[Superior vena cava thrombosis after in vitro fertilization]. / Vena-cava-superior-Thrombose nach In-vitro-Fertilisation.

HISTORY AND CLINICAL FINDINGS: A 29-year-old female was admitted with the diagnosis of multiple deep vein thrombosis of the upper limbs and neck and pneumonia secondary to pulmonary embolism on the right side. Medical history revealed that in vitro fertilization with hormone stimulation had been carried out 5 weeks before. For ten days the patient had noticed a growing, painful swelling on the right side of her neck accompanied by difficulties in swallowing. Since this time she had experienced episodes of shortness of breath without chest pain. Clinical findings showed a soft and slightly painful swelling of the right side of the neck without dyspnoea or cyanosis at rest. Breath sounds were decreased over the right lower lung on auscultation. INVESTIGATIONS: Magnetic resonance imaging (MRI) confirmed complete obstruction of the subclavian and brachiocephalic vein on the right side and clots in the superior vena cava, left subclavian vein, bilateral internal jugular veins and the right axillar vein. Chest x-ray showed pleural effusion on the right side. TREATMENT AND COURSE: As the seven-week pregnancy was found not to be viable anymore, fibinolysis with streptokinase was started under protection of a temporary cava filter. During the following hours the patient developed serious bleeding as a complication of this therapy and fibrinolysis had to be discontinued after 16 hours. In subsequent examinations the obstruction of the left internal jugular vein was unchanged but collaterals around the obstruction were noticed. The other veins affected were open, some with reduced flow. Several risk factors were found in the history of the patient such as smoking, immobilization, a positive family history, protein S deficiency and APC resistance. After 3 weeks of hospital therapy the patient was discharged under oral anticoagulation with coumarin. CONCLUSION: In vitro fertilization with hormonal stimulation may cause serious complications in patients with unknown coagulation disorders or with an ovarian hyperstimulation syndrome. Risk factors for thromboembolism need to be ruled out carefully before starting the procedure.

Persistent endocrine stress response in patients undergoing cardiac surgery.

To investigate the endocrine stress response in patients undergoing major surgery with general anesthesia using a balanced technique with sufentanil, isoflurane and midazolam up to the second postoperative day, blood levels of cortisol, epinephrine, norepinephrine, prolactin and growth hormone were determined in 68 males for elective coronary artery bypass grafting (CABG) surgery. Intraoperatively, during extracorporeal circulation none of the measured parameters were significantly increased compared to preoperative values. The endocrine response of patients with perioperative epinephrine medication (n = 32) was not significant different to patients that did not receive exogenous epinephrine (n = 36). On the evening of the day of surgery, levels of cortisol (3 fold), epinephrine (4.7 fold), norepinephrine (1.7 fold) and growth hormone (16.5 fold) were significantly increased. Compared to preoperative values levels of cortisol (3.3 fold), growth hormone (5.5 fold) and norepinephrine (1.8 fold) remained elevated up to the evening of the second postoperative day. In conclusion, the endocrine stress response in patients undergoing CABG-surgery under general anesthesia with sufentanil, midazolam, isoflurane is intraoperatively prevented by anesthesia. Although hemodilution or hormone degradation might be responsible for the lack of an increase in endocrine parameters during CPB, this study indicates that a balanced technique with isoflurane, sufentanil and midazolam is more effective in blocking the endocrine stress response than previously described anesthetic techniques. In the early postoperative period, a sharp increase in cortisol, epinephrine, norepinephrine and growth hormone occurred suggesting that the predominant endocrine stress response begins in the intensive care unit with end of anesthesia. The postoperative elevated levels of cortisol, growth hormone and norepinephrine indicate a persisting stress-response for more than two days after surgical trauma.

[The preparation for elective interventions--the spectrum and dissemination of somatic and psychological measures in Germany]. / Vorbereitung auf elektive Eingriffe--Spektrum und Verbreitung somatischer und psychologischer Massnahmen in Deutschland.

INTRODUCTION: The positive effects of preoperative preparation on postoperative recovery in patients undergoing elective surgery have been demonstrated. On that account, we surveyed the practice procedures of preoperative preparation for elective surgery patients at German hospitals. METHODS: During November 1994, we sent 1500 questionnaires to the directors of anaesthesiology departments in Germany. A total of 590 questionnaires (39.3%) were completed and returned. The participating hospitals range in size from 20 to 2600 beds (mean = 364; s = 334,97), totalling together more than 1.7 million surgical operations per year. RESULTS: The surveyed hospitals used one or more of the following procedures for pre-operative preparation: 573 (98.6%) of the replying hospitals used medical anxiolysis, 415 (71.3%) applied preoperative respiratory therapy. Furthermore, 222 (38.5%) of the studied hospitals trained their patients in postoperative relevant behaviour (respiratory therapy n = 167; physiotherapy n = 63 and patient-controlled analgesia n = 41). 74 (13%) offered psychological counselling, 29 (5%) made use of other psychological techniques (muscle relaxation; autogenic training, biofeedback) and 26 (4%) used other preparatory methods like video tapes (n = 13), music (n = 5), acupuncture (n = 4). DISCUSSION: Nearly all hospitals prepared their patients for surgery with a pre-op visit and anxiolytic medications. Further preparatory methods in most surveyed hospitals are only used on a case-by-case basis. At present psychological methods of preoperative preparation are not routinely used in clinical practice in Germany. CONCLUSIONS: Existing possibilities for optimising preoperative preparation in patients undergoing elective surgery are not used regularly. Preoperative preparation needs to be improved, especially in patients undergoing major surgery. Standardisation of management procedures and integration of several professional groups and regular application of known procedures for preoperative preparation may lead to cost-saving optimisation of the duration of hospital stay.