Miscellaneous III

S231 P451 P452 PENTOXIFYLLINE INCREASES OXYGEN EXTRACTION DURING TAMPONADE IN AN ENDOTOXIN SHOCK MODEL H. Zhano. H. Sen. M. Benlabed. N. Nbuyen. JL. Vincent FIBRINMONOMERCONCENTRATION IN SEPTIC AND TRAUMATIC SHOCK Pentoxifylline (PTX), a xanthine derivative used in the treatment of circulatory insufficiency, has been found to have protective effects in different models of sepsis. We hypothesized that this drug might either increase oxygen delivery (DO2) and/or increase tissue oxygen extraction to meet oxygen demand in sepsis. We studied the effects of PTX on the oxygen uptake/oxygen delivery (VO2/DO2) relationship and tissue oxygen extraction when blood flow was reduced by Inducing cardiac tamponade in 14 anesthetized, ventilated and paralyzed dogs. Via a left thoractomy, a catheter waa inserted into the pericardial space for saline injection. Each dog was given a 2 mg/kg bolus of E. coli endotoxin and received 20 mlkg.h of normal saline•duririg the study. In 7 dogs, PTX was administered as a 20 mg/kg i.v. bolus, followed by a continuous infusion at 20 mglkg.h. V02 was derived from the expired gases. 002 was calculated by the product of the modüution cardiac index and arterial oxygen content. Oxygen extraction ratio (02ER) was defined as the ratio of V02/002. Dual-line regression was used to determine the critical 002 (DO2crit) in each animal. ANOVA was used for statistical analysis. PTX resulted in significant increases in V02 and DO2. Critical V02 was slightly higher in the PTX-treated than in the control group, but it did not reach statistical significance (6.3 ± 2.4 vs 5.4 ± 1.0 ml/kg.min, NS). D02crit which was 11.3± 4.9 ml/kg.min in the control group, was decreased to 9.6 ± 3.6 mlkg.min in the PTX-treated group (p = 0.05). Critical 02ER significantly increased from 50 ± 20% in the control to 68 ± 19% in the PTX-treated animals (p< 0.05). The V02/D02 dependency slope was steeper in the PTX-treated than in the control group (0.77 ± 0.31 vs 0.46 ± 0.18, p< 0.05). At D02c rit, PTX-treated group had lower venoarterial PCO2 difference (12.9 t. 4.3 vs 18.4 ± 7.4 mmHg, p < 0.05) and arteriovenous pH gradient (0.08 ± 0.02 vs 0.11 ± 0.06 U, p < 0.05) than in the control group. Thus, the addition of PTX and fluid therapy can increase 002 and global oxygen extraction capabilities when cardiac output is progressively reduced in the endotoxemic dog. The exact mechanisms remain to be defined. - Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik. 808, B-1070 Brussels, Belgium 0.Kunitz, T.Hillermann, P.Glöckner, Chr.Agternkamp F.G.Muller, G.kalff During the last years a lot of experimental and clinical studies were made to show the important role of fibrinmonomers (fm) in identifying DIC. According to our animal study - after creating a septic shock in femal pigs by injection of a defined quantity of endotoxin - the fm-concentration raises up to more than 300 % - we started a . cinical study measuring the fmconcentration in different groups of patients. Fm-concentrations were measured in the following groups b using the spectrophotometric method (CoA Set Kabivit rum) group A: controlgroup, healthy patients n=30 group B: non septic / non traumatic patients n= 6 group C: patients with traumatic shock n= 6 group D: patients with septic shock (per definition) n=14 (Patients of group B to D were treated in an ICU) After a fixed schedule blood was taken from all patients for fm-analyse. Fm-concentration was measured in the first day every 4 hours, until the end of septic symptoms every 8 hours. In the controlgroup the fmconcentration was analysed once. In group A and B the fm-concentration was always below 20 nmol/l. In group C and 0 (septic and traumatic shock2 we found ncreases of the fm-concentration (more than increases 100 nmol./1) because of a changed coagulation system. An early increase before appearing oT clinical septic symptoms or a correlation to the clinical picture was not found. In difference to the animal study with 'suboptimal treatment' in our clinical study was shown that the fm-concentration interfeares extremely with the intensive therapy (volumetherapy, blood, heparin and AT III substitution) so that the measured fmconcentration does not relate to the coagulation status. - Department of Anesthesiology Univ.Dir. Prof. G.Kalff Pauwelstr.30 D-5100 Aachen Miscellaneous III P453 TRANSFUSION OF FRESH FROZEN PLASMA IN HEART SURGERY PATIENTS SR Leal,JM Flores,V Rivera,P Camacho,J Garnacho,F Murillc Most fresh frozen plasma (FFP) recipients are patients undergoing heart surgery.Although the reason most centers transfuse FFP is to replace clotting factors,it has not been demostrated that its routine use can reduce postoperative blood losses.The present study was designed to evaluate the effect FFP transfusions has on postoperative bleeding in heart surgery patients. undergoing and forty-nine patients A hundred cardiopulmonary bypass (CPB) during 1991 were studied.In the immediate postoperative period,78 patients (Group A) received four units of FFP,however,the remaining 71 (Group B) were not transfused.Average age was 53+12 years (Group A) and 56472 years (Group B) and average weight was 71±12 kg (Group A) and 71+11 kg (Group B).The following factors were evaluated:Surgical procedure (CABG and valve arterial replacement) ,history of heart surgery,NYHA hypertention,diabetes,previous functional classification,prior ingestion of aspirin,warfarin or heparin,graft type employed, numbers of CABGs performed,surgical complications,CPB time (mins),aortic cross clamp time (mins) and postoperative platelet count. First 24-hours and total postoperative blood losses were also recorded. Both groups were statistically homogeneous as far as the before mentioned factors were concerned.Total blood losses were 1022+698 cc and 8791699 cc (NS) and first 24-hours losses were 7451557 cc and 597+460cc (NS),for groups A and B, respectively. Pending confirmation,our results indicate that the routine use of FFP for patients undergoing heart surgery does not reduce postoperative bleeding. Unidad de Cuidados Intensivos.Hospital Universitario Virgen del Rocio.Avda Manuel Siurot s/n.41013.Sevilla.Espana. P454 MA. ULIBARRENA, N. SAINZ PARDO, JJ. BALLESTERO, V. BOADO JC. VERGARA, JR. IRURETAGOYENA. STERNAL WOUND COMPLICATIONS: A REVIEW OF 647 CONSECUTIVE OPERATIVE PROCEDURES. Sternal dehiscence and mediastinal infection are the major sternal complications following open-heart operations. The rate in some series is 0.5 to 5.9%, and several factors have been suggested as predisposing to this complication. The present retrospective clinical study designed to assess the incidence of major sternal wound complications and its relationship with the factors that appear to increase the risk of these complications. Sis hundred forty seven- operative procedures involving median sternotomy from 1989 to 1991 compose the study group, 67 patients experienced sternal dehiscence (10.4%) and 13 mediastinal infection. Risk factors associated with the development of a sternal wound complication included age, diabetes, chronic pulmonary disease, harvesting of the internal mammary artery, prolonged aortic cross-clamp time, early reesploration for bleding and prolonged respiratory assistance. All cases of mediastinal infection were associated with. sternal dehiscence. CRUCES HOSPITAL. INTENSIVE CARE UNIT. Plaza de Cruces sn, Cruces,Baracaldo, Vizcaya. SPAIN CP 48903 Fax 4992945 S232 P455 P456 MUSCLE TISSUE OXYGEN PRESSURE DURING CARDIOPULMONARY BYPASS. PRELIMINARY RESULTS. A.Kindlund; C.Ponte; J.M.Valle; F.Cienfuegos; F.Payo. IS ASPIRIN A RISK FACTOR FOR POSTOPERATIVE BLEEDING OF CORONARY ARTERY BYPASS GRAFT SURGERY? JM Flores,SR Leal,V Rivera,P Camacho,F Murillo Patients subjected to cardiac surgery under cardiopulmonary bypass and hypothermia show well-known clinical repercussions, derived from these procedures. Tissue perfusion is one determinant implicated in these problems. We have studied 9 patients who have undergone coronary revascularization surgery. We determine the PO of the muscle where the safena vein is taken t for^ use in the bypass operation using a 8 channel Clark type multisensor (MOO) together with an acquisition unit a special software developed at the Clinical Research Center (University Hospital of Linkoping. Sweden. Prof. D. Lewis). During the sampling period of 5-min the electrode is automatically sampled every 15 sec. with a total of 160 values after which the pressure distribution is presented in the form of histograms according to the literature. The initial muscle P 02 -pressures with the patient anaesthetized but be tf'ore the bypass, show normal values around 712.5 kPa with a rapid and important decrease to about 1.5±0.2 kPa during hypothermia and cardipulmonary bypass. After the bypass procedure the pressures raises rapidly' to stabilize at their previuus values. To conclude, there is a severe deterioration of the peripheral muscle oxygenation during the extracorporeal surgery which origin (hypothermia, decrease of oxygen delivery ...) need further evaluation. The anti-platelet-aggregation effect of aspirin may contribute to greater blood losses in the early postoperative period of patients undergoing Coronary Artery Bypass Graft (CABG) surgery.The aim of the present study was to analyze the relationship between aspirin and bleeding. Sixty-four CABG procedures performed in 1991 were reviewed. Forty-seven patients (Group A) ingested 125 mg/d while the remaining 17 did not take aspirin (Group B).None of the patients were administered other medication which could affect the platelet plug-forming •echanism.Most of the patients group A received -aspirin until the day prior to surgery and all of them had taken it during the previous week.The following factors were, analyzed: Ili story of arterial hypertension, diabetes mellitus, previous heart surgery, NYHA functional. classification, number of coronary grafts, type of graft employed and intraoperative complications. The average age of the patients was 58+7 years (Group A) and 59+9 years (Group B).Both groups were statistically homogeneous as far as their medical backgrounds were concerned.Blood losses during the first 24-hours in the ICU were 875+575 cc and 964±764 cc (NS) and total ICU losses were 1169+752 cc and 1186±845 cc (NS) for Group A and Group B, respectively. Pending' confirmation, our results suggest that preoperative ingestion of aspirin does not seem to effect the amount of early postoperative bleeding after the performance of CABG surgery. Department of Intensive Care. Hospital Central de Asturias. c/Julian Claveria s/n.Oviedo 33080. SPAIN. Unidad dc Cuidados Intensi.vos.Hospital Universitario Virgen del Rocio.Avda Manuel Siurot s/n. 41013. Sevilla.Espaiia. P457 P458 S[UDING THE CORONARY BLOOD FLOW WITH A SIMULATION PROGRAM. D. S;inchcz'; F. Palacios'`; M. Polo'; A. Toval'. THERAPEUTIC EFFORT AT THE ADMISSION IN WOMEN WITH ACUTE MYOCARDIAL INFARCTION J. Latour, J. Bonastre, J.S. Giner, V. Lopez-Camps, M. RodriguezSerra, L. Rosado. BACKGROUND: This paper present a concrete application of microcomputer based simulation in health sciences education and research. It shows a total regional coronary blood flow system dynamics model representing graphics and numerical behavior and relation between variables, with in addition allows int cruel ion with user for experimentation. METIIODS: The model is made using professional tools such as DYNAMO and DYNEX. A basic electrical model is used to model the process. BACKGROUND: Recent studies suggest that women with coronary artery disease undergo fewer major diagnostic and therapeutic procedures than men. The aim of the present study is to test the hypothesis that sex is an independent predictor of therapeutic effort in patients admitted with acute myocardial infarction. METHODS: Retrospective cohort study based on 429 males and 124 females admitted by acute myocardial infarction. The potential confounding effects were controlled using multiple linear regression analysis. I . Schematic Diagram of the model (1.1.E Iloffamn) RESUL'T'S: This model incorporates resistances, compliances, irtramiocaidial blood volums, pressure generator and it takes account of regional differences across the left vcntriculus wall. CONCLUSIONS: The work offers a way of exploring certain problems that up to now have been ignored. The model also illustrates a strategy tor introducing this kind of models in the classroom, as well as the suitability'of their implementation, in educational enviromcnts. [.C1.LUniv. Murcia; 2 UCLI lospihil L`Ichc. E.U.P.A.Univ. Alicante. RESULTS: The women were older than men (p<0.00001), more likely to be admitted with cardiac failure (p=0.00008), more severely diseased as measured by SAPS index, and more likely to die in the ICU (p=0.00002). As compared with men, women received less relative therapeutic effort measured by the TISS score. The variables that independently predicted therapeutic effort on admission were the Killip group (p<0.0001), SAPS score (p<0.0001) and age (p=0.0011) but not sex (p=0.3875). CONCLUSIONS: Women admitted with acute myocardial infarction receive less relative therapeutic effort than men. These differences seems attributable to the higher age of women, but no to social inequalities by sex. UCI, Hospital General d'Elx. Huertos y Molinos s/n. 03203 ELCHE (Spain) S233 P459 P460 THE APPEARANCE OF THE LEFT VENTRICULAR THROMBUS IN AN ACUTE MYOCARDIAL INFARCTION L.Dobrkovid,Lj.Georgievska,V.Spiroska, V.Borozanov,B.Mileti6 and L.Srbinovski J. CANOVAS, D. BARJA, A. PEREZ, P. MARCO, J. CATURLA, A. ESPASA - , J. In order to study the incidence of left ventricular thrombus(LVT) during acute myocardial infarction(AIM) we performed two dimensional echocardiography(2DE) in 63 consecutive pts within 72 hours after onset of AIM.Antikoagulants were used in 58 pts and in the other ones intravenous streptokinase. Evidence of LV mass suggesting thrombus by 2DE at 3rd day of AIM was found in 27/63 pts-(43%),neither one on streptokinase protocol.LVT involved an aki/dyskinetic apex in all pts.AVerage LV internal dyastolic dimension in pts with LVT was '59± 3,2mm.ECG-AIM location:27/29 anterior(9o%)and 2' inferior(lo%). CONCLUSION :l.LVT is an early complication. of anterior AIM with °vidence of aki/dyskinetic LV wall and wider LV internal dyastolic dimension;2.Appearance of the left ventricualr thrombus in AIM is independent of antikoagulant therapy;3.2DE is an good screening method in identification of left ventricular thrombus. Clinic of cardiology,University hospital, Vodnjanska 17,91000 Skopje,Makedonia FIBRINOLYTIC SYSTEM (FS) VARIATIONS INDUCED BY THROMBOLYTIC THERAPY ('Pr) IN ACUTE MYOCARDIAL INFARCTION (AMI). LUCAS. OBJECTIVE. To study activator and inhibitor proteins involved in PS and its variations after TT in AMI patients. METHODS. 20 consecutive patients, diagnosed of AMI. Mean age 6131,9 (m±SE). 18 sales and 2 females. All patients were included in TT protocol. We meassured plasmatic levels of:Tissue Plasminogen Activator (t-PA), Plaminogen Activator Inhibitor endothelial type (PAI-1), Prothrombin fragments (F.2 ) by ELISA method. Plasminogen (PI14), e, Antiplasmin (a -AP) by aminolytic method, a= Macroglobulin (az M), e,Antitripsin(e 1 -^APj by inmunologyc method. Ad admission, 24, 48 hours and S t day after TT. Statistical comparison of the results was performed using paired and nonpaired - Student's t test, and ANOVA test. RESULTS. Are shown in the following table. t-PA(ng/m)) PAI-1(ng/ml) PLM(%) 82-AP(%) a2-M al-AT F1+2(U/ml) ADMISION 24 HOURS f13s1,4 f29t4,6** 38±4,8 87±3 ** 184±7,5 120±8 ** 1197±30*. 4±1,3 35±4,5 40±5 *0 f 56±5,7 ** ** 98±9 f213± 11** 3,6±1,1 48 HOURS f 19,7±2,4 5th DAY 11,5±2** 31±3,6 40t4 73±4,5** 113±5** 184±4,8 101!9,8 1 277±18 9,3±4 101±4** 113±13 314±32** 6,5±3.7 f P<0.05 ** p<0.01 CONCLUSIONS. 1: Ad admission hypercoagulable state in A14I was demostrated by increased levels of F,, i . A hypofibrinolytic state was stablished by high levels of PAI-l. 2: Both byological situation remained unchange during the follow-up . .3: 24 h. after TT decreased levels of PLM and 0 4 -AP were observed. We assumed it as a direct effect of TT. 4: t-PA levels increased 24 h. after TT, related with endogenous synthesis. PAI-1 levels remained unchange at this time. Intensive Care Unit, Laboratory — and Hematology * Services, General University Hospital, Maestro Alonso 109, 03010 Alicante, Spain. P461 P462 AMRINONE IN THE TREATMENT OF SEVERE HEART FAILURE DEFIBRILLATION: AUTOMATIC IMPLANTABLE CARDIAC CONSIDERATIONS ON THE EARLY POSTOPERATIVE COMPLICATIONS. A.Marchini, P.Sebastiano, G.Benedini, P.Marzollo, F.Bianchetti, A.Picchioni, G.Pedersini. G. yoga, I. Duran, B. Krivec, F. krabl-Mocnik, R. Skale Amrinone is a bipyridine derivative and a member of phosphodiesterase inhibitors with inotropic and lusitropic effects and vasodilatory properties. Its action is not related to digitalis glycosides and catecholamines. We used amrinone in 25 patients with signs and symptoms of severe chronic heart failure (19 NYHA IV, 5 NYHA III) refractory to conventional treatment with vasodilators, diuretics and digoxin. Amrinone was given intravenously as boLus (0.75 mg/kg) and then continued in dosis 5 - 1,O'mcg/kg/min. Treatment was prolonged until satisfactory clinical and hemodynamic improvement was reached and lasted on average 22 hours (maximal 72 hours),. We found significanY2 increase of cardiac indes from 1.9 +/- 0.36 1/min/m to 2.74 +/- 0,73 1/min/m (p<0.001) and significant reduction of PAOP from 26 +/- 7 mm Hg to 16 +/- 4 mm Hg (p<0.001). The beneficial hemodynamic effects persisted 24 hours after the treatment with amrinone was discontinued. We observed transient side effects in 4 patients: short term reversible atrial fibrillation in 2, frequent VPB in 1 and headache in 1 patients. Side effects were mild and did not require discontinuation of therapy. We conclude that amrinone can be safely used as a short term inotropic and vasodilatory agent in patient with severe heart failure when conventional treatment fails. Department of Intensive Internal Medicine, General Hospital, Kersnikova 1, 63000 Celje, SLOVENIA During the early postoperative period after automatic implantable cardioverter-defibrillator(ICD) implantation, some relevant complications can often occur. The aim of our study is to discuss the better therapeutic approach to overcome these problems. METHODS 19 patients,49-69 years aged,affected by different cardiac disease,FE average 32%,and recurrent malignant drug refractory ventricular 'tachyerrhytmias,undervent ICD implantation in our institution. RESULTS .Significant early post-op complications have been observed in 5 pts, always after epicardial implantation. LV failure occurred in 2 pts and required adjustement of inotropic drugs and IABP, in spite of that 1 pt died 36 hrs after operation . Aggravation of cardiac arrhythmias has been observed,and successfully treated, in 3 pts:in 1 pt iterative ventricular tachycardias have required a change in antiarrhythmic drug regimen and temporary to turn-off of ICD and in 2 pts paroxysmal atrial fibbrillation with fast ventricular response have required addition of digitalis and calcium antagonist drugs and a reprogramming of ICD cutoff rate at higher values to prevent inappropriate shocks. No complications were observed after non-epicardial ICD implantation nor after generetor replacements. CONCLUSION We conclude that early post-op complications following epicardial ICD implantation are frequent and required specific and timely pharmacological and non-pharmacological therapeutic interventions. Rianimazione. cardiochirurgica - Spedali Civili, 25100 Brescia. Italy S234 P463 P464 SPECTRAL 7UL ULFN E CK THE VEZI1'RICULAR MYClCA IIM. REIATIVE TO TM ACPIVATION WAVEFRQiF IN THE WC LFF-PARKINS I9 WHIM SYNDI^^. ENERGY SP I1 A OF THE MYC CAMICM IN PATIENTS Wllli APPARENI4.Y N3I4AL HEARS AM PARCKYSMAL ATRIAL FIBRILLAna . J.M. Paylos, E. Löpez de Si, B. Codero, J. M. Martinez, C. Saenz de la Calzada JM. Paylos, B. Cordero, E. LDpez de Sa, C. Saenz de la Calzada To evaluate the energy contents of the spectral•:turbulence due to the activation wavefront over the accessory syndrome, we pathways in the Wolff-ParKinson-White studied 14 patients with manifest preexcitation (groupe I) (10 males, 4 females, mean age 45+15) and 14 normals (groupe II) (5 males, 9 females, mean age 34,5±12,5). After signal-averaging, a 60 mS segment-length (from the QRS peak backward to the PR interval), in the Z leads were analyzed in orthogonals X,_ Y, To evaluate if the energy spectrum of the atrial myocardium differentiate patients with sustained documented episodes of Paroxysmal Atrial Fibrillation (AF), we studied 42 subjects, 21 with AF and no structural heart disease (16 male, 5 female, 58+/-18.7 mean age), and 21 normal subjects (13 male, 8 female, 48.1+/-28.7 mean age). A 8OmS segment length of the PR interval was analyzed: 60mS backward into the P wave and 20mS in the isoelectric. interval. Fast Fourier Transform (FFT) analysis was performed applying a 4-Term Blackman-Harris window function and FFT magnitudes and log. transformations were ccmpäred and the energy distribution between 0 to 50Hz analyzed, relating the relative contribution of frequencies between 20 to 50Hz to those between 0 to 50Hz, in X,Y,Z orthogonal ECG leads. Lead Hz A.F. Control P value frequency-domain. Delta wave was complete include into the window of analysis on the group I. Fast Fourier Transform analysis were performed applying and Nanning 4-T Rectangular Blackman-Harris, window-funtions according to the target of the study. Magnitudes were compared and fixed frequency points used for the definition of the energy contents. P (Window) Hz W.P.W. CONTROL Mag.Ratio (Harming) 10 16.919+/- 6.4 29.599+/- 7.9 x0.0001 Mag.Ratio (B-H) 10 7.489+/- 3.4 20.829+/- 5.6 <0..0001 Mag.Ratio (Rectang.)26 26.414+/-12.2 74.129+/-21.6 <0.0001 Mag. Ratio (B-H) 10 7.934+/- 5.3 16.86+/- 6.8 <0.0007 Area-Rat. Z 425.5+/-549.3 994+/-1141.9 <0.05 Mag.Ratio X 10-25 3400.7+/-3305.4 7389.2+/-7732.5 <0.04 Mag.Ratio X 25-40 206.9+/-188.9 1025.9+/-1300.5 <0.007 Mag.Ratio X 25-40 559.5+/-432.7 1837.7+/-2294.4 <0.02 Log.A.-R. X 1.186+/-0.448 1.833+./-0.738 <0.002 Log.Mag.-R.X 25-40 2.09 +/-0.539 2.571+/-0.789 <0.03 Log.A.-R. X 1.413+/-0.413 1.982+/-0.71 <0.003 The energy spectra showed a less energy content of the low frequency components in the group I as a result of the abrupt ventricular activation over the accessory pathway. The delimitation of such a turbulence it can be useful to control the effectiveness of the radiofrequency catheter-ablation. The spectral analysis of signal-averaged ECG from patients with paroxysmal atrial fibrillation showed significant less energy content (25-40Hz) on the ECG leads facing the posterior and postero-lateral atrial myocardium, where zones of slow conduction and blocks have been described, which ones we "speculate" could be responsible for this energy distribution. Unidad de Arritmias, Iaboratorio de Electrofisiologia, Hospital "12 de Octubre", Crta. de' Andalucia Km 5,400, 28041 Madrid. Spain. Unidad de Arritmias, Laboratorio de Electrofisiologia, Hospital "12 de Octubre", Crta. de Andalucia Km 5,400, 28041 Madrid, Spain. P465 P466 CRITERION OF ELECTION OF A VARIATION MEASURE iN RR INTERVALS, BASED ON SPECTRUM ANALYSIS OF RR SIGNAL. F.Palacios'; S.Barro 2; R. Ruiz 3 ; J. Lopez Escudero'; ;M. Sanchez'. PHARMACOLOGIC CARDIOVERSION OF ATRIAL TACHYARRHYTHMIA IN PRESENCE OF THE WPW SYNDROME: CAN WE USE VERAPAMIL? J. Hluchy, M. Wieczorek, G.V. Sabin BACKGROUND: Several statistical methods have been applied in measuring the RR intervals variation in ECG. Standard deviation (SD„), coefficient of variation (CV,,=SD„/mean RR) and variation (V,, =quotient from the addition of absolute values of subtraction from consecutive RR intervals, divided by number of heart beats), have been the most widely used.This study intends to determine the correlation of these statistical methods among themselves, and find but in which of them the statistical transformation of the RR signal preserves the spectrum component of the original RR signal in a better way. METHODS: We studied 275 intervals, each of one hour of Holter printing (Elatec).They were obtained during the first 24 hours from patients with infarction.Regression analysis among V,,, SD„ and CV„ was performed. The spectrum of frequencies of the RR signal was compared in 5 Holler registers from healthy people. The statistical transformations used in V r ,r,SD,, and CV„ calculus were also compared. V„ = 0.487 + 0.048*SD,,; R=0.54;p<0.01. V„ = 0.277 + 41.38*CV,,; R=0.65;p(0.01. SD„= 19.81 '+ 552.57*CV,,;R=0.74;p<0.01. As expected, we found a similarity betwen the R regression value. The transformation of the RR signal obtained with the standard deviation showed a spectrum of frequencies similar to the original signal. CONCLUSIONS: The variation measures based on the transformation used in SD,,, besides being contrasted methods, keep the periodical components, of the RR signal. 'UCI. Hospital de Elche; 2 F.Fisica.S.Compostela; 3 ESII.Cartagcna. The authors present a 63-year-old man with the WPW syndrome admitted to the ICCU because of incessant tachyarrhythmia with a right bundle branch block QRS morphology and a minimum RR interval of 200 ms. On admission, episodes of regular or irregular arrhythmia with intervening sinus beats were present. Neither DC shock nor antiarrhythmic drugs of class I were effective in converting arrhythmia to sinus rhythm. During an emergency electrophysiologic study (EPS), atrial origin of arrhythmia was confirmed by (1) spontaneously occurring 2-nd degree AV block or ventricular pacing-induced AV dissociation during a regular tachycardia and (2) the occurrence of atrial fibrillation. Sinus node dysfunction and a left lateral accessory pathway with an effective refractory period of less than 230 tns were documented. By programmed atrial and ventricular stimulation, triggered activity as the mechanism of atrial tachyarrhythmia was suggested. Regarding these findings, oral therapy with verapamil in a dose of 240 mg a day was started and led to conversion of tachyarrhythmia to sinus rhythm. Because of risk for an acceleration of accessory pathway conduction due to verapamil and avoiding to use higher doses of this drug in order to achieve complete suppression of arrhythmia, sotalol in a dose of 320 mg a day was added. On this therapy, a complete control of arrhythmia was achieved. 14 days later, a successful elective radiofrequency catheter ablation of the accessory pathway was performed. The authors conclude that in presence of the WPW syndrome, an emergency EPS may be useful to elucidate the mechanism of refractory tachyarrhythmia and give reasons for an unusual therapy approach. Department of Cardiology and Angiology, Elisabeth Hospital, Moltkestr. 61, 4300 Essen 1, FRG 5235 P467 P468 PREDICTIVE VALUE OF ARRHYTHMIAS AFTER AMI ON. LONG-TERM INCIDENCE OF'. THE EVENTS. R. Ritz, H.P. Lede zmann, F. Follath, aasel University, Switzerland ATRIAL PRESSURE DYNAMICS I.N RELATION TO A PATENT FORAMEN OVALE. J.-P. Alexander, B:Cambier, M. Kockx, L. Missault, J: Vandenbogaerde, Y. Taeymans, Ph. Van Cauwelaert. The significa.nce of arrhythmias (AR) in patients with acute caD rega.rding the long-term incidence of the events is not yet clearly defined. In a previous study of antiarrhythmic long-term prophylaxis (JACC 1990) we des~rib the effect of3 different regimens (n=312) In a representative subgroup (n=104) frequency and severity of "PB's were'compared during the acute (CCU, 48h) and the subacute (10 ·days) pha~e, and 1 year after AMI. . Results: during the first 48 hours after AMI 1) The sum of VPB'S correIated with the number of AR·classified as Lawn ~ 3 2) The change of the mean number of VPB's over 4h-periods was small (min. 1 0 7 ~ 2 4 6 , max. 165 +576 per 4h) and without predictive significance for later AR 3).··we observed 4 f r equ'ency patterns of VPB's: "decr scend6~' (n=25), "crescendo II (n=12), "spike" (n=28); "irregular" (n=39), none of predictive value 4) Ranking the sums of VPB's the quartiles showed predictive significance for. frequency and severity of ventricular AR in the subacute phase of AMI and 1 year after (with and without antiarrhythmic t hezapy ). Conclusion: the arrhythmias during the acute phase of AMI could correspond to a continued arrhythmic manifestat·ion of the myocard for up to 1 year, with or without antiarrhythmic treatment, Rudolf Ritz, ICU, University Hospital, Kantonsspital, Petersgraben 4, CH-4031 Basel, Switzerland Reports on patency of the open foramen ovale. (OFO) due to an increased pulmonary resitan~ are frequently mentioned: These shunts can lead to a decrease in partial pressure of oxygen, which can not be corrected with higher concentrations of inspired oxygen. Other cliD!cal studies stress that patients with an OFO are at risk for paradoxical emboli and for decompression sickness. As it is currently believed that the OFO is functionally closed during cardiac cycle, and that the lung can filter venous emboli, no satisfying explanation can be found in literature to justify the paradoxical nature of emboli through a patent foramen. To elucidate these questions, we studied the interatrial septum motion and correlated our findings to the interatrial pressure dynamics as measured in post coronary bypass (CBP) patients. We demonstrated with transesophageal echocardiography a cyclic patency in cases of OFO (28 %). In the majority of the 109 consecutive analysed patients we observed a leftward deflection of the interatrial septum during parts of the cardiac cycle. To see whether this bulging was a pressure related phenomenon we measured the interatrial pressure difference in 17 post CBP patients with nonnal left ventricular function. In all patients a temporary reversal of the left pressure predominance was regis~d during the isovolumic phase of the ventricular systole. The amphtude and duration of the reversal increased significantly during breathing modes associated with lower intrathoracic pressure. This pressure reversal only bad been reported in cases of atrial septal defects. These data can explain the paradoxical nature of emboli through an OFO. The hypothesis that the left atrial pressure predominance keeps the one-way flap-valve closed against the OFO is no longer valid. Furthermore it can explain the high prevalence of ischemic stroke in younger adults by paradoxical embolism of latent venous thrombosis and can consolidate the hypothesis that an OFO is a risk factor for decompression sickness in scuba divers. Opts. of Intensive Therapy Unit and Cardiac Surgery, Middelheim GH, Antwerp, and Dept. of Cardiology, University Hospital, Ghent, Belgium. P470 P469 PSO CALCULATION IN ICU. LEVELS OF ~F, A. Guadagnucci, G. Vignali, v. twnde'llo, A. RutHi, ". "ariott; CABELLO--. Study objective: To deter.ine' the ability of O.Siggaard-Andersen algorit~. in the esti.ation of the "in vivo" pSO and standard p50 values frotl a smgle blood sanople with s02X<97. Design: COIIpIIrison between. .easured and calculated standard pSO values. Setting: A Intensive Care Unit of a genra~ hosphat. Patients: 5eventeefl cardio-pulllOO8ry critical ill patients. Mean age of sixty-eight years (range 31-81 years). Measureenta: The experi_ntal lteasurellent of standard pSO (pSOst) was perforlted tonoaetering the venous blood sallples (69 speci.ens) usi"'!9 an Il-237 tono.eter at 3rC, with two different gas .,ixtures to obtain pcoz at 40 IIIlHg (D~.4), and p02 et lev .l~ to achieve .s02 values close to SO%.lh~.p02 values were car-rec'!ecI to a pH of 7.40 using a Bohr factor=-o.48 and the pSO was t~k eo by s;lIple ;nterpol~tion of points on the sOr1rYJ2 <I;agra •. calculated stlllldard PSO (pSOst calc.) and calculated "in ~lVO" pSQ (p50 c~l.) venous spec:;IIefIS and the correspondent arter;al spechlens with sOzX<97 (n=57) ""re obt~ined by Sigll"ard-Anders... 's cOlipUterized ~gor;th •. BlOod specilNn analysis was perforaed by Mans of an ABLSQO-RadlOlieter gasanalyzer and an OSfG"Rac';OMeter o"j_ter. Data were cotIpared .by ANOVA test for liner regre$'sion. The ltean speri.ental .i,:,us calculated d~f e~ nc~s was called "bias" and .rror in precision was defined as SD of the dlStrlbutlon of the differences. The precision was also expressed by the 95% confidence interval for .an di1ferences. Results Un MHo) are. listed ·in the table below: a-ATRIAL ' wi~s: . NATRIURETIC J':~iu PEP'l'ID£ IN :Xi,~zNM. INFERIOR .l'.CUTE MYOCARDIAL ES'1'EBAN, R. ALPAYATP;- R.,J. Oa.:rBC'l'IYB. The . i . ot this st"udy was to compare the evolution pattern of a-Atrial Natriuretic Peptide (a-AMP) in patients with and without right ventricular extension (RV) in inferior acute .yocarcUal intarction. IIBTRODA 44 consecutive patients, group I de JCillip-ltiJiball and "ithout previou; ayocardial infarction were divided into two groups: Group A, (n-17), with criteria or (RV) and Group B, (n'""27), without criteria. There were no ditferences betweeen the two groups in relation to age and. tilDe passed since the onset of symtOll. (RV) diagnosis was established by ECG :~Chrieaplsm (a-AMP) levels fIRMA. AMERSHAN. N.V.-ll.4±L4 pJDol/L)," were obtained before and after acute volume expansion (VE) wlth colloids until the riqht atrial pressure (RAP), continuous .onitored, increased to 10 mmHq, durinq a period of 30 .inutes. Statistical co.parison of the results was perforaed using paired and nonpaired Student t"s 1:. test. aBSUL'l'S. Ar.. shown in the following table. on the Bias Error of Precision 95% Coof i dence Interval pSOst vs p50st ea l c . venous 0.72 0.76 +0.52 ..• +0.9Z pSOst vs pSOst calc .er-rer , 1.68 pSO calc. venous pSO calc.arter. RZ 88.7 GROUP A 2.54 1.3 +1.36 ••. +Z.O +Z.·Z 87±4 94±2 95±2 73±7 75±3 78±3 MAP(mmHg) 83±7 HR(B/min) 70±4 A-ANP(pmol{l) VE(ml) 1.21 VOLUME EXPANSION VOLUME EXPANSION RAP(mmHg) GROUP B INITIAL INITIAL 6.2±1.3 *** 12±0.9 43±6.3 **51±6.1 *** 8±0.4 41±4 31±3.3 *** 2.8±0.4 ** * 440±88 * 642±29 75.0 ... +2.9 77.3 * p<O.05 ** p<O.Ol *** p<O.001 MAP:Mean arterial pressure; HR:Heart rate; Values in m±SE Despite the higher initial plasma levels of o-ANP, in the patients with (av) extension, the response to acute (VB) was .arkedly attenuated. This fact suggest the possibility that right atrial ischemia or infarction added to (RV) infarction, may play a role in the s)'nthe~is and storage of Q-ANP by reducing the amount of atrial and subendOcard1.UJa ventricular tissues available. co.eLUSIONS. Conclusion,S: OUr results s':Iggest that the O.Siggaard-Andersen IN th~ .ical .xIel of O)(ygen dissociative curve describes the curve also at high saturation when it is not Longer linear. Accurate lteasure.ents (including dishellOglobin percentage) end sOzX<97 are necessary. We did not perfor. exper;eental IleaSLIretlent_ of ·in vivo'" p50 but we postulate that as the p59st was well calculated so too \IQ,Ild be the pSO "in vivo"-at" 37°C. DepartHf"lt of InCet1.ive Care, Head physician F.Leonardi, Cristoforo Hospitel, 1-54100 Massa, Italy S5. GiaCOllO e :lntensive Care unit, Laboratory· University Hospital, Maestro ~ l o n s o and cardioloqy·- Services, 109, 03010 Alicante, Spain. General S236 P472 P471 ,ARTERIOVENOUS DIFFERENCES IN PCO2 AND pH ARE BETTER INDEXES OF TISSUE HYPDXIA THAN ARTERIAL BLOOD LACTATE LEVELS DURING AN ACUTE REDUCTION IN BLOOD FLOW Hato ZHANG and Jean-Louis VINCENT This study was designed to examine the relationship between oxygen uptake (VOs), oxygen delivery (DO2), venoarterial difference in PCO2 (VAPCC^), and PH (AVpH), and blood lactate (LAC) levels during an acute reduction in blood flow induced by cardiac tamponade. In anesthetized, ventilated dogs (N=13), a catheter Was inserted into the pericardium to inject saline and to measure the intrapericardial pressure (IPP). V02 was derived from expired gas analysis. D02 was calculated independently by the product of the thermodilution cardiac index and the arterial oxygen content. The critical D02 (DOzcm) value below which V02 fell was determined by a plot of VO2/DO2 from each individual dog and was found at 9.9±1.8 mlkg.min. VAPCO2 and AVpH, which were 7.1±4.6 mmHg and 0.028±0.025 U at baseline, dramatically increased immediately below DO2oe to 17.5±6.6 mmHg and 0.114±0.054 U, respectively (both p<0.01). These changes were related to both arterial hypocapnia and venous hypercapnia. Endtidal carbon dioxide tension (PetCOz) abruptly fell from 28.1±10.2 mmHg at baseline to 22.0±6.2 mmHg at DOzde (p<0.01). This was associated with a significant increase in (PaCO2-PetCO2)/PaCO2 ratio. LAC which was 2.1±0.5 mMol/l at baseline, was increased to 3.5±0.5 mMol/I at DO2ora (p<0.01). This increase in LAC was more progressive than that in VAPCC2 and AVpH (Figure). The D0rom calculated for VAPCO2 (9.4±1.3 mlkg.min), AVpH (10.2±1.7 mllkg.min) and lactate (10.6±1.9 ml/kg.min) was found similar to the 002c,x calculated for V02 (9.9±1.8 mlikg.min). The present study suggests that both VAPCO2 and AVpH represent better parameters than LAC to detect the occurrence of tissue hypoxia in low flow conditions. NUTRITION AND ACUTE RENAL FAILURE (ARF) PROGNOSIS IN CHILDREN. U. Simeoni*, P. Desprez, P. Meyer, M. Fischbach, J. Geisert ARF mortality rates are persistently high despite the extensive use of extrarenal epuration techniques. Nutritional factors may account for a poor prognosis favorizing secondary complications such a sepsis and multiple organ system failure. Metabolic perturbations may provene from stress associated with the disease responsible for ARF, from ARF itself and from unappropriately, restrictive nutritional support. Few data are available in pediatric patients on the influence of nutritional factors on ARF outcome.- We -retrospectively studied the evolution of several nutritional indicators, including brachial/cephalic perimeter (B/C) and plasma prealbumin (PPA), in 58, 2 month to 9 year old children who presented ARF in the pediatric intensive care unit. Patients were divided into a normometabolic (Group 1 : n = 28) and an hypercatabolic (Group 2: n = 30) group according to Wesson's stress equation for basal metabolic rate estimation. Patients age and extrarenal epuration rates were similar in the two groups, whereas mortality rates were 18 % and 37 % respectively in each group. Brachial/cephalic perimeter-variation (d B/C) and plasma prealbumin variation (A PPA) during the course of ARF resulted significantly different between survivors (A B/C + 0.03 + 0.04 ; a PPA : + 41.7 + 38.2) and children who will decease (O B/C : - 0.09 + 0.04 ;O PPA : - 60.7 + 38.2) (pG 0.05) in the hypercatabolic group. A higher mortality rate iq associated with poor nutritional conditions in children with ARF and hypermetabolic conditions. Service de Pediatric 1, Höpitaux Universitaires de Strasbourg, 67098 France Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, B-1070 Brussels, BELGIUM P473 P474 MULTICENTRE SURVEY OF COMPLIANCE WITH HAND HYGIENE PRACTICE IN INTENSIVE CARE EPINEPHRINE INHIBITION OF FMLP INDUCED CHEMILUIIINESCENCE IS MEDIATED BY ß2-ADRENER6IC RECEPTORS EXPRESSED ON POLYMORPHONUCLEAR LEUKOCYTES LJ Sproat and TJJ Inglis Following a large multicentre survey of infection control practice in Intensive Care Units, which indicated a wide variation in handwashing policy, a more detailed multicentre survey was conducted into hand hygiene policy, comprehension and practice in 16 units. A wide variation from recommended practice was found. In some units hand washing was not required for procedures such as tracheal suction or mouth care, and in some units there was no formal policy on optimal hygiene practice during these procedures. Nurses' self-reported non-compliance with hand hygiene policy was poorest before tracheal aspiration(27%), but was also reported during line care, urinary catheter bag emptying and mouth care. Some categories of visiting hospital staff did not comply with hand hygiene recommendations during the majority of instances of patient contact. Our results show that some Intensive Care Units have unsatisfactory hand hygiene policies. In those units where satisfactory policies exist, self-reported compliance was variable and, at times, poor. Furher research is required in this area, particularly into staff motivation to comply with recommended infection control practice. Inglis TJJ, Sproat LJ, Hawkey PM et al. B J Apaes 1992;68:216-220. Department of Microbiology. University of Leeds, LS2 9JT, UK M WEISS 1 . A BIRKHAHNI, S METTLER 1 , M SCHNEIDER2, P. WERNET2, H. LEMOINE 3 Backgrounds and methods: EpineWine causes a dose-related reduction of oxygen free radical production by polymporphonuclear leukocytes (PMN) (1). PMNs express 62-adrenergic receptors (1). It was investigated whether epinephrine induced inhibition of oxygen free radical production is mediated by ß2-adrenergic receptors on PMNs. N-formyl-methionyl-leucyl-phenylalanine (FMLP. 10-4 Moi/i ) Induced oxygen free radical production of PMNs (10 6/ml) was detected by chemiluminescence experiments. The dose-response effects of epinephrine (10-9 up to 10-3 Mol/I) on FMLP induced P11N chemlluminescence with and without selective ß1-adrenergic and ß2-adrenergic blockade were investigated. In each case the effect on neutrophils of 10 healthy donors was tested. Selective ßi-adrenerglc blockade was employed with CGP-20,712 A and ß2-adrenergic blockade with ICI-118,551. Chemiluminescence response In presence of drugs is expressed as percentage of control activity, i. a chemiluminescence without drugs. op <0,01. statistically significant difference compared with control activity. Results: Epinephrine dose-dependently Inhibited FMLP Induced PMN chemiluminescence. A 559 t 2t% chemlluminescence response occurred at 10 -7 Mol/I epinephrine. This Inhibition was not reversed by selective 61edrenergic blockade (579 & IS%" chemiluminescence response), but by selective ß2-adrenergic blockade (90R * 27% chemiluminescence response), Conclusions: Epinephrine related depression of FIILP Induced PMN chemlluminescence Is mediated by ß2-adrenergic receptors ! expressed on PMNs. Literatur: 1. Bazzonl 6. DeJana E. Del Maschlo A. Adrenergic modulation of human polymorphonuclear leucocyte activation. Potentiating effect of adenosine. Blood 1991. 77 (9): 2042-2048. Departments of IAnesthesiology, 2 Blood Coagulation and Transfusion Medicine, 3 Clinical Physiology, Heinrich-Heine-Universitit, Iloorenstr. 5. 4000 Düsseldorf 1, Germany S237 P475 P476 MISMATCH BETWEEN LEVEL OF CARE ON THE LAST DAY ON THE ICU AND LEVEL OF CARE ON THE WARD R.G. Hulsebos, F.W . Beltran, D. Reis Miranda* EARLY ELECTROMYOGRAPHY (EMG) TO DIAGNOSE POLYNEUROPATHY IN CRITICALLY ILL PATIENTS. I.J.de Jong °, J.A.Haas +, A.J.J.Woittiez Discharge policies is ICUs in hospitals of different size were studied.. The level of can of patients on the day of discharge was analyzed following the hypothesis that the level of care would decrease ' during the admission until the last day,, when the required manpower would match the situation on the ward. In 1990 the ESICM proposed levels of care for ICUs based on patient/nurse (P/N) ratios. Level I was defined as P/N > 2.5,' evel I as P/N 1.6-2.5 and level III as P/N < 1.6. For each patient a level of care can be calculated by measuring the amount of woà a patient demands (TISS-score), compared to the amount of work one nurse can do during her shift (40 TISS points). Using this method, levels of can on the day of discharge were calculated on data from a large multi-centre study involving 36 Dutch ICUs, 11.665 patients and more than 37.000 patientsdays. Earlier research showed that ICU characteristics are . closely related to hospital size. Therefore ICUs were grouped based upon the number of beds in the hospital: rou <300 beds; slows 2300-500 beds; group 3 >500 beds; group 4 university hospitals.. The results of this analysis are reported in the table. Polyneuropatby of the critically ill ( PCP ) is a late complication of M.O.F., causing polyneuromyopathy. Early detection may be difficult by sedation and relaxation. In a pilot study we evaluated the the early EMG in the diagnosis of the PCP. Patients and methods : We studied 7 patients ( mean age 69.0 years ) at risk for developing PCP, i.e. > fifty years old, > five days in ICU, sepsis syndrome ,and/or APACHE-II score > 20 afther five days in ICU and/or failure of . two or more organs. Patients with pre-existing polyneuropathy and known causes like Guillain-Barre, diabetes, alcoholabuse, uremia were excluded. After clinical neurological examination an EMG was performed at the ICU. Five men and two women were included in the study. APACHE-II score mean 16.6 (10-26). Patients received enteral or parenteral nutrition and were not in a catabolic state. All patients were mechanically ventilated. No muscle-relaxants were used. Sedation was achieved by midazolam. Six patients received aminoglycosides during 5 days before the EMG was performed. Results : EMG was performed 6.7 days mean (1 - 19) after entrance in the study. In all seven patients an axonal degeneration was seen, compatible with PCP. Conclusion : We found electromyografical signs of a polyneuropathy in critically ill patients at risk for developing PCP within 8.4 days by using an early bedside EMG. With this technique polyneuropathy can be detected early in patients who are clinically difficult to examine. We suggest that PCP is an early sign of M.O.F. and that in at risk patients PCP must be considered, even without any clinical signs. Level I It Level 11 n Level III n Group 1 Group 2 Group 3 73.0% 528 21.5% 156 5.5% 41 56.3% 55.1% 1585 24.0% 689 20.9% 601 948 31.1% 524 12.5% 211 Group 4 15.1% 231 38.2% 583 46.7% 712 Total 48.3% 3292 28.7% 1952 23.0% 1565 In ICUs of group I most patients were discharged at level I (73 %) and only 5.5 , % on level III. In group 4 the majority of patients was discharged at level III (46.7%) and 15.1% at level I. Larger hospitals discharge patients to the ward on a higher level of care. The study shows that more than 50% of patients are dis the ICU on a level of care (levels II and III) which can not match-chargedfom the level of care on the ward. Conversely, it suggests that some activities on the ICU may be continued unnecessarily until discharge, increasing the level of care and the use of resources. Department of Surgery °, Neurology + and Intensive Care Twenteborg Hospital PO-Box 7600, 7600 SZ Almelo, They Netherlands. *Intensive Care Division, Dept. of Surgery, University Hospital, P.O. Box 30.001, 9700 RB Groningen, The Netherlands P477 P478 INHIBITION OF ACID SECRETION IN PATIENTS WITH MULTIPLE ORGAN FAILURE BY OMEPRAZOLE N. Spannbrucker, P. Braun, R. Kleinschmidt, H. Schulte-Witte, ANTITHRGMBIN III IN CRITICAL PATIENTS R.Lorenzo Torrent, M.S6nchez Palactos, J.Diaz Cremades, L.Fajardo FeO, P.Caballero Padr6n, D.Guerrero Arrate, D.Gonzälez Romero. C.Scheuerlen Low levels of Antithrombin III (AT 111) among critical patients, mainly septic and suffering from multiple trauma, are frequently reported, and this has been suggested as an indication of a poor prognosis The efficacy of a replacement treatment with AT III concentrates has not been conclusively established, however, in spite of several clinical trials. With the aim of evaluating its effect upon other hemostatic parameters, clinical evolution and mortality, we have carried out a prospective randomized trial, in septic and multiple trauma suffering patients with low levels of AT III admitted to an Intensive Care Unit. Levels of AT III below 70% were used as criteria to choose 36 patients, 20 of whom received treatment with AT III and 16 did not. The clinical state was evaluated by APACHE II system (16.00+-4.06 treated group, 15.93+-5.49 .untreated group) None of the patients chosen had manifest disseminated intravascular coagulation (DIC) although as well as the Low levels of AT 111 (52.3%+ -11.7 treated group, 48.3+-12.2 untreated group), they showed a decrease in protein C (55.9+-22 treated group, 52.2+-31.3 untreated group) and moderate thradweytopenia (146.9x10 3/ml+ -56.8 treated group, 143.3x105 /m1+ -79.5 untreated group). The administration of AT III did not contribute to modify the alterations in the haemostasis, nor the clinical evolution, nor the mortality rate (35.0% treated group, 31.2% untreated group), which were similar in both groups. Although the number of patients included in this study is too small to establish any definite conclusions, the results which were obtained suggest that the administration of AT III on critical patients with acquired low levels, but without manifest DIC may not be justified. The effect of omeprazole on gastric acid secretion was studied in 14 critically ill patients with multiple organ failure. After an initial bolus of 80 mg omeprazole was administered intravenously at two different dosages (20 mg or 40 mg omeprazole twice daily). The gastric acid production was monitored continuously by intragastric pH measurementover a 24 h period on the first and third day after start of treatment. Administration of omeprazole 20 mg twice daily after an initial bolus caused a rapid and profound suppression of gastric acid, secretion demonstrated by an immediate rise of intragastric pH to L6. However,., in 3 of 5 patients studied several episodes were registered with a marked pH fall to <3 during the observation periode. Increasing the dose of omeprazole to 40 mg twice daily resulted in a continuous inhibition of gastric acid production during the entire investigastion period. In all of the 9 patients receiving high dose regimen the intragastric pH could be maintained at values >6 whithout any decline during the observation time. We suggest high dose omeprazol treatment to be more effective in ICU patients with multiple organ failure because of sustained inhibition of gastric acid production. Medizinische Universitätsklinik Bonn - Allgemeine Innere Medizin Sigmund=Freud -Str. 25, 5300 Bonn 1, FRG Intensive Medicine Unit . Hospital Insular. PI.Dr Pasteur s/n. Palmas de Gran Canaria. 35016 Las S238 P479 P480 CLINICAL DATA, BACTERIOLOGICAL PROFII,ES AND OUTCOME OF SEPTIC SHOCK IN A MEDICAL INTENSIVE CARE UNIT. A ten FXWAL I«CIIIß IN IDJ PATIF1dIS füm Ill) wnmir F. Schneider, Ph. Lutun, I. Runge, A. Launoy, M. Hasselmann, J.D. Tempel. A.R.Moral.,E.TUmbay,B.ULusoy,N.A1<soy,A.t evik,R:trri 3O.D^r year survey. In an attempt to evaluate the actual incidence, the clinical characteristics, the infectious agents inducing septic shock (SS) and the outcome of the patients hospitalized during the last decade, we have studied the data concerning patients admitted for sepsis syndrome with hypotension (Bone R.C., Crit. Care Med. 1989.; 17:389) from January 1982 to December 199L Patients and methods : 466 patients (227 women, '239 men), mean age 64.3 ± 16.4 years, mean SAPS 17.7 ± 6.2, out of 11 582 admitted during the same period fulfilled Bone's criteria. They all required hemodynamic support and mechanical ventilation ; 26.6 % of them underwent haemodialysis. Only 7.8 % out of them had a surgical cause to sepsis. Steroids were given to 182 patients for their underlying illness ; 146 out of them presented with oncohaematologic diseases. Nosocomial infection was observed in 46,7 % of the patients. Patients were classified into 3 categories based on Mc Cabe's criteria (Mc Cabe W.R. et al, Arch. Inter. Med. 1962 ; 110:845). R esults : 1. Bacteriological data : hemocultures were found positive at onset of sepsis syndrome in only 71 % of the patients. One single bacterial strain was involved in 78,1 % of the blood samples (Gram negative bacilli 46,5 %, I Gram positive cocci 42,3 %, fungi 5,8 %, others 5,4 %). E.coli and S.pneumoniae were the commonest strains met in home infection, whereas P.aeruginosa and S.aureus were mainly responsible for nosocomial infections. 2. Survival rates : over-all mortality was 76,5 %, nosocomial infection providing 89,7 % death, home infection 68,8 %. In patients with cancer mortality was 90 %, in those given steroids for theirs underlying diseases 77,8 %. Annual mortality rates did not decrease significantly from 1982 to 1991. 3. Role of the underlying host disease : 23 out of 57 patients developped a mortal sepsis syndrome in the absence of any medical antecedent. Mortality rate increased from 68.2 % in patients with non fatal underlying diseases, to 79.75 % in ultimately fatal diseases and to 91.5 % when a rapidly fatal illness was present. C onclusion : these data obtained before monoclonal antibodies were routinely. included in the medical full treatment of severe sepsis demonstrate that mortality rate have not improved in our ICU during the past decade. Further breakthrough in this field will require a better prevention of sepsis in patient$ with ultimately and rapidly fatal underlying diseases. The effect of fluconaaole prophylaxis on the incidmep of ftngsl(yeast) infections in multidisciplinary 7(u pas wetze investigated.A total of 252 patients Were 11'ooiog ca l y screened in the first week of their hospitalisation and followingly once eveay aek.The specimens studied s re blood,catheters (blood std tsine),endottaciiea. tubes,oral cavity, mres,slan and rectal awabs.The fungus isolated Mss Candida.Of the patients 91 received flsxxmaoole 100 day intravenously or enteral.ly for prophylaxis and 161 served as the mntrol group. There were positive cultures in 111 of the 161 patients (69%) in control group and 49 of 91 patients (54%) in prophylaxis group. The results in concerning to time intervals are presented below. Weeks N.o.P. 1 2 3 4 5 252 127 8) 46 32 22 C(+) 112(44%) 75(583%) 57(71%) 32(7c) 25(7x%) 17(77%) ir N.o.P. C(+) N.o.P, 'MC(+) 161 75 44 24 51(61%) 2D 31(71%) 12 19(792) 18(9E) 12(107%) 91 52 34(37%) 24(46$) 35 15(42%) 22 13(59%) 12 7(58%) 10 5(5JP) 78(49%) i:Genexal U:Control group M:Prophylaxis grow N.o.P.:Nuomber of patients C(+):Culture(+) In cceclusion,it wes observed that 100 ng/day fl le prophylaxis is effective in ICU patients iyned reducing the incidence of yeast _^ ( infections significantl y (l,.C5). Deperttsart of Anesthesiology and Microbiology Aegean Unive city Ibspital,IznirfIURlCIYE Service de Reanimation MAdicale,.. liopital de Hautepierre, 67098 STRASBOURG Cedex, France. P481 P482 BYPOCALOIIC PERIPINRAL PARENTRRAL NUTRITION(BPPN) IN SUIGICAL PATIENTS.. usenet Jinenes J,Ortit Leyba C,Garnacho Nontero J,Barros Perez N,Raaila Alarcon F, Flores Corlero J,Gonzalez Nenendes E. A high rate of patients submitted to surgical procedures show different degrees of salnutrition after the obligated postsurgical fasting period.The au s of this research is to set the efficacy of RPPI testing different paraseters of nutritional assessment. NATNRIAL AID 1NT1088: 35 patients were studied after being submitted to a surgical procedure (colecistectoay or a gastrectoay is a majority cases). All of then bade least 2 of these 3 paraoeters:Serua albuain(A1b) < 3gr/dl,Prealbusin(Pre( <llsg/dl,and body seight(BW),<955 ideal BV.They were divided in three groups: Group I(control(:15 patients,they were supplied with dextrose 51(300 kcal+isotonic saline solution),Group II:10 patients with 1 gr protein/kg/d and 64o kcal as dextrose;Group III:10 patients, with the same asount of protein through the caloric source was glycerol(560 kcal).The following parameters were tested before the surgical intervention and 5 days later:triceps skin fold(TSF)(ss),Alb(g/dl),Pre(sg/dl),Retinol binding protein(RBP( •i/'dl,IItrogen balance(NB),g/24h,Triglycerides(TG)ag/di and urinary 3 aetyl histidine(3-NH)(uaol/1).Vilcoxon test performed as stathistical method, RESULTS: Group I Group II Group III 0d 5d p Od p 5d p 0d 5d TSF 13+4 15+5 .04 12,5+6 15+6 .04 13+3 13+4 NS Alb 3+3 3.3+4 NS 2,8+4 3,5+3 .02 3+0.7 3.6+3 NS Pre 10+4 11+4 NS 10+2 15+5 .02 14+8 17+7 .05 RIP 3.5+1 3.9+1 NS 2.9+1 4.3+1 .03 3.6+1 5.5+1 .02 NB -14+3 -9+2 NS -12+2 -2+2 ,.02 -12+3 -3+2 .02 TG 103+40 96+35 HS 99+43 114+53 HS 110+60 115+55 NS 318 320+160 200+155 .04 334+188 160+116 .001 266+85 150+69 .02 CONCLUSIOIS:Visceral proteins eher a trend to the recovery in group II and III.Nuscle protein catabolism decreases in all the groups in a very similar way. PREVENTION OF PULMONARY ASPIRATION BY MEANS OF ESOPHAGEAL BLOCKAGE WITH FOLEY TUBE C.DE LA CRUZ,A.CRIADO,L.DIAZ,A.SEIZ,P.L.VIDAUR,J.R.FRAILE - - - Intensive Care Unit .Hospital Virgen del Rocio.Sevilla, Spain. Pulmonary aspiration of gastric matter is a serious complication that occur during anaesthetic induction in pa tients submitted to emergency surgery with "full stomach". The severity of it depends on the volume and pH of the aspirated fluid. The mortality rate is 20-60%. Numerous techniques have been described dealing to avoid this complication. Our study evaluates the effective ness of the esophageal blockage (B-B) with Foley tube (F-T) in preventing the pulmonary aspiration. 24 patients subjected to emergency surgery were evalu ated. We introduced the F-T through the nose till it reached the medial esophagus.The inflation of the balloon was made till the tube was proven to be fixed or till the patients refered retroesternal pain. After the anaesthetic in duction and tracheal intubation we proceeded to verify radiologically the effficiency of the E-B by introducing 20 ml of iodine contrast at the posterior pharynx by direct laryngoacopy and by the torax radiography centered at the aediastinum while the patients bed was elevated to 45 2 , The median age was 60.3 ±11. The efficiency of the E-B was complete in 16 patients (66.6%), almost complete in 6 (25%) and ineffective in 2 (8.3%). In 6 radiography revealed a discrete protusion of the esophageal wall caused by inflated balloon. In 20 patients we used F-T ns14 with the inflating volumes of 19 ±2.6 ml and on 4 the F-T n 2 18 with the inflating volumes of 13 ±3 ml. We didn't obtain correlations between the efficiency of the blockage with the tube's caliber and the inflating volume. Tolerance was excellent. We consider that eventhough the technique is not all that efficient it is possible yet to obtain high percentage of complete E-B, which combined with its simplicity and excellent tolerance, accounts for its unique advantages in the field of emergency surgrey. DEPARTMENTT OF ANESTHESIOLOGY. UNIVERSITARY HOSPITAL PRINCIPE DE ASTURIAS. ALCALA DE HENARES. 28805 MADRID. .SPAIN S239 P483 P484 STUDY OF MINIMUM INHIBITORY CONCENTRATIONS (MIC) ON ADDITION OF TAZOBACTAM TO PIPERACILLIN IN ENTEROBACTERJACEAE DEPRESSION OF NEUTROPHIL CHEMILUMINESCENCE DUE TO BARBITURATE OR SOLUENT 4 M. WEISST, A. BIRKHAHN 1 , N. MIROWI, M. SCHNEIDER2, P.WERNET2 E. Crespo, L. Arcalfs (1), J.L. Hemindez-Cardona, M. A. Sempere (2), E. Martin (3), A. Gutierrez, M. Diez (4), F. de LaTorre, J. Picazo (5), D. Damaso (6), C.F. Mazarrisa, (7), A.R. Noriega (8), R. Cistema (9), M. de Ia Rosa (10). Backgrounds and methods: Oxygen free radical production Is the main A total of 1027 recent clinical isolates, resistant to piperacillin (MIC> 64 mcg/ml) were studied in a multicentre study. Isolates sensitive to piperacillin were also included, although they never exceeded 20% of the total studied. The antimicrobials included were piperacillin, tazobactam, and piperacillin/tazobactam at a 8:1 ratio. Mueller-Hinton agar dilutionmethod,10` u.fc. inocculum and E. coli ATCC 25922 controlstrain,wereused. Beta-Iactamasedefection wascarriedoutusingnitrocefine. The aim of this study was to evaluate the sensitivity obtained from all the isolates previously resistant to piperacillin after the addition of tazobactam by means of variations in the MICs. The addition of tazobactam decreased the MICof Piperacillin in all the isolates studied. In Klebsiella oxytoca, 15 out of 18 isolates (83.3%) were resistant to piperacillin and 6 (33.3%) to piperacillin/ tazobactam. In Proteus mirabilis, 76 out of 96 isolates (79.2%) were resistant to piperacillin and 5 to piperacillin/tazobactarn (5.2%). In Salmonella enteritidis, 22 out of 24 isolates (91.6%) were resistant to piperacillin and only one to piperacillin/tazobactam. In E. coil, 327 out to 370 isolates (88.4%) were resistant to piperacillin and 18 to piperacillin/tazobactam (4.9%). In Pseudomonas aeruginosa, 34 out of 35 isolates (97.1%) were resistant to piperacillin and 18 (51.4%) to piperacillin/tazobactam. According to our results, there was a significant decrease in the MICs of enterobacteriaceae, both sensitive and resistant strains, due to the beta-lactamase inhibiting effect of tazobactam. mechanism of bacterial killing by neutrophils Oxygen free radical production can be detected by chemilummescence. Up to now It has not been systematically investigated whether effects of barbiturates on neutrophil chemiluminescence by commercially available preparations are due to physicochemical properties, drug-free soluents or barbiturates per se. Therefore physicochemical properties and the effect of commercially available preparations and soluents of 4 barbiturates, i e methohexitone, pentobarbitone, phenobarbitone and thiopentone on FMLP and zymosan induced neutrophil chemiluminescence were tested in - 10) In each case three concentrations within as well as one and two log concentrations above therapeutic plasma level range of the respective barbiturate were tested Results; Commercial preparations and soluents of methohexitone and pentobarbitone showed no significant effect on FMLP or zymosan Induced neutrophil chemiluminescence. On the other hand commercial preparations of phenobarbitone and thiopentone dose-dependently and significantly decreased FMLP and zymosan Induced neutrophil chemiluminescence. In contrast to the soluent of thiopentone (no effect) the soluent of phenobarbitone depressed neutrophil chemiluminescence in the highest concentration used due to physicochemical properties (osmolallty of 531 mosmol/U. Conclusions: Depression of neutrophil chemiluminescence by commercially available barbiturate preparations was caused by the barbiturate per se in the case of thiopentone, but by the soluent in the case of phenobarbitone Depts. of Microbiology, Hospital Vail d'Hebrdn (1), Hospital Virgen de la Arrixaca (2), Hospital de Valrne (3), Ciudad Sanitaria La Paz (4), Hospital San Carlos (5), Clfnica Puerta de Hierro (6), Hospital Marquis de Valdecilla (7), Hospital 12 de Octubre (8), Hospital de Basurto (9), Hospital Virgen dc las Nieves (10), SPAIN. Departments of IAnesthesiology, 2Blood Coagulation and Transfusion Medicine. Heinrich-Heine- Universität, Moorenstr. 5. 4000 Düsseldorf 1, Germany P485 P486 FIBROPROLIFERATIVE PHASE OF ARDS. CLINICAL FINDINGS AND EFFECTS OF CORTICOSTEROIDS. Gianfranco'Umberto Meduri PROGNOSTIC FACTORS INFLUENCE THE PRESENCE OF ASCITIS IN THE POSTOPERATIVE OF LIVER RESECTION FOR HEPATOCELLULAR CARCINOMA. M.T. Anglada,P.Taurä,J. Fus ter,J. Bru ix,L.Alvarez,E.Izqui erdo,J. Beltrin. Surgical treatment of hepatocellular carcinoma includes liver resection in patients in Child-Pugh A. In order to perform a safe liver resection a vascular occlusion of the hepatic hilium should be carried out. The postoperative morbidity is featured by hepatic insufficiency and ascitis. AIM: To identify the prognostic factors that may induce the presence of ascitis in the postoperative period. PATIENTS and METHODS: We studied the relationship between haemodynamic changes, hormonal alterations and renal function in pre,per and postoperative period during liver resection, in 15 Hepatocellular carcinoma patients undergoing surgical treatment. Blood measurements of Aldosterone, Renina, Atrial Natriuretic Factor(AFN), Clearance of Creatinine(CrCI),Sodium.Potassium and water,were performed before and after laparotomy as well as during the different occlusive period, 24 and 48 hours after surgery . Intraoperative Measurement of Heart Rate, Cardiac Index, Medium Arterial Pressure, Medium Arterial Pulmonary Pressure,Pulmonary Systemic Vascular and Pulmonary Capillar Wedge Pressure, Resistance Index and Portal Pressure were performedas well as a postoperative daily evolution of ascitis. RESULTS.Ten patients developed ascitis while the other five could not be cases demonstrated. There were no significant differences on the haemodinamyc parameters between the two groups.Aldosterone (p<0.01) and AFN (p<0.001) samples in all periods of study were significantly more elevateds patients with ascitis. No significant differences were found in serum Renine levels. However 24 hours after surgery the values in the ascitis group were twice as high as those of the other group. Basal renal function was similar in both groups. However a decrease in of CrCI(p<0.001), water Clearance(p<0.001) and Urine output in all periods of study was found in ascitis group during surgical procedure.CONCLUSIONS:Our study suggest that hormonal factor are directly involved in renal impairement as well as in the incidence of ascitis in the postoperative liver resection. Departments of A nesthesiology.Surgery,lnternal Medicine and Laboratory.University Hospital Clinic.Villarroel 170. 08036 Barcelona.Spain Most patients with adult respiratory distress syndrome (ARDS) survive the initial insult which caused respiratory failure only to succumb later to sepsis caused by nosocomialpneumonia or to pulmonary fibrosis. Clinical criteria and analysis of the tracheal aspirate are notoriously inadequate for establishing a diagnosis of ventilator-associated pneumonia. We implemented a comprehensive diagnostic protocol to determine the cause of sepsis in ARDS patients ventilated for more than 3 days and who had no bronchoscopic evidence of pneumonia. Nine patients with late ARDS who had fever (89%), leukocytosis (89%), a new localized infiltrate (78%), purulent tracheal secretions (89%), low systemic vascular resistance (50%), and marked uptake of gallium in the lungs (100%) had no source of infection identified. Openlung biopsies from seven patients showed the fibroproliferative •phase of diffuse alveolar damage and confirmed absence of pneumonia. Treatment with prolonged high doses of corticosteroids was associated with marked and rapid improvement in lung injury score (p 0,003 at 5 days). Our findings indicate that the fibroproliferative process occurring in the lungs of patients with late ARDS (1) gives rise to clinical manifestations identical to those of pneumonia, and (2) is potentially responsive to steroid treatment. Department of Medicine, Division of Pulmonary and Critical Care University of Tennessee Health Science Center, Memphis, Tennessee .