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Zur Identifizierung des Epiduralraums bei Anlage ruckenmarknaher Regionalverfahren bedienen sich die meisten Anasthesisten der Widerstandsverlustmethode („Loss-of-resistance“-Technik). Diese Technik hat einerseits einen subjektiven Charakter und ist in gewissen Fallen nur bedingt verlasslich, weshalb wiederholt Ansatze zur Objektivierung unternommen worden sind. Die sog. CompuFlo®-Technologie wurde bereits vor einigen Jahren beschrieben und lieferte in ersten Studien vielversprechende Ergebnisse. Anhand dieser Fallserie werden die ersten Anwendungen im deutschsprachigen Raum illustriert.

Die aktuelle Kasuistik berichtet uber die Anwendung der venoarteriellen extrakorporalen Membranoxygenierung (va-ECMO) als „bridge to therapy“ im Fall einer massiven Lungenembolie mit konsekutivem Rechtsherzversagen. Eine 38-jahrige Frau prasentierte sich in einem Krankenhaus der Regelversorgung mit Dyspnoe und zunehmender Kreislaufinsuffizienz. Die Diagnostik zeigte eine massive Lungenembolie. Nach frustraner Thrombolyse und Entwicklung eines kardiogenen Schocks war die Indikation zur Thrombendarteriektomie gegeben. Um einen Transport der hochgradig instabilen Patientin in ein Zentrum der Maximalversorgung zu ermoglichen, wurde ein mobiles ECMO-Team alarmiert. Dies leitete vor Ort eine va-ECMO-Therapie an der wachen Patientin ein. Nach Stabilisierung der kardiopulmonalen Funktion mithilfe der extrakorporalen Unterstutzung erfolgten die sichere Verlegung und anschliesend die erfolgreiche Operation mit Restitutio ad integrum.

Hintergrund Die Therapie des akuten Lungenversagens („acute respiratory distress syndrome“, ARDS) besteht neben der spezifischen Behandlung der auslosenden Ursache aus einer lungenprotektiven Beatmung und einer Reihe von adjuvanten bzw. supportiven Masnahmen.

Die Spinalanasthesie wird als das Standardanasthesieverfahren zur Sectio caesarea angesehen. Zahlreiche Studien befassen sich mit der Dosisfindung der applizierten Lokalanasthestikamenge und -konzentration, um das Auftreten einer haufig assoziierten Hypotonie zu reduzieren. Die am Universitatsklinikum Wurzburg etablierte Technik der „High-volume-low-concentration“-Medikamentenkombination aus bis zu 12 ml isobarem 0,1 %igem Bupivacain (1 mg/ml) mit Sufentanil (1 µg/ml) ist bislang wenig verbreitet und wurde in dieser retrospektiven Studie hinsichtlich Zuverlassigkeit und Nebenwirkungen untersucht. Von 1424 Anasthesieprotokollen aus den Jahren 2001–2007 wurden 1368 ausgewertet. Erfasst wurden demografische Daten sowie Parameter wie Punktionshohe, Dosis und Ausdehnung, Kreislaufstabilitat und Medikamentenbedarf wahrend der Spinalanasthesie. Als Hypotoniegrenze wurde ein Abfall des systolischen Blutdruckwerts auf

Sonographisch gesteuerte Multiinjektionstechniken sind heute etablierte Standardverfahren bei der axillaren Plexusanasthesie. Bis heute gibt es allerdings nur wenige Studien, die die Nervenstimulation und die Sonographie als Steuerungsinstrument bei einer axillaren Multiinjektionstechnik vergleichen. In der vorliegenden Arbeit wurde eine ultraschallgesteuerte Vierfachinjektionstechnik (perineural, „out-of-plane“) mit einer nervenstimulationsgesteuerten Dreifachinjektionstechnik in einem prospektiven randomisierten und untersucherverblindeten Studiendesign verglichen. Es wurden 60 Patienten in 2 Gruppen (SONO, n = 30, und STIM, n = 30) randomisiert. Die Anlage der Plexusanasthesie erfolgte durch einen von 5 in beiden Methoden versierten Facharzten und in beiden Gruppen mit 40–50 ml 1,5 %igem Mepivacain sowie 5–10 ml 0,5 %igem Mepivacain. Primarer Zielpunkt war die Anasthesiezeit. Als sekundare Ziele wurden Durchfuhrungszeit (DZ) und die Anasthesiezeiten der Einzelnerven sowie die Erfolgsquote untersucht. Ein verblindeter Untersucher testete die Sensibilitat und die Motorik in den Innervationsgebieten der Nn. medianus (MED), radialis (RAD), musculocutaneus (MUC), ulnaris (ULN) und cutaneus antebrachii medialis (CAM) zu definierten Zeitpunkten. Die Patienten erhielten einen Fragebogen zum Patientenkomfort. Die Anasthesiezeiten der Plexusblockaden unterschieden sich nicht. Die Anasthesiezeiten der Einzelnerven und die Erfolgsquoten (90 vs. 89 %) waren ohne Unterschied. Die DZ war in der SONO-Gruppe signifikant kurzer (6,68 ± 1,72 vs. 8,05 ± 2,58 min, p = 0,02). Patientenzufriedenheit (92 % vs. 91 %) und Bewertungen in der visuellen Analogskala (VAS, 2 cm) zeigten jeweils gute Ergebnisse. Bezuglich des Blockadeerfolgs, der Blockadequalitat und der Patientenzufriedenheit sind die Verfahren gleichwertig; die Unterschiede zwischen den Verfahren sind geringer als erwartet.

Die voraussichtliche Eintreffzeit von Schockraumpatienten spielt fur die aufnehmende Klinik eine bedeutende Rolle. An einem uberregionalen Traumazentrum haben wir die Ubereinstimmung von voraussichtlicher und tatsachlicher Eintreffzeit uberpruft. Es wurde eine retrospektive Analyse aller Schockraumeinsatze von September 2010 bis zum Marz 2011 durchgefuhrt und die tatsachliche Eintreffzeit mit der voraussichtlichen Eintreffzeit verglichen. Der Erfolg des Alarmierungsalgorithmus wurde uberpruft. Es wurden 165 Einsatze in die Datenanalyse eingeschlossen. Eine exakte Ubereinstimmung der geschatzten und der tatsachlichen Eintreffzeit gab es in 14 min. Es konnte gezeigt werden, dass ein standardisierter Alarmierungsalgorithmus fur das Schockraumteam (Alarm 10 min vor geschatzter Ankunft des Patienten) in der uberwiegenden Zahl der Falle zu einem akzeptablen Ergebnis fuhrt. Insbesondere sind nur 3 % der Patienten in einem kritischen Zeitfenster zu fruh im Schockraum eingetroffen.

Im Rahmen dieser Studie wurde die aktuelle Verwendung i.v.-verabreichter Opioide – unter besonderer Berucksichtigung von Remifentanil als patientenkontrollierte intravenose Analgesie („patient controlled intravenous analgesia“, PCIA) – in der Geburtshilfe deutscher Kliniken untersucht. Ein Fragebogen wurde an 930 anasthesiologische Kliniken versandt. In dem zweiseitigen Fragebogen wurde nach Geburtenzahl, den alternativ zur Periduralanalgesie (PDA) verwendeten Methoden der geburtshilflichen Analgesie wie z. B. periodisch i.v.-verabreichten Opioiden, PCIA-Techniken bzw. alternativen Verfahren gefragt. Weiterhin zielten die Fragen auf Details bezuglich der Verwendung einer PCIA ab. Die Daten wurden mithilfe der Statistik-Software PASW Statistics 18.0 erfasst und ausgewertet. Es antworteten 343 anasthesiologische Kliniken (Rucklaufquote: 37%). Uber eine Geburtshilfestation verfugten 281 Kliniken. Alle Kliniken boten einen 24-stundigen anasthesiologischen Bereitschaftsdienst zur Durchfuhrung einer PDA an. Die meistverwendeten periodisch i.v.- oder i.m.-verabreichten Opioide waren Pethidin (19%), Meptazinol (17%) und Piritramid (16%). Nur 22 Kliniken (8%) boten eine PCIA als Alternative an; hierbei war Remifentanil (68%) das am haufigsten genutzte Opioid. Fur letzteren Fall gaben die meisten Befragten an, die Sauerstoffsattigung (91%) und den Blutdruck (95%) zu uberwachen, wahrend das EKG (18%) und die Atemfrequenz (19%) der Mutter weitaus seltener kontrolliert wurden. Diese aktuelle Umfrage zeigt, dass Pethidin, Meptazinol und Piritramid die gebrauchlichsten Analgetika fur eine opioidbasierte Therapie des Wehenschmerzes sind. Eine PCIA – in den meisten Fallen mit Remifentanil – bieten hingegen nur sehr wenige Kliniken an. Weiterhin weisen die Ergebnisse darauf hin, dass die aktuellen Uberwachungsstandards in den Kliniken, die eine PCIA im Rahmen der Geburtshilfe an bieten, verbesserungswurdig sind.

Die venovenose extrakorporale Membranoxygenierung (vv-ECMO) kann bei polytraumatisierten Patienten mit „acute respiratory distress syndrome“ (ARDS) zur Sicherung des Gasaustausches bei Versagen von konventionellen Beatmungsstrategien eingesetzt werden. Da eine systemische Antikoagulation zur Vermeidung von thrombembolischen Komplikationen empfohlen wird, ist die ECMO bei Patienten mit intrakraniellen Blutungen kontraindiziert. Es wird uber den mehrtagigen Einsatz einer vv-ECMO ohne systemische Antikoagulation zur Sicherstellung eines suffizienten Gasaustausches bei einem polytraumatisierten ARDS-Patienten mit schwerem Schadel-Hirn-Trauma (SHT) berichtet.

SUMMARY Aims: Statines, HMG-CoA reductase inhibitors, are widely used to treat hypercholesterinemia. These substances are well tolerated, but myotoxic effects have been reported. The exact mechanisms of the induced myotoxicity are unknown but an involvement of intracellular calcium handling is suspected. Individuals susceptible to malignant hyperthermia (MH) have an impaired calcium homeostasis. An in vitro test measuring contracture responses of isolated muscle bundles is used to investigate cellular processes of MH. Aim of this study was to investigate if statins modify the contracture response of isolated muscle bundles from MH susceptible (MHS) and nonsusceptible (MHN) pigs. Methodology: With approval of the local ethics committee muscle biopsies of 18 MH susceptible and 12 nonsusceptible pigs were performed. Muscle bundles were mounted on an isometric force transducer, preloaded, and electrically stimulated. After establishment of a stable baseline, muscle bundles were exposed to simvastatin, atorvastatin, gemfibrocil, and the pure solvent. Baseline tension was measured and analyzed for changes with P < 0.05 considered to be significant. Results: There were no differences in weight, length, and predrug baseline tension between the groups. Both simvastatin and atorvastatin induced significant contractures in muscle bundles from MHS pigs. Gemfibrocil and the solvent methanol showed no effect. In MHN muscle bundles, none of the tested substances induced a contracture. Statines induce contractures only in MHS muscle bundles. Conclusion: We therefore conclude that the underlying mechanism may be a pathologic influence on intracellular calcium handling that is absent in MHN. A preexisting impairment of the calcium homeostasis seems to be necessary for this behavior because muscle bundles of MHN pigs showed no pathologic reaction. A higher muscle cell vulnerability toward statins is assumed in MHS patients. Statins ought to be used with caution in these individuals. Analogous a diagnostic workup for MH should be considered for patients with statin-induced rhabdomyolyis.

Background Epidural analgesia is considered as the standard method for labor analgesia by inducing a minimal negative impact on labor while providing effective analgesia. Labor analgesia in the absence of epidural analgesia is difficult to achieve with the commonly used analgesic interventions. If epidural analgesia is not feasible due to coagulation disorders, anticoagulation, inability to insert an epidural catheter or due to the mother''s refusal to accept neuraxial analgesia, there is a need for interventions to cope with labor pain. So far, pethidine, diamorphine, meptazinol and spasmolytics remain the most widely used substances for IM and IV use. Unfortunately, in addition to not being very effective, these interventions may be associated with undesirable side effects for the parturient and the newborn. For a decade, anaesthesiologists have experienced the unique properties of remifentanil in the settings of surgical anaesthesia and conscious sedation since it was introduced for labor analgesia. Unfortunately, remifentanil is not licensed for administration to the pregnant patient, and it is unlikely that the manufacturers would consider the cost justified. Methods Therefore, relevant concerns, legal issues and precautions are discussed based on the presentation of case series and a protocol is presented on how the use of remifentanil can be safely implemented for labor analgesia in selected situations. Results and conclusions Proper informed consent, appropriate monitoring for the mother and the newborn, one-to-one nursing or midwifery care as well as the availability of an attending physician experienced in neonatal resuscitation and an anaesthesiologist with experience regarding the use of remifentanil are important to ensure that this method retains its good reputation for obstetric analgesia.

Background: Previous studies reported that propofol anesthesia is an effective means of preventing postoperative nausea and vomiting (PONV) after different types of surgeries. The present analysis of a large antiemetic trial is intend to compare propofol versus isoflurane, enflurane or sevoflurane with respect to the incidences of PONV after strabismus surgery. Methods: 238 ASA I - III inpatients, aged 4-65 years were randomly assigned to receive either isoflurane (group I, n = 60), enflurane (group E, n = 59), sevoflurane (group S, n = 59) or propofol (group P, n = 60) for maintenance as a subgroup of a larger trial of factorial design to investigate interventions to reduce PONV. After opioid application, patients in the inhalational groups (group I, E and S) had anesthesia induced with thiopental, those in group P received propofol for induction. Tracheal intubation was facilitated with succinylcholine. Patients were ventilated with N2O/O2 2:1. Incidence and severity of PONV as well as the need for antiemetic rescue treatment were studied during the first 24 hours after anesthesia. Paracetamol and tramadol was given to treat postoperative pain. Results: There were no significant differences between study groups with respect to patient demographics and risk factors for postoperative nausea and vomiting. Nausea was reported by 43%, 41%, 42% and 22% of patients in groups I, E, S and P, respectively (P = 0.043). The incidence of vomiting was 40%, 46%, 34% and 18% in groups I, E, S and P, respectively (P = 0.011). Conclusion: Patients anesthetized with propofol showed a significantly lower incidence of nausea and vomiting compared to volatile anesthetics, while there was no significant differences in emetogenicity between the volatile anesthetics.

Optical laryngoscopes have been developed to facilitate difficult airway management. The Airtraq is a single-use device and the GlideScope is reusable. In this study, the Airtraq and the Glidescope were compared in 60 ASA I-III patients with tumours of the upper airway undergoing direct endoscopic microlaryngoscopy. Patients were randomly assigned to the Airtraq or the Glidescope group and the Cormack and Lehane grade was assessed by Macintosh laryngoscopy prior to tracheal intubation. There were no differences in tracheal intubation success rates or duration of intubation attempts between both devices. The Cormack and Lehane grade was improved in 77% and 82% of cases in the Airtraq and Glidescope group, respectively. Blood traces on the device and traumatic pharyngeal lesions were found more frequently in the Airtraq group. The Airtraq and Glidescope laryngoscopes are valuable tools for the management of patients with potentially difficult airways with the Glidescope appearing to be less traumatic.

BACKGROUND Quality management and the early implementation of whole-body multi-slice spiral computed tomography (whole-body MSCT) are becoming increasingly important in the management of patients with multiple trauma. The aim of this study was to evaluate both components with respect to the time factor for treatment. METHODS The investigation involved a retrospective data analysis of the time needed in the emergency room for the initial stabilization (phase A), completing the diagnosis (phase B) and the emergency room treatment (phase C). The investigation included three groups: trauma patients imaged in the emergency room with conventional imaging procedures (group I), with whole-body MSCT alone (group II) and those who were imaged with whole-body MSCT after the introduction of a quality management system with standard operating procedures (group III). RESULTS The times for resuscitation (phase A), for diagnostic evaluation (phase B) and for total treatment (phase C) were analyzed. The times for phase A were for group I (n=79) 10 min (interquartile range, IQR 8-12 min), group II (n=82) 13 min (IQR 10-17 min) and group III (n=79) 10 min (IQR 8-15 min; p

Background The aim of this systematic review was to assess the benefits and harms of supplemental oxygen (HBOT/NBOT) for treating and preventing migraine and cluster headaches. Material and methods All randomized trials comparing the effect of supplemental oxygen on migraine or cluster headache with those that exclude supplemental oxygen were included in this review. The systematic search included all relevant sources according to the paradigms of the Cochrane Collaboration. Data were analyzed with RevMan 4.2. Results Nine trials involving 201 participants satisfied the inclusion criteria. HBOT was effective in relieving an acute migraine and seemed to be sufficient in the treatment of an acute cluster attack. NBOT was effective in terminating acute cluster headache compared to sham treatment, but not in comparison to sublingual ergotamine. There was no evidence for any prophylactic effects. Serious adverse effects were not noted in the trials investigated. Conclusions There is some evidence that HBOT is effective for termination of acute migraine. NBOT was similarly effective in cluster headache, however with sparse data. Because of costs and poor availability HBOT cannot be regarded as a routine therapy. Further indications in the case of treatment failure using standard therapy need to be defined based on data of future clinical trials.

UNLABELLED Interscalene plexus blocks are an important part of the peri-operative treatment in shoulder surgery. The nerve stimulation technique uses external landmarks for the definition of the injection site. Patient obesity is, therefore, one causative factor for a reduced success rate of the blockade. AIM This study investigated whether there are differences in visibility of the target nerves and in the success rate of the block between patients of normal weight (nw) and obese patients (ow), when portable sonography is used for guidance of the interscalene nerve blockade (ISB). METHODS We investigated 70 patients routinely scheduled for shoulder surgery (ASA status I-III). The patients were allocated to group nw (body mass index BMI 25). The interscalene part of the brachial plexus was examined using high-frequency portable ultrasound. The blockade was performed under continuous sonographic monitoring. The quality of the ISB was tested post-operatively, and the time required for the procedure was documented. RESULTS Identification of nerve structures in the obese patients did require slightly more time than in patients of normal weight, statistically (ow: 5 +/- 1 min versus nw: 4 +/- 2 min, p = 0.02). While in 33 patients (94 %) of group nw the plexus blockade was complete, in group ow 27 (77 %) of the blocks were sufficient. The difference in success, however, was not significant (p = 0.08). Visualisation of nerves was difficult in 3 patients in ow-group. CONCLUSION Portable ultrasound provides efficient depiction of the interscalene plexus structures in obese patients and, when used for guidance of regional blockade, renders similar results as in patients of normal weight.

Background We studied the anatomy of the sciatic nerve and its division into the tibial and peroneal part using handheld ultrasound in adults. We wanted to evaluate the feasibility of ultrasound-guided identification of the sciatic nerve in the popliteal fossa and the correlation of the findings by ultrasound with patients' characteristics. Methods 74 volunteers were randomly selected. Using a handheld ultrasound system with a 5-10 MHz linear array probe the popliteal fossa and the back of the thigh were examined and measured. Using a caliper the distance of the joint line to the nerve division was measured. The sciatic nerve and its division were depicted by ultrasound. Results We could depict the sciatic nerve in all volunteers and its division in 53 of 74 (72%) volunteers. The position of nerve division showed large anatomic variation. A significant correlation between the width of the knee-joint line and the depth of the nerve division could be demonstrated. We conclude that handheld ultrasound is able to depict the sciatic nerves division. To block the nerve by one injection a more proximal access or visualization by mobile ultrasound is recommended. In addition the surrounding anatomic structures can be depicted as well.

Aim High resolution ultrasound is a new method for detecting anatomical structures in the axilla. The visualisation of nerves can improve the quality of nerve blocks. The aim of our study was to investigate the feasibility of hand held ultrasound to perform sonographically guided blockades of the axillary plexus. Method We investigated 46 patients routinely scheduled for forearm and hand surgery (ASA physical status I-IV, age range 19 - 89 years, mean 47). The axilla was examined using a handheld ultrasound system with a 10 MHz linear array probe. The median, ulnar, radial and musculocutaneus nerve were visualised by ultrasound. Selective nerve blockade was performed under sonographic guidance. Real time monitoring of the local anaesthetic spread was performed. Time required to perform the block and onset times of anaesthesia were documented. Results Complete anaesthesia of the brachial plexus was achieved in all cases. The average time to perform the block was 5 minutes (SD 2 min). Onset time for the block was 7 minutes (SD 3 min). Conclusion Performing axillary nerve blockade using ultrasound guidance provides excellent anaesthesia and fast onset times.

Surgical procedures in the region of the shoulder joint are among the most painful interventions in orthopedic practice. For this reason, in addition to intravenous pain therapy with opioids, blockade of the brachial plexus has become established as an effective method to provide analgesia.High-resolution ultrasound offers the possibility of performing nerve blockades under visual monitoring. Studies on interscalene blockade performed under sonographic control provide evidence for both the high efficacy and safety of the procedure. Clinically manifest signs of nerve damage have not appeared with use of this method. Smaller operations can usually be adequately managed with perioperative single-shot blockade. More extensive operations for which severe pain lasting for several days can be expected and surgical interventions involving preexistent shoulder stiffness necessitate catheterization for uninterrupted pain therapy. Successful rehabilitation after shoulder surgery requires diligent perioperative pain blockade, which can primarily be provided by interscalene plexus blockade.

Background: Intra-abdominal pressure (IAP) elevation during CO2-pneumoperitoneum increases cardiac afterload and may enhance dysfunction of the already compromized heart. This study focused on the effects of acute IAP increases on left and right ventricular loadings and contractility in the heart with impaired global function. Methods: Impairment of myocardial function (IMF) was pharmacologically induced in 16 pigs by administration of halothane and propranolol, while baseline arterial pressure was maintained by intravenous phenylephrine. Intra-abdominal pressure was gradually increased by 10 mmHg up to 30 mmHg in the supine position (IMF group 1, n = 8) or in a head-down tilted position (IMF group 2, n = 8). In two control groups with normal myocardial function, IAP was also increased in the supine position or the head-down tilted position. Cardiac function in all groups was assessed by epicardial echocardiography, intraventricular pressure measurements and pulmonary artery catheterization. Results: The increase in IAP was accompanied by a transient rise in LV end-systolic wall stress and reduced cardiac output significantly by 16–24% in all groups. In the IMF groups, LV end-diastolic transmural pressure increased by 34–60% to peak values of 24 mmHg, while cross-sectional LV end-diastolic areas remained unchanged. Increases in right ventricular end-diastolic volume and decreases in right ventricular ejection fraction as well as in cardiac output were most pronounced at IAP 20 mmHg and significantly stronger in both IMF groups than in the control groups (P

Numerous factors have been claimed to influence postoperative nausea and vomiting (PONV). A critical review of the literature reveals, that strong evidence based on original double-blind, randomized, controlled trials or their meta-analyses is only available for very few risk factors. For most other factors, although mentioned in narrative reviews, there is insufficient evidence. Sufficient evidence on original data or meta-analyses is present for female gender, a history of PONV or motion sickness, non-smoking-status, young age, volatile anaesthetics, nitrous oxide and postoperative opioids. Factors with conflicting results are the menstrual cycle, hypnotics for induction, mask ventilation and nasogastric tube, the experience of the anaesthetist, muscle relaxants and their antagonists and laparoscopic procedures. Insufficient evidence is present for the other types of operation, psychological factors including anxiety and pain. No evidence due to lack of data applies to postoperative movement, hemodynamic stability, hypercarbia and acid-base-shifts. For adipositas++ there is not only a lack of evidence for an effect but evidence for a lack of effect based on several multivariate analyses. In conclusion, we have developed the following simplified view: PONV is mainly caused by opioids and volatile anaesthetics when applied to susceptible patients (females, non-smoker, positive history of previous sickness).

Continuous thermodilution (CT) using a pulmonary artery (PA) catheter with a thermal filament has the potential for intraoperative on-line monitoring of cardiac output. Liver transplantation frequently requires rapid fluid administration and often includes the use of an extracorporeal veno-venous bypass. To assess the agreement between CT and bolus thermodilution (BT) in such a setting, we conducted a prospective intraoperative study in 14 liver transplant patients. Throughout the operation, CT cardiac output was recorded and paired with BT measurements taken every 30 min and whenever indicated for clinical reason. Corresponding data were assigned to acquisition periods when patients were on or off veno-venous bypass (flow rate 2.5 +/- 0.2 L/min) and were discriminated by the various range of intravenous infusion rates (150 mL/h, 150-1000 mL/h, 1000-2000 mL/h, and 2000-4000 mL/h) and the magnitude of cardiac output (or = 7.5 L/min, 7.5-10.0 L/min,10.0 L/min). A total of 270 data pairs was obtained and examined by analysis of agreement (mean difference +/- SD), variance, error, and weighted regression. Trend analysis was performed for significant CT and BT cardiac output changes, defined as changes greater than 15%. Agreement of both methods was best at peripheral intravenous fluid infusion ratesor = 1000 mL/h and BT cardiac output10 L/min (0.0 +/- 0.6 L/min) and was unaffected by veno-venous bypass. Discrepancy was most evident at intravenous fluid infusion rates2000 mL/h and BT cardiac outputor = 7.5 L/min (2.1 +/- 1.7 L/min). Correlation of CT and BT cardiac output was excellent (r = 0.95, P0.001) for combined data from all patients. Changes in CT cardiac output15% (n = 116) correctly indicated the direction in 93% of BT cardiac output changes and were 74% sensitive and 75% specific for significant BT cardiac output changes. The thermal filament technique enhances the usefulness of PA catheterization during liver transplantation but reflects BT cardiac output with clinically acceptable error only at low peripheral intravenous fluid infusion rates.Cardiac output determines organ perfusion. In clinical practice, it is measured by intermittent thermodilution using right heart catheterization. This intraoperative study compared the intermittent method with a technique based on continuous thermodilution. The new technique provides logistical advantages and challenges the accuracy of the intermittent method during liver transplantation.

Objective: To examine the usefulness of preload indices obtained by transoesophageal echocardiography (TOE) for estimating stroke volume at various levels of cardiac index. Design: Prospective clinical study. Setting: Intensive care unit with surgical patients. Patients: 16 ventilated patients monitored via Swan-Ganz catheterization and TOE. Interventions: Echocardiographic images of left ventricular cross-sectional short-axis areas were analysed for the preload indices end-diastolic area (EDA), stroke area and end-diastolic wall stress. The relation between these indices and stroke volume, calculated from thermodilution cardiac output, was analysed in all patients and in nine patient groups discriminated by various ranges in heart rate (≤ 70 to > 110 beats/min), pulmonary artery occlusion pressure (≤ 8 to > 12 mm Hg) and cardiac index (≤ 3.0 to > 4.2 l/min per m2). Measurements and results: Overall stroke volume (n = 155) correlated significantly (p < 0.0001) with EDA (r = 0.89) and stroke area (r = 0.80). The correlation with end-diastolic wall stress was non-significant (r = 0.51). Linearity in the relation between stroke volume and EDA or stroke area was independent of variations in heart rate and pulmonary artery occlusion pressure. Stroke volume correlated well with EDA and stroke area, when cardiac index was normal or high, but the relation slightly deteriorated (r = 0.63 to ≤ 0.72) when the cardiac index was low. Changes in EDA and stroke area by more than 1, 2 or 3 cm2 were weak predictors for changes in stroke volume greater than 20 %. Conclusions: Stability of the relation between echocardiographic preload indices and stroke volume emphasize the potential of TOE for continuous preload monitoring in the critically ill.

In 35 ASA group I and II patients we investigated the influence of haemodynamic changes induced by increasing concentrations of halothane (from 0.0 to 0.6% halothane in 70% N20) on parameters of transesophageal echocardiography (TEE). Measurements by TEE were taken in manual and automatic boundary detection mode. In manual mode the left ventricular endsystolic area (ESA) increased significantly (+16.3%) and the fractional area change (FAC) decreased significantly (-14.9%). There was no significant change of left ventricular end diastolic area (EDA). In the automatic mode there was a significant increase of ESA and EDA (+13.8%; +6.0%) and a significant decrease of FAC (-10.9%). Peak ejection rate (PER) and peak filling rate (PFR) which were also assessed in automated mode decreased significantly (-10.0%; -5.7%) under halothane. No change occurred with manually determined left ventricular endsystolic wall stress (LVEWS). The endsystolic quotient decreased significantly both in manual and automated mode during halothane (-28.3%; -29.9%). No significant difference existed between TEE measurements under apnoea versus under controlled ventilation (except for EDA in automated mode). We conclude that there is no need for apnoea conditions for TEE measurements. In conclusion, TEE proves a useful monitoring system in anesthesia which enables the investigator to assess the negative inotropic effect of halothane. Problems in its practical usage are due to the wide variation of TEE measurements.

We report on a young patient with a positive family history for malignant hyperthermia (MH), who was diagnosed as susceptible to MH in our malignant hyperthermia laboratory by the in vitro-contracture test. Prior to the investigation of MH-susceptibility, the patient had been on medication with moclobemide, a monoamine oxidase (MAO) inhibitor, over a period of 13 months for treatment of a hyperactivity disorder. During the therapy with moclobemide no signs of relevant side effects were observed. However, some authors regard MAO-inhibitors as MH-triggering agents. The risk of MH-patients due to the therapy with MAO-inhibitors and the association between MH and the neuroleptic malignant syndrome is discussed in this case report.

The in vitro contracture test with ryanodine is a new method to distinguish malignant hyperthermia (MH) susceptible (MHS) from normal (MHN) patients. The purpose of our investigation was to determine whether smaller concentrations of ryanodine than those used previously may result in a better differentiation. We performed a ryanodine contracture test (RCT) using concentrations of 1 and 2 microM in muscle specimens of 41 MHS, 58 MHN, and 19 MH-equivocal (MHE) patients. Nine patients were excluded from the study due to neuromuscular diseases. All contracture levels (i.e., start of contractures, contractures of 0.2 g and 1.0 g) were attained significantly earlier in MHS than in MHN muscles at both concentrations of ryanodine. Using a ryanodine concentration of 2 microM, all contracture levels were reached significantly faster than with 1 microM. There was no overlap in the range of times between groups at all contracture levels with ryanodine 1 and 2 microM. The median threshold times for all MHE patients were always between those of MHS and MHN. Defining arbitrarily threshold times for MHS and MHN, an assignment of MHE patients to either MHS or MHN using 1 or 2 microM ryanodine was possible in most cases. Ryanodine administration at a concentration of 1 microM led to a better distinction of MHS from MHN patients than 2 microM. The RCT with ryanodine 1 microM should therefore be added to the current diagnostic methods.

We have measured the left ventricular (LV) end-systolic (ES) pressure-area product in 30 patients under general anaesthesia. We multiplied systolic arterial pressure with the ES cavity area obtained by transoesophageal echocardiography, and compared the product with M-mode derived ES wall stress before and during cardiovascular treatment. To attain appropriate mean arterial pressure during major non-cardiac surgery, 10 hypertensive patients required treatment with nitroglycerin, 10 septic patients received noradrenaline and 10 patients with intraoperative cardiac failure were given adrenaline. Baseline values and relative changes in the ES pressure-area product correlated well (r = 0.85 and r = 0.87; P < 0.05) with those of ES wall stress. Changes in the ES pressure-area product by more than 10% reflected ES wall stress changes with a sensitivity of 88% and a specificity of 94%. With adrenaline, the ES pressure-area product and ES wall stress did not change significantly, while systemic vascular resistance increased by 20%. The ES pressure-area product seems suitable for the detection of intraoperative LV wall stress changes.

In pigs genetically susceptible to malignant hyperthermia (MH), it has been shown that serotonin (5-HT2) receptor agonists can induce MH and "psychotic" behaviour. Both can be prevented by 5-HT2 receptor antagonists. Furthermore, free levels of serotonin in plasma increased concomitantly with clinical and laboratory parameters during halothane-induced MH in pigs. In this study the in vitro-effects of the 5-HT2 receptor agonist1-(2,5-dimethoxy-4-iodophenyl)-2-amino-propane (DOI) were investigated in muscle specimens of MH-susceptible (MHS) and normal (MHN) patients. METHODS. Muscle biopsies were obtained from 37 patients aged 5-69 years (23.6 +/- 5.3 years) with clinical suspicion for MH. The patients were first classified as MHS, MHN or MHE (MH equivocal) by the in vitro contracture test (IVCT) according to the European MH protocol. After MH classification, surplus muscle specimens were subjected to the DOI study. DOI was added to the organ bath in a concentration of 0.02 mmol/l. The in vitro effects on contracture development and muscle twitch were observed for 120 min. RESULTS. Muscle specimens of all patients developed contractures after administration of DOI. However, DOI produced an earlier development of contracture in MHS (17.0 +/- 1.8 min; n = 17) than in MHN (64.7 +/- 5.9 min; n = 15) muscles. In MHS muscles, contractures were more distinct than in MHN muscles; at the end of the experiment, contractures had reached a maximum of 12.5 +/- 0.9 mN in MHS and 5.1 +/- 0.7 mN in MHN muscles. Muscle twitch following DOI administration was reduced significantly in both MHS and MHN muscles. The results of four MHE muscles were comparable with MHS. CONCLUSION. The present study supports the assumption that an altered serotonin system might be involved in the development of MH. In further studies it should investigated whether 5-HT2 receptors of skeletal muscles from MHS subjects are disordered in function or structure. 5-HT2 receptor agonists should be considered as MH-triggering agents.

Die transosophageale Echokardiographie (TEE) ist ein bildgebendes Ultraschallverfahren, das bereits kurz nach seiner klinischen Einfuhrung Anfang der 80er Jahre Einzug in den Anasthesie- und Intensivbereich gehalten hat. Die Echokardiogramme liefern aufgrund der Sondenplazierung nahe am Herzen eine hohe Auflosung kardialer Strukturen und zeigen bei entsprechender Einstellung kontinuierlich den gesamten linksventrikularen Fullungs- und Kontraktionsablauf. Die hohe Sensitivitat der Methode, die zahlreichen Moglichkeiten zur Erfassung morphologischer und funktionsdiagnostischer Parameter und das damit verbundene nur geringe Risiko fur den Patienten erklaren das zunehmende Interesse an der TEE als perioperatives Uberwachungsverfahren. Diesem Einsatz sind derzeit jedoch einige Grenzen gesetzt, die hauptsachlich in den hohen Beschaffungskosten der Ultraschallgerate, den erforderlichen Spezialkenntnissen, dem noch nicht ausreichend geklarten Kosten-Nutzen-Verhaltnis des Verfahrens und der wenig verbreiteten Kenntnis Uber das Leistungsvermogen dieser Methode liegen. Der Informationsbedarf erhoht sich zudem durch die standige technische Weiterentwicklung der Gerate, die immer wieder eine Aktualisierung in der Bewertung der TEE erforderlich machen. Transoesophageal echocardiography (TEE) is a visualising ultrasound technique that has entered the arena of anaesthesiology and intensive care shortly after its clinical introduction in the early 80s. Due to transducer positioning close to the heart, two-dimensional echocardiograms render high spatial resolution of cardiac structures and in adequate views continuosly demonstrate the complete course of cardiac filling and contraction. The high sensitivity of the method, numerous options to assess morphological and functional parameters, and the low related risk involved for the patient explain the growing interest in TEE as a perioperative monitoring device. This utilisation, however, is currently limited by the high costs of the ultrasound equipment, the demand for specialists knowledge, the cost-benefit relation not yet thouroughly explored and the little propagated knowledge of the method's capacity. In addition, the need for information is growing due to the permanent technological progress of the equipment, which recurrently requires actualisation in evaluating TEE.

Objective Left ventricular end-diastolic wall stress (EDWS) ist an index for left ventricular preload. Utilising transoesophageal echocardiography, left ventricular dimensions can be obtained by two-dimensional (2d-) as well as M-Mode measurements, and each can be combined with pulmonary capillary wedge pressure (PCWP) for the calculation of EDWS. In the present examination, both methods were compared with regard to their technical accomplishment and reproducibility under clinical conditions. Methods EDWS was obtained in 24 ventilated patients by 2d-echocardiography (2d-EDWS) and M-mode-echocardiography (M-EDWS) before and after a change in PCWP by 3mmHg. In 12 patients, volume therapy with hydroxyethylstarch (HAES) was started when PCWP 14 mmHg. 2d-EDWS and M-EDWS were compared and their relation to thermodilution stroke volume and stroke work index analysed. Results 2d-EDWS and M-EDWS correlated well in both groups (HAES: r = 0.91; NITRO: r = 0.93), with M-EDWS being systematically lower than 2d-EDWS. The relative difference between 2d-EDWS and M-EDWS, and their mean value--calculated as the mean per cent error--was 11.2%. Directional changes in preload were reflected in all patients by 2d-EDWS and M-EDWS in accordance. Both correlated better with stroke volume and stroke work index than PCWP. Determination of 2d-EDWS showed better inter- and intraobserver variability in the echocardiographic measurements. Conclusions With regard to direction and quantity, changes of preload as seen with echocardiographic EDWS were according reflected by the 2d- and the M-mode technique. Determination of 2d-EDWS compared to M-EDWS was superior in reproducibility and more useful for the estimation of stroke volume changes.

OBJECTIVE AND STUDY DESIGN The identification of disposition for malignant hyperthermia (MH) is performed by the halothane-caffeine contracture test in skeletal muscle. However, testing currently renders about 14% of the patients MH equivocal (MHE). To reduce this number the "ryanodine contracture test" has been proposed in addition to the established procedure. As all ryanodine preparations used until now are combinations of ryanodine and dehydroryanodine, we investigate in this study the effects of the now available high-purity ryanodine (HPR) in concentrations of 2,5 and 10 mumol/l. RESULTS With all concentrations contractures appeared significantly earlier in MHS (malignant hyperthermia susceptible) than in MHN (malignant hyperthermia non-susceptible). However, only at 2 mumol/l a time overlap between both groups was not observed. By defining a time interval for MHS and MHN, three of the MHE patients could be assigned to MHS and three to MHN following their ryanodine-induced contractures. CONCLUSION The ryanodine contracture test should be added to the current diagnostics of malignant hyperthermia.

The early diagnosis of traumatic aortic dissections and aneurysms involving the thoracic aorta is of crucial importance for the outcome of patients suffering chest injuries. This subject is presented using two case reports; one illustrates the problems resulting from an overlooked traumatic aneurysm of the thoracic aorta and the second shows the possibilities of detecting such potentially lethal injuries early in patients with thoracic or multiple injuries, using the transesophageal Doppler echocardiography (TDE). The advantages and disadvantages of using TDE as compared to the more conventional methods such as the precordial Doppler echocardiography, computed tomography and angiography, are discussed. The particular advantage of this hardly invasive or burdening method is its immediate availability in the emergency room to assess patients with evident thorax trauma. In the intensive care unit TDE may be of value in screening polytraumatised patients who offered no primary evidence for chest injury upon arrival.

The classic Laryngeal Mask Airway (cLMA), ProSeal Laryngeal Mask Airway (PLMA), Intubating Laryngeal Mask Airway (ILMA), Combitube (CT), Laryngeal Tube (LT) and tracheal intubation (TI) were compared in a manikin study. Nurses, anaesthetic nurses, paramedics, physicians and anaesthetists inserted the devices three times in a randomised sequence. Time taken for successful insertion, success rates and ease of insertion were evaluated. Anaesthetists performed tracheal intubation significantly faster than other healthcare professionals (p0.05). Insertion times for the cLMA, PLMA, LT and CT were not significantly different between the groups. Insertion of the CT, ILMA and TI was associated with a significant learning effect in all groups. This was not observed with the cLMA, PLMA or LT. All non-anaesthetists were able to insert the cLMA, PLMA and LT within two attempts with a90% success rate on the first attempt. The ILMA and TI were the only devices where more than one subject experienced some difficulty in insertion. The cLMA, PLMA and LT should be evaluated for use in situations where only limited airway training is possible.

The halothane-caffeine contracture test is presently the most well-established method for identification of malignant hyperthermia susceptibility (MHS) or non-susceptibility (MHN). However, 10-20% of the patients tested are classified as equivocal (MHE), i.e. their susceptibility remains uncertain. A genetic disorder of the calcium releasing ryanodine receptor has been postulated recently. Therefore, 12 patients were tested in addition to the protocol of the European Malignant Hyperthermia Group (EMHG) for dose- and time-dependent contracture after ryanodine application. In this study, contracture of 0.2g appeared significantly earlier in MHS patients (17.5 +/- 1.7 min; n = 5) during cumulative ryanodine exposition (0.4-0.8-1.6-10.0 mumol/l) than in MHN (38.2 +/- 5.4 min; n = 5). A significant difference between MHS (10.0 +/- 1.7 min; n = 6) and MHN (19.8 +/- 0.6 min; n = 3) was also seen after bolus application of ryanodine (10.0 mumol/l). One patient classified as MHE according to the EMHG protocol, manifested as MHN after the ryanodine contracture test. This study supports previous work suggesting the ryanodine contracture test as an improvement in the in-vitro diagnosis of MH susceptibility.

Alpha-adrenoceptor stimulation may induce malignant hyperthermia (MH) in vivo. Consequently, we have investigated the effects of the alpha-adrenoceptor agonist phenylephrine and, for comparison, the effects of the beta-adrenoceptor agonist isoproterenol on inositol-lipid metabolism of malignant hyperthermia susceptible (MHS) and healthy control (MHN) swine. The experiments were performed on electrically stimulated (frequency 0.2 Hz) trabeculae isolated from the right ventricles of the hearts of MHS and MHN animals. After labelling with [3H]inositol for 6 h, different inositol phosphates were measured by high pressure liquid chromatography, including inositol 1-phosphate, inositol 1,4-bisphosphate, inositol 1,3,4-trisphosphate, inositol 1,4,5-trisphosphate (1,4,5-IP3) and inositol 1,3,4,5-tetrakisphosphate. After stimulation with isoproterenol, the inositol phosphate content did not increase or vary between muscle from MHS and MHN animals. In contrast, all inositol phosphates increased after stimulation with phenylephrine in both muscle types, the effects being greater in MHS than in MHN, especially as regards 1,4,5-IP3 content. As 1,4,5-IP3, a presumed second messenger, has been shown to mobilize intracellular calcium, it is concluded that an enhanced alpha-adrenergic response is involved in the development of MH.

The time course of changes in brain electrical activity during halothane anesthesia was examined in 12 malignant hyperthermia-susceptible (MHS) and 14 normal (nMHS) swine. Power densities in selected frequency bands were calculated from the electroen-cephalogram (EEG). EEG and systemic variables were determined over a period of 60 min after starting halothane (1% inspired). Malignant hyperthermia (MH) was triggered in all susceptible pigs. Initial changes in the EEG during development of MH consisted of a decrease in total power and a shift to lower frequencies (delta-theta activity) in all animals. These EEG alterations were noted when there was an increase in heart rate, but other systemic variables were still normal. EEG changes in all MHS animals started at an arterial oxygen tension (PaO2) greater than 90 mmHg and an arterial carbon dioxide tension (PaCO2) less than 50 mmHg. In 5 MHS animals EEG became isoelectric at a PaO2 of 61-82 mmHg and a PaCO2 of 53-68 mmHg. Mean arterial blood pressure at this time was 54-66 mmHg. To determine the effects of hypoxia on the EEG in 7 nMHS animals, oxygen was decreased over a period of 45-60 min to 7% inspired. In 7 other nMHS animals, hypercarbia was produced by admixture of carbon dioxide to the fresh gas supply to achieve incremental increases of PaCO2 to 110-120 mmHg. Significant EEG changes during hypoxia comparable to those seen at the onset of MH were noted at a PaO2 below 40 mmHg and during hypercarbia at a PaCO2 greater than 68 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

8 ASA class II-III patients (50-67 years) undergoing traumatic-surgical procedures were studied. Since the release of atrial natriuretic peptide (ANP) is stimulated by volume loading and increased right atrial pressure (RAP), the effects on incremental positive end-expiratory pressure (PEEP) on ANP-concentration, RAP and right atrial dimensions were investigated

Die aktuelle Kontroverse um den Pulmonalarterien-(PA)-Katheter verstarkt das Interesse an alternativen, weniger gefahrlichen Methoden. Die transosophageale Echokardiographie (TEE) ist ein minimal invasives Verfahren, das als diagnostisches Instrumentarium in der Intensivmedizin bereits etabliert ist, aber auch das Potential fur ein kontinuierliches automatisches Uberwachungsverfahren birgt. Die klinische Effizienz der TEE kann noch nicht mit der des PA-Katheters verglichen werden, weil es vergleichsweise wenige Studien zur TEE in der Intensivmedizin gibt. Der kurzlich gefuhrte Nachweis von Unkenntnis und Fehlern im Umgang mit dem PA-Katheter relativiert zudem die positiven wie negativen Studienergebnisse zu dessen klinischem Nutzen. Wahrend der PA-Katheter hauptsachlich direkt Informationen uber den rechten Ventrikel liefert, erlaubt die TEE zusatzlich eine Beurteilung der linksventrikularen Funktion. Daher kann die TEE die Ursache einer unerklarten kardiovaskularen Instabilitat meist zuverlassig fokussieren und die Indikation fur invasive Masnahmen wie die PA-Katheterisierung eingrenzen.

Cardiac dysrhythmias in septic patients often reflect hypovolaemia, hypokalaemia or endocarditis as cardiac manifestation of the infection, but may be indicative for underlying cardiac pathology previously undiagnosed. We report on the case of a patient with severe peritonitis, on whom transoesophageal echocardiography (TEE) had been performed intraoperatively due to progressive circulatory instability. TEE revealed first diagnosis of asymmetric hypertrophic cardiomyopathy, which complicated the features of septic syndrome. Further perioperative treatment to support the circulation was successfully adjusted on the grounds of this diagnosis.