[Euthanasia and physician-assisted suicide : Attitudes of physicians and nurses]. / Tötung auf Verlangen und assistierter Suizid : Einstellung von Ärzten und Pflegekräften.

BACKGROUND: The current debate about end-of-life decisions in Germany focuses on physician-assisted suicide (PAS). However, there is only limited information available on physicians' attitudes towards euthanasia or PAS, and no data on nurses' attitudes. OBJECTIVES: The aim is to explore attitudes of physicians and nurses with a special interest in palliative care and pain medicine using a case-related questionnaire. METHODS: An anonymous questionnaire, consisting of eight questions, was distributed to all participants of a palliative care congress and a pain symposium. The questions focused on two scenarios: (1) a patient with an incurable fatal illness, (2) a patient with an incurable but nonfatal illness. The question was: Should euthanasia or physician-assisted suicide (PAS) be allowed. In addition, the participants were asked what they wanted for themselves if they were the patient concerned. RESULTS: A total of 317 questionnaires were analyzed; the return rate was 70 %. The general support for euthanasia and PAS was high: 40.5 % supported euthanasia in case of a fatal illness ("definitely…", "probably should be allowed"), 53.5 % supported PAS. The support decreased in case of a nonfatal illness; however, it increased when the participants were asked about their attitudes if they were the patient concerned. Nurses were more open towards euthanasia and PAS. In physicians the rejection of PAS was directly related to a higher level of qualification in the field of palliative care. CONCLUSION: The fact that nurses had a more positive attitude towards euthanasia and PAS and that all respondents accepted life-ending acts for themselves more than for their patients hints to still existing severe deficits in Germany.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI).

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

[Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]. / Kurzversion S2e-Leitlinie - "Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen".

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

[An algorithm for postoperative pain management in visceral and thoracic surgery: an observational study]. / Algorithmus zur postoperativen Schmerztherapie in der Viszeral- und Thoraxchirurgie: Eine Verlaufuntersuchung.

INTRODUCTION: We report the results of an observational study of pain intensity before and after implementation of an algorithm for postoperative pain management. The algorithm included multiple factors for treatment. METHODS: Data of 130 consecutive patients with defined surgical procedures were extracted from charts before and after implementation of the algorithm. Our patients documented pain intensity at rest and on movement on a numerival rating scale (NRS) from 0 (= no pain) to 10 (=  worst pain). A successful pain management was definded as maximum pain intensity at rest ≤ 3 and on movement ≤ 5 on the NRS. For statistical analysis we used the Wilcoxon and the chi squared test. RESULTS: The frequency of a successful pain management increased from 49 % (individual pain management) to 85 % (algorithm) at rest 8 (p < 0.001), on movement the rates were 42 % and 86 %, respectively (p < 0.001). In the total group, we found a reduction of maximum pain intensity at rest (mean ±â€Šsd) from 4.05  ±â€Š 2.54 to 2.18 ±â€Š1.82 (p < 0.001) and with movement from 6.04 ±â€Š2.51 to 3.5 ±â€Š2.08 (p < 0.001). CONCLUSION: Implementing an algorithm for postoperative pain management resulted in a clinically relevant reduction of postoperative pain. Our findings reflect the result of a complex change in pain management, and therefore cannot be attributed to any single factors involved.

Meta-analysis of dropout rates in randomized controlled clinical trials: opioid analgesia for osteoarthritis pain.

BACKGROUND: The interpretation of opioid studies in patients with chronic pain due to osteoarthritis is limited by a high dropout rate. Therefore, the implication of dropouts on the recommendation of opioids in chronic osteoarthritis pain was analyzed. DATA SOURCES: The databases of Medline, Embase, the Cochrane Library, and the Internet from 1990-2009 were searched. STUDY SELECTION: Two independent authors included randomized controlled clinical trials investigating the effects of chronic opioid treatment for the management of osteoarthritis pain. In order to calculate the odds ratio, only placebo-controlled trials were included. DATA EXTRACTION: The primary outcome parameter was the dropout rate. Secondarily, the effect size was calculated. Data extraction was conducted by two independent authors. RESULTS: A total of 19 studies reporting results of 3,871 treatment and 2,080 placebo outcomes were retrieved. Compared to placebo, opioid treatment was associated with a significantly increased total dropout rate (OR = 1.3, 95%CI 1.2-1.4). Discontinuation of treatment was related to adverse events (OR = 4.0, 95%CI 3.4-4.6). Lack of analgesia was associated with a significantly reduced dropout rate in opioid groups (OR = 0.4, 95%CI 0.3-0.5). Analgesic effects were significantly better in opioid-treated patients (p = 0.01). CONCLUSION: In spite of analgesic effects, many osteoarthritis patients prefer to stop chronic opioid use, because of adverse events. Therefore, opioids are not generally recommended in osteoarthritis.

Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta-analysis.

Intrathecal morphine is often used for postoperative analgesia after surgery. We performed a meta-analysis to obtain more detailed information on the frequency of side-effects in patients receiving intrathecal morphine in combination with spinal anaesthesia compared with placebo treated patients. We clustered the analysis to patients receiving placebo, less than morphine 0.3 mg (M < 0.3), or equal to or more than morphine 0.3 mg (M > or = 0.3) and calculated the risk ratios of morphine vs placebo. Twenty-eight studies investigating 46 morphine groups vs placebo were included. A total of 790 patients with intrathecal morphine and 524 patients who received placebo were analysed. Compared with placebo the lower dose of morphine resulted in an increase of nausea (RR 1.4, 95% CI 1.1-1.7), vomiting (RR 3.1, 95% CI 1.5-6.4) and pruritus (RR 1.8, 95% CI 1.4-2.2). The higher dose resulted in an increased risk ratio for pruritus (RR 5.0, 95% CI 2.9-8.6), but not nausea (RR 1.2, 95% CI 0.9-1.6) or vomiting (RR 1.3, 95% CI 0.9-1.9). Overall, intrathecal morphine did not increase respiratory depression. However, the higher dose of intrathecal morphine was associated with more episodes of respiratory depression (7/80) compared with the lower dose (2/247). Intrathecal morphine is associated with a mild increase in side-effects. With a dose < 0.3 mg we found there were no more episodes of respiratory depression than in placebo patients who received systemic opioid analgesia.

The effective duration of analgesia after intrathecal morphine in patients without additional opioid analgesia: a randomized double-blind multicentre study on orthopaedic patients.

BACKGROUND AND OBJECTIVE: To know whether the application of patient-controlled analgesia devices could be avoided if intrathecal morphine is given in combination with spinal anaesthesia. METHODS: In a randomized, double-blind multicentre study, 188 orthopaedic patients were randomized to receive intrathecally placebo, 0.1 mg morphine or 0.2 mg morphine in addition to 15 mg bupivacaine. The primary outcome parameter was the number of patients without any additional request for opioid during a period of 72 h after surgery. RESULTS: Patients with 0.1 or 0.2 mg morphine showed a significant reduction in opioid requests compared with placebo during 72 h after surgery (P = 0.0001). At 24 h after surgery, the rate of patients who required additional opioid analgesia was 71% in the placebo group, 51% in the 0.1 mg morphine group and 31% of the patients in the 0.2 mg morphine group. After 0.2 mg morphine, systemic opioid requirements at 24 h were significantly lower than those in patients with 0.1 mg morphine (P < 0.05). Intrathecal morphine was not associated with an increased frequency of respiratory depression. Forty per cent of patients with intrathecal morphine did not ask for systemic opioids. CONCLUSION: Intrathecal morphine in a dose of 0.1 and 0.2 mg provides effective analgesia for up to 48 h without any need for systemic opioids at all in many patients.

[Ventilation hazard caused by a soft ventilation bag]. / Materialbedingte Gefährdung der Beatmung durch weichen Beatmungsbeutel.

The introduction of a new ventilation bag was associated with the occurrence of an unexpected ventilation problem. The analysis revealed a technical problem related to the high plasticity of the new bag allowing incomplete obstruction due to torsion of the anesthesia bag.

Epoetin alfa plus autologous blood donation in patients with a low hematocrit scheduled to undergo orthopedic surgery.

A low predonation hematocrit (Hct) can preclude the collection of sufficient autologous blood (AB) to meet the transfusion requirements of patients scheduled for orthopedic surgery. Subcutaneous (s.c.) administration of epoetin alfa, in conjunction with intravenous (i.v.) iron supplementation, has proved effective for the facilitation of AB donation by such patients. Compared with untreated controls and patients treated with i.v. iron alone, epoetin alfa 50 to 150 IU/kg SC plus i.v. iron twice weekly for 3 weeks prior to surgery significantly increased total red blood cell (RBC) production (P < .01) and the volume of RBCs donated (P < .05). Epoetin alfa was particularly effective in females and patients with a predicted blood volume (PBV) less than 5 L. Treatment with epoetin alfa led to an increase (albeit nonsignificant) in the number of AB units predonated compared with i.v. iron alone. However, in patients with a PBV less than 5 L, a substantially greater percentage of epoetin alfa-treated patients donated > or = 4 AB units (80% v 30%). Allogeneic blood requirements were reduced, albeit not significantly (P = .051), in patients treated with epoetin alfa. However, in comparison with untreated controls, there was a significant reduction in the mean volume of allogeneic blood transfused per transfused patient in the epoetin alfa groups. The optimum s.c. dose of epoetin alfa in patients with a low predonation Hct scheduled for orthopedic surgery appears to be between 100 and 150 IU/kg twice weekly for 3 weeks.

Epoetin alfa plus autologous blood donation and normovolemic hemodilution in patients scheduled for orthopedic or vascular surgery.

In previous studies, treatment with epoetin alfa facilitated preoperative donation of autologous blood (AB). However, some patients may not be able to donate sufficient AB to meet their surgical blood requirements when the time to surgery is short. In this multicenter, double-blind, placebo-controlled study, the ability of epoetin alfa combined with normovolemic hemodilution (NVHD) to facilitate the collection of > or = 4 AB units within 2 weeks of surgery was investigated in 112 nonanemic patients scheduled for elective orthopedic or vascular surgery. All patients received oral iron supplementation and were treated with three intravenous (i.v.) injections of epoetin alfa (300 or 600 IU/kg) on days 1,4, and 7; surgery, in combination with NVHD, was performed on day 13. A total of 4 units of AB were predeposited if the patient's hemoglobin (Hb) level exceeded 11 g/dL at each donation. Compared with placebo, epoetin alfa dose-dependently increased reticulocyte counts prior to surgery and significantly minimized the decrease in hematocrit (Hct) associated with AB donation, although there were no significant differences between dosages. While significantly more patients treated with epoetin alfa were able to donate > or = 4 AB units compared with placebo, there was no difference between the groups in exposure to allogeneic blood. This effect of epoetin alfa was particularly apparent in female patients. I.v. epoetin alfa 300 IU/kg, administered three times within 1 week, appears to be the optimum dose for facilitating the collection of > or = 4 units of AB in nonanemic patients scheduled for elective surgery and NVHD within 2 weeks.

The gastropulmonary route of infection--fact or fiction?

Published studies relating to whether medicinal stress-bleeding prophylaxis leading to an increase of gastric pH favors the development of bronchopulmonary infections are reviewed. Results from studies in healthy humans, patients with ulcer disease, and patients in the intensive care unit (ICU) clearly show that the risk of gastric bacterial colonization significantly increases relative to increasing gastric pH. Moreover, a drug-induced increase of gastric pH leads directly to gastric bacterial colonization also in patients in the ICU, above all with bacteria typical of the gastrointestinal tract. Comparing the different bacterial spectra of the oropharynx, stomach, and upper small intestine, it becomes clear that the stomach is a reservoir of bacteria independent of the oropharynx and also subject to retrograde colonization due to the duodenogastric reflux. Both by means of microbiological and in particular direct detection procedures, it can be demonstrated that in at least 30-40% of intubated patients a gastropulmonary route of colonization occurs. In patient groups without a medication-induced increase of gastric pH the number of bacteria detected in the tracheal secretion is about 33% less than in the case of conventional stress-bleeding prophylaxis. These findings make it understandable that a highly significant increase in the pneumonia rate is seen in patients receiving pH-increasing stress-bleeding prophylaxis versus control groups without therapy essentially influencing gastric pH. A risk score was developed that allows an easy description of those patients who are at an increased risk of pulmonary infections due to the gastropulmonary route of colonization.

Side effects of stress bleeding prophylaxis.

Conventional stress bleeding prophylaxis with antacids or histamine (H2)-antagonists, as well as the newer mucosa-protective drugs pirenzepine and sucralfate, are satisfying most of the clinicians with regard to efficacy of stress bleeding prevention. Therefore, potential side effects are attaining crucial importance with regard to the drugs to be used. Pharmacologic blockade of cardiac H2-receptors increases the risk of bradycardia and negative inotropic effects as well as coronary vasoconstriction at least in the presence of elevated plasma histamine levels. Intracardiac injection of pirenzepine can lead to temporary tachycardia. Elderly patients have been shown to be at an increased risk of side effects to the central nervous system when treated with H2-antagonists. These drugs can also induce toxic effects in the liver. Cimetidine leads to interactions with a number of drugs used in the intensive care unit. In patients with pre-existing pulmonary diseases, H2-antagonists have been demonstrated to increase pulmonary bronchoconstriction. Alkalinization of the gastric juice is associated with a significant increase in colonization of gram-negative bacteria in the stomach. In intubated patients, aspiration of stomach contents occurs in 30 to 40 percent of the patients. A number of studies have shown a direct correlation between alkalinization of the gastric juice and pulmonary infections. Sucralfate and to a lesser degree pirenzepine can reduce the risk of pulmonary infections. Sucralfate also exerts a bactericidal effect. Recent investigations support the hypothesis that alkalinization of the stomach also increases the risk of systemic infections. This may be the main reason for the observation that at least in ventilated patients sucralfate, unlike H2-antagonists or antacids, leads to a significant reduction of the mortality rate compared with conventional stress bleeding prophylaxis.

Risk of acute stress bleeding and nosocomial pneumonia in ventilated intensive care unit patients: sucralfate versus antacids.

In a prospective, controlled, randomized study of the prophylaxis of stress bleeding, 100 ventilated high-risk patients in a surgical intensive care unit received, on a daily basis, 1 g of sucralfate suspension (n = 50) every four hours, or an antacid (n = 50) every two hours. The mean duration of the treatment was about six days in both of the groups. Gastric pH was determined every eight hours. Bleeding was defined as macroscopically visible bleeding. The intragastric pH was less than 4 significantly more often in patients treated with sucralfate. In each group, one case of macroscopically visible bleeding occurred. Both of the patients had a very high risk of bleeding. None of the bleedings influenced the outcome of the patients. When patients with primary thoracic trauma or pneumonia were excluded, nosocomial pneumonia developed in significantly fewer (p less than 0.05) patients in the sucralfate group (three of 29) than in the antacid group (11 of 32). In four of the latter patients, pneumonia influenced the outcome of the patients. Sucralfate provides adequate protection against stress bleeding while also minimizing the danger of pneumonia caused by infection via the gastropulmonary route.

Antibacterial activity of sucralfate in human gastric juice.

A series of experiments was conducted to determine the rate of bacterial growth in human gastric juice at various pH values in relation to the addition of sucralfate and antacid. Whereas the addition of antacid resulted in bacterial growth in gastric juice, sucralfate showed an antibacterial effect. This may account for the decreased rate of pneumonia among intensive-care patients who are receiving artificial ventilation and being treated with sucralfate for the prevention of stress-induced gastrointestinal bleeding compared with the rate in patients receiving conventional prophylaxis with histamine (H2)-antagonists or antacids.

Prevention of acute stress bleeding with sucralfate, antacids, or cimetidine. A controlled study with pirenzepine as a basic medication.

In a prospective, controlled, randomized study of a prophylaxis for stress bleeding, 100 high-risk patients in an intensive care unit received, on a daily basis, 1 g of sucralfate every four hours, an antacid every two hours, or 2 g of cimetidine intravenously. All patients also received 50 mg of pirenzepine by intravenous infusion each day. Gastric pH was determined every eight hours. Bleeding was defined as macroscopically visible bleeding. The intragastric pH was less than 4 significantly more often in patients treated with sucralfate than in patients treated with the other agents, but stress bleeding occurred only in patients treated with cimetidine (n = 2) or antacids (n = 2). In the latter two treatment groups, the probability of bleeding correlated with the incidence of pH values below 4. No side effects of sucralfate therapy were observed. The results indicate that prophylactic treatment of stress bleeding with pirenzepine and sucralfate is at least as effective as combined treatment with pirenzepine and cimetidine or antacids.

Current guidelines on stress ulcer prophylaxis.

Acute uppergastrointestinal bleeding in intensive care unit (ICU) patients may occur due to peptic ulcer disease, adverse drug effects, gastric tube lesions, acute renal failure, liver failure or stress-induced gastric mucosal lesions. Gastric acid hypersecretion can be observed in patients with head trauma or neurosurgical procedures. Gastric mucosal ischaemia due to hypotension and shock is the most important risk factor for stress ulcer bleeding. Preventive strategies aim to reduce gastric acidity (histamine H2 receptor antagonists, antacids), strengthen mucosal defensive mechanisms (sucralfate, antacids, pirenzepine) and normalise gastric mucosal microcirculation (sucralfate, pirenzepine). However, the most important prophylactic measure is an optimised resuscitation and ICU regime aiming to improve oxygenation and microcirculation. All drugs approved for stress ulcer prophylaxis in Europe (H2 antagonists, antacids, pirenzepine, sucralfate) have been shown to be effective in prospective controlled randomised trials. However, due to insufficient clinical data, prostaglandins and omeprazole cannot be recommended for this use. Stress ulcer prophylaxis is indicated only in patients at risk, and not in every ICU patient. The selection of drugs today depends not only on efficacy but also on possible adverse effects and on costs. In this regard, the most cost-effective drug is sucralfate. The clinical relevance of nosocomial pneumonia due to gastric bacterial overgrowth has decreased during the past decade due to several changes in the management of critically ill patients.

Inotropic support of the critically ill patient. A review of the agents.

Intensive care patients often require inotropic support to stabilise circulation and to optimise oxygen supply. In this context, the catecholamines norepinephrine (noradrenaline), epinephrine (adrenaline), dopamine and dobutamine are still the mainstay of therapy. They provide, to different extents, a variety of adrenoceptor-mediated actions comprising vasoconstriction (via alpha-receptors) as well as vasodilatation (via beta 1-receptors), and an increase in cardiac output by enhancing inotropy and heart rate (again via beta 1-receptors). Because of their favourable pharmacokinetic profile (plasma half-lives of about 2 minutes) their actions can easily be controlled. Combinations of different catecholamines with each other or with other drugs such as phosphodiesterase inhibitors or nitrates lead to a broad spectrum of possible haemodynamic actions. However, the use of catecholamines is limited by side effects like tachycardia, hypertension and disturbances of organ perfusion caused by vasoconstriction. Furthermore, as a result of receptor downregulation during long term therapy, the efficacy of catecholamine treatment decreases. These shortfalls stimulated the search for alternatives to catecholamine treatment. Among these, phosphodiesterase inhibitors (e.g. enoximone and amrinone) appear to be the most promising drugs which have been introduced into acute clinical practice up to now. They act via inhibition of the phosphodiesterase isoenzyme III, leading to higher intracellular calcium levels by increasing cyclic adenosine monophosphate (cAMP) levels. These agents improve cardiac performance by enhancing contractility, reducing left ventricular afterload and improve diastolic relaxation. In cases of failing catecholamine therapy due to receptor downregulation, treatment with phosphodiesterase inhibitors may still be effective since their action is not receptor-mediated. Inhibition of the phosphodiesterase enzyme in vascular smooth muscle leads to vasodilatation. Therefore, in low cardiac output states combined with increased total peripheral or pulmonary vascular resistance, phosphodiesterase inhibitor therapy is particularly effective. Depending on the dosage and the speed of intravenous administration, the use of phosphodiesterase inhibitors sometimes results in pronounced decrease of blood pressure which may require vasopressor therapy. Other drugs including histamine H2-agonists are currently under investigation. Their value in the treatment of intensive care patients has still to be evaluated.

Critical care pharmacotherapy. A review.

During recent years, research in critical care medicine has focused on the role of the gastrointestinal tract in the pathogenesis of multiple organ failure and nosocomial infection, and on preventive measures. Gram-negative bacterial overgrowth of the oropharynx and stomach has been proved to be a cause of nosocomial pneumonia. Topical application of antibiotics into the oropharynx and stomach, and preservation of gastric acidity have been shown to be effective prophylaxis in ventilated patients. Recent studies have demonstrated that gastric alkalinisation is no longer necessary for the prevention of stress ulcer bleeding in critically ill patients. Tissue hypoxaemia, not gastric acidity, is the underlying pathomechanism of stress ulcer bleeding. In experimental investigations, pirenzepine and sucralfate improved gastric mucosal oxygen supply. Both compounds effectively prevent bleeding without increasing gastric pH. In mechanically ventilated patients, significantly lower rates of pneumonia occur with both of these drugs compared with antacids or histamine H2-receptor antagonists. Topical antibiotics (selective digestive decontamination) are most effective in patients with alkaline gastric juice, but of only marginal clinical relevance in those with acidic gastric contents. Isoflurane, propofol and clonidine have been recently investigated for sedation of ventilated patients. Isoflurane may lead to fluoride accumulation after more than 1 day. Propofol dosage has to be increased more often after 4 to 7 days, leading to fat overload and significantly increased costs. Clonidine was highly effective in patients with 'sympathetic overshoot', e.g. those experiencing alcohol or opioid withdrawal. Wound infections are an important problem in burn patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of roxatidine acetate in fasting patients prior to induction of anaesthesia as prophylaxis against the acid aspiration syndrome.

Aspiration pneumonitis is one of the major causes of anaesthesia related deaths. H2-receptor antagonists are effective drugs for the prevention of the acid aspiration syndrome (Mendelson's syndrome). The new long-acting H2-receptor antagonist roxatidine acetate may be the first H2-receptor antagonist which could effectively reduce acid secretion following a single bedtime premedication on the evening before an operation. A prospective controlled randomised double-blind study was conducted in 60 elective patients undergoing gynaecological operations requiring tracheal intubation. 30 patients received oral roxatidine acetate 150 mg at 10 pm, the other 30 patients received placebo. Immediately after intubation, at 15 minutes and at the end of the operation gastric pH and the volume of the aspirate were measured. In the placebo group, 13 patients (43%) had gastric pH values below the critical value of 2.5, while in the roxatidine acetate group gastric pH values were raised above 2.5 in all but 3 patients (10%) [p less than 0.05]. In the roxatidine acetate group pH values were significantly higher than in the placebo group (p less than 0.01). The mean gastric volume in the placebo group was 23.3 +/- 27.1 ml, compared to 14.5 +/- 9.4 ml for roxatidine acetate. The 5 highest gastric volumes were observed in the placebo group (max 146 ml). A single bedtime oral premedication with roxatidine acetate 150 mg ensures a gastric pH above 2.5 until 11 am the following day.