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16 patients (nine men, seven women; mean age 45 [23-62] years) with end-stage pulmonary disease underwent lung transplantation, 14 unilateral, three bilateral (one bilateral retransplantation). The diagnoses were: emphysema (n = 5), idiopathic pulmonary fibrosis (n = 5), emphysema in alpha 1-antitrypsin deficiency (n = 1), mucoviscidosis (n = 1), drug-induced fibrosis (n = 1), chronic lung rejection after heart-lung transplantation (n = 1), secondary pulmonary hypertension with persistent ductus arteriosus (n = 1), sarcoidosis (n = 1) and chronic transplant failure after unilateral transplantation (n = 1). Eleven patients survived long-term (mean follow-up period 247 [8-585] days). Ten of these patients have been independent of additional oxygen after an average of 8 months postoperatively, eight are physically active according to their age. Three patients died of reperfusion damage intraoperatively or in the early postoperative period. The two other patients died from septicaemia 5 1/2 and 7 months postoperatively. It is concluded that lung transplantation in end-stage pulmonary disease provides the only therapeutic means with any expectation of physical rehabilitation.

Objective: Endoscopic ultrasound (EUS) is a highly reliable procedure to localize insulinomas preoperatively. It has been considered to be important in planning surgical strategy, especially considering a minimal invasive approach. However, even under ideal conditions experienced examiners miss about 10–20% of insulinomas by EUS imaging. Design and methods: This retrospective study aimed to identify factors associated with negative EUS imaging. Twenty-nine consecutive patients (24 benign and 5 malignant) with sporadic pancreatic insulinomas confirmed by successful surgery and positive histopathology were included. All EUS examinations were performed by one single experienced examiner over a period of one decade. Results: Three of the tumors were not detected by preoperative EUS as they were isoechoic to the surrounding healthy pancreatic tissue; 25 could be detected as hypoechoic lesions, (including all malignant tumors), and one lesion was hyperechoic. Low body mass index (P=0.053) and young age (P=0.037) were associated with negative EUS imaging. All patients with negative imaging were females. The position on the examiner’s learning curve, the diameter and location of insulinoma, and endocrine parameters (insulin concentrations and insulin–glucose ratios in the prolonged fasting test) had no influence on the success of EUS imaging. Conclusions: Some insulinomas are missed by preoperative EUS imaging as they are completely isoechoic. A low body mass index, female gender, and young age might be risk factors for negative imaging.

The American Society of Echocardiography has published guidelines relating to standards for training (and certification), performance, nomenclature and measurement, and quality improvement related to echocardiography.1-15 However, the Society has not previously made recommendations about what constitutes the core variables, ie, measurements and other elements, to be included in a transthoracic echocardiographic report. A document addressing this topic would be timely and could serve the following purposes: (1) Promote quality by defining the basic core of measurements and statements that constitute the report; (2) encourage the comparison of serial echocardiograms performed in patients at the same site or different sites; (3) improve communication by expediting development of structured report form software; and (4) facilitate multicenter research and analyses of cost-effectiveness. Because of these considerations, Dr Richard Kerber, President of the American Society of Echocardiography, appointed a task force in 1998 to develop recommendations for a standardized report for adult echocardiography.Various international societies have recently addressed this issue and recommended standards. The purpose of this report is not to define how to record a proper adult cardiac ultrasound examination or how to perform the measurements but, rather, to serve as a guideline to what measurements and descriptive items should be included. It is the hope of the Task Force that publication of this document will further our ongoing efforts to improve the overall quality of the practice of echocardiography.

We report on a case of a lumbar epidural abscess with staphylococcus aureus following a catheter epidural anaesthesia in a previously healthy and not immunosuppressed 34-year-old female. The indication for the epidural anaesthesia was mobilization of the right knee following arthrotomy due to chronic synovitis. On postoperative day 7 the patient experienced lumbar pain, headache and meningism. Magnetic resonance imaging revealed an epidural abscess at the height of the 3rd and 4th lumbar vertebrae. A right-sided intralaminar fenestration with debridement and drainage of the abscess was carried out immediately after confirmation of the diagnosis. The patient was discharged from hospital on postoperative day 21 without any neurological sequelae. This is another addition to the published cases of epidural abscess following a epidural technique. It underlines the need for a proper aseptic technique, to abandon frequent changes of bacterial filters, daily examination of the entry site of the catheter and strategies for close and continuous monitoring of patients following epidural anaesthesia.

Mortality of severe acute respiratory distress syndrome (ARDS) in Germany is about 60%. Respiratory therapy can make the lung injury worse by high positive airway pressures, high tidal volumes and high inspiratory oxygen concentrations. Extracorporeal membrane oxygenation (ECMO) was employed to reduce aggressive mechanical ventilation, but it has not been proved to be superior to conventional ventilation. However, encouraged by recently developed improvements in the technique and concept of ECMO, we introduced this therapy into our program for the treatment of ARDS. PATIENTS AND METHODS. All patients with severe ARDS (lung injury score > 2.5) admitted to our multidisciplinary intensive care unit from March 1992 to March 1995 were evaluated prospectively. After admission, the patients first underwent a conventional therapeutic approach, including pressure-controlled inverse-ratio ventilation, permissive hypercapnia, changes in body position (in particular, the prone position), negative fluid balance, anti-biotics, and low-dose hydrocortisone infusion. ECMO via a covalently heparin-coated, venovenous bypass-system with a vortex pump and two membrane lungs was performed if ARDS did not improve after 24-96 h of conventional therapy and if two of three of the slow-entry criteria for ECMO were fulfilled: (1) PaO2/FiO2 5 mbar; (2) semistatic compliance 30%. Only in cases of life-threatening hypoxemia (PaO2 5 mbar for > 2 h (fast-entry criteria) was ECMO instituted immediately. RESULTS. Sixty patients fulfilled the entry criteria for our study. Thirty-nine patients were treated with a conventional protocol, 37 after improvement of ARDS and 2 who had not improved but in whom there were contraindications to the use of ECMO. ECMO was performed in 10 patients who had not improved, but who fulfilled the slow-entry criteria and in 11 primarily hypoxemic patients who fulfilled the fast-entry criteria. The survival rate was 30/39 (77%) for the conventional therapy group, 6/10 (60%) for the slow-entry group, and 11/11 (100%) for the fast-entry group. The onset of ECMO allowed a significant decrease in peak and mean airway pressures, tidal volume, ventilatory rate, minute volume and inspiratory oxygen concentration. Sufficient gas exchange was provided, and pulmonary artery pressures significantly decreased on bypass. The most frequent complications on bypass were pneumothorax (15/21 patients) and bleeding (7/21 patients). CONCLUSION. In comparison with the historical results at our own institution, the present study demonstrates an improvement in the survival rate from 56% to 78% since ECMO has become available. We conclude that venovenous ECMO with a heparin-bonded bypass circuit is an effective additional option for the treatment of patients with severe ARDS.

Activated recombinant factor VII (rFVIIa) has been approved for the treatment of bleeding diathesis. A growing number of case reports suggest that rFVIIa might have a distinct role in otherwise intractable surgical bleeding in patients without bleeding diathesis. We report here on a 22-year-old pregnant (week 26) patient who was involved in a car accident leading to premature placental separation. After emergency cesarean section during which 4 units of packed erythrocytes, 6 units of fresh frozen plasma and 32 pg of desmopressin were given, the patient was transferred to the ICU, where bleeding from wound drainages continued at a rate of > 300 mL/h. Despite a tendency towards normalization of the conventional laboratory coagulation parameters, and despite application of another 17 units of packed erythrocytes, 16 units of fresh frozen plasma, 2 units of thrombocytes and 2000 IU of antithrombin, bleeding could not be stopped. The decision was therefore taken to do a re-laparotomy to rule out any surgical source of bleeding that might have been overlooked. Because of hemodynamic instability and as an ultima ratio 360 kilounits (kIU) of rFVIIa were applied before transferring the patient to the operating theatre. Bleeding stopped immediately. No bleeding source could be identified upon surgical inspection. The post-operative course was uneventful and the patient could be discharged from the hospital on day 10. We assume that this otherwise untractable bleeding was stopped by the application of rFVIIa and feel that a broader indication for rFVIIa should be considered.

Die Pulskonturanalyse ist ein einfach anzuwendendes Verfahren zur kontinuierlichen Bestimmung des Herzzeitvolumens (PCCO) bei kritisch kranken Patienten. Die Berechnung des Schlagvolumens erfolgt uber die Analyse der arteriellen Pulsdruckkurve zusammen mit einem fur jeden Patienten mittels Referenzverfahren individuell zu bestimmenden Kalibrationsfaktor. PCCO wurde an 20 Intensivpatienten uber eine Gesamtzeit von 110 h gemessen und mit Thermodilutionswerten (TDCO) verglichen. Die relative Abweichung (±2 SD) von PCCO gegenuber TDCO wurde ermittelt: (1) unter hamodynamisch stabilen Bedingungen, und (2) unter Bedingungen von verandertem Vasotonus und Hamodynamik bei Dosisanderungen vasoaktiver Substanzen. Insgesamt wurden an 165 Meszeitpunkten TDCO-Messungen durchgefuhrt und die korrespondierenden PCCO-Werte registriert. Die relative Abweichung von PCCO gegenuber TDCO betrug ±23,9% (SD=0,85 l·min −1 ), wenn die PCCO-Methode einmalig bei jedem Patienten vor Beginn der Messerien kalibriert wurde. Die Differenz der Mittelwerte der Herzzeitvolumina (CO) beider Methoden (Bias) war dabei −0,09 l·min −1 . Durch zusatzliche Kalibrationen konnte die relative Abweichung (±2 SD) auf ±15,7% verbessert werden (SD= 0,56 l·min −1 ; Bias 0,003 l·min −1 ). Anderungen in der Dosierung vasoaktiver Substanzen in klinisch ublichen Grosenordnungen hatten keinen Einflus auf die Mesgenauigkeit von PCCO. Es konnte gezeigt werden, das die Pulskonturanalyse ein leicht anzuwendendes und klinisch ausreichend genaues Verfahren zur kontinuierlichen Messung des CO darstellt.

The risk factors for systemic fungal infections were analysed retrospectively in 186 orthotopic liver transplant procedures performed in 152 patients between June 1985 and January 1993. The total incidence of systemic fungal infections was 16.5% (25/152). The incidence of disseminated candidiasis, aspergillosis, and combined candidiasis and aspergillosis was 6.5% (n = 10), 7.2% (n = 11) and 2.6% (n = 4), respectively. Mortality associated with systemic fungal infections was 80% (20 of 25 patients). There were ten cases of disseminated candidiasis, with 4 patients surviving, and 11 cases of invasive aspergillosis, with 1 patient surviving. All patients with combined systemic fungal infection died. To identify perioperative risk factors, 39 variables were used to compare patients with systemic fungal infections versus those without fungal infections. Fourteen variables were significantly associated with systemic fungal infections by univariate analysis. A consecutive logistic regression analysis revealed that the amount of fresh frozen plasma transfused due to poor initial function of the allograft and acute renal failure requiring hemofiltration were independently significant risk factors for systemic fungal infections. There was no statistical correlation between systemic fungal infections and the underlying liver disease, previous long-term corticosteroids and the postoperative immunosuppressive therapy. Risk factors identified in this study should be considered in the postoperative care of the individual liver transplant recipient. In our study a poor initial function of the hepatic allograft substantially increased the risk of systemic fungal infection.

To compare 4 general severity classification scoring systems concerning prognosis of outcome in 123 liver transplant recipients. The compared scoring systems were: the mortality prediction model (admission model and 24 h model); the simplified acute physiology score; the acute physiology and chronic health evaluation (Apache II) and the acute organ systems failure score.Retrospective, consecutive sample.Adult intensive care unit in a university hospital.123 adult liver allograft recipients after admission to the intensive care unit.The scoring systems were calculated as described by the authors to classify the severity of illness after admission of the allograft recipients to the intensive care unit. The mean and median values of survivors and the group of patients, that died during hospital stay were compared. Receiver-operating characteristics were plotted for all scoring systems and the areas under the curves of receiver-operating characteristics were calculated. The predictive value of the 4 scoring systems was tested using a variety of sensitivity analyses. The mortality prediction model (24 h model) was found to have a high significance (p0.001) in predicting mortality and showed the greatest area under the curve (0.829). Simplified acute physiology score (p0.001) and acute physiology and chronic health evaluation (Apache II) (p0.01) had a high significance as well, but did not hit the level of prognosis of mortality prediction model, as shown in the area under the curves. Accordingly, sensitivity was highest in MPM-24 h (83%), followed by SAPS (72%) and Apache II (71%). MPM-24 h had a total misclassification rate of 22% (SAPS = 32%, Apache II = 33%). MPM-admission failed in predicting mortality (sensitivity = 52%). Organ systems failure score seemed not to be useful in liver transplant recipients.General disease classification systems, such as the mortality prediction model, simplified acute physiology score or acute physiology and chronic health evaluation are good mortality prediction models in patients after liver transplantation. We suggest that there is no need for improvement of a special scoring system.

Adenosine diphosphate-ribosylation is a post-translational modification mediated by intracellular and membrane-associated extracellular enzymes and many bacterial toxins. The intracellular enzymes modify their substrates either by poly-ADP-ribosylation, exemplified by ARTD1/PARP1, or by mono-ADP-ribosylation. The latter has been discovered only recently, and little is known about its physiological relevance. The founding member of mono-ADP-ribosyltransferases is ARTD10/PARP10. It possesses two ubiquitin-interaction motifs, a unique feature among ARTD/PARP enzymes. Here, we find that the ARTD10 ubiquitin-interaction motifs bind to K63-linked poly-ubiquitin, a modification that is essential for NF-κB signalling. We therefore studied the role of ARTD10 in this pathway. ARTD10 inhibits the activation of NF-κB and downstream target genes in response to interleukin-1β and tumour necrosis factor-α, dependent on catalytic activity and poly-ubiquitin binding of ARTD10. Mechanistically ARTD10 interferes with poly-ubiquitination of NEMO, which interacts with and is a substrate of ARTD10. Our findings identify a novel regulator of NF-κB signalling and provide evidence for cross-talk between K63-linked poly-ubiquitination and mono-ADP-ribosylation.

Continuous monitoring of blood gases and pH could add substantially to patient safety. During the last decade, efforts have been made to develop continuous optochemical blood gas sensors. The initial evaluation of such fibreoptic-based systems showed major patient-interface problems [11]. We evaluated a new intra-arterial blood gas monitoring system (PB3300, Puritan-Bennett, Carlsbad CA) under routine clinical conditions. Methods. After institutional review board approval and with written informed consent, 38 sensors were tested in 25 patients with acute respiratory failure (e.g., the acute respiratory distress syndrome, complications after lung transplantation). Two conventional bench-top blood gas analysers (ABL 520 and ABL 300, Radiometer, Copenhagen) served as criterion standards. The mean differences (bias) and standard deviations (SD) of the differences (precision) were calculated according to the method of Bland and Altman [2]. In addition, linear regression analysis and correlation coefficients were calculated. The quality of blood pressure tracings was assessed using a grading system. Results. The median sensor lifetime was 81.3 h; 869 blood samples (median 14 per sensor) were analysed for the comparison of continuous and conventional blood gas analysis. The ranges for measured parameters were: pH: 6.92 to 7.55; PCO2: 20 to 83 torr; PO2: 31 to 518 torr. The mean differences (SD) were: pH: −0.03 (0.03) or −0.4 (0.4)%; PCO2: −2.6 (4.1) torr or −6.9 (10.9)%; PO2: −3.4 (10.5) torr or −2.9 (7.0)%. The results of linear regression analysis and the correlation coefficients are depicted in Table 2. The mean grade of blood pressure tracings was satisfactory for the clinical setting. Conclusions. The continuous blood gas monitor is sufficiently accurate and precise for clinical use. Bias and precision are better than those known from former studies evaluating fibreoptic blood gas monitors under experimental conditions [7]. Cost-effectiveness was not an issue of this study.

Based on the imaging studies obtained from 13 patients after lung transplantation, radiological findings have been correlated with the clinical charts. The intention was to describe the radiological manifestations of the particular transplant complications of these patients. 12 episodes of reimplantation response were seen in the early postoperative period as a perihilar accented perivasal consolidation with typically short-termed appearances. 16 episodes of acute rejection showed various manifestations on the radiographs. They were characterised by immediate response to a bolus therapy with corticosteroids. This decisive observation allows the exclusion of other causes contributing to a condition following thoracotomy with similar radiological manifestations. Stenoses of the pulmonary or the bronchial anastomoses occurred once each and were confirmed in the course of further examinations. Chest radiograph proved to be the appropriate tool for the diagnosis of technical complications following iatrogenic measures (pleural effusion, pneumothorax). Clinical symptoms and follow-up observations are necessary for the interpretation of the radiographs. Chest radiography represents an important help concerning problems in differential diagnosis and further therapeutic decisions.

We present an unusual case of suprahepatic caval anastomotic stenosis after adult liver transplantation in the early postoperative period. Color flow Doppler sonography and cavography were used to confirm the clinical diagnosis. Success-ful nonoperative treatment of the obstruction was achieved by balloon dilatation and subsequent implantation of a vascular stent.

Background: While continuous positive airway pressure (CPAP) effectively treats obstructive sleep apnea (OSA), adherence to CPAP is suboptimal. The short-term efficacy of and adherence with a convenient expiratory positive airway pressure (EPAP) nasal device was evaluated in OSA patients non-adherent with CPAP. Methods: Participants were OSA patients who refused CPAP or used CPAP less than 3 h per night. After demonstrating tolerability to the EPAP device during approximately 1 week of home use, patients underwent a screening/baseline polysomnogram (PSG1) and a treatment PSG (PSG2). Patients meeting prespecified efficacy criteria underwent PSG3 after about 5 weeks of EPAP treatment. Results: Forty-seven of 59 eligible patients (80%) tolerated the device and underwent PSG1. Forty-three patients (27 m, 16 f; 53.7 ± 10.9 years) met AHI entry criteria and underwent PSG2. Mean AHI decreased from 43.3 ± 29.0 at baseline to 27.0 ± 26.7 (p < 0.001) at PSG2. Twenty-four patients (56%) met efficacy criteria; their mean AHI was 31.9 ± 19.8, 11.0 ± 7.9, 16.4 ± 12.2 at PSG1, PSG2, and PSG3, respectively (p < 0.001, PSG1 vs. both PSG2 and PSG3). Mean Epworth Sleepiness Scale (ESS) scores were 12.3 ± 4.8 at baseline, 11.1 ± 5.1 at PSG1, and 8.7 ± 4.4 at PSG3 (p = 0.001 compared to baseline). Device use was reported an average of 92% of all sleep hours. Conclusions: The improvements in AHI and ESS, combined with the high degree of treatment adherence observed, suggest that the convenient EPAP device tested may become a useful therapeutic option for OSA. 2010 Elsevier B.V. All rights reserved.

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.

Since the first characterization of the adult respiratory distress syndrome (ARDS), knowledge of its aetiology and pathogenesis has grown considerably. In spite of this, mortality remains up to 50 to 90%, particularly if multiple organ failure is present. Because no causative clinical therapy is available up to now, significant attention is given to preventive measures like early operative stabilisation of long bone fractures, or prophylaxis of nosocomial infections. After clinical manifestation of ARDS, treatment focuses on functional disturbances of the cardiopulmonary system and on the underlying disease. The aim of this symptomatic therapy is to ensure oxygen supply according to the organisms demand. It is still unknown, however, whether the mortality of patients with ARDS can be reduced by optimising the oxygen supply. In general, oxygen supply can be enhanced by improving pulmonary gas exchange, cardiac output and blood oxygen transport capacity. For practical use the therapy often ends up with a therapeutical dilemma: On one hand, the improvement of the pulmonary gas exchange by application of PEEP can be associated with a critical decline in cardiac output, particularly if the afterload of the right ventricle is elevated. On the other hand, to increase cardiac output, both volume replacement and vasodilators can severely affect pulmonary gas exchange if the alveolo-capillary permeability is increased and pulmonary hypoxic vasoconstriction is disturbed. Thus, oxygen supply can be optimised only via invasive monitoring of the cardiorespiratory system. Although still experimental, the most promising approaches seem to be pharmacological interventions directed at suppressing the formation and effects of various humoral and cellular mediators. An improved understanding of the inflammatory processes might provide new insights in the pathophysiology of ARDS and the related therapeutic interventions.

We have investigated the effects of open chest and open pericardium on the distribution of myocardial blood flow assessed with the radioactive microsphere technique (15 microns). Five dogs with intact thorax served as controls (group I) and six dogs were studied after a right-sided thoracotomy and pericardiotomy (group II). Global myocardial blood flow (mean +/- S.D.) was 0.73 +/- 0.17 ml.min-1.g-1 in group I and 1.22 +/- 0.09 ml.min-1.g-1 in group II (p less than 0.05). Analysis of transmural blood flow distribution revealed that flow was 44% higher in the right and 60% higher in the left ventricular endocardial layers in the open-chest animals, whereas epicardial flow increased by 105% and 90%, respectively. As a result of the preferential blood flow to the epicardial layers of the right ventricle, the endo/epi ratio was reduced from 1.30 +/- 0.26 in group I to 0.86 +/- 0.11 in the open-chest group (p less than 0.05). Left ventricular endo/epi ratio was 1.27 +/- 0.16 and 1.06 +/- 0.11 (n.s.), respectively. External work and diastolic filling pressure of the right ventricle did not differ between the two groups and therefore cannot account for the redistribution of myocardial blood flow. It is concluded that the distribution of myocardial blood flow, particularly in the RV, is severely disturbed by thoracotomy and pericardiotomy. This is an important aspect for the planning and evaluation of studies under open-chest/open-pericardium conditions.

We interviewed 45 patients, who answered advertisements (n = 21) or were referred by colleagues (n = 24), about their experience of intraoperative awareness using a standardized questionnaire. Auditory perceptions, hearing sounds or voices were mentioned by all patients (45 of 45): 33 of 45 patients understood and recalled conversations; 21 of 45 patients had visual perceptions; 12 of 21 recognized things or faces; 29 of 45 patients felt being touched; three patients had the sensation of moderate pain; and eight patients were in severe pain. Patients' feelings were mostly related to paralysis (27 of 45), helplessness (28 of 45), anxiety and fear (22 of 45); 18 were in severe panic. All patients (45 of 45) recognized the situation as a real event: 22 of 45 patients experienced unpleasant after effects; 11 suffered from anxiety and nightmares; and three developed post-traumatic stress disorder syndrome and required medical treatment. Twenty of 45 patients were especially attentive to emotionally relevant remarks on their own person, their disease and the course of their operation. The accuracy of sensory perception indicates a very high level of cognitive performance of patients during intraoperative awareness.

Plasma and tissue concentrations of amphotericin B were determined in a patient treated with liposomal amphotericin B during liver transplant failure. A cumulative rise in amphotericin B plasma concentrations was observed accompanied by an enhanced pulmonary deposition of the drug. Failure of the liver as a major component of the reticuloendothelial system may cause elevated plasma concentrations of liposomal amphotericin B and may consequently enhance deposition of liposomes in the lungs as a substitutive clearing organ.

To compare the adrenocortical response to corticotropin during septic shock and after complete recovery.Prospective clinical study.Multidisciplinary intensive care unit in a university hospital.20 consecutive patients surviving septic shock. All patients met the American College of Chest Physicians/Society of Critical Care Medicine criteria for septic shock. In addition, the presence of high-output circulatory failure with a cardiac index41/min per m2 was a criterion for enrollment in the study. Complete recovery from septic shock was defined as discontinuation of any supportive therapies. Severity of illness during septic shock and after recovery was graded using the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system.In each patient, two short corticotropin stimulation tests were done during septic shock and after recovery.Basal cortisol levels recorded during septic shock and after recovery did not differ (medians: 18.8 vs 18.9 micrograms/dl). However, the response to corticotropin was significantly attenuated during septic shock when compared with the response after recovery (medians: 7.7 vs 14.7 micrograms/dl; p = 0.02). After recovery, patients' stress response was less, as indicated by a reduction in APACHE II scores (medians: 21 vs 5 points; p0.01).Adrenocortical response to corticotropin is attenuated in patients with septic shock and high-output circulatory failure compared to the response in the much less stressful condition after recovery. The attenuated adrenocortical responsiveness may be explained by effects of circulating mediators from the systemic inflammatory response.

There is increasing evidence that the hypercortisolemia in inflammatory diseases suppresses the elaboration of proinflammatory cytokines, thus protecting the host from its own defence reactions. In severe sepsis and septic shock cortisol levels are usually elevated, but some patients may have relative adrenal insufficiency. This may contribute to the overwhelming systemic inflammatory response syndrome. We evaluated the impact of low-dose hydrocortisone infusion (10 mg/h) on the course of the systemic inflammatory response syndrome. This dose corresponds to a maximum secretory rate of cortisol achieved in corticotropin-stimulated healthy humans. In a prospective observational study 57 surgical patients with severe sepsis or septic shock were studied, of which in addition to the conventional treatment 12 patients were infused with low-dose hydrocortisone, and 45 were treated without any corticosteroid. In the longitudinal analysis the systemic inflammatory response--as judged by body temperature, cardiovascular response, and kinetics of inflammatory mediators such as phospholipase A2, C-reactive protein, and neutrophil elastase--started to differ in favor of the hydrocortisone-treated patients after 2 days of treatment (P < 0.05, Mann-Whitney U test). The difference disappeared after withdrawal of exogenous cortisol. Shock reversal was achieved in all patients treated with low-dose hydrocortisone. The data provide evidence that low-dose hydrocortisone infusion attenuates the systemic inflammatory response in human septic shock. From an immunological point of view a relative cortisol deficiency may contribute to the amplified immune response in systemic inflammatory diseases. A randomized clinical trial must clarify the impact of low-dose hydrocortisone infusion on the clinical course and outcome of septic shock patients.

Anastomotic stenosis of the pulmonary artery after lung transplantation is a rare complication, which commonly necessitates surgical correction. Transesophageal Doppler sonography and pulmonary arteriogram are standard diagnostic means for visualization of venous and arterial anastomoses. Balloon dilatation combined with implantation of a vascular endoprosthesis was successfully used for treatment of severe anastomotic stenosis of the pulmonary artery after lung transplantation.

Statins have neuroprotective properties including improved vasomotor reactivity, reduced platelet activation and anti-inflammatory effects [1]. A prospective observational controlled study was conducted to evaluate the impact of pravastatin on the development of delayed ischemic disease (DID) and ICU mortality after aneurysmal subarachnoid hemorrhage (aSAH).

Glycaemic control is another example of protocol-driven therapy in intensive care medicine to improve outcome in critically ill patients. While the advantage of this approach seems to be obvious, little is known about the problems of implementing such a protocol. The intention of this study was to evaluate problems of implementation and to develop strategies to overcome them.

Although a large number of epidemiological sepsis studies have been performed in Europe and the United States in the past years, sound data for Germany are so far lacking. In the 'Prevalence of Severe Sepsis and Septic Shock in Intensive Care Units in Germany' study, a prospective observational cross-sectional study, the network gathered data from 454 randomly selected ICUs in 310 hospitals in Germany and screened 3877 patients – according to the ACCP/SCCM Consensus Conference criteria – by local 1-day visits of trained physicians from the 17 German Competence Network Sepsis (SepNet) regional study centers. Visits were randomly distributed over a 1-year period (2003) to allow assessment of seasonal variations of sepsis prevalence. The ICU sample was taken from a registry of all German hospitals with ICUs (1380 hospitals with 2075 ICUs). Pediatric ICUs were not considered. The study was completed in January 2004 and the database was closed on 31 May. Seven percent of ICUs were situated in university, 34% in university-affiliated and 53% in general hospitals. Fifty-six percent of ICU directors were anesthesiologists and 26% internists. An infection was microbiologically documented in 22% and diagnosed by clinical criteria alone in 12% of screened patients. Respiratory tract infections were most common (52%), followed by intra-abdominal (15%) and urogenital infections (7%). Gram-negative and Gram-positive infections were nearly equally distributed (33% vs 35%); in 16% a fungal infection was suspected. The prevalence of sepsis was 12%, infection without SIRS was 7%, and severe sepsis/septic shock was 11%. There were significant differences in the prevalence of severe sepsis/septic shock over 1 year with the highest prevalence in May/June 2003 (18%). The infection was ICU acquired in 37%, hospital acquired in 20% and community acquired in 35.5%. ICU mortality in patients with severe sepsis/septic shock was 47% and hospital mortality was 54%. Based on these findings the incidence of severe sepsis/septic shock in German ICUs can be estimated as 75,000 cases per year (110 per 100,000 inhabitants), comparable with the incidence of acute myocardial infarction (143 per 100,000 inhabitants). With an estimated 40,000 deaths per year, severe sepsis/septic shock is the third most frequent cause of death in Germany after coronary artery disease and acute myocardial infarction. Incidence and mortality rate of severe sepsis and septic shock in German ICUs are higher than reported in recent studies. This may be due to the representative sample size, the more standardized diagnostic criteria and a lower interobserver variability.

Percutaneous cholecystostomy was performed in 17 poor surgical risk patients. 16 patients developed acute acalculous cholecystitis postoperatively in the intensive care unit, 1 patient had an acute cholecystitis with calculi. Diagnostic imaging using CT and US was specific for acute cholecystitis in 58% only. Percutaneous cholecystostomy was the definitive treatment in 69% of the patients. Additional cholecystectomy was required in 3 patients with complicated cholecystitis, in 1 patient with bile leakage after catheter dislocation and in 1 patient with gallbladder calculi. 3 patients died, 2 of them from reasons unrelated to the gallbladder disease. Radiology-guided percutaneous cholecystostomy performed by a transhepatic approach is a safe and effective procedure for acute cholecystitis in high-risk patients.

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.

Right ventricular (RV) epicardial tissue oxygen pressure (PtO2) was measured polarographically by means of a platinum multiwire surface electrode on the in situ beating heart of ten anesthetized dogs prior to and after moderate (Hct 28%) normovolemic hemodilution (HD) with dextran 60. In five dogs the effect of acute occlusion of the right coronary artery (RCA) on PtO2 was analyzed. The PtO2 histograms at baseline revealed a bell-shaped configuration and a mean PtO2 of 46.2 +/- 7.1 mm Hg which coincides with the PtO2 on the left ventricle (LV) reported by others. After HD mean PtO2 increased to 51.4 +/- 8.5 mm Hg (P = 0.02) without alterations of the histogram's configuration. Hemodynamics and blood gas analyses were unchanged after HD. RCA ligature was followed by non-uniform changes in the PtO2 pattern. Thus, despite marked differences in external work and O2 consumption, the PtO2 in both RV and LV myocardium are similar at rest. The increase of PtO2 in the RV at reduced Hct values, which is not seen in the LV myocardium, can be related to differences in functional capillary density between both ventricles.

The aim of this study was to establish a stable and reproducible model of pulmonary artery hypertension with concomitant ARDS-like changes of lung function and lung morphology. In eight anesthetized and ventilated dogs, 0.01 ml/kg oleic acid (OA) was given i.v. followed by repetitive injections of 100 microns glass beads (GB) into the right atrium until a mean pulmonary artery pressure of 35-40 mmHg was reached. Mean right ventricular (RVP) and pulmonary artery (PAP) pressures, pulmonary vascular resistance (PVR), lung compliance and resistance, PaO2, intrapulmonary shunt and colloidosmotic pressure (COP) were closely monitored for 150 min. PAP, RVP, and PVR considerably increased subsequent to OA/GB injection, and stabilized at a high level within 70 min, showing only a minimal decrease (PAP, RVP) or no change (PVR) during the following 80 min. A significant decrease of PaO2 and pulmonary compliance as well as an increase of resistance and intrapulmonary shunt were found as early as 30 min after the last embolization and they remained unchanged for 120 min. Reduction of COP suggested transcapillary leakage of macromolecules. Histology revealed an interstitial and intraalveolar edema. We conclude that the combined injection of oleic acid and glass beads provokes microvascular lung injury and results in stable pulmonary artery hypertension with concomitant ARDS-like changes of lung function. Thus, an acute model is provided in the dog allowing for the study of cardiac function in ARDS complicated by pulmonary artery hypertension.

The transport system for oxygen from the environment to the mitochondria comprises a highly complex sequence of diffusive and convective processes, providing several mechanisms to adapt oxygen delivery to the wide variations of metabolic needs in different tissues. If oxygen demand rises, most readily adjustments in pulmonary gas exchange, cardiac output, hemoglobin oxygen binding, vascular tone, distribution of flow and oxygen extraction increase the availability of oxygen to the cell. Hence, systemic oxygen need depends primarily upon the intrinsic metabolic rate, set by the actual physical activity, body temperature, nutritional and metabolic status, level of catecholamines and stress hormones.

Among surgeons the application of computer science and technology is still considered to be of minor importance because operating skills and experience do not profit from data processing. In other medical fields, such as radiology and anesthesiology, the advantages of employing computers were recognized much earlier and have led to the development of new diagnostic and therapeutic procedures, e.g., sonography, NMR tomography, monitoring in the ICU, and computer controlled closed-loop infusion [11]. In surgical research computers are becoming increasingly popular, but the range of applications is still limited. Personal computers today have a performance comparable to that of mainframe computers 15 years ago, but these are used primarily for simple applications such as word processing.

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.

Vascular patients are a cohort which have an increased surgical risk due to the high incidence of concomitant diseases. A retrospective study in 300 consecutively operated vascular patients demonstrated that mainly preexisting cardiac diseases, e.g., coronary heart disease or cardiac failure, are of greatest relevance. In approximately 60% of cases patients with an abdominal aortic aneurysm also suffered from coronary heart disease. The second most frequently diagnosed disease in these patients was cardiac failure. Further major findings of concomitant diseases in patients with vascular disease were preexisting angina, hypertension, and infarction [6]. These retrospective findings were corroborated by preoperative coronary angiography in patients with aortic aneurysm [7].

It is now well recognized that the application of positive end-expiratory pressure (PEEP) to the ventilation of patients with adult respiratory distress syndrome (ARDS) improves the arterial oxygen tension but may be associated with a fall in cardiac output, thus leading to the net effect of unchanged or even reduced systemic oxygen transport. However, the factors causing this decrease in cardiac output remain controversial (Craig et al. 1985).