Aims The aim of this study was to assess the guideline-adherent feasibility of area-wide primary angioplasty in rural German surroundings and its impact on reperfusion and outcome in patients with acute ST-elevation myocardial infarction (STEMI). Methods and results All consecutive patients with acute STEMI ( n = 347) admitted to any of the hospitals (5 non invasive and 1 invasive with established 24 h/7 days primary angioplasty service) in a 350.000 inhabitant rural area during the year 2002 ( n = 184) and 2005 ( n = 163) were included in this registry. In 2002, emergency medical services transferred acute STEMI patients to the nearest emergency room, where reperfusion therapy (fibrinolysis or primary angioplasty) was organised. In 2005, all patients were transferred directly to the cathlab bypassing any emergency room when possible. Primary angioplasty increased from 53 to 89% ( p < 0.01), fibrinolysis decreased from 27 to 2% ( p < 0.01) and the no revascularisation rate from 21 to 9% ( p < 0.01). Onset of pain to balloon time in primary angioplasty was reduced from median 339 to 191 min ( p < 0.01), median first medical contact to balloon time in 2005 was 101 min. Overall, 6-month mortality decreased from 19 to 10% ( p = 0.03). Conclusions After transition to a uniform primary angioplasty concept, an increase in overall reperfusion rates and a decrease in time delays could be observed in a rural German infarction network.

Berichtet wird der Fall einer 77-jährigen Patientin mit akut aufgetretenen Thoraxschmerzen und hämorrhagischem Pleuraerguss. Statt der vermuteten Aortendissektion fand sich eine spontane Ösophagusruptur. Ein zuvor stattgehabtes Erbrechen wurde erst auf Nachfrage berichtet. Das seltene Boerhaave-Syndrom wird differenzialdiagnostisch initial oft nicht bedacht, Fehldiagnosen sind häufig. Die Prognose hängt entscheidend von einer raschen Diagnosestellung ab. Eine operative Sanierung ist die Therapie der Wahl.

! The 48-year-old woman was found unresponsive and hypotensive with broad QRS, assuming an attempted suicide with Class I antiarrhythmic drugs. Cardiopulmonary resuscitation and advanced life support were sustained for 90 minutes. Following intravenous hypertonic saline and sodium bicarbonate the patients QRS narrowed and haemodynamics could be restored. Flecainide intoxication was approved by elevated serum level. The patient survived without neurological sequelae. Intoxication with Class I antiarrhythmic drugs should be considered in cases of cardio-genic shock with broad QRS-ecg

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Die Beatmung ist heutzutage ein wichtiger Bestandteil der intensivmedizinischen Therapie. Dem Intensivmediziner stehen eine Vielzahl von Beatmungsformen und Respiratoren zur Verfügung. Diese ermöglichen den individuellen patientenadaptierten Einsatzgeeigneter Atemhilfen von Beginn der Beatmung bis zur Respiratorentwöhnung. Dabei ist das Ziel, die Adaptierung der Atemhilfe an die Bedürfnisse des Patienten und nicht umgekehrt. Mit Wissen um die Risiken der künstlichen Beatmung sollten alle Maßnahmen zum Ziel haben, die Rückkehr des Patienten zu einer suffizienten Eigenatmung zu ermöglichen.

ZusammenfassungIn der Frühphase des akuten Lungenversagens verursachen inflammatorische Mediatoren eine Permeabilitätsstörung an der alveolo-kapillären Membran. In der Folge entsteht ein nicht-kardiales Lungenödem. Die alveolo-kapilläre Membran wird für Makromoleküle permeabel und der mikrovaskuläre Druck wird entscheidend für das Ausmaß der transvaskulären Flüssigkeitsfiltration. Determinanten des mikrovaskulären Druckes sind der linksatriale Druck, der postkapilläre Lungengefäßwiderstand und das Herzzeitvolumen. Die transvaskuläre Flüssigkeitsfil tration kann durch Negativbilanz nur dann effektiv verringert werden, wenn das Herzzeitvolumen sinkt. Die Abnahme des Herzzeitvolumens birgt die Gefahr der Splanchnikusischämie mit bakterieller Translokation und des akuten Nierenversagens. Deshalb darf eine Negativbilanz nur dann erfolgen, wenn der Kreislauf stabil ist und wenn eine Hypovolämie vermieden wird. Beim Volumenersatz scheinen kristalloide Lösungen Vorteile gegenüber kolloidalen Lösungen zu haben.

Background Thiopental is frequently used for the treatment of intracranial hypertension after severe head injury. Its long-term administration increases the incidence of nosocomial infections, which contributes to the high mortality rate of these patients. However, the mechanism of its immunosuppressing effect remains unknown. Methods The effect of thiopental (200-1000 microg/ml) on the activation of the nuclear transcription factor kappaB (NF-kappaB; electrophoretic mobility shift assays), on NF-kappaB-driven reporter gene activity (transient transfection assays), on the expression of NF-kappaB target genes (enzyme-linked immunoassays), on T-cell activation (flow cytometric analyses of CD69 expression), and on the content of the NF-kappaB inhibitor IkappaB-alpha (Western blotting) was studied in human T lymphocytes in vitro. Results Thiopental inhibited the activation of the transcription factor NF-kappaB but did not alter the activity of the cyclic adenosine monophosphate response element binding protein. Other barbiturates (methohexital), anesthetics (etomidate, propofol, ketamine), or opioids (fentanyl, morphine) did not affect NF-kappaB activation. Thiopental-mediated suppression of NF-kappaB could be observed in Jurkat cells and in primary CD3+ lymphocytes from healthy volunteers, was time- and concentration-dependent, occurred at concentrations that are clinically achieved, and persisted for hours after the incubation. It was associated with an inhibition of NF-kappaB-driven reporter gene activity, of the expression of interleukin-2, -6, and -8, and interferon gamma, and of the activation of CD3+ lymphocytes. Suppression of NF-kappaB appeared to involve reduced degradation of IkappaB-alpha. Conclusion The results demonstrate that thiopental inhibits the activation of NF-kappaB and may thus provide a molecular mechanism for some of the immunosuppressing effects associated with thiopental therapy.

Objective Repeated collapse and reopening of alveoli have been shown to aggravate lung injury, which could be prevented by positive end-expiratory pressure (PEEP). Yet, how to adjust optimum PEEP is a matter of debate. We suggest a new strategy to adjust PEEP, which is based on the analysis of the intratidal compliance-volume curve. This approach was compared with a strategy based on the static pressure-volume curve. Furthermore, two other ventilator settings were investigated. One served as a negative control likely to provoke atelectasis, and the other was expected to induce overdistension. Design Prospective, randomized block design. Setting Laboratory. Subjects Isolated, perfused, and ventilated rabbit lungs. Interventions Tidal volumes of 8 mL/kg of body weight were used throughout. After stabilization, the lungs were randomized to one of four protocols (lasting 120 mins; n = 6 per group). Group 1 was ventilated at zero end-expiratory pressure. In group 2, PEEP was set above the lower inflection point of the static pressure-volume curve. In group 3, adjustment of PEEP was based on the intratidal compliance-volume curve, as determined by the slice method. In group 4, increasing PEEP levels ensured a plateau airway pressure of 20–25 cm H2O likely to provoke overdistension. Measurements and Main Results The ventilation/perfusion (&OV0312;a/&OV0422;) distribution was analyzed by the multiple inert gas elimination technique. Alveolar derecruitment was indicated by shunt and low &OV0312;a/&OV0422; areas as observed in group 1. In groups 2 and 3, &OV0312;a/&OV0422; data initially indicated full recruitment. In contrast to group 3, shunt increased in group 2 near completion of the experiments. Group 4 showed complete recruitment, but the &OV0312;a/&OV0422; distribution included high &OV0312;a/&OV0422; areas. Conclusions The intratidal compliance-volume curve represents a rational basis for adjusting PEEP in the isolated lung model. Because this strategy does not require invasive measures and facilitates continuous assessment of ventilator settings, it may be of clinical interest.

The aim of the present study was to investigate the feasibility and efficacy of bronchoscopic surfactant administration in a noncontrolled multicentre study in five university centres.A total number of 27 patients, suffering from severe acute respiratory distress syndrome (mean±sem lung injury score: 3.15±0.06) and septic shock (Acute Physiology and Chronic Health Evaluation (APACHE) II score at study entry 33.2±1.3, lactate 4.3±0.6 mmol·L−1) were studied. The patients were ventilated with a mean tidal volume of 11.0±0.5 mL·kg−1body weight (bw), either volume or pressure controlled, with 16.3±2.8 cmH2O positive end-expiratory pressure, for an average of 3.5±0.3 days at study entry. A natural bovine surfactant extract (300 mg·kg−1bw Alveofact®; mean total volume 378 mL) was delivered in divided doses to each segment of the lungsviaflexible bronchoscope within ∼45 min.No untoward effects on gas exchange, lung mechanics and haemodynamics were noted during the procedure of surfactant administration. Within 12 h the oxygen tension in arterial blood/inspiratory oxygen fraction increased from a mean of 109±8 mmHg to 210±20 mmHg (p<0.001). In seven patients, in whom gas exchange again deteriorated with further progression of the disease, a second surfactant dose of 200 mg·kg−1was administered 18–24 h after the first application, again improving arterial oxygenation. A total of 15 patients survived the 28-day study period (mortality rate 44.4%, compared to a calculated risk of death for the given APACHE II scores of 74.0±3.5%), with all causes of death being nonrespiratory. The bronchoscopic application of a high dose of natural surfactant in patients with severe acute respiratory distress syndrome and septic shock is both feasible and safe, resulting in a pronounced improvement in gas exchange.

Objective Atelectatic alveoli can be recruited or kept open either by sustained inflation maneuvers or by positive end-expiratory pressure (PEEP). Little is known about potential interactions between both approaches. Especially, it is not known whether the recruiting effect of sustained inflation maneuvers is maintained in combination with a low PEEP, as suggested recently. In an attempt to answer this question, we combined sustained inflation maneuvers with either high or low PEEP. Both approaches were compared with a strategy likely to result in alveolar atelectasis and with another ensuring adequate alveolar recruitment by adjustment of PEEP alone. Design Randomized block design. Setting Laboratory. Subjects Isolated perfused rabbit lungs (n = 28). Interventions The lungs were ventilated with a tidal volume of 8 mL/kg. After stabilization, the lungs were randomized to one of four ventilatory strategies, which then were followed for 120 mins: a) PEEP 1 cm H2O (PEEP1, negative control); b) PEEP 1 cm H2O and 30 sec-sustained inflations (20 cm H2O) every 30 mins (SI-1); c) PEEP 3 cm H2O combined with sustained inflations (SI-3); and d) PEEP repeatedly adjusted following a previously established strategy ensuring full alveolar recruitment (DYN, positive control). Measurements and Main Results Distribution of ventilation and perfusion (&OV0312;a/&OV0422; distribution) was analyzed by the multiple inert gas elimination technique. Volume-dependent compliance within the tidal volume was determined by using the slice method. Shunt and &OV0312;a/&OV0422; mismatch significantly differed between SI-1 and SI-3, indicating full alveolar recruitment only in the latter. Data of SI-1 did not differ substantially from those of PEEP1, and data obtained in SI-3 were similar to those of DYN. Conclusions First, enduring alveolar recruitment by sustained inflation maneuvers is only possible when the alveoli are stabilized thereafter by sufficient PEEP. Second, a ventilation strategy that uses repeated sustained inflations on a comparably high PEEP may not be superior to adequate adjustment of PEEP alone.

OBJECTIVE:Volume-dependent alterations of lung compliance are usually studied over a very large volume range. However, the course of compliance within the comparably small tidal volume (intratidal compliance-volume curve) may also provide relevant information about the impact of mechanical ventilation on pulmonary gas exchange. Consequently, we determined the association of the distribution of ventilation and perfusion with the intratidal compliance-volume curve after modification of positive end-expiratory pressure (PEEP). DESIGN:Repeated measurements in randomized order. SETTING:An animal laboratory. SUBJECTS:Isolated perfused rabbit lungs (n = 14). INTERVENTIONS:Surfactant was removed by bronchoalveolar lavage. The lungs were ventilated thereafter with a constant tidal volume (10 mL/kg body weight). Five levels of PEEP (0-4 cm H2O) were applied in random order for 20 mins each. MEASUREMENTS AND MAIN RESULTS:The intratidal compliance-volume curve was determined with the slice method for each PEEP level. Concurrently, pulmonary gas exchange was assessed by the multiple inert gas elimination technique. At a PEEP of 0-1 cm H2O, the intratidal compliance-volume curve was formed a bow with downward concavity. At a PEEP of 2 cm H2O, concavity was minimal or compliance was almost constant, whereas higher PEEP levels (3-4 cm H2O) resulted in a decrease of compliance within tidal inflation. Pulmonary gas exchange did not differ between PEEP levels of of 0, 1, and 2 cm H2O. Pulmonary shunt was lowest and perfusion of alveoli with a normal ventilation-perfusion was highest at a PEEP of 3-4 cm H2O. Deadspace ventilation did not change significantly but tended to increase with PEEP. CONCLUSIONS:An increase of compliance at the very beginning of tidal inflation was associated with impaired pulmonary gas exchange, indicating insufficient alveolar recruitment by the PEEP level. Consequently, the lowest PEEP level preventing alveolar atelectasis could be detected by analyzing the course of compliance within tidal volume without the need for total lung inflation.

Summary Aim: To evaluate the extent to which single measurements of microvascular lung permeability may be relevant as an additional parameter in a heterogenous clinical patient collective with Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS). Methods: In 36 patients with pneumonia (13), non pneumogenic sepsis (9) or trauma (14) meeting the consensus conference criteria of ALI or ARDS double-isotope protein flux measurements (51Cr erythrocytes as intravascular tracer, Tc-99m human albumin as diffusible tracer) of microvascular lung permeability were performed using the Normalized Slope Index (NSI). The examination was to determine whether there is a relationship between the clinical diagnosis of ALI/ARDS, impaired permeability and clinical parameters, that is the underlying disease, oxygenation, duration of mechanical ventilation and mean pulmonary-artery pressure (PAP). Results: At the time of study, 25 patients presented with increased permeability (NSI > 1 × 10-3 min1) indicating an exudative stage of disease, and 11 patients with normal permeability. The permeability impairment correlated with the underlying disease (p >0.05). With respect to survival, there was a negative correlation to PAP (p <0.01). Apart from that no correlations between the individual parameters were found. Especially no correlation was found between permeability impairment and oxygenation, duration of disease or PAP. Conclusion: In ALI and ARDS, pulmonary capillary permeability is a diagnostic parameter which is independent from clinical variables. Permeability measurement makes a stage classification (exudative versus non exudative phase) of ALI/ARDS possible based on a measurable pathophysiological correlate.

When managing patients with acute respiratory distress syndrome (ARDS), respiratory system compliance is usually considered first and changes in resistance, although recognized, are neglected. Resistance can change considerably between minimum and maximum lung volume, but is generally assumed to be constant in the tidal volume range (V(T)). We measured resistance during tidal ventilation in 16 patients with ARDS or acute lung injury by the slice method and multiple linear regression analysis. Resistance was constant within V(T) in only six of 16 patients. In the remaining patients, resistance decreased, increased or showed complex changes. We conclude that resistance within V(T) varies considerably from patient to patient and that constant resistance within V(T) is not always likely.

OBJECTIVE:Extracorporeal membrane oxygenation (ECMO) is a supportive therapy used for severe acute respiratory distress syndrome (ARDS). We present outcome, clinical parameters, and complications in a cohort of 245 ARDS patients of whom 62 were treated with ECMO.METHODS:Data of all ARDS patients were prospectively collected between 1991 and 1999. Outcome and clinical parameters of patients treated with and without ECMO were evaluated.RESULTS:Hundred-thirty-eight patients were referred from other hospitals, 107 were primarily located in our hospital. About one fourth of these patients was treated with ECMO. The survival rate was 55% in ECMO patients and 61% in non-ECMO patients. ECMO resulted in very few complications, one of them was fatal. No parameter before or during ECMO could be used to predict the individual prognosis.CONCLUSION:ECMO is a therapeutic option for patients with severe ARDS, likely to increase survival. However, a randomized controlled study proving its benefit is still awaited. Until the development of a causal or otherwise superior therapy ECMO should be used in selected patients.

Background: Extracorporeal membrane oxygenation (ECMO) is a supportive therapy used for severe acute respiratory distress syndrome (ARDS). We present outcome, clinical parameters, and complications in a cohort of 245 ARDS patients of whom 62 were treated with ECMO. Methods: Data of all ARDS patients were prospectively collected between 1991 and 1999. Outcome and clinical parameters of patients treated with and without ECMO were evaluated. Results: One hundred thirty-eight patients were referred from other hospitals, 107 were primarily located in our hospital. About one fourth of these patients were treated with ECMO. The survival rate was 55% in ECMO patients and 61% in non-ECMO patients. Conclusions: ECMO is a therapeutic option for patients with severe ARDS, likely to increase survival. However, a randomized controlled study proving its benefit is still awaited. Until the development of a causal or otherwise superior therapy ECMO should be used in selected patients.