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"Axillary block is a common anaesthetic technique for operations on the hand and forearm . In our hospital , with many trainees in anaesthesia , only 250 - 300 axillary blocks per year are performed by about 30 colleagues . This implies a small number of blocks for each anaesthetist . The present study was designed to assess whether it is possible to teach this technique and use it with an adequate degree of success under these conditions . We used a nerve stimulator and studied whether the success of the block under these conditions is independent of anaesthetist's experience in this technique . Furthermore , we examined other factors involved in the success of the block . Methods . The study included 112 patients subjected to elective surgery of the upper extremity ; all received an axillary block . We used a nerve stimulator and injected mepivacaine 1% without adrenaline . The following parameters were recorded : the number of blocks to date performed by the anaesthetist ; the minimal current required for nerve stimulation ; the dose of local anaesthetic ; the time between the end of injection and the beginning of surgery ; the duration of surgery ; and the quality of sensory and motor blockade after 10 , 20 , and 30 min . Sensory blockade was assessed by the pinprick method ( no blockade , analgesia , anaesthesia ) ; motor blockade was judged by comparing the muscle strength of both arms ( no blockade , paresis , paralysis ) . Data were analyzed using the Mann-Whitney test , with P 0.05 considered statistically significant . Results . Of the 112 blocks , 95 ( 85% ) were successful ; 17 ( 15% ) failed and the patients required general anaesthesia . Eight of the successful blocks showed a decrease in analgesic quality after > =70 min and required additional analgesics or general anaesthesia . We found no correlation between the experience of the anaesthetist and the success of the block . The minimal required current for nerve stimulation in the success group was 0.4 mA and differed significantly from the value of 0.6 mA in the failure group ( Table 3 ) . The dose of mepivacaine was higher in the success group ( 5.9 vs. 5.3 mg/kg ) . Complete sensory blockade was more frequently achieved for the median , ulnar , and radial nerves than for the musculocutaneous and cutaneous brachii medialis ( Fig . 3 ) . The frequency of complete sensory blockade ( anaesthesia ) had increased by 21.9% between the 20th and 30th min . Complete motor blockade was less often achieved than sensory blockade ( Fig . 4 ) . Conclusions . Using the method of electrostimulation , the axillary block is an appropriate anaesthetic technique that can be applied in a hospital where each anaesthetist only occasionally performs it . Prior to injection of the local anaesthetic , the current for nerve stimulation should be reduced to 0.5 mA . The time between the end of injection and the beginning of surgery should be no less than 30 min because complete sensory blockade can more often be achieved . The dose of mepivacaine should be no less than 6 mg/kg body weight ."
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"Posttraumatic cardiopulmonary resuscitation ( CPR ) is associated with a poor outcome . When evaluating the literature according to the Utstein method , there were only 2 survivors ( 0.18% ) out of 1,135 CPR attempts after trauma ( Table 1 ) . Differences in the study populations and levels of prehospital trauma care led us to analyse the results of a physician-staffed prehospital trauma care system in Cologne . Methods . From January 1987 to December 1990 , a total of 49,054 emergency calls were registered using a standardised protocol . Among 9,595 trauma-related calls , 636 patients were found to be pulseless on arrival of the emergency team , 412 of these were pronounced dead . CPR was initiated in the remaining 224 patients , who comprise the study population ( defined as 100% ) . All patients who were admitted to a hospital were followed using a second protocol . Results . CPR in the field was successful in 68 ( 30.4% ) patients , who were then admitted to a hospital ; 42 of these died within the first 24 h . Four patients ( 1.8% ) could be discharged from hospital alive and were still living 1 year later , 1 with a lasting neurological deficit ( Fig . 1 ) . In 156 ( 69.6% ) cases resuscitative attempts were unsuccessful in the field . Conclusions . Even in a physician-staffed prehospital trauma care system , the chance of surviving a post-traumatic cardiac arrest is minimal . Survival has to be regarded as an individual fate ; the overall results are discouraging . Even though this study analyses the largest population of posttraumatic CPR ever published , prognostic factors could not be identified due to the few survivors . Nevertheless , the result does not justify general omission of CPR after trauma as : ( 1 ) prognostic factors for survival have not been identified thus far ; and ( 2 ) no significant additional costs arise from posttraumatic CPR ."
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DerAnaesthesist.40430835.eng.abstr | DerAnaesthesist.40430835.eng.abstr | [
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"In order to assess the significance of drug levels measured in clinical and forensic toxicology as well as for therapeutic drug monitoring ( TDM ) , it is essential that good collections of data are readily available . For more than 400 frequently used drugs therapeutic and , if data were available , toxic and fatal plasma concentrations as well as elimination half-lives were compiled in a table including , e.g. , hypnotics like barbiturates and benzodiazepines , neuroleptics , antidepressants , sedatives , analgesics , anti-inflammatory agents , antihistamines , anti-epileptics , beta-adrenergic antagonists , antibiotics ( penicillins , cephalosporins , aminoglycosides , gyrase inhibitors ) , diuretics , calcium-channel blockers , cardiac glycosides , anti-arrhythmics , anti-asthmatics , angiotensin converting enzyme inhibitors , opioid agonists , and local anaesthetics . Data have been abstracted from published information , both compilations and primary sources , and supplemented with data collected in our own forensic and clinical toxicology laboratories . Wherever possible , ranges for therapeutic plasma concentrations are expressed as trough concentration at steady-state . The range of ( or single ) half-life values given for each drug are chosen to represent the terminal log-linear phase at most . In addition to the assessment of significance of drug levels for the therapeutic monitoring of patients , this list can assist the diagnostic assessment in cases of intoxication ."
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DerAnaesthesist.50440024.eng.abstr | DerAnaesthesist.50440024.eng.abstr | [
{
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"Epidurography with contrast medium is used to verify the correct poition of an epidural catheter and to detect malpositioning . There is great variability in the distribution of contrast medium according to the individual morphology of the epidural space and the way it is injected . Results of investigations of the anatomy of the spinal canal and epidural space performed with anatomic specimens , epiduroscopy , and conventional and computed tomographic ( CT ) epidurography are sometimes contradictory . We have performed CT epidurography in approximately 30 patients to date . Insights regarding the distribution of contrast medium in the epidural space can help to interpret conventional epidurographies and to explain special features , such as the \" rail-road-track phenomenon \" or the plica mediana dorsalis . Methods . Patients scheduled for major abdominal operations were studied . Catheters were introduced into the thoracic epidural space on the day before the operation . Conventional epidurographies were performed routinely after insertion of the catheters with a mobile X-ray apparatus , usually in the recovery room , using 5 ml iopamidol ( Solutrast 250 M ) . Selected patients ( good mental state and stable psychic condition ) , after written consent and with approval of the local ethical committee , were investigated with CT epidurography using the same contrast medium ( partly diluted ) . From among the CT scans performed until now , five characteristic images are presented and compared to conventional epidurographies . Results . When small volumes ( 5 mL ) of iopamidol were injected slowly , we regularly observed a railroad-track phenomenon in the AP images of conventional epidurographies . After rapid injection of larger volumes ( 10 - 15 ml ) , the spread was more homogeneous and sometimes outline a lighter zone of contrast distribution in the midline . CT epidurography in these cases ( 5 out of 30 patients ) revealed a plica mediana dorsalis . In the majority of the CT scans of the thoracic epidural space its anterior ( ventral ) compartment was unfilled by contrast medium . According to the findings of several investigators , dura mater and ligamentum longitudinale posterius have grown together , so that an epidural space does not exist in ventral thoracic segments of the spinal canal . In lower thoracic and lumbar segments both structures are separate , and a wide anterior epidural space was present and filled with contrast medium . In other cases the dorsal and dorsolateral epidural space was completely filled , but the contrast medium stopped behind the spinal nerves and surrounding dural sheaths , as if these structures , together with the connective tissue strands between them , formed a membrane that spread in a frontal plane . A railroad-track phenomenon is interpreted in the literature as the X-ray correlate of contrast medium spread in the subdural space , indicating an incorrect catheter position . According to conventional epidurographies and confirmed by CT scans , this feature is also seen regulary in cases with correct catheter position . Small volumes of iopamidol spread preferentially into the wider parts of the epidural space between the gaps of the vertebral arcs , whereas the dura mater and periosteal layers touch at the inner side of the pedicules and laminae , allowing the existence of only a potential epidural space . This rhythmic widening and narrowing of the epidural space is the explanation of the \" railroad track \" in AP contrast epidurographies . Conclusions . CT epidurography is a valuable tool to provide better insight into the morphology of the epidural space when filled with fluid ( contrast medium , local anaesthetics ) , complementing findings using epiduroscopy and anatomic specimens . It stands to reason that this time- and cost-expensive method can never replace conventional epidurographies , but can help to interpret them properly ."
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DerAnaesthesist.50440037.eng.abstr | DerAnaesthesist.50440037.eng.abstr | [
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"The Acute Physiology and Chronic Health Evaluation model ( APACHE II , APACHE III ) is used to describe the severity of illness and predict the outcome in critically ill patients . APACHE III , introduced in 1991 , has not yet been validated in Europe . We calculated APACHE II and APACHE III scores in patients after admission to the intensive care unit ( ICU ) and compared the prognostic value on hospital mortality . Method . One hundred fifty patients with stay of over 24 h were enrolled in the study and prospectively and consecutively investigated . APACHE II and III scores were calculated as described by the authors . The mean and median values of the survivors were compared with the non-surviving group ( Mann-Whitney U test ) . Receiver operating characteristics ( ROC analysis ) and the areas under the ROC curves were plotted . Results . Of the 150 patients , 34 died during their hospital stay ( 22.7% ) . The mean and median APACHE II and III scores were significantly higher ( P 0.001 ) in the non-surviving group . The area under the ROC curve was higher for APACHE III ( 0.899 ) compared to APACHE II ( 0.847 ) . Conclusions . APACHE II and APACHE III were both found to have good prognostic value in general ICU patients . Our results suggest that the APACHE III version includes a more precise prediction of hospital mortality than APACHE II . A new aspect of APACHE III is an expanded modification of the Glasgow Coma Scale to assess neurologic derangements ."
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DerAnaesthesist.50440048.eng.abstr | DerAnaesthesist.50440048.eng.abstr | [
{
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"Surgery by three-dimensional ( 3D ) endoscopy is being used routinely in abdominal surgery and , in special cases , in thoracic surgery ; however , it has not been reported as being used in microlaryngeal surgery . Methods . We inserted a 3-D endoscope into a jet laryngoscope and studied the pressure properties at the tip of the laryngoscope as well as intrapulmonary pressures while applying superimposed high-frequency jet ventilation . The studies were conducted initially using a lung simulator , and then in seven patients undergoing microlaryngeal surgery . Results . Due to the rather large 3-D endoscope , the diameter of the jet laryngoscope was reduced by between 25.2% and 70.9% , depending on its size . The measurements on the lung simulator revealed that reduction of laryngoscope diameter leads to an increase in the following parameters : expiratory resistance , tidal volume , and peak inspiratory pressure . The mean FiO2 was 0.74 +/- 0.1 ; the mean paO2 was 169.2 +/- 80.4 mm Hg ; and the mean paCO2 was 40.9 +/- 2.4 mm Hg. The mean airway pressure was 19 +/- 5.3 mm Hg prior to insertion of the endoscope and 12.3 +/- 6.9 mm Hg after insertion . The mean positive end-expiratory pressure values increased from 2 +/- 0.6 to 3.6 +/- 2.3 mm Hg. Reduction of the working pressure resulted in restoration of the initial inspiratory pressures and tidal volumes . Conclusions . In the clinical application of 3-D endoscopy via a jet laryngoscope , it was possible to achieve sufficient ventilation , inspection of the surgical field , and performance of the surgical procedure . A CO2 laser was used without changing the ventilation regime . Although technical alterations would be desirable for its application to microlaryngeal surgery , it is presently possible to safely use the 3-D endoscope via the jet laryngoscope for microlaryngeal surgery , presenting the surgeon with new possibilities in voice-improving microsurgery of the larynx ."
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"Preventive strategies aim to reduce gastric acidity ( H2ms ( sucralfate , antacids , pirenzepine ) and to normalize gastric mucosal microcirculation ( sucralfate , pirenzepine ) . Thus , the most important prophylactic measure is an optimized emergency and ICU regime aiming to improve oxygenation and microcirculation . All specific drugs used for stress ulcer prophylaxis have been shown to be effective in prospective controlled studies . Furthermore , pirenzepine has been found to be superior to H2-antagonists, at least in neurosurgical patients . Insufficient or no data exist to support the use of prostaglandins or omeprazole for stress ulcer prophylaxis . The most important adverse effect of stress ulcer prophylaxis is nosocomial pneumonia due to gastric alkalinization . This may occur in long-term ventilated patients with a gastric pH > 4 and may account for up to 50% of all nosocomial pneumonias in certain groups of patients . Mortality is not influenced by antacids or H2-antagonists, while sucralfate has been shown to reduce mortality , most probably by inhibition of bacterial translocation ."
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"On the subject of natriuretic peptides there is a great deal of controversy , and intensive research efforts have been made studying their effects on electrolyte homeostasis . In the early 1980s , a peptide that caused diuresis , natriuresis , and had a relaxant effect on vascular smooth muscle was discovered independently by several groups . This was the breakthrough for the identification of natriuretic peptides , followed by the characterisation of the amino-acid sequences of several species . Synthesis of the peptide , cloning of the encoding gene , identification and characterisation of specific receptors , as well as the development of antibodies and radioimmunoassays were rapidly accomplished . Research on the immunohistochemistry of cardiodilatin/atrial natriuretic peptide ( CDD/ANP ) and the regulation of CDD/ANP gene expression led to detection of the peptide in extra-atrial tissues . Later on , two new peptides were discovered brain natriuretic peptide ( BNP ) and C-type natriuretic peptide ( CNP ) . These peptides share structural features with CDD/ANP with regard to their 17-amino-acid-exhibiting loop bridged by a disulfide bond . Another recently discovered peptide is urodilatin ( URO ) , a renal-borne new member of A-type natriuretic peptide . URO was isolated from human urine and consists of the same sequence as CDD/ANP , containing the 17-amino-acid residue loop of the circulating hormone with 4 additional amino acids located at the NH2-terminus of the peptide . Regarding physiological actions , data strongly support a close association between URO and urinary sodium excretion . The application of URO in animals revealed a stronger diuresis and natriuresis with a lower influence on arterial blood pressure compared to CDD/ANP-99-126. These results were encouraging for the use of URO in clinical trials as a tool to prevent acute renal failure ( ARF ) in patients following heart transplantation and for treatment of incipient ARF in patients following liver transplantation . Summarising the results of these two studies , URO represents a new approach for not only prevention , but also for treatment of ARF following organ transplantation . This opens up new possibilities for the treatment of ARF of other origins in intensive care medicine ."
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DerAnaesthesist.50440119.eng.abstr | DerAnaesthesist.50440119.eng.abstr | [
{
"id": "DerAnaesthesist.50440119.eng.abstr-passage-0",
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"Case Report . A 31-year-old pregnant woman had to undergo emergency abdominal surgery due to acute intestinal obstruction . The patient's preoperative history demonstrated multiple allergies as well as abdominal trauma several years before . The physical examination - including sonography of the two fetuses - showed no pathological signs . Anaesthesia was induced intravenously with the operating table tilted to the left side , using routine precautions pre-oxygenation , and rapid sequence intubation , and was maintained unproblematically . About 20 min after the onset of surgery , hypotension , tachycardia , and a drop in oxygen saturation appeared . Volume substitution and the application of vasoactive drugs failed to stabilise the haemodynamic situation . Elevation of the pregnant uterus and increased left tilzing of the operating table did not lead to improvement . The development of eyelid edema led to the diagnosis of an anaphylactic reaction . The patient was treated successfully with epinephrine , antihistamines , and corticosteroids ( prednisolone ) . The suspicion of latex-related allergy was verified postoperatively by radio-allergen-sorbent test ( RAST ) and prick and scratch tests ."
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"Methods . To assess the occupational exposure of the anaesthetist to anaesthetic gases , a total of 1 German and 25 Swiss hospitals were investigated . A Brueel & Kjær Type 1302 multi-gas monitor was used to measure concentrations of nitrous oxide and halogenated anaesthetic agents in the anaesthetist's breathing zone . Measurements were performed during 114 general anaesthetic , 55 of which were in patients under 11 years of age . In these 55 patients , the influence of various factors on the exposure ( time-weighted average concentrations ) was estimated by comparing different data groups . The efficiency of the applied scavenging equipment was examined by surveying the exhalation valve with a leak detector ( type TIF 5600 , TIF Instruments , Miami ) . Results . Sessions with patients under 11 years of age revealed much higher anaesthetic gas exposures compared to older patients . The concentrations of nitrous oxide were on average threefold ( Fig . 1 ) , those of the halogenated anaesthetics fivefold higher ( Fig . 2 ) for the younger patients . In 11- to 16-year-old patients the exposure level was the same as in adult patients . The measurements showed a reduction of 85% in exposure if an efficient scavenging system ( i.e. , no waste gas discharge to room air through the exhalation valve ) or lower fresh gas flow were used ( Fig . 4 ) ; 42% of the inspected scavengers were inefficient , and reduced the exposure on average by only 30% . In operating theatres with a ventilation rate of at least ten air changes per h , the measured concentrations of anaesthetic gases in the inhalation zone of the anaesthetists were reduced more than 50% compared to poorly ventilated rooms ( Figs . 4 and 5 ) . The use of tracheal intubation or laryngeal mask airway ( LMA ) anaesthesia resulted in a reduction of 80% in exposure compared to standard face masks if efficient scavenging was used . The exposures during sessions with inefficiently scavenged Bain coaxial systems or unscavenged semi-open delivery systems of the Jackson-Rees type were tenfold higher than with scavenged rebreathing circuit systems ( Fig . 6 ) . During anaesthesia with IV or double-mask induction , the average levels of inhalation anaesthetics were reduced by about 80% compared to inhalational induction with standard masks ( Fig . 7 ) . The anaesthetist's working technique is a very important factor that strongly influences the concentrations . Poor work practices , like lifting off the face mask with anaesthetic gas flow turned on , increased the exposure of the anaesthetist and other operating room personnel drastically , even if the other conditions ( scavenger and room ventilation ) were good . Discussion . The exposure levels of anaesthetic gases are generally higher during anaesthesia in children up to 10 years of age than in older patients . Nevertheless , the measurements showed that exposure during paediatric anaesthesia can be kept below the recommended limit ( 8-h TWA in Switzerland ) of 100 ppm nitrous oxide and 5 ppm halothane or 10 ppm enflurane or isoflurane . Causes of high exposures were particularly high fresh gas flows often applied without scavenging or together with inefficient scavenging devices and the high part of mask anaesthesia and inhalation induction with a loosely held mask . To achieve an effective reduction of occupational exposure , well-adjusted and maintained scavenging systems and low-leakage work practices are of primary importance . As leakage can never be completely avoided , a ventilation rate of at least ten air changes per h should be maintained in operating rooms and rooms where anaesthesia is induced to keep down concentrations of waste anaesthetic gases . High exposure during mask anaesthesia and inhalation induction can be prevented by further measures . Using a LMA instead of a standard mask reduces the exposure to the same level as endotracheal intubation ."
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DerAnaesthesist.50440171.eng.abstr | DerAnaesthesist.50440171.eng.abstr | [
{
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"text": [
"By measuring pulse rate ( PR ) , blood pressure ( BP ) , electrical integral skin resistance ( SR ) , and skin surface temperature in different areas , the activity of the sympathetic nerves in spinal anaesthetics of different levels was evaluated . It was found that the sympathetic subsystems for vasomotor and sudomotor activity have their own innervation and that the functionally different effectors also manifest different deficiency reactions in low- and medium-level spinal anaesthesia . Functional sympathetic innervation , however , is unimportant after high sensory spread of spinal anaesthesia . The sympathetic nerves show similar signs of deficiency during administration of centrally acting general anaesthetics . In contrast to these , however , high spinal anaesthesia does not block the vagal component of the autonomic nervous system . The unopposed parasympathetic nerves directly affect the heart and other effectors , which may result in life-threatening cardiovascular reactions with decreases in BP and bradycardia . If high sympathetic blockade is recognized early , such life-threatening situations can be managed successfully . Suitable means of measuring sympathetic activity are the observation of BP , HR , temperature , and particularly SR at the hand . Sympathetic nerve blockade due to spinal anaesthesia first causes a reduction of SR in the lower extremity . In high spinal anaesthesia there is also a loss of sympathetic activity at the hands . Subsequently , hand temperature increases , and finally bradycardia and hypotension occur . The functional reaction of sympathetic activity is indicated by correlation of the vasomotor and sudomotor activities in high and low spinal anaesthesia . Failure of sudomotor activity can be observed on average at least 3 min prior to an increase in acral temperature and 9 min at the hands in cases of high spinal anaesthesia . The maximum increase in temperature in the feet was 4 ° C in high spinal anaesthesia , which was equal to that measured at the hand during centrally acting general anaesthesia ."
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"The authors report a tracheal rupture in a 34-year-old patient who was primarily intubated following generalised seizures and loss of consciousness ( Ruesch endotracheal tube ) . Some hours later , she developed high ventilatory airway pressures and subcutaneous and mediastinal emphysema were noted . Reintubation with a high-volume , low-pressure endotracheal tube was planned when it was noted that the ballon of the Ruesch tube was grossly overinflated . Endotracheal tube cuff pressure was measured and found to be greater than 120 cm H2O ( the maximum measurement possible with the manometer ) . The diagnosis of tracheal rupture was confirmed by fiberoptic bronchoscopy . The patient immediately underwent a throacotomy and a 3-cm tear of the pars membranacea of the trachea was sutured with a dural patch . To maintain low airway pressures post-operatively , she remained sedated for 2 days and received a muscle relaxant to permit pressure-controlled ventilation . In this case , it can be concluded that excessive inflation of the endotracheal tube cuff resulted in the tracheal rupture . Other possible causes and results of tracheal rupture are discussed ."
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DerAnaesthesist.50440284.eng.abstr | DerAnaesthesist.50440284.eng.abstr | [
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"id": "DerAnaesthesist.50440284.eng.abstr-passage-0",
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DerAnaesthesist.50440288.eng.abstr | DerAnaesthesist.50440288.eng.abstr | [
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"id": "DerAnaesthesist.50440288.eng.abstr-passage-0",
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"This randomized , double-blind , multicentre , parallel-group study compared the efficacy and safety of an intravenous dose of ondansetron 4 mg for the prevention of postoperative nausea and vomiting ( PONV ) with metoclopramide 10 mg and placebo in patients undergoing major gynaecological surgery . A total of 1044 patients ( 465 ondansetron , 462 metoclopramide , 117 placebo ) received study medication immediately prior to induction of anaesthesia and were included in the analysis of data . The proportion of patients experiencing no emesis and no nausea or provided with rescue antiemetic medication , the number of emetic episodes , and the duration and severity of nausea were recorded during the 24-h period after recovery . Significantly more patients who received ondansetron had no emetic episodes ( 44% ) than those who received metoclopramide ( 36% , P=0.049) or placebo ( 25% , P 0.001 ) . A higher proportion of patients receiving ondansetron ( 32% ) did not experience nausea ( metoclopramide 24% , P=0.009; placebo 16% , P 0.001 ) . Significantly fewer patients in the ondansetron group required rescue medication or were withdrawn due to treatment failure ( P 0.05 ) . In the ondansetron group the total number of emetic episodes , the median time to the first emetic episode or treatment failure , and the duration and severity of nausea were reduced significantly compared with metoclopramide or placebo ( P 0.05 ) . The safety profile was similar for each treatment group ."
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"Induced hypotension is defined as a reduction in mean arterial blood pressure to 50-60 mm Hg in normotensive subjects . The aim of induced hypotension is to decrease intraoperative blood loss , decrease the need for blood transfusions and improve operating conditions . Most studies indicate that induced hypotension can decrease intraoperative blood loss by 50% in many surgical procedures ; however , some studies report that blood loss is not significantly reduced . Current methods of induced hypotension are based on the use of rapid and short-acting vasodilators as primary agents ( nitroprusside , nitroglycerine , urapidil ) , supplemented by volatile anesthetics ( isoflurane ) and/or -blockers ( esmolol ) to improve effect , reduce dosage and prevent side effects ( reflex tachycardia , tachyphylaxis , rebound hypertension ) . Proper positioning of the patient and controlled ventilation aid in reducing blood loss . Major risks of induced hypotension are a reduction in blood flow ( i.e. ischaemia ) of vital organs ( brain , myocardium ) and elevation of intracranial pressure in neurosurgical patients . Thus , major contraindications of induced hypotension are severe coronary artery disease , hypertension combined with arteriosclerosis of cerebral vessels and increased intracranial pressure in patients with cerebral disease . Complications are rare in otherwise healthy patients , but may be higher in elderly patients and those with underlying organ dysfunction . Therefore , careful assessment and selection of patients , together with consideration of the potential complications , appropriate choice of drugs and invasive beatby-beat monitoring , are essential for the safe practice of induced hypotension ."
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"Postoperative vomiting is induced by different mechanisms such as age , anaesthetic technique and medications , postoperative analgesia , and surgical traction on the extra-ocular muscles . The influence of anticholinergic premedication and the use of benzodiazepines as factors affecting the incidence of vomiting is controversial . In a prospective , randomised , single-blind study we examined two different treatments with regard to postoperative pain , vigilance , and vomiting in young children undergoing strabismus repair . Methods . After institutional ethical committee approval , informed written consent was obtained from all parents . The children were randomly assigned to three groups : ( 1 ) paracetamol ( P ) - 17 patients who received 250-500 mg paracetamol rectally ( dependent on body weight ) immediately after intubation of the trachea ; ( 2 ) bupivacaine ( B ) - 17 patients who received two drops 0.5% bupivacaine hydrochloride on the conjunctiva of the eye ( s ) being corrected following intubation of the trachea and again 10 min after intubation . After the surgeon had exposed the extra-ocular muscle and before readaptation of the conjunctiva , two drops of the same solution were applied again each time directly on the muscle ; and ( 3 ) controls ( C ) - 16 patients who received rectal paracetamol after completion of the operation but before extubation . The children were premedicated with 0.05 mg/kg flunitrazepam sublingually . After 0.25 mg atropine i.v. , anaesthesia was induced with 0.1 mg/kg vecuronium , 5 mg/kg thiopentone , 1.5 vol% enflurane , and N2O/O2 50:50 . When the trachea was intubated anaesthesia was maintained with enflurane as required and 70% N2O in oxygen . Extubation was performed only if the patient could touch or did not tolerate the tube . Oral diet was allowed 6 h after extubation at the earliest . Examination of vigilance and analgesia . The degrees of vigilance and pain were evaluated preoperatively and after extubation over 24 h using two different scales . Evaluation of the scales was performed during the first 3 postoperative h at 12 different time points ( Figs . 1 , 2 ) and 6 , 12 , and 24 h after extubation . The evaluation was conducted by nursing staff who were blinded to the treatment ( single-blind study ) . Postoperative analgesia consisted of 250-500 mg rectal paracetamol ( all patients ) . Parametric data were expressed as mean +/- SD , and comparisons were made with the one-way analysis of variance . Fisher's exact test was applied to ordinal data . P 0.05 indicates a statistically significant difference . Results . Two patients ( P ) were excluded from the study postoperatively because of refusing rectal paracetamol in spite of pain and postoperative infection of the upper airways , which had manifestated on the afternoon of the operative day . No significant differences were found between the three groups in patient characteristics ( Table 1 ) . The quantity of enflurane administered , rate , postoperative consumption of rectal paracetamol , and postoperative emesis were highest in the control group ( Tables 2 , 3 ) , but the incidence of postoperative vomiting ranged only between 13% and 24% ( Table 3 ) . Children with preoperative paracetamol needed more time to fulfill the criteria to \" stick out the tongue \" and \" recognising the mother \" . Vigilance . The time to postoperative crying or screaming and restlessness was shorter in the control group . The values reached significant difference at 10 min ( P ) and 25 min ( P and B ) after extubation compared with the other groups ( Fig . 1 ) . Analgesie . At 5 , 10 , and 150 min after extubation pain was significantly higher in patients in the control group ( Fig . 2 ) . Conclusions . Intraoperative administration of rectal paracetamol or topical 0.5% bupivacaine was most effective in the treatment of postoperative pain for strabismus surgery in younger children ."
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DerAnaesthesist.50440328.eng.abstr | DerAnaesthesist.50440328.eng.abstr | [
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"id": "DerAnaesthesist.50440328.eng.abstr-passage-0",
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"In animal models authors have dealt with the question of whether hypotension alone can cause an acute-phase response even in the absence of marked blood loss and trauma . Sodium nitroprusside ( SNP ) , which was employed in the animal models , is also used to induce hypotension in humans . Since no data are available on human subjects plasma concentrations of interleukin-6 ( IL-6), an important mediator of the acute-phase response , were studied in patients during SNP infusion for induction of hypotension ."
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DerAnaesthesist.50440345.eng.abstr | DerAnaesthesist.50440345.eng.abstr | [
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"Gamma-hydroxybutyric acid ( GHB ) is a naturally occurring transmitter in the mammalian brain , related to sleep regulation and possibly to energy balance in diving or hibernating animals . It has been used for almost 35 years as an intravenous agent for induction of anaesthesia and for long-term sedation . Its convincing pharmacological properties , without serious adresse effects on circulation or respiration , are compromised by its unpredictable duration of action . This is not a major problem with long-term sedation during ICU treatment . GHB has been used with good results for sedation of patients with severe brain injury , where it compares favourably with barbiturates . In animal studies , it seems to possess a protective action against hypoxia on a cellular and whole organ level . However , in some experimental animals GHB has been shown to produce seizure-like activities , and the compound is being used to produce absence-like seizures . GHB has been used in our ICU for years to provide adequate sedation for patients under controlled ventilation or for patients figthing the respirator during spontaneous respiration . No serious side effects were observed in these patients , while in some patients under haemodialysis hypernatraemia and metabolic alkalosis developed ; both were reversible after discontinuation of GHB and restriction of additional sodium input ( Somsanit , the commercially available GHB preparation in Germany , contains 9.2 mmol sodium/g ; the daily dose averages 20-40 g GHB , i.e. 180-370 mmol sodium ) ."
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"The occurrence of severe head injury , isolated or in connection with polytrauma , is a challenge for all physicians working in emergency care at the scene of an accident or afterwards in hospital care . It is an advantage to have a basic knowledge of neurological assessment . The Glasgow Coma Scale is widely used in this context ; we refer to mild , moderate , and severe injuries . It is very important to recognise concomitant injuries , which occur in about 40% of cases . As coexisting hypoxaemia and hypotension have an adverse effect on the time course of head injury by inducing secondary brain damage , it is essential in therapy to quickly restore the vital body functions . Unconscious patients are tracheally intubated and ventilated . Forced hyperventilation over a lengthy period seems to have an unfavourable effect on outcome . Anaesthetic drugs and adjuvant therapies are used that do not increase intracranial vessel diameter and consequently intracranial pressure ( ICP ) . This applies to all i.v. anaesthetics , sedatives , and opioids , as long as no respiratory depression occurs . Ketamine has been useful for many years at the scene of an accident . An existing low blood pressure ( BP ) is raised while a significantly increased BP is moderately lowered . It is necessary to have adequate cerebral perfusion pressure ( CPP ) , which is defined as mean BP minus ICP . In cases of polytrauma with heavy bleeding , e.g. , from the liver or spleen , the blood loss must be stopped before the neurosurgeon begins . Excessive i.v. administration of Ringer's lactate should be avoided . Today , the routine use of osmodiuretics , e.g. , mannitol , is not indicated . It has not yet been possible to show that using corticosteroids is definitely beneficial in human brain trauma ; there may be a positive effect in connection with spinal trauma . New therapies are being investigated , such as increasing CPP , administering AMPA/NMDA-antagonists , 21-aminosteroids , or hypertonic-hyperoncotic solutions . However , they have not as yet been proven effective for general clinical use or clinical use et al."
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"Pregnancy causes substantial changes in the cardiovascular system : cardiac output ( 40%-50% ) and blood volume ( 40% ) increase whereas systemic peripheral resistance and arterial pressure decrease . The rise in progesterone and estrogen levels accompanying pregnancy stimulates the renin-angiotension-aldosterone system . Increased prostaglandin production follows renin activation ; simultaneously , the arterial vessels show diminished angiotension sensitivity . The result is pronounced vasodilatation . Heart disease remains the most important nonobstetric cause of maternal death . The physiological changes in the cardiovascular system during pregnancy influence cardiac diseases in different ways . Pregnancy , labor , and delivery appear to be well tolerated in gravidae with an atrial septal defect , ventricular septal defect , and patents ductus arteriosus . Sometimes congestive heart failure occurs and appropriate medical therapy is necessary . Pregnant women with uncorrected cyanotic congenital heart disease ( Eisenmenger's syndrome , tetralogy of Fallot ) constitute a high-risk group because of right ventricular insufficiency and hypoxic attacks . The consequences for anaesthesia in parturients with congenital heart disease are discussed . The symptoms of acquired mitral or aortic stenosis are aggravated by the physiological changes in the cardiovascular system during pregnancy ; the clinical symptoms of valve insufficiency are ameliorated by vasodilatation . Peripartum cardiomyopathy clinically shows similar features to idiopathic dilated cardiomyopathy . The basis of treatment is the same as that of congestive heart failure , with the therapeutic spectrum ranging from diet to heart transplantation . Women with hypertrophic cardiomyopathy tolerate pregnancy , labor , and delivery surprisingly well . Vaginal delivery is possible , but epidural anaesthesia is contraindicated . Hypertensive disorders associated with pregnancy are classified into three groups : chronic , treatment , and preeclamptic hypertension . Whereas chronic and transient hypertension do not affect the outcome of pregnancy appreciably , pre-eclampsia presents a potential danger to mother and fetus . Pre-eclamptic hypertension is accompanied by low cardiac output and plasma volume . An upregulation of angiotension receptors enhances vascular reactivity , with the consequence of high peripheral resistance . For antihypertensive therapy hydralazine , -methyldopa , and magnesium sulfate are the drugs of choice . A generalised recommendation of anaesthesia for the pre-eclamptic gravida cannot be made because both general and epidural anaesthesia have risks of severe side effects ."
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"The quality , result , and prognosis of neurosurgery relies heavily on the anaesthetic technique . Many different classes of drugs have been used during neurosurgical anaesthesia . This article reviews the use of intravenous ( IV ) propofol as an alternative to volatile anaesthetic techniques . Anaesthesia requirements for neurosurgical procedures are elaborated upon in the first part of the article . The priority of neuroanaesthesia is to preserve neuronal function by avoiding complications such as hypoxia , hypercarbia , and cardiovascular instability . Thereafter , the chosen anaesthetic technique should minimally interfere with cerebral autoregulation and CO2 responsiveness , while brain relaxation is encouraged by decreasing the cerebral metabolic rate for oxygen ( CMRO2) and cerebral blood flow ( CBF ) . In addition , the anaesthetic technique should be associated with rapid and predictable recovery in the operating theatre in order to allow early evaluation of the surgery . The second part of the article describes IV techniques for neurosurgery as an alternative to volatile anaesthetics , all of which increase CBF , cerebral blood volume , and intracranial pressure ( ICP ) in a dose-related manner and diminish cerebral autoregulation and interfere with cerebrovascular CO2 reactivity . Nitrous oxide has a stimulant effect on cerebral metabolism and is associated with an increase in CBF . On the other hand , all IV agents except ketamine are associated with decreases in CMRO2 and are cerebral vasoconstrictors . For this reason , it is rational to use them for the induction and maintenance of anaesthesia for neurosurgery as part of a total IV anaesthetic technique . The third part of the article focuses on propofol as the newest representative of IV anaesthetics . It is a sedative-hypnotic agent that has a pharmacokinetic-dynamic profile ideally suited for continuous infusion . Propofol reduces ICP , CBF , and CMRO2. Animal models have suggested the possibility of cerebral protection . The responsiveness of the cerebral circulation to alterations in arterial blood pressure is maintained . Evaluating propofol for major neurosurgery demonstrated good quality and depth of anaesthesia , excellent brain relaxation , and minimal surgical bleeding . In conclusion , total IV anaesthesia with propofol has proven to be a valid alternative to conventional thiopentone-isoflurane anaesthesia for intracranial surgery ."
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DerAnaesthesist.50440417.eng.abstr | DerAnaesthesist.50440417.eng.abstr | [
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DerAnaesthesist.50440423.eng.abstr | DerAnaesthesist.50440423.eng.abstr | [
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DerAnaesthesist.50440436.eng.abstr | DerAnaesthesist.50440436.eng.abstr | [
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"The absorption of large volumes of irrigation fluid is a major problem in transurethral prostatic surgery ( TUR-P ) . Various indicators have been tested to monitor fluid absorption with regard to continuous registration and sufficient accuracy . The volumetric fluid balance is not suitable as a routine method because of its inaccuracy . Easily accessible parameters are unspecific because of surgical bleeding ( haematocrit [ Hct ] ) , or are interfered with by physiological counter-regulatory actions ( serum sodium [ Na ] concentration ) . In 1986 Hulten et al. suggested adding 2% ethanol to the irrigation fluid as a marker and investigated it intermittently in the expired air with an alcohol-test appliance . In a prospective clinical study of 17 patients undergoing TUR-P under spinal anaesthesia , expiratory concentrations of alcohol that was added to the irrigation fluid ( 2% ethanol in Purisole , Fresenius , Bad Homburg ) were monitored . Gas was continuously sampled from the nasopharynx through a nasal cannula and the ethanol concentration was measured using a modified diverting anaesthetic gas monitor ( Normac , Datex , Helsinki ) that allows continuous as well as early detection of the absorbed irrigation fluid with reliable accuracy for clinical use . In addition , at intervals of 10 minutes we measured blood alcohol , endtidal alcohol ( Alcotest 7110 , Drauml ; ger , Luebeck ) , haematocrit , serum Na concentration , and blood gases . Sixty-eight measurements were obtained from the 17 patients . As shown in other studies , serum Na ( r2 = 0.68 ) and Hct ( r2 = 0.39 ) correlated poorly with the irrigation fluid as determined by serum alcohol levels . In contrast , the expiratory alcohol measurements with the alcotest 7110 ( r2 = 0.93 ) and Normac devices ( r2 = 0.85 ) were closely related . Continuous monitoring of the expiratory alcohol concentration with a Normac monitor closely reflects blood alcohol concentrations , and may hence serve as a useful semiquantitative monitor of irrigation fluid absorption during TUR-P ."
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"Patients and methods . We have studied mid-latency auditory evoked potentials ( MLAEP ) during general anaesthesia with sufentanil in ten patients scheduled for elective major urological surgery . Anaesthesia was induced with sufentanil 2-3 µg/kg; for maintenance of anaesthesia a further bolus of sufentanil ( 1-2 µg/kg) 10 min before the start of surgery ( skin incision ) was given . MLAEP were recorded before and 10 min after the last sufentanil bolus on the vertex ( positive ) and mastoids on both sides ( negative ) . Latencies of the peaks V , Na , Pa , Nb , and P1 ( ms ) and amplitudes Na/Pa , Pa/Nb , and Nb/P1 ( µV) were measured ."
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DerAnaesthesist.50440483.eng.abstr | DerAnaesthesist.50440483.eng.abstr | [
{
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"Friedreich's disease is a very rare neurological disorder that causes degeneration of the posterior roots of the spinal nerves and progresses to the anterior roots , even in young adults . Hospital emergency teams face the question of choice of anaesthesia in such patients should general anaesthesia be preferred to regional anaesthesia . We report a 36-year-old patient with spino-cerebellar heredoataxia ( Friedreich's disease ) who underwent a proctological procedure after administration of spinal anaesthesia with 3 mg hyperbaric bupivacaine in a sitting position . Both the intra- and post-operative courses were unremarkable ; in particular , with regard to the underlying neurological disease , no complications were observed ."
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DerAnaesthesist.50440486.eng.abstr | DerAnaesthesist.50440486.eng.abstr | [
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DerAnaesthesist.50440545.eng.abstr | DerAnaesthesist.50440545.eng.abstr | [
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"After cardiac surgery , transient renal dysfunction often occurs . Regional differentiation of these processes is possible only using invasive techniques , including renal biopsy . Approximately 30 different plasma protein components have been identified in the urine of healthy individuals by means of qualitative and quantitative immunochemical methods . The detection of microalbuminuria has high diagnostic relevance for the early diagnosis of renal damage at a reversible stage . One typical urinary protein is Tamm-Horsfall protein ( THp ) . After histochemical staining of human kidney sections , activity is seen in the loop of Henle and initial distal tubule . The assay of -1 microglobulin ( MG ) in urine is considered one of the most efficient laboratory parameters for the diagnosis of tubular lesions . Serum concentrations of -1 MG are less dependent on extrarenal changes than are those of other low-molecular-weight proteins . -2 MG is also one of the standards used in recent years for diagnostic relevance . Urinary albumin excretion , normaly less than 30 mg per day , sometimes increases after glomerular damage . Some renal function tests are used daily in many intensive care units , e.g. creatinine clearance ( CCr ) or urea and sodium excretion . Renal dysfunction should , however , be further examined to localise regional damage and to seek new clinical standards in addition to the conventional tests ."
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DerAnaesthesist.50440581.eng.abstr | DerAnaesthesist.50440581.eng.abstr | [
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"Breathing filters or heat and moisture exchangers ( HME ) , which are placed between a tracheal tube and the Y-piece , allow reuse of breathing tubes without changing between operations . During low-flow and minimal-flow anaesthesia , condensed water accumulates in the breathing circuit . An evaluation of the volume of condensed water is given ( Fig . 1 ) . It may be possible that water flows onto the filter surface , for example , when the breathing tubes are lifted . The water permeability of such breathing filters and HME was tested . For the experiments , a commercial breathing circuit and ventilator ( Draeger Sulla 808+Ventilog) and patient model ( Fig . 2 ) were used ; 12 breathing filters/HMEs of different manufacturers were tested . Only 3 filters were not permeable to the test volume of 20 ml water . The authors suggest the water volume be checked routinely and the breathing tubes be emptied if necessary ."
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DerAnaesthesist.50440585.eng.abstr | DerAnaesthesist.50440585.eng.abstr | [
{
"id": "DerAnaesthesist.50440585.eng.abstr-passage-0",
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"text": [
"Adverse effects of resuscitation due to closed-chest cardiac massage are common , and the incidence is increased when an incorrect technique is used . Nevertheless , thrombolytic therapy of a myocardial infarction can become necessary even after cardiopulmonary resuscitation ( CPR ) . In these patients , the risk of thrombolytic therapy-induced bleeding is immanent ."
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DerAnaesthesist.50440631.eng.abstr | DerAnaesthesist.50440631.eng.abstr | [
{
"id": "DerAnaesthesist.50440631.eng.abstr-passage-0",
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0,
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{
"id": "DerAnaesthesist.50440634.eng.abstr-passage-0",
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"The following double-blind , randomised study dealt with three questions : ( 1 ) Is a multidimensional psychometric rating scale suitable for the measurement of mood before anaesthesia ? ( 2 ) What are the effects of the new benzodiazepine-like drug zolpidem on preoperative mood compared with phenobarbital ? ( 3 ) Is the combination with Promethazine suggestive ?"
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DerAnaesthesist.50440651.eng.abstr | DerAnaesthesist.50440651.eng.abstr | [
{
"id": "DerAnaesthesist.50440651.eng.abstr-passage-0",
"type": "abstract",
"text": [
"Oxygen radicals and oxygen radial mediators are thought to be important components in the development of acute lung injury , sepsis , and multiple organ failure . Injured patients , patients with pulmonary diseases , and multiple trauma patients also showed an elevated lipid peroxidation , indicating increased oxidant stress . N-Acetylcysteine ( NAC ) has been used as an antioxidant in a wide variety of experiments . NAC has been suggested to act by raising concentrations of cysteine , and hence glutathione , and by scavenging of oxidant species [ 1 , 11 , 17 , 29 ] . The present study was designed to investigate whether the application of NAC in intubated patients has an effect on concentrations of reduced glutathione in plasma and bronchoalveolar lavage fluid ( BAL ) and on the lipid peroxidation products malondialdehyde and conjugated dienes . Because NAC has been widely used as a mucolytic drug for the treatment of lung diseases , the influence on tracheobronchial mucus was studied , too ."
],
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"id": "DerAnaesthesist.50440651.eng.abstr-s3-t2",
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"id": "DerAnaesthesist.50440651.eng.abstr-s5-t3",
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"id": "DerAnaesthesist.50440651.eng.abstr-s5-t4",
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{
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{
"id": "DerAnaesthesist.50440651.eng.abstr-s5-t8",
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},
{
"id": "DerAnaesthesist.50440651.eng.abstr-s5-t9",
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DerAnaesthesist.50440700.eng.abstr | DerAnaesthesist.50440700.eng.abstr | [
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DerAnaesthesist.50440705.eng.abstr | DerAnaesthesist.50440705.eng.abstr | [
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"This case report describes cerebral monitoring of intracranial haemodynamics using transcranial Doppler sonography ( TCD ) and jugular bulb oxygen saturation ( SjO2) by fiberoptic jugular bulb oximetry during cardiac arrest following cardiac surgery involving cardiopulmonary bypass ( CPB ) . CPB for aortic valve replacement and coronary artery bypass grafting was performed in a 63-year-old patient previously operated upon for heart disease . Mean blood flow velocity was measured in the middle cerebral artery using a bidirectional 2 MHz TCD system . SjO2 was measured using a fiberoptic thermodilution catheter placed in the right jugular bulb via the right internal jugular vein under radiographic control . At the end of the operation , low cardiac output syndrome and cardiac arrest occurred , which required reopening of the thorax and cardiopulmonary resuscitation ( CPR ) until CPB could be resumed . Following extrathoracic cardiac resuscitation , systolic \" spikes \" , loss of the diastolic flow profile , and no increase in SjO2 were recorded by the monitors , indicating cerebral circulatory arrest . However , a normal flow profile with increasing diastolic portions and an increase in SjO2 to 52% were seen following optimisation of the open thorax cardiac resuscitation . This monitoring may be able to give information to optimise therapy during CPR to avoid ischaemic cerebral injury ."
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"The possibility that a patient during general anaesthesia is aware of the operation going on and aware of severe pain that might be remembered postoperatively must be very alarming to patients and anaesthetists alike . Furthermore , there is experimental evidence showing that conscious recall of intraoperative events is only the tip of an iceberg ; it seems very probable that there is even a higher incidence of unconscious perception during general anaesthesia . Therefore , the following stages of intraoperative awareness must be distinguished : ( 1 ) conscious awareness with explicit recall and with severe pain ; ( 2 ) conscious awareness with explicit recall but no complaints of pain ; ( 3 ) conscious awareness without explicit recall and possible implicit recall ; ( 4 ) subconscious awareness without explicit recall and possible implicit recall ; ( 5 ) no awareness . The incidence of conscious awareness with explicit recall and severe pain has been estimated at less frequent than 1/3000 general anaesthetics . Conscious awareness with explicit recall but no complaints of pain has been reported in the literature with an incidence of 0.5-2%. With 7-72% , conscious awareness without explicit recall and possible implicit recall shows a very wide range of variation and its occurrence probably depends on the anaesthetic drugs used . Subconscious awareness with possible implicit recall has an incidence of up to 80% , but there are many methodological problems in demonstrating implicit memory of intraoperative events . Reports of intraoperative awareness do not come exclusively from cardiac surgery and obstetrics , but also from all other operative specialities . Postoperatively , patients who experienced intraoperative awareness may develop a so-called post-traumatic stress syndrome . Symptoms involve re-experiencing the event awake or in dreams , sleep disturbances , depression , avoidance of stimuli associated with the event . The probability of the development of the post-traumatic stress syndrome seems to coincide with the experience of severe pain . When a patient complains of intraoperative awareness postoperatively the anaesthesiologist should discuss the event frankly with the patient . When the symptoms of the post-traumatic stress syndrome persist a psychotherapy should follow . Causes for intraoperative awareness may be : equipment failure , too-light anaesthesia , e.g. for a caesarean section or for emergency surgery in severely injured or polytraumatized patients , during cardiac surgery , bronchoscopy or difficult intubation . There is interindividual variability in anaesthetic effect ; for example , chronic drug or alcohol abuse or overweight may make increased anaesthetic doses necessary . They are at risk for intraoperative awareness . Some general anaesthetics or anaesthetic procedures , e.g. the combination of a relaxant and N2O, opioid mono-anaesthetics , or opioids combined with benzodiazepines , seem to involve a higher risk of intraoperative awareness than do volatile anaesthetics . The bases of litigation are medical malpractice , breach of contract by the anaesthesiologist or lack of informed consent from the patient . Therefore , patients who are at risk of intraoperative awareness should be given detailed information on this special risk before the operation ."
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DerAnaesthesist.50440761.eng.abstr | DerAnaesthesist.50440761.eng.abstr | [
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"Various in vitro models have been introduced for comparative examinations of post-dural-puncture trauma and measurement of liquor leakage through puncture sites . These models allow simulation of subarachnoid , but not of peridural , pressure . A new two-chamber-model realizes the simulation of both subarachnoid and peridural pressure and allows observation of in vitro punctures with video-documentation . Frame grabbing and ( computer-aided ) image analysis show new aspects of spinal puncture effects . Therefore , post-dural-puncture trauma and retraction can be objectively visualized by this method , which has not previously been demonstrated ."
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DerAnaesthesist.50440770.eng.abstr | DerAnaesthesist.50440770.eng.abstr | [
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DerAnaesthesist.50440785.eng.abstr | DerAnaesthesist.50440785.eng.abstr | [
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"For surgical removal of a malignant choroid melanoma , it is necessary to reduce systolic blood pressure to around 50-60 mmHg in order to prevent choroidal haemorrhages . However , blood pressure reduction is associated with the risk of cerebral ischaemia . We report a patient with a malignant choroid melanoma in whom waves I and II of the brainstem auditory evoked potentials ( BAEP ) disappeared during surgery under controlled arterial hypotension and hypothermia ( 31.1 ° C ) . The waves could be recorded again immediately after the mean arterial pressure was increased from 48 to 77 mmHg . The oesophageal temperature had dropped by 0.3 ° C at this time . The 2-channel electroencephalogram ( EEG ) showed no irregularities during this time period . A bilateral , reversible , apparently blood-pressure-dependent loss of waves I and II during arterial hypotension despite a normal EEG has to our knowledge not been previously described in the literature . The isolated loss of waves I and II with maintenance of waves III , IV , and V is unusual . The literature contains reports of acoustic neurinoma patients in whom only wave V could be recorded . This is regarded as an indication of continued impulse conduction despite the loss of waves I to IV . Others have observed a patient with temporary and reversible loss of BAEP wave I due to vasospasm of the internal auditory artery that apparently occurred during or shortly after manipulation of the internal auditory meatus . Assuming anatomic peculiarities in the blood supply to the generators of the BAEP waves , a stenosis of the basilar artery could be considered as the cause of the bilateral reversible loss of waves I and II . Another potential source could be the induced hypothermia , but this does not seem very likely because the patient's temperature was 0.3 ° C lower at the return of the waves than at their loss ."
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DerAnaesthesist.50440809.eng.abstr | DerAnaesthesist.50440809.eng.abstr | [
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DerAnaesthesist.50440863.eng.abstr | DerAnaesthesist.50440863.eng.abstr | [
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DerAnaesthesist.50440880.eng.abstr | DerAnaesthesist.50440880.eng.abstr | [
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"Acute respiratory distress syndrome ( ARDS ) is rare but beset with a high mortality rate . In recent years , however , a trend towards higher survival rates has been observed . High inspiratory oxygen concentrations , large tidal volumes , and high peak inspiratory airway pressures applied during mechanical ventilation have been identified as harmful to the lung and can contribute to the progression of ARDS . This had led to reconsideration of the sequelae of ventilatory therapy . Mechanical ventilation and other adjunctive strategies in ARDS have changed from the conventional approach aiming at normalisation of physiological ventilatory parameters to an elaborated approach that intends to protect the ventilated lung , prevent oxygen toxicity , recruit the infiltrated atelectatic and consolidated lung and reduce the anatomical and alveolar dead space . This new approach consists of various forms of pressure-controlled mechanical ventilation with PEEP and permissive hypercapnia , body position changes , and inhalation of nitric oxide . Should these procedures fail to improve impaired gas exchange , extracorporeal membrane oxygenation is an additional therapeutic option . None of these therapeutic procedures , however , has been tested against traditional standard treatment in a classical randomised controlled trial . The following review focuses on the latest insights into the pathophysiology , diagnosis , and treatment of ARDS ."
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DerAnaesthesist.60450019.eng.abstr | DerAnaesthesist.60450019.eng.abstr | [
{
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"Performed at the end of the mummification process , the \" mouth-opening \" ritual was a ceremony for the spiritual resurrection of the dead Pharaoh . The techniques used are astonishingly similar to modern emergency-room procedures . For example , the mouth-opening device was made of meteoric iron . In the Egypt of that time , the use of iron was very unusual and the higher levels of nickel in meteoric iron contributed to the stability of the instrument . There are other signs of medically sound methods in the mouth-opening ritual . Symbolically , the mummy's teeth were extracted , the eyes opened with a special device , and gold capsules inserted , perhaps in the sense of a breathing tube . There is a possibility that this ritual contains a forgotten synopsis of knowledge gained empirically in connection with the Egyptian cult of royal resurrection ."
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DerAnaesthesist.60450031.eng.abstr | DerAnaesthesist.60450031.eng.abstr | [
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"Sevoflurane is a \" new \" volatile inhaled anaesthetic . Owing to its lower blood-gas solubility coefficient , emergence from anaesthesia is faster with sevoflurane than with isoflurane , enflurane , or halothane . Sevoflurane undergoes metabolic biodegradation , releasing inorganic fluoride ions that could produce nephrotoxicity . In this study , we compared serum inorganic fluoride concentrations ( IFCs ) in patients receiving either sevoflurane or enflurane . Furthermore , indices of renal function were evaluated until the 3rd postoperative day ."
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DerAnaesthesist.60450047.eng.abstr | DerAnaesthesist.60450047.eng.abstr | [
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DerAnaesthesist.60450059.eng.abstr | DerAnaesthesist.60450059.eng.abstr | [
{
"id": "DerAnaesthesist.60450059.eng.abstr-passage-0",
"type": "abstract",
"text": [
"Portofemoro-axillary bypass systems are commonly used to treat adverse haemodynamic effects during the anhepatic phase of orthotopic liver transplantation ( OLT ) . However , low shunt flows may reduce the efficacy of these bypass systems . In order to improve veno-venous bypass management , a percutaneous cannulation technique ( PCT ) was used to insert large-bore catheters ( 21 F ) into the left femoral and subclavian veins . This study prospectively addresses the complications of the PCT in 195 adult patients undergoing 203 OLTs ."
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"This is a report of a case of a subdural haematoma with resulting paraplegia after attempted spinal anaesthesia . Epidural and subdural haematomas are rare complications after central neural blockade . The complication described here was the result of an unsuccessful attempt to puncture the spinal channel . The patient was a 72-year-old woman with a fracture of the left femoral neck , which it was intended to stabilize operatively . Findings that made lumbar spinal puncture difficult were severe overweight , and lordosis and scoliosis of the lumbar spine resulting from degenerative changes . Spinal anaesthesia was suggested because the patient had eaten shortly before and because she suffered from asthma . From the aspect of haemostasis no contraindications were present , and the anaesthesist was experienced in spinal anaesthesia even under difficult anatomical conditions . Several unsuccessful attempts were made to puncture the lumbar spinal channel while the patient was lying on her right side . It was also impossible to reach the spinal channel from a median or left paramedian approach . We used atraumatic pencil-point needles ( Sprotte gauge 24 , 90 mm ) . No blood was aspirated during any of the attempts . The surgical intervention was finally performed under a general anaesthetic in view of the urgency . No significant complications occurred during the operation , and no neurological abnormalities were observed immediately after or in the next 8 h after the operation . At 12 h after the operation a paraparesis was found caudal to L3. After this had been verified by radiological and neurological tests , neurosurgical decompression was carried out as quickly as possible . During the operation a distinct subdural haematoma without any detectable source of bleeding was discovered . Even after surgical revision and evacuation of the remaining haematoma it was not possible to reverse the paraplegia , in spite of rehabilitation measures . Despite a certain fragility of the vessel and pretreatment with pentoxifylline and thromboembolic prophylaxis with low-molecular heparin starting postoperatively , it must be assumed that a vessel accompanying one of the spinal nerves was punctured , possibly , the radiculomedullary vessel of Adamkiewicz . A similar case was published in 1988 by Parker . In the present case it must be assumed that the vessel was punctured during a paramedian approach in the area of the foramen intervertebrale , as the spinal channel was definitely not entered . Although this is an extremely rare complication , we conclude that close neurological controls are essential at least during the first 24 h after surgery , even after an unsuccessful attempt at central neural blockade ."
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"The current increase in the cost of health care must be considered as a severe threat to the prehospital emergency services system . Two examples have been selected - the patient with polytrauma and the patient in cardiac arrest - to demonstrate the dilemma between a need for objective data and the requirements of emergency patients . Study results obtained in trauma patients indicating that total prehospital time , including scene time , is correlated to patient outcome have led to the conclusion that at the scene treatment by emergency physicians may be dispensable . It has , however also been demonstrated that the time required for medical treatment at the scene is equivalent to 20% of the total scene time , thus representing only a fraction of the total prehospital time . Correlating the total prehospital time or scene time to outcome therefore appears absurd . The treatment principle of aggressive shock treatment in polytrauma needs critical reevaluation on the basis of results obtained by recent preclinical studies in patients with penetrating torso injuries . Small volume resuscitation could not be demonstrated to improve outcome in polytrauma patients , although a slight improvement in patients with brain injury may be assumed . Endotracheal intubation and early artificial ventilation are proven therapeutic principles in polytraumatized patients . Unfortunately , for ethical reasons randomised carefully controlled comparative studies can not be performed in polytrauma patients unless the patient is fully conscious . The importance of endotracheal intubation and artificial ventilation in unconscious trauma patients becomes apparent under conditions of anaesthesia where the application of the endotracheal tube averts regurgitation , aspiration and concomitant morbidity and mortality . The common causes of cardiovascular collapse and their pathomechanisms , as well as the mechanisms of cardiopulmonary resuscitation , have been widely investigated . Nevertheless , various aspects of their application are still controversial . The most recent study results have recommended initial ventilation prior to thoracic compression . New methods of assisting mechanical cardiopulmonary resuscitation , such as ACD CPR or vest CPR , have shown promising results in animal experiments . However , the importance of results obtained by preclinical randomised controlled investigations in humans need to be confirmed by further studies as to outcome . The efficacy of defibrillation in cases of ventricular fibrillation has been clearly demonstrated , particularly with a view to the interval between ventricular fibrillation and defibrillation . It has further been demonstrated that basic cardiopulmonary resuscitation preserves ventricular fibrillation and thus improves the chance of survival . The present generation of defibrillators has been further improved , particularly by the introduction of biphasic defibrillator wave forms , which may reduce the required energy , as well as possible complications , while offering an increase in the efficacy of defibrillation and a reduction in defibrillator size . Scientific emergency medicine is responsible not only for the development and validation of new methods and concepts , but in particular for their application under quality control conditions . Politicians require an improvement in the quality of the validation of emergency measures , although the instruments available for the investigation of these measures are known to be obsolete ( experimental models , experimental design ) . Additionally , the financial support of research in emergency medicine suffers from being accourded low priority by public research funds such as the German Research Fund . However , in view of the rapid application of experimental results to daily practice it should be emphasized that patients also support research in emergency medicine via their direct financial contributions to the health insurance companies ."
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"The era of modern anaesthesia in Germany began on January 24th , 1847. This day , professor in ordinary Johann Ferdinand Heyfelder anaesthetized a patient with sulphuric ether in the clinic of surgery and ophthalmology of the University of Erlangen . By March 17th , 1847 , Heyfelder had performed 121 surgical procedures under ether . The operations in majority were teeth-extractions , and a few more complex operations such as the treatment of a harelip or of lip cancer or the resection of the shoulder joint . Heyfelder described in detail 108 of these inhalations in a little book entitled The experiments with sulphuric ether . This monograph published in March , 1847 , represents one of the first complete dissertations on sulphuric ether in the German literature . In a special chapter he analyzed the development of various physiological and psychological parameters during etherization . Heyfelder also examined blood and urine of some etherized patients and reported that he did not find any important or specific alterations . In 1847 , Heyfelder was probably the first to apply salt-ether in man . After 4 administrations he concluded that salt ether acted more quickly but shorter than sulphuric ether . Advantageous were its application without problems and ease of induction . Disadvantageous were its high volatility , its price and the difficulty of getting it in a pure form . From December , 1847 , on Heyfelder started to use chloroform . He was now able to perform more major operations , for example the total resection of the hip-joint . In his book The experiments with sulphuric ether , salt ether , and chloroform he describes a great number of anaesthetic administrations using these 3 agents . In his summary Heyfelder concluded , that chloroform was undoubtly superior to sulphuric ether mainly because it was a quicker acting and longer lasting agent and leads to deeper narcosis . Moreover its application was much easier for it needed no special apparatus . However , because of its great anaesthetic potency , Heyfelder particularly demanded great caution in the application of chloroform . Explicitely he expected an assistant for chloroformizations , whose only duty was to supervise the inhalations and the patient - a forerunner of the modern specialized anaesthesiologist ."
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DerAnaesthesist.60450140.eng.abstr | DerAnaesthesist.60450140.eng.abstr | [
{
"id": "DerAnaesthesist.60450140.eng.abstr-passage-0",
"type": "abstract",
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"Desflurane is a new volatile anaesthetic with an extremely low blood/gas partition coefficient of 0.42. This should provide a rapid recovery from anaesthesia . Methods . We studied 100 adult patients , ASA class I or II , undergoing elective orthopaedic surgery randomly assigned to anaesthesia with desflurane ( n=50) or isoflurane ( n=50) supplemented by nitrous oxide in oxygen . Clorazepat was given for premedication , fentanyl and thiopental for induction of anaesthesia , followed by maintenance with desflurane or isoflurane as clinically appropriate . Emergence from anaesthesia was measured as well as return of cognitive functions ( extended Aldrete score , digit symbol substitution test , and visual analogue scales [ VAS ] ) . Results . While the demographic characteristics and administrated doses of fentanyl and thiopental were comparable , the recovery profiles in both groups were different . After discontinuation of the volatile anaesthetics , times to extubation and ability to follow simple commands were significantly shorter after desflurane than after isoflurane . Extended Aldrete scores , estimation of the patients ' physical condition , results of the digit symbol substitution test , measuring cognitive functions , and rates of drowsiness and weakness on VAS showed better recovery with less impairment of cognitive function in the desflurane group than in isoflurane patients even 120 min after anaesthesia . VAS pain scores and doses of analgesic drugs given within the first 2 postoperative hours , however , showed no significant differences . Desflurane patients were also judged fit for discharge from the recovery room significantly faster . Conclusions . Our results demonstrate that desflurane anaesthesia , even when supplemented by premedication , intraoperative opioids , and nitrous oxide may offer clinical advantages over isoflurane as far as the post-anaesthetic recovery profile is concerned ."
],
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"Since the introduction of propofol into clinical practice , dreaming during general anaesthesia has been frequently reported with this drug . We investigated the incidence and character of these dreams with regard to distinction from intraoperative awareness and in comparison with habitual dreams or dreams during general anaesthesia with enflurane . Method . A total of 230 patients ( ASA I-II ) undergoing minor elective surgery were randomly assigned to one of two groups . Both groups received the same premedication ( 1 mg flunitrazepam ) the previous evening . After induction using etomidate 2 mg/kg , anaesthesia in group I was maintained using 0.8%-1.5% enflurane supplemented in the sense of \" balanced anaesthesia \" with fentanyl , vecuronium , and nitrous oxide . Anaesthesia in group II was induced with propofol 2 mg/kg . After a saturation phase of approximately 10 mg/kg - h , 5-6 mg/kg - h was administered for maintenance supplemented by fentanyl , Vecuronium , and N2O as in group I. Interviews were conducted preoperatively , just after recovery from anaesthesia , and 24 h later . We inquired about preoperative fears or concerns , sensory perceptions , and the incidence and character ( pleasant , unpleasant , indifferent ) of habitual dreams . After recovery the patients were asked if they had had any conscious perceptions , whether they believe them to be dreams or reality , and repeated the preoperative questions as to common feelings and the character of sensory perceptions . Results . The two groups were not entirely comparable due to the distribution of sex and age , but we did not find any differences in preoperative grades of fear and incidence of dreams . Of the propofol patients , 60% dreamed intraoperatively versus 11% in the enflurane group . No evidence of any intraoperative awareness was found . Because of the low incidence of dreams in the enflurane group , a comparison of detailed information between the groups could not be provided . Except for 1 , all patients in the propofol group had very pleasant dreams compared to their habitual dreams ( 4.5% in the enflurane group ) . One day after surgery 37% of all patients in the propofol group remembered having dreamed intraoperatively . We did not found any correlation to the incidence of habitual dreaming , preoperative fear , age , sex , duration of anaesthesia , or total dose of propofol . Furthermore , intraoperative dreams differed from habitual dreams in character and content . Conclusions . We conclude that sensory experiences during propofol anaesthesia are not stimulus-related perceptions or awareness , but dreams similar to normal ones . In view of the absence of clear signs of stimulus-related response , we presume that dreaming is a specific side effect of propofol . Because of the absence of difficulties , dreaming during propofol anaesthesia appears not to be a disadvantage with regard to the quality of anaesthesia ."
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DerAnaesthesist.60450154.eng.abstr | DerAnaesthesist.60450154.eng.abstr | [
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DerAnaesthesist.60450171.eng.abstr | DerAnaesthesist.60450171.eng.abstr | [
{
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"A 3.5-year-old girl suffered from a thermal injury affecting 37% of the body surface area . The parents , being Jehovah's witnesses , refused permission for their child to receive blood transfusions . As the haemoglobin level was only 7.5% and a necrectomy was planned , the patient was likely to need blood transfusions . Indications for transfusion were defined as clinical signs of hypoxia and/or cardiovascular instability . A judicial declaration was proposed . Hb decreased during the therapy . To stimulate the erythropoiesis erythropoietin and iron were administered . During the clinical course the anaemia worsened . First , a conservative treatment with polyvidoniodine ointment for tanning was started , to avoid an operation during the acute phase after the injury , as in this case it was thought a blood transfusion would definitely be necessary . On the 19th day after the injury a necrectomy of 10% of the body surface was necessary because of fever and leucocytosis not responding to antibiotics . The most likely cause of the symptoms was an infection of the burned area . Hb was 4.6 g/dl%. General anaesthesia was performed with midazolam , ketamine and vecuronium and mechanical ventilation . No blood transfusion was required during the operation . Vital signs were stable during the preoperative period , during anaesthesia and following the operation . There were no signs of tissue hypoxia . Peripheral oxygen saturation ranged between 98% and 100% , lactate and arterial blood gas samples were normal , and the child was awake and cooperative before and after anaesthesia . The lowest Hb was 3.3 g/dl on the 22th day after injury ( 3rd postoperative day ) . In this phase the patient was still playing and riding a tricycle . On the 45th day after injury the child was discharged home with Hb of 10.9 g/dl and reticulocytosis of 33% ."
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DerAnaesthesist.60450231.eng.abstr | DerAnaesthesist.60450231.eng.abstr | [
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"Intraoperative paradoxical air embolism may occur even if a patent foramen ovale ( PFO ) is excluded by contrast transoesophagal echocardiography ( TEE ) under 20 cmH2O positive airway pressure . It is questionable whether the combination of PEEP and ventilation with a large tidal volume increases the sensivity of contrast TEE in detecting a PFO . Methods . Eighty healthy patients ( ASA status I , II ) scheduled for surgery in the supine position and ranging from 25 to 72 years of age were investigated by TEE , which was performed in the biatrial viewing mode ( short axis ) . Echocardiographic contrast ( 10 ml agitated gelatine solution ) was injected during two different ventilation manoeuvres . Manoeuvre I : Contrast injection during the application of 20 cmH2O positive airway pressure for 5 s. The pressure was released when the right atrium became completely opacified by echo targets . The injected bolus was observed throughout the ventilatory cycle , with special attention being given to early expiration and systole . A right-to-left shunt was assumed if five echo targets were observed in the left atrium . Manoeuvre II : Contrast injection during ventilation with PEEP ( 15 cmH2O), a tidal volume of 1,200 ml , and a respiratory rate of 6/min. Results . The frequency of a PFO causing a right-to-left interatrial shunt was 8.7% ( 7 cases ) in manoeuvre I and 15% ( 12 cases ) in manoeuvre II . In one case a PFO was diagnosed intraoperatively by chance . Discussion . The use of provocation manoeuvres including ventilation with PEEP and high tidal volumes might improve the ability to detect a PFO presenting with right-to-left interatrial shunt by intraoperative contrast TEE , but does not have 100% sensitivity . However , our results clearly indicate that ventilation with PEEP and high tidal volumes may predispose to paradoxical embolism ."
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Subsets and Splits