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S Zielmann

Publications and source records attributed to S Zielmann.

At least 19 recordsLinked to original sources
PubMed2003

[Intensive care of delirium syndromes].

Delirium is mental dysfunctions occurring as impaired attentional and memory systems with disturbances of consciousness, affectivity, psychomotor activity and sleep patterns. Numerous factors and underlying diseases may be responsible for these non-specific symptoms. Therefore, a thorough evaluation of preadmission history and current clinical status, supplemented by laboratory and extended technical diagnostic procedures, are always required. If delirium occurs in connection with emergency admission to hospital, an organic disease can most regularly be found. Due to its rapid time of onset and minor side-effects, the intravenous injection of 2.0 g gamma-hydroxybutyric acid is preferred for sedation of extremely agitated patients. Neuroleptic drugs are indicated in psychiatric patients. A central anticholinergic syndrome in the early postoperative period causative of the symptoms of delirium may respond to intravenous injection of physostigmine. Most of the time, however, these acute disturbances of brain function are best treated by correction of homeostatic imbalances, restoration of cardiovascular and respiratory stability and alleviation of pain. Postoperative delirium occurring two or more days later is frequently due to respiratory distress, followed by sepsis, alcohol withdrawal and many other causes including heart failure, exsiccosis and side-effects of drugs. In intensive care patients, delirium may be caused, for example, by withdrawal (alcohol, opioids, benzodiazepines), the onset of sepsis (often venous catheter related), side-effects of drugs, problems of communication, sleep deprivation and others. Treatment should focus on finding the right approach. Personal care should be intensified and include help from family members. Most problems arise from agitated, non-cooperative patients. Treatment with clonidine, gamma-hydroxybutyric acid or neuroleptic drugs like perazin and haloperidol may be required to reduce agitation and the activation of sympathetic influence.

Critical Care↗
PubMed1997

[S-(+)-Ketamine and circulation].

The S-(+) isomer of ketamine has about twice the analgesic potency of the clinically used racemic mixture. Therefore, the known side effects may be reduced when one-half of the usual dose is administered. Several prospective, randomised, and double-blinded studies have been performed to assess whether the S-(+) isomer of ketamine is superior to the racemic mixture with respect to circulatory side effects. Studies in young, healthy volunteers showed that heart rate (HR) and arterial blood pressure (ABP) rise significantly after injection of 2 mg/kg ketamine racemate and 1 mg/kg S-(+) isomer without any significant difference between groups. In the study of Doenicke et al. plasma levels of adrenaline (A) were higher in the racemate group, whereas no difference was found in elevated plasma levels of noradrenaline (NA). Premedication with midazolam blunted major haemodynamic changes. The investigation of Adams et al. confirmed that HR and ABP rise significantly after injection of 2 mg/kg ketamine racemate and 1 mg/kg S-(+) isomer without any significant difference between groups. In this study, no differences were found between groups concerning elevated plasma levels of A and NA. A further study in healthy volunteers also showed comparable haemodynamic changes following i.m.injection of 1.0 mg/kg ketamine racemate or 0.5 mg/kg S-(+) isomer without any significant difference between groups. In a previous clinical study including 40 elderly patients undergoing elective orthopaedic surgery, total intravenous anaesthesia (TIVA) was performed with S-(+)-ketamine or ketamine racemate as an analgesic compound. For induction of TIVA, patients received 0.1 mg/kg midazolam and 1 mg/kg S-(+)-ketamine or 2 mg/kg racemic ketamine, respectively. Throughout surgery, a continuous infusion of 2 mg/kg per hour S-(+)-ketamine or 4 mg/kg racemic ketamine was administered. Three patients in the racemate group showed severe arterial hypertension after induction of anaesthesia and were withdrawn from the study. In both groups plasma A and NA levels as well as HR and ABP increased significantly. In our own randomised, double-blinded study, haemodynamic effects of 2 mg/kg S-(+)-ketamine and 4 mg/kg ketamine racemate, respectively, were investigated in 14 patients undergoing elective aorto-coronary bypass surgery. In both groups HR and ABP significantly increased in 3 patients, each although all patients were deeply sedated with midazolam. One patient in the S-(+)-ketamine group showed severe arterial hypertension and tachycardia after induction of anaesthesia and was withdrawn from the study. With respect to haemodynamic changes, the pharmacodynamic effects of ketamine racemate and S-(+)-ketamine are comparable. Therefore, it can be concluded that neither ketamine nor S-(+)-ketamine should be used in patients who suffer, e.g., from arterial hypertension and coronary artery disease.

Anesthetics, General↗
PubMed1997

Effects of early treatment with immunoglobulin on critical illness polyneuropathy following multiple organ failure and gram-negative sepsis.

OBJECTIVE: The evaluation of incidences and relating factors of severe persisting critical illness polyneuropathy (CIP) in survivors of multiple organ failure (MOF). DESIGN: Prospective study with an entry period of 24 months. Electrophysiological studies for the diagnosis of CIP were performed 1 or 2 days before the patients were discharged from the intensive care unit (ICU). Factors which might have been related to the development of CIP were identified by a retrospective chart analysis. SETTING: The interdisciplinary ICU of a university hospital. PATIENTS: Thirty-three patients who survived MOF. Sixteen of these critically ill patients developed severe sepsis due to nosocomial infections with gram-negative bacteria. RESULTS: In seven survivors of MOF and sepsis typical electrophysiological features of CIP, like spontaneous fibrillations and low compound muscle action potentials, were detectable at the time of discharge from the ICU. Seventeen patients with MOF following multiple trauma who developed no sepsis, and nine survivors of MOF with sepsis showed no signs of persisting CIP at the end of their ICU stay. Chart analysis revealed that eight survivors of MOF with sepsis and without the development of CIP had been treated with intravenous immunoglobulin (IVIG) with a dosage of 0.3 g/kg per day for 3 days immediately (within 24 h) after the diagnosis of sepsis. Four out of seven patients with MOF and sepsis who developed CIP were transferred to our ICU after the onset of sepsis and had not received IVIG treatment. The IVIG treatment in three patients was delayed for more than 24 h after the diagnosis of sepsis and was then omitted. Obviously not related to the development of CIP were aminoglycoside antibiotics, steroids, nutritional disturbances and episodes of hypotension or hypoxia. Neuromuscular blocking agents were not used during intensive care treatment. CONCLUSIONS: A high incidence of severe CIP persisting until the day of discharge from the ICU was related to gram-negative sepsis but not to MOF alone. Retrospective chart analysis suggested that early application of IVIG may prevent or mitigate this severe complication. However, these results have to be confirmed in a prospective, placebo-controlled study.

APACHE↗
PubMed1997

Use of modified fluid gelatin and hydroxyethyl starch for colloidal volume replacement in major orthopaedic surgery.

We have compared 6% hydroxyethyl starch (HES 200/0.5) with 3% modified fluid gelatin (MFG) for volume replacement in major orthopaedic surgery and studied the effects on haemodynamic state, colloid osmotic pressure, blood clotting and plasma homeostasis. Using a controlled, randomized, single-blind clinical design, we studied 46 consecutive patients undergoing major elective orthopaedic hip surgery. The two groups were comparable in age, body weight and duration of surgery. Patients were maintained haemodynamically stable using both HES and MFG over the entire study. Fluid balance and colloidal replacement volumes were comparable in both groups (median perioperative infusion volume: HES 2500 ml, MFG 2400 ml). Laboratory variables were not clinically different. We conclude that both colloidal solutions were comparable in volume efficacy and effects on plasma oncotic pressure, clotting and plasma homeostasis. In the small number of patients studied, 6% HES 200/0.5 was found to be safe when administered in amounts corresponding to the currently accepted maximum daily dose in Germany and France of 33 ml/kg body weight and 2.0 g/kg body weight, respectively.

Adult↗
PubMed1996

[Diagnosis of magnesium deficiency in intensive care patients].

AIM: Magnesium deficiency was investigated in critically ill patients, comparing measurements of plasma concentrations with the results obtained by the magnesium tolerance test. DESIGN AND METHODS: 20 critically ill patients (5 females, 15 males) between the ages of 27 and 86 were investigated. Magnesium plasma concentrations were determined before the magnesium tolerance test according to Ryzen was performed. For this purpose, magnesium sulfate (0.1 mmol/kg) was infused intravenously over four hours. Renal magnesium excretion was measured in the 24 h urine beginning at the start of the infusion. Magnesium concentrations in plasma and urine were determined using atomic absorption spectrophotometry. MAIN RESULTS: In 12 patients magnesium plasma concentrations were decreased to 0.58-0.79 mmol/l. 6 patients showed values within the normal range of 0.80 to 1.0 mmol/l. In 2 patients the plasma concentration was increased to 1.07 and 1.27 mmol/l. Parenteral magnesium tolerance testing revealed a considerable magnesium deficiency by retention of 65-100% of the loading dose in 14 of the 20 patients. The remaining 6 patients retained 23-48% of the loading dose, thus demonstrating a moderate magnesium deficiency. CONCLUSION: Determination of magnesium plasma concentration appears suitable as an informative preliminary survey, since low values are reliable indicating a magnesium deficiency. However, this study confirms that normal magnesium plasma concentrations do not exclude a considerable magnesium deficiency, which is more sensitively determined by the magnesium tolerance test.

Adult↗
PubMed1995

[The determination of total protein is not a suitable diagnosis for the treatment of hypoalbuminemia in intensive care patients].

In clinical practice, the administration of supplementary albumin often depends on the measured plasma concentration of total protein (TPC). A TPC of less than 5 g/dl is generally accepted as an indication for albumin therapy, assuming an albumin concentration of less than 2.5 g/dl. However, a physiological relation between TPC and albumin cannot be expected in critically ill patients, and thus, measurement of TPC may be misleading as an indicator for the use of albumin. Therefore, we investigated the sensitivity and specificity of TPC testing for diagnosing hypoalbuminaemia requiring treatment. METHODS. In this prospective study, 210 consecutive patients were included. Protein electrophoresis was performed three times a week; the second electrophoresis was selected for evaluation. Applied statistical analysis revealed the number of positive total protein tests indicating hypoalbuminaemia requiring treatment (sensitivity) and the number of negative with tolerable reduced albumin concentrations (specificity). RESULTS. Of the investigated patients, 27.6% had normal TPCs between 6.2 and 8.0 g/dl. In 81.9% of cases an albumin concentration below 3.5 g/dl was found, while 43 patients had a concentration below 2.5 g/dl. The sensitivity and specificity of TPC measurement for the diagnosis of clinically relevant hypoalbuminaemia (albumin concentration < 2.5 g/dl) was calculated at different cutoff points for total protein. With a TPC of 6.0 g/dl, the sensitivity was 0.96 and the specificity 0.44. With a cutoff point of 5.0 g/dl, the sensitivity was reduced to 0.65 and specificity increased to 0.86. Finally, with a TPC of 4.0 g/dl sensitivity was 0.25 and specificity almost 1. CONCLUSIONS. Depending on the cutoff point for TPC, a relevant albumin requirement would frequently not be detected. In other cases, a need for albumin would be assumed from a reduced TPC even though the albumin concentration still exceeded 2.5 g/dl. Therefore, determination of TPC is not a suitable indicator of the need for albumin replacement. As a result, we suggest routine determination of albumin concentrations instead of TPC.

Adolescent↗
PubMed1995

[The effects of long-term sedation on intestinal function].

Gastrointestinal integrity with intact function are of main importance in critically ill patients, and not only as a route of nutritional support. Drugs used for long-term sedation can lead to disordered gastrointestinal motility. In this study we compared the influence of different combinations of analgesics and sedatives on the intestinal function in mechanically ventilated, critically ill patients. METHODS. A total of 190 patients were evaluated retrospectively. All patients required controlled mechanical ventilation and deep sedation (Ramsay Score 5-6) for 7 days or more due to acute respiratory failure or elevated intracranial pressure. In none of these patients was enteric tube feeding contraindicated. Intact intestinal function was assumed when full enteric tube feeding was achieved on days 5 and 6 of the treatment period. Furthermore, other gastrointestinal motility disorders (e.g. constipation) had to be absent. In all patients the feeding tube was placed in the stomach by the nasogastric route. Corresponding to different combinations of analgesics and sedatives, the 190 patients were divided into 11 groups. The following combinations were used: group 1 (n = 20), fentanyl+flunitrazepam; group 2 (n = 20), fentanyl+midazolam; group 3 (n = 20), fentanyl+thiopentone; group 4 (n = 20) piritramide+midazolam; group 5 (n = 20), piritramide and continuous epidural administration of bupivacaine+midazolam; group 6 (n = 20), piritramide+gamma-aminobutyric acid (GABA); group 7 (n = 20), ketamine+midazolam; group 8 (n = 10), ketamin+methohexitone; group 9 (n = 20), ketamine+propofol; group 10 (n = 10), ketamine+midazolam and GABA; group 11 (n = 10), sufentail+midazolam and methohexitone. Patients in groups 3, 8, 9, 10, and 11 all had severe head injury and elevated intracranial pressure. Group 6 was made up exclusively of elderly patients (> 65 years) without head trauma. RESULTS. The patients in groups 1, 2, and 3 received fentanyl for analgesia and were completely fed by enteric tube in 30%, 35%, and 15% of cases, respectively. In group 3 deep sedation was necessary because of elevated intracranial pressure. In groups 4, 5, and 6, piritramide was administered for analgesia, and normal enteric tube feeding was achieved in 70%, 75%, and 90% of cases. The best results were seen in group 6, and these elderly patients needed smaller amounts of piritramide for analgesia. In groups 7, 8, 9, and 10, ketamine was given for analgesia, and complete enteric tube feeding was carried out in 75%, 30%, 45%, and 60% of these patients. The best results in the ketamine groups were found in combination with midazolam as the sedating drug; however, the patients in group 7 did not have elevated intracranial pressure, in contrast to the patients in groups 8, 9, and 10. The last group received the combination of sufentanil, midazolam and methohexitone to achieve a deep sedation. The rate of normal enteric tube feeding in these patients with severe head trauma was 30%. CONCLUSIONS. In patients with severe head trauma who need deep sedation to prevent dangerous high intracranial pressure, gastrointestinal motility disorders are very commonly found. The results obtained suggest that ketamine should be regarded as the analgesic drug of choice, combined with propofol rather than a high-dose barbiturate therapy. The combination of ketamine with midazolam and GABA is an unusual strategy for long-term sedation, which resulted from our own clinical studies directed at an effective and well-tolerated regime for this high-risk patient group. Obviously, high-dose barbiturates and short-acting opioids, especially when combined, make enteric tube feeding more difficult. Therefore, we recommend piritramide or ketamine for analgesia. The basic sedating drug is midazolam, in special cases combined with or replaced by propofol. The position of GABA in long-term sedation is not yet clear, but a lack of side effects on the gastrointestinal tract became evident in this stud

Adolescent↗
PubMed1994

[Determination of intrinsic PEEP during mechanical ventilation. Validation of a new optional method of measurement provided by the EVITA mechanical ventilator].

Intrinsic positive end-expiratory pressure (PEEPi) occurring during mechanical ventilation depends on expiratory time constants, expiratory volume and expiration time as well as on external flow resistance (tubes, valves, etc.). It is not routinely determined in mechanically ventilated patients, but it is necessary to optimize respirator settings. The aim of the present study was the validation of an automated PEEPi determination method implemented in the respirator EVITA (Drägerwerke, Lübeck) in mechanically ventilated patients with acute lung failure. PATIENTS. The method was validated in ten sedated, myorelaxed patients with respiratory insufficiency of different etiologies (five with restrictive, and five with obstructive pulmonary disease). PEEPi was determined using the volume constant ventilatory mode at ZEEP or at an external PEEP of 5 as well as 10 cm H2O. METHOD. PEEPi was first determined with the automated method implemented in the EVITA (five measurements at each end-expiratory pressure level; PEEPEvita). Steady-state was attained between each measurement. These values were compared to the results obtained with end-expiratory occlusion (external, computer-controlled valve in the inspiratory limb of the circuit) at the respective pressure levels (PEEPEEO). The average of five measurements at each PEEP level with each method was defined as PEEPi for the particular ventilatory situation. Gas flow was measured at the proximal end of the endotracheal tube with a heated pneumotachometer (Fleisch no. 2, Fleisch, Lausanne, Switzerland) and a differential pressure transducer. Tracheal pressure was determined in the same position with a further differential pressure transducer (Dr. Fenyves & Gut, Basel, Switzerland). After A/D conversion, data were sampled with a frequency of 20 Hz and processing as well as for control of the occlusion valve was self-programmed. For the statistical analysis we used the Mann-Whitney U-test or Wilcoxon signed-ranks test; a P value less than 0.05 was considered significant. RESULTS. At the given respiratory setting and without PEEP patients with obstructive lung disease had a higher PEEPi (median: 6.4 cm H2O; range: 5.0-9.6 cm H2O) than those with restrictive pulmonary disease (median: 2.3 cm H2O; range: 0.8-3.0 cm H2O) (P < 0.05). Increasing external PEEP to 5 or 10 cm H2O significantly decreased the pressure difference between PEEPi and external PEEP (P < 0.05), but was unable to eliminate it completely. There was no statistically significant difference between PEEPEEO and PEEPEvita (P = 0.43; Wilcoxon signed-ranks tests). Regression analysis showed a highly significant correlation between PEEPEEO and PEEPEvita values (r = 0.985, P < 0.001; y = 1.03 x-0.18). DISCUSSION. PEEPi occurs during ventilation in patients with obstructive and restrictive lung disease. The difference between external end-expiratory pressure and PEEPi decreases with increasing external PEEP. However, PEEPi may increase with increasing external PEEP in some instances. The reason for this may be that the PEEPi determined at the proximal end of the endotracheal tube represents only a mean value of different PEEPi values of various lung regions. Increasing external PEEP only partially alters this mean value due to an effect on PEEPi values lower than external PEEP. The PEEPi values measured by the EVITA respirator compared with classical end-expiratory occlusion with an external valve were nearly identical. Unfortunately, PEEPi measurement of the EVITA can only be performed during controlled and not during assisting (PSV, BIPAP etc.) ventilation. Optimal respirator settings require a knowledge of PEEPi (i.e., adaption of external PEEP for lowering the work of breathing in COPD patients or prolongation of the expiratory phase to avoid unwanted side effects of an occult PEEPi on the circulation). Since mo

Aged↗
PubMed1994

[Fulminating E. coli sepsis in Fournier's gangrene].

Fournier's gangrene is a necrotising soft-tissue infection of the scrotum and perineal region caused by gram-negative and gram-positive Enterobacteriaceae. The disease is characterised by its unique appearance, its speed of onset, and its high mortality. CASE REPORT. A 26-year-old male presented to the emergency room complaining of a painful, tremendously swollen scrotum and penis (Fig. 1) that had developed within the past 24 h. Later, slurred speech, pallor, and hypotension were recognised, leading to the patient's admission to the intensive care unit. Suspecting a severe internal haemorrhage, vigorous volume therapy was started using crystalloids and colloids until blood and fresh frozen plasma were available. One hour later, septic shock was presumed and therapy augmented by IV antibiotics, tracheal intubation, and mechanical ventilation. Despite all efforts, the patients condition deteriorated rapidly and he died a few hours later due to multiple organ failure in septic shock. Postmortem, a perforated external hemorrhoidal node was found to be the primary focus of sepsis. Microbiologic cultures revealed Escherichia coli in blood and tissue samples. DISCUSSION. Fournier's gangrene is a rare disease; nevertheless, its clinical picture has to be recognised immediately in order to provide appropriate treatment in time. It occurs predominantly in males after minor trauma, colorectal or urological disease, and perineal or abdominal surgery. Fournier's gangrene usually begins with itching and pain in the scrotal region followed by swelling and dark-blueish discolouration of the scrotum and penis, occasionally including the lower abdominal wall. Fever and chills are usually present. The illness progresses to severe prostation and septic shock with a mortality of 20%-50%. Tissue cultures mostly reveal E. coli, gram-positive enterococci, Pseudomonas, Proteus, and various anaerobes. The treatment should include immediate radical surgical debridement, i.v. administration of broad-spectrum antibiotics, and cardiopulmonary support. CONCLUSION. The dramatic course of Fournier's gangrene requires early recognition, extensive surgical debridement, as well as intensive care treatment in order to prevent irreversible septic shock.

Adult↗
PubMed1994

A rational basis for the measurement of free phenytoin concentration in critically ill trauma patients.

Phenytoin binding to serum proteins and factors influencing protein binding were investigated in 38 critically ill trauma patients. In 24% of these patients, the free fraction of phenytoin was < or = 10%, whereas in 76%, the free phenytoin fraction was increased > 10%--up to 24%. Nonantiepileptic comedication, sex, or age had no influence on phenytoin binding in any of the 38 patients. Elevated free phenytoin fraction was found in those with hypoalbuminemia and hepatic and renal impairments. In these patients, the free phenytoin fraction should be measured routinely.

Adolescent↗
PubMed1994

Long-term effects of two different ventilatory modes on oxygenation in acute lung injury. Comparison of airway pressure release ventilation and volume-controlled inverse ratio ventilation.

A total of 18 patients with acute lung injury (ALI) were sequentially ventilated with two different modes of mechanical ventilation, each applied for a period of 24 h: (1) volume-controlled inverse ratio ventilation (VC-IRV), (2) airway pressure release ventilation (APRV). The individual sequence of both ventilatory modes was randomized. Ventilatory minute volume was adjusted for a PaCO2 of 35 to 45 mm Hg at the beginning of the study during the first ventilatory mode and then kept constant within preset limits. Hemodynamic variables were stable and similar during the 24-h periods of VC-IRV and APRV as well. Despite the lower sedation and spontaneous breathing during APRV, oxygen uptake was similar during both ventilatory modes. During the 24-h period of VC-IRV there was no relevant change of either airway pressures, alveolo-arterial O2 tension difference (AaDO2)/fraction of inspired oxygen (FIO2) or venous admixture. In contrast, peak airway pressures (Pawmax) during APRV were significantly lower (about 30%; p < 0.01), and decreased further within 24 h (p < 0.05). During APRV AaDO2/FIO2 and venous admixture improved significantly with time after more than 8 h (AaDO2/FIO2: 487 versus 414 mm Hg; p < 0.01; venous admixture: 20.6 versus 13.9%; p < 0.01; medians of onset versus end). The improvement was significantly different between both ventilatory modes (p < 0.01). We conclude that this indicates a progressive alveolar recruitment over time during ventilation with APRV.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1994

Comparison of the determination of magnesium by methylthymol blue spectrophotometry and atomic absorption spectrophotometry.

Plasma samples (n = 155) of 30 patients on an intensive ward were analysed for magnesium simultaneously by atomic absorption spectrophotometry (AAS) and methylthymol blue spectrophotometry. Methylthymol blue spectrophotometry was performed at the bedside, using two different multianalysers, Easy ST 1 and Easy ST 2, Merck, D-Darmstadt. Precision was 12.2% (Easy ST 1) and 17.1% (Easy ST 2), and the average value was 0.89 mmol/l, which was above the expected range (0.72-0.88 mmol/l). Accuracy was 16.25% (Easy ST 1) and 8.75% (Easy ST 2). Analyser 2 was more accurate (8.75% versus 6.25%) but less precise (17.1% versus 12.2%) than analyser 1. Precision of AAS was between the expected values of 0.69 and 0.84 mmol/l. Easy ST and AAS gave significantly different values (p < 0.0001) for 155 measurements. Comparison of AAS and methylthymol blue spectrophotometery showed that methylthymol blue spectrophotometry produced higher values than AAS (mean difference 0.186 mmol/l). Furthermore, analyses of 40 samples of a standardized plasma concentration with methylthymol blue spectrophotometry showed a very low precision (15.3%). Easy ST cannot be assigned for urinary measurements of magnesium. Experimentally measured samples gave unaccountable results.

Bromthymol Blue↗
PubMed1994

Cost containment: Europe. Germany.

The German healthcare system offers a social network guaranteeing almost complete healthcare coverage to the German population (prevention, treatment, and rehabilitation). The system is supported by a multistructured network of public and private healthcare insurers. Fees for public insurance are equally paid by employers and employees. Healthcare expenditures heavily impact the salary levels of employees and, as a result, production costs of employers. About one third of all national healthcare spending goes to hospital care. In 1991, there were ICUs in half of all German hospitals; 3.2% of all hospital beds were ICU beds. As in most countries, the expansion in national healthcare costs in the last decade has become a serious problem in Germany. At total of 8.1% of the entire German gross national product is spent on health care, which has led to drastic governmental healthcare reform that began in 1993. The key points of this reform are: a) strict limitations on hospital budgets at 1992 levels including a new structure of hospital financing; b) controlled reduction of expenditures for medical drugs (which were formerly at the highest level in Europe); and c) controlled restriction of regional distribution for physicians. In a large German university hospital (1,461 beds; 91 ICU beds) expenses for intensive care medicine comprise about 12% of all hospital spending (5,356 deutsche mark/patient). More than 60% of these expenses are for personnel; 37% go toward drugs and medical materials. There are several possible starting points for cost containment in intensive care medicine in Germany: a) a task-adapted, countrywide diffusion of ICUs within the different levels of hospitals; b) a more selective provision of intensive care medicine (primary as well as secondary) to patients, depending on patient needs; c) a centralized and task-oriented admission and discharge policy; and d) cost containment in the use of drug therapy by centralized hospital purchasing and by establishing strict, rational, therapeutic principles. Some examples of the author's personal experience follow. In all German hospitals, expenses for personnel are about 60% to 70%. These expenses are fixed by official, standard wages. Cost containment by further restricting the number of personnel impairs the care provided. Improvements in organization and management may contribute to a higher degree of personal motivation for employees and, in turn, may result in higher working efficiency.

Budgets↗
PubMed1993

High-dose intravenous magnesium sulfate in the management of life-threatening status asthmaticus.

In severe status asthmaticus basic medical treatment often fails to improve the patient's condition. Mechanical ventilation in this situation is associated with a high incidence of serious complications. After the bronchodilating effect of moderate-dose magnesium sulfate in asthmatic patients had been demonstrated in previous studies we treated five mechanically ventilated patients with refractory status asthmaticus successfully with high dosages of MgSO4 IV (10-20 g within 1 h depending on the bronchodilating effect). MgSO4 resulted in a significant decrease of peak airway pressure (43.0 +/- 6.8 to 32.0 +/- 8.0 cmH2O) and inspiratory flow resistance (22.7 +/- 7.0 to 11.9 +/- 6.0 cmH2O.l-1.s-1) within 1 h. The resulting serum magnesium levels after one hour were up to threefold of the normal serum levels. Although a maintainance dose of 0.4 g/h had been administered continuously during the following 24 h serum magnesium decreased towards normal values within this time. The only relevant side-effect was a mild to moderate arterial hypotension in two of the five patients during the high dose administration period of MgSO4 which responded readily to dopamine treatment.

Adult↗
PubMed1993

Intrinsic PEEP determined by static pressure-volume curves--application of a novel automated occlusion method.

OBJECTIVE: Evaluation of new computer-controlled occlusion procedure for determination of intrinsic PEEP in mechanically ventilated patients and comparison with the standard end-expiratory occlusion method. DESIGN: Prospective controlled study. SETTING: Intensive care unit of a university hospital. PATIENTS: 16 patients with acute respiratory failure of different degree and etiology. All patients were mechanically ventilated, heavily sedated and muscle paralyzed (non-depolarising relaxants). The type of ventilator, the inspiration/expiration ratio, FIO2 and PEEP were selected by the attending clinicians according to the patients' need and independently from the study. INTERVENTIONS: Static compliance of the respiratory system (Cstat) was determined at varying external end-expiratory pressure settings: ZEEP (= ambient pressure), PEEP of 5 cmH2O and 10 cmH2O. All other ventilator settings were kept constant during the entire procedure. MEASUREMENTS AND RESULTS: A computer-controlled occlusion method (SCASS) was used for determination of Cstat. Intrinsic PEEP was determined by SCASS as the extrapolated zero-volume intercept of the regression line of multiple pressure/volume data pairs (PEEPSCASSinspir and PEEPSCASSexpir). Directly thereafter intrinsic PEEP in this particular ventilatory setting was determined by end-expiratory occlusions (PEPPEEO). The intrinsic PEEP values of the different methods were nearly identical with a significant correlation (p < 0.0001). Mean values +/- SD: PEEPSCASSinspir 7.1 +/- 4.3 cmH2O; PEEPSCASSexpir 7.1 +/- 4.5 cmH2O; PEEPEEO 7.1 +/- 4.2 cmH2O. CONCLUSION: Since no significant difference between PEEPi values measured by the inspiratory and expiratory occlusion method (SCASS) was seen, this indicates that no alveolar recruitment occurred during the respiratory cycle. This study demonstrates that the automated occlusion method for measuring Cstat system can also be used with high accuracy for determination of intrinsic PEEP in mechanically ventilated patients.

Adult↗
PubMed1993

[Prevention of pneumonia by endotracheal micronebulization of tobramycin].

In 69 artificially ventilated patients the clinical, bacteriological and pharmacological effects of endotracheally administered tobramycin were studied in comparison to a control group. In the therapy group, 52% of all specimens were sterile, in the control group only 25%. During the first 4 days these changes were significant (p < 0.05). In the therapy group the endotracheal colonisation with ps. aeruginosa was significantly lower between the 4th and 14th day (p < 0.05). The incidence of secondary pneumonia was reduced from 42% to 17.5% (not significant). Systemic administration of antibiotics, e.g. of aminoglycosides, was significantly more often necessary in the control group. No increasing of growth of fungi in the upper respiratory tract was observed, but these was a non-significantly higher incidence mainly of staph. epidermidis. The application of 80 mg tobramycin four times a day as an aerosol was well tolerated by the patients. Under there conditions, tobramycin could not be measured in the serum. No allergic reactions, increased respiratory pressures or bronchoconstrictions were observed.

Adolescent↗
PubMed1993

Hepatic disposition of sufentanil in patients undergoing coronary bypass surgery.

In order to clarify the relative contribution of the liver to the short-term disposition of sufentanil, hepatic blood flow was measured during induction of anaesthesia with a 10 micrograms/kg i.v. bolus dose of sufentanil followed by a continuous infusion of 0.3 microgram/kg/min of sufentanil. The hepatic clearance of the drug was 0.57 l/min after induction and 0.55 l/min at sternotomy, its hepatic extraction 92% and 91%, respectively. As a consequence of the high hepatic extraction, the hepatic clearance of sufentanil was closely dependent on hepatic plasma flow. Comparing the hepatic clearance of sufentanil with data from the literature for total body clearance of sufentanil, there is a significant difference of more than 0.3 l/min. It is concluded that there is evidence for a relevant extrahepatic disposition of sufentanil.

Anesthesia, Intravenous↗