[Anesthesia and analgesia in obstetrics]. / Anästhesie und Analgesie in der Geburtshilfe.

Anesthesia in obstetrics includes the medical attendance of women in the delivery room as well as giving anesthesia for cesarean sections in the operating room. Over the last years the treatment of labor pain with epidural anesthesia has been modified. Whereas a couple of years ago local anesthetics were used almost exclusively, the recent trend goes toward a combination of local anesthetics with opioids. Using this combination the total amount of local anesthetic can be greatly reduced, whilst maintaining most of the motor function during labor. There is evidence the combination of local anesthetics with opioids can reduce the number of operative vaginal deliveries such as vacuum extraction or forceps. The systemic application of opioids remains unaffected by the local application and its significance is unaltered, even though the effectiveness compared to epidural application in managing labor pain is far inferior. Opioids applied systemically often have an unwanted sedative effect in the mother and have the potential for respiratory depression in the newborn. The question, whether epidural anesthesia increases the frequency of cesarean sections remains to be answered. Studies so far present discrepant results and do not show a causal relationship between the use of epidural anesthesia and increase in cesarean section rate. Regarding cesarean sections, there has been a trend in the operative field over the last years towards the use of regional anesthesia. This is the consequence of the fact that anesthesia related mortality during cesarean sections is still mainly due to hypoxia and aspiration during induction of anesthesia. The advantage of spinal anesthesia over epidural anesthesia is faster onset, more reliable sensitive block and a lower failure rate. Downside of the use of spinal anesthesia is a higher incidence of hypotension in the mother, which, however, is not a serious complication if treated adequately. Regarding the continuous application of local anesthetics via a spinal catheter, no definite statements towards benefits compared to other regional techniques can be made due to the lack of adequate amount of patient studies. Theoretically this method seems advantageous as it allows to adjust the administration of local anesthetics and opioids to the individual needs in a very refined way. Emergency situations, such as emergency cesarean sections, life threatening hemorrhage, eclampsia, and HELLP syndrome, are the main risks of the anesthetic practice in obstetrics. Their beneficial outcome is highly dependent on the coordination of logistic problems, good communication and coordination within an interdisciplinary team of obstetricians and anesthesiologists.

Neoadjuvant chemotherapy followed by tumor debulking prolongs survival for patients with poor prognosis in International Federation of Gynecology and Obstetrics Stage IIIC ovarian carcinoma.

BACKGROUND: Patients with advanced ovarian carcinoma of International Federation of Gynecology and Obstetrics (FIGO) Stage IIIC should be treated by radical surgical tumor debulking with the goal of complete tumor resection. Prolonged median survival can be achieved in those patients entirely free of tumor after surgery by the administration of postsurgical platinum/taxane-based chemotherapy regimens. However, residual tumor is present in the majority of patients, which limits survival prognosis. Different therapy approaches should be utilized to improve prognosis in these patients. Neoadjuvant chemotherapy could induce "downstaging" of the tumor and thus improve operability. Here, evidence of large ascites volume (>500 mL) can be used to identify those patients who could benefit from neoadjuvant chemotherapy. METHODS: In a prospective, nonrandomized Phase II study, 31 patients with advanced FIGO Stage IIIC ovarian carcinoma and large ascites volume (>500 mL) received 3 cycles of platinum/taxane-based combination chemotherapy, followed by tumor debulking surgery and 3 additional cycles of platinum/taxane-based combination chemotherapy. During the same period, 32 patients with advanced FIGO Stage IIIC ovarian carcinoma and large ascites volume (>500 mL) received conventional therapy (tumor debulking surgery followed by 6 cycles of platinum/taxane-based combination chemotherapy). The two groups were investigated and compared with respect to tumor resection rates, blood transfusion requirements, morbidity, and mortality during surgery, duration of surgery, and median survival. RESULTS: The tumor resection rate in the patient group receiving neoadjuvant chemotherapy was significantly higher (P = 0.04) than that of the conventionally treated group; the median survival time of 42 months versus 23 months also was significantly longer (P = 0.007). Time spent in surgery, blood transfusion requirements, morbidity, and mortality during surgery were not significantly different. CONCLUSIONS: Patients with advanced ovarian carcinoma of FIGO Stage IIIC who will benefit only marginally from conventional therapy can be identified by evidence of large ascites volume. Higher tumor resection rates and longer median survival can be achieved in these patients by the use of neoadjuvant chemotherapy. A prospective randomized multicenter study currently is being performed by the Society for Gynecological Oncology in Germany to confirm these findings.

[Prophylaxis against obstetric acid aspiration syndrome in the German Federal Republic in 1997. A review based on results of a federal survey]. / Prophylaxe des geburtshilflichen Säureaspirationssyndroms in der Bundesrepublik Deutschland 1997. Eine Bestandsaufnahme anhand der Ergebnisse einer bundesweiten Umfrage.

A survey of all German hospitals providing obstetric anesthesia was performed in 1997 (n = 1061, recovery rate 82%; comprising about 700,000 deliveries and 115,000 cesareans, resp.) concerning the routine prophylactic measures for acid aspiration syndrome (AAS) in pregnant patients and before obstetric procedures (i.e., prevention of aspiration by positioning, Sellick's manoeuvre, reduction of intragastric volume, or reduction of gastric content acidity). In pregnant patients, any prophylaxis of AAS is performed in 36%. Of the patients expecting delivery in the labour ward, only 7% receive pharmacological AAS treatment. Before scheduled (urgent, non-emergency) cesarean section in general anesthesia, 93% (94%) of patients receive prophylactic treatment, either pharmacological or non-pharmacological. Before regional anesthesia, the corresponding numbers are 52% for both scheduled or urgent CS.

Anesthesia for cesarean section and acid aspiration prophylaxis: a German survey.

UNLABELLED: We surveyed routine anesthetic practice and measures to prevent acid aspiration syndrome (AAS) in patients undergoing cesarean section (CS) throughout Germany. Of 1061 questionnaires, 81.9% were returned. For scheduled CS, general anesthesia was used in 63% of cases, and for urgent CS, it was used in 82% of cases. Regional anesthesia was used less often for both scheduled and urgent CS in smaller (< or =500 deliveries/yr; 28% and 16%, respectively) than in medium-sized (500-1000 deliveries/yr; 42% and 19%, respectively) or major obstetric departments (>1000 deliveries/yr; 45% and 21%, respectively). Among the regional techniques, epidural anesthesia (59%) was preferred more than spinal anesthesia (40%) in scheduled CS. In urgent CS, spinal anesthesia predominated (56% vs 42%). Pharmacological AAS prophylaxis is routinely used in 69% (68%) of departments before elective (urgent) CS under general anesthesia and in 52% under regional anesthesia. H2-blocking drugs are preferred for AAS prophylaxis over H2-blocker plus sodium citrate and sodium citrate alone. Both the incidence of and the mortality from AAS at CS are very low in Germany (<1 fatality per year). Nevertheless, AAS prophylaxis deserves more widespread use in obstetric anesthesia and in other patients at risk (e.g., children, outpatients). IMPLICATIONS: According to a countrywide survey, the use of regional anesthesia for cesarean section and pharmacological prophylaxis of acid aspiration syndrome is considerably less common in Germany than in the United States, United Kingdom, or other European countries.

[Use of mechanical autotransfusion in maxillofacial surgery in the mouth, jaw and face]. / Zum Einsatz der maschinellen Autotransfusion bei Dysgnathie-operationen in der Mund-, Kiefer- und Gesichtschirurgie.

OBJECTIVE: In maxillofacial surgery considerable blood loss is not uncommon. However, the use of autologous blood collected from the site of surgery is controversial. METHODS: Bacterial contamination of blood collected for autologous retransfusion was studied by standard microbiological methods in 25 patients undergoing elective non-malignant maxillofacial surgery. Swabs were taken from the pharynx and from the collected blood before and after routine treatment. The autologous blood was not used for transfusion. Preoperative antibiotic treatment consisted in amoxicilline plus clavulanic acid. RESULTS: The blood prepared for retransfusion was free of bacteria in only one case, while 24 samples contained up to five different bacterial species including some strains not preexistent in the pharyngeal swabs. CONCLUSION: Blood collected from the site of operation is not suitable for retransfusion in maxillofacial surgery.

[Anesthesia in cesarean section in the FRG in 1997. Results of a nationwide survey]. / Anästhesie zum Kaiserschnitt in der BRD 1997. Eine Bestandsaufnahme anhand der Ergebnisse einer Bundesweiten Umfrage.

A survey of all German hospitals providing obstetric anaesthesia in 1997 (n = 1061, recovery rate 82% comprising 115,000 Caesarean sections revealed that most Caesarean sections (CS) are performed under general anaesthesia (GA). For elective CS, the average was 63%, and 82% for urgent (non-emergency) section. Succinylcholine is the standard neuromuscular blocker for intubation. Of the regional techniques, epidural continuous anaesthesia (ED) is preferred for elective CS (59%) over subarachnoid (SA, 10%) and combined epidural and subarachnoid anaesthesia (CSE). In urgent CS, SA is used more often (56%) than ED (42%) and CSE. With increasing number of births per year, the use of regional techniques is more common.

The opiate-sparing effect of dipyrone in post-operative pain therapy with morphine using a patient-controlled analgesic system.

OBJECTIVE: To determine whether dipyrone has an opiate-sparing effect in post-operative pain therapy compared with placebo during patient-controlled morphine therapy (PCA) and to compare the effects on analgesia and respiratory and coagulation parameters. DESIGN: Randomized, observer-blind, parallel-group, placebo-controlled study. SETTING: Surgical intensive care unit of a university hospital. PATIENTS: 106 adult patients who were to undergo abdominal or urological surgery under 90-min standardized inhalational anaesthesia were entered and 103 were included in the efficacy analysis (53 on dipyrone, 50 on placebo). INTERVENTIONS: Preprogrammed PCA (0.03 mg morphine/kg per bolus) with either dipyrone (initially 2.0 g i.v. and 1.0 g/2 ml i.v. at 4, 8 and 16 h) or placebo (saline). MEASUREMENTS AND RESULTS: Cumulative morphine consumption was calculated automatically during PCA. Pain intensity and pain relief and the investigator's global assessments of efficacy and tolerability were recorded on five-point verbal rating scales. Vital signs, standard laboratory parameters, respiratory rate, partial pressure of carbon dioxide (PCO2) and of oxygen, partial thromboplastin time (PTT) and Quick values were recorded. Total consumption of opiates in the dipyrone group (median 31.6 mg) was significantly less (p = 0.00015) than in the placebo group (median 50.3 mg), while pain relief (area under the curve) AUC was the same for both PCA+dipyrone (median 4.1) and PCA+placebo (median 3.9). Global assessment of efficacy was good to excellent in more than 90% of cases in both groups. Vital signs, respiratory rate, PCO2, PTT and Quick did not differ between groups. Adverse events were mainly nausea and/or vomiting (dipyrone, n = 4; placebo, n = 1); 1 patient in the placebo group had bradycardia. Three serious adverse events were unrelated to study medication. In 1 patient, the PCA programme malfunctioned and had to be changed. CONCLUSIONS: Concomitant administration of dipyrone with on-demand morphine (PCA) reduces opiate consumption while maintaining post-operative pain relief with a low incidence of side-effects.

[Postpartum rupture of an aneurysm of the arteria lienalis]. / Postpartale Ruptur eines Aneurysmas der Arteria lienalis.

Spontaneous rupture of a splenic artery aneurysm is a very rare but severe complication after delivery associated with a high mortality. We describe a case of a 27-year-old woman with severe left upper abdominal pain and progredient shock symptoms after uncomplicated delivery. Due to a double-rupture phenomenon with bleeding into the bursa omentalis and subsequent intraabdominal haemorrhage, the shock symptoms showed a biphasic time course that was moderate in the beginning but deteriorated dramatically within a few minutes. Intraabdominal bleeding was verified by transabdominal echography only at the time of circulatory decompensation. Ruptured splenic artery aneurysm was diagnosed after emergency laparotomy for suspected intraabdominal haemorrhage. The aetiology and pathophysiology, time course, differential diagnosis of the disease and patient outcome are discussed in this case report. Early consideration of a diagnosis of a ruptured splenic artery aneurysm as opposed to other critical postpartal conditions might increase the likelihood of survival of the affected women.

[Left heart failure in anesthesia in a child pretreated with propranolol--case report]. / Linksherzversagen in Narkose bei einem mit Propranolol vorbehandelten Kind--kasuistischer Beitrag.

A 13-year-old girl suffering from nephrogenic hypertension, treated with high-dose propranolol and other antihypertensive medication, developed acute hypoxaemia (oxygen saturation at 60% at 100% oxygen ventilation) shortly after induction of anaesthesia. The auscultatory findings first suggested bronchospasm; however, specific measures failed to improve pulmonary function. The planned procedure was delayed and further investigations showed acute left heart failure due to beta-blockade combining with general anaesthesia.

[Anesthesia relevant features of laparoscopy--the value of capnometry]. / Anästhesierelevante Besonderheiten der Laparoskopie--Wertigkeit der Kapnometrie.

End-expiratory capnometrical and capnographical data correspond well with blood carbon dioxide content. Carbon dioxide insufflation for laparoscopy results in a big increase in CO2 uptake as well as in respiratory deterioration due to positioning and increased intra-abdominal pressure. We observed 226 female patients during laparoscopy under general anaesthesia (midazolam-alfentanil-atracurium or vecuronium) and artificial ventilation. Airway peak and plateau pressure increased by about 75% as compared to pre-insufflation levels. End-tidal carbon dioxide exceeded pre-insufflation levels by 2 to 19 mmHg (mean 9 mmHg). Both findings were correlated to speed and overall volume of CO2 insufflation. Major cardiocirculatory side-effects were not observed, except for rare bradycardia, which responded to atropine. Considerable regurgitation via or beneath the gastric tube occurred in 52%. Thus, general anaesthesia with endotracheal intubation and consistent monitoring, including capnometry, may be regarded as particularly safe as far as aspiration of gastric contents and ventilatory requirements are concerned.

[The determination of end-expiratory CO2 during resuscitation. Experience and results with the Normocap 200 (Fa. Datex) in preclinical resuscitation conditions]. / Wertigkeit der endexspiratorischen CO2-Messung bei der Reanimation. Erfahrungen und Ergebnisse mit dem Normocap 200 (Fa. Datex) unter präklinischen Reanimationsbedingungen.

Capnometers measure carbon dioxide (CO2) in inspired and expired air. Under physiological conditions end-tidal CO2 (peCO2) measurements closely reflect arterial pCO2 (paCO2). End-tidal CO2 concentration has been found to correlate with cardiac output in animal models and in clinical studies with cardiac arrest during cardiopulmonary resuscitation (CPR). In the present study in 23 cases of CPR end-tidal CO2 concentrations were registered during precordial compression with a transportable, battery-carried capnometer. In 7 cases of successful CPR mean concentrations of end-tidal CO2 were higher than in unsuccessful CPR (13 +/- 7 mmHg versus 8 +/- 6 mmHg). No statistical significance was found. In case of successful CPR there was a sudden rise in end-tidal CO2 up to 54 +/- 6 mmHg, indicating satisfactory spontaneous circulation. With capnometry it is possible to assess the efficacy of precordial compression during resuscitation and the return of spontaneous circulation in cardiopulmonary arrest.

[Blood coagulation and fibrinolysis in prostate surgery]. / Blutgerinnung und Fibrinolyse in der Prostatachirurgie.

In 23 patients undergoing transurethral resection of the prostate (n = 11) or suprapubic prostatectomy (n = 12), hemostasis and fibrinolysis were studied. In addition to basic coagulation tests, antithrombin III, plasminogen, antiplasmin and fibrin degradation products were determined preoperatively, intra-operatively and postoperatively over a period of 6 days. Evaluation of the results revealed slightly activated blood coagulation and fibrinolysis intraoperatively and postoperatively, with no significant differences being seen between the two groups. Routine use of antifibrinolytic drugs in patients undergoing surgery of the prostate is not recommended.

[Massive and multi-transfusions in polytraumatized patients: long-term serologic markers of hepatitis B, hepatitis C and AIDS]. / Massiv- und Multitransfusion bei polytraumatisierten Patienten: Langfristige serologische Befunde zu Hepatitis B, Hepatitis C und AIDS.

302 out of 712 (42%) consecutive polytraumatized ICU patients received ten or more units of stored blood during primary and/or intensive care (1982 to 1987) treatment. 120 of the 197 surviving patients with an average number of transfusions of 23 (10 to 89) units were followed up after a mean interval of 70 (20 to 104) months. Mean duration of continuous post-ICU hospital stay was 17 (2 to 160) weeks, mean number of additional operative procedures was three (0 to 23). Manifest hepatitis had not occurred, all samples were negative for HIV testing. In nine samples (7.5%), anti-HBc-antibodies were positive, while HBs-antigen was negative. Ten patients (8.3%) tested positive for anti-HCV-antibodies (one combined with positive anti-HBc). The rate of serologically positive samples increased with the number of blood units given, duration of overall hospital stay and/or number of secondary surgery; all these findings failed to prove statistically significant. The rate of seropositivity for anti-HBc-antibodies corresponded well with the rate found in voluntary donors in FRG. Manifest or chronic hepatitis B was not observed. As to hepatitis C, the incidence of seropositivity for anti-HCV was found tenfold higher than in healthy blood donors in FRG. The relevance of this result remains unclear, but might indicate chronic post-transfusional hepatitis with high risk of cirrhosis. Among the patients testing positive for anti-HCV, too, acute manifest hepatitis had not occurred. Recently developed RIBA kits might improve specificity and sensitivity of anti-HCV testing. Thus, the frequency of PTH-C could decrease considerably.

[A new tube for the endobronchial application of drugs]. / Ein neuer Tubus zur endobronchialen Applikation von Medikamenten.

During cardiopulmonary resuscitation, endobronchial administration of epinephrine, atropine and lidocaine is required as the initial step. This procedure provides a decisive time advantage, since it can be effected before venous access is established. The presently available techniques (direct application, catheter insertion, etc.), however, have disadvantages (interruption of ventilation, difficult catheter placement, time loss). For this reason we have developed a tube for endobronchial drug and gas application during resuscitation (EDGAR tube). It enables direct injection into the bronchial system via a separate injection canal within the wall of the tube that terminates at the tip of the tube. In this way, simple and safe application of the drugs to the appropriate absorption surface is ensured, without any loss of time. In view of these significant advantages, the use of the EDGAR tube is recommended for intubation for resuscitation purposes.

[Lung edema following intestinal irrigation with golytely solution]. / Lungenödem nach Darmspülung mit Golytely-Lösung.

A case of pulmonary edema following whole gut lavage with Golytely's solution is reported. The patient did not suffer from gastrointestinal obstruction, renal dysfunction or cardiac congestion.

[Intraoperative autologous blood transfusion. Value in major orthopedic surgery]. / Intraoperative Eigenblutretransfusion. Stellenwert bei grossen orthopädischen Eingriffen.

Intra-operative autologous blood transfusion (IAT) employing a cell separator has proved an effective and safe means of reducing the amount of homologous blood needed for major orthopedic operations. Homologous blood was required in only 15 or 26% of patients, who underwent cemented or uncemented total hip replacement. This is significantly less than in a control group without IAT, in which homologous blood was required in 65 and 71% respectively. In 33% of patients, who had an operation of the spine and in 35% of cases of revision total hip surgery homologous blood was necessary in addition to IAT. We feel, that preoperative blood donation is indicated in addition to IAT, in total hip revisions, major surgery of the spine, as well as in special situations when a total hip replacement is planned.

[Heart arrest in implantation of a cemented total hip joint endoprosthesis under spinal anesthesia--a case report]. / Herzstillstand bei Implantation einer zementierten Hüftgelenkstotalendoprothese unter Spinalanästhesie--Fallbericht.

A case of intraoperative death because of right heart failure due to extensive pulmonary fat and bone marrow embolism in an 85 year old woman during cemented total hip replacement under spinal analgesia is reported.

[Pharmacologic modification of vigilance in the postnarcotic phase-- naloxone or physostigmine?]. / Medikamentöse Beeinflussung der Vigilanz in der postnarkotischen Phase--Naloxone oder Physostigmin?

The usefulness of physostigmine in reversing post-narcotic depression after general anaesthesia is well proven; so is that of naloxone, a specific opioid analgetics antagonist, in reversing neuroleptic anaesthesia effects. Morphine-like analgetics are widely used as premedication agents, too; on the other hand, physostigmine reverses opioids as well as other psychotropic and narcotic agents. For that reason, positive post-narcotic physostigmine effects could be due to its anti-opioid potency as well. In a double-blind, randomised study, physostigmine and naloxone were evaluated using a clinically based vigilance protocol, and compared with saline solution. Naloxone did not have remarkable advantages as compared with placebo, while physostigmine led to a significantly higher level of vigilance; moreover, that level was reached sooner. The positive effects of physostigmine in restoring a sufficient level of vigilance after general anaesthesia are, in respect of our findings, unrelated to its antagonism to morphine-like analgetics.

[Injury severity score (ISS) in the classification of polytrauma patients]. / Der Injury Severity Score (ISS) zur Klassifizierung polytraumatisierter Patienten.

Differentiated classification of overall severity of a multiple injury is essential to proper assessment of therapeutic success in cases of polytraumatisation. The injury severity score (ISS) is a classification system primarily based on anatomic findings and has proved to be highly practicable and suitable for investigations of larger groups of traumatised patients and their verifiable comparability. Its use is described by examples. The informative potential of the ISS was verified by traumatic patterns and pathological courses of 1,017 patients with injuries from accidents. ISS was found to be well correlated with final courses of diseases, length of treatment and artificial ventilation of survivors as well as with the amount of banked blood required for preoperative management. Effects of age on prognosis are not considered in ISS. Conclusive information on individual prognosis cannot be derived from ISS.

[Value of the injury severity score (ISS)]. / Zur Aussagekraft des Injury-Severity-Score (ISS).

The injury severity score (ISS) has been most widely accepted as a practicable method of classifying traumatised patients (ie., patients with accident injuries) according to the severity of their injuries, and has become more popular than all other comparable classification systems. By allocating the patients to different severity groups, it facilitates their classification in respect of prognosis. Over and above this, it enables comparison of patient groups of different hospitals. The authors investigated the validity of ISS classification by studying the case records of 432 patients in a traumatological intensive-care ward. They found good correlation between ISS score on the one hand, and lethality, requirements of banked blood during first-aid care and duration of treatment and artificial respiration of survivors on the other. However, the mean survival time of those patients who had died, did not reveal any connection with the severity of the injury. It is definitely impossible to arrive at any prognosis for an individual patient on the basis of his ISS classification. With increasing age, lethality after an accident increases even if the injury is less severe. The validity of ISS could be increased further if the age of the patients could be taken into account as well.