[Ultrasound-guided anaesthesia of peripheral nerves. The new challenge for anaesthesiologists]. / Ultraschallgezielte Anästhesie peripherer Nerven. Die neue Herausforderung für den Anästhesisten.

Ultrasound-guided anaesthesia of peripheral nerves is a new challenge for anaesthesiologists. The number of ultrasound users in this field has increased over the last 10 years because of improved high frequency ultrasound technology and increased mobility of machines. There have been many publications on blocking procedures but many questions still remain unanswered on the practical aspects of ultrasound-guided techniques. Basic knowledge in ultrasound technology and image characteristics and a defined approach to blocking procedures to ensure sterile working conditions are necessary to guarantee optimal safety of patients. Furthermore economic questions and the implementation of a standardised education program are very important.

Prospective, randomized comparison of laryngeal tube and laryngeal mask airway in pediatric patients.

BACKGROUND: While reports of the use of laryngeal mask airway (LMA)-Classic in great patient numbers are available, data on the use of the laryngeal tube (LT) in this age group is limited. The two devices are compared in a prospective randomized trial to evaluate success rates and quality of airway seal. METHODS: Sixty children, aged 2-8 years, scheduled for elective surgical interventions were randomized to be ventilated with LMA or LT. Standardized anesthesia was induced with fentanyl and propofol. Number of insertion attempts, time until first tidal volume and intraoperative tidal volumes, and peak pressures were recorded. Airway leak pressure was measured with cuff pressure adjusted to 60 cmH(2)O. RESULTS: Demographic data were comparable, average age in the LMA/LT group was 5.2 +/- 1.9/5.3 +/- 1.9 years. Insertion was successful in 29 of 30 patients in the LMA group (second attempt 8) and in all patients in the LT group (second attempt 3). Time until first tidal volume for LMA/LT was 23.1 +/- 7.3/19.2 +/- 8.6 s (P < 0.05). Peak airway pressures for LMA and LT were 15.3 +/- 3.4 and 17.1 +/- 4.0 cmH(2)O (P < 0.05) with tidal volumes of 10.2 +/- 2.2 and 10.2 +/- 1.9 ml.kg(-1), airway leak pressure was 19.2 +/- 8.6 cmH(2)O for LMA and 26.3 +/- 7.3 cmH(2)O for LT (P < 0.001). CONCLUSION: Insertion success rate is high with both LMA and LT in the age group studied. The airway leak pressure, serving as an estimate to judge quality of airway seal, is higher with the LT.

Experience of 49 longitudinal intestinal lengthening procedures for short bowel syndrome.

PATIENTS, METHODS AND RESULTS: Forty-nine patients with a mean age of 25 months underwent a longitudinal intestinal lengthening procedure for short bowel syndrome (SBS) in our institution. Indications for the operation were dependence on parenteral nutrition in spite of adequate conservative management. The small bowel was lengthened from a mean of 27 cm to a mean of 51 cm. There was no intraoperative mortality. The following early complications occurred in our early series: ischemia of a short bowel segment of 2 cm, requiring resection in two patients, insufficiency of the longitudinal anastomosis in two patients and an intra-abdominal abscess in one. Four of 9 non-survivors died of liver failure and 3 of sepsis. Follow-up showed that 19 patients were weaned from parenteral nutrition after a mean of 9.1 months. Long-term complications encountered were dismotility with malabsorption due to bacterial overgrowth caused by progressive dilatation of the bowel, d-lactic acidosis, cholelithiasis and urolithiasis. CONCLUSIONS: A longitudinal intestinal lengthening procedure is an effective and safe surgical approach for SBS, provided it is performed in time, the patient's preoperative condition is optimized and technical surgical details are taken into account.

Neuromuscular recovery following rocuronium bromide single dose in infants.

BACKGROUND: Rocuronium bromide, a steroid nondepolarizing muscle relaxant, has a rapid onset and an intermediate duration of action in infants, children and adults. However, clinical evidence shows a longer duration of recovery in small infants. The aim of this study was to investigate the influence of age on rocuronium recovery during the first year of life. METHODS: ASA I-II infants, scheduled for elective surgery under general anaesthesia and intubation were included after ethics committee approval and parents' written consent. According to age the patients were randomly allocated to receive either 0.45 mg.kg(-1) or 0.6 mg.kg(-1) rocuronium bromide in three age-groups: (A) 0-1 month, (B) 2-4 months and (C) 5-12 months. After induction with thiopentone (5-7 mg.kg(-1)), anesthesia was maintained with isoflurane without opioids. Prior to surgery, caudal block with bupivacaine (0.125%) 1.0 ml.kg(-1) and paracetamol 25 mg.kg(-1) rectally were given for analgesia. Efficacy variables were intubation conditions 60 s after administration of muscle relaxant (T(0)) and recovery of neuromuscular blockade measured as T(1) at 10, 25, 50 and 75 % of baseline, train-of-four (TOF) of 0.7 and Recovery Index (RI). Data were characterized by summary statistics and analysis of variance. RESULTS: A total of 61 infants with a median age range of 67 (2-364) days were included. Intubation conditions were excellent or good in all dose and age groups. T(0) in group A was reached in a range of 15-30 s, in others up to 60 s. T(1) recovery (T75) after 0.45 mg.kg(-1) was 56.4 +/- 16 (A), 62.7 +/- 32 (B) and 45.8 +/- 18 (C) min. Recovery times for of 0.6 mg.kg(-1) were 100.8 +/- 35 (A), 70.6 +/- 19 (B) and 63.4 +/- 21 (C) min, respectively. The TOF ratio (0.7) was 62.3 +/- 18 (A), 64.1 +/- 27 (B) and 43.7 +/- 12 (C) min using 0.45 mg.kg(-1) compared with 94.8 +/- 31 (A), 63.8 +/- 14 (B) and 67.5 +/- 18 (C) min with 0.6 mg.kg(-1). The differences of T75 and TOF 0.7 in A and C were significant (P

The use of spectral measures of heart rate variability to differentiate between male snorers and patients with sleep apnoea syndrome.

Snoring is a characteristic feature of habitual snorers and patients with sleep apnoea syndrome. However, unlike snorers, sleep apnoea patients have an increased peri-operative morbidity. Presently available methods to differentiate between these two groups are either expensive, invasive or time consuming. As cardiac reflexes are impaired in sleep apnoea syndrome, we tested whether heart rate variability could discriminate between snorers and patients with sleep apnoea syndrome. Heart rate variability measurement detects cardiac autonomic dysfunction non-invasively in an ambulatory setting. We studied 32 male patients undergoing polysomnography for suspected sleep apnoea. Total, low- and high-frequency power were measured using a Holter electrocardiogram. Differences in night- and daytime variability were then calculated. Differences between day and night values were more pronounced in the sleep apnoea group and related to the apnoea-hypopnoea-index and low oxygen saturation. Higher values in sleep apnoea patients resulted from increasing variability at night. Heart rate variability might thus help to differentiate between snorers and patients with severe sleep apnoea syndrome.

Perioperative ST-segment depression and troponin T release. Identification of patients with highest risk for myocardial damage.

BACKGROUND: Patients undergoing major vascular surgery are at constant risk of developing perioperative myocardial complications, especially myocardial infarction. The following study was performed to answer the question whether ST segment changes, analysed by Holter monitoring and ST segment analysis, are accompanied by release of cardiac troponin T, a highly specific marker of myocardial damage. METHODS: Twenty patients undergoing elective aortic resection were studied by performing Holter ECG, including ST segment analysis, beginning on the evening before surgery until the third postoperative day. Within this period serum levels of cardiac troponin T were determined at 8 timepoints. RESULTS: A total of 8/20 of the patients (40%) showed significant ST depressions (range -0.17/-0.68 mV), without any clinical symptom, with a median of 9 episodes (range 2-24). In 3 of the 8 patients, each with repetitive periods of ST depression, elevated troponin T levels were found (0.45/0.52/1.69 micrograms/l). No troponin T release nor cardiac events were noticed in the remaining patients. No dependency could be found between troponin T release and the magnitude of ST depression or the number of ST depression episodes. CONCLUSION: Haemodynamic changes, oxygen imbalance and stress during major vascular surgery frequently lead to an ischaemic burden, which is indicated by ST segment changes during ECG ST analysis. Longlasting ST depression reaching an individual critical cut-off limit followed by structural myocardial damage may be verified by elevated levels of cardiac troponin T. Prolonged periods of ST depression should be followed by determination of cardiac troponin T.

Perioperative myocardial ischemia is associated with a prolonged cardiac vagal dysfunction after non-cardiac surgery.

BACKGROUND: Heart rate variability (HRV), a measure of cardiac autonomic balance seems to be linked to coronary artery disease (CAD). Impaired vagal input facilitates the generation of fatal arrhythmias and has a great impact on morbidity and mortality. The purpose of this study was to determine the relationship between perioperative HRV and the incidence of silent myocardial ischemia (SMI) and ventricular dysrhythmias in CAD-patients undergoing non-cardiac surgery. METHODS: 31 patients were studied by continuous Holter electrocardiography preoperatively and again on the evening before surgery until postoperative day 3. Three frequency and one time domain measures of HRV (TP, 0.01-1.00 Hz: total power of the amplitude spectral plot; LF, 0.04-0.15 Hz: low-frequency power; HF, 0.15-0.40 Hz: high-frequency power; MeanRR: mean of all coupling RR-intervals between normal beats) as well as ischemic events and ventricular couplets and runs were computed. RESULTS: Depending on the presence of ischemic episodes, each patient was assigned to either the no SMI-group (13 pts) or the SMI-group (18 pts). MeanRR, TP and LF significantly declined in both groups over time. The parasympathetically dominated index HF, however, only decreased in the SMI-group. Normalized HF power (HF/TP) even increased in the no SMI-group resulting in a postoperative decrease in LF/HF ratio. TP, LF, and HF inversely correlated with ischemia parameters whereas HF/TP and HF/LF ratio correlated with the number of ventricular couplets. Incidence and severity of SMI significantly increased after surgery. CONCLUSION: Postoperatively, a prolonged vagal withdrawal occurred in CAD-patients exhibiting perioperative SMI. Whether the increased incidence of SMI after surgery in conjunction with the observed parasympathetic derangement contributes to adverse cardiac outcome still has to be determined.

[Luxation of the shoulder joint in a horse. A case report]. / Luxation des Schultergelenkes bei einem Pferd.

Etiology, diagnosis and therapy of the luxation of the shoulder joint in the horse are described. The traumatic luxation is diagnosed by physical examination and radiography. Without complicating changings (like fractures) and in case of early correction the prognosis is good.

[Bilateral obstructive ecstasy of the kidneys in a newborn foal: a case study]. / Beidseitige obstruktive Nierenektasie bei einem neugeborenen Fohlen: ein Fallbericht.

A report is given of obstructive ectasy of both kidneys in a newborn foal. Diagnosis and therapy are described as well as differential diagnosis.

[ST trend analysis. Monitoring of risk patients?]. / ST-Trend-Analyse.Monitoring bei Risikopatienten?

ST-segment monitoring has been proved to be an effective tool in detecting silent myocardial ischaemia, which is an important factor for perioperative cardiac morbidity. The case of a 72-year-old patient with peripheral vascular disease who underwent iliaco-femoral bypass surgery due to acute occlusion of a existing femoropopliteal bypass is reported. As part of a study the patient had perioperative ST-segment holter monitoring which showed pre-, peri- and postoperative severe episodes of silent myocardial ischaemia. No episode was accompanied by anginal symptoms. Post-operatively, a long-lasting episode of severe ST-segment deviation with complex arrhythmias occurred, resulting in cardiac failure and lung oedema. This ST-segment deviation began when the surgical procedure had been concluded and the patient extubated. The peak of the deviation occurred during transport from the operating room the recovery room. The existing ECG changes and the raised heart rate, from the beginning of the time in the recovery room to arrival on the normal ward, were not adequately recognized. The lack of clinical symptoms was misinterpreted. Many hours before, ST deviations and higher heart rate could be seen as precursors of a severe cardiac event. This demonstrates the importance of silent ischaemia in the perioperative period and shows the usefulness of ECG monitoring, especially of the ST segment, in detecting silent ischaemia and enabling early treatment.

[Management of acute tendinitis]. / Management der akuten Tendinitis.

Ultrasonography must be used in combination with physical examination for the appropriate diagnosis of acute tendon injuries. Therapy should be designed to return the tendon to its normal function and appearance. Local and systemic anti-inflammatory agents, cold hydrotherapy and massage minimize excessive scar formation and progressively increasing tensile forces directs scar tissue to replace the tendon function.

[Riding arenas and different riding track surfaces in relation to the airway contamination in horses. Laboratory studies on riding surfaces]. / Untersuchungen in Reithallen und an verschiedenen Reitbahnbelägen unter dem Aspekt der Atemwegsbelastung beim Pferd. Laboruntersuchungen an Reitbahnbelägen.

29 samples of commonly used surfaces were tested for their water characteristics (litre weight, water capacity, water binding, water evaporation) and their contribution to airborne fungal spores (dust formation, dust setting). The results are discussed in comparison to the literature with regard to the environment. The results are: 1. Any surface--no matter of what material--eventually causes air pollution with fungal spores and dust. 2. Correct watering prevents air pollution by any surface. 3. Artificial products have no advantage over natural materials in the parameters tested. 4. The question of proper disposal of old surface material has to be clarified before purchase. The results show that a mixture of sand and wood shavings should be recommended as a surface for indoor arenas, especially in regard to environmental protection and proper disposal.

[Diagnosis and therapy of tendinitis exemplified by the athletic horse]. / Diagnose und Therapie von Tendinitiden am Beispiel des Athleten Pferd.

This paper reviews the literature and describes our experiences in the diagnosis and treatment of tendinitis in horses. Ultrasonography provides a sensitive tool to diagnose tendinitis and quantitate the degree of damage to the tendon; as well as provide differential diagnoses such as peritendinitis. The principles in therapy of acute tendinitis are: Immediate reduced exercise or rest, physical therapy to reduce inflammation and administration of local and systemic antiinflammatory drugs. The goal is restoration of the tensile strength of the tendon without peritendinous granulation tissue and adhesions. To achieve this goal it is important to maximize the intrinsic healing and to minimize the extrinsic healing. Any form of counterirritation is forbidden because of increase of inflammation. Passive motion and massage will help to increase blood flow and to decrease adhesions. Local injection (peritendinous and intratendinous) of hyaluronic acid seems to increase the intrinsic healing and to decrease adhesions without side effects. Depending on the extent of the tendon damage, which tendon is involved and the progress toward healing controlled ultrasonographically, the healing period can be divided in 4 phases: 1. Immobilisation (Cast), only in severe cases (for 1-2 weeks). 2. Passive motion and massage (starting as soon as possible, usually at once during bandage change). 3. Careful exercise, hand walk or walk under saddle (for 1-6 months, starting as soon as possible, usually about 5 days after initial treatment). 4. Controlled slow and gradual training, no turnout, long or pasture (for 1-6 months, after phase 3). Chronic tendinitis is often caused when the severity of the initial injury is underestimated and the treatment inappropriate. Chronic tendinitis is treated using similar principles starting with phase 2. Tendon splitting and other surgical approaches have been used in selected cases to enhance the prognosis.

[Studies in riding arenas and on different riding path surfaces with respect to respiratory tract contamination in horses. Air hygiene studies in riding arenas]. / Untersuchungen in Reithallen und an verschiedenen Reitbahnbelägen unter dem Aspekt der Atemwegsbelastung beim Pferd. Lufthygienische Untersuchungen in Reithallen.

Using the direct sedimentation method, the air pollution with fungal spores was measured in indoor riding arenas and compared to horse stables, outside riding arenas and covered sport courts. Depending on the location of indoor arenas and stables, the presence of "dust-nests", the number of horses ridden, and the moisture of the tread layer, an air pollution was measured which was equivalent to that in stables except at times of feeding and straw-giving. Outside and in sport arenas a low air pollution was found. Recommendations are given, regarding optimum air hygiene especially for horses with chronic and subclinical respiratory conditions.

[Perioperative myocardial ischemia in patients with peripheral arterial occlusive diseases]. / Perioperative Myokardischämien bei Patienten mit peripherer AVK.

Patients with peripheral vascular disease (PVD) often have coronary artery disease (CAD) which means an increased risk during anesthesia. The prevalence of CAD is nearly 50% among such patients. Owing to claudication, diagnostic stress tests can rarely be performed in PVD patients. In order to evaluate the frequency of transient perioperative myocardial ischemia, Holter monitoring was performed in 30 consecutive PVD patients with ASA II-III and AVK scale (Fontaine) II-IV who were undergoing femoropopliteal bypass surgery. Patients who had left bundle branch block and left ventricular hypertrophy or were taking digitalis medication were excluded from Holter monitoring. The ST-segment analysis of the frequency modulated recordings (n = 19) revealed episodes of myocardial ischemia in 26% of the patients. Most (75%) of the episodes occurred preoperatively, and 25%, during or after the anesthesia or during preparation for it. Risk factors for CAD were more often found in patients with ST segment alterations than in patients without ST segment deviations, even though the preoperative antianginal medication administered was comparable in the two subgroups. It is concluded that in a considerable subset of PVD patients silent myocardial ischemia occurs, which can be related to the different perioperative intervals by means of ST segment analyses of Holter recordings. The ST segment may allow a better insight into the cardiac state of PVD patients. Further studies are necessary in larger populations to test our suspicion.

[Changes in several blood and urine parameters during combined hyperfluid therapy for the treatment of chronic obstructive bronchitis (COB) in the horse]. / Untersuchungen über die Veränderung einiger Blut- und Harnparameter während der kombinierten Uberwässerungstherapie zur Behandlung der chronisch obstruktiven Bronchitis (COB) beim Pferd.

During the combination of oral and intravenous application of saline solution for treatment of the COPD of horses the level of hydraemia basing on the total protein concentration in the serum, the urine production and the specific weight of urine was determined. Additionally the development of serum concentration and of renal excretion rates of potassium, calcium and magnesium were ascertained. The level of hydraemia resulting from the combined method is almost identical with the solely intravenous performed hyperinfusion therapy. Due to the excessive application of fluid an extremely high level of urine production is reached which causes a reduced specific weight as well as an increased renal excretion of potassium, calcium and magnesium. The result is a real loss of electrolytes which is - apart from hydraemia - the reason for the lower level of the corresponding serum concentrations. This seems to be important, especially for potassium and magnesium, because the organism is unable to compensate the loss of these electrolytes in the same way as the loss of calcium. In connection with the renal loss of electrolytes during the high level of urine production glucosuria is observed.