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Objective: : Aim of this study was to evaluate the perioperative hemodynamic function using an apical suction device (Xpose = XS) versus standard pericardial retraction sutures (PS) during off-pump myocardial revascularization., Methods: : Twenty-seven consecutive patients (four female) with three-vessel disease receiving off-pump myocardial revascularization were prospectively evaluated. Mean age was 70 ± 8 years and mean ejection fraction was 55 ± 18%. Pulscontour continuous cardiac output, Swan Ganz catheter, and transesophageal echo measurements were performed. All patients received left internal mammary artery (LIMA)-left anterior descending grafting first. The XS or PS technique for marginal or right coronary artery branch exposure was used and after hemodynamic recovery the same measurements were performed using the other technique, thus each patient served as an intraindividual control. Finally, the anastomosis was performed in the respective territory., Results: : All procedures were completed as off-pump coronary artery bypass without perioperative complications. The mean confidence interval (L/min/m)/mean arterial pressure (mm Hg) was 2.8 ± 0.5/87 ± 11 after opening the pericardium and 2.4 ± 0.4/75 ± 12 during left anterior descending exposure. During lateral wall exposure, it was 1.8 ± 0.6/67 ± 12 using XS and 1.9 ± 0.6/68 ± 12 using PS (P = ns). During inferior wall exposure, it was 2.1 ± 0.4/69 ± 12 using XS and 1.9 ± 0.4/68 ± 13 using PS (P = ns). No significant differences were seen comparing other parameters (cardiac output (CO), heart rate (HR), intrathoracic blood volume index) as well., Conclusions: : The lateral and inferior coronary arteries can be safely exposed on the beating heart with PS or XS technique. In individual patients, either XS or PS exposure yielded a better preservation of cardiac index and blood pressure compared with baseline.

Purpose: We report about 5 cases of "puerperal sepsis" to elucidate the clinical significance and resulting therapeutic management of Sepsis, SIRS (Systemic inflammatory response syndrome) and MODS (Multiple organ dysfunction syndrome), whose definitions were introduced at the Consensus Conference of the American College of Chest Physicians/Society of Critical Care Medicine in 1992., Results: All patients had documented endomyometritis, 3 of them in combination with ovarian vein thrombosis. None of the patients responded adequately to conservative treatment with antibiotics and intravenously applied Heparin. After 12 to 72 hours, because of clinical deterioration, all women underwent laparotomy with hysterectomy combined with an ovarectomy in 3 cases. Although the inflammatory "septic" source was removed by the surgical intervention, the clinical condition of 3 of the patients further deteriorated; they were suffering from SIRS, and 2 developed MODS. Symptoms of MODS were DIC, hypotension, kidney failure and encephalopathy., Conclusions: Our results support the theory that infection or trauma may initiate an endogenous inflammatory response which could progress to MODS even after removal of the initial source. Our findings, however, do not support the view that septic endomyometritis and postpartum ovarian vein thrombosis should be treated nonsurgically, because the clinical course in our patients was less complicated the earlier the surgical intervention was initiated.

The HELLP syndrome (haemolysis, elevated liver enzymes, low platelet count) was first referred to by Weinstein in 1982 as an extremely progressive form of gestosis. In addition to the more common gestotic symptoms, such as oedema, proteinuria and hypertension, the clinical picture is characterized by microangiopathic haemolysis, thrombocytopenia and, especially, impaired hepatic function. Within this clinical picture severe complications can occur, such as eclamptic attacks, renal dysfunction, intracranial haemorrhage, intrahepatic haemorrhage and coagulopathy. An imbalance in prostanoid metabolism has been implicated in the pathogenesis. A decrease in synthesis of the vasodilator and thrombocyte aggregation inhibitor prostacyclin leads to a preponderance of the vasoconstrictor thromboxane A2, which promotes thrombocyte aggregation. This results in local vascular spasms and endothelial lesions, which in the case of hypercoagulopathy are accompanied by the formation of fibrin deposits with resultant vascular constriction. Intravascular fibrin deposits indicate that the coagulation system has been compromised and can lead to consumption coagulopathy in approximately 10% of cases. In the majority of cases, however, one finds low-grade disseminated intravascular coagulation (DIC), i.e. mild hypercoagulopathy with thrombocytopenia, a tendency to thrombocyte aggregation and fibrinogen deficiency in the presence of usually normal plasmatic coagulation. These vascular changes occur particularly in organs that have high blood flow, such as liver, kidneys and placenta. In the liver, sinusoidal obstruction causes vascular congestion, leading to an increase in intrahepatic pressure, dilatation of Glisson's capsule, development of subcapsular hepatic haematomas and hepatic rupture. Hepatic haematoma virtually always requires surgical treatment, and otherwise the patient has hardly any chance of survival. Nevertheless, mortality is around 35%.(ABSTRACT TRUNCATED AT 250 WORDS)

O2-uptake was measured continuously in 18 polytraumatized and 21 long-term ventilated patients. All patients were on assisted ventilation with sufficient sedation and analgesia. O2-uptake was measured every minute, the values were recorded over 24 h and the mean O2-uptake/min was calculated. At the same time, the O2-uptake of the last 15 min of every hour was measured separately (e.g. 7.45-8.00, 8.45-9.00, etc.). The mean O2-uptake/min measured continuously was compared and correlated with the mean O2-uptake per day, calculated on the basis of each of the short-term measurements. There were only slight differences between the mean values of the two procedures: In the group of long-term ventilated patients the mean O2-uptake was found to be 364 ml/min in continuous measurements and 363 ml/min in short-term measurements. This O2-uptake corresponded to an energy expenditure of 2360 kcal/day. The mean correlation coefficient was 0.89 (range: 0.79-0.96). If O2-uptake was measured over 2 periods of 15 min each, e.g. in the late morning and in the afternoon, the mean correlation coefficient improved to 0.94 and the standard deviation was reduced. Comparable results were obtained in the group of polytraumatized patients. This study shows that under certain preconditions short-term measurements of O2-uptake of 2 x 15 min allow sufficiently reliable predictions of the daily O2-uptake and energy expenditure in severely traumatized or critically ill patients.

The aim of the study was to use glucose, fructose and xylitol as alternative carbohydrates in hypocaloric parenteral nutrition (HPN) and to investigate their different nutritional effects. Twenty-four patients who had undergone elective gastrointestinal resection were examined in a prospective randomized study. Only metabolically normal patients between 30 and 65 years of age were admitted to the study. No patient with a body weight more than 20% above or below the normal weight of the patients was admitted. The study period extended from the operation day to the fifth postoperative day. The patients were given approximately 1.1 g amino acids and approximately 2.9 g carbohydrates per kg/B.W. and day using either glucose, fructose or xylitol as carbohydrates. The mean plasma glucose concentrations ranged between 6 and 8 mmol/l without insulin being supplied. There were no significant differences between the groups. However, the administration of glucose led to a somewhat larger dispersion range of the values. The labile plasma proteins (transferrin, prealbumin, retinol-binding protein) in the 3 groups revealed almost identical concentration courses. With N-losses between 51 and 57 g/4 days, only slightly negative cumulative N-balances were calculated (-4 to -13 g/4 days). No significant differences were observed between the 3 groups in the level of the urea-N production rates. Advantages which favor a general administration of fructose/sorbitol or xylitol in HPN could not be found in our investigation.