Kombinierte An?sthesie mit Epiduralkatheter Eine retrospektive Analyse des perioperativen Verlaufs bei Patienten mit radikalen Prostatektomien Eine retrospektive Analyse des perioperativen Verlaufs bei Patienten mit radikalen Prostatektomien

Patienten, die sich einer radikalen Prostatektomie (rPE) einschlie?lich retroperitonealer Lymphadenektomie (rLA) unterziehen, haben aufgrund ihres Alters und ihrer Begleiterkrankungen ein erh?htes perioperativen Risiko. Ziel dieser Untersuchung war es, den intra- und postoperativen Verlauf der standardisierten Operation rPE+rLA unter verschiedenen An?sthesieregimen zu analysieren.     

Anästhesie bei Patienten mit NBIA

Background

Neurodegeneration with brain iron accumulation (NBIA) forms a group of rare hereditary diseases with rapid neurodegenerative progression due to an abnormal accumulation of iron in the basal ganglia. This causes extrapyramidal symptoms as well as dystonia and mental retardation. The most common form of NBIA is pantothenate kinase-associated neurodegeneration (PKAN, formerly Hallervorden-Spatz syndrome). There are multiple anesthesiological challenges with great implications for the clinical routine, particularly regarding the preparation for general anesthesia and the premedication visits. As with other orphan diseases, the available recommendations are mainly based on case reports.

Objective and methods

This article gives a short overview of complications associated with NBIA pertaining to general anesthesia. This includes anesthesia-relevant clinical symptoms and perioperative management. The published literature and case reports (available on PubMed) were reviewed to extract a set of recommendations.

Results

So far only a few reports have included the anesthesia management of NBIA patients. Most of them refer to PKAN as the predominant type (50% of cases). Recommendations were found on www.orphananesthesia.eu and consensus guidelines on PKAN in general. In particular, dystonia-related restrictions in the maxillofacial area can complicate airway management and cause difficulties with respect to intubation. Furthermore, local or regional anesthesia as the sole anesthesia technique is not eligible/viable due to the reduced compliance of the patient. Special attention should be paid to a timely premedication visit and evaluation to ensure sufficient time to safely plan and prepare the anesthetic procedure.

Conclusion

The handling of NBIA patients requires good preparation, including an interdisciplinary team and customized time management. In principle, both general anesthesia as a balanced method and total intravenous anesthesia (TIVA) seem to be possible/viable options. The main focus is on airway management. Even after brief sedation in the context of diagnostic measures, the patient should be monitored for longer than usual.

     

Anästhesie bei Patienten mit Myasthenia gravis

Myasthenia gravis is a chronic autoimmune disease characterised by progressive weakness and easy fatigability of voluntary skeletal muscles. These symptoms are related to a decrease in the number of functional acetylcholine receptors, impaired neuromuscular transmission, and a broadened neuromuscular cleft. Symptomatic treatment is based on anticholinesterases in order to increase the synaptic dwell of acetylcholine. Immune therapy includes immune suppressive drugs, plasma exchange, immunoglobulins, and thymectomy. Anticholinesterase therapy should be continued in the current mode until anaesthesia. Regional anaesthesia should be preferred. Although sensitivity to non-depolarising neuromuscular blocking agents is increased, muscle relaxants can be administered during general anaesthesia as long as neuromuscular monitoring assesses their individual effect. Due to the individual variability in the response to muscle relaxants, accurate titration in combination with pre- and intraoperative neuromuscular monitoring is essential for myasthenic patients. Postoperatively, intensive care observation is mandatory including neuromuscular monitoring.     

Anästhesie bei Patienten mit akuter Porphyrie

Die Anaesthesiologie - Porphyrien sind eine Gruppe seltener, meist erblicher Stoffwechselstörungen der Hämbiosynthese. Jede Porphyrie beruht auf einem spezifischen Enzymdefekt und zeigt...     

Anästhesie bei Patienten mit chronisch obstruktiven Lungenerkrankungen

Chronic obstructive pulmonary disease (COPD/pulmonary emphysema) is a common disease with a high incidence and a medico-economical impact which should not be underestimated. Pathophysiologically it is defined as expiratory obstruction due to increased airway resistance. The extensive comorbidity of COPD patients as well as the impairment of the respiratory system make COPD a key challenge for anesthesiologists. Besides basic drug therapy, differentiated ventilation support represents a hallmark of perioperative management. This article includes the current recommendations of the German national care guidelines for COPD as well as the COPD guidelines of the American Thoracic Society.     

Anästhesie bei Patienten mit Glukose-6-Phosphat-Dehydrogenase-Mangel

Glucose-6-phosphate dehydrogenase (G6PD) deficiency, a frequent congenital human enzyme defect, is the most frequent cause of hemolytic anemia triggered by drugs or infectious diseases. Drugs which induce acute hemolysis in patients with G6PD deficiency are often used in anesthesia and perioperative pain therapy. Considering the fact that patients from geographic regions with a high prevalence of the disease are often treated in European hospitals, special attention should be paid to this problem. We report a case of a 30-year-old female patient with favism and review the disease and anesthesia-related implications.     

Anästhesie bei ambulanten Patienten

The share of ambulatory procedures is increasing with advances in operative and anesthesiological methods and pressured by economical necessities. Following legal regulations procedures with and without hospital stay underlie the same quality measures. Multimodal concepts comprising anesthesiological and operative procedures, pain therapy as well as postoperative care allow for quality improvements in respect to operative outcome and patient satisfaction.     

Permissive Anämie bei Patienten mit akutem Koronarsyndrom

Ohne Zusammenfassung     

Anästhesiologisches Vorgehen bei Patienten mit spinalem Querschnitt

Spinal cord injuries (SCI) are serious medical conditions, which are associated with severe and potentially fatal risks and complications depending on the location and extent of injury. Traffic accidents, falls and recreational activities are the leading causes for traumatic SCI (TSCI) worldwide whereas non-traumatic spinal cord injuries (NTSCI) are mostly due to tumors and congenital diseases. As chronification of the injuries progresses other organ systems are affected including anatomical changes, the respiratory and cardiovascular systems and endocrinological pathways. All these effects have to be considered in the anesthesiological management of patients with SCI. Autonomic dysreflexia (AD) is the most dangerous and life-threatening complication in patients with chronic SCI above T6 that results from an overstimulation of sympathetic reflex circuits in the upper thoracic spine and can be fatal. This article summarizes the specific pathophysiology of SCI and how AD can be avoided as well as also providing anesthetists with strategies for perioperative and intensive care management of patients with SCI.     

Anästhesie bei Patientinnen mit Präeklampsie und Eklampsie

Preeclampsia is a pregnancy-associated illness affecting multiple organ systems. Symptoms typically occur after the 20th week of gestation and consist of hypertension (>140/90 mmHg) and proteinuria (>300 mg/day). It is one of the leading causes of premature birth worldwide and early diagnosis and treatment are essential for both fetal and maternal health. Therapy is aimed at lowering blood pressure sufficiently to prevent the most severe complications such as intracranial hemorrhages. At the same time attention must be paid to the possible untoward effects of blood pressure medications on uteroplacental perfusion and fetal well being. Magnesium is the cornerstone for both prevention and control of eclamptic cerebrovascular events. In cases of severe preeclampsia and eclampsia prompt delivery is indicated, often carried out by Cesarean section (>34 weeks of gestation). Compared to general anesthesia, regional anesthesia techniques offer certain advantages to both mother and fetus and in the absence of contraindications are the methods of choice.     

Kombinierte Spinal-Epidural-Anästhesie und Läsionen des Epiduralkatheters

BACKGROUND: The purpose of this study was to investigate whether there is a risk of epidural catheter damage during the advancement of the spinal needle through an epidural needle in clinical use.METHODS: A total of 100 catheters (50 from CSE kits with a pencil-point type spinal needle and 50 from CSE kits with a Quincke type spinal needle) which had been used for routine CSE blocks were microscopically examined for any defects within the first 150 mm of the catheter. Additionally 10 unused new catheters were investigated.RESULTS: Among 10 unused catheters 5 slight scratches were found, 92 out of 100 used catheters did not show any signs of use or scratches, 7 showed some signs of use and longitudinal scratches whereas another 1 showed a moderate scratch of less than 25% of the wall thickness. There was no difference in the prevalence of scratches between the CSE kits with pencil-point type spinal needles compared to those with Quincke-type spinal needles.CONCLUSION: The CSE technique with either pencil-point type or Quincke-type spinal needles for subarachnoidal punctures was safe and showed no relevant epidural catheter damage.     

Molekulargenetische Analyse und klinische Aspekte bei Patienten mit hereditärer Hämochromatose

Background

The purpose of the study was to perform a molecular genetic analysis and to document clinical aspects in patients with hereditary hemochromatosis.

Patients and methods

The study included 33 outpatients (23 males average age 50.6 years and 10 females average age 60.6 years) with a disorder of iron metabolism (transferrin saturation >?75?%) as confirmation of hemochromatosis who were subjected to molecular genetic and clinical analyses.

Results

A homozygous mutation of the hemochromatosis (HFE) gene (C282YY) was detected in 63.6?%, a compound heterozygous mutation (C282Y/H63D) in 30.3% and no mutation of the HFE gene was detected in 6.1?%. The following organ manifestations could be objectified: arthralgia (78.8?%), liver disease (39.9?%), skin hyperpigmentation (30.3?%), osteoporosis (24.2?%), diabetes mellitus (24.2?%) and cardiomyopathy (12.1?%). Comparison between patients with heterozygous and homozygous hemochromatosis revealed the following differences: compound heterozygote patients presented less frequently with osteoarthritis of the metacarpophalangeal (MCP) joints and hands (85.7?%/71.4?% homozygotes vs. 60?%/60?% heterozygotes). Osteoarthritis of the shoulder joints and osteoporosis as well as hypothyroidism were more frequent in compound heterozygote patients, whereas osteoarthritis of the knee and hip joints as well as liver disease were more common in homozygote patients. No differences between both groups were seen with respect to the clinical manifestations of cardiomyopathy and diabetes mellitus.

Conclusion

Prevalent causes of death in hereditary hemochromatosis are heart failure, liver disease (cirrhosis and hepatocellular carcinoma) and portal hypertension. Therefore, an early diagnosis, adequate therapy and genetic screening of family members are of great importance. Medicinal treatment will only effectively prevent deleterious organ involvement and subsequent complications if initiated at an early stage. Furthermore, an overview of the current data is given.     

Cisatracurium bei Patienten mit eingeschränkter Nierenfunktion Pharmakodynamik und Intubationsbedingungen unter Isofluran-Lachgas-Anästhesie

Zusammenfassung Ziel dieser Untersuchung war es, Ver?nderungen der Pharmakodynamik von Cisatracurium (3 x ED₉₅) bei Patienten mit terminaler Niereninsuffizienz (Cis-2) im Vergleich zu Patienten ohne Nierenfunktionsst?rung (Cis-1) zu erfassen. Des weiteren sollten die Intubationsbedingungen sowie der Einflu? dieser Substanz auf den Blutdruck und die Herzfrequenz und Isofluran-Lachgas-An?sthesie untersucht werden. Methodik: 39 Patienten (ASA-Klassifikation I–III) wurden entsprechend ihrer Nierenfunktion den jeweiligen Gruppen zugeordnet (Cis-1: normale Nierenfunktion n = 19; Cis-2: Niereninsuffizienz n = 20). Die Narkoseeinleitung erfolgte mit Fentanyl (2–3 μg/kg) und Thiopental (4–7 mg/kg). Nach Bolusapplikation von 0,15 mg/kg (3 x ED₉₅) Cisatracurium wurden Anschlagzeit und Intubationsbedingungen ermittelt. Weiterhin wurden mittels Akzeleromyographie die klinische Wirkdauer (DUR 25%), der Erholungsindex (DUR 25%–DUR 75%) und die Spontanerholung auf 90% (DUR 90%) sowie die TOF-Ratio (T4:T1 > 0,7) bestimmt. Ver?nderungen des mittleren arteriellen Blutdrucks und der Herzfrequenz von < 20% zum Ausgangswert wurden als klinisch signifikant angesehen. Ergebnisse: Insgesamt 95% der Patienten konnten nach 120 s unter guten bis sehr guten Bedingungen intubiert werden. Die Anschlagzeit von 3,1 ± 0,8 min war bei den nierengesunden Patienten kürzer, unterschied sich aber statistisch nicht signifikant von 3,6 ± 0,8 min bei den niereninsuffizienten Patienten. Alle anderen pharmakodynamischen Parameter unterschieden sich ebenfalls nicht signifikant zwischen beiden Gruppen. Eine ausgepr?gte individuelle Schwankungsbreite der Spontanerholung war charakteristisch, besonders für die Patienten mit terminaler Niereninsuffizienz. 8 Patienten zeigten eine Abnahme des mittleren arteriellen Blutdruckes von > 20% des Ruheausgangswertes nach Cisatracurium. Die Herzfrequenz ver?nderte sich bei keinem der 39 Patienten. Schlu?folgerung: Cisatracurium in der 3fachen ED₉₅ ist für die Anwendung bei Patienten mit terminaler Niereninsuffizienz geeignet. Aufgrund der gro?en individuellen Schwankungsbreite der neuromuskul?ren Spontanerholung ist bei dieser Substanz, wie auch bei allen anderen bisher verwendeten Muskelrelaxanzien, ein intraoperatives Monitoring der neuromuskul?ren Blockade bei Patienten mit eingeschr?nkter Nierenfunktion zu empfehlen.      

Periduralanästhesie mit Ropivacain bei Friedreich-Ataxie

Friedreich’s ataxia (FA) is a hereditary disease, which leads to degenerative changes in the spinal cord and cerebellum (incidence 1:50,000). These changes are caused by a defect in the gene that encodes a mitochondrial gene called frataxin and causes muscle weakness, scoliosis, cardiomyopathy and impaired glucose tolerance. Therefore, these patients require special care during anaesthesia. We report the case of a 25-year-old primigravida with a history of FA and dorsal stabilisation of the vertebral column, who was admitted to our hospital for elective caesarean section. Due to increased sensitivity to muscle relaxants, peridural anaesthesia with 8 ml 0.75% ropivacaine and 10 µg sufentanil was used in this case. The perioperative neurological consultation revealed no undue exacerbation of symptoms.     

Nebenerscheinungen bei Lokalanästhesie mit Novokain-Suprarenin

Ohne Zusammenfassung (Mit 2 Kurven.)     

Anästhesie bei neuromuskulären Erkrankungen

Among the neuromuscular diseases (NMDs) over 800 individual entities have been identified. The vast majority of these diseases occur very seldom but all NMDs together add up to a prevalence of 1:1,500. Accordingly the conclusion “seldom diseases are common” seems to be appropriate. The scope of NMDs is very wide varying from the affection of single muscle groups to the complete musculature, from slowly progressive to fulminant progressive forms, from perinatal to the adult manifestation as well as number, course and character of associated comorbidities. Due to the wide heterogeneity concerning NMDs it is of great importance for anesthesiologists to be knowledgeable on relevant comorbidities as well as indications and contraindications for the various anesthetics.     

Prognoseabschätzung des Schwerverletzten – Eine Analyse von 2069 Patienten des Traumaregisters der DGU

On hospital admission numerous variables are documented from multiple trauma patients. The value of these variables to predict outcome are discussed controversially. The aim was the ability to initially determine the probability of death of multiple trauma patients. Thus, a multivariate probability model was developed based on data obtained from the trauma registry of the Deutsche Gesellschaft für Unfallchirurgie (DGU). Patients and methods. On hospital admission the DGU trauma registry collects more than 30 variables prospectively. In the first step of analysis those variables were selected, that were assumed to be clinical predictors for outcome from literature. In a second step a univariate analysis of these variables was performed. For all primary variables with univariate significance in outcome prediction a multivariate logistic regression was performed in the third step and a multivariate prognostic model was developed. Results. 2069 patients from 20 hospitals were prospectively included in the trauma registry from 01.01.1993–31.12.1997 (age 39±19 years; 70.0% males; ISS 22±13; 18.6% lethality). From more than 30 initially documented variables, the age, the GCS, the ISS, the base excess (BE) and the prothrombin time were the most important prognostic factors to predict the probability of death (P_(death)). The following prognostic model was developed: P_(death)=1/1+e^{{?[k+β1(age)+β2(GCS)+β3(ISS)+β4(BE)+β5(prothrombin time)]}} where: k=minus;0.1551, β1=0.0438 with p<0.0001, β2=?0.2067 with p<0.0001, β3=0.0252 with p=0.0071, β4=?0.0840 with p<0.0001 and β5=?0.0359 with p<0.0001. Each of the five variables contributed significantly to the multifactorial model. Conclusions. These data show that the age, GCS, ISS, base excess and prothrombin time are potentially important predictors to initially identify multiple trauma patients with a high risk of lethality. With the base excess and prothrombin time value, as only variables of this multifactorial model that can be therapeutically influenced, it might be possible to better guide early and aggressive therapy.