Biomedical subjects
Publications and source records attributed to R Ritz.
Factor VIII procoagulant activity, antigen concentration and von Willebrand activity as ristocetin cofactor were determined several times in 10 patients with DIC. These is a significant negative correlation between the DIC-score and the VIII:C/von Willebrand activity ratio.
In the management of coronary care patients, continuous ECG analysis is best performed by a computerized monitoring system. For more than 2 years all the patients in this CCU have been monitored by the 78220 Hewlett-Packard arrhythmia monitoring system. As a quality control of the system the data of 15,068 alarm situations in 300 patients were first analyzed: the specificity of the system varied from 3% to 83% according to type and severity of arrhythmias. To evaluate the sensitivity of the system the amount of VES registered by Holter monitoring was then compared with the analysis by computerized monitoring during the same period of time: in a total of over 10,000 VES in 14 patients the sensitivity was 90%. Although the personnel of a CCU still have to deal with a large number of false positive alarms, a computerized arrhythmia monitoring system offers a higher degree of security for the patient than conventional monitoring.
The relationship between clinical findings and invasively measured hemodynamic data was investigated in a prospective trial of 70 patients with acute myocardial infarction. In 26 out of 27 consecutive patients without clinical signs of disturbed myocardial function, normal hemodynamic values were also found invasively. In 43 patients, depressed myocardial function was diagnosed on the basis of the clinical findings. These findings were verified in 38 patients (88%) by means of cardiac catheterization; 5 patients (12%) had normal hemodynamic values. In 26 patients with clinical signs of congestive heart failure, an attempt was made to identify non-invasively those with a low output (cardiac index less than 2/min/m2). Only 3 of the 6 patients with a low output could be identified by clinical examination alone. In one patient a low output was clinically diagnosed despite normal cardiac function measured invasively. In 16 patients, 48 subsequent clinical examinations were performed during treatment of congestive heart failure to identify either persistent elevated left ventricular filling pressure or low output; 15 (31%) were found to be incorrect when compared with the cardiac catheterization data. Patients with acute myocardial infarction and normal ventricular function can be identified with high accuracy by means of clinical examination alone. The clinical diagnosis of congestive heart failure was incorrect in 12% of the patients. A low output state in acute myocardial infarction is often overlooked in clinical examination alone. Of the clinical examinations on patients during therapy, 30% were incorrect. Invasive hemodynamic monitoring in acute myocardial infarction therefore appears to be unnecessary in patients with normal clinical findings, but in those with clinically diagnosed congestive heart failure it is mandatory for precise indication and evaluation of therapy.
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In a critically ill patient referred to an intensive care unit, clinical evaluation remains the first method in the assessment of cardio-circulatory status. In more complex cases direct measurement of standard hemodynamics must be performed at the bedside, for instance by the use of a Swan-Ganz thermodilution catheter. As alternatives to hemodynamic parameters, non-invasive techniques for the evaluation of left ventricular function such as echocardiography, radionuclide angiography, measurement of systolic time intervals and electrical impedance are presented. Their indications and limitations in comparison with hemodynamics are discussed.
Furosemide was administered intravenously to 11 patients with cardiac failure after acute myocardial infarction. After an initial loading dose furosemide was given four-hourly if the pulmonary capillary wedge pressure (PCW) was not normalized, i.e. less than or equal to 15 mm Hg. The comparison of the hemodynamic results with the results of a previous study with nitrates was as follows: like the nitrates furosemide lowered the PCW early, i.e. within 15 minutes from 22 +/- 3 to 18 +/- 5 mm Hg, but the therapeutic objective (PCW less than or equal to 15 mm Hg) was reached later than with nitrates. During the 24-hour observation period PCW and total peripheral resistance decreased steadily. The decrease of cardiac index to critical low values in some patients after a mean of 7.5 hours of therapy, and of the mean arterial pressure from 100 +/- 13 to 91 +/- 14 mm Hg, may limit the use of furosemide alone in these patients. During nitrate therapy PCW started to rise again after 12 hours in some patients, necessitating higher doses of nitrates with a corresponding decrease of diuresis. A combination of both forms of therapy may be of value and needs further investigation.
The clinical course of a 26 year old female patient with acute liver necrosis and coma due to hepatitis B is reported. The disturbances of conciousness had improved. The patient survived 41 days after the beginning of the coma and developed liver cell regeneration and an acute post-hepatitic liver cirrhosis. As a grave complication a septicemia with aspergillus was observed. The patient died because of gastro-intestinal hemorrhage. At autopsy there were no signs of brain edema. The treatment consisted in: daily infusions with coenzyme A, nicotinamid-adenin-dinucleotide, alpha lipoic acid and cocarboxylase to improve the metabolic disorders and the clinical picture; mannitol intravenously to prevent and to treat cerebral edema; 33 charcoal-hemoperfusions to remove toxic substances of acute liver failure. Treatment of the aspergillus infection with 5-fluorocytosine and amphotericine B and infusion of concentrated ascites led to a decompensation of liver functions. From this observation the following conclusions can be drawn: after an acute viral hepatic necrosis, new synthetic functions and improvements of the disturbed intermediary metabolism in regenerated liver-cells can eventually be seen only after twenty-four to thirty days. With systematically applicated mannitol infusions it is possible to treat cerebral edema effectively.
Ten patients with severe congestive heart failure after acute myocardial infarction were treated with 40 mg isosorbiddinitrate-retard every 4 hours and additional sublingual nitroglycerine. There was a prompt improvement of hemodynamic parameters which was maintained for 24 hours: pulmonary capillary wedge pressure (PCW) decreased within 10 min from 26 +/- 5 (X +/- SEM) to 17 +/- 2 mm Hg (p less than 0.01) and mean arterial pressure from 109 +/- 7 to 98 +/- 6 mm Hg. The heart rate remained constant, and the cardiac index improved from 2.3 +/- 0.2 to 2.5 +/- 0.21/min/m2. The fall in blood pressure was dependent on the pretreatment pressure: it was significantly greater in patients with elevated blood pressure and only slight in those with a low pretreatment blood pressure. In the presented series of patients neither adverse effects or symptoms nor a critical reduction of blood pressure were observed. Combined oral treatment with isosorbiddinitrate and nitroglycerine can therefore be carried out without invasive blood pressure monitoring.
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In 150 ambulatory and 155 hospitalized patients the normal values for creatine phosphokinase (CK) and the isoenzyme CK-MB were determined using a simple test with inhibiting antibodies. In a series of 100 consecutive patients hospitalized for chest pain, CK-MB was measured over a 72-hour period in 6- to 12-hourly intervals. The results were compared to the clinical findings, ECG, total CK and SGOT. In addition, CK-MB was determined after elective DC countershock and intramuscular injections (12 patients in each group). Normal values for CK-MB were found to be less than or equal to 10 U/1 in all patients, whereas the values for total CK turned out to be male less than 125 U/1, female less than 100 U/1 in ambulatory patients and less than 50 U/1 in hospitalized patients. In 68 of the 100 patients hospitalized for chest pain, acute myocardial infarction was found. The specificity of CK-MB in patients with transmural infarction was calculated as 100%, and the sensitivity as 97%. After DC countershock and intramuscular injections, CK was markedly elevated whereas CK-MB only rose after cardioversion. We conclude that CK-MB may be of considerable value for the differential diagnosis of elevated total CK activities of unknown origin. It is a very specific and a sensitive parameter for the diagnosis and exclusion of acute myocardial infarction.
In the period 1972-1976, 5 of 17 patients admitted to the Cantonal Hospital, Basel, for falciparum malaria had to be treated in the intensive care unit. Two patients died. None had performed regular chemoprophylaxis and in all of them several days had elapsed between onset of symptoms and diagnosis. The importance of information on malaria to tourists and physicians is stressed.
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At least in its early stage, the syndrome of septicaemic-endotoxic shock gives rise to a heterogeneous clinical picture which often lacks definite clinical, haemodynamic and biochemical features. But even if this form of shock is merely suspected, adequate fluid supply and administration of appropriate antibiotics should be started, in addition to general supportive measures. The administration of vasoactive drugs and corticosteroids has provided favourable results. The low early mortality (10 among 50 patients) is probably due to the medical causes which precipitate shock in this group, and the early onset of treatment.
The admission data and the course of 58 episodes of severe diabetic ketoacidotic coma and of 28 episodes of non-ketotic coma are compared. The non-ketotic patients were older; initial blood glucose, osmolarity, blood urea and serum sodium concentration were higher than in the ketotic patients. Treatment in the first 24 hrs consisted of similar amounts of insulin in both coma forms, the presence of acidaemia did not increase the insulin needs. Acidaemia was corrected only when pH was below 7.20. The disadvantages of alkali therapy are emphasized. A comparison of the age groups of survivors and those patients who died within 72 hrs showed an increase in mortality with age. However, the mortality rates from ketotic and non-ketotic coma were similar in the age groups above 50 years. On admission, blood glucose, osmolarity and blood urea were higher in the fatal cases. Blood urea was the most important indicator of a fatal outcome. The response of blood glucose to insulin was impaired in the subsequently fatal cases. Insulin was given in "moderate" doses by constant infusion. The use of "small" doses is discussed. Early mortality was 14% in the ketotic and 29% in the non-ketotic cases. The most frequent causes of death were circulatory failure of undetermined origin, infections and thromboembolic complications.