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We are reporting on postoperative pain treatment using epidural analgesia in 1,822 patients, performed between 1995 to 2000, following continuous epidural anaesthesia combined with general anaesthesia for operations in various specialized areas (general or visceral surgery, vascular and thoraxic surgery, gynaecology, urology and orthopaedics). A total of 1,727 of these postoperative epidurals were included in a detailed evaluation. The postoperative epidural analgesia consisted of a continuous application of 0.25% bupivacain or 0.2% ropivacain. These local anaesthetics were administered epidurally in an hourly perfusion rate of 7.5 ml. We found "good" pain relief through continuous epidural administering of the local anaesthetics in 1,292 patients (74.8%). "Moderate" pain relief was achieved in 392 patients (22.7%). Sufentanil had to be epidurally administered in addition to local anaesthetics in 262 patients (15.2%) in the wake-up room. The sufentanil doses lay between 5 and a maximum 10 micrograms per hour. An additional epidural application of morphine-boli in a dose of 3 mg every 8-12 hours was necessary in 384 patients (22.2%) in the surgical wake-up stations. In 392 patients (22.7%), the additional systemic administering of antipyretic analgesics such as metamizol or paracetamol or spasmolytica was sufficient. In 43 cases (2.5%), sufficient pain relief could not be achieved with epidural analgesia even with additive applications of systemic functioning pharmaceuticals, so that the postoperative pain therapy had to be completely switched to a PCA. The lying time of the epidural catheter was 2-5 days. It was shortest with the gynaecological patients and longest with patients from general, visceral, thoraxic and vascular surgery areas. An important factor for a sufficient epidural analgesia is the exact epidural positioning of the catheter tip in the area of the spinal cord segments, which are affected by the operation. This reveals the required puncture height. The following side-effects resulting from the epidural analgesia were found: blood pressure loss of more than 20% of the starting value (21%), temporary bladder voiding disorders (8%), temporary sensory disorders of the lower extremities (6.5%), seldom nausea (2.4%) and post-puncture headaches (1.2%). The most important prerequisites for successful postoperative epidural analgesia and thus for increased patient satisfaction are correct selection of the insertion height in relation to the planned operation, constantly available medical pain service, the inclusion of trained care personnel and unequivocal written instructions.

Objective: Systems for direct retransfusion of blood salvaged from the surgical field and in drainage systems (direct autotransfusion) have been in use for many years. The quality of the blood obtained with such systems, however, has not been systemically assessed in a comparative manner. The aim of our study was the analysis of the quality of the blood, obtained with three commercially available direct autotransfusion systems (drainage systems with filters)., Methods: With ethics committee approval and informed consent, 30 patients receiving knee arthroplasty were randomly allocated to three groups. Each group of 10 patients received treatment with one drainage system (Consta Vac, Solcotrans, Haem-o-Trans). In the salvaged blood, we measured cellular elements, variables of coagulation and fibrinolysis, complement activation and cellular elements, both before and after passage of the autotransfusion system., Results: Analysis revealed a low haematokrit (< 30%) and platelet count (< 80 Gpt/l). The salvaged blood proved uncoagulable and defibrinised with no measurable clotting and fibrinogen; clotting activity, fibrinolysis and complement reaction were grossly induced (TAT, PAP and FDP high, C3 low). The blood was contaminated with cellular debris reflected by concentration of enzymes usually confined to the intracellular space (LDH, elastase, beta-thromboglobulin)., Conclusion: The systems/filters assessed in this study do not improve quality of blood drained from the surgical field. Retransfusion of such blood can not be recommended.

Objective: The use of latissimus-dorsi-flap with postoperative radiotherapy is method of choice in primary reconstruction of breast cancer. The efforts of radiotherapy on flap healing, cosmetic results and formation of edema in the arm were studied in 30 patients., Materials and Methods: 30 patients were followed in three to six months intervals clinically and sonographically (ATL-Ultramark 9, HDI)., Results: The most frequent symptom was a moderate edema. No healing problems or interference with cosmetic results were observed. Blood flow in the thoraco-dorsal vessels showed unchanged pre- and postoperatively., Conclusions: The complains might be the consequence of the combination of surgical dissection of the axilla, radiotherapy and possible additional factors such as trauma and overstress for example. Cosmetic result and healing seems to be impaired by 50 to 60 gy.

Based on our results and experiences, we consider the laryngeal mask anaesthesia a recommendable alternative to endotracheal intubation anaesthesia for adenotomies in children. Prerequisites with regard to the highest possible safety for the patient are specialist's knowledge, close anaesthesiological-otolaryngological cooperation and continuous clinical and apparative monitoring in order to detect possible accidental dislocations of the laryngeal mask without any delay. Using the laryngeal mask, disadvantages of endotracheal intubation, such as lesions of the vocal cords and damages to the tracheal mucous membrane can be avoided and the total time of narcosis can be reduced on average by about five minutes, particularly by shortening the recovery time of anaesthesia.

A therapy refractory brain edema is causally responsible for the death of approximately 50% of patients following severe craniocerebral trauma. The development of a brain edema which cannot be controlled by conservative means is also the most frequent cause of death with cerebral emergencies not caused by trauma. The cerebral perfusion pressure (CPP), which is the decisive factor for sufficient cerebral oxygenation, can be calculated on condition that the mean arterial pressure (MAP) and the intracranial pressure (ICP) are continually monitored: (CPP = MAP-ICP). On the basis of neurological observations, the computer tomographical results and the jugular vein oxymetry, an incipient cerebral decompensation and consequently the failure of the ongoing conservative treatment becomes apparent at an early stage. At this point at the latest, a bitemporal craniectomy should be considered for treatment. A drop in CPP to below 70 mmHg for adults and 50 mmHg for children is regarded as the intervention limits. Our experience shows that the outcome can be improved if the time of the bitemporal craniectomy lies before that of the cerebral decompensation.