Search

Administration of opioids to suppress pain plays a major role in modern anesthesia. Measuring depth of hypnosis and neuromuscular recovery are already well established, and devices for pain monitoring are available. Nonetheless pain monitoring is rare in clinical practice. Recently, the pain monitoring device PMD200 (Medasense Biometrics™ , Israel) was introduced. It non-invasively measures heart rate, heart rate variability, skin resistance, resistance variability, temperature and movement to calculate a nociception level (NoL) index. The NoL index range starts at zero, which is equivalent to being painless, and goes up to a value of 100. The validity and reliability of NoL monitoring is the content of current studies.We tested the hypothesis if the use of the PMD200 significantly reduces opioid consumption during da Vinci prostatectomy.A total of 50 male patients were included in this randomized, single blinded study. Exclusion criteria were arrhythmia because the pain monitoring device requires a sinus rhythm for reliable results. Patients received a weight-adjusted sufentanil bolus (0.3 µg/kg ideal body weight) during induction of anesthesia. Additionally, they received 10 µg of sufentanil before skin incision. Both groups received total intravenous anesthesia with propofol and continuous muscle relaxation through cis-atracurium. In the control group (CONT; n = 26), a standardized sufentanil bolus of 10 µg were administered by common criteria (heart rate/blood pressure increase, lacrimation, gut feeling) at the anesthesiologist's discretion. In the intervention group (INT; n = 24), patients received the standardized sufentanil bolus when the NoL index was above 25 for 2 min, which corresponds to the manufacturer's recommendation. The NoL index and bolus administrations were recorded for every patient. In the control group, the display of the pain monitor showing the NoL index was not visible for the anesthesiologist. Postoperatively, pain/nausea scores and piritramide consumption were taken every 10 min for 1h in the recovery room. None of the patients had prior chronic pain with long-term use of painkillers. Statistics were done using Mann-Whitney U‑test, Kolmogorov-Smirnov test and Levene test.Sufentanil bolus administrations, normalized for duration of surgery, were not significantly lower in the intervention group (p = 0.065). We noticed a significant difference in variation of opioid administrations (p = 0.033). Sufentanil boluses per hour in the INT were normally distributed (p = 0.2), whereas in CONT they were not (p = 0.003). Postoperative data like nausea, opioid consumption and pain scale showed no differences between groups.The use of PMD200 did not significantly reduce cumulative opioid consumption. Following on we must reject the initial hypothesis. The difference in sufentanil bolus variances may point to an individualized antinociceptive therapy when NoL monitoring is used. We suppose patients with high opioid demands are detected and patients with low opioid demands did not receive unnecessary opioids. This assumption is only true if the PMD200 measures the entity pain. Further studies with more participants during surgery with higher tissue damage could lead to more convincing data and conclusions.HINTERGRUND: Die Gabe von Opioiden zur Schmerzunterdrückung spielt eine zentrale Rolle in der modernen Anästhesiologie. Messungen von Hypnosetiefe und Muskelrelaxierung sind im Gegensatz zur Schmerzmessung seit Jahren etabliert. Seit Kurzem ist das PMD200 („Pain Monitoring System“; Fa. Medasense Biometrics™ Ltd., Ramat-Gan, Israel) verfügbar. Dieser Schmerzmonitor misst nichtinvasiv und errechnet einen dimensionslosen Schmerzindex („nociceptor level“, NoL). Die Validität und Zuverlässigkeit des Verfahrens sind Gegenstand von klinischen Studien.Reduziert die Verwendung des PMD200 die Gabe von Analgetika während einer Da-Vinci-Prostatektomie?In die Studie wurden 50 Patienten aufgenommen. Nach gewichtsadaptierter Sufentanilgabe zur Narkoseinduktion und einem 10 µg Bolus vor Hautschnitt erfolgte die intraoperative Analgesie durch subjektive Entscheidung (CONT) oder aufgrund eines erhöhten NoL-Index (INT). Die statistische Auswertung erfolgte durch Mann-Whitney-U-, Kolmogorow-Smirnow-Test und Levene-Statistik.In der INT-Gruppe war die Anzahl der Sufentanilboli/h nicht signifikant geringer als in der CONT-Gruppe (p = 0,065). Die Varianz der Sufentanilgaben unterschied sich signifikant (p = 0,033). In der CONT-Gruppe war die Applikation normal verteilt (p = 0,2), in der INT-Gruppe hingegen nicht (p = 0,003).Eine mögliche Interpretation der Daten ist, dass die Schmerzmittelgabe in der INT-Gruppe individualisierter erfolgte, d. h., es wurden nichterforderliche Schmerzmittelgaben vermieden, und gleichzeitig detektierte das NoL-Monitoring einzelne Patienten mit deutlich erhöhtem Schmerzmittelbedarf. Diese Schlussfolgerung ist nur unter der Voraussetzung zulässig, dass das PMD200 auch tatsächlich die Entität Schmerz misst.

Zusammenfassung: Fentanyl und Sufentanil sind zwei synthetisch hergestellte Opioide, die in der Anästhesiologie für die intraoperative Analgesie eingesetzt werden. Sie weisen ein unterschiedliches pharmakodynamisches Profil auf. Im Jahr 2014 wurde das Opioidregime für minimal-invasive Standardeingriffe im Klinikum Fulda von Fentanyl auf Sufentanil umgestellt. In der geplanten retrospektiven Datenerhebung sollten Daten von Patienten, die vor 2014 mit Fentanyl analgesiert wurden, verglichen werden mit Daten von Patienten, bei denen nach 2014 Sufentanil in die Narkoseführung implementiert war. Untersucht werden sollte, ob der Wechsel auf ein Opioid mit einem vermeintlich geeigneteren Profil für die Narkoseführung tatsächlich die kalkulierten Vorteile erbracht hat. Die retrospektive Datenerhebung sollte aufzeigen, ob Patienten während und nach MIC-CHE oder MIC-TEP von einer Sufentanil-Gabe gegenüber der Fentanyl-Gabe profitieren: Verkürzt sich die Ausleitungsphase, haben die Patienten bei Ankunft im Aufwachraum (AWR) eine bessere Oxygenierung und/oder eine stabilere Kreislaufsituation? Leiden die Patienten nach Sufentanil unter weniger postoperativer Übelkeit und Erbrechen (PONV), benötigen sie weniger Schmerzmittel? Die Untersuchung sollte zudem klären, ob biometrische Faktoren wie Geschlecht, Alter, Gewicht und BMI in Zusammenhang mit dem eingesetzten Opioid eine relevante Rolle für das postoperative Befinden der Patienten spielten, und ob sich aus der Umstellung von Fentanyl auf Sufentanil ökonomische Vorteile ergaben. Ergebnis: Kombination Desfluran mit Sufentanil für alle untersuchten Gruppen von klinischem Vorteil. Bevorzugter Einsatz bei MIC-Eingriffen in der Allgemein- und Viszeralchirurgie empfehlenswert. - Geringerer postoperativer Schmerzmittelbedarf - Bessere postoperative Oxygenierung - Kürzere postoperative Aufwachzeit - Niedrigerer intraoperativer Opioidbedarf - Wirtschaftlich/ökonomische Gleichwert Begründete Aussage, dass Sufentanil bei MIC-Eingriffen in der Allgemein- und Viszeralchirurgie im Vergleich zu Fentanyl das überlegene Medikament ist. (überwiegend statistisch signifikant) Steigerung dieses Effekts über die Kombination mit Desfluran möglich., Summary: Fentanyl and sufentanil are two synthetically produced opioids that are used in anesthesiology for intraoperative analgesia. They have a different pharmacodynamic profile. In 2014, the opioid regime for minimally invasive standard interventions at the clinic in Fulda was changed from fentanyl to sufentanil. In the planned retrospective data collection, data from patients who were analgesized with fentanyl before 2014 should be compared with data from patients in whom sufentanil was implemented in anesthesia after 2014. It should be investigated whether the change to an opioid with a supposedly more suitable profile for anesthesia has actually produced the calculated benefits. The retrospective data collection should show whether patients benefit from administration of sufentanil compared to administration of fentanyl during and after MIC-CHE or MIC-TEP: Shorter elimination phase? Better oxygenation-situation on arrival in the recovery room or a more stable circulatory situation? Do the patients suffer less postoperative nausea and vomiting (PONV) after sufentanil, do they need less pain-medication? The investigation should also clarify whether biometric factors such as gender, age, weight and BMI in connection with the opioid used to play an important role in the postoperative condition of the examined patients and whether there were any economic benefits in switching from fentanyl to sufentanil. Result: The combination of desflurane with sufentanil was of clinical advantage for all examined groups. Recommended for use in MIC- operations in visceral surgery. - Less need for post-operative pain medication - Better post-operative oxygenation - Shorter post-operative wake-up time - Lower intraoperative opioid requirement - Economic / economic equivalence Well-founded statement that sufentanil is the superior drug compared to fentanyl in MIC-procedures in visceral surgery. (mostly statistically significant) This effect can be increased by combining it with desflurane.

Fragestellung: Das Management starker postoperativer Schmerzen nach operativen Eingriffen in der Orthopädie/Traumatologie stellt eine besondere Herausforderung dar. Regelhaft ist eine Frühmobilisation für ein optimales Rehabilitationsergebnis gefordert. Seit Kurzem steht als innovatives[zum vollständigen Text gelangen Sie über die oben angegebene URL], Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2019)

Vergleich dreier Narkosetiefemonitore: AEP Monitor /2, BIS Vista und Narcotrend-Compact Monitor Version 4.0 unter Target-Controlled Infusion mit Propofol und Sufentanil 1 Zusammenfassung Um die Narkosetiefe von Patienten einzuschätzen, stehen für den klinischen Einsatz verschiedene Narkosetiefemonitore zur Verfügung. Das Ziel der vorliegenden Arbeit war, AEP Monitor /2 (er berechnet den composite Alaris AEP Index, cAAI), BIS Vista (er berechnet den Bispectral Index, BIS) und Narcotrend-Compact (er errechnet den Narcotrend Index) miteinander zu vergleichen. Durchgeführt wurde der Vergleich unter Effect-Site Target-Controlled Infusion von Propofol und Sufentanil. In die Studie eingeschlossen wurden 60 Patienten, die in drei Gruppen zu jeweils 20 aufgeteilt wurden. Die Gruppen unterschieden sich in der verabreichten Dosis von Sufentanil. Es zeigte sich, dass BIS die Narkosetiefe am genauesten abbildet, gefolgt vom Narcotrend Index, der dem cAAI noch überlegen war. Der Narcotrend-Compact Monitor hatte in der Studie die längsten Ausfallzeiten, Zeitspannen während derer keine Werte auf dem Bildschirm angezeigt wurden. Ferner zeigte sich, dass Sufentanil die Messgenauigkeit der verglichenen drei Narkosetiefemonitore nicht beeinflusst. Ergänzend wurde untersucht, ob von der Propofol-Effect-Site-Konzentration auf die klinische Sedierungstiefe, ermittelt mit Hilfe der „Observer’s Assessment of Alertness and Sedation“-Skala (OAA/S), geschlossen werden kann. Ein eindeutiger Zusammenhang konnte anhand der Daten aus dieser Studie nicht abgeleitet werden. Comparison of three monitors of depth of anaesthesia: AEP Monitor /2, BIS Vista and Narcotrend-Compact Version 4.0 under target-controlled infusion of propofol and sufentanil Summary When seeking to assess a patient’s level of sedation, clinicians face the choice of a number of different monitors of anaesthetic depth. The objective of this study was to compare AEP Monitor /2 (computing Alaris AEP Index, AAI), BIS Vista (computing Bispectral Index, BIS) and Narcotrend-Compact (computing Narcotrend Index). The comparison was performed under effect-site target-controlled infusion of propofol and sufentanil. The study comprised 60 patients who were allocated to three groups of 20. The groups differed in the effect-site concentrations of sufentanil. We found that BIS is the most accurate of the three indices at predicting levels of sedation, followed by Narcotrend Index, which proved to be still more accurate than AAI. Narcotrend- Compact proved to have the most outage time, i.e. periods in which no index values were displayed on the screen. In addition, we found that sufentanil does not influence the accuracy of the prediction of sedation levels of these three monitors. In addition, we investigated whether propofol effect-site concentration hints at the clinical depth of sedation, measured with the „Observer’s Assessment of Alertness and Sedation“ scale (OAA/S). A definite correlation could not be demonstrated on the basis of the data at hand.

Die Spinalanästhesie (SpA) gilt als Goldstandard zur Analgesie bei Kaiserschnittentbindungen. Im Rahmen der vorliegenden Arbeit sollte der Einfluss von subarachnoidal verabreichten Opioiden auf die intra- und postoperative Analgesiedauer & auf Nebenwirkungen bei Mutter & Neugeborenem untersucht werden. Es wurden 75 Patientinnen, die sich einer elektiven Sectio caesarea unter SpA mit Verwendung von 2 ml Bupivacain 0,5% isobar kombiniert mit 5\(\mu\)g Sufentanil, 100\(\mu\)g oder 200\(\mu\)g Morphin, untersucht. Anhand der Qualitätssicherungsdaten wurde der Zeitraum bis zur ersten Schmerzmittelanforderung, die postoperative Analgetikadosis sowie die Häufigkeit & Schwere von intra- & postoperativen Nebenwirkungen verglichen. Die Verwendung von 200\(\mu\)g Morphin führte zu einer signifikanten Verlängerung der postoperativen Analgesiedauer & Anstieg von postoperativer Übelkeit & Erbrechen. Die Verwendung von 200\(\mu\)g Morphin geht mit einer signifikanten Verbesserung der postoperativen Analgesiequalität einher.

Opioide stellen eine wichtige Säule der perioperativen Analgesie dar. Zunehmend wird das Vorhandensein pronozizeptiver Effekte diskutiert und untersucht. Die opioidinduzierte Hyperalgesie beschreibt die paradoxe Reaktion, bei der es nach einer zunächst vorliegenden Analgesie zu abgesenkten Schmerzschwellen und einem erhöhten postoperativen Schmerzmittelbedarf kommen kann. 16 Patientinnen wurden vor und 24 Stunden nach einer Segmentresektion der Mamma mittels Quantitativ Sensorischer Testung nach dem Protokoll des Deutschen Forschungsverbundes Neuropathischer Schmerz (DFNS) untersucht. Zwei verschiedene Anästhesieverfahren kamen zum Einsatz: Acht Patientinnen erhielten Sufentanil (0,25 µg × kg-1 initial, ggf. 0,15 µg × kg-1 Repetition nach 60 min), die andere Hälfte Remifentanil (0,4 µg × kg-1 × min-1). Die Aufrechterhaltung der Narkose erfolgte durch Propofol. Zur postoperativen Analgesie wurde bereits intraoperativ 1 g Paracetamol infundiert und anschließend die Gabe alle sechs Stunden wiederholt mit einer maximalen Tagesdosis von 3 g. Das untersuchte Areal der QST befand sich im Dermatom Th 5 auf der mittleren Axillarlinie beidseitig, auf der operierten sowie zum Vergleich auf der kontralateralen Seite. Im Vergleich zu gesunden Probanden traten pathologische QST-Werte weder präoperativ noch postoperativ signifikant häufiger in einer der beiden Gruppen auf. Mit Hilfe des Wilcoxon-Tests bzw. des Mann-Whitney-U-Tests konnten keine signifikanten Unterschiede zwischen den QST-Parametern im Intra- bzw. Intergruppenvergleich nachgewiesen werden. Lediglich in der Sufentanil-Gruppe zeigte sich ein Trend zur Entwicklung einer Hypästhesie in den thermischen und Vibrationsschwellen. Somit konnte 24 Stunden nach der durchgeführten Operation weder für die intraoperative Einnahme von Remifentanil noch von Sufentanil eine Veränderung des QST-Profils nachgewiesen werden. Insbesondere unter Remifentanil zeigte sich keine Entstehung einer opioidinduzierten Hyperalgesie.

Before the clinical diagnosis of brain death is made, toxicological analyses are often performed for the exclusion of effective serum levels of previously applied sedating drugs. For propofol and sufentanil there are no uniform recommendations for the usage of toxicology test results.To develop a standard practice in the diagnosis of brain death after therapeutic application of one of these drugs.Based on the current literature and the available analytical assays, an ad hoc working group consisting of specialists in toxicology and intensive care medicine compiled recommendations for the usage of toxicological analytics in the diagnosis of brain death at the Rostock University Hospital.For propofol, current analytical assays allow the quantification of serum concentrations of 0.2 μg/ml and lower; the execution of clinical brain death diagnostics is recommended by the ad hoc group only at propofol serum levels lower than 0.4 μg/ml. For sufentanil, the currently prevalent assays set lower determination limits of about 0.2 ng/ml in serum and 0.1 ng/ml in urine, which is above the cautiously adopted lower therapeutic serum concentration of 0.02 ng/ml. Therefore after negative determination of sufentanil ( 0.2 ng/ml) in blood serum, the following alternative procedures are recommended: (1) the execution of clinical brain death diagnostics under administration of naloxone; or (2) at intact renal function the additional negative determination of sufentanil in urine ( 0.1 ng/ml). If an assay allowing the detection of sufentanil at ≤ 0.01 ng/ml is available, brain death diagnostics should be carried out only at a serum level lower than 0.02 ng/ml.These recommendations may serve as a proposal for similar standards in other hospitals.

Background Despite well-designed concepts of perioperative pain management, recent studies have revealed that a large number of patients still suffer from unacceptable pain after surgery. The purpose of this prospective evaluation was to critically analyze postoperative pain treatment provided by a routinely established, DIN certified acute pain service (APS) at the University Hospital Groshadern in Munich. Materials and methods A total of 1,000 consecutive patients received one of the following analgesic procedures: continuous epidural analgesia (EA, n = 401), continuous and patient-controlled epidural analgesia (PCEA, n = 305), intravenous patient-controlled analgesia with opioids (PCA, n = 169) or continuous peripheral nerve block (CPNB, n = 125). For EA and PCEA, ropivacaine 0.2 % and sufentanil 0.24 µg/ml were administered while peripheral regional analgesia was performed with infusion of ropivacaine 0.2 % only. Patients with PCEA were allowed a 3 mg bolus once per hour on demand. Standardized intravenous PCA was performed with piritramide 2.5 mg/ml, a bolus of 2.5 mg, a lock-out time of 15 min, a maximum of 25 mg/4 h and no background infusion. During the daily visits the APS assessed pain intensity at rest and during movement on a numerical rating scale from 0 (no pain) to 10 (maximum pain), acceptance of pain, satisfaction with the analgesic procedure, demand of additional non-opioid analgesics, the need for optimization including bolus applications and changes of the infusion rate or retraction of the epidural catheter. The duration of the procedures, side effects and complications were documented. The catheter insertion sites were inspected daily for redness and tenderness on palpation. Results In general, epidural and peripheral regional analgesic techniques were superior in terms of postoperative analgesia to intravenous opioid PCA and were associated with fewer side effects, such as sedation, nausea, vomiting, obstipation and sensorimotor deficits. A subgroup analysis revealed that in major upper abdominal surgery, EA provided significantly better analgesia at rest and during movement than PCA. In lower abdominal surgery PCEA induced significantly better analgesia than both PCA and EA, especially during movement. Patient satisfaction was generally high and was best with PCEA (95 %) followed by CPNB (94 %), EA (91 %) and PCA (88 %). On the first postoperative day analgesic procedures had to be optimized (e.g. by bolus administration, retraction of catheters or changes to standardized PCA) in 23 % of EA patients, 10 % of PCEA patients, 6 % of PCA patients and 12 % of CPNB patients. Major complications, such as neuraxial hematoma, infections or respiratory depression were not observed. Conclusions As described in many prospective studies, this evaluation revealed that for postoperative pain control, regional anesthesia is superior to intravenous patient-controlled analgesia with strong opioids in terms of analgesia and side effects. In the setting of a well-organized acute pain service with frequent education and training of all members involved, postoperative pain management is safe and effective. However, regular re-evaluation of the defined and certified procedures is necessary.

Treatment of cancer pain includes invasive techniques of pain therapy if necessary. Here we report the management of a 55-year-old female patient with penetrating rectal cancer using continuous lumbal epidural anesthesia. After placement and dose-finding our patient was discharged from hospital and further treatment occurred at home.

Die Epiduralanalgesie hat sich in den letzten Jahren bei thoraxchirurgischen und abdominalchirurgischen Eingriffen als postoperative Schmerztherapie etabliert. Trotzdem gibt es bis heute keine allgemeingültige Dosisempfehlung von Sufentanil in Kombination mit 0,2%igen Ropivacain zur epiduralen Anwendung. Ziel der vorliegenden Arbeit war es, zu untersuchen, ob die höhere Dosierung an Sufentanil (1,0µg/ml versus 0,5µg/ml) eine effizientere postoperative Schmerztherapie bieten kann und welche der beiden Schmerzmittellösungen einen höheren Bedarf an Zusatzmedikation fordert. Insgesamt wurden dafür die Daten von 1000 Patienten ausgewertet, die zwischen Januar 2005 bis September 2007 vom Akutschmerzdienst der Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin der Charité – Universitätsmedizin betreut wurden. Die Patienten wurden dazu in zwei Gruppen eingeteilt: • Gruppe 1 (n=500): Patienten, bei denen der Epiduralkatheter mit einer Dosis von 0,2% Ropivacain und 1,0 Sufentanil zugesetzt wurde. • Gruppe 2 (n=500): Patienten, bei denen der Epiduralkatheter mit einer Dosierung von 0,2% Ropivacain und 0,5 Sufentanildosis bestückt wurde. Alle Patienten wurden aufgrund eines abdominalchirurgischen oder thoraxchirurgischen Eingriffs zur postoperativen Schmerztherapie mit einem thorakalen Epiduralkatheter versorgt. Zur Einschätzung der Effekte der unterschiedlichen Sufentanildosen wurden Daten der präoperativen Visite, die Narkoseprotokolle, die Katheteranlage- Protokolle, die Ver-laufsdokumentationen und die NRS-Überwachungsbögen analysiert. Insgesamt wurden 102 Thoraxoperationen und 892 Ober- und Mittelbauchoperationen erfasst. Zur Erfassung der Effizienz der Schmerztherapie wurden die numerische Ratingskala (NRS), der kumulative Schmerzmittelbedarf an dem Ropivacain/Sufentanil-Lösung, die geforderten und erhaltenen Patientenboli sowie die Menge an Zusatzanalgetika ermittelt. Zusätzlich wurden die Nebenwirkungen Übelkeit, Erbrechen, Pruritus, Atemdepression, neurologische Schäden und epidurale Infektionen erfasst. Der Beobachtungszeitraum erstreckte sich über acht postoperative Tage. Insgesamt waren die Patienten mit beiden Verfahren suffizient analgesiert. In der Gruppe 1 lagen die durchschnittlichen Schmerzangaben in Ruhe bei 0,72 und in Belastung bei 2,3 auf der NRS-Skala. Die mittlere Schmerzselbsteinschätzung der Patientengruppe 2 lag in Ruhe bei 1,53 und in Belastung bei 3,14 auf der NRS-Skala und damit signifikant höher als in der Gruppe 1. Beim Ropivacain- Sufentanil-Verbrauch zeigte sich auch ein deutlich signifikanter Gruppenunterschied. Die über den Beobachtungszeitraum verabreichte Durchschnittsmenge an Ropivacain-Sufentanillösung lag in der Gruppe 1 bei 716ml pro Patient und in der Gruppe 2 bei 1191ml pro Patient. Außerdem benötigte die Patientengruppe 2 einen wesentlich höheren Bedarf an Zusatzmedikation (34,9% mehr als in Gruppe 2). Dafür traten in der Gruppe 1 signifikant häufiger unerwünschte Nebenwirkungen auf. Übelkeit und Erbrechen waren in der Gruppe 1 bei 10% der Patienten, in der Gruppe 2 bei 8% zu beobachten. Das Auftreten von Pruritus wurde mit einer Inzidenz von 10,4% in der Gruppe 1 und von 4,4% in der Gruppe 2 ermittelt. Als Ergebnis dieser Arbeit kann abschließend folgendes resümiert werden: • Die epidurale postoperativen Schmerztherapie in der Dosierung Ropivacain 0,2% plus 1µg/ml Sufentanil ist der Dosierung Ropivacain 0,2% plus 0,5µg/ml Sufentanil überlegen. • Bei Patienten mit einer bekannten Neigung zu Übelkeit, Erbrechen und erhöhter Allergiedisposition sollte wegen der höheren Konzentrationen an Sufentanil der prophylaktische Einsatz von Antiemetika und Antihistaminika erwogen werden., Combining an opioid with peridural localanalgesia is an excellent technique to control post-operative pain. Sufentanil is a widely used opiod agent, but its optimal dosage has not yet been defined. In this study we wanted to determine the best dose of epidural sufentanil in major surgery.

Friedreich's ataxia (FA) is a hereditary disease, which leads to degenerative changes in the spinal cord and cerebellum (incidence 1:50,000). These changes are caused by a defect in the gene that encodes a mitochondrial gene called frataxin and causes muscle weakness, scoliosis, cardiomyopathy and impaired glucose tolerance. Therefore, these patients require special care during anaesthesia. We report the case of a 25-year-old primigravida with a history of FA and dorsal stabilisation of the vertebral column, who was admitted to our hospital for elective caesarean section. Due to increased sensitivity to muscle relaxants, peridural anaesthesia with 8 ml 0.75% ropivacaine and 10 microg sufentanil was used in this case. The perioperative neurological consultation revealed no undue exacerbation of symptoms.

In November 2005 a complex, multimodal anesthesia fast-track protocol (FTP) was introduced for elective cardiac surgery patients in the Cardiac Center of the University of Leipzig which included changing from an opioid regime to remifentanil and postoperative treatment in a special post-anesthesia recovery and care unit. The goal was to speed up recovery times while maintaining safety and improving costs.A total of 421 patients who underwent the FTP and were treated in the special recovery room were analyzed retrospectively. These patients were compared with patients who had been treated by a standard protocol (SP) prior to instituting the FTP. Primary outcomes were time to extubation, length of stay in the intensive care unit (ICU) and treatment costs.The times to extubation were significantly shorter in the FTP group with 75 min (range 45-110 min) compared to 900 min (range 600-1140 min) in the SP group. Intensive care unit stay and hospital length of stay were also significantly shorter in the FTP group (p0.01). The reduction of treatment costs of intensive care for FTP patients was 53.5% corresponding to savings of EUR 738 per patient in the FTP group compared with the SP group.The Leipzig fast-track protocol for cardio-anesthesia including the central elements of switching opiate therapy to remifentanil and switching patient recovery to a special post-anesthesia recovery and care unit, shortened therapy times, is safe and economically effective.

OBJECTIVES: Data of 248 patients who underwent percutaneous dilatational tracheostomy (PDT) from 2003 to 2006 were analysed retrospectively. Main interests were to determine how many and when patients were treated, what differences existed in demographical data, preexisting conditions and main illness between the early (< or = 7 days) and the late (> 7 days) tracheostomy group, also, to determine clinical outcome early vs. late and sedative and noradrenaline administration before vs. after PDT. METHODS: Data were derived from an internal and a clinic-wide database, patient charts and doctor´s letters. Parameters were defined and analysed. Where reasonable, statistical tests were performed. RESULTS: The percentage of ICU patients undergoing PDT rose from 9.9 % in 2003 to 12.8 % in 2006. Median time from ICU admission to PDT was 7 days. Patients admitted for general surgery were significantly more common in the late group (41 vs. 24 %), neurosurgical patients in the early group (28 vs. 12 %). The late group was significantly more severely diseased measured by SAPS II. Other data did not correlate with timing of PDT. ICU stay was significantly shorter for the early group (17 days vs. 29 days late, median), while mortality, complication rates, number of re-dilatations and number of patients discharged with or without tracheal cannula, did not significantly differ. Doses of propofol, midazolam, sufentanil and noradrenaline (norepinephrine) compared 3 days before PDT to 3 days after were significantly reduced. DISCUSSION: Patients profited by early PDT which was reflected in a shorter ICU stay. After PDT, medication could be significantly reduced. Therefore, a common effect of reduced sedation, catecholamine administration and accelerated weaning from MV could possibly explain the shorter ICU stay. Some parameters were distributed inhomogeneously, which is why further studies are needed to find predictors for who will profit more by early PDT and who will less.

A multimodal perioperative therapy strategy (fast-track) decreases the morbidity of general thoracic interventions and increases postoperative reconvalescence after lung resections. Thoracic surgery is associated with relevant pain and sufficient pain relief is essential for postoperative recovery. Epidural analgesia leads to adequate pain control with only minor side effects and complications and can therefore be a reasonable supplementation in a modern fast-track setting. The purpose of this study was to evaluate the benefits and risks of an epidural catheter placed prior to surgery and to analyse the postoperative recovery of patients undergoing thoracic surgery.277 patients undergoing pulmonary resection through an anterolateral thoracotomy were included in our study. Epidural analgesia was carried out through placement of an epidural catheter equipped with Naropine-Sufenta perfusor prior to surgery. Perioperative clinical parameters as well as postoperative management were evaluated. Pain intensity was documented using the visual analogue scale (VAS). Side effects and complications were summarised in five grades of severity (1-5). Insufficient pain relief was recognised when a VAS4 was registered.Median patient age was 59 years, the male / female relation was precisely 2 : 1, on average epidural analgesia was carried out for 4.9 days. Severe complications (grade 4 or 5) were not found. In 37 % of the cases, minor complications and side effects were found, in 1 % clinical relevant complications led to further diagnostic measures. For sufficient pain relief, 10 % of the studied population needed additional treatment with systemic opioids.We have shown that epidural analgesia in patients undergoing thoracotomy leads to sufficient pain control with only minor disadvantages and complications. These are easily mastered without expensive diagnostic or therapeutic interventions. Therefore, epidural analgesia is a safe and helpful tool for increased postoperative recovery within a modern fast-track setting.

Das Ziel der vorgelegten Studie war es, die klinische Durchführbarkeit und das Management einer TIVA mit Propofol und Ketamin anhand der eventuell auftretenden Nebenwirkungen mit einer Standard-TIVA aus Propofol und Sufentanil zu vergleichen. Hierzu wurden 120 Patienten (n=120) der ASA-Gruppen I-III, die sich im Bezug auf die demographische Zusammensetzung, Alter, Körpergröße und Gewicht nicht unterschieden, randomisiert einer der beiden Untersuchungsgruppen zugeordnet und erhielten während ihres operativen Eingriffs entweder eine TIVA aus Propofol/Ketamin (Gruppe A) oder eine TIVA aus Propofol/Sufentanil (Gruppe B). Die Patienten aus Gruppe A berichteten zwar häufiger über Traumerlebnisse als die Patienten aus Gruppe B, jedoch waren diese Träume nicht häufiger negativ besetzt, die Akzeptanz des Narkoseverfahrens war in beiden Gruppen gut und gleich hoch. Die intraoperative Steuerbarkeit beider Narkoseverfahren unterschied sich zwar in der häufigeren Notwendigkeit der antihypotensiven Intervention in Gruppe B, jedoch lag der Unterschied letztlich im nichtsignifikanten Niveau. Hinsichtlich der Wiederherstellung der kognitiven Fähigkeiten und der Verlegbarkeit aus dem Aufwachraum unterschieden sich beide Gruppen nicht. Bei einem vergleichbaren Ausgangsrisiko für PONV berechnet nach dem Apfel- Score, traten Übelkeit und Erbrechen in Gruppe A seltener auf, legt man den Schweregrad der Ausprägung zugrunde, zeigte sich eine Signifikanz auf dem 2%-Level (p=0,016). Ketamin reduziert somit im Vergleich zu Sufentanil wirkungsvoll die Inzidenz von PONV. Der postoperative Schmerzmittelbedarf lag in der Ketamingruppe niedriger, war jedoch nicht signifikant unterschiedlich (p=0,18). Die Kombination aus Propofol/Ketamin ist im Bezug auf die erzielte Analgesie als gleichwertig anzusehen und bei verbessertem Nebenwirkungsprofil für Patienten zu empfehlen, bei denen Opiate vermieden werden müssen. Gleichzeitig stabilisiert die Kombination aus Propofol und Ketamin die Kreislaufsituation während der Narkose und kann somit auch für Patienten empfohlen werden, die eine eher hypotone Kreislaufsituation aufweisen., The aim of this study was to compare the clinical feasibility and the management of a TIVA with Propofol and Ketamine with a standard TIVA from Propofol and Sufentanil by means of the incidence of side effects. 120 patients of the ASA-groups I-III, comparable with respect to demographic and biometric data were randomly assigned to one of the two studied groups. During the operation they were given a TIVA using Propofol and Ketamine (group A) or a TIVA with Propofol and Sufentanil (group B). Although the patients of group A dreamt more than the patients of group B, these dreams were not more negative; the acceptance of the anesthesia was good and equally high in both groups. Although the intraoperative control of both anaesthesias differed in the frequent necessity of antihypotensive intervention in group B, the difference was only marginal. The return of the cognitive ability and the move from the wake-up-room up to the station in an equally fast and good way did not differ between the two groups. Despite a comparable baseline risk for PONV, nausea and vomiting was more seldom in group A, taking as a basis the impact of PONV there was significance on the 2 percent-level (p=0,016). In this way Ketamine reduces efficiently the impact of postoperative nausea and vomiting compared with Sufentanil. The need for postoperative pain killers was lower in the Ketamine group, but it did not reach statistical significance (p=0,18). Nonetheless these results show that the combination of Propofol and Ketamine in regard to the pain therapy can be regarded as equal. With the same side effects it can be recommended to patients who have to avoid opioids. At the same time the combination of Propofol and Ketamine stabilizes the blood circulation during the anesthesia and can therefore be recommended to patients who have a low blood pressure.

Fast-track rehabilitation after elective colon resection is an interdisciplinary multimodal procedure, which combines surgical and anesthesiological aspects. This leads to an improved and accelerated recovery and avoids perioperative complications. This survey focuses on the extent and use of such concepts in Germany.In January 2006, a questionnaire was sent to 1270 anesthesiology departments in Germany in which they were asked to describe the standard anesthesia procedures based on a conventional sigmoid resection.The response rate was 385 out of 1270 (30.3%). Preoperative fasting of solid food 12 h before the operation was practiced in 52% and for 6 h in 44% of the clinics. For fluid intake the fasting time was 6 h in 47% and 2 h in 41%. Prophylactic measures for postoperative nausea and vomiting (PONV) were administered in 33% of clinics. Propofol (68%) was the leading narcotic, fentanyl (56%) and sufentanil (48%) were the most commonly used intraoperative analgesics and 75% of clinics used epidural analgesia.In Germany the anesthesiological treatment after elective colon surgery adheres broadly to the evidence-based recommendations for fast-track concepts.

Fragestellung: Vergleich der CSA mit der CSE bezüglich der Qualität der postop. Analgesie sowie Inzidenz der Nebenwirkungen. Methode: Von 74 Patienten, die sich einer Hüftgelenksimplantation unterzogen, erhielt Gruppe A postop. eine CSA mit 10 ml Bupivacain 0,25 %/24h, Gruppe B eine CSE mit 40 ml Bupivacain 0,25 % und 5 ml Sufenta mite 10 (25 ug) 4 ml/h. Die Effektivität der Analgesie wurde anhand eines Schmerzfragebogens erfasst, Nebenwirkungen/Komplikationen dokumentiert. Ergebnis: Am OP-Tag und am 1. postop. Tag zeigte die Auswertung des Fragebogens ein signifikant niedrigeres Schmerzniveau bei CSE. Fazit: Die CSE und die CSA erwiesen sich als sichere Verfahren. Die CSE war am OP-Tag und 1. postop. Tag das effektivere Verfahren.

In dieser prospektiven, konsekutiven klinischen Studie mit 63 Patienten (ASA I – III) wurde die Anwendung der einseitigen Spinalanästhesie untersucht. 4,0 mg Bupivacain 0,5% hyperbar und 1,0 µg Sufentanil wurden in Seitenlage gleichmäßig über drei Minuten injiziert, die anschließende Seitenlagerungszeit betrug zehn Minuten. Es wurde prä- und postoperativ seitengetrennt der sensorische und motorische Blockadeverlauf erfasst. Ebenfalls ausgewertet wurde das Auftreten von spinalanästhesietypischen Nebenwirkungen. Die Auswertung der gewonnenen Daten ergab, dass die maximale Höhe der sensorischen Blockade auf der operierten Körperseite nach 12 + 2 (9 – 20) Minuten erreicht wurde und im Mittel Th10 (L1 – Th7) betrug. Alle Patienten konnten als OP-fähig erklärt werden. Die motorische Blockade erreichte Stufe 1 – 3 nach Bromage und bildete sich binnen 110 + 16 (50 – 150) Minuten vollständig zurück. Die Regression der sensorischen Blockade auf das L3-Niveau erfolgte nach 130 + 16 (80 – 190) Minuten, die vollständige Rückbildung der Blockade (S2-Regression) nach 180 + 13 (130 – 210) Minuten. Bei 22,2% der Patienten kam es zu einem objektiv feststellbaren kontralateralen Übertritt der sensorischen Blockade, der von nur 3,2% der Patienten subjektiv bemerkt wurde. In einem Fall kam es zum Übertritt des motorischen Blocks. Bei einer Patientin wurde eine Kreislaufinstabilität nach Studienvorgabe dokumentiert, wobei keine Kausalität zur Spinalanästhesie bestand. Acht Patienten (12,6%) klagten über einen flüchtigen Pruritus. Übelkeit, Erbrechen, Kopfschmerzen oder ausstrahlende Rückenschmerzen traten bei keinem Patienten auf. Alle Patienten und Operateure waren mit dem Anästhesieverfahren zufrieden. Die Ergebnisse der Studie zeigen, dass die einseitige Spinalanästhesie eine sichere und gut kalkulierbare Anästhesiemethode ist. In this prospective, consecutive clinical study including 63 patients (ASA I – III) we investigated the effects of unilateral spinal anaesthesia. 4.0 mg hyperbaric bupivacaine 0.5% and 1.0 µg sufentanil was injected into the subarachnoid space in the lateral position over a period of three minutes. The patients were returned to the supine position 10 minutes after the injection. The onset and offset of sensor and motor block was monitored separately for each side of the body. We also documented anesthaesia-associated side effects. Data analysis demonstrated that the mean maximum height of the sensory block of the operating side was Th10 (L1 – Th7) and was reached after 12 + 2 (9 – 20) minutes. All patients received sufficient anaesthesia for the planned operation. The motor block came to Bromage-level 1 – 3 and disappeared within 110 + 16 (50 – 150) minutes. The regression of the sensory block down to Level L3 took 130 + 16 (80 – 190) minutes and 180 + 13 (130 – 210) minutes down to level S2 (complete regression), respectively. In 22.2% of the patients we found an objective measurable involvement of the contralateral side which was noticed by only 3.2 % of our patients. Motor block of the nonoperated side occurred only in one case. One female patient had a significant bradycardia which was not attributed to the anaesthetic procedure. Eight patients (12.6%) complained of pruritus. We did not detect any nausea, vomiting, headaches or backache in any of our cases. All patients and surgeons were satisfied with the quality of anaesthesia provided. Our study shows that unilateral spinal anaesthesia is save, predictable and reliable.

The management of tumor-related pain, particularly that which is neuropathic in origin, is both difficult and challenging. According to WHO guidelines, opioids are the first-line analgesics in case of severe tumor-related pain syndromes. Some patients receiving continuous opioid therapy rapidly require increase of the opioid dose. In this case it can be necessary to extend the analgesic regime and to either apply interventional procedures or change the opioid or the route of administration. The case presented is remarkable regarding the severity and persistent nature of the patient's pain despite a variety of commonly employed treatments.

Zwei Verfahren zur Schmerztherapie nach geplanter Sectio caesarea wurden hinsichtlich Analgesiequalität, Nebenwirkungen und Patientinnenzufriedenheit verglichen. Alle Patientinnen erhielten zur Sectio eine Spinalanästhesie mit Bupivacain. 25 Patientinnen erhielten postoperativ eine kontinuierliche intravenöse Novaminsulfoninfusion und bei Bedarf Piritramid intramuskulär (SPA-Gruppe). Die anderen 25 Patientinnen erhielten postoperativ eine kontinuierliche patienten-kontrollierte Epiduralanalgesie mit Bupivacain und Sufentanil und bei Bedarf Boli der Mischung (CSE-Gruppe). Die Schmerzquantität in Ruhe und beim Husten war signifikant niedriger in der CSE-Gruppe. Die Schmerzerleichterung nach Bolusgabe war signifikant besser als nach Gabe von Piritamid. Mobilitäts- und Sensibilitätseinschränkungen kamen signifikant häufiger in der CSE-Gruppe vor. Andere Nebenwirkungen waren selten. 88% der Patientinnen aus der CSE-Gruppe und 76% aus der SPA-Gruppe waren "sehr zufrieden" mit der Analgesie.

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.

The aim of the present study was to investigate postoperative motoric impairment during patient-controlled analgesia after major abdominal surgery with ropivacaine-sufentanil and bupivacaine-sufentanil via a lumbar epidural catheter.After approval of the local ethics committee, 40 patients scheduled for major lower abdominal surgery were randomly allocated to receive bupivacaine 0.25 % or ropivacaine 0.2 %, both with sufentanil 2 microgram/ml in a double blind manner. General anaesthesia (midazolam, etomidate, fentanyl, vecuronium, and desflurane in N2O/O2) and postoperative management of the patients were standardised. Postoperatively, the motoric function and ability for active early mobilisation was examined clinically (application of the Bromage scale, ability to leave the bed and ability to walk). Reduction of muscular force of the legs was measured postoperatively using a scale and compared with preoperative baseline values. To ensure a similar level of analgesia, a 10-cm visual analogue scale was applied at rest and while coughing.The two groups did not differ with respect to the demographic data and postoperative levels of analgesia. Less reduction of motoric function at rest was observed in the ropivacaine group (p = 0,044). However, this did not lead to an increased ability to get up from bed (p = 0,57) or to walk around (p = 0,17). A high number of patients did not meet the requirements for early ambulation. Almost half of the patients of both groups were unable to leave their beds in the morning of the first postoperative day. On the second postoperative day about 25 - 30 % of the patients could not walk even when support was applied. Furthermore, median reduction (10th/90th percentile) of muscular strength was reduced to 50 % (37 %/76 %) in the ropivacaine group and to 48 % (31 %/61 %) in the bupivacaine group compared with preoperative values.While quality of analgesia was similar, mobility of the legs at rest is better preserved with ropivacaine 0.2 % than with bupivacaine 0.25 %. However, despite the fact that high dose sufentanil was added to both local anaesthetics, there was marked motoric impairment in both groups probably due to the lumbar site of the epidural catheter. This was associated with an unacceptable high incidence of patients unsuitable for early postoperative mobilisation.

An improved opioid-free analgesia concept using thoracic epidural anlgesia with a low concentrated local anaesthetic alone could be of practical interest for hospitals which are unable to guarantee continuous monitoring on the wards.We have compared in a prospective, randomized, double-blind study, the analgesic effects and side effects of ropivacaine 0.2% (Group 1) with bupivacaine 0.125% plus 0.5 microgram ml-1 sufentanil (Group 2) via a thoracic epidural catheter during the first 24 hours after major abdominal surgery in 28 gynaecological tumour patients. Assessments were performed 8, 12, 16, 20 and 24 hours after surgery.No differences were seen in duration of surgery, intraoperative opioid and supplemental analgesic requirements. As a main result VAS values for pain during mobilisation were higher in Group 1 when compared with Group 2 (p0.01) after 20 and 24 hours of continuous epidural infusion (10 ml h-1) whereas VAS values at rest were comparable (p0.1) at all measurepoints. Intensity of motor block and side effects did not differ between groups.The present study shows that continuous epidural infusion of 0.2% ropivacaine alone provides comparable analgesia at rest, but less profound pain relief during mobilisation within the first 24 hours after major abdominal surgery than bupivacaine 0.125% with sufentanil.

Increases of heart rate and blood pressure during anaesthesia are interpreted as a response to surgical stimulation, although the endocrine response and the cardiovascular reaction can differ markedly. We compared remifentanil and sufentanil as part of a TIVA for retinal surgery with respect to the endocrine stress responses and haemodynamic reactions.After ethics committee approval and informed consent, 22 patients (ASA I-III) scheduled for retinal surgery were included in this patient-blind, randomized, prospective parallel-group study and allocated to one of the two groups receiving TIVA with propofol (4 mg/kg/h) and remifentanil (R-group) 0.25 microgram/kg/min, or sufentanil (S-group) 1 microgram/kg before surgery with dosage adjustments according to haemodynamic parameters. Prolactin, growth hormone, cortisol, epinephrine and norepinephrine were measured 60 min before anaesthesia, 30 min after start of surgery and 30 min after extubation.(Significance level: P0.05) Only prolactin increased significantly in both groups during the surgical procedure, the S-group showing a greater increase than the R-group. Cortisol and norepinephrine concentrations decreased during surgery in both groups significantly. Growth hormone and epinephrine concentrations only decreased in the S-group during operation while there was no significant change in the R-group. The blood pressure dropped by about 30% in both groups intraoperatively while there was a tendency towards lower heart rates in the R-group with 58/min vs. 64/min in the S-group (mean).The increase of prolactin concentrations could be interpreted as a result of the stimulation of mu 1-receptors. As all other measured stress hormones did not increase in both groups, remifentanil and sufentanil both provide an effective suppression of noxious stimulation induced endocrine response.

In a prospective study rnidlatency somatosensory evoked Potentials (SEP) were investigated in relation to explicit memory function during recovery from propofol/sufentanil anaesthesia.Anaesthesia was maintained in 20 patients with 8 mg kg-1 h-1 propofol and supplemented with sufentanil. SEPs (N20, P25, N35, P45 N50) elicited by median nerve stimulation were recorded at the day before surgery (AWAKE) and during recovery from anaesthesia, when patients were able to identify a shown object (RECOVERY). The day after surgery patients were interviewed about their memory of the recovery period.Hotellings' T2.One day after anaesthesia 9 patients could remember events during the recovery period. At RECOVERY SEP-latencies P45 and N50 were significantly shorter in the patients with recall for the wakeup-phase (p0.05).SEP latencies P45 and N50 indicated impaired explicit memory function during recovery from propofol/sufentanil anaesthesia.

Sufficient control of intraoperative bleeding in functional endoscopic sinus surgery is essential for obtaining adequate surgical results. The necessity of hypotensive anesthetic techniques is a controversial topic among anesthesiologists and ENT-surgeons. This prospective, randomized study compared N2O-supplemented intravenous anesthesia with propofol and fentanyl or sufentanil with respect to hemodynamic reactions, endocrine stress response, blood loss and surgical conditions, and recovery.After obtaining informed consent, 32 patients undergoing endoscopic sinus procedures were anesthetized with N2O, propofol, and fentanyl or sufentanil (dosage ratio fentanyl:sufentanil = 7:1). Arterial blood pressure was measured via an arterial line, blood samples for ACTH, AVP, and cortisol were obtained pre-, intra-, and post-operatively, and a psychomotor function test was conducted pre- and postoperatively. The ENT-surgeon estimated the dryness of the surgical field on a numeric scale ranging from 1 to 5, and intraoperative blood loss was measured.Hemodynamic reactions to surgical simulation were blunted more sufficiently in the sufentanil group. Surgical conditions were satisfactory in all patients, but significantly better in the sufentanil group; differences in blood loss did not prove statistically significant. The endocrine stress response was efficiently blunted without significant differences between the groups. Post-operative psychomotor testing showed better recovery in the sufentanil group.N2O-supplemented intravenous anesthesia is suitable for functional endoscopic sinus procedure without any further need for induced hypotension; sufentanil seems to be superior in regard to hemodynamic stability, surgical conditions, and psychomotor recovery.

Since we had the impression that there was an increase in blood loss during mammaplasties after a change in the anesthesiology department responsible, we conducted a study to compare 28 cases from each anesthesiology department. All operations were carried out by the first author in succession using the same operative technique. The two groups did not differ in age, BMI, operative time, weight of resected tissue or preoperative laboratory. Blood loss was calculated from the perioperative drop in hemoglobin and patient's blood volume. Blood pressure, heart rate, medication and intravenous fluid supply were obtained from the anesthetic protocols.Group I (n = 28) and [Group II (n = 28)]: total resected tissue 1862 +/- 928 g [1912 +/- 791 g]; Hb-preop. 13.6 +/- 0.9 g/dl [13.8 +/- 0.8 g/dl]; Hb-postop. 10.8 +/- 1.3 g/dl [9.7 +/- 1.3 g/dl] P = 0.006; Blood loss 970 +/- 339 ml [1443 +/- 456 ml] P0.001. After exclusion of surgical or biological causes hemodynamic effects of the anesthetic techniques were suspected as the reason for the significant difference in blood loss. MAP was elevated only initially, while the heart rate was considerably elevated throughout the procedures in group II. During anesthesia with nitrous oxide and enflurane, the dose of enflurane in group I could be limited to 0.3-0.5% after initial i.v. administration of 60 to 100 micrograms sufentanil, while in group II without opioids doses of 0.5-2% were required. The well-known dose-dependent effect of enflurane on the peripheral vascular tone was not masked by vasoconstrictors at the operative site.Blood loss during mammaplasties can be affected considerably by the anaesthetic technique--even without deliberate hypotension. Sufentanil can indirectly reduce the blood loss by lowering the necessary dose of enflurane. Blood transfusions can be avoided at mammaplasties.

There is controversy about relevant EEG signal changes indicating adequate or inadequate anaesthesia. Differences of drug-induced and nociceptive mediated signal changes have not been studied in detail. The present study investigates whether signal changes during decreases of depth of anaesthesia due to surgical stimulation depend on different isoflurane concentrations during sufentanil anaesthesia.Following IRB approval and written informed consent 28 patients (ASA: I; age 43 +/- 11 y) scheduled for elective abdominal surgery were included in the study. Anaesthesia: propofol (2.0 mg/kg) and sufentanil (1.0 micrograms/kg). Following endotracheal intubation (vecuronium 0.1 mg/kg) patients were normoventilated (P(ET)CO2: 36-38 mmHg). Randomly assigned to steady-state anaesthesia (group 1: P(ET)Isoflurane 0.2%, (14n); group 2: P(ET)Isoflurane 0.6%, (14n) during the start of surgery. Monitoring: heart rate (HF), mean arterial blood pressure (MAP), P(ET)CO2, arterial oxygen saturation and rectal temperature. EEG (16 channels referenced to Cz; CATEEM, Medisyst, Linden) recorded 5 min before until 10 min after the start of surgery. EEG-analysis (FFT: 4s, 256/s, 0.45-35.0 Hz): topographical distribution of power spectral densities (delta, theta, alpha 1, and alpha 2). Artifact control: ECG and EOG.Surgical stimulation resulted in increases of MAP in both groups (p0.05 vs BL), whereas HR was only slightly affected in group 2 when compared with BL. Other variables except of EEG data did not change over time. In group 1 (0.2% isoflurane) surgical stimulation resulted in decreases of delta over the whole cortex (F2, C3, P3, O1) and in marked increases of alpha predominantly at central leads (C3)(p0.05 vs BL). In group 2 (0.6% isoflurane) nociceptive stimulation was associated with decreases of faster waves (alpha: F3)(p0.05 vs BL) and increases in delta at fronto-central areas (F3, C3)(p0.05 vs BL).EEG recordings are useful in assessing pharmacodynamic drug effects. In contrast, intraoperative EEG recordings have a low correlation to clinical signs of changes in the anaesthetic state. Previous studies demonstrate paradoxical EEG-arousal reactions during isoflurane anaesthesia. The present data suggest that classical or even paradoxical EEG arousal due to nociceptive stimulation may depend on the isoflurane concentration. It seems reasonable that the ascending reticular formation is functionally blocked by isoflurane in a dose-dependent manner.

The efficacy of a 3-level regimen of analgesia and sedation was investigated in a clinical setting. Level 1 consisted of continuous administration of sufentanil, in level 2 continuous administration of midazolam and level 3 continuous administration of midazolam and clonidine was added according to patients' needs.Sufentanil at 1 microgram/kg/h was given initially. Later it was adjusted to patients' requirements in accordance with the Ramsay score (group 1). Long-term intubated patients received in addition midazolam 0.05 mg/kg/h (group 2). If needed, clonidine 1 microgram/kg/h was added (group 3). Mean drug requirements were investigated during controlled ventilation and during assisted ventilation with spontaneous breathing25% of total minute ventilation. In group 1 arterial paCO2 was measured to estimate drug-induced respiratory depression. Values given are median and ranges.With the 3-level-regimen of analgesia and sedation a Ramsay score of 2-3 was achieved in all intensive-care patients. In group 1 (n = 109; 36.7%) paCO2 values were similar at all times. Patients on controlled ventilation needed sufentanil 0.6 (0.075-2.5) microgram/kg/h, on assisted ventilation 0.4 (0.05-2.5) microgram/kg/h. Patients of group 2 (n = 113; 38.1%) had on controlled ventilation a higher requirement of sufentanil 1.2 (0.09-2.7) micrograms/kg/h, in addition Midazolam 0.05 (0.002-0.56) mg/kg/h was given. On assisted ventilation with spontaneous breathing25% sufentanil 0.9 (0.05-2.6) microgram/kg/h plus midazolam 0.04 (0.002-0.38) mg/kg/h was sufficient. Group 3 (n = 75; 25.2%) had on controlled ventilation a higher requirement of sufentanil with 1.5 (0.09-4.0) micrograms/kg/h and midazolam 0.05 (0.005-0.52) mg/kg/h, in addition clonidine 1.1 (0.12-2.88) micrograms/kg/h was given. On assisted ventilation with spontaneous breathing25% requirement of sufentanil with 1.1 (0.15-2.6) micrograms/kg/h and of midazolam with 0.05 (0.002-0.22) mg/kg/h was slightly lower, whereas more clonidine was needed with 1.3 (0.12-2.88) micrograms/kg/h.Continuous infusion of sufentanil only for analgesia and sedation is suitable for intensive-care patients with a short stay in the ICU. Respiratory depression during spontaneous breathing is not significant. The supplementary administration of midazolam and clonidine according to the presented regimen was shown to be of advantage for patients with a longer stay in ICU.

The purpose of our study was to find out whether patient-controlled epidural administration (PCEA) of a mixture containing a low-dose local anaesthetic, opioid and alpha 2-agonist provides as good or better postoperative analgesia as continuous epidural administration of the same analgetic solution.30 patients (ASA I-III), scheduled for major abdominal surgery, were randomly divided into 2 groups. 90 minutes after induction of general anaesthesia all patients received a continuous epidural infusion of 5 ml/h of the analgetic solution (50 micrograms sufentanil + 150 micrograms clonidine in 50 ml 0.125% bupivacaine) until the end of surgery. Immediately postoperatively the patients of group A received a continuous infusion of the study solution (5-8 ml/h), the patients of group B received a baseline continuous epidural infusion (3 ml/h), additionally they could self-administer 5 ml boli via a PCEA device. Measurements included the total dose of infused drug solution, pain at rest and on exercise by a visual analogue scale, cardiorespiratory data and side effects within the first 24 hours postoperatively. A standardised interview on analgesia and side effects was held 2 days after surgery.The PCEA group demanded less epidural analgesics (gr. B: 112 +/- 33 ml vs. gr. A: 135 +/- 20 ml) p0.01). Both continuous epidural infusion and patient-controlled administration provided very good analgesia at rest (gr. A: VAS 0.4 +/- 0.4 and gr. B: VAS 0.4 +/- 0.5) (n.s.). On exercise continuous epidural infusion of analgesics resulted in significantly lower pain scores (gr. A: 1.9 +/- 1.1) than patient-controlled application (gr. B: 3.4 +/- 1.1) (p0.01). We did not notice severe side effects such as respiratory depression or drop of heart rate or blood pressure.In patients at rest both continuous and patient-controlled epidural administration of analgesics provides excellent analgesia after major abdominal surgery. Contrariwise, patients on exercise who could use a PCA-device experienced more pain compared to those with a continuous epidural infusion technique. On the other hand the patients of the PCA-group consumed less epidural analgesics. We did not notice any severe side effects such as respiratory depression or cardiovascular instability during the study.

Intravenous patient-controlled analgesia (PCA-i.v.) has has markedly improved postoperative pain-relief. Alternatively, peridural anesthesia has been used successfully in high risk patients with the disadvantage of a more intense postoperative care. In this study we compared the applicability of intravenous vs. peridural patient-controlled analgesia on a general ward.In a prospective double blinded study 40 patients were randomized after extensive thoracic or abdominal surgery in two groups and received either intravenous PCA (n = 20) or epidural PCA (n = 20). Postoperative monitoring was performed on the general ward by specifically trained nurses. Physiological data, neurological status, the effects of the analgesia and complications were registered before and 48 hours after surgery. Pain intensity was determined by using the visual analog scale (VAS). For the evaluation of wellness and cognitive efficacy psychological tests were performed.Our results show that epidural PCA without administration of a basal rate is a safe method and can be performed on a general ward. Relevant postoperative complications or negative side effects were not registered in both groups. Sufficient analgesia was achieved with both methods. Patients treated with PCA-PDK had a significantly better score regarding vigilance and subjective wellness when compared to patients in the PCA-i.v. group.This study demonstrates that epidural PCA can be used on a general surgical ward as an alternative method compared to intravenous PCA. PCA-PDK may be advantageous over intravenous PCA since both techniques require similar intense monitoring and side effects in the PCA-PDK group appear to be less.

Improvement of the quality of analgesia, reduction of side effects and costs by application of epidural (PCEA) in comparison to intravenous patient-controlled analgesia (PCA) in postoperative pain treatment.62 patients with upper abdominal surgery took part in this randomised prospective study which was approved by the local ethics committee. Epidural catheters were inserted at T 8/9 (group PCEA). General anaesthesia was performed with propofol, sufentanil 2 micrograms/kg, pancuronium, enflurane and O2:N2O = 1:2. Postoperative analgesia consisted of epidural bupivacaine 0.25% + sufentanil 2 micrograms/ml (BS). (bolus 0.05 ml/kg, lockout 10 min) in group PCEA, or of intravenous morphine (bolus 2 mg. lockout 10 min) in group PCA. The following parameters were recorded until the evening of postoperative day 4: pain intensity at rest (VASR, 1-10) and on coughing (VASH, 1-10), blood pressure, heart rate, blood gas analysis, ability to ambulate, pruritus, nausea/vomiting (PONV), patient satisfaction (0-4), time and expenses for postoperative pain treatment.Median VASR (1 vs 2) and VASH (3 vs 4.5) were lower, cough intensity (2 vs 1) and patient satisfaction score (4 vs 3) were higher in PCEA compared to PCA. Ability to ambulate, pruritus, PONV, haemodynamics, paO2 and paCO2 were comparable. Postoperative pain treatment with PCEA was more time-consuming (407 vs 299 min) and expensive (71 vs 40 S/day) than PCA.PCEA in comparison to PCA after major abdominal surgery provides superior analgesia with comparable side effects at approximately 80% higher costs.