In this series, 36 heart Cristalloids have proven satisfactory, however, injuries are included. Mortality was 5.5%. intravascular refill requires 2.5 - 4 times the volume loss and intensive haemodynamic monitoring. Independent upon the initial fluid used, a fall of haemoglobin to 10 - 8 g/100 ml calls for red cells. RBC-concentrates/FFP and fresh whole blood are both efficient to control defi- cits of oxygen carriers and plasmatic clotting factors.

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CIRCULATORY FAILURE AND PHARMACOLOGIC SUPPORT EARLY RESPIRATORY FAILURE AND MANAGI~MI~T. G.Wolff, B. E. Strauer, Department of Medicine, University of Division of Cardiothoracic Surgery, University of Basel, CH 4031 BASEL. Munich, Klinikum GroBhadern. Acute respiratory failure (ARF) means increase of PaCO2 and/or low P O 2 ~ed to FIO2. After trauma a Cardiac failure may be due to abnormal alterations in number of pa~h61ogical conditions may cause these symptoms. Hypoxia/hypercapnia are produced by a reduction in venti- preload, afterload, contractility and heart rate. Therapy lation and/or by disturbance of gas exchange, l.Ventilation and management of the failing heart therefore has to con- may be limited mechanically (blocked airways, Pnet~othorax, sider positive inotropic drugs as well as vasodilating flail chest), by central nervous depression (coma) or by pain (rib fractures). If causal therapy is not effective and antiarrhythmic management. in~ediately, mechanical ventilation has to be installed without delay. High frequency ventilation may be adequate Pharmacologic report embraces positive inotropic drugs in selected cases. 2.Gas Exchange may be disturbed by loca- (dopamin, dobutamin, prenalterol, amrinone etc.), reduc- lined pulmonary lesions preventing ventilation in areas still perfused (pulmonary contusion, aspiration pne~nitis) tion in preload (enddiastolic wall stress) by vasodila- or in a diffuse change of pulmonary parenchyma beginning torn (diuretics, nitroglycerine, isosorbiddinitrate) and as interstitial edema progressing to alveolar edema and later on to interstitial fibrosis (ANDS). Although bio- reduction in afterload (systolic wall stress) by vasodila- chemical mediators may initiate ANDS, the first clinical torn with arterial action (dihydralazine, prazosine, ni- manifestation is a capillary leak associated with and partially due to hypoxic pulmonary vasoconstriction. fedipine etc.). Therapy cannot focus on the primary lesions but must (i) increase pulmonary gas voltm~ (mechanical ventilation with The use of inotropic drugs has to consider the inotropic PEEP ) to raise P_Or and to reduce hypoxic pulmonary vaso- related increase in oxygen consumption of the heart, constrlctlon, pulr~o~ary hypertension and capmllary leakage, and (2) increase cardiac output to reduce pulmonary which may be compensated by afterload reduction. Thus, vascular resistance and right ventricular failure. Intra- vascular volume must be optimised and vaso-active pharma- contractile enhancement as well as simultaneous preload cotherapy may be necessary. However, the ini0ortant goal and/or afterload reduction is discussed with regard to is difficult to reach : to get ventilation in match with perfusion. Early prophylactic steps are more effective the management of cardiac and circulatory failure in the than late therapeutic attenlos. Cortieostheroids, Heparin, critically ill patient Trasylol, etc. are not proven to have any effect. 171

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EARLY MANAGEMENT OF SEVERE HEAD INJURY. D.G. McDowall, Anesthesia in trauma victims Department of Anaesthesia, University of Leeds, England. Peter, K., Franke, N. Head trauma is common but severe brain injury is rare. Institut fGr An~sthesiologie der LM-Univ. In a few patients an injury which at first sight seems MGnchen, Klinikum Groghadern minor leads to severe brain damage due to intracranial In anesthesia under conditions of trauma and shock due to bleeding. The primary brain injury which occurs at the volume dificiency the pathophysiological alterations cau- moment of trauma may be complicated by secondary brain sed by these conditions have to be taken into account. injury if hypoxia, hypocapnia, hypo- and hyper-tension or On principle, trauma and shock result in an acute dispro- cerebral venous congestion are allowed to occur. The portion between oxygen supply and oxygen demand of the main problems in early head injury management are, there- organism. To the fore of the cardiovascular reaction fore, I) triage and 2) prevention of secondary brain there is the sympathico-adrenergic stimulation at an re- injury. duced cardiac Output which leads to a derangement within At the scene of the injury the first requirement is to the field of microcirculation. In a stage of compensated control the airway. Regurgitation of vomitus can shock constriction of arterioles, preeapillaries and ve- usually be prevented by correct positioning. Unskilled nules causes an impairment of inflow and outflow. As a attempts at tracheal intubation may make the brain injury result microcirculatory blood flow is redistributed thus worse. The second requirement is the support of the leading to a reduction in perfusion of nutritive capilla- circulation by controlling haemorrhage and/or infusing ries as well as to tissue hypoxia and anoxia. The aim of colloid. Once these primary resuscitative measures have therapy must therefore be an improvement of microcircula- been taken the level of coma should he assessed and tory blood flow. The most important factor in this connec- recorded using the Glasgow Coma Score and the reaction tion is a rapid and complete volume replacement by dex- of the pupils examined. trane, crystalloids and blood or blood fractions. Ade- The patient should be transported to hospital and a skull quate oxygenation and reduction of respiratory work must X-ray obtained. If he remains in coma as defined by be ensured early and with somnolent patients early intu- Jennett as "Not obeying commands, not uttering any bation is needed in order to protect respiration. With recognisable words and not opening the eyes" after patients in traumatic shock anesthesia should be induced correction of respiratory and circulatory inadequacy, with etomidate, ketamines or opioides because of the low then he should be transferred to a hospital able to negative inotropy and the modest influence on afterload provide CAT scanning. This should also occur immediately of these agents. Subsequent to a complete volume replace- if there is any sign of worsening of the conscious level. ment narcosis can be maintained by a combination of fen- If the CAT scan shows intracranial haemorrhage, craniotomy tanyl, for instance, and volatile anesthetics (enflurane, will usually be necessary and this should be followed by halothane). In order to decrease the pressure in situa- ICP monitoring. If there is no haematoma but the patient tion with circulatory hypertension the administration of remains in coma, ICP recording should be initiated. nitroelycerine should be preferred, since sodium nitro- Controlled ventilation is indicated for at least 12 hours prusside induces microcirculatory disorders. These ne- following any surgical haematoma evacuation. In the absence of surgery, controlled ventilation is indicated if cessary measure call for an invasive monitoring inclu- there is i) no reaction to pain, 2) extensor posturing, ding recording of cardiac output and pulmonary pressures. 3) convulsions, or 4) ICP over 25 mm Hg. During controlled ventilation ICP should be kept below 25 mm Hg by mannitol, frusemide and althesin, etomidate or thiopentone. Many severe head injuries also have other major injuries. Necessary surgery should always be covered by adequate 62 anaesthesia, using controlled ventilation and avoiding volatile anaesthetics. Chest injurSes may require the TRAb~,IA AND INFECTION. I.McA. Ledingham, I. Watt. use of positive airway pressure and this is acceptable University Department of Surgery, Western Infirmary, providing the patient is nursed head up to reduce cere- Glasgow Gll 6NT. bral venous pressure. Limb fractures should be managed The relationship between multiple trauma and infection by methods which do not require traction in the head down has been studied in 428 patients admitted to an ITU position. Maxillo-facial injuries can usually wait 24- between 1969 and 1982. Until 1980 mortality was 48 hours before surgery. It is very necessary to be on consistently around 25%. 62% of the non-survivors guard for visceral intra-abdominal bleeding which can died in less than 5 days from injury, decreasing readily be missed during controlled ventilation of the from 86% during the first two years to 35% during head injured patient. the last two years. The majority of the remainder died with septic complications and/or multinle organ failure. During 1981/82 the number of trauma referrals rose by 60%. Mortality also increased (from 25% to 44%); 33% of the non-survivors died in less than 5 days from injury. There mere no obvious changes in the pattern of referral, severity of injury, nature of bacterial infection or frequency of invasive procedures to explain the increase in mortality. Other factors influencing host defence both during early resuscitation and subsequent intensive care may adversely affect outcome. ARDS: Pathogenesis and Prognosis

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ROLE OF COMPLEMENT - C5a ACTIVATION AND STEROIDS IN ADULT THE ROLE OF PROSTACYCLIN (PG!?) AND THROMBOXANE A 2 IN RESPIRATORY DISTRESS SYNDROME, SEPTIC AND NON SEPTIC SHOCK COMPLEMENT INDUCED PULMONARY INSUFFICIENCY. Michael M. Dedhia H, Schiebel F, Bowen R, Koss W, Crompton J, Beatty Krausz, M.D., Takayoshi Utsunomiya, M.D.,Ph.D., Herbert J, Depts. of Anesthesia, Medicine and Pathology, West B. Hechtman, M.D., Dept of Surgery B, Hadassah University Virginia University Hospital and School of Medicine, Mor- Hospital, Jerusalem, Israel, and Dept of Surgery, Brigham gantown, WV 26506 USA and Women's Hospital and Harvard Medical School, Boston Use of high dose steroids in ARDS, septic and non septic HA, U.S.A. shock remains controversial. Complement activation, sp. Activation of the alternative pathway of the complement C5a may be important in those conditions. We are in- system leads to leukocyte aggregation, entrapment in the volved with a prospective study in humans, in hope to pulmonary microvasculature and release of vasotoxie agents clarify the issues. 31 patients with ARDS, septic or non which lead to increased physiologic shunting and perme- septic shock admitted to ICU have been studied. All pa- ability pulmonary edema. 51 sheep were infused with tients were on respirators and PEEP. Serum for C5a were zymosan activated plasma (ZAP): group I (n=ll) were un- drawn initially at the time of diagnosis and then daily. treated controls. In group II (n=10) imidazole, a throm- 82 samples from 31 patients were collected and analyzed. boxane synthetase inhibitor, 25mg/kg.h was started h Complement induced leukocyte aggregation was measured in before ZAP infusion. In group III (n=10), PGi 9 in a dose vitro and graded from i+ to 4+. From 31 patients, 5 were of I00 ng/kg.min was given 30 min before ZAP infusion. negative, 9 showed i+ to 2+, 17 demonstrated 3+ to 4+ and Within 5 min, lAP led to a fall in leukocyte count to were considered positive. SolumedrolR(Methylpredniso - 2900/mm 5 [p(0.001), rise in plasma thromboxane B 2 (TxB2) lone) 30 mg/Kg was given q6hr for 4 or 8 doses in i0 pa- from 14 to 246 pg/ml (p(0.001) rise in lymph, TxB 2 from tients. Classification of each group and results are 24 to 609 pg/ml (p(0.001) rise in mes-9, pulmonary artery shown below. pressure 0MPA) from 17 to 4SmmHg and Qs/Qt . from 13% to No. of CSa Outcome 51%..Both imidazole and PGI 2 prevented the rise in TxB 2 3roup Diagnosis Patient Activation Steroids S D and Qs/Qt and limited the increase in MPA to 25 and S0~ + + - Hg respectively. Imidazole but not PGI 2 prevented the 16 4 12 7 9 increase in lymph flow which in controls increased from I ARDS 24 8 4 4 5 3 2.8 to 8.S ml/50min (p40.01) and lymph albumin clearence 2 Septic which increased from 2.2 to 6.0 mi/30 min (p<0.01). The 2 i l 1 1 2 Shock high lymph concentration of TxA 2 suggests a pulmonary 3 Non-Septic site of production and its brqnchoconstrictive action may 5 0 5 1 4 Shock account for the increased Qs/Qt- TxA2 is only partly (S) indicates Survival + indicates C5a activation or responsibl e for the pulmonary hypertension and apparently (D) indicates Death steroid therapy unrelated to changes in permeability. The protective ac- - indicates no activation/ t/on of infused imidazole against increased permeability steroids not given appears to be independent of its inhibition of Tx synthe- *Preliminary data suggests tase. i) C5a activation occurs in a high percentage of patients with ARDS and carries high mortality. 2) C5a activation is absent in patients with non septic Shock.

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PLASMATIC FIBRONECTIN IN SEPTIC A.R.D.S. (CINETICS, HISTOMORPHOMETRY OF LUNG ELASTIC FIBERS DURING ARDS. EFFECTS CORRELATIONS, THERAPEUTIC TRIAL). F. Eourrier*,C. Chopin*, OF DISEASE DURATION AND TYPE OFVENTILATION. Y. Ozier, F.Steenhouwer*, A.Masurier**, J. Mangalaboyi*, A. Du- B. Franc, J.F. Prost, D. Barres, F. Jardin, A. Mignot. RSpital rocher*, D. Dubois*, M. Goudemand**, F. Wattel*, *Service Ambroise Par&, Boulogne, France. de RManimation,H@pital Calmette, CHR Lillej ** C.R.T.S. Lung elastic fibers of 27 patients deceased during ARDS have Li~le, FRANCE. Plasmatic fibronectin (PF) was daily been quantified in order to evaluate effects of disease dura- measured in 25 patients who developed septic ARDS and tion and type of ventilation. survived a 10 days period. The study was an attempt to 3 groups of 9 patients with comparable aetiology have been know if PE levels could be correlated with the clinical constituted according to the duration of the ventilation and evolution, the severity of respiratory impairment (Qs/Qt, the amount of PEEP appreciated with an index as follow: compliance, Vd/Vt) and the development of complement A- Prolonged ventilation (16j.) and low PEEP (index 3) activation and intra-vascular coagulation (I. V. C. ) PE was B- Prolonged ventilation (15j.) and high PEEP (index 18) compared with angiotensin convertingenzyme (A.C.E.) as C- Short ventilation because of early death indez of prolonged lung damage. All the patients needed D - Control group of deceased patients without lung pathology controlled ventilation. 32 ~ developed prolonged sepsis; Elastic fibers quantitation on randomly distributed prelev- 80~ had complement activation and 52 Z I.V.C. The results ment of lung parenchyma stained by orcein has been achieved are shown on table 1. In these different groups, the using i) a point counting method to measure the volume frac- respiratory functional data were not different at ad- tion of elastic fibers and the boundary length fraction ; and mission, but on the 4th dam were closely correlated with ii) anautomatic image analyser working on images by successi- low PF, with parallel decrease in A.C.E. and functional ve erosions. data. The lack of increased PF on the 4th dam was cor- The 3 groups A B C show a significant decrease of elastic fibers related with further death and sepsis (sensibility 100 ~, volume fraction compared with group D. The smallest value is in specificity 94 ~). group C. The 2 groups B and C show a significant decrease of e- Conclusion : these results are consistent with the lastic fibers boundary length fraction compared with groups A accurate value of PE levels as indez af prognosis and and D together. The elastic fibers boundary length fraction severity in septic ARDS. The variations of PF are in- have been appreciated first by the ratio of the total boundary dependant from I.V.C. 6 other patients with decreased PE length onthe volume fraction and secondly by the area of the were treated with enreached cryoprecipitate with complete 4th and 8th erosions given by the automatic device, recovery. Randomized therapeutic study i8 now under These histomorphometric results confirm the visual impression evaluation. -X-:P (.0~05 -X-'X-:P< 0,01 -X--X--X-:P(: 0~001 of elastic fibers destruction during the early phase of ARDS. In case of prolonged evolution these results suggest a partial All patients I. V.C. Prolonged sepsis regeneration to occur the quality of which being under the n = 25 + n = 13 [- n=~12 + n= 81- n =17 dependance of the type of ventilation. Indeed PEEP seems to maintain the elastic fibers in a fragmentation state close to Ist day 268 ~22 --123;26 ~ 212~31 204:;38ns 152;27 the state of the first day of the disease. ns ~ ns -X-X- In this group A, where mean venous admixture (40.9 ~ 10.4) 4th d~j 238 ~ 23 217 ~ 32 262 31 187 ~ 22 263r was not dif'ferent from group B (41.2 + 8, i) , a similar mean duration of ventilation was obtained despite the lack of consistant 8th 302 ~ 24 296~36 289r 178~27 331;271 PEEP using membrane lung oxygenation in several cases. 173

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ANGIOTENSIN CONVERTING ENZYME (ACE),A PROGNOSTIC ALTERATIONS OF PULMONARY GAS EXCHANGES AFTER PARAMETER IN ADULT RESPIRATORY DISTRESS SYNDROME ADULT RESPIRATORY DISTRESS SYNDROME FOLLOWING (ARDS)?H.Steppling,M.ReuS,W.M~ller,V.Schulz, PROLONGED NEAR gROWNING.G.Domenighetti,E.Buchser Universit~tskliniken Mainz,Abtl.f.Pneumologie ,L.Genoni,Ph. Leuenberger,Unit~ di cure intense u. II.Med.Klinik,D-6500 Mainz Ospedale La Carlt~,Locarno,D~partement d'Anesth~- ACE is present in high concentration in pino- sio~gie and Division de Pneumologie,CHUV,Lausan- cytotic vesicles on the luminal surface of the he,Switzerland. pulmonary capillary endothelium.Because damage of the pulmonary vascular endothelium is be- Pulmonary edema following near drowning in fresh lieved to be a cardinal pathogenetic feature of water is a frequent and severe early complica - ARDS it is the question,if serum ACE level can tion. Lung mechanics and pulmonary gas exchange be used as a marker for development and prog- studies were performed 6 and 12 months after the nosis of ARDS. accident in 2 survivors of adult respiratory Until now we have investigated 9 patients with distress syndrome(ARDS)following prolonged immer ARDS.ACE activity was measured spectophoto- sion(lO and 20 minutes)in fresh water. The pati- metrically in progress of ARDS (range 8-32 days; ents were 25 and 29 years old and non smokers. method described by Cushman and Cheung)and was Assisted ventilation was performed during Ig and correlated to data of pulmonary gas exchange 34 days respectively.Measurements included spi- (AaD0o,Pa02,PaC0o,O~/~t)and thoraco-pulmonary rometry,lung compliance,distribution of ventila- compllance. 60 h~al~y persons in comparable tion,transfer factor of carbon monoxyde(DLCO), age were used as contol group. membrane factor(DM),pulmonary capillary volume, In patients with ARDS ACE activity in serum was gas exchanges at rest and during exercise. Resulb found significantly lower(~• =11,9+7,7)than in indicate that lung mechanics returned to normal healthy controls(x~Xs=32,0• - within 8 months after the onset of ARDS.No alterations of DLCO or changes of the distribution Patients with relatively higher mean ACE levels nf ventilation were detected. Conversely,the ratb in progress of ARDS(~=13,0-24,0 U/ml)demonstrat- of dead space to tidal volume was significantly ed finally before death a marked increase of ACE increased at rest and during exercise,and the ra serum level (range 31,5-43,6 U/ml)corresponding tio of capillary volume to alveolar volume was to an extreme rise of pulmonary shunt perfusion. decreased in both patients.lt is concluded that This final increase of serum ACE was not found AROS following pro]onged near drowning in adults in patients showing continuously very low ACE causes late abnormalities of gas exchange proba- values during ARDS(:=3,3-9,3 U/ml).These pati- bly related to decreased pulmonary capillary vo- ents survived a shorter time on average(~=9d) lumed than those with higher ACE levels (~=25d). The final increase of serum ACE in ARDS could be a sign of terminal,massive damage of pulmonary vascular endothelium. If very low ACE values are measured in progress of ARDS an early, severe damage of endothelium could be supposed.

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PROGNOSIS OF ARDS : INTEREST OF GAS EXCHANGES AND COMPLI- ANCE MONITORING UNDER CONTROLLED VENTILATION (CMV). C. Chopin, F. Fourrier, J. Mangalaboyi, M.C. Chambrin, A. Du- rocher, D. Dubois, F. Wattel - HSpital Calmette - LILLE - The aim of this study was to point out the interest of g~ exchanges and compliance monitoring of the patients submitted to controlled ventilation during ARDS. 34 patients supported the study (Mendelson's syndrom 18 - Lung contusion 9 - Viral pneumonitis 4 - Fat embolism 3). The monitoring its based upon the continuous measurement of expired CO2, expired volume and airways pressure by the mean of an individual computerized device The monitoring was reali- + zed all along the controlled ventilation (4,5 ~ 1,8 days) and allows to obtain the following functional data : VA/V ratio, partial ductances of CO2 (expired/alveolar = DuVCO2 alveolar/arterial = DucC02) - VCO2 - static compliance (Cst). The therapeutic regimen included : CMV with PEEP, isovolemic deshydration, corticotherapy and heparin. 23 patients survived (group S). ii patients (31%) died, (group D). We compared the results (table) of functional data obtained at T6 (6th hour) - T24 - T48 between both groups (Student's t test). Discussion : at the early stage, DuCC02 seems to be the more significant pronostic index. As for recovery the predictive value (PV +) at T6, reaches 85 % when DucC02 0,70. However, when DucC02 < 0,70, the predictive value of death is bad (PV = 50 %). So we tried to define a more accurate index : IEM = DucC02 x Cst which has PV + = 94 % (when IEM 320) and PV - = 74 % (when IEM <20). Conclusion': So, IEM represents a compliance taking into account the functional qualities of the remaining lung areas. We propose to use it in further prospective studies T6 GROUP S GROUP D PaD2 (FIO2 = i) 153 : 112 154 -+ 88 NS VA/V mmHg IO,60 + O,137 0,45 $+ O,IIO p 40,01 DueCO2 10,68 ~ O,120 '0,55 ~ O,Ii p 40,001 Cst (ml/cmH~O) ] 36 $ 10,2 27 $ 8,1 p

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PEEP, VENOUS ADMIXTURE AND IRUE SHUNT IN ARF PATIENTS EFFECT OF OXYGEN ON THE BISTRYBBTION OF ~A/~ DURING I.V, ANAgSTRESIA. A Holmgren, E Anjou, L Broman, M Bremen, G Settergren, G 0hqvist A.Pesenti, A.Ribsni, L.Gattinonl, M.L.Caspa~i Dpt Anaesthesiology and Clinical Physiology, Thoracic Clinics, Istituto di Anesteslologia e Rian~mazlsne, Unlverslt~ degli Studl dl K~rolinska Hospital. (Stockolm, Sweden). M~lano, Via F.Sforza 33, 20122, Milano I.v. anaesthesia is generally considered to be accompanied by impaired al- OVA/SO2 (venous admixture) and Os/OtSF5 .(true shunt I) were measured veolar gasexchange with inpending hypoxemia. TO eliminate this risk use of in 15 occasions on IO ARF patients requiring pss~tive airway pressure oxygen enriched inspired air is the role. The aim of the present investigation is to study the role of inspired oxygen fraction For the distribution therapy. Measurements were done after 30 min stabilization at 5 of $A/~ during i, ~. anaesthesia in patients undergoing lung surgery. cm H20 below and repeated at Scs H20 over the cllnically chosen PEEP Methods. 14 patients (33-72 years) were investigated before lung surgery (13 + 6.5 SD cc H O) at maintenance F 0 (0.57 + 0.18 SD). because of lung tumour with the multiple inert gas elimination technique - 2 I2 - OVA/gO was then dlvided into two components, one due to true shunt according to Wagner and West during 4 experimental settings: I/ Before i.lr. d 2 ~uaesthesia anaesthesia (panic- an one due to maldistribution, computed as (QVAO2-QsSF6)/g. The (FIO2 = 0.21), 2/ 30 mln after induction of thai, diasepam, fentanyl, pancuronium and controlled ventilation) (FIO2 study showed: 0.21), 3/ 30 mi, after increasing FI02 to 0.5, 4/ 40 min after change in - OVA/gO2 and gs/gtSF 6 decreased slgnificantly increasing PEEP (from body p6sition from supine to lateral with FI02 still = 0.5. 0.36 + 0.12 SD to 0.27 + 0.11 and from 0.28 + 0.16 SD to 0.22 + Results are presented in table i and 2 as means, x) indicated significance 0.15 SD respectively); = <0.05 compared with proceeding measurement (paired t-test). - (gVAO2-QsSFd)/O : no s~gsiflcant changes in spite of m~nor unpredl- ~b I. ~I~ ~ ~I~N ctable variations in both directions (0.08 + 0.05 SD at - 5 vs 0.06 ~A/~ <0.005 0.005- 0.1- tA/~ log SD 0-10 i0- I00 ~A/~ log ED + 0.05 SD at + 5); O.l 1GO i00 - cardiac output waslnot_ significantly influenced_by~ the PEEP levels I 0.02 0.04 0.94 0.54 0.77 0.57 o.oi 0.42 0.87 0.58 (6.67 + 1.98 1 min at - 5 vs 6.52 + 1.97 1 mln at + 5); changes II 0.01x 0.08 0.92 o.71x 1.13xx o.65x 0.02 o.33XXl.51~x~0.69 Ill 0.03x 0.07 0.91 0.57x 1.19 0.64 0.02 0.34 1.45 0.82 were not correlated with changes in QVA/OO or Os/OtSF 2 6' IV 0.04x 0.07 0.89 0.53 1.14 0.58 0.05 0.3~~ 1.57 0.95 - the fraction of the total OVA/Q0 due to maldistrlbution 2 Tab 2 ~ FICK ~0 Pa0 ~C0 (QVAO -QsSF )/(gVAO ) (y) showed e significant negative correlation -i ~ 2 2 2 6 2 I x min mm x min-I kPa kPa with FIO2 (x) (y = 0.75 - 0.84 x; r = -0.75). x 6.o io.6 lO.1 ~.~ Concluslons: higher PEEP improved oxygenation mainly through a II 3.8xxx 7.8xxx i0.i 4.9xxx decreased true shunt. As expected at high F 0 the true shunt was Ill 4.8TM 9.3xx 26.6xxx 5.2TM I 2 very similar to OVA/gO . In patients tolerating lower F 0 a IV 5.0 9.0 27.8 5.5x 2 I 2 substantial amount of hypoxla was due to maldlstrlbution. Conclusion. Induction of anaesthesia during air breathing as well as %he References: increase of FE02 from 0.21 to 0.~. during anaesthesia was only accom~nied by minor changes in the distribution of perfusioo.Ventilationwas redis- I) Pesenti A., Latinl R., Riboni A., Gattinon~ L.: S~cple estimate of tributed on the induction of anaesthesia to regions with less pmrfnmion the true right to left shunt (Os/Ot) at malntenance F 0 by I2 as has been reported earlier. sulphur hexafluoride retention. Intensive Care Med. 8, 283, 19B2.

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VENTILATION-PERFUSION RELATIONSHIPS DURING ANAESTHESIA EFFECT OF VASODILATORS ON FULNONARY GAS EXCHANGE IN WITH VARYING INSPIRED OXYGEN CONCENTRATIONS. G. Heden- ADULT RESPIRATORY DISTRESS SYNDROME (ARDS). C. M@lg% , stierna, R. Lundh, Departments oCAnesthesia and Clini- N. Jasper, R. Naeije, R. Hallemans, P. Mole, P. Lejeune cal Physiology, Huddinqe University Hospital, Huddinge, Saint-Pierre University Hospital, B 1COO BRUSSELS Sweden. (Belgium) o Ventilation-perfusion relationships (~A/Q), assessed by a Vasodilators were given to 2 patients with ARDS and who multiple inert gas elimination technique, were studied were mechanically ventilated with positive end expira- durinq halothane anaesthesia and mechanical ventilation tory pressure (PEEP,cmH20). Hemodynamic, gasometric and at different inspiratory oxygen fractions (FTOe). Wide- lung mechanic parameters and continuous distribution ned %/Q-distributions were observed in all~n~ne pati- of ventilation-perfusion ratios (VA/Q) determined by ents (mean age 61 years, 4 smokers) during anaesthesia, the multiple inert gas elimination technique were indicating increased mis-matching between ventilation measured at baseline and after diltiazem (DI 0.5 m~Kg and blood flow. The ~a/Q-distribution was unaltered when IV) in the first patient and after sodium nitroprusside F~O2 was increased from a mean of 29% to 53%. A further (N P 7 ~Kg/min IV) in the second patient. In the two i~crease in FIO 9 to a mean of 85% caused a further wide- eases, pulmonary vasodilation ~ "L,.. ning of the ~A/Q-distribution, and an increase in true was obtained with a reduction ~ ' ,~,.x, ~'~" shunt (V8/Q = O) from 7% to 10% of cardiac output (p,~ in pulmonary arterial mean m, ii:i ~..~,~ 0.0]). Hdwever, there was no fractional increase in low" pressure (PAM,mmHg) and in i VA/Q, except for one patient. On the return to FTO? of pulmonary vascular resistance I ,~ 29%, the VA/O-distribution resumed the same patt@r~ as index (PVRI,dyne.s.cm-5.m2). seen prior to oxygen breathing, and true shunt was re- Systemic vasodilation was duced to the initial level except for one patient (the observed with a drop in mean one with an increase in "low" 9A/O during oxygen breath- arterial pressure (MAP ,ms Hg) ~ ~' ...,~" ~,," " ing). The findings may fit in wlth release of hypoxic and a slight increase in "]..... vaso-constriction when FTO2 is increased to 85%, or the cardiac index (CI,L/min/m2). ~ ' ,.... ~:'" openinq up of a certain population of shunt.vessels. A deterioration in pulmonary Only one patient displayed a change of the VA/QTdistri- gas exchange was observed =L bution during oxyfen breathing that could be explained with a decrease in arterial ~ .... /k by resorption atelectasis. PC2 (PaO2,mmHg) and increase in venous admixture (~s/Qt, % of total blood mow)' ~A/~ A distributions showed an in- i~.,~A,~....,m ,A,, crease in true shunt and in mismatchin Z) Pa02 Pv-O2 Qs~t C I MAP PAM PVRI 9i02 PEEPI Pat Baseline 58 30 29 3.7i67 37 473 0.5 *20' 1 DI 50 31 43 3.7156 31 318 Pat Baseline 80 39 24 2.3196 37 771 0.5 *i0 i 2 NP 4~ 30 53 2.6 51 23 343 In ARCS pulmonary vascular tone improves V~ Q matching. 175

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DISTRIBUTION OF REGIONAL VENTILATION-PERFUSION RATIO CORRECTION OF PUI~0NARY NON-GASEOUS ~0NCTIONS (O/Q) WITH KRYPTON 81M IN PULMONARY EMBOLISM. METABOLISM IN THORACIC OPERATIONS. 0.A. DOLINA, M. Meignan, G. Simonneau, L. Oliveir% A. Harf, S.G.PTUSCHKINA, N.V.KUKUSCHKINA L. Cinotti, J.F. Cavellier, P. Duroux, Intensive care I st Medical Institute, Moscow, USSR unit, HBpital Antoine B@cl~re, Clamsrt, Department of Studying of changes of lungs non-gaseous func- nuclear medicine, H~ptial Henri Mondor, Cr~teil 94010, France. tions is great importance for the choice of in- The diagnosis of pulmonary embolism (P.E.) is difficult with ventilation-perfusion scanning in patients tensive therapy. Complex investigations into the having a reduced ventilation in the region of the per- functions of respiration, circulation and meta- fusion defects (matched defect) as in.chronic obstructive lung disease (C.O.P.DJ Regional V/Q were there- bolic changes were applied in dealing with 180 fore computed in each region of a perfumion defect in 44 surgical patients undergone pulmonic operations. patients with angiographically confirmed P.E. and 40 patients with C.O.P.D. by dividing ventilation scan by Use was made of polycardiography, rheography, ca- perfusion scan obtained with Krypton 81m in tidal brea- pillaroscopy, of determining the acid-base aqu- thing with a gamma-camera linked to a computer. The regional ventilation-perfusion ratios were computed in ilibrium, lipid metabolism, blood circulation each region of a perfusion defect. All the patients were volume. An analysis of these investigations ena- studied supine in post6rior view. P.E. was characterized by mismatched defects (reduced perfusion and normal ven- bled it to educe the initial specific disturban- tilation) with a high V/Q (1.96 • O.1 SD) due to vascu- ces of microcirculation, metabolic components lar obstruction. A high O/Q (1.37 • 0.2 SD) was also found in the 25 out of 93 defects of perfusion which caused by pulmonary non-gaseous metabolism. The were matched by a ventilation defect or a radiological data thus obtained served as a groundwork for opacity in these patients. Low V/Q'S were observed in the non embolic lung due to relative hyperperfusion. elaborating differential indications for the cho- C.O.P.D. was characterized by matched defects with low ice of the method of general anaesthesia and pa- ~/~ in most of the cases (.74 ~ .1 SD) and the two groups (P.E. and C.O.P.D.) with matched defects diffe- thogenetic therapy, a special complex treatment red significantly (p < 0.01). This regional quantita- aimed at normalizing pulmonary ventilative-per- tive analysis provides a simple mean to discriminate the defects of perfusion due to P.E. from those due fused correlation. Special attention in the pro- to a reduced ventilation. phylaxis of pulmonary complications is paid to the use of hypocoagulative and vasoactive agents, lipoconraining medicines and preventing the development of hyperhydration syndrome. High Frequency Ventilation

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HIGH FREQUENCY JET AND CONVENTIONAL MECHANICAL VENTILATION ACCUMULATIVE HIGH-FREQUENCY JET VENTILATION.M.D. Aochi, O WITH PEEP: A COMPARISON OF AIRWAY PRESSURES AND CARDIO- Miyano, H.Hizuho-ku,Nagoya City University, Medical RESPIRATORY PARAMETERS AT SIMILAR ALVEOLAR VENTILATION. School, Nagoya City, Japan. A. Sladen, K. Guntupalli, M. Klain and R. Romano. Surgical High-frequency jet ventilation (HFJV) in animals and huma Intensive Care unit, Monte•177 Hospital, University of -n-be}ngs with normal lungs has been shown to provide Pittsburgh School of Medicine, Pittsburgh, PA 15213 USA adequate ventilation (V) and oxygenation (0) at lower High frequency jet ventilation with PEEP (HFJV) is used as airway pressure than IPPV without causing cardiac depre- an alternative to. conventional mechanical ventilation with ssion. However in those clinical cases with pulmonary PEEP (CPPV) for patients withacute respiratory failure. disorders like ARDS, it is difficult to improve V and 0 Complications of CPPV include high peak airway pressures by HFJV alone, because of extremely diminished lung (PAP) and their sequelae, barotrauma to the lung and re- compliance and increased dead space. duction in cardiac index. HFJV has been recommended to So we have attempted the new method, accumulated high- avoid high PAP. We observed when CPPV is changed to HFJV frequency jet ventilation(Acc.-HFJV), in which the jet there is a temporary decrease in PaO2 which lasts about 60 flow from HFJV generated by modified Bird Mark 8 has been min. Eleven patients admitted to the SICU had comparative accumulated by time-cycled regulation of the expiratory studies of PAP, mean airway pressure (P~ and card• valve of CV-2000 ventilator. respiratory parameters, initially with CPPV, and then with Aec-HFJV has improved V and 0 without compromising the HFJV at similar alveolar ventilation, to determine the characteristics of the jet flow, as compared with the etiology of the decrease in PaO 2 and the advantages, if superimposed mode. In addition, by using the technique any, of HFJV over CPPV. of periodic interruption of the jet flow adjusted by Results: respiratory cycles, it is possible to deliver accumulatiw CPPV: CI 2.54• L.min. M-2; P 97• SI 26.6• e jet flow in the inspiratory phase, the expiratory phase ml.M-2; LVSWI 34.5• gm.M.M-2; TPRI 2856• dyne.sec.cm or both.of them. -5.M-2;a-vo2 4.4• ml.dl; Q2 110.6• ml.min. M-2; PaO 2 We have compared Acc-HFJV with CPPV and conventional HFJV 30.01• QS.QT 8.6• pac02 5.24• PEEP in 40 patients with ARDS at same levels of PEEP.The 2.7• ~nHg; PAP 15.4• mmHg; P~ 4.41• nunHg results have indicated that adquate Vand 0 could be HFJV: CI 2.59f0.07; P 97• SI 27.1fi.3; LVSWI 37.0• maintained more effectively by using Acc-HFJV than the TPRI 2912f265; a-vo 2 4.5• Q2 i17.2f5.9; PaO 2 23• other two modes of ventilation. No adverse circulatory QS.0T 11.7• PaCO 2 5.27• PEEP 2.4• PAP 9.1• effects have been observed. P~ 4.99• This studydemonstrated that there was no significant difference in CI, P, SI, LVSWI, TPRI, a-vo2, Q2 and P~ between CPPV and HFJV at 100.min and at the same PaCO 2 and PEEP. There was significant difference in Pa02 P < 0.004; QS.OT P < 0.025 and PAP P < 0.001. HFJV should reduce barotrauma because of the reduction in PAP. It is advisable to start with an FIO 2 0.9 and decrease FiO 2 as indicated by PaO 2.

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HIGH FREQUENCY JET VENTILATION VERSUS INTERMITTENT CO~-~I~TIC~ DURING HIGH F~E~UK~CY VErmilION WITH POSITIVE PRESSURE VENTILATION IN'THE HYPOVOLEMIC DOG. TO LUNG VOLU94E. N.Mutz, M.Bat~n, H.Benzer, U.Losert M.Chiaranda, G.Fiore, E.Facco, G.P.Giron, Inst. of Anaesth. Forschungsstelle fitr Intensivmedizin, KlJxuik f~r Anaesthe- and Intensive Care, University of Padua, Italy. sie, Wien, Osterreich The reduction observed in airway pressure when using high frequency jet ventilation (HFJV) instead of intermittent The influence of different lung volumes on various fre- positive pressure ventilation(IPPV),could be advantageous quencies of nigh frequency ventilation was studied in 5 in all conditions in which aminimal variation of intrathoracic anesthetized mongrel dogs (x=28.9kg). After intubation, using a special developed endotracheal tube, dogs were pressure markedly modifies cardiovascular functions. placed in a rigid heat-exchanged pressure box (p.b.) with This study compares the cardiovascular effects of IPPV and variable internal pressure (range: -1o to +5 cmH20). Ven- HFJV in experimentally induced haemorrhagic shock. Five healthy Beagle dogs, 12 ~ 15 kg, were anaesthetized, tilation was performed: A. under conditions of IPPV (f= o.2 Hz), B. as "forced d~ffusion ventilation"(FDV), a paralized and intubated in the standard fashion. Sistemic, ~mdified nigh frequency jet ventilation(f=6Hz,5oHz, central venous and pulmonary arterial pressures, cardiac cont.=jet stream without any chopper frequency). By vari- output via the thermodilution technique, arterial and ing b.p. (-1o/o/+5cmHgO), different levels of lung volume mixed venous blood gases, airway pressure (Paw) at the end were achieved. PartiCular combinations of b.p. and respi- of the endothracheal tube and oesophageal pressure were rator settings were selected in random fashion. Blood monitored, Cardiac and stroke indices (Cl, SI), pulmonary gases, mixed expiratory CO_ (Fm-CO9) and minute volume z and sistemic vascular resistances (PVR, SVR) and right and were measured 3o man. after eac~q ~etting was performed. left ventricular stroke Work~ indices (RVSWI, LVSWI) were At b.p. -Io cm H~O(=increased lung volume) PaCO rises calculated using standard equations Wentilation was performed statistically significant in comparison to b.p.~, in con- randomly with a volume-cycled ventilator (3100 Roche) at trast, paCO~ decreases, if b.p. is elevated (lung volume 15 b/m and with an HFJV apparatus (VJP system) at 60, 120, diminished),z as scheduled in table: 240, 480 b/m, regulating tidal volume to maintain PaCO2 at Table (paCO9 x SD) 38 ~ 2 mmHg. Cardiorespiratory data were obtained for both b.p. o. 2Hz~IPPV) 6Hz (FDV) 5oHz (FDV) cont. modes of ventilation before and after lowering CI by inter 0 36.2 _+5.5 34.o +6.5 49.6 +7.6 49.7 + 3.1 mittent bleeding to about 50% of the initial value. +5 35.2 +5.7 34.6 +5.6 44.8 +5.6 43.o + 6.6 Mean and peak airway pressures were significantly lower -Io 41.4 +3.5 45.4 +12.9 62.2 ~5.2 65.0 + 4.6 with HFJV at 60 ~ 240 b/m; at 480 b/m, the end expiratory pressure was 3,7 ~ 1,2 mmHg, giving an increased mean Paw. F~CO~ shows an inverse proportional behaviour. Using HFJV at 60 § 240 b/m during haemorrhagic shock, CI, B~se~ on our results, there is good evidence, that CO 2- SI and LVSWI were significantly enhanced, by respectively elimination is markedly diminished in existanee Of augme- +20%, +21% and +38%, in comparison to the control values ted lung volume during FDV, especially using very high in IPPV; a cardiovascular depression appeared at 480 b/m. frequencies (~5oHz) due to a decreasing CO2-elLmination These results confirm that when there is an haemodynamic capacity of the jet. impairment, as in the anaesthetized hypovolemic dog, HFJV reduces the deleterious cardiovascular effects of conven tional positive pressure Ventilation. 177

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PHYSIOLOGICAL DEAD SPACE VERSUS TIDAL VOLUME DURING HIGH DIGITAL VENTILATION - A BRIDGE BETWEEN HFV AND FREQUENCY JET VENTILATION IN THE DOG. M.Chiaranda, A.Rubi CONVENTIONAL VENTILATION. M.Wendt,L.Freitag, ni, R.Brigi, G.P.Giron, Inst. of Anaesthesiology and Int~ F.Dankwart,J. Hansen ,Klinik fUr An~sthesiologie sive Care, University of Padua, Italy. und op. Intensivmedizin,Universit~t MUnster, The authors investigated the relationship between physio- W.-Germany logical dead space (Vd) and tidal volume (Vt) during high The enthusiasm about ventilation of patients frequency jet ventilation (HFJV) at different positive end with higher frequencies has changed a lot from expiratory pressure (PEEP) levels (0 - 2.0 kPa). the beginning.Two disadvantages are dominating, Four healthy Beagle dogs, IIM7 kg, were anaesthetized, pa one is the impossibility of pressure measurement ralized and intubated in the standard fashion; ventilatio~ at alveolar level and the other is the difficulty was performed with intermittent (IPPV) or continuous (CPPV) of application at normal ICU-patients.So a new positive pressure at 15 b/m and HFJV at 60, 120, 240, 480 system has been developed,giving the chance of b/m, while minute volume (~)wasregulatedtomaintain PaCO2 HFV (high frequency positive pressure ventila= at 38 ~ 2 mmHg. For each mode of ventilation arterial blood tion),HFO (high frequency oscillation) and samples for gas analysis were taken after 10 min of stabi- CMV (conventional mechanical ventilation) using lization. The volume of alveolar ventilation in a single normal endotracheal tubes with only one small breath (Va) and in a minute (~a) were calculated analyzing ventilator.This system - nothing more than a the values obtained with a pneumotachograph (Vt) and with small computer - gives the possibility to Bohr's equation modified by Enghoff (Vd). generate any new ventilatory pattern in future. The results obtained show that there is a progressive redu We compared HFV,HFO and CMV generated with ction in Vt,VaandVd and a progressive~increase in Vd/Vt- higher or lower frequencies.The research is done ratio with increasing ventilatory frequency. The increase using two groups of ICU-patients,one,which does of PEEP values from 0 to 2.0 kPa increases Vd and lowers only need mechanically support and another,which the respiratory frequency value at which Vt falls below Vd has lung disease.ln both groups similar hemody= measured at 15 b/m. namic data were found under similar airway In conclusion, the authors stress that it is possible to pressures.Gas exchange may be better using maintain an adequate alveolar ventilation utilizing tidal generated frequencies under some circumstances. volumes lower than the anatomical dead space volume. The ha~ to be increased with the increasing ventilatory frequen cy; this is due to an augmented wasted ventilation (~d). -

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HIGH FREQUENCY JET VENTILATION AND PEAK AIRWAY PRESSURE SYNCHRONIZATION WITH ECG. M.Chiaranda, A.Rubini, M.Trevi san, G.P.Giron, Inst.of Anaesthesiologyand Intensive Care~ University of Padua, Italy. The use of ECG triggered jet ventilation is still controversial.The authors investigatedthe haemodynamicinfluence of high frequency jet ventilation (HFJV) with inspiratory peak synchronized with different phases of the cardiac cycle. Four;healthy Beagle dogs, II~17 kg, were anaesthetized, paralized and intubated in the standard fashion.Catheters were introduced for the measurement of sistemic, central venous and pulmonary arterial pressures, arterial and mixed venous blood gases; cardiac output was evaluated via the thermodilution technique. Cardiac and stroke indices (Cl,Sl), pulmonary vascular and total peripheral resistan ces (PVR,TPR) and right and left cardiac work indices (RCWI,LCWI) were calculated using standard equations. HFJV was performed at 120 b/m, with minute volume (V) regulated to maintain PaC02 at 38 ~ 2 mmHg and a positive end expiratory pressure (PEEP) from 0 to 2.0 kPa. The haemodynamic influence of HFJV was evaluated when progres sively delaying the inspiratory peak corresponding to th~ onset of the 'R' wave on the ECG trace. The mean pulmonary arterial pressure oscillations decrease as PEEP rises and their value reaches a maximum of 15% at zero PEEP. Lowest PVR and RCWI values were observed when the inspiratory peak coincided with the protomesodiastolic phase of the cardiac cycle (that is at 30-70% of R-Rinter val) and the highest values when the peak drops close to- the R wave (~ 20% R-R). This phenomenon occours indepen- dently from the PEEP level applied. The results demonstrate the absence of significant haemodynamic effects due to ECG and inspiratory peak synchroni zation when HFJV is applied to anaesthetized dogs with normal cardiovascular reserve and lung compliance. COPD, Embolism, Asthma

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HEMODYNAMIC~FECTS OF PHENTOL~2~INE IN PULMONARYHYPER- EFFECTS OF KETANSERIN IN CHRONIC OBSTRUCTIVE PULMONARYP~- T~SION FOLLOWING ACUTE EXACERBATION OF CHRONIC OBSTRUC- SEASE (COPD) Y. HUET, M. GERDEAUX, A. ABDEL RAZEK, D.PAYEN TIVE PULMONARY DISEASE. G. Dmmenighetti, Ph. Leuenberger, F. LEMAIRE, F. LHOSTE. R4animation M4dicale - HENRI MONDOR CI. Perret. Institute of Pathophysiology and Intensive HOSPITAL - FRANCE - Care Unit, Dept of Medicine, C.H.U.V., Lausanne. Serotonin, recognized as a potent vasoactive agent is involved in pulmonary hypertension mechanism in patients with ~he usefulness of vasodilators in the treahnent of pulmo- COPD. In order to validate this hypothesis, KETANSERIN (K) nary hypertension (PHT) following chronic obstructive a specific 5 HT2 receptor antagonist, was used in COPD. pulmonary disease (COPD) has not yet been established, METHODS : 9 patients (ranged 50 to 75 years old) with COPD especially during acute exacerbation of the disease. ~I Research Council Criteria) were studied during phentolamine (Ph), a potent systemic vasodilator drug, is acute exacerbation of respiratory failure (4 breathing, known to act on the pulmcnary circulation as well. The spontaneously 5 mecanically ventilated). All were free of recognized spa~nolytic action of Ph on the bronchial treatment except antibiotics. Haemodynamic parameters were ~noothmuscle could represent a further advantage in the systemic arterial pressure (MAP), pulmonary capillary we- management of COPD. dge (PWP), pulmonary arterial (PAP), and right atrial pressure (RAP) (Swan-Ganz 7F), cardiac output (CI) (Thermodi- Seven patients (6 males, I female) with an acute exacer- lutiontechnique), heart rate (HR). Simultaneous sampling bation of COPD (Pa02 49 + 3 r~n Hg, PaC02 59 + 4 r~n Hg; or arterial (a) and venous (v) blood permitted measurement mean + S~M), aged 49-74,--underwent hemodynamic investiga- of oxygen and carbon dioxide tension, hemoglobin satura- tionbeforeandduring Ph infusion (10-15m g/h), without tion leading to calculate venous admixture (Qs/Qt) 02 therapy. Baseline hemodynamic data showed a moderate (Fi02 : .21). Then 10 mg of (K) were given intravenously PHT (P~44,5 ~ 7 nm Hg) with raised right atrial pres- followed by a continuous infusion of 4 mg/hour. sure and a normal pulmonary wedge pressure (POD 11 + 2 RESULTS : are summarised in the table (mean • SD) nm Hg; P~ 9 _+ 2 mm Hg) . Ph produced a significant ~educ- RAP PWP MAP Qs/Qt V02 I 2 tion in P-~, P~and P~ (p < 0,05; p < 0,01; p 4 0,02). mmHg mmHg mmHg % ml/minT m There was no change in cardiac index, Pa02, PaC02 and BASAL 13 • 5 17 • 7 87 • 17 37 f 12 148 • 25 mean systemic arterial pressure. A further fall in P~ (K) 10 • 5** 14 • 5* 79 • 18"** 46 • 14" 133 • 24** followingan initial reduction with 02 therapy was obser- Paired t test : *p < 0.05 ; **p < 0.01 ; ***p < 0.001 ved in onepatient. CI, Pa02, P~02, and HR remains unchanged. No relationship In conclusion, in patients with an acute exacerbation of was observed between Cl and Qs/Qt and between Pv02 and COPD, phentolamine has a beneficial effect on pulmonary Qs/Qt. hemodynamics without detrimental changes in Pa02 , PaC02 CONCLUSION : I) KETANSERIN acts as a balanced vasodilator drug. 2) The constant increase in venous admixture is not and 02 delivery. ~he mechanics responsible for the always related to CI changed so, when Cl decrease lowers decreased pressures in the pulmonary circulation induced P~02, its variation may explain venous admixture increment by phentolamlne are discussed. 3) On the other hand, the constant decrease in V02 may be related to sympathetic blocking property of this drug.

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ACUTE LIFE THREATENING PULMONARy HYPERTENSION TREATED OVER PERFUSION OF NON EMBOLIC LUNG AS A CAUSE OF HYPO- WITH IBUPROFEN. K.Eliasen, T.Mogensen, J.B.Andersen, L. XEMIA ZN PULMONARY EMBOLISM (P,E.). HasselstrCm, N.H.Jensen, I.Brynjolf, J.Godtfredsen. De- M. Meignan9 A. Harf9 L. 01iveira~ G. Simonneau, partment of Anesthesia and Department of Cardiology, L. Cinotti 9 P. Duroux9 Intensive care unit, H6pital An- Herlev Hospital, University of Copenhagen, Denmark. toine B4el~re, Clamart, Department of nuclear medicine 9 It has been shown, that the ratio between thromboxane HOpital Henri Mondarj Cr6teil 940109 France. and prostacyclin might be an important factor in acute In order to validate the hypothesis that hypoxemia pulmonary hypertension in sheep treated with E.coli en- in P.E. can be related to the shift of perfusion away dotoxin (i). On this basis we gave ibuprofen to two pa- from the embolie zone we have computed regional VA/Q ra- tients with acute pulmonary hypertension to convert the tios and measured arterial PO 2 in a group of 44 patients thromboxane/prostacyclin ratio in advantage of prosta- width P.E. proved by angiography. Distribution of VA/Q cyclin. One patient suffering from severe ARDS (effecti- was obtained with a minicomputer linked to a gamma- ve compliance below 18 ml/cm H20 , pulmonary artery pres- camera from ventilation and perfusion lung scans with sure (PAP) 56/38 mm Hg, P O 2 i0 kPa F.O~ 0 6 PEEP i0 Krypton 81m a short lived radionuclide (TI/2 = 13 sec) " i z " ' cm H20, balloon occlusion pulmonary angiogram showed delivered by continuous inhalation and infusion in ti- pulmonary artery filling defects and thrombi) - and an- dal breathing. All 44 patients were studied supine and other patient suffering from multiple pulmonary embolism the ~ercentage of lung field with VA/Q. Iess than 0.75 verified by ventilation-perfusion scintigraphy. In the (VA/Q 0.75) was computer (The overall VA/0 was norms- first case a dose of 50 mg/honr of ibuprofen was given lized to i). The mean values of PaO 2 and VA/Q 0.75 were i.v., and in the second case a dose of 1200 mg daily was respectively 67 mmHg ~ 2.35 SD~ and 21.6 % ~ 9 SD . given orally. In both cases PAP fell - in the first case There was a significant, inverse relation shi~ between from 56/38 mm Hg to 40/15 mm Hg, and in the second case individual PaO 2 and VA/Q 0.75 PaO 2 = - 2 VA/Q 0.75 + from 92/37 rm~ Hg to 25/12 mm Hg. PAO2 increased in the 112.2, r = ~67 p~/-.O.Ol. patient with ARDS with 4s9 kPa with a constant FiO 2 and Nine patients with unilateral embolism were also constant PEEP. In the second case the P 02 increased studied on lateral deeubitus with the non embolie lung from 8,8 kPa to 10,4 kPa. No adverse e~ects were seen. in dependent position in order to change the distribu- These two cases suggest, that ibuprofen might be bene- tion of perfusion. In all cases the VA/Q of this non ficial in the treatment of acute pulmonary hypertension. embolic lung decreased due to the increase of perfusion i. W.D.Watkins, P.C.H~ttemeier, D.Kong and M~ (VA/Q supine 0.83 ~ 0.1 SD, lateral decubitus 0.72 • Thromboxane and pulmonary hypertension following E. 0.08 SD p

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THE OXYGEN COST OF BREATHING IN PATIENTS AFTER STATUS ASTHMATICUS : LETHALITY AND INTENSIVE THE- MITRAL VALVE REPLACEMENT. A. Fournell, K. Falke, M. RAPY. A .S. Za rza r,R .A.Pavl ova ,Sh .A .Murtalibov, Zindler, H. Schulte, Instlt~t of Anesthesiology and O.P.Khan,B.I.Makhkamov,Advanced Training Insti- Department of Surgery B, University of Duesseldorf, tute for Doctors,Tsshkent,USSR D-4000 Duesseldorf, West Germany The amount of oxygen consumed by the work of breath- Lethality among status asthmaticus cases ranges ing can be calculated as the difference in total 0a- between 7 and 16 % at the peak of the attack.This uptake (V02) during controlled mechanical ventilation aecessitates a clinical analysis of each lethal (CMV) and spontaneous breathing (SB). Whereas this case.Studies were conducted of 320 case histories difference is well known in normal subjects (I - 2%) of status asthmaticus with 38 deaths (11.9 %).An the oxygen cost of breathing in patients with mitral analysis showed that 7 patients died of ass valve disease is still subject of discussion. aggravated by cardiovascular insufficiencyi7 more In 8 patients V02 was measured continously according patients died after entering hospital in irrever- to the method of Neuhof (Crlt.Care Med. 6:155,1978) sible hypoxia coma,1 patient developed an anaphy- durlng CMV after mitral valve replacement on the ope- laxic shock from medication,yet another suffered rative day and on the first postoperative day from cerebral blood circulation disorder result- after weanlngfrom the respirator during SB. In every ing from the removal of a catheter from the cent- patient mean V02 was increased during SB (172,0 + 14, ral vein,a patients developed irreversible hypo- ml 02/m2/min) in comparlslon to CMV (137,5 ~ 12,~ xia coma durinu couwh fits resultin 9 from trache- ml 02/m2/min), the mean difference was 25,5~, with a al manipulation,1~ patients died as a result of range of.7,4% to 34,9%. Other factors which might in- incorrect treatment of the nronchial obturation fluence V02 (physical activity, body temperature, syndrome or failure to administer treatment.This nutrition, and acid-base status) did not change sig- means that 65.~ % of the l~thal cases could have nificantly during both periods of investigation. been avoided by timely and correct treatment. Because the cardiac index did not vary (2,73 + 0,76 Prevention of lethality in status asthmaticus 1/m2/mln during SB, 2,68 ~ 0,79 i/m2/min during CMV) cases requires : urgent hospitalization of pa- the grea~er 02-demand during SB could only be met by tients sufferin 9 from a prolonged attack of hron- an increase in av-D02 (6,50 + 1,22 ml 02/100 ml du- thial asthma; resuscitation treatment subdivided ring SB, 5,15 ~ 1,12 ml 02/I~0 ml during CMY). The into 1) intensive therapy when the patient is results confirm that the oxygen cost of breathing is fully conscious (control of the cout~h reflex, a significant fraction of whole body V02 during the restoration of sputum theology by microtracheost- immediate postoperative period in patients after omia with follow-up bronchoscopy,and 2) resusci- mltral valve replacement. tation when the patient is unconscious (artificial ventilation of the lungs,washing,microtra- cheostomia or forced tracheostomia). In admini- sterin.q treatment the physician must foresee possible clinical state of the patient.

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B~SIDE ~TI~ OF BRON~ OBSTRUCTION DURING STATUS AS~MATICUS. M. Padanl, FI. DepeursingeI , A.K. Boutaleb2 , Ch. Depeursinge2 , J.-C. Willemetz2 , CI. PerretI . Institute of PathophysiologyI , CHUV, and Federal Institute of Tech- nology2 , EPF, Lausanne (Switzerland) . Usual pulmcnary function tests are not easily available for bedside evaluation of bronchial obstruction in patients with status asthmaticus. A global evaluation of lung function and degree of airway obstructien is made possible by the measur~nent of the high frequency respiratory impedance (HFRI) with the forced oscillatiens method. %~nepur- pose of this study was to assess the interest of HFRI in evaluating bronchial obstruction during status asthmaticus Preliminary studies on asymptcmatic asthmatics in the laboratory have shown a statistically identical percentage of good classificatien with the HFRI (95,8%) as with the body plethysmography (93,8%). Similarly, the method has given significant correlatiens between several derived mathematical parameters and usual functien tests : Paw (%) : R = 0,73, FEF 25-75 (%) : R = 0,74, RV/TLC (%) : R = 0,74, FEVI (%) R = 0,82 (in all p < 0.001). Sixteen patients with status asthn~ticus, aged 17-68 y., were investigated in the respiratory unit. Mean Pa02 and mean PaC02 were respectively 66,4 + 19 and 41,9 + 9,6 mm Hg at the time of the first evaluation. The HFRI proved to be able to assess bronchial obstruction and quantify its degree in terms of usual function tests. It allowed an adequate lung functicn monitoring, a reliable evalua- ticn of drugs effectiveness and short term evolution. This method demonstrated a frequent discordance between the rapid clinical improvement and a persistant functional impairment. The measurements are short (about ene minute) , easily performed at bedside and do not require any active cooperation. Mechanical Ventilation

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INSPIRATORY FLOW INFLUENCE ON PULMONARY GAS EXCHANGE: COMPARISON BETWEEN INDEPENDENT LUNG VENTILATION (ILV) IN BILATERAL A MODIFIED SINE WAVE AND A SQUARE CURVE VENTILATION. G. Damia, M. Solca, LUNG DISEASES. A. Pellzzola, A. Pesenti, M.L. Caspaol, R. Marcelin, 0. Mascheroni, P. Ausenda, P. Forlani. Istituto Anestesiologia e Rianimazione, Universit~ A. Gasparetto, A. Candiani, G. Crim• Istituto Milano, and R ~ D Dept., Kontron Milano, Italy. di Anestesiologia e Rianimazione. Universit~ degli Studi di Roma (Italia). We studied pulmonary gas exchange under different inspiratory Flow patterns in 5 lambs (22.4 ~ 2.3 kg), uslng a high performance ventilator The purpose of this study was to demonstrate that in presence of bilateral lung diseases leading prototype, which can be switched from a modified sine wave (MSW) to a to ARF, the finding of a difference in stat• square (S) insplratory Flow curve keeping a11 other parameters unchan- compliance between the two lungs makes ILV pre- ged. The animals were tracheostomized, anesthetized and curarized; a OF ferable in order to differentiate the ventilato- Swan Ganz catheter was inserted in pulmonary artery, and a peripheral ry support. artery cannulated. Each animal was ventilated alternatively with MSW and Six patients with ARF caused by bilateral patho- S. At the end of each period (20 min) we recorded mean arterial, logy were studied. All of them showed marked difference in static compliance between the two pulmonary artery and airways pressures, and we measured arterial and lungs. They were first ventilated in a conventio- pulmonary artery blood gases, tidal volume, mean expired CO fraction 2 nal way, using IMV-CPAP, IRV or HFV.Hemodinamic and end-tidal CO . Venous admixture (Q /Q) and physiological dead space monitoring was instituted together with control 2 VA (V /V ) were computed, inspired 0 Fraction was kept constant. After 5 of tissue pH and P02. As their conditions did D I ' 2 -i periods with both curves we injecTCed in the animals trachea 10 ml kg not show any improvement, they were switched to of HCI O.01M to produce acute respiratory insufficiency, and we repeated ILV, thus allowing the demonstration of a persi- sting gradient in static compliance and the sub- IO to 14 times our measurements varying the inspiratory flow pattern. sequent modulation of the ventilatory techniques. Tidal volume, mean airways pressure and total ventilation were identical The less compliant lung was ventilated with HFV, in the two sets. PaO did not appreciably change with the different the other either with IMV-CPAP or with HEY. ~ e 2 curves, nor OVA/Q did, both in physyological and pathological state; The results are consistent with our hypotesis. PaCO during basal period was Found significantly lower, by analysis of All patients showed significative improvements .2 varlance, with MSW (33.7 + 3.8 vs. 32.0 + 3.t torr, P< 0.02). At the of gaseous exchanges together with a normaliza- tion in peripheral oxygen transport and utili- contrary, V /VT was not significantly different; however, changing from zation. NSW to S Dit consistently increased, and correspondingly decreased It is concluded that in bilateral lung diseases passing From S to MSW. The variation was statlstlcally slgniflcant refractory to conventional ventilatory therapy, (P":: 0.05). After pulmonary lesions were established, both PaCO a significant difference • compliance must be 2 and V /V were significantly lower with MSW: 40.0 + 5.2 vs. 41.8 + 5.1 suspected between the two lungs, thus indica- D T - - ting the institution of ILV with selected ven- torr (P< 0.05), and 0.64 + 0.08 vs. 0.87 + 0.08 (P

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DIFFERENTIAL VENTILATION DURING ROUTINE ANAESTHESIA IN IMPROVEMENT OF GAS EXCHANGE BY PROLONGED AND THE LATERAL DECUBITAL POSITION. S. Baehrendtz, C. Kling- DIMINISHED EXPIRATORY FLOW DURING IPPV. W. van shedt, G. Hedenstierna and 3. 5antesson. Dept of Medicine Rooyen, J.R.C. Jansen, H.A. Bruining, A. South Hospital,Stockholm, Sweden. Versprille, Dept. of pulmonary diseases, paths- Differential ventilation (DV) in the lateral posture has physiological laboratory and Dept. of surgery, shown to improve the gas-exchange in patients with severe Erasmus University, P.O. Box 1738, 3000 DR Rot- acute respiratory failure due to bilateral lung disease. terdam, The Netherlands The mechanism is most certainly the countering of airway IPPV, especially to patients with chronic ob- closure (AC) within the dependent lung. Also patients structive pulmonary disease, may necessitate undergoing sus in the lateral position have a prefer- either a relatively high tidal volume or a posi- ential spread off AC towards the dependent lung. The pres- tive end expiratory pressure to obtain suffi- enl study was thus undertaken to evaluate fihe efiFect of cient gas exchange. The risks are barotrauma DV during routine anaesthesia in the lateral position. during peakinflation and airtrapping during de- Ten patients without history of cardio-pulmonary disease flation. To avoid these harmful effects we were investigated prior to major surgery. The patients searched for another mode of ventilation, which were intubated by a double-lumen catheter. Ventilation improves gas exchange. The effects of prolonged was performed with ONE ventilator (i.e conventional ven- and diminished expiratory flow during IPPV was tilation) and by TWO ventilatos with 50 % of the tidal studied on gas exchange in pigs. Under normal volume to each lung (DV). Anaesthesia was maintained with pulmonary conditions these animals were ventl- enflurane and the patients were kept in the lateral posi- lated with a Servo-900 A ventilator an a mean tione during the ceus off the study. Ventilation of each tidal volume of 15 ml kg -I , and a rate of i0 lung was determined by Argon dilution technique and a min -I. If spontaneous explration was retarded masspeetrsmeher. Central heamodynamies was measured using to the total available expiratory time, a signi- a Swan-Ganz thes catheter. In some of the pat- ficant increase in Pa02(10%) and decrease in ients , regional perFusion through each lung was studied PACO2(8.5%) was observed. Physiological dead by a gamma-camera. space was decreased as well (28%). These effects Results: DV as compared to conventional ventilation res- were compared to those of a PEEP which increased ulted in a 26 % decrease in venous admixture and a 23 % mean tracheal pressure to the same extent as the increment of arterial oxygen tension (p

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ECMO IN THE COMPLEX TREATMENT OF ACUTE RESPIRAT- ORY INSUFFICIENCY. E.M.Nicolayenko, A.A.Pisarev- sky, B.S. Lazarev, A.B.Karasev, S.V.Gvozdev. Research Institute of Transplantology and Artif- icial Organs, Moscow, U.S.S.R. Intrapulmonary gas exchange, effective pulmQna~ blood flow,ventilation-perfusion matching (V/Q), respiratory mechanics (in vivo oxyhemometry,mass spectrometry, pneumotacho~raphy ), systemic and pulmonary hemodynamies (SWAN - GANZ catheter, thermodilution)were studied in 300 patients with respiratory insufficiency (RI) who needed re~ir- atory support. ECMO ( Oxygenator MOST-122, USSR) was used in11 patients with acute R!: in 5 patients as an extreme measure in the irreversible terminals tate, and in 6 patients along with other measures of intensive care with mechanical ventilation (MV) in an extremely intensive regime ( high PEEP , toxic FvOo)and progressively reducing PaOo/FvO ~. During EChO PaOo in all the patients in~reas~d and it became possible to pass over to a less intensive MV regime. ( One patient survived smc~g 6 patients). Venous-venous ECMO effectively increases blood oxygenation and favcurably influences the pulmonary tissue metabolism and V/Q. Venous-arterial ECMO is advisable in such cases with concomitant cardiac failure. The low frequency of favourable outlets after EOMO may be explained by limitat~n of indications for it, the retarded beginning, hematologic and technical problems. In the conditions of progressive reduction of PaO~/ FTO~ (FTO~I,0 ; high PEEP,dehydration, cardiac~the2ah PY2 St is advisable to apply ECMO before the development of critical hypoxia. Mechanical Ventilation: Side Effects

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CARDIAC STRETCH RECEPTORS BLOCKADE DOES NOT THE USE OF MILITARY ANTI-SHOCK TROUSERS (MAST) AS A ELIMINATE RENAL RESPONSES TO POSITIVE AIRWAY REVERSIBLE FLUID CHALLENGE IN PATIENTS ON HIGH FEEP:M. PRESSURE - IMV VERSUS CMV. H.H. Steinhoff, K.J. Falke, JASTREMSKI, K. BENEY, N. MATTHIAS: CCM&EM, Upstate L.F. Samodeldor, Institut fiir Anaesthesiologie der Universit~t Medical Center, Syracuse, New York, U.S.A. Diisseldor f, Germany. Fluid management in the critically ill patient on high An increase in intrathoracic pressure as a consequence of levels of PEEP can be a difficult task. PEEP may cause positive airway pressure leads to a depression of renal func- the cardiac index to fall due to a decrease in left tion. In the past this has been contributed to a rise in anti- ventricular preload. However, the high interthoracic diuretic hormone secretion mediated by the cardiopulmonary pressures produced by PEEP negate the usefulness of the stretch receptors. However, experiments interrupting afferent PAo as a measure of left ventricular preload. Thus, one pathways of this reflex by cutting or cooling the vagus nerves, often has to give fluid challenges with the risk of failed to eliminate the typical renal response to shifts in po- worsening the acute respiratory failure for which the sitive airway pressure. patient is being treated with PEEP. Inflation of the MAST The influence of changes in intrathoracic pressure by inter- compresses the venous capacitance reservoir and auto- mittent mandatory and controlled mechanical ventilation (IMV transfers 500-1000 cc's to the central circulation. This /CMV) on renal function without and with a specific blockade autotransfusion is fully reversible by deflating the MAST. of cardiac stretch receptors using 2 % procaine instillation in The MAST were used as a reversible predictor of the the pericardium (PLA) was studied in anaesthetized dogs. effect of fluids on 14 critically ill patients being Institution of PLA during spontaneous breathing depressed all maintained on PEEP greater than 10 cm N20 with decreased measured parameters of global circulatory and renal function cardiac index. Hemodynamic variables were measured such as urine flow, osmolar-, inulin-, and PAH-clearance. before, during, and after the application and inflation During mechanical ventilation (IMV/CMV) circulatory and re- of the trousers. After MAST inflation, fluids were given nal function parameters further decreased and showed the in a quantity sufficient to maintain the same PAo after most detrimental effects during CMV. However, IMV and CMV MAST deflation as was achieved with the initial MAST still caused similar changes in the kidney function as without inflation. The table below shows the results. the blockade of cardiac stretch receptors as described previ- PAo CI QS/QT ously by us. Hence, although there is a marked influence of PREMAST 16.1434.05 2.97• .162~.045 the stretch receptor volume regulating reflex on kidney func- MAST 20.00• 3.36~.79 .189~.057 tion, this mechanism does not primarily govern the alteration POST MAST 20.64~2.94 3.20~.79 .174~ .065 in renal function induced by shifts in airway pressures. *Pearson r .91 .62 .82 Amount of fluids given = 1093 cc~I046cc We conclude that in critical ill patients on high PEEP, application of MAST is a useful tool for predicting optimal fluid treatment by challenging the patient with a totally reversible volume load. This provides better physiologic criteria for important decisions in fluid management, predicting both hemodynamic responsiveness and gas exchange deterioration after fluid management.

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CEREBROVASCULAR EFFECTS OF PEEP IN MAN ; D. PAYEN, B.LEVY, EFFECT OF LUNG AND CHEST WALL COMPLIANCES ON THE M, P~NAUD, D~partement d'Anesth~siologie et de R~anima- HEMODYNAMIC RESPONSE TO PEEP. F. BONNET, M. FISCHLER, ti~n M~dicale, Nantes, and U 141 INSERM Paris, France. C. DUBOIS, D. BRODATY , G. VOURCH. H6pitaux LA PITIE - Positive end-expiratory pressure (PEEP) increases intra- FOCH - PARIS - FRANCE thoracic pressure and superior vena cava pressure impai- Contro~ed ventilation with PEEP increases intrathoracic ring jugular venous return (1). Arterial blood pressure pressures and decreases Cardiac output. In order to and cerebral blood flow (CBF) may be also modified. evaluate the influence of lung and thoracic compliances AIM : to quantitate the effects of PEEP increments on pha- (CI, Ccw) on the hemodynamic response to PEEP, we studied s~ common carotid blood flow as index of CBF (2) and oxy- 11 patients following cardiac surgery. 5 patients had gen metabolism. mitral valve replacement (MV) and 6 patients aorto METHODS : 10 patients (age 30 to 52 years) were studied du- coronary graft (ACG). Static lung and total thoracic ring anesthesia for cerebral angiography. Relevant parame- compliances were measured in patients sedated and curari- ters were measured of calculated : common carotid blood sed with 1.5 1 syringe and Ccw was computed as flow (CCBF) (Pulsed Doppler flowmeter), arterial pressure i/Ccw = 1/Ct + 1/CI. PEEP levels were increased fr6m 0 to (CAP), systolic (Qs), diastolic (Qd) flow fractions, sys- 20 cm H~O with 5 cm H20 steps. For each level, oesophagal, tolic (Ts) diastolic (Td) times, systolic (Vs) diastolic pleuralZand pericardial pressures were measured using (Vd) blood volumes, jugular pressure (Pjug) perfusion water filled catheters and hemodynamic data were recorded pressure (Pperf. = CAP-Pjug), vascular resistance (CVR = from a Swan-Ganz catheter. Pperf./CCBF), heart rate (HR), arterial and jugular blood PEEP (cm H20 ) 0 20 gazes at ZEEP and PEEP 15 for arterio venous difference (A-VD 0~) and oxygen consumption (VO~ = A-VD 02 x CCBF). ACG - 0.5 + 1.7 8.9 + 2.1 RESULTS-: gazometric and metabolic p~rameters remained un- Pper (mm hg) MV - 2.8 u 1.6 6,0 + 2.3 c-~. Table summarizes the significant modification Paw - Ppl (mm Hg) ACG 1.2 u 0.9 9.2 u 1.5 (oneway variance analysis). MV 7.87 3.1 12.1 u 2.9 CCBF Pperf Pjug HR Qs Vd IC % ACG - 18.1 u 3.5 cm3/min, mmHg mmHg b/min, cm3/min, cm3 HV 13.6 T 4.3 ZEEP 283 67 6 78 409 ?.16 Cl and Ccw were both decreased in MV patients (el 32 + 6; PEEP 5 231 64 7.9 80 380 1.97 Ccw 165 + 2b ml/cm HpO) compared to ACG patients PEEP 10 224 63 10 83 313 1.60 (CI : 65-+ 6 ; Ccw 5BO ~ 95) and pericardial and pleural PEEP 15 229 61 12.1 88 311 1.50 pressures-increased in the same range in the two groups P < 0.01 < 0.001 < 0.0001 <0.001 < 0.05 <0.01 of patients while increasing PEEP. The decrease in car- DISCUSSION : CAP remains constant by baroreflexe involve- diac output was significantly more important in ACG ment, but Pjug increases with PEEP increments, reducing patients. It is suggested that both C and Ccw could Pperf, allowing to a CCBF decrease. Qs decreases according impair the hemodynamic response to PEEP by means of oppo- to the aortic stroke volume reduction under PEEP ventila- site effects on airway pressures transmission. tion (3). Furthermore QD is maintained in spite of VD reduction linked to CVR (r=0.72 ; p < 0.001) due to cerebral volume increase (1). REFERENCES : (1) LUCE et al : J.Appl. Physiol. 52 1982 ; (2) PAYEN et al.: Stroke 13 1982 ; (3) CASSIDY S et al. Amer.J.Physiol. 24__221982 -- 183

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THE EFFECT OF TRACHEAL SUCTIONING OVER TRANSCUTANEOUS P02. IMPAIRED PHAGOCYTIC FUNCTION OF LEUCOCYTES DURING IN- E. Mesalles, S. Armengol, J. Vallds, A. Artigas. I.C.U. CREASED PHOSPHOLIPID SYNTHESIS IN ISOLATED TYPE II Hospital de la Santa Creu i Sant Pau. Barcelona. Spain. ALVEOLAR CELLS. INTRODUCTION: The purpose was to analyze the effect of tra K. Geiger cheal suctioning (TS) in the gaseous interchange and comp~ Institut f~r An~sthesiologie und Reanimation an der re different methods. Fakult~t f~r klinische Medizin Mannheim der Universit~t ~THODS: The transcutaneous P02 (Ptc02) was monitored with Heidelberg (Direktor: Prof. Dr. H. Lutz) D-6800 Mannheim 1 transcutaneous sensor (Kontron-La Roche) with simultaneous Polymorphonuclear leucocytes constitute a major line of measurements of Pa02 in all patients (p). defense for the lung against the dangers of acute bacte- When there was no correlation between the Ptc02 and Pa02 rial infection by virtue of their ability to phagocytize the p was excluded. and kill the invading organisms. Since phagocytosis is .We first studied two groups of ten patients: G:I= Fi02 associated with an increased phospholipid synthesis pre- 50%, PEEP=O sumably serving in renewal and modification of membranes G:2=Fi02~ 50%, PEEP~IO cm H20 required for phagocytic function we asked thequestionis this Aspirations (2-4) of 10 seconds were made in all patients. function impaired in situations where other cell types may ..Secondly we comparatively studied two groups of 5 p. compete for the same substrates of phospholipid metabolism Grup 3= Fi02 ~ 50%, PEEP=O as occurs in the lung where type II alveolar cells are Grup 4=Fi02 ~50%, PEEP~IO cm H20 known to have a high phospholipid turnover. We therefore in whom 3 different methods of TS were applied. studied the rate of phagocytosis during increased phospho- Method A: 2 aspirations of 10 sec. lipid synthesis in isolated type II alveolar cells. Method B: 2 aspirations of 10 sec plus Ambu 100% Type II cells isolated from rabbit lungs were incubated in between aspirations and 1 minut after. Krebs-Ringer phosphate (KRP) medium (pH 7.4) containing Method C: the same as method B, plus 1 minut before. thyrotropin (TSH) for i hr at 37~ The same volume of There was a more marked descent of Ptc02 in group 2 than solvent was added to paired control incubations. Type II in group 1 (36/16 mmHg, p < O. 05) and stabilization time cells were transferred into one of two compartments of a was also more prolonged in the former group. dialysis cell the other one harboring rabbit PMN-leucocy- There was a more marked descent of Ptc02 in group 4 than in group 3 (20/10 mmHg) with all methods, and stabiliza- tes in KRP-medium. After adding paraffin oil emulsion containing Oil Red 0 incubation was continued for i0 min. tion was also more prolonged in group 4. Metabolic activity of PMN-leucocytes was stopped with i mM In group 3 the methods applying Ambi 100% provoked hyperoxia (until 200 mmHg in some cases). N-ethylmaleimide. Oil Red 0 was extracted from washed cell CONCLUSIONS: TS in ventilated patients provokes hypoxia, pellets with p-dioxane and the OD determined at 524 m~. especially in patients with PEEP~IO cm H20. TSH stimulated the uptake of 3H-palmitic acid into type II cells by 60%. 57% • 4.98 (SE) of radioactivity was in leci- Application of Ambu 100% does not prevent hypoxia in p with PEEP~IO am H20. thin. Particle uptake in leucocytes was 32.17% • 1.71 (SE) less during increased phospholipid synthesis in type II These methods provoke detrimental hyperoxia in patients without PEEP. cells. We conclude that phagocytic activity of PMN-leucocytes can be depressed during stimulated phospholipid metabolism of type II cells. Coronary Care and Cardiac Failure

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SLOW AND RAPID VENTRICULAR TACHYCARDIA IN THE CCU - INCI- EFFECT OF ANRINONE ON METABOLIC AND HENODYNA- DENCE, PROGNOSTIC AND THERAPEUTIC IMPLICATIONS. Johan Hul- MIC PARAFfETERS IN PATIENTS WITH CORONARY ARTE- ting and Mats-Erik Nyg~rds. Medical Intensive Care Unit, RY DISEASE. F. Saborowski, R. Griebenow, S~der@jukhuset, Stockholm and Department of Medical In- W. Kaufmann, Dept. Internal Medicine II, Uni- formatics, Link~ping University, Link~ping, Sweden. versity of Cologne, FRG The occurence of slow (rate 121-180/min) and rapid (rate Amrinone (A) is a new non-glycoside and non- ~/181/min) ventricular tachycardias (VT) has been studied catechol positive inotropic agent which pro- In 1348 CCU pts with an automated monitoring system deve- bably acts directly on the myocardium. In dO loped at our institutions. Acute myocardial infarction male patients (mean age = 53.g ys) with coro, (AMI) was diagnosed in 548 pts. nary artery disease (CAD) hemodynamic and me- The incidence of slow and rapid VT was 26 and ll%,respec- tabolic measurements were done in the arterial tively, in AMI, and 9 and 4%,respectively. in non-AMl pts. (a) and coronary venous blood before and q5 On admission, 3 pts with AMI, presented with VT (I slow), min. after administration of A (1.5 mg/kg body all electroconverted. In non-AMl pts 15 (I0 slow) had VT weight i.v.). on admission (electroconversion in II). Five pts with VT Results (5): (rapid; n = 3) after admission, were electroconverted. Thus most runs of rapid VT were short (less than 25 beats). before after A p About half of pts with rapid VT had their VT within 12 h HR (bpm) 70.1 76.9 0.05 after admission. Rapid VT usually developed before slow VT LVSP (mm Hg) q53.5 129.6 0.0125 in pts with both forms. LVEDP (mm Hg) q5.0 6.~ 0.0005 In AMI, about I/3 of pts with rapid VT had their VT with- LV dp/dt max. 2q9q 26q2 o.oq out prior signs of hypotension or left heart failure.Prog- (mm ~g/sec) nosis in this group was good. In AMI, rapid VT preceded Lactate-Ex. (%) 1~.~ 0.9 0.0005 ventricular fibrillation (VF) in 12 pts, in 5 of these 0xygen,Ex. (%) 63.6 62.1 n.s. first VT progressed to VF; in one pt VF preceded rapid E (a) (ng/ml) 0.29 0.39 n.s. VT. NE (a) (ng/ml) 0.79 1.0 n.s. In AMI, slow VT was associated with a hospital mortality E = Epinephrine NE = Norepinephrine of 14%, not different from figure in pts without VT. I17%); however, mortality in rapid VT was markedly raised A increases significantly the contractility of (53%) and 3/4 of deaths occurred in the CCU. the myocardium in patients with CAD (+ J9.2 %) In AMI, the incidence of rapid VT was strongly correlated accompanied by a decrease of the lactate ex- to myocardial infarction size. In non-AMl, a history of cretion (- 93.8 %). myocardial infarction was related to the incidence of rapid VT. In the total material, a slight but statistically significant relationship between rapid VT and a serum po- tasium on admission below average was observed.

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RECORDING OF DELAYED POTENTIALS IN PATIENTS CORRELATION OF NONNUTRIENT BLOOD FLOW AND CARDIAC INDEX IN WITH ACUTE MYOCARDIAL INFARCTION. PATIENTS WITH LOW CARDIAC OUTPUT STATES J. Potratz, H. Djonlagic, K; B. Diederich Robert Bowen, Kevin Farrell, John Beatty, Harakh Dedhia, Medical School of Lflbeck, West Germany Depts. Anesthesia and Surgery, West Virginia University Ventricular arrhythmias very often represent an Medical Center, Morgantown WV 26506 important problem in the treatment of acute Direct quantitative assessment of parameters of tis- myocardial infarction. Although the origin of sue oxygenation and of reserve 02 transport utilization in cardiac arrhythmias is no~ yet understood the critically ill patients have remained an unobtained goal. role of delayed potentials in ventricular A new approach to these goals is the assessment of non- arrhythmias in connection with myocardial in- nutrient blood flow (NNBF). farction has been of increasing interest in re- A set of 4 equations interrelating oxygen delivery cent years. In order to get further information (DO2) , oxygen consumption (V02) , and NNBF have been de- about delayed electrical activity, we studied a rived: %NNBF=(DO2m/D02n - i) + (vo2n/v02 m - i) x i00 for group of 50 patients in the acute phase of myo- DO 2 increased and VO 2 decreased; %NNBF=(vo2n/vo2m - i) - cardial infarction with ventricular arrhythmias. (DO2n/D02 m - i) x i00 for DO2 decreased and VO2decreased; Intracardial recordings were obtained in these %NNBF=(DO2m/DO2n - i) - (vo2m/v02 n - 1) x 100 for DO2 inpatients using an intracardial bipolar elec- creased and consumption increased; %NNBF=-(DO2n/D02m - i) trode and an amplifier with different filter - (vo2m/vo2 n - I) x 1O0 for D02 decreased and V02 in- frequencies. In 30 of these 50 patients we re- creased. corded delayed potentials 150-200 ms after the The superscript (n) values are "normal" values for beginning of ORS. 14 patients showed delayed DO 2 and VO 2 estimated from basal metabolic rate for age electrical activity in the diastole even after and sex and measuring or assuming a value for the resFira- the T-wave. In several examples we could show tory quotient and assuming a value of (.25) for the oxygen that these delayed potentials initiated ventri- utilization coefficient, lhe superscript (m) values are cular premature beats. 10 of the 50 patients determined from a single set of measurements of C.I., pVO2 suffered from ventricular tachycardia. These PaO2, and Hgb. Positive values imply "non-nutrient blood all showed delayed potentials after the T-wave. flow" or wasted 02 delivery. Negative values imply utili- In 3patients the onset of sustained ventricu- zation of reserve 02 Lransport capacity. 63 estimations lar tachycardia induced by delayed potentials of NNBF in 16 cardiac patients were done. Graphic analy- were recorded. The same potentials obtained by sis of this data demonstrates only a loose correlation intracardial recording techniques could also be between CI and NNB~ with a value for r = .42. Determina- recorded from the body surface by using a tions of CI are often used to guide therapy in the post signal averaging technique. These delayed po- MI or cardiac surgery period. This data suggests Lhat in tentials can inhibit pacemakers. We found that this subset of patients other factors influenced reserve the delayed potentials could be abolished by 02 uransport besides CI and that an expression for reserve antiarrhythmic drugs. Thus there seems to be an 02 transport which integrates the factors responsible for important relationship between electrical 02 delivery and VO 2 into one expresszon may provide addi- activity and the occurence of ventricular tional physiological information over that obtained from arrhythmias. determination of cardiac index alone. 185

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I-UC,H DOSE GLUCOSE THERAPY OF CARDIOGEI~C SHOCK HEMODYNAMIC EFFECTS AND PHARMACOKINETIC PARAMETERS OF 3. Schrezenmeir, 3. Epping, M. Pfeiffer, S. Marcin, W.H. HSrl, AR-L 115 BS IN PATIENTS WITH SEVERE HEART FAILURE. Med. Univ.-Klinik, 8700 W~'zburg, FR(3 D. E1 Allaf, S. Cremers, V. D'Orio, A. Dresse, J. Carlier Glucose controlled infusion systems allow the treatment of Institut de M6decine et Laboratoire de Pharmacologic, cardiogenic shock with pharmacological doses of insulin. Universit6 de Liege, Liege, Belgique. Methods: 12 critically ill patients in prolonged cardiogenic shock AR-L 115 BS is a new positive inotropic agent, struc- after myocardial infarction with fatal prognosis and exhausted turally not related to glycosides nor to catecholamines. therapy received a 2000 IF- insulin bolus and 2000 IE insulin per AR-L 115 BS was infused at 1,4 mg/min for 6 hours, then hour in the following. Blood glucose was automatically regulated discontinued, after another 6 hours the drug was with 70 % glucose sell,ion by a glucose controlled infusion readministered for 6 more hours in 11 patients with system (Biostator GC[IS'~). Prior to and 30, 60, 120, 180, 240 severe heart failure (NYHA class IV). Hemodynamic min. after the beginning of therapy and 2,4 and l0 hours after measurements and plasma level were obtained before therapy the hemodynamic changes, insulin, glucagon, pyruvate, administration (C), hourly during both perfusions, and lactate, citrate, 2-oxogluturate, 13-hydroxybuturate and aoeto- during the 6 hours following each perfusion period. The acetate were determined. cardiac index (CI), the stroke volume index (SVI) and the Results: Insulin therapy resulted in an increase of cardiac output, left ventricular stroke work index (LVSWI) were signifi- ~as significant (p < 0,05) at all times of determination and cantly increased. The pulmonary artery wedge pressure amounted 11,3 % after 30 minutes and 23 % after 4 hours. Heart (PWP) and the systemic vascular resistance (SVR) fell rate remained unchanged except for the first 30 rain. where a significantly. Heart rate and blood pressure remained significant increase of 5.6 % was recorded; according to this unchanged (x = p < O.OO5). stroke volume attained values after 1 h which were 20 % higher than before therapy and remained at this elevated level during PWP Cl I SVI _ LVSN~ SVR -S the four hours period of insulin treatment. Weiler index ~ Hg l.min- .m-2 ml/beat/m z g-m/m d.s.cm decreased significantly about 34 % indicating increased myo- C 23 2,07 22 20 1759 cardial contractility. Beyond this we found a significant increase hr 6 13x 2,99 x 31~ 32; 1263x of central venous oxygen saturation, a significant decrease of hr 18 14 x 2,89 x 30 31 1298 x lactate and a tendency of decreasing of citrate and 2-oxo- Maximum plasma levels averaged 5,63 ! 1,05~g/ml after gluturate levels. Glucose and potassium blood levels remained in the first perfusion and 3,03 2 1,O7~g/ml after the the desired range after substitution. After disruption of insulin second perfusion. treatment the hemodynamic starting level was reattained. The plasma half-life was 1,43 • 0,31 hr after the first Discussion: After exhausting conventional measures - including perfusion and 0,95 • 0,28 hr after the second. The catee"-o'h~'amines - this therapy resulted in an improvement of activation of hepatic metabolism may explain this cardiac index, myocardial contractility and chemical parameters difference. Thus AR-L 115 BS appears to be a promising in blood. The two receptor modetl of insulin effects may explain, inotropic agent in severe heart failure. why high insulin doses can achieve effects, which cannot be found after lower insulin doses.

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CHANGES IN HEMOSTASIS BY CONGESTIVE HEART FAILURE INFLUENCE OF BODY POSITION ON CARDIORESPIRATORY VARIABLES H.Straub, W.Schregel, H.D.Kuntz, C.MUller-Haake Luis Teba and Graziano C. Carlon, Department of Critical Med.Universit~tsklinik Bergmannsheil, Bochum, W.Germany Care, Memorial Sloan-Kettering Cancer Center, 1275 York In the beginning of recompensation of congestive heart Avenue, New York, NY 10021 USA failure (CHF) it was possible to show that of 65 patients The purpose of this investigation was to determine the 9.2% had accompanying peripheral thrombosis of the deep effect of changing body position on arterial oxygenation veins of the legs (1-125 fibrinogen technique). Possible and cardiac functions. The study included 28 patients causes may be slowed blood flow or changes in hemostasis. admitted to an ICU[ Initially; patients were placed in a supine position for one hour. Cardiac output (CO), sys- a) Swan-Ganz catheterisation, heart volume by X-rays, temic and pulmonary arterial pressures were measured at liver enzymes, liver function (ICG- and BSP-half live), the end of the hour. Arterial and mixed venous blood clotting tests (aPTT,Quick,TZ,fibrinogen) and anti- samples were also obtained. Hemodynamic, oxygen trans- thrombin III (AT III, chromogene substrates) were de- port (02 Del), and intrapulmonary shunt (Qs/Qt variables termined in 43 patients with heart failure. AT III were measured. The patients were then placed in a sit- levels were compared with 2o healthy persons. ting position at 45 ~ for One hour. All measurements were b) AT III was tested for 14 days during cardiac recompen- thereafter repeated. Only patients with stable cardio- sation of 19 patients with CHF. respiratory functions were included in the study. The AT III was statistically significant reduced in the group above results shown in the following table were compared. of 43 patients with heart failure. In the subgroup (n=17) C.O. SVR 02 Del with right heart failure and peripheral edema AT III Was SUPINE 7.2 + 1.7 985 + 313 1069 + 250 9.6 IU/ml, in the contro]groupof healthy persons 13.2 . SITTING 6.5 ~ 1.6 1133 ~ 387 995 + 268 AT III showed a.statistically significant correlation with Pa02 A 02 Sat Qs/Qt right atrial pressure and liver congestion. SUPINE 78 + 15 .94 + .02 .25 + .09 Group B showed AT III reduced to 8.7 IU/ml. AT III was SITTING 83 ~ 19 .94 + .02 .23 ~ .09 11.5 IU/ml after one week of treatment and 11.6 IU/ml None of the variables considered were significantly dif- after two weeks. The difference was significant. ferent in the two positions. Cardiac output, however, was higher in 20/28 patients while in the supine position, These results show changes of hemostasis in CHF by changed We conclude that the change in body position per se has liver functions. This could be the reason of the higher no beneficial influence on respiratory functions and sit- rate of peripheral thrombosis in CHF, so that the testing ting may decrease cardiac output as a consequence of re- of AT III could be a possible early indicator to prevent thrombosis in CHF. duced venous return from lower extremities and increased systemic vascular resistance. Cardiac Anesthesia and Surgery

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EFFECTS OF FLUNITRAZEPAM (F) ON MYOCARDIAL PERFORMANCE MYOCARDIAL PROTECTION BY HIGH INSULIN SUPPLY. AND CORONARY CIRCULATION. J. Marty, A. Nitenberg, F. S.Duma, I.Krisch, W.SchOtz, C.Spiss, W.Haider. Blanchet, S. Zouioneche, J.M. Desmonts, HSpital Bichat, Clinic of Anaesthesia and General Intensive Paris, France Medicine, University of Vienna, Austria. Sedation and anesthesia of patients with ischemic heart disease must use drugs which do not impair myocardial A preventive accumulation of the myocardial function and oxygenation. The present study was glycogen stores should save the myocardial via- designed to evaluate the effects of F, a potent long bility during hypoxia, since an anaerobic avai- acting benzodiazepine, on left ventricular (LV) lability of energy is maintained. The thera- performance, coronary circulation and myocardial peutic administration of high doses of insulin metabolism in humans. together with glucose and potassium achieves a shifting of metabolism us glycogenesis and gly- Methods. LV and aortic pressures (micromanometry), cardiac output, coronary sinus blood flow (CSBF), colysis, providing an increased amount of energy rich phosphates. One half out of 16 patients myocardial oxygen uptake (MV02), myocardial lactate balance and their derivatives were studied before (C) undergoing mitral valve replacement received and 2, 5, I0 and 15 min after F (15 mcg/kg, IV) in 9 insulin I U/kg/h together with glucose 0.5 g/ patients with coronary artery disease (Class 2-3 NYHA) kg/h from onset of anaesthesia until aortic undergoing heart catheterization. cross clamping. After a 26 min average time of ischaemia a cut-out papillary muscle-tip was Results. F administration produced a decrease of mean immediately plunged into liquid nitrogen and aortic pressure (MAP) (significant at 2, 5, I0 and 15 the content of ATP, ADP and CP (creatine phos- min) and of systemic vascular resistances (SVR) phate) was determined. In contrast to the con- (significant at 5, I0 and 15 min) with maximal changes trol group (Ringer's lactate) the insulin group from C values observed at 15 min (- 16 per cent for MAP) showed a significant (p

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CONTINUOUS BLOOD GLUCOSE '(BG) ~0NITORING IN PATI~TS Mitral s~rgery and pulmonary arterial hypertension (mean PAP superior ~DEI~OING BTI~Yn~ER~IC (28 ~ C) CARDTO-I~'L~C~A~ BYPASS to 40 mmHg) : post-operative hemodynamicstudy. (CPB) WITH DIFFERENT CRYSTALLOID BYPASS R/MP pRIMING C.Isetta*, J.J. Arnulf*, F.Mannot*, F.Montiglio, C.Dusaintpere. FLUIDS. O.K. MeXnight~ )LJ. Elliot% t Department of Service du Pr V.Dor. Institut A.Tzanck 06 700 Saint Laurent du var. Cardi0thorasis A~aesthesia and Surgery t University of * D.A.R. Pr Maestracci, Nice, France. Newcastle-upon-Tyne t Freeman Hospital ~ England, The postoperative hBx~ynamic effects of mitral valve replacBnent are Dramatic alterations in blood glucose (BG) concentration studied in patients with severe pulmonary arterial hypertension. during open-heart surgery ha~e been reported on the basis This hemDdynamic study turns on fifty patients, (mean age 53 + 12 of intermittent sampling. There is a lack of controlled years) with a predominant mitral pathology without any assocT-ated studies on the effect of different pump p~imes on coronaropathy. The preoperative status of these patients shows a glucose homeostasis. We report here the findings of a cardiac index of 2,6 + 0,76 llmlm2 ; an ejection fraction (EF) of prospestive~ randomised study of hypothermic CPB with 0,57 + O, II ; pulmonaryarterial pressures (PAP) : systolic : 79 + four different priming fluids~ namely non-glucose/ non- 17, dTastolic : 35 + 8, mean 50 + lO ~ ; a pulmonary capillar~ lactate, hi~h-gluoose/non-lactate, high-glucose/hi@h- R wedge pressure of 30-+ 5 m~Hg ; a Tight atrial pressure (RAP) : 9 + 5 lactate and non-glucos~non-lacta te utilising Biostator m~Hg. ~ PAP, RAP,-left atrial (LAP) and arterial pressures Tre continuous blood glucose monitoring. Such monitoring continuously menitored in postoperative time. Measures of cardiac allows changes in BG concentration which are masked ~y output are carried out at the first, 12 th, 24 th hour. An hemodynamic intermittent sampling to be visualised. We have control is madeat the third postoperative week. identified phases of the procedure which are associated For these fifty patients : the pulmonary arterial (PA) pressures with rapid and large changes. register a significant {~crease of 4~ at the first hour, 32 % at the A modest rise in BG occurred after skin incision in 12 hour, and 46 % at the third week. The LAP register a significant all patients (1.3 mmol/l +- 0.3 SEN). Glucose+cOntaining, decrease of 50 % from the first hour and after doesn't change any primes resulted in a marked rise in BG (25.5 - 0.5 stool/ longer. The RAP and the cardiac index don't differ from their I) on inststution of bypass followed by a sharp fall to preoperative values al] along the first 24 he~s. 15 mmol/l - 2.5 which level was maintained during the Six patie~ die after the eight postoperative day : their PA hypothermio phase. With non-glucose containing primes pressures only register a decrease of 29 % at the first hour and 23 % there was a rapid, short-lived fall (2 + 0.5 stool/l) in at the 24 th one, their mean PA stays at a rate of 40 mug. In the BG due %o dilution on institution of bypass t followed preoperative time, only a cardiac index which is lower than two by a steady rise during hypothermia. On re-~amming I/me/m2, significantly differs. Five out of these patients present a there was a further rapid rise in BG of c. 3.0 ~mol/l preoperative tricuspid insufficiency (TI). above 30~ C with all primes. A marked rise (3 ~0.4 Seventy eight % of patients presenting a TI linked with the mitral stool/l) in BG was seen with all primes when sympatho- valvulopathy requiere the use of intravenous nitroglycerin and/or mime%is a~ents were infused. tonicardiac drug. Our results have clearly shown the magnitude end The PA pressures progress in two phases. The PA pressures values of rapidity of cha~ges in blood glucose during and after the first postoperative hour and the third week control are the same. CPB. This new knowledge is of crucial importance in After mitral valve replace, a mean PA pressure of 40 mHg has a the ma~ment of diabetics requiring this type of poor prognosis. surgery. Two criteria of seriousness are noted : a CI lower than two I/me/m2 in the preoperative time and a TI liaV.ed with the mitral valvulopathy. 187

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POSTOPERATIVE MAINTENANCE OF PROPRANOLOL THERAPY BY EXTRAVASCULAR LUNG WATER AND "CLOSING VOLUME" INPATIENTS CONTINUOUS I.V. INFUSION. D. VlLLERS, M. PINAUD, B. FRISON, AT THE EARLY PERIOD AFTER VALVE REPLACEMENT.E.M.Nicolay- M. BOURIN, R. SOURON et F. NICOLAS, D~partements de R~a- enko, Researcb Inst. Transplantology & Artificial Or- nimation, d'Anesth~siologie et de Pharmacologie Clinique, gans. Moscow. USSR. HStel-Dieu, C.H.U~ Nantes, France. Feasibility of propranolol (P) infusion to maintain Closing volume" (CV), closing capacity (CC), FRC, extra- chronic P therapy in the postoperative period was studied vascular lung water (ELW) and pulmonary hemodynamics ha- when patients cannot take drugs orally. ve been measured by the methods based on mass-spectrome- Methods : Seven coronary patients (angina grade III NYHA, try, pneumotachography, Swan-Ganz catheterization and 56 ~ 4 yrs) undergoing intraabdominal surgery were thermodilution in 47 pts before and at the early period selected. They received their last P dose (60-120 mg daily) after valve replacement (VR). Postoperative changes in at 8 pm the day before surgery (Po). Postoperatively P ELW were expressed by a ELW/FRC ratio because ELW depen- infusion started at about 2 pm (B) (normothermia and ded on antropometric characteristics and effective al- normal blood gases) with a first iv dose (0.2 mg/kg in i0 veolar volume even in healthy persons. The ELW/FRC in- min) followed by a constant infusion (I mg/kg/day) until creased almost twice during first postoperative hours oral P could be taken again (24-66 hrs). Plasma P compared with preoperational value and remained at the concentrations (C) were measured at Po, B and 5, i0, 60 same level for 2-3 p.o. days. Close correlation (r=0,67) min, 4, 6, 12, 18, 24 hrs after B. Haemodynamic data were has been observed between ELW/FRC and CC/FRC. CC/FRC in- simultaneously collected from radial artery and Swan Ganz creased after VR and became more than 1,0 in most cases. catheters. Holter monitoring was performed before and A more pronounced CC/FRC and ELW/FRC increase was obser- after P infusion. ved in pts with LV cardiac failure. Hemodynamic improve- Results : From 60 min to 24 hrs mean C (58-80 ng/ml) was ment (isuprel, dopamine, nitroprussid) and lung ventila- in the therapeutic range (i). At B there was a statis- tion optimization resulted in a ELW/FRC decrease, gas tically significant increase in heart rate (HR), rate exchange improvement, and allowed adequate infusion the- pressure product (RPP) and cardiac index (CI), when rapy. No dependance of ELW elevation on qua2ity and quan- compared to Po data. Beneficial haemodynamic results tity of infused solutions and on pulmonary artery pressu -~ (decrease of HR and RPP compared to B, p

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COMPREHENSIVE PRE- AND POSTOPERATIVE EVALUATION OF AS- CENDING AORTIC DISSECTIONS (TYPE I AND II) BY ECHOAORTO- GRAPHY. P.Bubenheimer, M. Schmuziger, Rehabilitations- zentrum Bad Krozingen, West-Germany From 1977 to 1982, 22 patients underwent operative treatment for ascending aortic dissections (type i: n=15, type II: n=7) by dacron graft replacement of the ascending aor- taalone (n=7) or combined with aortic valve replacement (eomposite graft) in 15 patients. For preoperative evaluation and postoperative follow-up of the disease, we pre- fered echographic imaging of the aorta and its major branches, using a system of multiple short and long axis cross-sections obtained from parasternal, suprasternal, paravertebral, subcostal and abdominal echowindows. In 17 patients the dissection was primarily defined by echo- graphy, in 5 patients by angiography prior to the echographic examination. In 14 patients the operation was based on echographic findings without angiography. In all cases the echoaortographic findings were confirmed. Preoperative echoaortography demonstrated aseending aortic aneurysms in 21 (diameter 5-9 cm), aortic valve regurgitation in 15, perieardial effusion in 15, distal extension of the dissection to the aortic arch in 15, to arch branches - especially to the brachiocephalic artery - in 8, to the descending aorta in 14, and down to the iliac arteries in 4 cases. Serial postoperative follow-up (from I week to 5 years) of type I dissections (n=12 survivors) which were corrected only partially by the ascending aortic graft, revealed occlusion of the distal dissection in 8, persistence in 4, and progression in I patient. Descending aortic aneurysms developed within 2 years in 4 patients, leading to successful reoperation in I patient. Conclusion: Echoaortography is not only an excellent method for the diagnosis of aortic dissections, but may also improve the understanding of aortic pathology in chronic dissection by serial longtime follow-up. Vasoactive Drugs

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ALTERATION IN MYOCARDIAL 02 EXTRACTION (E. 02) EFFECTS OF PRENALTEROL ON CARDIAC PERFORMANCE DURING MYOCARDIAL (M) DEPRESSION IN SEPTI~ SHOCK: AND TRANSMURAL MYOCARDIAL PERFUSION IN PATIENTS EFFECTS OF DOBUTAMINE (Db). J.F. Dhainaut, B. WITH RENAL FAILURE. T. Pedersen, I. Brynjolf, K. Schlemmer, M.F. Huyghebaert, V. Fouresti@, O. Cleemann-Rasmussen, P.E. Nielsen, K. Rasmussen. Salmon, A. Carli, J.F. Monsallier. R@a. Med. Department of Anaesthesia and Department of Ne- H~p. COCHIN F 75674 PARIS. phrology, Herlev Hospital, University of Copen- Systemic O2'extraction (EsO2) is impaired hagen, Denmark. during severe sepsis, leading to a state of ischemia in muscles. To test the hypothesis that Tie acute haemodynamic effects of a new beta-ad- E. O2 may also be altered such 6 pts were studied renoceptor agonist, prenalterol, were studied in G~sometric, metabolic (lactate) and hemodynamic 6 patients with renal failure. Using impedance investigations were performed using Swan-Ganz cardiography and radionuclide angiocardiography, and Wilton-Webster catheters respectively for left ventricular function was investigated be- cardiac output (CO) and coronary si.nus flow fore and during increasing doses of prenalterol (CSF) by thermodilution technics. Systemic and 0.8 mg, 1.6 mg and 3.2 mg injected i.v. every M 02 consumption (~O2, M?O2) and M lactate 15. min. extraction (EwL) were calculated. The doses of Prenalterol induced a positive inotropic respon- Db were gradu~lly increased until the vanishing se. Stroke volume increased from 42.5 • 14.4 to of peripheral signs of shock. The pulmonary 51.3 • 13.6 ml/beat/m 2 (p ~ 0.05) and left ven- wedge pressure was maintained to i0 mm Hg using tricular ejection fraction increased from 69 • volume expansion and dopamine (Dp) : 3 Ng/kg/ni~ 7% to 77 • 7% (p z o.o5). The doses of Dp were increased to iO pg when A dose dependent chronotropic effect was demon- the doses of Db were higher than 20 pg, in re- strated as heart rate increased gradually from lation to vasodilatator effects of Db. 74 • 5 to 94 • 5 beats/min (p z 0.05). Results : Wp <.O1 C vs Db + Dp. The transmural myocardial perfusion (ratio of the flow from subendocardial to subepicardial CO(l~/m2 CSF(ml/min)3~O2~i/m~ E M 02 I layers) determined from the oxygen supply/demand Control 2.2 • 137 • 2~ ~.s• .50t.lOj' ratio (DPTI/SPTI) decreased from i.io - o.08 to 0.86 • o.06 (p ~ 0.05) signifying a transitory [Db + Dp 4.1 ~.5 w 192 ~ 53" 15 ~ 4 ~ .49t.i0] underperfusion of the subendocardium. In conclusion, prenalterol increased cardiac IE M 02 was very low despite profound M ischemia performance in patients with renal failure rein 2 cases (EML <.20) and was closely related flected in increasing stroke volume and ejection to E~ 02 (p<.Ol). Thus 02 supply became the fraction. A chronotropic effect was seen, which majo~ determinant of MVO2 and closely related caused a greater incidence of myocardial under- to M~O2 (p <.01). Despite high levels of ino- perfusion. tropic drugs, M ischemia tended to decrease because the induced M 02 supply was higher than the induced M 02 demand.

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CO~IPARATIVE HEMODYNAMIC EFFECTS OF DOPAMINE, DOBUTAMINE ADENOSINE TRIP~SPHATE - A NEW VASODILATOR AND ISOPROTERENOL IN ACUTE EXPERIMENTAL PULMONARY VASCULAR HYPERTENSION. A.Artigas, R.Martine~, A.Roglan, O. Bonnin. C. Anger, C. Puchstein, H. Van Aken, J. Thys, P. Lawin ICU. Hospital de la Santa Creu i Sant Pau. Barcelona. Spain. Klinik ffirAn~sthesiologie und operative Intensivmedizin The present study was designed to compare the hemodyn~nic M~nster effects of dopamine(DP), dobutamine(DB) and isoproterenol For a long time Adenosintriphosp~ate(ArP) has been (I) in acute pulmonary artery hypertension (PAH). known as a potent vasodilator. Purine nucleotides play METHODS: The hemodynamie response to different drugs was a physiological role in regulating coronary blood flow. studied in 24 dogs. Anaesthesia was induced with pentobar- ATP may be released from intramural purinergic nerves, bital and pancuronium. Animals were ventilated with VT 15 acting on purinoceptors in the vessel wall and therefore ml/Kg and Fi02 1. Catheters were introduced into the left producing vasodilation. This study evaluates the possible and right ventricles, pulmonary artery and aorta. All hem~ role of ATP in producing deliberate hypotension in dogs. dynamic parameters and left and right ventricular dp/dt In 6 piritramide anaesthetized dogs, ventilated with 0J were measured at basal level, after inducing PAH and follo N20, a femoral artery catheter and a Swan Ganz thermod~- wing infusing of DP (4,8 and 12/~g/kg/min), DB(5,10 and 2~ lution catheter were introduced. Mean arterial pressure Fg/kg/min) and I (0.1,0.3 and 0:4~g/kg/min). The PAH(mean (MAP), mean right atrial pressure (RAP), mean pulmonary pulmonary artery pressure PAm~ 25 mmHg) was obtained by artery pressure (PAP), heart rate (HR)~ pulmonary wedge pulmonary Vascular obstruction (OVP). pressure (PCWP), cardiac output (CO), systemic vascular RESULTS: There was a progressive and statistically signifi resistance (SVR), pulmonary vascular resistance (PVR) cative increase of PAH after administration of the three and stroke volume :(SV) were estimated. A continous i.v. drugs at equivalent doses. Following the administration of infusion of ATP was given, starting with a dose of I mg/ DB and I there was an increase of cardiac index (CI) kg/min and stepwise increasing it every five minutes to a (p < O. 001) and both left and right ventricular function maximum dose of 5 mg/kg/min. All data were analyzed by with a decrease of pulmonary (PVRI) and systemic vascular students' t-test, p~ 0.05 was considered significant. A (SVRI) resistence indexes. dose dependent decrease in MAP, PAP, RAP, PCWP, SVR, PVR HR ~pm MAP mm~ PAm~ gI ~/~I~' PVRI SVRI occured in all dogs inraediately after ATP administration. Basal 159~25 I07~20 12~3 3.3z0~9 279~108 2826~816 The decrease in MAPwas 55 % +/- 8 % with 5 mg/kg/min. OVP 134~15 83~19 25 ~ 6 2.1~0.5 1011~445 :3416~1526 During the whole experiment CO and HRincreased, SV DP~159• ~ 148~29 d 37~15 a 2.7r [275~509' 5651• remained unchanged. ATP seems to be a possible agent for DB~0~164~115 b 90• 43~12 ~ 3.8• d 888~198 1844~ 356 ~ deliberate hypotension. I ~i~e~154~1~ 76~13 50Z 5~ 4.4~0.6 ~ 911~122 1316• Statisticai ~etween OVP an~ drugs: &.p ~ 0.05, kp

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MITOCHONDRIAL SYSTEMS IN SHOCK STATES. G.C. Corbucci, A.Candiani,G.Crimi and A.Gasparetto, Istituto di Anes- tesiologia e Rianimazione, UniversitA degli Studi di Roma. The source of our results is a group of ten patients with a diagnosis of shock based upon hemodynamic and metabolic criteria together with the monitoring of tissular P02. The above shock states, either hypo or hyperdynamic, were studied with regard to the redox mitochondrial activity and the levels of some substrates of Krebs'Cycle in muscular needle biopsies. During the evolution of shock in the examined patients we have observed a significant reduction (one tenth of normal values) of the activity of cyt. oxydase (COx), of succynate cyt.c reductase (SCR) and of~- oxogIUtarate cyt.c reductase(OgCr). Moreover in all the hypodynamic shock states we have observed an irreversible "inhibition" of cyt.c oxydase. The tissue and plasma levels of some substrates of Krebs'Cycle (cytrate, succynate,malate,~-oxoglutarate,pyruvateand lactBte) have shown a close biofunctional relationship with the redox capacity of the electron transport chain (ETC). We could demonstrate a good correlation among tissue perfusion, intracellular 02 metabolization and mitochondrial oxydative capacity. Our results seem to open new and un- explored fields for the research on shock states in the human being. Cardiovascular Monitoring

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CONTINUOUS MEASUREMENT OF DESCENDING AORTIC BLOOD FLOW BY IMPROVEMENT OF CARDIAC OUTPUT ESTIMATION WITH OESOPHAGEAL ULTRASOUND PROBE (comparison with cardiac out- THERMODILUTION IN CPPV BASED ON A TWO POINT AVER- put by thermodilution technic). J.Motin~ R.Muchada~ B.Bui AGING METHOD. J.R.C. Jansen, A. Versprille, Dept. Xuan~ D.Cathignolle~ B.Rousselet~ M.FauvetT of pulmonary diseases, Pathophysiological labora- + D~partement d'Anesthgsie-R~animation, HSpital Edouard tory, Erasmus University, P.O. Box 1738, 3000 DR Herriot, 69374 LYON Cedex 08 Rotterdam, The Netherlands ~ INSERM, SCR 2, 69500 LYON. We have built a new display which measures the blood flow The feasibility of cardiac output estimation in the descending portion of the thoracic aorta with an with thermodilution was studied in anesthetized oesophageal probe. The instrument consists of : and artificially ventilated pigs. Fifty randomized measurements - equally spread over the ven- - a Doppler directional velocimeter of continuous frequency emission, tilatory cycle - showed a maximal variation of 60-150% from their mean, and demonstrated a - an ultrasonic pulse echo system for measurement of aortic section. cyclic modulation with the ventilatory cycle. This work compares measurements of thermodilution cardiac When volemic load, positive end .expiratory pres- output (TDco) with descending aortic blood flow (Ao DF 2). sure (PEEP), ventilatory pattern or frequency The cardiac output range was between 1.9 to 13.1 1 x min -I were changed, a shift in the modulation with The correlation between theses methods, based on 300 simu- respect to the cyclic period was found. Due to ltaneous determinations involving 21 patients is the fol- this shift there was not one defined moment in lowing : TDco : 0,473 = (1,110 xAoF) the ventilatory cycle for all circumstances to r = 0,977 p < O,001 estimate mean cardiac output. The measurement of descending aortic blood flow by the ul- To reduce the deviation of individual measure- trasound oesophageal probe here described is of easy rea- ments from the mean we have averaged the paired lisation, non invasive and non traumatic for the uncons- measurements with a difference of half a venti- cious patient. latory cycle,-giving 25 new estimates for each The obtained values are well correlated with those of car- series. These results were compared with the diac output obtained by thermodilution technic. The method mean cardiac output obtained from all 50 measure- has the advantage upon thermodilution of providing conti- ments and Fick's method for oxygen respectively. nuous recording, which is an important element in the prevention of haemodynamic complications occuring during sur- This averaging technique improved the estimation gery. of cardiac output for the individual paired I. Chavez I: "Introduction g~n~rale" in "Haemodynamie values (n= 1525) to a range between 80 and 120% changes in anaesthesia", vth European Congress of Anaes- of the mean. Moreover, a characteristic pair of thesiology, P 15-18, SNPM, Paris 1979. points in the ventilatory cycle, at the end of 2. Fourcade D, Cathignolle D, Muchada R, Chapelon JY, insufflation and half a cycle later resp., could Bui Xuan B, Bouletreau P, Motin J : Validation de la be selected. These selected estimates had a mean d~bitm~trie aortique par capteur ultrasonore oesophagien of 101% (+ 6% SD, n= 61) of the average of all dans la surveillance h~modynamique non sanglante. Agresso- measurements (n = 3050). logie, 21 (C) : 121-128, 1980.

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NON ~-AS~TE ~T~TION OF ~ PU~RY C~ILT~Y Calcium antagonists versus calcium in CPR.G.H.Meuret,HFO. WEDGE PRESSURE IN LEF~HEARTFAILURE. Schindler,Anaesthesiol.lnst.,Universit~t Freiburg i.Br. FRG FI. Depeursinge I , F. FeJ-hl I , M. Badan I , CI. Perret I , This experimental study compares the effects of Calcium to Ch. Depeursinge 2 , A.K. Boutaleb 2 , J.-C. Willemetz 2 . Institute of Pathophysiology I , C.H.U.V., and Federal that of Calcium antagonists in CPR,and advocates the thera Institute of Technology 2 , EPF, Lausanne (Switzerland). peutic use of the latter. The following parameters were

Pulmonary function alterations induced by left heart measured during (phase II)and after(phase Ill) resuscita- failure (LHF) are known to be related to h~nodynamic tion from asphyxial arrest: I. haemodynamics 2. bloodgases impairment. The purpose of this study was to assess and electrolytes 3. variables of aerobic and anerobic meta the adequacy of high frequency acoustical respiratory impedance (HFRI) measurements by a forced oscil- bolism 4. histology and electron microscopy (E1mi) at the lations method in evaluating pulmonary functional end of the observation period (2-4 h). The-~2 dogs were disturbances induced by an increased pulmonary capillary wedge pressure (PCW) in critically ill divided into three groups: E (n=11) : epinephrine (50 ~kg patients. bw), Ca (n=10):2Omg/kg bw CaCLz 30 sec after E,D:Diltia- Repeated measurements of the HFRI and PCWhave been zem (150 /kg bw bolus) 30 sec after E, 25-50 /kg bw performed inpatients with acute LHF. Discriminant (infusion) after onset of spontaneous circulation. analysis on indices derived from the frequency dependence of the HFRI shows 96% of correct classification Results: I. circulation restored : E: 11/11, D: 11/11, between PCW< 15 and ~ 20 n~n Hg. Correlations between Ca : 7/10 2. VentricuIar fibrillation (VF) : same incident PCWandHFPI indices have been ccraputed for patients with and without conccn~nitant chrcnic obstructive rate in a11 groups\in phase II, phase Ill:no VF in D,but pulmonary disease (OOPD). Correlations as high as in E and Ca. With Ca\VF was irreversible in two cases, R = 0.9 (p < 0.001) have been obtained for non rapidly transient changes of PCW in both qroups of patients. myocardial contracture occured in one case.3.Haemodynamic Repeated measurements of the HFRI yield a suitable param~tersofm)ocardial O~requir~mentswerelowestin D. 4.Coronary monitoring of the trend of PCW. blood flow was higher and Oz consumption lower in D compa- In ccnclusion, the sensitivity of the HFRI measure- red to E and Ca. 5. Elmi : highest rate of ultrastructural ments allows a non invasive estimation of the PC~ at the bedside. The specificity of the HFRI is high destruction with Ca, lowest with D. Conclusion : whereas enough to distinguish between LHF with and without Calcium has deleterious effects,calcium antagonists protect conccn~nitant COPD. The measure~nent is easily performed and does not require any active cooperation of the the heart in CPR. patient. 191

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PROSPECIIVE CLINICAL ANO RADIOLOGICAL STUDY ON THE RATE T~E INFLUENCE OF ARTERIAL HYPEROX~MIAONTISSUEpO,. OF THROMBOSES OF CENTRAL VENOUS CATHETERS IN A MEDICAL INTENSIVE CARE UNIT: L.S. Weilemann, H. Reuss, J. Majdand- K.H.Kopp, E. Kammer, N. Krieg, Institut f0r Anaesthesiolo- zic, H.P. Schuster, II. Medizinische Universit6tsklinik gie der Universit~tskliniken Freiburg i.Br., BRD Mainz. Previous investigations indicate impaired peripheral oxy- Methods and patients: prospective clinical and X-ray exam~ gen supply os tissue under the influence of arterial hy- nations of 63 cases with central venous catheters (CVC) peroxemia. Own results aroused suspicion, that these di- in situ for at least 12 hrs.X-ray control of the catheter sturbances were dependant on cardiac output. Therefore position after insertion and /or correction of the cathe- muscle oxygen supply was investigated (using a pO, multi- ter and every second day. Daily clinical control and assay wire surface electrode) in 46 ICU-patients under normoxe- of coagulation parameters. mic and hyperoxemic Conditions. The ,46 patients were divi- Phlebography immediately after remoral of the CVC. ded into 4 groups; I Ci-5.99 I/min/m BS n : 9; II Ci-4.99 Results: Radiological alteration in 27/63 cases with com- n = 19; III Ci-5.99 n = Io; IV Ci>6 n : 8. ~rombosis in 19 cases and incomplete thrombosis in Besults: I. A similar increase of paO2from similar base 8 cases..Only 21/27 patients with incomplete or complete [i-~ues could be observed ,nder Fi(~ : l in all of the thrombosis had clinical signs or symptoms. Thromboses 4 groups. 2. The 4 groups showed a decreasing Ci under according to access vein: v. basilica 51%, v. cephalica hyperoxemia, the most pronounced decrease occured in group 55 %, v. subclavia 14 %.- Period of intravenous position IV (-13.6%). 3. Under normexemia group I and II had simi- of the CVC 319 • 158 hrs in cases with - and 264 • 215 lar mean muscle pO, values (pmO:), group III and IV howe- hrs in cases without thrombosis (p>O,05). Most of the ver showed higher values (tab.l). 4. A increase of pm~ thromboses (71%) occurred 193 to 312 hrs after insertion under hyperoxemia was found only in group II, Ill and IV, of the CVC. The dosage of heparin (lowdose Or therapeutic slightly decreasing pmO, values however could be seen in dose) had no influence upon the rate of thromboses. group I (tab.l). To sum-up: highest rate of thromboses in CVC positioned vla arm velns. Heparin dosage and mean length of intra- Tab. 1 Normexemia Hyperoxemia &% venous position had obviously no effect upon the rate of I 344 338 1 8 thromboses. II 3.38 5.22 + 54.4 IlI 4.42 7.o5 + 59.4 IV 4.96 7.66 kPa + 54.4 5. A disturbed muscle pO, distribution under hyperoxemia was present in all of the 4 groups. Conclusions: l. Under hyperoxemia microcirculatory disturbances of skeletal muscle occured in most of the ICU- patients. 2. The amount of pmO, increase under2hyperoxemia seems to be dependant on Ci. At Ci< 4 1/min/m BS no improved peripheral oxygen supply could be detected during arterial hyperoxemia.

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BAROREFLEX FAILURE IN GUILLAIN-BARRE SYNDROME (G.B.S.) J.C. RAPHAEL, D. PATTE, V. MORICE, Ph. GAJDOS, M. GOULON. Hopital Raymond Poincare. 92380.GARCHES. France. Autonomic dysfunction can occure in the acute phase of G.B.S. In order to explain the mechanism of these anomalies hemodynamical and autonomic tests have been done in the acute phase of the disease (phase A) and during recovery (phase R). Methods. 31 patients were studied (average age 33 + 16 years) without previous cardiovascular disease or complications, 24 required mechanical ventilation. The fol lowing tests have been performed : measure of arterial pressure (A.P.), cardiac index (C.I.), total peripheric resistance (TPR) in supine position (n=31) and after 30mn of 30 ~ tilt (n=22), valsalva manoeuvre (n=19), changes of AP after injection of phentolamine (5mg), constant infusion of noradrenaline (0,05 ug/kg/mn) and angiotensine (0,01 ug/kg/mn), studies of urinary catecholamines, measure of blood volume (131 I Labeled albumine). Results. The comparison of tests during phase A and R (t test for matched series) demonstrate : i) an increase in phase A of supine mean A.P. (p <0,001) and TPR (p~ 0.05). 2) Tilt test induces a greater fall in AP during phase A (p < 0,01) explained by a lower increase of TPR (p 0,03). No change in blood volume is observed. 3) Valsalva ratio is lower in phase A (p 0,001). 4) urinary excretion of catecholamines is higher in phase A (p~ 0,001). 5) phentolamine induces a greater fall in AP during phase A (pL 0,001). Changes of AP after infusion of noradrenaline and angiotensine are identical in both phases. Conclusions.Impair- ment of barorefdex arc in the acute phase of G.B.S. is proved by orthostatic hypotension and anomalies of the valsalva manoeuvre. This fact cannot be explained by a lesion of the autonomic efferent pathway. These results suggest an afferent block in the acute phase of G.B.S. Intoxication, Metabolism

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PROPOSITIONS THERAPEUTIQUES DANS L'INTOXICATION P~ P/qNITIDINE : ONSET AND DURATION OF ACTION. H.G. CYANHYDRIQUEA PROPOS DE 24 CAS SANS MORTALITE. D~m~nn, P. M~ller, B. Simon , t'edizinische Universit~.ts- C. BISMUTH, F. BAUD, J. PRONGZUCK de GARBINO. kliniken Hamburg und Heidelberg, F.R.G. Clinique Toxicotogique, H6pital F. WIDAL, 200 faubourg Pulmonary acid aspiration syn~ has been recognized Saint-Denis 75010 PARIS - Universit~ Paris VII. as a major hazard in the practice of emergenoy anesthesia This r~sk has been tightly correlated with a gastric fluid Inhibiteurs de la cytochrome-oxydase, les cyanures entra['nent pH of less than 2.5 and a volume of more than 25 ml. This une anexie cellulaire rapidement mortelle et sont eouramment study was designed to investigate the onset and duration consid4r4s comme l'agent suicidaire le plus sot de notre civi- of action of the new H2-receptor antagonist ranitidine in lisation. r~9/1. After an overnight fast a nasogastric tube was placed L'4tude r6trospective de 24 cas d'intoxication cyanhydrique in the stc~ach of 12 healthy male subjects. The gastric sans moFtafit6 permet d'insister sur : contents were aspirated and the starting pH was determi- - la fr4quence des arr~ts cardiorespiratoires 4ventueHement ned. 50 mg ranitidine as i.v. bolus or placebo (0.9% pla- inauguraux (7/24), cebo) was given in a randomized fashion. Gastric juice - I'intensit4 de I'acidose (8/24) qui peut ~ elle-seule faire was continuously aspirated over a test period of 6 hours, suspecter I'intoxication et 4valuer son intensit4, pH of the gastric aspirates and gastric volt~es were de- - la possibilit4 d'intoxications asymptomatiques ma!gr4 la termined in l-hour fraction. prise certaine suicidaire de sels de cyanure (par p4remption 50 mg of ranitid/ne induced a rapid increase in gas- de conditionnements vieillis). tric pH.45 rain after ranitidine all 12 subjects had a ga- Parmi les th4rapeutiques classiques : stric aspirate pH of more than 5 re~aining at this level - les m6th~moglobinisents apparaissent actuellement d6pass4s. over the whole test period. By contrast, in the controls - te t4trac4mate dicobaltique, efficace mais dangereux en the pH-values ranged between 1.30 and 1.90 over the whole dehors de I'intoxication eyanhydrique, doit &tre r4serv4 aux 6 hour test period. sujets pr4sentant des signes objectifs (au minimum 4bri4t4) Gastric vol~ne secretion in the ranitidine experiments d'intoxication. was reduced from 60 ml/br in the first collection period - I'hyd:oxocobolamine, associ4e au thiosulfate de sodium, pre- to volumes below 35 ml/hr (i.e. 45-50 % inhibition), tiquement sans effet secondaire, permet une neutralisation whereas in the placebo-experiments vol~ne secretion re- et une 41imination r4nale rapide des cyanures ; son efficacit4 mained almost unchanged. est conditionn4e par I'importance de la dose (au minimum 4g) Our data reveal that 50 mg of ranitidine as i.v. bo- - le traitement symptomatique reste essentiel, e'n particulier lus induces an immediat~ (within 30 min) increase in ga- la ventilation en oxyg~ne put qui a permis a elle-seule la stric aspirate pH and a concomitant drastic reduction of gu4rison d'intoxications cyanhydriques, connues ou m4connues, volume secretion in all subjects. This rapid onset of ac- sans traitement antidotique associ4, avec des taux de cyanure tion allows a short time interval between administration spontan4ment I~thaux. of this H~-blocker and induction of anesthesia. The pro- Cette s4rie epporte Is notion d'absence de taux sanguin mol- longed activity of ranitidine (for more than 6 hours) may tel de cyanures ehez le sujet pris en charge pr~coc~ment en indicate that at time of extubation the pH of gastric con r4animation. tents is still high. Premedication with ranitidine may, therefore, be helpful in patients at risks.

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THE INFLUENCE OF THE KALLIKREIN-KININ SYSTEM ON INTENSIVE THERAPY AND RESUSCITATION IN PATIENTS WITH PULMONARY MORPHOLOGICAL ALTERATIONS IN EXPERI- ACUTE POISONING BY PHOSPHOORGANIC COMPOUNDS. MENTAL ACUTE HEMORRHAGIC PANCREATITIS (AHP), AA.Togaibaev, Vl.Lapin, GD.Sheinin, LA.Badelbaeva, H,Kortmann, RoBassermann Dep, of Surg, & Inst, Alma-Ata, USSR, Kazakstan. of Pathol, t Universf~y of Munich~ KI,GroBhadern We studied 126 cases of acute poisoning by phosphoorganic Respiratory insufficiency is a common severe substances. This kind of pathology was treated by a complication in the course of AHP and often an specific therapy consisting in combinated use of cholin- ominous sign for a beginning shock with high olitics (atropin) and reactivators of cholinesterase mortality, The liberation of Minins is generally (isonitrosine). We payed a special attention to sympto- considered essential for the induction of pan- matic therapy aimed at decrease of hypoxia and its creatic shock, - An AHP was induced in 1 5 pigs secondary effects, control of convulsious, prevention by intraductal injection of taurocholic acid of inflammatory changes of the respiratory organs and (TCA), The 6 controls were only sham operated. control of pulmonary and brain edema. We used as obliga- In another group of 5 pigs bradykinin (BK) was tory the gastric and intestinal lavage, intensive urea- infused together with the kininase II inhibitor poiesis, hemoresorption, hemodialysis and blood transfusion. Captopril, Besides blood gas analysis lung biop- We noted a marked decrease in fatal outcome in this group sies were taken in the course and at the end of of patients as a result of the treatment above described. the experiments, - All pigs with AHP died of hypovolemic shock. The kallikrein levels increased immediately after the onset of AHP (~x: +75~), The total kininogen decreased about 70~, CO and CVP decr@ased whereas PAP and TPR increased (p

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CRITERION OF EFFECTIVENESS OF HEMOCARBOPERFUSION IN ACUTE EXOGENIC INTOXICATION. LV.Usenko, VA.Krauz, EP.Litvin, Medical Institut, Dnepropetrovsk, USSR. Despite the broad use of hemocarboperfusion method in a reanimation clinic many problems bound up with the reliable criterions of estimation of effectiveness of this method remain unsolved. We studied the effectiveness of a single and multiple hemocarboperfusions on the dynamics of clinical, biochemical, electrophysiological and psychophysiological indices of hemostasis. 200 patients and 65 dogs were observed in the condition of acute intoxication with phosphoro- organic insecticides, alcohol and psychotropic agents. It was shown that we can speak of effectiveness of hemocarboperfusion, that is, of its curable effect in case of intoxication according to complex estimation of different indices. The most informative characteristics as well as clinical ones are bioelectrical brain activity, attention and memory function, indices of functional condition of sympathoadrenal, cholinergic, kallicreinekinin systems and acid-base. Criterions of effectiveness of a single hemocarboperfusion operation as well as determination of a number of necessary operations in cases of exogenetic intoxication include overall the bioelectrical brain activity, and then the indices of attention and memory function. Neurophysiological mechanisms are analysed on the basis of experimental data. Neonatology and Pediatrics

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EFFECT OF CONTINUOUS POSITIVE PRESSURE VENTILA- RENAL VENOUS THROMBOSIS (RVT) IN INFANCY - THROMBOLYTIC TION ON THE SHUNT THROUGH THE FORAMEN OVALE. TREATMENT IN 17 CASES. F. Beaufils, N, Schlegel, G. Pil- R. Spritzer, A. Versprille, W.J. Gussenhoven, lion, C, Loirat, J.C. Mercier, H8pital BRETONNEAU, PARIS, Dept. of pulmonary diseases, pathophysiological We report our experience ~-ith 22 cases of RVT in infants laboratory, Dept. of pediatrics, subdivision of (age I to 87 days). Etiologic factors were : hypertonic neonatology, Interuniversity Cardiology Insti- dehydration (n=11) perinatal anoxia (n=11). Diagnosis cri- tute, Erasmus University, P.O. Box 1738, 3000 DR teria were the following : clinical kidney enlargement Rotterdam, The Netherlands gross hematuria, associated with non secreting kidney on Artificial ventilation has proven to be benefi- intra venous pyelogram IVP and or anuria. RVT was unilateral in 10 cases and bilateral in 12 cases all with anu- cial for many newborn infants. Little is known ria.9 infants required peritoneal dialysis.Surgical throm- about the effects of continuous positive pres- bectomy was rejected, most of these RVT being mainly in- sure ventilation (CPPV) on the neonatal circulation trarenal. 5 infants were not treated (3 because of early death). 3 were treated by Heparln (H) and Streptokinase The effects of CPPV on the R-L shunt through the (SK) : loading dose 2000-2500 U/kg/20 minutes maintenance foramen ovale (FO) were studied in newborn pigs. dose 750-1200 U/kg/hours 24-48 hours. 14 were treated by Indicator dilution curves from the right atrium and the abdominal aorta after injection in the H and Urokinase (UK) : loading dose 4000 UCTA/kg/20 minu- inferior caval vene were analysed The shunt tes maintenance dose 3000 UCTA/kg/hour 24-72 h. 2 of them received plasminogen 6 hours before UK. through the FO appeared periodic and within the 4 infants (3 not treated I SK) died at the acute phase. ventilatory cycle. This period was estimated Bilateral RVT was found in the 3 autopsied eases. ] in- from the shortest transit times, i.e. the time fant (OK) died after 3 months of chronic peritoneal dia- between arrival of indicator in right atrium and lysis. 17 infants (2 not treated 2 SK 13 UK) survived. aorta. The period of shunting was dependent on I (SK) kept end stage renal failure (RF) and hypertension the ventilatory pattern. and entered on hemodialysis programm at 6 years of age. Non invasive detection of shortest transit time I (UK) had mild RF (follow up 21 months). The 15 remai- between right ventricular outflow tract and ning patients (2 not treated I SK 12 UK) have normal glo- aorta by means of contrast echocardiography cor- merular filtration rate and blood pressure (follow up 5 related closely to the invasive dilution method. to 48 months). Evolution of IVP was evaluated for survi- We concluded that the cyclic changing shunt ving patients according to the overall number of kidneys through the FO during CPPV is mainly dependent which were altered in acute phase. 9 out of these 26 kid- on the cyclic differences in venous return to neys are normal. 9 are non secreting. 8 are atrophic. Fi- right and left atrium, and that the non invasive nally 6 (I non treated 5 UK) out of the 22 patients fully detection of transit time promises clinical recovered (normal IVP and renal function). Poor factors application. of prognosis were bilateralitT (5 deaths 2 BF) and dehydration (5 deaths I RF). The benefit of thrombolytic a- gents cannot be clearly evaluated because of the small number of patients. Further studies can be performed with UKbecause of its small risk of bleeding (0/14) if appropriate biological monitoring is performed.

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LONG TERM RESULTS FOLLOWII~G REPAIR OF ESOPHAGEAL ATRESIA. AN IMPROVED TECHNIQUE FOR NON-INVASIVE ICP MEASUREMENTS C. Mercier, ~[. Cordier, H. Robert, A. Laeombe, F. Gold, IN NEONATES. F.Fallenstein, A.Huch, R.Huch, Dept. of J. Laugier, Centre de P~diatrie, C.H.R. Tours, France. Obstet.and Gyn., University Hospital, ZUrich, Switzerland. We have reported on the possibility of continuous non We report our experience about i00 cases of esophageal invasive monitoring of ICP in neonates and its clinical atresia admitted to our unit from 1968 to 1900. The aim diagnostic relevance (I). It is our aim to develop a Of this study is to appreciate respiratory and esophageal sensor which measures ICP with sufficient precision and complications. 52 % of the infants were considered at which is inexpensive and easy to handle. Our latest high risk (in accordance with the French Society of developement uses a commercially available strain gauge Pediatric Surgery, classification 1969). 82 % survived pressure transducer with a flat surface which is in after the surgical management of the esophageal atresia. direct contact with the skin of the head above the fonta- The long term survival rate was 74 % : death oceured as nelle. This method requires the pressure transducer to be a result of cardiac or multiple malformations, 3 to 36 pressed against the head skin with a certain force. This months after surgery. 74 children were followed up pros- is accomplished individually in each application by a pectively for periods between 3 and 6 months, then every step motor drive which can alter the depth of the trans- year Data were obtained from physical examination and ducer relatively to the sensor case. The action of the esophagography (performed at one year) Other investi- step motor is controlled by a microprocessor which also gations, such esophagoscopy, tracheoscopy were performed porvides an automatic routine to find the optimum posi- in case of respiratory complication. tion by analyzing the signal of the transducer in rela- Results : The following diagnosis were established : tion to its deflection. In order to investigate the chronic suppuration of the bronchus in 24 % influence of the skin membrane on the accuracy of pressure esophageal stricture in 28 % transmission between the intracranial system and the gastroesophageal reflux in 23 % transducer, we applied membranes with various compliances Correlation between respiratory and esophageal sequelae to a water filled artificial head with a fontanelle opening. was noted By varying the water pressure below these simulated "head Our results stress the need for an early and systematic skins" and recording the transducer signal, we found a detection of esophageal abnoma]ities, particularly when linear function within the physiological range (10-50 cm responsible for the recurrent respiratory problems, and water) for all kinds of membranes. We averaged the various for an antiref]ux procedure slpoes and found a maximum deviation of 6%. For this reason, we assume the real head skin to have similar pressure transmission characteristics. Consequently a sensivity calibration is not necessary before in vivo application. (I) A.Huch, F.Fallenstein, R.Huch and JL.Peabody (A new device for non-invasive measurement of intracranial pressure (ICP) in newborns), Med.Prog.Technol. 6, 185-187, 1979. 195

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IS NASOTRACHEAL INTUBATION (NTI) A PROCEDURE OF CHOICE IN PROGNOSIS FACTORS OF SEVERE INFECTIOUS PURPURAS THE MANAGEMENT OF SEVERE LARYNGOTRACHEOBEONCHITIS (LTB) ? (90 cases from the French group of pediatric intensive Y. Bompard, S. Bobin, J.C. Mercier, P. Narcy, F. Beaufils care) H8pital BRETONNEAU - PARIs - FPANCE F. LECLERC, R. BEUSCART, B. GUILLOIS, J.F. DIEPENDAELE Intubation has been proposed as an alternative of trache- G. KRIM, D. DEVICTOR, Y. BOMBART ostomy for the airway stabilization in LTB. But this pro- Calmette Hospital-59037 LILLE Cedex-FRANCE cedure for some authors, might cause secondary subglottic stenosis. The purpose of this retrospec~e study is to analyze the immediate and secondary outcome of 40 LTB The French group of pediatric intensive ca- treated by NTI. re has prospectively studied 90 cases of infectious pur- PATIENTS : lh girls (32%), 30 boys (68%), age g weeks to puras which were hospitalized in 1981 ; the purpose of 12 years. Etiology : 9 measles, 10 bacterial proved in- this study was to determine prognosis factors. fections, 10 viral infections, 15 unknown. Tube size was : for 21 patients, 1 size (0,5 mm) smalle~ than the The statistic study (X 2 test) of all these recommanded size for age (I), for 16 patients~/ to the cases is in agreement with the litterature data and recommanded size for age and unknown for 3 patients. shows that the mortality is significantly higher when RESULTS : Mortality O;good outcome 37;subglottic steno- there is : a shock (p<0,001), a coma (p5mEq (p

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ARRHYTHMIA MONITORING IN PEDIATRICS R. Frey, RENAL EFFECTS OF CALCIUM CHLORIDE INFUSION IN OLIGURIC I. Bergmann, D.Widmann, G.Brueggemann, A.A. CHILDREN AFTER OPENHEART SURGERY. M.Dechaux, B.Marie t Schmaltz, J. Apitz A. Dequirot, Y.Durandi, Mankikian, C. Sachs, Services de Physiolo- Dept. of Pediatric Cardiology, University gie et de Chirurgie Cardio-Vasculaires, H6pital La~nnec, Paris France. Children's Hospital, Tuebingen/FRG Renal dysfunction (oliguria, renal insufficiency a.s.o.) after cardio- With the rise in the number of heart pulmonary by pass for open heart surgery is a frequent and sometimes operations and the improved accuracy of severe complication, especially in infants and young children. CaCI2 pediatric monitoring, arrhythmia and its infusion is known to reverse these urinary troubles. The aim of this detection has become an increasing problem in study is to try and determine the exact nature of these desorders and pediatric cardiology. the mechanism (s) of CaCI2 infusion action. Six child~n (weight range Our department provides preoperative, 8 to 15 kg) with congenital heart diseases have beenLstudied before postoperative, and general cardiologic care (period I) and after (period II) infusion of 0.5 mEq/kg b.w. of CaCI2. for children with heart disease between the In one of the patients 2 subsequent studies have been performed. ages of one day and 16 years. The following methods have been used : standard inulin clearance We adapted the alarm limits and conditions for glomerular filtration rate (G.F.R.)~P.A.H. clearance for renal blood of an arrhythmia computer (HP-78525) to our flow (R.B.F.) measurements. Plasma total and ionized calcium, plasma intensive care and long-term ECG monitoring citrate, urinary sodium (UNa) and osmolality (Uosm) were also measu- problems and to the field of pediatrics. red. Plasma filtration fraction (F.F.) and urinary flow (~ were calcula- For quality control, statistical analysis ted. Results are summarized in table I reporting mean values -+ 1 SD . was used to examine all stored QRS complexes of each patient after the control by the GFR RBF FF ~/ Uosm Ca++ cardiologist and to assess sensitivity and specificity results in a 4-field table. I 12.3 +--50 386+--15z~ 33%+7 0.7+0,3 736+145 2,39+0,32 Continuous storage makes possible the U 123+45 L~70+154 26%+3,5 2,2+-2,1 557+150 3,1+0,42 detection of false negative as well as false positive results. The control by the T n,s. n.s. * * 8 , cardiologist occurs through the EDIT and Citrate values and GFR were in normal range and unchanged before RECALL system. and after CaCI2 infusion. Initial values for R.B.F. were low with increa- The results obtained over a 24-hour period sed F.F. and urinary osmolarity was elevated, CaCl2 for 10 patient were presented and compared infusion produced an increase of V with a decrease of U osm. Ca§247 with the interpretations acquired with Holter tially in the normal-low range,iincrease(Jdramaticany. All these chan- monitoring. ges were statistically significant as est#~lished by a non parametric test The accuracy of QRS analysis ranged between (WILCOXON). 80%-99% for good ECG quality but dropped to Ine aumors suggest that these phenomenons could be explained as 5% for instable ECG qualitiy for the same follow ; - low PAH clearance with elevated FF suggest an insufficient patient. RBF - the initial oliguria with elevated Uosm suggest a vasopressin hy- persecretion - infusion produced hypercalcemia might induce a stimulation of PGE2.The latter is known to increase RBF, U and antagonize vasopressin tubular action - hypercalcaemia might ai~lsaohave a direct inhibitory effect on vasopressin release, Acid-base Status, Metabolism

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HYDROCHLORIC ACID INFUSION FOR TREATMENT OF HYPERCAPNIA. LACTIC ACID METABOLISM IN ALK~I,0SIS S Brimioulle, JL Vincent, J BerrY, P Dufaye and RJ Kahn. W.Druml,A.Laggner,K.LenztW.Base,G.Kleinberger;I.Med. Department of Intensive Care, Erasme University Hospital, Univ.Klinik/Intensivstation,University Vienna,Austria Free University of Brussels, Belgium. Alka~osis may induce hyperlactemia representing a Hypercapnia is commonly associated with surimposed metabo- mechanism of metabolic compensation of the alkalotic lic alkalosis (SMA), defined as an excessive increase in State. It is however not known whether alkalosis per se bicarbonate concentration, which can itself contribute to or hypocapnia and whether an increased production or a further increase the PaCe 2. We tested the hypothesis that decreased hepatic utilisation of lactic acid causes the correction of SMA by HCI infusion could decrease PaCe 2 in rise of plasma lactate concentration (=LAC).We therefore patients with acute ventilatory failure associated with investigated the influence of alkalosis on the elimina- SMA. Concentrated HCI (.25 N) was infused in 15 critically tion of parenterally infused L-lactic acidT ill patients who presented either with a pH of A40-145 and Patients and methods:6 patients(3 2,3 ~,mean age 57.5 a) a PaC02 >45 torr (group A, n=9), or with a pH of Z35-%40 with respira[ory failure were evaluated, l mmol/kg b.w. and a PaCO 2 torr (group B, n=6). Ten patients had been L-lactic acid was infused in io min.LAC and blood gas treated by mechanical ventilation (MV). NaCI administra- status was determined befere,2,3,1o,2o,3o,6o and 90 min tion was either contra-indieated or ineffective to correct after the infusion.The study was performed in a basal SMA. Serum potassium was 4.2 1.4 mM/L. Reduction of FiO 2 condition with noinnal pH (7.44+O.02)and a pCO of 39.2+ -- 2 -- had not resulted in any decrease in PaCe2. HCI was infused 6.33)and during controlled mechanical hyperventilation into the superior vena cava at the rate of lO0 ml/hour and respiratory ~alkalosis (pH 7.59+__O.03)and hypocapnia until the bicarbonate concentration was below 26 mM/L, or (pCO 2 29.3+_4.1). the pH below ~35 (group A) or 730 (group B). Results:Basal LAC was 1.87+0.37 at normal pH and 2.6+ ~_!!~_~_!~__~__~_~!! ~_!~_~_~i__m~__~_~!! 0.37 mmol/l in alkalosis(#~o%).The elimination half~ime was 2.55+0.25 min at normal pH and 11.04+3.34 min in al- • pH Z43 • --> Z36 • ~ ~37 --->230 • ~-~ kalosis(e320%).The clearance rate decreased from 64.23+ HC03- mM/L 32 • 2 --> 24 I ~ 36 • 3 --> 26 • 3 ~ 38.4 ml/kg b:w./min to 25.7+5.01 in alkalosis (-6o%). PaCO 2 torr 49 • 3 --> 43 2 ~ 63 • 6 ---> 55 • 6 ~ Despite constant pH and pCO 2 LAC decreased below basal PaO 2 torr 77 • 19 --> 96 • 25~ 77 • 22 --9 9| • 24~ values after 9o min 0.37 mmol/l in normal pH(=m2o%)and p ~.01 ~ p <.OOl 0.4 mmol/l in alkalosis(=-15%)~ The decrease in PaCe 2 was still significant 12 hours after Conclusion:Hyperlactemia in alkalosis is caused mainly the end of the HCI infusion. In our opinion, these effects by a decreased utilisation and is mediated by the pH on PaCe 2 contributed to the successfull weaning in 7 of value and not pCO2.The pH optimum for lactate metaboli- the ]0 patients treated by MV, and to a brisk clinical sation seems to be below pH 7.44.As a clinical impli- improvement in the other 5 patients. No hematological or cation alkalisation therapy in post-shock states should vascular complication due to HCI was observed. be performed carefully since the induction of alkalosis We conclude that HCI infusion can significantly improve may result in an impairment of lactate removal.- ventilation and oxygenation in patients who present with hypereapnia and SMA. Aggressive correction of SMA should be actively considered in the management of acute ventilatory failure in critically ill patients.

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SOME UNKNOWN EFFECTS OF NH.C1 AND ARGININE-HCI THE USE OF THE ARI-FICIAL PANCREAS FOR TPN IN THERAPY. K.F. Rothe, Dept.~of Anaesthesiology, CRITICAL METABOLIC STATES. University of T[ibingen, D 7400 Tfibingen, 3. Schrezenmelr, 3. Epping, S. Barthel, W.H. HSrl, Med. Univ.- Calwerstr. 7, FRG Klinik, 8700 W{]rzburg, FIRG In acute disease, catabolism, a negative nitrogen balance and the Though agents for correction of metabolic acid- Joss of funtional proteins remain problems facing parenteral base disturbances are widely used in the daily nutrition. When sugar substitutes are used instead of glucose, practice of intensive care medicine, there is metabolic disorders can only be detected by an increase in only little information about their effects on secondary metabolites. The problems of high dose glucose the intracellular acid-base status. In this stu- therapy such as variations in osmolarity, alterations in hemody the effects of NH4CI and arginine-HCl on in- globin-O~-dissociation and impaired substrate utilization, may be tra- and extracellular acid-base equilibria of avoided t~y using the artificial pancreas (AP). rats were examined. The "mean whole body phi", 24 critically ill patients who received high dose parenteraI an overall estimate of the intracellular pH, as glucose therapy and who had blood glucose concentrations of complementary to the in vivo determined extra- more than 500 mg% and daily variations of more than 500 mg% cellular plasma pH, was determined with 14C la- inspite of insulin per infusion, were placed on the AP. The beled DMO ( 5,5-dimethyl-2,4-oxazolidinedione ). insulin infusion rate was set to maintain blood glucose values For evaluation of buffering, extra- and intra- between 150 - 200 mg%. With the AP mean blood glucose levels cellular bicarbonate was calculated from the of 198 + 79 mg% were obtained, compared to 552 + 149 rag% Henderson-Hasselbalch equation. For treatment of (p ~ 0,01T with conventional therapy. Although more ~ucose was metabolic alkalosis therapeutic agents are infused, the maximal serum glucose amplitude per day was given to reduce intracellular pH and intracellu- significantly reduced (115 + 97 mg% compared to 262 + 131 lar bicarbonate concentration. It was found e~t mg%; p~0,01) and a s|gnlf~ant fall (p< 0,05) of lactate-blood that after application of the agents extracellu- levels from 2,45 + 1,15 to 1,25 _+ 0924 mg/l with unchanged lar bicarbonate was reduced but there was only la~tate-pyruvate ratio and a decrease of citrate and oxo- little influence on intracellular bicarbonate gIutarate concentrations indicated a better fuel consumption. concentration. In addition it could be demonstra After attaining a dynamic equilibrium, insulin glucose ratio was ted that both agents cause a significant increa- 13.2 + 21.1 IE insulin/g glucose and could be used for further se of intracellular pH which cannot be detected therapy without the AP. This parameter of insulin resistance by blood-gas measurements. The intracellular pH correlated with insulin levels at equilibrium but not with proteo- increase that was observed following application lyric activity (digestion of azocasein and phosphorylase kinase} of NH4CI or arginine-HCl application may have titration of protease inhibitor capacity of plasma, 0(-2-macro- adverse consequences for patients and raises globulin, ~c-l-antitrypsln). Thus the marked resistance in sepsis objections to the use of both agents in the could not be explained by immunologically detectable insulin treatment of metabolic alkalosis. degradation or by alteration of the proteolytie activities and protease inhibitors we determined in plasma. The AP enables us to administer high caloric parenteral nutrition to critically ill patients without the hazards of conventional therapy and to study the mechanisms of insulin resistance in these patients. 197

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USE OF THE ARTIFICIAL PANCREAS (BIOSTATOR GCIIS) DURING AND AFTER TOTAL PANCREATECTOMY. S.Del Prato, F.Giunta,U. Baccaglini, M.Calabrb,E.Pizzinari, C.Tremolada, G.P.Giron A. Tiengo. Universit~ di Padova Italy. Hypo- and hyperglycemic events and acute metabolic derangement are common complications in patients undergoing total pancreatectomy. We evaluated the effect of glucose control with Biostator on intermediary metabolism. 5 non diabetic patients affected by pancreatic adenocarcinoma (age 58• ideal body weight 93• were studied throu ghout operation (S) and 24 H post operative period (PS).- 3 patients (PXB) were put under Biostator control, while 2 patients (PXC) were treated according to a conventional protocol. Arterial blood samples were frequently taken for hormone and metabolite determination. In PXB glycemia during S and PS was 11~33mg/dl and 290• in ,PXC. C-peptide became undetectable in all PX (3~9• to

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ACUTE RENAL FAILURE IN A MEDICO-SURGICAL INTENSIVE CARE UNCOVERED T-ANTIGEN AS PATHOGENETIC FACTOR OF ACUTE RENAL UNIT. V. Ninane, M. Marchal, J.L. Vanherweghem, FAILURE.G.Lenz, H.Junger, U.Goes, D.Baron, and U.Sugg. J.P. Degaute, R.J. Kahn. Erasme Hospital, University of Institute of Anesthesiology, University of TUbingen. Brussels, Brussels, Belgium. F.R.G. Among 2319 patients admitted in a medico-surgical intensi- The enzyme neuraminidase produced by some viruses and ma- ve care unit in 1980 and 1981, i01 developed acute renal ny bacteriae unmasks a cryptantigen(Thomsen-Friedenreich- failure (ARF : blood urea > i00 mg/dl, blood creatinine Antigen, T-antigen). on the membrane of red cells and other > 2.5 mg/dl). ARF was related to surgery (n = 33), to one cells.The T-antigen react with T-agglutinins present in of the following medical insults : hypovolemia, cardiac failure, sepsis, rbabdomyolysis, exposure to nephrotoxic all human sera resulting in a damage of these cells.lncrea- agents (n = 36) or to several of these factors (n = 32). sing attention has been focused on the in vivo action of Median age was 62 years (range, 19-89). The management of neuraminidase as pathogenetic agent for the hemolytic ure- these patients included fluid challenge and/or furosemide mic syndrome (HUS) in phildren, Therefore, T-activation of (n = 85), mechanical ventilation (n = 73), parenteral nu- red cells was investigated in 60 surgical ICU patients trition (n = 36), hemodialysis (n = 32) and peritoneal with suspected sep'ticemia and positive culture results. dialysis (n = 2). Oliguria (urine flow < 400 ml/day for T-activated red cells were detected by apositive aggluti- 3 days) was present in 38 patients. Sixty-nine of the i01 nation reaction with peanut agglutinin anti-T (lecitin- patients died. Mortality was not significantly affected of Arachis hypogea) and by an indirect hemagglutination by the association of several etiological factors and by Ah test using rabbit antiserum against anti-T. In 17 pa- the medical or the surgical setting of the patient. Inci- tients a significant uncovering of T-antigens on red Ah dence of non oliguric renal failure was not influenced by cells was detected in vitro. In 5 of these patients an fluid challenge or diuretic administration: Dialysed and acute renal failure developped,whereas only 2 of 43 T-ne- non dialysed patients have a similar mortality rate. Pa- gative patients had renal problems. There is strong ~vi- tients who presented with a blood urea > 200 mg/dl during dence that the unmasking of T-antigens is not only limi- hospitalisation have a comparable mortality to other ted to red cells but also does take place in the renal ca- patients. pillary endothelium.According to these results the neura- Age Mechan. vent. Oliguria Dialysis Urea minidase induced activation of T-antigens may be an impor- <59 >59 + + - + <200 >200 tant factor in the etiology of acute renal failure in N 40 61 73 28 38 53 34 67" 40 61 adult septic patients. S 19 13m 18 14mm 7 23m i0 22 16 16 S = survivors. N = number of patients, mp<.05 - m~p <.01 Increased survival was associated with younger age, non oliguric ARF and the absence of mechanical ventilation. Our data suggest that the mortality of ARF in critically ill patients is more related to the general status of patients than to the severity and management of uremia.

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NUTRITIONAL STATUS AND IMMUNOLOGIC FEATURES IN PATIENTS HIGHZBLEEDING RISK IN ACUTE RENAL FAILURE : HEMODIALYSIS WITH ACUTE RENAL FAILURE (ARF). WITH DIPYRIDAMOLE AS THE SOLE ANTITHROMBOTIC AGENT. M. GarrY, J.M. Boles, P. Youinou, P. Miossec. H~pital Mor- Y. PAGE, J.J.LEHOT, B. ROUSSELET, B. BUI-XUAN, J.P. HOEN van 29200 Brest, France. J. MOTIN - D6partement d'Anesth6sie-R6animation - Pr J. MOTIN - H6pital Edouard Herriot - 69374 LYON CEDEX 08. 31 patients with ARF (creatininemia ~ 200 micromol/l) due to acute tubular necrosis were assessed for nutritional A feasibility study of the efficiency of Dipyridamole status and cellular immunity. The series comprised ]5 M, (DPM) was made to find out how to prevent clotting of the 16 F, mean age 54.3 years, range 19-83. The nutritional extra-corporeal circuit during hemodialysis (HD) in 13 evaluation included : mid arm muscle circumference (MAMC); high-bleeding risk patients (pts). The bleeding risk serum albumin (Alb), thyroxin binding prealbumin (TBP), factors were active gastro-intestinal bleeding (7 pts), transferrin (Tr). The immunologic assessment included : aeute head trauma (3 pts), haemoperieardium (2 pts), total lymphocyte (Ly) count, T Ly count, active (act) T others (3 pts). There were 2 bleeding faetors in 2 pts. Ly count ; skin tests using PPD, mumps and streptokinase- DPM was infused (25 mg/h) in the "arteria~ line of a streptodornase antigens. unipuncture HD cireuit filled with normal saline. Four

Most of the nutritional values were lower+ than those of benign bleeding complications (6 %) and no neurologieal 40 healthy controls : MA~+C males 22.9 - 3.5 vs 25.3 ~ 2.5 deterioration were noticed among 66 courses of HD. A cm (P< 0.002), Alb 2.91 - 0.78 vs 3.55 ~ 0.53 g/di clotting of the circuit (C.C.) needing to stop HD.(with- (P< 2.001), TBP 4| ~ 10 vs 29 ~ 5 mg/dl (P< O.OO1), Tr out any dangerous consequence) occured in 12 courses 148 T 68 vs 253 - 43 mg/dl (P< O.OOl). On the othe~ hand, (18.2 %). A platelet count above 100 O00/mm3 was associa- cellu~ar immunity was greatly depressed ~ Ly 1400 - 492 vs ted with a 23.3 % oecurenee of C.C., whereas there was 2384 - 627 per q ~mu (e

THERAPY RESISTANT BRONCHIAL ASTHMASUCCESSFULLY PLASMAPHERESIS: CONTROL OF VOLUME-SUBSTITUTION BY MEASURE TREATED WITH PLASMA EXCHANGE. R. Bambauer +, ~ENT OF COLLOID-OSffOTIC PRESSURE? A. Laggner, Y. Druml, M. Austgen ++, K. Mic,ka ++, P. Schlimmer ++ und K. Lenz, W. Base, G. Kleinberger, I. Dent. Medicine(Head: F. Trendelenburg ++ Prof.Dr.Dr.h.c.E.Deutsch)Vienna University, Austria. +) Department for Nephrology, ++) Department for The role of colloid-osmotic pressure (COP) in determining Pneumology at the Medical University Hospital, intravascular forces in health and disease is generally D-6650 Homburg/Saar, W-Germany accepted. In plasmapheresis the Dlasma is separated and has to be replaced by volume-substitution. This therapY Therapeutic plasma exchange (TPE) experienced has to be iso-colloid-osmotic to prevent patients from rapid world wide dissemination on the introduc- renal failure or pulmonary edema. tion of hollow fibre membranes. New areas of Material and Methods: 9 patients underwent therapeutic application where TPE combined with conservative plasmapheresis for various reasons. 25 plasmaseparations therapy appear very promising as a symptomatic were performed. COP, albumin(ALB), total protein(TP) and treatment procedure are increasingly reported. hematocrit(HK) were determined before and after Dlasma- In 1978 GARTMANN (Lancet 1978) reported for the Dheresis and calculated as % increase(+) or decrease(-). first time on the successful use of TPE for In group A 10 Dlasmaseparations were replaced by 5% human bronchial asthma. We were able to considerably albumin, group B: 8 nlasmaseoarations received 10 or less improve the condition of 2 patients with thera- packs of fresh-frozen plasma(FFP) and in group C received py resistant bronchial asthma using a techni- plasmasenarations more than 10 oacks of FFP. cally simplified TPE system. A 33 year old Results: Group A Group B Group C patient with medication dependent, therapy re- n=lO n=8 n=7 sistant bronchial asthma suffered no further + sd +sd + sd attack after only 1 exchange treatment. The condition of the patient improved so much that she Volume seoarated l 3.17 0.46 3.48 0.51 3.54 0.61 was discharged after 7 further treatments. The Volume infused 1 3.36 0;53 3.54 0.63 4.11 0.41 extremely high level of IgE decreased under COP % +0.90 18.12 -I.23 12.54 +1.48 7.72 plasma exchange and the pulmonary function also ALB % +12.95 10.67 +16.00 29.00 +3.31 9.24 considera'bly improved. A 52 year old patient TP % +8.75 7.94 +5.82 17.81 -0.20 6.92 with therapy resistant bronchial asthma also HK % -9.48 13.48 +2.88 14.49 0.00 10.38 showed a distinct improvement after only 3 treat- Discussion: After volume-substitution in plasmapheresis ments. no significant change in volume infused, volume seDarated The technique, the exchange method of plasma COP, ALB, TP, HK could be documented between the 3 groupm filtration and the course of the diseases trea- Only ALB increased slightly in groups A and B. Measure- ted are reported. ment of COP seems to be a reliable parameter for guiding volume-substitution therapy in plasmapheresis. Further- more it is easy performable and quickly obtainable in modern intensive care units. Central Nervous System

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MANAGEMENT OF PATIENTS ~ITH RAISED INTRACRANIAL PRESSURE PROGNOSTIC VALUE OF EARLY SOMATOSENSORYEVOKED POTENTIALS AND ACUTE RESPIRATORY FAILURE, L.Holzapfel, P.L. Blanc, IN THE ACUTE STAGE OF POSTANOXIC AND TRAUMATIC COMA. L.Thomas, A. Mercatello, M. G6rard, D. Robert, A.Bertoye. D. Zegers de Beyl ~, S. Borenstein ~2 E. Brunko 2. Dpt of H6pital de la Croix-ROusse, Lyon, France. Neurology~ H6pital Erasme and Brain Research Unit 2, Patients with raised intracranial ~ressure (ICP) may re- University of Brussels, Belgium. quire ventilation with positive end expiratory pressure The prognostic value of somatosensory evoked potentials (PEEP)if acute respiratory failure (ARF) is associated. (SEPs) was evaluated soon after onset of coma secondary But PEEP can increase ICP and reduce arterial pressure to brain anoxia, brain ischemia after cardiac arrest or (AP) ; these changes could critically reduce cerebral per- head trauma. The SEPs were correlated with neurological fusion pressure (CPP) and initiate neurological deterioration. state and SEPs were followed over several weeks in surviving patients. SEPs were elicited by unilateral stimula- 10 patients with coma and raised ICP were studied;age tion of the median nerve at the wrist. SEPs were recor- was 37* 18 y; 3 had meningitis, 3 encephalitis, 4 head ded at the wrist, Erb's point (NIO), the neck (N15) and trauma. During 5.6• 3. I days, PEEP was 12.4 ~ 3.2 cmH20, the contralateral parietal (PI5-N20-P25 complex) and fron- FI02,47~5, Pa02 83 ~ 19 mm H~, body temperature 37.9 +1.3 ~ tal scalp regions using a Pathfinder II (8 channels) from C and body weight was increased by 5.2 ~ 2.3 kg due to Nicolet Biomedical. The analysis time was 50 msec. fluid therapy for hemodynamic support . ICP was monitored Our group of 30 patients with acute anoxic-ischemic brain in 8 patients with an epidural pressure-transducer (Phi- injury showed that no patient with major abnormality of lips) and in 2 With an intraventricular catheter. Technics the N20-P25 complex recovered; they remained in a vegeta- for reducing ICP were : - hyperventilation (PaC02 30 + 4 tive state and SEPs remained grossly abnormal. This pre- mmHg~ adaptation to the respirator with pancuronium ~o- dictive value of the abnormality of the N20-P25 complex mide - drugs given on a regular basis or on an+emergency is not found in the group of patients with acute head basis when ICP was ~ 25 mm H_' Mannitol: .87 .33g/kg/ trauma. Major abnormality of the N20-P25 complex bilate- day and Pentobarbital(P) 35 !glO mg/kg/day; serum P level rally hours after trauma did not exclude recovery of was 76 ~ 55pm/l (2.2 measurements per oatient)#In 2 oa- higher cortical function after several weeks. tients ventF~cular drainage was performed (112 _ 47 ml/ day and 335 _ 261 ml/day). 5 patients needed Dopamine 13.4 ~ 2.5v/kg/mn to maintain MAP~ 80 mm Hg. PEEP was briefly discontinued in 8 patients (10 ~ 8 times oer oatient) when CPP was 435 mm Hg and promptly restored after action of adequate therapeutic procedure. Resul~ (base line values) :ICP was 21.8 ~ 4.7 mm ' MAP : 86 - 11 mm Fig and CPP iMAP-ICP): 64 • 9 mm Hg. H,7gDa - tients survived (2 with neurological deficit), 3 eventually died, but pulmonary and neurological lesions were not directly responsible for the death. Conclusion : patients with raised ICP and ARF can be treated with PEEP and fluid infusion provided that ICP ~ ~in~alomednC~.d adequate therapeutic procedures are taken

194. 196

AUDITORY BRAINSTEM RESPONSES IN POST-TRAUMATIC COMATOSE SHORT LATENCY MEDIAN NERVE SOMATOSENSORYEVOKED PATIENTS: ASSESSHENT OF BRAINSTEM DAHAGE AND PROGNOSTIC POTENTIALS AND EEG IN ACUTE ANOXIC COMA IHPLICATIONS. E.Facco, A. Nartini~ Zuccarello +, H. H. WALSER, H.M. KELLER, NEUROLOGISCHE KLINIK, Chiaranda, G Trincia§ G P. Giron. Institute of UNIVERSITAETSSPITAL ZUERICH Anaesthesiology and Intenslve Care, Dept. of Otolaryngo 21 patients in acute anoxie coma after cardiac surgery logy-sect, of Audiology~ and Dept. of Neurosurgery+, - with cardiopulmanary bypass (9 patients), after cardiac University of Padua, Italy. infarction (7 patients), accidental anoxia during Auditory brainstem responses (ABRs) were recorded and ana anesthesia (2 patients), hemorrhagic shock (I patient), ly~ed in 35 patients with severe head injuries, who we~ drowning (i patient) and poising by fumes (1 patient) admitted to the intensive care unit] of the university of were examined with short-latency median nerve somato- Padua over the last 12 months. The patients were selected sensory evoked potentials (SEP) and EEG. as follows: a) age range from 15 to 60 years; b) presence of a supratentorial post-traumatic lesion and absence of For the SEPs, the amplitude ratio (R) between the first primary brainstem damage at the CT scan; c) absence of negative response recorded from the contralateral temporal bone fracture at the X-ray skull films;d) absence parietal scalp (N20 - P25) and the negative response from of an anamnestic otologic pathology; e) normal canal oto- the neck at the level of C2 (N14), and the latency microscopy with normal tympanogram. difference between the contralateral scalp response and The level of consciousness was defined using the Glasgow the eervikal response (Central Conduction Time, CCT) Coma Score evaluation and the brainstem disfunction with were used as parameters. For the EEG, visual inspection a clinical assessment of brainstem reflexes and posture. was performed only. The CT scan findings were classified in four grades, rela A significant difference of the mean value of R was ting to the onset of descending transtentorlal herniatio~ observed in the group of patients with anoxic coma with The ABRs were recorded and analyzed many times according a measurable response, as compared to an age- and sex- to the clinical evolution from the moment of admission to matched group of healthy volunteers (p~: 0.005, T-test the final outcome. Patients who died from causes unrelated of the means). No significant difference of the CCT was to the brain were excluded from the analysis. found between the two groups. Furthermore a significant The results show that a severe br~in~em disfunction, as relation betw~n the mean value of R of the 2 hemispheres defined by ABRs, is closely correlated with high mortality and the clinical outcome was also found (p ~ 0.002, while a normal brainstem function is indicative of a good Fisher's exact probability test). prognosis. ABR seems to provide more reliable information about brainstem damage than the neurological signs and The only EEG pattern with a clearly dismal prognostic is closely correlated with CT scan findings. Information significance - other than the pattern of electrocerebral from these techniques may thus supplement that obtained silence - were suppression bursts. Amplitude of the from clinical examination, allowing early prediction of cortical SEP is therefore considered as the most final outcome. promising prognostic parameter in acute anoxic coma 20]

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URAPIDIL VERSUS PROPRANOLOL IN THE NANAGEN2NT OF CEREBRAL TISSUE ACIDOSIS DURING SODIUNNITR0- POSTHYPOTENSIVE HYPERTENSION IN NEUROSURGICAL PRUSSIDF-INDUCED HYPOTENSION AND ITS PREVEN- PATIENTS. TION BY THIOSULPHATE. D.Heuser, H. Guggenberger, R. Schneble, J.Ebe- H.Guggenberger, D.Heuser, P.J. Norris*, Depart- ling;Department of Anaesthesia,University of ments of Anaesthesia, Universities of TGbingen T~bingen, TGbingen, FRG (FRG) and Leeds*(UK) It is well known that rebound Nypertension Sodiumnitroprusside (SNP) may be regarded as following discontinuation of Sodiumnitropruss- drug of choice to electively induce arterial ide can be hazardous and possibly outweigh the hypotension, especially when very low levels benefits of deliberate hypotension, mainly at of systemic blood pressure (NABP) are desi- neurosurgical interventions, thus emphasizing rable. However recent animal studies have in- the necessity of an adequate posthypotensive dicated a progressive development of cerebral therapeutic management. In a controlled clini- e.c.f, acidosis during administration of the cal study we compared the effectiveness of drug even when normal CBF values are main- Propranolol with that of a new antihypertensive tained and the critical dosage of SNP is not drug Urapidil on 36 patients subjected to con- exceeded. In order to elucidate whether this trolled hypotension in the course of neurosur- acidosis is due to cerebral cyanide intoxica- gical interventions. In 24 patients intracrani- tion, we tried to prevent development of e.c.f. al interventions were performed, whereas 12 acidosis by simultaneous administration of patients (volunteers) with lumbar disc opera- thiosulphate in 8 cats out of J9 animals sub- tions served as controls. One half of each jected to controlled hypotension with SNP. group was treated with either Propranolol or E.C.F. pH was measured continuously with pH Urapidil pre- and intraoperatively, the desi- microelectrodes implanted in the cerebral cor- red hypotensive level was 66% of the control tex of the animals. In both groups of animals value. At certain intervals we neasured Plasma MABP was lowered to 30 mmHg for 30 minutes, Renin activity, Catecholamines, free fatty followed by a period of 15 minutes with 28 acids, arterial blood gas tensions, electro- mmHg. The results indicate that atSNP dosage lytes, hemoglobin, P.C.V., whereas NABP and of

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NOSOEOMIAL INFECTIONS IN PATIENTS WITH SEVERE HEAD SEVERE ACUTE PNEUMONIAS AND CYTOMEGALOVIRUS (CMV) - INJURY. Margaret HEMMER g Robert HEMMER, Depart- J.J.Lehot, Y.Page, D.Perrot, B.Delafosse, C.Guillaume, ments of Surgical intensive Gate and of Infectious J.C.Tardy, B.Bui Xuan, J.Motin - Service de R~animation - Diseases. Centre Hospitalier Luxembourg - LUXEMBOURG. HSpital E.HERRIOT - F 69374 LYON CEDEX 2

We studied retrospectivel V 91 consecutive patients We studied, between october 1980 and august 1982, 18 with severe head injur V ( Glasgow coma scale 3 to B, cases of pneumonia which required mechanical respiration most under G ) to determine the incidence and the and in which CMV was involved. Antibody titers were deter outcome of infection and the value of prophv1actic mined by complement fixation, immunofluorescence and antibiotics. Mean age WaS 32 veers ( range 1-7G ); ELISA (IgG and IgM for the last two methods). In most of ell patients had aorticnsteroid treatment end 45 the patients, a check-list for pneumonia in immunocompro- were induced to barbiturate comb for ICP control. mised patients was realised by means of bronchic endosco- 59% received prophvlsctic antibiotics, mostly Peni- py (bacteriology; Myco-bacterias, Pneumocystis, Mycoplas- cillin G, sometimes in association with Gentemicin. ma, Chlamydia, Legionella, mycology, virus). CHV were is~ 45 patients (32 with prophvlectic antibiotics and lated on human embryonic lung diploid cells. 13 without) had one or more episodes of infection. Nearly all the patients had underlying diseases (hematol Tvpee of infection were: 27 Septicemias, 22 urinar V gic diseases, marrow transplantations, lung or heart tract infections, 14 Sinusitis, ll earl V Pneumonias, transplantation, plasmocytom, systemic lupus erythemato- 3 late Pneumonias, 3 Meningitis, 30titis, 2 Wound sus, great obesities, chronic respiratory failures, carc~ infections. Microorganisms responsible for severe nologic or vascular surgery, intestinal amibiasis). The infections (i.e. septicemia, pneumonia and meningi- chest x-ray often showed a bilateral alveolar pattern, an tis) were: 9 S.epidermidie; G Streptococcus faecalis; intersticiai pattern was seen in 28 per cent. Pulmonary G E.coli; 5 S.aureus; 5 Peeudomonea sp. (among them pathologic findings showed cytomegalic inclusions cells one P.maltophilie); 5 Proteus sp.; 1 Bacteroidee fre- in 2 of 8 cases, and once in myocard. ELISA method had gills; i Acinetobacter calcoaaeticua ver. anitratus; the best sensitivity, but 6 of 11 patients in which CMV 1 Flavobecterium ap.; 1 Corvnebacterium "group J M "; was isolated in the lungs presented no seroconversion. 1 Candide albicans. In 12 patients infection was Other infecticas diseases Were associated in i0 patients. leading to death. All microorganisms responsible for 11 patients finally died. The average duration of mecha- severe infection were resistent to the prophv1actic nical respiration was 5 weeks in the survivors. This stu- antlbiotios administered. dy emphasizes the role of CMV in severe pneumonias, often We conclude (1) Nosocomial infection oocured in 49% associated with other pathogens. We underline the usual of our patients with severe head injur V. (2) Prophv- absence of specific symptoms and frequent negative sero- lactic antibiotics did not prevent infection. (3)The logies in immunocompromised hosts. high proportion of opportunistic and often multire- sistant microorganisms ( 5.epidermidle, P. meltophi- liB, Acinetobecter sp., Flsvobecterium sp., Corvne- bacterium " group J M ", Osndlda albicans ) suggest that severe heed trauma patients are compromised hosts at high risk for nosscomial infections.

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PULMONARY ARTERY CATHETER-RELATED SEPSIS. W. Kaye, M. THE RELATION BETWEEN BUCCO-PHARYNGEAL FLORA AND Wheaton, G. Potter-Bynoe. Brown University-The Miriam INFECTIOUS PNEUMONIA DURING MECHANICAL VENTILA- Hospital, Providence, Rhode Island, U.S.A. TION IN I.C.U. PATIENTS. Several reports have documented that' the risk of catheter C. GRANTHIL, S. VALERO, T. FOSSE, d.L. BLANC, (cath)-related sepsis for intravenons caths increases M. ALAZIA, Dep. Anesth. R6a.(Pr.G. FRANCOIS) after 3 or 4 days (d) of cannulation. However, there is G.H. La Timone, 13385 Marseille, France. a paucity of data examining the relationship between Bronchopulmonary infection is known as being duration of cannulation and oath-sepsis from pulmonary the most frequent complication of mechanical artery (PA) caths. The purpose of this study was to ventilation. The predisposing factors for determine the overall incidence of PA cath-related superinfection are numerous and well documented. bacteremia and the relationship between length of time However the initial localisation of these germs in place and incidence of infection. From March through cannot always be determined. Seventeen tracheo- August, 1982, 239 PA caths were inserted. All were tomized patients were studied in order to followed prospectively, but complete data were available examine the relationship betweencro-pharyngeal for 120 PA caths (in 107 patients) which were inserted flora and broncho-pulmonary secondary infections. percutanecusly into internal jugular or subclavian vein. All the patients were mechanically ventilated A rigid protocol was followed to provide aseptic tech- for reasons other than pulmonary infection. nique for PA cath insertion, inspection and care of Buccal, pharyngeal and bronchial samples were insertion site every 48 hours, and removal. After collected within 24 hours of tracheotomy.Durlng removal, the excised oath tip was rolled across a blood the study-period 9 patients developed secondary agar plate which was then incubated at 37 ~ All colony pneumonia as defined by clinical, biological and types were enumerated and identified. Following the radiological criteria. The results show: criteria of Maki et al, 15 or more colonies (pos cult) I) a colonisation of the buccopharyngeal cavity were considered to signify infection. Cath-related with a high prevalence of negative gram bacilli bacteremia was determined by isolating the same organism 2) an early tracheo-bronchlal colonisation by at from the blood. least one the oro-pharyngeal germs in 16 out oE The incidence of pos cult was 9% (Ii/120). Non-fatal 17 patients. bacteremia occurred in 2.5% (3/120) overall or in 27% 3) that the germ held responsible for the super- (3/11) pos cult. The incidence of pos cult relative to infection in the 9 cases of secondary pneumonia duration of qannulation was: 1 d, 2.5% (1/40); 2 d, 2.9% was always present in the initial buccopharyngeal (1/35); 3 d, 21% (4/19); 4 d, 0 (0/8); 5 d, 11% (1/9); samples (Proteus:3; Klebsiella: 2; E. coli: 1; 6 d, 40% (2/5); more than 6 d, 50% (2/4). The incidence pseudomonas Aer.: 1; enterobacter: 1, Serratia: of pos cult for 2 days or less was 2.7% (2/75) vs. 20% I ). Given the above circumstances, it is (9/45) for three days or longer. reasonable to perform an initial clinical exam We conclude: (i) there is a real risk of infection (9%) as well as systematic bucco-denta] and naso- and bacteremia (2.5%) for pulmonary artery catheters; pharyngeal care in order to reduce local bacterial (2) after 2 days in place, the risk of infection growth. increases sevenfold. 203

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VALUE OF EARLY BACTERIOLOGICAL EXAMINATIONS FOR THE MANA- THE USEFULNESS OF SKIN TESTS IN AN INTENSIVE CARE UNIT. GEMENT OF SYNERGISTIC BACTERIAL GANGRENES. Fiehelle A., P, DAr~AS, D~t of Anesthesia, Hosp.Bavi~re, University Mourlon M., Seardin A.~ Orsoni J.L., Desmonts J.M. of Liege, Belgium. Synergistic bacterial infections are involved in most ex One hundred and six traumatized or oost surgical oatients tensive cellulitis oceuring in patients treated by routine admitted to our intensive care unit were followed we~kly anLibiotherapy. This study was performed to evaluate the by skin tests with three types of antigens (PPD, candi- value of early bacteriological diagnosis snd adequate anti din, varidase). Anergy is defined as no reaction to any biotherapy CAB)on the prognosis. of the three antigens while reactivity is defined as one Patients and methods. Eighteen patients with extensive gan or more oositive reactions. The factors related to aner- grene were studied (12 men 6 women). Mean age was 57 years gy are : older age, renal failure, major septic compli- (24-82). Eleven patients had signs of systemic toxicity ; cations, lenght of hospital stay and death. Hore inte- mecehanieal ventilation was required in l] patients. Anu- resting the outcome of the ~atients according to their ric renal failure observed in i patient wss treated with skin t~treactivity : of the 56 reactive oatients at the hemodislysis. According to the location of gangrene, pa- beginning of the study, 61 remained oositive and 4 of tients were divided in 4 groups : perineal (8), abdominal them died; among the 5 oatients who became anergic 4 wall (2), limb (6), neck (2) eellulitis. Results. Eleven of 18 patients had been treated before ad died. Of the 40 anergic patients, 26 remained anergic mission with penieilline G ossoeiated with imidazole deri during all the study and there were 17 deaths; among the vate (n=9) and amimosides (n=6). Four patients developped 14 oatients who became reactive only 2 died. eellulitis despite treatment withampicillin. Bacteriolo 66 reactive 61 reactive; 4 deaths (6 %) 5 anergic; 4 deaths (80 %) p40.01 gieal examinations on admission was negative in 5 patients; only gram negative stains (GN5) were isolated in patients 40 anergic 26 anergic; 17 deaths (65 %) 14 reactive; 2 deaths (14 %) D<0.01 having sntianaerobic prophylaxis (n=4) ;GNS were associated with different types of streptococci (n=6). Shaphyloco Those anergic who became reactive, had a good outcome eci were observed in association with different types of comnared to those who stayed positive during all their streptococci (n=5), GNS in=l) ; in one patient, D.Strept. i~ness Among the factors which influence the skin tests was associated to El. perfingens. Specific antibiotics reactivity, we retain the caloric intake : the anergic according to bacteriological results stopped gangrene ex patient had a mean caloric intake of 25.5 kcal/kg day, tension in all patients. Four patients died ; the death compared to a mean of 41.2 kcal/kg day for those who re ~ was related to the septic shock in two patients and to covered a nositive reaction. Other factor will be discus- other cause in two patients. sed. Conclusions. Early identification of microbial sgents In conclusion, the reoetition of skintests allowed us to involved zn synergistic-bacterial gangrene has likely evaluate the efficacy of treatment particularly caloric played a msjor role in the management of these severe intake and to Dick uD the high risk oatients in the infections. Specific antibiotherapy associated with surge intensive careunit. ry may improve significantly the prognosis of these infec tioms.

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ELECTROMYOGRAM (EMG) AS DIAGNOSTIC AID IN TETA- IMMUNOLOGICAL ASPECTS IN SERIOUSLY TRAUMATIZED NUS. H.P. Ludin, F. Roth, University Hospital, PATIENTS. F. Murillo, M.A. Munoz, A. Nunez, C. Berne, Switzerland Ortiz-Leyba, Ciudad Sanitaria Virgen del Rocio, In developing countries tetanus is still a real Seville, Spain. problem in respect to both occurence and mortality rate. In all countries with high medical Immunodeficiency has proved to play an important role in the outcome of critical patients. The standard it has become an uncommon disease. In present communication will investigate, in a our own hospital the number of tetanus cases prospective manner, the sensitivity and precoci- per year has decreased from iO - 12 in the sixty of the different parameters measuring the ties to 2 - 3 in the last three years. Because immunological competence, as well as its changes of this relative rarity, very few clinicians as an indez of septic risk. see more than an occasional case. The diagnosis Nineteen patients were studied. All of them were is therefore often missed or recognized quite seriously traumatized ( multiple trauma or head late as it is still based on clinical observa- injury ). Within the first 24 hours, they were tion only. Till now no laboratory or other test submitted to the following: Skin testing (ST), is accepted, although various suggestions have T lymphocytes, B lymphocytes, total lymphocyte been made. The problem of diagnosis is further count, and total hemolytic complement (CH50). complicated because cases of pseudotetanus are In a sub-group of seven patients, the same study occasionally seen. Since 1978 we have taken was repeated a week later. EMGs in all patients who were suspect for teta- The results showed that T-rosettes was an useful method for prediction on septic risk (p 0,05) nus but whose case history or clinical symptoms as ST were, but with more promptness and sta- left some doubt. In 6 cases the EMGs were typi- tistic significance ( p 0,01 versus 0,05 ). CH50, cal for tetanus with a shortening or absence of B lymphocytes and total l~aphocyte count were the silent period after a stretch reflex or not specific as an index of evolution nor of after supramaximal stimulation and with a conti- septic death or complications. nuous activity of motor units which could not be As a conslusion, the determination of T-rosettes influenced voluntarily. In two patients we found has proved to be, in this group of patients, a a normal EMG. In all 8 cases the acuracy of the valuable test, higher than ST, as a prognosis electromyographic diagnosis of tetanus was con- of septic complica~i6ns and as a rapid checking firmed by the further development of the di- of im/nuno-competence state associated to high sease. Therefore we think that Electromyography risk. is a very useful and reliable tool either to confirm or to rule out the diagnosis of tetanus. Infection in the iCU

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BACTERIOLOGIC DIAGNOSIS OF NOSOCOMIAL PNEUMONIA IN PP~EDICTION OF SEPTIC SHOCK UNFAVOURABLE OUTCOI~E VENTILATED PATIENTS. A. Bouchama, A. Akesbi, J. Pierre, V.A. Gologorslcy, B.R. Gelfand, V.E.Bagdat jev, A. j. P. Brun, F. Viau, J. Chasfre and C. Giberf. R6animation Schichov, l.J.Lapschina. 2-rid Moscow ~edical In- M@dicaLe, H6pifeL Bichat, Paris, France stitute, ~oscow, USSR. To determine the relative cuLturaL accuracy of protected A comparative analysis of different physiologi- specimen brush (PSB) through a fLexibLe bronchoscope in cal parameters was made for prediction oZ out- nosocomiaL pneumonia of ventilated patients, we compared come in 116 patients with septic shock due to this method with histoLogicaL and bacterioLogicaL peritonitis. examination of pulmonary specimen. The procedures were Indicator dilution method, intravascular pressu- made just after death when venfiLatory supply was stiLL re measurements,blood gas analysis and poliear- in place. SampLes via the PSB were taken into e branch diogram were used to investigate hemodynamic of the anterior basal bronchus of the Left Lower Lobe. and oxygen transport parameters.Cardiac perfor- Immediate Left fhoracotomy was performed fo obtain 6 mance was estimated by volume loading and alma- peripheral specimens from the corresponding segment. wing Starling curves. BacterioLogicaL specimens were eventuaLLy crushed, Blood volume and arterial pressure did not va- vortexed vigorously in I mL of medium and quanfilative ry in survived and nonsurvived patients during cultures performed. intensive care.There was significant differen- 26 patients were studied. HietoLogic evidence of ce in pulmonary arterial pressure and resistan- pneumonia was associated with pulmonary cuLture > 10 ~ ce which increased in nonsurvived patients and cfu per g. A correL~fio 0 between PSB and Lung cultures remained higher than normal up to the lethal was showed (r = 0.57 ; p <0,.01). For patients ventilated outcome.The most considerable difference was Less than 10 days, a better'correLation was found marked in cardiac output,left and right cardi- (r = 0.71 ; p < 0.001). Wi~h a threshold of 103 cfu per ac work,and heart performance index.These pa- mL for PSB quantitative cuLtures, no false negative rameters are considerable lower in nonsurvi - results were observed for the 26 patients and for the vers at all stages of the investigation.Accor- 55 microorganisms. With a threshold of 10~ cfu per mL, ding to received date unfavourable outcome pre- faLse positives wereonLy 25 %, but false negat]ves were diction or death risk indices were as f~llo- observed (17 %). We conclude that cuLture results wing: cardiac index less than #L/min./m=; left obtained by PSB should be useful in differentiating cardiac work less than 6kgm/min.;right cardiac bacterial coLonization of the airways frbm pneumonia work less than 1.Ykgm/min.;total ~ascu~ar rein ventilated patients in the presence of diffuse sistance higher than 2000dynes/ca /secY.lpulmo- pulmonary infiLtrates. n ya~i vaGcular resistance higher than 200dynes/ cm /sect;slope of ventric~lar performance curve less than 0,15L/min./m /tort;arterial pO 2 less than 70 mm Hg;arterial-v~nous gradient of oxygen content higher than 5ml/10Om~; oxy~oen availability less than #OOml/min./m~; oxygen extraction higher tan 40%.

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MICROBIOLOGICAL VALUE OF SELECTIVE STERILE BRUSH CULTURE ~NTENSIYE THERA~I AND RESUSGITATION OF SEPTIC IN ACUTE RESPIRATORY FAILURE. E. Quintana, A. Roglan, SHOCK. L.F.Kosonogov, V.N.Rodionov, J. Vall~s, S. Armengol, J. Castella, ~. Puzo, V. Ausina, ~edical Institute, Voronezh, USSR. A. Artigas. I.C.U. Hospital de la Santa Creu i Sant Pau. The efficiency of hemosorption and subsidiary Barcelona. Spain. circulation with extracorporal oxygenation Due to controversy in the microbiological diagnosis of was studied in 32 patieats with septic shock. pulmonary infection (PI), the following prospective study Signs of the liver and kidneys diaseases,high was made. plasma toxicity, homeostatic disorders were revealed by clinical and laboratory findings. M~THODS: 30 selective bronchofiberscopic aspirations with Before hemoscrption sanative operations were doublelumen Barlett catheter (BAB), were made in 28 me- performed to all the patients, and they chanically ventilated patients with clinically demonstra- received conventional intensive therapy ted respiratory infection. Bacterial cultures of lower without positive results. Hemosorption gave a respiratory tract samples with BAB and tracheal aspirates marked clinical and laboratory effect in all (TA) were compared. Blood, urine and respirator-air cul- observations. In q2 patients with marked tures were madesimultaneously. Studies wer~ repited eve- hemodynamic disorders hemosorption was carried ry 4 days when PI persisted. out by subsidiary circulation with blood RESULTS: Mean number of microorganisms par sample was oxygenation from the vein into the artery. 0,83~ 0,65 in BAB and 1,73~ 0,37 in TA (p6 0.001). The Stabilization of the general state normaliza- microbiological culture of BAB samples was positive in tion of the functions of the liver and kidneys 70% of cases, w~th monobacterial culture in 66,6%. Micro- sharp decrease of plasma toxicity were clearly biological results of BAB and TA were identical in 33,3% observed after the given therapy. 30 patients and partially coincided in 52,3%; a total difference was out of 52 recovered. Hemosorption has a great observed in 3 cases. The Gro3r~negative microorganisms detoxicologic effect with intensive therapy predomined (84,6%: Pseudomonas spp and Serratia). Only of septic shock. 11,5% were Gra~positivr and 3,8% Candida spp. The blood cultures were negative in all cases and respiratory-air cultures were positive en 3 cases. These date were rela ~ ted to duration of mechanical ventilation and radilogic pattern. CONCLUSIONS: BAB is a more selective technique in the dia~nosi~ of PS in patients with acut~ pulmonary failure. Metabolic Problems, Varia 2o5

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ENDOCRINOLOGY OF THE CRITICALLY ILL . A.Luger, Acute Poisoning.A comparison of experiences in 1971 and H.Graf,R. Prager,H~K.Stummvoll,M.Weissel 1981. D.GILLMANN, M.REUSS, L.S.WEILEMANN, H.P.SCHUSTER Departement of MedicineII,University of Vienna II. Medizinische Universit~tsklinik Mainz. Vienna,Austria Methods and patients: 330 cases of acute poisoning were Hormonal status of prior untreated patients ad- treated in 1971 and 340 in 1981. Patients were compared in mitted to the intensive care unit were evaluated respect to biosocial data, incorporated poisons, severety of intoxication and treatment. Stress hormones (cortisol,prolactin,growth hor- Results: The ratio of female to male pat. varied from mone),thyroidal hormones (T4,ET~,TSH) and the 1.25:1 (1971) to 0,8:1 (1978) (p< 0,01). Alcohol intoxi- renin-angiotensin-aldosterone system were stu- cation increased significantly in 1981 (p<0,01) wheras died by RIA in 15 pts with various underlying clinically treated hypnotic drug intoxications decreased. acute diseases.Patients with abnormal serum-elec Severety of intoxication was judged by 7 parameters: loss trolytes or blood glucose were excluded. of consciousness, loss of pain reaction, circulatory arrest and/or respiratory failure, areflexia, arterial Stress hormones: As anticipated cortisol and hypotension SAP< 90 mm Hg, hyperglycemia> 200 mg/dl, arti- p~o~a~n-[~[s were elevated(cortisol 4o,97~ ficial respiration. 2 or more of theses parameters were 2o,89 ug/dl((normal 6-19 ug/dl)) prolactin 59,6+ present in 27 (1971) and 33 (1981) pat. and the number of 32,4 ng /ml((normal rangel-25 ng/dl)).Growth pat. with more than 3 parameters increased significantly. hormone levels were not elevated in our pts Of the most severe intoxications 9/Z7 (1971) resp. 15/33 (1,43• 1,o2ng/ml, normal range I-5 ng/ml). (1981) were due to barbiturates. In 1971 39% of pat. were Thyr2!da!_h2~m2nes:T4,ETR,TSH were normal in all treated in the ICU, in 1981 only 15% (p<0,01). There was pts. (T4 8,46 ~ 3,57,normal 4,4-14,4 Ug/dl;ETR no significant difference in frequence of unconsciousness, o,98• o,87-1,13;TSH 4,57• 1,o3,normal loss of pain reaction, areflexia, light reaction of pupils, -6uU/ml)Thus at admittance the pts did not show arterial hypotension and hypothermia, but pat. with heart the well known "iowT3,T4-syndroms rate<80/min, circulatory arrest, respiratory failure, #~!DC~gis163 All levels artificial respiration were more frequent in 1981 (p< of this system were in the normal range (renin 0,01). Gastric lavage was performed in 80% in both periods, 1,7~o,91 ng/ml/h,normal o,1-2,62ng/ml/h; angio- forced diureses decreased from 48% (1971) to 13% (1981) tensin II17,23 Z 5,71 pg/ml;normal 8-25 pg/ml ; (p

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HYPOADRENALISM IN ACUIE STRESS. W.E.I.Finley, 3.I.McKee. HEMOFILTRATiON IN ACUTE RENAL FAILURE (ARF).J.Feret,N.Si- Western Infirmary, Glasgow, U.K. mon~J.Verrier~O.Simons~D.Duru 7 and F.Nouailhat.R4animatlon Adrenocortical hypofunction is not uncommon in critically et Urgences m4dicales,CHl POISSY,78303,France. ill patients and daily serum cortisol measurements may Twenty-two courses of hemofiltration(HF) were assessed in have prognostic importance. 1 In a previous study of 132 ten patients with ARF(mean age 65 years;range 38-79). The patients 34 who had oortisol levels remaining <350 nmol/l initial affection was peritonitis in 3,pancreatitis in 2, all died. This report refers to a trial of replacement ARDS in 2 and septicemia in 2 patients. The rotation speed therapy in cortisol deficient patients. Using a radio- ~qf the three pumPS used'during HF was either electronical- immuno assay [Corning], daily 08.00h serum cortisol ly monitored or manually adjusted according to lost and measurements were made on 70 consecutive patients, who reinjected volumes.Thirteen hollow-fiber polyacrilonitrile were allocated randomly to one of 2 groups. 18 [25.7%] filters were used (ASAHI Pan20).Post-dilution reinjection patients had cortisol values below the critical level of fluid was buffered with lactate(35.75 mM/l)in 18 courses 350 nmol/l. I 12 of these had l-hour adrenal stimulation and alternate lactate/acetate in 4. The vascular access tests using synthetic aorticotrophin. All tests were was femoro-femoral(16 courses),subclaviam-femoral(4)and a negative, All patients received treatment appropriate double-lumen venous catheter in 2 patients.Throughhigh to their conditions but additionally patients in group 2 blood-flow 21.5~5~41 were exchanged in a mean time of received hydrocortisone replacement while group 1 acted 229~70min and with a mean filtration rate of 95.5• ms controls. Table I reports weight loss ( W)and extraction of urea(U) creatinine(C),aminosides(A),mezlocillin(M)and vancomycin(V) Results: 18 patients 08.OOh cortisol <350 nmol/l. W(kg) U(mM) C(mM) A(mg) M(,g) V(mg) No. of patients Hydrocortisone Died .n 22 19 13 5 4 1 Group I 10 No s m• 3.05• 655~270 9• 24• 3.56• 200 Group 2 8 Yes table 2 shows plasma values measured before (T0)and after Oifference between outcome R <0.002 (T1 )HF. pa mM/IlKmM/llCa raM/lIP mM/IIUmM/IIC..~M/1 IProt@l It is concluded that cortisol replacement therapy may be Oeneficial in some severely stressed patients. The To 1132• 14.5 o t 2• 1,•174 39 8 420• 56• I duration course end eetiology of the observed T 1 113~• 1'3.6•177177 1257•177 adrenocortical insufficiency will be discussed. Conclusion:HF with high blood-flow is adequate for metabolic adjustment and water depletion in ARF in intensiye care I. FINLAY, W.E.I. MCKEE, J.l. Serum cortisol levels in patients. Antibiotics removal was high even for vancomycin, severely stressed patients. Lancet 1982 i 1414. a non-dialysable substance 206

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USE OF TAUROLINE AND DQPAMINE OR DOBUTAMINE IN INTENSIVE CARE IN DEVELOPI~G COUNTRIES: "CUI DHOCKED HYPOVOLEMIC RATS. PG.WASER, E.BIBLER, PRODEST"? A.Gasperi, Maputo Central Hospital, Pharmakologisches Institut, Universit~t ZUrich. M aputo, Peoples' Republic of Mozambique.

Tauroline is applied intravenously as a chemothe- Intensive Care Medicine still represents a "no- rapeutic in infections and septic cases. A veery" in most developing countries, because hypothetic interaction of injected tauroline on ot~er priorities have to be dealt with by local the hypertensive effect of dopamine or dobutamine was tested in hypovolemic rats and compared health authorities, and because of the need of with an injection of saline instead of tauroli- very expensive investments. Nevertless, within dine. The blood pressure was lowered in WISTAR- the frame of projects of technical cooperation rats by reducing the blood volume by Iml within between industrialized and developing countries, 1 minute. The blood pressure was continuously some attempts have been made to establish and, measured with a Statham blood pressure transdu- where already existing,to ameliorate project~ in cer connected to a cannula in the carotid artery and recorded on a Beckman Dyonograph. 4 rats the field o9 intensive care medicine. The received 3 minutes after th~ artificial blood Author, after a five years service,spent as res- pressure decrease 0,6 x I0 mol dopamine, follo- ponsible os projects of technical assistance in wed by an infusion of 2 ml Taurolin ~ NaCl or intensive care and anaesthesiology, in african 2 ml saline within 7 minutes. 4 rats received developing countries, comments in the present an infusion of 0,6 x I0 ~mol and 2 ml Taurolin paper the following points: 2% or saline simultaneously. These procedures were repeated several times with the same rats. - definition os intensive care: possibilities In all experiments, there was no significant and limits in developing countries. difference in the sympathomimetic effect of - practical aspects linked with the speciality, dopamine. 2 hypovolemic rats reveived 0,7 xlO -6 such as teaching, training, type of technology mol dobutamine, followed by 2 ml Taurolin needed. NaCI or sal!~e. 2 rats received an infusion of 0,7 x I0 mol dobutamine and 2 ml Taurolin ~. - priorities which should be taken in conside- 2% or saline simultaneously. In these experiments, ration when planning projects os technical aid. taurolidine even increased the pressure action of - costs versus benefits analysis. dobutamine when injected simultaneously. Therefore Finally, on the basis of previous experience, it must be concluded that taurolidine has no the Author presents some suggestions to those, depressive effect on the vasopressive action of dopamine and shock cases. It was also shown in (institutions,aid organisms)who mightbe inter- previous experiments, that there are no inter- ested in projects of technical cooperation actions of taurolidine with some other biogenic with developing countries in intensive care amines as epinephrine, noradrenaline or histamine. medicine.

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THE INFLUENCE OF TAUROLIN ON THE ~DYNA/~IC ~_~,~,.~TS Antipyretic therapy with Diclofenac Sodium in ICU patients. OF DOPANINE. M.K. Browne, Nonklands District General Effects and side effects of 109 mq suppository versus 0,2 mq/kg i.m. Hospital~ Airdrie~ Glasgow~ Scotland. Zandstra D.F., Stoutenbeek Cb., Miranda D.R. ICU University Hospital, Groningen, The Netherlands. Taurolin is a chemotherapeutic agent with antiendotoxin Diclofenac sodium 100 mg suppository proved to be a potent properties which can be administered intravenously (IV) antipyretic drug. However severe side effects: oligo-anuria and or intraperitoneally (IP). It is specially indicated protractive shock necessitating increasing amounts of i.v. fluids in the treatment of peritonitis and septic shock. and dopamine, make this drug in this dosage unsuitable for use in In vitro, it reacts with Dopamine to inactivate it. ICU patients. Whether these effects were dose related or not we It has been recommended that the two drugs should be studied the effect of 0,2 mg/kg bw km. in 8 ICU patients. Antipyretic used alternately in two hour cycles. This sequence is effect, as were bloodpressure diuresis and therpeutic measures of not appropriate in the clinical care situation. Experi- both groups were compared. mentally this has been tested by studying nine dogs In both groups this drug proved to be a potent antipyretic drug, anaesthetised and ~entilated. Measurement of pressure However dose related effects could be observed, was by a tl~r~sducer placed in the right femoral artery~ Significant decrease ~in bloodpressure was observed up to 6 hrs in renal blood flow was measured by a Statham guage in the the suppository group, as in the 0,2 mg/kg group only in the first left renal artery and urinary output by a catheter in 2 hrs this was seen, In both groups we observed a significant the bladder. These were recorded simultaneously on a decrease in diuresis, Polygraph (Gould ESllOO0~. Dopamine was infused in a Therapeutic measures to maintain adequate circulation and diuresis dose of 6.25 Ug.Eg- min- for 8 hours. Taurolin 2% i~ were the same in both groups on 3 hrs after application; additional Na~l 0.45% was infused in a dose of 15.37+ 1.58 mg.Eg-~ i.v. fluids (600 +75 ml) and a 100% increase of the dose dopamine h- for 6 hours commencing one hour after--the Dopamine administered. infusion. A control group was given a saline infusion Conclusion= in place of Taurolin. Taurolin did not significamtly Serious side effects; acute oligo-anuria and severe fall in blood- alter the presser effects of Dopamine or its effects on pressure necessitating the administration of increasing amounts of the kidney. Clinically five patients with septic shock depamine and i.v. fluids makes diclofenac sodium ~ven in a small who were requiring Dopamine infusions were given dq.se of 0,2 mg/kg i.m. unsuitable for use in ICU patients, as an Taurolin in addition. Two patients received 200 ml antipyretic agent. of 2% Taurolin b.d. intraperitoneally while three received 250 ml of 2% Taurolin intravenously over 2 hours twice d~ily. In none of these cases was there any loss of the alpha or beta adversgis aotion of the Dopamine. From these animal and clinical results it is concluded that there is no centre-indication to the simultaneous administration of these two valuable drugs in the intensive care situation. 207

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IS PURE HIGH FREQUENCY VENTILATION A MISCON- CEPTION? REPORT ON CLINICAL APPLICATION OF SUPERIMPOSED HIGH FREQUENCY JET. K. Czech, Unfallkrankenhaus Lorenz Boehler, Vienna, Austria High frequency ventilation offers some advantages over IPPV (oxygenation, removal of secretions etc.) but it is difficult to handle and adequate CO2 elimination is not always easily achieved. By superimposing HF Jet impulses on conventional ventilation or even spontaneous breathing the following effects could be observed. I. Clearing of atelectatic:areas that have been refractory to conventional therapy (bronchoscopic suctioning, CPPV, external vibration). 2. Improvement of blood gas values in ARDS (Fi02 reduced from 1.0 to 0.5 within 8 hours~ 3. In patients breathing oxygen by face mask PaO2 could be raised from.less than 60 torr = 8 kPa (in one case 34 torr = 4.5 kPa) to levels between 90 and 100 torr (12 and 13.5 kPa). This was achieved by repeated 5-min treatment sessions with oral HF-Jet, mechanical ventilation or CPAP was not necessary. 4. It has been successfully used to prevent posttraumatic ARDS. Detailed case histories and x-ray-photos will be presented. Conclusion: With the exception of a few clearcut indications (eg. large bronchopleural fistulae) many clinical effects seen in HF-ventilation could be achieved by superimposed HF-Jet technique. The new method is easier, safer and cheaper than sophisticated HF ventilation techniques. Polytrauma

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PROGNOSIS OF POLYTRAUMATIZED PATIENTS[PPIIN A MULTI - FIBRONECTIN PLASMA LEVEL (FPL) IN PATIENTS WITH DISCIPLINARY I C U (M.I.C.U.).- C. GRANTHIL, J. FORGET, MULTIPLE INJURIES:ITS RELATIONSHIP WITH SEVERI- M. ALAZIA, A. CALDERON, G. FRANCOIS - Dept. Anesth.- TY OF THE CLINICAL CONDITION. A. Salgado, S. R~ R@animation Pr.G. FRANCOIS, G.H. La Timone, 13385, Marseille, France. drlguez, C. Miquel, M.A. Le~n, J. Ordi y M.C. V~zquez-Prada. C. S~ Valle de HebrOn. Barcelona. 3 i/2 year retrospective study on the prognosis of PP The administration of exogenous fibronectin ge_a was performed in a M.I.C.U.. The Injury Severity Score (I.S.S.), a reliable index of seriousness, was calculated red to avoid some complications in critically for 96 consecutive admissions and correlated with age and ill traumatic patients (sepsis, ARDS) relates final prognosis. The I.S.S. values were from 20 (3 PP) to to the important role played by this glycopro- 66 (10 PP) points (m = 43+13), according to trauma rein in the inespecific opsonization of the re- severity. The ages ranged'from 16 to 77 (m = 36t17),and ticuloendothelial system. The change in the PPL hospitalization from 1 to 173 days (m = 17,4• The in these patients and its dependence on the se- statistical results show : i ~) a significant correlation between overall mortality verity of the trauma were investigated, The PPL and I.S.S values (Mann-Whitney test, p < 0,05). However, was measured by inm~unoelectrophoresis in 29 pa- contrary to various studies, no I.S.S. values is 100 % tients with multiple injuries and they were re- lethal : in 22 PP with an I.S.S. of 50 or more points, lated to an injury severity score (ISS). The m~ the survical rate was 50 % (1.2.3.) an value for the FPL was %8,6 ~ 18% as compared 2~ ) a very significant correlation between mortality and to the 98,% ~ 2056% of the control group of he- age, showing the importance of the latter (Mann-Whitney althy human beings (p O,OO1). There was no sta- test, p < 0,01). However, contrary to previously published results the mortality rate is identical in both age tistical significance in the correlation betwe- groups (below and above age 45) as long as the I.S.S. is en the FPL and the ISS in all the patients stu- below 38 points (1.2) died. Patients with only head trauma (with an 3~ ) a highly significant correlation between the length ISS = 25,% ~ 0,3) however had a higher FPL (68,5 of hospitalization in I C U and I.S.S. in the discharged + 20%) than the rest of patients with multiple group (Spearman test, p < 0,001). But, in opposition to injuries (ISS = 35,3 J iO and FPL = 54,8 ~ 16%). previous data, there is not a negative correlation between length of survival and I.S.S. in the group of patients These results demostrate that the FPL is redu- who died (3). ced in patients with multiple injuries. This l~ In conclusion, the above results are different from vel, however, is better correlated with the vo- previous studies. The reasons for the differences are lume of tissue involved than with the possible analysed: population characteristics, quality of care, injury of vital organs (head trauma). This is to length of time before admission into ICU, and transport be taken into account when facing a possible th~ conditions. rapeutic infusion of this protein. Ill BAKER: J. of Trauma,1976, 16: 882-$85 BULL: Acc. Anal. Prey., 1975, 7:249-255 SEMMLOW: Health Serv. Research, 1976,11: 45-52.

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SEVERITY SCORES ON MULTITRAUMATIZED PATIENTS: A PROG- BEDSIDE PREDICTION OF OUTCOME OF SEVERE HEAD INJURIES NOSIS APPROACH. N. Dufeu, A. Margenet, P. Huguenard., DURING CONTROLLED VENTILATION S. Firn, Pinderfields D@partement d'An@sth@sie R@animation,Hopital Henri Mondor Hospital, Wakefield; A. Z. Keller Post-Graduate School F 94010 Cr@teil France. of Studies in Industrial Technology, University of Bradford On 570 multitraumatized patients hospitalized in a traumatologic intensive care unit, severity scores have been Predicting the outcome in severe Head Injuries (H.I.) established, and compared to clinical evolution. is notoriously difficult. The "Glasgow Coma Scale", Three types of severity scores were performed at the which is widely used can be a valuable indicator of patient's admission: H.I. outcome in patients breathing spontaneously, but - the Injury Severity Score ( ISS ), summarizing is of little practical use if Controlled Ventilation the victim's injuries ( based on the Abreviated Injury is required as part of the patient's overall management, Scale ), especially if relaxant and sedative drugs are used. - the Respiratory Index ( RI ) integrsling Pa02 A Ventilation Observation Chart in usa at Pinderfields and its corresponding Fi02, Hospital appeared to offer a prediction of ultimate - the C.H.0.P. ( using Creatinine, Hematocrit, prognosis. It was based on a simple scoring system 0smolarity, and first systolic blood pressure ). of 15 parameters routinely monitored in such patients. Added and compared to these, classical cutaneous immunity tests ( tuberculin, candidine, varidase ) were reali- When these charts were subjected to a Discriminant zed , having only a value on patients hospitalized more Analysis Package 8 of the 15 parameters were identified than 48 hours. as being of significance in predicting outcome and The results show out, first, a very significant diffe- were arranged in order of importance by their weighting rence of Severity Scores Values in the two series indi- factor. Prediction of outcome was calculated using vidualized:" cured " and " deceased " the formula of Sayles et al (1982). Secondly, comparing severity scores values together and one to another, by including them into differents 100% Separation into survival and fatality groups was tables, an idea on the patient's prognosis can be given obtained. A pocket computor was programmed with the in chances of survival. Prediction Formula allowing rapid day to day Outcome Concerning immunity response, prognosis interest is Predictions. maximum in the non reactive group ( nearly 60 % of the patients which stay in the unit was over 48 hours ). Reference Based on a two years experience, and on a population of 570 patients, correlating severity scores to clinical Sayles et al (1982) Proceedings 7th Advances in evolution can allow an early theoritical prognosis Reliability Technology Symposium approach of the multitramatized patient survival. 209

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CHANGES IN CARDIORESPIRATORY PROFILES TO INDUCED TOTAL BODY HYPERTHERMIA. A. Sladen; K. Guntupalli, R. Selker, E. Weinstock, D. Wilks and M. Klain. Surgical Intensive Care Unit, Montefiore Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213 U.S.A. Clinical trails currently are being undertaken to study the enhancement of radiation and chemotherapy with total body hyperthermia (TBH), to 41 ~ C, for patients with advanced malignant disease. The objectives of this study were to compare changes in cardiorespiratory profiles, pre, intra and post TBH to determine the appropriate therapeutic maneuvers which are required to maintain hemodynamic and respiratory stability during TBH. Sixteen treatments, each of 4 hours, were given with the following results. Pre Intra Post CVP mmHq 6.2• 13.2• 8.2• MAP mmHq 88.2• 69.3• ~ 85.8• PAWP n~nHg 7.5• 13.2• ii.2• ~ Cl L.min.M 2 3.1• 7.7• 3.8• ~ P.min 92• 139• 90• LVSWI qm.M.M 2 41.7• 51.9• 49.5• TPRI dyne.see.em-5.M 2 2167• 613• 1766• RVSWI 9m.M.M2 7.6• 16.7• 10.8• PVRI dyne.sec.cm-5.M 2 203• 86.4• 143.3• ~ ~ 02 ml.M 2 126.5• 168.9• ~ 129.3• Qsp. QT % 5.8• 22.6• 11.9• Lactate m9 % 8.8• 26.9• 12.9• pHa 7.4• 7.31• ~ 7.41• COP ~Hq 20.4• 14.9• 17.5• ~ COP-PA[,~ mmHg 13.0• 1.6• 6.78• ~ Statistical analysis comparing pre with intra and pre with post TBH revealed e significance of *P<0-0001 and ~ During TBR CI increased by >100%, TPR decreased by >70% and }~P by >20%. To maintain an adequate MAP wig~ these hemodynamic changes, crystalloid was infused to a positive mean fluid balance of 4814• ml. Post hyperthermia, pulmonary edema was demonstrated in 30% of treatments and was associated with a low COP-PAWP. Increase in Qsp.QT, lactate and a mild metabolic acidosis also occurred during TBH. Nutrition

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~CT OF NAFTIDROFURYL ON PROTEIN METABOLISM AFTER CONTINUOUS ENTERAL HYPERALIMENTATIONIN THE TREA INJURY. H. Burns, C. Porteous, D. Galloway, TMENT OF SEVERE ACUTE PANCREATITIS.EFFECT ON I. McA. Ledingham, G. Beastall, Departments of Surgery NUTRITION,COURSE AND PROGNOSIS (65 CASES) and Biochemistry, University of Glasgow, Scotland. E.L4vy;L.Hannoun,P.Frilsux,C.Huguet,J.Loygue, Centre de Chirurgie Digestive USI.INSERM. Naftidrofuryl (Praxilene) reduces lactate levels and H6pital Saint-Antoine. Paris.France. increases ATP content of ischaemic tissue apparently Continuous enteral hyperalimentation can reduce by stimulating aerobic metabolism. We have examined the deaths rate associated with severe acute the metabolic effects of this drug in injured patients. pancreatitis by atleast one-third. In a randomised study of 90 patients undergoing surgery 85 patients while in an intensive care unit of moderate severity, 46 received infusions of after digestive tract surgery are reviewed. naftidrofuryl 400 mg/day for three days after In any case,destructive changes are seen in operation. All patients, Including 44 controls, part or in all of the glands at operation or at received a standard dextrose/saline fluid regimen providing 400 kcal/day. Both groups were similar in autopsy;46% of the patient had diffuse necrotic hemorrhagic involvement. severity of operation, nutritional state, age and sex. Acute pancreatitis in these patients was the Results three d~ys after operation are in the table. result of biliary lithiasis (53%),alcoholism, (mean + 2 S~). trauma~ sphineterotomy~gastrectomy or colecto Naftidrofuryl Controls my. Symptoms or consequences of the pancreatitis Cumulated N included encephalopathy,collapse,renal organic Balance (g) -23.09+3.8 -30.95_+2.7p <0.001 insufficiency,digestive hemorrhage,icterus, Serum total intraperitoneal abscess,septicemia,respiratory proteins g/l 62.0 +_I .6 54.7 +4.9p <0.05 distress severe enough to require assistance, Sertra Every patient is in a critical condition with albumin g/l 35.5 +I .9 31.7 +2.2 p <0.05 an average of 2.9 criteria of severity. 20 patients died during the first week.65 sur- There was no significant difference at any time viving patients were started on continuous between the two groups in plasma insulin, glucose, enteral feeding between the 3rd and 12th day lactate, pyruvate or ketone levels. This study after resection or drainage of Pancreas:t7 died suggests that pharmacological treatment of post (26%). The continuous feeding was administered injury metabolism can produce si~Ftificant protein by means of a jejunostomy and was mixed with sparing effects. Additional animal data suggest increasing amounts of carbohydrate and protein naftidrofuryl may act by stimulating glucose until an optimal level was reached of 75 KCal oxidation and reducing amino acid oxidation in the per Kg b,w.per day.The tqtal mortality rateis Krebs cycle. 42.~%.This is a obvious improvement over the mortality of 72~ observed in a previous comparable series of 68 patients underwent a convert tional treatment without enteral hyperaliment..

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"ALL IN ONE" VERSUS CONVENTIONAL TOTAL pARENTERAL NUTRI- EFFECTS OF LEUCINE VS. KETOLEUCINE ON NITROGEN (N) TION IN SURGICAL ICU-PATIENTS. A. Leutenegger, M. Buch- METABOLISM FOLLOWING GYNECOLOGIC SURGERY. G. Frangois, mann, A. Frutiger. Department of Suxgery, Kantonsspital, M. Blanc, A. Calderon, F. Ros~, Dept. of Anesthesia and Chur, Switzerland. Intensive Care, G.H. La Timone, Marseille, France. In I0 randomly selected surgical ICU-patients a new regi- It has been shown that ketoleucine (KIC) spares N during men of total parenteral nutrition (TPN) using a so-called early fasting while leucine does not. In vitro KIC has all in one (AIO) solution was tested prospectively. An- been reported to inhibit muscle protein breakdown while other 10patients receiving conventional TPN served as leucine stimulated protein synthesis. Surgery is followed control group. For a minimum of 7 days the patients were by increased muscle protein breakdown. Thirty patients given either &n AIO solution containing 40 g of crystal- undergoing gynecologic surgery (hysterectomy with or line L-aminoacids, 38 g fat, 75 g Sorbit and 45 g Xylite without lymphadenectomy)were randomized to receive for (4180 Joules/l, 600 Joules/gN, fat: carbohYdrates = 4:6) the first post-operative 3 days one of the following or a conventional TPN with glucose and aminoacids. The I.V. solution per kg and per day : 3 gm glucose (G), regimens were identical regarding caloric intake and 3 gm glucose + 89mg leucine (L) or 3 gm glucose + 104 mg Joule/N ratio. Amounts of infused solutions were adjusted NaKIC (K). The output of 3 methylhistidine (3MH), total according to patient weight. Both regimens were well to- N and creatinine were measured daily.Values are expressed lerated and side effects urging us to interrupt the proper kg B.W. and per day, (table) tocol did not occur. A set of 23 laboratory parameters Group Creat.mmol Ng 3MH ~mol 3MH/creat. taken each day underwent different statistical analysis. i Efficiency of both regimens to improve nutritional status A could be documented. In both group~ values for albumin, n = 30 0,167• 0,I06• 5,25• 32,1 protein and nitrogen balance improved significantly from B day I to day 7. Comparing the two groups, we found only n = 30 0,165• 0,115• 5,64• 34,7 two significant differences: glucose levels in the AIO group were significantly lower than in the control group C 4,67• 28,4 (6.87 - 8.97 mmol/1 and 10.28 - 13.09 mmol/1, p ~ 0.001). n = 30 0,165• 0,114• The bilirubin increase observed in both groups, probably mean • confidence l' nits. a sign of cholostasis, was significantly higher in AIO The values were tested for statistical difference using patients (p < 0.05). the Kruskal Wallis test. Urinary creatinine and total Conclusions: Immediate postoperative or posttraumatic N did not differ significantly in G, L and K. Muscle nutrition with an AIO solution was safe and its handling protein breakdown measured as urinary 3MH/creatinine was simple. Because glucose metabolism is only minimally significantly reduced in K as compared with G or L. strained, AIO compares favorably with conventional TPN Thus, I.V. KIC reduced muscle protein breakdown but did not reduce total nitrogen excretion. Leucine administered and is a promising alternative, when stress induced glu- under the same conditions did not. cose intolerance occurs. However, the influence of AIO on hepatic function deserves further investigation. 211

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THE EFFECT OF BRANCH-CHAINAMINO ACIDS ON SYSTOLIC PROPE- RTIES OF THE NORMAL AND SEPTIC ISOLATED RAT HEART. H.R. Fretmd, E.J~ Darm, Y. Hassin, Hadassah University Hospital, Jerusalem, Israel. We investigated the effect of different amino acid formu- lations on systolic properties of the isolated normal & septic heart in 59 rats(220-510 gm). Hearts were rapidly removed & perfused as Langendorff preparations with Krebs solutionS8.5 mM glucose, or Krebs+5 mM glucose+3.5 mM amino acids containing: 15%,42%,or 100% branch-chain amino acids (BCAA). Developed force (F) & force velocity (df/dt) were measured for 1.5 hours at paced rates of 100,200,300 & 400 heats/minute. Sepsis was induced by cecal ligation & perforation, animals being studied 12-24 (19+5) hours after induction of sepsis. TAB: Percent change in developed force (F) & force velocity (df/dt) over 1.5 hours. Beats/min i00 200 300 400 F df/dt F df/dt F df/dt F df/dt

Krebs - Normal -20 + 4 -20 + 4 -13 + 3 -23 + 4 Krebs - Sepsis +21 +34 + 6 +i0 -i0 - 5 -17 -20 BCAA 15%- N -28 -18 -37 -23 -42 -32 -49 -39 BCAA 15%- S +22 + 6 - 8 - 9 - 5 - 1 - 9 - 9 BCAA 42%- N -ii -12 -26 -21 -28 - 1 -33 -28 BCAA 42%- S +94+106 +106 +90 +28 +41 - 4 +19 BCAA 100%- N -32 -21 -44 -30 -52 -33 -54 -46 BCAA 100%- S +23 + 3 0 - 1 -21 -14 -27 -12

In normals: both Krebs and the 42% BCAAmaintained near normal F and df/dt while the 15% or i00% BCAA resulted in a significant decrease of both F and df/dt. In sepsis all four solutions improved F and df/dt compared to normal hearts, pointing towards different nutritional requirements of the septic heart. Exceptionaly good improvement was achieved by the 42% BCAA formulation. ARDS: Pathophysiology

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ORGANIZATION OF A CENTER FOR ACUTE RESPIRATORY DISTRESS SYNDROME BIOLOGICAL ALTERATIONS OF BLOOD COAGULATION IN ADULT (ARDS) TREATMENT: PROBLEMS ABOUT COMMUNICATIONS AND SANITARY TRANSFER RESPIRATORY DISTRESS SYNDROME. J. Fontcuberta, S. Benito, A. Artigas, J. Castella, J. Vall~s, S. Armengol, M. Rut- SYSTEM. G. Bordone, G.P. Rassi, F. Scarani, W. Zuliani, A. Pesenti, A. llant. Servicio Cuidados Intensives. Hospital de la Santa Pelizzela, G.C. Fantana. Imt. Anestesiolegia e Rianlmazione, Universi- Creu i Sant Pau. Barcelona. Spain. t~ di Milane, Italy. The alterations of blood coagulation were studied in 16 In the last three years we organized the transfer Qf 32 ARDS patients patients with adult respiratory distress syndrome (ARDS). refractory to cenventianal therapy, from other hospitals tn our All patients required mechanical ventilation lot7 days, Institution as candidates for treatment with Low Frequency Positive Fi02 0.8t0.2, PEEP max. 10 ~ 5 cm H20 with a P(A-a)O2/PA02 Pressure Ventilation with Extrscerpereal CO~ Removal (LFPPV-ECCOR). 0.74• 0.13 and Qs/Qtot 38t6%. The following parameters Oar managing strategy develops as fellows: 11 a network ef communlca- were analized in plasma and bronchoalveolar lavage fluid tlenm with peripheral hospltals to collect detailed informations abaut (BLF) at O, 24, 72 hours and I0 days: fibrinogen ([, Van Claus), fibrin degradation products (PDF, Merskey), factor clinical condition and evolution ef the patient; 2) cooperation with VIII antigen (F, VIII ag, Laurell), platelet factor 4 (PF4 private and pubblic Institutions in order t 9 obtain the most suitable Ria) and beta-tromboglobulin (~TG, Ria). A control group means of transport (air and ground); 3) continuous training of a of 10 patients was included. medical team; N)the availability of sanitary equipment of smallest RESULTS: Mean values of the first 3 days are shown in the size, rationally arranged in standard kits and battery operated. Our table: criteria for sanitary transfer of these patients can be summarized: PLASMA BLF use of the most suitable mean of tranmport (sanitary flight, helicopter, ambulance); patient assessement amd preparation before F g/l 6.08t 1.9 0 PDIF ~g/ml 25.58 t 27,1 10.7 t 18.98 leaving; sedation and ~urarizatlen of the patients, artificial F. VIII ag% 583~312 0 ventilation with positive end expiratory pressure, possible infusion ng/ml 49.22 ~ 28.42 24• 25.7 of sympathomimetic agents; continuous monitoring of respiratory and BT~ ng/ml 89.38 • 46.31 46.94 ~ 50.9 hemodynamio paramethers; travel performed as fast as possible. We In all cases all parameters analized were higher than transferred 32 patients from as far as 1.200 km using ambulance (8N%), normal values and an increase of PDF, PF4 and BTG in BLF hellcopter (3%) and sanitary flight (12.5%).Mean PaO on leaving was was observed. 51.02 mm Hg (ranging from 95 to 23 mm Rg); on arriva~ was 63.83 mm Rg These data suggest an endothelial vascular lesion together (ranging from 147.5 to 27.5 mm Hg).Mean PaCO on leaving was ~7.12 with an increase of fibrin deposits and platelet aggrega- (ranging from 63 to 27 mm Hg); on arrival was ~3.9 (ranging from 79.3 tion in the pulmonary microcirculation. to 24.5 mm Rg). 17 of our patients were treated with conventional respiratory therapy, 15 of them underwent LFPPV-ECCO2R; none of them died during the transport.Being our Institution, at present, the only center in Italy where LFPPV-ECCO R is carried out the transfer of patients with ARDS may be considered an integral part in this type of life saving procedure.

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Neurogenic ARDS - its frequency and relevance ~c ALVEOLAR-CAPILLAR DUCTANCE FOR CARBON MONOXYDE AS A RELIABLE INDEX OF SEVERITY IN PULMONARY EMBOLISM. J.F. Prost, outcome in patients with isolated head injury. P. Desfonds, P. Lacombe, M. Leroy, Y. Ozier, F. Jardin. H6pital G. Singbartl, G. Cunitz, Dept.Anaesthesiology Ambroise Par4, Boulogne, France. Alveolo-cap ilIar ductance for carbon monoxyde (defined by a and Intensive Care Medicine, Ruhr-University of mathematical expression [(Pl - PA)/PI ] identical to efficient Bochum, D - 4630 Bochum 7 alveolar ventilation) represents the pulmonary blood volume close to ventilated alveolar space. Though ARDS following sepsis, trauma or coagula- With an original informatic method, i t 's measurment in s ready tion disturbances is well known, the same does s tare cohditions can be performed at bed s [de and in mechanica- not hold true for centally-initiated impaired ly ventilated patients. pulmonary gas-exchange or neurogenic ARDS, re- Aprospective study has been conducted in order to assess the spectively. Therefore, in a prospective clinical diagnostic and pronostic value of DuACCO in pulmonary embo- study in 129 patients with isolated head injury lism. This day 12 patients were entered in the study. frequency of ARDS, its relation to severity of On the first day following the admission in the intensive care cerebral trauma and its relevance to clinical unit, blood gases and DuACCO were measured and a pulmonary an- outcome were examined. Severity of head injury giography was performed. A long term follow up was obtained by was graded by meansof the Glasgow-Coma-Scale repeated measurments of DuACCO. (GCS)and pulmonary gas-exchange was expressed On day i, DuACCO reached a mean of O.43 (i.e. 61% of the theore- by the quotient A-aDOp/PAO p (Q). Patients with ti cal value) with a minimum of O. 24 and a maximum of O. 60, PaO 2 additional trauma suc~ as Nemorrhagic shock, reached a mean o f 53 mmHg with a minimum of 35 mmHg and a maxi- fractures of the large bones, direct ehesm-mrau- mum of 70 mmHg. The pulmonary hypoperfusion degree, as it can ma or aspiration were excluded. Our results de- be evaluated on pulmonary angzograms according to WALSH index, monstrate a relationship between the severity of head injury and impaired pulmonary gas-exchange. reached amean of lOwith a minimumof 2 and amaximumof 15. A 22.5 % of all patients suffer from a severe closed correlation is observed between Walsh Index and DuACCO neurogenic ARDS(Q> 0.6) while in additional 26.3 (r = - O. 78, p <0.O1). In one case of massive pulmonary embo- % pulmonary gas-exchange was moderately impaired lism (Walsh index = 20) with slight hypoxemia (PaO2 = 62 mmEg) (Q>O.L<0.6). With increasing severity of neuro- DuACCO remained dramatically lowered (DuACCO = 37, i.e. 53 % enic ARDS survival rate decreased from 58.3% of the theoretical value). ~ severe head injury but without ARDS) and 55.3% On day 40, DuACCO reached s mean of 0.59 (i.e. 84 % of the theo- (severe head injury with a moderate degree of ret ical value) in 6 patients despite the lack of thrombolytic ARDS) down to 24.1 % (severe head injury with the rapy. severe ARDS) despite an increase of ~ontrolled We conclude that DuACCO zs a non invasive reliable measurment ventilation from 66.6 to 89.1 %. Moreover, neuro allowing severity evaluation and longterm follow up of pulmo- logical outcome is significantly worse in the nary embolism. latter group than in the former ones. Cardiovascular Problems ~3

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REGIONAL LUNG PROTEIN TRANSCAPILLARY ESCAPE RATE RIGHT VENTRICULAR PERIPHERIC BLOCK IN ACUTE EKPERII~ENTAL (TCER) IN CHRONIC LEFT VENTRICULAR FAILURE (CLVD. PULMONARY ARTERY HYPERTENSION. R. Martinez, A. Roglan, JO. MEASUREMENT BY A SCINTILLATION CAMERA. Bonn~n, A. Bay,s, R. Oter. I.C.U. Hospital de la Santa F.A. Grimbert, F. Dubois, J.C. Peyrin, Creu i Sant Pau. Barcelone. Spain. J.P. Caravel, P. Gelas, D~partement d'Anesth~- The present study was designed to determine the changes of siologie et Service de M~deeine Nucl~aire. electrophysiological patterns in acute pulmonary hyperten- C.H.U. de GRENOBLE F-38700 LA TRONCHE sion (PAH). We measured regional lung TCER of lll~-transfer- METHODS: Using intracardiac recording techniques, His bund le (H) and right ventricular apical (RVA) electrograms rin (mol wt 76000) in 5 normal volunteers and in were recorded si~ltaneously with I, II and VI leads in 5 patients with CLVF studied before left heart 10 dogs anaesthetized with pentobarbital (15 mg/Kg) and valvular surgery. All subjects were studied semi- pancuronium (0.10 mg/Kg), ventilated with 15 ml/Kg and recumbent. The equilibration process of 111In- transferrin -diffusible label- and 99mTc-labeled Fi02 1. Catheters were introduced into the right ventricle red blood cells -nondiffusible label- in lung (RV) ~d pulmonary artery. P~lmonary arteries were dissec- was followed by a scintillation camera for 60 ted by ~ilateral thoracotomy and two epicardial bipolar electrodes were placed on the postero-inferior (PI) and minutes after intravenous administration of tra- antero-superior (AS) wall of the RV. PAH was obtained by cers. The proportion of diffusible and nondif- pulmonary vascular obstruction. The His (H), RVA, I, II, fusible labels in venous blood samples was used and V1 leads, RVA-IP and RVA-AS were recorded simultaneous to partition count rates made over the lung into contributions from an intravascular and an extra- ly at basal level and following induced PAH (mean pulmonary artery pressure > 27 mnBg). vascular compartment. Protein TCER in lung of CLVF patients, 4.8 • 3.2 x I0 -3 min-! (m ~ s.d.), RESULTS: No significative differences were seen in P wave, PR interval or AQRS. Yhere was no r' wave in V1 following was within the normal range. However time to half-equilibrium concentration (tl/2) of trans- PAH. There was significative increase of the H-RVA (p

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EFFECTS OF ESCHERICHIA COLI ENDOTOXIN ON DISTRIBUTION OF STUDY OF TRANSCUTANEOUS P02 IN SHOCK. E. Mesalles, S. Ar- CARDIAC OUTPUT IN ANESTHETIZED PIGS. A.Mercatello,A.Bon- mengol~ J. Vall~s, A. Artigas. Servicio de Cuidados Inte~ martin, B.Bui-Xan, M.Li6vre, J.J.Mallet, J.~otin. sivos. Hospital de la Santa Creu i Sant Pau. Barcelona. Laboratoires de biophysique (Pr. J.O Peyrin) et de pharma- Spain. cologie (Pr. G.Faucon) ; Facult~ de M~decine Grange Blan- The purpose of this study is to evaluate the transcuta- che, Universit~ Lyon I, Lyon , France. neous P02 (Ptc02) in different hemodynamic patterns and The experiments were performed. ~n 10 pigs (5 for contro~ its relationship with pa02. and 5 animals received 1,5 mg of escherichia coli endoto~ Twenty-six patients (p) in shock with clinical signs of xin). The animals were tracheotomised and anesthetized peripheral underperfusion and needing inotropic drugs (or with Halothane (0,5%).the cardiac output (C.O) was measu- fluids) were studied. red by thermodilution. The distribution of C.O was measu- Pulmonary and radial arteries were catheterized and car ~ red by injection nuclide labeled radioactive microspheres diac output was determined by thermodilution. Ptc02 was (15#m in diameter)(New England nuclear) into the left measured with transcutaneous sensor (Kontron-La Roche) ventricule. Particles were injected before (57 Co) and at with simultaneous measurements of Pa02 and all hemodyna- 5 (113 Sn) and 60 mn (46 Sc) after administration of end~ mic parameters. toxin. After the pigs were killed, 50 samples of the or- Patients were divided in three groups: gans were dissected, weighed and counted in a gamma scin- A: 7 p. with low CI ~2,5 1/mixm2)-MAP: 75,8~ 8 m~Hg. tillation counter. The 15#m microspheres measured only B: 14 p. with normal CI (2,5-4 I/mixm2)-MAP 87~ 17 mmHg. the ca~illary blood flow (nutrient blood flow). Particles C: 7 p. with increased CI (>4 I/mixm2)- MAP 77,6 ~14 mmHg shunted through the systemic circulation (arteriovenous Forty studies were analysed with student T and linear re- anastomoses) were stopped in the lungs. gression tests. 3 groups of organ blood flow were individualized (for RESULTS: Sun~arized in the table. 100 g of tissue, percentage of C.O, before and at 5 and 60 mn after infusion). - coronary (2.32,4.18,6.31") pancreas (0.46,1.03,1.49 ~) A B C CI~2,5 2,5~CI~4 4~CI aorta (0.12,0.21,0533) blood flow were increased. NO data~nO p 16/7 21/14 10/7 - liver (0.98,0.63 ,0.54 ~) adrenals (2.57,4.49,2.48) muscle (0.11,015,0.11) and total gastro-intestinal tract Pa02 vs Ptc02 blood flow were well maintained. l~near regression -spleen (3.71,1.85~,2.32 *) brain (l.94,2.97,0.81)kidneys r=value O, 43 O, 95 O, 77 (4.16,4.58 ,2.65 ) and ears (0.042,0.025,0.019) blood ~P02 7,8t14 7,05+.12 12,8+-12 flow were decreased. During early endotoxemia the ears and spleen blood flow were decreased in contrast the kidney PtcO2/pa02 0,9 ~ 0,14 0,95~-0SI 0~88t 0,12 and brain blood flow were maintained. The pancreas (0.46, 1.03,1.49 ~) adrenals (2.57,4.49,2.48) and pituitary (1.95, 1.80,2.00) blood flow were maintained. The relationship was not dependent on different levels of The fraction of cardiac output passing to the lung (ar- C(a-v)02, V 02 and systemic vascular resistances. teriovenous anastomoses and bronchial arteries) was signi- CONCLUSION : Ptc02 and Pa02 were equivalent at normal CI ficantly decreased (5.68,5.5+,2.21m). P ~0.05 but not in low output shock and hyperdynamic shock. Mechanical Ventilation: Techniques and Complications

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SEFARATFD ARTIFICIAL LUNGVENTILATION. A. Margenet, C. ~TP~I~qT DUP/ING P~GH FREQUENCY JET VI~TIIATION: Herv@, Y. Morin, P. Huguenard, D@partement D'Anesth4sie CLINICAL IM2LICAT!ONS FRCM STJDIES b!l~H A MODEL R4animation, Hopital Henri Mondor F 94010 Cr@teil LUNG. A.J. Mortimer, J-L. Bourgain, Nuffield Department France of Anaesthetics, Radcliffe Infi~nary, Oxford~ U.K.

The technic, largely fused in bronchopulmonary surgery The purpose of this study was to Lnvestigate the occur- may find a more recent indication concerning fence of ambient gas entrairmmm during jet ventilation intensive care patients. at different respiratory frequencies and I:E ratios. _.A This type of ventilation has been performed on 17 model lung (Manley B.O.C_~) o_ficcmpliance 50 ml ~ H90 i patients of a traumatologic and surgical intensive care mqd resistance 5 mn H~0 1 -sec - was ventilated in a - unit, using: closed plethysmograp~ by a solenoid-operated jet venti- - P.V.C. endotracheal tubes ( Bronchocath TD ), laP.or. ~ The ventilator output %~s directed into the without ergot, lung through a i. 8 ma nozzle in a T-piece oonnected to a - Two ventilators msking possible a totsly asyn- 9 nm ET tube. At a driving pressure of 45 psi tb~ chronous ventilation. Asynchronism seems to be one of the degree of entrainaent was measured with I:E ratios of necessary conditions to the efficiency of the technic; 1:2 and 1:4 at frequencies of i, 3, 5 and i0 hertz. and this is shown by its positive effects on: The tidal volume delivered to the lung (VT I//h~) was hematosis : arterial ( 106 +45 versus derived frGm the pressure swings of the plethysmograph, 351 + 106 mmHg in Fi02 = I ) and venous blood gases. and the tidal volt.he delivered frcml the jet (VT VISIT) was the haemodyrmmic parameters:cardiac obtained by dividing the minute volllne of the ventilator index (2.8 + 1.6 v. 3.2 + 1.6 ), arterial pulmonary by the frequency under observation. The rat%o of VT resistance , arterial pulmonary pressure ( 17 + 6 versus I//NG to VT V~NT gave a measure of the entrainment. 13 + 1.5 mmHg ) and pulmnary capillary wedge pressure ( 9+ 5v. 4+ 6mmHg). Results: Vf I;3h~/VT VI~f Local tolerance to the double lumen endotracheal Frecfaency (F~z) I:E 1:2 1:4 tube, has been appreciated on fiheroptic bronchoscopic criteria i I.Ii 1.19 Instead of waiting for the advent of a severe 3 0.84 1.00 hypoxemia, a precocious indication of such technic can 5 0.72 0.89 be discussed in the following situations : i0 0.40 0.50 - after an unilateral aspiration, Clinical In~lications: - when different FF~P levels are requested for each lung, i. The F_O^ and humidity of the inspired gas are large- - to finish haemodynsmic tolerance during high ly de~e~ined by the gas delivered frGm the jet. PEEP levels is largely improved by the separated artifi- 2. The minute volume of the ventilator is not a useful cial lung ventilation. guide in assessing the minute volume of the patient.

310 312

CONTINUOUS POSITIVE AIRWAY PRESSURE IN HEALTHY VOLUNTEERS: HIGH FREQUENCY JET VENTILATION DURING B~ONCHOSCOPY, SUR- EFFECTS ON RESPIRATORY PATTERN AND FUNCTIONAL RESIDUAL VEILLANCE BY TRANSCUTANEOUS PCO 2 MEASUREMENTS. M. FISCHLER CAPACITY. F. MICHON, J.C. MELCHIOR, F. SEIGNEUR, G. VOURC'H, Hopital P. Constantin, A. Forster, D. Morel and P.M. Suter. D~- FOCH, SURESNES, FRANCE. partment of Anesthesiology, Surgical ICU, H6pital Canto- nal, 1211Gen~ve 4, Suisse. High frequency jet ventilation (HFJV) has been widely used during bronchoscopy ; the main problem during HFJV is CO 2 Continuous positive airway pressure (CPAP) has been shown elimination. The accuracy of a cutaneous eapnometer (Roche to increase functional residual capacity (FRC) in healthy Kontron) was evaluated in this clinical situation. volunteers proportionally to the level of positive pres- 6 patients were investigated under general anesthesia. sure (1). Different methods of ventilation were used successively The purpose of this study was to evaluate the changes in over a ]0 mn period : manual jet ventilation, HFJV at respiratory pattern and the duration of increase in FRC rates of ]50/mn, 300/mn and 500/mn. The jet ventilator induced by CPAP (I0 cm HpO) in nine healthy volunteers. MK 800 (Acutronic mediea! system) was used with a driving Before and after CPAP, FRC was measured by multiple pressure of 5 bar and a ]6 gauge injector. Measurements breath nitrogen washout. During CPAP, changes in FRC and of arterial and transcutaneous PCO 2 were made simulta- respiratory pattern were continuously monitored with neously before anesthesia and atthe end of each period pre-calibrated bellows pneumographs. of ventilation. Results : The increase in FRC (+ 22% of control level) Satisfactory correlation was found between transcutaneous ~d under CPAP varied with time (range: + II% to PCO 2 and arterial PCO 2. Thus it appears transcutaneous + 41% of control level) and disappeared within the first PCO 2 measurement can minute after discontinuation of CPAP. Tidal volume in- be used for evalua- creased significantly during CPAP while minute ventilating CO 2 elimination Transcutaneous tion remained stable. during HFJV in such 7E.CO2 tenslon(~mH9)~ Conclusions : In patients with normal lungs, the effect procedures as hron- of CPAP on FRC ends with the removal of the positive ehoscopy where no 5{ pressure. The mean increase in FRC observed with bellows important hemodyna- pneumographs during I0 cm HpO CPAP is similar to the one mic changes are ex- st n =30 measured with the helium di?ution method (I) but varies peeted. ,C ".'-/ : : ;~1x'0.76 greatly breath by breath and thus may give additional information to the results of former studies where only 3G ./( r =0.90 intermittent measurements of FRC were performed. 20 .S* " SEE =5 4 I. Gherini S. et al., Chest 76: 251-256, 1979. lO

o ,o 2o 9o ~o 50 6o 7o" Arterial PCO2 (mmHg] 215

313 315

MANUAL JET VENTILATION (JV) OR HIGH FREQUENCY JET A NEU RESPIRATOR BASED ON HIGHLY ACCURATE FLO~'I- VENTILATION (HFJV) DURING LASER RESECTION OF TRACHEO- CONTROL AND FLOW-MEASURE~4ENT. A. Heier, BRONCHIAL STENOSIS. M. FISCHLER, G. VOURC'H, F. MICHON, Hamilton Medical, Bonaduz, Switzerland. J.C. MELCHIOR, F. SEIGNEUR. Hopital FOCH, SURESNE% FRANCE The desirability of changin~ the behaviour of HFJV has been proved to be satisfactory during broncho- a Respirator, according to the differing and scopy at a frequency of 60/mn. We compared JV with HFJV changing needs of the critically ill patient, during laser resection of severe tracheo-bronchial ste- can only have a meaning if precise control and nosis under general anesthesia, JV using the Sanders measurement of relevant data can be achieved. technique, HFJV the Jet ventilator MK 800 (Acutronic medical system). During both methods FiO 2 of the injected Our way to comply with these clinical specifi- gases was 0.5, the driving pressure was 5 bar. Ventila- cations has been the construction of a simple tory rate was 20/mn for JV and 300/mn for HFdV with an proportional valve with extremely few movable I/E ratio of 0.25. A 16 gauge tube welded on the broncho- parts but designed specifically to interact scope permitted ventilation. Arterial blood was withdrawn with the advanced and reliable microprocessor before anesthesia (A) and at the tenth minute of surgery technology, This combination has provided us (B). Results (mmHg) are expressed as mean • SD, statis- a highly versatile operational Respirator, tical analysis used t test. which allows the clinician a very broad range The results are summarized in the table. of operationality, concerning any ventilatory JV (20 patients) HFJV (20 patients) mode or function. The device is conceived with clear and precise PaO 2 PaCe 2 PaO 2 PaCO 2 settings; identified patient alarms; patient monitoring with trends, and warning for (A) 67.2 + 11.6 36.3 + 5.1 73.7 + 11.3 36.1 + 4.4 erroneous settings.

(B) 126.8 • 39.1 32.6 + 6.8 z 112.3 -+ 49.6 40.8 + 13.2~ p <0.02

PaCe 2 is significantly higher under HFJV. In cases with tracheal stenosis this difference does not occur ; on the other hand in cases with bronchial stenosis PaCO 2 was 31.9 • 5.2 under JV and 44.1 • 12.1 under HFJV (p 0.02). The location of the stenosis and so the location of the tip of the injector influence gas exchanges under HFJV. This method can be used for tracheal stenosis. JV will be preferable for treatment of bronchial stenosis.

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CLINICAL VALIDATION OF A NEW DEVICE FOR STATIC THORACO- A BIDIRECTIONAL PEEP VALVE AND ITS POSSIBLE APPLICATIONS PULMONARY COMPLIANCE COMPUTERISATION DURING MECHANICAL A.Frutiger,M.D.Surgical ICU Kantonsspital Chur,Switzerland VENTILATION. J.P. Viale, B. Bui Xuan, G. Annat~ Y. Khater Currently available Peep valves work unidirectionally,i.e. J.Motin; HSpital Edouard Herriot, 69374 LYON CEDEX 08 gas flow through them is only possible in one direction. The optimal management of critically ill ventilated pa- Peep is produced by preloading these valves, which permits tients often requires repeted measurements of static tho- gas flow only from a set opening pressure. Once the ope- racopulmonary compliance (Cs~. However the conventional ning pressure is overcome, ideally gas flow should occur methods which are-used for this measurement are generally unobstructed. No gas flow is possible in the opposite di- laborious and request a possibly dangerous interruption rection. There are many techniques to produce Peep, they of the ventilation. The new device Spirolog IIR Dragger involve water columns, springs, magnens, coun~erpressure, which takes into account cycle by qycle informations balls, etc..; but one feature common to all currently used of expired flow and pressure from the~nasotracheal tube valves is their unidirectional function. We present a bi- calculates continuously C:ST in ventil'ated patients. directional Peep valve which not only exerts Peep in one The aim of the present study was : direction, but also permits unobstructed flow in the oppo- I) to compare the values of CST calculated by the site direction. The Peep ranges between 3 and 20mbar. Its Spirelog II (CsT-SP) with those measured by the syringe resistance is 0.8 mbar at a gas flow of 0.5 L/sec and 2.45 method (HARP 1975) during inspiration (CsT-iusp) and mbar at 1 L/sec respectively. Two porns allow suctionning expiration (CsT - exp), and airway pressure measurements. 2) to determine the normal values of CsT-SP by measuring this parameter in anesthetized surgical patients with The suggested clinical application of the described valve clinically normal respiratory function and normal X ray isle produce differential Peep in artificially ventila- chest. ted patients with assymmetrical lung disease or patients 3) to test the usefulness of this calculator for the es- in lateral position during chest surgery. The valve is timation of the "best-PEEP" level (SUTER 1975). simply placed on line into the selected branch of a double The results were as follows (mean • SE ml/cmH20) : lumen endotracheal tube. Peep is applied to the less com- i) CsT-SP (46,9 • 5,6, n=15) was well correlated pliant lung in unilateral lung disease Dr to the dependent (p O,OO1) with csT-ins (64,9 ! 6,5, n = 15) and with lung in lateral position during 2hest surgery. The ~echni- C.ST -eXp. (49,1 _+ 4,6, n = 15). CsT-SP was lower than CST- que of differential Peep is thus much simplified. More ins (p

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COMPLICATIONS ASSOCIATED WITH PROLONGED HIGH FREQUENCY ACUTE COLONIC DILATATION WITH MECHANICAL VENTILATION~PO- VENTILATION. J. Berr6, A.M. Ros, J.L. Vincent, P.Dufaye, TENTIAL PHENOPERIDINE INVOLVEMENT ?:F. LEMOINE, JL. RICOME R.J. Kahn. Department of Intensive Care, Erasme University C. RICHARD, D. KHAYAT, A. RIMAILHO, Ph. AUZEPY - H6pital Hospital, Free University of Brussels, Belgium. de Bic@tre - 94270 LE KREMLIN-BICETRE (France).

The type and the incidence of complications during Acute colonic dilatation (ACD) were one of the most dele- treatment with high frequency ventilation (HFV) were terious side effects of mechanical ventilation. The aim of evaluated in 7 patients (age 17 to 74) who presented with this work was to assess. acute respiratory failure. HFV was used for 6 to 34 i) etiologic factors of ACD (median 9) days for management of bronchopleural fistulas 2) ACD treatment. (5), associated in one case with %racheo-esophageal Patients and methods : fistula, tracheal rupture (i) or voluminous lung abcesses 9 patients with radiologically proved ACD (ie coecal (i). Four of the 7 patients died from multisystem R diameter> 7 cm) were selected. The four following etiolo- failure. HFV was delivered using a ventilator ACUTRONIC gic features were studied : a) ventilation modalities VS 600 (3) or MK 800(4), at rates 100-250 cycles/min. (naso-tracheal tube, tracheotomy), b) hypokalemia, Inspiratory time was 90-40 % and driving pressure c) cirrhosis, d) patients sedation with phenoperidine. 2-4.5 bar FiO ranged from O.S to 0.9. Jet injector Used treatment were : I) symptomatic medical therapy (DESERET ~- 142GA-8.3 cm with 2 side-holes) was secured in (enteral nutrition and eventually phenoperidine withdrawa~ the endotracheal tube. Inspiratory gases were carefully nasogastric suction), 2) surgical therapy (decompression humidified. We identified technical complications and local resection). associated with insufficient humidification, leading to Results : viscous secretions (3 cases), desiccation of the tracheo- 6 patients were ventilated by nasotracheal tube, 3 by bronchial tree (2 cases) and total obstruction of the tracheotomy. As other etiologic factors we found 2 hypo- endotracheal tube (one case). Disconnection or kinking of kalemia, 3 cirrhosis and 5 patients treated by phenoperi- the catheter were not rare events. One ease of severe dine. None patient were dead during ACD period. High risk hypcthermia was attributed to humidification with a cold of colonic perforation, in spite of initial medical treat- solution. Ventilator noise was sometimes hardly tolerated ment was the reason for surgery in 5 patients. and two patients developped acute confusional state. Sleep Conclusion : disturbances were variable. On the other hand, abrupt Multiple factors inducing ACD with mechanical ventilation disconnection of the noise could give rise to panic. were discussed, but we would emphasize the potential Acceptation of HFV by nursing staff was directly phenoperidine involvement. In fact, for three patients proportional to their knowledge of the device. Technical ACD resolution followed phenoperidinewithdrawal. In one problems occured more commonly during nights or week-ends. patient a threefold phenoperidine using had induced a Inadequate alarms were generally incriminated. Easy, threefold ACD. In patients submitted to mechanical venti- practical solutions can be suggested to improve lation phenoperidine will be used with dramatic care- humidification and monitoring of HFV, and thereby limit fulness. High risk of colonic perforation due to medical the incidence and the severity of complications. treatment inefficacy allowed surgical therapy.

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HIGH FREQUENCY JET VENTILATION-A PROSPECTIVE REVIEW OF I00 COMPARISON OF THE CARDIOVASCULAREFFECTS OF HIGH FREQUENCY PATIENTS. A. Sladen, K. Guntupalli, J. Marqllez, M. Klein, JET VENTILATIONAND CONTINUOUSPOSITIVE PRESSURE VENTILATION and C. McConaha. Surgical Intensive Care Unit, Montefiore IN THE NORMOVOLEMIC DOG. M.Chiaranda, E.Facco, G.Fiore, G. Hospital, University of Pittsburgh School of Medicine, Pittoni, G.P.Giron, Inst. of Anaesthesiology and Intensive Pittsburgh, PA 15213 U.S.A. Care, University of Padua, Italy. High frequency jet ventilation (HFJV) has been recommended High frequency jet ventilation (HFJV) has proved to ensure for treatment of acute respiratory failure (ARF) in crit- an adequate alveolar ventilation with low peak airway pressure ically ill patients during the postoperative period. The and small tidal volume (Vt) This may be advantageous in goals of this study were to assess the feasibility and situations when the Vt at conventional intermittent (IPPV) practicality of HEJV for a heterogeneous group of criti- or continuous (CPPV) positive pressure ventilation encroaches cally ill patients, with ARF, during the postoperative on the horizontal portion of the lung P-V curve. period, to define optimal initial HFJV settings and to ob- Six healthy Beagle dogs, II § 17 kg, were anaesthetized, serve the concurrent effects of HPJV with PEEP, endotra- paralized and intubated in the standard fashion. Sistemic, eheal suctioning and weaning. One hundred patients ad- central venous and pulmonary arterial blood pressure, cardiac mitted to the SICU and NICU were ventilated with HFJV. The output via the thermodilution technique, arterial and mixed age group ranged from 10-92 years with 75 ~ 65 years. The venous blood gases, airway pressure (Paw) at the end of the operations included craniotomies and thoracic, abdominal endotracheal tubeand oesophageal pressure were monitored. and major vascular procedures. Optimum initial settings The cardiac (CI), stroke (SI) and other cardiorespiratory were driving pressure 35 psi, frequency 100.min, IE ratio indices were calculated using the standard equations. 30:70, FiO2 0.90 and PEEP 3-4 mmHg. The driving pressure Ventilation with air was performed randomly alternating a proved to be the pr'imary mode of CO 2 elimination, initial volume-cycled ventilator at 15 b/m with an HFJV apparatus mean PaCO 2 35.8. FIO2 and PEEP were adjusted to provide (VJP system) at 60, 120, 240, 480 b/m, Vt was regulated to the desired PaO 2 and optimum QsP.QT. Cardiorespiratory maintain PaCO? at 38~2 mmHg. Cardiorespiratory values were profiles indicated that Qsp.OT would be reduced a mean of obtained afte~ stabilization for both modes of ventilation 30% by the addition of PEEP i0 mmHg but was associated increasing positive end expiratory pressure (PEEP) progress~ with a simultaneous decrease in mean CI from 3.39 to 2.81 vely from 0 to 2.0 kPa. L.M 2. Endotraeheal suctioning with HFJV resulted in a A The use of PEEPsignificantly decreased the CI in all modes PaO 2 of 15 n~Hg compared to 90 nm~Hg without HFJV. Weaning of ventilation. The transition from IPPV or CPPV to HFJV at was achieved by progressively decreasing the driving pres- 60 andl2Ob/m,withPEEPheldconstant, led to a significant sure. Patients subsequently reported that they were com- reduction of the inspiratory peak and an improvement of CI fortable spontaneously breathing at a rate of 10-20.min and SI due to the reduction of mean Paw. This improvement while HFJV continued at 100.min. ICU physicians and nurses was more evident at PEEP 2.0 kPa. At frequencies of 480 b/m found the patients were easyto wean using HEJV. Eighty- the increase of intrathoracic volume and of mean Paw markedly five of the i00 patients were extubated within a 24 hour increased haemodynamic depression. period; fifteen demonstrated criteria consistent with con- The results confirm the efficacy of HFJV, at adequate tinued ARF and required HFJV for ~ 14 days. frequencies, when the reduction of Vt brings about a HFJV offers a new and improved technique for patients with reduction of the cardiovascular depression and reduces the ARF in the postoperative period. risk of 'barotrauma'. 217

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SUPPRESSION OF SPONTANEOUS BREATHING DURING HIGH CORRELATION OF END=TIDAL TO ARTERIAL CARBON DIOXIDE TEN- FREQUENCY VENTILATION. A.J. van Vught, A. SION IN ADULTS ON CONTROLLED VENTILATION Versprille, J.R.C. Jansen, Pathophysiological A.Vuori and P.Jaakkola, Department of Anaesthesiology, lab., dept. of pulmonary diseases, Erasmus Uni- University of Turku, Turku, Finland. versity, P.O. Box 1738, 3000 DR Rotterdam, and Alveolar carbon dioxide tension is in balance with the the Pediatric Intensive Care Unit, University pulmonary capillary and arterial blood carbon dioxide Children's Hospital Het Wilhelmina kinderzieken- tension. Thus, end-tidal carbon dioxide tension (PETCO~) huis, P.O. Box 18009, 3501 CA Utrecht, The can offer useful information concerning the adequacy of- Netherlands ventilation. In order to find out the correlation between We investigated whether and under which circum- PETC02 and the arterial carbon dioxide tension (PaC02), stances suppression of spontaneous breathing linear reqression analysis was performed between 250 occurs during high frequency ventilation. values of PETCO2 and simultaneously obtained P.CO2 values. Yorkshire piglets were ventilated with a high The PETC02 was determined usine an infrared carbon dioxide frequency jet ventilator under pentobarbital an- analyser (Datex Normocap). aesthesia. The highest PaCO^ at which the animals The correlation was found good in patients on controlled z did not breath against the ventllator (Pacop- mechanical ventilation (CMV) after open-heart surgery. apnea) was established during different patZerns The correlation coefficient (r) was 0.858 for a volume- of ventilation. Where necessary for compensation cycled ventilator (Servo 900B; n=176) and the r was 0.722 of hyperventilation this was done by adding CO 2 for a ventilator using a continuous fresh gas flow via the to the respiratory gases. Arterial oxygen tension T-piece (IMV Bird; n=29). The gas samples were obtained was kept above i00 mmHg. from a sampling adapter interposed between the intubation Suppression of spontaneous breathing activity tube and the T-piece. Thus, with the sampling method could be obtained during ventilation with higher used, fresh gas flow Via the T-piece may mix with the frequencies, irrespective the tidal volume and respiratory gases and affect the reliability of PETCO2 the insufflatory flow velocity. So, the mode of monitoring. In another series of samples, obtained from dynamic activation of the stretch receptors was patients on CMV using the Servo 900B ventilators, the r rejected as a causal mechanism. Positive end was 0.898 for samples drawn directly from the intubation expiratory pressure (PEEP), increasing with tube at the mouth level (n=26), while the r was 0.792 for higher frequencies, suppressed the spontaneous samples drawn from the aforementioned adapter (n=19). breathing activity, also at a constant ventila- Both samples correlate well with the PaC02, but it may be tory rate. However, a hysteresis effect in the concluded that for best precision it is advantageous to relation PaCo~-apnea versus PEEP was found, which draw the expiratory gas sample directly from the intuba- z suggests that the s~ppression of spontaneous tion tube. breathing duringhigh frequency ventilation depends on the end expiratory volume rather than the end expiratory pressure.

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EVALUATION OF THE ADVANCED EARLY ARTIFICIAL PULMONARY EMBOLISM (P.E. IN ACUTE RESPIRATORY FAILURE RESPIRATION IN CASE OF A POLYTRAUMA. dePay,A.W., (ARE) OF CHRONIC OBSTRUCTIVE LUNG DISEASE (COLD) " Hohlbach,G. , Kllnik fur Chirurgie der Medizl- INTEREST OF TEE MAXIMUM EXPIRED PARTIAL PRESSURE OF 6"02 nischen Hochschule L~beck (PEMC02), C. Chopin, J. Mangalaboyi, F. Fourrier, A. The development of post-traumatic respiratory Durocher , D. Dubois, F. Wattel , Service de Rdanimation , insufficiency has been known for a long time, HBpital Calmette, C.E.U. Lille, FRANCE. In the patient, but the question of when r@spiratory therapy ~ithout any previous lung disease, the measurement of the should be initiated is still debated. 21.6% of difference between PaCO 2 and end ezpiratory PC02.~ 236 emergency-treated polytraumatized (PT) P(a-ET)CO 2) may be an aid for diagnosis of pulmonary patients of the degree II and III showed embolism (PE). On the contrary~P(a-ET)CO 2 in COLD pati- respiratory insufficiency already at the place ents, i8 increased whatever be the co~se of the ARE. Then of accident and during transport. Only 12.7% the difference i8 linked with the ventilation/perfusion were intubated and 11.8% were treated with ratio mismatching and i8 due to both alveolar mixing respiratory therapy prior to hospitalization. defect (ventilatory mechanism) and dead space effect 27.9% had to undergo a respiratory therapy after (circulatory mechanism). We speculate that the ventilatory hospitalization Necause of acute respiratory part of the difference could be cancelled by forced insufficiency. A p]rospective study in 56 poly- expiration. 18 COLD patients with suspicious PE support traumatized patients showed that already 15 our study. Pulmonary angiography and PEMCO 2 are performed minutes after the trauma a clear reduction of the 8~e day. PEMCO 2 is calculated by continuous recording the respiratory function could be observed, of forced ezpired CO 2 and simultaneous determination of which could not be adequately treated with the PaCO 2. AP(a-PEM)CO 2 is then computed, and also the ratio shock therapy. 50% oT the PT II and 75% of the D = ~P(a-PEM)CO2/PEMCO 2. The diagnosis of PE was supported PT Ill patients developed acute respiratory when D ~5 % and ezeluded when D< 5 %. It was confirmed by insufficiency within 24 hours, making artificial pulmonary angiography. The results are reported on the respiration imperative. Depending on the degree table. of severity, the patients who were not given We concluded that the determination of PEMCO 2 is an artificial respiration at the place of accident easily, quickly performed test and i8 an accurate criteria were liable to a 20 to 40% higher letality rate. for angiography indication during ARF in COLD patients. The period of artificial respiration after hospitalization had to be longer to the same ANGIOGRAPHY extent as the artificial respiration had been PE + PE - Chi square test delayed after the accident. The conclusion is P with that all PT II and PT III patients, in particu- E D ~5~ 9 2 Yates correction lar highrisk patients, should be intubated and M p < 0,01 given respiratory therapy already at the nlace C D <8% 0 ? of accident even if their consciousness has 02 been maintained. 218

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DIAZEPAM: HAZARDOUS SEDATION OF VENTILATED PATIENTS. DETECTION OF C5a IN ACUTE RESPIRATORY FAILURE BY CHEMILU- H.J.Rapold, F.Follath, G. Scollo, R. Ritz (Basle) MINESCENCE.*J.M. Coulaud,*J. Labrousse,**B. Descamps,0~Ph. Diazepam is among the most widely used drugs fortheseda- Lesavre,*A. Boudjadja,*J. Lissac.*HSpital Boucicaut~*HSpi- tion of ventilated patients. However, it does not appear to tal Necker - F 75730 PARIS (France). be generally recognised that this kind of treatment might be responsible for a prolonged depression of the central An increase of C5a measured by in vitro aggregation of po- nervous system and therefore a delay in extubationfor many lymorphonuclear granulocytes (PMN) has been detected in plasma of adult respiratory distress syndrome (ARDS) by days. Hammerschmidt et al (Lancet, 1980, I, 947-949). To assess Analysing two cases with massive accumulation of Diazepam this phenomenon C5a activity was measured by chemilumines- and persistent coma the problem of Benzodiazepine-intoxica- cence (CL) in control AB serum before (CS) and after zymo- tion during sedation of ventilated patients is demonstrated san activation (CSA) and in serum of patients with acute on the basis of measured plasmaconcentrations and the dia- respiratory failure : ARDS, cardiogenic pulmonary edema gnostic and therapeutic use of a new Benzodiazepine-anta- (CPE), chronic obstructive pulmonary disease (COPD). gonist (Ro 15-1788): i. a previously healthy 70 year old CSa triggered the production by PMN of free radicals (O2~ female with respiratory insufficiency following pulmonary H202/02, OH) which were assessed by CL (at the Ist mn). embolism remained comatous during 12 days following admini- The results were first measured in relative light units stration of a total dose of 260 mg Diazep~m withinthefirst (RLU), then a CL index was calculated : RLU (test serum) - RLU (CS). 3 days. Plaemaconcentrations of Diazepam and Desmethyldia- CLI % = 100 ~ ...... zepam were 437 and 483 ng/ml, 150 hours after the last medication; the calculated elimination-halflifes of the two C5a activity was measured in whole serum and in serum substances were 109 and 403 hours. 2. a 63 year old man fractionated with sephadex G75, fraction<20 000 daltons. with preexisting liver disease had to be ventilated because Results in CLI % are given on the table (~ • SE). of severe bacterial pneumonia; following sedation during 16 CSA ARDS CPE COPD days with a total dose of 245 mg Diazepam he remained cc~a- Whole tous for additional 6 days. The semiquantitative urinary serum 246• 6• 23• 4]• test for Diazepam was still positive i0 days after discon- (n = IO) (n = 15) (n = 7) (n = 7) tinuation of the drug. In both cases the Diazepam-induced depression of the central nervous system could be demon- Fractionated 277• 128• -18• 4• strated and reversed under EEG-controlled conditions by the serum (n = 7) (n = 7) (n = 5) (n = 6) new Benzodiazepine-antagonist Ro 15-1788. We conclude that Diazepam is not an appropriate drug for The present study shows that low molecular weight frac- long-term sedation because of its pharmacokinetic tions of ARDS serums are able to induce a CL response, characteristics; the new Benzodiazepine-antagonist Ro 15- suggesting the presence of C5a. The non activation of PMN 1788 seems to be a valuable tool in the diagnostic and by whole serum is probably due to CSa inhibitors. By de- therapeutic management of Benzodiazepine-intoxications. tecting the production of oxygen radicals, only with ARDS serums, our results contribute to the pathogenesis of th~ syndrome.

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COLLOID OSMOTIC-PULMONARY ARTERY WEDGE PRESSURE GRADIENT INCREASED WORK OF BREATHING WITH DE~,~ND FLOW- IN ACUTE RESPIRATORY FAILURE.A.B~ienga,F.Bruno,G.Belpiede CPAP-SYSTEMS. W.R. Thies, P. H~rter, K.J. Falke and M.P.Cecere. Institute of Anesthesiology,University of Universit~tsklinik DUsseldorf, FRG Patients receiving CPAP-therapy frequentlydeve~ Bar• Italy. op signs of respiratory distress, especially To evaluate the relationship between different colloid os- infants, when a demand flow type of ventilator motic-pulmonary artery wedge pressure gradients(COP-PAPW) is employed. We compared several demand flow and gas exchange,COP-PAPW values (Group A: > 9 torr; B:9-5; systems with a continuous flow system in respe~ C:5-3; D<3)were correlated with shunt(Qs/Qt) and alveolar of the inspiratory work of breathing using a arterial oxygen difference(A-aDO 2) in 15 septic patients mechanical lung model. The continuous flow system consisted of a reservoir of 15 lald a gas Z~ (12 died)in Acute Respiratory Failure(ARF).ARP was charac- of 7ol/min. Endotracheal tubes of 4.5, 6.5, and terized by:A-aDOo=313*llS;Qs/Qt=22*9 %;Cardiac Index (CI)= 8.5 mmID, various tidal volumes, and different 4,1.3 (mean*sd) ~and radiological findings of oedema. respiratory frequencies were used. 2ressure- The mean~sd values of pressures were:COP=16*3.6 torr,PAPW volume-, pressure-flow-, and flow-volume-curves =13"4 torr,COP-PAPW=3.3• torr. Data were obtained by onto- were recorded. A strong dependency between work of breathing and tube diameters became evident. meter and Swan-Ganz thermodilution catheters. A typical example is demonstrated below, simu- Results. Different COP-PAPW did not correlate with Qs/Qt lating conditions in an infant: tube diameter and A-aDO 2 (see Table). 4.5 mm, V T 8o ml, RF 24/min, PEEP o. The total inspiratory work of breathing increased with the Group n* r p demand flow system by 2o% and the inspiratory (COP-PAPW)-Qs/Qt A 16 -0.41 flow resistive work by Ioo%. During the first " " B 23 O. Ol third of the breathing cycle those values were " " C 9 -0.53 24o% and 4oo% respectively. That enlights the " " D 52 -O. 35

n *= number of measurements Conclusions.ln ARF different COP-PAPW values do not influence the gas exchange 219

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MONITORING OF GAS EXCHANGE AND ENERGY EXPENDITURE IN NITROGLYCERIN INFUSION EFFECTS IN PATIENTS WITH RESPIRATOR PATIENTS. P Krill, B H~gman, CHRONIC OBSTRUCTIVE LUNG DISEASE UNDER CONTROL- Engstr6m Medical AB, Box 20109, S-16120 Bromma, Sweden LED VENTILATION. B, Stiramesse, A. Boillot, F. Barele. Service de R~animation, C.H.U. Saint-Jacques, Besanqo~ , Information regarding 09-uptake, C02-elimination, France. respiratory quotient an~ metabolic Fate is important for the determination of both certain haemodynamic parameters The aim of this research was to determine the effects of Ni- and relevant supply of parenteral nutrition. Until troglycerine (NG) infusion on pulmonary circulation in pa- recently, the most commonly used method of getting these tients with chronic obstructive lung disease (C.O.L.D.). pieces of information involved using a Douglas bag and In 26 patients with severe C.O.L.D. under controlled ventila- mass spectrometry. Drawbacks with this method are: tion, we have studied, after insertion of right heart and ar- - the equipment is huge and expensive. terial radial catheters, haemodynamic effects and blo~d gas - the operation of the equipment is time consuming and changes for an infusion rate of NG ol 10, 20, 40 pg.mn . In requires special education. addition, 10 of the 26 patients had a volume loading with NG, In order to avoid those drawbacks we have designed a and without NG after return to control values. device based on indirect calorimetry and intended for measurements on patients connected to an Engstr~m Erica Before NG infusion, we observed, in all cases, an increase ol respirator. Inspired and expired gas samples are analysed mean pulmonary pressures (PAP), an increase of pulmonary re- by an electrochemical 02-sensor and an external CO2- sistances, and an increase of right systolic work index. None analyser. Tidal volume ~nformation is retrieved from the oI the patients had features of left heart failure. After NG ventilator. From values measured every 30 seconds, the infusion, we noted a significant decrease in the systolic car- 02-uptake, C02-elimination, respiratory quotient and diac index producing a reduction of PAP, without any changes metabolic rate are calculated. The results are available in pulmonary or peripheral resistances. Left and right systolic both as one-minute mean and as trend values. work decreased. All these haemodynamic changes were in di- The difficulties associated with all the methods used rect proportion with NG rate. There were no significant consist in that changes in PaO2, PaCO2 except an increase in 2, 3 Diphospho- - the gas samples are taken at different humidity, glycerate with NG. In addition, volume loading, resulted in an temperature and pressure levels. increase of right and left pre-loads and after loads, with and - inspired and expired volumes differ. without NG. Cardiac out put and the systolic index increased - the small concentration differences to be measured. with volume loading with NG, while they did not change with The influence of these factors has been minimized with volume loading without NG. the aid of automatic 02-sensor calibration, micropro- These results suggest that~ during the acute course of respira- cessor-based numerical compensations and gas sample tory failure in patients with C.O.L.D. under controlled venti- adaptation in a special tubing. lation, NG, may be useful particularly on right overlaod allo- Comparison tests with a mass spectrometer using a test wing the patient to leave the artificial respirator more quickly. model show a difference of less than 8 percent between the two methods. Clinical evaluation on patients is in progress.

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ENERGY EXPENDITURE DURING PARENTERAL NUTRITION PNEUMONIA COMPLICATING SELF POISONING WITH PSYCHOACTIVE IN CHRONIC OBSTRUCTIVE LONG DISEASE WITH ACUTE EXA- DRUGS.Offenstadt G,Gabillet G,H~ricord P,Pinta P,Tembely A, CERBATIONS REQUIRING ARTIFICIA'L VENTILATI3N Amstutz P - H6pital Saint-Antoine - 75012 Paris France. H.D. Forsberg~E,M.D. Carl~m~on,M, M.D. Nordenstr~m,J, 474 patients admitted in ICU between 1976 and 1981 were Karolinska Institute, Huddinge Hospital, retrospectively analysed. Pneumonia (P) was assessed by Stockholm, Sweden. condensation on chest X ray. - P developped in 67 patients (group l).In group I mean Patients with COLD undergoing acute exacerba- + .... tions are often malnourished and may require age (40,4-18 years) was hlgher than zn patlents wzthout P TPN during the initial phase of artifical venti- (group II) p~O,O01. In group I,P was present at admission lation. In this study energy expenditure was ex- in 53,7 p.eent of the cases. 24 hours after admission 77,6 amined in 6 patients. Energy expenditure (EE)was p.cent of P had appeared. measured by indirect calorimetry using a new de- - Initial location was unilateral in 79,4 p.cent with pre- vice connected to a respirator. A 0 -microfuel- dilection to the inferior half of the right lung (72p.cent). cell takes alternate sampies from t~e inspirator} Fever was more frequent in group I (89,5 p.cent) than in and exspiratory gases and the difference in oxy- group If (37,7 p.eent) p

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PROCOLLAGEN-III-PEPTIDE IN PROGRESSIVE RESPIRA- PULMONARY FUNCTION WITH ACUTE LOSS OF EXCESS LUNG WATER TORY FAILURE AFTER PARAQUAT INTOXICATION. J.Loh- BY HEMODYALISIS IN PATI~NTS WITH CHRONIC UREMIA. A. Arti- msnn, G.Pott, H.P.Bertram, U.Gsrlach, Medizini- gas, S. Benito, J. Sanchis, M. RodE. Hospital de la Santa sche Universit~tsklinik,MUnster,W-Germany Creu i Sant Pau. Barcelone. Spain. Patients with severe psraqust poisoning oftsn Lung function in 12 patients with advanced renal failure died because of respiratory failure. Changes in on chronic hemodialysis program was studied. With de pa- pulmonary function are due to a progressive pul- tients in the seated position, both before and after hemo- monary fibrosis 8 to 10 days after intoxication. dyalisis lung volumes, flow rates, diffusing lung capacity Procollsgen-III-peptide (P-III-P) was measured (DLcq) by the single breath technic and arterial blood enhanced by rsdioimmuno assay in patients with fibrosis of the liver.We determined P-III-P in gases were measured. The P(A-a)02 and Qs/Qtot were measured with a Fi02 1. Before dialysis a restrictive pattern serum of 4 patients who died after ingestion of paraquat and in 2 petients who survived.ln case was observed~ with normal FEF25_75% and reduced lung vo- of the non-survivors P-III-P increased to 4 lumes, with removal of body fluid (/\weight 4,2• 1,01%) fold of normal values. In case of the survivors the residual volume decreased (p~ 0,01) further with a P-III-P slightly increased then no further pro- concomittant increase in vital capacity and FEF25_75% grsssion was seen. Our data suggest that esti- (p ~ 0,01) with an increase in the bronchodilator test mation of P-III-P in serum of patients with pera (p ~ O, 05). Dialysis resulted in no significant change in qust intoxications may represent paraQuat-in- TLC, FRC or DLco. P(A-a)02 (76 +- 25 m~nHg before dialysis) duced pulmonary complications. improvised in 8 patients after dialysis (mean value 64 ~- 15 mmHg, p < O, 05). These results reflected reversible airway closure and gas trapping due to accumulation of edema around small airways with improvement of ventilation-perfusion ratio. Infections, Metabolism n]

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INVASIVENESS SCORING SYSTEM (ISS):STUDY ON THE PROCEDURE- MICROBIAL SPECTRUM AND RESISTANCE TO ANTIBIOTICS RELATED INFECTIONS IN INTENSIVECARE PATIENTS. P.Geraci,R.V. IN A MEDICAL INTENSIVE CARE UNIT DURING THE COUR~ Dionigi, L.Carnevale, A.Pernigotti, M.Maurelli, G.Lorenzon SE OF 4 YEARS.J.~{ajdandzic,H.P.Schuster,M.ReUZ, L.S.Weilemann.ll.Med. Clinic of the University, Vos, A.Mapelli, Rianimazionell, Policlinico, Pavia, Italia D-6500 Mainz,FRG. Invasive procedures that are potential vehicles ofinfecti- on were scored according to seat, technique and during of In a retrospective study we compared routinely performed done microbiological analyses of tra- application, using ascoring system(ISS)~,in order to value cheal secretions (TS) and catheter urine (CU) in the relationamong nosocomialinfections, extent ofinvasion the period of 1976/77 to 1978/79.The percentage and other risk factors in IntensiveCare(ICU) patients(pts). of sterile TS-specimen remained constant (17%) I00 pts (9-82 years,mean 50.7), admitted to ICUfor 3days at while nixed cultures decreased from 47% to 39% least because of different ailments, were sorted in 4 groups of positive cultures.The relative frequency of (A-D) according to the aggregate score of ISS (IS),growing from different bacterias found in TS changed remarkably:1976/77 Klebsiellae were found most often A roD, during their stay in ICU (15.5 ~9.3 days). (36%) fo~lowed by Pseudomonas aeruginosa (3~%) The mean infection rate was 60%: 18.5% in group A, 100% in D. and E.coli (18%).1978/79 Pseudomonas aer. remai- Significative correlation was found between IS and number of ned equally frequent (35%),Klebsiellae fell back infectious episodes per patient (ni/p)(p

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SPECTRUM OF NOSOCOMIAL MICROORGANISMS IN AN ICU ACQUIRED PNEUMONIA: A PROSPECTIVE STUDY. M.Langer, ORIGINALLY OPEN AND LATER ON STRICTLY CLOSED S.Vesconi, M.Solca, A.Graziina. letituto di Anestesiologia NEUROSURGICAL INTENSIVE CARE UNIT (DAILY MICRO- e Rianima~ione, Ospedale Policlinico, Nilan/Italy BIOLOGICAL SURVEILLANCE OF 6oi PATIENTS). Incidence t time of onset,and mortality of ICU acquired A. Karimi und K.P. Sohaal; Neurochirurgisehe Klinik und Hygiene-lnstitut der Universit[t zu pulmonary infection was evaluated in 96 pts from 2 Units K61n. (general and neurosurgical) in a period of 6 months. Pts Before reconstruction and air-conditioning of with an ICU stay less than 48h, preexisting pulmonary in- two neurosurgioal operating-theatres and an ad- fection and irreversible brain damage were excluded. jacent, completely open intensive care unit, In the 96 stud~Ls the mean value of Therapeutic Index traeheobronehial secretions and urine samples Score System (CULLEN) was 33.9-+ 13. 68 pts (71%)~equired from Ioo patients attended in this unit were daily examined for nosocomial and other micro- continuous mechanical ventilation fo~ longer than 24h organisms. After the reconstruction project (median 8 days). Pts were considered • have eithe~espi~a including installation of an air-conditioning tory tract infection if they had persistent fever and con- system with highperformance filters and strict sistent clinical data, or pneumonia if a persistend in- structural and organizational separation of filtrate on chest X-ray film was also present. the unit from other parts of the hospital had Overall mortality was 25/96 pts (264). 46 pts had pulmo- beed completed, the daily microbiological surveillance was continued for two years and nary~nfection, 25 pneumonia (mortality=60%), 21 respirato- provided data from 50o patients. ry~raot infection without infiltrate (mortality=28.5~.~); A comparison of frequency, species distri- 50 pts(mortality=8%)did not develop pulmon~.ry infection. bution and clinical significance of the Mortality rates observed in the 3 groups are significantly microbes obtained from the unit which was run different (p ~ O.OO05). all the time with the same personnel, before Among pig with pneumonia, the onset of infection was sur- and after reconstruction revealed the specific problems associated with a strictly isolated prisingly early in over 50%of cases.(teble) ward. In addition, the changes observed in pneumonia onset(ICU day) 1-3 4-7 8 the spectrum of the nosocomial bacteria, their antibiotic susceptibility patterns and their No pt s/expired 14/5 6/5 6/6 clinical significance could be used to % of TCU acquired pneumonias 5g 24 20 evaluate the therapeutic measures employed Pneumonia with later onset was associated with a sig- and to establish more appropriate therapeutic schemes if necessary. nificantly higher mortality (P(0.O25). Beside the well ~own high mortality rate associated with pulmonary infection in ICU pts, this study emphasizes the high incidence of early onset pneumonias. 222

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LEGIONEILA INFECTION IN AN INTENSIVE CARE UNIT STAPHYLOCOCCUS COAGULASE NEGATIVE (STAF-) IN BLOOD SAMPLES. FROM 1977 TO 1952.W. Donald Munro, City Hospital EVALUATION AND CLINICAL IMPLICATIONS. E, Domfnguez de Vi- the University of Nottingham, England. ]]ota, JM Mosquera, A. Aigora, JJ Rubio, M. Roig, P. Gal- Iegionaires disease first appeared in an ident- dos. Intensive Care Unit. Clinics Puerta de Hierro. San ifiable form in the Nottingham area in 1977. Martin de Porres 4. Madrid 35 SPAIN Initially identification of the disease was dif- The STAF ~ isolated in blood may be dismissed as contami - ficult and early blood specimens had to be sent nants. However, STAF- septicaemlas (SEPT) are well recog- to the National Centre for Disease Control in nized in patients with intravascular fore[ng bodies (car- Atlanta, Georgia, USA, for identification of diac prostheses, ventricular-atrial shunts, vascular grafts) antibodies. This did not help early diagnosis| Intravascular catheters (VASCATH) are very commonly used even when immunological identification became in critically ill patients and they may favour the prese~ available locally the delay of fourteen days ce of STAF- SEPT. in them for a significant antibody response precluded CRITERIA to diagnose a STAF- SEPT in this study were: the rapid recognition of the disease by that I/ clinical septic condition, 2/ isolation of means. Fortunately distinctive radiological, STAF- in at least two blood culture bottles and 3/ presen biochemical and haematological changes came to ce of VASCATH whether or not the STAF - was isolated fro~- be reeognised. Patients could therefore be tre- tem. ated early on the basis of these findings alone RESULTS.- Among the 1141 admissions to our ICU, 504 had with Erythromycin, which appears to be almost blood cultures taken and they were positive in the only available effective antibiotic which 210 patients (15% incidence). is effective in this disease, In 44 (9% of all blood cultures) STAF- was isolated. How- Almost all the patients referred to the intens- ever, in 32 (73%) was considered as contaminant and only ive care unit required prolonged lung ventilat- in 12 (27%) as pathogenic for the above criteria were met. ion with (at times) very high levels of inspir- The STAF - was iso]ated in 4 patients in the course of a ed oxygen. Intravenous nutrition was often requ- "multip]e species septicaemia'= and in 8 was the only or- ired for long periods although naso gastric ganism isolated (mean of 3.6 bott]es). One patient with feeding was preferred when ever this was poss- endocarditis in a valvular prostesis was excluded. Hence ible. Renal failure, when it occurred required in 7 patients the STAF- was thought to be the responsible dialysis. of a " primary STAF- SEPT". A review of the incidence of pneumonia cases Their mean age was 68.3 years (range 51-73 years). All pa- since 1973 suggests that there is now a cyclical tients had VASCATH (mean 1.9/per patient) with a mean du- legionalla factor occurring every two years ration of catheterization (n=6) of 7.2 days (range 2-15 in those patients requiring mechanical respir- days). In 5 STAF- was cultivated from the catheter's tip. atory support. One patient developped shock during the SEPT. CONCLUSIONS STAF- appears frequently in blood samples, but usually represents a contamination. How- ever, the repetitive isolation of STAF- in blood samples in patients with VASCATH must be considered as a relevant finding concerning the posibility of a STAF - SEPT.

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ACUTE GENERALIZED PERITONITIS (AGP) DEVELOPMENT IN INTEN= P50 AND 2-3 DPG IN SEPS!S.Pinta P,Tran-Minh T,France- SIVE CARE UNIT (IOU). F.Bobbio Pallavieini,A.Braschi,V. Montoya ML,Offenstadt G,Clair B,Cannone C,Hatzfeld D. Emmi, G. Negri, C. Reposi, G. Iotti, F. Raimondi, M. Fisehetti, P. H6pital Saint-Antoine - 75571 PARIS Cedex 12. Tosi, M. Fez~rera,D. Carbonera. Rianimazione I o, Ospedale San Nineteen patients (A) admitted in ICU for a severe sepsis Matteo,Universit~ di Pavia, Italia. were studied:septicemia (7),pneumonia (6),peritonitis (5), extensive eeliulitis (1).There were lO men and 9 women.The According to literature,mortality of patients suffering mean age wee 57 years. Death rate was 79 %. from AGP is higher than 50% (in some cases,higher than On arterial blood we measured:blood gas,hemoglobin (Hb), 90%).In 115 patients (68 primary AGP,47 secondary AGP) oh= 2-3 diphesphoglycsrate (2-3 DPG),standard P50 (PSO std)from the oxyhemoglobin dissociation curve (OCD)(dynamio method). served over 20 months,admitted in ICU for a stay over 5 49 samples were performed,ll patients have had daily stu- days,were investigated some factors of probable prognostic dies.12 healthy subjects (B) were also studied. meaning: pathogenesis (primary, seeondary),source of in= fection (supra- or infra-mesocolic), interval between eli= A B 2-3 DPG PSQ Std nical onset and operation, interval between operation and IPa 02 71,4 ~6,689,6 ~ " P50 Std 'r=0,80 ~* admittance in ICU, stay in ICU, percentage of complica= Torr t26,4 J ** .. i (39.7'% tione. Total mortality was 40.9% in primary AGP, pH 7,42 ;~I pH r=0,51 r:0,38 1 42.6% in secondary AGP), while mortality in infra-mesoco= 0~0~ .... lic AGP was significantly lower. The interval between ope= I' iP50 Std 28,7* 1~%27,2 3 I1 Pa 02 NS NS ration and admittance in ICU was nearly the some in the ITorr 1,9. .... patients who recovered (1.0+2.6 days) and in those who 12-3 DPG 18,5 , 14,8 l Hb NS NS died (0.6+1.4 days).The interval between clinical onset ~mol/g Hb and operation was remarkably longer for the patients who died. In this last group, the percentage of complications ~lOOml was significantly higher too. According to literature, the investigation confirmed a higher mortality in secondary Large and unforeseeable variations of PSO Std and 2-3 DPG AGP, a clear connection between operation delay, compliea= were observed.There was a etricking right shift of the ODC. tions percentage and mortality. In opposition to literatu= We found no definite explanation to this shift.Hypoxemia and re, it showed a mortality significantly higher in the su= anemia are theorical causes,but in our study there was no pra-mesocolic versus infra-mesocolic peritonitis. The low correlation between PSO Std and Pa 02 or Hb,either between 2-3 DPG and Pa 02 or Hb. total mortality percentage is probably due to the early In current practice, blood oxygenation should be assessed admission to ICU, immediately after the operation, 3oefore by simultaneous measurement of oxygen arterial pressure and the onset of haemodynamic, respiratory and~or renal com= oxyhemoglobin saturation. plications 2 223

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CIMETIDINE VERSUS CIMETIDINE PLUS PIRENZEPINE IN PREVEN- COMPUTER-ASSISTeD METHOD FOR EVA///ATIC~ AND ~TICN TING UPPER GASTROINTESTINAL TRACT BLEEDING IN PATIENTS OF OF DATA FR~ GLUCOSE C~TI,~ ]i~$7/LI~ INFUSION SYSTem2 AN INTENSIVE CARE UNIT - A RANDOMISED, PROSPECTIVE, IN CRITICALLY ILL PATII~NTS. G.M~ller-Esch, A. Peters, CONTROLLED CLINICAL TRIAL - M. C~'hl, M. Mewes, P. C. Scriba,Klinik f'dr Innere Medi- zin, Medizinische Hcchschule L'dbeck, L'dbeck, Gezre~ny. R.-D. Eanrath, H.K. Bouillon, W.-P. Fritsch, T. Scholten, Med. Kliniken, Universit~t Dl3sseldorf, FRG Glucose controlled insulin infusion systems (GCIIS) seem to be a valuable tool in the metabolic treatment of Introduction: The combination of cimetidins and pirenzepi- critically ill patients. The incidence of 4320 measure- ne results in a stronger and longer lasting suppression of ments frcm the GCIIS during a 24-hour control period is gastric acid secretion than cimetidine alone. Therefore the main reascn for developing this method, which permits cimetidine plus pirensepine should be more effective in a ccmfortable handling of a vast number of data. The the prevention of upper GI-tract bleeding than cimetidine procedure is based on a BASIC ccrnputer pr6grar~ne,that alone. Methods: Patients admitted to the medical intensi- will be demcnstrate~. ve care unit of the University of D~sseldorf from May 1982 /mFatmode: An interface between the GCIIS and the micro- to November 1982 were included in the study. Upon admission ccmputer PC 800 (MAGIRUS [I~TKNTEC~IK) has been employed all patients were randomized into one of the two treatment to transfer all data directly at one minute intervals. groups A or B by a table of random numbers. Patients with Further, comments concerning actual therapy can be upper GI-tract bleeding, recent GI-tract operations,etc. inserted manually. were excluded from the protocol. Those in group A received Calculations:The following parameters,characterizing the 200 mgs cimetidine iv every 3 hours during the entire stay state of carbohydrate metabolism, may be calculated: in the intensive care unit. Those in group B additionally - MBG = mean blood glucose received 40 mgs of pirenzepine/day by continuous infusion. - M-value = a measure for the duration and the degree of Results: 95 patients of group A and 105 patients of group pathological blood glucose levels (I) B met the criteria. The distribution of patients with - MAGE = mean anplitude of glycemic excursions (2) regard to sex, age, and severity of illness were compa- - an index, indicating the sensitivity to insulin. rable for both treatment groups. There was only i patient Record:Blood glucose, insulin rate and dextrose rate are with acute upper GI-tract bleeding and I with chronic plotted continuously. CcGments will be printed, too. bleeding in group B. No bleeding was observed in group A. Documentation: All recorded data are stored on a 5 inch Conclusions: In patients of a medical intensive care unit floppy disk. the prophylaxis of upper GI-tract bleeding by cimetidine Conclusion: The method permits cc~plete processing of alone proved to be effective. Therefore no additional po- GCIIS-data, which is almost inpossible when confined to sitive effect of a combined treatment with cimetidine plus manual ccmputaticn. Its usefulness in the treatment of pirenzepine could be shown. critically ill patients, especially during metabolic therapy with glucose-insulin-potassium in acute myocar - dial infarcticn, will be de/ncnstrated (Supported by the Federico Fo~dation). I. Schlichtkrull, J. et al.:Acta med.Scand.177(1965), 95 2. Service, F. J. et al.: Diabetes 19(1970), 644 Respiratory Failure

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ARE PROSTAGLANDINS INVOLVED IN THE DEVELOPEME~T NEUROGENIC ETIOLOGY OF RESPIRATORY ~SU~F~T~..N- OF ARTERIAL HYPOXIS? R.SCHERER,H.VAN AKEN,P.LAWIN Klinik f.Anaesthesiologie u.operat.lntensivmedizin CY. L,M. Popova, Institute of Neurology of the Jungeblodtplatz I,D4400 M~nster,West Germany USSR Academy of Medical Sciences, ~oscow, USSR Persistance of blood flow through atelectatic areas of the lung cause hypoxia by increased ven- The purpose of the study was a quantitative de- ous admixture.Hypoxie pulmonary vasoconstriction termination of functional pulmonary tests in (HPV)should reduce ventilatio~perfusion-mismatch- disturbances of cerebral control of breathing ing.0ne-lung-anaesthesia is an example of massive and in paralysis of respiratory muscles. atelectasis and a suitable model to study the in- Spirometry was made by means of the "POOL" appa- fluence of prostaglandins(PG)on intrapulmonary ratus (USER). Gas composition of theblood and shunting and HPV. acid-base balance were determined by using the Nine patients were studied during esophageal sur- equipment of the "Radiometer" Company (Denmark). gery under two- and one-lung ventilation(TLV,OLV) Disturbance of cerebral control of breathing with 66%02in N20 and neurolept anaesthesia. Sys- occurs in lesions of the corticospinal and cor- temic and pulmonary arterial pressures and blood ticonuclear connexions: a) Unilateral destruc- gases and cardiac output were measured. During TLV tion of these systems in the right hemisphere and OLV arterial and mixed venous levels of PGE 2 causes the syndrome of partial loss of cerebral and PGF~ were determined. control. Spirometry indicated restrictive forth Cardiac~output and pCOodid not change significant- of respiratory insufficiency, b) Bilateral des- ly,pOo decreased from 219+42mmHg(TLV) to 7~+18 truction of the corticonuclear and corticobul- mmHg(@LV)(p~0,01) and Q ~Q~increased from 74i4% bar connexions in the brain stem leads to comp- (TLV) to 43+10%(0LV)(p~8~O1y.PGE 2 increased f~em lete loss of cerebral control and consequently 2.83+1,59ng~ml(TLV) to 3,06A2,21ng/ml(OLV)(n.s.) of voluntary breathing and cough. Automatic con- and ~GFo~decreased from 0,35+0,53ng/ml(TLV) to trol provides gas exchange under condition of 0,19+0,~ng/ml(OLV)(n.s.).Dur~ng TLV and OLV PGE o free airways (tracheostomy, suction from the was ~ignificantly above normal values (0,76+0,47 tracheobronchial tree). Respiratory insufficien- ng/ml), while PGFo~ was below normal level(~,87+ cy was referred to obstructive type. 0,2ng/ml). Mixed ~enous PG levels were generall~ Diseases of peripheral neuron (paralysis of res- below the arterial levels. piratory muscles and bulbar palsy) are followed These findings indicate a clear prevalence of by respiratory insufficiency of restrictive-ob- vasodilating PGE 2 during mechanical ventilation structive type. Restoration of pulmonary func- even if massive atelectasis is present. PGE tions occurs within 8 to 12 months from the de- may have partly offset HPV in the presence ~f velopment of paralyses in acute polyradiculo- atelectasis.0ther metabolites of arachidonic neuritis. In severe form of myasthenia gTavis acid like prostacyclin could also be inv&ved. this type of respiratory insufficiency has been observed for many years.

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ACIDIC PHOSPHOLIPIDS IN BRONCHOALVEOLAR LAVAGE NEW SAMPLING TECHNIQUE FOR RESPIRATSRY GAS MEASUREMENTS. DURING RESPIRATORY FAILURE OF THE ADULT. A.Gedeon +, K.Hamilton +, S.H~ggmark, S.Reiz +Engstr~m J.Tahvanainen, M.Hallman, P.Nikki, Department of Anaesthesia, Helsinki University Central Hos- Medical, Bromma, Regionsjukhuset Ume~, Ume~, Sweden pital, and Children's Hospital, University of In order to simplify the clinical handling and to improve Helsinki, SF-00290 Helsinki 29, Finland Normal lung surfactant contains prominent phos- the response time of medical gas analyzers a new sampling phatidylglycerol (PG), or phosphatidylinositol line has been developed that eliminates water fall out (PI), but only trace of phosphatidylserine (PS). These phospholipids were investigated in lung from the sampled gas by acting as a selective permeable effluent from 14 adult patients with acute res- membrane for water vapor. piratory failure. 31 samples were obtained by bronchoalveolar la- Results: As the gas is drawn into a CO2 or an 02 analyzer vage using a 70 cm silicone catheter. PG, PI it passes along the sampling tube and by diffusion is and PS were measured as percentages of total phospholipids in lavage return. Prior to samp- gradually equilibrated with the ambient air as regards ling pulmonary venous admixture (Qs/Qt) and temperature and relative humidity. lung thoracic compliance (CLT) were measured. At a flow of I00 ml/min a 98% equilibration is achieved CLT correlated significantly with PG (r=0.61, p<.001)and PS (r=-0.62, p<.O01), but not with in a 30 cm long tube of diameter 1 mm. For a similar PI. No correlation between any of the phospho- effect to occur at a flow of 400 ml/min an 80 cm long lipids and Qs/Qt was found. Patients who died of respiratory failure (n=8) tube is needed. had higher PS than those who survived (n=8), Conclusion: Since no dead space in the form of water i.e. 8.4 • 1.2% vs 3.8 • 1.1% (p<.05). CLT was 30 + 3ml/cm H20 in the former group and 46 ! 8 traps needs to be introduced in the sampling system~he ml/cm H^O in the latter one (p<.O5). PG, PI or response time of an instrument is improved by a factor of ~s/Qt v~lues did not differ significantly between these two groups. 3-4 compared to current sytems. In measuring 02 uptake Our data suggest that deficient surfactant phos- the source of error due to the variable moisture content pholipids are at least partly responsible of of inspired and expired gas is effectively eliminated reduced lung elasticity in acute respiratory failure of the adult. Furthermore, a patient using the present sampling technique. In addition, all with deteriorated lung nechanics and a promi- units can run continuously and unattended with no risk to nent PS has poor prognosis. the sensors or sampling systems of the instruments. Supported by the Academy of Finland. 225

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LABORATORY EVALUATION OF AN EQUI~ENI FOR CONTINUOUS OXYGEN THE SIGNIFICANCE OF HYPOXEMIA ON LOWERING FI02 CONSUMPTION MO NIIORING IN MECHANICALLY VENTILATED PATIENTS BEFORE EXTUBATION. P.Nikki and J.Tahvanainen, M. Carlsson, E. Forsberg, A. Th6rne, J. Nordenstr6m, G. Denartment of Anaesthesia, Helsinki University Hedenstierns, Departments of Ansestesielogy, Surgery and Central Hospital, Haartmaninkatu 4, 00290 Clinical Physiology, Karolinska Institute at Huddinge Uni- Helsinki 29, Finland versity Hospital, Sweden. In order to evaluate the significance of hypox- Continuous measurement of energy expenditure by methods of emia.arising from ventilation to perfusion indirect calorimetry in vsntilatory assisted intensive care (VA/Q) abnormalities, PaO2, arterial 02 satura- patients has therapeutic as well as prognostic implications. tion (Sa02), and transcutaneous 02 tension The ventilator Erika (Engstr~m Medical AB, Sweden)has been (PteO 2) were measured on lowering FIO 2 in 47 pa- supplemented with a device for oxygen uptake measurement tients before extubation. All patients had been and energy expenditure calculation, the Engstr6m Netabolie weaned from mechanical ventilation and CPAP af- Computer (EMC). In the EMC, inspiratory and expiratory 02 ter respirator treatment of at least 36 hours. eomentrations are determined by an electroDhemical 02 The patients entered the study on the following sensor(Catalyst Research). The inspiratery flow (V~ mea- extubation criteria: no mechanical breaths,CPAP sured by a pneumotachygrsph, is used in the calculation of of 5 cm H20 , FIO 2 of 0.35, PaO 2 60 mmHg and oxygen consumption. This study examines the influence of PaCO 2 45 mmHg. In the study, FIO 2 was lowered different Oe concentrations (F02) , ventilatory frequencies in the following order: 0.40, 0.35, 0.30, 0.25 (f), tidal ~ volume~vt) and PEEP on the EMC. and 0.21. Oxygen concentrations (21-i00%) measured by the EMC were eompsredwith values from a masspeetrometsr(Centronie 200). No significant difference was found in PaO 2 or The inspiratory flow signal was compared with values from SaO 2 with any FIO 2 between those who were suc- s Bernstein mechanical spirometer at different ventilator cessfully extubated (group S, n=38) and those settings. who required reintQbatlon within 24 hours (group R, n=9). On the other hand, PtcO2/PaO ~ Results and conclusion ratios decreased from 0.82 to 0.66 in group K T~est analysis gave no difference at [02=21% , but signifi- whereas those remained above 0.8 in group S. Hb cant differences (p:O,O01) for F02~212. concentrations ~nd P58 values were lower and The eoeffieient of variation at FO 2 21-100Z was 0,03-0~0~ septic hypermetabolism more frequent in group R. 02 for the EMCand O,04-O,lOZ O~ for the mssspectrometer. The inspiratory flow meter was ~ependant on F02, f, vt and These data indicate that hypoxemia arising from PEEP. Thus, increasing FO 2 from 21 to lO0~ decreased ~I by VA/Q abnormalities do not solely predict sueces- 6%;inereasingvt from 0,3 to 1,1 1 increased V I by 6%; in- ful extubation in patients with eompromized oxy- creasing ffrom i0 to 20 bpm increased V I by 72 and increa- genation. The safe lower limit of PaO 2 depends sing PEEP from 0 to 20 em H20 decreased 91 by 32. In most on extrapulmonary factors, such as Hb, P50 and clinical situations (Flo ~ 21-60% f 10-20 bpm, vt 0,5-0,9 it metabolic state, PteO2/PaO 2 ratio seems to be a PEEP 0-20cm HgO), the o~ygen and flew meter of the EMC valuable eriterla of weanlng, because it probab- will yield an ~rror in the calculation of oxygen consump- ly reflects peripheral tissue oxygenation. tion of less than • 5 Z. Supported by the Academy of Finland. Cardiac Intensive Care, Resources, Metabolism

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QUANTITATIVE DETERMINATION OF DYNAMIC PRELOAD IN A NORMAL PARADOXICAL EMBOLISM: HEMODYNAMIC,ANGIOGRAPHIC I]~FT V~VfRICLE DURING REST AN EXF/%CISE. H.Lauboeck, AND ECHOOARDIOGRAPHIC FEATURES-TRERAPEUTIO Zentrale Anaesthesieabteilung,Bergmannsheil, Ruhruniver- APPROAOH.J.d'Enfert,T.Deliere,O.Dubourg, sit//t Bochum, BRD. Ch.Conseiller,J-C.Patel,J-P.Bourdsrias. HBpital The term "preload" usually denotes the force that must Ambroise Par@. 92100. Boulogne. France. be supported by the ventricles of the heart at the end of the diastolic phase: the maximum of diastolic filling In two patients who were admitted for systemic pressure, volume an muscle fiber tension ( as given by arterial embolism,the development of clinical; Laplace relation) is reached; rising ventricular pressure raOiogrmphis sod electrocardiographic signs of crosses atrial pressure, atrioventricular valve closes. pulmonary embolism suggested paradoxical embo- In contrast to this the d~amic point of view leads to lism (PE).Blood gases showed moderate to severe quite different conclusions. The prupose of the present arterial hypoxemia and pulmonary angiography investigation is to describe the dynamic relationship demonstrated bilateral pulmonary embolism.Two- between pressure and flow across the mitral valve. Due dimensional contrast eohocardiography visuali- to inertia of mitral blood flow, valve clnsure is de- zed right-to-left shunt through a patent foramen layed for a certain time after the atrioventricular pres, ovsle (PFO).Right heart catheterization confir- sure crossover. This delay has been investigated by means med the PFO and e• an atrial septal de- of dLmensional analysis. A nondimensional number occur- fect. Leg: deep vein thrombosis was confirmed by ring in this analysis has been "taken from the report of phlebocavography (oase~" and pathological stu- an experiment with dogs and then used to determine the dies (case 2). conditions of mitral valve closure ( i.e. the magnitude In these two patients,~r~stment of PE associated of dynamic preload) in man. Results: rat/ler high (&p 80 1-heparinotherapy 2-embolectomy following peri- Torr) pressure are obtained during e~ercise( heart rate pheral arterial angiogrsphy 3-partial interrup- 172/ rnin. ) and about 10% of the stroke volume enters the tion of the inferior vena csva using Adam de ventricle and increases its volt~L~ before the mitral val- Weese clip or Greenfield filter 4-1cog term ve closes. The theoretical prediction is 'then verified by anticoagulation. echocardiography of the isovolumetric peried(IP).Mitral With s follow-up of more than one year,there was valve closure and aortic valve opening are picked up no reccurence of pulmonary or arterial smbolism simultaneously with two echeoardiographic apparatus. Thus despite the persistence of PFO. IP can be measured directly.Result: IP decreases at a In conclusion,l-contrast echocardiography should rate greater than that of the increase in heart rate be performed whenever PE is suspected 2-inter~ resulting from exercise and even disappears altogether ruption of the inferior vena cava proved useful when the heart rate reaches a sufficiently high level in preventing reccurent pulmonary and systemic (140/min.). It is possible for the dynamic preload to arterial embolism, overlap with the beginning of the afterload period, as indicated by aortic valve opening.

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ACUTE MYOCARDIAL INFARCTION COMPLICATED BY RESPIRATORY "TORSADES DE POINTES" AND POTASSIUM DEFICIENCY : FAILURE: THE EFFECTS OF MECHANICAL VENTILATION. J.R~s6nen A. Rimailho, J. Litwin, JL. Ricome, C. Richard, Ph. Auz6py- and P. Nikki, Department of Anesthesiology, Helsinki Uni- HSpital de Bie6tre - Service de R~animation M~dicale - versity Central Hospital, Helsinki, Finland 94270 LE KREMLIN BICETRE (France). Controlled mechanical ventilation (CMV), intermittent man- Within a period of one year, in our intensive care unit datory ventilation (IMV) and spontaneous breathing with five patients developed "torsades de pointes" (TP) with continuous positive airway pressure (CPAP) were compared production of syncopes. In all patients E.C.G. revealed in 9 patients with acute myocardial infarction complicat- QT prolongation longer than 0,55 see and mild bradycardia ed by respiratory failure. Cardiopulmonary function was just before the onset of TP ; at the same time, in three assessed by measuring thermodilution cardiac output, circ- patignts a markedly hypokaliemia (<3 meq/l) was noted, ulatory pressures, blood gases and the sum of the ST-seg- but in two others, kaliemia was normal (4,6 and 4,7 meq/l). ment deviations in a 12-lead ECG (AZST). The ventilator The~e two ones, 74 and 79-year-old women, presented no frequency was altered to deliver i00% (CMV), 50% (IMV) and congestive heart failure, cirrhosis, denutrition, diarrhea, 0% (CPAP) of the patient's minute ventilation with a tidal rena~ or surrenal dysfunction ; calcemia, magnesemia, volume of 12 ml/kg. The end-expiratory pressure (range protidemla andhlood pH were normal ; no antiarythmic, 5-10 cmH20) and the inspired oxygen concentration were diuret~6, mineraloeortico~d or laxative drugs were given ; kept unchanged. The arterial blood oxygen saturation was daily urinary potassium was in both eases about 50 meq, > 90% at all times. The respiratory rate during CPAP was balancing imputs ; a measurement of total exchangeable 10-24 breaths/min; no CO 2 retention was seen. The essen- potassium by K 42 revealed a significant depression of 30 % tial results were as follows: and 28 %. In all our patients ventricular pacing was CMV IMV CPAP safely rapidly and temporary used, and at the same time large daily amounts of parenteral potassium were given. MAP (mmHg) 77!16 86• 90• In the two normokaliemic patients kaliemia and kaliuresis HR (bpm) 2 93• 91• 94• were without appreciable change, QT returned to normal CI (i/min/m) 2.9fi.3 3.1• 2.9fi.0 within three and four days, and under daily potassiu m C(a-9)O 2 (ml/dl) 5.8• 5.3fi.6" 5.3• supplements, none episode of TP occured later without any SVR (dyn.sec.cm -5 ) 1193• i189• 1344f479"* other treatment. It seems thus that some patients present PVR (dyn.sec.cm -5 ) 171• 130• 139• unexplained potassium deficiency without hypokaliemia and AZST (mm) 12f7 13• 15• that potassium chronic Supply should be an appropriate Qs/Qt (%) 8• 8• 13i7 measure to prevent dramatic episodes of TP. PcwP (mmHg) 14i6 18• 19• * = p<0.05 to CMV, ** = p<0.01 to CMV (MEAN • SD) We conclude: • used with PEEP, CMV impairs cardiac function by reducing venous return even in patients with acute myocardial infarction and high filling pressures. 2)The withdrawal of ventilatory support is associated with an increase in systemic vascular resistance and may cause myocardial ischemia with reduced cardiac performance even when the blood gases and the respiratory rate are norraal. 227

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RETENTION OF CARDIOPULMONARY RESUSCITATION (CPR) SKILLS ~-OR B-SYMPATHOMIMETIC STIMULANTS IN CPR ? AFTER INITIAL OVERTRAINING. G.H. Meuret, H.G. Lenders, H.F.O. Schindler J.L. Blache, B. Laurent, C. Soler, c. Chaillol, F. Dubouloz, Dept. d'Anesth@sie R@anlmation (Pr.G. Frawois) G.H; La Timone, 13385, Marseille, The effects of orciprenaline I~ (B-stimulant)and France. norfenefrine ~] (-stimulant) to those of epi- The authors have examined CPR skills retention in a nephrine [E] (~- and B-stimulant) in CPR was com- Medicine University. 150 pregraduate medical students received a 8 hours course of Basic Cardiac Life Support pared in this experimental study in dogs. as defined by American Heart Association with recording After five minutes of anoxial cardiac arrest we manikins. Each training session was followed by a written test and measured continuosly the following parameters: a performance test on the recording manikin (post-test). hemodynamics, blood gases and electrolytes,bin- 105 of them reached the instructor's level tape criteria as defined by the standard. chemic parameters of aerobic and anerobic meta- 12 to 18 months later, the 105 students who had reached bolism. this high level performance were retested of cognitive knowledge and performance skills in a similar test Left ventricular and central aortic pressure was situation ( re test). significantly higher in the E- (n=11) and N- The first min of one-man CPR on the two tapes was compared. Retention was expressed as a percentage group (n=8) than Ln the O-group (n=8) during i.e. re test score / post test score x 100. Statistical internal cardiac massage.lncidence of fibrill- comparison was made by a student's t test for paired samples. ation was equal in all three groups. The pres- i Post test Re test Retention P sures after defibrillation were significantly score score ( % ) hLgher with E than with N and 0 (p 0.001). Written test I 80% 84% > 100% Consequently the coronary blood flow was better VentilationsN~ of adequate I 7,7 4 52% < 0,001 with E as well. This was strongly correlated N~of adequate with survival.( E: 11/11, N: 5/8, O: 2/8 ) compressions 59,2 36 60% < 0,001 We conclude that epinephrine is superior to N With the effort and cost devoted to CPR training there is an evident need for mn~m research in teaching methodology and 0 to restard spontaneous circulation because and skills retention. The present study demonstrates that of its combined 4- and B-stimulating activity. even overtraining of medical basic rescuers results in unsatisfactory psychomotor sk~lls retention for a year But epinephrine is not yet the ideal drug in CPR. but satisfactory knowledge retention.

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CARDIAC PACING DURING CPR BY MEANS OF AN EXTeR- BEDSIDE COMPUTER FOR PATIENT SAFETY, DATA COL- NAL MECHANICAL STIMULATIgN DEVIUE. L.^Binner . LECTION AND DATA PROCESSING. U. Frucht, P. Kunow, A. Schmidt ,W I Nechwatal ,H. HeinrichL,0.Wess ~ Th. Kersting, K. Reinhart and R. Dennhard, Dept. and M. Stauch . Division of Cardiology(1) and of Anesthesiology and Operative Intensive Care, Department of Anesthesia(2), University of Ulm, Free University, Berlin, FRG Germany. Dornier System GmbH Friedrichshafen(3) Introduction: In applying vasoactive substances, Germany. false dosages can lead to dangerous cardiovas- Electrical intracardiac stimulation during drug cular alterations. The prevention of blood pres- resistant cardiac arrest usually is not avail- sure crises resulting from sudden changes in able in the ambulance; furthermore correct po- systemic vascular resistance (SVR) and cardiac sitioning of the endocardial lead may be dif- output (CO) signifies an advance in therapy with ficult and time-consuming during CPR. There- these substances. fore we have employed an external mechanical Methods: We have developed a computer the size device for cardiac stimulation during the lag of a standard clinical monitor, which , as part period until definitive placement of the endo- of a control system, safely doses vasoactive cardial lead. Pressure waves are applied in substances. The advantages of this system (mon- the 4th intercostal space, using a 2.5 cm itor, computer and metering pump) consist in its diameter thumper with variable rate and ad- safety and variability. After input of the ap- justable mechanical energy. With proper angu- plied substance, the maximal dose and a code for lation and sufficient energy, electrical car- the direction of the blood pressure change, the diac potentials are induced with subsequent contraction of the heart. In 8 patients with program functions automatically. Fixed limits cardiac arrest we used this device during CPR. (dose, blood pressure) are maintained; an alarm In 4 of these patients it was possible to ob- is set off when they are reached. In addition, tain a sufficient circulatory function without important calculations (hemodynamic profile, cardiac massage until stable endocardial elec- pulmonary shunt volume and P50) can be made with trical pacing could be established. As could a separate computer program (I) and a data log- be expected, in cases of electromechanical ger. dissociation no effective circulation was ob- Conclusion: The computer stores the dose of the vasoactive substance, the changes in the hemo- tained. In these 4 patients no mechanical response followed the induced cardiac poten- dynamic parameters and the calculated parameters tials. This was Confirmed by subsequent elec- for further statistical evaluation. References: trical stimulation. These preliminary results indicate, that external pacing with a mechani- I. Th. Kersting, K. Reinhart, G. Gassch~tz and K. cal pressure wave device may be useful in the Eyrich: Easy-to-operate computing system for emergency treatment of patients with cardiac haemodynamic parameters, pulmonary shunt and arrest, whileendocardial pacing is accom- P50: Anaesthesia. 6th European Congress of plished. Anaesthesiology, 1982, Academic Press, Inc., London 1982, p. 263. 228

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COMPUTER EVALUATION OF HENOD~NAMICS IN VVI-STIMULATION IN IDIOPATHIC SUBAORTIC POSTOPERATIVE INTENSIVE CARE UNIT.Prof.R.N. STENOSIS (IHSS) - A THERAPEUTIC ALTERNATIVE. Lebedeva, A.A. ~eriomenko, V.V. Abbacumov. J.H~cking, H.Feigel~ M.Schwartau, H.Voss, Intensive Care Unit, National Research Center AK St. Georg, Hamburg, W.-Germany. of Surgery, Moscow, USSR A g8 year old patient (pt.) with IHSS having Hemodynamie parameters obtained by heart been under medical control for q2 years ran chambers and major vessels catheterization into clinical state IV NYHA. She was treated are registered automaticall F wi~h the help of by means of right ventricular stimulation in computer based monitoring system.Oxygen oalan- VVl-mode only. The preexisting tachyarrhythmia was suppressed by 5o mg Atenolol. Heart rate ce and acid base status data input to assess fell from qq0 to 8o. A stimulation rate of 90 the adequacy of circulation is performed with was high enough to provide only pacemaker the use of bedside microcomputer key board. stimulation. Thus the pt. recovered to such The algorFthm is based on clarification of an extend that we decided to implant a perma- images.Normal type of hemodynamics, hyperkine- nent pacemaker. tic, hFpokinetic type / hypovolemia, compen- The following criteria proved benefit from this procedure at the moment of changing from spon- sated and dscompensated heart failure and taneous rhythm to pacemaker rhythm: shock / are defined.Left ventricular and right q.Arterial blood pressure raised from 8o to ventricular pump function are estimated sepe- qqo mmHg. rately.By the experts' assessment 93% of com- 2.Left ventricular high pressure (apex) fell puter conclusions apNearsd to be correct. from 23o to qgo mmHg. 3.Echoeardiography showed remarkable reduction of SAM. Conclusion. The "false" way of excitation of the myocardium causes the apex parts of the heart to contract prior to the septal parts. Therefore the typical trapping phenomenon of IHSS cou~ be diminished.

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COMPUTER-ASSISTED THERAPY IN I. C. U. : DESCENDING AORTIC DISSECTION+ ~ : PREOPERATIVE++ AND INTRAOPE-+ OOPAMINE INFUSION. RATIVE ASSESSMENT.+ M. Dan+ , A Milano~ ~ C Sorbara~ G. Pelosi, R. Proietti, F. Loririo, L. Cristald[, F.M. Cir$~lo , P. Cantele , G.M. Aru , G.P. Giron , V. Gallucci V. Per.llLi, V. Perott], A. ArcangelJ. Cattedra di Anestesia e Rianimazione, ++Cattedra di Chi- Istituto Anestesiologia e Rianimazione - Universit~ rurgia Cardiovascolare, Universitg di Padova, Italy. Cattolica del Sacro Cuore - Roma In order to improve the surgical treatment of patients Several and complex problems associated to the (pts) with Type II-I aortic dissection we reviewed the re- hemodynamic conditions and the peculiar pharmacology cords of 36 consecutive pts operated on by our surgical of dopamine , are frequently met by clinicians tPeatin9 group between march 1971 and november 1982. Sixteen pns required an operation ou emergency basis shock syndPom e. ~group A) because of signs of impending aortic rupture The following report is a preliminary attempt to (12) oliguria (i), development of neurologic defict (2), design a system of physician-computer interaction in failure co control hypertension (I). Twenty ~ts had un- the management of shock syndrome and in particular in complicated dissection and the operation was performed the adjustment of an optimal pharmacological (dopamine) after stabilization with medical treatment (group B). intervent ion. The overall mortality rate was 33% with i0 hospital deaths in group A (62%) and 2 in group B (10%). The report describes a system of dopamine infusion We performed 15 operations uszng femoro-femoral by-pass automatic control as well as the general procedure ado_. with 7 deaths (46%), 16 using Gott shunt with ~ deaths pred. Clinical application of the system allows to speci- (25%), 4 using simple cross-cl~aping technique with I fy the following advantages: death (25%). Only in one patient we used successfully left

- proper collection and organisation of specific da- atrial-femoral artery bypass. ta; The main complications were spinal cord injury in 5 pus, renal insufficiency in 5, left ventricular failure in 4, - rapid computation of hemodynamic data and esti- hemorrhage in 3. mation of optimal dopamine infusion which is con- We concluded that the cperauive survival race is signifi- stantly adjusted; canr higher (p(O.05) in stabilized patients; tat spinal -computer-aided measurements and calculations; cord znjury is unpredictable and probably not related co - data storage; perfusion techniques; renal failure seems to be related co low perfusion; the Gott procedure zs more satisfactory - educational and training capabilities. in providing proximal decompression 229

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RESULTS OF SURGICAL THERAPY OF DESCENDING AORTIC Comparison of metabolic and endocrine changes produced by balanced ANEURYSMS (DAA). J.LAAS, E.STRUCK, F.GRIESHECK, anesthesia vs narconeuroleptanalgesia during cardiac surgery. E.MEISNER, P.SCHMIDT-HABELMANN, F.SEBENING, GERMAN HEART CENTER, MUNICH, W.-GERMANY J.J Arnulf*,C.Isetta*, F.R.Kuntschen**, P.M Galetti *~* Service Pr V.Dor. Institut A.Tzanck 06700 Saint Laurent du Var - F- The optimum treatment of DAA- surgical or solely medical- * D.A.R. Nice Pr P.Maestracci remains uncertain. Since there is little information about ** Fondation organes articiels. Clinique de Genolier. Pr CH. Hahn - CH- long term results this study persnes prognoeie of opera- *** Artificiel organ laboratory Brown university RI - USA - tive therapy of DAA over a 7-year period. ~ Since 1974, an unselected cohort of 32 patients had surgical therapy of To compare the degree of metabolic protection afforded during cardio- DAA. All patients were followed up until July 1982, datas pulmonary bypass (CPBP) by the two most widely used techniques of were analyzed retrospectively (76.8 pat.yrs,max.surv. 7.2 anesthesia, 15 patients (14 mons and I women) undergoing elective yrs). 27 aneurysms were dissected (84%). There were 17 coronary surgery (If) or cardiac valve replacement (4) had their blood traumatic(S3%) andl3 arteriosclerotic (41%) DAA. In glucose levels contineusly monitored by means of the Biostator glucose either 16 patients (50%) clinical course was acute or controller. The patients received no exogenous dextrose and no insuline chronic. 30 patients had replacement of DAA by vascular from either the anesthesiologist or the priming fluid of the heart graft, 2 had local correction. All but i patient were lung machine. Blood sa~oles for metabolic and endocrine determinations operated with ECC or temporary shunt. ~ Overall operative were obtained before induction of anesthesia, before CPBP, after 30 mortality (OM) was 37.5%, dn dissecting DAA 41% (ii/24). min of CPBP, at the end of CPBP and 50' after discontinuation of CPBP. OM in traumatic DAA was 18% (3/17), 2/3 patients died Eight patients were operated under balane~ analgesia using enflurane, in table due to acute rupture. OM in arteriosclerotic flunitrazep~n,fentanyl, pancuroniem and nitrous oxide, whereas 7 DAA was 54% (7/13). Postop. no patient had paraplegia; 4 patients received narceneurolept analgesia using thiopenthal, patients (13%) required hemodialysis because of temporary droperidol, phenoperidine, pancuroniem and nitrous oxide. renal failure, i patient with replacement of DAA died 3 Starting from the same fasting blood glucose level as the balanced months postop., all other patients were alive on control anesthesia group, the patients under narconeuroleptanalgesia exhibited key date, 61% resuming their professional activities. a lower hyperglycemic response to non pulsatile CPBP with the same We conclude that best operative results can be achieved levels of circulation insulin.This was coupled with lower blood levels in traumatic DAA . However, the high incidence of intraop. of cortisol, and highter levels of glucacon. The narconeurelept- rupture in this group emphasizes the need of rapid dia- analgesia group also showed significantly lower levels of alanine and gnosis and surgery. Patients with arteriosclerotic DAA 3 - hydroxybutyrate compared to the balanced analgesia group. Lactate, have the highest OM due to poor quality of aortic tissue pyruvate, epinephrine, norepinephrine, growth hormone, free fatty and to the elevated morbidity of these patients. Although acids, glycerol, triglycerides and cholesterol leve|s did not differ none of our patients suffered paraplegia the incidence of significantly between the two groups. NA, K, mg, Ca and P remanied renal dysfunction underlines the importance of ECC or within normal limits. sufficient shunt. Late mortality after surgical therapy These observations suggest that during narconeuroleptanalgesia, there of DAA is low, patients generally resume normal private is an increased glucose utilization by peripheral tissues, coupled and professional activities. with reduced proteolysis and glyconeogenesis as compared with balanced anesthesia. Lipolysis is not affected by the type of anesthesia used for cardiac surgery.

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COMPLICATIONS POST-OPERATOIRES DES DISSECTIONS AIGUES DE ELECTROCARDIOGRAPHIC AND ENZYMATIC CHANGES FOLLOWING AORTO L'AORTE ASCENDANTE : INTERET DE LA, COLLE GELATINE-RESOR- CORONARY BYPASS SURGERY. R. Martinez, D. Obrador, J. G6mez, CINE-FORMOL (G.R.F.) A. Aris, R. Fort, F. Oca, E. Trilla, A. Bayds, A. Artigas. DUBOIS C., BRODATY D., SCHLUMBERGER S., BACHET J., S. Cuidados Intensivos. Hospital de la Santa Creu i Sant GOUDOT B., GUILMET D.' P.LOIRAT. Pau. Barcelona. Spain. Entre Janvier I970 et D~cembre I980, 74 patients ont @t6 Fifty-six patients were studied following coronary revascu lari~atian (CR). Five ECG's (preoperative, inmediately - op@r6s d'une dissection aig~e de l'aorte ascendante. De postoperative, at 24 and 48 hrs and on discharge) and 5 I970 ~ 1976, 25 patients ont 6t6 op6r6s avec des techni- isoenzime C~-MB (u/l)determinations (preoperative, @,12,24 ques classiques (groupe I). Entre Janvier I977 et D6cem- and 48 hrs) were made. Pre and postoperative VCG's were ma bre 1981, la colle GNF a 6tg utilis6e chez 49 patients de in only 40 patients. Patients were classified according pour renforcer les tissus diss6qu6s (groupe II). II n'y a ausnne diff6rence significative entre les deux groupes to appearance of postoperative electrocardiographic chan- concernant l'gge, le sexe, l'6tat pr6-op6ratoire et le ges. Group A (23,2%) with ECG or VCG criteria of myocardial infarction; group B (12,5%) with intraventricular con type anatomique. L'aorte ascendante a @t6 remplac6e chez duction disturbance (IVCD) and severe repolarization dis- tous l~es patients, la valve aortique a gt~ remplac6e turbance (SRD) defined as 2 mm ST ascent or depression or dans 12 cas du groupa I (48%) et dans 8 cas du groupe II 5 mm negative T wave; group C (17, 8%) with SRD only; group (16%). Le volume moyen de transfusion per-op6ratoire a D (46,4%) without ECG changes (IVCD not associated to SRD 6t6 de 5800 ml pour le groupe Iet de 2980 pour le grou- were included). pe II. 4 patients du groupe I (16%) sent d@c6d6s en salle d'op6ration pour 0 dans le groupe II. Les compli- RESULTS: Enzimatic results (maximum value) were: group A= cations post-op6ratoires sent significativement moins 119~ 70; group B= 136 ~ 77; group C= 61~ 31 and group D= importantes en gravit6 et en fr@quenee dans le groupe II 51~ 28. No significative difference was found between A/B que dans le groupe I. and C/D. Enzymatic level CK-MB in group A and B was higer ...... than group C and D: A/C (p ~ 0.05), A/D (p < 0.001), B/C Groupe I Groupe II (p

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HOW TO WEAN IN THE POST OPEN-HEART SURGERY PERIOD (CPAP OVERESTImaTION OF MEAN CARDIAC OUTPUT DURING AN VERSUS Q-INSUFFLATION). U.Fina, Ch.Spiss, W.Koller, END EXPIRATORY PAUSE IN CPPV. A. Logmans, H.Benzer, Research Center for Intensive Care, Clinic of A. Versprille, J.R.C. Jansen, Dept. of pulmonary Anaesthesia, Spitalgasse 23, A-Io9o Vienna, Austria. diseases, Pathophysiological laboratory, Erasmus The pulmonary lesion produced by ECC causes a decrease University, P.O. Box 1738, 3000 DR Rotterdam, in FRC and in arterial oxygenation. In the iranediate The Netherlands postoperative period the addition of PEEP can reverse Under circumstances of intermittent and continu- this effect. 64 patients (42male, 22 female, mean age ous positive pressure ventilation (IPPV and CPPV) 55 years) who had undergone CABG (n=4o) or valve replace- right ventricular output (Qrv) was measured by ment (n=24) were included in this study. Group I (n=34) means of a flow probe on the pulmonary artery in were weaned with CPAP 7, group II (n=3o) were weaned pigs (closed chest) and analysed beat-to-beat. with Q-insufflation. Weaning was started 9.25• hours Calibration was done by means of the Fick's after ending operation. The patients did not receive any method for oxygen. narcotic or sedative, nor were they on any vasopressor Qrv decreased during insufflation and recovered agents. Blood gases and respiratory rate (RR) were docu- during spontaneous expiration via an overshoot mented and PAO2-PaO2/PAQ (AaD% quotient) was calculated to an end expiratory plateau. This plateau was in each of these 3 conditions: I. CMV, both groups PEEP7; constant when the expiratory pause was length- 2. Intubated, spontaneous breathing PEEP 7 (group I), ened and appeared to be dependent on the level ZEEP (group II); 3. I hour after extubation, both groups of positive end expiratory pressure (PEEP). The ZEEP. Each patient had only I FiQ throughout the study. end expiratory flow was considered to be the The data presented in the following table. baseline value for its changes during insuf[lation. The deficit of flow during insufflation I 2 3 was much larger than the expiratory overshoot. Thus, mean cardiac output was lower than end PaO2 14@26 CPAP 121~6 !23• ZEEP 118~28 expiratory flow. Decrease of mean cardiac output by PEEP or hypo- PaCt 35~5 CPAP 4oZ4 4~4 ZEEP 38Z3 volemia increased the insufflatory deficit but did not increase the compensatory overshoot. pH 7.44!o.o 7 C~AP 7.39Z0.o4 ZEEP 7.4ofo.o4 7"39• We concluded that - an estimation of cardiac output during an end AaD%/Q 49~13 CPAP 55Z13 53~i 2 ZEEP 57• expiratory plateau phase overestimates mean cardiac output, which was confirmed with the RR 12 CPAP 16• 18~4 ZEEP 18• thermodilution technique, - the overestimation is higher at lower values The variables did not show any statistically signifi- of mean cardiac output, cant changes. It is concluded that CPAP did not improve - the end expiratory flow depends on PEEP and pulmonary gas exchange in patients who had undergone mean cardiac output on PEEP and superimposed open heart surgery. insufflation.

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SPECTRAL ANALYSIS OF ASCE~!DING AORTA DOPPLER SIGNAL. CARDIOVASCULAR AND RENAL EFFECTS OF DOBUTAMINE A. TEDGUI, D. PAYEN, M.• B. LEVY and M. MclLROY COMBINED WITH DOPAMINE. N.Spannbrucker,F.Vogel~ INSERM U 141, 41 Bd de la Chapelle 7'5010 Paris, France, Medizinische Klinik der Universit~t Bonn, CNRS ER 248, 96 rue Didot, 75014 Paris France. Bonn, West - Germany In an attempt to obtain quantitative blood flow infor- Although the combined use of dobutamine and do- mations from Doppler signals recorded in the ascending pamlne in treatment of cardiac failure has been aorta, the mean Doppler shift frequency must be measured recommended in several recen[ studies ~ %he and the extraneous signal from vessel walls represents effects of this combination have not yet been noise that needs to be recognized and eliminated. If mul- demonstrated. In 12 patients with severe con - tiple frequencies are present, especially if the signal/ gestive heart failure we compared the effect of noise ratio is low, zero crossing detectors introduce si- a combined dobutamine/dopamlne infusion (5 ~g/ gnificant errors (LUNDT 1975) and spectral analysis is ne- kg/min dobutamine - 5 pg/kg/min dopamine} on cessary to determine the amplitude of each frequency compo- hemodynam~cs and renal blood flow with changes nent and to calculate the average frequencies. Several measured under dobutamine (10 ~g/kg/min) and do - approaches to this problem have been employed, utilizing pamine (I0 ~g/kg/min) given seperately. Dobuta- parallel narrow band filters, or digital fast Fourier mmne combined with dopamlne and dobutamine alone transform. We used a laboratory-built Walsh transform ana- increased cardiac index by 61% without ehan~in~ log system to calculate spectral components. The spectrum mean arterial pressure. Under dopamine cardiac is displayed in the usual "sonagram" format with frequency index increased ~5 % with a slight increase of as ordinate, the time axis as abscissa, and spectral power mean arterial pressure (+6%). There was a sig- as trace brightness. The directional ultrasonic Doppler is nifican% fall in preload under dobutamine and also available for digital data acquisition. dobutamine combined with dopamine. In conzrasz, The accuracy, reproductibility and ease of use of a pul- dopamlne alone increased left ventricular sed Doppler machine (Alvar 4mHz) associated to the direc- filling pressure. Corresponding co the rise of tional spectral analysis system has been investigated in cardiac index the renal blood flow increased normal subjects and in critically ill patients in artifi- under dobutamine 59 ~ - whereas dobutamine com- cially or spontaneous ventilation. An ultrasonic probe bined with dopamine and dopammne alone doubled (diameter lOmm) was positioned in the suprasternal notch, the increase of renal blood flow (+ 125 %) . The angle between the ultrasonic beam and the axis of the ascending aorta blood flow is assumed to vary from zero to 3 deg. the angle error is then less than 15 %. From first results, it appears that : 1) spectral analysis provides a valuable velocity signal even though the signal noise ratio is too low for zero crossing detection. 2) individual stroke volumes values calculated from spectral analysis are well correlated with those simultaneously measured by the thermodilution technique. 231

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DOSE-RELATED HEMODYNAMIC AND RENAL EFFECTS OF DOPAMINE OXYGEN TENSION AND MICROFLOW OF THE MYOCARDIUM (DP) IN SEPTIC SHOCK.A.Esteban,M.A. de la Cal,E.Mirav~ FOLLOWING HEMODILUTION WITH FLUOSOL DA 20 %. Vogel, H. +, GOnther, H., Harrison, D.K., HOper, J. lles,T.Pascual.Hospital Central de la Cruz Roja,Unive~ Frank, K.H., and Kessler, M.. Inst. for Physiolo- sidad Complutense,Madrid,Espafia. gie und Kardiologie der UniversitQt Erlangen,Inst. f0r Anaesthesiologie der Universit~t M0nchen +. The assumed prerequisite for blood substitutes We have studied hemodynamic and renal effects of in with a high solubility for oxygen is that an ar- creasing dosage of DP in 7 patients with peritonitis - terial oxygen tension {PaO 2) of at least 300 mmHg and therefore a high inspiratory oxygen fraction and clinical findings of septic shock. Studies were hegun when each patient had reached a- (FiO 2) is necessary for the adequate oxygen supply to the organism. This would seriously limit steedy hemodynamic state with diuresis greater than. 7 ml/min while treated with DP.Once the first determina- the application of such substances in clinical practice. In order to investigate the validity of tions were recorded~the dose of DP wes increased by 5- this hypothesis, we measured myocardial oxygen ~g/Kg/min. and after 45 min the determinations were - tension (PmO~) using a multiwire surface electro- repeated.Glomerular filtration rate and renal plasmatic de and myocardial microflow (mMF) by means of flow were measured by Inulin and paraminohypurate cle~ hydrogen clearance following hemodilution (HD) rances respectively (Cin,Cpah). We have observed augmentation of stoke index (p<.01), with Fluosol DA 20 % (F DA) at FiO 2 of 1.0, 0.5, and Blood pressure (p<.01),without significant increase and 0.3. Eight anesthetised (Fentanyl/Diazepam) and artificially ventilated dogs were thoraco- in Heart Rate,total systemic resistances,pulmonary pr~ tomised and hemodiluted with Hydroxyethylstarch ssure and pulmonary wedge pressure.Renal response - showed augmentation of diuresis (p<.01),Cin (p<.05) and (HES) to hematocrit (hct) 14 % and then with F DA sodium fractional excretion (p=0.2) without significant to hct 7 %. Fluorocrit (fct) was 10 %. Results: changes in either Cpah or filtration fraction. At FiO 2 1.0 (PaO 2 466 mmHg) , F DA led to a 70 % We concluded that incrementing dosage in DP in sep increase of mean PmO 2 as compared to HES-HD and tic shock patients may he useful even with hyh dosage- mMF increased by 7 %. At FiO 2 0.5 (PaOp 212 mmHg) PmO o still exceeded pre-HD control valhes and mMF of DP.Increased natriuresis wes not due to changes in- remained unchanged . At FiO 2 0.3 (PaOp 91 mmHg) plasmatic renal flow. there was no further change in mMF an~ PmO 2 de' creased below control values. In those dogs where hypoxic tissue areas were observed acute moycar- dial failure occured. Conclusion: under our conditions of dilution with Fluosol DA(hct 7,fct 10) myocardial oxygen supply was well maintained at FiO 2 0.5 provided that the coronary reserve was normal. At FiO 2 0.3, however, myocardial hypoxia was observed.

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ABSENCE OF EFFECT OF CAPTOPRIL ON PULMONARY HEMODYN~MIC DETERMINATTON OF AMYE~ASE ISOENZYMES AND PANCRE~ C. RICHARD, A. RI~ILHO, JL. RICOME, Ph. AUZEPY - H0pital TIC HORMONES DURING SHOCK. J.Lchmann, Th. Hoss- de Bic~tre - 94270 LE KREMLIN BICETRE (France). doff, N.van Husen, U.Gerlach,Madizinische Uni- We studied effects of oral administrafion of CAPTOPRIL on versit~tsklinik,M~nster,W-Germany pulmonary hemodynamic in two groups of six patients, one In patients with shock of different etiology including subjects with chronic respiratory failure (CRF) activity of alpha-amylase in serum is signifi- and the other subjects with chronic heart failure (CHE) and cantly increased. This increase of total amylase high plasma aldosterone (PA) level and plasma renin activity activity represents a relative enhancement of (PRA). The reason for this choice of patients was to assess salivary isoamylase while the activity of the two potential mechanisms of CAPTOPRIL action : hypoxic vaso- pancreatic isoamylase is decreased. Furthermore constriction inhibition and inhibition of eventual role of we measured in serum of 11 patients by radio- angiotensin II on pulmonary circulation. Following Swan immuno assay human pancreatic poiypeptide(Hpp), Ganz and arterial radial catheter insertion, mean pulmonary insulin and C-peptide. ln follow'u p studies arterial pressure (pAP), mean pulmonary capillary wedge during shock the decrease of pancreatic amylase pressure (PCWP) and mean systemic arterial pressure (MAP) activity correlates with an increase of Hpp. were measured. Cardiac output was determined in triplicate Concentration of insulin and C,peptide are in- using thermodilution method. P_RA and PA were measured in creased in the beginning of the shock later on the CRF group. All measurements were performed 0 and 60 followed by a decrease. minutes after oral administration of CAPTOPRIL 50 mg. Sta- Our results suggest that the exocrine function tistical analysis was performed within each group using a of the pancreas might be diminished during shock paired student t test. In the two groups of patients whereas Hpp seems to play a regulative role in decrease in MAP and in systemic arterial resistance asso- the endocrine function of human pancreas. ciated with cardiac index improvement was significant (p

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MODIFICATION OF BLOOD VISCOSITY DURING EXPERIMENTAL HE- COMPLICATIONS OF FEMORAL ARTERY CATHETERIZATION MORRHAGIC SHOCK. S.Faenza, S.Taddei, Istituto di Aneste- siologia e Rianimazione, Universit~ di Bologna, Italia David Belvedere, Dan Thompson, Robert Lumlsh, The purpose of this study was to analyze the changes in and John O'Donnell; Merey Hospital, Pittsburgh~ blood viscosity during hypovolaemic experimental shock PA, USA in relationship to the simultaneous variations o2 pulmonary vascular resistance (PVR) and systemic vascular re- A prospective study of all femoral artery sistance (SVR). Te~ piglets were submitted to hypovolae- catheters inserted in an intensive care unit mic shock for 4 hours, and at the end o2 that period the was undertaken to study the incidence of blood removed was transfused. Arterial and venous blood complications. A total of 138 catheters were samples were taken tmder basal conditions (To) , after 4 placed and remained in place until they were no hours o2 hypovolaemic shock (T~) and 30' a2ter full longer required, malfunctioned, or were transfusion (T~). At the same %ime hemodynamic parameters suspeeted as a possible source of infection. (cardiac output, systemic and pulmonary pressure) were Duration ranged from Ii hours to 34 days. determined using a Swan-Ganz catheter. There were no instances of mechanical Viscosity was measuredp on citrated samples~ by means complications. Of these catheters 105 were os a cone-plane vlscosimeter under thermostatic_ condition available for microbiologic study; 51% showed (36.5~ ranging from 646 to 8075 sec . colonization at the skin site, 20% colonization Results showed a decrease in arterial blood viscosity of the catheter, and 5% resulted in baeteremia. (ABV) from 3.41 • 0.1 centipoise (cp) at T^ to 2,57 • 0.2 Analysis of risk of baeteremia by days cp at T~ followed by an increase to 4.09 ~UO.4 cp at T2; indwelling revealed: 0% at 4'days, 2% at 5-6 venous ~lood viscosity (VBV) was 3.64 • 0.3 ep at TO, days, 5% at 7 days, and 21% at 14 days. This 2,99 ~ 0.1 at T. and 4.91 ~ 0.4 cp at T 2. data compares favorably with published data for An increase in ~VR os 27% was seen at T I and a reduction radial artery catheters, and supports the os 2% at T 2 in respect to the basal values. PVR increa- conclusion that catheters placed by the femoral sed o2 67% from T O to Tp. route are as safe as those placed by the radial In conclusion the-resul~s showed: approach. ABV was always smaller than VBV (the principal causes seem to be pH, RBC volume,O 2 and CO contents) during hemorrhagic shock we observe~ a reduction in blood viscosity that partially made up for vascular resistance increase (dependln~ from hemodilution mechanism?) at the end of tras2usion (T2) PVR and SVR showed a dlf- ferent behaviour in relationship to the viscosity modifications: the increase os VBV made worse pulmonary cir-- culation while the rise in ABV didn't modify systemic one.

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EVALUATION OF DOPAMINE IN THE TREATMENT OF SEP- M. HUBMANNand A. WEIKL, Cardiol. Dep. (Mod. Superintendent: Prof.Br.E.Lang), TIC SHOCK WITH THE QUANTITATIVE ASSESSMENT OF Clinic for Internal Diseases of the Waldkrankenhaus,Erlangen a~at the 3rd Clinic ARTERIAL AND PORT~L BLOOD FLOW TO THE LIVER BY for Internal Diseases (Med. Superietendent:Prof.Dr.H.Kleinfelder),Clinical Center SEQUENTIAL LIVER PERFUSION SCINTIGRAPHY. Nuremberg HoJ.Klein~ A.Thoma,Mo$ch~s PD, Neurosurgical SELDINGER EFFECTWITH A NEW CENTRALVEIN CATHETER Dept.Univ. ULM. BKH. RFA. A new central vein catheter for puncturing the subclavian vein or the in. or external jugular vein is introduced, and its function is based on a modified Soldin- Liver perfusi0n scintigraphy in 40 patients ger technique, lfs operational principle is that a normal-lumen catheter is inserted with septic shock following neurosurgical ope- through a small puncture needle and therefore a thin capillary tube. This is rations showed significant diminuition of por- achieved by puncturing the pationtTs vessel with a small-lumen needle of only half tal blood flow. Portal blood flow contribution the diameter of catheter sets used up to now together with a capillary tubs pushed dropped to about 34,5 % ( normal range 50 - 75 over the needle. After the needle (Braunble syringe system) is removed the normal- % ). Following the administration of dopamine lumen catheter is pushed through the thin, tapered Braun~le syringe. The catheter ( 3,5 - 5,bAng/ks body weight ) a significant dilates the capillary tube at pre-formed spots and can thus be pushed further and increase of portal blood flow (A 39 % ) is ob- placed. The capillary tube is then pushed back or is pulled of by splitting it to. servable in all cases except one. tally. The catheter is made of polyurethans. By means of a newly devslopped guide Our results indicate that the decrease in por- which can be pro.formed it is possible to master even vascular anomalies or severe tal perfusion is caused mainly by the hepato- vessel kinks. This new central ~in catheter has been applied about ?DO timesso splanchnic pooling. Dopamine when administered far. Vein catheters were inserted in the subclavian vein, the in- or external ju- in doses Which do not affect mean blood pressu- gular vein as well as peripherally. Complications occurring during catheterisations re elicits selective vasodilation in the renal, are reported, but they are by far less critical than with traditional systems. superior mesenteric and celiac vascular beds Advantages of thenew system are as follows: suggesting that this is the underlying mecha- I Evidently less extensive puncture traumas and thus a deminuation of the dangers nism which causes the increase of portal perfu- of a false puncture (arterioal puncture). sion after dopamine infusion. 2 A total sealing of the catheter within the vessel: Due to the small puncture The method of sequential liver perfusion soin- opening and the widening of the puncture site by pushing forwand the normal-lu- tigraphy~ the criteria of septic shock and the men catheter a firm, tight sealing is created at the vessel/catheter interface basic pathophysiological mechanisms are discus- which is vital expeoially for anticoagulated patients or for patients suffering sed in detail. from thrombopathy. 3 The catheter is suitable also for juveniles and children due to its small puncture trauma. 4 The new steel guide allows pro-forming in the case of vascular anomalies and shows up much better on opaque material than traditional guides. 5 Guiding the catheter is stabilized substantially by the new guide. 6 Due to the sealing erect at the vessel this system is quite suitable for arterial puncturing (arterial pressure monitoring), too. 233

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HAEMODYNAMICS IN SEVERE TETANUS: INFLUENCE OF EPIDURAI PATIENT NUMBER AND RESOURCE EXPENDITURE IN A MEDICAL IN- BLOCK. T. Fiore, A. Brienza, A.M. Leone, R. Giuliani, In- TENSIVE CARE UNIT. M. Reuss, L.S. Weilemann, J. Majdandzic H.P. Schuster, II. Medizinische UniversLt~tsklinik Mainz. stitute of Anesthesiology, University of Bari, Italy. Intensive care units (ICU) are the most expensive parts Spinal block has been proposed for the control of adrene~ of hospitals. Resource expenditure can be easily estimated gic hyperactivity in tetanus (I) This paper is concerned by using EOV. In the period from Apr. 1980 to Dec. 1981 with haemodynamic changes induced by extradural block. (21 mths.) the percentage of covered beds estimated by Material and method. Through a spinal catheter introduced midnight statistics was 85.95 % in the tota] hospital and 67.33 % in the ICU. Based upon the daily maximum covered into the extradnral space at L3-L4, 6 ml of 0.25% bupiva- beds the percentage was 72 %, and 75 % when calculated caine were injected twice with a 6 hrs' interval to 3 pa- upon the maximum number of patients treated daily. The tients with severe tetanus, automatically ventilated un- whole hospital (180 beds) had 4515 nursing days per month, der neuromuscular block with heavy sedation,in whom signs the ICU (10 beds) Darticipated with 205 nursing days per of adrenergie hyperactivity were evidencedr Values of ha~ month (4.5 %). The monthly resource expenditure for the modynamic parameters were obtained with a cardiac output hospital averaged 232 717,- DM, for the ICU 93 393,- OM according to 40.56 % of the total expenditure for 5.6 % thermodilution apparatus using Swan-Ganz catheters;values of the total number of beds. Resource expenditureswere in the Table represent post-injection average per cent va 91.92 DM per day in general, they were 462.87 DM in the riations at different times from mean pre-injection data. ICU. The mean length of stay was 15 days in the whole hospital and 5.5 days in the ICU. Thus resource expenditure Time 10" 20* 30* 45* per patient was only 3 times higher for an intensive care Case Ist 2nd 3rd Ist 2nd 3rd Ist 2nd 3rd Ist 2nd 3rd patient in comparison to an average hospital patient. CO -I0 -16 -19 -13 -21 -17 -14 -19 +19 -7 -20 +2 The resource expenditures were divided into the following SV -8 -2 -14 -12 -5 -12 -8 -3 +25 -6 +2 +6 groups: Hospital ICU HR -5 -17 -6 0 -21 -6 0 -17 -6 0 -25 -5 29.20 % drugs (incl. infusion solutions) 42.56 % MAP -10 -15 -9 -24 -10 -2 -20 -14 +5 -5 -13 +11 13.74 % blood products 27.18 % PWP -33 -10 -25 -50 0 -31 -33 +10 -25 -33 +10 -31 26.25 % medical material 25.84 % SVR -5 0 +13 -8 +11 +22 -3 +3 -8 • +7 +13 10.81% others 4.42 % * minutes after epidural injection of bupivacaine Results. Cardiac output and pulmonary wedge pressure show ed a tendency to decrease; data referring to other parame ters indicated wide individual variations. Conclusions. Under the conditions prevailing in our investigation, adrenergic hyperactivity in severe tetanus did not seem to be effectively influenced by epidural block. References. Mollaret, P. et al.:Presse M4d.,73:2153,1965.

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ACUTE ALCOHOLIC INTOXICATION IN ADULTS DOES NOT INDUCE SHOULD HAVE LIMITED AGE FOR INTENSIVE CARE?R.B.Carrington LACTIC ACIDOSIS AND HYPOGLYCEMIA : Ph. Auz~py, H.F. Boutron, da Costa,J.Pimentel,J.Gongalves,A.Rebelo,J.J.da Costa. In- J.M. Gauthier and G. SouIed - Unit~ de r~animationm~dicale- tensive Care Unit,Coimbra University Hospital, PORTUGAL. H6pital de Bic~tre - 94270 LE KREMLIN BICETRE (France). Investigation, teaching,monitoring and practice of Intensi ve Care Medecine have reached a high level.However, less Classically severe acute alcoholic intoxication (A.A.I.) atention has been paid to the older patients.One of therea in adults induces hypoglycemia and lactic acidosis (L.A.). sons for this has been the negative relationship costs/be- According to our clinical experience, this assertion has nefits mentioned.We think that the problem must be dealt not proved correct. In this regard, all A.A.I. (without with. The retrospective analysis of patients admitted in simultaneous drug ingestion) admitted to emergency unit of our ICU in the last 22 years has shown that 440 were over Bic~tre Hospital from 1976 to 1981 were studied. 64 years, 273 of them men. The varied pathology that deter- METHODS : From admission for 57 A.A.I. (including 30 "pure" mined admissions is referred to.This is no intention of ethylic comas) concomitant samples of arterial blood were comparing results as it is difficult to establish groups obtained -pH, PaCO 2, PaO 2 and HCO 3 - (ABL I Radiometer) corresponding either to different previous heath status or lactate (Bohringer and Sigma containers) glucose (Auto to the severity of acute illness on the day of admission. analyser Technicon) and ethyl alcool levels (Test U.V. It was found that mortality among the patients over 64 Bohringer~ were measured. years was 43,4%,being comparable in both sexes.Among the RESULTS : I) Acidosis, if an~ was h~rpercapnic and mechani- remaining 3.403 patients it was 28,9%,Dividing our sample cal ventilation may be necessary. However, no correlations of aged patients in groups taking into account the morta- between blood ethyl alcohol and ions H + range in 30 ethylic lity we can see an increasing mortality:39,7% in the group comas existed (r =0,14). Only two cases (one with anorexia 65 to 75 years (n=312),50% in the group 75 to 80 years nervosa and other one with prolonged starvation) showed (n=82) and 56,5% in the group >80 years (n=46).There is a hypoglycemia and L.A. significant difference in these mortalities (xZ=6,328 § p

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EVALUATION AND QUANTIFICATION OF STRESS IN CRITI- BIOAVAILABILITY OF METRONIDAZOLE ADMINISTERED THROUGH CAL CARE PATIENTS. G.Pauser, B.Bunzel, and CH. RECTAL AND INTRAVENOUS ROUTE. Fichelle A.~ Farinotti R., Gollner, Forschungsstelle f~r Intensivmedizin, Dauphin A., Mourlon M., Desmonts 3.M. H6pital Bichat - Klinik f~r Anaesthesie, Univ.Wien, 0sterreich Paris France. In combination with 52 self designed items we Metronidazole (M) is widely used as prophylactic and curs evaluated the answer of 5o patients transferred rive treatment of anaerobic infections in abdominal surge recently from ICU to regular ward to the questi- ry. The cost of injectable M led us to use M by rectal on: Are environmental situations as emerging un- route as proposed by Ioannides and el*. This study was der ICU-conditions comparable in terms of their designed to compare the bioavailsbility of intravenous (IV) or rectal (R) metronidszole. stress producing power? The patients had to bring the various stress items in a sequence of in- Patients and methods. The inclusion criteria in the study were the following : no alteration in blood volume, no creasing annoyance just one day after dismission abnormalities in rectum and in sphincter function, no from the intensive care unit. The most annoying diarrhea. Eight patients were given successively a single factor for all patients, almost sex and diagn3sis dose of 0.5g via IV and R route. The interval between the independent, was the item lack of information successive administrations was 48 hours. The IV M was and communication. The item noise and unrest cau- Flsgyl* (Specie) and the suppositories were made of MO.5g sed by the daily routine and the nursing staff and aerssil 200 O.Olg and suppocire AS2 qsp 2g. The study on the intensive care unit was quoted o~ the started by random administration of M either IV or R ac- first place by patients more than 50 y~ars. Help- cording to the admission. Plasma levels of M were measured lessness and physical impairment are the most before and 30, 60, 90, 120, 180 min and 4, 5, 6, 8, 12 and 24 annoying factors by the ventilated patients. hours after administration. The item dependence on technical devices (e.g. Results. Peak plasma concentration was observed at 3hours ventilators, dialyzer etc.) was surprisingly after the beginning of administration. The mean value + quoted low by our patients. In conclusion to SD Was 8.2 • 1.7 ug/ml (IV route) and 6.8 + 1.5 ug/ml ~R those facts a human orientated intensive care route). The elimination half life was 6.26~+ 3.04 hours medicine should be claimed. Further investiga- (1V rout~ and 6.29 ~ 2.23 hours (R route) re~pectively.Bio tions concerning the psychical care and help availability expressed as extrapolated area under the cur should be done. ve was 102.4 + 41.8 pg/ml/h (IV route)and 91.1 + 40.8~g/ ml/h (R route~in 7 patients having normal hepatTc function ; in one patient with cholestasis bioavailability was increased, 266pg/ml/h (IV route) and 241pg/ml/h (R). Conclusions. This study demonstrated that M plasma concentrations reached same levels after R administration as after IV route. When dosage and intervals of administration of M is adequately determined, Rroute is s good alternative compared to IV route. The main advantage is the drastic reduction in cost of the treatment : the R form is 35 times cheaper than the IV form. *loannides L. and el: N. Emgl. J. Ned., 1981, 305.

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SUPPRESSION OF LYMPH~]YTE-PROLIFEBATION IN PAqZENqS CORRECTION OF NEUROHUMORAL IMPAIRMENT OF SEVERE CEREBRAL FOLLOWING INJ~Z~ION OF THIOPEN~L..P.Schmucker, C.Hammer, TRAUMAWITH DIFFERENT METHODS OF PHARMACOLOGICAL PROTEC- K. Taeger, K.Peter, W. Brendel, Institute f. Surgical Re- TION OF BRAIN FROM HYPOXIA. LV.Usenko, VP.Tuz, EN.Kligu T search and Inst.f.Anesthesiology, University of Munich, nenko, GB.Nazarenko, Medical Institute, Dnepropetrovsk, Klinikum Grosshadern, Munich, FRG USSR. Suppression of mitogen-induced lymphocyte-proliferation by various concentrations of ~hiopental (T) in vitro has Various degrees of impairment of neurohumoral homeostasis already been reported. In the present investigation, the according to sympathico-adrenal, kallikrein-kinine, responsiveness to mitogens of lymphoeytes prepared from serotonine, histaminreactive system, functional erythro- patients after a single injection of qhiopental has been cyte condition data were determined in 310 patients with studied. severe cerebral trauma in an acute period with prolonged In 8 patients undergoing coronary surgery, anesthesia was loos of consciousness. The following mechanisms of neuro- induced by • in3ection of T. 5 mg/kg bw. Blood samples tumoral impairment were observed : arterial hypoxemia, were collected before (K) as well as 3 min (3') and 40 respiratory alkalosis, hypercatabolism resulted in acti- min [40') after injection. Lymphoeytes prepared from vation of the system studied. An impairment of mechanisms these samples were kept in culture and stimulated with of compensation hypoxia was noted : decrease of 2,3 DFG Phytohemagglutinin (Pli%), Pokeweed Mitogen (PWM) and level in erythrocytes, progressive anemia while blood Concanavalin A ~o~A). ~e stimulation-rates were assayed loos was absent. The use of catecholamine and gluco- by 3H-Uhymidine-incorporation. T-levels were measured by corticoid precursors did nor improve the treatment results. gas-chromatography. ~he results are shown in the cable : Methods of pharmacological protection of brain from hypoxia were used in a second group of patients with Ph~ 64,5 + 9,5 54 Z 8,3xx 5~ - iO,O § glucocorticoids and an early intensive therapy. The best PWM 23,0 ~ 3,5 15,5 + 2,5x 17,5 T 3,0 +) resluts were obtained with combined administration of C orA 50 + 8,0 38,3 - 7,5xx 35,[ - 8,0 +) barbiturate and dosium hydroxybutyrate. High stability ~level O 83,O 7 18,5 4,2 T 0,7++) and adaptation of neurohumoral systems to stress and preservation of their reserves, were due to a decreased n=8; x ~ SEMx:p O,O5 +) ~cpm x 10 -3 hypoxia (pa02 + 4,1 kPa), metabolism restoration in xx:p 0,O1 ++) ~g x ml -] erythrocytes, mange of their composition and correlation of hemoglobin fractions. The recovery from coma was Conclusion: Mitogen-induced lymphocyte-proliferation is shortened by an average of 3 days, fatal outcomes decrea- significantly reduced after injection of Tniopental, and sed to 15,2 %. during high T-levels are high. ~ese results demand further investigation with particular Eespecz no patients receiving high-dosage qhiopental-therapy for brain protection. 235

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PR0~q0STIC FACI]DRS IN SHOCKED PATIENTS. B Cowan, HAEMODYNAMICAND INTRACRANIAL EFFECTS OFANEW H. Burns, I. Mc~. Ledingham, P. Boyle, Department ANTIHYPERTENSIV AGENT KETANSERINE IN DOGS of Surgery, University of Glasgow, Scotland. H. Van Aken, C. Puchstein, C. Anger, P. Lawin Klinik ffir An~sthesiologie und operative Intensivmedizin In a prospective study of shocked patients we have Mfinster assessed the prognostic significance of single and serial estimations of whole blood lactate (WBL) and Increases in intracranial pressure (ICP) occur with the compared their usefulness with simple hae~aodyrmmic most commonly used antihypertensive drugs. In patients measurements. Thirty patients suffering from with space-occupying lesions such incrases in ICP may shock of varyin~ aetiology were studied. Arterial lead to cerebral ischemia from decreased perfusion WBL, mean arterial pressure (MTP), urine voltmm (UV) pressure or even to brain herniation. and core-peripheral temperature gradient (CPTG) were Ketanserine is a new quinazoline derivate. It is a measured after 3 hours and 24 hours resuscitation. potent and selective 5 HT-serotonine-blocker. At high There were 15 survivors. There was no significant concentrations it has alpha I -adrenergic, antihistaminic, difference between survivors and non survivors in antidopaminergic and antiangiotensin properties. This either lactate or haemodynamic values at the time study examines the effects of high dose Ketanserine up of adnission. In survivors, WBL improved after to 14 mg/kg on haemodynamic parameters and on ICP in resuscitation (see table). dogs without (Group I) and with (Group II) intracranial hypertension. Admission 3 hrs 24 hrs Haemodynm, ic measurements including mean arterial resus, resus. pressure (b~LP), mean pulmonary arterial pressure (PAP), Survivors (n=15) 4.39~0.73 3.2-~0.43" ~]~--!0.22" mean right atrial pressure (RAP), pulmonary wedge Non survivors(n=15) 4.9520.90 4.98,~0.90 4.13+I .50 pressure (PCWP), heart rate (~), cardiac output (CO), WHOLE BLOOD lACTATE n~4ol/l * p<0.01 systemic vascular resitance (SVR), and stroke volume (SV) were made. ICP was measured via an intraventricular However, improvement in haemodynamic values was also catheter. Ketanserine was given as a bolus of I mg/kg significant in survivors. Using logistic regression followed by an infusion up to a total dose of 14 mg/kg. analysis, outcc~e in a shock episode can be predicted All data were analyzed by student's t-test p~0,05 was after three hours with 91.5% accuracy if UV, MAP and considered significant. CPTG are known. Adding WBL only increases the Uniform blood pressure reductions occured in each group. accuracy of prediction to 93%. l~asurements of The maximumdecrease (35 % • 18 in group I, 35 % • 19 in lactate production in some of the non survivors group II) occured at the end of the Ketanserine infusion. suggest that in shock, lactate production by skeletal An increase in ~ and decrase in SVR could also be muscle significantly decreases, explaining the observed~ICP did not change. CO, SV, RAP, PCWP remained relative mreliability of lactate as a predictor unchanged. Ketanserine is a safe antihypertensive agent, of outcome. even in patients with poor intracranial 6ompliance. Intensive Care: General Problems

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A NEW MOBILE INTENSIVE CARE ~IT, COMPARISON OF THREE SEVERITY SCORE INDEXES IN ACUTE HEMOR- A.B.M.Telfer,Royal Infirmary, Glasgow,Scotland. RAGIC PANCREATITIS (AHP). Ph. LO!RAT, M. GAYRAUD, F. BON- NET, S. RIGATTIERI, J.R. LEGALL~ HOPITAL FOCH, SURESNES, The movement of critically ill patients has been HOPITAL HENRI MONDOR, CRETEIL, FRANCE. X ~ ~uP~DPV~C described by several authors (Ledingham, 1980; Aitkenhead, 1980). Special trolleys have been A severity score index is needed in AHp for classification designed or existing dnes adapted for local of patients, comparison of groups and evaluation of new requirements, depending, for example, on whether therapies because of the broad spectrum of the illness. or not the trolley has to fit into an ambulance. The aim of this study was to compare a specific index as the one proposed by RANSON (I) (R) to two non specific in- The new Mobile Intensive Care Unit (~I.I.C.U.) dexes, acute physiologic score (APS) (2) and a resumed se- in Glasgow Royal Infirmary has been designed to verity index (RSI). APS is based upon the results of 34 use as many standard and familiar components as biological and clinical values. RSI is calculated from the possible. It is basically a conversion of a results of 14 biological and clinical values generally ob- standard hospital trolley and is intended for tained in all ICU patients. RSI has been validated in 789 use only within the hospital complex. It French ICU patients. provides facilities forcardiovascular ~onitoring, 31 patients with AHP were studied within the first two continuous infusion of drugs by infusion pumps, days after their admission to two ICUs. R, APS and RSI we- I.P.P.V. with P.E.E.P. and I.~1.V. With any non- re measured in each patient. The prediction of dgath was hypoxic mixture of Nitrous Oxide and oxygen, used to evaluate the efficacy of each index. A highly si- and spontaneous respiration with any mixture of gnificant correlation (p

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VALIDATION OF A RESUMED SEVERITY INDEX (RSI) for INTENSIVE IN VITRO MEASURES OF I~ORESPONSIVENESS IN CARE (ICU) PATIENTS. 3.R. LE GALL, r GRANTHIL, P. LOIRAT SURGICAL PATIKNTS ADMITTED TO AN ITU. A. ALPEROVITCH, P. GLASER t, F. WATTEL, R, THOMAS, D. J.A. Bradley, V. Jackson, D.N.H. Hamilton, VILLER5. Commission d'Evsluation de la Soci@t6 de R@ani- I.McA. Ledingham, Department of Surgery, marion de langue Frangaise. University of Glasgow, Scotland. The acute physiology score (APS) proposed by W.A.KNAUS and validated by an international multieentric study (I) Critically ill surgical patients have a reduced is made of 34 parameters. Vie proposed a RSI with 13 para- response to recall skin antigens. The meters from APS,: pulse, mechanisms underlying this is ~clear but may Mortality % systolic blood pressure, include altered lymphocyte responsiveness or respiratory rate or venti- decreased inflarmnatory cell mobilisation. 70_ -- lation, diuresis, central Peripheral blood lymphocytes from surgical patients temperature, hematocrit, in an ITU were tested for their response to the white cells count, blood mitogens Concanavallin A (Con A), Phytohaemagglutinin 60 urea, glucose~ Na, K, HC03 (PHA) and Pokeweed Mitogen (PWM) and peripheral Glasgow coma score, plus blood mononuclear cells and granulocytes were 50 age of patient. tested for their chemotaetic response towards From 789 patients from 8 casein. The results (median and range) are ICUs, correlations between shown below: 40 APS and RSI and TISS points Control (n=14) Patients (n=17) p Con A (c.p.m. 30 !v I weresnd r := r 0.52= 0.90 (p< (p

(1. W.A. KNAUS, 3.R. LE GALL, ET AL. : Lancet 1982, Patients' ly~hocytes showed a reduced response to i : 642-645) Con A and phagocyte chemotaxis was increased, This supports the hypothesis that critically ill patients have a defect in T cell function. 237

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COMPARATIVE STUDY OF,GERM'S COUNTS (GC) PERFORMED ON PROXI MAL BRONCHIAL ASPIRATION (PBA) AND DISTALBRONCHIAL ASPIRA TION (DBA) IN INTENSIVE CARE. D.BRUNEL,M.GUENOUNOU, J.P.NGUYEN,E.RONCO,J.PILIIOT,J.C.RAPHAEL,M.GOULON.CliniqUe de Reanimation.H~pital Raymond Poincard.92380.GARCNES.Fran Ceo Many studies have pointed out the interest of GC in trach6 obronchial secretions and of DBA about patients under assis ted ventilation by endotracheal tube. The purpose of this study is to compare the data of GC performed, or estimated on proximal and distal secretions of such patients. The PBA are realised by sterile probe.After dilution the secretions are submitted for culture. Each type of colony is numera~d and identified after 48h of incubation.Germs are consider6d as pathogen if the number of colonies is equal or higher than 106/ml. The DBA are realised on the same day, according to Matthew's technic. The number Of colonies, iA the distal sample is estimated after incubation. According to the data of a previous study of in vitro simulation, we have considered that the DBA were contaminated by the proximal bronchial flora, when the number of colonies/ml is equal or lower than 102, and uncertain between 102 and 104. 83 DBA and PBA have been performed on 48 patients with pneumopa- thy. 38 PBA (46%) did not have any pathogen germs ("sterile"), 24 (29%) had one~ 21 (25%) more than one. 50 DBA (60%) were "sterile", 12 (14%) had one pathogen germ, 9 (11%) more than one. 12 DBA were uncertain. For 42 (51%) simultaneous PBA and DBA, the bacteriological information was the same. When the results were different, the DBA was able to isolate one germ 8 times, whereas the PBA~terile. On the opposite, on 14 times, the DBA was sterile or con- tainingonly one germ whereas several germs were isolated in the corresponding PBA. The GC in PBA and DBA makes the diagnosis easier in pneumopathies in intensive care, owing to the smaller number of identified microbial species.The GC in DBA may give greater information for the diagnosis when the PBA is out. Central Nervous System

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ELECTROENCEPHALOGRAPHIC PATTERNS IN ACUTE POST- CREATINE KINASE ISOENZYMES IN SEVERE HEAD INJURY. TRAUMATIC COMA. L.F. Comelli, M.G. Pignatelli, P,HA~IS, J.D. BORN, J.LENELLE, E.SPYROPOULOS..Service G.F. Testa, M. Avalle, Ospedale San Giovanni, d'AnesthEsiologie, HEDital de BaviEre, boulevard de la UniversitA di To~ino, Torino, Italia. Constitution 66, 4020 LiEge, Belgique.

The aim of this study was to assess the diagno= - The study has been carried out to compare blood and stic and prognostic value of the electroenceph! cerebro-spinal fluid (C.S.F.) creatine kinase (CK) values, to correlate brain type CK (CK BB) activity with braindy~ logram ~EEG) in acute post-traumatic coma. function and to assess the prognostic value of CK assay. Five hundred patients were selected in whom the - 53 severe head injured patients (mean age = 24 + 14 EEG tracings were recorded upon admission and years) have been included in the study. 34 % suffered ~m then repeated over successive periods. Five EEG cranial trauma only and 66 % were multiDle injured pa~ patterns Were identified: borderline (41 cases) tients. Blood and ventricular C.S.F. samples have been diphasic with sleep-like spindles (161 patients) collected at 9 + 5 hours after the trauma. Total CK activity has been measured spectrophotometrically at 37oC. T~ diphasic (139), monophasic (109), and silent isoenzymes have been separated electrophoretically and (50). Mortality was maximum (100%) in the flat quantified by densitometry. Brain dysfunction has been EEG (brain death), very high (86%) in the mono= graded according to the Glasgow coma scale (G.C.S.) and to phasic pattern (deep coma with decerebration), the LiEge coma scale (L.C.S.) which uses elements of the decreased in both the diphasic (60%) and border G.C.S. and the study of 5 brain stem reflexes. The ~a- line (51%) types, and minimal (13%) in the tient's outcome after six months has been assesed according to the Glasgow outcome scale. sleep-like pattern. Therefore, the finding os - There is a good correlation between total CK and CK BB cortical electrical activity resembling that activities in C.S.F. only (r = 0.992). There is no rela- of physiological sleep offered the highest per= tionshi~ between CK BB activities in the serum and in the centage of remission. On the other hand, the mo C.S.F. (r = 0.139)~ There is an inverse relationshi~ bet- nophasic EEG was very unfavourable. Patients ween C.S.F. CK activity and brain dysfunction. The Corre- with borderline tracings h~d a high mortality lation between these two narameters is better with the LCS (r = 0.8) than with the GCS (r = 0.635). There is a rate in spite os the relatively good EEG orga= significant difference in C.S.F. CK BB mean values between nization. The present results tend to confirm patient's groups classified according to a bad and a good the utility of EEG assessment in cases os trau outcome (F = 5.85 n 0.006), matic coma. Moreover, this procedure may be us~ - The CSF CK BB activity is more reliable than serum acti- fully employed in evaluating the course os pa: vity. C.S.F.CK BB activity can be correlated with brain dysfunction. The L.C.S. allows a better assessment of tients with head injury and monitoring the es brain dysfunction. High C.S.F. CK BB activity is signifi- cacy os the treatment protocol. cantly associated with a bad outcome.

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Central somatosensory conduction time in post- AMINOPHYLLINE IN CONTROLLING THE INTRACRANIXA traumatic comatose states. PRESSURE. B.Mazzarella, P.Mastronardi,T.Cafiero, G.Gargiulo, L.Stella, R.Falivene~ II Facolt~ di Rumpl,E.,Prugger,M.,Gerstenbrand,F.,Hackl,J.M. Medicina e Chirurgia, Universit~ di Napoli, Ita- and Pallua,A. lia. Short latency evoked potentials (SEP) were elic- ted by stimulation of the median nerve at the wrist and recorded simultaneously from the neck The purpose of the study is to check the in- and the contralateral scalp in 44 patients with terferences of aminophylline with intracranial signs of brain stem impairment due to head in- pressure (ICP). jury. Brain stem involvement was divided clini- We have monitored, by intraventricular cathe- cally and by CT scan into secondary lesions due to supratentorial mass displacement and primary ter, transducer, amplifier and recording system, lesions due to direct violence to the brain 12 patients of either sex, with mean age of 43,5 stem. The central conduction time (latency bet- years and with hypertensive liquoral pathology. ween N14 and N20 - CCT) and the amplitude ratio We have monitored also mean arterial pressure (N20/NI4-AR) were close to normals in patients (MAP) and PCO . After recording the basic values with supratentorial lesions and good outcome. we have adminzstered aminophylline 2 mg.kg -I in CCT increased and AR decreased with the worsening of outcome. Asymmetries in SEP indicated a single bolus intravenously. moderate or severe disability outcome. Patients In every cases we have achieved rapid decre- with absent SEP over one or both hemispheres ase whether in ICP or in cerebral pulse. No si- died. In patients suffering from primary brain gnificant changes in PCO . The values of MAP 2 stem dysfunction, confirmed by a normal or were steady and consequently we have achieved slightly abnormal CT scan, prolonged CCT, asym- metric but also absent SEP were also found in an improvement of the cerebral perfusion pres- patients with good outcome. AR was generally sure (CPP). low in these cases. Early appearance of SEP or early recovery of initially distorted SEP and decrease of CCT in control examinations was a favourable prognostic sign. Therefore even absent or severely distorted SEP should be interpreted cautiously, if patients may suffer from primary brain stem involvement. 239

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BRAIN INJURED PATIENTS - THE OUTCOME ONE WEEK EXPERIMENTAL ACUTE HYPOXIA. EFFECTS OF PHENOBARBITONE AFTER ACCIDENT. D. Hausmann, K. Rommelsheim, PRE-TREATMENT (HYSTOLOGICAL STUDY) G.di Trapani, S.I. K.U. Josten, Institut fur An~sthesiologie, Uni- Magalini, A.L. Abbamondi,M.Lazari, A.F.Sabato. Ist. Anes- versity of Bonn, K.O. Mosebach, R. Caspari, tesiologia e Rianimazione,Universita Cattolica S. Cuore, R. Lippoldt, Physiologisch-Chemisches Institut, Roma,ltalia. University of Bonn, Germany. A histological study is carried out on five groups of 50 In order to find out guiding parameters for quinea pigs each (control-after 20min.of hypoxia-2Omin. correction of care, the average levels of about of hypoxia+2Omin, of oxygen therapy-pretreatment with phe- 60 substances in plasma and urine of 18 sur- nobartitone(lO0 mg kg-l)and 20min. of oxygen therapy). vivors (S), 13 traumatized (T) and 5 burned (B), The light microscopy results can be summarized as follows: as well as 16 nonsurvivors (N), 11 T and 5 B, The hystological study did not show significant differen- were compared from day I until about 10 days after accident. Only patients were elected who ces between barbiturate-treated and untreated hypoxic survived the acute phase (3 days). The combined brains, in fact, the severity of ischaemic damage as well enteral and parenteral nutrition included 430 g as its distribution were similar in all the experimental mixed carbohydrates, 70 g fat, and 150 g amino groups. The lesion mainly affects the areas which are acids per day. The nutritional assessment com- known to be most sensitive to hypoxia. It is suggested prised the aminograms of serum and urine (24- that in the experimental conditions barbiturates did not hour excretions), the serum concentrations of act as a protective agents at least as assessedmorpho- 5 proteins and 6 hormones as well as the nitro- logically. gen balance taking in account the reflux rates following tube feeding. The mortality passed through a maximum between day 6 and day 7 after accident. During this period about 85 % of all N died and the reflux rates reached the highest values (> 80 %!). In the case of N, many parameters showed a corresponding maximum, but I or 2 days earlier, for example nitrogen balance, serum urea, total concentration Of serum amino acids, GOT, GPT, and prolactin. Due to the high reflux rates we propose a TPN at least until 10 days after accident. We have no explanation for the mentioned maxima.

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WATER AND SODIUM BALANCE AND RENAL FUNCTION CORRECTION OF NEUROTRANSMITTER FAILING AS PART OVER THREE WEEKS AFTER SEVERE.ACCIDENTAL TRAUMA OF BRAIN RESUSCITATION. H.Schoeppner, L.Rolf, U. Finsterer, U. Jensen, A. Beyer, U. Schied, S.Wagner, J.Zander. University hospita 1 of an- W. Kellermann, K. Unertl, K. Peter, Klinikum esthesiology and crticsl care medicine, Muenster GroBhadern, University of Munich, Munich, FRG Federals ~epublic of Germany. Breakdown of neurotransmitter balance represants Careful monitoring of water-electrolyte balance an essential component o f posttraumatic,ischs- and renal function is not yet common practice mic encephalopsthy. The consequences are seizu- in intensive care units and might probably help res by overwhelming of cholinsrgic transmission to reduce acute renal failure (ARF). From March and cerebral coma by missing of cortical activa 1980 to May 1982 we studied 32 patients after tion. 20 patients, suffering from brain lesion severe trauma :(mainly brain trauma, who could ( soma scale 5 - 5 7 have been treated with be observed for at least 21 days and did not de- drugs of 6ABAergic and c holinolytic potency velop ARF, which had to be treated by dialysis. ( 5 oases each by infusion of barbiturate, eto- The most prominent features of this study were: midate, gamma - OH - butyrate and procaine.) a) positive water balance throughout inspite of The effecti~ty control h as been carried out by a significant weight loss (which points to high I. Determination of the cellular ( platelet ) fluid losses with perspiration), b) high osmolar content of serotonin and dopamin by means of excretion, due to high urea excretion with post- spectralfluorometric method. traumatic protein catabolism, c) antidiuresis 2. Comparison of the lactate ladles of arterial throughout with urine osmolality around 600 blood and GSF. mosm/l and high negative free-water-clearance 3. Recording of the EEG ( 8 channels ) {due to high osmolar clearance), d) cumulated 4. Determination of cateaholamine and cortisol sodium balance was negative and averaged - releasing prae and post the infusion time of 440 mmol/21 days, e) normal creatinine clearance 8 hours. (occasionally unusual high values), f) normal The lasting effect, concerning the augmentation creatinine excretion. We conclude that patients of cellularcontent of Serotonin and dopamin after severe trauma generally have good renal has bsenreached ,employing butyrste and procai- function and tend to antidiuresis, high osmelar ne. In last case the EEG course changed from excretion and negative sodium balance. generalized subdelta activity %o finally reinte grstion of alpha activity and patients in consciousness.The approach of the lactate levels of arterially blood and CSF showed to be opta- mally in case of procaine. The depletion of sstecholsmin and sortisol secretion developed step like from barbiturate and atomidate to butyrots and procaine. 240

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SPECIFIC INTENSIVE CARE PROBLEMS IN HIGH-DOSE BARBITURATE THERAPY. C. Krier, K. Wiedemann, H. Polarz, Department of Anesthesia, University of Heidelberg, F R G Despite of the fact that the beneficial effect of barbiturates on the outcome of severe head- injury pat&ents remains controversial,high-dose barbiturate therapy is now commonly used in the management of raised intracranial pressure. The purpose of the study was to investigate the potential side-effects of high-dose thiopentone therapy in a total of 30 patients with focused interest on cardiovascular effects, effects on liver metabolism, qastro-intestinal complications and respiratory complications.The barbiturate- treated patients were compared to a group of 27 patients with severe head-injury without high- dose barbiturate therapy. The data obtained indicate i. a low incidence of hemodynamic changes when a regimen of slow initial loading is adopted. 2. a low incidence of hepatotoxic effects. 1 case of transient drug-induced jaundice is reported. 3. a high incidence of gastro-intestinal complications, ranging from benign erosions to acute upper gastro-intestinal hemorrhage. The occurence of oesophagitis is related to the esophageal sphincter dilatation and reflux, due to the high-dose barbiturates and demonstrated by endoscopic findings. 4. a h~gh incidence of contamination of the upper respiratory tract and of pneumonia., It is suggested that the sup- pressive effect of thiopentone on the immune response is 9esponsible for the high incidence of pulmonary complications. It is concluded that the high-dose barbiturate therapy is connected with high risks for the patient due to the multiple side-effects of barbiturates and that this form of therapy requires a extended monitoring and specific preventive measures. Intoxications 241

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Accidental occupational intoxication with CLINICAL INFORMATION FURNISHED BY BRAINSTEM AUDITORY di-and trimethyltinchloride. Experiences in EVOKED RESPONSE (BAER) DURING TOXIC COMAS 6 patients. L. BARRET, S. GARREL, Ph. ARSAC, J.L. DEBRU, J. FAURE C.H.U. GRENOBLE Ch. Rey, R. Besser, H.J. Reinecke,L.S.Weilemann, J. Majdandzic, M. Reu$ II. Med. Uniklinik Mainz This is a review of 30 deep toxic comas studied by BAER At the end of June 1981, 6 workers were intoxica- to establish its value in diagnos~g and prognosis in ted wlth the above mentioned substances while association with a physical determination of the level cleaninq an industrial basin. After a latent of the coma and toxic analysies. period of I to 3 days, symptoms of the neuroloqic- psychic kind occured in all patients with a Importance in diagnosis, a normal response was the most upward tendency up to a clouding of consciousness 9ommon finding, but in almost 40 % of the cases, we and in the mogt severe cases even to a central observed a delayed latency at different level of coma of resoiration depression, A development of different toxic etiologies. This result is opposed the pulmonary complications with massive infiltrations commonly accepted idea that BAER are always normal in was observed. Artificial resniration theraoy was toxic coma and represent a strong argument to evocate necessary in 3 patients. In 4 oatients epileptic the toxic origin. Therefore, delaye d latency should not activity was reqistered in the EEG. Iniatially exclude the diagnosis. all patients showed a leucocytosis up to 3o.ooo/mm 3, transaminases were slightly increased Importance in prognosis : a normal response or a delayed with an unward tendency. The execretion of tin latency is always associated with a good prognosis. But in the urine corralated with the severity of in the latter case the duration of the coma seems longer. intoxication as well as a hypokalemia un to So BAER might represent an argument for the use of an 1,9 mval/l. The alasmasenaration done in 4 patients epuration method. On the other hand if we note a peak did not lead to the expected decline in the urine disappearrance as observed in 2 cases, the outcome will tin execretion. The aoplication of metalcaDtase R be poor~ perhaps due to anoxia. This could be screened did not show a tendency to a higher tin execretion for, rapidly, using this method. in the urine. The main treatment consisted in intensive care procedures. One oatient died because of eulmonary complications, liver cell damage and final kidney insufficiency. The neurohistoloqic findings showed remarkable changes in the central nervous system. I patient still needs intensive care because of hypotone hyperkinetic syndrome. The patient with the third hiqhest tin level still suffers from slightly cerebral deficit. Up to now, there is no report of human toxicological and intensive care experiences in the case of acute intoxications with these substances.

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RESCUCITATION OF INTENSIVE THERAPY IN PATIENTS POISONED TOXIC EPIDERMAL NECROLfSIS : COMPLICATIONS SYN- BY ACONITE. AA.Togaybaev, GD.Sheinin, Vl.Lapin, BK.Sultan- DROMES AND INTENSIVE THERAPY. A.S.Yarzar,A.K.Ab- baev, AA.Sovetov, Hospital Alma-Ata, State Medical Insti- dullayev,V.P .Kurenkov,A .A .Khon,T .T .Azimova, tute, USSRo N.I.Sokolova,N.R.Sukhanova,Advanced Traininy In- stitute for Doctors,Tashkent,lISSR We studied 135 patients with aconite poisoning fatal dose taken p.o. is 2-4 mg. The main symptom in this state was In 3956,Dr.Lye[t (Britain) described a serious acute cardiac arrhythmia developing suddenly during the disease of the skin and mucous membranes result- first 30-50 minutes. The changes were characterized by iny from the use of medications which he called progressive disturbance in conduction, excitability and "toxic epidermal necrolysis".By 19~0,there were automatism of the heart. Antidote therapy was not used, some 150 registered cases of the disease with a as it doesn't exist in this sphere. The patients were mortality of between 30 and 50 %.The case histo- treated by intense therapy and resuscitation consisted ry of a 25-year-old woman patient illustrates in use of antiarrhythmic drugs (lidocaSne, novocaTnamide, hypersensibilization to penicillin resultin 9 in etal), electric-pulsating therapy, electrocardiostimula- overall lesion of the ski. and mucous membranes ting procedure, intensive ureapoiesis, gastric lavage plus universal vasculitis.The patient spent 52 and hemoresorption. We noted the high effectiveness of days in the resuscitation ward and the followin~ electro-pulsating therapy. The mortality rate was decrea- ranqe of syndromes was repistered ia the course sed in this group of patients by the described type of of the disease : toxic-allerpic epidermal necro- treatment. lysis affecting 70-~0 % of the skin,blepnaroeon- juctivitis and temperature of up to gO~ ; lei- kemoidal-eosinophilic reaction of the blood coupled with the appearance of all types of lymphocytes and enlar6ement of all lymphatic nodes (leucocytosis -- 145,000,eosinophilia -- up to 57 % with appearance of blastocells);acute retJal iusufficiency (mild form) ;acute toxic hepatitis; pneomonia with wet pleurisy ; acute myocarditis; coagulatin~ system lesion syndrome with hypocoa- gulation in all phases; toxic hyperchromic anae- mia ; allergic polyarthritis. Treatment : abstention from medications with the exception of diuretics and corticosteroids ; ab- solute fastin 9 with follow-up non-protein diet ; forced diuresis with a load of up to ~ litres of liquid to produce 6-~ litres of urine per day. Result of treatment : full recovery. 242

395

@XYTOCIN INDUCED WATER INTOXICATIONS D.Perrot, J.J.Leho~, Y.Bouffard, B.Delafosse, C.Guillaume, J.Motin. H6pital Edouard HERRIOT 69008 LYON (FRANCE). We report one new case of acute water intoxication (AWl) induced by oxytocin (OXY) infusion during therapeutic abor tion , in a 30 year old primigravida at 20 weeks'gestation After intraamniotic injection ~f Pro~taglandins ~ this patient received 210 units (u) of OXY in 2,5 liters (I) of a 5 % Dextrose in water solution, auring a period of 15 hours (h) 30 minutes (mn)(infusion rate (IR) of about 226 mU/mn), and twice i00 mg IM of Pethidin. Whereas she had vomitings and headache, a grand mal seizure then a deep coma occured. Serum sodium level was 112 millimoles/l and serum osmelarity 259 milliOsmoles/l. With interruption of oxytocin and sodium administation, a marked diuresis occured, with positive free water clearance ; electrolytes nor malized within 48 hours and consciousness cleared within 4 days. She was discharged completely recovered. About this new case and 41 cases previously reported in litterature, circumstances of occurence of this uncommon entirely iatrogenic disease were treatment of incomplete abortion (13 cases), post partum hemorrhage (5), induction of labour (6) or abortion (18). Isolated or associated symptoms were neurologic. In 11 cases, alarm but disregar- ded signs were headache, nausea, vomiting, or mental confu sion. In 4 cases, no symptom was observed except oliguria which is a constant finding. No correlation was found between severity of clinical signs sodium serum level, total volume perfused, total dose of oxy and duration of treatment (p>0,05). OXY antidiuretic effect depends on its IR. Then concomitant fluid administration may induce an AWl, facilitated by physiologic water and salt retention in pregnancy, individual sensitivity, and morphinics. In 39 patients recovery was complete. In 3 patients, serious neu rologic sequels were reported. 2 maternal deaths occured . 2 newborns presented severe signs of AWl but rapidly recovered. So, such accidents must be prevented by clinical survey, survey of OXY IR, minim fluid and proportional salt intakes. Metabolism, Nutrition 243

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CIMETIDINE-PIRENCEPINE VERSUS ANTACIDS FOR STRESS MEASUREMENT VS.CALCULATION OF COLLOIDOSMOTIC PRESSURE(COP) BLEEDING PROPHYLAXIS IN INTENSIVE CARE UNIT PA- JM Mosquera,P Galdos,E Dominguez de Villota,Ml Tomas, TIENTS. D. Engelhardt, R. Karl, D. Inthorn, V Diez-Balda,JL de la Serna,JJ Rubio. lntensive Care Unit. D. H~Izel, Klinikum GroBhadern, Universit~t Cl$nica Puerta de Hierro.Madrid-35. Spain. M~nchen, M~nchenr Deutschland MEASUREMENTS.-COP was measured ~n duplicate in 316 samples Preliminary results of a randomized controlled of plasma (217 patients end 99 blood donors)with an IL-WEIL clinical trial of preventing upper gastroin- Oncometer,at 24~ measured values were corrected for testinal bleeding in intensive care unit patients 37~ the arithmetical mean for paired samples was cal- were presented. A group of 44 patients (A) recei- culated (C-~'F,37~.Duplicatedmeasurements differed only in ving a combination of cimetidine and pirencepine 0.22• mmHg (p=O.81).However,paired comparison of mean is compared with a group of 42 patients (B) re- value of C--0ff,24(27.48• and C-Off,37(28.68• sig- ceiving an aluminium magnesium hydroxide concen- nificative(p

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CONTINUOUS pH MEASUREMENTAND RANITIDINE IN SERIOUSLY PHARMACOKINETICS OF PARENTERAL METRONIDAZOLE IN ACUTE RE- ILL PATIENTS. M. Albin, J. Friedlos, K. Hillman, Inten- NAL FAILURE. G. DABROWSKI, T~ BEN ABDALLAH, B. FLOUVAT, sive Care Unit, Charing Cross Hospital, London, UK. and Ph. LOIRAT. HOPITAL FOCH, SURESNES, HOPITALAMBROISE Stress ulceration is common in patients treated in Inten- PARE, BOULOGNE, FRANCE. sive Care and when associated with active bleeding Anaerobic infection is frequently suspected in post sur- carries a high mortality. Antacids effectively increase gical acute renal failure (ARF). The aim of this study the stomach pH and decrease the evidence of GI bleeding, was to evaluate the pharmacokinetics of parenteral metro- whereas cimetidine is not as effective in increasing pH nidazole in ARF patients treated by hemodialysis. nor in preventing GI bleeding in seriously ill patients. 7 patients with post-surgical ARF, treated every other (I) A new histamine H~-receptor antagonist, ranitidine, day by hemodialysis, received parenteral metronidazole in has not been evaluated in these patients. The object of a dose of 500 mg administered in 20 minutes, eight hourl~ this study was to evaluate the effectiveness of raniti- In the 7 patients serum values of metronidazole (high dine in controlling the gastric pH at above 4. If the pH pressure liquid chromatography assa~were obtained before was ~elow 4 a bolus dose of 50 mgm iv of ranitidine was hemodlalysis, after the first injection, every 15 minutes given and an infusion of Imgm/hr corm~eneed. The infusion for 2 hours and every hour for 8 hours. During hemodialy- was increased up tO 15 msm/hr pr decreased aecording to sis serum levels were obtained after a second infusion the pH of the stomach. A further object of the trial every 30 mn for 2 hours and every hour to the end of he- was to evaluate a continuous method for measuring gastric modialysis. In 3 patients the therapy was maintained for pH. This is necessary if the effectiveness of a contin- 3 to 8 days and peak and trough levels were obtained be- uous technique to increase pH is to be assessed. A pH fore and after each injection. electrode (Novo Indnstri A/S) was inserted together with After the first injection peak levels were 19.03 • 3:47 the NG tube. The pH was continually measured and dis- mg/l (mean • SD). Elimination half life (T I/2 B) was played enabling rapid adjustments to infusion rates of 7.06 • 1.95 h. Trough levels were 5.92 • 2.85 mg/l. These ranitidine to be made. This method was successfully reSults were not different from those obtained in normal employed in all patients and no adverse reactions attri- subjects. During hemodialysis T i/2 B was 3.45 • 0.5 h butable to ranitidine were noted. It is hoped that this corresponding to a mean decrease of 35 % in 4 to 6 h. technique will be the basis for a closed loop servo There was no rebound after hemodialysis. In the three pa- control system for cnntrolling gastric pH in seriously tients receiving repeated infusions the mean peak and ill patients. trough values for the last five infusions were 18.5 mg/l andP.Omg/l, not different from values obtained after repeated infusion in normal subjects. Hemodialysis preven- (I) Priebe HJ, S~illman JJ, Bushnell LS et al: Antacid ted significant accumulation of the drug. versus cimetidine in preventing acute gastrointes- In conclusion : pharmacokinetics of I.V. metronidazole in tinal bleeding. A randomized trial in 75 criti- ARF are similar to those of normal sujects. Hemodialysis cally ill patients. N Engl J Med 1980; 302:426-30 increases the elimination rate. The usual frequency of infusion in normal subjects is suitable for treatment of ARF patients submitted to hemodialysis every other day. 244

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DESIALYLATED GLYCOPROTEINS IN CRITICALLY-ILL PATIENTS. TPN WITH SOLUTIONS OF DIFFERENT AA COMPOSITION:EFFECTS ON J.M. Coulaud~ N. Serbource-Goguel~*J.P. Seta~ J. Labrouss~ CRITICALLY ILL PATIENTS NB.-F. Bobbio Pallavicini, V. Emmi, G. Durand,~-~J. Lissac~ Service du Professeur Lissac~ HSpi- A. Brssehi, C. Reposi, G. Negri, F. Raimondi, M. Fischetti, P. Tosi, tal Boucicaut, Service du Professeur Agneray~Hipital H@- rold, F 75730 PARIS (France). G. Iotti,A.Gasperi.Ospedale San Matteo, Pavia, Italia. Authors aim was to investigate how TPN with solutions of Liver is responsible for biosynthesis and degradation of different AA composition effects on NB in critically ill sialoglycoprotein such as~] acid-glycoprotein (o<] AGP) patients with a medium-high proteie catabolism.Patients and ~ ] anuitrypsin (~ 1 AT). The plasma of normal subjects contains negligible amounts of asialoglycoprotein because were on TPN for i0 days.The work focused on the identifi= of the ability of the normal liver to clear them almost cation of the AA solution,if one,whose composition eoult instantaneously from the circulation. In hepatic diseases, let in the NB reach positivity sooner,expeeially aceor= the presence of serum desialylated material has already ding to significantly different BCAA contents.Three ty= been evidenced, but in this study, the hepatic insuffi- pes of AA solutions(A-B-C)were used.They had the follo= ciency was often associated with other organ failure (J. wing contents,expressed as grams in i000 ml of solution. Marshall et al, J. Lab. Clin. Med., ]978, 92, 30-37). The actual cause of this desialylation is still not well A B C The were provided with known : isolated hepatocellular damage (HCD) or multi vi~ BCAA: 19.20 28.40 47.77 the equivalent daily ceral failure. AAA : 8.20 6.26 8.20 quantity total calorie To answer this question we have studied the degree of de- 8(130% of their RME).Each of the 32 patients was suffe= sialylation ofo< I AGP and o<] AT in serum of 26 patients ; ring from acute generalized peritonitis.They were set in all had multivisceral failure, associated (n = 9) or not (n = 17) with HCD evidenced by usual liver tests. The de- one of 3 groups(A-B-C)at random.For survived patients,NB sialylation of~ ] AGP and ~] AT was determined By compa~ was computed by determinating the urine urea and its evo= ring radial i~munodiffusion and electroimmunodiffusion ~r lution was daily compared by evaluation of the confiden= each glycoprotein. Results were given in percentage (%) tial limits of the means differences,the variances homo= asialoglycoprotein. The presence of a desialylation>5 % geneity being previously evaluated by F test.No remarks= was considered as a desialylated serum. ble difference in reaching the NB positivy was demonstra= Percentage of desialylated serums te even if A and C group reached it after 5 days and B Without HCD =< ] AGP% ~I AT% ~j AGP~AT% n = 17 ]7.6 0 17.6 group after more than i0 days.Consequently,there is no si With HCD gnificant statistical difference inter activity of AA so= n = 9 55.5 33.3 77.7 lutions used.Altough further studies are necessary,the re The resulta::were statistically different in the two groins suits obtained suggest that "balaneed"AA solutions impro= (p

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ACUTE RENAL FAILURE IN CRITICALLY ILL PATIENTS : IM- NITROGEN AND ENERGY INTAKE EFFECTS ON NITROGEN PROVEt4ENT OF INTRADIALYTIC TOLERANCE WITH BICARBONATE IN BALANCE. G. lapichino, D. Radrizzani, A. Ferro, DIALYSATE. D. Mathieu, B. Cosselin, A. Durocher, C. M. 5olca. Intensive Care Unit, 0spedale Policli- Chopin, F. Wattel, EBpital Calmette, C.H.U. Lille, FRANCE nieo, and Istituto Anestesiologia e Rianimazio- Patients hospitalized in critical unit for acute renal failure (ARF) in a multiorgan failure syndrome have often ne, UniversitA degli 5tudi, Milano, Italy. a poor intradialytic tolerance. Change from acetate to 0nehundred and fiftyseven measurements of daily bicarbonate for dialysate buffering has been advocated to nitrogen balance (NB) were made on 34 patients improve this dialytic tolerance. In a retrospective (pts) under total parenteral nutrition (TPN). study, ?0 patients who received bicarbonate hemodialysi8 Nitrogen was administered as 10%.' essential are compared with 106 patients who received acetate hemodialysis. If the mortality is not different between this aminoacid solution, while glucose was the two groups, intradialytic tolerance is significantly non-protein calorie (Einp) {ouree. Mean nitrogen better (p< 0.001) in the bicarbonate group according to intake (Ni) was 0.~i g kg- (range 0-0.$9), and the mean intradialytic systolic blood pressure decrease, Einp 31.8 kcal kg-- (0-54.6). Ni/Einp ratio was the collapse number and the mean vascular volume in- 0.0066 (0-0.0184); mean total calorie intake on fusion. Ultrafiltration rate is higher and reach more basal energy expenditure (El/BEE) ratio was 1.64 often the previous values. On a biochemical point of (0-2.75). view, hemodialysis efficacy is the same in the two groups according to the urea and creatinin clearance, but end According to Kinney, 17 pts were moderately dialysis bicarbonate plasma concentrations are higher and catabolic (M), and 17 severely catabolic (5). In nearer the normal range in the bicarbonate group even both groups, NB was positively correlated to Ni, tough predialysis plasma concentratio~ were similar. Only. Ni/Einp, Einp and El/BEE (P < 0.001). However, one hypoglycemia without clinical consequence is observed when these factors were considered together, due to the lack of gluOoee ine the bicarbonate dialysis. Nevertheless, in patients undercontrolled ventilation, a only Ni and El/BEE appeared to influence NB: end dialysis alcalosis can occur ira hyperventilation is (M) NB = 0.025 Ei/BEE + 0,504 Hi - 0.167 imposed. (P< 0.005); Conclusion : change from acetate to bicarbonate in (S) NB = 0.046 El/BEE + 0.620 Ni - 0.275 dialyeate buffering improve the intradialytic tolerance (P < 0.005). of patients with ARF in a multiorgan failure syndrom. The difference between the 2 groups was stati- This kind of hemodialysie is now use routnily in our critical unit. stically significant (P<0.025). The analysis of the 2 equations evidenced that: I) NB is always better in M pts; 2) Ni is the major determinant of NB in both groups; 3) Ei effect on protein sparing and utilization is bigger in S pts. 245

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PRE AND POSTOPERATIVE NITROGEN BALANCE IN PATIENTS METABOLIC LONOITUDINAL STUDIES IN SEPTIC PATIENTS x X , x x UNDERGOING OPEN HEART SURGERY. INFLUENCE OF TYPE AND W.Maur~tz, E.Roth , F.M~hlbacher , J.Funov~cs , J.Karner , SEVERITY OF CARDIOPATHIES. G. Barbier-B~hm, J.P. P.Sporn: 1st ICU, Clinic of Anesthesia nd General Inten- Depoix, M. Videcoq, J. Hazebroucq, R. Couturier, E. sive Care, and ist Surgical Clinic x, University of Vienna, Bedairia, J.M. Desmonts, HSpital Bichat, Paris, France Austria Aim of this study was to evaluate the effect of parentera~ Introduction The possible incidence of nutritional nutrition (PN) with high dose amino acids (AA) in malnou- disturbances in the oceurence of post-operative rished septic patients. Sepsis is known to cause severe infectious complications led us to study nitrogen (N) metabolic disorders: reduction of plasma and muscle amino balance in forty adult patients undergoing surgical acid levels, especially muscle glutamine (arterio-venous procedures with CPB. differences showing an increased peripheral release of Patients and methods. Three groups were definited: muscle AA), decrease in short life plasma proteins, in- group I and group II, 13 patients class NYHA I-II and Ii crease in hormone levels, increase in free fatty acids patients class NYHA III-IV respectively underwent valve and triglycerides. As we could show earlier there are replacement The third group, 16 patients, submitted significant metabolic differences between surviving and coronary artery bypass (2 + 1 grafts) The study was non surviving patients. performed in a time interval starting 3 days before Five patients with normal renal function were studied. operation (D - 3) and ending Ii days after (D + Ii). They were manourished transferred from other hospitals, The scheme of caloric and N intake was similar in the 3 all survived. The received 2,5 g AA, 5 g glucose, and groups : 1950 KCal/day with 13 g N/day before operation 1,5 g fat/kg BW/day. After starting PN, every 2. day and increased from 700 KCal/day with 5,5 g N/day to 2300 plasma AA (art.&ven.), plasma short lif~ proteins; plasma KCal/day with 14 g N/day over the postoperative period insulin, cortisol, qndglucagon; fat metabolites; and ni- Nitrogen loss was evaluated from the measurement of trogen balance were determined until discharge from the daily urinary N output. The N balance was calculated ICU. from cumulative data of three days. Results: Nitrogen balances averaged -4 g/day. BUN was Results and conclusion. Our study has shown the normal and renal excretion of AA below 3 %~ indicating following points: i) postoperative N losses were very good utilisation. Side effects, as vomiting, flush, or high in our patients and were not related to type and mind confusion, were not seen. Plasma insulin levels re- severity of cardiac diseases; 2) positive balance could mained unchanged, glucagon levels decreased as well as be obtained only 9 days after operation with minimum N cortiaol levels. Free fatty acid and triglyceride levels intake of 14 g/day and in absence of infectious normalized. Prealbumin, retinol binding protein and trans complications. If these complications are related to ferrin levels ir~reased, indicating stimulated liver pro- decreased immunologic responses to infection observed in tein syn{hesis. altered nutritional status, some part of prophylaxis In conclusion, PN with high dose AA could not establish could be afforded by a higher caloric and N intake than positive nitrogen balance, but normal levels of total it is routinely prescribed after cardiac operation. plasma AA and short life proteins were archived. We assigns,, that increased peripheral AA release in septic patients may be lessened by exogenous administered AA.

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PHOSPHATE AND CALCIUM METABOLISM DISFUNCT!ON FOLLOWING PERSONAL EXPERIENCES IN THE TREATMENT OF CRUSCH TOTAL PHARYNGOLARYNGECTOMY AND THYROPARATHYROIDECTOHY. SYNDROM AFTER THE 1980 EARTHQUAKE IN SOUTHERN A. Eiman, C. Metrot-Magny, 3.P. Gardin, D. Levy, J.N. ITALY. G.F, Mostarda, E lannuzzi, A. De Sic, D.V. Graziano, H$pital Maillard, P. 3olis. Louis Mourier, 178 rue des C. Luongo. I st Faculty of Medicine, Chair of Intensive Care, Universi- Renouillems, 92701 Colombes Cedex, France et Universitg de Paris VII. ty of Naples, Naples, Italy The work aims to report the results obtained in patients with crush The variations of the phosphate and calcium metabolism syndrom (C.S.), treated with hyperbaric oxygen therapy (OHB) and after total parathyroidectomy on healthy glands have never been reported. This occurs in patients suffering from peritoneal dialysis (PD) or extra-corporeal dialysis (ED). There were 9 carcinoma of cervical esophagus treated by total pharyngo- patients aged 17 to 45 years with lesions of the limbs (complicated in laryngectomy. In two years, 17 patients, 14 men and three 3 cases by gaseous gangrene) and acute renal failure (AR F) (7 oligoani- women (of mean age 53 years with normal thyroid and para- uresis, 2 aniuresis). 7 to 24 hours passed between the quake and their thyroid functions checked) were operated. Serum and urina- first aid and a period of 1 to 6 days during which they passed into our ry calcium and phosphate level measurements have been care. Besides the contribution of calories and hydroelectrolites, done after operation. The hydroeleetrolytic adjustements and the parenteral feeding were carried on with glucose therapy was based on contemporary, daily dialysis (7 ED, 2 PD) ad and amino-acid solutions avoiding phosphate and contai- OHB (2 ATA for 2 hours a day for the first 4 days - 2 ATA for 1 hour ning known and stable calcium rate. From the enterai fee- a day for the following days). OHB was used for 7 to 70 days and ding on, thyroxine, alumine-hydroxyde and eholecalciferol when used for more than 23, gangrene was present. Diuresis started were added. again on the 8 th to the 1 lth day with PD and the 6 th to the 15 th with After total thyroparathyroidectomy, calcium and phosphate ED Final results: 6 patients cured, 1 amputated, 1 trasfered impro- serum and phosphate urinary levels significantly decrease ved, 1 desceased due to hepatitis. We can therefore confirm the (respectively 10 • 9 mg/l p<0,01, 5,6 i 6,3 mg/l p< validity of the association of precocious ED with OHB. 0,05; -0,28 • 23 mg/mg urinary cmeatinine p<0,005). Indicating the lack of parathormone, the urinary calcium excretion increases, depending on the filtrated load (calcium serum level) and as long as the phosphorus intakes remain low, a real low calcium serum level can be noted without clinical signs. In spite of high frequency surgical complications (93 for 17 patients) the variations of phosphate and calcium metabolism are not affected by them. Pediatrics

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BLOOD VOLUME CHANGES DURING SEPTIC SHOCK IN CHILDREN. MANAGEMENT OF SEVERE HYPONATREMIA IN CHILDREN: UTILITY OF D. DEVICTOR*, J.M. ROCCHISANI**, g. HUAULT* UREA. G. Siro Brigiani, T. Fiore, R. Giuliani,M. Mieelli, * H6pital BICETRE - ** H6pitsl COCHIN - PARIS - France Institute of Anesthesiology, University of Bari, Italy. Urea has been proposed for continued treatment in cases Septic shock may induce hypovolemia by increasing fluid of syndrome of inappropriate secretion of antidiuretic leakage from the capillary bed. The purpose of the pre- hormone in adults (I) In the present study, rapid cor- sent study was to test the effects of macromolecular infusions on the red cell mass (RCM), plasma volume (PV), rection of hyponatremia has been attempted in children. and total blood volume (TBV~. We used Tc 99 labelled ery- Clinical material and method. Two pediatric cases (aged throcytes to measure RCM in 6 c611d~ren aged from 4 months 90 and 8 years respectively) of head injury in deep coma to 7 years with infections purpura and shock. Haematocrit are described, which neurologically exhibited a downfall was measured simultaneously for calculation of PV and TBV course, accompanied by I) hyponatremia and hypoosmolali- For ethical reasona~ the study took place during therapy which included 18 to 72 hours infusions of whole blood ty, 2) inappropriately high urinary osmolality and natriu and of plasma, albumin, gelatin and dextran. The rate of resis, 3) no impairment of renal function,normal volemia, infusion averaged 180 ml/kg with large interindividusl absence of oedema. Fluid restriction having been followed variations depending on the patient's condition. by no favourable result, the acute administration of urea Results were as follow : (500 mg/Kg in 50 ml of water) through a naso-gastric tube age - watched controls patients was carried out twice with an interval of 24 hours. Results. Values of plasma sodium and osmolality, together RCM ml/kg 18.5 • 3 21 ~ 6 * with natriuresis, gradually returned to normal within 16 PV ml/kg 36.6 • 6 45.3 • I0 * TBV ml/kg 57.1T 9 66.5 i 13 * hours after the second administration of urea(see Table). C a s e s ]st 2nd Mean ~ SEN * = NS T i m e s tO* t1* t2* tOw t1* t2* Since statistical significance was not demonstrated by pNa (mEq/l) 120 132 141 123 ]30 136 t-test comparison with Lhe controls, these data indicate pOsm(mOsm/Kg H20) 239 271 293 251 284 285 that TBV was normalized in the children studied. The fact uNa (mEq/hr) 91 6 3,6 9] 9,6 5,4 fhaf the rapid fluid infusion did not increase blood volume beyond its normal limit, suggests that a large uOsm(mOsm/Kg H20 ~ 905 478 998 979 873 863 fraction of the macromolecular solutions infused disap- *t0=before,tl & t2=16 hrs after ]~ & 2 ~ dose,respectively peared from the vascular bed. Conclusions. Urea,which represents the main solute in the countercurrent mechanism, proved to be effective in the correction of decreased plasma sodium content and osmola lity with a sparing effect on sodium loss; a concurrent improvement of the neurological picture was observed. References. I) Decaux, G. et al.: JAMA, 247(4): 471,9982.

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COLLOID OSMOTIC PRESSURE AND RESPIRATORY FUNCTION TREATMENT OF MENINGITIS ASSOCIATED WITH VENTRICULAR 8HUNT. EXPERIENCE OF EXTERNAL VENTRICULAR DERIVATION IN PEDIATRIC INTENSIVE CARE~PATIENTS. OF LONG DURATION. M.Abel, J.Otto und W.Vogel A.Barois, F.Veber, B.Estournet Service de P4diatrie-R6animation Infantile University Hospital of Pediatrics and Institut Hapital R.Poincar6, 92 380 Garches - France. of Anaesthesia University Hospitals Freiburg, 11 children suffering from meningitis associated D-7800 Freiburg. West-Germany. with a ventricular shunt.were admitted in the department. Mean age : 3 + 3,5 Y (range : 15 days to In the last decade osmotic pressure measurement 12 years~, 8 boys and 3 girls. took place in control of fluid and oneotie im- The ventricular shunt was put for hydrocephalus post neonatal meningitis 5 times, following intracranlal balances in adult patients . Its usefullness in hemorrhage once, complicating a spina bifida the management of oedematous lung dysfunction in 5 times and due to congenital malformations twice. Meningitis occured 26,8 + 40,8 months after the first pediatric intensive care patients seems still un- shunt was put and 9,9 + 8,5 days after a new surgical intervention for obstructed shunt in 9 cases. The clear. germs were meningococcus once, staphylococcus 7 In 22 infants and neonates with respiratory times, streptococcus 4 times and Gram negative insufficiency we studied total serum protein, bacillus twice. Several germs were found 4 times. The treatment included adjusted antibiotics with good colloid osmotic pressure and ventilation para- CSF penetration andexternal ventricular derivation, after the contamined material was removed, in all the meters. cases except the meningococcal meningitis. Positive correlations between high fluid re- The cerebrospinal fluid (CSF~ became germ-free in 15,8 + 12 days and a new internal derivation placement, lowered colloid osmotic pressure and (ventriculc-peritoneal shunt 5 times, ventricnlo- respiratory function problems could be establish- cardiac shunt 4 times) was put after 33,9 + 13,7 days of external derivation. ed. Ten children recovered without new sequelae. One Colloid and crystalloid volume replacement died in two days of staphylococcal sepsis and peritonitis ; she was 17 days old. therapy in pediatric intensive care patients with In conclusion treatment of prolonged and severe shunt respiratory insufficiency should be controlled infections by external ventricular drainage of long duration and specific antimicrobial therapy may offer by colloid osmotic pressure measurement. Our re- improvement in most of the cases. sults were presented and discussed with statistical significance set at p< 0.05 value. 247

412 414

MECHANICAL VENTILATION AT HOME FOE A LONG TIME. P~SENCE OF _~NATYPICAL CATHODICALLY HIflD~TING CREAT!NE RESULTS IN 115 CASES IN CHILDREN. KINASE IN CHILD AFTER C~RDIAC SURGERY. A. Dequirot, B.ESTOURNET, A.BAROIS. N.T. Lequang, F. Labrousse~ A. Roy, F. Trinquet, Service de R~animation Infantile, HSpital R.Poincar~ C. Rocchiccioli ; Unit6 de R6animation de chirurgie 92 580 GARCHES FRANCE. cardiovasculaire et Laboratoire de biochimie, HSpital La~nnec, 42, rue de S~vres, F 75007, Paris, France. 115 patients, admitted in the department during Some data concern the presence inhuman tissues of an their childhood for chronic diseases, came back home atypical creatine kinase (CK) isoenzyme, migrating to the with an intermittent mechanical ventilation by, oral cathod, which is possibly coming from mitochondria (CKm). ~ osit!ve pressure breathing (60 cases ~, tracheostomy Sera from 320 infants and children younger than 5 years 46 cases ~ or iron lung (9 cases ~. The neuromuscular undergoing open heart surge~/were examined. Samples were disorders responsible for respiratory failure done at the arrival in ICU and the morning of the next included = Poliemyelltis (47 case~ Werdnlg Hoffmann 3 days. We electrophoretically senarated and fluorometri- diseases (20 easee~ Congenital Myopathles (10 cases~ cally detected CK isoenzvmes according to Rosalki (et al) Muscular dystrophy of Duchenne (8 cases~ Nyasthenia modified by Szasz (et ali. Gravis (4 cases ~ and other disorders affecting the In 38 patients, besides the 3 well kn~nC~l, C~ and lower neuron motor unit (5 oases~. CKBB isoenz]anes, we have isolated an atypical CK isoen- Head and spinal cord injuries are responsible in 11 zyme. We have verified that this abnormal fraction is cases. Thoracic ~istorsion are observed in 5 cases antigenically "no H, no B" and have the same cathodic and chronic lung disease by bronchopulmonary mobility t.hat CKm that we have found in organ extracts dysplasia in 5 cases also. (hear% lung, liver, ...). From data profile there is Mean age when children cameback home is I~,5 ~ 6,4 3 groups in patients. Group I (4/38) where CKm is pre- years. sent as early as the arrival in ICU ; Group II (9/38) Death occured in 22 c~ses. where CKm appears the day foll~r operation ; Group III Mean age of the survivors is 20~6 ~ 8,6 years. (25/38) where CKm is present only the second post opera- The worsening of respiratory insufficiency made tra- tive d~ whereas C~ is nearly vanished. We have veri- cheostomy indispensable in 7 cases in the group of fied that CKm does not result from eventual transforma- children ventil~ted~ by oral positive pressure brea- tion of ~ or BB isoenzymes. CKm disappears the next thing. The experience of mechanical ventilation at days. Two of the 38 patients are died, that is ~emean home started in 1970 with teenagers, hospltalised in mortality rate. the department since their childhood, permitted to extend its indications and thanks to the equipment CKm occurrence in infants and children after open heart improvement to send back home children younger and surge~/ does not seem to have pejorative signification. younger. Significance of this is still uncertain and further studies are necessa~/.

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EFFECT OF OPEN-HEART SURGERY ON PLAS~IA FIBRONECTI:J POST SURGICAL BODY WEIGHT (BW) CHANGES WITH CORRECTIVE LEVELS IH CHILD. A. Dequirot, F. Labrousse, H.T. Lequang, CARDIAC SURGERY IN PEDIATRIC PATIENTS. CORRELATION WITH A. Roy, C. 2occhiccioLi, F. Trinquet. Unit~ de 26anima- VENTILATORY WEANING TIME AND !~ORBIDITY. tion de chirurgie cardiovasculaire et Laboratoire de rI.E.FAY!IONVILLE, Dept of Anesthesiology, Hosn. Bavi6re, biochimie, HSpitaL La~nnec, 42 rue de S~vres, F 75007 University of Liege, Belgium. PARIS, France. J. CHAREST, Dept of Anesthesiology, Hosp. Ste Justine, Opsonic fibronectin depletion decreases resistance to University of Montreal. Canada. sepsis (!~.E. Lanser, T.~I. Saba, Ann. Surg., 195, 3 z 1982) with the aim of studying factors predisposing to infec- 420 oatients (nremature : 3 %; age~l month : 6 %; 1 to 24 tions complications, we analyse plasma fibronectin (PF) months : 31%; 2 to 6 y.o.: 38 %; 6 y.o.: 22 %) submitted rate variations following open-heart surgery. congenital corrective cardiac surgery were studied. Car- This study concerns 10 pediatric patients, aged between dio~ulmonary bYbaSS was used in 82 %. Weights were measu- 9 months and 13 years, after cardio pulmonary bypass for red before and after surgery. 125 oatients have lost surgical correction of congenital heart diseases. BLood weight during the procedure, average:l.66 % + 1.58 samples, anticoagulated with Na Citrate, were taken be- 295 natients have increased their initial BW~ average : fore operation and 6 hours, I day and 7 days after surgi- 1.84 % + 2.02. Five subgroups were used for statistical cal procedure. After centrifugation, plasma samples were analysis : Grou~ 1 : loss> 2 % BW immediately frozen. ~leasurements of PF were done by ra- qrouo II: loss 0-2 % BW dial immunodiffusion. For statistical analysis non para- qroun Ill:gain 1% BW metric Wilcoxon paired T test were used. Groun IV: gain I-2 % BW Before operation, baseline Level of plasma fibronectin qroun V : gain~ 2 % BW (I) is 303 • 59 mg/l (mean ~ SD). At the sixth postopera- The nostsurgical comnlications : cardiac failure, arryth- tive hour (2) PF = 314 • 52 mg/l ; the first postoperati- mias, atelectasis, oleural effusion, and the nostsurgi- ve day (3) PF : 270 • 26 mg/l ; the seventh day (4) PF = cal ventilatory weaning delay were statistically analysed 330 • 36 mg/l. Statistical comparison gives : for 1 vsa, in these 5 grouDs. The number of postsurgical comnlica- I VS3, 2 VS3, 3 VS4 : p ~ 0.01 ; but for I VS4 ;IS. Plas- tions was increased in correlation with the BW gain duma fibronectin levels decrease as early as the 6th hour ; ring the surgical nrocedure. For instance,, mean inci- the 7th day PF levels are nearly returned to the baseline dence of comolications get patients averages 0.51 in rate. group I and 1.15 in grouo V (~<0.001). The nostsurgical Thus, cardiac surgery with cardiopulmonary bypass may ventilato~ weaning orocedure has been more difficult in induce a drop of PF level. It is possible that fibronec- patients with increased BW;~group I endotracheal intu- tin might lower resistance to sepsis which is a dreaded bation duration averages : 9 H; it averages 24 hours in complication of this surgery. group V (p

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MONITORING OF THE EXPIRED CO 2 IN PRETERM INFANTS A.Vuori, P.Jaakkola, Department of Anaesthesio- iogy, University of Turku, Turku, Finland. The validity and usefulness of capnography in monitoring ventilation in preterm infants was studied comparing the correlation of end tidal pCO^ to arterial pCO 9. A t6tal of 69 sample~ were included in this study. The patients were preterm infants treated with CPAP or IMV for IRDS (hyaline membrane disease) in most cases. The Baby Bird ventilator was used. Because of small tidal volumes, gas samples were taken from the intubation tube near the patient by Cutting the tube and connec- ting a T-piece between the ends. Gas samples from this T-piece were continuously drawn to a fast-response infrared carbon dioxide analyser connected to a recorder (Datex Normocap DC-102 & CR-I02). The method turned out to be easy to employ and valid. There was a good correlation between ETpCO 2 and arterial pCO 9 in ~ase the plateaux on the capnograms were Droad and/or of equal height. The severity of the IRDS had influence on the correlation, whereas gestational age and birth weight seemed not to affect the correlation.