General versus locoregional anesthesia in carotid surgery: a prospective randomised trial.

BACKGROUND: To evaluate the influence of anesthetic technique on perioperative neurological and cardiopulmonary complication rates in patients undergoing carotid endarterectomy. PATIENTS AND METHODS: 186 patients with symptomatic internal carotid artery (ICA) stenosis > 70% or asymptomatic ICA stenosis > 80% were prospectively randomized for either locoregional (LA) or general anesthesia (GA). RESULTS: Neurological complication rates were similar in both groups (GA 2% vs. LA 2%). Cardiopulmonary complication rates were not significantly different (GA 4% vs LA 1%). There were no stroke-related deaths, but one patient from the GA group died from severe postoperative pneumonia. Thus, a significant difference in combined stroke/cardiopulmonary related death between the two groups (GA 1% vs LA 0%) could not be found. However, perioperative cardiopulmonary monitoring showed that significantly more patients operated under general anesthesia had hypertensive events, with systolic blood pressure values greater than 180 mmHg on postoperative day one. There were no differences in the number of postoperatively hypotensive episodes (systolic blood pressure values < 100 mmHg) between the two groups. CONCLUSIONS: Significant differences in the perioperative neurological and cardiopulmonary complication rates between general and locoregional anesthesia in patients undergoing carotid endarterectomy could not be observed.

Variability of outcome after lumbar disc surgery.

STUDY DESIGN: A prospective, consecutive study of patients' outcome at three subsequent follow-up times after lumbar disc surgery. OBJECTIVES: To evaluate how consistent outcome remained in a group of patients after lumbar disc surgery. SUMMARY OF BACKGROUND DATA: Despite similar results concerning the overall outcome, results in most studies show different prognostic factors for lumbar disc surgery at different follow-up times. A reason for this observation could be that patients shift to a different outcome group during the observation period. METHODS: Before surgery and at the three follow-ups (3, 12, and 28 months after surgery) the Low Back Outcome Score was calculated. Groups with favorable and unfavorable outcome were determined after each follow-up according to the scores. RESULTS: Ninety-eight patients were studied. Forty percent showed an unstable outcome at different follow-up times. For each follow-up, three prognostic factors were determined. No prognostic factor showed significance at all follow-up examinations. CONCLUSIONS: Patients whose outcome after lumbar disc surgery does not remain stable present a major problem in the calculation of prognostic factors.

Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients.

Although chronic back pain is one of the most frequent reasons for permanent impairment in people under 65, the neurobiological mechanisms of chronification remain vague. Evidence suggests that cortical reorganisation, so-called functional plasticity, may play a role in chronic back pain patients. In the search for the structural counterpart of such functional changes in the CNS, we examined 18 patients suffering from chronic back pain with voxel-based morphometry and compared them to 18 sex and age matched healthy controls. We found a significant decrease of gray matter in the brainstem and the somatosensory cortex. Correlation analysis of pain unpleasantness and the intensity of pain on the day of scanning revealed a strong negative correlation (i.e. a decrease in gray matter with increasing unpleasantness/increasing intensity of pain) in these areas. Additionally, we found a significant increase in gray matter bilaterally in the basal ganglia and the left thalamus. These data support the hypothesis that ongoing nociception is associated with cortical and subcortical reorganisation on a structural level, which may play an important role in the process of the chronification of pain.

[How reliable is our memory for acute postoperative pain]. / Wie zuverlässig ist unser Gedächtnis für akute postoperative Schmerzen?.Vergleich der retrospektiven Schmerzeinschätzung mit den Aufzeichnungen während postoperativer PCA.

OBJECTIVES: Clinicians use patients' recall of pain as an important source of evidence both in diagnosis and in assessing improvements following treatment. Yet very little is known about the accuracy of these retrospective accounts up to now. METHODS: We examined patients' retrospective evaluations of the pain they experienced at the first postoperative day and related these evaluations to the pain intensity which was recorded in the PCA-report. RESULTS: We found that recall was moderately accurate. Patients mostly overestimated their pain intensity. We could demonstrate that patients who overestimated their pain differed significantly from those who did not. The patients who overestimated showed no significant pain relief over the first three postoperative days. Other influences were the pain intensity of the third day and patients' expectations of the postoperative pain intensity. Our results could be embedded within the theoretical framework of general memory research. CONCLUSIONS: We conclude that real-time evaluations of pain intensity should be recorded additionally to retrospective accounts. Retrospective ratings are important too, because we suggest that the memory of pain more than the experience of pain itself form the basis of patients' future decisions about treatment including their compliance and their satisfaction with pain management.

[Patient-controlled analgesia: psychological predictors of pain experience, analgesic consumption and satisfaction]. / Patientenkontrollierte Analgesie. Psychologische Prädiktoren des postoperativen Schmerzerlebens, des Schmerzmittelverbrauchs und der Patientenzufriedenheit.

INTRODUCTION: The present study examines the relationship between different psychological variables (including anxiety, depression, locus of control, expectations of pain intensity and social support) and postoperative pain, analgesic consumption and satisfaction with the pain management in a study sample of 67 patients. METHODS: Intravenous patient-controlled analgesia was used for postoperative analgesia. Pain intensity was assessed by numerical rating scales and obtained from the PCA-report. On the fourth day after surgery, the patients estimated retrospectively the pain intensity of the first day. RESULTS: The results show that postoperative pain experience correlates significantly with several variables raised preoperatively. The retrospective variables were predicted by psychological measures. There was no relationship to the pain measurements of the PCA-report. CONCLUSIONS: While pain experience could be predicted by stable psychological traits, satisfaction was associated with the state variables, like anxiety and depression. It is precisely satisfaction with the pain therapy that could be improved by special preoperative psychological training and/or general information about the postoperative pain intensity.

[Autologous transfusion -- from euphoria to reason: clinical practice based on scientific knowledge (Part II). Intraoperative blood salvage with blood irradiation -- from an anaesthesiological point of view]. / 3. Internationales Symposium: "Autologe Transfusion -- Von der Euphorie zur Ratio: Praktisches Handeln aus wissenschaftlicher Sicht" (Teil II).

The requirement for intraoperative blood salvage (IBS) in cancer surgery stems from the high transfusion rate, the unfavourable effects of an anaemia, and the impact of transfusion risks like immunomodulation in tumor patients. The advantages of IBS are availability, the low waste rate, and the excellent quality of this autologous, unstored blood. The only effective elimination of the risk of tumor cell dissemination after retransfusion of wound blood is achieved by blood irradiation. The combination of the established methods of IBS and blood irradiation is practical, and allows a very efficient saving of blood. For Jehovah's witnesses it may open the possibility for tumor surgery. From an anaesthesiological point of view it is part of the therapy, but any context that puts it compatible to medicolegal regulations is welcome. For him as the one responsible for the therapy of intraoperative blood loss it represents the safest and best blood for an optimal hemotherapy in tumor patients. In addition, first data indicate a better outcome of these patients.

[Patient-controlled analgesia. PCA in a three year old child after traumatic amputation]. / Elternkontrollierte Analgesie. PCA bei einem dreijährigen Kind nach traumatischer Amputation.

We report the case of a 3-year-old boy, who received long-term parent-controlled analgesia after traumatic amputation of one leg. He underwent surgery 17 times for a period of 25 days. Parent-controlled analgesia was started four days after admission because analgesia with non-opioid analgetics (acetaminophen) proved to be insufficient. The pump was set to a bolus-dose of 23 micrograms kg-1 piritramide (dipidolor) and a lockout interval of 10 minutes. Permitted maximum cumulative dose in four hours was 5 mg piritramide. There was no continuous infusion of opioid. PCA and possible adverse effects were explained to the mother. A monitoring regimen was used to assess efficacy (pain intensity estimated by the mother), adverse effects (sedation score, occurrence of nausea and vomiting) and piritramide consumption. For fear of side effects opioid administration was insufficient in the beginning. After three days the mother used the PCA effectively and no additional analgesic medication was required. Nausea or other side effects were not observed. After seven days opioid consumption nearly doubled. Apart from tolerance, this might have resulted from the mother's caution in the first days. After 17 days the PCA was discontinued. Oral analgetics (tramadol) controlled the pain adequately. Management of postoperative pain in children is difficult and too often insufficient. PCA is a safe and effective method of providing postoperative pain relief. Feasibility was shown in adolescents and, more recently, in children aged five years and over. Only few reports are available describing long term use of PCA in children younger than five years. Our case suggests that PCA may also be used effectively and safely in children younger than five years, if experienced staff, a monitoring regimen and cooperative and well instructed parents are available.

Blood irradiation for intraoperative autotransfusion in cancer surgery: demonstration of efficient elimination of contaminating tumor cells.

BACKGROUND: Intraoperative blood salvage is contraindicated in cancer surgery because of contaminating tumor cells and the risk of systemic dissemination. On the basis of the radiosensitivity of cancer cells, irradiation of salvaged blood with 50 Gy is proposed as a way to allow return of salvaged blood. STUDY DESIGN AND METHODS: Elimination of tumor cells by blood irradiation was studied in vitro with cells from 10 cell lines and from 14 tumor preparations after their addition to red cells in high numbers, or with blood shed during cancer surgery. Before and after gamma radiation, tumor cells were isolated by density gradient centrifugation and tested for their proliferative capacity in a cell colony assay. DNA metabolism was analyzed by incorporation of 5' bromodesoxyuridine. RESULTS: Survival curves of cells from various tumors confirmed D0 (the dose required to reduce the fraction of surviving cells to 37 percent of the original value) values in the range of 1.2 to 2.2 Gy. After irradiation of tumor cell-contaminated blood with 50 Gy, no cell colony formation was observed, which indicates a reduction rate exceeding 10 log. Irradiated cancer cells showed viability, but no residual DNA metabolism. CONCLUSION: The level of inactivation by a 50-Gy dose far exceeds that needed to inactivate the number of proliferating tumor cells observed or expected in wound blood. These results provide the experimental basis for the clinical application of blood irradiation for intraoperative blood salvage in cancer surgery.

[Brachial plexus. Long lasting neurological deficit following interscalene blockade of the brachial plexus]. / Plexus brachialis. Langanhaltendes neurologisches Defizit nach interskalenärer Blockade des Plexus brachialis (Winnie).

An interscalene block of the brachial plexus was combined with general anaesthesia for repair of a complex chronic lesion of the shoulder. The localisation of the plexus with electro-stimulation and the injection of Bupivacain 0.5% were accomplished easily and without painful sensations. 48 hours later the block was still partially present. Paraesthesia and a sensory and motor innervation deficit affected mainly the dorsal fascicle, but also areas innervated by the median and lateral fascicles. The deficit did not completely disappear for 18 month. The cause could have been due to direct traumatisation during blockade or operation, toxic action of the injected substance (Bupivacain 0.5%, 30 ml), distension of the plexus, a cervical syndrome or an aseptic plexitis, although a definite determination is not possible. However, the pattern of the lesion and the lack of pain during localisation of the plexus and injection favour traumatisation during the acromioplasty.

Composition and characteristics of an autologous thrombocyte gel.

BACKGROUND: The purpose of the current study was to characterize and compare an autologous thrombocyte gel containing several blood components with a commercially available glue. MATERIALS AND METHODS: Twenty-five volunteers had blood drawn, and lab values, characteristics of the platelet-enriched plasma (PRP), thrombocyte aggregation, electron microscopic examinations, and the breaking strength were determined and compared to a commercial glue. RESULTS: Overall 65% of the total thrombocytes could be isolated from the volunteers and an enrichment of 300% with an autotransfusion device could be achieved. Thrombocyte aggregation as a marker for thrombocyte function decreased from 92% in patients to 71% in the PRP. The autologous glue demonstrated a significant reduced breaking strength (0,76 N/cm(3)) compared to the commercial glue (7.42 N/cm(2)), P < 0.05. The decrease in breaking strength could be correlated with the thrombocyte concentration, P < 0.05. CONCLUSIONS: In the present study we have shown that an autologous platelet-enriched plasma cannot be used as a glue in the common sense to seal stitches or prosthesis. Platelet gels, however, have a high concentration of platelets that release the bioactive proteins and growth factors are necessary to initiate and accelerate tissue repair and enhance dermal and epidermal regeneration. To evaluate the possible clinical implication prospective, randomized studies should be performed to examine the effect of autologous plasma platelet-enriched plasma on wound healing.

[Evaluation of postoperative pain therapy with patient-controlled analgesia from the viewpoint of the patient and nursing staff]. / Bewertung der postoperativen Schmerztherapie mittels PCA aus Sicht der Patienten und des Pflegepersonals.

Patient-controlled analgesia has been proven to be an effective technique in postoperative pain management. The aim of our study was to evaluate PCA on general surgery wards. 311 patients and their nurses were questioned about their experiences in using PCA for postoperative pain management. Satisfaction with pain relief judged by both patients and nursing staff, incidence of negative side effects and technical problems were studied. The great majority of patients and nursing staff rated the quality of pain relief as being satisfactory. Incidence of negative side effects was extraordinarily low. There was no respiratory depression observed, technical problems hardly arose. Most of the patients coped very well with operating their PCA-pumps. We conclude that PCA is a safe and effective method in postoperative pain management on surgical wards. Under the condition of regular monitoring of pain intensity, of analgesic consumption, level of sedation and of side effects by trained medical and nursing staff, monitoring of respiration and vigilance is not necessary for the PCA regimen we used.

[Irradiation of wound blood from tumor surgery for retransfusion]. / Die Bestrahlung von Wundblut aus Tumoroperationen zur Retransfusion.

Intraoperative autotransfusion is contraindicated in tumor surgery because of the danger of tumor cell dissemination. We have tested the elimination of tumor cells in blood by irradiation for safe retransfusion. Tumor cells of various origin were mixed to washed red blood cells from volunteer blood donations. The blood was irradiated with 50 Gy. After isolation of the tumor cells by density gradient centrifugation they were tested for colony formation. While with different tumor cell lines (n = 12) 10 cells were sufficient to yield several colonies, as many as 10(10) cells did not result in any colony after irradiation of the blood. Similar results were obtained with cells cultured from blood salvaged during tumor surgery (n = 3), and with tumor cells prepared from various carcinomas (n = 10). Flow cytometric DNA analysis showed the irradiated cells in mitotic arrest. None of these cells had residual DNA metabolism expressed as incorporation of BrdUrd. We were able to demonstrate a rate of reduction in dividing cells of up to 10(9). With the typical irradiation sensitivity of tumor cells, with D0 values between 1 and 2 Gy, a dose of 50 Gy results in an effective log 12 reduction, sufficient for safe elimination of tumor cells found in shed blood. No adverse effects of the gamma-irradiation on the blood cells are to be expected, especially since the blood is retransfused without storage.

[Anaesthesia for radiation therapy of brain tumours in children. A multidisciplinary challenge]. / Anästhesie zur Radiotherapie kindlicher Hirntumoren. Eine multidisziplinäre Herausforderung.

Radiation therapy of childhood intracranial malignancies is always a challenge for radiation oncologists, anaesthetists and paediatric oncologists. Detailed knowledge of the course of the disease prior to radiation therapy and a critical evaluation of the child's actual physical status are mandatory in each case. Furthermore the anaesthetist should be informed about the child's individual preferences and aversions. The optimum prearrangement of the radiation therapy is of paramount importance. Interdisciplinary communication structures which must always involve the child's parents have to be established. Perfect adjustment of the mask that fixes the head during each radiation procedure is necessary to give the child the possibility to breathe spontaneously without an endotracheal tube or a laryngeal mask. Two case reports highlight these aspects of the complex procedure of paediatric radiation therapy which are relevant for the anaesthetist.

[Quality assurance in blood salvage and variables affecting quality]. / Ergebnisqualität bei der Maschinellen Autotransfusion und Einflussfaktoren.

Also intraoperative blood salvage (IBS) requires a system for quality management with controls of product an process quality. These can help early detection of malfunctions. For proper reaction and for improvement of quality a deep understanding of the process of blood salvage is necessary. This is supported by experimental testing of equipment, programs, and process variables, and by analysis of their effects on the process. The use of fresh whole blood and total protein as wash-out parameter in these tests is superior to outdated banked RBC and free haemoglobin. The process of aspiration turns out much less harmful than expected, when tested with fresh blood. Low wash volumes, fast washing rates, and half full bowls should be avoided. Plasma wash-out is improved by slower washing or by higher wash volumes, but the latter decrease RBC recovery. Such quality management helps to provide blood of excellent quality by IBS for optimal haemotherapy.

[Experimental principles and general practice of intraoperative autotransfusion with blood irradiation in tumor operation]. / Experimentelle Grundlagen und Praxis der intraoperativen Autotransfusion mit Blutbestrahlung bei Tumoroperationen.

Clinical studies fail to verify or to exclude the lethal risk of tumor spread after intraoperative autotransfusion in tumor surgery. An alternative approach is the development of methods for the elimination of tumor cells in the salvaged blood. The radiosensitivity of tumor cells especially in oxygenated single cell suspensions is well known, while the non-nucleated red blood cells are radioresistant. With 50 Gy a 12 log reduction in proliferating cells is expected. This we have tested experimentally and put into clinical practice. The suppression of colony formation in cell culture by irradiation with 50 Gy was tested with tumor cells from established cell lines or from solid tumors after admixture in high cell number to red blood cells from volunteer blood donations. DNA metabolism was tested by incorporation of bromodesoxyuridine (BrdUrd) and staining with mcab-anti-BrdUrd. Colony formation and DNA metabolism was absent in all samples of cell lines or tumor cells in blood after irradiation with 50 Gy, reflecting a 10 log, or 7 log reduction, respectively. In clinical practice the method of intraoperative blood salvage during tumor surgery with blood irradiation showed its practicability and efficacy in reducing homologous transfusions.