Search

Copyright of Anaesthesist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Anaesthesist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Historically, recovery rooms were established in order to reduce complications in the period immediately following surgery and anaesthesia, utilising staffing and equipment resources economically. To minimise the incidence of postoperative complications remains the main task of post anaesthesia care units (PACU). However, especially in hospitals with a high degree of surgical emergencies, the scope of tasks and procedures within the PACU has expanded. Facing restricted capacities in intensive therapy (ITU) and high dependency units (HDU) the PACU serves as a buffer; intensive care functions can be covered here until the patient can be admitted to an intensive care unit. In this context, the PACU also has a switch function; postoperatively, the patient is evaluated here and the level for further treatment determined: ITU, HDU, or normal ward. The PACU period can be utilised to improve the patient's condition (upgrade function) enabling continuation of treatment on a lower level (HDU instead of ITU, normal ward instead of HDU). This combination of buffer, switch and upgrade function is of special importance when ITU and HDU resources are limited. A new task for the PACU arises from efforts to optimise acute pain therapy; initial adjustment of continuous infusion systems according to the patients' needs can be performed here without additional staffing requirements. Finally, the PACU can be used preoperatively for "tune up" procedures in high risk patients. The basis for co-operation between anaesthetist and surgeon is the separation of responsibilities in combination with mutual trust. Accordingly, the anaesthetist is responsible for monitoring and maintenance of vital functions. Consequently, the anesthetist has a professional and organisational responsibility in the PACU. The surgeon can and must rely on notification whenever surgical complications may require his intervention. With increasing comorbidity of patients and complexity of surgical procedures the anaesthetist's responsibility in the immediate perioperative period gains a new quality. The number of surgical procedures requiring intraoperative intensive therapy from the anaesthetist is increasing; the delivery of anaesthesia becomes a background task during these operations. Thus, the anaesthetist becomes responsible for perioperative patient treatment in the operating room area which divides into three phases: preoperative "tune up" in the PACU (e.g.) haemodynamic optimisation, starting continuous regional anaesthesia techniques), anaesthesia and support of vital functions in the OR, and immediately postoperative treatment in the PACU. [ABSTRACT FROM AUTHOR]

Bacteraemia and septicaemia are generally thought to be relative or absolute contraindications for central neural axis (CNA) blocks. Postulated mechanisms for haematogenous infection of the central nervous system (CNS) caused by subarachnoid or epidural puncture might be an accidental vessel puncture, a change of pressure in the subarachnoid space, and the induction of a "locus minoris resistentiae." Infectious complications of diagnostic lumbar puncture, spinal or epidural anaesthesia are very rare. Although in animals meningitis can be induced by subarachnoid puncture during bactaeremia, there is no study that proves an increased risk for bacteraemic patients. Transient bacteraemia is common, especially in urological and obstetrical-gynecological procedures that are often done in regional anaesthesia, but the incidence of infectious complications is low. This review investigates the few published cases in which a haematogenous infection of the CNS may have been caused by regional anaesthesia. Based on current knowledge, bacteraemia cannot be an absolute, but only a relative contraindication for CNA blocks. Antibiotic chemoprophylaxis should be given before the puncture and the patients must be closely followed after the anaesthesia, particularly for the development of spinal epidural abscess. Because of the possibly increased risk of infectious complications, informed consent should be obtained from the patient. [ABSTRACT FROM AUTHOR]

Benzodiazepines are the most commonly used anxiolytic agents. Among the benzodiazepines, midazolam has the advantage of a short elimination half-life, which is especially useful in outpatient surgery. However, in contrast to other commonly prescribed benzodiazepines, such as chlorazepate dipotassium, oral premedication with midazolam has not been thoroughly investigated. Therefore, the present study was performed to compare anxiolysis, sedation and stress reduction with midazolam and clorazepate dipotassium in adults. METHODS. After IRB approval and informed consent had been obtained, 85 patients scheduled for breast biopsy were studied. The patients were chosen at random to receive either 7.5 mg midazolam (n = 29), 20 mg clorazepate dipotassium (n = 28) or placebo (n = 28) preoperatively. Before premedication, immediately prior to surgery and postoperatively in the recovery room, the following parameters were determined with visual analogue scales (VAS): "asthenia," "depression," oral salivation, muscle tension, motoric restlessness and sweating of the palms. In addition, anxiety (STAI-G-X-1, Spielberger), heart rate and arterial blood pressure were measured. Before patients underwent surgery, the degree of sedation was evaluated by the anaesthesiologist. RESULTS. Clorazepate dipotassium and midazolam both caused a reduction in anxiety as compared with the placebo (P < 0.05). Only clorazepate dipotassium reduced anxiety postoperatively (P < 0.05). Neither midazolam nor clorazepate dipotassium caused a reduction in "asthenia" and "depression." Midazolam was more effective in preventing increased blood pressure than clorazepate dipotassium and the placebo (P < 0.05). Furthermore, after premedication with midazolam, salivation, muscle tension, motoric restlessness and sweating of the palms remained stable, in contrast to the results after premedication using clorazepate dipotassium or placebo (P < 0.05). CONCLUSIONS. The anxiolytic effects of 7.5 mg midazolam and 20 mg clorazepate dipotassium were similar after oral application. However, the anxiolytic effect of midazolam is shorter-lived than that of clorazepate dipotassium. In contrast to clorazepate dipotassium, midazolam produced no increase in arterial blood pressure and stabilized oral salivation, production in the palms, muscle tension and motoric restlessness. [ABSTRACT FROM AUTHOR]

The conversion of an "attempt to treat" to "prolongation of dying" represents an important problem in modern intensive care. If the actual or presumed will of the patient is unknown, the physician has to decide about the extent of treatment in a paternalistic manner. In these difficult decisions the physician has to consider prognosis, and certainty of prognosis and has to carefully balance between the right to live and the right to die. This decision about the extent of therapy is a very personal medical activity and can be taken off the physician's shoulders by nobody. Consultation with other physicians involved, relatives, nurses and clergy, however, is mandatory, as a joint decision should be sought. If the situation is hopeless and further medical interventions are futile, then allowing the patient to die by therapy reductions is not only a possibility but a mandatory act of humanity. In that case it does not matter whether new treatment modalities are abandoned or whether already instituted medical measures are withdrawn. In clinical practice, however, the "fine tuning" of therapy reduction has to be tailored to the individual case and largely depends on prognostic certainty. [ABSTRACT FROM AUTHOR]

Serious neurological complications caused by spinal hematoma or abscess following central neuraxial block have been reported more often during the last years. In contrast, severe complications are extremely rare associated with peripheral nerve blocks. Concerned about the safety of spinal and epidural anesthesia, we encourage the use of peripheral regional techniques for procedures on the lower extremity and especially for postoperative regional analgesia. Motor block due to lumbar epidural anaesthesia using high concentrations of local anesthetic makes spinal hematoma or abscess difficult to recognize. Therefore, low concentrations of local anesthetic should be used for postoperative epidural analgesia. Any increase in motor block following neuraxial blockade should raise the suspicion of a spinal compression (e.g. hematoma or abscess). Other symptoms are back pain, radicular pain or paresthesia and incontinence. Disastrous neurological injuries can only be prevented by immediate diagnosis (MR, CT or myelography) and therapy (surgical decompression).

Cost reduction in fluid therapy may be possible without a loss in quality of medical therapy if the following principles are adhered to. 1: Compare the prices of different manufacturers. 2: The greater the product unit, the cheaper the milliliter. Adherence to this principle is limited by hygienic and logistic considerations. 3: 0.9% NaCl-solution is cheaper than Ringer's lactate-solution. Lactated Ringer's solution should be used, only, if there are contraindications against the higher solute concentrations and tonicity of 0.9% NaCl. 4: Crystalloids are cheaper than colloids. When choosing between these two options intravasal duration of action and specific adverse events must be considered. 5: Cost reduction by differential indication of artificial colloids. Comparing prices, one must consider risk of anaphylactoid/anaphylactic reactions, duration of action, limitation of dosage and possible hemostasis disorders. 6: Restrictive use of albumin. Albumin is the most expensive colloid. There are no reasons for routine use.

Historically, recovery rooms were established in order to reduce complications in the period immediately following surgery and anaesthesia, utilising staffing and equipment resources economically. To minimise the incidence of postoperative complications remains the main task of post anaesthesia care units (PACU). However, especially in hospitals with a high degree of surgical emergencies, the scope of tasks and procedures within the PACU has expanded. Facing restricted capacities in intensive therapy (ITU) and high dependency units (HDU) the PACU serves as a buffer; intensive care functions can be covered here until the patient can be admitted to an intensive care unit. In this context, the PACU also has a switch function; postoperatively, the patient is evaluated here and the level for further treatment determined: ITU, HDU, or normal ward. The PACU period can be utilised to improve the patient's condition (upgrade function) enabling continuation of treatment on a lower level (HDU instead of ITU, normal ward instead of HDU). This combination of buffer, switch and upgrade function is of special importance when ITU and HDU resources are limited. A new task for the PACU arises from efforts to optimise acute pain therapy; initial adjustment of continuous infusion systems according to the patients' needs can be performed here without additional staffing requirements. Finally, the PACU can be used preoperatively for "tune up" procedures in high risk patients. The basis for co-operation between anaesthetist and surgeon is the separation of responsibilities in combination with mutual trust. Accordingly, the anaesthetist is responsible for monitoring and maintenance of vital functions. Consequently, the anesthetist has a professional and organisational responsibility in the PACU. The surgeon can and must rely on notification whenever surgical complications may require his intervention. With increasing comorbidity of patients and complexity of surgical procedures the anaesthetist's responsibility in the immediate perioperative period gains a new quality. The number of surgical procedures requiring intraoperative intensive therapy from the anaesthetist is increasing; the delivery of anaesthesia becomes a background task during these operations. Thus, the anaesthetist becomes responsible for perioperative patient treatment in the operating room area which divides into three phases: preoperative "tune up" in the PACU (e.g.) haemodynamic optimisation, starting continuous regional anaesthesia techniques), anaesthesia and support of vital functions in the OR, and immediately postoperative treatment in the PACU.

Bacteraemia and septicaemia are generally thought to be relative or absolute contraindications for central neural axis (CNA) blocks. Postulated mechanisms for haematogenous infection of the central nervous system (CNS) caused by subarachnoid or epidural puncture might be an accidental vessel puncture, a change of pressure in the subarachnoid space, and the induction of a "locus minoris resistentiae." Infectious complications of diagnostic lumbar puncture, spinal or epidural anaesthesia are very rare. Although in animals meningitis can be induced by subarachnoid puncture during bactaeremia, there is no study that proves an increased risk for bacteraemic patients. Transient bacteraemia is common, especially in urological and obstetrical-gynecological procedures that are often done in regional anaesthesia, but the incidence of infectious complications is low. This review investigates the few published cases in which a haematogenous infection of the CNS may have been caused by regional anaesthesia. Based on current knowledge, bacteraemia cannot be an absolute, but only a relative contraindication for CNA blocks. Antibiotic chemoprophylaxis should be given before the puncture and the patients must be closely followed after the anaesthesia, particularly for the development of spinal epidural abscess. Because of the possibly increased risk of infectious complications, informed consent should be obtained from the patient.

Benzodiazepines are the most commonly used anxiolytic agents. Among the benzodiazepines, midazolam has the advantage of a short elimination half-life, which is especially useful in outpatient surgery. However, in contrast to other commonly prescribed benzodiazepines, such as chlorazepate dipotassium, oral premedication with midazolam has not been thoroughly investigated. Therefore, the present study was performed to compare anxiolysis, sedation and stress reduction with midazolam and clorazepate dipotassium in adults. METHODS. After IRB approval and informed consent had been obtained, 85 patients scheduled for breast biopsy were studied. The patients were chosen at random to receive either 7.5 mg midazolam (n = 29), 20 mg clorazepate dipotassium (n = 28) or placebo (n = 28) preoperatively. Before premedication, immediately prior to surgery and postoperatively in the recovery room, the following parameters were determined with visual analogue scales (VAS): "asthenia," "depression," oral salivation, muscle tension, motoric restlessness and sweating of the palms. In addition, anxiety (STAI-G-X-1, Spielberger), heart rate and arterial blood pressure were measured. Before patients underwent surgery, the degree of sedation was evaluated by the anaesthesiologist. RESULTS. Clorazepate dipotassium and midazolam both caused a reduction in anxiety as compared with the placebo (P < 0.05). Only clorazepate dipotassium reduced anxiety postoperatively (P < 0.05). Neither midazolam nor clorazepate dipotassium caused a reduction in "asthenia" and "depression." Midazolam was more effective in preventing increased blood pressure than clorazepate dipotassium and the placebo (P < 0.05). Furthermore, after premedication with midazolam, salivation, muscle tension, motoric restlessness and sweating of the palms remained stable, in contrast to the results after premedication using clorazepate dipotassium or placebo (P < 0.05). CONCLUSIONS. The anxiolytic effects of 7.5 mg midazolam and 20 mg clorazepate dipotassium were similar after oral application. However, the anxiolytic effect of midazolam is shorter-lived than that of clorazepate dipotassium. In contrast to clorazepate dipotassium, midazolam produced no increase in arterial blood pressure and stabilized oral salivation, production in the palms, muscle tension and motoric restlessness.

The conversion of an "attempt to treat" to "prolongation of dying" represents an important problem in modern intensive care. If the actual or presumed will of the patient is unknown, the physician has to decide about the extent of treatment in a paternalistic manner. In these difficult decisions the physician has to consider prognosis, and certainty of prognosis and has to carefully balance between the right to live and the right to die. This decision about the extent of therapy is a very personal medical activity and can be taken off the physician's shoulders by nobody. Consultation with other physicians involved, relatives, nurses and clergy, however, is mandatory, as a joint decision should be sought. If the situation is hopeless and further medical interventions are futile, then allowing the patient to die by therapy reductions is not only a possibility but a mandatory act of humanity. In that case it does not matter whether new treatment modalities are abandoned or whether already instituted medical measures are withdrawn. In clinical practice, however, the "fine tuning" of therapy reduction has to be tailored to the individual case and largely depends on prognostic certainty.

The provision of separate rooms for the induction of anesthesia and the recovery phase is said to allow for a higher frequency of surgical procedures. However, the use of special rooms for the recovery phase is unnecessary from a practical and economic point of view. The availability of separate rooms for the induction of anesthesia may be important whenever the frequency of regional anesthesia is high. The induction of general anesthesia in low-risk patients can be performed in the operating room (OR) without too much delay between cases. Anesthesia in high-risk patients should be induced and reversed in the OR while problems of monitoring during transport remain unsolved.

Respiratory failure after smoke inhalation injury is usually preceded by a 12-48 h interval with only minor clinical symptoms. Since pulmonary lesions show a patchy distribution, it has been postulated that vasoconstriction in more severely damaged areas induces a shift of pulmonary blood flow to less severely damaged areas, minimizing venous admixture. This hypothesis was tested in a sheep model in which only one lung was exposed to smoke. Six chronically instrumented (arterial, central venous, pulmonary artery thermodilution, and left atrial catheters; ultrasonic transit time flow probe around the left pulmonary artery) range ewes were intubated with a modified Carlens tube under halothane anesthesia. Smoke from smoldering cotton was insufflated into the left lung until a carboxyhemoglobin level of 50% was achieved. After the smoking procedure, the animals were awakened, extubated, and studied for 24 h. During this time, the pulmonary vascular resistance of the left lungs increased fourfold while the pulmonary vascular resistance of both lungs only doubled. Left pulmonary artery blood flow decreased progressively to 37% of control at 24 h, while cardiac output decreased by only 25%. PaO2 decreased from 107 +/- 12 to 77 +/- 15 mmHg at 24 h. Mean pulmonary arterial pressure rose from 18 to 23 mmHg. Heart rate, mean arterial pressure, left atrial pressure, and PaCO2 showed no statistically significant changes. The results indicate that the response of the pulmonary vasculature to smoke inhalation injury is a two-phase phenomenon. In the first phase, vasoconstriction occurs to counterbalance injury-induced ventilation-perfusion mismatching.(ABSTRACT TRUNCATED AT 250 WORDS)

Propofol, in both its new oil-in-water emulsion and the former cremophor-EL solution, is known to produce significant decreases in arterial blood pressure. The aim of this study was to obtain a precise hemodynamic profile of anesthesia induction with propofol under conditions of daily routine (additional 70% nitrous oxide) and to evaluate the influence of (1) premedication with lormetazepam and (2) additional i.v. injection of fentanyl. Forty patients (ASA classes I and II) were randomly assigned to one of four groups (A, B, C, and D). Anesthesia was induced with a sleep dose of propofol (mean: 2.4 mg/kg) and the patient was ventilated with 30% O2 and 70% N2O via a face mask. In groups B and D, 3 micrograms/kg fentanyl were injected immediately prior to propofol injection. Patients in groups A and B received no premedication. Patients in groups C and D received 2 mg lormetazepam on the evening prior to the anesthetic and 1 mg 2 h prior to the anesthetic orally. The following parameters were determined immediately prior to induction of anesthesia and 1, 3, 5, 8, and 10 min after the start of the propofol injection: heart rate (HR), mean arterial blood pressure (MAP), mean pulmonary artery pressure (PAP), central venous pressure (CVP), pulmonary occlusion pressure (POP), cardiac output (CO), stroke volume (SV), and systemic vascular resistance (SVR). In all four groups a slight decrease in HR and SVR occurred while a marked decrease in arterial blood pressure (SAP, MAP, DAP) and cardiac output was seen. PAP and preload pressures showed no significant changes.(ABSTRACT TRUNCATED AT 250 WORDS)

Physical phenomena that occur during magnetic resonance imaging (MRI) and the position of the patient inside the scanning tube necessitate adaptations of anesthetic techniques and devices. An anesthesia unit is presented that operates in close proximity to the patient without interfering with the imaging process. This unit enables the anesthesiologist to be close to the patient and his equipment, and minimizes the length of necessary tubing between patient and anesthesia apparatus. The unit consists of commonly used, commercially available devices with only minor modifications.