[Pharmacotherapy of post-traumatic and postoperative pulmonary insufficiency. Substitution of natural surfactants].
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Humans↗
Biomedical subjects
K Rommelsheim
Publications and source records attributed to K Rommelsheim.
Pharmacokinetics and pharmacodynamics of propofol/alfentanil infusions for sedation in ICU patients.
OBJECTIVE: Population pharmacokinetic analysis and pharmacodynamic profile of propofol/alfentanil infusions for sedation and analgesia of intensive care unit patients for up to 24 h. DESIGN: Institutional Review Board-approved prospective clinical trial. SETTING: The ten-bed intensive care unit of an university hospital. PATIENTS: 18 consecutive patients (ten men/eight women; age: 17-73 years, mean 51.6 +/- 16.7 years, SD; body weight: 60-110 kg, mean 82.9 +/- 11.2 kg, SD) requiring mechanical ventilation and prolonged sedation/analgesia after major surgery or trauma. INTERVENTIONS: Plasma propofol and alfentanil concentrations were measured at regular intervals during the long-term drug infusion using a high-performance liquid chromatography (propofol) and radioimmunoassay (alfentanil) analysis. The depth of sedation was controlled by monitoring a two-lead online EEG. Thus, drug application was computer controlled via a closed-loop EEG median-frequency feedback system. RESULTS: ICU long-term infusion population pharmacokinetics (open three-compartment model) revealed for propofol: central compartment distribution volume (V1): 31.2 +/- 5.3 l; steady-state distribution volume (Vdss): 499 +/- 173 l; total clearance (Cltot): 1001- +/- 150 ml/min; redistribution half-life (t1/2 gamma): 90 +/- 23 min; elimination half-life (t1/2 beta): 558 +/- 218 minutes. For alfentanil: V1: 31.9 +/- 10.1 l; Vdss: 124 +/- 41 l; Cltot: 345 +/- 70 ml/min; t1/2 gamma: 36 +/- 15 min; t1/2 beta: 275 +/- 94 min, respectively. CONCLUSIONS: The population pharmacokinetic analysis of propofol/alfentanil for ICU sedation therapy revealed increased volumes of drug distribution and decreased elimination characteristics as compared to pharmacokinetic data from short-term infusions in surgical patients. This can be attributed in part to altered distribution/redistribution processes and/or drug elimination under the condition of ICU therapy. No significant drug accumulation was observed. For future long-term sedation and analgesia of ICU patients with propofol/alfentanil, this altered pharmacokinetic behaviour should be taken into consideration to allow a more individualized and safer dosing of this drug combination.
Adolescent↗
[Luxatio cordis after blunt thoracic trauma and pneumonectomy].
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Accidents, Traffic↗
[Electrophysiologic studies in polyneuropathy of intensive care patients].
Polyneuropathy of the critically ill patient has gained attention in recent years. The symptoms of muscle weakness and impaired somatosensory perception are more obvious for the observer and recognizable for the conscious patient, if heavy long-term sedation is avoided. The cause of polyneuropathy remains unclear and diagnostic findings are still rare and partly controversial. In five of our patients with multiorgan failure and clinical signs of muscle weakness, cortical somatosensory evoked potentials (SEP) and the evoked electromyogram (EMG) were recorded simultaneously after the stimulation of mixed peripheral nerves to test the functional integrity of the efferent and afferent neuronal pathways. We observed different degrees of SEP and EMG alterations, which were more pronounced in the lower than in the upper extremities and which may be explained by an axonal degeneration. Such a process may be caused by multiple factors and pathophysiological mechanisms. An influence of neostigmine on a reduced EMG response could not be found.
Aged↗
[Prevention of pneumonia in artificial respiration therapy].
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Bacterial Infections↗
[The efficacy of the benzodiazepine antagonist flumazenil (Ro 15-1788) based on the EEG of mechanically ventilated intensive care patients].
To evaluate the efficacy of flumazenil in intensive care medicine, the benzodiazepine antagonist was administered to 20 intubated and ventilated patients. In 18 cases the drug was used to interrupt long-term sedation (midazolam in combination with piritramide) for a short period of neurological examination. In two cases it was used to diagnose a coma of unknown origin. The patient's alertness was evaluated by clinical observation and electroencephalography. Blood pressure and heart rate were monitored continuously. The two patients with coma of unknown origin demonstrated no clinical response to flumazenil at a dosage of 2 mg. However, there was a change in the EEG: before administration of the antagonist, slow delta waves predominated; after administration there was an increase in theta activity. This activity shift was associated with a slight increase in the median frequency from 1.6 to 2.1 Hz. Serum level analysis confirmed a non-benzodiazepine-induced coma. The other 18 patients (average serum midazolam concentration: 0.27 microgram/ml) were awake and oriented after a dose of between 0.3 and 0.6 mg flumazenil. This clinical finding correlated with the EEG which showed an increase in the median frequency from 2 Hz to 6-7 Hz. Even after receiving the antagonist, the patients were able to tolerate intubation and ventilation without problem. No significant adverse effects were observed.
Adult↗
[The effectiveness of intratracheal antibiotic administration. Clinical, microbiologic and pharmacologic results].
In 199 artificially ventilated patients of an internal intensive care unit clinical, bacteriological and pharmacological effects of endotracheally administered gentamicin were investigated. The dose schedule was 2-4 x 40 mg gentamicin/day. The incidence of secondary achieved pneumonia was reduced from 70% to 18%. The endotracheal colonization of pathogenic microorganisms reached 29.6% concerning bacterial microorganisms and 61% concerning fungi, 51.8% of all specimen were sterile. During 4 years of investigation there were found 19 secondary resistances of different bacteria, 12 persisted. Serum concentrations of gentamicin under endotracheal administration of 40 mg in 6-h-intervals didn't reach therapeutic values. In case of renal disorder the dose interval should be prolonged to twelve hours.
Adult↗
[Preventive use of Pentaglobin in intensive care treatment of trauma patients].
Basing on 50 posttraumatic intensive-care patients with medium grade lesions (ISS criteria), the prophylactic effect of an intravenously applicable IgM preparation (Pentaglobin) against nosocomial infections was investigated. The prophylaxis group received on the 3rd, 4th and 5th day a daily dose of 10 g each. At the same times the controls were given 12.5 g human albumin each. Whereas no difference was seen between both groups regarding the definitive outcome of the treatment, the prophylaxis group clearly showed fewer infection pointers during the clinical course. In particular, the incidence and magnitude of febrile temperatures were significantly lower between the 4th and 8th days of treatment. Our results indicate, however, that the prophylactic use those patients who are at particularly high infection exposure risk, e.g. through reintervention surgery, haemorrhage complications or extensive diagnostic interventions.
Adolescent↗
[Laboratory diagnostic possibilities in fungus infections in intensive care patients].
Severe yeast infections of intensive care patients are promoted by numerous predisposing factors among which antibacterial broad spectrum therapy plays an important role. Since typical clinical pictures are lacking, basic procedures of mycological diagnostics are culture and differentiation of yeast strains and detection of immunological reactions against yeast antigens as well. Among 200 intensive-care patients with suspected systemic mycosis, Candida albicans was the prevailing yeast, followed by Torulopsis glabrata and Candida krusei. In the immunocompetent patient, serological procedures discriminating between antibodies of the IgG and IgM class may be suitable for the surveillance of the course of the disease. - In early stages of endomycotic infections and in the immunocompromised host as well, detection of candida antigens by means of specific latex tests and the detection of yeast-specific metabolites (e.g. arabinitol) by gas chromatographic methods provide helpful tools in the diagnosis of severe opportunistic fungal infections.
Antibodies, Fungal↗
[Vena cava thrombosis: a rare complication in changing a central venous catheter].
Two cases of complete thrombosis of the superior vena cava are reported as rare complication of changing a catheter in heavily traumatised patients. Thromboses are frequent findings in pathological and radiological examinations, but clinically they become manifest only rarely. If a disease takes a severe course, thrombogenic factors may accumulate. Attention is drawn to the risk implied in changing a catheter especially in situations of marked cardiovascular depression, artificial respiration with a high positive end-expiratory pressure (PEEP) and if there are changes in coagulation physiology. These possible risks must be taken into consideration when performing a routine change of catheters.
Adult↗
[Aspergillosis following liver transplantation as a hospital infection].
In the first four weeks after a liver transplantation, there was an invasive aspergillosis with a lethal course in three out of five patients who were treated postoperatively in the same room. The clinical symptoms were very different. One patient was asymptomatic, and the diagnosis could only be made by autopsy. In another patient, pulmonary symptoms, and in the third patient, cerebral symptoms were the most prominent. In the two latter patients, the infection was demonstrated in the sputum and by bronchoalveolar lavage. The disease course was fulminant in all patients, and therapy was without success. Owing to this high incidence, mycological investigations were carried out on the ward. A flower bench in the hall beside the ward was probably the main focus of distribution. To avoid such nosocomial infections, foci of aspergillus distribution should if possible be removed from the surroundings of patients with weakened immune resistance.
Adult↗
Combined use of phage typing, enterococcinotyping and species differentiation of group D streptococci as an effective epidemiological tool.
Ninety-five group D streptococcal isolates from the feces of 95 healthy persons were compared with 157 group D streptococcal isolates from 38 patients of the surgical intensive care unit (sICU). The typing systems consisted of phage typing, enterococcinotyping and species differentiation. Strains isolated from fecal specimens showed high individuality (66 combination types) whereas strains from the sICU revealed strongly uniform types (32 combination types, three types comprised 83 isolates, i.e. 52.8%). Endogenous colonization was demonstrated by isolation of strains from different locations (throat, trachea, wounds, blood, urine, drains, catheters, and vaginal swabs) from the same patient, and routes of transmission of the same strains to several patients were traced. The combination of three systems revealed a good discrimination between isolates of fecal and extrafecal specimens. The investigation detected highly preferred types in strains of extrafecal origin which were rarely isolated from fecal specimens. This may indicate that only strains with special characters preferably were able to colonize extraintestinal sites.
Bacteriophage Typing↗
[Difficulties in extubation--example of an extubation hindrance caused by a stomach tube].
Difficulties in effecting extubation are rare incidents that are difficult to assess systematically, the reasons being often of a rather odd nature. In the example reported here a stomach tube had been responsible for extubation problems. The authors review the literature published so far on this subject.
Adolescent↗
[PMN elastase in extracorporeal circulation procedures].
Proteolytic enzymes released by polymorphonuclear neutrophils are assumed to be important mediators in the development of shock-induced and sepsis-induced organ failure, especially of ARDS. The most remarkable of these enzymes is elastase because of its relatively high intracellular concentration and low substrate specificity. The release of elastase can be monitored by measuring the plasma concentration of elastase-proteinase inhibitor complex. In this study, the elastase concentration pointed towards side effects of methods of extracorporeal circulation. The elastase concentration rose more than sixfold in 20 patients during membrane oxygenation (mean time 124 min) and 15 patients during bubble oxygenation (mean time 77 min). We found that the elastase concentration was affected by the kind of foreign material surface, the time of perfusion and the perfusion volume. The comparison of in-vitro and in-vivo circulation underlines the importance of the terminal capillary bed (in the lung) and of a pre-existent activation of leukocytes, since elastase levels rose only insignificantly during in-vitro recirculation. These results confirm that extracorporeal circulation seems to be able to induce harmful disturbances of the ARDS type. This fact should be taken into consideration when using methods of extracorporeal gas exchange.
Adolescent↗
[Erroneous determination of arterial blood pressure depending on the site of measurement, in excessive catecholamine therapy in low cardiac output syndrome].
Five cases are presented where invasive measurement of blood pressure in the femoral or radial artery alone resulted in considerable underestimation of the systemic pressure. This underlines the need to compare measurement values obtained by an invasive method, critically with the overall clinical pattern presented by the patient and to countercheck on these data--as the case may be--by effecting appropriate measurements in other arteries as well.
Aged↗
[Use of the double-lumen tracheostomy tube (Tracheopart) in bronchial stump insufficiency in long-term artificial respiration. Case report].
In long-term artificial respiration an insufficiency of the bronchial stump after pneumectomy must be considered as a result of the positive pressure respiration. Respirator treatment can be continued by means of a twin-lumen tracheostomy tube, the bronchial fistula being relieved of the stress while offering it an opportunity to close spontaneously. Good experience collected with the practical use of this method points to its suitability in prophylaxis as well.
Adult↗
[Therapy of hydrofluoric acid burns].
Treatment of hydrofluoric acid burns differs very much from treatment of other acid burns. Incorrect anamnestic data caused a delayed specified therapy on one of our patients, who had a cardiac arrest several hours after the accident. We suggest to control serum-electrolytes frequently in every major acid burn and have a chemist analyse the acid at the site of the accident, even if the anamnestic statements seem "reliable".
Adult↗
[Dangers in the use of high-frequency surgical instruments in anesthesiologic monitoring].
Although the use of high-frequency units is routine in all surgical disciplines, there is still a justification for reminding users of the attendant risks. The most common injuries sustained by patients are burns caused by fault currents. Such risks increase when a combination of several electric devices is used, and in particular when the operation is performed with simultaneous anesthesiologic monitoring. All electrically conductive, direct or indirect contacts between the patient and the ground lead potential, and all connections resulting in a low resistance or a shorter distance between the active and "neutral" high-frequency electrode than the correct current pathway, may become competing "neutral" electrodes with high current densities. It is therefore imperative that all those involved should strictly observe the safety rules. The systematization of problem points is intended to introduce greater clarity into the relatively long list of admonitions, and to indicate possible organizational solutions.
Anesthesia, General↗