[Propofol administration systems. Handling, hemodynamics and propofol consumption]. / Propofolapplikationssysteme: Handhabung, Kreislaufverhalten und Propofolverbrauch.

BACKGROUND: During anaesthesia propofol is administered either by manual controlled infusion (MCI) or by target controlled infusion (TCI) techniques. In this study two different TCI systems for propofol administration were evaluated with regard to handling, patient safety, and costs and compared to administration of propofol by the MCI technique. METHODS: In a prospective study, 90 patients scheduled for elective surgery of the nose or nasal sinuses were randomly enrolled in three groups. The two TCI systems were examined in two groups of 30 patients: one group received propofol following the pharmacokinetic TCI model of Schnider (TCI-Schnider) and the other group received propofol following the TCI model of Marsh (TCI-Marsh). A manual perfusion technique (MCI, n=30) was used in the control group. Depth of anesthesia was controlled using the bispectral index (BSI) which was adjusted to fall within the range of 40-55. Hemodynamics, extubation times and time of awaking, rate and quality of propofol dose adjustment, total drug requirements, costs, and quality of recovery were documented. The incidence of postoperative nausea and vomiting (PONV) as well as shivering and patient satisfaction were also documented. RESULTS: Demographics, hemodynamics and perioperative data did not differ between the groups. Propofol consumption within the first 60 min also showed no significant differences. In the course of extended anaesthesia, propofol consumption was significantly less in both TCI groups compared to the control group (MCI) and the TCI-Schnider group also showed less episodes of bradycardia. The necessity of propofol dose adjustment did not differ significantly between the TCI groups. Administration and consumption of anaesthesia co-medication (fentanyl, remifentanil, cisatracurium) did not differ between the groups. CONCLUSION: The investigated propofol administration procedures using the MCI or TCI techniques were safe and easy to handle under BIS monitoring. No differences were found concerning extubation times and time of awaking. During extended anaesthesia procedures (>60 min), propofol consumption was lower with both TCI techniques and thus costs could be saved.

Individual titration of propofol plasma target improves anaesthetic stability in patients undergoing major abdominal surgery: a comparison with manually controlled infusion.

BACKGROUND AND OBJECTIVE: The impact of anaesthesia using target-controlled infusion with propofol on intraoperative stability, recovery and cost compared to manually controlled infusion has been evaluated with inconsistent results. We studied a new device that allows more individual titration of propofol target-controlled infusion by using the effect-site concentration at the loss of eyelash reflex to predict the maintenance infusion rate (FM-TCI). METHODS: Fifty-six patients undergoing major abdominal surgery lasting >2 h were randomly assigned to receive either FM-TCI (n = 28) or MCI-controlled (n = 28) anaesthesia. Both groups were Bispectral Index-monitored and thoracic epidural analgesia was established. Anaesthetic stability, incidence of haemodynamic abnormalities, time to extubation, propofol consumption and patient satisfaction were assessed. RESULTS: In the FM-TCI group, a significantly improved anaesthetic stability was achieved (0.43 +/- 0.44 vs. 1.31 +/- 0.78 adjustments of propofol infusion per patient per hour, P = 0.003) and time to extubation was significantly shorter (9.6 +/- 2.1 vs. 15.7 +/- 9.6 min P = 0.011). With FM-TCI, propofol consumption was significantly lower. Haemodynamic stability and patient satisfaction did not differ between the groups. CONCLUSION: FM-TCI helps to provide more stable anaesthesia conditions requiring less-frequent adjustments of the propofol infusion compared to manually controlled infusion in patients undergoing major abdominal surgery.

[Comparison of a propofol-based anesthesia regimen using optimated-target-controlled-infusion (OTCI) and manually-controlled infusion (MCI) technique]. / Propofol-Anästhesie mittels Target-Controlled-Infusion (TCI). Ein Vergleich der Verfahren: Optimated-Target-Controlled Infusion (OTCI) und Manually-Controlled-Infusion (MCI).

BACKGROUND: Propofol anesthesia based on target-controlled-infusion (TCI) has been shown to be superior to a manually-controlled-infusion (MCI) technique. A new optimal-target-controlled-infusion (OTCI) technique enables an individual plasma-targeted adjustment by including the concentration in the effect-compartment. This study compared practicability and costs of the new system with a conventional MCI-based propofol anesthesia regimen. METHODS: In a prospective study, 50 patients scheduled for elective surgery of nose or nasal sinuses were randomly enrolled to receive BIS-controlled anaesthesia (level: 40-55) using either OTCI (n = 25) or MCI (n = 25). Hemodynamics, extubation times and time of awaking, rate and quality of propofol adjustment, total drug requirements, costs, postanaesthetic care unit (PACU) stay, Aldrete and pain scores, and adverse effects (postoperative nausea and vomiting (PONV), shivering) were recorded. RESULTS: Demographics, hemodynamics, and perioperative data including extubation times were comparable for both study groups. Propofol consumption was similar within the first 60 min for both groups, thereafter, significantly less propofol in the OTCI group (5.03 mg/kg/h) than the MCI group (5.79 mg/kg/h) was used. Costs for propofol was significantly reduced with OTCI (0.2 vs. 0.23 Cent/anaesthesia minute/kg), the administration of other anaesthetics (fentanyl, remifentanil, cis-atracurium) did not differ between the groups. The number of infusion adjustments to BIS values were not significantly different. CONCLUSION: The new OTCI-system is a safe and easily controllable technique. The obvious advantage of this infusion system appears to be a reduction in propofol consumption and direct drug costs for anaesthesia lasting longer than 60 min.

[ProSeal-laryngeal mask versus endotracheal intubation in patients undergoing gynaecologic laparoscopy]. / Ein Vergleich der ProSeal(R)-Larynxmaske mit der konventionellen endotrachealen Intubation bei Laparoskopien in der Gynäkologie.

BACKGROUND: The aim of this study was to assess the practicality of the ProSeal laryngeal mask (PS-LMA) airway during laparoscopic surgery with capnoperitoneum compared to endotracheal intubation (ET). METHODS: Prospective, randomized study. 104 patients undergoing gynaecologic, laparoscopic surgery were allocated randomly to two groups: 1. ET-group (n = 50). 2. PS-LMA-group (n = 54). Total intravenous anaesthesia was performed by the same anaesthesiologist. MEASUREMENTS: Mean arterial pressure, heart rate, at 4 and circuit pressure at 2 measurement points, and the incidences of coughing and sore throat. Insertion of the ET and the PS-LMA was scored by using a four-point scale. Ease of placing the gastric tube was judged by measuring the number of attempts at insertion and the insertion times. A p-value of < 0.05 was considered as significant. RESULTS: There were no differences between PS-LMA and ET concerning circuit pressure at any measurement point. At the end of anaesthesia, mean arterial pressure (92 +/- 13 vs. 100 +/- 14 mmHg; p < 0.01) and heart rate (66 +/- 13 vs. 76 +/- 14 beats/min; p < 0.01) were lower in the PS-LMA-group compared to the ET-group. At the end of anaesthesia 25 patients of the ET-group coughed but nobody in the PS-LMA-group (p < 0.00001). There was no difference with regard to postoperative sore throat. The insertion of the PS-LMA was easier compared to ET (p < 0.05), but we found no significant difference concerning insertion times. Fewer attempts at insertion of the gastric tube were necessary in the PS-LMA-group than in the ET-group (p < 0.01), whereas insertion times did not differ. CONCLUSION: The PS-LMA is a convenient and practicable approach for anaesthesia in patients undergoing laparoscopic surgery.

[Prevention of post-operative nausea and vomiting. Randomised comparison of dolasetron versus dolasetron plus dexamethasone]. / Prophylaxe von postoperativer Ubelkeit und postoperativem Erbrechen. Randomisierter Vergleich von Dolasetron versus Dolasetron mit Dexamethason.

BACKGROUND: Postoperative nausea and vomiting (PONV) are frequent complications after operations. The aim of this study was to assess the efficacy of combined dolasetron plus dexamethasone versus dolasetron alone with respect to the incidence and severity of emetic symptoms and patients satisfaction. METHODS: In a prospective, randomised, double-blind study, 150 patients scheduled for hysterectomy or breast surgery were allocated to one of the following two groups: group A received 50 mg dolasetron orally and group B 50 mg dolasetron orally plus 8 mg dexamethasone intravenously. The follow-up was for 24 h after surgery. RESULTS: In group A PONV was significantly more frequent (28%) compared to group B (12.0%). The incidence of vomiting was significantly lower in patients receiving dolasetron plus dexamethasone (0%) in comparison to patients receiving dolasetron (8.0%). Furthermore,patients satisfaction was significantly higher in group B compared to group A. About 6 or 7 patients need to be treated with additional dexamethasone instead of a placebo for one patient to benefit from this intervention (i.e. to stay free from PONV) who otherwise would have suffered from PONV. CONCLUSIONS: Combining oral dolasetron with intravenous dexamethasone further improves the antiemetic efficacy of dolasetron. With a number-needed-to-treat of about 6 the additional benefit might be considered clinically relevant.

Placebo-controlled comparison of dolasetron and metoclopramide in preventing postoperative nausea and vomiting in patients undergoing hysterectomy.

BACKGROUND AND OBJECTIVE: In a randomized, placebo-controlled, double-blind trial, we compared the efficacy of dolasetron and metoclopramide in preventing postoperative nausea and vomiting in women undergoing hysterectomy. METHODS: Patients were allocated randomly to one of three groups: group A (n = 50) received 50 mg dolasetron orally, group B (n = 50) received 20 mg metoclopramide intravenously and placebo orally, group C (n = 50) received placebo orally. If patients complained of retching or vomiting, or if patients demanded an antiemetic, 1.25 mg droperidol was administrated intravenously. To quantify postoperative nausea and vomiting the following score was used: 0 = no nausea, 1 = nausea, 2 = retching, 3 = single vomiting, 4 = multiple vomiting. The Raatz test was used to analyse postoperative nausea and vomiting (PONV) scores. RESULTS: Dolasetron reduced the postoperative nausea and vomiting score significantly (P < 0.02 vs. metoclopramide; P < 0.0001 vs. placebo). Metoclopramide also reduced the postoperative nausea and vomiting score (P < 0.02 vs. placebo). Fisher's exact test showed a significant reduction of vomiting in the dolasetron group compared with metoclopramide-treated patients (P < 0.007) and placebo-treated patients (P < 0.000006) and a significantly lower rate of nausea in comparison to the placebo group (P < 0.009). There were no significant differences between the metoclopramide and the placebo groups (in Fisher's exact test). The use of postoperative droperidol per patient was significantly lower in the dolasetron group (P < 0.04 vs. metoclopramide; P < 0.0001 vs. placebo) than in the metoclopramide (P < 0.02 vs. placebo) and in the placebo groups. CONCLUSIONS: Oral dolasetron is more effective than either metoclopramide given intravenously or placebo for preventing vomiting after hysterectomy. It also was significantly superior to either metoclopramide or placebo concerning the PONV score and the need for droperidol rescue.

[Prevention of postoperative nausea and vomiting after hysterectomy with oral dolasetron, intravenous dehydrobenzperidol or a combination of both substances]. / Prophylaxe von postoperativer Ubelkeit und Erbrechen nach Hysterektomie mit oralem Dolasetron, intravenösem Dehydrobenzperidol (DHB) oder einer Kombination beider Substanzen. Eine placebokontrollierte Untersuchung.

OBJECTIVE: PONV is a frequent postoperative complication. The aim of this study was to assess the efficacy of oral dolasetron in comparison to intravenous droperidol (DHB) and to a combination of both drugs for prophylaxis of PONV. METHODS: 80 patients (ASA I-III) were randomly allocated to one of four groups and received the following medication: group A: 50 mg dolasetron was given orally 45-60 minutes before anaesthesia was induced, group B: 2.5 mg i.v. DHB + placebo p.o. was administered while inducing anaesthesia (positive control group), group C: 50 mg dolasetron was given 45-60 minutes before anaesthesia was induced and 2.5 mg i.v. DHB was given while inducing anaesthesia, group D: placebo tablet was administered 45-60 minutes before anaesthesia was induced (negative control group). PONV was assessed using a 5-point score: 0 = no symptoms, 1 = nausea, 2 = retching, 3 = vomiting, 4 = multiple vomiting. Metoclopramid was given as antiemetic if a patient reached two or more score points. RESULTS: PONV scores were significantly lower in group A and C (p < 0.001) compared to the control group. Patients treated with DHB showed a significantly lower PONV score in comparison to the placebo treated patients (p < 0.05). Between the groups A, B and C we found no significantly different PONV scores. Postoperative consumption of metoclopramid was significantly lower in the groups A (2.4 +/- 5.2 mg) and C (1.0 +/- 3.1 mg) than in the placebo group (6.0 +/- 6.8 mg), whereas between group B (3.0 +/- 5.7 mg) and D we found no significant differences. CONCLUSIONS: Single dose of oral dolasetron and single dose of intravenous DHB reduced PONV effectively, in patients undergoing gynaecologic surgery. A combination of dolasetron and DHB has no better effect than a single dose of oral dolasetron. Contrary to DHB the application of dolasetron decreased the postoperative antiemetic requirement significantly.

A randomised comparison of three laryngoscopes with the Macintosh.

The Macintosh laryngoscope blade was compared with three modified blades--the Bizzarri-Giuffrida, the 'Improved Vision' Macintosh, and the Wiemers blade. Before and after a training session 24 participants intubated a Laerdal Airway Management Trainer with the four blades in random order. Intubation time was measured, oesophageal malpositions and 'clicks' indicating possible teeth damage, were counted. Each participant scored the handling of each blade on a 6-point scale (1 = very good, 6 = very poor). Intubation times before training were 10.6 +/- 5.3 s for the Macintosh, 16.7 +/- 9.2 s for the Bizzarri-Giuffrida, 13.3 +/- 9.0 s for the 'Improved Vision' Macintosh and 11.7 +/- 6.1 s for the Wiemers. Intubation times after training were 7.1 +/- 2.5 s for the Macintosh, 10.6 +/- 5.4 s for the Bizzarri-Giuffrida, 8.1 +/- 3.4 s for the 'Improved Vision' Macintosh and 7.6 +/- 2.5 s for the Wiemers. The handling scores were: 2.0 +/- 0.8 for the Macintosh, 3.9 +/- 1.2 for the Bizzarri-Giuffrida, 2.1 +/- 0.8 for the 'Improved Vision' and 2.3 +/- 0.8 for the Wiemers. In regard to the intubation time before training (P < 0.02), the intubation time after training (P < 0.003), and handling (P < 0.0005), the Bizzarri-Giuffrida was significantly inferior to the Macintosh. The 'Improved Vision' Macintosh and the Wiemers were not significantly different to the Macintosh. No significant difference was seen for oesophageal malpositioning and 'clicks' between any of the blades.

Critical illness polyneuropathy following cardiac surgery.

Critical illness polyneuropathy (CIP), a neurologic complication which may occur secondary to surgery, trauma and coma, is associated with sepsis or multiple organ failure (MOF). CIP is characterized by an axonal distal degeneration of sensory and motor fibres. The patients will often become neurologically conspicuous when weaning from mechanical ventilation is unexpectedly difficult. In such cases electrophysiologic examinations must be performed. CIP following cardiac surgery is widely unrecognized. The most important aspect of CIP therapy is treatment of the underlying disease, because no specific treatment for CIP exists. We report on a 64-year old patient who developed sepsis and CIP following cardiovascular surgery. The neurological complication was initially misinterpreted as hypoxic brain damage.

[Neurologic symptoms in acute thoracic aortic dissection--a case report]. / Neurologische Symptome bei akuter thorakaler Aortendissektion--ein Fallbericht.

Acute thoracic aortic dissection is a life-threatening illness. It is often difficult to diagnose preclinically due to its many possible symptoms. One out of three patients has neurological deficits. The prognosis depends on rapid diagnosis and immediate adequate therapy. Therefore, every emergency physician should know the signs and risk factors of this disease. The most important goals of prehospital therapy are management of pain and anxiety and pharmacological control of the systolic blood pressure and heart rate. We report on a 46-year-old female patient who developed neurological deficits caused by an acute thoracic aortic dissection.

[Prophylactic nefopam administration for post-anesthetic shivering]. / Prophylaktische Nefopamgabe schützt vor postanästhetischem Shivering.

PURPOSE: Shivering is a frequent postanaesthetic complication. Its definite reason is unknown. Patients with cardiovascular or pulmonary diseases are endangered by postanaesthetic shivering. The aim of this study was to assess the efficacy of nefopam in prophylaxis of shivering. Additionally we investigated the influence of nefopam on haemodynamic parameters and on the time until extubation. METHODS: 30 patients (ASA I-II) were randomly allocated in a double-blind fashion to one of two groups to receive directly after the end of isoflurane application either nefopam (0.15 mg/kg) or placebo (0.9% saline). The period of anaesthesia had to be longer than 60 minutes. All patients received a premedication with lorazepam (0.02 mg/kg) 30-45 minutes prior to surgery. Induction of anaesthesia was standardised: fentanyl (3 micrograms/kg), thiopentone (5 mg/kg), atracurium (0.4 mg/kg). Intraoperatively a mixture of isoflurane, nitrous oxide (60%) and oxygen was used to maintain anaesthesia. The following parameters were evaluated: Age, sex, duration of operation and anaesthesia and the time between the end of application of volatiles and extubation. Heart rate (HR), mean arterial blood pressure (MAP), rectal temperature and O2-saturation were measured at predefined data points. Postoperatively the consumption of analgesic was documented. The severity of shivering was classified in five grades. RESULTS: In the control-group nine patients shivered (60%), whereas in the nefopam group only one patient (6.6%) shivered (p < 0.05). In comparison to the placebo group we observed in the nefopam group a significantly decreased HR 30 and 60 minutes postoperatively (p < or = 0.007 and p < or = 0.002). We did not observe prolonged awakening in the nefopam-treated patients. MAP and O2-saturation showed similar reactions in both groups. CONCLUSION: The data indicate that prophylactic administration of nefopam can suppress postanaesthetic shivering. Prolonged awakening was not observed.

Unexpected return of spontaneous circulation after cessation of resuscitation (Lazarus phenomenon)

Since 1982, more than 20 patients with return of spontaneous circulation after cessation of cardiopulmonary resuscitation (Lazarus phenomenon) have been published. We report on another case here. Such cases are probably underreported due to medicolegal concerns. After cessation of resuscitation, each patient should be further monitored for at least 10 min to detect a possible Lazarus phenomenon.

Point-of-care (POC) measurement of coagulation after cardiac surgery.

OBJECTIVE: Two different point-of-care (POC) systems for the monitoring of coagulation variables at the bedside were evaluated with regard to practicability, accuracy and costs. DESIGN: Prospective, descriptive study. SETTING: Single-institutional, clinical investigation on an intensive care unit (ICU) of an urban, university-affiliated hospital. PATIENTS: Eighty cardiac surgery patients were studied postoperatively. INTERVENTIONS: Arterial blood samples were drawn postoperatively on the ICU at different data points. MEASUREMENTS AND RESULTS: Activated partial thromboplastin time (aPTT) and prothrombin time (PT) were measured using two POC systems (Thrombolytic Assessment System [TAS] and CoaguCheck Plus). At the same time coagulation parameters were measured by the central laboratory of the hospital. Measurements were carried out at different data points after cardiac surgery on the ICU. The direct and indirect costs of measuring aPTT/PT were also assessed. Bias analyses revealed good agreement of the POC-based monitoring of aPTT/PT with laboratory-based monitoring of coagulation (e. g. aPTT CoaguCheck: bias of -2.8 s with +/- 2 SD [limits of agreement] of +13.7 and -19.1 s). Mean turn-around time (TAT; time from blood sampling until availability of data for the ICU physicians) was significantly longer for the central laboratory-based coagulation monitoring (130 +/- 38 min) than for the two POC systems (aPTT-TAS: 9.6 +/- 2.7 min; aPTT-CoaguCheck: 6.5 +/- 1.9 min). Blood sampling at unfavorable times increased the TAT for laboratory-based measurements considerably. The direct costs for measuring aPPT and PT were significantly higher using both POC systems (aPTT-TAS: $4.84; aPTT-CoaguCheck: $4.34) than for the central laboratory ($1.59). Costs for transportation increased the laboratory-based monitoring considerably ($3.77). CONCLUSIONS: Both POC analyzers may reduce the potential for preanalytical errors associated with coagulation measurements at the central laboratory, hasten TAT significantly and may improve patient therapy by reducing inappropriate administration of blood products.

Myxoma complex associated with transient hyperthyroidism: are diseases of the thyroid part of the complex?

The myxoma complex is a very rare disease. We report on a 31-year-old woman who suffered a hyperthyreosis, which resolved spontaneously. A few months later she developed a Cushing's syndrome, caused by a primary adrenocortical nodular dysplasia. A bilateral adrenalectomy had to be performed. 15 months after this operation she developed a cerebral infarction caused by an embolus from a left atrial myxoma. Our patient is a further case of Carney's syndrome. The aspect of the hyperthyreosis is interesting: Perhaps disease of the thyroid represents a new element of Carney's syndrome.