The influence of Sir Robert Reynolds Macintosh on the development of anaesthesia.

Fifteen years ago, on the 28th of August 2004, one of the British pioneers of anaesthesiology, Sir Robert Reynolds Macintosh, died in Oxford. Since he had a major influence on the development of anaesthesia in Europe and the rest of the world, we felt it would be appropriate to review his life and work. Macintosh was the first Nuffield Professor of Anaesthetics in the University of Oxford, so we provide a brief biography of Lord Nuffield and describe the historical background to the creation of the chair. We then outline Sir Robert's early life and describe pre-war developments at Oxford, including the development of the calibrated Oxford vaporizer for ether and laryngoscope. We discuss the wartime research into survival at high altitudes, the design of life-jackets and the efficiency of methods of artificial ventilation, and then show how Sir Robert pioneered a more open approach to the problem of anaesthetic-related deaths. We list some of the anaesthesiological textbooks which were translated into German, and then describe how his overseas travels influenced the teaching of anaesthesiology all over the world. We record Sir Robert Macintosh's connections with East and West Germany and note how he encouraged the development of academic departments of anaesthesia worldwide.

[Relations of German anesthesiology to east European societies of anesthesiology]. / Die Verbindungen der deutschen Anästhesiologie zu den Anästhesiegesellschaften Osteuropas.

On the occasion of the 50th anniversary of the foundation of the "German Society of Anaesthesiology" (DGA)--later called "German Society of Anaesthesiology and Intensive Care Medicine" (DGAI)--which was founded on 10 April 1953, and in memory of the foundation of the "Section of Anaesthesiology", which was founded in East-Berlin ten years later on 25 October 1963 and later called "Society of Anaesthesiology and Intensive Therapy of the GDR" (GAIT), the development of relations between German anaesthetists and anaesthesiological societies in East Europe are described. The limited economic base of the medical-technical and pharmaceutical industries, a chronic lack of hard currencies and economic and political restrictions on travel activities by East German and East European anaesthetists to West European countries resulted in improved contacts between East German and East European anaesthesiological societies. This, in turn, led to the holding of "International Anaesthesiological Congresses" of the so-called socialist countries and "Bilateral Symposia of the Anaesthesiological Societies of Czechoslovakia and the GDR" and also bilateral meetings of nurses of anaesthesiology and intensive therapy from both countries. These congresses and in particular the "3rd European Congress of Anaesthesiology", which was hosted by the "Czechoslovak Society of Anaesthesiology and Resuscitation" in Prague in 1970, were of high value for the further development of anaesthesiology in these countries. Furthermore, congresses held in East Europe but outside the GDR, were especially important for meetings between East German anaesthetists and their West German colleagues, who regularly took part in these congresses as invited speakers, because West German anaesthetists were not allowed to participate in East German anaesthesia congresses, on the one hand, and East Germans were not allowed to attend West German anaesthesia congresses, on the other. There were also regular meetings of the boards of East European anaesthesia societies in order to discuss the further development of anaesthesiology as an independent new academic field of medicine. Both East and West German anaesthetists were very often invited as guest lecturers by various East European societies and anaesthesiological departments. They were always deeply impressed by the tremendous hospitality of their hosts. During the "Cold War", many anaesthetists from East European countries were also invited as guests by anaesthesia departments of East and West Germany. Most of the East European anaesthetists preferred West German departments because they were better equipped and some of them used these trips to the West also to escape from communism. Shortly before and mainly after the political changes in 1989 and the dissolving of the "Society of Anaesthesiology and Intensive Therapy of the GDR" in 1990, the "German Society of Anaesthesiology and Intensive Care Medicine" improved its contacts to the East European anaesthesiological societies. The "Bavarian Section" of the "German Society of Anaesthesiology and Intensive Care Medicine" organized joint meetings with the Romanian, Bulgarian, Latvian and Russian societies of anaesthesiology in Bucharest (1987), Riga (1989), Moscow (1989) and Sofia (1991). In 1996, an "Association of German and Russian Anaesthetists" (ADRA) was founded in Moscow, which now has both a German (Prof. Dr. Dr. h.c. Joachim Nadstawek/Bonn) and a Russian (Prof. Dr. Armen Buniatian/Moscow) President. The German members of this association, in particular its Secretary-General, Prof. Dr. Reinhard Purschke/Dortmund, organize postgraduate courses including theoretical lectures and practical work not only in Russia but also in Armenia and Usbekistan.

[25 years "Anesthesiology and Reanimation"--a historical review]. / 25 Jahre "Anaesthesiologie und Reanimation"--Ein historischer Rückblick.

The 25th anniversary of the foundation of the journal "Anaesthesiology und Reanimation" seems to be a good occasion, first of all, to look back at the special situation regarding the opportunities open to East German anaesthetists for publishing anaesthesiological papers before and after the Berlin Wall was built and then to give a review of the history of this journal. As the author's own publication list shows, East Germans could publish papers in West German journals without any problems before a major reform of the universities, bringing drastic changes, was introduced in East Germany in 1969. It became practically impossible to publish papers in West German journals because the "Directorates of International Relations", which had been installed at all universities in 1969, supervised the entire correspondence with persons and institutions in all foreign countries, in particular West Germany, the other West European countries and the countries of North and South America. Thus, East German anaesthetists were forced to publish in non-anaesthesiological East German journals because there was no journal of anaesthesiology in East Germany until "Anaesthesiologie und Reanimation" was founded as journal of the "Society of Anaesthesiology and Reanimation of the GDR" in 1976. The problems arising from the introduction of this journal under socialist conditions, including political pressure and control through the "General Secretariat of the Medical Scientific Societies of the Ministry of Health of the GDR" as well as technical problems with the publisher and the printers, are described. In spite of all these problems, which were overcome by the editor-in-chief with the aid of his colleagues on the editorial board and the scientific advisory council, this journal was initially published with a circulation of 1,200 copies in 1976 and its circulation increased to 1,600 copies in 1989. The journal proved to be of great benefit to East German anaesthetists and anaesthetists from other East European countries. It was included in an international exchange programme of anaesthesiological journals, which was particularly helpful for East German anaesthetists because they could not subscribe to West German, West European or American journals due to a lack of hard currency. The international exchange of the journal led to an increasing number of authors from West Germany and other West European countries and even from the USA and Canada who published papers in "Anaesthesiology und Reanimation". The "silent revolution" in 1989 brought new problems. The journal was primarily an organ of the "Society of Anaesthesiology and Intensive Therapy of the GDR", but with the end of the GDR, this society was dissolved on 23rd October 1990. Fortunately, "Anaesthesiologie und Reanimation" was taken over by the "German Society of Anaesthesiology and Intensive Medicine" as an organ of this society, in which the former members of the East German society were gathered. The next problem was that the publisher "VEB Verlag Volk und Gesundheit", Berlin and "Verlag Gesundheit GmbH", Berlin respectively ceased to exist in 1992 and we had to look for another publisher. We were very happy that "Selecta Verlagsgesellschaft mbH", Munich, later Wiesbaden, was interested in this journal and took it on in the same year and has now published it since that time with a circulation of 1,000 copies. The chequered history of "Anaesthesiology und Reanimation", the subtitle of which has been changed to "Journal of Anaesthesiology, Intensive Therapy, Emergency Medicine and Pain Therapy" in 1991, clearly shows, on the one hand, the difficult political circumstances under which the development of anaesthesiology took place in East Germany, and demonstrates, on the other, the special problems of the foundation of a medical journal under socialist conditions with which the editorial board in general and the editor-in-chief in particular were confronted and how they tried to overcome the

[Measuring muscle relaxation with mivacurium in comparison with mechano- and electromyography]. / Relaxometrische Untersuchungen mit Mivacurium zum Vergleich von Mechano-und Elektromyographie.

Based on survey of the literature, methodological problems of electromyographic and mechanomyographic neuromuscular monitoring are presented. Often mechanomyography (MMG) is accompanied by mechanical problems during the registration of the contractions in the operating theatre. In contrast to mechanomyography the registration of electromyographic signals is easier whereas the processing of electromyographic signals is more difficult. In the operating theatre, registration problems can also occur with electromyography (EMG) from artefacts arising from stimulation impulses, high frequency apparatus and alternating current. During neuromuscular monitoring using MMG, a positive drift of the amplitudes of the contractions can be observed, whereas EMG leads to a negative drift of the amplitudes of the action potentials. Both observations can lead to misinterpretation of the degree of neuromuscular block measured by single twitch stimulation during the recovery period. Both the positive and negative drifts can be prevented by single twitch stimulation lasting for up to 10 minutes before the start of the neuromuscular monitoring of the effect of a given dose of a muscle relaxant. Finally, a clinical study of simultaneous registration of the MMG at the M. adductor pollicis and of the EMG at the M. interosseus dorsalis DI under total intravenous anaesthesia using propofol and alfentanil and muscle relaxation with a bolus dose of 75 mg/kg mivacurium is described. During the mechanomyographic studies, a decrease in the preload by an average of 1.2 Newton (N) with a maximum level of 4.0 N occurred. The decrease in preload was less than 25%. The mechanomyographically measured onset time of an ED95 of mivacurium amounted to 3.5 +/- 1.2 minutes on average and the degree of maximum neuromuscular block on average (95.1 +/- 5.6%) tallied very well with the expected value of 95.0%. The electromyographically measured onset time of an ED95 of mivacurium amounted to 4.3 +/- 1.2 minutes on average and the degree of maximum neuromuscular block amounted to only 91.3 +/- 8.1% on average. A comparison of the mechanomyographic values and the electromyographic values leads to the following results: the MMG showed a significantly shorter onset time (p < 0.0001) and a significantly deeper maximum neuromuscular block (p = 0.0004) than the EMG. There were also significant differences between mechanomyographically and electromyographically measured recovery values regarding T1(75) (p = 0.0007), T1(90) (p < 0.0001), TOF0.8 (p = 0.0386) and T1(25-75) (p < 0.0001). On average, an ED95 of mivacurium showed a significantly slower recovery in the mechanomyogram than in the electromyogram.

[Sore throat after use of the laryngeal mask and intubation]. / Halsschmerzen nach Anwendung der Kehlkopfmaske und nach Intubation.

The laryngeal mask was developed by Brain in 1981 and described for the first time in 1983. It has been applied a few million times worldwide since 1988. One of the main complication is soreness of the throat. Two hundred unselected patients who had gynaecological procedures under general anaesthesia--100 under laryngeal mask airway and 100 under intubation--were surveyed to ascertain the incidence of sore throats under laryngeal mask airway. Each patient was asked about soreness of the throat during the next two days. The incidence and duration of sore throats were recorded using a pain scale (0-100). After narcoses with the laryngeal mask, 63 patients had no complaints. Thirty-seven had sore throats with an average pain score of 8.1 +/- 13.8 on the day of operation. The average pain scores showed a decreasing tendency (4.2 +/- 9.5 and 0.4 +/- 2.6) for the first and second postoperative day. After intubation narcoses, we recorded sore throats significantly more frequently (p < 0.05) and the average pain score on the day of operation was significantly higher (13.2 +/- 17.5; p < 0.05) than after narcoses with the laryngeal mask. Also after narcoses with the laryngeal mask, the average pain scores decreased quickly on the first and second postoperative days (5.1 +/- 9.0 and 0.2 +/- 1.4). There were no differences regarding sore throats between narcoses with the laryngeal mask or intubation on these two postoperative days. Using both anaesthesiological methods, sore throat was not related to duration of anaesthesia or the experience of the anaesthetist.

[Introduction of patient-controlled analgesia--an interim report]. / Zur Problematik der Einführung der patientenkontrollierten Analgesie--ein Zwischenbericht.

In spite of improved therapeutic methods, the number of patients who suffer from moderate or severe postoperative pain remains high at 30 to 70%. It is accepted that improvement of the organization of postoperative pain therapy is a necessary precondition for changing this situation. Therefore, patient-controlled analgesia (PCA) using pain-pumps should be recognized and the effect on the whole postoperative pain therapy of a university clinic observed. The authors report on the introduction of general therapeutic guidelines for the use of patient-controlled pain-pumps. The recovery ward takes on a central role for both the beginning of pain therapy and the further care of the patient in various peripheral wards. It proved to be advantageous to use a bed-side protocol to document the programming of the pain-pumps and to register the pain-scores and side-effects. Because of these fundamental changes, the frequency of the application of pain-pumps increased six-fold within one year. Additionally, rapid pain treatment based on patients' needs increased clearly from 9.2 to 30.8%. The standardized introduction of PCA had an extremely favourable effect on the whole postoperative pain therapy and can thus be wholeheartedly recommended.

[Comparison of dosage relations of prilocaine and bupivacaine for axillary plexus anesthesia]. / Vergleich verschiedener Mengenverhältnisse von Prilocain und Bupivacain zur axillären Plexusanästhesie.

The effects of 40 ml of prilocaine 1% compared to 30 ml prilocaine 1% added to 10 ml bupivacaine 0.5% and 20 ml prilocaine 1% added to 20 ml bupivacaine 0.5% after injection into the brachial plexus sheath were evaluated. In a prospective study, 90 patients who underwent surgery on the upper limb were randomly allocated to one of these three groups. In each group 15 patients were treated using nerve stimulation with an immobile needle and 15 using a plexus catheter. We assessed the sensory and motor blockade of the appropriate nerves every 5 minutes after injection for a period of 45 minutes (pin-prick testing or strength of the appropriate muscles). Postoperatively the patients documented the strength of their pain on a score of 0 to 10 four hours, six hours and 24 hours after injection. There were no differences in onset time between the groups, the operation normally starting after about 30 minutes. Compared to other nerves, blockade of the musculocutaneous nerve was delayed and not as complete. The quality of the blockade of the radial nerve was not worse than that of the ulnar and median nerve. Eighty-four patients were operated on in regional anaesthesia, 74 patients without supplementary measures. There were no differences in postoperative pain between the two different techniques. Significant differences, however, were found between the three drug groups: Patients given 40 ml of prilocaine 1% documented pain (0.75) 4 hours after injection; the other two groups reported nearly none. Six hours after injection the patients who had received 40 ml of prilocaine 1% had significantly more pain (2.25) than patients who had received 30 ml of prilocaine 1% plus 10 ml of bupivacaine 0.5% (0.96); patients who had received 20 ml of prilocaine 1% plus 20 ml of bupivacaine 0.5% had nearly no pain (0.19). We can conclude that mixing of prilocaine 1% with bupivacaine 0.5% is a useful way to achieve adequate duration of anaesthesia and to reduce postoperative pain without extending onset times for axillary plexus block. Postoperative application of analgetics can often be avoided completely.

[Successful resuscitation of a hypothermic patient with extracorporeal circulation--a case report]. / Erfolgreiche Reanimation eines unterkühlten Patienten mittels Extrakorporaler Zirkulation--Ein Fallbericht.

A case of cardiopulmonary arrest due to accidental hypothermia and its successful therapy is described. A 46-year-old man with deep accidental hypothermia (25.3 degrees C esophageal) was found outside showing respiratory and cardiac arrest. Resuscitation was immediately started and continuously performed during the transport to the University Hospital of Rostock, where a treatment with extracorporeal circulation was possible. After cardiopulmonary resuscitation for 120 minutes, the patient could finally be connected to the extracorporeal circulation. Over a period of 130 minutes the patient could be rewarmed up to a body temperature of 36.0 degrees C. The following therapy was complicated by the development of an alcoholic delirium, which was treated by clomethiazol, droperidol and clonidin infusion. After seven days of intensive therapy, he recovered completely and could be transferred from the intensive care unit to the department of psychiatry without neurological deficits showing only healing of frostbite of the feet. Based on this case report, the use of extracorporeal circulation for adequate rewarming in combination with cardiopulmonary resuscitation is described. Compared to other therapeutic measures such as peritoneal dialysis or veno-venous haemofiltration treatment with extracorporeal circulation is the method of choice.

[Mivacurium in pediatric anesthesia]. / Mivacurium in der Kinderanästhesie.

Mivacurium is a potent, short-acting, nondepolarizing relaxant of the benzylisoquinoline series. In adults endotracheal intubation can be performed after a 2 x ED95 dose of 0.15-0.2 mg/kg within 2-2.5 minutes. In infants onset time and clinical duration of mivacurium are significantly shorter than in adults. Although the onset time of mivacurium is similar to that of other relaxants like vecuronium and atracurium, its clinical duration is unique in comparison with all other nondepolarizing relaxants currently available. Mivacurium shows no cumulative effect either after repeated injections or after continuous infusion. In contrast to other relaxants, an increasing dose of mivacurium leads only to a slight increase in clinical duration and has no effect on the recovery index. After spontaneous recovery has reached 10-25% of the control value, the neuromuscular block can be easily antagonized with neostigmine or edrophonium. The properties of mivacurium described above are related to patients with normal pseudocholinesterase activity. Particularly patients with atypical pseudocholinesterase show a marked increase in clinical duration. Side-effects due to significant histamine release with flush, tachycardia and hypotension are seldom observed if mivacurium is injected slowly over a period of more than 30 seconds and bolus injections of more than 2 x ED95 or 3 x ED95 are avoided.

Time-course of action and intubating conditions with rocuronium bromide under propofol-alfentanil anaesthesia.

Thirty ASA I and II patients received either an intubating dose of 0.6 mg kg-1 rocuronium (2 x ED95, group 1) or 0.06 mg kg-1 as a priming dose followed by an intubating dose of 0.24 mg kg-1 rocuronium (group 2) 4 min later. Anaesthesia was induced with propofol (2.0 mg kg-1) and alfentanil (0.02 mg kg-1) and maintained with nitrous oxide/oxygen and propofol (6.0 mg kg-1 h-1). Neuromuscular function was monitored mechanomyographically and electromyographically with train-of-four (TOF) stimulation at the wrist every 10 s. The following parameters were measured and compared between the two groups: time to 90% block (intubation time), time to maximum block (onset time), and the times for T1 (25%, 75% and 90%) and TOF > 70%. In group 1 the intubation time was significantly shorter (40 +/- 10 s) than in group 2 (51 +/- 11 s). Intubating conditions were good or excellent in both groups. The clinical duration of action was 28 +/- 8 min in group 1 and 15 +/- 3 min in group 2, respectively. Mechanomyography showed a significantly faster development of neuromuscular block than electromyography. The comparison of mechanomyographically and electromyographically measured recovery times did not show any differences. In 60% of the patients a priming dose of 0.06 mg kg-1 was followed by a considerable decrease in neuromuscular function.

[Comparison of neuromuscular blockade by mivacurium and atracurium]. / Vergleich der neuromuskulären Blockade von Mivacurium und Atracurium.

The aim of our randomized controlled study was to compare the neuromuscular characteristics of mivacurium and atracurium by evaluating the intubation conditions, intubation times, onset times and the duration of action of these two muscle relaxants using two different dosing principles. Forty-eight patients were included in this study. All patients were premedicated orally with 0.2 mg/kg diazepam. Anaesthesia was induced with 2.0 mg/kg propofol and 0.02 mg/kg alfentanil and maintained with 6 mg/kg/h propofol and 60% nitrous oxide in oxygen. Neuromuscular monitoring was carried out with supramaximal TOF-stimulation (2 HZ) of the ulnar nerve every 10 seconds and recording of the mechanomyogram (MMG) (Myograph 2000, Biometer) at the adductor pollicis muscle. The patients of group 1 (n = 12) received an intubation dose of 0.15 mg/kg mivacurium (2 x ED95) and the patients of group 2 (n = 12) received a priming dose of 0.015 mg/kg mivacurium (20% of ED95) followed by an intubation dose of only 0.07 mg/kg mivacurium (ED95) two minutes later. The patients of group 3 (n = 12) were intubated with 0.46 mg/kg atracurium (2 x ED95) and the patients of group 4 (n = 12) received a priming dose of 0.046 mg/kg atracurium (20% of ED95) and an intubation dose of 0.23 mg/kg atracurium (ED95) four minutes later. The patients were intubated under normocapnic conditions and following stabilisation of the palmar skin temperature after a 90% neuromuscular block (T1) had occurred. The intubation conditions were measured semiquantitatively using an intubation score.(ABSTRACT TRUNCATED AT 250 WORDS)

[Documentation and information processing in clinical anesthesia]. / Dokumentation und Informationsverarbeitung in der klinischen Anästhesie.

Whereas anaesthesia recording was already introduced by Codman and Cushing in 1894 and is now stipulated by law, work registration in anaesthesia and work comparison between departments of anaesthesia have only been built up in the last ten years. Based on the rapid development of computer technology specific solutions were found, ranging from simple software developments to complex on-line monitor systems. The basic data bank published by the German Society of Anaesthesiology and Intensive Medicine represents a minimum of data, which can be added to at will. We report on our new anaesthesia record and corresponding software with computer supported manual data registration, which was developed at our clinic, taking into account state-of-the-art data processing and quality assurance. A new development, which includes on-line data processing with automatic data registration followed by graphic or numeric data print-out, is now presented by Datex. In combination with manual data input of all parameters of work registration, complete automatic anaesthesia recording can be achieved. The authors report on their first own experience with this system.

[EEG changes during propofol-alfentanil-nitrous oxide anesthesia]. / EEG-Veränderungen unter Propofol-Alfentanil-Lachgas-Narkose.

Blood pressure, heart rate and perspiration were and still are the only clinical signs for recognizing the depth of balanced anaesthesia in combination with muscle relaxants. Even experienced anaesthetists sometimes have difficulties in recognizing the necessary depth of anaesthesia using these parameters and in relatively rare cases the very unpleasant symptom of awareness occurs. Nowadays, processed EEG monitoring (pEEG) is used scientifically and also clinically for exact controlling of general anaesthesia. We report on our first experience with this method in 21 patients who were anaesthetized with propofol, alfentanil and nitrous oxide and relaxed with atracurium and whose depth of anaesthesia was carefully controlled by pEEG using the pEEG Monitor of Drägerwerke. The following parameters were recorded continuously: Spectral Edge Frequency (SEF) 50, SEF 90, SEF 95 and power between 8 and 20 Hz in relation to the power between 0 and 4 Hz (delta ratio). In agreement with other investigators we found that a sufficient depth of anaesthesia could be expected when the SEF 50 ranged between 2 and 6 Hz (4.9 +/- 0.9), the SEF 90 ranged between 10 and 13.5 Hz (11.9 +/- 0.6), the SEF 95 ranged between 14 and 16 Hz (14.8 +/- 0.8) and the delta-ratio ranged between 0.7 and 1.4 (1.1 +/- 0.2). Using this anaesthetic technique and a premedication with benzodiazepine, SEF 90 SEF 95 are the best parameters for monitoring the depth of anaesthesia. In one patient blood pressure and heart rate remained constant intraoperatively, but she described intensive dreams postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transfusion incidence and indications for homologous blood sparing measures in single stage breast carcinoma operations]. / Transfusionshäufigkeit und Indikationen für fremdblutsparende Massnahmen bei einzeitigen Mammakarzinom-Operationen.

Under a ruling by the Bundesgerichtshof from December 17, 1991 (AZ VI ZR 40/91), the surgeon is obliged to inform a patient about the risks of a possible blood transfusion if the transfusion frequency is 5% or more. Between January 1989 and December 1994, 273 patients with primary breast cancer at the stages pT1-3, N1-2, M0 underwent one-time modified radical mastectomy (n = 164) or a breast conserving operation (n = 109) in our hospital. The number of blood transfusions, pre- and postoperative haemoglobin, age, tumour size, lymph node involvement, kind and duration of the operation and the postoperative course were analysed. In all, 44 of the 273 patients (16.1%) received an homologous blood transfusion perioperatively. The annual transfusion rates were 39.4% (1989), 44.8% (1990), 12.2% (1991), 16.6% (1992) and 3.1% (1993), falling to 2.2% in 1994. The mean pre- and postoperative haemoglobin concentrations did not differ significantly (p > 0.05) over the years: 13.4 +/- 1.0 g/dl and 12.0 +/- 1.1 g/dl in 1989 and 13.7 +/- 1.2 g/dl and 11.8 +/- 1.2 g/dl in 1994. Patients who received transfusions had preoperative anaemia (p < 0.021), bigger tumours (p < 0.0005) and mastectomy operations significantly more frequently than patients not given transfusions. There were no correlations between transfusions and age, lymph node involvement and kind and duration of operation. We conclude that, cognizant of a transfusion frequency of 2.2% in our hospital in one-time breast cancer operations, only patients with anaemia or large tumours require blood transfusions, for which autologous blood donations or normovolaemic haemodilution are the choices. The patients' attention is to be drawn to these. In cases of normal preoperative haemoglobin and small tumours, the physician should inform the patient that experience has shown that in all probability a blood transfusion will not be necessary and so a preoperative autologous blood donation or normovolaemic haemodilution can be dispensed with.

[The risks of anesthesia in obstetric interventions]. / Die Risiken der Anästhesie bei geburtshilflichen Eingriffen.

In obstetric anaesthesia, general anaesthesia combined with endotracheal intubation, spinal anaesthesia and peridural anaesthesia is used. The main risks of general anaesthesia are: difficult intubation, aspiration of acid gastric content in non-fasting patients, depression of the fetus with narcotics and the occurrence of awareness of the mother. The main dangers of spinal anaesthesia are: hypotension of the mother leading to reduced utero-placentar blood flow due to sympathetic block, post-spinal headache and vomiting. The specific risks of peridural anaesthesia are: maternal hypotension, the possibility of inadvertent intravenous injection of local anaesthetics leading to cardiac and cerebral intoxication, inadvertent intrathecal application of local anaesthetics followed by total spinal block which requires reanimation and inadvertent dura perforation followed by long-lasting headache. Most anaesthesia-related maternal deaths by far occur during Caesarean section performed under general anaesthesia, but at present there is no clear evidence that the anaesthetic risk of spinal or peridural anaesthesia, on the one hand, is lower than that one of general anaesthesia, on the other.

[Mechanomyographic and electromyographic studies of endotracheal intubation with 2 different rocuronium dosages]. / Mechanomyographische und elektromyographische Untersuchungen zur endotrachealen Intubation mit zwei verschiedenen Rocuronium-Dosierungen.

Rocuronium is a new, intermediate-acting, nondepolarizing relaxant with rapid onset of action leading to both good and very good intubation conditions. It was the aim of our study to investigate the onset of action, the intubation conditions and the course of relaxation using two different dosage regimes. Thirty consenting ASA 1 and 2 patients received either 0.6 mg/kg (2 x ED 95; group 1) or 0.06 mg/kg as priming dose followed by an intubating dose of 0.24 mg/kg rocuronium (group 2) four min later. Anaesthesia was induced with propofol (2 mg/kg) and alfentanil (0.02 mg/kg) and maintained with nitrous oxide/oxygen and propofol (6 to 8 mg/kg/h). Neuromuscular function was monitored mechanomyographically and electromyographically with TOF stimulation at the wrist every 10 seconds. Intubation conditions were determined using a semiquantitative score system, and times to 90% block (intubation time), maximum block (onset time) and recovery from neuromuscular blockade to 25%, 50%, 75% and 90% were calculated and comparisons were made between the corresponding results of the two groups. The intubation dose of 2 x ED 95 (group 1) was followed by a significantly shorter intubation time (39.1 +/- 9.6 sec.) than in group 2 with priming and an intubation dose of 0.24 mg/kg (50.7 +/- 11.0 sec). The intubation conditions showed no differences. In both groups they were good or very good. The clinical duration of action was significantly longer in group 1 (28.4 +/- 8.0 min) than in group 2 (14.8 +/- 2.5 min). It can be concluded that rocuronium which has shorter intubation times than atracurium and vecuronium is very useful for endotracheal intubation in both dosage regimes in long and very long lasting operations. Using the "priming principle" the patient has to be carefully controlled during priming time.

[LEVEL 1--a new blood warming device]. / Der LEVEL 1--ein neues Bluterwärmungsgerät.

Hypothermia of less than 35 degrees C, which frequently occurs in connection with massive blood transfusion, is a serious problem in many patients, in particular in those with polytrauma. The restoration of normal body temperature is very important and requires the use of a rapidly-acting, efficient and safe blood warmer, which is able to work effectively at high flow-rates. The LEVEL 1 (Technologies, Rockland, MA) is such a new blood warmer and works as a heat-exchanger via an aluminium column. This system is highly effective. Six hundred ml of sodium chloride 0.9% are warmed from 4 to 35 degrees C within one minute. This device is quickly operational and has a low priming volume. The LEVEL 1 is the only device currently available which is able to warm blood sufficiently during a very rapid blood transfusion.

[The treatment of status asthmaticus using ketamine--experimental results and clinical experience]. / Zur Behandlung des Status asthmaticus mit Ketamin--Experimentelle Ergebnisse und klinische Erfahrungen.

Intensive therapy of a patient with status asthmaticus must lead to a reduction of vital threat by improving respiratory and cardiac functions. Because of the bronchodilating effect of ketamine, analgesic sedation with ketamine and benzodiazepines is extremely useful for prolonged ventilation. At the beginning of this treatment it can be necessary to supplement the continuous intravenous infusion of ketamine and diazepam or ketamine and midazolam with small bolus doses of up to 3.5 mg/kg/h of ketamine. Experience has shown that the combination of ketamine and midazolam has better controllability. In some of our patients the bronchodilating effect of ketamine was not sufficient and therefore ventilation with halothane was necessary at least intermittently. In contrast to halothane, ketamine can be combined with vasodilators and sympathomimetics as our own experience has shown. The combined application of ketamine with glycerol trinitrate or sodium nitroprusside is indicated in the event of pulmonary or general hypertension. The use of sympathomimetics--mainly beta-sympathomimetics--antagonizes the negative inotropic effect of ketamine, improves the circulatory system and leads to a direct bronchodilating effect. Progress in treatment was mainly achieved by continuous intravenous infusions of terbutaline (Bricanyl). Aminophylline is very compatible with ketamine, but because of its stimulating effect the use of aminophylline seems to be reasonable only during weaning from the ventilator. Control of the usually deep analgesic sedation and an accompanying optimum drug therapy are only possible with complete cardiorespiratory monitoring including invasive blood pressure measurement and catheterization of the pulmonary artery. In our clinic 24 patients with status asthmaticus were treated. Sixteen asthmatic patients were treated with analgesic sedation using ketamine and benzodiazepines, three of them without intubation and ventilation. In spite of the life-threatening situation and reanimation before admission to the intensive care unit, only one patient died. Our experience has shown that intensive therapy including analgesic sedation with ketamine and benzodiazepines, optimized by application of sympathomimetics and vasodilators, is suitable for overcoming the life-threatening situation of patients with status asthmaticus.