[Bronchoscopy in ventilated patients: full narcosis or local anesthesia?]

In a prospective, randomised trial bronchoscopy was performed either in local anaesthesia (LA) or general anaesthesia, each on 15 ventilated patients. LA was carried out with oxybuprocain-hydrochloride 1% in repeated doses injected into the trachea and main bronchi, general anaesthesia with midazolam, piritramide and vecuronium bromide. Measurements were performed before, 3 minutes after induction of anaesthesia, immediately after bronchoscopy and 15 and 60 minutes after bronchoscopy. There was no effect on cardiocirculatory function during bronchoscopy in both groups, but we found a decrease in paO2 from 97 to 80 mmHg (median) after application of LA. Subsequent bronchoscopy did not significantly influence paO2. The present study shows that in ventilation patients undergoing fibreoptic bronchoscopy, the application of LA will usually result in a decline of arterial oxygen tension. This procedure should therefore only be performed if general anaesthesia is undesirable, as e.g. in patients being weaned from ventilation.

[Bacterial pneumonia in ventilated patients. The role of bronchoalveolar lavage in diagnosis and therapy]

In the diagnosis and treatment of bacterial pneumonia, the isolation and resistance pattern of the causative organisms are very relevant. Bronchoalveolar lavage (BAL) with quantitative culture is the best technique to obtain material for bacteriological investigations in nonintubated medical patients and in a baboon model. The present study was designed to clarify the following questions: What is the value of BAL compared to tracheal secretion (TS) in ventilated patients with regard to antibiotic therapy? Is it possible to distinguish colonization and infection by investigation of BAL? MATERIAL AND METHODS. In 34 ventilated patients, we studied the diagnostic and therapeutic value of BAL in comparison to TS. Thirteen patients suffered from pneumonia, 9 patients were colonized, and in 12 pneumonia was uncertain. These terms are defined as follows: 1. Pneumonia: temperature over 38.5 degrees C, leukocyte count over 12,000/mm3, infiltrate in the x-ray compatible with pneumonia, purulent tracheal secretion, positive bacteriological findings. All criteria must be fulfilled. 2. Colonized patients: mechanical ventilation more than 7 days, no signs of infection, isolation of the same bacteria species in two previously obtained tracheal secretions. 3. Uncertain pneumonia: not all criteria mentioned above were fulfilled. BAL was performed in the usual manner. The bronchoscope was wedged into a distal airway and 6 x 20 ml of sterile, nonbacteriostatic saline (0.9% NaCl) was instilled through the suction channel and subsequently aspirated. All investigation materials were immediately processed in the bacteriological laboratory. From the BAL specimen Giemsa and Gram preparations were performed to look for contamination from the throat and intracellular bacteria. RESULTS. Patients with pneumonia: In all patients the TS and BAL were positive. Cultures from BAL and TS were in agreement in 77% of the cases. In 10 patients intracellular bacteria (BAL) were present, in two patients the Gram preparation was nonapplicable because of destroyed cells. In one patient Haemophilus spp. could be isolated in the BAL (10(5)/ml BAL), but not in TS, which definitely influenced therapy. Colonized patients: In all patients TS and BAL were positive, with exact agreement in 33% of the cases. The concentration of isolated bacteria (BAL) was not as high in these patients as in the patients with pneumonia (median: 8 X 10(3) vs 6 X 10(4]. However BAL allowed no differentiation between colonization and infection in individual cases. Uncertain pneumonia: TS was positive in 8 patients, no TS could be obtained in 4. BAL was sterile in 4. Only in 2 bacteria greater than or equal to 10(4)/ml were isolated and both patients had intracellular bacteria. The results (BAL) influenced therapy in 5 cases (4 patients received no antibiotics; in 1 patient the antibiotics were modified). CONCLUSION. BAL is very helpful in patients suspected of having pneumonia and in sepsis of unknown origin when pneumonia should be excluded...

[Acute respiratory distress syndrome of the adult (ARDS) and artificial respiration--results in surgical intensive care patients]

A prospective clinical trial was performed in an operative intensive care unit to examine the incidence and outcome of patients with adult respiratory distress syndrome (ARDS) and the outcome of intensive care patients on mechanical ventilation and the incidence of barotrauma and pulmonary infection. 161 mechanically ventilated patients showed an overall mortality of 19.9%. The mortality rate in the ARDS patients was 11 of 26. Most of these patients with ARDS died from multiorgan failure. Pulmonary infection was the most frequently registrated complication of mechanical ventilation. We conclude from these data that --according to the literature the outcome of surgical ICU patients on mechanical ventilation with and without ARDS is more favourable than that of medical ICU patients; --the interpretation of therapeutic results and of epidemiological data in ARDS patients is possible only by providing exact and detailed criteria; these should include compliance data; --evaluation of present ARDS therapy by comparison to previous data, even when the same criteria are applied, e.g. ECMO-criteria, may fail as the outcome of conventional therapeutic measurements - mechanical ventilation - may have improved. A controlled randomised trial might be more suitable for evaluation of alternative therapy in ARDS.

[Monitoring infection at the intensive care unit--a multicenter pilot study]

During a period of 3 months an infection survey was carried out in 4 intensive care units (ICUs), 2 in Vienna, Austria, and one each in Ulm and Münster, Federal Republic of Germany, using a common protocol. A total of 329 patients was monitored prospectively. This pilot study was performed to evaluate the usefulness of parameters included in the monitoring form. It was attempted to characterize the patient populations of the four units. Mean duration of stay (1-12 days), mortality (8-26%), leading diagnosis upon admission, intubation rate (41-91%) and use of pulmonary artery catheter (12-35%) were distinctly different. The rate of patients admitted already with an infection was 9-43%, septicemia was diagnosed in up to 27% of the diseased. The rate of infection acquired in the unit was between 12 and 37%, the most frequent types were bronchopneumonia, septicemia and urinary tract infection. When septicemia patients were compared to non-septicemia patients who had been admitted for more than 3 days, it appeared that the latter stayed significantly shorter at the ICU and showed less frequently bronchopneumonia or urinary tract infection at the time of admission. Septicemia patients acquired more frequently additional infections like broncho-pneumonia or urinary tract infection while staying at the ICU. The median day of onset of septicemia was the fifth day and only in a quarter of cases diagnosis could be supported by a positive blood culture. The use of antibiotics in the 4 ICUs is compared and shows marked differences. Based upon experience with this type of infection survey a new modified protocol is introduced, which displays the time course of documented events.

[Decrease in paO2 following intratracheal application of a local anesthetic and a 0.9% sodium chloride solution. A prospective study on the use of fiberoptic bronchoscopy in ventilated patients during local anesthesia]

Flexible fiberoptic bronchoscopy of intubated patients can be performed in general or local anesthesia (LA). Up to now, no results have been published on the effects of LA for bronchoscopy in ventilated patients. We studied the hemodynamic changes caused by bronchoscopy under LA in mechanically ventilated patients and the effect of LA on the endoscopic decline in arterial pO2. Differences between the widely used agents lidocaine and oxybuprocaine hydrochloride were also studied. We found a decline in paO2 after the administration of LA and further investigated the influence of bronchial lavage on paO2. METHOD. A total of 70 ventilator patients, excluding patients with atelectasis, massive mucous-plug retention, and those under muscle relaxants, were examined in a surgical intensive care unit. In 40 long-term ventilator patients bronchoscopy was performed with either oxybuprocaine hydrochloride 1% (Novesin) (group 1; n = 20) or Lidocaine 1% (Xylocaine) (group 2; n = 20) (2-3 ml LA in repeated doses into the trachea and main bronchi; total amount 10 ml). We looked for hemodynamic changes and effects of LA on the bronchoscopic decline in paO2. In 15 long-term ventilator patients (group 3), LA was applied without bronchoscopy to investigate the duration of the LA-caused decline in paO2. In 15 intubated patients (group 4), the influence of intratracheal administration of 10 ml normal saline was examined. Patient data are shown in Table 2. Measurements were performed in groups 1 and 2 before and after LA, immediately after bronchoscopy and 15, 30, and 60 min after bronchoscopy and in groups 3 and 4 before and 5, 15, 30, and 60 min after LA. RESULTS. There was no effect on cardiocirculatory function during bronchoscopy in LA, but we found a decrease in paO2 after administration of LA in all patients (median in group 1 from 100 to 78 mmHg in group 2 from 104 to 86 mmHg). The subsequent bronchoscopy caused only a small, nonsignificant further decline in paO2. The administration of LA without bronchoscopy (group 3) was followed by a fall in paO2 from 86 +/- 12.5 to 69 +/- 11.7 mmHg (mean +/- SD) with oxybuprocaine hydrochloride and from 87 +/- 12.4 to 72 +/- 8.7 mmHg with lidocaine. Even after 30 min the paO2 had not returned to the initial value. The intratracheal application of 10 ml 0.9% NaCl caused a decline in paO2 from 101 +/- 20 to 78 +/- 12 mmHg (mean +/- SD), which also persisted for more than 30 min. CONCLUSIONS. The study shows that in ventilator patients undergoing fiberoptic bronchoscopy in LA, the administration of the LA is an essential factor in the decline in paO2 associated with bronchoscopy. A similar fall in paO2 is observed by intratracheal

[Frequency of colonization and pneumonia and development of resistance in long-term ventilated intensive-care patients subjected to selective decontamination of the digestive tract]

Colonization of the oropharynx with potentially pathogenic microorganisms (PPM) is a highly significant factor in the pathogenesis of bacterial pneumonia in intensive care patients. Via colonization of the oropharynx, bacteria pass into the tracheobronchial tree, where they can give rise to pneumonia after overcoming pulmonary resistance mechanisms. By a new, prophylactic antibiotic treatment schedule consisting in selective decontamination of the digestive tract (SDD) with locally applied nonabsorbable antibiotics, Stoutenbeek achieved drastic lowering of the colonization and infection rate in trauma patients. In the present study, we wanted to check whether this new prophylactic antibiotic schedule can be applied on a surgical intensive care ward in all patients with long-term ventilation, irrespective of the diagnosis, and whether it affords advantages over a conventional antibiotic schedule. MATERIALS AND METHODS. All patients on a surgical intensive care ward in whom it was expected that mechanical ventilation would be necessary for more than 4 days were included in the study. During the first 6 months 83 patients were investigated, in whom antibiotics were only administered when the presence of infection had been confirmed, in accordance with generally accepted guidelines (control group). In the second 6-month period, 82 patients were selectively decontaminated with 4 x 100 mg polymyxin E, 4 x 80 mg tobramycin and 4 x 500 mg amphotericin B, administered through the gastric tube and in an antimicrobial paste in the oropharynx (SDD group). The SDD schedule entailed systemic administration of cefotaxime in the first 3-4 days. RESULTS. In the control group, enterobacteria/Pseudomonas spp. were isolated significantly more frequently than in the SDD group (P less than 0.001): in the pharyngeal smear in up to 53%, in the tracheal secretion up to 36%, and in the rectal smear in up to 93% of the patients In the SDD group in the 1 week the frequency of gram-negative aerobic bacteria in the pharynx decreased from 33% to 5%, in the tracheal secretion from 23% to 14% and in the rectum from 86% to 52% (24% in the second week). However, the decrease in gram-negative microorganisms was accompanied by significant increase in the frequency of Staphylococcus epidermidis and enterococci. The SDD schedule proved to be effective with regard to the rate of infection. In the control group, 35 patients developed pneumonia (42%) as against 5 patients receiving SDD prophylaxis (6%). The duration of mechanical ventilation in the patients with pneumonia was 5 days longer than in patients without pneumonia.(ABSTRACT TRUNCATED AT 400 WORDS)

[Alarms of medical-technical equipment in the surgical intensive care unit. A prospective study]

To test the need for a graded system of alarms on ICU we examined this aspect of present management by recording the number of devices and alarm-releasing facilities, the interpretation of alarms and type of response of the nursing staff. The data were recorded on multiphase basis at the operative ICU of a university hospital. The mean number of devices per patient was 4.3 and per room 11.5. The mean interval between 2 alarms was 5 min 30 s. In more than 50 per cent the first reaction of the staff was alarm-related. We conclude that the number of alarm signals should be reduced and unique signals used for each group of medical devices.

[Monitoring of bronchoscopy in artificially ventilated patients using peripheral pulse oximetry--a useful monitoring method?]

In the present study, flexible bronchoscopy was monitored by means of peripheral pulse oximetry in 62 artificially ventilated patients of a surgical intensive-care ward. The study was designed to establish whether falls of arterial oxygen saturation due to bronchoscopy can be detected at an early stage and whether they can possibly be influenced by an appropriate investigation technique. 270 comparative measurements of hemoglobin oxygen saturation were carried out; the oxygen saturation directly measured in the arterial blood served as reference value. The statistical analysis revealed a correlation of r = 0.85. In ten patients, there was an impairment of respiratory function and hypoxemia due to bronchoscopy. In all cases, this could be detected in good time from the fall of oxygen saturation. Pulmonary impairment was partially prevented or further impairment was avoided by an appropriate technique of investigation.

[Behavior of blood gases in patients with craniocerebral trauma at the accident site and at the time of admission to the clinic]

It is known that early mortality after acute craniocerebral trauma (CCT) depends heavily on the extent of any hypoxia and, even more, hypercapnia in the early phase after the trauma. Hypoxia and hypercapnia are very difficult to appraise at the scene of an accident without measuring instruments. It is now generally recognized that appraisal in accordance with the Glasgow coma scale (GCS) is a suitable way of estimating the depth of impairment of consciousness (eye opening in response to stimuli, verbal response to stimuli, motor response to stimuli). The maximum number points is 15, and the minimum, 3. We therefore decided to investigate whether there is a correlation between the degree of impairment of consciousness measured with the GCS and onset of hypercapnia or hypoxia soon after. In 33 patients with acute CCT, arterial blood was taken for analysis of blood gases at the scene of the accident before therapy was started. At the same time, we evaluated the level of consciousness on the basis of the GCS. The blood samples were taken within 6-21 min after the trauma in all patients. It was shown that there is a very close correlation between the severity of trauma (measured with the GCS) and the degree of hypercapnia (r = -0.88). This was true of all CCT patients with multiple trauma without exception. The PaO2 correlates with the severity of trauma (r = 0.60) far less closely, and above all much less consistently.(ABSTRACT TRUNCATED AT 250 WORDS)

The hygienic situation in 56 German, 33 Austrian, and 25 Belgian intensive care units

The intensive care unit (ICU) creates the unique situation of subjecting highly susceptible patients to a variety of invasive procedures that are concentrated in a small unit. Effectively providing life-saving care is considered more important than other measures, such as infection control. Nevertheless, it is frustrating to lose a patient due to a sepsis that could have been prevented by simple hygienic arrangements, the application of aseptic techniques, and infection control measures. There is some confusion about the necessity and efficacy of many of these prescriptions, and some of them must certainly be considered rituals: only controlled studies demonstrating the influence of the specific measure on the infection rate will give a decisive answer about usefulness. Most factors determining the occurrence and transmission of infections lie with the patient's resistance and treatment, but technical, diagnostic, and curative measures may also influence the infection rate. Facilities, techniques followed, and prescribed procedures may differ from hospital to hospital. If we want to draw a conclusion from the comparison of infection rates in different ICUs, it is desirable to compare not only the different preventive measures in nursing procedures and techniques, but also the organization and structure of the units. Therefore, our committee decided to study the hygienic situation of ICUs before elaborating a practicable and valuable system for the registration of nosocomial infections. The study was not limited to the small group of interested teaching hospitals with high standards, but rather, was extended to all Austrian (A) ICUs and a significative sample of German (D) and Belgian (B) ICUs.

The respiratory aspect of the treatment of brain injury associated with acute alcohol intoxication--results of an animal experiment

The effects of spontaneous respiration and mechanical ventilation were examined by investigating the interaction between elevated intracranial pressure and alcohol intoxication. Ethanol (200 ml 48%) was infused in 11 young pigs with elevated cerebral pressure during mechanical ventilation (group 1), 7 young pigs with elevated cerebral pressure during spontaneous respiration (group 2), and 4 young pigs without elevated cerebral pressure during spontaneous respiration (group 3). While the behavior of intracranial pressure during mechanical ventilation in the animals from group 1 was inhomogeneous with a tendency to rise (29-34 mmHg), cerebral pressure (28-55 mmHg) increased drastically in the animals from group 2. This increase was associated with a sharp rise of Pa,CO2 (37.6-73.3 mmHg) and a decrease of Pa,O2 (74 mmHg to 13 mmHg). None of the animals in group 2 survived. Pa,CO2 also rose in alcoholized animals without elevated cerebral pressure (group 3) (41.9-63.9 mmHg); intracranial pressure, however, remained within the normal range. All animals in group 3 survived. Our findings indicate that elevated intracranial pressure and alcohol intoxication have a cumulative or potentiating effect on depression of the respiratory center. Respiratory depression can be prevented by mechanical ventilation and, therefore, a further rise of intracranial pressure generally avoided.

[Comparative humidity measurements in semiclosed and semiopen systems with the additional use of artificial noses]

The administration of dry anesthetic gases for ventilation lasting more than 1 h leads to morphological changes of the tracheobronchial epithelium that may cause postoperative pulmonary complications. Therefore, additional humidification is suggested for ventilation during anesthesia, particularly when using semiopen breathing systems. Recommendations concerning the use of semiclosed systems are controversial: previous studies have shown sufficient humidification on the one hand, and insufficient water content in the inspired air on the other hand. In this study, comparative humidity measurements in a semiopen and a semiclosed system were carried out during anesthesia and mechanical ventilation. We particularly wanted to find out whether placement of the fresh gas inlet into the circle before or behind the soda lime canister influences the humidity of the inspired gas. In addition, we tested three types of "heat and moisture exchanges"--Engström "Edith", Siemens "Servo Humidifier", and Portex "Humid Vent". A total of 58 patients between 23 and 78 years of age were studied. They were divided into three groups. Group I: In 10 patients comparative humidity measurements were carried out using both a semiopen and a semiclosed system. Group II: The time course of water saturation during a 3-h period was determined in 10 patients ventilated with a semiopen and 8 patients ventilated with a semiclosed circle system. Group III: In 20 patients we tested the effect of "heat and moisture exchangers". All patients were intubated and ventilated with the Spiromat 656 and the Circle System 8 (Drger) that made ventilation in both a semiclosed and a semiopen system possible. The humidity measurements were carried out using a psychometric method.(ABSTRACT TRUNCATED AT 250 WORDS)

[The behavior of intracranial pressure under spontaneous respiration or artificial respiration in hemorrhagic shock during volume substitution]

Haemorrhagic shock and cranial injury frequently present together in the polytraumatised patient. The effect of different forms of ventilation--spontaneous respiration, controlled normoventilation, and intubation followed by hyperventilation--on the raised intracranial pressure of young pigs given volume replacement subsequent to haemorrhagic shock, was therefore investigated. During volume substitution, the intracranial pressure (initially 30 mmHg) both of those animals breathing spontaneously and of those being ventilated rose significantly (44.6 and 49.2 mmHg respectively). In contrast, intubation and hyperventilation resulted in an initial fall in intracranial pressure to 18.6 mmHg, and a rise to just below initial values (27.4 mmHg) after volume replacement. A similar blood pressure rise was noted in all three groups but arterial PCO2 changes were analogous to those of intracranial pressure. In the presence of both haemorrhagic shock and cranial injury, volume replacement alone is not sufficient treatment, and can in some circumstances be dangerous. Early intubation and controlled hyperventilation course a fall in intracranial pressure secondary to decreasing the PCO2.

[Early measurement of intracranial pressure in polytrauma with associated craniocerebral trauma. II: Clinical and therapeutic aspects]

During the time from 1982/83 the intracranial pressure was continuously measured from patients who were polytraumatized and also had severe head injuries. In 53% of these cases the first readings could be obtained within 6 hours after the injury and in 33% first after 12 hours. During the time of evaluation this relationship shifted to earlier implantation. From 27% of these patients the intracranial pressure values fell into a range that instigated immediate therapeutical measures. This proves how important it is to have a direct reading from the intracranial pressure as soon as possible after injury. The aspects of therapy by increased intracranial pressure were discussed.

[Early measurement of intracranial pressure in polytrauma with associated craniocerebral trauma. I: Principles]

In West Germany, head injury is the major cause both of death following trauma and of irreversible cerebral damage. The successful management of these cases largely depends on the prevention and treatment of secondary rises in intracranial pressure. The only certain way of detecting such increases is with the invasive technique of intracranial pressure monitoring. The pressure module should be implanted as soon as possible, ideally, before extensive definitive surgical treatment is carried out. Ease of usage has led us to prefer epidural pressure monitoring systems. Being relatively easy to learn and apply, this form of monitoring should be used in all hospitals involved in the treatment of severe head injury.

The effect of ketamine on intracranial pressure during haemorrhagic shock under the conditions of both spontaneous breathing and controlled ventilation

Seventeen piglets of both sexes, seven with O2/air-buprenorphine anaesthesia and controlled ventilation, and ten unanaesthetized animals with normal, spontaneous respiration, were used for the study. The intracranial pressure of both groups of animals was raised by insufflation of an epidural balloon and the arterial blood pressure was reduced to approximately 70% of the original value by controlled haemorrhage. 0.5 mg/kg body weight of ketamine was given intravenously, followed by a further dose of 2.0 mg/kg body weight of ketamine five minutes later. Both ketamine doses led to a significant rise in the intracranial pressure of those animals breathing spontaneously (31.8 mm Hg to 39.1 mm Hg). In contrast, the ventilated animals showed a significant reduction in intracranial pressure. No changes in arterial PCO2 were observed in this group, while those piglets breathing spontaneously had dangerous PCO2 rises. At both ketamine doses a significant correlation could be found between the PCO2 and the intracranial pressure.

[The semi-closed filter circuit]

In a semi-closed circle system, the inspiratory and expiratory limbs are completely separated and part of the patient's expired air recirculates. CO2 rebreathing is prevented by CO2- absorption with soda lime, which is always incorporated in such a circle. The inspiratory and expiratory valves ensure that gas flow is unidirectional and also prevent rebreathing, even at tidal volumes of 10 ml and ventilation frequencies of 60 c . min-1. This circuit can be used as an universal anaesthetic system for all age groups, simply by changing the hoses and connecting pieces. The values of expiratory resistance are within the recommended limits of the ISO; prewarming and humidification of the inspiratory gas mixture are sufficient without additional equipment. Standard monitoring of the circuit such as measurement of inspiratory O2 concentration and ventilation pressure, including a disconnection alarm, can be used for all age groups; spirometry or end-tidal CO2 measurements ensure normoventilation. The fresh gas flow required in a semi-closed circle system is about 2-4 1 . min-1, so that costs and environmental contamination with anaesthetic gases are relatively low in comparison with a semi-open system.

[Acute coronary insufficiency during induction of anesthesia following anthracycline chemotherapy]

Cytostatic treatment with anthracyclines lines can lead to acute or chronic myocardial insufficiency. A cumulative dose of less than 500 mg/m2 body surface area can in general be regarded as safe. A case of acute cardio-circulatory insufficiency during induction of anesthesia is described, in which the total cumulative dose did not exceed 250 mg/m2 body surface area. The pathophysiological mechanisms occurring and the diagnostic and therapeutic measures necessary are discussed.