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  • 1
    Electronic Resource
    Electronic Resource
    Referat Möglichkeiten und Grenzen der Computertomographie in der Gynäkologie (1983)
    Springer
    Archives of gynecology and obstetrics 235 (1983), S. 143-151 
    Details
    ISSN: 1432-0711
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF02428724
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  • 2
    Electronic Resource
    Electronic Resource
    Small-volume Resuscitation beim hypovolämischen Schock Konzeption, experimentelle und klinische Ergebnisse — eine Standortbestimmung (1997)
    Springer
    Der Anaesthesist 46 (1997), S. 309-328 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Hypovolämischer Schock ; Hyperosmolare Lösungen ; Dextran ; Hydroxyäthylstärke ; Small-volume Resuscitation ; Mikrozirkulation ; PMNL-Funktion ; Endothel-Reperfusionsschaden ; Bauchaortenaneurysma ; PFC ; Key words Hypovolemic shock ; Hyperosmolar solutions ; Dextran ; Hydroxyethyl starch ; Small-volume resuscitation ; Microcirculation ; PMNL function ; Endothelium ; Reperfusion injury ; Abdominal aortic aneurysm ; PFC
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract The concept of small-volume resuscitation, the rapid infusion of a small volume (4 ml/kg BW) of hyperosmolar 7.2–7.5% saline solution for the initial therapy of severe hypovolemia and shock was advocated more than a decade ago. Numerous publications have established that hyperosmolar saline solution can restore arterial blood pressure, cardiac index and oxygen delivery as well as organ perfusion to pre-shock values. Most prehospital studies failed to yield conclusive results with respect to a reduction in overall mortality. A meta-analysis of preclinical studies from North and South America, however, has indicated an increase in survival rate by 5.1% following small-volume resuscitation when compared to standard of care. Moreover, small-volume resuscitation appears to be of specific impact in patients suffering from head injuries with increased ICP and in severest trauma requiring immediate surgical intervention. Results from clinical trials in Austria, Germany and France have demonstrated positive effects of hyperosmolar saline solutions when used for fluid loading or fluid substitution in cardiac bypass and in aortic aneurysm surgery, respectively. A less positive perioperative fluid balance, a better hemodynamic stability and improved pulmonary function were reported. In septic patients oxygen consumption could significantly be augmented. The most important mechanism of action of small-volume resuscitation is the mobilisation of endogenous fluid primarily from oedematous endothelial cells, by which the rectification of shock-narrowed capillaries and the restoration of nutritional blood, flow is efficiently promoted. Moreover after ischemia reperfusion a reduction in sticking and rolling leukocytes have been found following hyperosmolar saline infusion. Both may be of paramount importance in the long-term preservation of organ function following hypovolemic shock. An increased myocardial contractility in addition to the fluid loading effects of hyperosmolar saline solution has been suggested as a mechanism of action. This, however, could not be confirmed by pre-load independent measures of myocardial contractility. Some concerns have been raised regarding the use of hyperosmolar saline solutions in patients with a reduced cardiac reserve. A slower speed of infusion and adequate monitoring is recommended for high risk patients. Recently, hyperosmolar saline solutions in combination with artificial oxygen carriers have been proposed to increase tissue oxygen delivery through enhanced O2 content. This interesting perspective, however, requires further studies to confirm the potential indications for such solutions. Many hyperosmolar saline colloid solutions have been investigated in the past years, from which a 7.2–7.5% sodium chloride in combination with either 6–10% dextran 60/70 or 6–10% hydroxyethyl starch 200,000 appear to yield the best benefit-risk ratio. This has led to the registration of the solutions in South America, Austria, the Czech Republic, and is soon awaited for North America.
    Notes: Zusammenfassung Die Bolusinfusion einer hyperosmolaren Kochsalzlösung (4 ml/kg, 7,2–7,5% NaCl) führt im hypovolämischen Schock zur raschen Normalisierung der zentralen Hämodynamik und zur Restitution der Organperfusion (Small-volume Resuscitation). Nach Ischämie ist die Wiederherstellung der Perfusion in der mikrovaskulären Strombahn vorrangig. Hyperosmolare Lösungen verbessern die Mikrozirkulation durch Reduktion der Endothelzellschwellung und Verminderung der Leukozytenadhäsion am Endothel. Die Wirkmechanismen und die Effizienz hyperosmolarer Lösungen sind durch experimentelle Untersuchungen gut belegt. Hingegen konnte bislang keine der präklinischen Studien die Überlegenheit hyperosmolarer Lösungen hinsichtlich der Überlebensrate sichern! Eine Metaanalyse der bei Traumapatienten vorliegenden Ergebnisse (n = 1.889) zeigte eine Reduktion der Letalität bei den mit hyperosmolarer Lösung behandelten Traumapatienten. Vielversprechende neue Indikationsgebiete für hyperosmolare Kochsalzlösungen stellen der Einsatz in der Kardio- und Gefäßchirurgie, bei Brandverletzten, bei Patienten mit Sepsis sowie die gezielte Therapie des postischämischen Reperfusionsschadens dar. Die Kombination hyperosmolarer Lösungen mit künstlichen Sauerstoffträgern ist zur Zeit in experimenteller Erprobung.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050406
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  • 3
    Electronic Resource
    Electronic Resource
    Neurologische Komplikation nach Totalendoprothesenimplantation der Hüfte in Katheterperiduralanästhesie (1996)
    Springer
    Der Anaesthesist 45 (1996), S. 1192-1195 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Periduralanästhesie ; Peridurales Hämatom ; Neurologische Komplikation ; Niedermolekulares Heparin ; Key words Epidural anaesthesia ; Epidural haematoma ; Neurological complication ; Low-molucular-weight heparin
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract This case report describes paralysis of the plantar flexors and extensors after a total hip replacement in a 33-year-old woman performed under epidural anaesthesia (PDA). Six years previously, the patient had undergone a bone marrow transplantation for chronic myeloid leukaemia. She had developed a deep vein thrombosis, a pulmonary embolus, and a severe graft-versus-host reaction of the skin, leading to markedly reduced mouth opening. The hip operation was performed using PDA following antithrombotic prophylaxis with low-molecular-weight heparin. Blood could initially be aspirated after advancing the PDA catheter, and a second puncture of the epidural space 1 segment higher enabled correct placement of the catheter. The patient received 500 ml Dextran 60 perioperatively and the operation was completed without any further problems. The PDA cath-eter was removed 2 h after the operation following the return of movement of both thighs. Fourteen hours after the completion of surgery it was noticed that the dressing over the epidural puncture site was blood-stained, the patient was incontinent, and complete loss of movement of the operated leg was present. An epidural haematoma was the suspected cause, but could not be definitely confirmed by a CT scan. Nevertheless, a laminectomy was undertaken to evacuate the suspected haematoma. As expected, tracheal intubation was only possible bronchoscopically. Intraoperatively, some low-grade epidural oozing at the level of the initial puncture site was observed, and a hemilaminectomy of 5 was performed. For the first time postoperatively, the bleeding time was measured and was markedly prolonged to 20 min (as described by Mielke, normal value up to 8 min). A coagulopathy was suggested, with the differential diagnosis of impaired platelet function. The paralysis of the plantar flexors and extensors and some sensory loss were still present 6 months after the operation. It remains uncertain whether the PDA in a patient receiving low-molecular-weight heparin resulting in a the suspected epidural haematoma was the cause of the neurological sequelae and in agreement with the consultant neurologist, we believe that a direct traumatic lesion of the L5/S1 segment or damage to the sciatic nerve are also likely causes of the symptoms. Undoubtedly, the lack of adequate postoperative neurological monitoring and the intraoperative administration of dextran despite the known epidural vascular lesion deserve criticism. This case report demonstrates the often complex development of neurological complications after nerve blocks, where a definite cause can frequently not be determined.
    Notes: Zusammenfassung Der vorliegende Fallbericht beschreibt eine neurologische Komplikation nach Implantation einer Hüftendoprothese bei einer 33jährigen Patientin. 6 Jahre zuvor hatte die Patientin nach allogener Knochenmarkstransplantation eine Lungenembolie sowie eine Graft-versus-Host-Reaktion der Haut mit eingeschränkter Mundöffnung entwickelt. Am Vorabend sowie am Abend der Operation erhielt sie je 24 mg eines niedermolekularen Heparins. Die Operation wurde bei normalen globalen Hämostaseparametern in PDA durchgeführt. Nach Blutaspiration durch den ersten Katheter ermöglichte die zweite Punktion eine regelrechte PDA. Intraoperativ erhielt die Patientin 500 ml Dextran. Bei unauffälligem perioperativem Verlauf und rückläufigen motorischen Effekten der PDA wurde der Katheter 2 h nach OP-Ende gezogen. 10 h später fielen eine blutige Punktionsstelle, Inkontinenz sowie ein motorisches und sensibles Defizit im linken Bein auf. Die Computertomographie (CT) ergab keinen sicheren Hinweis einer intraspinalen Blutung. Dennoch wurde die Indikation zur raschen operativen Intervention gestellt. Die postoperativ erstmals gemessene Blutungszeit nach Mielke betrug 〉20 min und begründete den Verdacht auf eine vaskuläre Störung der Hämostase. Eine eindeutige kausale Zuordnung der neurologischen Befunde zu dem fraglichen periduralen Hämatom ist nicht möglich. Wahrscheinlicher ist eine segmentale Läsion in Höhe L5/S1 oder eine hohe Läsion des N. ischiadicus. Der vorliegende Fallbericht unterstreicht die multifaktorielle Genese neurologischer Komplikationen bei rückenmarksnaher Anästhesie.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050357
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  • 4
    Electronic Resource
    Electronic Resource
    Veränderungen der Flüssigkeitsfiltrationskapazität und des Blutflusses nach Tourniquet bei Knieoperationen in Spinalanästhesie (1998)
    Springer
    Der Anaesthesist 47 (1998), S. 460-468 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Mikrozirkulation ; Gefäßpermeabilität ; Tourniquet ; Ischämie ; Reperfusionsschaden ; Dextran ; Key words Microcirculation ; vascular permeability ; tourniquet ; ischemia reperfusion ; Dextran
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract An increased microvascular water permeability has been reported after ischemia/reperfusion both in animal models and in human studies. We studied the changes in fluid filtration capacity (FFK) after ischemia/reperfusion due to tourniquet in patients undergoing arthroscopy of the knee. Method: Healthy male volunteers (n=24, mean age 46.9±3.5) were studied prior to, 1 and 6 hours after arthroscopy of the knee, during which a tourniquet was applied to the thigh. FFK, isovolumetric venous pressure (Pvi) and arterial blood flow in the limb was measured in both legs (tourniquet leg and control leg) using computer assisted venous congestion plethysmography. Venous blood samples were obtained from a cubital vein prior to and from the femoral vein 2 mins after deflation of the tourniquet cuff. 12 patients received preoperatively an infusion of 6% Dextran (D) and 12 patients 500 ml of electrolyte solution (VE) an. Results: The mean duration of the tourniquet was (D) 56.0±6.9 min and (VE) 53.9±4.2 min which resulted in a significant increase in venous lactate concentration from (D) 1.4±0.1 mmol.l−1 to 2.7±0.3 mmol.l−1 and (VE) 1.3±0.1 mmol.l−1 to 2.7±0.3 mmol.l−1 (p〈0.001). A significant decrease in pH from (D) 7.39±0.01 to 7.32±0.01 (p〈0.001) and from (VE) 7.39±0.01 to 7.32±0.01 (p〈0.001) was also seen. Preoperatively no significant differences in the FFK values of the tourniquet leg (D=5.3 (4.8–10.7) ml.×10−3 min–1. 100 ml tissue−1 mmHg−1=FFKU) and the control leg (5.2 (4.7–8.6 FFKU)) were observed. The maximum FFK value in D was seen 1 hour after ischemia/reperfusion in both, the tourniquet leg (7.5 (4.6–14.2 FFKU) and the control leg (7.8 (5.5–9.4 FFKU). In VE however the maximal FFK value were measured 6 hours after ischemia/reperfusion with an increase in the tourniquet leg from 5.2 (4.2–6.2 FFKU) to 8.1 (3.7–10.4 FFKU) and the control leg from 6.1 (3.6–7.0 FFKU) to 7.3 (6.1–8.3 FFKU) (Median (Range), One-way ANOVA). There were no significant differences in the FFK values between D and VE except for a lower Pvi in VE at the third measurement. No significant changes in the arterial blood flow were seen perioperatively as well as between the operated and non-operated leg. Conclusion: A tourniquet of 〈1 hour does impair tissue oxygenation as indicated by the increase in lactate and the decrease in pH. The duration of the tourniquet was however to short to have caused sufficient microvascular damage result in a more pronounced increase in fluid filtration capacity.
    Notes: Zusammenfassung In der vorliegenden Studie untersuchten wir, ob ein Tourniquet von einstündiger Dauer mit anschließender Reperfusion eine signifikante Zunahme der Flüssigkeitsfiltrationskapazität zur Folge hat. Methode: Bei 24 männlichen Patienten mit Knieverletzungen (Durchschnittsalter 46,9±3,5 Jahre), die sich einer Arthroskopie mit Tourniquet unterziehen mußten, wurden plethysmographische Messungen der Flüssigkeitsfiltrationskapazität (FFK) am Vorabend der Operation, unmittelbar nach und 6 h postoperativ simultan an beiden Beinen durchgeführt. Prospektiv randomisiert erhielten 12 Patienten unmittelbar präoperativ 500 ml Vollelektrolytlösung (VE) bzw. 500 ml 6% Dextran 60 (D) intravenös infundiert. Ergebnisse: Die durchschnittliche Dauer des Tourniquets betrug (D) 56,0±6,9 min bzw. (VE) 53,9±4,2 min. Die Laktatkonzentration im venösen Serum stieg (D) von 1,4±0,1 mmol.l−1 auf 2,7±0,3 mmol.l−1 und (VE) von 1,3±0,1 mmol.l−1 auf 2,7±0,3 mmol.l−1 (p〈0,001). Präoperativ bestand weder ein signifikanter Unterschied in den FFK Werten zwischen (VE) und (D) noch zwischen dem Tourniquetbein (D=5,3 [4,8–10,7] ml.×10−3. 100 min Gewebe−1 mm Hg−1=FFKU) und dem Kontrollbein (5,2 [4,7–8,6 FFKU]) (Median [Bereich], One-way ANOVA). Die maximalen FFK Werte wurden in (D) 1 h nach Ischämie Reperfusion (I/R) in beiden Beinen, Tourniquet (7,5 [4,6–14,2 FFKU]) und Kontrollbein (7,8 [5,5–9,4 FFKU]) gemessen. In VE hingegen 6 h nach I/R, mit einem Anstieg der FFK von präoperativ 5,2 [4,2–6,2 FFKU] auf 8,1 [3,7–10,4 FFKU] und den Kontrollbein von 6,1 [3,6–7,0 FFKU] auf 7,3 [6,1–8,3 FFKU]. Die Gabe von 500 ml Dextran 60 hatte weder einen signifikanten Einfluß auf die FFK noch auf andere blutchemische Parameter. Schlußfolgerungen: Die blutchemischen Veränderungen lassen vermuten, daß es durch den Tourniquet zu einem I/R Schaden gekommen ist. In unseren Untersuchungen zeigte sich ein Trend einer Zunahme der FFK an beiden Beinen. Wir schließen daraus, daß generalisierte Veränderungen in der Mikrozirkulation (z.B. Aktivierung von Leukozyten) für die Zunahme der FFK verantwortlich sind. Über die Bedeutung der prophylaktischen Gabe von Dextran zur Verminderung eines I/R Schadens lassen diese Untersuchungen keine Rückschlüsse zu, da die Ischämiezeit wahrscheinlich zu kurz war.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050583
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  • 5
    Electronic Resource
    Electronic Resource
    Perioperative Veränderungen der Flüssigkeitsfiltrationskapazität bei gefäßchirurgischen Patienten (1999)
    Springer
    Der Anaesthesist 48 (1999), S. 9-18 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Flüssigkeitsfiltrationskapazität ; Narkoseeinleitung ; Epiduralanästhesie ; Gefäßchirurgie ; Volumensubstitution ; Key words Microvascular permeability ; Vascular surgery ; Induction of anaesthesia ; Epidural anaesthesia ; Volume replacement
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Patients undergoing major vascular surgery frequently require a substantial intraoperative fluid replacement to assure hemodynamic stability, which is in excess of the expected fluid requirements due to starving, blood and insensible losses. This leads to a positive fluid balance which can not be readily explained. Method: We have used venous congestion plethysmography (VCP) a non-invasive method for measurement of microvascular parameters in limbs to investigate the changes in microvascular permeability (FFK) and the balance of Starling forces of patients undergoing surgery for unilateral femoral artery reconstruction (FEM) under epidural anaesthesia or abdominal aortic aneurysm repair (AAA) under general anaesthesia. The control group consisted of patients scheduled for inguinal hernia repair or hand surgery under general anaesthesia. All patients were measured 24 hours pre-operatively, immediately after the induction of anaesthesia or completion of epidural anaesthesia and on the 1st. 5th and 10th postoperative day. The perioperative patient management followed a standard protocol and all patients with vascular disease were invasively monitored using indwelling arterial lines and central venous catheters. Continuous infusion of Ringers lactate and 6% Dextran 60 was sustained during the induction period. Each patient gave informed consent. Results: Preoperatively we found no significant difference in the mean FFK- values of controls (4.1±0.4, ml. min−1 100 ml tissue−1 mmHg−1×10−3=FFKU), the AAA (3.6±0.3 FFKU) and FEM (4.2±0.3 FFKU). After induction of anaesthesia the mean FFK value in the controls fell to 3.5±0.5 FFKU (p=0.07), whereas in the AAA patients we observed a significant increase to 4.7±0.2 FFKU (p〈 0.005) and after epidural anaesthesia in FEM to 5.5±0.4 FFKU (p〈0.001) respectively. Those post anaesthetic FFK values where significantly higher in FEM and AAA than in the controls (p〈0.02). In AAA we found a significant positive correlation between the increase in FFK and the intraoperative fluid balance (r2=0.69, p〈0.01). No such correlation was found in controls and FEM. The postoperative values of FFK where unchanged in the control group, whereas a further increase was seen in both patient groups with vascular disease, with a maximum in AAA on the 1st postoperative day (to 5.4±0.4 FFKU mean both legs) and the 5th postoperative day in FEM (to 7.3±1.7 non-ischemic leg, 7.1±1.2 ischemic leg FFKU). In both groups normal FFK values where found on the 10th day after the operation. Conclusion: The data presented suggests an increase in extravascular fluid loss in patients undergoing vascular surgery, which becomes evident after the induction of general anaesthesia or completion of epidural anaesthesia. The positive correlation with the intraoperative fluid requirements may partially explain the often reported large intraoperative fluid requirements of patients undergoing AAA repair. The fact that the maximum change in fluid filtration capacity is found postoperatively may be explained by the additional effect of an ischemia/reperfusion injury in response to both the clamping an declamping of the artery and the increase in arterial blood flow to the limb due to the successful reconstruction of the blood vessel.
    Notes: Zusammenfassung Patienten, die sich einer gefäßchirurgischen Operation unterziehen müssen, benötigen intraoperativ häufig weit mehr Flüssigkeit als durch präoperative Nüchternheit, intraoperative Flüssigkeitsverluste und Beatmung zu erwarten ist. Veränderungen der Starlingkräfte – insbesondere der Gefäßpermeabilität – spielen hier möglicherweise eine Rolle, ohne daß diese bisher näher untersucht wurden. Methode: Wir verwendeten die von uns entwickelte venöse Kompressionsplethysmographie (VKP), um perioperative Veränderungen der Flüssigkeitsfiltrationskapazität (FFK) (Maß der Gefäßpermeabilität) zu untersuchen. FFK wurde bei 3 Patientengruppen untersucht, nämlich 11 Patienten, die sich einer Resektion eines Bauchaortenaneurysmas in Allgemeinanästhesie unterziehen mußten (BAA), 8 Patienten, die eine einseitige Rekonstruktion der A. femoralis in Epiduralanästhesie erhielten (FEM) und eine Kontrollgruppe von 12 jungen gesunden Patienten, die eine Allgemeinanästhesie für die Operation einer Leistenhernie oder einen handchirurgischen Eingriff benötigten. Die Messungen erfolgten präoperativ, nach Narkoseeinleitung bzw. Vervollständigen der Epiduralanästhesie, am 1., 5. und 10. postoperativen Tag. Ergebnisse: Präoperativ bestand kein Unterschied in den FFK-Werten der Kontrollgruppe (4,1±0,4, ml min−1 100 ml Gewebe−1 mm/ Hg−1×10−3=FFKU), BAA (3,6±0,3 FFKU) und FEM (4,2±0,3 FFKU). Nach Narkoseeinleitung fiel die FFK in der Kontrollgruppe auf 3,5±0,5 FFKU (p=0,007), wohingegen sie sowohl bei den BAA-Patienten (4,7±0,2 FFKU, p〈0,005) als auch bei FEM (5,5+0,4 FFKU, p〈0,0001) anstieg. Bei BAA fanden wir eine positive Korrelation zwischen den Veränderungen der FFK und der intraoperativen Flüssigkeitssubstitution (r2=0,69, p〈0,01), die in der Kontrollgruppe und bei FEM nicht beobachtet wurde. Postoperativ wurden in der Kontrollgruppe keine signifikanten Veränderungen der FFK gemessen, wohingegen ein weiterer Anstieg bei beiden gefäßchirurgischen Patientengruppen nachzuweisen war. Dieser erreichte bei den Patienten mit BAA am ersten postoperativen Tag sein Maximum mit (5,4±0,4 FFKU Mittelwert beider Beine) und bei Patienten mit FEM am fünften postoperativen Tag (7,3±1,7 FFKU nicht ischämisches Bein, 7,1±1,2 FFKU ischämisches Bein). Schlußfolgerungen: Die in dieser Untersuchung beobachtete Zunahme der Flüssigkeitsfiltrationskapazität nach Narkoseeinleitung bzw. Epiduralanästhesie bei gefäßchirurgischen Eingriffen erklärt möglicherweise die intraoperativ häufig positive Flüssigkeitsbilanz bei diesen Patienten. Die positive Korrelation der Veränderungen der FFK mit der intraoperativen Flüssigkeitsbilanz bei BAA-Operationen läßt vermuten, daß einige Patienten besonders gefährdet sind, ausgeprägtere intraoperative Flüssigkeitsverschiebung zu erleiden. Inwieweit die verwendeten Medikamente und intravenösen Flüssigkeitstherapien hier eine Rolle spielen, muß in weiteren Untersuchungen geklärt werden. Wir vermuten, daß die postoperative Zunahme der FFK auf einen Ischämie/Reperfusionsschaden, bedingt durch das intraoperativ notwendige Abklemmen der betroffenen Arterie und die plötzlich verbesserte Perfusion der vormals chronisch ischämischen Extremität, zurückzuführen ist.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010050662
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  • 6
    Electronic Resource
    Electronic Resource
    Online-Kurs Notfallmedizin Kurrikulare Integration von Computer-based Training (2000)
    Springer
    Der Anaesthesist 49 (2000), S. 881-886 
    Details
    ISSN: 1432-055X
    Keywords: Schlüsselwörter Computer-based Training ; Notfallmedizin ; Internet ; Interaktion ; Feedback ; Keywords Computer-based training ; Emergency medicine ; Internet ; Interaction ; Feedback
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract Emergency medicine is characterized by rapid decision making to help patients in life-threatening situations. Teaching these skills requires a high level of interaction between medical students and the lecturer. We designed, implemented, and evaluated a generic computer-based training (CBT) system to provide a more active way of learning emergency medicine. The content of the training program is adapted to the knowledge of third year medical students and is focused on basic skills and real-world problems. The teacher presents the case with authentic video sequences and slides. The cases are classified into four groups: heart (e.g., myocardial infarction), respiration (e.g., asthma bronchiale), trauma (e.g., car accident), and loss of consciousness (e.g., coma). Within a realistic time frame, the students have to answer free text and multiple choice questions on a workstation. All answers given by the students are processed anonymously by the CBT system via a central server and displayed on a large video screen, thus enabling a detailed discussion without intimidation of individual students. This interactive technique allows for immediate feedback from the lecturer based on the specific knowledge of his group and his own experience. The IT concept, which is scalable to many subjects, is based on state of the art Internet technology and therefore suitable for teleteaching. A major design objective for the program was a self-explaining and robust user interface. The system has been in routine use since 1998. We designed an evaluation form consisting of 21 items focused on subjective rating of learning success, acceptance of CBT, and technical feasibility. We analyzed forms from 138 students and found high scores for acceptance and learning success (median 5 on a 6-point scale). User problems with the program were denied (median 1 on a 6-point scale). Computer-based training with Internet technology can provide a successful method for interactive teaching of emergency medicine and is well accepted by students.
    Notes: Zusammenfassung Die Notfallmedizin ist gekennzeichnet durch das Treffen schneller Entscheidungen, welche Patienten in lebensbedrohlichen Situationen helfen sollen. Um diese Fähigkeiten zu trainieren, benötigt man ein hohes Maß an Interaktion zwischen Studenten und Unterrichtenden. Zu diesem Zweck konzipierten und evaluierten wir ein neues Computer-based-Trainings (CBT)-System: Der Dozent demonstriert echte Notfallsituationen anhand von Videos und Bildmaterialien. Die Studenten müssen unter Zeitdruck Freitext- und Multiple-choice-Fragen am Computer beantworten (je Kurseinheit ca. 20 min Video und 15 Fragen). Die mit dem CBT-System gesammelten Antworten werden anonymisiert über einen Beamer projiziert und anschließend in der Gruppe unbefangen diskutiert. Dieses interaktive Verfahren ermöglicht unmittelbares Feedback basierend auf dem spezifischen Wissen der Studentengruppe und den Erfahrungen des Lehrenden. Der 8-stündige Kurs ist vollständig internetbasiert und daher für Tele-teaching geeignet. Das System wird seit 1998 regelmäßig im Routineunterricht eingesetzt. Die Auswertung mit einem elektronischen Fragebogen (21 items) bei 138 Studenten zeigte ein hohes Maß an Akzeptanz und subjektivem Lernerfolg bei den Lernenden (5 von 6 Punkten); Probleme mit dem Computer wurden verneint.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001010070041
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  • 7
    Electronic Resource
    Electronic Resource
    Increased microvascular water permeability in patients with septic shock, assessed with venous congestion plethysmography (VCP) (1998)
    Springer
    Intensive care medicine 24 (1998), S. 18-27 
    Details
    ISSN: 1432-1238
    Keywords: Key words Septic shock ; Non-septic shock ; Microcirculation ; Water permeability ; Filtration capacity ; Invasive monitoring ; Strain gauge plethysmography
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Objectives: To investigate microvascular water permeability (filtration capacity, Kf) in patients with septic and non-septic shock using a new non-invasive method for studying microvascular parameters in man. Setting: Intensive Care Unit of a university hospital. Patients and methods: We investigated 28 patients, presenting with cardio-vascular instability due to either septic shock, or non-septic shock (haemorrhage, multiple trauma, respiratory and/or cardiac failure). Interventions: We used standard invasive methods of monitoring (in-dwelling arterial lines and pulmonary artery flotation catheters) in combination with computer assisted venous congestion plethysmography (VCP) measurements, for a parallel assessment of peripheral microcirculatory parameters. Results: On admission to the ICU, patients with septic shock revealed a significantly higher mean value of filtration capacity Kf = 6.1 ± 0.4 × 10–3 (mean value ± standard error of the mean, ml. min–1. 100 ml tissue–1. mmHg–1 = KfU) than non-septic patients Kf = 3.5 ± 0.3 KfU (p 〈 0.02). The Kf values of the septic patients were significantly higher than those from age-matched patients with peripheral vascular disease (4.1 ± 0.2 KfU, p 〈 0.001) and those of healthy controls (4.3 ± 0.2 KfU, p 〈 0.001); the Kf values of the non-septic patients, however, were not significantly different. The highest mean Kf value observed during the stay on ICU was Kfmax 11.6 ± 0.2 KfU in the septic group and 5.7 ± 0.1 KfU in the non-septic group (p 〈 0.001). Pvi, a value reflecting the balance of hydrostatic and oncotic forces in the microcirculation, was elevated in both patient groups. On admission, in septic patients Pvi was 39.2 ± 3.3 mmHg and in non-septic patients 35.1 ± 2.7 mmHg, these values were not significantly different, but significantly higher than the Pvi value of healthy controls (Pvi 21.5 ± 0.8) (p 〈 0.001). A weak, however significant, positive correlation was found between Kf and Pvi in both patient groups. No correlations were found between Kf, as well as Pvi, and cardiac index (CI), oxygen delivery index (DO2I), oxygen consumption index (VO2I) and systemic vascular resistance index (SVRI). Conclusions: An increase in permeability of microvessels will cause a loss of intravascular fluid and may therefore partially explain the large fluid requirements of patients in shock. It will also favour the development of oedema, which is often found in septic patients. We propose that changes in Kf are useful indices of microvascular malfunction and that VCP allows the non-invasive assessment of these parameters.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/s001340050509
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  • 8
    Electronic Resource
    Electronic Resource
    CHEMICAL METHOD OF PREVENTING LOSS OF INDUSTRIAL AND FRESH WATERS FROM PONDS, LAKES AND CANALS (1973)
    Oxford, UK : Blackwell Publishing Ltd
    Journal of the American Water Resources Association 9 (1973), S. 0 
    Details
    ISSN: 1752-1688
    Source: Blackwell Publishing Journal Backfiles 1879-2005
    Topics: Architecture, Civil Engineering, Surveying , Geography
    Notes: Preventing or markedly reducing the loss of aqueous fluids from a variety of reservoirs is becoming increasingly important. Fear of pollution from industrial waters and sewage impoundments as well as the economic factors involved in loss of fresh water add impact to this problem. This paper reviews the seriousness of the problem and methods that have been used to reduce loss of fluid are discussed. New materials for control of water loss are constantly being advocated, and chemical research has provided new systems that work extremely well. These systems, which combine unique chemicals and novel methods of application, are described. Specific case histories are also included.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1111/j.1752-1688.1973.tb01794.x
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  • 9
    Electronic Resource
    Electronic Resource
    Pathologische Glucosetoleranz bei Schwangeren (1973)
    Springer
    Archives of gynecology and obstetrics 215 (1973), S. 95-109 
    Details
    ISSN: 1432-0711
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Zusammenfassung Das geburtshilfliche Kollektiv des Jahres 1971 der Erlanger Universitäts-Frauenklinik (n=1752) wurde auf die Häufigkeit von latent und manifest diabetischen Stoffwechselstörungen sowie auf die Häufigkeit von überschweren Kindern untersucht. Übergewichtigkeit, familiäre Diabetesbelastung werden ebenso wie die Wahl des Geburtstermins, des Geburtsmodus, Behandlung der Stoffwechselstörung zueinander in Beziehung gebracht wie Apgarbenotung, perinatale mütterliche und kindliche Mortalität und Glucosetoleranzstörungen im Wochenbett. Bei 147 überschweren Neugeborenen (8,48%) betrug die kindliche Mortalität 0%. 44,25% der Mütter (n=45) hatten eine pathologische Glucosetoleranz im Sinne eines latenten Diabetes mellitus. Die kindliche sowie die mütterliche Mortalität bei manifest diabetischen Schwangeren (n=9; 0,51%) betrug jeweils 0%. Eine Gruppe klinisch erkannter und betreuter Schwangerer mit verminderter Glucosetoleranz (n=106; 6,05%) wies eine perinatale kindliche Mortalität von 1,89% (n=2) auf. Sie wurde einer Gruppe klinisch nicht behandelter latent diabetischer Schwangerer gegenübergestellt mit einer perinatalen kindlichen Mortalität von 5,35%. In beiden Gruppen betrug die mütterliche Mortalität ebenfalls 0%. Der latente Diabetes bei Schwangeren wurden ausschließlich diätetisch behandelt. Die Wahl des Geburtstermins wurde individuell getroffen entsprechend der Östriolausscheidung im 24 Std-Sammelurin, der diabetischen Stoffwechsellage und geburtshilflichen Komplikationen. Bei 7 der 9 manifest diabetischen Schwangeren wurde die Geburt vor dem errechneten Geburtstermin beendet. Der früheste Termin war die 37. Schwangerschaftswoche. 30,2% der klinisch erkannten und betreuten Schwangeren mit latentem Diabetes mellitus wurden vor dem errechneten Geburtstermin, 45,3% am errechneten Geburtstermin und 24,5% in der 41. Schwangerschaftswoche entbunden. Die Sectiohäufigkeit bei latent diabetischen Schwangeren betrug 15%, die bei manifest diabetischen Schwangeren 33%. Bei 56 Schwangeren, die erst bei Wehenbeginn oder nach Blasensprung stationär kamen, wurde innerhalb der ersten 72 Std post partum eine pathologische Glucosetoleranz-festgestellt. Diese Gruppe wies mit 5,35% die höchste perinatale kindliche Mortalitätsrate auf.
    Notes: Summary The 1971 obstetrical collective of the Department of Obstetrics and Gynecology, University of Erlangen, has been examined for the frequency of latent and manifest diabetes as well as for the frequency of newborns with overweight. Overweight and familial diabetes were correlated with the following parameters: The time of delivery, mode of delivery, therapy of metabolism disturbances, Apgar-Score, perinatal maternal and infant mortality, glucose tolerance disturbance in childbed. The infant mortality in 147 newborns (8.48%) accounted 0%. 44.25% of the women (n=45) showed a pathological glucose tolerance test according to a latent diabetes mellitus. The infant as well as the maternal mortality of pregnant women showing a manifest diabetes (n=9) was 0%. One group of pregnant showed a reduced glucose tolerance (n=106; 6.05%) and became clinically supervised. Their perinatal infant mortality was 1.89% (n=2). This group was compared with another group of clinically not treated latent diabetic pregnant women with a perinatal infant mortality of 5.35%. Both groups showed a maternal mortality of 0%. Diet was the only treatment of the latent diabetic metabolic disorder. The time of delivery was chosen individually according to the 24 hours urine excretion of estriol as well as to the situation of the latent diabetic metabolism of the given time and the obstetrical complications occuring. In 77.8% of pregnant women with manifest diabetes the delivery was finished before the due date. Before the 37th week of gestation no delivery was induced. From the known and followed up pregnant women with latent diabetes mellitus 30.2% delivered before the estimated time of birth, 45.3% at the estimated time of birth and 24.5% in the 41th week of gestation. The frequency of Cesarian sections in latent diabetic pregnant women was 15%, in manifest diabetics 33%. The pathological glucose tolerance test was found within 72 hours post partum in 56 pregnant women whose first visit to the hospital was after beginning of labor or after membranes had ruptured. This group showed the highest infantal perinatal mortality rate of 5.35%.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF00668366
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  • 10
    Electronic Resource
    Electronic Resource
    Changes in urethral closure pressure after radical hysterectomy for cervical cancer (1985)
    Springer
    Archives of gynecology and obstetrics 237 (1985), S. 93-99 
    Details
    ISSN: 1432-0711
    Keywords: Urethral closure pressure ; Urodynamics ; Cervical cancer ; Radical hysterectomy
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Summary The behaviour of the urethral closure pressure at rest (UCP) both before and 14 days and 3 months after radical surgery for cervical cancer was examined. The results were compared with those of other authors. In contrast to the latter we were only able to establish a constant pressure drop in patients using a transurethral catheter at the time of the first postoperative measurement. Patients using a suprapubic catheter showed non-uniform postoperative UCP-changes. This pattern was comparable to that found after simple abdominal hysterectomy, performed for other reasons, in which a transurethral catheter had been in place for a maximum of 60 h. In contrast to our predecessors we were unable to confirm a causal relationship between surgical damage to the sympathetic system and postoperative falls in pressure, except after extremely radical surgery. The cause appears to be a complex process involving wound healing problems (edema, infection, scar formation and organ position changes) and direct traumatization of the urethra (transurethral catheter).
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF02199713
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