Miscellaneous III

P451PENTOXIFYLLINE INCREASES OXYGEN EXTRACTION DURINGTAMPONADE IN AN ENDOTOXIN SHOCK MODELH. Zhano. H. Sen. M. Benlabed. N. Nbuyen. JL. Vincent

Pentoxifylline (PTX), a xanthine derivative used in the treatment of circulatoryinsufficiency, has been found to have protective effects in different models ofsepsis. We hypothesized that this drug might either increase oxygen delivery(DO2) and/or increase tissue oxygen -extraction to meet oxygen demand insepsis. We studied the effects of PTX on the oxygen uptake/oxygen delivery(VO2/DO2) relationship and tissue oxygen extraction when blood flow wasreduced by Inducing cardiac tamponade in 14 anesthetized, ventilated andparalyzed dogs. Via a left thoractomy, a catheter waa inserted into the per-icardial 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 7dogs, PTX was administered as a 20 mg/kg i.v. bolus, followed by a conti-nuous infusion at 20 mglkg.h. V02 was derived from the expired gases. 002was calculated by the product of the modüution cardiac index and arterial oxy-gen content. Oxygen extraction ratio (02ER) was defined as the ratio ofV02/002. Dual-line regression was used to determine the critical 002(DO2crit) in each animal. ANOVA was used for statistical analysis. PTX resul-ted in significant increases in V02 and DO2. Critical V02 was slightly higher inthe PTX-treated than in the control group, but it did not reach statistical signifi-cance (6.3 ± 2.4 vs 5.4 ± 1.0 ml/kg.min, NS). D02crit which was 11.3± 4.9ml/kg.min in the control group, was decreased to 9.6 ± 3.6 mlkg.min in thePTX-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). TheV02/D02 dependency slope was steeper in the PTX-treated than in thecontrol group (0.77 ± 0.31 vs 0.46 ± 0.18, p< 0.05). At D02c rit, PTX-treatedgroup had lower venoarterial PCO2 difference (12.9 t. 4.3 vs 18.4 ± 7.4mmHg, p < 0.05) and arteriovenous pH gradient (0.08 ± 0.02 vs 0.11 ± 0.06U, p < 0.05) than in the control group. Thus, the addition of PTX and fluidtherapy can increase 002 and global oxygen extraction capabilities when car-diac output is progressively reduced in the endotoxemic dog. The exact me-chanisms remain to be defined.

Department of Intensive Care, Erasme University Hospital, Free University ofBrussels, Route de Lennik. 808, B-1070 Brussels, Belgium

Miscellaneous IIIP453TRANSFUSION OF FRESH FROZEN PLASMA IN HEART SURGERYPATIENTSSR Leal,JM Flores,V Rivera,P Camacho,J Garnacho,F Murillc

Most fresh frozen plasma (FFP) recipients are patientsundergoing heart surgery.Although the reason most centerstransfuse FFP is to replace clotting factors,it has notbeen demostrated that its routine use can reducepostoperative blood losses.The present study was designedto evaluate the effect FFP transfusions has onpostoperative bleeding in heart surgery patients.A hundred and forty-nine patients undergoingcardiopulmonary bypass (CPB) during 1991 were studied.Inthe immediate postoperative period,78 patients (Group A)received four units of FFP,however,the remaining 71 (GroupB) were not transfused.Average age was 53+12 years (GroupA) and 56472 years (Group B) and average weight was 71±12kg (Group A) and 71+11 kg (Group B).The following factorswere evaluated:Surgical procedure (CABG and valvereplacement) ,history of arterialhypertention,diabetes,previous heart surgery,NYHAfunctional classification,prior ingestion ofaspirin,warfarin or heparin,graft type employed, numbers ofCABGs performed,surgical complications,CPB time(mins),aortic cross clamp time (mins) and postoperativeplatelet count. First 24-hours and total postoperative bloodlosses were also recorded.Both groups were statistically homogeneous as far as thebefore mentioned factors were concerned.Total blood losseswere 1022+698 cc and 8791699 cc (NS) and first 24-hourslosses were 7451557 cc and 597+460cc (NS),for groups A andB, respectively.Pending confirmation,our results indicate that the routineuse of FFP for patients undergoing heart surgery does notreduce postoperative bleeding.

Unidad de Cuidados Intensivos.Hospital Universitario Virgendel Rocio.Avda Manuel Siurot s/n.41013.Sevilla.Espana.

S231

P452FIBRINMONOMERCONCENTRATION IN SEPTIC ANDTRAUMATIC SHOCK

Chr.Agternkamp 0.Kunitz, T.Hillermann, P.Glöckner,F.G.Muller, G.kalff

During the last years a lot of experimental andclinical studies were made to show the important roleof fibrinmonomers (fm) in identifying DIC. According toour animal study - after creating a septic shock infemal pigs by injection of a defined quantity ofendotoxin - the fm-concentration raises up to more than300 % - we started a . cinical study measuring the fm-concentration in different groups of patients.Fm-concentrations were measured in the following groupsb using - the spectrophotometric method (CoA Set Kabi-vitrum)group A: controlgroup, healthy patients

n=30group B: non septic / non traumatic patients

n= 6group C: patients with traumatic shock

n= 6group 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 allpatients for fm-analyse. Fm-concentration was measuredin the first day every 4 hours, until the end of septicsymptoms every 8 hours. In the controlgroup the fm-concentration was analysed once.In group A and B the fm-concentration was always below20 nmol/l.In group C and 0 (septic and traumatic shock2 we found

increasesncreases of the fm-concentration (more than100 nmol./1) because of a changed coagulation system. Anearly increase before appearing oT clinical septicsymptoms or a correlation to the clinical picture wasnot found. In difference to the animal study with'suboptimal treatment' in our clinical study was shownthat the fm-concentration interfeares extremely withthe intensive therapy (volumetherapy, blood, heparinand AT III substitution) so that the measured fm-concentration does not relate to the coagulationstatus.

Department of Anesthesiology Univ.Dir. Prof. G.KalffPauwelstr.30 D-5100 Aachen

P454MA. ULIBARRENA, N. SAINZ PARDO, JJ. BALLESTERO, V. BOADO

JC. VERGARA, JR. IRURETAGOYENA.

STERNAL WOUND COMPLICATIONS: A REVIEW OF 647 CONSECUTIVEOPERATIVE PROCEDURES.

Sternal dehiscence and mediastinal infection are the majorsternal complications following open-heart operations. Therate in some series is 0.5 to 5.9%, and several factorshave been suggested as predisposing to this complication.

The present retrospective clinical study designed to assessthe incidence of major sternal wound complications and its

relationship with the factors that appear to increase therisk of these complications.

Sis hundred forty seven- operative procedures involving me-dian sternotomy from 1989 to 1991 compose the study group,

67 patients experienced sternal dehiscence (10.4%) and 13mediastinal infection. Risk factors associated with thedevelopment of a sternal wound complication included age,

diabetes, chronic pulmonary disease, harvesting of the in-ternal mammary artery, prolonged aortic cross-clamp time,early reesploration for bleding and prolonged respiratory

assistance. All cases of mediastinal infection were asso-ciated with. sternal dehiscence.

CRUCES HOSPITAL. INTENSIVE CARE UNIT.

Plaza de Cruces sn, Cruces,Baracaldo, Vizcaya. SPAINCP 48903 Fax 4992945

S232

P455MUSCLE TISSUE OXYGEN PRESSURE DURING CARDIOPULMONARYBYPASS. PRELIMINARY RESULTS.A.Kindlund; C.Ponte; J.M.Valle; F.Cienfuegos; F.Payo.

Patients subjected to cardiac surgery under cardiopulmo-nary bypass and hypothermia show well-known clinicalrepercussions, derived from these procedures. Tissueperfusion is one determinant implicated in theseproblems.We have studied 9 patients who have undergone coronaryrevascularization surgery. We determine the POof the muscle where the safena vein is taken t for^use in the bypass operation using a 8 channel Clarktype multisensor (MOO) together with an acquisitionunit a special software developed at the ClinicalResearch Center (University Hospital of Linkoping.Sweden. Prof. D. Lewis). During the sampling periodof 5-min the electrode is automatically sampled every15 sec. with a total of 160 values after which thepressure distribution is presented in the form ofhistograms according to the literature.The initial muscle P 02 -pressures with the patientanaesthetized but betf'ore the bypass, show normalvalues around 712.5 kPa with a rapid and importantdecrease to about 1.5±0.2 kPa during hypothermiaand cardipulmonary bypass. After the bypass procedurethe pressures raises rapidly' to stabilize at theirpreviuus values.To conclude, there is a severe deterioration of theperipheral muscle oxygenation during the extracorporealsurgery which origin (hypothermia, decrease of oxygendelivery ...) need further evaluation.

Department of Intensive Care. Hospital Central deAsturias. c/Julian Claveria s/n.Oviedo 33080. SPAIN.

P456IS ASPIRIN A RISK FACTOR FOR POSTOPERATIVE BLEEDING OFCORONARY ARTERY BYPASS GRAFT SURGERY?JM Flores,SR Leal,V Rivera,P Camacho,F Murillo

The anti-platelet-aggregation effect of aspirin maycontribute to greater blood losses in the earlypostoperative period of patients undergoing Coronary ArteryBypass Graft (CABG) surgery.The aim of the present studywas to analyze the relationship between aspirin andbleeding.Sixty-four CABG procedures performed in 1991 werereviewed. Forty-seven patients (Group A) ingested 125 mg/dwhile the remaining 17 did not take aspirin (Group B).Noneof the patients were administered other medication whichcould affect the platelet plug-forming •echanism.Most ofthe patients group A received -aspirin until the day priorto surgery and all of them had taken it during the previousweek.The following factors were, analyzed: Ili story ofarterial hypertension, diabetes mellitus, previous heartsurgery, NYHA functional. classification, number of coronarygrafts, type of graft employed and intraoperativecomplications.The average age of the patients was 58+7 years (Group A)and 59+9 years (Group B).Both groups were statisticallyhomogeneous as far as their medical backgrounds wereconcerned.Blood losses during the first 24-hours in the ICUwere 875+575 cc and 964±764 cc (NS) and total ICU losseswere 1169+752 cc and 1186±845 cc (NS) for Group A and GroupB, respectively.Pending' confirmation, our results suggest that preoperativeingestion of aspirin does not seem to effect the amount ofearly postoperative bleeding after the performance of CABGsurgery.

Unidad dc Cuidados Intensi.vos.Hospital Universitario Virgendel Rocio.Avda Manuel Siurot s/n. 41013. Sevilla.Espaiia.

P457S[UDING THE CORONARY BLOOD FLOW WITH ASIMULATION PROGRAM.D. S;inchcz'; F. Palacios'`; M. Polo'; A. Toval'.

BACKGROUND: This paper present a concrete application ofmicrocomputer based simulation in health sciences education andresearch. It shows a total regional coronary blood flow systemdynamics model representing graphics and numerical behavior andrelation between variables, with in addition allows int cruel ion withuser for experimentation.

METIIODS: The model is made using professional tools such asDYNAMO and DYNEX. A basic electrical model is used to model

the process.

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 certainproblems that up to now have been ignored. The model alsoillustrates a strategy tor introducing this kind of models in the

classroom, as well as the suitability'of their implementation, ineducational enviromcnts.

[.C1.LUniv. Murcia; 2UCLI lospihil L`Ichc. E.U.P.A.Univ. Alicante.

P458

THERAPEUTIC EFFORT AT THE ADMISSION IN WOMENWITH ACUTE MYOCARDIAL INFARCTIONJ. Latour, J. Bonastre, J.S. Giner, V. Lopez-Camps, M. Rodriguez-Serra, L. Rosado.

BACKGROUND: Recent studies suggest that women with coronaryartery disease undergo fewer major diagnostic and therapeuticprocedures than men. The aim of the present study is to test thehypothesis that sex is an independent predictor of therapeutic effortin patients admitted with acute myocardial infarction.METHODS: Retrospective cohort study based on 429 males and124 females admitted by acute myocardial infarction. The potentialconfounding effects were controlled using multiple linear regressionanalysis.RESULTS: The women were older than men (p<0.00001), morelikely to be admitted with cardiac failure (p=0.00008), moreseverely diseased as measured by SAPS index, and more likely todie in the ICU (p=0.00002). As compared with men, womenreceived less relative therapeutic effort measured by the TISS score.The variables that independently predicted therapeutic effort onadmission 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 myocardialinfarction receive less relative therapeutic effort than men. Thesedifferences seems attributable to the higher age of women, but noto social inequalities by sex.

UCI, Hospital General d'Elx. Huertos y Molinos s/n. 03203 ELCHE(Spain)

P459THE APPEARANCE OF THE LEFT VENTRICULAR THROMBUSIN AN ACUTE MYOCARDIAL INFARCTION

L.Dobrkovid,Lj.Georgievska,V.Spiroska,V.Borozanov,B.Mileti6 and L.Srbinovski

In order to study the incidence of left ventri-cular thrombus(LVT) during acute myocardialinfarction(AIM) we performed two dimensionalechocardiography(2DE) in 63 consecutive ptswithin 72 hours after onset of AIM.Antikoagu-lants were used in 58 pts and in the other onesintravenous streptokinase. Evidence of LV masssuggesting thrombus by 2DE at 3rd day of AIMwas found in 27/63 pts-(43%),neither one onstreptokinase protocol.LVT involved an aki/dys-kinetic apex in all pts.AVerage LV internaldyastolic dimension in pts with LVT was '59±3,2mm.ECG-AIM location:27/29 anterior(9o%)and2' inferior(lo%).

CONCLUSION :l.LVT is an early complication. ofanterior AIM with °vidence of aki/dyskineticLV wall and wider LV internal dyastolic dimen-sion;2.Appearance of the left ventricualrthrombus in AIM is independent of antikoagulanttherapy;3.2DE is an good screening method inidentification of left ventricular thrombus.

Clinic of cardiology,University hospital,Vodnjanska 17,91000 Skopje,Makedonia

S233

P460

FIBRINOLYTIC SYSTEM (FS) VARIATIONS INDUCED BY THROMBOLYTIC THERAPY ('Pr)IN ACUTE MYOCARDIAL INFARCTION (AMI).J. CANOVAS, D. BARJA, A. PEREZ, P. MARCO, J. CATURLA, A. ESPASA - , J.LUCAS.

OBJECTIVE. To study activator and inhibitor proteins involved in PS and itsvariations 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), Prothrombinfragments (F.2) by ELISA method. Plasminogen (PI14), e, Antiplasmin (a -AP)by aminolytic method, a= Macroglobulin (az M), e,Antitripsin(e 1 -̂APj byinmunologyc method. Ad admission, 24, 48 hours and S t day after TT.Statistical comparison of the results was performed using paired and non-paired - Student's t test, and ANOVA test.RESULTS. Are shown in the following table.

ADMISION 24 HOURS 48 HOURS 5th DAY

t-PA(ng/m)) f13s1,4 f29t4,6** f 19,7±2,4 11,5±2**

PAI-1(ng/ml) 38±4,8 35±4,5 31±3,6 40t4

PLM(%) 87±3 ** 40±5 *0 73±4,5** 113±5**

82-AP(%) 184±7,5 f 56±5,7 ** 184±4,8 101±4**

a2-M 120±8 ** ** 98±9 101!9,8 113±13

al-AT 1197±30*. f213± 11** 1 277±18 314±32**

F1+2(U/ml) 4±1,3 3,6±1,1 9,3±4 6,5±3.7

f P<0.05 ** p<0.01

CONCLUSIONS. 1: Ad admission hypercoagulable state in A14I was demostratedby increased levels of F,,i . A hypofibrinolytic state was stablished by highlevels of PAI-l. 2: Both byological situation remained unchange during thefollow-up . .3: 24 h. after TT decreased levels of PLM and 04-AP wereobserved. We assumed it as a direct effect of TT. 4: t-PA levels increased24 h. after TT, related with endogenous synthesis. PAI-1 levels remainedunchange at this time.

Intensive Care Unit, Laboratory— and Hematology * Services, GeneralUniversity Hospital, Maestro Alonso 109, 03010 Alicante, Spain.

P461

AMRINONE IN THE TREATMENT OF SEVERE HEART FAILURE

G. yoga, I. Duran, B. Krivec, F. krabl-Mocnik, R. Skale

Amrinone is a bipyridine derivative and a member ofphosphodiesterase inhibitors with inotropic and lusi-tropic effects and vasodilatory properties. Its actionis not related to digitalis glycosides and catechola-mines.We used amrinone in 25 patients with signs and symptomsof severe chronic heart failure (19 NYHA IV, 5 NYHAIII) refractory to conventional treatment with vasodi-lators, diuretics and digoxin. Amrinone was given intra-venously as boLus (0.75 mg/kg) and then continued indosis 5 - 1,O'mcg/kg/min. Treatment was prolonged untilsatisfactory clinical and hemodynamic improvement wasreached and lasted on average 22 hours (maximal 72 ho-urs),. We found significanY2 increase of cardiac indesfrom 1.9 +/- 0.36 1/min/m to 2.74 +/- 0,73 1/min/m(p<0.001) and significant reduction of PAOP from26 +/- 7 mm Hg to 16 +/- 4 mm Hg (p<0.001). The bene-ficial hemodynamic effects persisted 24 hours after thetreatment with amrinone was discontinued.We observed transient side effects in 4 patients: shortterm reversible atrial fibrillation in 2, frequent VPBin 1 and headache in 1 patients. Side effects were mildand did not require discontinuation of therapy.We conclude that amrinone can be safely used as a shortterm inotropic and vasodilatory agent in patient withsevere heart failure when conventional treatment fails.

Department of Intensive Internal Medicine, General Hos-pital, Kersnikova 1, 63000 Celje, SLOVENIA

P462

AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATION:CONSIDERATIONS ON THE EARLY POSTOPERATIVE COMPLICATIONS.P.Marzollo, P.Sebastiano, G.Benedini, A.Marchini,F.Bianchetti, A.Picchioni, G.Pedersini.

During the early postoperative period after automaticimplantable cardioverter-defibrillator(ICD) implantation,some relevant complications can often occur. The aim ofour study is to discuss the better therapeutic approach toovercome these problems.METHODS19 patients,49-69 years aged,affected by different cardiacdisease,FE average 32%,and recurrent malignant drugrefractory ventricular 'tachyerrhytmias,undervent ICDimplantation in our institution.RESULTS.Significant early post-op complications have been observedin 5 pts, always after epicardial implantation. LV failureoccurred in 2 pts and required adjustement of inotropicdrugs and IABP, in spite of that 1 pt died 36 hrs afteroperation . Aggravation of cardiac arrhythmias has beenobserved,and successfully treated, in 3 pts:in 1 ptiterative ventricular tachycardias have required a changein antiarrhythmic drug regimen and temporary to turn-offof ICD and in 2 pts paroxysmal atrial fibbrillation withfast ventricular response have required addition ofdigitalis and calcium antagonist drugs and a reprogrammingof ICD cutoff rate at higher values to preventinappropriate shocks. No complications were observed afternon-epicardial ICD implantation nor after generetorreplacements.CONCLUSIONWe conclude that early post-op complications followingepicardial ICD implantation are frequent and requiredspecific and timely pharmacological andnon-pharmacological therapeutic interventions.

Rianimazione. cardiochirurgica - Spedali Civili, 25100Brescia. Italy

S234

P463SPECTRAL 7UL ULFN E CK THE VEZI1'RICULAR MYClCA IIM. REIATIVETO TM ACPIVATION WAVEFRQiF IN THE WC LFF-PARKINS I9 WHIMSYNDI^^.J.M. Paylos, E. Löpez de Si, B. Codero, J. M. Martinez,C. Saenz de la Calzada

To evaluate the energy contents of the spectral•:turbulencedue to the activation wavefront over the accessorypathways in the Wolff-ParKinson-White syndrome, westudied 14 patients with manifest preexcitation (groupeI) (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 (fromthe QRS peak backward to the PR interval), in theorthogonals X,_ Y, Z leads were analyzed infrequency-domain.Delta wave was complete include into the window ofanalysis on the group I.Fast Fourier Transform analysis were performed applying4-T Blackman-Harris, Rectangular and Nanningwindow-funtions according to the target of the study.Magnitudes were compared and fixed frequency points usedfor the definition of the energy contents.

(Window) Hz W.P.W. CONTROL PMag.Ratio (Harming) 10 16.919+/- 6.4 29.599+/- 7.9 x0.0001Mag.Ratio (B-H) 10 7.489+/- 3.4 20.829+/- 5.6 <0..0001Mag.Ratio (Rectang.)26 26.414+/-12.2 74.129+/-21.6 <0.0001Mag. Ratio (B-H) 10 7.934+/- 5.3 16.86+/- 6.8 <0.0007

The energy spectra showed a less energy content of thelow frequency components in the group I as a result ofthe abrupt ventricular activation over the accessorypathway.The delimitation of such a turbulence it can be usefulto control the effectiveness of the radiofrequencycatheter-ablation.

P464ENERGY SP I1 A OF THE MYC CAMICM IN PATIENTS WllliAPPARENI4.Y N3I4AL HEARS AM PARCKYSMAL ATRIALFIBRILLAna .JM. Paylos, B. Cordero, E. LDpez de Sa, C. Saenz de laCalzada

To evaluate if the energy spectrum of the atrialmyocardium differentiate patients with sustaineddocumented episodes of Paroxysmal Atrial Fibrillation(AF), we studied 42 subjects, 21 with AF and no structuralheart disease (16 male, 5 female, 58+/-18.7 mean age),and 21 normal subjects (13 male, 8 female, 48.1+/-28.7mean age). A 8OmS segment length of the PR interval wasanalyzed: 60mS backward into the P wave and 20mS in theisoelectric. interval. Fast Fourier Transform (FFT)analysis was performed applying a 4-Term Blackman-Harriswindow function and FFT magnitudes and log.transformations were ccmpäred and the energy distributionbetween 0 to 50Hz analyzed, relating the relativecontribution of frequencies between 20 to 50Hz to thosebetween 0 to 50Hz, in X,Y,Z orthogonal ECG leads.

Lead Hz A.F. Control P valueArea-Rat. Z 425.5+/-549.3 994+/-1141.9 <0.05Mag.Ratio X 10-25 3400.7+/-3305.4 7389.2+/-7732.5 <0.04Mag.Ratio X 25-40 206.9+/-188.9 1025.9+/-1300.5 <0.007Mag.Ratio X 25-40 559.5+/-432.7 1837.7+/-2294.4 <0.02Log.A.-R. X 1.186+/-0.448 1.833+./-0.738 <0.002Log.Mag.-R.X 25-40 2.09 +/-0.539 2.571+/-0.789 <0.03Log.A.-R. X 1.413+/-0.413 1.982+/-0.71 <0.003The spectral analysis of signal-averaged ECG from patientswith paroxysmal atrial fibrillation showed significantless energy content (25-40Hz) on the ECG leads facingthe posterior and postero-lateral atrial myocardium, wherezones of slow conduction and blocks have been described,which ones we "speculate" could be responsible for thisenergy distribution.

Unidad de Arritmias, Iaboratorio de Electrofisiologia, Unidad de Arritmias, Laboratorio de Electrofisiologia,Hospital "12 de Octubre", Crta. de' Andalucia Km 5,400, Hospital "12 de Octubre", Crta. de Andalucia Km 5,400,28041 Madrid. Spain. 28041 Madrid, Spain.

P465

CRITERION OF ELECTION OF A VARIATION MEASURE iNRR INTERVALS, BASED ON SPECTRUM ANALYSIS OF RRSIGNAL.F.Palacios'; S.Barro 2; R. Ruiz3 ; J. Lopez Escudero'; ;M. Sanchez'.

BACKGROUND: Several statistical methods have been applied inmeasuring 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 subtractionfrom consecutive RR intervals, divided by number of heart beats),have been the most widely used.This study intends to determine thecorrelation of these statistical methods among themselves, and findbut in which of them the statistical transformation of the RR signalpreserves the spectrum component of the original RR signal in abetter way.METHODS: We studied 275 intervals, each of one hour of Holterprinting (Elatec).They were obtained during the first 24 hoursfrom patients with infarction.Regression analysis among V,,, SD„and CV„ was performed. The spectrum of frequencies of the RRsignal was compared in 5 Holler registers from healthy people. Thestatistical transformations used in V r,r,SD,, and CV„ calculus werealso 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 standarddeviation showed a spectrum of frequencies similar to the originalsignal.CONCLUSIONS: The variation measures based on thetransformation used in SD,,, besides being contrasted methods, keepthe periodical components, of the RR signal.

'UCI. Hospital de Elche; 2F.Fisica.S.Compostela; 3ESII.Cartagcna.

P466PHARMACOLOGIC CARDIOVERSION OF ATRIAL TACHYARRHYTHMIAIN PRESENCE OF THE WPW SYNDROME: CAN WE USE VERAPAMIL?J. Hluchy, M. Wieczorek, G.V. Sabin

The authors present a 63-year-old man with the WPW syndr-ome admitted to the ICCU because of incessant tachyarrhy-thmia with a right bundle branch block QRS morphology anda minimum RR interval of 200 ms. On admission, episodesof regular or irregular arrhythmia with intervening sin-us beats were present. Neither DC shock nor antiarrhyth-mic drugs of class I were effective in converting arrhyt-hmia to sinus rhythm. During an emergency electrophysiol-ogic study (EPS), atrial origin of arrhythmia was confir-med by (1) spontaneously occurring 2-nd degree AV blockor ventricular pacing-induced AV dissociation during aregular tachycardia and (2) the occurrence of atrial fib-rillation. Sinus node dysfunction and a left lateral acc-essory pathway with an effective refractory period ofless than 230 tns were documented. By programmed atrialand ventricular stimulation, triggered activity as themechanism of atrial tachyarrhythmia was suggested.Regarding these findings, oral therapy with verapamil ina dose of 240 mg a day was started and led to conversionof tachyarrhythmia to sinus rhythm. Because of risk foran acceleration of accessory pathway conduction due toverapamil and avoiding to use higher doses of this drugin order to achieve complete suppression of arrhythmia,sotalol in a dose of 320 mg a day was added. On thistherapy, a complete control of arrhythmia was achieved.14 days later, a successful elective radiofrequency cath-eter 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 mechanismof refractory tachyarrhythmia and give reasons for anunusual therapy approach.

Department of Cardiology and Angiology, ElisabethHospital, Moltkestr. 61, 4300 Essen 1, FRG

P467PREDICTIVE VALUE OF ARRHYTHMIAS AFTER AMI ON. LONG-TERMINCIDENCE OF'. THE EVENTS. R. Ritz, H.P. Ledezmann,F. Follath, aasel University, Switzerland

The significa.nce of arrhythmias (AR) in patients withacute caD rega.rding the long-term incidence of theevents is not yet clearly defined. In a previous studyof antiarrhythmic long-term prophylaxis (JACC 1990)we des~ribed the effect of3 different regimens (n=312)In a representative subgroup (n=104) frequency andseverity of "PB's were'compared during the acute (CCU,48h) and the subacute (10 ·days) pha~e, and 1 yearafter AMI. .Results: during the first 48 hours after AMI 1) Thesum of VPB'S correIated with the number of AR·classi-fied as Lawn ~ 3 2) The change of the mean number ofVPB's over 4h-periods was small (min. 107~246, max.165 +576 per 4h) and without predictive significancefor later AR 3).··we observed 4 f r equ'ency patterns ofVPB's: "decrescend6~' (n=25), "crescendo II (n=12),"spike" (n=28); "irregular" (n=39), none of predictivevalue 4) Ranking the sums of VPB's the quartilesshowed predictive significance for. frequency andseverity of ventricular AR in the subacute phase ofAMI and 1 year after (with and without antiarrhythmict hezapy ).Conclusion: the arrhythmias during the acute phaseof AMI could correspond to a continued arrhythmicmanifestat·ion of the myocard for up to 1 year, withor without antiarrhythmic treatment,

Rudolf Ritz, ICU, University Hospital, Kantonsspital,Petersgraben 4, CH-4031 Basel, Switzerland

P469PSO CALCULATION IN ICU.A. Guadagnucci, G. Vignali, v. twnde'llo, A. RutHi, ". "ariott;

Study objective: To deter.ine' the ability of O.Siggaard-Andersen algorit~. inthe esti.ation of the "in vivo" pSO and standard p50 values frotl a smgleblood sanople with s02X<97.Design: COIIpIIrison between. .easured and calculated standard pSO values.Setting: A Intensive Care Unit of a genera~ hosphat.Patients: 5eventeefl cardio-pulllOO8ry critical ill patients. Mean age ofsixty-eight years (range 31-81 years).Measureenta: The experi_ntal lteasurellent of standard pSO (pSOst) was per-forlted tonoaetering the venous blood sallples (69 speci.ens) usi"'!9 an Il-237tono.eter at 3rC, with two different gas .,ixtures to obtain pcoz at 40 IIIlHg(D~.4), and p02 et leve.l~ to achieve .s02 values close to SO%.lh~.p02 va-lues were car-rec'!ecI to a pH of 7.40 using a Bohr factor=-o.48 and the pSO wast~keo by s;lIple ;nterpol~tion of points on the sOr1rYJ2 <I;agra•. cal-culated stlllldard PSO (pSOst calc.) and calculated "in ~lVO" pSQ (p50 c~lc.)

on the venous spec:;IIefIS and the correspondent arter;al spechlens withsOzX<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 gas-analyzer and an OSfG"Rac';OMeter o"j_ter. Data were cotIpared .by ANOVA testfor liner regre$'sion. The ltean speri.ental .i,:,us calculated d~ffe~enc~s wascalled "bias" and .rror in precision was defined as SD of the dlStrlbutlon ofthe differences. The precision was also expressed by the 95% confidenceinterval for .an di1ferences.Results Un MHo) are. listed ·in the table below:

Error of 95% Coof i denceRZBias Precision Interval

pSOst vs 0.72 0.76 +0.52 ..•+0.9Z 88.7p50st ea l c .venous

pSOst vs 1.68 1.21 +1.36 ••. +Z.O 75.0pSOst calc .er-rer ,

pSO calc. venous 2.54 1.3 +Z.·Z ... +2.9 77.3pSO calc.arter.

Conclusion,S: OUr results s':Iggest that the O.Siggaard-Andersen INIth~t.ical.xIel of O)(ygen dissociative curve describes the curve also at high satura-tion when it is not Longer linear. Accurate lteasure.ents (including dishellO-globin percentage) end sOzX<97 are necessary. We did not perfor. exper;een-tal IleaSLIretlent_ of ·in vivo'" p50 but we postulate that as the p59st was wellcalculated so too \IQ,Ild be the pSO "in vivo"-at" 37°C.

DepartHf"lt of InCet1.ive Care, Head physician F.Leonardi, S5. GiaCOllO eCristoforo Hospitel, 1-54100 Massa, Italy

5235

P468ATRIAL PRESSURE DYNAMICS I.N RELATION TO APATENT FORAMEN OVALE.J.-P. Alexander, B:Cambier, M. Kockx, L. Missault,J: Vandenbogaerde, Y. Taeymans, Ph. Van Cauwelaert.

Reports on patency of the open foramen ovale. (OFO) due to anincreased pulmonary resistan~ are frequently mentioned: These shuntscan lead to a decrease in partial pressure of oxygen, which can not becorrected with higher concentrations of inspired oxygen. Other cliD!calstudies stress that patients with an OFO are at risk for paradoxicalemboli and for decompression sickness. As it is currently believed thatthe OFO is functionally closed during cardiac cycle, and that the lungcan filter venous emboli, no satisfying explanation can be found inliterature to justify the paradoxical nature of emboli through a patentforamen. To elucidate these questions, we studied the interatrial septummotion and correlated our findings to the interatrial pressure dynamicsas measured in post coronary bypass (CBP) patients. We demonstratedwith transesophageal echocardiography a cyclic patency in cases ofOFO (28 %). In the majority of the 109 consecutive analysed patientswe observed a leftward deflection of the interatrial septum during partsof the cardiac cycle. To see whether this bulging was a pressure relatedphenomenon we measured the interatrial pressure difference in 17 postCBP patients with nonnal left ventricular function. In all patients atemporary reversal of the left pressure predominance was regis~ered

during the isovolumic phase of the ventricular systole. The amphtudeand duration of the reversal increased significantly during breathingmodes associated with lower intrathoracic pressure. This pressurereversal only bad been reported in cases of atrial septal defects.These data can explain the paradoxical nature of emboli through anOFO. The hypothesis that the left atrial pressure predominance keepsthe one-way flap-valve closed against the OFO is no longer valid.Furthermore it can explain the high prevalence of ischemic stroke inyounger adults by paradoxical embolism of latent venous thrombosisand can consolidate the hypothesis that an OFO is a risk factor fordecompression sickness in scuba divers.

Opts. of Intensive Therapy Unit and Cardiac Surgery, Middelheim GH,Antwerp, and Dept. of Cardiology, University Hospital, Ghent,Belgium.

P470LEVELS OF a-ATRIAL NATRIURETIC PEP'l'ID£ IN INFERIOR .l'.CUTE MYOCARDIAL

~~F~~~~,wi~s:~~ J':~iu~~:Xi,~~z~NM. ES'1'EBAN, R. ALPAYATP;- R.,J.CABELLO--. ' .

Oa.:rBC'l'IYB. The .i. ot this st"udy was to compare the evolution pattern ofa-Atrial Natriuretic Peptide (a-AMP) in patients with and without rightventricular extension (RV) in inferior acute .yocarcUal intarction.IIBTRODA 44 consecutive patients, group I de JCillip-ltiJiball and "ithoutpreviou; ayocardial infarction were divided into two groups: Group A,(n-17), with criteria or (RV) and Group B, (n'""27), without criteria. Therewere no ditferences betweeen the two groups in relation to age and. tilDepassed since the onset of symtOll. (RV) diagnosis was established by ECG

:~~Ch~:~~~~r~~hi~e~~~~~~iaplasma (a-AMP) levels fIRMA. AMERSHAN.N.V.-ll.4±L4 pJDol/L)," were obtained before and after acute volumeexpansion (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 non-paired Student t"s 1:.test.aBSUL'l'S. Ar.. shown in the following table.

GROUP A GROUP BVOLUME INITIAL

VOLUMEINITIAL EXPANSION EXPANSION

MAP(mmHg) 83±7 87±4 94±2 95±2

HR(B/min) 70±4 73±7 75±3 78±3

RAP(mmHg) 6.2±1.3 *** 12±0.9 2.8±0.4 *** 8±0.4

A-ANP(pmol{l) **51±6.1 43±6.3 ** 31±3.3 *** 41±4

VE(ml) * 440±88 * 642±29

* p<O.05 ** p<O.Ol *** p<O.001MAP:Mean arterial pressure; HR:Heart rate; Values in m±SE

co.eLUSIONS. Despite the higher initial plasma levels of o-ANP, in thepatients with (av) extension, the response to acute (VB) was .arkedlyattenuated. This fact suggest the possibility that right atrial ischemiaor infarction added to (RV) infarction, may play a role in the s)'nthe~isand storage of Q-ANP by reducing the amount of atrial and subendOcard1.UJaventricular tissues available.

:lntensive Care unit, Laboratory· and cardioloqy·- Services, GeneralUniversity Hospital, Maestro ~lonso 109, 03010 Alicante, Spain.

S236

P471,ARTERIOVENOUS DIFFERENCES IN PCO2 AND pH ARE BETTERINDEXES OF TISSUE HYPDXIA THAN ARTERIAL BLOOD LACTATELEVELS DURING AN ACUTE REDUCTION IN BLOOD FLOWHato ZHANG and Jean-Louis VINCENTThis study was designed to examine the relationship between oxygenuptake (VOs), oxygen delivery (DO2), venoarterial difference in PCO2(VAPCC^), and PH (AVpH), and blood lactate (LAC) levels during an acutereduction in blood flow induced by cardiac tamponade. In anesthetized,ventilated dogs (N=13), a catheter Was inserted into the pericardium to injectsaline and to measure the intrapericardial pressure (IPP). V02 was derivedfrom expired gas analysis. D02 was calculated independently by the productof the thermodilution cardiac index and the arterial oxygen content. Thecritical D02 (DOzcm) value below which V02 fell was determined by a plot ofVO2/DO2 from each individual dog and was found at 9.9±1.8 mlkg.min.VAPCO2 and AVpH, which were 7.1±4.6 mmHgand 0.028±0.025 U at baseline, dramaticallyincreased immediately below DO2oe to 17.5±6.6mmHg and 0.114±0.054 U, respectively (bothp<0.01). These changes were related to botharterial hypocapnia and venous hypercapnia. End-tidal carbon dioxide tension (PetCOz) abruptly fellfrom 28.1±10.2 mmHg at baseline to 22.0±6.2mmHg at DOzde (p<0.01). This was associated witha significant increase in (PaCO2-PetCO2)/PaCO2ratio. 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 moreprogressive 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 similarto the 002c,x calculated for V02 (9.9±1.8mlikg.min). The present study suggests that bothVAPCO2 and AVpH represent better parametersthan LAC to detect the occurrence of tissuehypoxia in low flow conditions.

Department of Intensive Care, Erasme University Hospital, Free University ofBrussels, Route de Lennik 808, B-1070 Brussels, BELGIUM

P473MULTICENTRE SURVEY OF COMPLIANCE WITH HAND HYGIENE PRACTICEIN INTENSIVE CARE

LJ Sproat and TJJ InglisFollowing a large multicentre survey of infection controlpractice in Intensive Care Units, which indicated a widevariation in handwashing policy, a more detailed multicentresurvey was conducted into hand hygiene policy, comprehensionand practice in 16 units.A wide variation from recommended practice was found. Insome units hand washing was not required for procedures suchas tracheal suction or mouth care, and in some units therewas no formal policy on optimal hygiene practice duringthese procedures.Nurses' self-reported non-compliance with hand hygienepolicy was poorest before tracheal aspiration(27%), but wasalso reported during line care, urinary catheter bag empty-ing and mouth care. Some categories of visiting hospitalstaff did not comply with hand hygiene recommendationsduring the majority of instances of patient contact.Our results show that some Intensive Care Units have unsat-isfactory hand hygiene policies. In those units wheresatisfactory policies exist, self-reported compliance wasvariable and, at times, poor. Furher research is requiredin this area, particularly into staff motivation to complywith recommended infection control practice.

Inglis TJJ, Sproat LJ, Hawkey PM et al. B J Apaes1992;68:216-220.

Department of Microbiology. University of Leeds, LS2 9JT, UK

P472NUTRITION AND ACUTE RENAL FAILURE (ARF) PROGNOSIS INCHILDREN.U. Simeoni*, P. Desprez, P. Meyer, M. Fischbach,J. Geisert

ARF mortality rates are persistently high despite the ex-tensive use of extrarenal epuration techniques. Nutritio-nal factors may account for a poor prognosis favorizingsecondary complications such a sepsis and multiple organsystem failure. Metabolic perturbations may provene fromstress associated with the disease responsible for ARF,from ARF itself and from unappropriately, restrictivenutritional support. Few data are available in pediatricpatients on the influence of nutritional factors on ARFoutcome.-We -retrospectively studied the evolution of several nutri-tional indicators, including brachial/cephalic perimeter(B/C) and plasma prealbumin (PPA), in 58, 2 month to 9year old children who presented ARF in the pediatric in-tensive care unit. Patients were divided into a normome-tabolic (Group 1 : n = 28) and an hypercatabolic (Group 2:n = 30) group according to Wesson's stress equation forbasal metabolic rate estimation. Patients age and extra-renal epuration rates were similar in the two groups,whereas mortality rates were 18 % and 37 % respectivelyin each group.Brachial/cephalic perimeter-variation (d B/C) and plasmaprealbumin variation (A PPA) during the course of ARF re-sulted significantly different between survivors (A B/C+ 0.03 + 0.04 ; a PPA : + 41.7 + 38.2) and children whowill 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 nutritio-nal conditions in children with ARF and hypermetabolicconditions.

Service de Pediatric 1, Höpitaux Universitaires deStrasbourg, 67098 France

P474

EPINEPHRINE INHIBITION OF FMLP INDUCED CHEMILUIIINESCENCE ISMEDIATED BY ß2-ADRENER6IC RECEPTORS EXPRESSED ONPOLYMORPHONUCLEAR LEUKOCYTESM WEISS 1 . A BIRKHAHNI, S METTLER 1 , M SCHNEIDER2, P. WERNET2, H.LEMOINE 3

Backgrounds and methods: EpineWine causes a dose-related reduction ofoxygen free radical production by polymporphonuclear leukocytes (PMN) (1).PMNs express 62-adrenergic receptors (1). It was investigated whetherepinephrine induced inhibition of oxygen free radical production is mediated byß2-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 ofepinephrine (10-9 up to 10-3 Mol/I) on FMLP induced P11N chemlluminescencewith and without selective ß1-adrenergic and ß2-adrenergic blockade wereinvestigated. In each case the effect on neutrophils of 10 healthy donors wastested. Selective ßi-adrenerglc blockade was employed with CGP-20,712 A andß2-adrenergic blockade with ICI-118,551. Chemiluminescence response Inpresence of drugs is expressed as percentage of control activity, i. achemiluminescence without drugs. op <0,01. statistically significant differencecompared with control activity.Results: Epinephrine dose-dependently Inhibited FMLP Induced PMNchemiluminescence. A 559 t 2t% chemlluminescence response occurred at10-7 Mol/I epinephrine. This Inhibition was not reversed by selective 61-edrenergic blockade (579 & IS%" chemiluminescence response), but byselective ß2-adrenergic blockade (90R * 27% chemiluminescence response),Conclusions: Epinephrine related depression of FIILP Induced PMNchemlluminescence Is mediated by ß2-adrenergic receptors ! expressed on PMNs.

Literatur: 1. Bazzonl 6. DeJana E. Del Maschlo A. Adrenergic modulation ofhuman polymorphonuclear leucocyte activation. Potentiating effect of adenosine.Blood 1991. 77 (9): 2042-2048.

Departments of IAnesthesiology, 2Blood Coagulation and Transfusion Medicine,3Clinical Physiology, Heinrich-Heine-Universitit, Iloorenstr. 5. 4000Düsseldorf 1, Germany

P475MISMATCH BETWEEN LEVEL OF CARE ON THE LAST DAY ON THEICU AND LEVEL OF CARE ON THE WARDR.G. Hulsebos, F.W. Beltran, D. Reis Miranda*

Discharge policies is ICUs in hospitals of different size were studied.. The level ofcan of patients on the day of discharge was analyzed following the hypothesis thatthe level of care would decrease ' during the admission until the last day,, when therequired 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 asP/N < 1.6. For each patient a level of care can be calculated by measuring theamount of woà a patient demands (TISS-score), compared to the amount of workone nurse can do during her shift (40 TISS points). Using this method, levels ofcan on the day of discharge were calculated on data from a large multi-centrestudy involving 36 Dutch ICUs, 11.665 patients and more than 37.000 patients-days. Earlier research showed that ICU characteristics are . closely related tohospital size. Therefore ICUs were grouped based upon the number of beds in thehospital: rou <300 beds; slows 2300-500 beds; group 3 >500 beds; group 4university hospitals.. The results of this analysis are reported in the table.

Group 1 Group 2 Group 3 Group 4 TotalLevel I 73.0% 56.3% 55.1% 15.1% 48.3%

It 528 948 1585 231 3292Level 11 21.5% 31.1% 24.0% 38.2% 28.7%

n 156 524 689 583 1952

Level III 5.5% 12.5% 20.9% 46.7% 23.0%n 41 211 601 712 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 ahigher level of care. The study shows that more than 50% of patients are dis

-charged from the ICU on a level of care (levels II and III) which can not matchthe level of care on the ward. Conversely, it suggests that some activities on theICU may be continued unnecessarily until discharge, increasing the level of careand the use of resources.

*Intensive Care Division, Dept. of Surgery, University Hospital, P.O. Box30.001, 9700 RB Groningen, The Netherlands

P477

INHIBITION OF ACID SECRETION IN PATIENTS WITH MUL-TIPLE ORGAN FAILURE BY OMEPRAZOLEN. Spannbrucker, P. Braun, R. Kleinschmidt, H. Schulte-Witte,

C.Scheuerlen

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 measure-

mentover a 24 h period on the first and third day after start of treat-

ment.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 in-

tragastric 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 ICUpatients with multiple organ failure because of sustained inhibition ofgastric acid production.

Medizinische Universitätsklinik Bonn - Allgemeine Innere Medizin -

Sigmund=Freud-Str. 25, 5300 Bonn 1, FRG

S237

P476EARLY ELECTROMYOGRAPHY (EMG) TO DIAGNOSE POLY-NEUROPATHY IN CRITICALLY ILL PATIENTS.I.J.de Jong °, J.A.Haas +, A.J.J.Woittiez

Polyneuropatby of the critically ill ( PCP ) is a late complication ofM.O.F., causing polyneuromyopathy. Early detection may bedifficult by sedation and relaxation. In a pilot study we evaluatedthe the early EMG in the diagnosis of the PCP.Patients and methods :We studied 7 patients ( mean age 69.0 years ) at risk for developingPCP, i.e. > fifty years old, > five days in ICU, sepsis syndrome,and/or APACHE-II score > 20 afther five days in ICU and/orfailure of . two or more organs. Patients with pre-existingpolyneuropathy and known causes like Guillain-Barre, diabetes,alcoholabuse, uremia were excluded. After clinical neurologicalexamination an EMG was performed at the ICU.Five men and two women were included in the study. APACHE-IIscore mean 16.6 (10-26). Patients received enteral or parenteralnutrition and were not in a catabolic state. All patients weremechanically ventilated. No muscle-relaxants were used. Sedationwas achieved by midazolam. Six patients received aminoglycosidesduring 5 days before the EMG was performed.Results :EMG was performed 6.7 days mean (1 - 19) after entrance in thestudy. In all seven patients an axonal degeneration was seen,compatible with PCP.Conclusion :We found electromyografical signs of a polyneuropathy in criticallyill patients at risk for developing PCP within 8.4 days by using anearly bedside EMG. With this technique polyneuropathy can be de-tected early in patients who are clinically difficult to examine. Wesuggest that PCP is an early sign of M.O.F. and that in at riskpatients PCP must be considered, even without any clinical signs.

Department of Surgery °, Neurology + and Intensive CareTwenteborg Hospital PO-Box 7600, 7600 SZ Almelo, They

Netherlands.

P478

ANTITHRGMBIN III IN CRITICAL PATIENTSR.Lorenzo Torrent, M.S6nchez Palactos, J.Diaz Cremades, L.Fajardo FeO,P.Caballero Padr6n, D.Guerrero Arrate, D.Gonzälez Romero.

Low levels of Antithrombin III (AT 111) among critical patients, mainlyseptic and suffering from multiple trauma, are frequently reported, andthis has been suggested as an indication of a poor prognosisThe efficacy of a replacement treatment with AT III concentrates has notbeen conclusively established, however, in spite of several clinicaltrials.With the aim of evaluating its effect upon other hemostatic parameters,clinical evolution and mortality, we have carried out a prospective ran-domized trial, in septic and multiple trauma suffering patients with lowlevels 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 trea-ted group, 15.93+-5.49 .untreated group)None of the patients chosen had manifest disseminated intravascular coa-gulation (DIC) although as well as the Low levels of AT 111 (52.3%+ -11.7treated group, 48.3+-12.2 untreated group), they showed a decrease inprotein C (55.9+-22 treated group, 52.2+-31.3 untreated group) and mode-rate 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 altera-tions in the haemostasis, nor the clinical evolution, nor the mortalityrate (35.0% treated group, 31.2% untreated group), which were similar inboth groups.Although the number of patients included in this study is too small toestablish any definite conclusions, the results which were obtained sug-gest that the administration of AT III on critical patients with acqui-red low levels, but without manifest DIC may not be justified.

Intensive Medicine Unit . Hospital Insular. PI.Dr Pasteur s/n. 35016 LasPalmas de Gran Canaria.

S238

P479

CLINICAL DATA, BACTERIOLOGICAL PROFII,ES AND OUTCOMEOF SEPTIC SHOCK IN A MEDICAL INTENSIVE CARE UNIT. A tenyear survey.F. Schneider, Ph. Lutun, I. Runge, A. Launoy, M. Hasselmann, J.D. Tempel.

In an attempt to evaluate the actual incidence, the clinical characteristics, theinfectious agents inducing septic shock (SS) and the outcome of the patientshospitalized during the last decade, we have studied the data concerning patientsadmitted for sepsis syndrome with hypotension (Bone R.C., Crit. Care Med.1989.; 17:389) from January 1982 to December 199LPatients and methods : 466 patients (227 women, '239 men), mean age64.3 ± 16.4 years, mean SAPS 17.7 ± 6.2, out of 11 582 admitted during thesame period fulfilled Bone's criteria. They all required hemodynamic supportand mechanical ventilation ; 26.6 % of them underwent haemodialysis. Only7.8 % out of them had a surgical cause to sepsis. Steroids were given to 182patients for their underlying illness ; 146 out of them presented withoncohaematologic diseases. Nosocomial infection was observed in 46,7 % ofthe patients. Patients were classified into 3 categories based on Mc Cabe'scriteria (Mc Cabe W.R. et al, Arch. Inter. Med. 1962 ; 110:845).Results :1. Bacteriological data : hemocultures were found positive at onset of sepsis

syndrome in only 71 % of the patients. One single bacterial strain wasinvolved in 78,1 % of the blood samples (Gram negative bacilli 46,5 %,Gram positive cocci 42,3 %, fungi 5,8 %, others 5,4 %). E.coli andS.pneumoniae were the commonest strains met in home infection, whereasP.aeruginosa and S.aureus were mainly responsible for nosocomialinfections.

2. Survival rates : over-all mortality was 76,5 %, nosocomial infectionproviding 89,7 % death, home infection 68,8 %. In patients with cancermortality was 90 %, in those given steroids for theirs underlying diseases77,8 %. Annual mortality rates did not decrease significantly from 1982 to1991.

3. Role of the underlying host disease : 23 out of 57 patients developped amortal sepsis syndrome in the absence of any medical antecedent. Mortalityrate increased from 68.2 % in patients with non fatal underlying diseases, to79.75 % in ultimately fatal diseases and to 91.5 % when a rapidly fatalillness was present.

Conclusion : these data obtained before monoclonal antibodies were routinely.included in the medical full treatment of severe sepsis demonstrate that mortalityrate have not improved in our ICU during the past decade. Furtherbreakthrough in this field will require a better prevention of sepsis in patient$with ultimately and rapidly fatal underlying diseases.

Service de Reanimation MAdicale,.. liopital de Hautepierre,67098 STRASBOURG Cedex, France.

P480FXWAL I«CIIIß IN IDJ PATIF1dIS füm Ill) wnmir

A.R.Moral.,E.TUmbay,B.ULusoy,N.A1<soy,A.t evik,R:trri3O.D^r

The effect of fluconaaole prophylaxis on the incidmep of ftngsl(yeast)infections in multidisciplinary 7(u pas wetze investigated.A totalof 252 patients Were 11'ooiog ca l y screened in the first week of theirhospitalisation and followingly once eveay aek.The specimens studieds re blood,catheters (blood std tsine),endottaciiea. tubes,oral cavity,mres,slan and rectal awabs.The fungus isolated Mss Candida.Of thepatients 91 received flsxxmaoole 100 day intravenously or enteral.lyfor prophylaxis and 161 served as the mntrol group.

There were positive cultures in 111 of the 161 patients (69%) incontrol group and 49 of 91 patients (54%) in prophylaxis group.The results in concerning to time intervals are presented below.

Weeks 1 2 3 4 5

I N.o.P. 252 127 8) 46 32 22C(+) 112(44%) 75(583%) 57(71%) 32(7c) 25(7x%) 17(77%)

ir N.o.P. 161 75 44 24 2D 12C(+) 78(49%) 51(61%) 31(71%) 19(792) 18(9E) 12(107%)

N.o.P, 91 52 35 22 12 10'M C(+) 34(37%) 24(46$) 15(42%) 13(59%) 7(58%) 5(5JP)

i:Genexal U:Control group M:Prophylaxis growN.o.P.:Nuomber of patients C(+):Culture(+)

In cceclusion,it wes observed that 100 ng/day fl le prophylaxisis effective in ICU patients_

(

iyn̂edreducing the incidence of yeastinfections significantly (l,.C5).

Deperttsart of Anesthesiology and MicrobiologyAegean Unive city Ibspital,IznirfIURlCIYE

P481

BYPOCALOIIC PERIPINRAL PARENTRRAL NUTRITION(BPPN) IN SUIGICAL PATIENTS..usenet Jinenes J,Ortit Leyba C,Garnacho Nontero J,Barros Perez N,Raaila AlarconF, Flores Corlero J,Gonzalez Nenendes E.A high rate of patients submitted to surgical procedures show different degreesof salnutrition after the obligated postsurgical fasting period.The au s of thisresearch is to set the efficacy of RPPI testing different paraseters ofnutritional 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 least2 of these 3 paraoeters:Serua albuain(A1b) < 3gr/dl,Prealbusin(Pre( <llsg/dl,andbody seight(BW),<955 ideal BV.They were divided in three groups: GroupI(control(:15 patients,they were supplied with dextrose 51(300 kcal+isotonicsaline solution),Group II:10 patients with 1 gr protein/kg/d and 64o kcal asdextrose;Group III:10 patients,with the same asount of protein through the caloric source was glycerol(560kcal).The following parameters were tested before the surgical intervention and5 days later:triceps skin - fold(TSF)(ss),Alb(g/dl),Pre(sg/dl),Retinol bindingprotein(RBP( •i/'dl,IItrogen balance(NB),g/24h,Triglycerides(TG)ag/di and urinary3 -aetyl - histidine(3-NH)(uaol/1).Vilcoxon test performed as stathistical method,

RESULTS:Group I Group II Group III

0d 5d p Od 5d p 0d 5d pTSF 13+4 15+5 .04 12,5+6 15+6 .04 13+3 13+4 NSAlb 3+3 3.3+4 NS 2,8+4 3,5+3 .02 3+0.7 3.6+3 NSPre 10+4 11+4 NS 10+2 15+5 .02 14+8 17+7 .05RIP 3.5+1 3.9+1 NS 2.9+1 4.3+1 .03 3.6+1 5.5+1 .02NB -14+3 -9+2 NS -12+2 -2+2 ,.02 -12+3 -3+2 .02TG 103+40 96+35 HS 99+43 114+53 HS 110+60 115+55 NS318 320+160 200+155 .04 334+188 160+116 .001 266+85 150+69 .02CONCLUSIOIS:Visceral proteins eher a trend to the recovery in group II andIII.Nuscle protein catabolism decreases in all the groups in a very similar way.

Intensive Care Unit .Hospital Virgen del Rocio.Sevilla,Spain.

P482

PREVENTION OF PULMONARY ASPIRATION BY MEANS OF ESOPHAGEALBLOCKAGE WITH FOLEY TUBEC.DE LA CRUZ,A.CRIADO,L.DIAZ,A.SEIZ,P.L.VIDAUR,J.R.FRAILE

Pulmonary aspiration of gastric matter is a seriouscomplication that occur during anaesthetic induction in patients submitted to emergency surgery with "full stomach".The severity of it depends on the volume and pH of the as-pirated fluid. The mortality rate is 20-60%.

Numerous techniques have been described dealing toavoid this complication. Our study evaluates the effectiveness of the esophageal blockage (B-B) with Foley tube (F-T)in preventing the pulmonary aspiration.

24 patients subjected to emergency surgery were evaluated. We introduced the F-T through the nose till it rea-ched the medial esophagus.The inflation of the balloon wasmade till the tube was proven to be fixed or till the pa-tients refered retroesternal pain. After the anaesthetic induction and tracheal intubation we proceeded to verify ra-diologically the effficiency of the E-B by introducing 20ml of iodine contrast at the posterior pharynx by directlaryngoacopy and by the torax radiography centered at theaediastinum while the patients bed was elevated to 452 ,

The median age was 60.3 ±11. The efficiency of the E-Bwas complete in 16 patients (66.6%), almost complete in 6(25%) and ineffective in 2 (8.3%). In 6 radiography revea-led a discrete protusion of the esophageal wall caused byinflated balloon. In 20 patients we used F-T ns14 with theinflating volumes of 19 ±2.6 ml and on 4 the F-T n 218 withthe inflating volumes of 13 ±3 ml. We didn't obtain corre-lations between the efficiency of the blockage with the tu-be's caliber and the inflating volume. Tolerance was exce-llent.

We consider that eventhough the technique is not allthat efficient it is possible yet to obtain high percentageof complete E-B, which combined with its simplicity and ex-cellent tolerance, accounts for its unique advantages inthe field of emergency surgrey.DEPARTMENTT OF ANESTHESIOLOGY. UNIVERSITARY HOSPITAL PRINCIPEDE ASTURIAS. ALCALA DE HENARES. 28805 MADRID. .SPAIN

P483STUDY OF MINIMUM INHIBITORY CONCENTRATIONS (MIC) ONADDITION OF TAZOBACTAM TO PIPERACILLIN INENTEROBACTERJACEAE

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).

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 alsoincluded, although they never exceeded 20% of the total studied. The antimicrobialsincluded were piperacillin, tazobactam, and piperacillin/tazobactam at a 8:1 ratio.Mueller-Hinton agar dilutionmethod,10` u.fc. inocculum and E. coli ATCC 25922controlstrain,wereused. Beta-Iactamasedefection wascarriedoutusingnitrocefine.The aim of this study was to evaluate the sensitivity obtained from all the isolatespreviously resistant to piperacillin after the addition of tazobactam by means ofvariations in the MICs. The addition of tazobactam decreased the MICof Piperacillinin all the isolates studied. In Klebsiella oxytoca, 15 out of 18 isolates (83.3%) wereresistant to piperacillin and 6 (33.3%) to piperacillin/ tazobactam. In Proteusmirabilis, 76 out of 96 isolates (79.2%) were resistant to piperacillin and 5 topiperacillin/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 topiperacillin/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 ofenterobacteriaceae, both sensitive and resistant strains, due to the beta-lactamaseinhibiting effect of tazobactam.

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 deOctubre (8), Hospital de Basurto (9), Hospital Virgen dc las Nieves (10), SPAIN.

S239

P484DEPRESSION OF NEUTROPHIL CHEMILUMINESCENCE DUE TOBARBITURATE OR SOLUENT 4M. WEISST, A. BIRKHAHN 1 , N. MIROWI, M. SCHNEIDER2, P.WERNET2

Backgrounds and methods: Oxygen free radical production Is the mainmechanism of bacterial killing by neutrophils Oxygen free radical productioncan be detected by chemilummescence. Up to now It has not been systematicallyinvestigated whether effects of barbiturates on neutrophil chemiluminescenceby commercially available preparations are due to physicochemical properties,drug-free soluents or barbiturates per se. Therefore physicochemicalproperties and the effect of commercially available preparations and soluents of4 barbiturates, i e methohexitone, pentobarbitone, phenobarbitone andthiopentone on FMLP and zymosan induced neutrophil chemiluminescence weretested in - 10) In each case three concentrations within as well as one and twolog concentrations above therapeutic plasma level range of the respectivebarbiturate were testedResults; Commercial preparations and soluents of methohexitone andpentobarbitone showed no significant effect on FMLP or zymosan Inducedneutrophil chemiluminescence. On the other hand commercial preparations ofphenobarbitone and thiopentone dose-dependently and significantly decreasedFMLP and zymosan Induced neutrophil chemiluminescence. In contrast to thesoluent of thiopentone (no effect) the soluent of phenobarbitone depressedneutrophil chemiluminescence in the highest concentration used due tophysicochemical properties (osmolallty of 531 mosmol/U.Conclusions: Depression of neutrophil chemiluminescence by commerciallyavailable barbiturate preparations was caused by the barbiturate per se in thecase of thiopentone, but by the soluent in the case of phenobarbitone

Departments of IAnesthesiology, 2Blood Coagulation and Transfusion Medicine.Heinrich-Heine-Universität, Moorenstr. 5. 4000 Düsseldorf 1, Germany

P485FIBROPROLIFERATIVE PHASE OF ARDS. CLINICALFINDINGS AND EFFECTS OF CORTICOSTEROIDS.Gianfranco'Umberto Meduri

Most patients with adult respiratory distresssyndrome (ARDS) survive the initial insultwhich caused respiratory failure only tosuccumb later to sepsis caused by nosocomial-pneumonia or to pulmonary fibrosis. Clinicalcriteria and analysis of the tracheal aspirateare notoriously inadequate for establishing adiagnosis of ventilator-associated pneumonia.We implemented a comprehensive diagnosticprotocol to determine the cause of sepsis inARDS patients ventilated for more than 3 daysand who had no bronchoscopic evidence ofpneumonia. Nine patients with late ARDS who hadfever (89%), leukocytosis (89%), a new localizedinfiltrate (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. Open-lung biopsies from seven patients showed thefibroproliferative •phase of diffuse alveolardamage and confirmed absence of pneumonia.Treatment with prolonged high doses of corti-costeroids was associated with marked and rapidimprovement in lung injury score (p 0,003 at5 days). Our findings indicate that the fibro-proliferative process occurring in the lungs ofpatients with late ARDS (1) gives rise toclinical manifestations identical to those ofpneumonia, and (2) is potentially responsive tosteroid treatment.

Department of Medicine, Division of Pulmonaryand Critical Care University of Tennessee HealthScience Center, Memphis, Tennessee

P486PROGNOSTIC FACTORS INFLUENCE THE PRESENCE OF ASCITIS IN THEPOSTOPERATIVE OF LIVER RESECTION FOR HEPATOCELLULARCARCINOMA.M.T. Anglada,P.Taurä,J. Fus ter,J. Bru ix,L.Alvarez,E.Izqui erdo,J. Beltrin.Surgical treatment of hepatocellular carcinoma includes liverresection in patients in Child-Pugh A. In order to perform a safe liverresection a vascular occlusion of the hepatic hilium should be carriedout. The postoperative morbidity is featured by hepatic insufficiencyand ascitis.AIM: To identify the prognostic factors that may induce the presenceof ascitis in the postoperative period.PATIENTS and METHODS: We studied the relationship betweenhaemodynamic changes, hormonal alterations and renal function inpre,per and postoperative period during liver resection, in 15Hepatocellular carcinoma patients undergoing surgical treatment.Blood measurements of Aldosterone, Renina, Atrial NatriureticFactor(AFN), Clearance of Creatinine(CrCI),Sodium.Potassium andwater,were performed before and after laparotomy as well as duringthe different occlusive period, 24 and 48 hours after surgery .Intraoperative Measurement of Heart Rate, Cardiac Index, MediumArterial Pressure, Medium Arterial Pulmonary Pressure,PulmonaryCapillar Wedge Pressure, Systemic Vascular and PulmonaryResistance Index and Portal Pressure were performedas well as apostoperative daily evolution of ascitis.RESULTS.Ten patients developed ascitis while the other five could notbe cases demonstrated. There were no significant differences on thehaemodinamyc parameters between the two groups.Aldosterone(p<0.01) and AFN (p<0.001) samples in all periods of study weresignificantly more elevateds patients with ascitis. No significantdifferences were found in serum Renine levels. However 24 hours aftersurgery the values in the ascitis group were twice as high as those ofthe other group. Basal renal function was similar in both groups.However a decrease in of CrCI(p<0.001), water . Clearance(p<0.001) andUrine output in all periods of study was found in ascitis group duringsurgical procedure.CONCLUSIONS:Our study suggest that hormonalfactor are directly involved in renal impairement as well as in theincidence of ascitis in the postoperative liver resection.Departments of A nesthesiology.Surgery,lnternal Medicine andLaboratory.University Hospital Clinic.Villarroel 170. 08036Barcelona.Spain