Ketaminrazemat bei „Fast-track“-Anästhesie

Introduction

In this study the impact of 25 mg of ketamine racemate given just before surgery on recovery times and postoperative analgesic needs in patients undergoing vaginal hysterectomy and receiving propofol-remifentanil anaesthesia was investigated.

Methods

With ethics committee approval 70 female patients aged 25–65 years were enrolled. All patients received a total intravenous anaesthesia with remifentanil and propofol with the propofol infusion being controlled to a Narcotrend index of 40. Patients in the ketamine group (n=35) received additionally a bolus dose of 25 mg ketamine racemate intravenously 3 min before skin incision. In addition to monitoring haemodynamics and circulation parameters, recovery times, postoperative pain and opioid needs were also recorded. Patients were also questioned on their satisfaction with the pain therapy.

Results

All 70 patients completed the study and the groups were similar with respect to demographic data. The haemodynamics of the patients were stable in both groups and the postoperative pain measured over a 24-h period as well as the opioid needs were also comparable. However, recovery times were significantly prolonged in the ketamine group, e.g. the times to extubation were 8.3±4.0 min with ketamine compared to 6.1±2.1 min in the control group (p<0.01). Undesired side effects were overall rare but occurred to the same extent in both groups.

Conclusions

This study demonstrated that 25 mg ketamine racemate given just before surgery significantly prolongs recovery times without reducing post-operative analgesic needs when applied to patients undergoing vaginal hysterectomy and receiving propofol-remifentanil anaesthesia. A bolus dose of 25 mg ketamine racemate cannot therefore be recommended for preemptive analgesia under these conditions.     

Radikale Prostatektomie – pro laparoskopisch

Recent publications have failed to demonstrate significant differences in perioperative oncological and functional outcomes between laparoscopic radical prostatectomy (LRPE) and R-LRPE. Reports suggesting better functional results, in particular better potency rates for R-LRPE, are rare. However, to date no large prospective, randomized, multicenter studies have compared the two methods. With an experienced operator both methods produce comparably good results. The monopoly of the intuitive system with extremely high cost of purchase and maintenance are the major disadvantages of R-LRPE.     

„Fast-track“-Chirurgie

Zusammenfassung Die fast-track-Chirurgie ist ein multimodales Behandlungskonzept zur Beeinflussung pathophysiologischer funktioneller Veränderungen nach elektiven Eingriffen mit dem Resultat der verminderten Morbidität und beschleunigten Rekonvaleszenz. Erreicht wird dies durch eine optimierte interdisziplinäre (Chirurg, Anästhesist, Pflegepersonal, Physiotherapeut) und perioperative Fürsorge, welche zu einer verminderten operativen Stressreaktion des Patienten führt. Hierdurch konnten z. B. nach elektiven Kolonresektionen die Rate allgemeiner postoperativer Komplikationen und die Krankenhausliegezeiten deutlich gesenkt werden. Voraussetzung bei der Einführung der fast-track-Chirurgie ist der Wille der verantwortlichen Chirurgen zur Veränderung konventioneller Konzepte. Das Grundprinzip des fast-track-Managements wird zunehmend mit Erfolg auch auf andere abdominalchirurgische Operationen und andere operative Fächer wie z. B. die Urologie ausgeweitet.     

Klinischer Behandlungspfad „laparoskopische Prostatektomie“

METHODS: In this study we investigated the anesthesiological module of a clinical pathway. We chose the pathway of "laparoscopic prostatectomy" as an example for time-consuming minimally invasive surgery and 40 patients were randomly assigned to 2 groups receiving either total intravenous anesthesia (TIVA) using propofol/ remifentanil or balanced minimal flow anesthesia using desflurane/ remifentanil. During this module the indicators of quality such as vigilance, pain, postoperative nausea and vomiting (PONV) and mobilization were measured. Costs were evaluated and analyzed by a bottom-up procedure. RESULTS: There were no anesthesia-related deviations from clinical pathways and both forms of anesthesia management were equally well tolerated by the patients. No significant difference was observed regarding hemodynamic measurements or PONV. The patients in the desflurane/ remifentanil group recovered more rapidly (p=0.037) and had more pain. The amount of analgesic agents given immediately following anesthesia was significantly higher than in the TIVA group (p=0.017). The median anesthesia costs per minute for laparoscopic prostatectomy in the propofol group were 2.79 EUR (minimum cost 2.41 EUR, maximum cost 3.21 EUR) and in the desflurane group 2.68 EUR (minimum cost 2.45 EUR, maximum cost 3.39 EUR). The total anesthesia costs for both groups were within the proceeds matrix range for diagnosis-related groups (DRG). However, the cost analysis for medication was slightly higher than the proceeds matrix range for DRGs. CONCLUSION: Both forms of anesthesia can be implemented for time-consuming surgical procedures and allow a cost-effective anesthesia management. Anesthesiological procedures must go hand-in-hand with the type of anesthesia selected. The prophylactic use of analgetics for desflurane/ remifentanil anesthesia should be given earlier and in higher doses than in propofol/ remifentanil anesthesia. The prophylactic use of antiemetics following laparoscopic procedures of long duration is indicated. Optimizing anesthesiological procedures could lead to a continuous improvement in the quality of therapeutic pathways.     

Operative Korrekturm?glichkeiten der Anastomosenstriktur nach radikaler Prostatektomie

Background

Anastomotic strictures following radical prostatectomy for prostate cancer are reported in about 1?C8% of all patients. Endourologic management usually does not result in very high cure rates but is associated with very high rates of recurrences. There is no standard management of these postoperative long-term complications and quite often the patient ends up having a transurethral or suprapubic catheter as a simple long-term solution.

Results

Twenty-four patients with recurrent anastomotic strictures and a mean of 3.5 (2?C9) previous transurethral surgical interventions were operated between 2004 and 2011. All patients underwent perineal bladder neck closure and a continent vesicostomy with either an appendiceal or an ileal stoma implanted in the bladder. The mean OR time was 125 (100?C195) min, and the mean time of hospitalisation was 12.5 (9?C27) days. There were no significant intra- or perioperative complications. Three patients developed a significant urinary tract infection, two patients had to be treated for the development of a paralytic ileus and one patient needed to undergo revision surgery for a urethral fistula. After a mean follow-up of 37 (10?C78) months, two patients developed a stomal stenosis which was corrected surgically.

Conclusions

Based on our experience, bladder neck closure and continent vesicostomy represent a valuable therapeutic option in the management of recurrent anastomotic strictures following radical prostatectomy.     

Krankheits- und behandlungsbedingte Sexualstörungen nach radikaler Prostatektomie

Between 20% and 25% of the patients seeing a doctor have sexual problems. These have various causes: somatopsychological, psychosomatic, social-somatic and psychological factors can play an important role. For an effective therapy, a biopsychosocial understanding of the development of these diseases is necessary. Tumor-patients belong to a special group who frequently develop sexual problems. There are many patients with prostate cancer who, after a radical prostatectomy, suffer from erectile dysfunction. As sexuality always has a social dimension, there is no sexual dysfunction which can be seen as separate from partnership and social environment. Hence the couple is the patient, not the malfunctioning penis. Sexual rehabilitation's main aim is therefore not the repair the malfunctioning organ but rather the improvement of the quality of the sexual relationship beyond penetration.     

Leipziger „Fast-track“-Protokoll in der Kardioanästhesie

Background

In November 2005 a complex, multimodal anesthesia fast-track protocol (FTP) was introduced for elective cardiac surgery patients in the Cardiac Center of the University of Leipzig which included changing from an opioid regime to remifentanil and postoperative treatment in a special post-anesthesia recovery and care unit. The goal was to speed up recovery times while maintaining safety and improving costs.

Method

A total of 421 patients who underwent the FTP and were treated in the special recovery room were analyzed retrospectively. These patients were compared with patients who had been treated by a standard protocol (SP) prior to instituting the FTP. Primary outcomes were time to extubation, length of stay in the intensive care unit (ICU) and treatment costs.

Results

The times to extubation were significantly shorter in the FTP group with 75 min (range 45–110 min) compared to 900 min (range 600–1140 min) in the SP group. Intensive care unit stay and hospital length of stay were also significantly shorter in the FTP group (p<0.01). The reduction of treatment costs of intensive care for FTP patients was 53.5% corresponding to savings of EUR 738 per patient in the FTP group compared with the SP group.

Conclusions

The Leipzig fast-track protocol for cardio-anesthesia including the central elements of switching opiate therapy to remifentanil and switching patient recovery to a special post-anesthesia recovery and care unit, shortened therapy times, is safe and economically effective.     

Evaluation von Art und Ausmaß der präoperativen Bildgebung vor radikaler Prostatektomie

Background

According to current guidelines, in cases of newly diagnosed prostate cancer the type and extent of imaging to be performed should be based on the patient’s risk profile. We investigated the rate of computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy carried out before radical prostatectomy (RP) depending on the individual risk profile.

Patients and mehod

Between 1 January 2006 and 31 December 2007, a total of 1,018 consecutive patients who had not received neoadjuvant hormone therapy were treated with RP in our department. We determined the preoperative rates of CT, MRI, and bone scintigraphy by reviewing the medical charts. The patients were stratified according to the D’Amico criteria into low-risk, intermediate-risk, and high-risk groups.

Results

Of the 1,018 subjects, 493 (48%) were classified as low-risk, 403 (40%) as intermediate-risk, and 122 (12%) as high-risk patients, respectively. The rate of preoperative abdominal CT/MRI and bone scintigraphy was 17 and 23% in the low-risk group, 25 and 39% in the intermediate-risk patients, and 39 and 57% in the high-risk group.

Conclusion

The rate of preoperative CT and bone scintigraphy is extremely high in the low-risk group. In contrast the rate in the high-risk patients more likely appears to be too low. The discrepancy between the rates of preoperative imaging subject to the patient’s risk profile shows that precisely formulated guidelines addressing this issue are needed.     

„Critical illness myopathy“ bei Intensivpatienten

Intensive care patients are at increased risk of developing sepsis with multi-organ failure during treatment (severe sepsis) possibly leading to complications of the central and peripheral nervous system. Among these, septic encephalopathy, critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are the most important. Neuromuscular complications in particular are difficult to diagnose as they mostly become apparent only when sedation has ceased and the awakening patient experiences difficulties in weaning from the respirator and reduced voluntary strength. CIP and CIM are generally self-limiting, however, they greatly prolong ICU stay and rehabilitation, thus nowadays also imposing a real budget threat. The diagnostics, especially the differentiation between CIM and CIP is difficult and a multi-disciplinary approach involving ICU physicians, anesthetists and neurologists is needed. Our knowledge of the causes of the primary ICU myopathy, although rapidly evolving during recent years, is still in its infancy and specific treatment of CIM is not yet available. The present overview summarizes insights into clinical and new diagnostic strategies for early detection of neuromuscular dysfunction in ICU patients. This article focuses on current concepts and results revealing the pathomechanism(s) of CIM and some simple therapeutic or preventive measures have been deduced which are summarized and discussed.     

Stellenwert der radikalen Prostatektomie bei ≥?70-J?hrigen

Surgical treatment of prostate cancer (PCa) in patients older than 70 years is controversially discussed. Although the prevalence and presumably also the aggressiveness of PCa increase with age, a survival advantage by radical prostatectomy (RPx) is questionable. The current review will discuss the oncological outcome of RPx in the elderly. Moreover, the pros and cons of different surgical approaches will be evaluated.     

Die örtliche Betäubung bei radikaler Mammaamputation wegen Krebs

Ohne Zusammenfassung     

Bedeutung von Komorbidität und Alter bei der radikalen Prostatektomie

The coexistence of another diagnosis beside the index disease under study is defined as comorbidity. Comorbidity increases with advancing age. In candidates for radical prostatectomy, two aspects of comorbidity are of interest: its association with perioperative complications and long-term survival. The Charlson score is the most extensively studied comorbidity classification for the prediction of long-term outcome. Several studies have identified this score as an independent prognostic factor in the prostate cancer setting. In addition to the Charlson score, data collected during the preoperative cardiopulmonary risk assessment may deliver information identifying patients with an increased long-term mortality risk. The meaningfulness of comorbidity in predicting overall mortality seems to be comparable to that of the Gleason score, the most important tumor-related predictor of survival in prostate cancer. The identification of prognostically relevant single conditions and the development of a "radical prostatectomy-specific" comorbidity classification might improve the stratification of candidates for radical prostatectomy in the future.     

„Negative pressure wound therapy“ bei sternalen Wundinfektionen

Zeitschrift für Herz-,Thorax- und Gefäßchirurgie - Die mediane Sternotomie ist in der Herzchirurgie der am häufigsten durchgeführte chirurgische Zugang. Gleichwohl treten...     

Intramedulläre Injektion bei „tethered cord“

Die Anaesthesiologie - Schwere neurologische Komplikationen bei der Durchführung von Spinalanästhesien (SA) sind selten. Wir berichten über eine Rückenmarkschädigung bei...     

„Work hardening“ bei chronischen Rückenschmerzen

Work hardening is aimed at a reestablishment of the potentials needed in occupational everyday life. Fundamental motor abilities, such as strength, stability, flexibility and persistence, are restored and merged into the everyday life so that psychological contents, such as fear avoidance behavior will be positively affected. The design of work hardening is interdisciplinary in the sense of a holistic approach to back pain. Handling the pain under load requires sophisticated treatment and the training demands a high degree of individual design. A trusting and mutual agreement between therapist and patient is essential. Work hardening represents an important part of the therapy of chronic back pain and greatly supports regaining confidence in the physical efficiency and the ability to control the body.