[Postoperative nausea and vomiting-recommendations for its prevention and therapy in paediatric medicine]. / Postoperative Übelkeit und Erbrechen ­ Handlungsempfehlungen zur Prävention und Therapie bei Kindern.

Post-operative nausea and/or vomiting (PONV/POV) are among the biggest problems occurring in the paediatric recovery room and in the course of the following post-operative period. Apart from pain and emergence delirium, PONV is one of the main causes of post-operative discomfort in children. The DGAI Scientific Working Group on Paediatric Anaesthesia already worked out recommendations for the prevention and treatment of PONV in children years ago. These recommendations have now been revised by a team of experts, the current literature has been reviewed, and evidence-based core recommendations have been consented. Key elements of the new recommendations consist of effective individual measures for prevention and therapy, next to the implementation of a fixed dual prophylaxis in the clinical routine applicable to all children ≥ 3 years of age.

Reduction of highly elevated plasma levels of gamma-aminobutyric acid does not reverse hepatic coma.

The pathogenesis of coma in patients with fulminant hepatic failure is still unknown, but there is some evidence that decreased hepatic metabolism of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) may be involved. If this hypothesis is true, reduction of increased GABA levels in patients with hepatic encephalopathy should reduce the depth of hepatic coma. In the case described here, highly elevated plasma GABA levels were reduced by cross-circulation with baboon liver. No amelioration of the coma was observed, thus suggesting that decreased hepatic metabolism of GABA is not critically involved in hepatic encephalopathy.

[Risks and dangers in pediatric regional anesthesia]. / Fehler und Gefahren in der Regionalanästhesie bei Kindern.

In recent years peripheral and central regional anesthesia have become increasingly more important in pediatric anesthesia. Unlike adult patients, children typically receive regional anesthesia while under general anesthesia, an approach generally accepted among pediatric anesthesiologists. A well-founded knowledge of the specific anatomical, physiological and pharmacokinetic characteristics of pediatric patients is indispensable for safely practicing pediatric regional anesthesia. If attention is paid to these characteristics, complications are rare. The use of ultrasound when administering regional anesthesia can help reduce the risk of complications even further. Peripheral and central regional anesthesia are safe procedures which pediatric patients should not be deprived of. The present article discusses frequent as well as rare complications of pediatric regional anesthesia.

[Nausea and vomiting in the postoperative phase. Expert- and evidence-based recommendations for prophylaxis and therapy]. / Ubelkeit und Erbrechen in der postoperativen Phase. Experten- und evidenzbasierte Empfehlungen zu Prophylaxe und Therapie.

There are no consensus guidelines for the management of postoperative nausea and vomiting (PONV) in German speaking countries. This meeting was intended to develop such guidelines on which individual health care facilities can derive their specific standard operating procedures (SOPs). Anesthesiologists reviewed published literature on key topics which were subsequently discussed during two meetings. It was emphasized that recommendations were based on the best available evidence. The clinical relevance of individual risk factors should be viewed with caution since even well proven risk factors, such as the history of PONV, do not allow the identification of patients at risk for PONV with a satisfactory sensitivity or specificity. A more useful approach is the use of simplified risk scores which consider the presence of several risk factors simultaneously. Most individual antiemetic interventions for the prevention of PONV have comparable efficacy with a relative risk reduction of about 30%. This appears to be true for total intravenous anesthesia (TIVA) as well as for dexamethasone and other antiemetics; assuming a sufficiently high, adequate and equipotent dosage which should be weight-adjusted in children. As the relative risk reduction is context independent and similar between the interventions, the absolute risk reduction of prophylactic interventions is mainly dependent on the patient's individual baseline risk. Prophylaxis is thus rarely warranted in patients at low risk, generally needed in patients with a moderate risk and should include a multimodal approach in patients at high risk for PONV. Therapeutic interventions of PONV should be administered promptly using an antiemetic which has not been used before. The group suggests algorithms where prophylactic interventions are mainly dependent on the patient's risk for PONV. These algorithms should provide evidence-based guidelines allowing the development of SOPs/policies which take local circumstances into account.

[Efficacy of clonidine in paediatric anaesthesia]. / Clonidin in der Kinderanästhesie.

Clonidine is a mixed alpha (2)-/alpha (1)- adrenoceptor agonist. It decreases sympathetic tone and increases parasympathetic tone, which results in a lowering of blood pressure and heart rate. It was introduced as an antihypertensive medication in the late sixties. Yet Clonidine also has a sedative effect due to alpha (2)-adrenoceptor stimulation in the locus coeruleus and antinociceptive action caused through postjunctional noradrenergic pathways in the brainstem and spinal cord. This analgesic property of Clonidine has raised broad interest in its beneficial use in anaesthesiology. In adults and pediatric anaesthesia, clonidine can be safely and effectively used for premedication, intraoperative and postoperative analgesia, postoperative shivering, and for analgo-sedation in intensive care. This article will consider possible indications of Clonidine in children's anaesthesia and intensive care medicine.

[The effectiveness of the benzodiazepine antagonist Ro 15-1788 after the induction of anesthesia with midazolam]. / Die Wirksamkeit des Benzodiazepin-Antagonisten Ro 15-1788 nach Narkoseeinleitung mit Midazolam.

UNLABELLED: The benzodiazepine antagonist Ro 15-1788 has now been added to the series of antagonists which have been routinely used for a long time. In the present prospective, randomized double-blind study, it is investigated whether Ro 15-1788 is able to antagonize the effect of midazolam applied at a dosage of 0.2 mg/kg for induction of anesthesia. PATIENTS, MATERIAL AND METHODS: Thirty female patients (age between 19 and 44 years) undergoing laparoscopy were included in the study. Premedication consisted of an oral dose of 2 mg flunitrazepam given on the evening before the intervention and a 7.5 mg oral dose of midazolam 45 min prior to the induction of anesthesia. After preoxygenation, midazolam was given intravenously at a dose of 0.2 mg/kg body weight for induction of anesthesia. Following extubation either Ro 15-1788 at a dosage of 0.2 mg (2 ml) or an adequate volume of placebo was given according to a randomized double-blind scheme. Those patients whose vigilance status did not change received either Ro 15-1788 or placebo every 60 s up to a maximum total dose of 10 ml. Prior to induction of anesthesia, 5 min after midazolam dosing, prior to and 5, 15, 30, 60 and 120 min after the application of Ro 15-1788, the following parameters were assessed using a multistep rating scale: degree of sedation, comprehension and collaboration, orientation in space and time, anterograde amnesia as well as blood pressure and heart rate.(ABSTRACT TRUNCATED AT 250 WORDS)

[The functional principle, reliability and limitations of pulse oximetry]. / Funktionsprinzip, Zuverlässigkeit und Grenzen der Pulsoximetrie.

Pulse oximetry has found wide-spread application in recent years. It is simple, noninvasive and continuous method for measuring arterial oxygen saturation. This survey deals with the history of pulse oximetry, its technical foundations, the differential indications and contraindications, and its limitations and possibilities for error. A number of suggestions are made for improving the accuracy of measurement and the interpretation of values. These include improved calibration, including low saturation ranges (below 70%) and the development of pulse oximeters that measure with more than two wavelengths, which would eliminate measuring errors due, for example, to carboxyhemoglobin.

[A child with a full stomach has to be anaesthesized]. / Ein nicht nüchternes Kind kommt zur Narkose.

In the present paper the problem of giving anaesthesia to a child with a full stomach is discussed using a case report. Children are not by nature more in danger of aspiration than grown-ups. Even the higher risk of aspiration in children with a full stomach, which seems plausible, is not proven in all published studies on this subject. Since there is a more or less large amount of residual gastric secrete even 6 - 10 hours after the accident, due to stress or opioids, and prophylaxis against aspiration must be taken in any case, narcosis for the emergency treatment of these children can be applied immediately at the same risk. Rapid sequence induction is the world-wide standard as prophylaxis against aspiration today. Should aspiration happen, bronchoscopic draining is the main measure. Artificial ventilation is not a cogent measure, if the airway is free as far as the visible segmental bronchus and there are no disruptions in the respiratory exchange.

[Ontogenesis of anesthesia-relevant receptors]. / Ontogenese anästhesierelevanter Rezeptoren.

The particularities in the medical treatment of children, especially those concerning premature infants, new-borns and babies, do not only stem from the immaturity of the organs (kidneys, liver etc.) but also from pharmacokinetic factors which are result of the immaturity of the brain. There are maturation deficits on all levels of transmission, from the nerve with electric transmission to the synapsis with neurotransmitter propagation, even though the whole system is basically laid out. The presented paper concerns itself mainly with the ontogenesis of the receptor-systems, a small part is dedicated to the question of myelination. Number and distribution of the receptors in premature or new-born infants and babies should not only be viewed in the context of the future function in mature humans (i.e. transmission and modification of information) - the receptors themselves are important factors in the maturing process of neuronal pathways, synapses and the differentiation of the neuronal cells themselves. Basically the number of receptors can change as follows: 1. Continuous increase until maturity, 2. Increase to a maximum during maturation with slight or stronger decrease after, 3. High initial number with following distinct decrease, 4. Even number throughout maturation, 5. Passing expression during maturation. The aim of this paper is to present an overview on the ontogenesis of opioid-, NMDA-, GABA-, dopamine-, acetylcholine- and serotoninreceptors. The data derived from animal and human-pharmacological experiments will be used to carefully conclude how the particularities of drug reactions of children (i.e. increased respiratory depression after opioid application in premature and newborn infants, higher incidence of paradox reactions to benzodiazepines etc.) can be explained.

[Asystole in extreme hyperkalemia, and successful resuscitation]. / Asystolie bei extremer Hyperkaliämie und erfolgreiche Reanimation.

Cardiac arrest in a twenty-year-old patient was caused by hyperkalaemia of 11.8 mmol/l. Cardiorespiratory resuscitation and emergency treatment of hyperkalaemia saved the life of this patient without residual neurological or mental disorders. We discuss pathophysiological mechanisms.

[Management of pediatric airway--anatomy, physiology and new developments in clinical practice]. / Der kindliche Atemweg--Anatomische und physiologische Besonderheiten sowie neue Erkenntnisse zum Airway-Management in der klinischen Praxis.

Due to the special features of paediatric anatomy and physiology, the expected and unexpected difficult paediatric airway is one of the major challenges to every anaesthesiologist, paediatrician and emergency physician. During the last years, some new devices have been made available to improve airway management in children and infants, and several studies have advanced our understanding of the risks and benefits of our clinical practice. Certain risk factors for airway related problems during anaesthesia in children having a "cold" have been identified, and there are new aspects of the controversy concerning the use of cuffed endotracheal tube (ETT) in children. New video assisted systems have been introduced for the management of the difficult airway in paediatric patients, and new applications for well-known devices have been suggested, e.g. the laryngeal mask airway (LMA) serving as guidance for fibreoptic intubation. Recent studies have also demonstrated specific problems with the LMA in infants, as well as possible advantages of a new prototype LMA for children, similar to the ProSeal. Furthermore, the following review presents data about the use of the Cuffed Oropharyngeal Airway (COPA) and the Laryngeal Tube (LT) in paediatric patients.

[Gamma-aminobutyric acid concentrations in the plasma in unconscious patients with severe craniocerebral trauma or nontraumatic intracranial hemorrhage]. / Die Gamma-Aminobuttersäurekonzentration im Plasma bei bewusstlosen Patienten mit schwerem Schädelhirntrauma oder nichttraumatischer intrakranieller Blutung.

The detection of cerebral lesions by chemical laboratory studies has not as yet been possible. Tests were carried out to determine whether there was an increase in plasma concentration of the neurotransmitter gamma-aminobutyric acid (GABA) in 12 unconscious patients: 6 with severe craniocerebral trauma (CCT) and 6 with spontaneous intracranial hemorrhage. Normal plasma concentrations were detected in the central venous blood of patients with severe CCT (normal range 366 +/- 123 pmol/ml); in patients with intracranial hemorrhage the values were partially elevated. Maximal values in arterial blood were around 613 pmol/ml (patients with CCT) and 1723 pmol/ml (patients with spontaneous intracranial hemorrhage). The influence of fluid turnover on plasma GABA concentrations is discussed.

[Possible intubation difficulties after cricotracheal resection--a casuistry]. / Mögliche Intubationsprobleme nach cricotrachealer Resektion--ein Fallbericht.

Since the 1960s neonatal intensive care therapy made great progress. Along with the new possibilities of treatment unknown complications occurred especially in the upper respiratory tract. To relieve these respiratory complications new surgical techniques were developed in the 1980s. Children that were successfully operated on may now present to an anesthetist as a teenager or young adult. The serious anatomic deviations may cause unexpected problems during the induction of anesthesia. This casuistry will show a possible algorithm that may keep patient and physician save from difficulties and surprises.

Marked increases of plasma gamma-aminobutyric acid concentrations in cirrhotic patients with portacaval shunts are not associated with alterations of cerebral functions.

Several previous studies have shown that the plasma concentration of gamma-amino-butyric acid (GABA) is markedly increased in patients with hepatic encephalopathy, and it has been suggested that decreased metabolism of peripheral GABA might contribute to the cerebral dysfunctions observed. In the present study, plasma GABA-like activity was determined by a radioreceptor assay in 21 cirrhotic patients in whom, at least 2 months prior to the study, portocaval shunt surgery had been performed for treatment of recurrent variceal bleeding. Compared to 10 healthy volunteers, plasma GABA concentrations were increased in all cirrhotic patients, whereas most other amino acids, including those known to interfere with the GABA radioreceptor assay at elevated concentrations, were within the normal range. Despite an about 3- to 16-fold increase in individual GABA concentration, none of the patients showed clinical signs of overt hepatic encephalopathy on conventional neurologic (including EEG) and mental status examination. Furthermore, when a psychometric test system was used for evaluation of intellectual and psychomotor functions, all patients performed within the normal range and could not be distinguished from healthy volunteers. The data indicate that, at least in chronic liver disease, impaired metabolism of peripheral GABA does not lead to cerebral dysfunctions.

[The blood level of gamma-aminobutyric acid in patients with liver cirrhosis and portacaval anastomosis]. / Der Serumspiegel der Gamma-Aminobuttersäure bei Patienten mit Leberzirrhose und portocavaler Anastomose.

Venous blood was collected from 21 patients with liver cirrhosis and portocaval anastomosis for routine laboratory tests and determination of GABA levels by radioreceptor assay. The patients additionally underwent psychometric tests for determining the degree of hepatic encephalopathy. No differences were seen in psychometric tests and laboratory parameters between patients and normals. However, GABA serum levels showed a 10-fold increase and the difference was highly significant. The fact that these patients did not show any signs of hepatic encephalopathy is probably due to an intact blood-brain barrier that prevents the uncontrolled influx of GABA. Therefore, not even high GABA serum levels are associated with symptoms of encephalopathy.

[Nalbuphine and tramadol for the control of postoperative pain in children]. / Nalbuphin und Tramadol zur postoperativen Schmerzbekämpfung bei Kindern.

The postoperative treatment of pain in children is often inadequate: Periphal acting analgetics are not sufficient, opioids are believed to be dangerous because of their respiratory depression. Nalbuphine and tramadol are two narcotics with only a few side effects. The aim of this trial was to investigate the efficacy and safety of these drugs in postoperative pain therapy in children aged 1-9 years. 30 children in each group received in a double-blind and randomized manner either 0.15-0.2 mg/kg nalbuphine or 0.75-1.0 mg/kg tramadol im. Pain intensity and sleep-awake behaviour were documented by a visual analogue scale for 24 h. After 1 h 70% of the patients in both groups had no pain and were sleeping. There was no change in heart rate and systolic blood pressure. Only the diastolic blood pressure decreased as did the respiratory rate, while the tcpCO2 estimated in some patients remained constant. Narcotic reinjections were necessary three times in the nalbuphine group and four times in the tramadol group. Typical opioid side effects were found to be equal in both groups.

[Oral premedication with clorazepate dipotassium. Comparison with oral premedication with flunitrazepam and intramuscular premedication with promethazine, pethidine and atropine in adults]. / Die orale Prämedikation mit Dikaliumclorazepat. Vergleich zur oralen Prämedikation mit Flunitrazepam und der intramuskulären Prämedikation mit Promethazin, Pethidin und Atropin beim Erwachsenen.

UNLABELLED: The purpose of premedication and the best form have been frequent subjects of controversy among anaesthetists in the past few years. Anxiolysis is now accepted as the main purpose. The preferred route of administration is by mouth. The intention of this study was to examine whether clorazepate dipotassium has the same sedative-hypnotic and anxiolytic effects as i.m. premedication with promethazine, pethidine and atropine. METHODS: A total of 100 patients aged 20-65 years and due to undergo arthroscopy took part in this study. Patients in group I were given 1 mg flunitrazepam p.o. on the evening before the operation and the i.m. premedication described above. The premedication for group II consisted in clorazepate dipotassium, 50 mg on the evening before operation and 25 mg on the morning of the day of the operation. The sedative-hypnotic effects were measured on a four-point scale. The Erlangen anxiety scale (EAS) and a visual analogue scale (VAS) were used to evaluate the anxiolytic effects according to the patient's own and the observer's evaluation of mood. In addition to this, we measured amnesia, heart rate and blood pressure. RESULTS: Clorazepate dipotassium or flunitrazepam p.o. significantly reduces anxiety 1 h after administration as measured by the EAS (P < 0.05) on the evening before the operation. This result was not, however, confirmed by the VAS for self-assessment. Patients who received premedication with clorazepate dipotassium are less anxious on the morning of the operation than patients given flunitrazepam the evening before the operation (P < 0.05); this, however, does not correspond to the VAS results. There were no differences in the other parameters compared. DISCUSSION: Oral premedication with clorazepate dipotassium has the same sedative-hypnotic, anxiolytic and amnestic effects as i.m. premedication with promethazine, pethidine and atropine. The results of this study are better than those obtained by Tolksdorf et al., owing to the higher dosage used in our study (50 mg as against 20 mg). Tolksdorf et al. [21] failed to show any improvement on a placebo. Our results correspond to those of Drautz et al. [2] who used 50 mg of clorazepate dipotassium on the evening before and 25 mg on the morning of the day of the operation.

[Anesthetic-induced heart arrest. A case report of 2 infants with previously unrecognized muscular dystrophy]. / Anästhetikainduzierter Herzstillstand. Kasuistik zweier Säuglinge mit zuvor nicht bekannter Muskeldystrophie.

We report two boys aged 4 and 10 months who suffered cardiac arrests after induction of anaesthesia. Both infants had no personal or family history of myopathy. In both cases anaesthesia was induced by inhalation with halothane and N2O/O2 (70/30). To facilitate tracheal intubation both were given succinylcholine after the administration of atropine. The 4-month-old developed muscle rigidity and cardiac arrest occurred immediately after tracheal intubation. Resuscitation was unsuccessful. Laboratory findings during resuscitation showed elevated serum potassium levels of more than 10 mmol/l and serum creatine phosphokinase 17.700 IU/l. Histopathologic examination of the skeletal muscle revealed congenital muscular dystrophy. In the older boy no muscle contractures were noted after administration of succinylcholine. He developed bradycardia that progressed to asystole 15 min after induction of anaesthesia. After 1 h of resuscitation a sinus rhythm could be established. The boy developed myoglobinuria and his serum creatine phosphokinase reached a maximum level of 45,000 IU/l on the 2nd day. The child survived and made a complete recovery. Two months later a muscle biopsy taken from the quadriceps showed marked muscular dystrophy. Duchenne's muscular dystrophy could be excluded. The most likely underlying reasons for these complications are discussed: anaesthesia-induced acute rhabdomyolysis or malignant hyperthermia.