[Length of hospital stay for patients with proximal femoral fractures : Influencing factors]

BACKGROUND

In departments of orthopedic and trauma surgery patients with proximal femoral fractures constitute the largest proportion of trauma patients. The length of stay (LOS) has economic consequences and prolonged LOS leads to a shortage in bed capacity.

OBJECTIVES

In this study treatment and patient-related factors that influence the LOS of patients with proximal femoral fractures were investigated.

MATERIAL AND METHODS

Treatment and patient-related data of 242 patients (age >64 years) were recorded retrospectively and included residential aspects, legal guardianship, time of admission and surgery, hospital mortality, LOS, diagnosis, comorbidities, medication, surgical treatment, general and surgical complications, intensive care therapy and American Society of Anesthesiologists (ASA) classification.

RESULTS

Of the patients, one fifth came from a nursing home and were under supervised care or a healthcare proxy at the time of admission. Two thirds were admitted to hospital and operated on during on-call service periods. One half of the patients did not return to their previous domestic environment and were usually admitted to a nursing home. Patients who came from or were admitted to nursing homes, who were under healthcare supervision as well as patients who rapidly underwent surgery had a shorter LOS. Hospitalization and surgery during on-call service periods did not extend the LOS and showed a tendency towards reduction. Older age correlated with a longer LOS and surgical complications doubled the LOS.

DISCUSSION

Surgical treatment during on-call service periods, short preoperative waiting times and avoidance of surgical complications shortened LOS and thus had an impact on costs and bed capacity.

[Emergency radiographs in injured children and adolescents]

BACKGROUND

Adequate interpretation of radiographs of injured children and adolescents is key for appropriate treatment. For the purposes of structuring in-hospital education and training, conventional radiographs obtained in the emergency department (ED) should be analyzed.

MATERIAL AND METHODS

A total of 10,232 radiographs of children and adolescents (0-17 years old) were analyzed retrospectively. Data was analyzed according to sex, age, time, radiograph, and type of insurance.

RESULTS

The male to female ratio was 3:2. In all, 76% of all radiographs were processed during on-call duty hours. Radiographs of the ankle were ordered most at a rate of 11%. Radiographs of the skull, wrist, finger, and ankle stood out from the sum of all radiographs and together accounted for 40%.

CONCLUSION

Radiographs of injured children are analyzed predominantly during on-call duty hours. Frequently mandated radiographs should be diagnosed accurately and standard injuries should be well known. Particular attention should be directed to the typical injury patterns of the ankle joint.

[X‑ray of the thoracic and lumbar spine in injured children and adolescents : Incidence, fracture rates and therapeutic consequences]

INTRODUCTION

Usually, conventional radiographs are appropriate for injuries in the region of the thoracic and lumbar spine (TLS) in children and adolescents. The aim of our study was to determine the incidence of trauma-associated radiographic findings in this anatomical region and to present the therapeutic consequences.

MATERIAL AND METHODS

In a retrospective cohort study (2007-2015) of a level 1 trauma center all children and adolescents (0-17 years) with a TLS-trauma, in which conventional radiographs were performed anteroposterior and lateral as the initial imaging modality, were included.

RESULTS

In 396 children and adolescents conventional radiographs were performed, but only 5.6 % suffered a fracture. Conventional radiographs were performed in 188 cases of the thoracic spine, in 43 cases in the thoracolumbar junction and in 255 cases in the lumbar spine. On average, children and adolescents with fractures were 12.5 (5-17) years old. Fractures were classified as 38.7 % A1.1, 51.6 % A1.2, and 9.7 % were fractures of the transverse process. B and C fractures could not be detected. Of all fractures, 80 % were found in the mid-thoracic spine and the thoracolumbar junction. All fractures could be treated conservatively.

CONCLUSION

With 5.6 % TLS-injuries in children and adolescents, the study revealed a low fracture rate in a highly radiosensitive region. With regard to an expected stable fracture morphology and the absent surgical consequences, the indication for emergency radiographs should be provided restrictively.

[Injuries in children and adolescents in emergency services]

BACKGROUND

A differentiated knowledge of trauma in children and adolescents is essential for the treatment of injured minors. The aim of this study was to present the focus of treatment in trauma emergency services.

MATERIAL AND METHODS

Over a period of 2 years all acutely injured children and adolescents (n = 4784) in the emergency service were analyzed prospectively. The data were analyzed according to sex, age, date of examination, indications for x-ray imaging, diagnosis and therapy.

RESULTS

Seasonal differences in the treatment spectrum were detected. In total 34.4 % of the patients presented with bruises/contusions, 23 % wounds, 19.9 % fractures, 14.9 % sprains/strains/ligament ruptures, 4.1 % craniocerebral trauma, 1.5 % dislocations, 1.1 % muscle/tendon injuries and 0.9 % burns. Of the patients 60 % underwent an x-ray examination and 8.3 % were hospitalized. Different injuries were found in the different age groups. Most fractures (25.7 %) were found at the distal forearm and most osteosyntheses (22.5 %) were also carried out at this anatomical location.

CONCLUSION

Knowledge of the frequency and age dynamics is essential for competent treatment of injuries in children and adolescents. Analysis of the reality of the treatment in emergency services allows a much better evaluation of the requirements with respect to this clientele. The collected data can serve as a basis for the development of major capability foci, training concepts, treatment algorithms as well as prevention measures.

[The posterocentral approach to the posterior tibial plateau]

OBJECTIVE

An anatomically preformed approach to the posterior tibial plateau is described. In avulsion fractures of the posterior cruciate ligament (PCL), the aim is to restore stability of the knee joint with functional treatment, while in posterior shearing tibial plateau fractures the aim is to restore anatomical dorsal alignment of the tibia.

INDICATIONS

Avulsion fracture the PCL, posterior shearing tibial plateau fracture.

CONTRAINDICATIONS

Knee infection, compartment syndrome, joint instability, and osteoarthritis in avulsion fractures of the PCL.

OPERATION TECHNIQUE

Supine position, L-shaped skin incision, dissection of the fascia, protection of the sural nerve, separation of the gastrocnemial heads, identification of the neurovascular bundle, retraction of the gastrocnemial heads. Fixation of the bony avulsion using screws. In tibial plateau fractures, dissection of the soleus and popliteus muscle, fracture reduction, and plate fixation.

POSTOPERATIVE MANAGEMENT

Due to the approach no specific treatment necessary. PCL: functional treatment, with knee brace full weight bearing possible, without 20 kg weight bearing using crutches for 4-6 weeks, tibia: CT for postoperative result and planning of the ventral osteosynthesis after about 5 days, then weight bearing 20 kg and functional treatment for 8-12 weeks.

RESULTS

A total of 33 patients were operated using a posterocentral approach, 22 had a posterior shearing tibial plateau fracture, and 11 an avulsion fracture of the PCL. Temporary hypesthesia around the scar, at the lateral foot, and lateral lower leg were observed in 3 patients, each having one (area supplied by the sural nerve). In 3 cases screw tips at the anterior proximal tibia were palpable. The posterocentral approach reveals a low complication rate due to the anatomical approach.

[The DRG responsible physician in trauma and orthopedic surgery. Surgeon, encoder, and link to medical controlling]

BACKGROUND

Precise coding is an essential requirement in order to generate a valid DRG. The aim of our study was to evaluate the quality of the initial coding of surgical procedures, as well as to introduce our "hybrid model" of a surgical specialist supervising medical coding and a nonphysician for case auditing.

MATERIALS AND METHODS

The department's DRG responsible physician as a surgical specialist has profound knowledge both in surgery and in DRG coding. At a Level 1 hospital, 1000 coded cases of surgical procedures were checked.

RESULTS

In our department, the DRG responsible physician who is both a surgeon and encoder has proven itself for many years. The initial surgical DRG coding had to be corrected by the DRG responsible physician in 42.2% of cases. On average, one hour per working day was necessary.

CONCLUSION

The implementation of a DRG responsible physician is a simple, effective way to connect medical and business expertise without interface problems. Permanent feedback promotes both medical and economic sensitivity for the improvement of coding quality.

[ProFI reduction of pediatric pulled elbow]

BACKGROUND

Pulled elbow is a common injury in children under the age of 5 years which is usually treated by manual reduction. Supination of the forearm is recommended as opposed to pronation or other maneuvers. The author has developed a manipulative intervention for reduction of pulled elbow in young children on the basis of the pronation technique and called ProFI reduction.

PATIENTS AND METHODS

The ProFI method was performed on 41 children and the group was analyzed prospectively according to effectiveness of the ProFI repositioning.

RESULTS

Among the 41 children the initial diagnosis was incorrect in 7 cases (17%) and in 11 children (27%) more than one doctor's visit was necessary to reposition successfully. Repositioning with the ProFI method was immediately successful in all cases.

CONCLUSION

The application of the ProFI method as a modified pronation technique was shown to provide excellent effectiveness with respect to the patients treated.

Delays in diagnosis in early trauma care: evaluation of diagnostic efficiency and circumstances of delay

BACKGROUND

Trauma centers, trauma management concepts, damage control surgery and the integration of whole-body CT scanning into early trauma care have reduced mortality in traumatized patients significantly. However, some injuries are still initially missed. In this study, the diagnostic efficiency of early trauma care and the circumstances of delays in diagnosis were evaluated.

MATERIALS AND METHODS

Initially missed diagnoses in 111 traumatized patients were recorded retrospectively. "Primary diagnoses" after the emergency room (ER) phase including CT scanning with immediate data evaluation were compared to "secondary diagnoses" after a secondary survey of the CT data, as well as to discharge diagnoses. Circumstances of delay were assessed according to injury severity score (ISS), hospital admission, mechanism of injury, diagnostics, treatment, time in the intensive care unit, hospitalization and mortality.

RESULTS

73% of the patients arrived at the ER during on-call hours. In 23% of all patients, diagnoses were missed after the ER phase, while in 12% of the patients diagnoses were missed after the secondary survey of the CT data. One half of the missed diagnoses were almost impossible to detect; the other half were judged to be acceptable. During on-call hours, 9% more patients with delays in diagnosis were observed. Injury severity in patients with delays in diagnosis was significantly higher than in patients without.

CONCLUSIONS

Although diagnostic quality in early trauma care has improved, some diagnoses are initially missed. Severely injured patients with life-threatening or potentially life-threatening injuries arriving at the ER during on-call hours were at higher risk for delays in diagnosis. A secondary evaluation of acquired CT data and repetitive examinations are essential.

[Avulsion fracture of the lesser trochanter]

An avulsion fracture of the lesser trochanter is a very rare injury often misdiagnosed as a muscle lesion or hip distortion. This report concerns the avulsion fracture of the lesser trochanter of a 13-year-old boy, suffered on a runway preparing for a long jump. Conservative treatment without weight-bearing was indicated for 6 weeks. Twelve weeks after the injury the patient resumed his normal sport activities.

[The mature twoplane and triplane fracture. Transitional fractures of the distal tibia combined with typical fracture patterns of adults]

Physiologic closure of the growth plate of the distal tibia occurs between the ages of 12 and 14 years in girls and 1 year later in boys. The closure of the tibial physis starts eccentrically at the ventrolateral zone of the medial malleolus extending dorsally and ends laterally. Therefore, the anterolateral zone is the last to ossify. The process of closure lasts about 18 months. During this period the growth plate loses its joint-protective function and transitional fractures may occur. The more the closure progresses the more lateral the location of the fracture. In addition to the typical transitional fractures, typical fracture patterns of adults in the ossified physis are possible due to a mature bone structure. We report two cases of transitional fractures combined with typical fracture patterns of adults due to a dorsomedial ossified physis in the distal tibia.

[Preclinical prediction of prehospital injury severity by emergency physicians : approach to evaluate validity]

BACKGROUND

The prognosis of polytraumatized patients is basically dependent on the quality of emergency room (ER) management and a smooth transition from prehospital emergency therapy to ER therapy is essential. The accurate prediction of the prehospital injury severity by emergency physicians influences prehospital therapy and level of care of the destination hospital. Furthermore it helps to provide medical resources on time. Overestimation of injury severity wastes resources, underestimation puts patients at risk. Prehospital misjudgement of injury severity is common. The aim of this study was to evaluate reliability of the injury severity estimated by emergency physicians.

MATERIALS AND METHODS

For comparison of the prehospital and hospital injury severity the Injury Severity Score (ISS) and Trauma-ISS (TRISS) were calculated. The TRISS consists of the ISS and the Revised Trauma Score (RTS). All diagnoses of the prehospital and admission charts were collected and an injury severity was allocated according to the Abbreviated Injury Scale (AIS). The concordance of prehospital and hospital injury severity at different ranges and according to different body regions was evaluated. A difference of more than 25% between the prehospital injury severity and the injury severity calculated after ER diagnostics was considered as being relevant and judged as overestimation or underestimation. The documented injury severity in the emergency physician protocol was judged as detailed, satisfactory and poor.

RESULTS

Of the patients 73% reached the ER during on-call hours. The mean ER-ISS was 19 (1-50). At a range of ±25% referring to the ER-ISS, 30% overestimation and 36% underestimation of the prehospital injury severity was observed. A concordance of 34% was found. At a range of ±50% the concordance between the prehospital injury severity and the injury severity calculated after ER diagnostics was 57%, at a range of ±75% the concordance was 73%. The mean ER-TRISS was 6.9 points (0.3-98.6) and the mean ER-RTS was 7.569 points (0-7.841). Using the TRISS with a range of ±25% a concordance of 28% was observed. A high concordance of the prehospital and hospital injury severity was found in the region of the face (70%) and external soft tissue injuries (80%). The concordance in the body region of the abdomen was 55%, of the thorax 40%, of the extremities and pelvis 37% and of the head 33%. Underestimation in the region of the abdomen was 32%, of the head 37%, of the thorax 42% and of the extremities and pelvis 47%. Missed injuries were the reason for underestimation in the body region of extremities and pelvis in half of the cases. Of the patients 61% suffered a traffic accident, 25% a fall of less than 3 m and 8% of more than 3 m. In 5% of the cases other mechanisms of injury were observed. Injury severity was documented in a detailed manner in 61% and satisfactory in 26%.

CONCLUSIONS

The prediction of prehospital injury severity is difficult and less reliable. Relevant underestimation of injury severity was observed in visceral cavities. In order to evaluate injury severity the use of anatomical trauma scores alone might be not sufficient. In addition, the mechanism of injury and the deduced consequences, such as prehospital therapy, the choice of destination hospital and the need of ER treatment should be taken into account.

[The painful os intermetatarseum]

The os intermetatarseum is an uncommon accessory bone of the foot, usually found between the bases of the first and second metatarsal bones. Two cases of a painful os intermetatarseum in athletes are reported. Surgical excision of the os intermetatarseum relieved the pain in both patients. Case reports concerning athletes with a painful os intermetatarseum are rare. An os intermetatarseum should be taken under consideration when evaluating dorsal midfoot pain.

Cryopreservation of platelets at the end of their conventional shelf life leads to severely impaired in vitro function

Storage time for platelet concentrates (PCs) is limited to five days due to 'aging' of the platelets and an increasing risk of bacterial proliferation. Storage time can be prolonged by cryopreservation. We investigated in vitro function of six consecutive PCs at the end of their conventional shelf life followed by cryopreservation for 24 hours. Spontaneous, adenosine diphosphate (ADP)-induced and collagen-induced activation before and after cryopreservation were determined by flow cytometry. Additionally, ADP- and collagen-induced aggregation was measured. After cryopreservation two-thirds of the platelets were spontaneously activated, twice as many as before the procedure (p < 0.001). ADP-induced activation was significantly reduced (p = 0.014). Collagen-induced activation was unchanged. Aggregation stimulated by ADP and collagen was significantly reduced (p = 0.005 and p = 0.009, respectively). Our results show severely impaired in vitro function of platelets after storage at 22 degrees C for five days followed by cryopreservation. Cryopreservation of PCs after a storage time of five days cannot be recommended.

The functional integrity of platelets in volume-reduced platelet concentrates

Premature and low-birth-weight infants usually require small-volume platelet transfusions to treat thrombocytopenia. Also, infants undergoing open-heart surgery with extracorporeal circulation and with compromised cardiac function are at risk for excessive intravascular volume. The small-volume platelet substitution can be achieved by dispensing an aliquot from the unit of a standard single-donor platelet concentrate (PC). Alternatively, there is an indication for volume reduction of PCs to maximize the number of platelets transfused in the smallest possible volume. We determined the spontaneous and induced activation of platelets before and after volume reduction in 20 consecutive single-donor-apheresis PCs. After a mean storage time of 2 days, the PCs were plasma-depleted by centrifugation. Spontaneous, adenosine diphosphate (ADP)-induced, and collagen-induced activation were determined by flow cytometry. Furthermore, ADP- and collagen-induced aggregation were measured. A total of 33.8% of platelets in standard PCs were activated spontaneously. Volume reduction of PCs led to a mild but significant increase of spontaneous activation of platelets (43.2%). Additionally, volume reduction resulted in an impaired ADP-induced aggregability of platelets, whereas collagen induction was unaffected. Transfusion of volume-reduced PCs is an effective alternative to use of standard PCs in patients at frequent risk for excessive intravascular volume, because equal volumes increase the platelet count twice as effectively.

Platelet activity in washed platelet concentrates

Life-threatening anaphylaxis or febrile nonhemolytic transfusion reactions after transfusion of platelet concentrates (PCs) is a serious clinical problem caused by the sensitizing of recipients to plasma components, such as immunoglobulin A, or by cytokines. There is a possible indication for washing of PCs in these thrombocytopenic patients. However, only platelets that show activation after physiological stimulation are useful. We determined the spontaneous and induced activation of platelets before and after washing. We investigated 11 consecutive single-donor-apheresis PCs. After production and leukocyte-depletion the PCs were washed in 15%, acid-citrate-dextrose-solution. The spontaneous and the adenosine diphosphate (ADP)-induced, as well as collagen-induced activation, were determined by flow cytometry. Additionally, ADP- and collagen-induced aggregation were measured. Unwashed platelets (16.1%) were activated spontaneously. The washing of PCs led to a threefold increase of spontaneous activation of platelets (47.4%). Because of increased spontaneous activation after washing we could demonstrate cytometrically a loss of induced activation of washed platelets. Furthermore, washing resulted in an impaired ADP-induced aggregability of platelets. These results have led us to reduce the frequency of washing of PCs in our institution, where the only current indication for washing of PCs is in patients with a history of severe nonhemolytic transfusion reactions.

Pre-operative intercostal nerve blockade for minimally invasive coronary bypass surgery: a standardised anaesthetic regimen for rapid emergence and early extubation

BACKGROUND

Minimally invasive direct coronary artery bypass grafting (MIDCAB) has become a popular adjunct to cardiac bypass surgery in selected patients. Although MIDCAB without cardiopulmonary bypass is considered to be a relatively noninvasive procedure, the trauma to the muscle tissue caused by the anterolateral thoracotomy often leads to more pain than that of patients undergoing routine sternotomy. The purpose of our study was to evaluate the pre-operative application of an intercostal nerve blockade, combined with general anaesthesia for peri- and postoperative pain control, and its efficacy for early extubation.

METHODS AND RESULTS

Nine consecutive patients undergoing MIDCAB surgery were evaluated. Pre-operative ipsilateral intercostal nerve blockade was employed in all patients. After induction, isofluran (0.4-0.8%) and nitrous oxide in combination with the pre-operative nerve blockade provided sufficient anaesthesia throughout the procedure (mean operative time: 147 min). Only 2/9 patients required additional small doses of narcotics. All patients could be safely extubated within 15 minutes of skin suture. Postoperative discomfort and pain were minimal.

CONCLUSION

From our initial experience with preoperative intercostal nerve blockade for the MIDCAB procedure, we concluded that it provides profound somatic analgesia as an effective adjunct to general anaesthesia with reduced doses of narcotics and sedatives. MIDCAB impresses with its ease of technical performance, its reliability and safety. The minimised chest-wall pain improves patients' chances of early tracheal extubation. In accordance with the minimally invasive surgical approach, it provides a contribution towards 'minimally invasive anaesthesia'. The surgeons' and the patients' acceptance is excellent. Because the results of this study are based on observation and verbalisation of the investigators' impressions, and no objective measurements were made which would have allowed a comparison between the MIDCAB technique and the golden standard of general anaesthesia with opioid analgesia, a further study should be conducted to prove our theory.

Bedside exclusion of clinically significant recirculation volume during venovenous ECMO using conventional blood gas analyses

STUDY OBJECTIVE

To investigate prospectively whether blood gas samples drawn from extracorporeal membrane oxygenation (ECMO) cannulae help to exclude at least clinically significant recirculation volumes in patients with acute respiratory failure.

DESIGN

Feasibility study.

SETTING

Intensive care unit at a university-affiliated hospital.

PATIENTS

Ten consecutive adult patients suffering from severe respiratory failure and undergoing ECMO.

INTERVENTIONS

The drawing (venous) ECMO cannula was placed into the inferior vena cava via a femoral vein, and the oxygenated blood was returned via the right subclavian vein by supraclavicular access directly into the right atrium. Blood gas samples were obtained from both cannulae.

MEASUREMENTS AND MAIN RESULTS

The median arterial oxygen tension (PaO(2)) obtained from the arterial cannula was 537 mmHg (range, 366 to 625 mmHg), the median mixed venous oxygen tension (PvO(2)) drawn from the venous cannula was 42 mmHg (range, 25 to 54 mmHg), which was less than 10% of that observed in the arterial cannula, and also within the physiologic range of PvO(2). The ECMO flow necessary to maintain patients' oxygen saturation above 90% (4.1 L/min; range, 1.95 to 5.8 L/min) was significantly lower than the patients' cardiac output (CO; 6.2 L/min; range, 4.1 to 7.9 L/min; p < 0.001). CONSLUSIONS; We recommend obtaining blood gas samples-immediately after initiation of ECMO-from both cannulae. A PvO(2) within physiologic range and below 10% of PaO(2) rules out any clinically relevant recirculation volume.

Survival improvement in patients with glioblastoma multiforme during the last 20 years in a single tertiary-care center

METHODOLOGY

The survival of 357 consecutive patients with newly diagnosed glioblastoma multiforme (GBM) in three treatment groups reflecting different time-periods of diagnosis (A: 1982-1984; B: 1994/1995; C: 1996-1998) was analysed to assess the impact and the potential improvement of changing treatment strategies in our tertiary-care center.

PATIENTS AND METHODS

Group A (n = 100) included all consecutive patients diagnosed from 1982 to 1984 and served as the historical control. Group B (n = 93) included all consecutive patients diagnosed in 1994/1995 and group C (n = 164) those diagnosed from 1996 to 1998. Survival in the three treatment groups (A vs. B vs. C) was analysed according to treatment given after neurosurgical intervention (i.e. no specific therapy versus radiotherapy versus combined radio-/chemotherapy), and according to first-line chemotherapy, age (< 40, 40-60, > 60), sex, and tumor location (hemispheric versus bilateral or multifocal tumors, and tumors involving eloquent brain areas). Survival was analysed using Kaplan-Meier's non-parametric method. A p-value < 0.05 was considered statistically significant.

RESULTS

Patients in groups A and B received radio- and/or chemotherapy to a varying extent (radiotherapy: group A: 22%, group B: 62%; chemotherapy: group A: 6%, group B: 33%). Chemotherapy was administered after termination of radiotherapy in both groups. In group C, 96% of patients received combined radio-/chemotherapy which was administered concomitantly and started within three weeks after surgery. Median survival was 5.2 months in group A, 5.1 months in group B and 14.5 months in C (p < 0.0001). Nine patients in group A (9%), 9 in group B (10%) and 40 in group C (25%) survived more than 18 months (p < 0.05).

CONCLUSIONS

Survival improvement in group C might be attributable to the early start of combined radio-/chemotherapy. Therapy was administered on a complete outpatient basis, enabled by a dedicated interdisciplinary neuro-oncologic team caring for group C. Toxicity was mild and patients' acceptance excellent.

Central venous catheter pinch-off and fracture: recognition, prevention and management

The so-called pinch-off syndrome is observed in up to 1% of all central venous catheters (CVCs), and is a valuable warning prior to fragmentation, which occurs in approximately 40% of the respective cases. As long-term indwelling CVCs are used with increasing frequency, this paper describes the necessity of pinch-off monitoring following the experiences of a case study and a review of the current literature on this specific topic in order to point out preventive practice guidelines. Besides easy preventive practices such as a high level of suspicion and adequate X-ray controls, findings give strong evidence that the most important specific factor might be the adequate approach. In our hands, the supraclavicular technique has provided the best results with regards to percutaneous introduction of large bore CVCs.

Unexpected out-of-hospital deaths in persons aged 85 years or older: an autopsy study of 1886 patients

PURPOSE

The aim of this study was to determine the causes of death in the very elderly.

METHODS

We reviewed 24,081 consecutive autopsies performed over 10 years (1989 to 1998) at the Institute of Forensic Medicine, Vienna, Austria. We focused on autopsies of people aged 85 years or older who died unexpectedly out of hospital.

RESULTS

The mean age of the 1886 patients (561 men and 1325 women) at the time of death was 88 +/- 3 years (range, 85 to 108 years). Thirty-one percent (n = 588) of those who died were described as having been previously healthy. Cardiovascular disease was the most common cause of death (n = 1465 [77%]). Thirteen percent (n = 246) died of respiratory illness, 5% (n = 94) of gastrointestinal disorders, and 3% (n = 53) of diseases of the central nervous system. Genitourinary and metabolic diseases were uncommon.

CONCLUSION

Although this out-of-hospital sample is not representative of the entire elderly population, postmortem examinations emphasize the importance of cardiovascular diseases in causing unexpected deaths in older persons.

Feasibility and toxicity of CCNU therapy in elderly patients with glioblastoma multiforme

In our institution, 103 glioblastoma multiforme (GBM) patients aged from 55 to 83 years were treated since November 1994 as follows. All patients underwent surgical intervention (gross total resection, n = 35; subtotal resection, n = 38; stereotactic biopsy, n = 30). Subsequently all patients were offered radiotherapy and chemotherapy with CCNU. Results were as follows: 101 patients started radiotherapy, 93 patients completed it (96% of the patients aged < 65 years and 85% of the patients > or =65 years). All patients received at least 1 cycle of chemotherapy (median 3 cycles). Chemotherapy-associated toxicity was generally mild, more pronounced in females and did not increase with age. Median time to progression was 10.5+/-3.2 months for the patients < 65 years and 5.1+/-1 months for patients > or =65 years. median overall survival was 17.5+/-3.8 months in patients < 65 years and 8.6+/-1 months in patients > or =65 years (p < 0.0001). In multivariate analysis, age and female sex remained independent prognostic factors. Our data indicate that a treatment concept including concomitant radio- and chemotherapy is feasible even in elderly patients with GBM.

Emergency percutaneous retrieval of a silicone port catheter fragment in pinch-off syndrome by means of an Amplatz gooseneck snare

Rupture of a silicone Port-a-Cath catheter may occur, especially with costoclavicular pinch-off syndrome (POS), which is a typical consequence of fatigue when the catheter is introduced in the subclavian vein too medially. This case report describes the percutaneous retrieval of a fractured silicone port catheter fragment, which had migrated into the internal jugular vein. Extraction was complicated by the presence of an internal jugular vein stenosis and the fact that the catheter fragment was looped upon itself. Several retrieval devices failed before an Amplatz gooseneck snare finally allowed retrieval of the fragment. We recommend this device for extraction of silicone port catheter fragments. Rerupture of the port catheter occurred 7 months after surgical reinsertion at the same infraclavicular site, as a consequence of constant compression by POS. Alternative approaches should be used after catheter failure due to POS.

Carotid resection and reconstruction for locally advanced head and neck tumors

Head and neck surgeons hesitate to resect the carotid artery because of the postoperative risk of neurologic sequelae. However, there is no curative therapeutic option for head and neck neoplasms involving the carotid artery, with the exception of complete tumor removal. To evaluate the benefits and risks of carotid revascularization techniques in locally advanced head and neck tumors we performed a retrospective analysis in an institutional, tertiary care medical center. Seven patients (5 males, 2 females) with a median age of 58 years underwent en bloc removal of locally advanced head and neck tumors, including carotid resection and revascularization, in the University of Vienna General Hospital, over a 15-year period. In six patients carotid reconstruction was accomplished by bypass grafting (five autologous grafts, one synthetic graft) and in one patient angiopatchplasty was used. There were no perioperative neurologic complications or deaths. Survival was > 12 months in 5/7 patients; the other 2 patients died within 6 months due to untractable progression of cancer. We conclude that carotid revascularization techniques offer the possibility of better local control for advanced head and neck tumors without additional risks of neuromorbidity or mortality.

Alterations in intestinal permeability following the intensified polydrug-chemotherapy IFADIC (ifosfamide, Adriamycin, dacarbazine)

PURPOSE

The aim of this study was to investigate the severity and time-course of alterations in gastroduodenal and intestinal permeability in relation to nausea/emesis following administration of the highly emetogenic polydrug regimen IFADIC (ifosfamide, Adriamycin, dacarbazine) using a differential lactulose/mannitol absorption (SLM) test. We also assessed the ease of administration and patients' tolerance of the SLM test.

METHODS

The SLM test was performed in seven patients with soft tissue sarcomas on days 1, 3 and 14 of cycle I and cycle III of chemotherapy; seven healthy volunteers served as controls. The degree of correlation between the clinical grade of nausea/emesis according to WHO criteria and gastroduodenal permeability, expressed in terms of urinary sucrose excretion, and intestinal permeability, expressed in terms of the permeability index (urinary lactulose to mannitol permeability ratio), was also assessed.

RESULTS

The permeability index values were significantly different (P < or =0.01) on days 1, 3 and 14 during both cycles of chemotherapy. The median permeability index on day 3 was higher (P < =0.01) in patients with nausea/emesis than in those without symptoms. Additionally, the permeability index when nausea was present (day 3) was higher (P < or =0.01) than when nausea/emesis was absent (days 1 and 14). In 59% of patients the increased permeability index on day 3 was accompanied by nausea/emesis of WHO grade 3. Gastroduodenal permeability did not alter consistently following chemotherapy.

CONCLUSIONS

Our study confirms an acute, transient increase in intestinal permeability following the polydrug regimen IFADIC, accompanied by nausea/emesis of WHO grade 3 in the majority of patients. Normal intestinal permeability was achieved on day 14 in all patients, thus allowing intensified 2-weekly treatment administration. The SLM test may be recommended as a feasible test for the objective assessment of alterations in intestinal permeability following chemotherapy administration.

Unilateral chronic thromboembolic pulmonary disease associated with combined inherited thrombophilia

Chronic thromboembolic pulmonary hypertension (CTEPH) is considered to be an extreme variant of pulmonary thromboembolism. The underlying mechanisms for the failure of thrombus resolution are still unclear. In looking for inherited thrombophilia, an association with a lupus anticoagulant has been described repeatedly, and single cases of anticoagulant deficiencies (ie, antithrombin [AT], protein C, and protein S) have been reported. We describe a young patient with type I AT deficiency, the heterozygous prothrombin G20210A mutation, and unilateral chronic thromboembolic pulmonary disease presenting after a single thrombotic event. Pulmonary vascular patency was restored successfully by surgical pulmonary thromboendarterectomy. This case is unique because unilateral CTEPH is extremely uncommon, and it illustrates the severe clinical sequelae of the cosegregation of inherited thrombophilic defects.

Expanding our interventional skills: placement of totally implantable injection ports by internists/intensivists

Totally implantable injection ports are usually placed by surgeons or radiologists using fluoroscopic guidance. In a prospective study we evaluated the efficacy of percutaneous insertion of these devices without the use of fluoroscopic control by internists/intensivists experienced in the placement of permanent cuffed catheters. The supraclavicular approach to the subclavian vein was chosen for first line puncture site because of its low rate of malpositions and complications. 101 ports were inserted in 101 consecutive patients, 96 from the supraclavicular approach. Difficulties in introducing the catheter through the peel-away sheath, misplacement into adjacent vessels, secondary migration, or fragmentation of a line were not observed. Function was excellent in all ports. Three pneumothoraces (3%) and three arterial punctures (3%), none of which required intervention, were recorded. Two ports (2%) had to be revised, one due to local hematoma and another because of inadequate catheter length. Catheter survival was 94% in a 30-month observation period. Placement of totally implantable port systems by internists/intensivists experienced in placing central venous lines is safe and efficient, thus the implantation can easily be performed with minimal technical expenditure in the setting of an intensive care unit. The supraclavicular approach is suitable for insertion of permanent infusion port systems without fluoroscopic control.

Barriers in cancer pain management

Inadequate pain management of cancer patients remains a striking problem despite impressive scientific progress in the knowledge of the pathophysiology, pathogenesis and therapy of pain. Our paper focuses on three topics: 1. physician-related barriers, 2. patient-related barriers, and 3. society- and tradition-related barriers as well as government regulations. It is imperative to overcome these barriers, especially since legal regulations for pain management were embodied into statutory regulations in Austria two years ago.

Inadvertent transpericardial insertion of a central venous line with cardiac tamponade failure of preventive practices

A 56-year-old man who had undergone cardiac surgery suffered from cardiac tamponade after administration of contrast-medium through a central venous catheter. Pericardiotomy showed the catheter transversing the pericardial sac just beneath an unusual high reflection and then reentering the superior vena cava. Preventive practices including chest radiography, confirming free venous blood return and manometry may fail to detect catheter malposition in rare cases. Knowledge of potential pitfalls in using generally recommended safety practices and continuous vigilance are essential for the anesthesiologist and intensivist in avoiding potentially lethal hazards.

Prostaglandin E(1) does not influence plasmatic coagulation, hepatic synthesis, or postoperative blood loss in patients after coronary-artery bypass grafting

STUDY OBJECTIVE

To assess whether postoperatively administered prostaglandin E1 (PGE1) might prevent bleeding in patients after coronary artery bypass grafting (CABG).

DESIGN

Prospective, randomized, placebo-controlled trial.

SETTING

University-affiliated hospital.

PATIENTS

49 patients scheduled for elective CABG surgery.

INTERVENTIONS

The PGE1 group received intravenous PGE(1) up to 15 ng/kg/min for 72 hours after surgery, whereas the placebo group received isotonic saline for the same time period.

MEASUREMENTS AND MAIN RESULTS

Nine patients (4 in the PGE1 group vs. 5 in the placebo group) had to be excluded because of hemodynamic instability, and 1 in the placebo group because of gastric bleeding. In the remaining 39 patients (20 vs. 19), no significant differences with regard to hemoglobin levels or platelet count could be observed. There was no significant difference between the groups concerning the amount of packed red blood cells, platelet concentrates, or fresh frozen plasma transfused. No significant differences could be observed regarding laboratory markers of coagulation activation or hepatic synthesis either.

CONCLUSIONS

PGE1 did not prevent coagulation disturbances and blood loss when administered postoperatively in patients undergoing CABG. The absence of these expected effects might be explained by the concomitant administration of acetylsalicylic acid, whose antiaggregatory acivity seems to exceed the effects of PGE1.

[Pain management in view of current new legislative updates and their practical consequences in Austria]

Although the WHO edited guidelines for pain treatment as early as 1986, practical management has frequently remained inadequate, especially in cancer patients. Traditional adherence to restrictions from the former Austrian Controlled Drug Act which have resulted in ongoing limitations in the prescription of opioids as well as complicated formal regulations in the current law represent two major obstacles. As a consequence, recent legislation of a "state of the art" pain management in Austria facilitates adequate provision of analgesics on the one hand, and may, on the other, even result in claims for indemnity should these be withhold.

Safe and efficient emergency transvenous ventricular pacing via the right supraclavicular route

Infraclavicular and internal jugular central venous access are techniques commonly used for temporary transvenous pacing. However, the procedure still has a considerable complication rate, with a high risk/benefit ratio because of insertion difficulties and pacemaker malfunction. To enlarge the spectrum of alternative access sites, we prospectively evaluated the right supraclavicular route to the subclavian/innominate vein for emergency ventricular pacing with a transvenous flow-directed pacemaker as a bedside procedure. For 19 mo, 17 consecutive patients with symptomatic bradycardia, cardiac arrest, or torsade de pointes requiring immediate bedside transvenous pacing were enrolled in the study. The success rate, insertional complications, pacemaker performance, and patients' outcomes were recorded. Supraclavicular venipuncture was successful in all patients, in 16 of 17 at the first attempt. Adequate ventricular pacing was achieved within 1 to 5 min (median, 2 min) after venipuncture and within 10 s to 4 min (median, 30 s) after lead insertion (</=30 s in 15 of 17 patients). The median pacing threshold was 1 mA (range, 0.7 to 2.5 mA). No procedure-related complications were recorded. Throughout the pacing period of 1538 h (median: 62 h, range, 1-280 h) two reversible malfunctions caused by inadvertent lead dislodgement after 122 and 171 h were recorded; in one patient the pacemaker had to be removed because of local infection after 14 days of pacing. We conclude that the right supraclavicular route is an easy, safe, and effective first approach for transvenous ventricular pacing and might provide a useful alternative to traditional puncture sites, even in a preclinical setting.

IMPLICATIONS

Temporary transvenous cardiac pacing can yield high complication rates especially under emergency conditions. We investigated emergency pacing via the right supraclavicular access in 17 consecutive hemodynamically compromised patients and found good safety, efficacy, and a low complication rate.

[Glomus caroticum chemodectoma. Review on current diagnosis and therapy]

Carotid body tumors are rare neoplasms arising from the small chemoreceptor organ in the adventitia of the common carotid bifurcation. Patients with carotid body tumours usually present with a gradually enlarging non-tender anterolateral neck mass. Differential diagnosis includes metastatic lymph nodes, carotid artery aneurysm, salivary gland tumour, branchial cleft cyst, and neurogenic or thyroid tumours. When such a lesion is suspected, a non-invasive Doppler colour flow ultrasonography enables the clinician to arrive at a definite diagnosis. Subsequent arteriography is mandatory, because the finding of an intensely blushing hypervascular mass spreading into the carotid bifurcation further supports the diagnosis and provides accurate preoperative information concerning arterial blood supply. Computed tomography scanning is appropriate to delineate the relation of the tumour to adherent structures, while magnetic resonance tomography demonstrates the relation of the tumour to the adjacent internal jugular vein and the carotid artery. Selective embolization should be performed for safe surgical removal with less bleeding. Early surgery is the treatment of choice and is recommended in order to minimize major risks. Subadventitial resection is the most established technique. Radical resection prevents local recurrence and has the best long-term results. Removal of the internal or common carotid arteries can become mandatory in selected cases of extensive disease. Surgical treatment by an experienced team is associated with considerably low mortality and morbidity.

Pulmonary artery thromboendarterectomy: a comparison of two different postoperative treatment strategies

Pulmonary artery thromboendarterectomy (PTE) is a potentially curative surgical procedure for chronic thromboembolic pulmonary hypertension. It is, nevertheless, associated with considerable mortality caused by postoperative complications, such as reperfusion pulmonary edema (RPE) (i.e., pulmonary infiltrates in regions distal to vessels subjected to endarterectomy) and right heart failure (RHF). However, there are no reports about the influence of different postoperative treatment strategies on complications and mortality. Therefore, we compared two different treatment strategies. In Group I (n = 33), positive inotropic catecholamines and vasodilators were avoided during termination of cardiopulmonary bypass (CPB) and thereafter, and mechanical ventilation was performed with low tidal volumes < 8 mL/kg, duration of inspiration:duration of expiration = 3:1, and peak inspiratory pressures < 18 cm H(2)O. In Group II (n = 14), positive inotropic catecholamines and vasodilators were regularly used for termination of CPB and thereafter, and ventilation was performed with high tidal volumes (10-15 mL/kg) and peak inspiratory pressures up to 50 cm H(2)O. Hemodynamics, the incidence of RPE and RHF, duration of ventilation, morbidity, and mortality were recorded. Cardiac index was comparable before surgery (2.11 +/- 0.09 vs 2.08 +/- 0.09 L. min(-1). m(-2)) and 20 min after CPB (2.26 +/- 0.09 vs 2.60 +/- 0.20 L. min(-1). m(-2)). RPE occurred in 6.1% (Group I) versus 14.3% (Group II), and RHF was observed in 9.1% (Group I) versus 21.4% (Group II). Mortality was 9.1% (Group I) versus 21.4% (Group II). Thus, the avoidance of positive inotropic catecholamines and vasodilators in combination with nonaggressive mechanical ventilation after PTE was associated with a low incidence of RPE, RHF, duration of ventilation, and mortality after PTE.

IMPLICATIONS

The avoidance of positive inotropic catecholamines and vasodilators in combination with nonaggressive mechanical ventilation was associated with a low incidence of reperfusion pulmonary edema and/or right heart failure after pulmonary artery thromboendarterectomy.

[Informed consent and responsibility for patient education in oncology. Review of Austrian and German jurisprudence]

Informed consent is currently an ethical, medical and legal requirement. Increasing public discussion concerning real or supposed malpractice has caused patients to adopt a critical attitude and has caused courts to increasingly demand informed consent for patients. Unfortunately, the legal requirements for informed consent have developed from atypical situations involving dissatisfied and injured patients rather than from the more common occurrence of physicians helping patients and having satisfied patients. In addition, the law has failed to establish explicit guidelines for physicians. We review the elements of informed consent based on current Austrian and German jurisdiction in the particular field of oncology and summarise the legal and medical realities with the aim of delineating specific criteria for decision making.

Reversible sensorineural hearing impairment induced by a carotid body tumor

A case of a 62-year-old Austrian man having a 25-year history of a right-sided carotid body tumor (CBT) is presented. Three months before being transferred to the University of Vienna for tumor resection the patient developed symptoms of tinnitus, progressive ipsilateral hearing loss and dysphagia. Pure-tone audiometry demonstrated a 50 dB right sensorineural hearing loss. A 6 x 6 x 4 cm firm, pulsatile mass was found in the right carotid triangle and extending towards the base of the skull. One week after radical tumor resection all preoperative symptoms disappeared and hearing of the right ear recovered. Review of the available literature showed that hearing loss and tinnitus are unusual symptoms of a CBT. Our findings suggest that routine audiometric evaluations in such cases of CBT patients should be obtained in order to determine the real incidence of audiological disorders.

Foreign body asphyxiation--an autopsy study

PURPOSE

Food asphyxiation is a common problem whenever and wherever people eat. A knowledge of predisposing factors might help to prevent this problem.

SUBJECTS AND METHODS

We reviewed 34,476 consecutive autopsies done during a 14-year period (1984 to 1997) at the Institute of Forensic Medicine, Vienna. Demographic features and predisposing factors were determined for the 191 cases of fatal foreign body asphyxiation.

RESULTS

Old age, poor dentition, and alcohol consumption were frequent findings. Other risk factors included chronic disease, sedation, and eating risky foods. On 120 (63%) of the 191 occasions, observers were present at the time of the incident and subsequently called the Emergency Service. In 110 (92%) cases, neither the observers nor the majority of the emergency medical technicians and physicians who would have been able to intervene recognized the definite diagnosis. Only 10 cases were correctly identified during cardiopulmonary resuscitation.

CONCLUSIONS

These fatal accidents could be prevented easily. Effective prevention depends on understanding the nature and frequency of accidental deaths due to asphyxiation and the factors that lead to their occurrence and having a high degree of suspicion.

Routine fluoroscopic guidance is not required for placement of Hickman catheters via the supraclavicular route

The purpose of this study was to evaluate the efficacy and safety in placement of Hickman catheters via the supraclavicular route without fluoroscopic guidance. We studied 81 consecutive percutaneous placements of dual lumen Hickman catheters via the supraclavicular route without the use of fluoroscopic guidance. Success rates, technical problems, complications, infections and reasons for explantation were recorded prospectively. Seventy-nine punctures were successful (97.5%). One pneumothorax (1.2%) and three accidental arterial punctures (3.7%) occurred. Difficulties in introducing the catheter through the peel away sheath or misplacement were not observed. The catheters remained in place for a total of 7657 days (mean 94.5, range 3-392 days). Sixteen blood cultures were positive (2.1/1000 catheter days). Five catheters (6.1%) were lost because of mechanical complications. Forty-two lines (52%) were removed electively, 23 (28.4%) because of suspected infection, and two (2.5%) because of tunnel infection. Nine patients died with a functioning catheter. We conclude that the supraclavicular approach to the subclavian vein is safe and efficient for introduction of Hickman catheters. Using this access, routine fluoroscopic or sonographic guidance is not required for proper placement. Implantation of the lines in an intensive care unit did not lead to higher infection rates than those reported in the literature.

[Risk and procedure education in anesthesiology. Overview of Austrian and German legal regulations]

Informed consent is currently an ethical, medical and legal requirement. An increase in public discussion of real or supposed malpractice has led to critical attitude in patients and increased demands on informed consent by the courts. Unfortunately, the legal requirements of informed consent have developed from atypical situations involving dissatisfied and injured patients rather than from the more usual occurrences of physicians helping patients with subsequent patient satisfaction. In addition, laws have not set forth clear guidelines for physicians to follow. We review the elements of informed consent based on current Austrian and German jurisdiction in the particular field of anesthesiology and summarize the legal and medical realities in order to point out specific criteria for decision making.

Supraclavicular approach to the subclavian/innominate vein for large-bore central venous catheters

Infraclavicular and internal jugular catheterization are commonly used techniques for hemodialysis access, but may at times be impeded in patients whose anatomy makes cannulation difficult. In an effort to enlarge the spectrum of alternative access sites, we evaluated the supraclavicular approach for large-bore catheters. During an 18-month period we prospectively collected data on success rate and major and minor complications of the supraclavicular access for conventional dialysis catheters as well as Dacron-cuffed tunneled devices in 175 adult patients admitted for various extracorporeal therapies and bone marrow transplantation. Two hundred eight large-bore catheters (99 conventional dialysis catheters, 63 semirigid tunneled Dacron-cuffed catheters, and 46 Hickman catheters) were successfully placed in 164 patients (success rate, 93.8%), 58 (33.1%) of whom had been previously catheterized. Complications included pneumothorax (one patient), arterial puncture (seven patients), and puncture of the thoracic duct (two patients) without sequelae. Postinsertional chest radiographs demonstrated impressive coaxial lie of most catheters. Catheter malpositions occurred only sporadically (1%). Difficulty of introducing the catheter via a placed sheath was rarely observed. There was no clinically significant evidence of catheter-induced venous thrombosis or stenosis. We conclude that the supraclavicular route is an easy and safe first approach for large-bore catheters, as well as a useful alternative to traditional puncture sites for precatheterized and anatomically problematic patients.