Kognitive St?rungen in der frühen postoperativen Phase nach Remifentanil/Propofol- und Sevofluran/Fentanylan?sthesie

Fragestellung: Schnelles Erwachen und eine rasche Erholung der kognitiven Funktionen geh?ren zu den wesentlichen Auswahlkriterien von An?sthetika für ambulante Eingriffe. Die vorliegende Untersuchung befasst sich mit der Frage, ob die Erholung kognitiver Funktionen nach einer TIVA mit Remifentanil/ Propofol (P/R) rascher erfolgt als nach einer balancierten An?sthesie mit Sevofluran/Fentanyl (S/F).     

Remifentanil und Alfentanil: Sympathiko-adrenerge Effekte in der frühen postoperativen Phase beim kardiovaskulären Risikopatienten

Extubation and the immediate postoperative period are critical periods with strong sympatho-adrenergic stimulation. The aim of the present study was to investigate this period after balanced anaesthesia with remifentanil and alfentanil in cardiac risk patients. METHODS: 52 patients with coronary artery disease or with risk factors for coronary heart disease scheduled for elective extraperitoneal and extrathoracic operation were included in this study. Anaesthesia was induced by intravenous administration of etomidate, vecuronium and remifentanil (n = 27, 1 microgram/kg) or alfentanil (n = 25, 25 micrograms/kg). Anaesthesia was maintained with an Isoflurane/N2O/O2 mixture and by continuous intravenous infusion of remifentanil (0.25 microgram/kg/min) or alfentanil (45 micrograms/kg/h). During the first 60 minutes after extubation haemodynamic parameters were monitored and catecholamines were determined at defined time intervals. Parameters of recovery, the requirement of analgesics and cardiac medications were compared in both groups. Myocardial ischaemia was assessed by two-channel Holter electrocardiography. RESULTS: The beginning of spontaneous respiration and time of extubation were similar in both groups. The time interval until opening eyes and the time between the beginning of spontaneous respiration and extubation was shorter in the patients treated with remifentanil. In this group patients suffered earlier from pain and had a higher pain score. Although the plasma catecholamines were comparable in both groups, in the patients treated with remifentanil changes in haemodynamic parameters were more pronounced. The incidence of shivering and the requirements of analgesics and cardiac medications were higher in these patients. The incidence of ST-segment changes indicating myocardial ischaemia was similar. CONCLUSIONS: After balanced anaesthesia with remifentanil a more pronounced sympatho-adrenergic stimulation occurs because of the more rapid clearance of the analgesic effect in the recovery period compared to alfentanil requiring more analgesics and medications for the control of the haemodynamic parameters. Because of these specific pharmacological effects the use of remifentanil in cardiac risk patients has to be critically discussed.     

Fulminante Lungenarterienembolie in der frühen postoperativen Phase

Acute pulmonary embolism is a serious perioperative complication with a high mortality. A case of early onset pulmonary embolism with acute right heart failure and resuscitation after spinal surgery is reported. The diagnosis was rapidly and reliably confirmed by transesophageal echocardiography (TEE) and a right atrial thrombus was detected. Persistent life-threatening hemodynamic instability required thrombolysis with 100 mg recombinant tissue-type plasminogen activator (rt-PA). The patient survived this critical situation but sustained permanent paraparesis.     

Kognitive Störungen nach Distorsion der Halswirbelsäule?

Cognitive disturbances are frequent complaints in patients following whiplash injury and form the basis of attempts to claim that minimal brain damage has been caused, even in the absence of clinical or imaging evidence to support these claims. Pain and cognitive deficits are the most commonly feigned medical complaints. However, the boundary between aggravation and/or malingering is generally not easy to identify. Relevant indications include discrepancies between the reported symptoms and the findings identified in the immediate post-trauma phase.     

Propofol/Remifentanil versus Sevofluran/Remifentanil zur Anästhesie bei Unterbaucheingriffen im Säuglings-, Kindes- und Jugendalter

INTRODUCTION: The aim of this study was to compare total intravenous anaesthesia (TIVA) using propofol and remifentanil (P/R-group) and balanced anaesthesia (BA) using sevoflurane and remifentanil (S/R-group) for paediatric surgery. PATIENTS AND METHODS: A total of 120 patients aged 6 months to 16 years scheduled for elective minor lower abdominal surgery were randomly assigned to receive either propofol (5-10 mg/kg/h) and remifentanil (0.125-1.0 microgram/kg/min) or sevoflurane (1.0-1.5 MAC) and remifentanil (0.125-1.0 microgram/kg/min). Perioperative haemodynamics as well as recovery and discharge times, PONV and side-effects were studied. The patients vigilance, comfort and pain intensity were assessed postoperatively using the objective pain discomfort scale, the Steward post-anaesthetic recovery score and a visual analogue scale. RESULTS: Postoperative recovery (9.0 vs 11.6 min) and extubation times (11.8 vs. 15.0 min) as well as the time taken until a Steward post-anaesthetic recovery score > 3/4 (15.2 vs. 21.4 min) was reached were significantly shorter in the P/R-group. However, the length of time until discharge to the ward, postoperative comfort, pain intensity and analgesic requirements as well as PONV were comparable in both groups. CONCLUSIONS: With regards to the investigated parameters, TIVA with propofol and remifentanil is equally effective as BA with sevoflurane and remifentanil in paediatric patients. However, considering the selected dosing regimen, recovery times were significantly shorter for children after TIVA.     

Postoperative Übelkeit und postoperatives Erbrechen nach Strabismuschirurgie bei Kindern Inhalationsanästhesie mit Sevofluran/Lachgas im Vergleich zu intravenöser Anästhesie mit Propofol/Remifentanil

BACKGROUND: Postoperative nausea and vomiting (PONV) is still one of the major problems in strabismus surgery, especially in children. In recent years many studies have been published, suggesting that choosing propofol as the anaesthetic agent may help to reduce the high incidence of PONV in children undergoing strabismus surgery. Experience with remifentanil in children is still very limited and little is known, whether propofol in combination with this new short acting opioid is also superior regarding PONV in squint surgery compared to sevoflurane/N2O. Additionally, little is known, whether the type of operation or the muscle which is operated on has any influence with respect to PONV. METHODS: Following sample size estimation, ethics committee approval and parents informed consent in a prospective, randomised, observer-blind study 105 ASA I and II children aged 3-8 years scheduled for elective strabismus surgery were assigned into one of the following groups: Group TIVA (propofol/remifentanil, n = 53): anaesthesia was induced by remifentanil 0.5 microgram kg-1 min-1 over 2 min (loading phase), followed by 3 mg kg-1 propofol along with 30% O2 in air. After endotracheal intubation anaesthesia was maintained initially with remifentanil 0.25 microgram kg-1 min-1 and propofol 10 mg kg-1 h-1 by constant infusion. In the course of the operation the infusions of the anaesthetics were adjusted to the decreasing need for anaesthesia. Group VOLATIL (sevoflurane/N2O, n = 52): anaesthesia was induced by inhalation of sevoflurane along with 50% O2 in N2O. After endotracheal intubation anaesthesia was maintained with sevoflurane 1.0-1.5 MAC along with 30% O2 in N2O and in the course of the operation the administration of the inhaled anaesthetics was adjusted correspondingly. Preoperatively collected data included gender, age, weight and history of PONV. Intraoperatively collected data consisted of data belonging to routine monitoring (heart rate, blood pressure, peripheral oxygen saturation and temperature) as well as the duration of the operation and anaesthesia and specific data regarding the operation (including the number and type of muscles as well as the kind of operation). Data collected within the first 24 hours postoperatively in the recovery room and on the ward by blinded observers included any PONV events as well as the antiemetics and analgesics applied. RESULTS: Vomiting was observed less frequently in the TIVA-group than in the VOLATIL-group (21 of 53 vs. 32 of 52, p = 0.03) within the first 24 hours postoperatively. Posterior fixation suture ("faden-operation") compared to other operations was followed rather frequently by nausea and vomiting (30 of 44 and 33 of 44, respectively), whereas recessions were rarely associated with nausea and vomiting (12 of 35 and 9 of 35, respectively). CONCLUSIONS: TIVA with propofol/remifentanil proved to be a suitable form of anaesthesia for children in this setting. Propofol showed advantages over sevoflurane/N2O with respect to PONV after squint surgery in children also when applied in the combination with remifentanil. TIVA with propofol/remifentanil may therefore be one way to reduce the high incidence of PONV in this setting, bearing in mind, that PONV is not only influenced by the regimen of the general anaesthesia but rather by the combination of many other factors, in particular the type of operation.     

Psychoreaktive Störungen nach Verkehrsunfällen

The aim of this study was to assess common risk factors for the early development of psychoreactive disorders during traumatological treatment and to estimate their predictive potential. The sample consisted of 126 consecutive patients with accidental injuries recruited in an emergency room of the university hospital. We assessed this population 1 week (T1) and-on average-8 months following the accident (T2). At T1 34.5% of all patients indicated moderate and 26.4% strong symptoms of an acute stress disorder; 26.7% of all patients assessed at T2 suffered from severe post-traumatic symptoms. Linear regression analysis, using morbidity status at T2 as the dependent variable, allowed the explanation of 46.2% of the variance. The degree of early acute stress symptoms, injury, and pain intensity contributed significantly to the predictive model. We conclude that a substantial proportion of severely injured accident victims that will develop PTSD can be screened to some degree by the assessment of early stress disorder, the degree of their injury, and pain intensity, enabling secondary prevention of trauma-dependent symptomatology.     

Pflichten des Arztes in der postoperativen und postanästhesiologischen Phase

Ohne Zusammenfassung     

Funktionelle Symptome und somatoforme Störungen in der Notaufnahme

Background

Functional somatic symptoms and somatoform disorders are common in community samples. Persons troubled with these symptoms are characterized by an excessive use of health care resources. Thus, it seems probable that they will also attend the emergency department.

Objectives

The aim of this article is to introduce the topic of functional somatic symptoms and to critically discuss the current state of research on functional somatic symptoms in the emergency department.

Materials and methods

Selective, narrative review.

Results

Empirical evidence concerning functional somatic symptoms and somatoform disorders in the emergency department is limited. The prevalence rates range between 2.9 and 16.5 %. Structural characteristics of the emergency department, especially the focus on the rule out of medical conditions, represent barriers for the early identification and proactive management of these patients. The current German clinical practice guideline on nonspecific, functional and somatoform bodily complaints provides information on diagnosis, which is also important for the management of these patients in emergency medicine. Main issues are avoiding iatrogenic chronification, early consideration of psychosocial factors and cooperation with psychosomatic consultation-liaison services.

Conclusion

Functional somatic symptoms and somatoform disorders represent a challenge to patient management in the emergency department. There is a need for well-founded studies on occurrence and management of these patients in the emergency department.

     

Störungen des Wasser- und Elektrolythaushaltes nach Gallenoperationen

Ohne Zusammenfassung Mit 7 Abbildungen Vortragender:A. Sapkas-Athen.     

Störungen im Bereich der zuführenden Schlinge nach Magenoperationen und ihre klinische Auswertung

Ohne Zusammenfassung     

Übelkeit und Erbrechen in der postoperativen Phase

There are no consensus guidelines for the management of postoperative nausea and vomiting (PONV) in German speaking countries. This meeting was intended to develop such guidelines on which individual health care facilities can derive their specific standard operating procedures (SOPs). Anesthesiologists reviewed published literature on key topics which were subsequently discussed during two meetings. It was emphasized that recommendations were based on the best available evidence. The clinical relevance of individual risk factors should be viewed with caution since even well proven risk factors, such as the history of PONV, do not allow the identification of patients at risk for PONV with a satisfactory sensitivity or specificity. A more useful approach is the use of simplified risk scores which consider the presence of several risk factors simultaneously. Most individual antiemetic interventions for the prevention of PONV have comparable efficacy with a relative risk reduction of about 30%. This appears to be true for total intravenous anesthesia (TIVA) as well as for dexamethasone and other antiemetics; assuming a sufficiently high, adequate and equipotent dosage which should be weight-adjusted in children. As the relative risk reduction is context independent and similar between the interventions, the absolute risk reduction of prophylactic interventions is mainly dependent on the patient's individual baseline risk. Prophylaxis is thus rarely warranted in patients at low risk, generally needed in patients with a moderate risk and should include a multimodal approach in patients at high risk for PONV. Therapeutic interventions of PONV should be administered promptly using an antiemetic which has not been used before. The group suggests algorithms where prophylactic interventions are mainly dependent on the patient's risk for PONV. These algorithms should provide evidence-based guidelines allowing the development of SOPs/policies which take local circumstances into account.     

Primär neurogene und myogene Störungen der Körperhaltung

Disturbance of posture may occur in a variety of neurological disorders and occasionally is the presenting or even the only sign. In the majority of cases, the head or the trunk or both are bent forward (bent spine syndrome, dropped head syndrome). A feature of these primary neurogenic or myogenic postural disturbances that is in contrast to antalgic contraction or ankylosis is that they are not fixed, but the trunk or head are easily erected by the examiner and show a characteristic sagging. Neuromuscular disorders are a frequent cause. They may be confined to the paraspinal muscles. Axial computed tomography of the spine, electromyography of the involved muscles, and muscle biopsy help to make the diagnosis. However, also central movement disorders may lead to a sagging of the head or trunk or of both due to a lessened tone of the head and trunk extensors. This is frequently seen in the various parkinsonian syndromes which may, however, occur in association with a focal myopathy of the paraspinal muscles. Occasionally, sagging of the trunk is seen as a side effect of neuropharmacologic medication. Sagging of the trunk or head should be differentiated from a pathologically increased innervation of the ventral muscles in dystonic movement disorders such as antecollis or camptocormia.Pathologic reclination of the head or trunk or both is a rare disturbance of posture. It may occur in dystonia (retrocollis) or, occasionally, as a consequence of musculotendinous contractures secondary to certain neuromuscular disorders such as the rigid spine syndrome.     

Motilitätsstörungen in der blinden schlinge nach Roux-y-rekonstruktion

Zusammenfassung Störungen der intestinalen Motilität, bakterielle Fehlbesiedlung und pankreozibale Asynchronie werden im Patienten nach Roux-Y-Rekonstruktion (RYR) beschrieben. Im Tierexperiment (Hund, n = 6) ergab die elektromyographische Registrierung der Motilität nach 2/3-Resektion des Magens mit Roux-Y-Rekonstruktion in der Roux-Schlinge keinen signifikanten Unterschied zu Kontrollwerten. Ausgeprägt sind jedoch die Veränderungen der Motilität in der blinden Schlinge. Das elektromyographische Bild ist sowohl in der Nüchternphase als auch postprandial gekennzeichnet durch einen erheblichen Aktivitätsverlust. Eine Aktivitätsfront des migrating motility complex trat nur in 25% der Nüchternexperimente auf und war zeitlich nicht mit der Motilität angrenzender Darmabschnitte koordiniert. Nach Nahrungsaufnahme war der Motilitätsindex mit 27,8 ± 4,1 in der blind endenden Schlinge ebenfalls deutlich geringer als in der Roux-Schlinge (60,2 ± 10,5). Pharmakologisch ist die ausgeprägte Hypomotilität der blinden Schlinge mit Cisapride zu durchbrechen — Anstieg des Motilitätsindex auf 111,2 ± 16,5. Bei Patienten mit RYR und klinischer Symptomatik ist daher ein therapeutischer Einsatz zu erwägen.

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Motility disturbances in the blind loop after Roux-en-y reconstructionElectromyographic studies in dogs

Disturbances of intestinal motility, bacterial overgrowth and pancreocibal asynchrony are frequent findings in patients after Roux-en-y reconstruction (RYR). In dogs (n = 6) electromyographic recording of motility after partial gastrectomy with Roux-en-y reconstruction revealed no significant differences from controls in the Roux limb. However, changes in intestinal motility were extensively in the blind loop. The electromyographic pattern was characterized by an extreme loss of activity in the fasted and postprandial state. The activity front of the migrating motility complex occurred only in 25% of the fasting studies and was not correlated in time with motility patterns of connected small intestine. Food intake led to a significant increase in the motility index in the Roux limb (60.2 ± 10.5), but not in the blind ending loop (27.8 ± 4.1). Pharmacological stimulation of the hypomotile blind loop with cisapride is successful; increase of the motility index to 111.2 ± 16.5. It might be useful in the treatment of symptomatic patients after RYR.

     

Die Serumeiweißkörper und die Elektrolyte in der postoperativen Phase

Ohne ZusammenfassungMit 1 Textabbildung.     

Aktueller Stellenwert der konventionellen Radiographie und Sonographie in der frühen Versorgung traumatisierter Patienten

Conventional radiography (CR) and ultrasound are an elementary part of the diagnostic workflow in the early phase of trauma management. In recent years their clinical value has decreased due to the innovations of computed tomography (CT). The diagnostic superiority of CT has been shown by the higher sensitivity for the detection of traumatic organ lesions. As a result CR has already been become obsolete for head injuries. Furthermore, CT is continuously gaining importance concerning the management of thoracic, pelvic and spinal injuries; however, CR remains the first-line method for the evaluation of simple trauma of the extremities and in contrast, ultrasound is considered to be a sensitive modality for the detection of free fluid after blunt abdominal trauma. In addition the combination of widespread availability, easy handling and the lack of ionizing radiation contribute to the value of ultrasound as a screening method.