- Email: [email protected]
Pressure-volume curve analysis in patients with severe head trauma and acute lung injury (DS20)
Abstracts
24
DS19
Results. Parameters of circulation are given in table. Stage Group A Syst. BP 1 2 3 4 5
Group B Ps
SaO2
Syst. BP
Ps
156.366.7 97.465.4 93.563.4 161.465.8 93.466.7 144.263.8 101.568.0 96.762.5 126.564.6** 96.866.3* 151.467.0 86.666.5 98.261.1 121.865.5** 72.163.9** 158.768.2 91.364.9 96.460.8 130.466.1** 68.566.2** 151.166.9 103.268.8 95.063.3 128.464.7** 74.665.4**
SaO2
REMIFENTANIL-PROPOFOL PROVIDES IMMOBILE VOCAL CORDS DURING LARYNGOSCOPIC SURGERY
92.762.1 97.061.1 99.160.3 96.561.1 97.161.0
E. Ladner1, R. Plattner1, S. Natter1, H. Sparr2, W. PoÈlz3, W. Schimetta3
* - P<0.05 ** - P<0.005
Conclusion. Regional anesthesia can prevent blood pressure disturbances and pain syndrome during surgery in patients with electric burns of the upper extremities. The improvement of periferal circulation makes this method of anesthesia a component of the intensive care process.
THE COST-EFFECTIVENESS OF DROTRECOGIN ALFA (ACTIVATED) FOR THE TREATMENT OF SEVERE SEPSIS IN AUSTRIA Neilson A.R.1, Sporn P.2, Frass M.3, Sumann G.4, Graebe A.5, Schneider H.1, PROWESS Economic Team 1 HealthEcon, Basel, 2RH Rudolfstiftung, Wien, 3AKH, Wien, 4 UniversitaÈtsklinik, Innsbruck, 5Lilly Austria, Wien Background and Goal of Study. Drotrecogin alfa (activated) is an effective new therapy for patients with severe sepsis recently demonstrated in the PROWESS trial [1]. In Austria, the mean total direct ICU costs of (conventional) care were recently estimated at = C 28,600 [2]. The present
study estimated the cost-effectiveness of the new therapy in addition to conventional therapy for patients with severe sepsis in Austria.
Materials and Methods. Our base case analysis combines data from the PROWESS trial with Austrian-speci®c unit costs. Total direct costs of care included days spent in ICU, duration of organ support, other hospital stay and new therapy costs. We used a price of = C 244 per 5mg vial for the
new therapy based on the US price of $210 used by Angus et al. [3]. Life expectancy of hospital survivors was based on Austrian life tables and the age-sex distributions of trial survivors. We also performed analyses from a) the European PROWESS patients only and b) directly from an Austrian cost study. We tested the results with a number of sensitivity analyses.
Results and Discussion. The reduction in hospital mortality in PROWESS at Day 28 was 6.0% (30.1% for placebo and 24.1% for the new therapy). The additional hospital survivors have a mean life expectancy of 18.5 years based on age and sex alone. Adjusting life expectancy due to comorbidity, ICU stay and severe sepsis, gives 9.4 years per additional survivor or a gain of 0.56 years per patient treated. The expected total costs C 21,500 standard of treatment are = C 30,100 for the new therapy and =
care. This yields an incremental hospital cost per life year gained of = C 15,400. The modi®ed analyses produced cost-effectiveness ratios of = C 15,900 and = C 14,900. Sensitivity analyses produced cost-effectiveness estimates within the published ranges for other life saving interventions.
Conclusion(s). From the standpoint of cost-effectiveness, treatment of severe sepsis with drotrecogin alfa (activated) is an economically viable treatment option in Austria. Acknowledgements including ®nancial support. This study was supported by Eli Lilly Austria. References 1. Bernard GR et al. N Eng J Med 2001;344(10):699-709. Ef®cacy and Safety of Recombinant Human Activated Protein C for Severe Sepsis. 2. Schmid A et al. (accepted for publication 2002) Wien Klin Wochenschr. Burden of illness imposed by severe sepsis in Austria. 3. Angus DC et al. Crit Care Med 2002; 30(2):493 The cost effectiveness of drotrecogin alfa (activated) (Xigris TM) in severe sepsis.
Background. The aim of the present study was to assess whether a combined technique using remifentanil (remi) and propofol (prop) is equivalent to anaesthesia with succinylcholine-fentanil-propofol (succfent-prop) in surgical procedures requiring immobility of the vocal cords. Patients and methods. After approval by the Ethics Committee and obtaining written informed consent, 22 patients, ASA grades I and II, scheduled for short vocal cord surgery were enrolled in the study. After premedication with midazolam 0.1 mg/kg p.o. anaesthesia was induced with remi (5 mg/kg given over a period of 2 min) and prop 2.5 mg/kg. Surgery using direct laryngoscopy began at 1 min. Operating conditions were assessed by means of an intubation score1. In addition RRsyst/diast, MAP and heart rate were recorded. Assuming that induction of anaesthesia with succ-fent-prop always provides very good intubating conditions, including optimal immobilisation of the vocal cords, this technique served as `historical' control. The margin of equivalence was prospectively determined to be 20%. Results. Twenty-one of the 22 patients (95.5%; 95%CI: 86.8%; 100%) showed `excellent' intubating conditions and no response of the vocal cords to the surgical stimulus. In one patient intubating conditions were `good' (vocal cords immobile and in intermediate position). Based on the prospectively determined 20% margin of equivalence treatment with remiprop and succ-fent-prop is equivalent (p<0.05). In three patients (12.5%) heart rate and blood pressure dropped to levels that required therapeutic intervention. Conclusion. Regarding vocal cord immobilisation in short surgical procedures with direct laryngoscopy the combination of remi (5 mg/kg given over a period of 2 min) and prop 2.5 mg/kg is an equivalent alternative to anaesthesia induced with succ-fent-prop. Reference 1. Viby-Mogensen J, Engbaek J, Eriksson LI, et al. Acta Anaesthesiol. Scand 1996;40:59-74
DS20 PRESSURE-VOLUME CURVE ANALYSIS IN PATIENTS WITH SEVERE HEAD TRAUMA AND ACUTE LUNG INJURY M.M. Pylypenko, MD, C. Krenn, MD, C. Weinstabl, MD, A.F. Hammerle, MD. Department of Anesthesiology and Critical Care Medicine, General Hospital, Univ. Vienna, Austria. Background and goal of study. The level of positive end expiratory pressure (PEEP) setting in mechanically ventilated severe head injured (SHI) patients who developed acute lung injury (ALI) remains debatable (1). The assessment of P-V curves, in particular the lower in¯ection point in patients with ALI indicated the lung recruitment pressure, which is important to ascertain optimal PEEP levels (2). Materials and methods. We performed daily measurement of pressurevolume (P-V) curves with constant low ¯ow techniques (single breath with inspiratory ¯ow 9 l/min, tidal volume 12 ml/kg) in SHI patients who ful®ll criteria of ALI (Murrey Injury Score >1) to investigate changes in lower in¯ection point (LIP). The level of PEEP, which is 2 cm over LIP (LIP measured in static or quasi static conditions), is generally considered as the `best PEEP' (2). Measurement of P-V curves with constant ¯ow 9 l/min leads to right shift of LIP by nearly 1 cm, that is why the `best PEEP' is considered as LIP + 1 cm (3). We compared the data of LIP + 1 cm with PEEP levels setting, according to clinical criteria, in these patients.
Downloaded from http://bja.oxfordjournals.org/ at University of Birmingham on July 16, 2015
DS18
1 Dept. of Anaesthesia and Intensive Care Medicine, District Hospital Reutte; 2Dept. of Anaesthesiology, University of Innsbruck; 3Dept. of Applied System Research and Statistics, University of Linz; Austria
Abstracts Results and discussion. In 9 consecutive patients who ful®lled criteria of ALI 64 measurements of P-V curves were performed. 47 measurements in 7 patients resulted in LIP. There were no complications during measurements of P-V curves. The data of LIP+1 was lower than PEEP levels (8.762.3 cm H2O vs. 10.262.5 cm H2O; p<0.01). In 23 measurements we obtained differences of 3 cm H2O or more between clinically set PEEP levels and the data of LIP+1. In 20 measurements the PEEP levels were 3 cm H2O or more higher than the data of LIP+1. In 3 measurements the PEEP levels were 3 cm H2O or more, lower than the data of LIP+1. The Murray Injury Score in patients with a PEEP difference >3 cm H2O was signi®cantly higher compared to the patients with a PEEP difference <3 cm H2O (2.3 vs.1.8; p<0.001). We concluded that daily measurement of P-V curve in SHI patients with ALI showed statistically signi®cant differences between the data of LIP+1 and the PEEP levels clinically set. The difference between the data of LIP+1 and the PEEP levels signi®cantly increased in patients who had a Murray Injury Score >2. Daily monitoring of lung mechanics based on the P-V curve analysis is safe and can easily be performed as a bedside method, and can provide useful clinical information.
DS21 THE LOCAL IMMUNITY STATUS IN PATIENTS WITH SEVERE EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE Spytcin O., Satsuta S. Department of Anesthesiology of Lugansk State Medical University, Lugansk, Ukraine Keywords. local immunity, chronic obstructive pulmonary disease The role of local immunity of the upper and lower airways in the pathogenesis of severe exacerbations of chronic obstructive pulmonary disease (COPD) is poorly understood. Despite this, treatment has been aimed at advancing anti-in¯ammatory and immunomodulator therapy [1]. This study was designed to evaluate the type of airway in¯ammation and local immune status in patients with severe exacerbations of COPD. A prospective bronchoscopic study evaluated 20 patients with severe exacerbations of COPD (group-1). Bronchoalveolar lavage ¯uid was analyzed for cytology and concentration of SIgA and IgG [2,3,4]. Endobronchial and transbronchial biopsies were performed in selected patients for morphometric evaluation of macrophage/monocytes, neutrophils, eosinophils and lymphocytes. These results were compared with lavage and endo- and transbronchial biopsy studies in normal controls (group-2). Data ise presented as mean 6 SEM. Statistical signi®cance (p < 0,05) was determined using Student's t-test. The patients with severe exacerbations of COPD demonstrated a twofold higher concentration of neutrophils in lavage than the normal controls (p < 0.05). Similar results were obtained in the endobronchial and transbronchial biopsy specimens, which consistently showed signi®cantly higher numbers of neutrophils in the group-1 than in the control group. The concentration of SIgA in bronchoalveolar lavage ¯uid was also highest in the control group, but the concentration of IgG was highest in the group-1 (differences among the groups, p = 0.001 and p < 0.05, respectively). We conclude that the low concentration of SIgA in bronchoalveolar lavage ¯uid in patients with severe exacerbations of COPD is the important factor in the development and continuation of the in¯ammatory process in the upper and lower airways. References 1 E. Wenzel, S. Sze¯er, M. Leung et al. Am. J. Respir. Crit. Care Med., 1997;156;737-743. 2. Bernstein, I., H. Boushey, R. Cherniack, et al . Am. Rev. Respir. Dis. 1985;132;180-182.
3. Chastre, J., J. Y. Fagon, M. Bornet-Lecso, et al. Am. J. Respir. Crit. Care Med. 1995;152;231-240 . 4. RodrõÂguez de Castro, F., J. Sol, and R. Elcuaz. Am. J. Respir. Crit. Care Med. 1994;149; 320-323.
DS22 COMBINED ANESTHESIA IN CARDIAC SURGERY Schachner T.*, Bonatti J.*, Balogh D., Mair P., Laufer G.*, Putz G. *Department of Cardiac Surgery and Department of Anesthesiology and Critical Care Medicine, University Hospital, Innsbruck Background and goal of study. In cardiac surgery several advantages of epidural anesthesia combined with general anesthesia such as improved myocardial protection due to sympatholysis and better pain therapy are reported [1, 2]. We want to report our experience with this technique. Materials and methods. 73 patients scheduled for cardiac surgery were screened to participate in this series which has been analysed retrospectively. Exclusion criteria were coagulopathy, platelet aggregation inhibitor intake within the last 5 days, ejection fraction < 0.4 and nonelective surgical interventions. 24 patients (18 male, 6 female; 42-78 years) decided for combined anesthesia. The epidural catheter was placed before operation and epidural space located at C7/Th1 or C6/C7 level by midline approach (Tuohy needle, hanging-drop technique) [3]. A 20 G catheter was advanced and after aspiration a test dose (4 ml lidocainhydrochloride 2 % plus epinephrine 0.01 mg/ml) injected. Anesthetic level was determined by testing of skin sensation. Epidural anesthesia was started with ropivacaine 0.375 % (10 ml) plus sufentanyl (25 mg). General anesthesia was induced by midazolam (5-10 mg) and sufentanyl (25 mg), and patients were intubated with rocuronium (0.7 mg/kg). Anaesthesia was maintained by propofol (5-7 mg/kg/h i.v.) and ropivacaine 0.2% plus sufentanyl (0.5 - 1 mg/ml, 5 ml/h). Postoperatively, analgesia was maintained by patient-controlled epidural anesthesia pump (5ml/h, bolus 2 ml) of ropivacaine 0.2% plus sufentanyl (0.5-1 mg/ml). Pain level was determined by visual analog score (VAS). Epidural catheter remained routinely in place for 3 days. Results and discussion. Out of 73 patients screened 41 were rejected because of exclusion criteria. 26 patients decided for and 6 against combined anesthesia. In one patient location of epidural space was unsuccessful. In another patient epidural catheter was placed intravenously. Relocation of tip allowed uncomplicated anesthesia. Sensory block was from C2 to Th8. No adverse intraoperative hemodynamic events were observed. Postoperatively VAS scores of < 2 could be achieved. Conclusion. We conclude that combined anesthesia in cardiac surgery is routinely feasible for elective cardiac surgery if exclusion criteria are consequently met. References 1. Loick HM, et al. Anesth Analg 1999;88:701-709. 2. Priestley MC, et al. Anesth Analg 2002;94:275-282. 3. MuÈllejans B, personal communication
DS23 CLINICAL AND BIOCHEMICAL PARAMETERS IN PREDICTING MORTALITY IN THE EARLY POSTOPERATIVE PERIOD FOLLOWING OESOPHAGECTOMY T. Szakmany1, S. Marton, T. Koszegi1, Z. Molnar 1 Dept. of Clinical Chemistry, Dept of Anaesthesiology and Intensive Care, University of PeÂcs, PeÂcs, Hungary
Background and goal of the study. Predicting the outcome in critical care remains dif®cult.1 The aim of this study was to evaluate the early course and predictive value of organ dysfunction monitored by the Multiple
Downloaded from http://bja.oxfordjournals.org/ at University of Birmingham on July 16, 2015
References 1. McGuire G, Crossley D, Richards J,. et al. Crit Care Med 1997; 25:1059-62. 2. Amato MBP, Barbas CSV, Medeiros DM, N Engl J Med 1998;338:347354. 3. Lu Q, Vieira SRR, Richecoeur J, et al. Am J Resp Crit Care Med. 1999; 159: 275-282.
25
24
DS19
Results. Parameters of circulation are given in table. Stage Group A Syst. BP 1 2 3 4 5
Group B Ps
SaO2
Syst. BP
Ps
156.366.7 97.465.4 93.563.4 161.465.8 93.466.7 144.263.8 101.568.0 96.762.5 126.564.6** 96.866.3* 151.467.0 86.666.5 98.261.1 121.865.5** 72.163.9** 158.768.2 91.364.9 96.460.8 130.466.1** 68.566.2** 151.166.9 103.268.8 95.063.3 128.464.7** 74.665.4**
SaO2
REMIFENTANIL-PROPOFOL PROVIDES IMMOBILE VOCAL CORDS DURING LARYNGOSCOPIC SURGERY
92.762.1 97.061.1 99.160.3 96.561.1 97.161.0
E. Ladner1, R. Plattner1, S. Natter1, H. Sparr2, W. PoÈlz3, W. Schimetta3
* - P<0.05 ** - P<0.005
Conclusion. Regional anesthesia can prevent blood pressure disturbances and pain syndrome during surgery in patients with electric burns of the upper extremities. The improvement of periferal circulation makes this method of anesthesia a component of the intensive care process.
THE COST-EFFECTIVENESS OF DROTRECOGIN ALFA (ACTIVATED) FOR THE TREATMENT OF SEVERE SEPSIS IN AUSTRIA Neilson A.R.1, Sporn P.2, Frass M.3, Sumann G.4, Graebe A.5, Schneider H.1, PROWESS Economic Team 1 HealthEcon, Basel, 2RH Rudolfstiftung, Wien, 3AKH, Wien, 4 UniversitaÈtsklinik, Innsbruck, 5Lilly Austria, Wien Background and Goal of Study. Drotrecogin alfa (activated) is an effective new therapy for patients with severe sepsis recently demonstrated in the PROWESS trial [1]. In Austria, the mean total direct ICU costs of (conventional) care were recently estimated at = C 28,600 [2]. The present
study estimated the cost-effectiveness of the new therapy in addition to conventional therapy for patients with severe sepsis in Austria.
Materials and Methods. Our base case analysis combines data from the PROWESS trial with Austrian-speci®c unit costs. Total direct costs of care included days spent in ICU, duration of organ support, other hospital stay and new therapy costs. We used a price of = C 244 per 5mg vial for the
new therapy based on the US price of $210 used by Angus et al. [3]. Life expectancy of hospital survivors was based on Austrian life tables and the age-sex distributions of trial survivors. We also performed analyses from a) the European PROWESS patients only and b) directly from an Austrian cost study. We tested the results with a number of sensitivity analyses.
Results and Discussion. The reduction in hospital mortality in PROWESS at Day 28 was 6.0% (30.1% for placebo and 24.1% for the new therapy). The additional hospital survivors have a mean life expectancy of 18.5 years based on age and sex alone. Adjusting life expectancy due to comorbidity, ICU stay and severe sepsis, gives 9.4 years per additional survivor or a gain of 0.56 years per patient treated. The expected total costs C 21,500 standard of treatment are = C 30,100 for the new therapy and =
care. This yields an incremental hospital cost per life year gained of = C 15,400. The modi®ed analyses produced cost-effectiveness ratios of = C 15,900 and = C 14,900. Sensitivity analyses produced cost-effectiveness estimates within the published ranges for other life saving interventions.
Conclusion(s). From the standpoint of cost-effectiveness, treatment of severe sepsis with drotrecogin alfa (activated) is an economically viable treatment option in Austria. Acknowledgements including ®nancial support. This study was supported by Eli Lilly Austria. References 1. Bernard GR et al. N Eng J Med 2001;344(10):699-709. Ef®cacy and Safety of Recombinant Human Activated Protein C for Severe Sepsis. 2. Schmid A et al. (accepted for publication 2002) Wien Klin Wochenschr. Burden of illness imposed by severe sepsis in Austria. 3. Angus DC et al. Crit Care Med 2002; 30(2):493 The cost effectiveness of drotrecogin alfa (activated) (Xigris TM) in severe sepsis.
Background. The aim of the present study was to assess whether a combined technique using remifentanil (remi) and propofol (prop) is equivalent to anaesthesia with succinylcholine-fentanil-propofol (succfent-prop) in surgical procedures requiring immobility of the vocal cords. Patients and methods. After approval by the Ethics Committee and obtaining written informed consent, 22 patients, ASA grades I and II, scheduled for short vocal cord surgery were enrolled in the study. After premedication with midazolam 0.1 mg/kg p.o. anaesthesia was induced with remi (5 mg/kg given over a period of 2 min) and prop 2.5 mg/kg. Surgery using direct laryngoscopy began at 1 min. Operating conditions were assessed by means of an intubation score1. In addition RRsyst/diast, MAP and heart rate were recorded. Assuming that induction of anaesthesia with succ-fent-prop always provides very good intubating conditions, including optimal immobilisation of the vocal cords, this technique served as `historical' control. The margin of equivalence was prospectively determined to be 20%. Results. Twenty-one of the 22 patients (95.5%; 95%CI: 86.8%; 100%) showed `excellent' intubating conditions and no response of the vocal cords to the surgical stimulus. In one patient intubating conditions were `good' (vocal cords immobile and in intermediate position). Based on the prospectively determined 20% margin of equivalence treatment with remiprop and succ-fent-prop is equivalent (p<0.05). In three patients (12.5%) heart rate and blood pressure dropped to levels that required therapeutic intervention. Conclusion. Regarding vocal cord immobilisation in short surgical procedures with direct laryngoscopy the combination of remi (5 mg/kg given over a period of 2 min) and prop 2.5 mg/kg is an equivalent alternative to anaesthesia induced with succ-fent-prop. Reference 1. Viby-Mogensen J, Engbaek J, Eriksson LI, et al. Acta Anaesthesiol. Scand 1996;40:59-74
DS20 PRESSURE-VOLUME CURVE ANALYSIS IN PATIENTS WITH SEVERE HEAD TRAUMA AND ACUTE LUNG INJURY M.M. Pylypenko, MD, C. Krenn, MD, C. Weinstabl, MD, A.F. Hammerle, MD. Department of Anesthesiology and Critical Care Medicine, General Hospital, Univ. Vienna, Austria. Background and goal of study. The level of positive end expiratory pressure (PEEP) setting in mechanically ventilated severe head injured (SHI) patients who developed acute lung injury (ALI) remains debatable (1). The assessment of P-V curves, in particular the lower in¯ection point in patients with ALI indicated the lung recruitment pressure, which is important to ascertain optimal PEEP levels (2). Materials and methods. We performed daily measurement of pressurevolume (P-V) curves with constant low ¯ow techniques (single breath with inspiratory ¯ow 9 l/min, tidal volume 12 ml/kg) in SHI patients who ful®ll criteria of ALI (Murrey Injury Score >1) to investigate changes in lower in¯ection point (LIP). The level of PEEP, which is 2 cm over LIP (LIP measured in static or quasi static conditions), is generally considered as the `best PEEP' (2). Measurement of P-V curves with constant ¯ow 9 l/min leads to right shift of LIP by nearly 1 cm, that is why the `best PEEP' is considered as LIP + 1 cm (3). We compared the data of LIP + 1 cm with PEEP levels setting, according to clinical criteria, in these patients.
Downloaded from http://bja.oxfordjournals.org/ at University of Birmingham on July 16, 2015
DS18
1 Dept. of Anaesthesia and Intensive Care Medicine, District Hospital Reutte; 2Dept. of Anaesthesiology, University of Innsbruck; 3Dept. of Applied System Research and Statistics, University of Linz; Austria
Abstracts Results and discussion. In 9 consecutive patients who ful®lled criteria of ALI 64 measurements of P-V curves were performed. 47 measurements in 7 patients resulted in LIP. There were no complications during measurements of P-V curves. The data of LIP+1 was lower than PEEP levels (8.762.3 cm H2O vs. 10.262.5 cm H2O; p<0.01). In 23 measurements we obtained differences of 3 cm H2O or more between clinically set PEEP levels and the data of LIP+1. In 20 measurements the PEEP levels were 3 cm H2O or more higher than the data of LIP+1. In 3 measurements the PEEP levels were 3 cm H2O or more, lower than the data of LIP+1. The Murray Injury Score in patients with a PEEP difference >3 cm H2O was signi®cantly higher compared to the patients with a PEEP difference <3 cm H2O (2.3 vs.1.8; p<0.001). We concluded that daily measurement of P-V curve in SHI patients with ALI showed statistically signi®cant differences between the data of LIP+1 and the PEEP levels clinically set. The difference between the data of LIP+1 and the PEEP levels signi®cantly increased in patients who had a Murray Injury Score >2. Daily monitoring of lung mechanics based on the P-V curve analysis is safe and can easily be performed as a bedside method, and can provide useful clinical information.
DS21 THE LOCAL IMMUNITY STATUS IN PATIENTS WITH SEVERE EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE Spytcin O., Satsuta S. Department of Anesthesiology of Lugansk State Medical University, Lugansk, Ukraine Keywords. local immunity, chronic obstructive pulmonary disease The role of local immunity of the upper and lower airways in the pathogenesis of severe exacerbations of chronic obstructive pulmonary disease (COPD) is poorly understood. Despite this, treatment has been aimed at advancing anti-in¯ammatory and immunomodulator therapy [1]. This study was designed to evaluate the type of airway in¯ammation and local immune status in patients with severe exacerbations of COPD. A prospective bronchoscopic study evaluated 20 patients with severe exacerbations of COPD (group-1). Bronchoalveolar lavage ¯uid was analyzed for cytology and concentration of SIgA and IgG [2,3,4]. Endobronchial and transbronchial biopsies were performed in selected patients for morphometric evaluation of macrophage/monocytes, neutrophils, eosinophils and lymphocytes. These results were compared with lavage and endo- and transbronchial biopsy studies in normal controls (group-2). Data ise presented as mean 6 SEM. Statistical signi®cance (p < 0,05) was determined using Student's t-test. The patients with severe exacerbations of COPD demonstrated a twofold higher concentration of neutrophils in lavage than the normal controls (p < 0.05). Similar results were obtained in the endobronchial and transbronchial biopsy specimens, which consistently showed signi®cantly higher numbers of neutrophils in the group-1 than in the control group. The concentration of SIgA in bronchoalveolar lavage ¯uid was also highest in the control group, but the concentration of IgG was highest in the group-1 (differences among the groups, p = 0.001 and p < 0.05, respectively). We conclude that the low concentration of SIgA in bronchoalveolar lavage ¯uid in patients with severe exacerbations of COPD is the important factor in the development and continuation of the in¯ammatory process in the upper and lower airways. References 1 E. Wenzel, S. Sze¯er, M. Leung et al. Am. J. Respir. Crit. Care Med., 1997;156;737-743. 2. Bernstein, I., H. Boushey, R. Cherniack, et al . Am. Rev. Respir. Dis. 1985;132;180-182.
3. Chastre, J., J. Y. Fagon, M. Bornet-Lecso, et al. Am. J. Respir. Crit. Care Med. 1995;152;231-240 . 4. RodrõÂguez de Castro, F., J. Sol, and R. Elcuaz. Am. J. Respir. Crit. Care Med. 1994;149; 320-323.
DS22 COMBINED ANESTHESIA IN CARDIAC SURGERY Schachner T.*, Bonatti J.*, Balogh D., Mair P., Laufer G.*, Putz G. *Department of Cardiac Surgery and Department of Anesthesiology and Critical Care Medicine, University Hospital, Innsbruck Background and goal of study. In cardiac surgery several advantages of epidural anesthesia combined with general anesthesia such as improved myocardial protection due to sympatholysis and better pain therapy are reported [1, 2]. We want to report our experience with this technique. Materials and methods. 73 patients scheduled for cardiac surgery were screened to participate in this series which has been analysed retrospectively. Exclusion criteria were coagulopathy, platelet aggregation inhibitor intake within the last 5 days, ejection fraction < 0.4 and nonelective surgical interventions. 24 patients (18 male, 6 female; 42-78 years) decided for combined anesthesia. The epidural catheter was placed before operation and epidural space located at C7/Th1 or C6/C7 level by midline approach (Tuohy needle, hanging-drop technique) [3]. A 20 G catheter was advanced and after aspiration a test dose (4 ml lidocainhydrochloride 2 % plus epinephrine 0.01 mg/ml) injected. Anesthetic level was determined by testing of skin sensation. Epidural anesthesia was started with ropivacaine 0.375 % (10 ml) plus sufentanyl (25 mg). General anesthesia was induced by midazolam (5-10 mg) and sufentanyl (25 mg), and patients were intubated with rocuronium (0.7 mg/kg). Anaesthesia was maintained by propofol (5-7 mg/kg/h i.v.) and ropivacaine 0.2% plus sufentanyl (0.5 - 1 mg/ml, 5 ml/h). Postoperatively, analgesia was maintained by patient-controlled epidural anesthesia pump (5ml/h, bolus 2 ml) of ropivacaine 0.2% plus sufentanyl (0.5-1 mg/ml). Pain level was determined by visual analog score (VAS). Epidural catheter remained routinely in place for 3 days. Results and discussion. Out of 73 patients screened 41 were rejected because of exclusion criteria. 26 patients decided for and 6 against combined anesthesia. In one patient location of epidural space was unsuccessful. In another patient epidural catheter was placed intravenously. Relocation of tip allowed uncomplicated anesthesia. Sensory block was from C2 to Th8. No adverse intraoperative hemodynamic events were observed. Postoperatively VAS scores of < 2 could be achieved. Conclusion. We conclude that combined anesthesia in cardiac surgery is routinely feasible for elective cardiac surgery if exclusion criteria are consequently met. References 1. Loick HM, et al. Anesth Analg 1999;88:701-709. 2. Priestley MC, et al. Anesth Analg 2002;94:275-282. 3. MuÈllejans B, personal communication
DS23 CLINICAL AND BIOCHEMICAL PARAMETERS IN PREDICTING MORTALITY IN THE EARLY POSTOPERATIVE PERIOD FOLLOWING OESOPHAGECTOMY T. Szakmany1, S. Marton, T. Koszegi1, Z. Molnar 1 Dept. of Clinical Chemistry, Dept of Anaesthesiology and Intensive Care, University of PeÂcs, PeÂcs, Hungary
Background and goal of the study. Predicting the outcome in critical care remains dif®cult.1 The aim of this study was to evaluate the early course and predictive value of organ dysfunction monitored by the Multiple
Downloaded from http://bja.oxfordjournals.org/ at University of Birmingham on July 16, 2015
References 1. McGuire G, Crossley D, Richards J,. et al. Crit Care Med 1997; 25:1059-62. 2. Amato MBP, Barbas CSV, Medeiros DM, N Engl J Med 1998;338:347354. 3. Lu Q, Vieira SRR, Richecoeur J, et al. Am J Resp Crit Care Med. 1999; 159: 275-282.
25