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Acute renal failure after major abdominal surgery is a severe complication in critically ill patients in intensive care units (ICU). The aim of the study was to investigate the effect of urodilatin on the peak value and course of serum creatinine in patients with acute renal insufficiency after major abdominal surgery and the necessity of apparatus-based renal replacement treatment. Furthermore, the incidence and nature of adverse events under urodilatin was documented. In a prospective randomized double-blind placebo-controlled study, 12 critically ill patients after major abdominal surgery with acute renal failure in an intensive care unit (ICU) received 20 ng/kg b.w./min urodilatin (ularitide, INN) or placebo in addition to the standard diuretic therapy or low-dose dopamine (2.5 micrograms/kg b.w./min) and furosemide (1000 mg/24 hr) for a minimum of 96 hours. All patients received mechanical ventilation. Both groups had similar serum creatinine values on the day before the onset of urodilatin/placebo infusion (2.80 +/- 0.24 mg/dl, 2.93 +/- 0.48 mg/dl). Peak serum creatinine was lower in the urodilatin group (4.65 +/- 0.57 mg/dl) compared to vehicle treatment (5.78 +/- 1.58 mg/dl), although the difference did not reach statistical significance (P = 0.148). The total number of hemodialyses due to oligo-/anuria and/or hyperkalemia was the same in both groups during the study. In 4 patients of the placebo group, diuresis was reduced to anuria, whereas only 1 of the patients treated with urodilatin became anuric. No hemodynamic side effects or adverse events due to urodilatin were observed. This clinical study under double blind conditions revealed that the addition of urodilatin to the standard diuretic therapy of low-dose dopamine and furosemide failed to improve renal function in patients with established acute renal failure and that urodilatin did not eliminate the need for apparatus-based renal replacement treatment.

Neurogenic inflammation is evoked by neuropeptides released from primary afferent terminals and, presumably, by other secondarily released inflammatory mediators. This study examines whether prostaglandins might participate in the development of neurogenic inflammation in humans and whether cyclooxygenase inhibitors have any anti-inflammatory effect on this type of inflammation. In healthy volunteers, neurogenic inflammation was elicited by epicutaneously applied capsaicin (1%), after systemic pretreatment with acetylsalicylic acid, or topically applied indomethacin compared to pretreatment with saline or vehicle, respectively. The extent of neurogenic inflammation was quantified by planimetry of visible flare size and recording the increase of superficial cutaneous blood flow (SCBF) with a laser Doppler flowmeter. Capsaicin-induced flare sizes and outside SCBF (both representing neurogenically evoked inflammation) were unaffected by acetylsalicylic acid or indomethacin. Only the capsaicin-induced increase of inside SCBF was attenuated by local pretreatment with indomethacin, reflecting the participation of prostaglandins in the inflammatory response of those areas which were in direct contact with capsaicin.

Capsaicin applied to human skin provokes a response known as neurogenic inflammation. Neuropeptides (substance P, CGRP), released from afferent C-fiber terminals and histamine, secondarily released from mast cells, are supposed to participate in this reaction. We investigated the contribution of arachidonic acid and metabolic products to neurogenic inflammation, using a potent topically applied glucocorticoid and the corresponding vehicle. Arachidonic acid is liberated from membrane phospholipids by phospholipase A2, an enzyme that can be blocked by glucocorticoids. In 12 healthy volunteers, neurogenic inflammation was induced by capsaicin 1% on both upper forearms after 16 h of topical pretreatment with either prednicarbate or vehicle. Neurogenic inflammation was assessed by laser Doppler flowmetry and by planimetry of flare sizes. Prednicarbate significantly reduced the laser Doppler flow values inside the flare responses, as well as the flare sizes themselves. These results show that to some extent glucocorticoids reduce capsaicin-induced neurogenic inflammation.

A case of tuberculous meningitis in a 2-year-old boy is reported. The main critical care problems are irregular breathing, raised intracranial pressure and syndrome of inappropriate secretion of antidiuretic hormone. Cranial CT-Scan and ventricular shunting are shown to be of high importance for this disease.

This study compared both etomidate and methohexitone for intravenous anaesthesia with alfentanil and nitrous oxide/oxygen in 2 X 20 patients scheduled for ENT-surgery, in a double blind, random fashion. Apart from the alternative use of etomidate and methohexitone the anaesthetic procedure did not differ: After a small dose of alfentanil anaesthesia was induced by a bolus dose of the hypnotic followed by a continuous infusion of the drug. In case of inadequate analgesia alfentanil was injected. This technique provided a good quality of anaesthesia and a remarkable cardiovascular stability. Critical arterial pressures or heart rates never occurred. During the operation patients receiving etomidate exhibited a moderate rise in blood pressure and a significantly lower heart rate than patients anaesthetised with methohexitone. After some 90 min of anaesthesia patients awoke on the average 7 min after the end of the operation and could be extubated at once. During the first three postoperative hours there was no difference in recovery between groups. Whereas half an hour postoperatively the capacity of immediate memory was limited to 44 bit following etomidate and 48 bit following methohexitone, i.e. to 47 and 54% of its normal capacity, there was only a minimum but significant impairment of cerebral function after 3 h. There was no difference in the need for alfentanil. The dosage of etomidate and methohexitone was lowe than that reported in the literature. It proved to be impossible for the anaesthetist to decide which drug he was using. Hence both anaesthetic techniques compare favourably with each other.

The heart rate of anaesthesiologists under defined physical and psychological stress as well as during normal anaesthetic practice was studied. An acceleration of heart rate during induction and management of anaesthesia did not occur except in the presence of complicating circumstances. A phone call or a beeper alarm led to a rather ergotropic heart rate reaction (increase of 21%), especially when sleep was interrupted (increase of 75%). Locomotion for a professional reason, whether urgent or not, enhanced the heart rate up to 121/min. A simultaneous subjective feeling of psychological stress had no additional effect. The heart rate during the treatment of life-threatening situations remained at 109/min and often exceeded that of exhaustive running. The mean heart rate during the normal narcotic programe (90/min) was not uncommon and comparable with that of other surgical disciplines. However an increasing tolerance was seen with growing experience. Physical and psychological stress during the anaesthesiologist's work could be differentiated by means of heart rate except in some single observations. In the presence of both stressing factors the heart rate seems to be determined by the motor effort required.

Each of 24 patients undergoing transurethral prostatectomy under spinal anaesthesia received 1000 ml HES and, depending from the clinical situation, some patients received blood-transfusion. Afterwards two groups were formed: group A (11 patients), who received HES only, and group B (13 Patients) with additional blood-transfusions. The following parameters were monitored simultaneously: blood pressure, heart rate, stroke index, cardiac output, active blood volume, hemoglobin and hematocrit in whole blood as well as in the irrigatin fluid of the bladder. They showed HES to be a useful plasma substitute for older patients. It is well tolerated and has a slow stabilising effect on circulation, which was effective for several hours. Furthermore, HES-infusion reduced the average need of bloodtransfusion by 500 ml.

The clinical course and the treatment of a case of severe haemolytic ABO-incompatibility are described. In addition to the routine therapy 3 times 2000 units of haptoglobinconcentrate were given since it is known according to the literature to metabolize free haemoglobin. The clinical result seems to confirm the beneficial effect. The course remained free of complications and the hospital stay was not prolonged. Further clinical experience is needed to confirm the effectiveness of the treatment with haptoglobin in cases with severe haemolysis.

Intestinal dysfunction is well known after narcotic analgesics and anaesthetics. The site and extent of this action is not really known in man. We investigated the direct effect of morphine, thiopentone and droperidol on human taenia libera in vitro. The spontaneous motility of strips of fresh resected human taenia libera induced by a suitable preload was observed by isometric measurement of developed tension. Cumulative doses of morphine 1 X 10(-8) - 3.89 X 10(-6) g/ml, thiopentone 2.5 X 10(-6) - 9.75 X 10(-5) g/ml or droperidol 2.5 X 10(-8) - 9.72 X 10(-6) g/ml were added to the bath solution. The following parameters were analysed: amplitude, frequency and performance (Montevideo Units MU) of the spontaneous contractions and also the basal tone between contractions. Morphine showed no effects. Thiopentone reduced basal tone to 45.5% of the initial value and frequency to zero. The amplitude of contractions and the MU decreased with thiopentone more than 22.5 X 10(-6) g/ml. All effects are reversible. Droperidol has no significant effects with the exception of a light increase of frequency in high doses. The well known in vivo effect of morphine is therefore not induced by direct action on the smooth muscle of human intestine. Thiopentone in high dose can reduced intestinal motility by direct action on the smooth muscle. Droperidol in the dose used is probably without clinical relevance.

In five patients with acute respiratory insufficiency the changes in tracheal pressure (P), lung volume (V) and transthoracic electric impedance TEI (Z) were measured during delayed expiration all over the inspiratory capacity (IC) from TLC to FRC. The quasi-static V/Z- and Z/P-curves were two-dimensionally displayed, and the Z/P-curve was volume-calibrated on the Y-axis (Z) using the linear V/Z-relationship. During high-frequency jet ventilation (HFJV, 200/min), the Z- and P-excursions were displayed on the "frozen" Z/P-curve as flat discs. By well-aimed increase in driving pressure and I/E-ratio the unknown FRC was enhanced in 4 stages (I-IV) by 0.33 IC, 0.5 IC, 0.66 IC and 0.75 IC, to measure haemodynamic reactions 10 minutes later (Swan-Ganz catheter). The pulmonary vascular resistance remained unchanged between stage I and II. It changed moderately in stage III (+14%) and was found to be markedly increased in stage IV (+45%). The increase in PVR was well parabolically correlated (r = 0.88) to the fraction of IC by which FRC was expanded. In a previous study a very similar function could be documented by us for the end-inspiratory lung volume during conventional PEEP ventilation. Concomitant to the increase in PVR the CI fell linearilly (r = 0.95). We conclude from our results: 1. TEI may be of value in monitoring HFJV. It offers the possibility to measure the increase in lung volume ("PEEP effect") and to titrate it deliberately within the usable volume range IC. 2.(ABSTRACT TRUNCATED AT 250 WORDS)

This study was designed to differentiate possible amnesic effects of diazepam, flunitrazepam and fentanyl into impairment of storage, retention or retrieval of information and to correlate them with alterations in a vigilance task. 4 groups of 7 volunteers each were studied in a double-blind, random fashion. They performed a quasi continuous word recognition task i.e. after a preload list of 150 words played on a tape they had to indicate if the following words (grouped into 10 blocks of 100 words each) were new ones or had occurred already. Interposed were measurements of reaction time to a visual stimulus, and of concentration and short-time memory. During the experiment, unknown to the test person, diazepam 10 mg/70 kg, flunitrazepam 1 mg/70 kg, fentanyl 0.15 mg/70 kg or placebo were infused over 3 min. For evaluation of the word recognition task the d' index drawn from signal detection theory was employed. The results clearly indicated that both benzodiazepines specifically impair memory function the effect of flunitrazepam being more pronounced and longer in duration. Since retrieval of information learnt before administration of either drug was completely unaffected it was concluded that both drugs specifically influence encoding and registration of information. Reaction times were not significantly altered after diazepam, whereas they were prolonged by more than 50% after flunitrazepam indicating a pronounced sedative action of this drug. However, even during this period of maximal effect of flunitrazepam, recognition of words first presented prior to injection was not impaired.(ABSTRACT TRUNCATED AT 250 WORDS)

Eighty women undergoing surgery of at least 2-h duration were randomly allocated to receive either alfentanil or fentanyl to supplement a diazepam nitrous oxide/oxygen anaesthetic. Anaesthesia was induced with fentanyl 0.2 mg and diazepam 10-20 mg and continued with nitrous oxide/oxygen. Analgesia was provided by injection of the narcotic using unlabelled ampoules that contained either alfentanil 0.5 mg ml-1 or fentanyl 0.05 mg ml-1. Apart from a marginally higher heart rate when alfentanil was used, there was no significant difference between groups at any time during the operation. Patients woke 2.7 +/- 3.1 min following discontinuation of nitrous oxide and were extubated after 10.3 +/- 7.6 min (alfentanil) and 17.3 +/- 19.0 min (fentanyl) (P = 0.1). However, following alfentanil significantly more patients could be extubated within 20 min to 30 min after completion of the operation (P less than 0.01). The last top-up dose of alfentanil had to be given nearer the end of the operation than the last dose of fentanyl (P less than 0.01). Patients receiving alfentanil needed significantly more (P less than 0.01) post-operative analgesia.

In this study the hypothesis was tested that the substituent at the C 2 position of the barbiturate molecule is crucial for the obvious differences in inhibitory potencies between various barbiturates with respect to neutrophil functions in vitro. Using isolated neutrophils from healthy volunteers, the comparative effects of two pairs of sulphur or oxygen-substituted analogues on chemiluminescence, random and chemotactic migration were examined. Five other i.v. barbiturates were also tested in the chemiluminescence assay. The key observation with all the assay systems was that the oxybarbiturates proved ten to a hundredfold less suppressive than their sulphurated analogues or the other thiobarbiturates. Thus, enhanced inhibitory potency was dependent on the presence of the sulphur atom in the barbiturate molecule and could no longer be explained exclusively on the basis of divergent physicochemical features.

Methodological differences between techniques used to examine recovery from anesthesia prevent direct comparison of results. Also psychological tests are not validated for certain anaesthesiological considerations. The two tests presented here combine ease of use for a bedside test with the advantage that the results are expressed as absolute values of cerebral depression. Based on Wieck's concept of symptomatic or functional psychosis they were developed to document the course of neuropsychiatric illness. Their application following anaesthesia seems to be justified as anaesthesia may be regarded as being a deliberately induced functional psychosis characterized by extremely compressed dynamics. The target of a first pilot study were 60 patients following neuroleptanalgesia with and without antagonization with naloxone, or enflurane anaesthesia, respectively. Psychopathometric evaluation yielded an obvious post-operational decline in the SKT-scores which clearly remained below the pre-operative values even after three hours. All the patients revealed a severe transient syndrome after thirty minutes, a moderate syndrome after one and two hours and a mild syndrome after three hours. The only exception were patients antagonized with naloxone who initially showed an improvement but who afterwards did not behave any better. Neither duration of anaesthesia nor total dose of drugs administered showed any significant correlation to the extent of postoperative cerebral depression. Being uninfluenced by moderating variables such as age and IQ, the psychopathometric tests presented here seem to provide a sensitive and reliable method for quantification of recovery from anaesthesia.

In 1986 the discussion on the further use of halothane broke out anew, especially after the Bristol symposium and the European Congress of Anesthesiology in Vienna. Everywhere there is great uncertainty on whether or not halothane should continue to be used. A critical analysis of the literature shows that there are two standards applied to halothane. When judged by the same stringent criteria as halothane other anesthetic techniques are also dubious, e.g. neuroleptanesthesia or epidural block. Finally, experience with isoflurane, the strongest rival of halothane, is not adequate to warrant abandoning halothane, especially as long as the question of coronary steal is still open. At present there is no solid scientific basis for vanishing halothane.

Tramadol-HCl was used clinically in the form of a continuous infusion as the analgesic component of a balanced anaesthetic technique. In over 90% of the anaesthetics a further injection of barbiturate and/or supplementary muscle relaxant was necessary because the patients did not tolerate the operative procedure. Although a higher dosage of Tramadol reduces significantly the supplementary barbiturate dosage per kilogram bodyweight per minute which is required, it has no effect on the incidence of reflex movements, nor does it prevent the marked intraoperative rise of diastolic blood pressure. The balanced anaesthetic with Tramadol-HCl is characterized by prompt awakening, total amnesia, good post-operative analgesia and minimal side effects (occasional nausea). In particular, there was no case in which there was noticeable respiratory depression. As insufficient analgesia and hypnosis is provided by Tramadol-HCl, making the administration of muscle relaxants and barbiturates obligatory, there is no significant advance in our technique of using Tramadol-HCl, despite the advantages which have been outlined.

A case of oesophageal perforation after extraction of a foreign body from the hypopharynx of a 14-month-old boy is reported. General anaesthesia is shown to be of high importance for the extraction of foreign bodies in infants.

The course of the illness of a 56 year old female patient is reported, who is still surviving one and a half years after developing advanced, presumably progressive, so called "shock-lung syndrome". Following two episodes of hemorrhagic shock due to intestinal hemorrhage and post-operative secondary hemorrhage, interstitial lung edema developed, which was resistant to therapy. During the following weeks this was followed by bronchopneumonia with symptoms of sepsis persisting over several weeks. Between the third and seventh week of artificial ventilation X-ray of the lungs showed significant progressive changes of the interstitial tissues. This correlated with a progressive deterioration in gas exchange for O2 and CO2, which reached its peak in the seventh week with a paO2 of 71 mm Hg at a FIO2 = 1 and a paCO2 of 68 mm Hg at a minute volume of 15,51. The compliance of lung and thorax was severely reduced at 19 m1/cm H2O. At this apparently unfavourable time the patient was weaned off the respirator, and subsequently, over a period of three weeks, from oxygen insufflation. After eleven weeks of therapy, transfer to the medical ward was possible, with discharge from the hospital following three weeks later. The lung function tests at the time of discharge revealed a high grade reduction of all lung volumes and capacities without a significant obstructive component. The findings have shown a definite improvement during the following one and a half years. In retrospect the polypragmatic intensive therapy measures do not allow valid generalised therapeutic guidelines to be derived. We conclude, however, from this single observation, that therapeutic nihilism is not justified even in a progressive shock-lung syndrome which appears clinically and radiologically to be at an "irreversible" end stage.

Polygeline (haemaccel 35 Behringwerke) was tested in 1147 patients in a prospective and multicentre study facing systemic anaphylactoid or cutaneous anaphylactoid side effects. 8 patients showed mainly cutaneous reactions (redness and itchy swelling) and only one an increase of ventilating pressure during anaesthesia (0.78%). Polygeline showed according to an improved preparation unexpected reactions only of the cutaneous anaphylactoid type (no severe systemic life threatening reaction, histamine liberation 1 ng/ml or less according to Lorenz).

Isolated human taenia libera shows spontaneous motility in the organ bath. The active basal tone, force development and frequency of spontaneous contractions and total power parameter "Montevideo Units" were first analysed under control conditions. Halothane lowered the active basal tone, frequency and the total power of the muscle strip in a dose-dependent manner. The amplitude and force of contraction of human taenia libera first began to increase under halothane, attaining its maximum at 1.0 vol.%. Halothane concentrations above 1.5 vol.% at first caused a depression and finally abolished spontaneous motility. The changes in the spontaneous motility pattern brought about by halothane were completely reversible. Possible causes for the halothane effect were considered as to the possible relevance to the in vivo situation.