Comparison of Two Clinical Protocols for Total Intravenous Anesthesia (TIVA) for Breast Surgery Using Propofol Combined With Either Sufentanil or Alfentanil.

BACKGROUND: Sufentanil and alfentanil have pharmacokinetic and dynamic properties which make them favourable substances for total intravenous anesthesia (TIVA) in combination with propofol. OBJECTIVES: We planned to compare two clinical protocols for TIVA with propofol, and either sufentanil or alfentanil in regards to postoperative pain, hemodynamic stability during the case and time for emergence from anesthesia. PATINETS AND METHODS: Treaty eight patients scheduled for general anesthesia for breast surgery were included in this Double-blind, randomized, controlled trial. All patients received a standardized TIVA with propofol and either 0.2 µg kg(-1) sufentanil or 20 µg kg(-1) alfentanil for induction and 0.3 µg kg(-1) h(-1) sufentanil or 30 µg kg(-1) h(-1) alfentanil for maintenance with additional propofol boluses as needed. During anesthesia, heart rate, non-invasive blood-pressure, peripheral oxygen saturation and depth of anesthesia, were recorded. In the post anesthesia care unit, pain scores, nausea and vomiting as well as medications were recorded. RESULTS: Patients in the sufentanil group required less often additional opioid and propofol boluses to maintain adequate anesthesia. We did not observe a significant difference in time to extubation. Postoperatively, patients in the sufentanil group had less pain (P = 0.03) and required less i.v. opioids (0.4 vs. 1.9 mg piritramid, P = 0.04). CONCLUSIONS: Both protocols provide excellent anesthesia, but patients receiving sufentnail had more stable anesthesia and less postoperative pain.

[Anaesthesia under unfavorable conditions - rescue helicopter]. / Anästhesie in anästhesiefeindlicher Umgebung - Tätigkeitsfeld Rettungshubschrauber.

Rescue helicopters are used for emergency care and transport of emergency patients. The dimension of the cabin is clearly limited. A transport is carried out under spatial narrowness and high noise levels. Acoustic alarms or noises caused by the patient are hardly to be perceived, so that the view at optical alarms is necessary. Environmental conditions affect the concentration on the patient. Rearrangement maneuvers represent the most critical phases. Always the whole apparative monitoring and respirator must be in the field of view of the emergency doctor, drugs to the care must be handy to be quickly administered, the quantity of oxygen has to be observed. Infusions and option of airway management are ready to set in advance. Standardized work with the aid of algorithms and knowledge of treatment recommendations and guidelines help to prevent errors. To optimize the care of emergency patients, special training courses for the crew of rescue helicopters are offered. A training simulator to practice different scenarios and the establishment of a CIRS system are recommended.

Two serial check valves can prevent cross-contamination through intravenous tubing during total intravenous anesthesia.

BACKGROUND: Nonsterile handling of propofol for anesthesia has been linked with severe sepsis and death. Placing a single check valve in the IV tubing does not prevent retrograde ascension of pathogens into propofol-filled syringes, so we designed an IV tubing set with multiple check valves. To estimate the efficacy of this design, we measured the concentration of pathogens detected upstream in the IV tubing in relation to the pathogen concentration in a model of a contaminated patient. METHODS: A glass container with a rubber sealed port was filled with a suspension of either bacteria or phagocytes and kept at 37°C ("contaminated patient" model). A bag of normal saline was connected to an IV cannula, punctured through the rubber sealed port of the patient model. Two additional sidestream infusion lines were connected to syringes in 2 standard infusion pumps. One of the syringes contained propofol and the other contained normal saline as a substitute for an opioid preparation. After 5 hours of infusion, we obtained samples from different parts of the infusion lines and syringes. The samples were streaked out on blood agar plates and incubated at 37°C for 24 hours. We repeated this experiment with 6 different pathogens. RESULTS: We incubated 825 agar plates. Whereas the concentration of bacteria and phagocytes in the "patient" had significantly increased during the 5-hour experiments (positive control), no bacterial growth could be detected in any of the incubated plates. CONCLUSION: The data from this experimental setting suggest that the design with multiple check valves in paired configuration prevents retrograde contamination. Of note, this does not permit the reuse of propofol syringes because reusing is against the manufacturer's recommendations.

[Amputation of upper extremity: a case report - preclinical care of an 37 year old man]. / Kasuistik interaktiv: Amputation - Spektakuläre Verletzung, unkomplizierte Versorgung.

This case report describes the prehospital care of a person after an occupational accident. The amputation of whole extremities is rare and needs a standardized procedure: at first lifesaving procedures are necessary before saving the limb. The work at a conveyor belt resulted in taking of an arm. On the basis of this case report the prehospital management is discussed focalizing the complete treatment of the patient and his amputated extremity as well as the transport from the scene of accident to a suitable hospital.

[Case report: severe hypothermia in a newborn infant - challenges in preclinical emergency medicine]. / Kasuistik interaktiv: Neugeborenes mit schwerer Hypothermie - Eine notärztliche Herausforderung.

On the basis of a case report the prehospital management of a newborn child with deep accidental hypothermia (22oC) is discussed. The child was found in a garbage can. The continuous resuscitation during the transport into the clinic is done in an incubator and the child survives without neurologic damages. The used measures of the resuscitation are discussed on the basis of the therapy.

[Case report: prehospital therapy of the severely burned patient]. / Kasuistik interaktiv: grossflächige Verbrühung - Das Einmaleins der Brandverletzten-Versorgung.

On the basis of a case report the prehospital management of severely burned patients is discussed. The prevention of hypovolemia, hypothermia or hypoxemia are the primary targets. It is necessary to estimate the burn size and depth. The burn shock fluid resuscitation, prevention of hypothermia, pain- and airway management are described as well as the transport from the scene of accident to a proximal emergency unit or to a specialized burn intensive care unit.

[Case report: severe polytrauma after traffic accident]. / Kasuistik interaktiv: Schwerer Verkehrsunfall--Eingeklemmt, und die Zeit läuft.

This case report describes the prehospital care of a person with severe polytrauma due to being jammed in a vehicle in a traffic accident. After understanding the forces involved in causing the trauma, the therapy of impaired vital functions is demonstrated with particular regard to time management. Use of a rescue helicopter allowed for minimizing the delay to initial treatment as well as the duration of transport.