Recombinant activated factor VII has been used successfully in many cases of traumatic and surgical bleeding complications that were unresponsive to standard treatment. However, because disseminated intravascular coagulation can develop from a thrombin burst as a side effect of recombinant activated factor VII, it is not yet established for bleeding complications induced by disseminated intravascular coagulation. This article presents 3 patients with severe sepsis and fulminant disseminated intravascular coagulation. Excessive microvascular bleeding persisted despite conventional therapy, and surgical intervention and radiologic embolization did not control bleeding. After administration of recombinant activated factor VII, bleeding ceased in all patients, and no overt thromboembolic events occurred. One patient survived to be discharged from the hospital. The other 2 patients died from refractory multiorgan failure and overall poor prognosis. Recombinant factor VIIa might be an option for the treatment of severe bleeding complications in the case of DIC refractory to the conventional therapy.

BACKGROUND:Reduction of potential pathogens by selective intestinal decontamination has been proposed to improve intensive care. Despite large scientific interest in this method, little is known about its benefit in homogeneous trauma populations.METHODS:In a prospective, controlled study, we enrolled non-infected trauma patients (age over 18 years, mechanical ventilation > or = 48 hours, intensive care for more than 3 days) who primarily were admitted to our university medical center. We randomized patients to be treated with two different topical regimens (polymyxin, tobramycin, and amphotericin (PTA) or polymyxin, ciprofloxin, amphotericin (PCA)) or the carrier only (placebo), administered four times daily both to the oropharynx and to the gastrointestinal tract. All patients received intravenous ciprofloxacin (200 mg, bd) for 4 days.FINDINGS:Of 357 enrolled patients, 310 (age 38.0 +/- 16.5 years, Injury Severity Score 35.2 +/- 12.7) met all inclusion criteria. Selective decontamination successfully reduced intestinal bacterial colonization. However, we did not identify significant differences between groups regarding pneumonia (PTA 47.5%, PCA 39.0%, placebo 45.3%), sepsis (PTA 47.5%, PCA 37.8%, placebo 42.6%), multiple organ failure (PTA 56.3%; PCA 52.4%, placebo 58.1%), and death (PTA 11.3%, PCA 12.2%, placebo 10.8%). Total costs per patient were highest with the PTA regimen.CONCLUSIONS:We found no benefit of selective decontamination in trauma patients. Apparently, bacterial overgrowth in the intestinal tract is not the sole link between trauma, sepsis, and organ failure.

Lingnau, Werner; Javorsky, Fritz; Resch, Dietmar; Berger, Josef; Mutz, Norbert Author Information

Die Entwicklung neuer Methoden, welche durch entsprechende technische Voraussetzungen ermöglicht wurden, hat insbesondere in den letzten Jahren zur Erweiterung und Differenzierung der Verfahren zur künstlichen Beatmung beigetragen. Solleine kritische Analyse, besonders bei sog. Alternativverfahren, durchgeführt werden, muß zunächst nach den prinzipiellen Voraussetzungen gefragt werden, die zur Entwicklung dieser neuen Techniken geführt haben und führen.

In patients with multiple injuries, the development of permeability edema can be assumed. However, no uniform shape of this fluid accumulation can be found even in the presence of severe injuries. Based on the first clinical observations, our aim was to search for correlations between the development of extravascular lung water (EVLW) and the individual injury pattern in severely traumatized ICU patients. PATIENTS and METHODS. Our investigations were performed in 48 artificially ventilated ICU patients. According to the prevailing injury pattern patients were divided into three groups: group A: 18 patients (mean age: 32 years, mean Injury Severity Score (ISS) = 29) with isolated thoracic trauma; group B: 10 patients (mean age: 27 years, mean ISS = 42) with severe multiple trauma but without any thoracic injury; group C: 20 patients (mean age: 33 years, mean ISS = 43) with severe multiple trauma and concomitant thoracic trauma. In all patients (group A, B, C), EVLW was determined by means of a double indicator method on a daily basis from the patient's admission to the ICU (day of trauma) until day 10. Additionally, the hemodynamic parameters (heart rate, mean arterial pressure, mean pulmonary arterial pressure, pulmonary capillary wedge pressure and cardiac index) were determined at the same time. RESULTS. As shown in Fig 1, EVLW was slightly elevated on day 1. However, on day 2 EVLW decreased within normal values and remained in that range until the end of the observation period. On day 3 a slight and fleeting increase of EVLW, but within normal range, can be seen. In group B (Fig.2), EVLW can be observed within normal range within a period of 4 days. Starting from day 5 until day 7 a marked increase (p greater than 0.01) in EVLW can be seen. From that maximum point EVLW development reverses slightly until day 10--however, without returning to the normal range. In group C, a marked biphasic pattern can be seen due to EVLW maximum values on post-traumatic days 3 and 7. However, in this group the EVLW was in the pathological range during the whole observation period. No statistically significant differences could be seen, when looking at hemodynamic variables. CONCLUSION. Isolated thoracic trauma will not lead to a marked pathological elevation of EVLW within the lungs. Moreover, EVLW decreases rapidly within a short time period. Based on our results, it seems that severe extrathoracic injuries will intensify microvascular injury in the initial period, as shown in our patients in group C. Increase of EVLW at a later time (day 7), as observed in groups B and C, is possibly the expression of a mediator and activator-induced "septiformal" injury of the microvascular endothelium. This may be caused by the underlying massive peripheral soft-tissue trauma. Specific elevations of EVLW subsequent to the individual injury pattern can indicate that that process has begun and is responsible for the origin of the microvascular injuries.

The sequence of lung microvascular permeability (LMVP) changes in early direct posttraumatic and late indirect pancreatitis-induced adult respiratory distress syndrome (ARDS) was studied and compared with that of a control group, as well as non-ARDS ICU patients. A computerized large field of view gamma camera was used to measure LMVP simultaneously over both lungs by In 113m-labeled transferrin and Tc 99m-labeled erythrocytes. The LMVP index (LMVPI) (%/h) was used to quantify LMVP in the dynamic scintigraphic measurement. In the control group the LMVPI was 2.6 +/- 2.8%/h for the right and 2.0 +/- 2.8%/h for the left lung. Similar values were found in mechanically ventilated ICU patients without ARDS (group A) on admission (right LMVPI 3.2 +/- 2.6, left LMVPI 2.6 +/- 2.7%/h) and 4 days later (right LMVPI 3.9 +/- 2.6, left LMVPI 2.3 +/- 1.8%/h). Interestingly, the initial evaluation of patients with direct early posttraumatic ARDS (lung contusion) (group B) showed significantly (p less than .01) elevated LMVP for the contused side (LMVPI 10.8 +/- 5.1%/h), but normal values for the nontraumatized lung (LMVPI 3.9 +/- 3.4%/h), whereas 4 days later the LMVP increased significantly (p less than .05) on the primarily healthy side (LMVPI 8.0 +/- 5.0%/h) while remaining elevated for the traumatized lung (LMVPI 10.9 +/- 6.0%/h).(ABSTRACT TRUNCATED AT 250 WORDS)

We have examined the effect of varying end-expiratory lung volume on carbon dioxide elimination in 10 mongrel dogs undergoing conventional mechanical ventilation at 12 b.p.m. and forced diffusion ventilation (FDV) at 6 Hz and 50 Hz and continuous flow. End-expiratory volumes were altered by changing the pressure in a plethysmographic box in which the dogs underwent ventilation. The pressures studied were atmospheric, sub-atmospheric (box pressure -1.0 kPa) and increased atmospheric (box pressure + 0.5 kPa). The results indicated that more carbon dioxide was eliminated at low lung volumes and this was most pronounced with HFV at 50 Hz and continuous flow. It is postulated that changes in airway geometry and different lung volumes may alter the distance between the gas interface in the conductive airways and the respiratory zone and so alter the efficiency of ventilation during FDV.

Acta Anaesthesiologica ScandinavicaVolume 33, Issue s90 p. 140-144 Clinical experience with several types of high frequency ventilation N. MUTZ, Corresponding Author N. MUTZ Clinic for Anaesthesia and General Intensive Care Medicine, University of Innsbruck, AustriaClinic for Anaesthesia and General Intensive Care Medicine University of Innsbruck Anichstr. 35 A-6020 Innsbruck AustriaSearch for more papers by this authorM. BAUM, M. BAUM Clinic for Anaesthesia and General Intensive Care Medicine, University of Innsbruck, AustriaSearch for more papers by this authorH. BENZER, H. BENZER Clinic for Anaesthesia and General Intensive Care Medicine, University of Innsbruck, AustriaSearch for more papers by this authorG. PUTZ, G. PUTZ Clinic for Anaesthesia and General Intensive Care Medicine, University of Innsbruck, AustriaSearch for more papers by this author N. MUTZ, Corresponding Author N. MUTZ Clinic for Anaesthesia and General Intensive Care Medicine, University of Innsbruck, AustriaClinic for Anaesthesia and General Intensive Care Medicine University of Innsbruck Anichstr. 35 A-6020 Innsbruck AustriaSearch for more papers by this authorM. BAUM, M. BAUM Clinic for Anaesthesia and General Intensive Care Medicine, University of Innsbruck, AustriaSearch for more papers by this authorH. BENZER, H. BENZER Clinic for Anaesthesia and General Intensive Care Medicine, University of Innsbruck, AustriaSearch for more papers by this authorG. PUTZ, G. PUTZ Clinic for Anaesthesia and General Intensive Care Medicine, University of Innsbruck, AustriaSearch for more papers by this author First published: September 1989 https://doi.org/10.1111/j.1399-6576.1989.tb03020.xCitations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume33, Issues90September 1989Pages 140-144 RelatedInformation

The effects of high frequency ventilation in combination with sustained inflations was studied in the surfactant-deficient lungs of 18 New Zealand White rabbits (weight 1.9-2.1 kg) during anaesthesia with urethane and neuromuscular block with pancuronium. Lung damage was induced by repeated lung lavage. In nine rabbits (group I) baseline ventilator settings were maintained constant throughout the study and airway pressure was readjusted to achieve a constant tidal volume. In the other nine rabbits (group II), ventilation was reinstituted after lung lavage with one period of four sustained inflations followed immediately by high frequency ventilation. In group I there was a significant decrease in gas exchange for oxygen and deterioration in pulmonary mechanics, whereas in group II there was little change in baseline blood-gas values or pulmonary mechanics. These data suggest that, with adequate ventilatory management during the period of lung lavage, the lung damage produced by this manoeuvre may be obviated.

The impact of different modes of artificial ventilation on intracranial pressure (ICP) curves has been reported by several groups in patients as well as in animal experiments (Richard and Karimi-Nejad 1977; Shapiro and Marshall 1978; Babinsky et la 1981; Mutz et al. 1984; Schedl et al. 1984; Schedl et al. 1986). In this retrospective study we analyzed changes of ICP-course in severely brain injured patients, that were weaned from controlled mechanical ventilation (CMV).

Acta Anaesthesiologica ScandinavicaVolume 33, Issue s90 p. 46-50 Physical characteristics of a jet in the airways MARCEL BAUM, MARCEL BAUM Clinic for Anaesthesia and General Intensive Medicin, University of Innsbruck, AustriaSearch for more papers by this authorNORBERT MUTZ, Corresponding Author NORBERT MUTZ Clinic for Anaesthesia and General Intensive Medicin, University of Innsbruck, AustriaClinic for Anaesthesia and General Intensive Care Medicine University of Innsbruck Anichstr. 35 A-6020 Innsbruck AustriaSearch for more papers by this author MARCEL BAUM, MARCEL BAUM Clinic for Anaesthesia and General Intensive Medicin, University of Innsbruck, AustriaSearch for more papers by this authorNORBERT MUTZ, Corresponding Author NORBERT MUTZ Clinic for Anaesthesia and General Intensive Medicin, University of Innsbruck, AustriaClinic for Anaesthesia and General Intensive Care Medicine University of Innsbruck Anichstr. 35 A-6020 Innsbruck AustriaSearch for more papers by this author First published: September 1989 https://doi.org/10.1111/j.1399-6576.1989.tb03003.xCitations: 7AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume33, Issues90September 1989Pages 46-50 RelatedInformation

This study was designed to compare the effects of Continuous Positive-Pressure Ventilation (CPPV) and, by using the same unmodified conventional ventilator, High-Frequency Positive-Pressure Ventilation (HFPPVkonv). First, CPPV and HFPPVkonv were studied in a lung model with both normal (R = 5 mbar/1/second) and elevated (R = 20 mbar/1/second) resistance. Our results indicate that in HFPPVkonv the large compressible volume of the conventional ventilator did not influence lung model ventilation at normal resistance. The adjusted (300 ml) tidal volume (VT) and the measured volume of actual expiration (270 ml) were about the same (Fig. 1). However, with elevated resistance air trapping occurred. The large compressible volume influenced model ventilation during both CPPV and HFPPVkonv (Fig. 2). As a second step we evaluated the effects of HFPPVkonv on gas exchange, airway pressure, and hemodynamics in 12 patients (aged 43-69) postoperatively after elective cardiac surgery. After a period of stabilization at the intensive care unit every patient was first ventilated with CPPV. The ventilator settings were: VT = 10-12 ml/kg, inspiratory: expiratory ratio (I:E) = 1:2, frequency (F) = 12/min, V = 60 1/min, PEEP = 5 cm, FiO2 = 40%. After 20 min of CPPV baseline measurements were made (series I). Then the initial ventilator settings of CPPV were switched to HFPPVkonv, the conventional ventilator remaining unmodified. The settings were changed as follows: I:E = 1:3, F = 60/min, V = 120 1/min, PEEP = 5 cm, FiO2 = 40%. During 60 min of HFPPVkonv variables were measured first after 20 min (series II) and again after another 40 min (series III). Minute volume had to be doubled after changing from CPPV to HPFFVkonv to achieve eucapnia. As a result of the new ventilatory settings, VT and hold showed a significant decrease (P less than 0.01) (Table 2).(ABSTRACT TRUNCATED AT 250 WORDS)

Bei der Auswahl einer geeigneten Beatmungsmethodik habe ich u. a. zu differenzieren, welche Teilfunktionen der äußeren Atmung vorwiegend gestört sind (Abb. 1).