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Description / Table of Contents: Abstract During pressure support ventilation (PSV), the timing of the breathing cycle is mainly controlled by the patient. Therefore, the delivered flow pattern during PSV might be better synchronised with the patient's demands than during volume-assisted ventilation. In several modern ventilators, inspiration is terminated when the inspiratory flow decreases to 25% of the initial peak value. However, this timing algorithm might cause premature inspiration termination if the initial peak flow is high. This could result not only in an increased risk of dyssynchronization between the patient and the ventilator, but also in reduced ventilatory support. On the other hand, a decreased peak flow might inappropriately increase the patient's inspiratory effort. The aim of our study was to evaluate the influence of the variation of the initial peak-flow rate during PSV on respiratory pattern and mechanical work of breathing. Patients. Six patients with chronic obstructive pulmonary disease (COPD) and six patients with no or minor nonobstructive lung pathology (control) were studied during PSV with different inspiratory flow rates by variations of the pressurisation time (Evita I, Drägerwerke, Lübeck, Germany). During the study period all patients were in stable circulatory conditions and in the weaning phase. Method. Patients were studied in a 45° semirecumbent position. Using the medium pressurization time (1 s) during PSV the inspiratory pressure was individually adjusted to obtain a tidal volume of about 8 ml/kg body weight. Thereafter, measurements were performed during five pressurization times (〈0.1, 0.5, 1, 1.5, 2 s defined as T 0.1, T 0.5, T 1, T 1.5 and T 2) in random order, while maintaining the pressure support setting at the ventilator. Between each measurement steady-state was attained. Positive end-exspiratory pressure (PEEP) and FIO2 were maintained at prestudy levels and remained constant during the study period. Informed consent was obtained from each patient or his next of kin. The study protocol was approved by the ethics committee of our medical faculty. Gas flow was measured at the proximal end of the endotracheal tube with a pneumotachometer (Fleisch no. 2, Fleisch, Lausanne, Switzerland) and a differential pressure transducer. Tracheal pressure (Paw) was determined in the same position with a second differential pressure transducer (Dr. Fenyves & Gut, Basel, Switzerland). Esophageal pressure (Pes) was obtained by a nasogastric balloon-catheter (Mallinckrodt, Argyle, NY, USA) connected to a further differential pressure transducer of the same type as described above. The balloon was positioned 2–3 cm above the dome of the diaphragm. The correct balloon position was verified by an occlusion test as described elsewhere. The data were sampled after A/D conversion with a frequency of 20 Hz and processed on an IBM-compatible PC. Software for data collection and processing was self-programmed using a commercially available software program (Asyst 4.0, Asyst Software Technologies, Rochester, NY, USA). Patient's inspiratory work of breathing Wpi (mJ/l) was calculated from Pes/volume plots according to the modified Campbell's diagram. Dynamic intrinsic PEEP (PEEPidyn) was obtained from esophageal pressure tracings relative to airway pressure as the deflection in Pes before the initiation of inspiratory flow Patient's additive work of breathing (Wadd) against ventilator system resistance was calculated directly from Paw/V tracings when Paw was lower than the pressure on the compliance curve. Two-way analysis of variance (ANOVA) was used for statistical analysis, followed by post hoc testing of the least significant difference between means for multiple comparisons. Probability values less than 0.05 were considered as significant. Results. COPD patients had significantly higher pressure support than control patients. With decreasing inspiratory flow, Wpi increased significantly in COPD patients. Additionally, the duct cycle (Ti/Ttot) significantly increased with decreased flow rates which resulted in a higher PEEPidyn compared to the baseline. At T 1.5 and T 2 with lower flow rates, the pre-set pressure support level was not achieved within inspiration in the COPD patients. Wadd increased significantly at T 1, T 1.5 and T 2 in COPD patients and at T 1.5 and T 2 in the control group. In one patient, premature termination of inspiration owing to high initial peak flow was corrected by adjustment of the inspiratory flow. Conclusion. Our results demonstrate that a decreased peak flow during PSV resulted in increased patient's work of breathing in COPD patients. During lower flow, the pre-set pressure support level was not attained and additional work had to be done on the ventilator system. Furthermore, the higher PEEPidyn during lower flow rates indicates a higher risk of dynamic pulmonary hyperinflation in patients with COPD. We conclude that the use of pressurization times ≥1 s to decrease inspiratory peak flow during PSV is of no benefit and should be avoided, particularly in COPD patients. However, in selected cases, slight decrease of inappropriately high peak flows might be useful for optimization of PSV setting to avoid premature termination of inspiration.

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

Description / Table of Contents: Zusammenfassung An 16 druckunterstützt beatmeten Patienten, davon acht mit chronisch obstruktiver Lungenerkrankung (COPD) und acht ohne obstruktive Lungenkrankheiten wurde der Einfluß eines PEEP von 5 cmH2O und einer Druckunterstützung von 5 und 10 cmH2O auf die mechanische Atemarbeit und andere atemmechanische Meßgrößen untersucht. Sowohl durch PEEP wie auch durch Druckunterstützung konnte die Atemarbeit gesenkt werden. Die Kombination beider Maßnahmen wirkte additiv. Ein PEEP von 5 cm H2O und eine Druckunterstützung von 10 cmH2O senkte die Atemarbeit im Durchschnitt um mehr als 50% in beiden Patientengruppen. Ohne Druckunterstützung leistet der Patienten mehr als 20% seiner gesamten Atemarbeit auf Widerstände des Beatmungssystems (z.B. Gasflußanlieferung, Triggermechanismus etc.). Durch 10 cmH2O Druckunterstützung war dieser Atemarbeitsanteil nahezu kompensiert und zu vernachlässigen. Ein bestehender intrinsischer PEEP bei COPD-Patienten erhöhte die Atemarbeit und wurde durch Applikation eines externen PEEP vermindert. Die Höhe der Atemarbeit war in unserer Untersuchung interindividuell sehr unterschiedlich. Daher erscheint uns eine individuelle Anpassung von PEEP und Druckunterstützung anhand der gemessenen Atemarbeit sinnvoll.

Description / Table of Contents: Summary Experiments by a high-frequency method are described, which were carried out in order to investigate the achievable concentrations in systems of hydrargillite and sodium hydroxide in water as well as the kinetics of dissolution and cristallisation of hydrargillite in such systems. The temperature was varied from 30° to 70° C, the sodium hydroxide concentration from 3 to 4 n and the caustic rate Na2O∶Al2O3 from 1,35 to 1,9. The results will be discussed in two following papers.