Digital palpation of the pilot balloon vs. continuous manometry for controlling the intracuff pressure in laryngeal mask airways.

This study compared two methods of controlling the intracuff pressure in laryngeal mask airways. One hundred and eighty patients were randomly assigned into two groups. In the first group (n = 90), after training, the intracuff pressure was controlled using digital palpation of the pilot balloon. In the second group (n = 90), continuous manometry was used to control the intracuff pressure. An upper pressure limit of 60 cmH2 O was set. The median (IQR [range]) intracuff pressure in the palpation group was 130 (125-130 [120-130]) cmH2 O compared with 29 (20-39 [5-60]) cmH2 O in the manometry group (p < 0.001). In the palpation group, 37% of patients experienced pharyngolaryngeal complications vs. 12% in the manometry group (p < 0.001). We conclude that the digital palpation technique is not a suitable alternative to manometry in controlling the intracuff pressure in laryngeal mask airways.

[Impact of characteristics related to patients and interventions on revenues and costs of hospitals]. / Einfluss leistungs- und fallbezogener Faktoren auf Erlöse und Kosten der Krankenhäuser.

Since introduction of the German refined DRG system, the, in relation to other countries, relatively long hospital stay has been reduced significantly. The analyses presented here examine the hypothesis that only few impact factors allow for good hospital management and that length of stay is a performance indicator. The analyses were based on remuneration data of 20 German hospitals for 2007-2009, comprising details of 963 923 patient cases, and cost data for 2007-2010. Using simple and multiple linear regressions, the impact of hospital length of stay and case-based factors on case mix index (CMI) and cost categories were explained. The variance of the case mix index was best explained by the length of hospital stay, showing an adjusted regression coefficient ß=0.488 (p<0.001), followed by the number of coded procedures (ß=0.35, p<0.001). Other predictors played a minor role. The regression coefficient was higher for conservative (non-operative) than for surgery (operative) departments. In the regression on costs, the length of hospital stay explained the variance of total costs by ß=0.391 (p<0.001), among these personnel costs of the nursing staff correlated most highly (ß=0.595, p<0.001). The analyses confirm the working hypothesis with length of stay impacting CMI and costs most significantly. Treatment effort and complexity level, mortality rate, patient age or gender are well discussed factors but their joint impact on the CMI is minor. Consequently, cockpits for operational length of stay management comprising key data and ratios should be introduced on the department level.

[The role of anesthesiology in fast track concepts in colonic surgery]. / Die Aufgabe der Anästhesiologie bei der Umsetzung operativer "Fast track-Konzepte". Darstellung am Beispiel der Fast-track-Kolonchirurgie.

In the present study the "fast-track rehabilitation" protocol of the Charité university hospital for patients undergoing elective colonic resection is described. The underlying principles, clinical pathways and outcome data from 208 patients are shown. Particularly anesthesiological aspects of this multimodal approach, such as modified preoperative and postoperative fluid management, changed guidelines for preoperative fasting, effective analgetic therapy using epidural analgesia and avoiding high systemic doses of opioids, use of short-acting anesthetic agents, and maintenance of normothermia as well as normovolemia are presented and discussed. In comparison to outcome data before "fast-track rehabilitation" was established, the duration of postoperative hospital stay has been reduced from 12 to 5 days, the number of general complications (pneumonia, duodenal ulcer bleeding, urinary tract infection, cerebral, cardiac and renal dysfunction) decreased from 20% to 7%, whereas surgical complications remained constant at 17% (8% wound infections, 3% anastomotic insufficiency).

Presence of 14Hz spindle oscillations in the human EEG during deep anesthesia.

OBJECTIVE: To report on presence of human EEG spindle oscillations on the cortical level within flat periods of the burst-suppression pattern during propofol-induced anesthesia; to search for corresponding oscillations and possible functional connections. METHODS: Artefact-free epochs of spindle activation were selected from the electroencephalograms of opiate-dependent patients undergoing rapid opiate detoxification. Power spectral analysis and source localization using low-resolution-brain-electromagnetic-tomography (LORETA(Key)) were performed. RESULTS: Sinusoidal rhythms with waxing and waning amplitudes appeared after propofol-induced narcosis but no direct correlations could be determined between individual dosage and characteristic spindle attributes. The power maximum stood midline over the cortical areas, especially around C(z). We calculated a peak frequency of 14(+/-1.2) Hz. Motor fields, particularly in the frontal, parietal, and various cingulate areas, were found to be the primary sources of spindle oscillations in the cortex. CONCLUSIONS: The frequent occurrence of these localized spindle sources demonstrates the preference for motor fields. Spindle oscillations observed during propofol-induced narcosis were similar in frequency and shape to those observed in natural sleep. SIGNIFICANCE: The results lend support to models that postulate a close link between the motor system and the organization of behavior. In addition, spindle rhythms under propofol bore some resemblance to spindle types which occur during sleep.

[Topographic electroencephalography: endotracheal intubation during anaesthesia with propofol/fentanyl]. / Topographie des Elektroenzephalogramms: Endotracheale Intubation unter Narkose mit Propofol und Fentanyl -- EEG-Mapping während Intubation unter Propofol-/Fentanyl-Narkose.

OBJECTIVE: We used quantitative analysis of the electroencephalogram (EEG) during routine clinical practice to assess the effect of tracheal intubation following induction of anesthesia with propofol and fentanyl. METHODS: The topographic EEG was recorded from eight bipolar electrode derivations in 25 patients. Z-scores relative to age expected normative data were computed for relative power in the delta, theta, alpha and beta frequency bands. Multivariate statistics (Hotellings' t-sqare) were used to evaluate changes in regional brain electrical activity. RESULTS: Tracheal intubation induced an increase in alpha and beta frequencies, while delta power was reduced (F-values: Delta: 7.68, p = 0.011; Alpha 31.93; p < 0.001; Beta 12.85, p = 0.001). The most pronounced regional effect was seen for the alpha frequency band with the largest increase in both fronto-temporal regions (F-value 33.89, p < 0.001). During clinical practice the patients received propofol 2.7 (+/- 1.2; minimum: 0.5, maximum 6.9) mg kg (- 1) and fentanyl 2 (+/- 1; minimum 1, maximum 4) microg kg (- 1). Vital parameters did not change during intubation. CONCLUSION: Individual titration of the dose of propofol and fentanyl as done during routine clinical practice is not sufficient to block the strong noxious stimulation of intubation. Tracheal intubation resulted in "classical" cortical arousal. It remains open whether this cortical wake-up phenomenon has a clinical impact.

[Implementation of modern operating room management -- experiences made at an university hospital]. / Implementierung eines OP-Statuts -- Erfahrungen unter den Bedingungen einer Universitätsklinik.

Caused by structural changes in health care the general need for cost control is evident for all hospitals. As operating room is one of the most cost-intensive sectors in a hospital, optimisation of workflow processes in this area is of particular interest for health care providers. While modern operating room management is established in several clinics yet, others are less prepared for economic challenges. Therefore, the operating room statute of the Charité university hospital useful for other hospitals to develop an own concept is presented. In addition, experiences made with implementation of new management structures are described and results obtained over the last 5 years are reported. Whereas the total number of operation procedures increased by 15 %, the operating room utilization increased more markedly in terms of time and cases. Summarizing the results, central operating room management has been proved to be an effective tool to increase the efficiency of workflow processes in the operating room.

[Intrathecal misplacement of an interscalene plexus catheter]. / Intrathekale Fehllage eines interskalenären Plexuskatheters.

For perioperative anesthesia in a case of shoulder arthroscopy, a continuous interscalene plexus block according to Meier was performed in a 51-year-old female patient. The catheter was placed after stimulator-assisted punction and application of a local anesthetic. A few minutes after a further dose of local anesthetic was given via the catheter, the patient had to be intubated and ventilated with signs of total spinal anesthesia. The cervical CT showed the intrathecal displacement of the catheter, reaching the spinal canal near the root of the 7th spinal nerve. Blind advancement and deep placement increase the risk of an abnormal catheter position. Intraspinal misplacement should be reliably excluded.

Splanchnic oxygen transport, hepatic function and gastrointestinal barrier after normothermic cardiopulmonary bypass.

BACKGROUND: The effect of non-pulsatile, normothermic cardiopulmonary-bypass (CPB) on the splanchnic blood-flow and oxygen-transport, the hepatic function and the gastrointestinal barrier were observed in a prospective observational study in 31 adults undergoing cardiac valve replacement surgery. METHODS: The splanchnic (i.e. hepatic) blood-flow (HBF) was measured by the constant infusion of indocyanine-green (ICG) using a hepatic-venous catheter. Liver function was examined by calculation of lactate uptake, ICG extraction and the monoethylglycinexylidide (MEGX) test. A day before and after surgery the gastrioduodenal and intestinal permeability was measured by determination of sucrose and lactulose/mannitol excretion. RESULTS: Splanchnic blood flow and oxygen delivery did not decrease during and after surgery while splanchnic oxygen consumption (P < 0.0125) and arterial lactate concentrations increased. The splanchnic lactate uptake paralleled the lactate concentration. After but not during CPB an increase of systemic oxygen consumption was observed. The MEGX test values decreased on the first day after surgery. The ICG extraction was attenuated during the operation. The gastroduodenal and the intestinal permeability increased significantly postoperatively (P < 0.002, respectively, P < 0.001). There was no correlation between these findings and the duration of CPB. There was a significant correlation of the intestinal permeability but not of the gastroduodenal permeability between the prior and after surgery values (P < 0.001). CONCLUSION: Increased oxygen consumption during CPB may indicate an inflammatory reaction due to the pump beginning in the splanchnic area or a redistribution of the splanchinc blood flow during the CPB. Normothermic CPB does not lead to a significant or prolonged reduction of liver function. Normothermic CPB causes an increase of gastrointestinal permeability. The intestinal barrier function prior to surgery was accountable for the degree of loss of intestinal barrier function following surgery.

Comparison of the concentration-dependent effect of sevoflurane on the spinal H-reflex and the EEG in humans.

BACKGROUND: It has been shown that spinal reflexes such as the H-reflex predict motor responses to painful stimuli better than cortical parameters derived from the EEG. The precise concentration-dependence of H-reflex suppression by anaesthetics, however, is not known. Here we investigated this concentration-response relationship and the equilibration between the alveolar and the effect compartment for sevoflurane. METHODS: In 26 patients, the H-reflex was recorded at a frequency of 0.1 Hz while anaesthesia was induced and maintained with sevoflurane at increasing and decreasing concentrations. Population pharmacodynamic modelling was performed using the NONMEM software package, yielding population mean parameters as well as indicators of interindividual variability. RESULTS: Suppression of H-reflex amplitude occurred at lower concentrations (mean EC(50) 1.04 +/- 0.10 vol%, SE of NONMEM estimate) than the effect on either BIS or SEF(95) of the EEG (mean EC(50) 1.55 +/- 0.08 and 1.72 +/- 0.18 vol%, respectively), and exhibited a higher interindividual variability. The concentration-response function for the H-reflex was also steeper (mean ë 2.83 +/- 0.25). In addition, the equilibration between alveolar and effect compartment was slower for the H-reflex (mean k(e0) 0.15 +/- 0.01 min(-1)) than for BIS or SEF(95) (mean k(e0) 0.22 +/- 0.02 and 0.41 +/- 0.05 min(-1)). CONCLUSION: The differences in EC(50) and slope of the concentration-response relationships for H-reflex suppression and the EEG parameters point to different underlying mechanisms. In addition, the differences in time constant for equilibration between alveolar and effect compartment confirm the notion that immobility is caused at a different anatomic site than suppression of the EEG.

The Patient State Index as an indicator of the level of hypnosis under general anaesthesia.

BACKGROUND: This retrospective study describes the performance of the Patient State Index (PSI), under standard clinical practice conditions. The PSI is comprised of quantitative features of the EEG (QEEG) that display clear differences between hypnotic states, but consistency across anaesthetic agents within the state. METHODS: The PSI was constructed from a systematic investigation of a database containing QEEG extracted from the analyses of continuous 19 channel EEG recordings obtained in 176 surgical patients. Induction was accomplished with etomidate, propofol, or thiopental. Anaesthesia was maintained by isoflurane, desflurane, or sevoflurane, total i.v. anaesthesia using propofol, or nitrous oxide/narcotics. It was hypothesized that a multivariate algorithm based on such measures of brain state, would vary significantly with changes in hypnotic state. RESULTS: Highly significant differences were found between mean PSI values obtained during the different anaesthetic states selected for study. The relationship between level of awareness and PSI value at different stages of anaesthetic delivery was also evaluated. Regression analysis for prediction of arousal level using PSI was found to be highly significant for the combination of all anaesthetics, and for the individual anaesthetics. CONCLUSIONS: The PSI, based upon derived features of brain electrical activity in the anterior/posterior dimension, significantly co-varies with changes in state under general anaesthesia and can significantly predict the level of arousal in varying stages of anaesthetic delivery.

Changes in cortical electrical activity during induction of anaesthesia with thiopental/fentanyl and tracheal intubation: a quantitative electroencephalographic analysis.

BACKGROUND: There are regional differences in the effects of anaesthetics agents and perioperative stimuli on the EEG. We studied the topography of the EEG during induction of anaesthesia and intubation in patients receiving thiopental and fentanyl to document regional electrical brain activity. METHODS: EEG was recorded in 25 patients in the awake state, after pre-medication, during induction, at loss of consciousness and after intubation. Eight bipolar recordings were made and the relative power of the frequency bands delta, theta, alpha, and beta were used (after z-score transformation for age) to measure changes in regional EEG activity. RESULTS: Noxious stimulation during tracheal intubation partially reversed the slowing of the EEG caused by anaesthesia. During induction of anaesthesia alpha activity was most reduced in temporal and occipital regions. The most prominent EEG changes after intubation were an increase in alpha and a decrease in delta power (P<0.001). The largest changes were in the frontal and temporal leads for alpha and in the frontal and central leads for delta. Heart rate and arterial pressure remained constant during intubation. CONCLUSIONS: Changes in alpha and delta power were identified as the most sensitive EEG measures of regional changes in electrical brain activity during anaesthesia and noxious stimulation.

Effects of different steroid treatment on reperfusion-associated production of reactive oxygen species and arrhythmias during coronary surgery.

BACKGROUND: During conventional cardiac surgery ischemia and reperfusion may cause excessive production of reactive oxygen species leading to tissue damage including early arrhythmias. We therefore assessed the kinetics of markers of radical stress including oxidized and reduced glutathione (GSSG/GSH), oxidized proteins (PCG) and malondialdehyde (MDA), and tested the hypothesis that different steroid treatments inhibit these markers and early reperfusion-associated supraventricular and ventricular extrasystolic beats. METHODS: In a randomized, controlled, blinded, prospective trial 36 patients received a preoperative infusion of methylprednisolone (MP, 15 mg kg-1, n = 12), tirilazad mesylate (TM, 10 mg kg-1, n = 12) or placebo (PL, NaCl, n = 12). Coronary sinus and arterial blood was drawn at baseline and 2, 5, 15, 30, 60 and 240 min after aortic declamping. Holter-ECG analysis was used to identify arrhythmias. RESULTS: Cardiac GSSG release occurred very early (< 15 min) and was not significantly attenuated by either drug treatment. Cardiac PCG production showed biphasic increases, lasted > 4 h and was significantly reduced only by TM. Cardiac MDA release was short (< 30 min) and significantly reduced by MP and TM. Neither treatment had a significant influence on the early occurrence of ventricular or supraventricular arrhythmias. The number of patients needing cardioversions or defibrillations also were not different. CONCLUSIONS: The results indicate that cardiac production of reactive oxygen species occurs after reperfusion in humans and is not inhibited by steroid treatment. Steroid treatment effectively reduces lipid peroxidation during cardiac surgery but has no influence on arrhythmias.

[Clinical results with the "open lung concept"]. / Klinische Ergebnisse bei der Anwendung des "Open-Lung-Konzepts".

Elements of the "open lung concept" are being increasingly included in clinical ventilatory strategies. Despite encouraging experimental investigations to date, relatively few studies exist that examine the clinical application of the complete concept. The aim of this study was to prove that with effective recruitment maneuvers and titrated PEEP levels this concept is applicable in clinical settings. We sought to determine if it was possible to achieve a significant improvement in oxygenation and also to examine what side-effects resulted. Twenty consecutive patients who had had an acute lung injury (ALI) for less than 72 hours, with an oxygenation index (P/F-Ratio = quotient from arterial partial pressure of oxygen [PaO2] and the inspiratory fraction of oxygen [FiO2]) of less than 200 torr, and with a PEEP > or = 10 cmH2O were treated using a recruitment manoeuvre (RM). A PEEP was titrated to keep the lung open, and the patients were kept under pressure-controlled ventilation. The P/F-Ratio increased while using a recruitment pressure of 66 +/- 13 cmH2O from 137 +/- 41 to 381 +/- 150 torr (p < 0.001). The titrated PEEP which kept the lung open after recruitment was 17 +/- 3 cmH2O. One patient developed a pneumothorax. The dose of norepinephrine was increased in ten patients from 0.24 +/- 0.12 to 0.31 +/- 0.1 microgram/kg/min. Due to elevated liver enzymes within the first 48 hours, titrated PEEP had to be decreased in three patients. The clinical application of the "open lung concept" demonstrated a quick and effective improvement in oxygenation in many patients. Side-effects in some patients limited the use of high PEEP levels.

[Can alcoholic withdrawal delirium be prevented?]. / Gibt es eine Prophylaxe des Alkoholentzugssyndroms?

In alcohol-dependent in-patients, an adequate drug prophylaxis should be made in order to lower the degree of a developing alcohol withdrawal syndrome (AWS) or to prevent a life-threatening delirium tremens. Pre-condition of successful therapy is a precise diagnosis. In patients, the beginning of whose abstinence is known, carefully-targeted pharmacological interventions can prevent severe imbalances of neurotransmitters. Typical time courses of destabilisation of neural balances should be considered. Since there is no single drug which is able to influence various transmitter systems, normally the use of drug combinations is necessary. In ENT-patients, traumatologic patients and patients from the department of maxillo-facial surgery, screening methods based on a simply-structured questionnaire relating to information from the patient and his surroundings and selected laboratory parameters should be used. High-risk patients who could get an AWS or delirium tremens should be treated prophylactically during their oral premedication period. Important drugs for successful prophylaxis of an AWS are benzodiazepines, clonidin, magnesium and vitamin B 1. A close-meshed control of the glucose metabolism, electrolyte and acid-base balance should be performed. Neuroleptica can be used if there is any indication for their adjuvant use. In severe cases that require deep sedation or hypnosis, propofol or gamma-hydroxy-butyric acid should be used. Perioperative infusion of alcohol as a prophylactic agent against delirium tremens is regarded as an obsolete therapeutic measure for ethical reasons and because equally good or better results can be achieved by carefully-targeted drug therapy. Due to its easy use, however, the application of alcohol has not yet completely disappeared from the therapeutic spectrum.

[Septic encephalopathy. Diagnosis und therapy]. / Septische Enzephalopathie. Differentialdiagnose und therapeutische Einflussmöglichkeiten.

23% of all septic patients develop septic encephalopathy which is associated with an increased mortality rate. Symptoms such as agitation, confusion and disorientation ranging from stupor to coma often develop in early sepsis. Severe hypotension is significantly associated with the development of septic encephalopathy. Several other factors which may play a role are also discussed: effects of inflammatory mediators on the brain, inadequate cerebral perfusion pressure, blood-brain barrier derangements, disturbances of the cerebral microcirculation, cerebral ischemia e.g. due to hypocapnia,metabolic changes, altered amino acid levels, transmitter imbalances, liver insufficiency, multiple organ failure and infections of the CNS, respectively. Compared to patients with an isolated infection,patients in septic shock have increased levels of aromatic amino acids such as phenylalanine and tryptophan in the plasma and brain as well as decreased levels of branched chain amino acids. Patients who died had higher levels of aromatic amino acids than the survivors. The correlation between aromatic amino acids and the APACHE II score was significant. The tryptophan metabolite quinolinic acid which can be synthesized in activated macrophages could act as an excitatory transmitter on the N-methyl-D-aspartate (NMDA) -receptor. Observations from experimental models indicate that activated NMDA receptors activate the neuronal isoform of the NO-synthase and other calcium dependent enzymes. This releases free radicals which may damage the DNA and activate the nuclear enzyme Poly-ADP-ribose-synthetase (PARS), resulting in energy depletion and cell death. Sepsis is the main cause of metabolic encephalopathies in critically ill patients. The differential diagnoses include hepatic, renal,hypoxic-ischemic or cardiovascular encephalopathies as well as encephalopathies,metabolic disorders and organ dysfunctions of other origin. Therapeutic interventions are numerous,however, so far only investigated in few controlled studies. The primary therapeutic goal is to maintain an adequate perfusion pressure and to prevent hypoxia and hypocapnia. Although the infusion of branched chain amino acids is controversial, experimental investigations demonstrated improvements improvements in an animal model with septic encephalopathy. Further investigations with respect to glutamate receptor antagonists, new radical scavengers, NO- and PARS-inhibitors may show whether these substances are suitable for the prophylaxis or early therapy of septic encephalopathy.

[The effect of dopexamine and iloprost on plasma disappearance rate of indocyanine green in patients in septic shock]. / Einfluss von Dopexamin und Iloprost auf die Plasma-Disappearance-Rate von Indozyaningrün bei Patienten im septischen Schock.

OBJECTIVES: To evaluate the effect of dopexamine and iloprost on the plasma disappearance rate (PDR) of indocyanine green (ICG) in patients in septic shock in a prospective clinical trial. METHODS: In 40 consecutive patients in septic shock, a femoral arterial fiberoptic catheter (COLD system) and a gastrotonometric probe were placed. Patients received either dopexamine infusion (0.5 microgram/kg body weight/min) or iloprost (1 ng/kg body weight/min) for 24 h i.v. PDR, intramucosal pH of stomach wall (pHi), cardiac index (HI) and intrathoracic blood volume (ITBV) were determined before, 1, 6, and 24 h after dopexamine or iloprost infusion and 1 h after end of infusion. RESULTS: PDR was significantly increased 24 h after starting dopexamine infusion from 12.2 +/- 1.8%/min to 17.8 +/- 2.2%/min (+45.9%) and 1 h after the end of infusion PDR decreased to baseline values. PDR increased to 16.4 +/- 2.1%/min, 1 h after starting iloprost infusion and increased to a maximum value of 18.6 +/- 2.2%/min (+33.8%, p < 0.05) 24 h after start of infusion compared to the baseline (13.9 +/- 1.7%/min). After the end of infusion PDR decreased to baseline values. Baseline values of pHi were in normal ranges in all groups and there was no change during the observation period. Cardiac index and ITBV were stable during the study. Dosage of norepinephrine could be reduced by dopexamine infusion. CONCLUSIONS: Dopexamine and iloprost have a positive effect on the plasma disappearance rate of ICG and therefore have a protective effect on splanchnic perfusion and liver function, respectively.

[Preoperative fasting. An update]. / Präoperative Nahrungskarenz. Ein update.

In Germany the predominant standard of preoperative care for elective surgery is fasting after midnight, with the aim of reducing the risk of pulmonary aspiration. However, for the past several years the scientific evidence supporting such a practice has been challenged. Experimental and clinical studies prove a reliable gastric emptying within 2 h suggesting that, particularly for limited intake of clear fluids up to 2 h preoperatively, there would be no increased risk for the patient. In addition, the general incidence of pulmonary aspiration during general anaesthesia (before induction, during surgery and during recovery) is extremely low, has a good prognosis and is more a consequence of insufficient airway protection and/or inadequate anaesthetic depth rather than due to the patient's fasting state. Therefore, primarily to decrease perioperative discomfort for patients, several national anaesthesia societies have changed their guidelines for preoperative fasting. They recommend a more liberal policy regarding per os intake of both liquid and solid food, with consideration of certain conditions and contraindications. The following article reviews the literature and gives an overview of the scientific background on which the national guidelines are based. The intention of this review is to propose recommendations for preoperative fasting regarding clear fluids for Germany as well.

[Use of peridural catheters in the treatment of postoperative pain after spinal instrumentated fusion--an experience report]. / Postoperative Schmerztherapie mittels PDK nach instrumentierten Wirbelsäulenoperationen - ein Erfahrungsbericht.

AIM: In a prospective randomized clinical study we investigated in a group of 20 patients after spinal instrumentation surgery the analgesic efficacy and the safety of epidural analgesia. Intraoperatively an epidural catheter was placed by the orthopedic surgeons for postoperative pain control. METHOD: For epidural catheter analgesia a mixture of the local anesthetic ropivacaine and the opioid sufentanil was used with an initial bolus, followed by a continuous infusion and the possibility of patient-controlled bolus administration (PCEA). Pain-scores (VAS) were measured pre- and postoperatively at rest, and during active mobilization maneuvers like turning around in bed and standing. The neurological status, side effects, and complications were evaluated. RESULTS: Mean pain-scores (VAS) were 3.8 pre-operatively at rest, after initiation of epidural analgesia 0.3 at rest, 1.6 at turning around in bed and 0.8 at standing (6.8 pre-operatively). Transient sensible or motoric deficits, due to the local anesthetics' effect, occurred in 8 respectively in 3 of the patients. Drug-induced typical side-effects were pruritus, nausea and emesis. No cardiopulmonary complications happened. CONCLUSION: The epidural lumbal analgesia is an effective and safe method to control postoperative pain after spinal instrumentation surgery. Precondition is the knowledge about the safe and standardized technique of intraoperative catheter placement by the orthopedic surgeon, the choice of the appropriate analgesic drugs and a good cooperation between the departments of anesthesiology and orthopedic surgery and nursing staff.