The cerebellar bioenergetic state predicts treatment response in COQ8A-related ataxia.

INTRODUCTION: Primary coenzyme Q10 (CoQ10) deficiency, a recessive disorder associated with various defects of CoQ10 biosynthesis and widely varying clinical presentation, is customarily managed by oral Q10 supplementation but the benefit is debated. METHODS: To address this question, we mapped individual responses in two patients with COQ8A-related ataxia following coenzyme Q10 supplementation using noninvasive imaging. Metabolic 31phosphorus magnetic resonance spectroscopy imaging (31P-MRSI) and volumetric cerebellar neuroimaging were performed to quantify the individual treatment response in two patients with COQ8A-related ataxia, each compared with eight age- and gender-matched healthy control subjects. RESULTS: Post-treatment change in energy metabolite levels differed in the two patients, with higher energy levels and improved dysarthria and leg coordination in one, and decreased energy levels without clinical benefit in the other. CONCLUSIONS: Our results suggest that the cerebellar bioenergetic state may predict treatment response in COQ8A-related ataxia and highlight the potential of pathophysiology-orientated neuroimaging evidence to inform treatment decisions.

Indication for resuscitative thoracotomy in thoracic injuries-Adherence to the ATLS guidelines. A forensic autopsy based evaluation.

BACKGROUND: The appropriate indications for Resuscitative Thoracotomy (RT) are still debated in the literature and various guidelines have been proposed. This study aimed to evaluate whether Advanced Trauma Life Support (ATLS) guidelines for RT were applied correctly and to evaluate the proportion of deceased patients with potentially reversible thoracic lesions (PRTL). METHODS: The database at the Department of Forensic Medicine at Copenhagen University was queried for autopsy cases with thoracic lesions indicated by the SNOMED autopsy coding system. Patients were included if thoracic lesions were caused by a traumatic event with trauma team activation. Patient cases were blinded for any surgical intervention and evaluated independently by two reviewers for indications or contraindications for RT as determined by the ATLS guidelines. Second, autopsy reports were evaluated for the presence of PRTL. RESULTS: Sixty-seven patients met the inclusion criteria. Two were excluded due to insufficient data. The overall agreement with guidelines was 86% and 77% for blunt and penetrating trauma, respectively. For patients submitted to RT the overall agreement with guidelines was 63% being 45% and 74% for blunt and penetrating trauma, respectively. For patients who did not undergo RT the agreement with guidelines was 100%. In all cases where RT was performed in agreement between guidelines and the clinical decision the autopsy reports showed PRTL in 16 (84%) patients. In cases of non-agreement PRTL were found in 9 (82%) patients. CONCLUSIONS: Agreement with ATLS guidelines for RT was 63% for intervention and 100% for non-intervention in deceased patients with thoracic trauma. Agreement was higher for penetrating trauma than for blunt trauma. The adherence to guidelines did not improve the ability to predict autopsy findings of PRTL. Although the study has methodical limitations it represents a novel approach to the evaluation of the clinical use of RT guidelines.

Distributions of local oxygen saturation and its response to changes of mean arterial blood pressure in the cerebral cortex adjacent to arteriovenous malformations.

BACKGROUND AND PURPOSE: To test the hypothesis that neither "steal" as cortical ischemia caused by reduced perfusion pressure nor "breakthrough" on the grounds of loss of pressure autoregulation exist in brain tissue surrounding arteriovenous malformations (AVMs), we established patterns of cortical oxygen saturation (SO(2)) adjacent to AVMs and its behavior after alterations of mean arterial blood pressure. METHODS: With a microspectrophotometer, SO(2) was scanned in the cortex around AVMs of 44 patients before and after resection and in that of a non-AVM group (n=42) before transsylvian dissection. Autoregulation was evaluated by linear regression analysis after elevation of mean arterial blood pressure (5 microg/min IV noradrenaline). SO(2) values were calculated as medians, percentage of critical values (<25% SO(2)), and coefficients of variance (approximate heterogeneity of SO(2) distributions). All values are given as mean+/-SD. RESULTS: Forty patients with AVM had an uneventful postoperative course (group A). Four hyperemic complications ("breakthrough") occurred (group B). Autoregulation was tested intact in all groups at all times. Preoperative SO(2) distributions in groups A and C (non-AVMs) were identical. In group B, significantly (P<0.05) lower medians (group A, 52.9+/-16.3%; group B, 44.2+/-17.1%; group C, 51.9+/-11.5% SO(2)), more critical values (group A, 6.5+/-5.1%; group B, 14.7+/-11.1%; group C, 7.1+/-4.9%), and heterogeneous SO(2) distributions (group A, 20.2+/-12.7%; group B, 27.9+/-12.4%; group C, 26.8+/-10.9%) were seen. Increase of median values was significantly higher in group B (76.3+/-10.4% SO(2)) than in group A (65.9+/-13.4% SO(2)) after resection. CONCLUSIONS: Severely hypoxic areas are uncommon in the cortex adjacent to AVMs and occur predominantly in patients prone to hyperemic complications. Reduced perfusion pressure is compensated in most cases, and moderate hyperemia prevails after excision. Reperfusion into unprotected capillaries of severely hypoxic cortical areas results in "breakthrough," for which vasoparalysis appears not to be the underlying mechanism.

[Concentration-dependent changes in the latency and amplitude of somatosensory-evoked potentials by desflurane, isoflurane and sevoflurane]. / Konzentrationsabhängige Veränderungen der Latenz und Amplitude somatosensorisch evozierter Potentiale durch Desfluran, Isofluran und Sevofluran.

PURPOSE: Comparison of the influence of desflurane, isoflurane, and sevoflurane on the parameters of cortical somatosensory evoked potentials (SEP). METHODS: A total of 41 patients were randomly allocated to either the isoflurane, desflurane or sevoflurane group. Following induction with propofol and intubation, concentration of the volatile anaesthetic was kept constant at 1.3, 1.0, and 0.7 MAC for 15 minutes each in randomised sequences. No opioids or N2O were used. Cortical somatosensory evoked potentials were recorded following median nerve stimulation at the wrist with 1.5 times motor threshold current. SEP were evaluated for latencies of peak N20 and P25 as well as peak-to-peak amplitude N20P25. Measurements at the end of the 15 minute equilibration intervals were compared by analysis of variance for repeated measurements. Latencies and the logarithm of the amplitudes were assumed to be normally distributed. RESULTS: SEP could be recorded in all patients and at all concentrations. Latency of cortical SEP increased with anaesthetic concentration in a linear manner. No differences in latency increase were found between the three anaesthetics (ANOVA). In contrast, the decrease in amplitude with increasing anaesthetic concentration was non-linear. It was large from control to 0.7 MAC, but small in the range between 0.7 and 1.3 MAC. Amplitude reduction was larger with isoflurane than with sevoflurane or desflurane. CONCLUSION: 1) Sevoflurane and desflurane are better suited for anaesthetic management during intraoperative electrophysiological monitoring than isoflurane, because SEP amplitudes are better preserved. 2) SEP amplitude is less altered by changing anaesthetic concentrations in the concentration range from 0.7 to 1.3 MAC than SEP latency.

Relation between sodium balance and menstrual cycle symptoms in normal women.

OBJECTIVE: To determine whether sodium balance affects expression of menstrual symptoms. DESIGN: Prospective study of menstrual symptoms during three cycles: a baseline month (usual intake of sodium, 115 mmol/d) followed by 2 months of sodium restriction (intake of sodium, 73.0 mmol/d). Added salt was allowed during the last month. Investigators were aware of the diet sequence. SETTING: Outpatient. Meals were prepared by a metabolic kitchen during the 2 months that the participants received salt-restricted diets. PARTICIPANTS: 13 healthy menstruant women. MEASUREMENTS: Plasma sodium levels, urinary sodium excretion, and plasma renin activity were measured for five time periods during the baseline cycle and the two cycles of salt-restricted diet. Eleven women completed a questionnaire assessing somatic symptoms and sensory cravings at the same time every day during the 3-month study period. RESULTS: Sodium restriction was associated with a mean decrease (+/- one half of the 95% CI) in plasma sodium levels of 0.9 +/- 0.9 mmol/L from a mean of 139.3 mmol/L during the baseline cycle (P = 0.018), a decrease in urinary sodium excretion of 40.3 +/- 18 mmol/d from a mean of 117 mmol/d during the baseline cycle (P = 0.001), and an increase in plasma renin activity of 0.14 +/- 0.08 ng/(L . s) from a mean of 0.28 ng/(L . s) during the baseline cycle (P = 0.008). During the luteal phase of the sodium restriction cycle, significant decreases in plasma sodium levels of 1.23 +/- 0.5 mmol/L (from values of 138.8 mmol/L during the follicular phase) and increases in urinary sodium excretion of 27.2 +/- 10 mmol/d (from values of 65.5 mmol/d during the follicular phase) preceded periods when menstrual symptoms were most severe. Ratings of breast tenderness increased sixfold to eightfold in the late luteal phase (P < 0.001) and those of swelling or bloating increased twofold to threefold during early menses (P < 0.001) compared with nadir symptom ratings during each cycle. Sodium cravings increased in the luteal phase of all cycles but were not accompanied by increased sodium intake when access to added salt was allowed. CONCLUSIONS: Breast tenderness and bloating did not result from sodium retention in the luteal phase of the menstrual cycle. During normal and sodium-restricted diet cycles, women actually had urinary sodium loss, not retention, during the luteal phase; severity of menstrual symptoms was unchanged.

[Profile of the effect of succinylcholine after pre-curarization with atracurium, vecuronium or pancuronium]. / Das Wirkungsprofil von Succinylcholin nach Präcurarisierung mit Atracurium, Vecuronium oder Pancuronium.

OBJECTIVE: The depolarizing muscle relaxant succinylcholine (SCh) may cause several side effects including muscle fasciculations and postoperative myalgia. These can be attenuated or even prevented by prior administration of a non-depolarizing muscle relaxant. A study was conducted to detect any difference between clinically established approaches concerning the successful prevention of muscular side effects and the influence on the time profile of SCh action. METHODS: The study included 64 patients (ASA status I or II) who underwent elective surgery under general anesthesia. The patients were divided into four groups; the demographic data did not differ significantly between the groups (see table 1). Before the injection of SCh (1 mg/kg) for intubation, the control group received saline (K), the other groups 5 mg Atracurium (A), 1 mg Vecuronium (V), or 1 mg Pancuronium (P), respectively. Neuromuscular block was quantified after train-of-four (TOF) stimulation of the tibial nerve by accelerometry at the toe. The first response was used to determine the onset time, duration of effect, and recovery index. It was noted whether SCh led to muscular activity. Postoperatively, patients were asked whether they experienced any muscular sequelae. Statistical significance was assessed at the 5% probability level by the Mann-Whitney-U test and the CHi2 test (Fisher's exact test, if appropriate). RESULTS: SCh caused a complete neuromuscular block in all patients. Most patients in the control group exhibited muscular contractions than in the other groups (see table 2), but only two patients reported light myalgia. There was no statistically significant difference between the four groups in the onset time and the recovery index of SCh. The duration of the effect was significantly reduced by atracurium (7.5 min) or vecuronium (8.2 min) as compared to the placebo (11.8 min) and pancuronium (13.5 min) (see figure). CONCLUSION: The prolonged duration of the SCh effect after pancuronium is probably due to the known inhibition of cholinesterase by pancuronium. The short duration of action after Atracurium and Vecuronium can be explained by the competitive antagonism at the receptor causing an increased amount of unbound SCh. The duration of the SCh effect may be influenced according to clinical needs by the choice of the non-depolarizing muscle relaxant. The significantly reduced duration of complete neuromuscular block after Atracurium or Vecuronium as precurarizing agents may be advantageous in cases where a fast recovery of spontaneous breathing is essential. If a reduction of the SCh blockade has to be avoided, Pancuronium should be selected for prior administration.

[Objective quantification of spinal anesthesia by somatosensory evoked potentials after tibial nerve stimulation]. / Objektive Quantifizierung einer Spinalanästhesie durch somatosensorisch evozierte Potentiale nach Tibialis-Stimulation.

Eight patients (ASA status I) who had to undergo minor surgery of the knee received spinal anaesthesia by 80 mg hyperbaric mepivacaine. Clinical parameters of the block were compared with somatosensory evoked potentials (SEP) after tibial nerve stimulation. Depending on the degree of nervous block, the early components P40, N50 and P60 of the cortical tibial SEP underwent characteristic changes. After the injection of the local anesthetic, the latencies of the early components rapidly increased. The tibial SEP completely disappeared after 15 min (median). At this time pin prick testing revealed a complete somatosensory block in the corresponding dermatomes. With one exception, motor block was also complete. After 115 min (median) the early components could be recorded again, with latencies significantly increased. The maximum latency shifts were 22.2% (P40), 19.6% (N50), and 11.8% (P60). When the latencies recovered to less than 10% of the starting value, anaesthesia became clinically insufficient. The recovery of the afferent pathway was complete within 5 hours. Because of the good correspondence with the clinical blockade, the latency shift of P40, N50 and P60 is useful in objectively evaluating a spinal anesthesia with mepivacaine. The use of the method is limited by increased equipment and staffing requirements; however, it facilitates the development of optimised dosing strategies.

[Severe impairment of peritoneal cavity muscles in intensive care patients (comparative anatomic studies of respiration)]. / Die schwerwiegenden Störungen der Bauchhöhlenmuskulatur bei Intensivpatienten (vergleichende anatomische Untersuchungen zur Atmung).

The vital function respiration is kept up by the modifiable basal activity of the thin muscles of the abdominal cavity. The diaphragm is an important part of the respiratory muscular system. The muscular system of the 'splanchnocranium' exhibits a normal spontaneous activity, which is mostly open in the laryngeal region and mostly closed in the anorectal continence organ. In animals missing an abdomen, e.g. turtles, we find that the complete abdominal muscle system is connected to the lungs functioning as respiratory muscles. The most powerful lungs that exist are found in birds. Their lungs, which are situated in a stiff thorax are only ventilated through the air compartments, mostly by the abdominal muscles. By this, the role of abdominal muscles for respiratory function is shown. We studied intensive care patients requiring ventilatory support and found that the electromyogram of the external abdominal oblique muscle can be impaired or extinguished. In some cases the cause is a polyneuropathy, which can be reversible. In consequence, positioning measures, as prone positioning are capable of preventing progressive deterioration of ventilation/perfusion relationship.

Molecular analysis of mutations in thyroid tumors with TGGE.

Immunohistochemical demonstration of overexpression of the p53 protein indicates a mutational alteration of the gene. Our own investigations of 59 differentiated thyroid carcinomas revealed an overexpression in 15% of the tumors. A correlation to unfavourable tumor prognosis was found (stage I and II: 0/11 (0%); stage III: 4/26 (14%); stage IV: 5/22 (23%)). For screening of one out of more than 300 possible mutations temperature gradient gel electrophoresis was employed. Analysis of the highly-conserved regions of the p53 gene (exon 5 to 8) could demonstrate a mutation in only 1 out of 31 differentiated thyroid carcinomas. The question arises whether accumulation of the protein is due to a mutational event or rather other molecular mechanisms.

[Muscle relaxation with no effect on oxygen uptake during isoflurane anesthesia?]. / Muskelrelaxierung ohne Effekt auf die O2-Aufnahme bei Isofluran-Anästhesie?

To determine the effects of vecuronium neuromuscular blockade on O2 consumption (VO2) during isoflurane anaesthesia 12 patients were studied. 12 patients (ASA-PS I-II, 37.1 +/- 12.1 yr, 173 +/- 8 cm, 70.1 +/- 8.6 kg), scheduled for urological lower abdominal surgery, received isoflurane-N2O-O2-anaesthesia under steady-state conditions (1.3 MAC). Duration of anaesthesia was 169 +/- 32 min and 0.057 +/- 0.016 mg/kg/h vecuronium were needed. The desired level of neuromuscular transmission was set to 10% of control. This level of neuromuscular blockade was kept constant for 60 min by a negative feedback controlled infusion of vecuronium. VO2 was measured by an indirect calorimetry device (MMC Horizon, STPD). During and after recovery of neuromuscular function anaesthesia was maintained and oxygen measurements were continued. Preanaesthetic values of VO2 were in the predicted range for basal metabolism. Steady-state general anaesthesia lead to an 26-28% reduction of VO2 (Range: 144-232 ml/min) compared to the preanaesthetic values (202-288 ml/min, p < 0.01). Neuromuscular blockade showed no significant effect on O2 uptake. We conclude that in patients with adequate depth of anaesthesia vecuronium-induced neuromuscular blockade does not lead to a further reduction of oxygen consumption, since muscular tone is already reduced by general anaesthesia.

[A difficult intubation in a case of endolaryngeal paraganglioma]. / Erschwerte Intubation bei endolaryngealem Paragangliom.

In a female patient aged 71, a tumor of unknown histology almost completely occupied the whole of the supraglottic space. Because of the valve-like behaviour of the tumor, the patient could not be ventilated by mask. Therefore, preoxygenation and preservation of spontaneous breathing were essential. Anaesthesia was induced by titration of etomidate, and no muscle relaxant or opioid was administered. The patient was successfully intubated by means of direct laryngoscopy. In all probability the blind nasal technique or the use of a fiberoptic device would not have been helpful, because the tumor had to be luxated before the endotracheal tube could be placed. Figure 1 shows the tumor (a) with a diameter of approximately 3 cm, which has displaced the epiglottis (b) to the left. A part of the endotracheal tube is visible at the bottom left. The spiral tube had to be replaced by a tube suitable for laser surgery. After resection (see Fig. 2) the coagulated tumor base (a) and the right vocal cord (b) can be seen with the laser tube still in place. Postoperatively extubation was possible. The histological examination revealed a paraganglioma without signs of malignancy. Apart from occlusion of the upper airway, the main danger stems from the considerable vascularization of such a paraganglioma. Not only the surgical procedure, but also minor manipulations during the endotracheal intubation may cause significant blood loss. In a small percentage of cases hormone-mediated cardiocirculatory complications may occur. If a difficult intubation is expected because of an endolaryngeal tumor, management should be based on the diagnostic findings and the planned surgical procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of fallopian tube pregnancies with prostaglandins]. / Behandlung von Eileiterschwangerschaften mit Prostaglandinen.

In a study, the clinical use of prostaglandin F2 alpha in local and systemic application in women with ectopic pregnancies were studied (1, 9). Two different treatment schedules were defined and applied. In group A, patients with a diagnosed ectopic and beta-HCG level lower than 850 mIU/ml were treated with prostaglandin F2 alpha i.m. injected only. In group B, prostaglandin F2 alpha were injected in the chorionic cavity of the ectopic by laparoscopy after localisation with a thin needle. In spite of prostaglandin F2 alpha treatment, 6 of 30 patients (20.0%) had to be operated by microsurgery because of increasing serum beta-HCG levels. A control of tubal patency 6 month later showed one closed tube only (4.5%). Up to now, 8 spontaneous intrauterine pregnancies occurred in our study groups after successful prostaglandin F2 alpha treatment; one pregnancy was seen in a women with a single fallopian tube. The conserving treatment of one ectopic pregnancy using prostaglandin F2 alpha yields positive results, if serum beta-HCG levels are below 2000 mIU/ml.

Adaptive feedback-controlled infusion versus repetitive injections of vecuronium in patients during isoflurane anesthesia.

STUDY OBJECTIVE: To compare vecuronium requirements using repetitive injections and a model-based, closed-loop, feedback-controlled infusion during isoflurane anesthesia. DESIGN: Randomized open study. SETTING: Departments of Anesthesiology and Ear, Nose, and Throat Surgery at a university hospital. PATIENTS: Twenty-two patients of ASA physical status I or II undergoing elective otolaryngological surgery requiring general anesthesia. INTERVENTIONS: Vecuronium was used for muscle relaxation. The desired level of neuromuscular transmission was set to 10% of control. All patients received vecuronium 0.08 mg/kg for intubation. Thereafter, vecuronium was injected repetitively in 11 patients (Group 1) whenever spontaneous recovery had reached the 10% level. In the other group of 11 patients (Group 2), relaxation was maintained by an adaptive closed-loop feedback system, which was based on a pharmacokinetic-dynamic model. MEASUREMENTS AND MAIN RESULTS: Neuromuscular transmission was quantified by the evoked electromyogram of the hypothenar muscles. In Group 1, the first repetition of 0.02 mg/kg had to be administered after 27.0 +/- 5.5 minutes, followed by repetitions of the same dose every 16.3 +/- 3.0 minutes. The induced neuromuscular block ranged from 83% to 100%. The mean vecuronium demand was 0.123 +/- 0.018 mg/kg/h. In Group 2, stable relaxation of 90% +/- 2% was achieved within 19.2 +/- 7.5 minutes after a period of damped oscillations. The mean offset from the target value of 90% blockade was 0.65% +/- 0.32%. The average vecuronium requirement was 0.056 +/- 0.021 mg/kg/h during steady state. The difference between the groups in muscle relaxant demand was statistically significant. CONCLUSIONS: The model-based adaptive feedback system proved to be useful in maintaining a stable degree of paralysis, adjusting relaxant input to individual demand, and minimizing drug requirement, as compared with repetitive injections.

[Electrophysiologic studies in polyneuropathy of intensive care patients]. / Elektrophysiologische Untersuchungen bei der Polyneuropathie von Intensivpatienten.

Polyneuropathy of the critically ill patient has gained attention in recent years. The symptoms of muscle weakness and impaired somatosensory perception are more obvious for the observer and recognizable for the conscious patient, if heavy long-term sedation is avoided. The cause of polyneuropathy remains unclear and diagnostic findings are still rare and partly controversial. In five of our patients with multiorgan failure and clinical signs of muscle weakness, cortical somatosensory evoked potentials (SEP) and the evoked electromyogram (EMG) were recorded simultaneously after the stimulation of mixed peripheral nerves to test the functional integrity of the efferent and afferent neuronal pathways. We observed different degrees of SEP and EMG alterations, which were more pronounced in the lower than in the upper extremities and which may be explained by an axonal degeneration. Such a process may be caused by multiple factors and pathophysiological mechanisms. An influence of neostigmine on a reduced EMG response could not be found.

[An infusion model for intraoperative peridural anesthesia by catheter using mepivacaine]. / Ein Infusionsmodell zur intraoperativen Katheterperiduralanästhesie mit Mepivacain.

With the introduction of repetitive or continuous catheter techniques in regional anaesthesia, potential systemic intoxication hazards have increased. Especially high dose techniques such as peridural anaesthesia or plexus brachialis blockade consecutively generate high blood levels. In this study, blood levels collected from 20 patients (36 +/- 19 y, 173 +/- 9 cm, 73 +/- 15 kg) after lumbar epidural anaesthesia with mepivacaine led to the development of a linear open one-compartment-model (VD,ss: 109 l, Cltot: 594 ml/min, t1/2abs: 13 min, t1/2 beta: 149 min). With that model, dosage strategies could be studied via computer simulation. A mepivacaine dosage regimen for lumbar epidural anaesthesia, consisting of 250 mg as an initial bolus dose and an infusion rate of 150 mg/h after 15 min, cumulated to maximum concentrations of 2.5-3.5 micrograms/ml after 150 min. Such an infusion regimen may lead to concentrations of more than 4 micrograms/ml if applied for longer than 4 h. The pharmacokinetic computer simulation proved to be precise and could be compared to the measured blood levels of mepivacaine.

[The efficiency of prehospital cardiopulmonary resuscitation. Which factors determine the outcome?]. / Effizienz der präklinischen kardiopulmonalen Reanimation. Welche Faktoren bestimmen den Erfolg?

Survival rates following cardiopulmonary resuscitation differ widely with regard to the diverse rescue systems where the investigations were performed, and also with regard to the different patient populations. From 1981 to 1986, 1037 patients with out-of-hospital cardiac arrest were investigated in the city of Bonn. It was the purpose of this study to differentiate between various patient populations and to analyze factors which are responsible for CPR success. Survival rates following CPR could be increased from 8% in 1981 to 23% in 1984. Thereafter, a relatively stable survival rate of 20.1 +/- 1.7% with an initial CPR success rate of 62.5 +/- 8.1% was observed. Patients with ventricular fibrillation showed significantly higher survival rates (33.2 +/- 2.9%) when compared to asystolic victims (11.3 +/- 1.9%). The worst results were seen in these patients where CPR was initiated following trauma (8%) or in paediatric patients (8%). Factors which significantly determine survival following CPR are: initial ECG finding, therapeutic delay with regard to bystander-initiated basic life support, as well as advanced life support by emergency physicians. In addition, well standardized therapeutical strategies are of importance with early defibrillation, rapid endotracheal intubation and swift epinephrine application mostly by endobronchial administration.

[Interdisciplinary computerized evaluation of perioperative risk factors]. / Interdisziplinäre EDV-gerechte Evaluierung perioperativer Risikofaktoren.

The identification and assessment of perioperative risk factors combined with interdisciplinary management may lead to minimized risk for the patient. The numerous medical and administrative data should be collected by a computer. This was done in a preliminary study at the university of Bonn, where 9772 anaesthesias given for general surgery were evaluated. The necessary outcome studies should be based on statistical evaluation of the data (factor analysis) and their interpretation should be an interdisciplinary concern.

[Perioperative morbidity and mortality of geriatric patients. A retrospective study of 3905 cases]. / Perioperative Morbidität und Mortalität geriatrischer Patienten. Eine retrospektive Studie an 3905 Fällen.

3905 patients of more than 60 years of age who underwent surgical, urological, orthopaedic or opthalmologic interventions, were retrospectively investigated with respect to preoperative condition, intraoperative peculiarities and postoperative complications. Only 3.2% of the old patients (of more than 75 years of age), but 7.2% of elderly patients (between 60 and 74 years of age) had no coexisting disease. Preexisting diseases were myocardial (54.5%) and respiratory diseases (41.3%), hypertension (32.6%), dysrhythmia (30.8%) and diabetes mellitus (17.6%). From the old patients, 58.1% were classified into ASA physical status III to V but only 43.2% from the elderly patients. Peculiarities during anaesthesia and recovery period were (in total): dysrhythmia (8.3%), blood pressure decrease (5.9%) and increase (1.6%) that were significantly more often seen in old than in elderly patients whereas bleeding (4.5%) in the old was not different from the elderly. Independent of age, 11.6% of patients were monitored postoperatively on an intensive-care unit. 47.3% of all patients did not develop any postoperative complication. The incidence of postoperative cardiac, respiratory, central nervous, and lethal complications was not significantly higher in old than in elderly patients. However, the incidence of complications increased significantly with ASA physical status. Mortality of elderly and old patients after emergency interventions was 17.8% and 24.7% respectively and about 10 times that high as after elective surgery (2% in both groups.)

[Endobronchial administration of adrenaline in preclinical cardiopulmonary resuscitation]. / Endobronchiale Applikation von Adrenalin in der präklinischen kardiopulmonalen Reanimation.

The present clinical study was designed to investigate the effectiveness of epinephrine when administered endobronchially (e. b.) in patients undergoing out-of-hospital cardiopulmonary resucitation (CPR). Plasma catecholamine measurements during and following CPR in 30 patients revealed plasma levels of epinephrine and norepinephrine with tremendous variations and elevated, sometimes, for nearly 1,000 fold when compared to normal resting levels. In patients with ventricular fibrillation (VF) native epinephrine concentrations (23.5 +/- 20.4 ng/ml) were significantly different from asystolic victims (2.1 +/- 1.2 ng/ml). This finding once more supports the importance of early defibrillation as main therapeutical step in VF. When epinephrine (2-3 mg) was instilled endobronchially shortly after endotracheal intubation therapeutic concentrations of more than 10 ng/ml of epinephrine were measured when the first venous access was achieved. In 7 patients with successful CPR e. b. epinephrine was the only pharmacological therapy provided to support the cardiovascular system. Under these circumstances plasma epinephrine levels remained within the therapeutic range of 10-20 ng/ml for about 30 minutes. By these clinical findings it becomes clear that e. b. epinephrine (2-3 mg in 5-10 ml of NaCl 0.9%) instilled deeply by a catheter following intubation is the pharmacological therapy of choice in asystolic patients.