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Systemic inflammation and sepsis are accompanied by severe metabolic alterations, including insulin resistance together with increased levels of triglycerides (TGs) and decreases in high- and low-density lipoproteins. Clinical studies have clearly established a link between lipid metabolism and systemic inflammation. Lipoproteins were shown to neutralize LPS and to exert direct anti-inflammatory actions. High- and low-density lipoproteins are thus thought to be important regulators of the host immune response during endotoxemia, which may also have the potential of improving the care of patients with Gram-negative sepsis.Nutritional lipids supplied during critical illness have been shown to modulate the host response to inflammation. In particular, inclusion of omega-3 fatty acids seems to have beneficial effects on cellular immunity and helps to maintain the balance between pro- and anti-inflammatory cytokines thereby preventing hyperinflammatory complications. In addition to improvements in the profile of lipid mediators generated, omega-3 fatty acids act as activating ligands of peroxisome proliferator-activated receptors and directly inhibit nuclear factor kappaB mediated proinflammatory signaling. We present an overview on the alterations in the metabolism of serum lipoproteins during sepsis and present data from clinical studies and discuss the significance of nutritional lipids and their role in immunomodulation with special emphasis on omega-3 fatty acids.

The report describes a method of impedance cardiography using an improved estimate of thoracic volume. The formulas and their implementation in hardware and software are explained and new shortband electrodes are described which generate a good homogeneous thoracic field. Examples of stroke volume and cardiac output curves underline the capabilities of the monitoring system "Task Force Monitor". In several experiments, results are compared to thermodilution as well as to BioZ measurements: the new method excels in comparison with thermodilution and is comparable to the BioZ device. Compared to traditional electrodes, the new shortband electrodes are shown to provide better reproducibility.

The context and setting In aviation, one aspect of safety improvement for over 30 years has been the implementation of crew resource management (CRM) seminars. This psychological teaching form focuses on the CRM competencies task management, dynamic decision making, teamwork and situation awareness. The same competencies can be applied to the medical field. Until now, training of these basic skills has not been established in undergraduate medical education, although they would be as helpful for medical teams as they are for people working in other complex environments. Why the idea was necessary Full-scale patient simulators have been available for more than 15 years. Crisis resource management courses have been developed for doctors with a focus on the CRM competencies. In contrast to aviation, most medical CRM courses are held without psychologists, although the course objectives are psychological competencies. Furthermore, no psychological exercises concerning CRM skills are offered, in contrast to CRM seminars for air crews. In particular, beginners in the medical profession have difficulty applying knowledge and working effectively under stress. For this reason, nontechnical skills should already be taught during undergraduate medical education. What was done We established a curriculum for medical students to teach non-technical skills. A 3hour pilot course with a focus on situation awareness was set up as part of the mandatory 2-week course in ‘Anaesthesiology’ for students between the third and the fifth year. After a lecture about human factors and error prevention (20 minutes), 1 psychologist and 2 anaesthesiologists demonstrated a short resuscitation sequence on a METI-ECS patient simulator (METI, FL, USA). The students had to observe the scenario and discuss how CRM skills were practised (40 minutes). This was followed by a 45-minute seminar about situation awareness, held by a psychologist. The exercises were designed for a medical context by a team of psychologists prior to the course. After the seminar the students completed a resuscitation scenario with the simulator, followed by a debriefing focussed on situation awareness. In all, the simulator training lasted 60 minutes. Participants were asked to complete a questionnaire at the end of the course. Evaluation of results and impact We received 22 evaluation questionnaires from the 22 students who took part in the course. The overall mark was 1.8 ± 0.8 [marks from 1 (excellent) to 6 (poor), mean ± standard deviation (SD)]. The course was rated as suitable for linking theoretical knowledge with clinical contents (2.0 ± 1.0). The marks for the simulator training and the psychological seminar were 1.5 ± 0.7 and 2.0 ± 0.9, respectively. The lecture was marked with 1.7 ± 0.9. The content versus time ratio revealed an average mark of 4.2 ± 0.5 (1: too much content to 7: too much time; 4: ideal ratio) and the theory versus practice ratio was rated nearly perfect (3.9 ± 0.4, 1: too much theory to : too much practice). As our students valued teaching about error prevention and crisis management, we will offer similar courses focusing on the other 3 CRM competencies within the next semester.

The complement system is a multifactorial protein cascade system which is essentially involved in the early unspecific immune response. Its major function is the activation of cellular defense mechanisms, opsonisation of foreign particles and the destruction of target cells. While the impact of the different complement components for bacterial elimination still remains controversial, overwhelming activation of the complement cascade, however, can induce life threatening tissue damage due to the effective cytotoxic properties. In the last years a variety of studies demonstrated beneficial, organ protective effects of complement modulation in models of severe inflammation. Attempts to control the complement system include the application of endogenous complement inhibitors e.g. C1-inhibitor (C1-INH) or the administration of recombinant complement receptors such as the soluble complement receptor 1 (rsCR1). Moreover antibodies against key proteins (C3, C5), against their activation products (C5a) or against complement receptor 3 (CR3, CD18/11b) mediated adhesion of leukocytes to the vascular endothelium, represent effective options of complement modulation. Besides this, insertion of membrane bound human complement regulators (DAF- CD55, MCP- CD46 or CD59) into xenogenic donor organs has proven effectiveness to prevent xenograft rejection. The described interventions protected from severe organ damage in various animal models of sepsis, myocardial and intestinal ischaemia-reperfusion injury, ARDS, nephritis, and xenograft rejection. With respect to recent clinical data, complement inhibition could represent a useful therapeutic strategy to control overwhelming inflammation. Own experiments demonstrated protective effects of complement modulation with C1 INH and rsCR1 in a model of complement induced pulmonary injury. With respect to sufficient host defense, however, the use of complement inhibitors must be considered carefully.

INTRODUCTION Using the surgical procedure OPS 5-604.0 (radical retropubic prostatectomy) as an example, our study identifies revenue-relevant patient characteristics and describes the impact of the perioperative application of thoracic epidural analgesia (TEA). METHODS Factors affecting duration of stay were determined in 460 patients undergoing OPS 5-604.0 in the year 2001 and 2002 using multifactorial regression analysis. Preoperative parameters served as factors for matched-pair analysis of the effects of TEA. RESULTS Characteristics significantly affecting length of postoperative hospital stay were ASA status, age, preoperative haemoglobin concentration, postoperative tachycardia, number of transfused packed red cells, wound infection and surgical revision. Based on identical matching criteria 27 pairs (with/without TEA) could be formed. While the induction time in the TEA group was 8+/-18 min longer (p=0.04), emergence was briefer by 3+/-9 min (p=0.045). Neither anaesthesia presence time nor anaesthesia costs or total costs of surgery differed significantly between the pairs. However, duration of epidural postoperative pain therapy was longer with TEA but in contrast, the postoperative length of hospital stay after TEA was reduced. Assuming a continuous demand for OPS 5-604.0 procedures, TEA enables 32 more procedures to be carried out per year with an increased yield on turnover of 2.7%. CONCLUSION At first sight combined anaesthesia procedures require more human resources and material, however, as a result of shortened hospital stay and optimized pain therapy patient satisfaction increases and a substantial potential for increased revenue is gained.

A new method and apparatus for non-disruptive blood pressure (BP) recording in the finger based on the vascular unloading technique is introduced. The instrument, in contrast to intermittent set point readjustments of the conventional vascular unloading technique, delivers BP without interruptions, thus refining the Penaz' principle. The method is based on concentrically interlocking control loops for correct long-term tracing of finger BP, including automatic set point adaptation, light control and separate inlet and outlet valves for electro-pneumatic control. Examples of long-term BP recordings at rest and during autonomic function tests illustrate the potential of the new instrument.

Nitric oxide synthase (NOS) inhibitors are considered promising as a therapeutic option in severe septic shock. The aim of this study was to investigate the effects of N ω -nitro-L-arginine methyl ester (L-NAME) application on neutrophil (PMN) respiratory burst, phagocytosis, and elimination of Escherichia coli from blood and tissue in rabbits. Twenty-eight female chinchilla rabbits were randomized to a treatment and control group. To quantify the bacterial clearance process, 10 8 colony forming units (CFU) of E. coliwere injected intravenously into anesthetized rabbits. Animals in the L-NAME group had a significantly higher mortality compared with controls. NOS inhibition resulted in a significant delay of bacterial clearance (P < 0.001). These findings correlated with a significant augmentation of all organ E. coli findings (P= 0.002-0.035). PMN phagocytosis activity was notably reduced by L-NAME treatment during the experimental observation. Neutrophil burst, on the other hand, was amplified by NOS inhibition (P = 0.008). Our findings point to an interference with the PMN-dependent immune mechanisms after L-NAME treatment. The augmented PMN burst reaction could be a compensatory mechanism, potentially leading to tissue damage. Therefore, in this model, we find sufficient evidence pointing to a possible cause for the deleterious effect of early nonselective NOS inhibition in critically ill patients.