[Cardioprotection by thoracic epidural anesthesia? : meta-analysis]. / Kardioprotektion durch thorakale Periduralanästhesie? : Metaanalyse.

BACKGROUND: Thoracic epidural analgesia (EDA) is thought to provide cardioprotective effects in patients undergoing noncardiac surgery. The results of two previous meta-analysis showed controversial conclusions regarding the impact of EDA on perioperative survival. The purpose of the present meta-analysis was to evaluate, whether thoracic EDA has the potential to reduce perioperative cardiac morbidity or mortality on the basis of available randomized controlled trials. PATIENTS AND METHODS: A systematic literature search was conducted in medical databases (Med-Line, EBM-Reviews, Embase, Biosis and Biological Abstracts) and relevant clinical trials including patients undergoing noncardiac surgery were evaluated by two independent investigators. All randomized controlled trials investigating the effects of thoracic EDA on perioperative outcome, published from 1980 up to the end of 2008 were included into this quantitative systematic review. Calculations were performed using the statistics program Review Manager 4.1 using a fixed-effects model. RESULTS: Nine studies with a total of 2,768 patients were included in the meta-analysis. Thoracic EDA did not reduce perioperative mortality [odds ratio (Peto OR): 1.08; 95% confidence interval (CI) 0.74-1.58]. Patients receiving thoracic EDA demonstrated a tendency to a lower rate of perioperative myocardial infarction. However, this effect of thoracic EDA did not reach statistical significance (Peto OR: 0.65; 95% CI 0.4-1.05). CONCLUSIONS: The present meta-analysis did not prove any positive influence of thoracic EDA on perioperative in-hospital mortality in patients undergoing noncardiac surgery. Furthermore, it remains questionable if thoracic EDA has the potential to reduce the rate of perioperative myocardial infarction.

[Delta(9)-tetrahydrocannabinol and the opioid receptor agonist piritramide do not act synergistically in postoperative pain]. / Keine synergistische Wirkung der Kombination von Delta(9)-Tetrahydrocannabinol und Piritramid bei postoperativen Schmerzen.

BACKGROUND: It is concluded from animal experiments that cannabinoid receptor and mu-opioid receptor agonists act synergistically with respect to antinociception. In order to demonstrate this effect under clinical conditions, we conducted a randomized double blind trial with patients after radical prostatectomy. PATIENTS AND METHODS: From the evening before the operation until the morning of the second postoperative day, all patients received eight oral doses of either placebo or 5 mg Delta(9)-tetrahydrocannabinol (dronabinol). Postoperatively patients had access to patient-controlled analgesia with the micro-opioid agonist piritramide for 48 h. We expected patients receiving dronabinol to require significantly less piritramide compared to patients on placebo. RESULTS: The consumption of piritramide was recorded in 100 patients after radical retropubic prostatectomy with regional lymphadenectomy. Patients in the placebo group consumed 74 mg (median), interquartile range (IQR) 44-90 mg, patients in the verum group consumed 54 mg (median) IQR 46-88 mg. The difference between groups was not statistically significant. Plasma concentrations of Delta(9)-THC were measurable in all patients in the verum group. The levels (median) were 1.5 ng/ml (IQR 0.6-2.3), 1.3 ng/ml (IQR 0.5-2.2) and 1.9 ng/ml (IQR 0.8-2.7) on the day of operation, the first and second postoperative day, respectively. CONCLUSION: We found neither a synergistic nor even an additive antinociceptive interaction between Delta(9)-tetrahydrocannabinol and the micro-opioid agonist piritramide in a setting of acute postoperative pain.

[Intraoperative bronchospasm during paranasal sinus surgery -- indicator of aspirin intolerance syndrome?]. / Intraoperativer Bronchospasmus bei Nasennebenhöhlen-Operationen -- Hinweis auf ein Analgetikaintoleranz-Syndrom?

BACKGROUND: The aim of this study was to evaluate whether an intraoperative bronchospasm is more frequent in sinus surgery than in non-sinus surgery, whether its appearance after application of a non-steroidal anti-inflammatory drug (NSAID) is an indicator of an aspirin intolerance syndrome, and whether its appearance can be interpreted as an aspirin provocation test. METHODS: Anaesthesia charts from 5 years were retrospectively analysed whether anaphylactic/allergic reactions or bronchospasm were observed intraoperatively. In these cases the ENT charts of the patients were analysed and the occurrence of an analgesic-induced bronchospasm was assumed according to a probability algorithm. PATIENTS: All operations in general anaesthesia of an otorhinolaryngology clinic were analysed. RESULTS: An intraoperative bronchospasm was observed significantly more often in patients undergoing sinus surgery than during other ENT operations. In 17 of 23 patients a possible/probable analgesic-induced bronchospasm after application of NSAID was found. Diclofenac was intraoperatively given in 3 patients, diclofenac and metamizole in 5 patients, metamizole in 7 patients, paracetamol in 1 patient, and paracetamol and metamizole in 1 patient. CONCLUSIONS: An intraoperative bronchospasm during sinus surgery is not a clear indicator of an aspirin intolerance syndrome. An analgesic-induced bronchospasm can also be observed after paracetamol and metamizole. It can not be interpreted analogous to an aspirin provocation test.

[The ASA-score as a comorbidity index in patients with cancer of the oral cavity and oropharynx]. / Der ASA-Score als Komorbiditätsindex bei Mundhöhlen- und Mundrachenkarzinomen.

BACKGROUND: The American Society of Anesthesiologists Physical Status Scores (ASA-Score) may serve as a valuable indicator of comorbidity in head and neck cancer patients. METHODS: In 135 patients with squamous cell carcinoma of the oral cavity and/or oropharynx, the relation of disease free and overall survival and the ASA-score was evaluated in a univariate (logrank-test) and a Cox regression model. In the Cox model, age, tumor site and stage, and therapeutic modality served as covariates. RESULTS: In the univariate model, overall 5 year survival in ASA I and II patients was 44 %, and in ASA III and IV patients, it was 16 % (p < 0.005). The ASA-score also significantly influenced survival in the multivariate model. The hazard ratio (ASA I and II vs. ASA III and IV) was 2.1 (95 % confidence interval 1.3 to 3.4; p < 0,005). This corresponds to a 8 times higher risk to die, even when the effects of age, tumor site and stage, and therapeutic modalities are compensated for. CONCLUSION: The ASA-score is a valuable indicator of comorbidity in patients with oral cavity and oropharyngeal tumors. An essential advantage is its easy availability in most clinical settings.

[Influence of postoperative pain on morbidity and mortality.]. / Beeinflußt die Schmerztherapie postoperative Morbidität und Letalität?

Postoperative pain can intensify the sympathoadrenergic reaction, which is commonly seen after surgery, and thus possibly pave the way for certain complications, such as coronary ischemia, bronchopneumonia, intestinal stasis, thromboembolism, infection, sepsis, and metabolic disturbances. Investigations of cardiovascular, respiratory, gastrointestinal, metabolic, and immunologic function indicate that high-quality pain relief can diminish postoperative organ impairment and failure. Some aspects of the improvements attributed to the quality of analgesia, such as prevention of tachycardia and hypertension, attenuation of hyperglycemia and catabolism, improvement of gastrointestinal motility and cellular immunity cannot be definitely distinguished from the effects of sympathetic blockade due to epidural analgesia with local anesthetics, however. There is another aspect of the problem. The better the quality of postoperative pain relief, the more likely it is that analgesia-related complications, such as respiratory depression (opioids), cardiovascular depression (epidural local anesthetics), renal failure (NSAIDs) and bladder dysfunction (epidural opioids and local anesthetics) will occur. The question of whether postoperative morbidity and mortality can be reduced by effective analgesia has been investigated in the past few years. Some studies indicate that better analgesia is advantageous for the patient, especially with respect to postoperative complications, hospital stay, long-term well being, and costs. In other clinical trials incorporating more patients, however, this hypothesis had to be rejected. At present, therefore, we cannot state that effective pain relief influences postoperative morbidity and mortality.

[Unilateral epidural anesthesia]. / Die einseitige Epiduralanaesthesie.

Four cases of unilateral spread of epidural anesthesia are presented. All were documented by X-ray epidurography. In two patients the catheter had passed immediately into one of the intervertebral foramina so that the local anesthetic had almost totally been injected into the paravertebral space. In the third and fourth cases a membrane was present in the dorsal epidural space that had prevented bilateral spread of the local anesthetic. This article discusses the fact that strands of the dorsomedian connective tissue band of the lumbar epidural space can cause catheters to coil up, be diverted, and not infrequently be directed into the next intervertebral foramen. These strands sometimes form a dense membrane, which together with the plica mediana of the dura mater prevent symmetrical spreading of epidurally injected fluids. When informing a patient about epidural anesthesia, the anesthesiologist should mention that anatomical variations in the epidural space can cause epidural anesthesia to spread unilaterally.

Fungaemia due to Candida pelliculosa in a case of acute pancreatitis.

We describe a case of fungaemia due to Candida pelliculosa (teleomorph: Hansenula anomala) in an otherwise non-immunocompromised patient with acute necrotizing pancreatitis of unknown origin. This species of Candida should be added to the list of pathogenic fungi which are increasingly important not only in patients with underlying immunosuppressive disease but also in patients with, for instance, severe surgical illness.

[Epidural and intrathecal administration of alpha 2-adreno-ceptor agonists for postoperative pain relief]. / Epidurale und intrathekale Anwendung von alpha2-Adrenozeptor-Agonisten zur postoperativen Analgesie.

Spinal clonidine interacts with pre- and postsynaptic alpha(2)-adrenoceptors on afferent neurons in the superficial dorsal horn of the spinal cord: it causes analgesia by inhibition of the synaptic and electrotonic neurotransmission of nociceptive impulses. Epidural doses higher than 4 microg/kg have an analgesic onset time of less than 30 min, reduce pain by more than 70 %; these effects last for 4-5 h. Epidural clonidine analgesia is accompanied by a reduction in heart rate, cardiac output and blood pressure of approximately 20 % compared with baseline. The haemodynamic side effects mean close supervision is needed during the first hour after epidural application and limit the use of epidural clonidine to patients who are refractory to the analgesic effects of epidural opioid or local anaesthetics. In these patients excellent results can be achieved either with clonidine alone or with a combination of clonidine and an opioid or a local anaesthetic to exploit the additive or supra-additive interactions of these drugs.

[Complications of the postoperative use of lumbar epidural catheters in place for surgery]. / Komplikationen bei der postoperativen Verwendung von zur Operation gelegten, lumbalen Epidural-Kathetern.

Two cases of secondary subarachnoidal dislocation of lumbar epidural catheters are reported. The first catheter was placed, tested, and injected with 20 ml local anesthetic in order to achieve intraoperative anesthesia up to the T4 level. On the 2nd postoperative day the test dose produced paralysis of the lower extremities; liquor now could be aspirated. The second catheter had been introduced into the epidural space immediately after injection of 15 ml local anesthetic through the needle. Use of this catheter for postoperative analgesia led to total spinal anesthesia in spite of negative aspiration and test dose prior to injection of 7 ml local anesthetic. Implications of these two cases concerning placement procedures and monitoring during reuse of catheters placed some time before are discussed.

[Collecting end-expiratory air for capnography in high-frequency jet ventilation]. / Gewinnung endexspiratorischer Luft für die Kapnographie bei hochfrequenter Jetbeatmung.

By means of an ejector attachment to the endotracheal tube a negative intratracheal pressure of approx. -1 mmHg is created during an interruption of HFJV. Within 4 to 10 sec. this suction supplies alveolar air to the distal end of the endotracheal tube where capnographic analysis is possible in the mainstream or bystream. The end-tidal pCO2 differs by 0.1 mmHg (mean) from the arterial carbon dioxide partial pressure with a highly positive correlation (R = 0.98).

[Introduction of an insertion aid for nasal intubation]. / Vorstellung einer Einführhilfe für die nasale Intubation.

Naso-tracheal intubation can lead to complications. We describe a device for protecting the nasal passage and preventing a false passage. Clinical studies show that this significantly reduces the incidence of bleeding, mucosal damage, failure and mucosal erosion.

Prophylactic use of epidural mepivacaine/morphine, systemic diclofenac, and metamizole reduces postoperative morphine consumption after major abdominal surgery.

BACKGROUND: Surgical trauma induces nociceptive sensitization leading to amplification and prolongation of postoperative pain. While preemptive analgesic treatment with numerous agents has been successful in experimental animals, results of human studies remain conflicting. The authors used a multimodal approach for preemptive analgesia before abdominal surgery: diclofenac and metamizole inhibit prostaglandin synthesis, thus influencing peripheral sensitization; epidural local anesthetics induce conduction block, epidural opioids inhibit nociceptive synaptic transmission, and metamizole induces descending inhibition. The interaction of these drugs might suppress spinal nociceptive sensitization and postoperative analgesic demand. METHODS: One hundred forty-two patients scheduled for major abdominal surgery were randomly assigned to one of three groups and studied prospectively. Epidural catheters in groups 1 and 2 were placed at interspaces T8-T10, the position of the catheter was confirmed by epidurography, and sensory testing after administration of 5 ml mepivacaine 1%. Group 1 received 75 mg intramuscular diclofenac, 1000 mg intravenous metamizole, 5.3 +/- 1 mg epidural morphine, and 15-20 ml mepivacaine 1% 85 +/- 41 min before skin incision. Epidural analgesia was maintained by injections of 0.1 ml.kg-1.h-1 mepivacaine 1%. Group 2 patients received the balanced analgesia regimen before wound closure (221 +/- 86 min after skin incision). Group 3 patients did not receive any study substances. General anesthesia was induced with 5 mg/kg thiopental and 2 micrograms/kg fentanyl and maintained with enflurane and nitrous oxide. Postoperative analgesia consisted of patient-controlled intravenous morphine over 5 days. RESULTS: Median visual analog scale pain intensities were < 3 cm and did not differ among the groups. Morphine consumption per hour on postoperative day 2 was 0.8 +/- 0.1 mg/h (group 1) < 1.2 +/- 0.1 mg/h (group 2) = 1.1 +/- 0.1 mg/h (group 3) and cumulative morphine consumption (in mg) on the morning of day 5 was 95 +/- 9 (group 1) < 111 +/- 11 (group 2) < 137 +/- 10 (group 3). CONCLUSIONS: A significant reduction of patient controlled analgesia requirements could be achieved by our preincisional balanced analgesia regimen compared to application before wound closure. The more distinct difference between patients receiving balanced analgesia and those in the control group is based on the analgesic action of the study substances, which lasted about 14 h.

[The effect of changes in lung compliance on ventilation in newborns. Results of animal experiments with two different respirators]. / Einfluss von Störungen der Lungencompliance auf die Ventilation von Neugeborenen. Tierexperimentelle Untersuchung mit zwei verschiedenen Respiratoren.

In most ventilators used in anaesthesia tidal volume delivered during mechanical ventilation is different from the tidal volume preset at the respirator on the basis of respirator and circuit compliance and gas compression during inspiration. The error in ventilation due to the compressed volume is especially significant clinically when the tidal volume is very small or when the airway pressure is very high. In newborns and neonates in particular, decreasing lung compliance during a surgical procedure may contribute to marked hypoventilation. We therefore investigated ventilation in newborn piglets during decreasing lung compliance induced by tension pneumothorax. We used the anaesthesia ventilator CICERO (Dräger, Lübeck, Germany) and the SERVO 900 C ventilator (Siemens-Elema, Sweden). MATERIALS AND METHODS. Two anaesthesia ventilators, the CICERO (group I, n = 8) and the SERVO ventilators (group II, n = 8) were investigated following randomized selection in a group of 16 newborn piglets (Table 1). After normoventilation for 60 min a tension pneumothorax at +10 mbar was induced. After 15 min the pneumothorax was increased to +20 mbar and maintained at this level for the rest of the study. When hypercapnia (PaCO2 > 45 mmHg) resulted, the respiratory rate was increased by +10/min after 15 min with pneumothorax at +20 mbar. When hypercapnia continued, the respiratory rate was increased again 25 min and if necessary also 35 min after the induction of pneumothorax at +20 mbar. After normoventilation for 60 min (T1) (Table 2), after 15 min with pneumothorax at +10 mbar (T2) and after 15 min (T3), 25 min (T4), 35 min (T5) and 45 min (T6) with pneumothorax at +20 mbar the following parameters were obtained: central venous (CVP) and mean arterial pressure (MAP), heart rate (HR), arterial (PaCO2) and end-tidal CO2 tension (PetCO2), peak inspiratory pressure (PIP), respiratory frequency (RF) and expiratory tidal (Vtex) and minute volume (VE). RESULTS. In group I the pneumothorax resulted in a significantly smaller increase in PaCO2 (43.3 +/- 6.2 mmHg) than in group II (Fig. 1), and hypercapnia was present in only 3 piglets. Vtex (Fig. 2), VE (Fig. 3) and PIP (Fig. 5) increased significantly, with significantly higher values than in group II, while PetCO2 (Fig. 6) decreased significantly. In group II the pneumothorax was attributed to a significant increase in PaCO2 and a marked hypercapnia in all piglets (PaCO2 61.2 +/- 5.9 mmHg) (Fig. 1). Vtex (Fig. 2) and VE (Fig. 3) remained unchanged, while PIP (Fig. 5) and PetCO2 (Fig. 6) increased. Following the increase in RF (Fig. 4) in all piglets, Vtex and VE increased and PaCO2 and PetCO2 decreased. CONCLUSIONS. During ventilation of neonates with the SERVO ventilator a decrease in lung compliance will cause hypoventilation and hypercapnia. This reflected by an increase in peak inspiratory pressure and can be corrected by increasing the respiratory rate. In contrast, the CICERO is able to preserve ventilation by an internal correction for gas compression, but it does not guarantee normoventilation in all cases. In neither group does the end-tidal PCO2 reflect the true ventilation during decreasing lung compliance, so that arterial blood gas analysis seems to be mandatory for the diagnosis of hypercapnia in such situations.

Epidural bolus clonidine/morphine versus epidural patient-controlled bupivacaine/sufentanil: quality of postoperative analgesia and cost-identification analysis.

UNLABELLED: We compared the costs, quality of analgesia, and side effects of postoperative patient-controlled epidural analgesia (PCEA) with bupivacaine/sufentanil versus an epidural bolus (BOLUS) of clonidine/morphine in 68 patients with pancreatic surgery. Postoperative pain treatment was performed over 4 days: the PCEA pump was filled with bupivacaine 0.25% and sufentanil 2 micrograms/mL and set to 3-mL bolus and 10-min lockout time. BOLUS patients received injections of clonidine 150 micrograms plus morphine 2 mg on demand. Visual analog scale (VAS) score at rest and during coughing, heart rate (HR), systolic arterial pressure (SAP), incidence of postoperative nausea and vomiting, pruritus, duration of intestinal paralysis, hospital treatment, and costs for personnel and material were recorded. VAS scores during coughing (3 +/- 2.5 vs 5 +/- 3, P < 0.001) was higher, and HR (79 +/- 13 vs 89 +/- 15, P < 0.001), and SAP (110 +/- 18 vs 124 +/- 23, P < 0.001) were lower, in the BOLUS compared with the PCEA group. The incidence of hypotension (SAP < 80 mm Hg) was greater (6 vs 0, P < 0.001) in the BOLUS group. The incidence of all other side effects was comparable. The costs of personnel ($204 +/- $40 vs $166 +/- $38, P < 0.001) were higher in the BOLUS group, but the costs of material ($51 +/- $17 vs $87 +/- $18, P < 0.001) were higher in the PCEA group. Total costs ($62 +/- $9 vs $62 +/- $11 per day, P = 0.9) were comparable. We conclude that because of superior analgesia and reduced side effects at analogous costs, PCEA is preferable to the BOLUS technique for the treatment of postoperative pain. IMPLICATIONS: An epidural clonidine/morphine bolus technique resulted in inferior analgesia, more side effects, and comparable costs compared with a bupivacaine/sufentanil patient-controlled regimen in a randomized controlled trial after abdominal surgery.

Reduced postoperative analgesic demand after inhaled anesthesia in comparison to combined epidural-inhaled anesthesia in patients undergoing abdominal surgery.

We studied the effect of epidural/general combination anesthesia, in comparison to inhaled anesthesia, on postoperative pain and analgesic consumption in patients undergoing upper abdominal surgery. Anesthesia was induced with propofol and maintained with enflurane in 70% N2O as necessary to maintain arterial blood pressure within 20% of baseline. Group I received bupivacaine 0.25% 0.2 mL/kg and sufentanil 1 microgram/kg 65 +/- 3 min before dermal incision and 0.1 mL/kg bupivacaine 0.25% + sufentanil 2 micrograms/mL (BS) every hour thereafter. Group II received 0.2 mL/kg of BS 316 +/- 15 min after dermal incision in the recovery room. Postoperative patient-controlled epidural analgesia (PCEA) with BS was provided. Pain intensities and consumption of PCEA BS were recorded on postoperative days (PODs) 1 to 5. Inspiratory fraction of enflurane was lower (0.5% +/- 0.01% vs 1.6% +/- 0.04%; P < 0.001) in Group I compared with Group II. Cumulative postoperative consumption of PCEA BS was higher in Group I compared with Group II from the evening of POD 2 until the end of the study (301 +/- 19 mL vs 249 +/- 17 mL; P < 0.001), while pain intensities were comparable at all times. The intraoperative effects of combined BS and enflurane/N2O (inspiratory fraction [Fi] approximately 1 minimum alveolar anesthetic concentration [MAC]) did not preempt postoperative pain in contrast to enflurane/N2O anesthesia (Fi approximately 2.8 MAC).

[Effectiveness, side effects and costs of postoperative pain therapy: intravenous and epidural patient-controlled analgesia (PCA)]. / Wirksamkeit, Nebenwirkungen und Kosten postoperativer Schmerztherapie: Intravenöse und epidurale patientenkontrollierte Analgesie (PCA).

PURPOSE: Improvement of the quality of analgesia, reduction of side effects and costs by application of epidural (PCEA) in comparison to intravenous patient-controlled analgesia (PCA) in postoperative pain treatment. METHODS: 62 patients with upper abdominal surgery took part in this randomised prospective study which was approved by the local ethics committee. Epidural catheters were inserted at T 8/9 (group PCEA). General anaesthesia was performed with propofol, sufentanil 2 micrograms/kg, pancuronium, enflurane and O2:N2O = 1:2. Postoperative analgesia consisted of epidural bupivacaine 0.25% + sufentanil 2 micrograms/ml (BS). (bolus 0.05 ml/kg, lockout 10 min) in group PCEA, or of intravenous morphine (bolus 2 mg. lockout 10 min) in group PCA. The following parameters were recorded until the evening of postoperative day 4: pain intensity at rest (VASR, 1-10) and on coughing (VASH, 1-10), blood pressure, heart rate, blood gas analysis, ability to ambulate, pruritus, nausea/vomiting (PONV), patient satisfaction (0-4), time and expenses for postoperative pain treatment. RESULTS: Median VASR (1 vs 2) and VASH (3 vs 4.5) were lower, cough intensity (2 vs 1) and patient satisfaction score (4 vs 3) were higher in PCEA compared to PCA. Ability to ambulate, pruritus, PONV, haemodynamics, paO2 and paCO2 were comparable. Postoperative pain treatment with PCEA was more time-consuming (407 vs 299 min) and expensive (71 vs 40 S/day) than PCA. CONCLUSION: PCEA in comparison to PCA after major abdominal surgery provides superior analgesia with comparable side effects at approximately 80% higher costs.

[Differential indications for non-opioids for postoperative analgesia III. Analgesic effect of perioperative administration of metamizole plus diclofenac after spinal anesthesia]. / Untersuchungen zum differenzierten Einsatz von Nichtopioiden zur postoperativen Analgesie III. Analgetischer Effekt einer perioperativen Gabe von Metamizol plus Dicllofenac nach Spinalanästhesien.

PURPOSE: In a previous study we investigated the analgesic efficacy of a combination of metamizol plus diclofenac after general anaesthesia. After minor orthopaedic surgery postoperative opioid requirements were reduced by 73% during the first 24 h after surgery. In the present study, we have investigated the efficacy of this analgesic combination after minor orthopaedic operations performed in spinal anaesthesia. METHODS: Seventy four patients, scheduled for minor orthopaedic surgery, participated in this double-blind, randomised, placebo-controlled study. The setting was comparable to our previous study. Before induction of spinal anaesthesia, verum-treated patients received a diclofenac suppository (100 mg), and metamizol (1 g/100 ml NaCl 0.9% intravenously over 15 min). These infusions were repeated at 6 h and 12 h. In addition to the third infusion, the patients received a further diclofenac suppository (100 mg). Cumulated doses of buprenorphine (PCA, patient-controlled analgesia), pain scores (0-10), blood pressure, heart rate and side effects were recorded during the first 6 h and again at 24 h. RESULTS: After spinal anaesthesia had subsided, all patients required increasing doses of buprenorphine. Verum-treated patients required significantly lower doses during the first 24 h after surgery (median -29%). CONCLUSIONS: The combination of metamizol and diclofenac causes a clinically relevant reduction in opioid requirements after minor orthopaedic surgery in spinal anaesthesia.

[No reduction in postoperative complications by the use of catheterized epidural analgesia following major abdominal surgery]. / Keine Verminderung postoperativer Komplikationen durch Katheterepiduralanalgesie nach grossen abdominellen Eingriffen.

This study was designed to assess whether intra- and postoperative epidural analgesia would diminish the overall rate of postoperative complications after major abdominal operations when compared to a standard anesthetic and postoperative analgesic regimen. A total of 214 patients undergoing infrarenal aortic bypass operations, gastric resection, gastrectomy, Whipple's operation, or duodenum-preserving pancreatic resection were randomly divided into two groups. Patients in the epidural group (n = 98) were operated on under light general anesthesia (midazolam, low-dose fentanyl, N2O/O2, pancuronium bromide). In addition, a mixture of bupivacaine (0.25%) and fentanyl (2 micrograms/ml) was infused (6-10 ml/h) via a thoracic epidural catheter intra- and postoperatively for 76:1.45 h (logarithmic normal distribution). Patients in the control group (n = 116) were operated on under a standard general anesthesia (midazolam, fentanyl, N2O/O2, isoflurane, pancuronium-bromide). Piritramid was injected for postoperative pain relief, either i.v. (recovery room, intensive care unit) or i.m. (surgical ward). In the epidural group the quality of analgesia and ability to cough were significantly better (2 P less than 0.0071) than in the control group (four observations each on the 1st and 2nd postoperative days). Heart rate and mean arterial pressure were lower in the epidural group at the same points of observation (2 P less than 0.01), as was the plasma glucose on the 1st postoperative day. The time up to the first postoperative defecation was shorter in the epidural group (79:1.51 h) as compared to the control group (93:1.38 h; 2 P less than 0.0167). The time to hospital discharge was equal in both groups (epidural group 19:1.6 days, control group 18:1.6 days).(ABSTRACT TRUNCATED AT 250 WORDS)

[Analgesia and hemodynamics under 8 mu/kg clonidine for pain therapy following major abdominal surgery]. / Analgesie und Hämodynamik unter 8 mu/kg Clonidin epidural zur Schmerztherapie nach grossen abdominellen Eingriffen.

OBJECTIVE: To characterise the haemodynamic profile after epidural injection of high-dose clonidine for postoperative pain management and to establish recommendations for the therapy of haemodynamic instabilities. DESIGN: 20 patients with major surgery on pancreas, stomach or infrarenal aorta took part in the study. Anaesthesia was a combined epidural/inhalational regimen with bupivacaine 0.25%, enflurane, oxygen/nitrous oxide, fentanyl 0.1 mg and pancuronium. Postoperative analgesia consisted of morphine 50 micrograms/kg in 10 ml NaCl 0.9% for the first 12 postoperative hours; if pain > = 5 points on the VAS occurred after > 12 h postoperatively clonidine 8 micrograms/kg in 10 ml NaCl 0.9% was injected epidurally and the pain intensity (self-assessment by the patient using the visual analog scale) and circulation (invasive pressure monitoring, pulmonary artery catheter) was monitored for 60 minutes in ten minutes intervals. RESULTS: The reduction of the initial VAS score of 6 was 50% after 20 minutes and 100% after 60 minutes. We observed a significant decline in heart rate (87 +/- 11 (t0), 74 +/- 10 min-1 (t60)), mean arterial pressure (97 +/- 17 (t0), 72 +/- 15 mmHg (t60)) and cardiac output (8.7 +/- 1.3 (t0), 7.0 +/- 1.3 l.min-1 (t60)) (all p < 0.001) and no change of systemic vascular resistance. Filling pressures (CVP and PCWP) remained stable. In 9 patients the mean arterial pressure fell below 60 mmHg (always within the first 40 min); 6 of these patients responded to infusion of a colloid (500 ml of hydroxyethyl starch at > = 2 ml/kg.min) whereas the other 3 patients needed a bolus injection of a betamimetic catecholamine (theodrenaline/cafedrine, Akrinor). CONCLUSION: Epidural clonidine 8 micrograms/kg causes rapid and intense analgesia. Haemodynamic instability is a consequence of a drop in heart rate and has to be treated accordingly. The application of a pure vasopressor does not seem to be indicated taking in account the fact that the total peripheral resistance remains unchanged and in the normal range.

Effect of phenylephrine bolus administration on left ventricular function during high thoracic and lumbar epidural anesthesia combined with general anesthesia.

The effect of phenylephrine (PHE) boluses on left ventricular (LV) function was examined in patients without cardiovascular disease who developed arterial hypotension during high thoracic epidural anesthesia (TEA) combined with general anesthesia (GA) (group 1) or lumbar epidural anesthesia (LEA) combined with GA (group 2). LV function was assessed by transesophageal echocardiography (TEE) before and after central venous injection of 1 microgram/kg PHE. Fractional diameter shortening (FDS), end-systolic wall stress (ESWS), and rate-corrected velocity of circumferential fiber shortening (mVcfc) were determined. PHE effectively restored arterial blood pressure in both groups with a peak effect between 30 and 45 s after injection. FDS was reduced from 38% to 25% (mean, P < 0.01) in group 1 and remained unchanged in group 2. ESWS increased from 70 to 143 x 10(3) dyne.cm-2 (P < 0.01) and from 57 to 86 x 10(3) dyne.cm-2 (P < 0.05), in groups 1 and 2, respectively. mVcfc was significantly reduced from 1.11 to 0.80 circ/s (P < 0.05) in group 1 and was not altered in group 2. The authors conclude that PHE given as an intravenous bolus to patients under high TEA plus general anesthesia causes a transient impairment of LV function.