[Preoperative evaluation and risk estimation in thoracic surgery]. / Präoperative Evaluation und Risikoeinschätzung in der Thoraxchirurgie.

Preoperative evaluation of patients undergoing lung resection remains an interdisciplinary challenge. Despite substantial progress in anesthesiology, intensive care medicine and surgery, mortality of patients undergoing pneumonectomy remains high at 5-9%. Guidelines were developed to identify patients with an increased perioperative risk for morbidity and mortality. These guidelines are focused around the forced expiratory capacity (FEV) measured by spirometry, following further investigations in patients with limited FEV(1). Extended testing includes measurement of the diffusion capacity, calculation of postoperative predicted values of lung function and spiroergometry to determine maximal oxygen uptake. In this article the methods to measure parameters of lung function and gas exchange are described and evaluated in the context of the current guidelines.

[Epidural cooling. Neuroprotective treatment of thoracoabdominal aortic aneurysms]. / Epidurale Kühlung. Neuroprotektive Versorgung thorakoabdominaler Aortenaneurysmen.

The risk of paraplegia and paraparesis during thoracoabdominal aneurysm surgery still represents a major threat. In 1993, Cambria and coworkers applied for the first time a method of regional spinal cord hypothermia by epidural cooling and significantly diminished the rate of neurological deficits. In this article the first clinical application of this neuroprotective method in Germany will be reported. This neuroprotective method was used in seven patients who underwent elective thoracoabdominal aortic aneurysm repair. The spinal cord was cooled with ice-cold saline via an epidural catheter during surgical repair. Cerebrospinal fluid pressure was measured on-line via a spinal catheter and controlled using active cerebrospinal fluid drainage. Of these seven patients, four showed no postoperative neurological deficit and were released from hospital. The other three patients died in the intra-operative or post-operative phase due to complications other than spinal cord injury arising from pre-existing comorbid conditions. The described method of epidural cooling represents a preliminary experimental method, which might reduce spinal cord injury during surgical repair of thoracoabdominal aneurysms.

[Traumatic thoracic aorta rupture: preclinical assessment, diagnosis and treatment options]. / Traumatische thorakale Aortenruptur: Präklinische Beurteilung, Diagnostik und Therapieoptionen.

Traumatic aortic rupture is a life-threatening injury which is frequently associated with blunt thoracic trauma or found coincidentally in heavily traumatized patients. Depending on the degree of disruption of the damaged aortic wall, vascular injury is associated with a high primary mortality rate and a significant risk of secondary aortic rupture. Early clinical signs which may indicate a ruptured thoracic aorta are left sided thoracic pain, reduced ventilation, tachycardia and dyspnoe as well as hypotension in the lower extremities. The primary aim for emergency treatment is to maintain vital organ function and to hemodynamically stabilize the patient. Surgical treatment was previously performed by either direct aortic suture or segmental alloplastic graft interposition using the clamp and sew technique with or without extra-anatomic shunts or extracorporeal circulation. However, endovascular stent graft implantation has now become another treatment option for traumatic aortic rupture. According to the reported data and our own experience there is increasing evidence that endovascular aortic repair might become the treatment of choice for patients with traumatic aortic rupture, with the option of an early, less invasive intervention thus avoiding thoracotomy. Regular follow-up is necessary to detect possible stent graft migration or leakage which could require additional endovascular or open surgical re-interventions.

No effect of the cyclooxygenase-2 inhibitor etoricoxib on pre-emptive and post-operative analgesia in visceral surgery: results of a randomized controlled trial.

BACKGROUND: Pre-emptive analgesia in perioperative care has potential benefits for patients. The pre-emptive and postoperative analgesic effects of the cyclooxygenase-2 inhibitor etoricoxib have been investigated using a 2 × 2 factorial trial design. METHODS: According to the 2 × 2 factorial study design, 103 patients scheduled for visceral surgery, were randomly allocated to two groups prior to surgery. Patients could receive either etoricoxib or placebo (to investigate pre-emptive analgesia). Subsequent to surgery, patients randomly received either etoricoxib or placebo, again. It follows, that four treatment modalities (continuous or replaced intervention) result, to investigate postoperative analgesia. Main Outcome Measure was the cumulative morphine use 48 h post-surgery. Other outcomes included pain intensities, pain thresholds and sensory detection. RESULTS: Eighty-six patients (female n = 42; mean age 53.82 ± 13.61 years) were evaluated on the basis of an intention to treat analysis. Pre-emptive administration of 120 mg etoricoxib did not significantly reduce the cumulative morphine dose within the first 48 h after surgery, when compared to the administration of placebo. The analysis of the post-operative treatment groups showed a non-significant 8% reduction in morphine dose during the continuous administration of etoricoxib. There were no changes in sensory perception as detected with QST before and after surgery or between groups. CONCLUSIONS: The effect of administering etoricoxib was not superior to placebo in reducing the morphine dose required for postoperative analgesia. The lack of changes in peripheral nociception suggests that central algetic mechanisms are of higher impact in the development of postoperative pain following abdominal or thoracic surgery.

Endovascular treatment of an intramural aortic haematoma following cardiopulmonary resuscitation for myocardial ischemia with ventricular fibrillation.

Cardiopulmonary resuscitation by manual cardiac compression can restore cardiocirculatory function but can also injure patients. Commonly reported are skeletal fractures of the rips and sternum, while injuries to the large thoracic vessels will frequently be lethal. We report the case of a 57-year-old male patient with sudden cardiac arrest because of myocardial ischemia with ventricular fibrillation, successful cardiopulmonary resuscitation, associated with an intramural haematoma (IMH) of the descending thoracic aorta treated by endovascular aortic repair. Secondary coronary angiography revealed a severe three vessel coronary disease with an occlusion of the proximal anterior descending branch and a subtotal stenosis of the first segmental branch of the left coronary artery (LCA) and a high-grade stenosis of the posterolateral segmental branch of the circumflex left coronary artery. Stenotic segments of coronary arteries were treated successfully by implantation of three drug-eluting stents followed by dual antiplatelet therapy. The patients recovered almost completely and was discharged for further rehabilitation after 3 weeks.

[Comparison between TCI-TIVA, manual TIVA and balanced anaesthesia for stereotactic biopsy of the brain]. / Vergleich zwischen TCI-TIVA, manueller TIVA und balanzierter Anästhesie während stereotaktischer Gewebsentnahme in der Neurochirurgie.

PURPOSE: Total intravenous anaesthesia (TIVA) is increasingly used in diagnostic surgery such as stereotactic biopsy of the brain. TIVA could lead to a faster recovery of cerebral function, which may lead to a better behavior and advantages in the postoperative management. The aim of this prospective, single-blind study was to compare the hemodynamics, the postoperative recovery period, the side-effects and the need for additional cardiovascular medication during and after the operation between the three study groups. PATIENTS AND METHODS: After giving informed consent and approval by the ethical committee of our hospital, 51 patients (ASA I and II) undergoing stereotactic biopsy of a brain tumor were randomized to receive either propofol via the TCI-system (group 1: TCI-TIVA), propofol by a manual technique (group 2: MAN-TIVA) or methohexitone-sevoflurane (group 3: BAL-SEVO). Remifentanil was used as the analgetic component in all groups. Systolic and diastolic blood pressure, heart rate und transcutaneous oxygen saturation were noted before and after induction and before and after the end of anaesthesia. The time until return of complete orientation relative to person, location and time were measured. The patients' ranking of their satisfaction with the anaesthesia was questioned 60 min and 24 hours after the end of the procedure (VAS). Undesirable side-effects (i. e. PONV, shivering, pain, dysphoria, tiredness) were noted, whenever they occurred. The number of hemodynamic interventions by the anaesthesiologist was counted, and the total doses of remifentanil and propofol were quoted. Depth of anaesthesia was monitored by using a BIS-system, a range between 40 and 50 was thought to be adequate. Besides this, the total doses of remifentanil, propofol and sevoflurane were ruled out and the costs of the three regimens were ranked. RESULTS: Heart rate dropped markedly in all groups with a maximum in the TIVA-collective. Systolic and diastolic pressure also fell in the groups. In the SEVO-group, the difference was statistically significant only at the end of anaesthesia. After extubation, the three groups reached their hemodynamic starting-point with a slight overshoot in the SEVO-group. The number of required hemodynamic interventions was two (TCI-TIVA) vs. 7 (MAN-TIVA) vs. 8 (BAL-SEVO) in each group, respectively. The difference scarcely failed to get significance. The remifentanil requirements were similar between the collectives, group 1 needed more propofol per time than group 2. The number of side-effects was very little after the different regimens. There were no differences with regard to the other measured parameters between the groups. The use of TCI-TIVA was more expensive than manual TIVA (18,85 euro vs. 12,50 euro). Surprisingly, balanced anaesthesia using Sevoflurane was the most expensive method during the first hour, mainly due to the use of methohexitone as the induction agent (23,90 euro). CONCLUSIONS: Each of the three techniques compared in our study is suitable for anaesthesia in diagnostic neurosurgery. Since fast recovery of vigilance is important to justify the neurological outcome, none of the methods seems to be superior to the others. The hemodynamics were largely stable with a strong trend towards minor necessity for hemodynamic intervention in the TCI-TIVA group. This is also the best method from the subjective point of view of the anaesthesiologist due to the easy handling and the low number of interventions. The use of newer TCI-systems (e. g. fm-controller, Braun, Melsungen) not operating with special application syringes will cheapen TCI-TIVA.

[Low alkali-hydroxide content in soda limes does not lead to reduction of compound A formation from sevoflurane during low-flow anesthesia]. / Einfluss von niedrigem Alkalimetallgehalt im Atemkalk auf Compound-A-Bildung während Low-flow-Narkosen mit Sevofluran.

The alkali hydroxide content in soda lime induces Compound A formation from Sevoflurane (Sevo). This study was designed to answer the question if the use of potassium hydroxide-free Soda Lime (SL) would lead to lower Compound A levels as compared to Sodasorb (SO). A total of 30 patients scheduled for elective laparoscopic cholecystectomy received Sevo anaesthesia under low-flow conditions (0.8 l/min fresh gas flow). Each absorbent was used in 15 patients, but 3 patients of the SO group were excluded due to technical problems with Compound A analysis. Hemodynamic parameters, parameters of ventilation and gas concentrations were documented. Compound A concentrations were measured by gas chromatography from gas samples before Sevo application and 20, 40, 60, 90 and 120 min after low-flow start. Mean endtidal Sevo concentrations were 1.94 +/- 0.17 (SO) and 1.97 +/- 0.15 (SL) vol %, the total anaesthetic exposition was 1.52 +/- 0.36 (SO) and 1.64 +/- 0.47 (SL) MAC-h (n.s). The maximum Compound A concentration was significantly higher in SL group (19.6 +/- 2.8 vs. 11.7 +/- 4.1 ppm, p < 0.001). Therefore, elimination of potassium hydroxide from carbon dioxide absorbents alone did not lead to a reduction of Compound A formation during low-flow anaesthesia.