Anaesthesia for caesarean section — a German survey

Background: Anaesthetic practice for caesarean section has changed during the last decades. There is a world-wide shift in obstetric anaesthetic practice in favour of regional anaesthesia. Current data concerning anaesthetic practice in patients under-going caesarean section from Germany are not available. A comparison with figures from the UK, USA, Norway and other European countries might be of general interest.
Methods: Questionnaires on the practice of anaesthesia for caesarean section and anaesthetic coverage of the obstetric units were sent to 1178 university, tertiary care, district, community and private hospitals in Germany.
Results: The 532 completed replies of this survey represent 46.9% of the German obstetric units. Most hospitals (42.3%) have delivery rates between 500 and 1000 per year. General anaesthesia is the most common anaesthetic technique for elective (61%), urgent (83%) and emergency caesarean section (98%). Epidural anaesthesia is performed in 23% of scheduled and 5% of non-scheduled caesarean sections, and spinal anaesthesia in 14% and 10%, respectively. Acid aspiration prophylaxis before elective caesarean section is used in 68.7% of the departments. The majority of the departments provide a 24-hour anaesthetic coverage; however, in only 6.2% of the units, this service is assigned to obstetric anaesthesia, exclusively.
Conclusion: Compared to data from 1978, anaesthetic practice for caesarean section has changed with an increase in regional anaesthesia. However, German anaesthetists prefer general anaesthesia for caesarean section. In contrast, anaesthetists in other countries predominantly use regional techniques, and the difference to German practice is striking. International consensus discussion and recommendations as well as comparable European instruments of quality control in obstetric anaesthesia are desirable.     

Prevention of nosocomial infection in a pediatric intensive care unit (PICU) through the use of selective digestive decontamination

Objective: To assess the effectiveness of selective digestive decontamination (SDD) on the control of nosocomial infection (NI) in critically ill pediatric patients. Design: A prospective, randomized, non-blinded and controlled clinical microbiology study. Setting: The pediatric intensive care unit (PICU) of a tertiary level pediatric university hospital. Criteria for inclusion: Patients 1 month to 14 years old, who underwent some kind of manipulation or instrumentation (mechanical ventilation, vascular cannulation, monitoring of intracranial pressure, thoracic or abdominal drainage, bladder catheterization, peritoneal dialysis, etc.) and/or presented a neurological coma requiring a stay in the PICU of 3 or more days. Patients: Over a period of 2 years, 244 patients met the inclusion criteria; 18 patients were withdrawn because of protocol violation. The treatment group comprised 116 patients and the control group, 110 patients. Intervention: The treatment group received a triple therapy of colimycin, tobramycin and nystatin administered orally or via nasogastric tube every 6 hours. All patients with mechanical ventilation or immune-depression received decontamination treatment of the oropharyngeal cavity with hexitidine (Oraldine® 0.5 mg/ml) every 6–8 hours in accordance with the PICU's conventional protocol. Method: Up to 10 types of nosocomial infection were diagnosed following criteria of the Centers for Disease Control (CDC). The severity and manipulation of the patients on admission was assessed using the therapeutic intervention scoring system (TISS) and multi-organ system failure scores (MOSF). Measurements and main results. Univariant analysis: SDD did not significantly reduce the incidence of NI, antibiotic use, the length of stay, or mortality; although a small percentage of respiratory and urinary tract infections was detected, catheter-related bacteremia was the most common infection. Multivariant analysis: Controlling the risk factors for each child through log regression showed that SDD acted as a protective factor for more than 90% of the sample with respect to the appearance of respiratory and urinary tract infections, reducing the risk of such infections to 1/5 and 1/3, respectively. Conclusions: SDD was effective in controlling respiratory and urinary tract infections in children admitted to the PICU, but it did not reduce the incidence of other types of nosocomial infection.     

Survival compared to the general population and changes in health status among intensive care patients

In order to evaluate intensive care, all adult patients (980) admitted to a multidisciplinary intensive care unit (ICU) during 1 year were followed prospectively. The ICU mortality was 9.6%. One year after admission the survival was 73.6%. By that time the surviving patients had a further survival that was 96% of that of the general population. Of the 1-year survivors, 22.3% had deteriorated in health status compared to 3 months before the stay in ICU. In the admission groups with high mortality the survivors had a more pronounced deterioration in health status. Increased age and length of stay in the ICU were associated with higher mortality but not with changes in health status. We conclude that the outcome of intensive care can be evaluated by studying only the survival, since the survival rate is correlated to changes in health status among survivors in the different admission groups. One year after admission most of the surviving patients had regained their previous health status and their further survival was almost the same as that of the general population.     

Intra-arterial and extra-arterial pH, PCO2 and PO2 monitors

In vitro blood gas analysers inherently limit the frequency of serial blood gas measurements because of blood loss and cost. In vivo blood gas monitors eliminate an inherent cost and blood loss associated with measurement. Optode microsensing is a technology that can be readily adapted to in vivo measurement of pH, PCO₂ and PO₂. Optode-based intra-arterial devices that display continuous values have been developed that are practical for routine use but consistent performance remains a problem; an extra-arterial device that provides intermittent values has been shown to be consistent but is not yet available for routine use. The transfer of blood gas measurements from laboratory analysers to the combination of point-of-care analysers and monitors should have as profound an impact on acute respiratory care as did the introduction of laboratory-based blood gas analysers over 30 years ago. However, we must be sure these devices are reliable, consistent and cost beneficial in order to avoid widespread adoption of yet another technology that provides more data, more cost, and questionable patient benefit.     

全麻下空气灌肠治疗小儿急性肠套叠

为了提高小儿急性肠套叠复位的成功率，近年来我们试行在基础全麻下实施空气灌肠治疗小儿急生套叠１５例收到了良好效果，全部病例皆治愈。结果提示，全麻下空气灌肠治疗小儿急性肠套叠优于单纯空气灌肠     

INTENSIVE CARE OF SMALL PREMATURE INFANTS: I. Clinical findings and results of treatment

Clinical findings and results of treatment in a series of 49 premature infants with birth weights between 850 and 1250 g are presented. The “intensive care” included nursing in incubators with high environmental humidity maintaining skin temperature at 36.5°C, umbilical catheterisation (both arterial and venous), intravenous glucose infusions, correction of metabolic acidosis by rapid sodium bicarbonate infusions, oxygen therapy and finally endotracheal intubation and mechanical ventilation. The series was divided into 3 categories according to the severity of respiratory symptoms. There was only one survivor out of 12 cases in the category of severe RD, whereas 14 of 21 with moderate RD and 9 of 16 with slight or no RD survived. The overall survival rate was 45%. The correlation between clinical findings, arterial blood gases and pH, chest X-rays, response to treatment and outcome in each of the 3 categories is discussed. The preliminary data from our follow-up studies indicate that there are only a few cases showing signs of permanent brain injury at the age of two years.     

The cuff method: a pilot study of a new method of monitoring neuromuscular function

BACKGROUND: A new method of monitoring neuromuscular blockade based on a modified blood pressure cuff that incorporates stimulating electrodes was compared with mechanomyography (MMG) ('gold standard'). METHODS: Forty adults and 20 children (ASA I-II) underwent neuromuscular blockade monitoring on the contralateral arms and on the same arm using the new cuff method and MMG. Only train-of-four (TOF) ratios > 0.1 and T(1) heights > 0 were studied. Supramaximal stimulation was also assessed. A device based on a PC with an analogue-to-digital conversion card was used to control and synchronize MMG and the cuff method. The agreement between both methods was assessed using the statistical method of Bland and Altman. RESULTS: When TOF ratios were >0.7, the bias between the two methods was -0.04 with the limits of agreement ranging from -0.21 to -0.12 (95% CI -0.06 to -0.02). The T(1) > 0 heights bias was -0.01 with the limits of agreement ranging from -0.26 to 0.24 (95% CI -0.02 to -0.003). The sensitivity of the cuff method was 88%, with a specificity of 85% and an accuracy of 86%. CONCLUSION: This pilot study indicates that the cuff method could be useful to monitor neuromuscular blockade according to the bias and limits of agreement compared with MMG, particularly when the degree of blockade was evaluated by TOF ratios > 0.7. The new cuff method is easy and simple to use. However, further studies in a larger number of patients are necessary to confirm these favourable preliminary results.