Intensive care as ethical problem. Opening address of the 21st Symposium of the German-Austrian Society of Neonatology and Pediatric Intensive Care Medicine in Mannheim 26 October 1995

The lecture focuses on two issues related to intensive care in pediatrics: uncertainty in prognosis and plurality in ethics. Despite the increasing plurality in ethics consensus can be achieved about the basic moral principles in medicine. The principles of medical ethics--mainly autonomy, beneficience, nonmaleficience and justice--provide an acceptable normative basis. The uncertainty of prognosis is described as an unavoidable element of acting in medicine, in particular in intensive care. Internalized dispositions are proposed to be a morally adequate answer to this structure given in medicine: conscientiousness, carefulness, engagement.     

Guidelines for the pre-hospital care of patients with severe head injuries. Working Group for Neurosurgical Intensive Care of the European Society of Intensive Care Medicine

OBJECTIVE: To evaluate the absorption of oral ciprofloxacin within 24 hours of laparotomy for major elective surgery or peritonitis. DESIGN: In this prospective trial, patients were given a 750-mg oral close the morning after major elective surgery (n=15) or surgery for peritonitis (n=7). Healthy volunteers served as controls (n=9). Serial urine and blood samples were drawn during the subsequent 12 hours, and pharmacokinetic measures were determined by standard high-performance liquid chromatography assay procedures. SETTING: Multicenter, university-affiliated hospitals. MAIN OUTCOME MEASURES: Drug absorption as determined by area under the concentration time curve, maximum concentration, and time to maximum concentration. RESULTS: Oral bioavailability was reduced in elective surgery and peritonitis patients compared with controls. Among the 15 elective surgery patients, 27% (4/15) showed no absorption. The remaining 73% (11/15) had an area under the curve comparable with that of controls (8.3+/-1.6 (mg/[L x h]). Among all patients, those who showed drug absorption vs those who showed no absorption did not differ with respect to malignant neoplasm, case type, age, or biochemistry. However, patients showing no absorption were significantly heavier than patients showing absorption (patients showing absorption, 15%+/-3% over ideal body weight vs patients showing no absorption, 29%+/-6% over ideal body weight; P<.05). When elective surgery patients were stratified by presence or absence of obesity (25% above ideal body weight), mean area under the curve in nonobese patients was 9.80+/-2.37 vs 0.91+/-0.56 (mg/(L x h) in obese patients (P<.05). CONCLUSIONS: Oral bioavailability was reduced for peritonitis surgery patients on the first day postoperatively, and for obese elective surgery patients. To achieve adequate serum levels requires continuation of intravenous antibiotics in patients with peritonitis, and adjustment of oral dosage in obese patients in the early period after elective surgery.     

Enteral nutrition in intensive care patients: a practical approach. Working Group on Nutrition and Metabolism, ESICM. European Society of Intensive Care Medicine

Severe protein-calorie malnutrition is a major problem in many intensive care (ICU) patients, due to the increased catabolic state often associated with acute severe illness and the frequent presence of prior chronic wasting conditions. Nutritional support is thus an important part of the management of these patients. Over the years, enteral nutrition (EN) has gained considerable popularity, due to its favorable effects on the digestive tract and its lower cost and rate of complications compared to parenteral nutrition. However, clinicians caring for ICU patients are often faced with contradictory data and difficult decisions when having to determine the optimal timing and modalities of EN administration, estimation of patient requirements, and choice of formulas. The purpose of this paper is to provide practical guidelines on these various aspects of enteral nutritional support, based on presently available evidence.     

Guidelines/algorithms of the German Society of Otorhinolaryngology, Head and Neck Surgery

Prolactin-secreting adenoma, which usually presents with amenorrhea and galactorrhea syndrome, is quite rarely diagnosed in the prepubertal age group. We reported a rare case of a prepubertal prolactin-secreting adenoma and discuss its clinical, radiological and histological features. An 8-year-old girl presented with headache, progressive visual deterioration and precocious puberty. The serum prolactin level was 57.8 ng/ml. Computerized tomography and magnetic resonance imaging revealed an invasive suprasellar tumor. The tumor was partially resected through an interhemispheric approach in a first operation, and residual tumor was resected through the right pterional approach in a second operation. The histological diagnosis was a prolactin-secreting adenoma with high cellular pleomorphism. The Ki-67 labeling index was 5.7%, indicating aggressive biological behavior. Postoperatively, the patient was prescribed bromocriptine as maintenance therapy, and the serum prolactin level became normalized. There is a tendency for diagnosis of a prepubertal prolactin-secreting adenoma to be delayed because there are no endocrinological manifestations. Therefore, the tumor tends to become larger and invasive. Although it is rarely experienced, a prolactin-secreting adenoma should be considered in the differential diagnosis of a large, invasive parasellar lesion in the prepubertal age group.     

Guidelines/algorithms of the German Society of Otorhinolaryngology, Head and Neck Surgery

Prader-Willi Syndrome (PWS) is a multisystem defect characterized by obesity, hypogenitalism and short stature for genetic background. Low GH serum levels have been found in patients with PWS and were related to a hypothalamic-pituitary dysfunction. We studied spontaneous nocturnal GH secretion and GH-response to provocative tests in five patients affected by PWS. We observed in three of them (Group A) abnormally low GH and IGF-1 serum levels. In the other two patients (Group B) GH secretion and IGF-1 serum levels were normal. In all patients no thyroid dysfunction was observed. These data might suggest the presence of two different subgroups of patients affected by PWS, from an endocrinological point of view. An abnormally low GH secretion would be evident only in a subgroup of patients, which appears to be normal in the remaining patients. This casistic is small in number, but if our data will be confirmed by more extensive studies it may be possible to identify a specific population of PWS patients who could benefit from recombinant GH-therapy.