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  • 1
    ISSN: 0273-1177
    Source: Elsevier Journal Backfiles on ScienceDirect 1907 - 2002
    Topics: Mechanical Engineering, Materials Science, Production Engineering, Mining and Metallurgy, Traffic Engineering, Precision Mechanics , Physics
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  • 2
    ISSN: 1432-1041
    Keywords: Paracetamol ; drug conjugation ; renal elimination ; glucuronidation ; sulphation ; metabolic capacity
    Source: Springer Online Journal Archives 1860-2000
    Topics: Chemistry and Pharmacology , Medicine
    Notes: Summary Factors which might affect paracetamol disposition have been studied in a heterogenous group of patients in need of mild analgesia in an intensive care unit. Following oral administration of 1 g of paracetamol, plasma and urinary concentrations of the parent compound and metabolites were assessed by HPLC. The renal clearance of paracetamol was significantly correlated with urine flow (r=0.84) and creatinine clearance (r=0.77), but not with urine pH. Metabolite output was diminished in patients with reduced renal function. Despite the heterogeneity of patients and the diversity of drug treatment, the urine to plasma paracetamol concentration ratio appeared remarkably constant in patients with normal renal function (9.8±2.7). It is concluded that the metabolite to paracetamol ratio may only be regarded as a measure of the drug metabolizing capacity in subjects with normal renal function, if factors influencing urine volume and paracetamol absorption are standardized.
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  • 3
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    Springer
    Der Gynäkologe 33 (2000), S. 726-733 
    ISSN: 1433-0393
    Keywords: Schlüsselwörter Tumorschmerztherapie ; Palliativmedizin ; WHO-Stufen-Schema ; Nichtopioide ; Opioide ; Adjuvantien ; Lebensqualität ; Keywords Tumor pain therapy ; palliative medicine ; World Health Organization(WHO) ladder ; nonopioid medications ; opioids ; adjuvant therapy ; quality of life
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract In Germany, as in all industrial nations, there has been an increase in the number of cases of cancer and in cancer-related mortality. According to the German Federal Bureau of Statistics, in 1998 nearly 213,000 persons died due to malignant cancer. Cancer patients generally have physical and psychological dysfunction that may in turn cause a significant reduction in quality of life if treatment is performed insufficiently or not at all. Pain is the dominant symptom and can have serious effects on the patient and his or her family. Although various organizations have published treatment plans for adequate pain therapy, in many cases they are not adequately applied by physicians. This work therefore offers a comprehensive review of pain therapy as an essential component of palliative medicine.
    Notes: Zum Thema In Deutschland ist wie in nahezu allen Industrieländern eine Zunahme der Zahl von Tumorerkrankungen und der Krebsmortalität zu verzeichnen. Gemäß den Angaben des Statistischen Bundesamtes starben 1998 nahezu 213.000 Personen infolge einer bösartigen Erkrankung. An Krebs Erkrankte leiden in der Regel an einer Vielzahl von physischen und psychischen Funktionsstörungen, die bei unzureichender oder fehlender Behandlung zu einem deutlichen Verlust an Lebensqualität führen. Schmerzen sind dabei das dominierende Symptom mit entsprechend gravierenden Auswirkungen auf den Patienten und seine Angehörigen. Zwar gibt es von verschiedenen Organisationen Therapiekonzepte für eine suffiziente Schmerztherapie, doch diese werden häufig nicht in ausreichendem Maße umgesetzt. Dieser Beitrag stellt daher umfassend die Schmerztherapie als einen entscheidenden Eckpfeiler in der Palliativmedizin dar.
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  • 4
    ISSN: 1432-055X
    Keywords: Schlüsselwörter: Messung der Sauerstoffaufnahme – Methodenvergleichsstudie – Inverses Ficksches Prinzip – Indirekte Kalorimetrie – Intrapulmonaler Sauerstoffverbrauch ; Key words: Measurement of oxygen uptake – Method comparison study – Reversed Fick principle – Indirect calorimetry – Intrapulmonary oxygen consumption
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract. Automated measurements of respiratory gas exchange recently became available for the determination of oxygen uptake (V˙O2) in critically ill patients. Whereas these metabolic gas monitoring systems (MBM) are assumed to measure total body V˙O2, the reversed Fick method in principle excludes intrapulmonary V˙O2. Previous clinical reports comparing V˙O2 measured by the reversed Fick principle (V˙O2  Fick) with V˙O2 measured by MBM (V˙O2  MBM) found that V˙O2  MBM was significantly greater than V˙O2  Fick. It was suggested that these differences between methods represent V˙O2 of pulmonary and bronchial tissue, as intrapulmonary V˙O2 had been estimated to account for 15% of total body V˙O2 in dogs with experimental pneumonia. The objective of this study was to compare V˙O2  Fick with V˙O2  MBM in patients with and without pneumonia and to assess the reproducibility of both methods in critically ill patients. Method. With institutional approval nine critically ill patients with acute pneumonia were studied under controlled mechanical ventilation. The diagnosis of pneumonia was based on respective changes of chest X-rays, body temperature 〉38 °C, and WBC counts 〉12,000/mm3. Inspiratory oxygen fractions (FIO2) ranged from 0.3 to 0.6; all patients routinely received opioids and hypnotics. Complete muscle relaxation was achieved during the periods of measurement to avoid sudden changes in V˙O2 due to shivering or involuntary movements. Arterial and pulmonary-arterial blood samples were drawn simultaneously after aspiration of the sevenfold catheter dead space. Measurements of haemoglobin concentration (Hb), fractional oxygen saturation (SO2), and O2 partial pressure (PO2) were performed by use of a calibrated haemoximeter and blood gas analyser, respectively; 2×5 thermodilution measurements of cardiac output (CO) were spread randomly over the respiratory cycle for each determination of V˙O2  Fick. To minimise systematic errors of CO measurements, the CO computer was calibrated in an extracorporeal model using an electromagnetic flowmeter. Calculations of V˙O2  Fick were based on an oxygen binding capacity of 1.39 ml/g Hb. Simultaneous measurements of V˙O2  MBM were obtained by use of a Datex Deltatrac MBM that had been validated in vitro with a gas dilution model of respiratory gas exchange. Calibration of the MBM was performed prior to each measurement. Gas supply of the respirator was provided by an external high-precision mixing device to reduce errors in V˙O2 measurements that may arise from short-term oscillations in FIO2. All patients with pneumonia were studied on three consecutive days; thus, measurements from 27 days could be analysed. On each day two sets of measurements were performed at an interval of 60 min to assess the reproducibility of differences between methods. During each set of measurements duplicate blood samples were drawn twice, before and after thermodilution measurements of CO, to evaluate the short-term repeatability of V˙O2  Fick. The beginning and the end of each set of measurements were marked in the computer record of the MBM to assess the respective repeatability of V˙O2  MBM. Fifty control measurements were performed in ten patients undergoing major neurosurgical procedures. None of these patients exhibited signs of pulmonary infection. Except for the number of repeated measures, all V˙O2 measurements were obtained in the same way as in the study group. Descriptive statistical analysis was performed according to Bland and Altman; comparisons between methods were done by multivariate analysis of variance for repeated measures. Results. Neither in the study group nor in the control group could a significant difference between methods be demonstrated. In patients with pneumonia the mean difference between methods (V˙O2  Fick−V˙O2  MBM) was 15.2 ml/min (4.2%); the double standard deviation of differences (2 SD) was 59.2 ml/min (19.2%). Control patients exhibited a mean difference of 7.2 ml/min (3.1%); 2 SD was 41.1 ml/min (20.4%). Duplicate determinations of V˙O2  Fick and V˙O2  MBM within one set of measurements showed a repeatability coefficient (2 SD of differences between repeated measures) of 43.8 ml/min (13.2%) and 15.3 ml/min (5.1%), respectively. The large variation of duplicate measurements of V˙O2  Fick was caused rather by the variability of arteriovenous O2 content determinations than by the variability of CO measurements. Discussion. These results are in contrast to previous method comparison studies, which suggested that in infected lungs V˙O2 of pulmonary and bronchial tissue represents up to 15% of total body V˙O2. Since the mean differences between V˙O2  Fick and V˙O2  MBM did not differ between the two groups of patients, pulmonary infection did not seem to cause a considerable increase in intrapulmonary V˙O2. A minor effect of intrapulmonary V˙O2 on differences between methods cannot be excluded because of the variability of data. The poor repeatability of V˙O2  Fick measurements, however, seems to limit the use of method comparison studies for estimation of intrapulmonary V˙O2.
    Notes: Zusammenfassung. Automatisierte metabolische Monitorsysteme (MBM) ermöglichen nahezu kontinuierliche Messungen der Sauerstoffaufnahme (V˙O2) aus respiratorischen Gasen. Das inverse Ficksche Prinzip unterscheidet sich bei der Bestimmung der Gesamt-V˙O2 von diesen Verfahren insofern, als die intrapulmonale V˙O2 durch Lungen- und Bronchialgewebe nicht mit erfaßt wird. In der vorliegenden Untersuchung wurde daher unter besonderer Berücksichtigung der Methodenreproduzierbarkeit das inverse Ficksche Prinzip (V˙O2 Fick) mit V˙O2-Messungen aus respiratorischen Gasen (V˙O2  MBM) verglichen. Unter der Annahme, daß akute entzündliche Lungenerkrankungen zur Steigerung des intrapulmonalen Anteils der V˙O2 führen, wurden Vergleichsmessungen sowohl bei kritisch kranken Patienten mit akuter Pneumonie (n=9) als auch bei lungengesunden Kontrollpatienten (n=10) durchgeführt. Weder in der Studien- noch in der Kontrollgruppe fand sich eine signifikante Differenz zwischen den untersuchten Meßverfahren. Die mittlere relative Methodendifferenz V˙O2  Fick−V˙O2  MBM betrug +4,2% (2 SD=19,2%) in der Studiengruppe und +3,1% (2 SD=20,4%) in der Kontrollgruppe. V˙O2  Fick-Bestimmungen wiesen in Abhängigkeit von der Anzahl der gemittelten Blutanalysen eine zwei- bis dreifach schlechtere Reproduzierbarkeit auf als simultane V˙O2  MBM-Messungen. Die vorliegenden Befunde widersprechen der Hypothese, daß die intrapulmonale O2-Aufnahme bei Patienten mit pulmonalen Infektionen bis zu 15% der Gesamtkörper-V˙O2 repräsentiert. Ferner ist aufgrund der engen Übereinstimmung der systematischen Methodendifferenzen von Studien- und Kontrollpatienten nicht von einer klinisch bedeutsamen Steigerung der intrapulmonalen V˙O2 infolge von Pneumonien auszugehen.
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  • 5
    ISSN: 1432-055X
    Keywords: Schlüsselwörter: Totale intravenöse Anästhesie: Etomidat, Midazolam, Fentanyl – Kardiochirurgie – Streßreaktion: Kortisol, Aldosteron, ACTH, β-Endorphin, Katecholamine ; Key words: Anaesthesia, intravenous – Anaesthetics, intravenous: etomidate, midazolam, fentanyl – Cardiac surgery: coronary artery bypass grafting – Endocrine stress response: cortisol, aldosterone, ACTH, β-endorphin, catecholamines
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract. Etomidate is a hypnotic with only minor effects on haemodynamics. Although its rapid elimination kinetics would suggest its use in total intravenous anaesthesia (TIVA) and sedation, its administration in higher doses or for a prolonged period has been discouraged due to its inhibitory effects on corticosteroid synthesis. Newer evidence that the suppression of cortisol synthesis might not be total requires a re-evaluation of this drug as a component of a TIVA technique. The effects of high-dose etomidate with fentanyl on spontaneous and stimulated corticosteroid levels as a measure of the magnitude and duration of adrenocortical suppression, as well as on plasma concentrations of adrenocorticotropic hormone (ACTH) β-endorphin, and catecholamines during cardiac surgery were investigated in a prospective, randomised study and compared to those following the administration of midazolam-fentanyl. Patients and methods. Nineteen patients undergoing myocardial revascularisation were assigned to two groups: group 1: etomidate-fentanyl (n=9) and group 2: midazolam-fentanyl (n=10). Anaesthesia was induced with fentanyl 0.5 mg and either etomidate 0.3 mg/kg or midazolam 0.2 mg/kg. Relaxation was achieved with pancuronium 0.1 mg/kg. Anaesthesia was maintained during extracorporeal circulation (ECC) with an infusion of etomidate (0.36 mg⋅kg−1⋅h−1) or midazolam (0.16 mg⋅kg−1⋅h−1) and fentanyl (10 µg⋅kg−1⋅h−1. Blood samples were drawn before induction, before ECC, and 1, 6, and 20 h after surgery. Cortisol secretion was stimulated with 0.25 mg ACTH1 – 24 IV at 6 and 20 h postoperatively. Results. The total drug doses were etomidate 87±3 mg and midazolam 46±2 mg. Plasma cortisol concentrations decreased in the etomidate group from 20 (10 – 31) to 10 (6 – 31) µg⋅dl−1 (median and range) before ECC, but had returned to baseline at 1 h and were significantly increased at 6 h [29 (15 – 47) µg⋅dl−1] and 20 h [46 (29 – 62) µg⋅dl−1]. There was no difference between the groups except at 20 h, when cortisol levels were higher in the etomidate group. The stimulated cortisol increase was markedly impaired in this group at both measuring points. ACTH and β-endorphin were markedly increased in the etomidate group and ACTH concentrations were eight times greater than the corresponding values in the midazolam group after surgery (ACTH 141 vs. 18 pmol⋅l−1). Plasma catecholamine concentrations increased significantly in both groups. Noradrenaline concentrations were greater in the etomidate group at 6 h after surgery. Two patients in the midazolam group and none in the etomidate group required circulatory support with exogenous catecholamines. Discussion. It is concluded that the stress of cardiac surgery can overcome the block in cortisol synthesis caused by the administration of high-dose etomidate by substantially increasing ACTH secretion. The administration of high-dose etomidate was not associated with cardiovascular instability. The use of etomidate as a component of TIVA can therefore not be ruled out on the grounds of insufficient cortisol secretion.
    Notes: Zusammenfassung. Etomidat ist ein Hypnotikum mit hervorragender kardiovaskulärer Stabilität und rascher Elimination, das sich als Bestandteil einer totalen intravenösen Anästhesie bei kardialen Risikopatienten anbietet. Die nachgewiesene Hemmung der Kortisolsynthese führte dazu, daß von einer repetitiven oder kontinuierlichen Etomidatgabe abgeraten wurde. Hinweise auf eine unvollständige Inhibition der Kortisolsynthese machen eine erneute Überprüfung der endokrinen Wirkungen erforderlich. 19 Patienten zur Myokardrevaskularisation nahmen an der Studie teil. Sie erhielten randomisiert eine intravenöse Anästhesie mit Etomidat-Fentanyl oder Midazolam-Fentanyl. Es wurden serielle Bestimmungen der Parameter Kortisol, Aldosteron, ACTH, β-Endorphin, Adrenalin und Noradrenalin durchgeführt sowie mehrfache Nebennierenrindenstimulationen mit exogenem ACTH. Es zeigte sich, daß die Kortisolkonzentrationen in beiden Gruppen sich nicht signifikant unterschieden, bis auf den ersten postoperativen Tag, an dem die Kortisolspiegel in der Etomidatgruppe signifikant höher lagen. Die ACTH-, β-Endorphin- und Katecholaminkonzentrationen lagen postoperativ in der Etomidatgruppe signifikant höher als in der Midazolamgruppe. Nach diesen Ergebnissen kann die Hypothese einer unmittelbaren Gefährdung aufgrund einer etomidatbedingten Kortisolsynthesehemmung im perioperativen Zeitraum nicht aufrechterhalten werden. Vielmehr sollte die totale intravenöse Anästhesie mit Etomidat in Kombination mit einem Opiat in der Kardiochirurgie einer neuerlichen, umfangreichen Überprüfung unterzogen werden.
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  • 6
    ISSN: 1432-055X
    Keywords: Schlüsselwörter: HZV-Messung – Pulmonaler Blutfluß– Thermodilutionsmethode – Intrakardialer Links-Rechts-Shunt ; Key words: Cardiac output measurement – Pulmonary blood flow – Thermodilution method – Intracardiac left-to-right shunt
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract. Thermodilution measurements of cardiac output (CO) by means of Swan-Ganz catheters, in a strict sense, represent pulmonary arterial blood flow (PBF). In principle, this is also true in the presence of intracardiac left-to-right shunts due to atrial or ventricular septal defects. However, early recirculation of indicator may give rise to serious methodological problems in these cases. We sought to determine the influence of intracardiac left-to-right shunts on different devices for thermodilution measurements of CO using an extracorporeal flow model. Methods. Blood flow was regulated by means of a centrifugal pump that at the same time enabled complete mixing of the indicator after injection (Fig. 1). Pulmonary and systemic parts of the circulation were simulated using two membrane oxygenators and a systemic-venous reservoir to delay systemic recirculation of indicator. Control measurements of PBF (Qp) and systemic (Qs) blood flow were performed by calibrated electromagnetic flow-meters (EMF). Blood temperature was kept constant using a heat exchanger without altering the indicator mass balance in the pulmonary circulation. Left-to-right shunt was varied at different systemic flow levels applying a Qp:Qs ratio ranging from 1:1 to 2.5:1. Thermodilution measurements of PBF were performed using two different thermodilution catheters that were connected to commercially available CO computers. Additionally, thermodilution curves were recorded on a microcomputer and analysed with custom-made software that enabled iterative regression analyses of the initial decay to determine that part of the downslope that best fits a monoexponentially declining function. Extrapolation of the thermodilution curve was then based on the respective curve segment in order to eliminate indicator recirculation due to shunt flow. Results. At moderate left-to-right shunts (Qp:Qs〈2:1) all thermodilution measurements showed close agreement with control measurements. At higher shunt flows (Qp:Qs≥2:1), however, conventional extrapolation procedures of CO computers considerably underestimated PBF (Fig. 2). This was particularly true when a slow-response thermistor catheter was used (Fig. 3). The reason for this underestimation of Qp was an overestimation of the area under curve because of inadequate mathematical elimination of indicator recirculation by standard truncation methods (Fig. 4). However, curve-alert messages of the commercially implemented software did not occur. A high level of agreement could be consistently obtained using a fast-response thermistor together with individual definition of extrapolation limits according to logarithmic regression analyses. Discussion and conclusion. Under varying levels of left-to-right shunt, both the reponse time of thermodilution catheters and the algorithms for calculation of flow considerably influenced the validity of thermodilution measurements of PBF in an extracorporeal flow model. The use of computer-based regression analyses to define the optimal segment for monoexponential extrapolation could effectively eliminate indicator recirculation from the initial portion of the declining thermodilution curve and showed the closest agreement with EMF measurements of Qp. The quality of thermodilution curves with respect to recirculation peaks in the flow model was slightly better than in clinical routine. Nevertheless, the clinical applicability of the modified extrapolation algorithm could be illustrated during pulmonary thermodilution measurements in an exemplary patient with a ventricular septal defect (Fig. 5). PBF at extremely high shunt ratios, however, cannot be assessed by monoexponential extrapolation in principle (Fig. 6). Insufficient elimination of indicator recirculation resulted in flow values that closely resembled systemic rather than PBF. This finding is in accordance with a mathematical analysis of the underlying Steward-Hamilton equation if an infinite number of recirculations would be included in the area under curve.
    Notes: Zusammenfassung. Thermodilutionsmessungen des HZV mittels pulmonal-arterieller Einschwemmkatheter repräsentieren im engeren Sinne den pulmonalen Blutfluß (Qp). Bei Vorliegen eines Vorhof- oder Ventrikelseptumdefekts können jedoch unphysiologisch frühe Rezirkulationen des injizierten Indikators zu methodischen Problemen führen. In der vorliegenden Untersuchung wurde daher in einem Kreislaufmodell der Einfluß eines Links-Rechts-Shunts auf 2 unterschiedliche HZV-Meßsysteme überprüft. Die Flußmessungen erfolgten bei 37 °C in zirkulierendem Blut unter Variation des Qp:Qs-Verhältnisses von 1:1 bis 2,5:1, eine Zentrifugalpumpe diente als Flußgenerator und als Mischkammer für den injizierten Indikator. Referenzmessungen des pulmonalen und des systemischen Stromzeitvolumens (Qs) wurden mittels elektromagnetischer Flowmeter durchgeführt. Hohe Shuntvolumina führten aufgrund einer mangelhaften Diskriminierung der Shunt-bedingten Kälterezirkulation zu einer erheblichen Unterschätzung des aktuellen Qp. Abweichungen von den Referenzflußmessungen fanden sich insbesondere bei einer vergleichsweise hohen Zeitkonstante des verwendeten Thermistors sowie bei Verwendung konventioneller Auswertungsalgorithmen, die eine monoexponentielle Extrapolation auf der Basis eines schematisch definierten Kurvenintervalls beinhalten. Die mangelnde Abgrenzung rezirkulierender Indikatoranteile führte zur Ermittlung eines Stromzeitvolumens, das an Stelle von Qp näherungsweise Qs repräsentierte. Eine bessere Übereinstimmung mit Qp-Referenzmessungen konnte durch ein dem Einzelfall angepaßtes Extrapolationsverfahren erzielt werden, das mittels Regressionsanalysen denjenigen Kurvenabschnitt ermittelt, der einem monoexponentiellen Abfall tatsächlich am nächsten kommt.
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  • 7
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Fehlerquellen ; Gefahren ; Motorspritzenpumpen ; Infusionssysteme ; Key words Source of faults ; Dangers ; Syringe drivers ; Infusion systems
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Syringe drivers are used in anaesthetics, intensive care and emergency medicine to deliver small volumes of highly potent drugs with continuous, constant and reproducible flow. For early recognition of interruptions of the drug delivery caused by occlusion of the infusion system, an alarm is triggered as soon as the system pressure exceeds a certain limit. The sensitivity of this alarm depends on the flow rate, type-specific cut-off pressure and the elastic parameters of the infusion system. The sudden release of pressure built up in the system after occlusion occurred can cause delivery of an uncontrolled drug bolus and hence an additional hazard. Methods: Six syringe drivers that are widely used in clinical practice were tested for alarm delay and bolus delivery in the event of an occlusion in the system. First, the alarm pressures at flow rates of 10, 50 and 100 ml/h were measured. Then the alarm delay time and bolus volumes post-occlusion were assessed, using a basic infusion system (syringe+single infusion set). Finally, several alterations to the system like extension, tap battery with germ filters or branching were made and their impact on alarm delay and bolus volume measured. Results: Because of the great differences in alarm pressures between the devices tested, there were marked differences in the alarm delay at same flow rates. Predictably, there was an indirect proportional link between alarm delay and flow rate. Using the basic infusion system, alarm delays between 23 s and 143 min were measured. In two of the tested syringe drivers, a pressure-release mechanism is activated with the pressure alarm, which prevented bolus application. In the other devices, release of the pressure in the occluded system caused boli of 0.5–7 ml. Variations in the actual syringe volume and insertion of a second connection tube had no impact on alarm delay and bolus volume. Tap batteries, parallel running syringe drivers or trapped air in the system, however, caused marked increase in both alarm delay (107%) and bolus volume (+147%). Discussion: Unidentified occlusions of the system cause grave malfunctioning of syringe drivers. While applying highly potent drugs, the discontinuation of drug delivery with subsequent bolus application can cause vital danger to the patient. As a result of the significant time delays in the pressure alarms, the devices tested do not provide sufficient protection against unrecognized system occlusion. Syringe drivers with adjustable alarm pressure can be set close to the actual infusion pressure. A further important point is that one should aim at a reduction in the elastic properties of the infusion set because of the great impact on alarm delay and bolus volume.
    Notes: Zusammenfassung Im Modell wurde die Gerätefunktion verschiedener gebräuchlicher Motorspritzenpumpen bei akzidentellem Verschluß der Infusionsleitung untersucht. Dabei zeigte sich, daß insbesondere Geräte älterer Bauart ohne die Möglichkeit zur Variation der Druckabschaltgrenzen erhebliche Alarmverzögerungen aufweisen. Bei Verwendung eines einfachen Infusionssystems (50 ml-Spritze mit 200 cm-Druckinfusionsleitung) wurden in Abhängigkeit der eingestellten Förderrate Verzögerungszeiten zwischen 23 s und 143 min gemessen. Die meisten der untersuchten Pumpen gaben nach Druckentlastung Flüssigkeitsboli ab, deren Volumen zwischen 0,5 und 1,7 ml lag. Einzelne Modifikationen am Infusionssystem (zusätzliche parallelgeschaltete Pumpen, Lufteinschlüsse in den Spritzen, zugeschaltete Hahnbänke und Infusionsfilter etc.) hatten zum Teil erhebliche Zunahmen der Verzögerungszeiten (bis zu 107%) und der Bolusvolumina (bis zu 147%) zur Folge. Aus den Ergebnissen wird gefolgert, daß Motorspritzenpumpen zur Applikation hochpotenter kreislaufwirksamer Medikamente bei niedrigen Förderraten über variabel einstellbare Abschaltdruckgrenzen verfügen sollten. Unerwünschte Bolusapplikationen müssen ausgeschlossen sein.
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  • 8
    ISSN: 1432-055X
    Keywords: Schlüsselwörter: Kardiopulmonale Reanimation: Defibrillation – Halbautomatische Defibrillatoren –Überlebensrate – Neurologische Langzeitprognose – Rettungssystem: Behandlungsqualität – Logistische Strukturen ; Key words: Cardiopulmonary resuscitation: defibrillation – Semi-automatic defibrillators – Survival – Neurology – Emergency medical services systems: quality – Logistic structures
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract. In a controlled prospective randomized study, defibrillation by emergency medical technicians (EMTs) was compared with the current standard of care in Germany (basic life support by EMTs and defibrillation by emergency physicians only) in order to answer the following questions: 1. Does EMT defibrillation improve the survival rate and long-term prognosis of patients in ventricular fibrillation as compared to the current German standards in resuscitation (basic life support by EMTs and defibrillation by emergency physicians)? 2. Are the prerequisites for the use of semiautomatic defibrillators fulfilled in the emergency medical systems (EMS) of the participating centers? Methods. The study phase includes randomization of 121 adult patients with witnessed cardiac arrest and ventricular fibrillation (VF) as first ECG rhythm. Prior to the onset of the study, all EMTs of the participating EMS systems were retrained in basic life support (BLS) measures. In each center, randomly assessed EMT-Ds (EMTs trained in Defibrillation) were trained to use semiautomatic defibrillators. With the help of one-line tape recording, the time intervals during resuscitation and treatment steps were evaluated. Successfully resuscitated patients were followed up with the help of the Glascow Coma Scale and the Pittsburgh Cerebral and Overall Performance Categories. Results. From 1 February 1991 until 28 June 1992, 159 patients with VF were randomized. In 121 cases, collapse was witnessed. 25% (14/57) of the patients receiving defibrillation by EMT-Ds (study group=S) were discharged from the hospital alive. In the control group, 52 patients were defibrillated by emergency physicians, following BLS by EMTs [control group 1=C1; discharged: 29% (15/52)]. Fifty patients received BLS and advanced cardiac life support (ACLS) by the emergency physicians crews [control group 2=C2; discharged 18% (9/50)]. In the study group, the median time interval from collapse of the patient until initiation of BLS measures was 7.7 min, 7 min in C1 and 8 min in C2. ACLS measures were initiated significantly earlier (P〈0.05) in the control groups, as compared to the study group [S: 13 min, C1: 11 min; C2: 10.3 min]. Sixty-seven percent (30/45) of the study patients and 46% (36/76) of the control patients were defibrillated within 12 min. Study patients were defibrillated earlier (P〈0.05) (S: 9.9 min; C1: 12.2 min; C2: 12.75 min); return of spontaneous circulation (ROSC) was achieved earlier (P〈0.05) in the study group [S: 14 min; C1: 19 min; C2: 18.2 min] and the number of patients in the study group requiring no epinephrine during resuscitation was higher (P〈0.01) than in the control groups [S: 35.3% (12/34); C1: 10% (4/40); C2: 10.5% (4/38)]. Furthermore, the total amount of epinephrine [mean (±standard error)] administered in the study group [S: 2.35 (±0.49) mg; C1: 6.71 (±0.98) mg; C2: 7.71 (±1.31) mg] was significantly lower (P〈0.05). No significant differences in neurological long-term prognosis were found for the groups investigated. Conclusion. Neither the initial survival rate the number of patients discharged alive, nor the neurological long-term prognosis was significantly different for any of the groups investigated. Because of apparent differences in indirect prognostic parameters (time interval until ROSC, number of patients requiring no epinephrine) and because of the fact that the time interval to the first defibrillation was reduced by EMT defibrillation, EMT-Ds may perform defibrillation if: (a) they reach the patient before the emergency physician and (b) if they are trained intensively and supervised continuously. In order to increase the efficiency of defibrillation by EMT-Ds, far-reaching changes in our EMS are mandatory: (a) a reduction in the time interval from collapse until initiation of BCLS measures by intensifying layperson CPR training; (b) an increase in the number of emergency units equipped with semiautomatic defibrillators; (c) the consistent implementation of a tiered EMS.
    Notes: Zusammenfassung. In einer prospektiven Multicenterstudie wurde der Einfluß der Defibrillation durch Rettungsassistenten im Vergleich zum bisher praktizierten Verfahren (Basismaßnahmen der kardiopulmonalen Reanimation durch Rettungsassistenten und Defibrillation ausschließlich durch den Notarzt) auf die Überlebensrate und die neurologische Langzeitprognose bei 159 Patienten mit außerklinisch aufgetretenem Kammerflimmern untersucht. Alle Zeitintervalle des Reanimationsablaufs und die Behandlungsqualität wurden mittels Diktaphon erfaßt und nachvollzogen. Es bestanden keine signifikanten Unterschiede in der primären Überlebensrate, der Entlassungsrate und der neurologischen Langzeitprognose zwischen den untersuchten Gruppen. Aufgrund deutlicher Unterschiede zugunsten der Studiengruppe (Defibrillation durch Rettungsassistenten) in indirekten Parametern (kürzerer Zeitraum bis zur Wiederherstellung spontaner Kreislaufverhältnisse und größere Anzahl an Patienten, die kein Adrenalin benötigten) und der Tatsache, daß in den untersuchten Zentren der Zeitpunkt bis zur ersten Defibrillation signifikant nach vorne verlagert werden konnte, empfehlen wir die Defibrillation durch Rettungsassistenten: a) wenn sie den Patienten vor dem Notarzt erreichen, b) nach straffem Ausbildungsprogramm und unter kontinuierlicher ärztlicher Kontrolle. Um die Defibrillationsmaßnahme durch Rettungsassistenten effektiver werden zu lassen, müssen tiefgreifende Veränderungen im Rettungssystem vorausgehen: Verkürzung des Zeitintervalls bis zum Beginn von Basismaßnahmen sowie konsequente Durchführung eines gestaffelten Rettungssystems.
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  • 9
    Electronic Resource
    Electronic Resource
    Springer
    Der Anaesthesist 46 (1997), S. 275-281 
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Ethik ; Ethische Prinzipien ; CPR ; Herz-Lungen-Wiederbelebung ; Notfallmedizin ; Key words Ethics ; Ethical principles ; CPR ; Resuscitation ; Emergency medicine
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Objective: Thirty years ago, cardiopulmonary resuscitation (CPR) was primarily developed for otherwise healthy individuals who experienced sudden cardiac arrest. Today, CPR is widely viewed as an emergency procedure that can be attempted on any person who undergoes a cessation of cardiorespiratory function. Therefore, the appropriateness of CPR has been questioned as a matter of the outcome, the patient’s preferences, and the cost. The objective of this article is to analyse ethical issues in prehospital resuscitation. Arguments: CPR is bound by moral considerations that surround the use of any medical treatment. According to Beauchamp and Childress, the hierarchy of justification in biomedical ethics consists of ethical theories, principles, rules, and particular judgements and actions. The decision to start CPR is based on the medical judgement that a person is suffering from circulatory arrest. The decision is justified by the moral rule that the victim of a cardiac arrest has the right to survive and to receive CPR. Moral rules are more specific to contexts and are based on ethical principles. The principle of beneficence means the provision of benefits for the promotion of welfare. Talking about beneficence in resuscitation means once again reporting stories of success, as many victims of pre- and in-hospital sudden death have been saved in the past. Nevertheless, resuscitative efforts still remain unsuccessful in the majority of cases, involving the principle of nonmaleficence. There is potential harm in CPR. Survivors may recover cardiac function, but sustain severe hypoxic brain damage, at worst surviving without awakening for months or years. In particular, post-traumatic CPR is associated with an extremely poor outcome, leading to the issue of futility. However, futility should be defined in a strict fashion, as there might be an individual chance of survival. The principle of respect for autonomy means the right of a patient to accept or reject medical treatment, which continues in emergency conditions and after the patient has lost consciousness. The time frame in CPR requires medical decision-making within seconds, and CPR is usually initiated without the patient’s involvement. If the patient’s wish’s can be ascertained later on, life-sustaining therapies might be withdrawn at that time. Terminally ill but still competent patients should be encouraged to write a no-CPR document, which does not deny patients relief from severe symptoms, but might facilitate withholding resuscitative efforts at the scene. The principle of justice affects priorities in the allocation of health care resources. The decision made for a particular patient might delay or prevent emergency treatment in other patients who could receive greater benefit. Conclusions: The standard of care remains the prompt initiation of CPR. However, ethical principles such as beneficene, nonmaleficence, autonomy, and justice have to be applied in the unique setting of emergency medicine. Physicians have to consider the therapeutic efficacy of CPR, the potential risks, and the patient’s preferences.
    Notes: Zusammenfassung Im Zentrum der Notfallmedizin steht die Herz-Lungen-Wiederbelegung. Allerdings muß sich unter den schwierigen Bedingungen der präklinischen notfallmedizinischen Versorgung auch der Reanimationsversuch, wie jede andere medizinische Maßnahme, an allgemeinen ethischen Prinzipien orientieren. Ethische Prinzipien: Das Wohl des Patienten sollte im Vordergrund stehen (Prinzip des Nutzens), es sollte ihm kein Schaden zugefügt werden (Prinzip der Schadensvermeidung) und sein Recht auf Selbstbestimmung muß Berücksichtigung finden (Prinzip des Respekts vor der Autonomie). Jeder Patient sollte in gleicher Weise Zugang zur notfallmedizinischen Versorgung haben (Prinzip der Gerechtigkeit). Umsetzung der Prinzipien: Die Umsetzung des Prinzips des Nutzens in der präklinischen Notfallmedizin erscheint angesichts erfolgreicher Wiederbelebungsversuche offensichtlich. Zahlreiche Menschenleben konnten dank rechtzeitiger Hilfe gerettet werden. Auch das ethische Prinzip der Schadensvermeidung ist bei der Durchführung von Reanimationsmaßnahmen zu berücksichtigen. Mancher Patient verstirbt nach zunächst erfolgreicher Wiederherstellung der Kreislauffunktion Tage oder Wochen später auf der Intensivstation, ohne das Bewußtsein wiedererlangt zu haben. Andere können nur mit schweren neurologischen Einschränkungen aus der Klinik entlassen werden. Das Recht des Patienten, eine autonome Entscheidung zu treffen, also eine medizinische Maßnahme zu befürworten oder abzulehnen, bleibt grundsätzlich in einer Notfallsituation bestehen. Der Betroffene kann allerdings aufgrund der schnell eintretenden Bewußtlosigkeit dieses Recht nicht mehr aktiv wahrnehmen. Patienten, die sich im Endstadium einer chronischen Erkrankung befinden und Wiederbelebungsmaßnahmen ablehnen, können diesen Entschluß durch eine entsprechende Verfügung festhalten. Gerade in der Praxis der präklinischen Reanimation ist jedoch die Berücksichtigung einer solchen Verfügung aufgrund der äußeren Bedingungen und des Zeitdrucks stark eingeschränkt. Im Einzelfall kann ein solcher Hinweis die notärztliche Entscheidung, auf Wiederbelebungsmaßnahmen zu verzichten, erleichtern. Im Zweifel müssen immer Wiederbelebungsmaßnahmen begonnen werden. Unter stationären Bedingungen kann im weiteren Verlauf die Indikation zur Reanimation überprüft werden und ggf. nach sorgfältiger Abwägung ein sekundärer Therapieverzicht erfolgen. Schlußfolgerung: Der Standard medizinischer Hilfe bei einem Herz-Kreislaufstillstand besteht in der Einleitung von Wiederbelebungsbemühungen. Die genannten ethischen Prinzipien sollten bei der Indikationsstellung unter Beachtung der individuellen Voraussetzungen jedes notfallmedizinischen Einsatzes berücksichtigt werden.
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  • 10
    ISSN: 1432-055X
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
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