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Die Optimierung der Ablaufe im Operationssaal (OP) ist eine Aufgabe, die samtliche beteiligten Berufsgruppen einbinden muss. Durch fruhzeitige Vorplanung, eine Feinplanung mit hoher Planungstiefe, ein gestaffeltes Schleusen am Morgen, kurze Wechselzeiten, Pufferzeiten am Ende des Tages und klare Entscheidungshierarchien lassen sich durch organisatorische Voraussetzungen viele kritische Punkte entscharfen. Elementar fur kurze Wechselzeiten ist die Parallelisierung von Ablaufen. Nur so kann die Vielzahl der notwendigen Prozesse innerhalb eines kurzen Zeitfensters ablaufen. Dabei sollten Prozesse und Zustandigkeiten schriftlich definiert werden. Neben der QM-Dokumentation hat sich das OP-Statut als zentrales Dokument in vielen Kliniken bewahrt. Die kontinuierliche Messung der Leistungszahlen, im operativen als auch im anasthesiologischen Bereich, sind Grundvoraussetzung, einen kontinuierlichen Verbesserungsprozess aufrecht zu erhalten.

Nosocomial pneumonia continues to represent a significant cause of morbidity and mortality in hospitalized patients. Bacteria are responsible for greater than 90% of the pneumonias, the most common isolates being aerobic Gram-negative bacilli and S. aureus. Cornerstones of treatment are intravenous antibiotics and supportive care. In the individual case the true etiology is usually unknown; therefore empiric broad spectrum treatment is commonly used based on the prevalence of local pathogens, their antibiotic sensitivity pattern and on host factors. Combination antibiotic regimens, including beta-lactams and aminoglycosides, are considered as standard therapy and are associated with clinical success rates of greater than 80%. Monotherapy with broad spectrum antibiotics, such as third generation cephalosporins, imipenem and fluoroquinolones, can be considered as equally effective in non-neutropenic patients and in the absence of P. aeruginosa infection. More active and less toxic antibiotics are still needed for problematic pathogens such as methicillin-resistant S. aureus strains, multiresistant Enterobacteriaceae and Pseudomonas species. Because further improvement in morbidity and mortality may be limited with antibiotics alone, new emphasis should be placed on prevention of infection and the use of immunotherapy.

It is mandatory to include all professions involved in the operating room (OR) in any attempt to improve the process. Early and detailed planning, short interruptions to change OR patients and a variable end of the day combined with transparent decision hierarchies help to ensure that things run smoothly. Parallel processes are essential for accelerating the change of patients. The different duties and responsibilities have to be documented. This can be done either in the records of quality management or in a special OR statutes. The evaluation and analysis of process critical parameters, including surgery as well as anesthesiology, are essential for maintaining the continuous process of improvement.

Although impairment of splanchnic perfusion may induce mucosal hypoxia and endotoxaemia during orthotopic liver transplantation (OLT), little is known about the changes in mucosal oxygenation during and after the procedure. To study the effects of liver surgery itself on mucosal pH (pHi) and the response of pHi to acute changes in portal flow, we measured gastric pHi during six liver resections using tonometry: in two patients, after clamping of the hepatoduodenal ligament, pHi decreased within 30 min and recovered promptly after reperfusion. We then investigated gastric and sigmoid pHi (pHig, pHis) during the perioperative phase in 18 OLT. Median pHi values were low before surgery (pHig 7.28 (first/third quartiles 7.22/7.34); pHis 7.27 (7.12/7.36)). Although global oxygen delivery and haemodynamic variables remained constant and veno-venous bypass (VVB) was used to maintain portal flow, pHi declined during the anhepatic phase (pHig 7.19 (7.13/7.23), P0.01; pHis 7.13 (7.06/7.24), P0.05). After reperfusion of the graft, pHi recovered and did not differ from baseline values by the end of OLT. After operation pHig increased further, reaching the highest values 30 h after ICU admission (7.34 (7.26/7.38)). In the intraoperative period, no significant endotoxaemia was observed either in portal or systemic blood. The maximum reduction in pHi was related neither to the duration of VVB and OLT nor to the number of red cell units transfused. pHi after reperfusion did not correlate with graft viability or dysfunction of the lung or kidney. We conclude that pHi indicates mucosal ischaemia during OLT which is not necessarily associated with endotoxaemia, and intraoperative pHi monitoring does not appear to be a valuable predictor of postoperative graft failure and organ dysfunction.

Dextran-60 is widely used as a colloid volume substitute and for thromboprophylaxis. In order to avoid the most dangerous complication associated with dextran, the dextran-induced anaphylactic/anaphylactoid reaction (DIAR), hapten dextran is infused before starting the first application of dextran. We report of a 60-year-old man with multiple trauma, who received a dextran infusion for thromboprophylaxis because of high risk for thrombosis due to a severe thrombocytosis developing in the late postoperative period. Despite prophylaxis with monovalent hapten dextran, an anaphylactic reaction occurred. Although a serum sample drawn prior to the reaction is lacking, the causal relationship to dextran can be classified as likely, due to the close time relationship to the dextran-60 infusion. In addition, there were high titers of dextran-reactive antibodies in the blood drawn immediately after the reaction occurred. It is concluded that even after correct application of monovalent hapten dextran, dextran infusions carry the risk of severe anaphylactic reactions. They should therefore only be administered if clinical observation of the patient and the possibility of resuscitation are guaranteed.

Leitungsanasthesien werden im Rahmen operativer Eingriffe, zur Diagnostik und zur Therapie des akuten und des chronischen Schmerzes durchgefuhrt.

Charakteristische hamodynamische Befunde bei Sepsis sind der verminderte periphere Gefaswiderstand, ein hohes Herzzeitvolumen und meist ein erhohter Widerstand in der pulmonalen Strombahn [31, 79]. Die Tatsache, das nach Volumenzufuhr Herzzeitvolumen und Schlagvolumen bei den meisten Patienten im septischen Schock normal oder sogar gegenuber der Norm erhoht sind, hat dazu gefuhrt, das oft die Einschrankung der myokardialen Pumpfunktion unterschatzt oder als ein Spatsymptom der hypodynamen Schockform angesehen wird. Ein erhohtes Herzzeitvolumen allein bedeutet aber bei extrem erniedrigtem peripherem Gefaswiderstand noch nicht, das auch die Myokardfunktion normal oder dieses Herzzeitvolumen den Bedurfnissen des Organismus adaquat ist [59].

Serious injuries of the larynx or trachea during tracheal intubation are rare but potentially life-threatening complications. This case report describes the diagnostic procedures and therapeutic management of an intubation-induced tracheal rupture in a young female patient with a musculoskeletal disorder (rigid spine syndrome). Interdisciplinary treatment requires precise documentation of the extent of the injuries, including advanced imaging techniques. Removal of the endotracheal tube prior to accurate diagnosis can result in immediate airway obstruction. Because of the risk of infection, as a rule surgical treatment is indicated.

Patienten, die thorakotomiert werden, haben oft eine Reihe von Vorerkrankungen des kardiopulmonalen Systems, das wiederum durch den chirurgischen Eingriff zusatzlich beeintrachtigt wird.

Ein modernes Sedierungsschema soil ein breites Repertoire an Forderungen idealerweise erfullen. Amnesie, Analgesie, Anxiolyse, psychomotorische Ruhigstellung, Schutz for vegetativen Entgleisungen, keine Beeintrachtigung von Organfunktionen, kurze Halbwertszeit, keine Kumulation, keine Interaktion mit anderen Pharmaka und Erhaltung der Kooperationsfahigkeit gehoren zu den am haufigsten geauserten Anspruchen an die Sedierung eines Intensivpatienten. Die Untersuchungen zur Sedierung langzeitbeatmeter Patienten in den letzten Jahren haben sich v. a. mit Benzodiazepinen in Kombination mit Opioiden befast (Behne et al. 1987; Cohen 1987; Hopkinson u. O’Dea 1987; Oldenhof et al. 1988; Park et al. 1987). Die Ergebnisse dieser Untersuchungen haben gezeigt, das die Benzodiazepine sehr gut fur die Langzeitsedierung geeignet sind. Allerdings erfullen sie keineswegs alle oben genannten Forderungen. Dies betrifft vor alien Dingen die Halbwertszeit, so das die Gefahr der Kumulation ohne begleitende Messung der Substratspiegel wahrend Langzeitanwendung sehr gros ist. Allerdings ist die Aussage des Substratspiegels nur bedingt von klinischer Relevanz, da klinische Wirkung und Hohe des Substratspiegels nicht korrelieren mussen (Oldenhof et al. 1988). UInteraktionen mit anderen Pharmaka ist ebenfalls nur wenig bekannt (Clarke 1981). Eine weitere nicht geloste Frage betrifft die immunsuppressive Potenz dieser Pharmakongruppe unter den Bedingungen der Langzeitanwendung an kritisch kranken Patienten (Crozier et al. 1987; Descotes 1988; Kress u. Segmuller 1987; Moudgil 1981; Pasini et al. 1987). Vor alien Dingen aber ist die Erhaltung der Kooperationsfahigkeit des Patienten auch unter den Bedingungen der Langzeitbeatmung ein ungelostes Problem. Insbesondere ist die kurzfristige Beurteilung der Neurologie solcher Patienten unter den bisher bekannten Sedierungsschemata nicht gewahrleistet.

Infection has remained a significant cause of morbidity and mortality in critically ill patients despite the discovery of potent antimicrobials and sophisticated supportive treatment measures. Infections in general ICU occur at rates of 15–20 per 100 patient admissions, thereby exceeding the average rates in general wards by approximately 3–4 fold [1,2]. Intubated patients are a subset of patients who exhibit an extraordinary high risk of developing respiratory infections [3]. Rates of pneumonia in intubated patients receiving mechanical ventilation are increased about 10 fold compared to patients with no respiratory device so that the majority of the pneumonias in the ICU occur in patients who are receiving or have had ventilatory support [3, 4]. Patients with nosocomial infections show prolonged hospitalization and increased risk of death as compared to their matched controls [5, 6]. Bacteremias and pneumonias are not only the predominant infections in ICU patients, but are also associated with the highest mortality rate [7]. Crude mortality rates for pneumonias have been reported to be in the range of 30 to 50% [3, 7]. However the mortality attributable to infection is difficult to assess and varies considerably between various groups. Patients with advanced underlying diseases or multiorgan failure run a very high risk of developing life-threatening infection and are also very likely to die in consequence of infection. Nevertheless, infection may contribute little to the overall mortality in these patients since their risk of dying is very high anyway. On the other hand, patients who do not suffer from serious underlying disease can be expected to have a relatively low infection risk and also a low mortality rate, but severe infection in these patients may largely influence the outcome [7].

In an open prospective study the efficacy and tolerance of imipenem/cilastatin was investigated in 24 critically ill patients on mechanical ventilation with nosocomial respiratory tract infection. Nine patients had previously received antibiotic therapy, eight of them with various other beta-lactam antibiotics which had failed. Imipenem was given in a dose of 1-3 g/24 h over 5-37 (mean 11) days. Seven patients were additionally treated with aminoglycosides, one patient with erythromycin. Pseudomonas aeruginosa (n = 14), Staphylococcus aureus (n = 4), Haemophilus influenzae (n = 4) and Escherichia coli (n = 3) were the potential pathogens most frequently isolated from tracheo-bronchial secretions. All of the isolates were susceptible to imipenem. 91% of the infections without and 77% with involvement of P. aeruginosa were successfully treated. Two patients who had not responded to previous treatment succumbed to the consequences of progressive respiratory distress syndrome. All of the gram-positive and 85% of the gram-negative pathogens (Pseudomonas not included) were eliminated in the course of therapy. By contrast, 64% of the isolates of P. aeruginosa persisted; half of these became imipenem-resistant. Nine patients showed adverse reactions including one case of pseudomembranous colitis or laboratory abnormalities which were all reversible. Imipenem/cilastatin proved highly effective and was relatively well tolerated; it is suitable as a single agent for the initial treatment of nosocomial respiratory tract infections in ventilated patients, although only with limitations in cases of infection due to P. aeruginosa.

The first pancreatic transplant at the University of Munich was performed in August 1979. Since then, 91 pancreatic transplants have been performed: combined pancreas and kidney transplantation (n = 80), pancreas transplantation alone (n = 7), and pancreas retransplantation (n = 4). In all cases, duct obliteration with prolamine in a segmental pancreatic graft was used as the standard procedure. Patient selection criteria, surgical technique of recipients’ operations, postoperative management, and immunosuppressive protocols were modified several times, however, during the past 7 years. Recently, assessment of a potentially beneficial effect on secondary complications was studied more intensively.

Nach einer bekannten Hypothese soll die zunehmende Haufigkeit an Herzinfarkten in den Industrielandern durch den erhohten Konsum von Saccharose verursacht sein. Als ein Argument fur diese Hypothese wird ein starkerer Anstieg des Triglyceridspiegels im Serum nach Saccharosereicher Kost im Vergleich zu einer Kost mit einem grosen Anteil Glucose oder Starke angefuhrt [1, 2]. Die technische Durchfuhrung dieser Ernahrungsversuche kann jedoch nicht befriedigen, da die Versuchsdauer meist zu kurz war, die Versuchspersonen wahrend des Versuchs Gewicht verloren und Kohlenhydrate sehr unterschiedlicher Struktur, z. B. das Disaccharid Saccharose mit dem Polysaccharid Starke, verglichen wurden. Vergleichbare Voraussetzungen sind nur bei Verwendung von Saccharose und dem ihr entsprechenden Disaccharid Maltose unter den Bedingungen einer Formeldiat gegeben [3].

In a randomized clinical trial the prophylactic effects of locally administered antimicrobials on quantitative colonization and respiratory infections were studied in intubated patients with an expected period of mechanical ventilation of greater than 6 days. Nineteen patients received 50 mg of polymyxin B and 80 mg of gentamicin distributed among nose, oropharynx and stomach at 6-h intervals, as well as 300 mg of amphotericin B in the oropharynx. Twenty untreated patients served as controls. In the control group colonization by respiratory pathogens was more common (oropharynx 19 vs 6 patients (p less than 0.001); trachea 19 vs 11 (p less than 0.01)), and the number as well as the count of the colonizing species was usually higher. Fourteen patients of the control group developed respiratory infections, including nine cases of pneumonia, as compared to four patients with prophylaxis, including one case of pneumonia (p less than 0.01). Pneumonia-associated deaths were prevented with prophylaxis; however, the overall mortality remained unchanged. Respiratory infections in the prophylaxis group were associated with organisms resistant to the agents used, but the overall occurrence of resistance was not increased, as compared to the control group. We conclude that unrestrained upper airway colonization by respiratory pathogens and respiratory tract infection were causally related. Local antimicrobial prophylaxis proved to be a highly effective strategy for the prevention of potentially life-threatening pneumonias in critically ill patients, but in the present study the host setting appeared to be the major determinant of outcome.

Die Aufgaben in der Transplantationsmedizin beanspruchen nach Losung der grundlegenden technisch-chirurgischen Probleme und der Verbesserung der Immunsuppression einen zunehmenden Raum im Bereich der Intensivmedizin. Die Bedeutung der Uberwachung und der Therapie von Komplikationen in der postoperativen Phase wachst auserdem mit der zunehemden Zahl dieser Patienten, die auf der Intensivstation behandelt werden.

In an open prospective study the efficacy and tolerance of imipenem/cilastatin was investigated in 24 critically ill patients on mechanical ventilation with nosocomial respiratory tract infection. Nine patients had previously received antibiotic therapy, eight of them with various other beta-lactam antibiotics which had failed. Imipenem was given in a dose of 1-3 g/24 h over 5-37 (mean 11) days. Seven patients were additionally treated with aminoglycosides, one patient with erythromycin. Pseudomonas aeruginosa (n = 14), Staphylococcus aureus (n = 4), Haemophilus influenzae (n = 4) and Escherichia coli (n = 3) were the potential pathogens most frequently isolated from tracheo-bronchial secretions. All of the isolates were susceptible to imipenem. 91% of the infections without and 77% with involvement of P. aeruginosa were successfully treated. Two patients who had not responded to previous treatment succumbed to the consequences of progressive respiratory distress syndrome. All of the gram-positive and 85% of the gram-negative pathogens (Pseudomonas not included) were eliminated in the course of therapy. By contrast, 64% of the isolates of P. aeruginosa persisted; half of these became imipenem-resistant. Nine patients showed adverse reactions including one case of pseudomembranous colitis or laboratory abnormalities which were all reversible. Imipenem/cilastatin proved highly effective and was relatively well tolerated; it is suitable as a single agent for the initial treatment of nosocomial respiratory tract infections in ventilated patients, although only with limitations in cases of infection due to P. aeruginosa.

In an open prospective study the efficacy and tolerance of imipenem/cilastatin was investigated in 24 critically ill patients on mechanical ventilation with nosocomial respiratory tract infection. Nine patients had previously received antibiotic therapy which had failed. Imipenem was given in a dose of 1-3g/24 h over 5-37 (mean 11) days. Seven patients were additionally treated with aminoglycosides, one patient with erythromycin. Pseudomonas aeruginosa, Staphylococcus aureus, Hemophilus influenzae and Escherichia coli were the most frequently isolated pathogens from tracheobronchial secretions. 91% of the infections without and 77% with involvement of Pseudomonas aeruginosa were successfully treated. All of the gram-positive and 85% of the gram-negative pathogens (Pseudomonas not included) were eliminated in the course of therapy. By contrast, 64% of the isolates of Pseudomonas aeruginosa persisted; half of these became imipenem-resistant. Nine patients showed adverse reactions including one case of pseudomembranous colitis which were reversible. Imipenem/cilastatin proved highly effective and was relatively well tolerated; limitations in the efficacy were seen in cases of infection due to Pseudomonas aeruginosa.

Im Jahr 1985 fanden sich unter 959 ausgewerteten Patienten unserer anasthesiologischen Intensivtherapiestation insgesamt 102 Falle mit Multiorganversagen. Von diesen Patienten starben 42. Die Mehrzahl aller Organversagen trat bei Patienten in Verbindung mit grosen operativen Eingriffen auf. In diesen Fallen spielte sicher auch die Schwere der Grundkrankheit eine Rolle. Multiorganversagen in Verbindung mit einem Trauma trat bei 20 Patienten mit einer Letalitat von 25 % auf. Im folgenden soll als Fallbeispiel der klinische Verlauf eines Multiorganversagens nach schwerem Trauma dargestellt werden.

Die Bemuhungen um eine diatetische Senkung des Serumcholesterinspiegels konzentrierten sich bisher auf eine Verringerung der Gesamtfettzufuhr oder auf einen Austausch der gesattigten Fettsauren, vor allem in Fetten tierischen Ursprungs, gegen mehrfach ungesattigte Fettsauren in Pflanzenolen. In den USA und in Westeuropa erwiesen sich diese Masnahmen nur als sehr begrenzt durchfuhrbar, und zwar sowohl wegen des diesbezuglichen Nahrungsmittelangebots, aber auch weil die Bevolkerung sich nur schwer von den uberlieferten Ernahrungsgewohnheiten losen kann. Wir haben deshalb versucht, durch einfache Zulage von 50 g Linolsaure/Tag zur ublichen Kost [1], den Serumcholesterinspiegel zu senken.