C. Sirtl

Hydroxyethyl starch antibodies in humans: incidence and clinical relevance.

Hydroxyethyl starch (HES) is a plasma expander used for perioperative IV fluid management, as well as for resuscitation from trauma and shock.HES is very well tolerated, and the incidence of anaphylactic reactions is lower than with dextran or gelatin. Dextran anaphylaxis is caused by circulating dextran-reactive antibodies (ABs) of the immunoglobin G (IgG) class found in most adults. Histamine release from mast cells induces adverse reactions after gelatin infusion. The cause of adverse reactions due to HES is not yet clear. To investigate AB formation due to HES, we collected sera of 1004 patients at least 14 days after starch administration. Using a highly sensitive enzyme-linked immunoabsorbent assay technique, we found one patient with a low 1:10 titer of HES-reactive ABs (immunoglobin M [IgM] class). Despite repeated HES infusions, no clinical reaction could be detected in this patient. On the basis of a binomial distribution, a one-tailed confidence interval (99%) was used to calculate the percentage of the occurrence of ABs in general with maximum of 33 in 10,000 persons (IgM) and 23 in 10,000 persons (IgG). We suggest that HES-reactive ABs are extremely rare and that they do not necessarily induce anaphylaxis. Other mechanisms may be responsible for adverse reactions due to HES. Implications: The frequency of antibody formation due to hydroxyethyl starch, a commonly used plasma expander, was prospectively investigated in 1004 patients. Only one patient showed transient antibody formation, which was not harmful to the patient. This low antigenicity could explain the excellent tolerance of hydroxyethyl starch compared with other plasma expanders. (Anesth Analg 1998;86:1123-6)

Technical Performance and Reflection Capacity of the Anaesthetic Conserving Device—A Bench Study with Isoflurane and Sevoflurane

ObjectiveThe anaesthetic conserving device (AnaConDa®, Sedana Medical, Sundbyberg, Sweden) facilitates administration of isoflurane or sevoflurane by liquid infusion. An anaesthetic reflector inside the device conserves exhaled anaesthetic and re-supplies it during inspiration. In this bench study, we examined the influence of infusion rates and ventilatory settings on the resulting anaesthetic concentrations on patient (Cpat) and ventilator side of the reflector (Closs) to describe its technical performance.MethodsA Puritan Bennett 840 ICU ventilator (Pleasanton, US), AnaConDa®, and a test lung (3 l-chloroprene-bag) were assembled. Infusion rates (IR, 0.2-50 ml h-), respiratory rates (RR, 5-40 breaths min-1), and tidal volumes (VT, 0.3, 0.5, and 1.0 l) were varied. Cpat was measured via a thin catheter in the middle of the 3 l-bag in steady state (online data storage and averaging over >10 min). Closs was calculated from IR (to yield the volume of vapour per unit of time), and expired minute volume (in which the vapour is diluted) on the assumption that, in the steady state, input by liquid infusion equals output through the reflector.ResultsAt lower concentrations (Cpat< 1 vol%) the ratio Closs/Cpat was constant (RC = 0.096 ±±0.012) for all combinations of IR, RR and VT, both for isoflurane and sevoflurane. The device could efficiently reflect up to 10 ml vapour per breath (e.g. 2 vol% in 0.5 l). When exceeding this capacity, surplus vapour “spilled over” and RC markedly increased indicating decreased performance.ConclusionsThe triple product minute volume times RC times Cpat describes anaesthetic losses through the reflector. It can easily be calculated as long as the 10 ml reflection capacity is not exceeded and thus RC is constant. Increased minute ventilation necessitates increasing the IR to keep Cpat constant. When using large VT and high Cpat “spill over” occurs. This effect offers some protection against an inadvertent overdose.

Die Alveolargasgleichung Anmerkungen zu M. Kleen und B. Zwißler, Anaesthesist (2000) 49:153–154

Der erste Satz ist falsch! Zwar ergäbe der Term 1 FiO2 für FiO2 = 1 durchaus null, allerdings gilt das Assoziativgesetz nicht für die Kombination Multiplikation und Subtraktion und die Hierarchie der Rechenoperationen ist zu beachten („Punkt vor Strich“)! Der Korrekturterm in eckigen Klammern strebt bei hoher FiO2 gegen RQ (s.Anhang). Nach den Regeln der Bruchrechnung kann RQ gekürzt werden, es bleibt übrig: