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Background Children with congenital heart defects (CHDs) are at high risk for myocardial failure after operative procedures with cardiopulmonary bypass (CPB). Recent studies suggest that microRNAs (miRNA) are involved in the development of CHDs and myocardial failure. Therefore, the aim of this study was to determine alterations in the miRNA profile in heart tissue after cardiac surgery using CPB. Methods In total, 14 tissue samples from right atrium were collected from patients before and after connection of the CPB. SurePrint™ 8 × 60K Human v21 miRNA array and quantitative reverse transcription-polymerase chain reaction (RT-qPCR) were employed to determine the miRNA expression profile from three patients before and after connection of the CPB. Enrichment analyses of altered miRNA expression were predicted using bioinformatic tools. Results According to miRNA array, a total of 90 miRNAs were significantly altered including 29 miRNAs with increased and 61 miRNAs with decreased expression after de-connection of CPB (n = 3) compared to before CPB (n = 3). Seven miRNAs had been validated using RT-qPCR in an independent cohort of 11 patients. Enrichment analyses applying the KEGG database displayed the highest correlation for signaling pathways, cellular community, cardiovascular disease and circulatory system. Conclusion Our result identified the overall changes of the miRNome in right atrium tissue of patients with CHDs after CPB. The differentially altered miRNAs lay a good foundation for further understanding of the molecular function of changed miRNAs in regulating CHDs and after CPB in particular. Electronic supplementary material The online version of this article (doi:10.1186/s12967-017-1213-9) contains supplementary material, which is available to authorized users.

Aim: To provide data on the inadequate use of emergency medical transports services (EMTS) in children and underlying contributing factors. Methods: This was a prospective single-center cohort study (01/2017-12/2017) performed at the Saarland University Children's Hospital, Homburg, Germany. Patients ≤20 years of age transported by EMTS for suspected acute illness/trauma were included and proportion of inadequate/adequate EMTS use, underlying contributing factors, and additional costs were analyzed. Results: Three hundred seventy-nine patients (mean age: 9.0 ± 6.3 years; 55.7% male, 44.3% female) were included in this study. The three most common reasons for EMTS use were: central nervous system (30.6%), respiratory system affection (14.0%), and traumas (13.2%). ETMS use was categorized as inadequate depending on physician's experience: senior physician (58.8%), pediatrician (54.9%), resident (52.7%). All three physicians considered 127 (33.5%) cases to be medically indicated for transportation by EMTS, and 177 (46.7%) to be medically not indicated. The following parameters were significantly associated with inadequate EMTS use: non-acute onset of symptoms (OR 2.5), parental perception as non-life-threatening (OR 1.7), and subsequent out-patient treatment (OR 4.0). Conversely, transport by an emergency physician (OR 3.5) and first time parental EMTS call (OR 1.7) were associated with adequate use of EMTS. Moreover, a significant relation existed between maternal, respectively, paternal educational status and inadequate EMTS use (each p = 0.01). Using multiple logistic regression analysis, non-acute onset of symptoms (OR 2.2) was associated with inadequate use of EMTS while first time parental EMTS call (OR 1.8), transport by an emergency physician (OR 3.3), and need for in-patient treatment (OR 4.0) were associated with adequate use of EMTS. Conclusion: A substantial number of pediatric EMTS is medically not indicated. Possibly, specific measures including multifaceted educational efforts may be helpful in reducing unnecessary EMTS use.

The article provides an overview of the reactor dynamics code DYN3D. The code comprises various 3D neutron kinetics solvers, a thermal-hydraulics reactor core model and a thermo-mechanical fuel rod model. The implemented models and methods and the capabilities and features of the code are described. Latest developments of models and methods are delineated. An overview on the status of verification and validation is given. Code applications for selected safety analyses are described. Furthermore, multi-physics code couplings to thermal-hydraulic system codes, CFD and sub-channel codes as well as to the fuel performance code TRANSURANUS are outlined. Developments for innovative reactor concepts, in particular Molten Salt Reactor, High Temperature Gas-cooled Reactor and Sodium Fast Reactor are delineated. The management of code maintenance is briefly described. An outlook on further code development is given.

This paper describes the derivation of the nodal flux expansion method HEXNEM3, its implementation into the nodal diffusion code DYN3D and the corresponding testing versus benchmarks. As in the earlier versions of expansion method HEXNEM1 and HEXNEM2, the neutron flux in a hexagonal node is expanded into superposition of orthogonal polynomials and exponential functions. The main difference of the HEXNEM3 method is the additional use of tangentially weighted exponential functions and the coupling of neighboring nodes by tangentially weighted fluxes and currents on node surfaces. The HEXNEM3 method was tested in several benchmark problems, including numerical benchmarks with given cross sections set and reference solutions by fine-mesh finite difference diffusion and a real plant benchmark with Monte Carlo reference solution. The test results demonstrate good agreement with reference solutions and improvement of method accuracy in comparison with HEXNEM1 and HEXNEM2.

Tagtaglich mussen Anasthesisten entscheiden, ob und ggf. wann bei Patienten eine ruckenmarksnahe Anasthesie durchgefuhrt werden kann, die eine Thromboembolieprophylaxe erhalten haben oder unter einer antithrombotischen Medikation stehen. Zur Erleichterung dieses Entscheidungsprozesses hat die Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin (DGAI) mit Beschluss vom 21.07.2014 nunmehr in 3. Uberarbeitung Empfehlungen bezuglich der einzuhaltenden Zeitintervalle herausgegeben und als S1-Leitlinie „Ruckenmarksnahe Regionalanasthesien und Thromboembolieprophylaxe / antithrombotische Medikation“ publiziert 1 . Die Uberarbeitung war notwendig geworden, weil seit dem Erscheinen der letztmaligen Fassung im Jahr 2007 mehrere neue orale Antikoagulanzien (NOAKs) und Thrombozytenaggregationshemmer fur den deutschen Markt zugelassen wurden. Unsicherheiten hinsichtlich ihrer Verordnung vor und nach ruckenmarksnaher Punktion bzw. Katheterentfernung sollten nun ausgeraumt werden. In der nachfolgenden Ubersicht werden die wichtigsten Empfehlungen zusammengefasst und erlautert.

Background Little is known about the incidence of severe critical events in children undergoing general anaesthesia in Europe. We aimed to identify the incidence, nature, and outcome of severe critical events in children undergoing anaesthesia, and the associated potential risk factors. Methods The APRICOT study was a prospective observational multicentre cohort study of children from birth to 15 years of age undergoing elective or urgent anaesthesia for diagnostic or surgical procedures. Children were eligible for inclusion during a 2-week period determined prospectively by each centre. There were 261 participating centres across 33 European countries. The primary endpoint was the occurence of perioperative severe critical events requiring immediate intervention. A severe critical event was defined as the occurrence of respiratory, cardiac, allergic, or neurological complications requiring immediate intervention and that led (or could have led) to major disability or death. This study is registered with ClinicalTrials.gov, number NCT01878760. Findings Between April 1, 2014, and Jan 31, 2015, 31 127 anaesthetic procedures in 30 874 children with a mean age of 6·35 years (SD 4·50) were included. The incidence of perioperative severe critical events was 5·2% (95% CI 5·0–5·5) with an incidence of respiratory critical events of 3·1% (2·9–3·3). Cardiovascular instability occurred in 1·9% (1·7–2·1), with an immediate poor outcome in 5·4% (3·7–7·5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10 000. This was independent of type of anaesthesia. Age (relative risk 0·88, 95% CI 0·86–0·90; p

Die perioperative Uberwachung und Steuerung der Herz-Kreislauf-Funktion zahlt mit zu den wichtigsten Aufgaben der anasthesiologischen Patientenversorgung. Da schwerwiegende Kreislaufreaktionen jederzeit auftreten konnen, sind eine hohe Vigilanz und ein schnelles zielorientiertes Handeln zwingend erforderlich und bedingen u. U. eine Therapie mit kardiovaskular wirksamen Medikamenten, die in diesem Kapitel vorgestellt werden.

Background Intraoperative blood salvage and processing it with commercially available devices is a widespread standard procedure to reduce allogeneic blood transfusion in patients undergoing major orthopedic surgery. The aim of this study was to investigate the impact of such processed blood on the immune system by measuring pro- and anti-inflammatory cytokines. Study Design and Methods Salvaged blood from 20 patients undergoing hip arthroplasty was processed with a continuous autotransfusion system. One part of the processed blood was left without further treatment, one part was additionally leukoreduced, one part was irradiated, and one part was separated into its cellular and soluble fraction by centrifugation. Specimens from each part were mixed in vitro with venous blood from the patient in ratios of 3:1, 1:1, and 1:3 and incubated with endotoxin for 24 hours. Tumor necrosis factor (TNF)-α and interleukin (IL)-10 were measured in cell culture supernatants by enzyme-linked immunosorbent assay. Results All parts of the salvaged blood were without a significant influence on TNF-α release. In contrast, IL-10 was significantly increased, independently of the admixtured salvaged blood being plain, additionally irradiated, or additionally leukoreduced. This IL-10 increase was also found with the cellular fraction of the plain salvaged blood, whereas the soluble fraction had no influence on IL-10 release. Conclusion Intraoperative salvaged blood is not immunologically inert. We observed a significant increase in the anti-inflammatory IL-10 response without affecting the proinflammatory TNF-α release. Neither leukofiltration nor gamma irradiation eliminated this effect that was limited only to the cellular fraction of the salvaged blood, suggesting red blood cells to be responsible for the observed immunomodulation.

The aim of this study was to evaluate the applicability of the laryngeal tube (LT) size 2 and the classical laryngeal mask airway (LMA) size 2 in different head–neck positions under positive pressure ventilation in children by measuring leak pressures, peak pressures and the achievable tidal volumes under positive pressure ventilation. Forty children were randomized to receive airway management by either the LT or LMA as the primary device. Leak pressures, peak pressures and tidal volumes under positive pressure ventilation were measured in the neutral, anteflection, retroversion, left-rotation and right-rotation head–neck positions. In all head–neck positions, the leak pressures were significantly higher for the LT than for the LMA (neutral 25.9 ± 7.0 vs. 19.1 ± 5.7 cmH2O; anteflection 29.7 ± 7.1 vs. 24.2 ± 8.9 cmH2O; retroversion 24.1 ± 7.6 vs. 17.2 ± 6.9 cmH2O). In both devices, the peak ventilation pressures were higher in the anteflection position (LT 27.1 ± 6.3 cmH2O; LMA 17.8 ± 6.7 cmH2O) than in the retroversion position (LT 13.7 ± 3.9 cmH2O; LMA 12.7 ± 3.6 cmH2O). Compared to the respirator settings, lower tidal volumes were achieved in the anteflection position (LT 65 ± 48 vs. 129 ± 38 ml, LMA 100 ± 21 vs. 125 ± 29 ml) as compared to the other positions. Based on our results, we suggest that in anaesthetized children, the size 2 LT, compared to the size 2 LMA, may be more suitable for positive pressure ventilation due to favorable leak and peak pressures. Both devices can be safely used in head–neck positions other than neutral. Most disadvantageous with regards to the measured parameters was the anteflection position, especially for the LT.

The development of spatial dynamics code for molten salt reactors (MSRs) is reported in this paper. The graphite-moderated channel type MSR – one of the ‘Generation IV’ concepts – was selected for the numerical simulation. It has several peculiarities (e.g. the drift of delayed neutrons precursors), which disable the use of standard dynamics codes. Therefore, the own DYN3D-MSR code was developed. It is based on the light water reactor code DYN3D and it allows transients simulation by 3D neutronics and parallel channel thermal-hydraulics. The neutronics and thermal-hydraulics were modified for the MSR peculiarities, where the experience from DYN1D-MSR development was exploited. The code was validated on experimental results from the MSRE experiment done in Oak Ridge National Laboratory and by the comparison with other codes especially with the 1D version. However, by the 3D code transients can be simulated, where space-dependant efforts are relevant, like local blockage of fuel channels or local temperature perturbations.

Nach intrakraniellen Eingriffen, z. B. Operationen an supratentoriellen Hirntumoren, mussen Patienten auf der Intensivstation oft analgosediert und beatmet werden; anschliesend sind ein zugiges Erwachen und damit die Moglichkeit zur neurologischen Untersuchung wunschenswert. In dieser retrospektiven Untersuchung wurden zwei Konzepte der Anasthesiefuhrung und der anschliesenden Analgosedierung auf der Intensivstation (Fentanyl-Midazolam- und Remifentanil-Propofol-Kombination) hinsichtlich der Extubationszeiten und der Verweildauer auf der Intensivstation verglichen. Intraoperativ erhielten die Patienten entweder eine kontinuierliche Infusion von Fentanyl (0,2–1,0 mg/h) und Midazolam (2–10 mg/h) oder Remifentanil (0,2–0,5 µg/kgKG/min) und Propofol (3–6 mg/kgKG/h). Nach dem Eintreffen auf der Intensivstation wurden Fentanyl (0,03–0,2 mg/h) und Midazolam (2–12 mg/h) oder Remifentanil (0,1–0,2 µg/kgKG/min) und Propofol (0,5–3 mg/kgKG/h) infundiert. Hierbei wurde ein Ramsay-Score von 4 angestrebt. Als Zielparameter wurden die Zeiten vom Stopp der Infusion bis zur Extubation und die Gesamtaufenthaltsdauer auf der Intensivstation untersucht. Insgesamt wurden 60 Patienten (je n=30) einer neurochirurgischen Intensivstation in diese Untersuchung aufgenommen. Die Patienten der Remifentanil-Propofol- und der Fentanyl-Midazolam-Gruppe waren hinsichtlich des Alters (53,7±13,5 vs. 51,3±16,3 Jahre), des Gewichts, der American-Society-of-Anesthesiologists- (ASA-)Gruppe, der Art der Operation sowie der Dauer der Anasthesie und der anschliesenden Analgosedierung auf der Intensivstation (528±382 vs. 548±360 min) vergleichbar. Anschliesend betrugen die Zeit vom Stopp der Analgosedierung bis zur Extubation in der Remifentanil-Propofol-Gruppe 47 min und die Dauer des Gesamtaufenthalts auf der Intensivstation 1,8 Tage. Diese Zeiten waren damit signifikant kurzer als die der Fentanyl-Midazolam-Gruppe: Stopp der Analgosedierung bis zur Extubation 481 min und Dauer des Gesamtaufenthalts auf der Intensivstation 3,7 Tage. Wegen fortbestehender Bewusstlosigkeit und nichtdurchfuhrbarer neurologischer Beurteilung wurde bei 3 Patienten der Fentanyl-Midazolam-Gruppe eine kraniale Computertomographie (CCT) zum Ausschluss von Komplikation durchgefuhrt; dies war in der Remifentanil-Propofol-Gruppe nicht erforderlich. In der vorliegenden Untersuchung konnte gezeigt werden, dass der Einsatz von Remifentanil und Propofol zur Anasthesiefuhrung und anschliesenden Analgosedierung auf der Intensivstation deutlich kurzere Extubationszeiten und einen kurzeren Intensivaufenthalt ermoglicht als die Kombination aus Fentanyl und Midazolam. Zudem kann durch die Fentanyl-Midazolam-Kombination die neurologische Beurteilung so erschwert werden, dass eine letztlich unnotige CT-Diagnostik durchgefuhrt wird.

In this prospective, double-blind, randomized, placebo-controlled study we compared the efficacy of three IV non-opioid analgesics for postoperative pain relief after lumbar microdiscectomy. Eighty healthy patients were randomly divided into 4 treatment groups (n = 20 each) to receive either parecoxib 40 mg, paracetamol 1 g, metamizol 1 g, or placebo IV 45 min before the end of surgery. In the postanesthesia care unit (PACU) patients were treated using patient-controlled analgesia (PCA) with piritramide. In the metamizol group the pain score at arrival in the PACU was significantly lower compared with the paracetamol, parecoxib, and placebo groups. In addition, in the metamizol group significantly fewer patients required additional PCA compared with the other groups studied. However, in those patients who required additional pain therapy in the four treatment groups, there was no significant difference in time to first request for piritramide and cumulative consumption of piritramide as assessed by the PCA data in the PACU. The incidence of adverse side effects was infrequent in all groups. These results suggest that in patients undergoing lumbar microdiscectomy, metamizol is superior to parecoxib, paracetamol, and placebo for immediate postoperative pain relief with minimal side effects.

Die Minimierung des perioperativen kardiovaskularen Risikos durch medikamentose Interventionen spielt in der Anasthesie eine wichtige Rolle. So hat z. B. die Therapie mit β-Blockern inzwischen einen festen Stellenwert in der perioperativen anasthesiologischen Behandlung erlangt. In der Literatur gibt es eine zunehmende Fulle an Hinweisen auf einen myokardprotektiven Effekt der volatilen Anasthetika. Dieses Phanomen wird mit dem Begriff der anasthetikainduzierten Prakonditionierung (AP) beschrieben. Tierexperimentelle Daten sind vielfaltig und komplex. Die Mechanismen der anasthetikainduzierten Kardioprotektion wurden eingehend untersucht, sind aber letztlich nicht abschliesend geklart. Auch erste klinische Daten belegen einen protektiven Effekt der inhalativen Anasthetika anhand von myokardialen Funktions- und Schadigungsparametern. Daher stellt sich fur den klinisch tatigen Anasthesisten die Frage einer praktischen Relevanz fur die Narkosefuhrung bei Patienten mit entsprechendem Risikoprofil. Die vorliegende Arbeit gibt einen Uberblick uber die derzeitigen wissenschaftlichen Ergebnisse mit einer Fokussierung auf die Mechanismen der anasthesiologischen Prakonditionierung und auf klinische Untersuchungen.

Die pharmakodynamische Wirkung zahlreicher Anasthetika und Muskelrelaxanzien, u. a. Rocuronium (Roc), wird auch durch das Geschlecht der Patienten beeinflusst. Frauen haben eine um ca. 30% erhohte Sensitivitat (verkurzte Anschlagzeit und tiefere neuromuskulare Blockade) gegenuber Roc als Manner. Ob damit auch eine Verbesserung der Intubationsbedingungen einhergeht, ist unklar. Nach Zustimmung der Ethikkommission wurden 60 Frauen und 60 Manner jeweils in 2 Gruppen randomisiert, um 0,6 mg/kgKG Roc oder 1,0 mg/kgKG Succinylcholin (Sux; Kontrollgruppen) zu erhalten. Narkoseeinleitung: Fentanyl (3 µg/kgKG), Thiopental (5,0 mg/kgKG) und Roc/Sux; endotracheale Intubation: 60 s spater. Bestimmt wurden Anzahl der Intubationsversuche, Intubationszeit, Larynxbefund nach Cormack u. Lehane sowie Intubationsbedingungen („Kopenhagener score“). Manner waren signifikant schwerer und groser (p

Delayed awakening after general anaesthesia is in the majority of cases due to prolonged effects of anaesthetic drugs. However, intracerebral processes are also associated with disturbances of consciousness. Here, we report a case of a female patient who developed an intracerebral haemorrhage because of an arteriovenous malformation during routine surgery. This shows that in the case of delayed awakening after general anaesthesia the possibility of an intracerebral process should be considered early even after routine surgery.

The OECD/NRC BWR Turbine Trip Benchmark was analysed by the codes DYN3D and the coupled code system ATHLET/DYN3D. Considering the calculations with given thermal-hydraulic boundary conditions of the core for the Exercise 2 of the benchmark the analyses were performed with the core model DYN3D. Concerning the modelling of the BWR core in the DYN3D code several simplifications and their influence on the results were investigated. The standard calculations with DYN3D were performed with 764 coolant channels (1 channel per fuel assembly), the assembly discontinuity factors (ADF) and the phase slip model of MOLOCHNIKOV. Comparisons were performed with the results obtained by calculations with 33 thermal-hydraulic channels, without the ADF and with the slip model of ZUBER-FINDLAY. It is shown that the influence on core-averaged values of the steady state and the transient is small. Considering local parameters the influence of the ADF or the reduced number of coolant channels is not negligible. For the calculations of Exercise 3 the DYN3D-model validated during the Exercise 2 calculations in combination with the ATHLET system model, developed at GRS for Exercise 1 has been used. Calculations were performed for the basic scenario as well as for all specified extreme versions. They were carried out using a modified version of the external coupling of the codes, the ?parallel? coupling. This coupling shows a stable performance at the low time step sizes, which are necessary for an appropriate description of the feedback during the transient. The influence of assumed failures of different relevant safety systems on the plant and the core behaviour was investigated in the calculations of the extreme scenarios. The calculations of Exercise 2 and 3 contribute to the validation of DYN3D and ATHLET/DYN3D for boiling water reactor systems.

The Organization for Economic Cooperation and Development (OECD) Main Steam Line Break (MSLB) Benchmark was defined to validate the thermal-hydraulic system codes coupled with three-dimensional (3-D) neutron kinetic codes. The reference problem is an MSLB in a pressurized water reactor at end of cycle. The analyses were performed with the 3-D core model DYN3D, the thermal-hydraulic system code ATHLET, and the coupled code DYN3D/ATHLET. The results of the DYN3D and ATHLET simulations based on the specification are compared with the results of other participants in the final OECD reports. The effect of the thermal-hydraulic nodalization of the core, i.e., the number of coolant channels, and the influence of the coolant mixing inside the pressure vessel are studied in the paper. Calculations with a reduced number of coolant channels are performed often in coupled calculations for saving computational time. Results of a 25-channel model were compared with the 177-channel calculation (1 channel per assembly). The results for global parameters like nuclear power show only small differences for the two models; however, the prediction of local parameters such as maximum fuel temperatures requires a detailed thermal-hydraulic modeling. The effect of different coolant mixing within the reactor pressure vessel is investigated. It ismore » shown that the influence of coolant mixing mitigates the accident consequences when 3-D neutron kinetics is applied. In case of point kinetics, coolant mixing leads to an opposite effect. To profit from the 3-D core model, a realistic description of the coolant mixing in the coupled codes is a topic of further investigations.« less

Background: Cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction. Microcirculation-dependent alteration of the gut mucosal barrier with subsequent translocation of endotoxins is a postulated mechanism for this inflammatory response. This study was designed to elucidate whether two different approaches to modulate splanchnic perfusion may influence systemic inflammation to CPB. Methods: We examined 40 patients scheduled for elective coronary bypass surgery in a prospective, randomized study. One group (DPX) received dopexamine (1 µg · kg−1 · min−1) continuously after induction of anesthesia until 18 h after CPB. The control group (CON) received equal volumes of NaCl 0.9% in a time-matched fashion. In a third group (EPI) a continuous epidural infusion of bupivacaine 0.25% [(body height (cm) – 100) · 10−1=ml·h−1] was administered for the whole study period. Procalcitonin (PCT), tumor necrosis factor (TNF-α), soluble TNF receptor, human soluble intercellular adhesion molecule-1, C-reactive protein (CRP) and leukocyte count were measured as parameters of inflammation. Results: All parameters significantly increased following CPB. Increases of PCT, TNF-α and leukocyte count were significantly attenuated in the DPX and EPI groups at different time points. However, neither splanchnic blood flow nor oxygen delivery and consumption were different when compared with the CON-group. Conclusion: These results do suggest that mechanisms other than an improved splanchnic blood flow by DPX and EPI treatment have to be considered for the anti-inflammatory effects.

We investigated the specificity for gram-negative stimuli as well as the contribution of signal transduction pathways for leukocyte hyporesponsiveness in sepsis or following cardiopulmonary bypass (CPB). Whole blood of nine patients undergoing CPB and 25 patients with severe sepsis was stimulated ex vivo with LPS (E. coli O111:B4) or with Staphylococcus aureus Cowan strain I (SAC-I) lysate in the absence or presence of inhibitors of protein kinase C (PKC), protein-tyrosine kinase (PTK), or protein-tyrosine phosphatase (PTP). Both toxins stimulated a TNF-alpha response through PTK signaling. Although suppression of the cytokine response was similar for LPS and SAC-I after CPB, it was significantly more pronounced for SAC-I in sepsis. Inhibition of PTP failed to increase TNF-alpha upon LPS, whereas a moderate increase was observed with SAC-I. Impaired TNF-alpha responses occur in sepsis and after CPB. Although this has primarily been reported for gram-negative stimuli, our data suggest that this is even more pronounced for gram-positive stimuli in severe sepsis. Although PTK was the predominant signaling pathway, inhibition of PTP only partially restored the TNF-alpha response to SAC-I. Our results suggest that cellular mechanisms underlying monocyte deactivation are different in sepsis or following CPB and are discriminate for gram-positive and gram-negative toxins.

BACKGROUND: Nitrous oxide (N2O) has been suggested to contribute to bowel distension, resulting in worsened operating conditions for laparoscopic surgery, and to increase incidence of postoperative nausea and vomiting. Therefore, our objective was to assess the feasibility of two remifentanil-based anaesthetic regimens free from N2O with special regard to recovery profile, postoperative analgesic demand and side effects in patients undergoing laparoscopic cholecystectomy. METHODS: Fifty patients (ASA I-II, 23-65 yr) were randomly assigned to receive remifentanil-based anaesthesia in conjunction with propofol (group R/P) or desflurane (group R/D). After standardised induction of anaesthesia, analgesia was continued with remifentanil in all patients. For maintenance of hypnosis, propofol or desflurane were used in concentrations to ensure loss of consciousness, lack of awareness, and maintenance of heart rate and blood pressure within +/- 25% of initial values. At the end of surgery all anaesthetics were discontinued without tapering and early emergence and recovery were recorded. Pain scores were assessed by using a visual analogue scale. Patient-controlled analgesia with i.v. piritramide was used for treatment of postoperative pain and recorded for 90 min in the postanaesthesia care unit (PACU). In addition, side effects were noted. RESULTS: Early emergence from anaesthesia did not differ between the groups. In group R/P, time to eye opening, spontaneous respiration and extubation was 4.4 +/- 2.9 min, 5.2 +/- 3.4 min and 5.5 +/- 3.3 min respectively, compared with 4.7 +/- 2.7 min, 5.3 +/- 2.4 min and 5.7 +/- 2.5 min in group R/D. While pain scores did not differ between both groups on admission to the PACU, patients receiving desflurane required more i.v. piritramide as compared to those receiving propofol, 22.0 +/- 6.5 mg and 17.9 +/- 7.0 mg, respectively (P

Background The ability of leukocytes to release proinflammatory cytokines on lipopolysaccharide stimulation in vitro is impaired after cardiopulmonary bypass (CPB). This study tested contribution and interaction of humoral factors in altered leukocyte responsiveness to lipopolysaccharide. Methods Whole blood and isolated peripheral-blood mononuclear cells (PBMCs) from 10 patients obtained after induction of anesthesia (T1) and 20 min (T2) and 24 h (T3) after CPB were cultured in the absence or presence of lipopolysaccharide and assessed for release of tumor necrosis factor alpha (TNF-alpha) and interleukin (IL)-1beta and their functional antagonists, IL-1 receptor antagonist (IL-1ra) and IL-10. In addition, dose-response characteristics and interaction of IL-10 and norepinephrine as modulators of TNF-alpha release were studied. Results Cardiopulmonary bypass induced release of antiinflammatory (T2: IL-10: median 25 pg/ml, 25th-75th percentile 9-42; IL-1ra: median 1,528 pg/ml, 25th-75th percentile 1,075-17,047; P < 0.05 compared with T1) but failed to induce proinflammatory cytokines (T2: TNF-alpha: median 0 pg/ml, 25th-75th percentile 0-6; IL-1beta: median 1 pg/ml, 25th-75th percentile 0-81; nonsignificant). Removal of plasma at T2 increased TNF-alpha response to lipopolysaccharide (+83.8%; P < 0.05), whereas it suppressed IL-10 (-36.8%; P < 0.05). Similarly, incubation of PBMCs (T1) with plasma obtained after CPB (T2) as well as addition of IL-10 or norepinephrine in concentrations present in plasma after CPB led to a reduced lipopolysaccharide-stimulated TNF-alpha and an increased IL-10 response. Coadministration of norepinephrine and IL-10 had synergistic effects. Although pretreatment with an anti-IL-10 antibody and labetalol before addition of plasma obtained at T2 largely restored the TNF-alpha response in vitro, their addition post-treatment failed to restore the monocytic TNF-alpha response. Conclusions Plasma contains interacting factors that inhibit the release of TNF-alpha and increase the release of IL-10, presumably attenuating the inflammatory response to CPB. Although norepinephrine fails to induce a cytokine response in the absence of other stimuli, its administration seems to augment the antiinflammatory IL-10 response while attenuating the TNF-alpha response.

Fragestellung. Die pharmakodynamische Wirkung zahlreicher Anasthetika und Adjuvanzien wird auch durch das Geschlecht der Patienten beeinflusst. Ziel der vorliegenden Studie war es zu untersuchen ob es zwischen mannlichen und weiblichen Patienten Unterschiede im Verlauf der neuromuskularen Blockade von 0,45 mg/kg Rocuronium (1,5 × ED95) gibt. Methodik. Mittels Elektromyographie wurde an jeweils 20 weiblichen (Gruppe A) und 20 mannlichen Patienten (Gruppe B) der zeitliche Verlauf der neuromuskularen Blockade und die maximale Muskelblockade nach 0,45 mg/kg Rocuronium untersucht. Ergebnisse. Die Patientinnen waren 38 (±8) Jahre, die Patienten 37 (±10) Jahre alt (n.s.). In Gruppe A betrug der body mass index (BMI) 24,2 (±2,9)kg/m2, in Gruppe B 25,2 (1,7) kg/m2; n.s. Die mannlichen Patienten waren signifikant schwerer und groser als die weiblichen Patienten: 77,5 (±5,5) kg vs. 65,7 (±9,3) kg; p

Study Objective: To compare recovery, hemodynamics, and side effects of remifentanil-based anesthesia with hypnotic concentrations of isoflurane or propofol. Design: Multicenter, prospective, randomized, two-group study. Setting: 15 university and 5 municipal hospitals. Patients: 249 ASA physical status I, II, and III adult patients scheduled for elective gynecological laparoscopy, varicose vein, or arthroscopic surgery of at least 30 minutes' duration. Interventions: Anesthesia was induced in the same manner in both groups: remifentanil-bolus (1 μg/kg), start of remifentanil-infusion (0.5 μg/kg/min), followed by propofol as needed for induction. Five minutes after intubation, remifentanil was reduced to 0.25 μg/kg/min, and it was combined with either a propofol-infusion (0.1 mg/kg/min) or with isoflurane (0.6 vol% end-tidal) in O 2 /air. Adverse hemodynamic responses of heart rate and systolic blood pressure were recorded and treated according to a predefined protocol. With termination of surgery, anesthetic delivery was discontinued simultaneously without tapering, and recovery times were recorded. Measurements and Main Results: No significant differences were observed between the remifentanil-isoflurane or remifentanil-propofol treatment regimens. Recovery times (means ± SD) were similar for spontaneous ventilation (5.8 ± 3.2 min vs. 6.3 ± 3.7 min), extubation (7.6 ± 3.5 vs. 8.5 ± 4.2 min), eye opening (6.8 ± 3.2 vs. 7.5 ± 3.8 min), and arrival to the postanesthesia care unit (16.5 ± 7.0 vs.18.0 ± 7.2 min). There were no significant differences in adverse hemodynamic responses, postoperative shivering, nausea, or vomiting between the groups. Conclusions: Emergence after remifentanil-based anesthesia with 0.6 vol% of isoflurane is at least as rapid as with 0.1 mg/kg/min propofol. Both isoflurane and propofol are suitable adjuncts to remifentanil, and the applied dosages are clinically equivalent with respect to emergence and recovery. Therefore, both combinations should be appropriate, particularly in settings in which rapid recovery from anesthesia is desirable, such as fast tracking and/or ambulatory surgery.

A new nodal method HEXNEM2 for hexagonal geometry is described. The method is based on a two-dimensional expansion of the intranodal fluxes. Polynomials up to the second order and exponential functions are used in each group. By this method the singular terms occurring in the transverse integration methods are avoided. Side averaged and corner point values of fluxes and currents are used for the coupling of nodes. A calculation scheme for the outgoing partial currents at the sides and similar expressions for the corners from given incoming values are used in the inner iteration which gives a fast running scheme. The method is tested against 2-dimensional hexagonal benchmark problems for the VVER-type reactors. The results show that the multiplication factor and nodal powers are predicted accurately. A considerable improvement can be shown of the results for the VVER-1000 benchmarks compared with the method developed previously for the code DYN3D and the simpler method HEXNEM1.

In der vorliegenden Studie wurde der Einflus von Dopexamin auf die Splanchnikusperfusion und die allgemeine Hamodynamik wahrend einer aortokoronaren Bypassoperation untersucht.

Subsequent studies have identified many scenarios, which can lead to reactivity excursions due to boron dilution. The comparative study, presented in this paper, deals with the so-called “restart of the first reactor coolant pump’’ scenario and its reactor-dynamic consequences for both Russian designed VVER reactor types, VVER-440 and VVER-1000. The transient simulations were performed using the three-dimensional core dynamics code DYN3D. The DYN3D modeling features, including recent developments, as well as the cross-section methodology involved in these calculations, are described. The analyzed accident scenario is outlined together with the assumptions made. The results of core response in this boron dilution accident for both VVER reactors are compared within the ranges, determined by the two reactivity values of interest: the criticality limit and the reactivity initiated accident (RIA) limit.

Der Syntheseort fur das inflammatorische Peptid Procalcitonin (PCT) ist bisher nicht bekannt. In der vorliegenden Studie wurde bei kardiochirurgischen Patienten nach Hinweisen fur einen Syntheseort nach extrakorporaler Zirkulation (EKZ) gesucht.

Das Inhalationsanasthetikum Desfluran ist aufgrund seiner geringen Loslichkeit durch ein rasches Ein- und Auswaschverhalten gekennzeichnet. Dies konnte gerade im Kindesalter bei kurzdauernden HNO-Eingriffen von Vorteil sein, wenn dadurch die Intubationsbedingungen zu verbessern und die Aufwachphase zu beschleunigen waren. Dies sollte in der vorliegenden Untersuchung im Vergleich mit Isofluran uberpruft werden. Methodik: Untersucht wurden 4–12jahrige Kinder (ASA I–II), die sich einem kurzdauernden HNO-Elektiveingriff (z.B. Tonsillektomie) unterziehen musten. Die Narkose wurde intravenos mit 5–8 mg/kg Thiopental eingeleitet; die anschliesende Maskenbeatmung erfolgte mit 6 l/min O2, wobei der Desfluran- bzw. Isofluran-Vapor auf 1 MAC (altersadaptiert) geoffnet wurde. Nach 3 Beatmungshuben wurden 0,05 mg/kg Vecuronium injiziert und die Intubationsbedingungen 3 min spater beurteilt. Die weitere Narkosefuhrung erfolgte nach den ublichen klinischen Kriterien mit Desfluran oder Isofluran in 50% N2O/O2, die Zufuhr endete mit der letzten operativen Masnahme, danach wurden die ublichen Aufwachzeiten ermittelt. Gemas Poweranalyse (α-Fehler

Intraoperative blood salvage and processing it with commercially available devices is a widespread standard procedure to reduce allogeneic blood transfusion in patients undergoing major orthopedic surgery. The aim of this study was to investigate the impact of such processed blood on the immune system by measuring pro- and anti-inflammatory cytokines.Salvaged blood from 20 patients undergoing hip arthroplasty was processed with a continuous autotransfusion system. One part of the processed blood was left without further treatment, one part was additionally leukoreduced, one part was irradiated, and one part was separated into its cellular and soluble fraction by centrifugation. Specimens from each part were mixed in vitro with venous blood from the patient in ratios of 3:1, 1:1, and 1:3 and incubated with endotoxin for 24 hours. Tumor necrosis factor (TNF)-α and interleukin (IL)-10 were measured in cell culture supernatants by enzyme-linked immunosorbent assay.All parts of the salvaged blood were without a significant influence on TNF-α release. In contrast, IL-10 was significantly increased, independently of the admixtured salvaged blood being plain, additionally irradiated, or additionally leukoreduced. This IL-10 increase was also found with the cellular fraction of the plain salvaged blood, whereas the soluble fraction had no influence on IL-10 release.Intraoperative salvaged blood is not immunologically inert. We observed a significant increase in the anti-inflammatory IL-10 response without affecting the proinflammatory TNF-α release. Neither leukofiltration nor gamma irradiation eliminated this effect that was limited only to the cellular fraction of the salvaged blood, suggesting red blood cells to be responsible for the observed immunomodulation.

Delayed-type hypersensitivity reactions (DTHRs) after subcutaneous application of unfractionated heparins or low-molecular-weight heparins are not uncommon. Standard allergological testing usually includes intracutaneous skin tests and patch testing of different heparins, heparinoids, and thrombin inhibitors followed by subcutaneous and/or intravenous challenge with skin test-negative drugs. We present data from a single-center case series of 15 patients with DTHR after low-molecular-weight heparin administration. Intracutaneous testing that can be considered as gold standard identified the suspicious elicitor in 11 (73.4%) of 15 of the patients. Patch testing was positive in 5 (33.4%) of 15 of the patients and was only positive in patients who were also reacting in the intradermal testing. Intravenous challenge with heparin sodium was performed in 10 of 15 patients and was well tolerated in all cases, despite prior positive intracutaneous tests with the same substance. Intracutaneous documentation of DTHR was not an adequate predictor of intravenous challenge. Keywords: heparin, allergy, alternatives, pregnancy, cardiac surgery, thrombosis

Wenige Stunden nach einer laparoskopisch durchgefuhrten Cholezystektomie wird eine 62-jahrige Patientin auf der Normalstation von einer Krankenschwester kreidebleich mit einem schnellen, kaum tastbaren Puls vorgefunden. Der sofort hinzugezogene Stationsarzt misst einen systolischen Blutdruck von 60 mmHg bei einer Pulsfrequenz von 145/min. Er muss nun zunachst durch symptomatische Masnahmen die Kreislaufsituation stabilisieren, bis nach Klarung der Ursache kausale Therapiemasnahmen greifen. Dazu wird die Patientin im Bett flach gelagert, die Beine werden zur Autotransfusion angehoben. Uber die noch liegende intravenose Verweilkanule werden 500 ml einer Hydroxyathylstarkelosung rasch infundiert und zweimal 0,5 ml Akrinor injiziert. Unter dieser Therapie steigt der Blutdruck auf 80/60 mmHg und die Herzfrequenz fallt auf 120/min. Bei dem V. a. eine intraabdominelle Nachblutung wird eine Sonographie des Abdomens durchgefuhrt; hier findet sich reichlich freie Flussigkeit, sodass die Patientin unter Fortsetzung der Infusionstherapie und weiterer repetitiver Akrinorgaben zur Relaparotomie in den OP gebracht wird.

Background: Anaesthesia in patients with ischaemic heart disease may cause adverse haemodynamic reactions. This investigation compares the cardiovascular effects of equipotent concentrations of desflurane and isoflurane in 30 patients (ASA III) with coronary artery disease before surgical stimulation. Methods: After standardised induction of anaesthesia with etomidate, fentanyl and pancuronium and tracheal intubation patients randomly received either desflurane (group I, n = 15) or isoflurane (group II, n = 15) in slowly increasing concentrations. ST-segment analysis and haemodynamic measurements were performed at 0.25, 0.5, 0.75 and 1.0 MAC of desflurane or isoflurane. Results: Cardiac index did not change significantly in the two groups during the administration of the inhalational anaesthetics. Desflurane and isoflurane both caused a dose-dependent significant decrease of mean arterial blood pressure (group I: −16%; group II: −18%). As with isoflurane, the decrease of mean arterial pressure produced by desflurane primarily resulted from a decrease in systemic vascular resistance (group I: −26%, group II: −21%). Central venous pressure was not affected by the two volatile anaesthetics. Pulmonary artery pressure and pulmonary capillary wedge pressure remained unchanged during the administration of isoflurane, but in contrast both parameters significantly increased in patients receiving desflurane (PAP 24%, PCWP 40%). ST-segment analysis provided no signs of myocardial ischaemia. Conclusion: The results of this study demonstrate that in patients with coronary artery disease the haemodynamic effects of equipotent concentrations of desflurane and isoflurane are similar except for a significant increase in PAP and PCWP caused by desflurane. Therefore, desflurane should be administered with great caution if it is used as an alternative anaesthetic in patients with ischaemic heart disease.

To compare the Parker Flex-It intubation stylet with a 90-degree curved stylet using the McGrath videolaryngoscope in 5 airway scenarios (from easy to difficult) in a manikin.Prospective, randomized study.Academic hospital.20 staff anesthesiologists with no previous experience in videolaryngoscopy.Subjects performed a total of 200 intubations with the McGrath Series 5 videolaryngoscope and completed a questionnaire afterwards.Overall success rate was significantly higher with the Parker Flex-It intubation stylet (96 successful intubations with the Parker Flex-It vs 79 intubations in the 90° curved stylet group; P0.05). Intubation time was not significantly different. Subjects rated the Parker Flex-It intubation stylet as the better device for intubation with the McGrath videolaryngoscope in routine or emergency situations.Intubation of the manikin with the McGrath videolaryngoscope had more success with the Parker Flex-It intubation stylet than a 90° curved stylet.

Epidural blockade in major abdominal surgery bears the potential to increase gastrointestinal perfusion and thus to improve patient outcome. The aim of this study was to assess the differential influence of thoracic and lumbar epidural anaesthesia and analgesia (EAA) on blood lactate levels and central venous oxygen saturation (ScvO2) as parameters of global oxygen supply/demand ratio, as well as on the plasma disappearance rate of indocyanine green (PDR(ICG)), a noninvasive method to evaluate liver perfusion.We enrolled 17 patients receiving thoracic and 17 patients receiving lumbar EAA in addition to general anaesthesia for major abdominal surgery. Lactate, ScvO2 and PDR(ICG) were measured postoperatively on the ICU. Subsequently, epidural application of local anaesthetics was started with a bolus of bupivacaine 0.25% (thoracic 10 ml, lumbar 12 ml) followed by continuous infusion of bupivacaine (thoracic 8 ml h(-1) 0.175%, lumbar 10 ml h(-1) 0.125%) and fentanyl (2 microg ml(-1)). Central venous pressure was maintained by titrated volume replacement. Lactate, ScvO2 and PDR(ICG) were measured again after 2 h.In both the groups, the mean arterial pressure and heart rate as well as lactate levels and ScvO2 did not change significantly. Although there was a slight but not significant decrease of PDR(ICG) in patients with lumbar EAA (from 25.9 +/- 7.68 to 23.2 +/- 5.90; NS), thoracic EAA resulted in a significant increase of PDR(ICG) (from 21.3 +/- 5.13 to 24.0 +/- 6.66; P0.05) for the group mean, but with substantial variability in individual patients in the lumbar EAA group.Liver perfusion was increased with thoracic but not lumbar EAA after major abdominal surgery in most patients. PDR(ICG) allows assessment of individual changes of liver blood flow due to therapeutic intervention, for example, EAA.

Contains fulltext : 81731.pdf (Publisher’s version ) (Closed access) BACKGROUND: We compared dose-response curves of the hypnotic effects of desflurane, sevoflurane and isoflurane. In addition, we analyzed the k(e0) values of the different anesthetics. The EEG parameters Bispectral index (BIS, Aspect Medical Systems, Natick, MA, version XP) and Narcotrend index (MonitorTechnik, Bad Bramstedt, Germany, version 4.0) were used as measures of the pharmacodynamic effect. METHODS: With IRB approval and informed consent we analyzed the data of three studies including 61 adult patients scheduled for radical prostatectomies. At least 45 min after induction of general anesthesia, end-tidal concentrations of desflurane, sevoflurane or isoflurane were varied between 0.5 and 2 MAC. We transferred the end-tidal concentrations into age-related MAC values. The relationship between MAC effect compartment concentrations and EEG was modeled with a variation of the classical fractional sigmoid E(max) model with two linked sigmoidal curves. All parameters were calculated as a population fit by NONMEM V (GloboMax, Hanover, USA) by minimizing log likelihood. RESULTS: The k(e0) values of the population fit derived from BIS data were 0.54 min(-1) for desflurane, 0.24 min(-1) for sevoflurane and 0.16 min(-1) for isoflurane, from the Narcotrend index 0.43 min(-1) for desflurane, 0.26 min(-1) for sevoflurane and 0.18 min(-1) for isoflurane. The change between the first and the second sigmoidal curve was positioned at nearly the same Narcotrend- and BIS index values between 41 and 44. CONCLUSIONS: The first order rate constant (k(e0) value) determining the equilibration between age-related MAC values and MAC effect site concentration is substantially higher for desflurane than for sevoflurane or isoflurane.

BACKGROUND: Although the use of pulse oximeters may be regarded a standard of care for monitoring anesthesia procedures, these monitors may be susceptible to various kinds of disturbances. Recently, it was suggested that neuronavigation equipment may interfere with pulse oximeter accuracy. In this study, we evaluated the effect of a neurosurgical image guidance system on the performance of six different pulse oximeters. Two simple shielding methods were evaluated. METHODS: Twenty healthy, adult, nonsmoking volunteers were equipped with six different pulse oximeters on both hands. Baseline values for heart rate, arterial oxygen saturation, and signal quality were assessed. After activation of the Brain Lab VectorVision Neuronavigation System, the effects on signal quality and saturation recognition were evaluated. Measurements were repeated using two different shielding techniques, a cotton blanket and aluminum sheets. RESULTS: Activation of the image guidance system resulted in a significant disturbance of signal quality and saturation detection, which was partially reversible by both shielding techniques. Significant differences were noted among the six brands of pulse oximeters for signal quality (P < 0.001) and saturation recognition (P < 0.001), and for the response to shielding methods (P < 0.001). Coverage of the probes with aluminum foil resulted an in undisturbed saturation recognition in all subjects with almost all monitors. CONCLUSIONS: Infrared pulse waves from neurosurgical navigation equipment may interfere with pulse oximeter measurements. Shielding the probe with aluminum foil sufficiently eliminated the infrared interference.

Contains fulltext : 70879.pdf (Publisher’s version ) (Closed access) BACKGROUND: We compared two pharmacodynamic models, one with and one without a plateau effect. Bispectral indices (BIS, Aspect Medical Systems, Natick, MA, version XP) and Narcotrend (NCT, MonitorTechnik, Bad Bramstedt, Germany, version 4.0) were used as an electroencephalographic measure of sevoflurane drug effect. In addition, we tried to analyze the origin of the plateau. METHODS: We investigated 26 adult patients scheduled for radical prostatectomy. At least 45 min after induction of general anesthesia, end-tidal sevoflurane concentrations were varied between 1 vol% and 4 vol%. To evaluate the relationship between concentrations and electroencephalographic indices, two different pharmacodynamic models were applied: a conventional model based on a single sigmoidal curve, and a novel model based on two sigmoidal curves for BIS and NCT values with and without burst suppression. The parameters of the models were estimated by NONMEM V (GloboMax, Hanover) by minimizing log likelihood. Statistical significance between the two models was calculated by the likelihood ratio test. RESULTS: The end-tidal sevoflurane concentration ranged from 1.04 +/- 0.17 vol% to 4.43 +/- 0.43 vol%. The difference between the log likelihood values of the new pharmacokinetic/pharmacodynamic model with two connected sigmoidal curves and the classical E(max) model with one sigmoidal curve is 396 (P < 0.001) for the BIS monitor and 1121 (P < 0.001) for the NCT. The plateau is positioned at the change between the maximum delta power and the increase of burst suppression ratio. CONCLUSION: A pharmacokinetic/pharmacodynamic model consisting of two sigmoid curves with an intervening plateau describes the effect of sevoflurane on BIS and NCT indices better than a model with a single sigmoid curve.

Dynamics of the Molten Salt Reactor, one of the 'Generation IV International Forum' concepts, was studied in this paper. The graphite-moderated channel type MSR was selected for the numerical simulation. The MSR represents a liquid fueled reactor with very specific dynamics because of two physical peculiarities: the delayed neutrons precursors are drifted by the fuel flow and the fission energy is immediately released directly into the coolant. Presently, there are not many accessible numerical codes appropriate for the MSR simulation, therefore the DYN1D-MSR and DYN3D-MSR codes were developed based on the Light Water Reactor dynamics code DYN3D. It allows calculating of full 3D transient neutronics in combination with parallel channel type thermal-hydraulics. The codes were validated on experimental results of Molten Salt Reactor Experiment from Oak Ridge National Laboratory and applied to several transients typical for the liquid fuel system. Those transients were initiated by reactivity insertion, by overcooled or overfueled fuel slug, by the fuel pump start-up or coast-down, or by the blockage of single fuel channels. In these considered transients, the response of the MSR is characterized by the immediate change of the fuel temperature according to the power level. This causes fast feedback reactivity insertion, which is negative in the case of power increase. On the other hand, the graphite response is slower and its feedback coefficient is in some cases positive. The addition of erbium to the graphite can ensure the negative feedback and inherent safety features. The DYN1D-MSR and DYN3D-MSR codes have been shown as an effective tools for MSR dynamics studies.

The number of diagnostic and therapeutic procedures done outside of the operating room and the intensive care unit has increased substantially in recent years. In parallel, the management of acute pain and anxiety in children undergoing therapeutic and diagnostic procedures has developed considerably in the past two decades. The primary goal of procedural sedation and analgesia is the safe and efficacious control of emotional distress and pain. The availability of non-invasive monitoring, short-acting opioids and sedatives has broadened the possibilities of sedation and analgesia in children in diverse settings. While most of these procedures themselves pose little risk to the child, the administration of sedation or analgesia may add substantial risk to the patient. This article reviews the current status of sedation and analgesia for invasive and non-invasive procedures in children providing an evidence-based approach to several topics of importance, including patient assessment, personnel requirements, equipment, monitoring, and drugs.

Impedance Cardiography (ICG) has been shown to be a feasible and accurate method for non-invasive measurement of cardiac index (CI). Aim of this investigation was the correlation of hemodynamic variables under exercise as measured by a specific ICG-monitor (Solar IKG-Modul, Version 3.0, GE-Healthcare, Freiburg, Germany) with metabolic variables.Ten healthy volunteers were included in the investigation doing ergometer exercise (5 min equilibration followed by 5 min each at 50, 75, 100 and 125 W). Hemodynamic parameters were obtained by ICG. Metabolic variables were assessed by indirect calorimetry with the Deltatrac II Metabolic monitor using a helmet system for spontaneous respiration.CI increased throughout exercise (baseline: 3.0 +/- 0.4 l/min/m(2); 125 W: 4.8 +/- 0.5 l/min/m(2)). Heart rate (baseline: 87.2 +/- 13.4 bpm; 125 W: 152.7 +/- 22.4 bpm) and contractility (velocity index) (baseline: 48.9 +/- 9.3/1000 s; 125 W: 70.5 +/- 10.0/1000 s) showed a continuous rise while the stroke index decreased after an initial rise (baseline: 35.0 +/- 4.6 ml/m(2); 50 W: 37.6 +/- 4.9 ml/m(2); 75 W: 41.2 +/- 5.9 ml/m(2); 125 W: 32.3 +/- 6.1 ml/m(2)). VO(2) (baseline: 335.2 +/- 84.1 ml/min; 125 W: 1298.9 +/- 282.3 ml/min) and VCO(2)(baseline: 255.4 +/- 74.5 ml/min; 125 W: 1342.5 +/- 282.5 ml/min) increased throughout exercise. There was a good correlation in the individual fits between hemodynamic and metabolic variables.CI in healthy volunteers, as measured by the Solar IKG-Modul, correlates well with O(2)-consumption and CO(2)-production in individual subjects, thus indicating the metabolic needs under exercise conditions in healthy individuals.

This paper reports about the DYN1D-MSR code development and dynamics studies of the molten salt reactors (MSR) – one of the ‘Generation IV International Forum’ concepts. In this forum the graphite-moderated channel type MSR based on the previous Oak Ridge National Laboratory research is considered. The liquid molten salt serves as a fuel and coolant, simultaneously and causes two physical peculiarities: the fission energy is released predominantly directly into the coolant and the delayed neutrons precursors are drifted by the fuel flow. The drift causes the spread of delayed neutrons distribution to the non-core parts of primary circuit and it can lead to a reactivity loss or gain in the case of fuel flow acceleration or deceleration, respectively. Therefore, specific 3D tool based on in house code DYN3D was developed in FZR. The code DYN3D-MSR is based on the solution of two-group neutron diffusion equation by the help of a nodal expansion method and it includes models of delayed neutrons drift and specific MSR heat release distribution. In this paper the development and verification of 1D version DYN1D-MSR of the code is described. The code has been validated with the experimental data gained from the molten salt reactor experiment performed in the Oak Ridge and after the validation it was applied to several typical transients (overcooling of fuel at the core inlet, reactivity insertion, and the fuel pump trip).

Background The Narcotrend monitor (MonitorTechnik, Bad Bramstedt, Germany) has recently been introduced as an intraoperative monitor of anesthetic state, based on a classification scheme originally developed for visual assessment of the electroencephalogram. The authors compared the performance of the Narcotrend index (software version 4.0) to the Bispectral Index (BIS, version XP; Aspect Medical Systems, Natick, MA) as electroencephalographic measures of isoflurane drug effect during general anesthesia. Methods The authors observed 15 adult patients scheduled to undergo radical prostatectomy with a combined epidural-isoflurane general anesthesia technique. At least 45 min after induction of general anesthesia, during a phase of constant surgical stimulation, end-tidal isoflurane concentrations were varied between 0.5 and 2.0 multiples of minimum alveolar concentration, and the BIS and the Narcotrend index were recorded. The prediction probability (PK) was calculated for the BIS and the Narcotrend index to predict isoflurane effect compartment concentration for each measure. The correlation analysis of the BIS and the Narcotrend index with the isoflurane effect compartment concentration was obtained by pharmacodynamic modeling based on two sigmoidal curves to account for the discontinuity in both indices with the onset of burst suppression. Results The prediction probabilities were indistinguishable (BIS PK = 0.72 +/- 0.07 (mean +/- SD); range, 0.61-0.84; Narcotrend index PK = 0.72 +/- 0.10; range, 0.51-0.87), as were the correlations between the electroencephalographic measures and isoflurane effect compartment concentrations (BIS R = 0.82 +/- 0.12; Narcotrend index R = 0.85 +/- 0.09). The pharmacodynamic models for the BIS and the Narcotrend index yielded nearly identical results. Conclusions The BIS and the Narcotrend index detected the electroencephalographic effects of isoflurane equally. Combining two fractional sigmoid Emax models adequately described the data before and after the onset of burst suppression.

Background The purpose of this study was to compare the classical laryngeal mask airway (LMA) with the laryngeal tube (LT) in anaesthetised non-paralysed patients. Patients and methods A total of 100 patients scheduled for minor elective surgery were included. After standardised induction and maintenance of anaesthesia with propofol and remifentanil, patients were randomly allocated to receive either a LMA or LT; muscle relaxants were not applied. Selection of the appropriate size and the initial inflation volume were chosen according to the manufacturers instructions. Ease of insertion, initial intra-cuff pressure, oropharyngeal leak pressure at an intra-cuff pressure of 60 cm H(2)O and incidence and severity of complications during and after anaesthesia were compared. Results The LT was inserted significantly quicker than the LMA (35.1+/-15.9 s vs. 56.6+/-42.5 s; mean+/-SD). Insertion of the LT was successful within 1 attempt in 90% and within 2 or 3 attempts in another 4% of patients for the LT compared with 68% and 20% of patients for the LMA, respectively. For the LT the initial cuff pressure was significantly lower (75.1+/-16.2 cm H(2)O) and the oropharyngeal leak pressure after adjustment of the intra-cuff pressure to 60 cm H(2)O was significantly higher (27.2+/-6.9 mbar) compared with the LMA (109.5+/-25.7 cm H(2)O and 19.9+/-4.0 mbar, respectively). Incidence of postoperative laryngeal complications in the LT group (31%) was lower compared with the LMA group (54%). Conclusion In anaesthetised non-paralysed patients the LT compares favourably to the LMA in terms of ease of insertion and postoperative morbidity.