[Lethal vascular erosion after percutaneous dilatation tracheostomy]. / Tödliche Gefässarrosion nach Dilatationstracheotomie.

We report on a patient who underwent dilatational tracheostomy (Ciaglia technique) because of ARDS. 29 days after the procedure she died of hemorrhage from an arrosion of the bracheocephalic trunk, caused by the cuff of the tracheal cannula. This complication has, so far, been reported only after surgical tracheostomy. The fracture of tracheal cartilages is considered to be the specific cause of this fatal complication. The consequent loss of circular stability of the trachea demands increased cuff insufflation and pressure to tighten the airway. Prevention and therapy consist in control of the cuff pressure and caudal placement of the tracheal cannula.

[Use of the laryngeal mask in adenoidectomy in childhood--a comparison with endotracheal intubation]. / Die Anwendung der Larynxmaske bei Adenotomien im Kindesalter--ein Vergleich zur endotrachealen Intubation.

PURPOSE: Anaesthesia for adenoidectomy is possible during infancy without succinylcholine. One possibility is intubation with vecuronium bromide, whereas another possibility is the use of the laryngeal mask (LMN). The conditions for intubation as well as further details during anaesthesia are listed and compared. METHODS: 200 children are divided into 4 groups. Group A: intubation with thiopental and vecuronium bromide. Group B: LMN with thiopental, Group C and D: as A and B but the thiopental replaced by propofol. The following aspects are compared: the conditions of intubation; circulation conditions; oxygen saturation; the behaviour when coming out of anaesthesia; complications; the assessment by the surgeons. A further control of 100 routine LMN covers the complications which arose. RESULTS: Adenoidectomy can be carried out successfully with both kinds of anaesthesia. Tracheal intubation attained a better assessment by most surgeons and is easier to administer. Brief declines in the saturation of oxygen occur more frequently when using LMN. LMN has its advantages in the low irritation of the respiratory mucous membranes and results in improved behaviour on coming out of the anaesthesia, especially if used with propofol. Problems arise mainly through the use of the mouth clamp which can result in obstructions of the respiratory tract and re-intubation. These problems arise less frequently when the use of this method has become routine. CONCLUSION: LMN takes time to get used to, and places greater demands on the anaesthetist. Success of LMN depends on the cooperation and collaboration to the surgeon to lower the risk of complications. Once specific improvements in the LMN have been made, it may become the standard method for adenoidectomy in future. It is already used by us and in some outpatient departments, as well as in England and America. Our suggestions are as follows: Aims at convincing the surgeons and improving their co-operation; No routine fixation of the laryngeal mask. The laryngeal mask should be kept slightly taut before opening--preferably slowly--the mouth clamp; possible technical modifications of the mouth clamp itself, which produce a wider gap, could be adapted to the new conditions of the wider LM; reaching the necessary depth of anaesthesia through higher doses of propofol or possibly by total intravenous anaesthesia; routine wearing of the LM in the recovery room until it is no longer tolerated by the child.

[Preoperative stress. Research approach and methods of treatment]. / Der präoperative Stress. Forschungsansätze und Behandlungsmethoden.

The scientific approach to preoperative stress includes the identification of stressors and the measurement of stress responses. The stress responses include physiological (sympathetic nervous system, hypothalamic--hypophyseal and adrenocortical system), psychological (anxiety, depression etc.) and behavioural ones. The choice of variables to be measured should allow answers for our questions, i.e., they must be adequate and economic, without or only minimal disturbance of the preoperative situation. The value of physiological and biochemical parameters is often overestimated. Their assessment is indicated in special scientific settings. For simple questions such as premedication studies, the measurement of blood pressure and heart rate is sufficient. Anxiety should be self-estimated by the patient, using visual analogue scales, questionnaires or adjective check lists. Depression and other emotional stress responses can be assessed if necessary. For physicians and nurses, an observation of the patient's behavioural stress responses is a useful criterion for assessing patient stress. One important stress-reducing approach is prevention: identification and avoidance of stressors. This includes organisation and a high degree of self-control by the medical personnel. Premedication with benzodiazepines is the most successful pharmacological approach.

Respiratory changes during laparoscopic operations.

The influences of laparoscopic techniques on respiratory function are reviewed according to the published literature. The influences are aroused by the applied pressure and the diffusion and absorption of the gas used. The published incidents of the technique are commented and the necessity of meticulous monitoring of the applied pressure and gas exchange is stressed.

[Acupressure in the prevention of postoperative nausea and vomiting]. / Akupressur zur Prophylaxe postoperativer Ubelkeit und Erbrechen.

Despite modern anaesthetic procedures, postoperative nausea and vomiting are still the side-effects most often mentioned: acupressure is reported to be an additional method of preventing these effects in minor gynaecological surgery. We investigated the effectiveness of acupressure in patients undergoing gynaecological operations of longer duration (6-8 h) in a verum acupressure group compared to a placebo group. Before beginning the study we investigated a control group to find out the frequency of emesis. In the worst case of nausea that we encountered, 80% in the 0-6 h postoperative period, the number of random samples for the acupressure and placebo groups was calculated (30 patients in each group). The error for alpha was established at 5% and the reduction of nausea was 50%. METHODS. The female patients were 18 to 65 years old (ASA group I and II). Acupressure was carried out by fastening small metal bullets at the point P 6 to each forearm by means of an elastic bandage. The bullets were left there for 24 h. The premedication anaesthesia, postoperative analgesia, and antiemetic treatment were standardized. During a 24-h period we investigated the incidence of nausea and vomiting. RESULTS. The anthropometric data, the duration of surgery and the amount of postoperative analgesia were comparable between the three groups. Verum acupressure obtained a statistically significant and relevant reduction in nausea up to the 6th postoperative hour in comparison with the placebo group (P = 0.03). Nausea was reduced from 53% in the placebo group to 23% in the acupressure group. CONCLUSION. As demonstrated in this group of longer gynaecological surgery patients as well as in chemotherapy-induced nausea and vomiting, we were able to demonstrate that acupressure is an effective method of preventing nausea and vomiting without any side-effects. It is a valuable addition to the prevention of postoperative nausea and vomiting. Further studies should be conducted to investigate this possibility further.

[Oral ketamine as preferred preanesthetic medication of uncooperative patients]. / Orales Ketamin zur vorgezogenen Anästhesieeinleitung bei behandlungsunwilligen Patienten.

We report on oral ketamine for the preinduction of 3 patients who aggressively refused the commonly used induction of anaesthesia, due to young age or mental retardation. One child and two mentally retarded patients aged 30 and 31 years who were to undergo dental surgery aggressively refused the induction of anaesthesia, either by inhalation or rectal, intramuscular, or intravenous application of drugs. One of them previously injured the medical personnel and destroyed the interior equipment of a gynaecologist, who tried to perform an examination. After having received 6 to 8 mg/kg body weight ketamine in 10 ml water, which they accepted well, probably because of the long lasting fluid restriction (about 12 hours), they tolerated the induction of anaesthesia by inhalation (2 patients) or intravenously (1 child). Two patients remained awake, but calm, one fell deeply asleep. After several hours of surgery in inhalation anaesthesia they could be extubated within several minutes and discharged the same day. We conclude that 5 to 10 mg/kg oral ketamine in water which has a bioavailability of approximately 20% is a useful agent for the preinduction of patients who aggressively refuse medical treatment. Because deep sleep states cannot be excluded, we recommend a careful supervision after the application of ketamine. Nevertheless, we could discharge our patients on the same day even after long lasting surgical procedures; this makes this method useful in day case surgery.

[The action of flumazenil in combination with fentanyl on spontaneous respiration]. / Die Wirkung von Flumazenil in Kombination mit Fentanyl auf die Spontanatmung.

Whereas the efficacy of flumazenil (Fl) for improving vigilance in the presence of other benzodiazepine agonists (BZA) is undoubted, its effect on BZA- and/or opioid agonists (OA)-induced respiratory depression is the subject of controversies. Some authors describe an improvement of a midazolam (Mi)-induced increase in paCO2, whereas others cannot find any influence on diazepam-induced respiratory depression. In two studies in which Fl was used to antagonize Mi/Fentanyl (Fe) anaesthesia we found even worse oxygen saturation values than with placebo (Pl). All our previous studies indicate a slight intrinsic activity of Fl on respiration in the presence of opioids. We therefore investigated the influence of Fl and Pl on expiratory pCO2 and oxygen saturation (SAT). METHODS. A group of 15 male, healthy volunteers aged 20-30 years gave written informed consent to participate in this double blind study, which was approved by our Institutional Review Board. Each subject received 3 micrograms/kg body wt. Fe + 0.5 mg Fl and 1 week later 3 micrograms/kg body wt. Fe + 5 ml NaCl 0.9% (Pl) i.v., in random order. They were undisturbed and breathed spontaneously. The following parameters were measured: SAT, pCO2 and heart rate (HR) continuously, using a pulse oximeter (SAT, H) and CO2 infrared absorption monitor (Oscar, Messrs., Datex). The blood pressure was recorded before and after a 5-min preinjection period (baseline) and at the end of the procedure (25 min). The data were stored in a microcomputer (Multitalent, Messrs. ZAK) and transmitted to a PC after each trial. STATISTICS. The groups were compared with the Wilcoxon rank sum test. P less than 0.05 is significant. RESULTS. In trials 1 and 2 there was an increase of pCO2 and a drop in SAT. The changes in pCO2 and SAT were more pronounced after Fe+Fl in 12 subjects (80%), as against 1 subject with the opposite result. There were 2 subjects who showed no difference between trials 1 and 2. The combination of Fe and Fl caused significantly higher increases in pCO2 (P = 0.007) and more pronounced decreases in SAT (P = 0.04) than Fe and Pl. DISCUSSION. These results indicate a slight enhancement of Fe-induced respiratory depression by Fl. In a previous study it could be shown that Fl antagonized the respiratory depressive effect of Mi, but baseline paCO2 was not completely recovered. In previous studies respiratory function impaired by Mi+Fe was initially improved by Fl, but rebound effects on SAT were observed, which were more pronounced than those after Pl. Therefore, respiratory function must be closely monitored in Fl-antagonized patients after Mi/Fe anaesthesia.

[Epidural steroid injections in the treatment of back pain. A retrospective and prospective analysis.]. / Die Therapie von Schmerzsyndromen der Wirbelsäule mit periduralen Kortikoiden : Ergebnisse einer retro- und prospektiven Untersuchung.

Epidural steroid injections are frequently used in the conservative treatment of backache, although they are still subject to critical discussion. Relief of pain is attributed to the anti-inflammatory effect of the steroid. During a 3-year period, 53 patients with back pain or differing aetiology were treated with one or more epidural injections of 14 mg betamethasone (2 ml Celestan) in a prospective and retrospective fashion. Patients were followed up for 1 year. Immediately after the injection 68% free of pain. Freedom from pain or improvement totally free of pain. Freedom from pain or improvement was reported by 39% of patients after 2 weeks and by 31% after 6 months to 1 year. Patients with acute pain (up to 6 months) responded better than patients with chronic symptoms. No significant correlations were detected between response and other characteristics, e.g. age, sex, number of injections, type of pain, intensity of pain, or psychological overlay. For patients with acute pain epidural steroid injections seem to be a safe, appropriate and promising procedure.

[Acupuncture for the treatment of pain-a prospective study.]. / Schmerztherapie mit Akupunktureine prospektive Studie.

Acupuncture is increasingly being used in Western medicine. In the present study the effect of acupuncture treatment was examined in 60 patients with chronic pain. The long-term success after 6 months was evaluated in 45 patients. Calculated on the basis of an index of the frequency of pain, its duration and intensity, a global success rate of 64% was found directly after the therapy and of 69% 6 months later. Furthermore, we examined to what extent the success of the therapy was dependent on several variables. It appeared that the consumption of analgesics could be reduced significantly in patients in whom the treatment was successful. All patients had been treated before by several methods. Because of the small number of side-effects and the patients' high degree of acceptance as well as the success of the treatment, we consider acupuncture an effective method in the treatment of chronic pain.

[The effects of the carbon dioxide pneumoperitoneum in laparoscopic cholecystectomy on postoperative spontaneous respiration]. / Die Auswirkungen des Kohlendioxid-Pneumoperitoneums zur laparoskopischen Cholezystektomie auf die postoperative Spontanatmung.

Laparoscopic cholecystectomy (LSC) is being performed increasingly often. The carbon dioxide cavity increases end-expiratory carbon dioxide (exCO2), which can be regulated by mechanical ventilation. Because about 20-40% carbon dioxide remains in the patient at the end of surgery, we were interested in its influence on spontaneous respiration. PATIENTS AND METHODS. Fifteen patients classed as ASA 1-2 and undergoing LSC were compared with 15 patients (also ASA 1-2) undergoing laparotomy for cholecystectomy (LAP). All patients had balanced anaesthesia with fentanyl, enflurane, nitrous oxide and vecuronium. After surgery they were extubated when spontaneous respiration and vigilance were adequate. In the next 3 h we continuously determined exCO2 in the expired air through an intranasal catheter, and oxygen saturation (SAT), respiratory rate (RR) and heart rate (HR) using Oscar (Datex) and Ohmeda (Braun) apparatus while the patients were breathing room air. The blood pressure (BP) was determined intermittently. Postoperative pain treatment was standardized. RESULTS. The groups were reduced comparable with respect of the anthropometric data, because the weight was significantly higher in the LAP group. Fentanyl consumption was also significantly higher in the LAP group, reflecting the more pronounced trauma than with LSC. Mean exCO2 was 46 mmHg after LSC and 36 mmHg after LAP (P less than or equal to 0.05), continuously decreasing in the LSC group and increasing in the LAP group to 40 mmHg after 3 h. Mean RR was 18-20.min-1 after LSC and 12-15.min-1 after LAP during this period (P less than or equal to 0.05). There were no differences in SAT (94-96%), HR (75.min-1) and BP (130/80 mmHg). DISCUSSION AND CONCLUSIONS. The remaining carbon dioxide after LSC has important implications for postoperative spontaneous respiration. Probably due to an activation of carbon dioxide receptors, RR is increased to eliminate residual carbon dioxide. This is confirmed by a significantly increased exCO2 compared with that in the LAP group. This effect lasts at least 3 h, exCO2 being comparable in both groups, but RR is still increased after LSC. This different respiratory pattern does not affect SAT, being normal without hypoxic episodes. Cardiovascular parameters were also normal without group differences. We conclude that the carbon dioxide peritoneal cavity has important consequences for postoperative ventilation. Using our anaesthetic technique and postoperative treatment exCO2 reaches normal values after about 3 h due to an increased RR. If other methods, e.g., stronger opioids, which decrease carbon dioxide response are used, this effect may even be prolonged and more pronounced. We are now performing an investigation to evaluate this effect.

Drug-related methods for alleviation of stress in dentistry.

For many patients, dental procedures can cause a great deal of anxiety and fear. These emotions are part of a stress reaction, which, in physiologic terms, can pose a serious risk, particularly to patients with pre-existing cardiopulmonary disorders. In each case the dentist must decide whether anxiolytic stress-reducing treatment is indicated, and which method should be used. Besides certain psychotherapeutic techniques, numerous drugs (neuroleptics, barbiturates, beta-blockers, and benzodiazepines) are available for this purpose. This paper reviews these types of drugs and offers recommendations for their use.

[Rectal, oral and nasal premedication using midazolam in children aged 1-6 years. A comparative clinical study]. / Rektale, orale und nasale Prämedikation mit Midazolam bei Kindern im Alter von 1-6 Jahren. Eine vergleichende klinische Untersuchung.

Midazolam is often used for the premedication of children in the pre-school age group. Different noninvasive routes of administration have been described. In a prospective study we compared the effects of oral, rectal, and nasal midazolam in commonly used dosages. PATIENTS AND METHODS. Ninety children undergoing surgery under general anesthesia were assigned to oral (0.4 mg/kg) (MO), rectal (0.5 mg/kg) (MR), or nasal (0.2 mg/kg) midazolam (MN), according to the child's and/or parent's preferred route of administration, after having obtained the parent's informed consent. It was applied on the ward before transport to the operating room. The following parameters were assessed by the observer and the anesthesiologist at different times: sedation, acceptance (child, anesthesiologist), mood, emotion, resistance, pain, nausea and vomiting, blood pressure, and heart and respiratory rates. The Wilcoxon test (P less than 0.05) was used for statistical analysis. RESULTS. All groups were comparable with respect to age, weight, and surgery experience. There was no difference in the anesthesiologist's acceptance of the premedication or the cooperation of the children. The children accepted MO significantly better compared to MN and MR. The fastest onset of sedation was found after MR. Immediately after MN many children became euphoric, and it turned out that the effect of MN was rather euphoric than sedative. The effect of MO was good in many children, but less predictable. This led to a significant delay in transport to the operating room. MO children experienced more nausea and vomiting (P less than 0.05) in the postoperative period. There were no differences in physiological parameters. DISCUSSION AND CONCLUSIONS. The results can be explained by the different characteristics of absorption and patient acceptance. The route of administration according to the child's or parent's choice can be recommended but does not guarantee success. MR had the fastest onset of sedative action due to faster absorption of the drug. MN had a euphoric effect that resulted almost immediately. Oral premedication was best accepted, nasal administration worst. MO produced more side effects than MR and MN in the postoperative period. If the child accepts the rectal route of administration, this should be preferred because of the high success rate and few side effects.

[Perioperative treatment of a patient with myotonic muscular dystrophy (Curschmann-Steinert disease)]. / Perioperative Behandlung eines Patienten mit myotoner Muskeldystrophie (M. Curschmann-Steinert).

The perioperative period is hazardous for patients with neuromuscular disorder. In case of dystrophia myotonica the anaesthesist must avoid all stimuli that may cause a myotonic crisis. If neuromuscular blockade is required, the moderately long-acting vecuronium bromide seems to be the drug of first choice. Blockade and recovery should be monitored. Postoperative pulmonary complications can be minimised by using regional anaesthetic techniques including epidural anaesthesia with local anaesthetics and/or opioids.

[The effect of fentanyl on spontaneous respiration]. / Der Einfluss von Fentanyl auf die Spontanatmung.

UNLABELLED: AIM OF THE INVESTIGATION: The effects of fentanyl on spontaneous respiration have been investigated in both animals and humans. The investigations in humans have been performed under circumstances and using methods that do not relate the results to clinical practice, e.g., predicting the effects of opioids used for postoperative pain relief on the ward. We investigated the effects of fentanyl on mechanical parameters, oxygen saturation (SAT), and end-expiratory CO2 (exCO2) in humans. METHODS: Fifteen male volunteers took part in this study, which was approved by the local ethics committee. Each received 3 micrograms/kg fentanyl intravenously after 5 min measurement of base-line values and were observed for 30 min. We continuously registered thoracic (A1) and abdominal (A2) extension and respiratory rate (RR) using piezoceramic elements. SAT, heart rate (HR), and exCO2 were measured with a pulse oximeter and infrared absorption (OSCAR, Datex). All data were transferred to a high-performance microcomputer (Multitalent, ZAK). The statistical analysis included descriptive and correlation statistics. RESULTS: After the injection of fentanyl A1, A2, RR, HR, and SAT were reduced; exCO2 increased. After a few minutes A1 increased, occasionally exceeding the base-line value. A2, RR, HR, and SAT increased without reaching base-line values. ExCO2 remained increased. The best overall correlation was found between A2 and SAT (r = 0.87). DISCUSSION: As far as comparable, our results are in accordance with those of the majority of other investigators. The difference between thoracic and abdominal extension, the latter being closely correlated with tidal volume, has not previously been described quantitatively. We attribute this result to the different innervation of the phrenic and intercostal nerves. Whereas the influence of fentanyl on SAT and exCO2 during the first 8 min can easily be explained, the varying behavior in the following minutes has not previously been described and may be due to the different binding characteristics of O2 and CO2. Alteration of the CNS setting for pCO2 may also contribute to this result. The time course of the measured parameters seems to be of clinical importance for the detection of respiratory problems in spontaneously breathing patients.