Kontinuierliche β-Blockade mit Esmolol in Kombination mit Enoximon-Gabe

BACKGROUND: The aim of this study was to assess cardiac function in vascular surgery patients with known coronary artery disease (CAD) who received continuous perioperative beta blocker therapy with esmolol alone versus esmolol in combination with the phosphodiesterase (PDE) III inhibitor enoximone. PATIENTS AND METHODS: Over a period of 24 h, 28 patients were assigned to receive heart rate (HR) control by continuous infusion of esmolol in combination with the PDE III inhibitor enoximone (Esmolol+Enoximone group) or esmolol alone (Esmolol group; n=14). Cardiac function was assessed by the use of a pulmonary artery catheter and serial measurements of plasma troponin T (TnT) und B-type natriuretic peptide (BNP). RESULTS: The heart rate significantly decreased to the target rate of 50-60 min(-1) in both groups over the observation period. Cardiac index increased significantly only in Esmolol+Enoximone-treated patients (from 2.4+/-0.2 lxmin(-1)xm(-2) to 3.1+/-0.1 lxmin(-1)xm(-2)) and was significantly higher than in the esmolol alone group (from 2.5+/-0.2 lxmin(-1)xm(-2) to 2.4+/-0.1 lxmin(-1)xm(-2)). No patient had detectable levels of cTnT perioperatively. Peak plasma BNP concentrations were significantly increased in both groups but the highest values were measured in the esmolol alone group. CONCLUSION: Inotropic therapy with the PDE III inhibitor enoximone improves cardiac function in high risk patients with known CAD undergoing vascular surgery and also when receiving systematic heart rate control by continuous infusion of esmolol.     

Erfahrungen mit medialen monokondylären Prothesen mit mobilem Plateau

Background

Unicompartmental knee arthroplasty (UKA) has become an accepted therapy for medial osteoarthritis. The main reasons for its popularity are the minimally invasive surgical technique and the reports of excellent long-term results including high patient satisfaction and good knee joint function especially in younger patients.

Objectives

The purpose of our retrospective study was to evaluate the physical activities of patients who had undergone an Oxford III medial UKA. Special attention was paid to implant positioning and osteoarthritis of the patellofemoral joint.

Materials and methods

Of 181 implanted Oxford III prosthesis, 136 (75.1%) could be followed up. The mean age at time of surgery was 65.2 years; the average time of follow-up was 4.2 years. In addition to a physical examination and x-ray, the following scores were obtained: WOMAC (Western Ontario and McMaster Osteoarthritis Index), OKS (Oxford Knee Score), KSS (Knee Society Score), UCLA activity and the Turba score.

Results

The majority of the patients (81%) returned to their sporting activity following knee surgery. Higher complication rates or progression of osteoarthritis associated with sporting activities were not observed. The active patients had significantly higher scores for the OKS, KSS, WOMAC, and UCLA scores. The correct implant position, especially avoiding overcorrection to valgus malalignment, is important for good clinical outcome.

Conclusion

Our results demonstrate that a high degree of patient satisfaction in terms of physical and sporting activity can be achieved using the Oxford III UKA for medial osteoarthritis without an increased risk for complications.     

Intoxikation mit γ-Hydroxybutyrat

The drug gamma-Hydroxybutyrate (GHB), also known as liquid ecstasy, has now reached Europe. Estimating the dosage of liquid GHB is especially difficult leading to unintentional intoxication because the exact concentration is not known. We repeatedly had to treat young patients intoxicated by GHB in our intensive care unit. We describe the course and treatment of three patients with GHB intoxication. If alcohol or mixed intoxication with drugs detected in traditional hospital toxicological assays has been excluded as the cause of unconsciousness in young patients from disco's, an intoxication with GHB should be considered. The therapy is mainly symptomatic and supportive but monitoring in an intensive care unit with the option of short term respirator therapy is necessary. Serum and urine samples taken on arrival should be conserved for further investigation in a forensic institute.     

Rückenmarkstumoren mit Stauungspapille

Zusammenfassung Im allgemeinen können bei Rückenmarkstumoren die Resorptionsbahnen oberhalb des spinalen Blockes die Behinderung der besonders wichtigen Liquorabflußbahnen im Konus- und Caudabereich ausgleichen. Wenn es in seltenen Fällen — besonders bei caudalen spinalen Prozessen — zu einer Erhöhung des intracraniellen Druckes und der Entwicklung einer STP kommt, so dürften neben der mechanischen Abflußbehinderung noch weitere Faktoren beteiligt sein. Neben einer sich in der Liquorproduktion auswirkenden ausgeprägten vegetativen Labilität ist vor allem eine supraläsionelle Eiweißerhöhung wirksam, die das Liquorproduktions- und Resorptionsgleichgewicht stört. Dies geht aus der Zusammenstellung von 21 in der Weltliteratur veröffentlichten Fällen und einem eigenen Fall hervor. Auffällig häufig wurden im Cisternen- und Ventrikelliquor Werte über 100 mg% Gesamteiweiß gemessen, wobei manchmal nur eine unerhebliche Dissoziation zwischen Cisternen- und Lumballiquor vorlag.

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Summary In general, with spinal cord tumours, the resorption pathways above the spinal block compensate for the obstruction of the especially important c. s. f. return flow pathways in the conus and caudal regions. If in rare cases—especially with caudal spinal lesions—a rise in the intracranial pressure occurs with the development of papilloedema, additional factors ought to be invoked as well as that of mechanical obstruction of flow. In addition to the pronounced vegetative lability affecting c. s. f. production, a supralesional c. s. f. protein elevation, which disturbs the balance of c. s. f. production and resorption, is the main relevant factor. This paper summarizes 21 published eases in the world literature and adds one personal case. Almost always total protein levels of over 100 mg% were found in the cisternal and ventricular fluids, as a result there was frequently only a trivial disparity between the cisternal and the lumbar fluids.

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Resumen En general cuando existen tumores de la columna los mecanismos de reabsorción por encima del bloqueo compensan la obstrucción del paso del líquido a las zonas de reabsorción del cono y la región caudal. Si en algún caso raro se produce un aumento de la presión intracraneal con edema papilar para explicar este fenómeno debe recurrirse a factores adicionales, además de la obstrucción mecánica del flujo del líquido. Junto con una labilidad vegetativa acentuada que afecte la producción de l. c. r. es factor relevante un aumento del contenido de proteinas por encima del bloqueo, que da lugar a trastornos del balance de producción y reabsorción del l. c. r.En este trabajo se resumen 21 casos publicados de la literatura y se añade un caso personal. Prácticamente siempre se encontró niveles de proteina superiores a 100 mg.% en el líquido ventricular y cisternal.

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Résumé En général, dans les tumeurs médullaires les voies de résorption situées au-dessus du blocage médullaire remplacent les voies de retour du L.C.R. particulièrement importantes dans la région du cône dure-mèrien.Si dans de rares cas, en particulier lors de lésions spinales caudales, une augmentation de la pression intra-crânienne se produit parallèlement au développement de l'oedème papillaire, d'autres facteurs doivent être invoqués en dehors de l'obstruction mécanique.En plus de la labilité végétative marquée qui affecte la production de L. C. R. une élévation des protéïnes supralésionnel, qui perturbe l'équilibre production-résorption est le facteur principal.L'article résume 21 cas publiés dans la littérature mondiale et apporte un cas personnel. Presque toujours des taux de protéïnes total supérieur à 100mgr. sont trouvés dans les liquides cisternaux et ventriculaires. De même qu'il y avait fréquemment une différence minime entre les liquides lombaires et de la citerne.

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Riassunto In genere nei tumori del midollo spinale le vie di riassorbimento al di sopra del blocco spinale possono compensate l'ostruzione delle vie di deflusso del liquor, particolarmente importanti, nella zona del cono midollare terminale.Quando, in rari casi, — specie in processi spinali caudali — si verifica un aumento della pressione endocranica con conseguente papilla da stasi, si deve supporre che, oltre gli impedimenti meccanici al deflusso, vi partecipino altri fattori.Accanto ad una pronunziata labilità vegetativa, che si manifesta nella produzione del liquor, agisce soprattutto un aumento dell'albumina al di sopra del blocco, che turba l'equilibrio della produzione del liquor ed il suo riassorbimento. Ciò si ricava dall'esame di 21 casi pubblicati nella letteratura mondiale e di un caso trattato dall'A. Dà all'occhio la frequenza, nel liquor delle cisterne e dei ventricoli cerebrali, di valori superiori a 100 mg% di albumina, mentre talvolta la dissociazione tra liquor delle cisterne e quello lombare era appena apprezzabile.

     

Peniskarzinom — Nachsorge mit Konsequenz

Penile cancer is a rare tumor entity but penile carcinoma is characterized by a high recurrence rate regarding local, lymphatic, and hematogenous recurrence. The critical period for tumor recurrence is in the first 5 years. Therapeutic options for tumor recurrence can be differentiated by the type of recurrence and the preceding therapy. The prognosis of local or small lymphatic recurrence-if detected early and diligently diagnosed-can be improved significantly by radical surgery. On the other hand, systemic therapy of advanced lymphatic recurrences and hematogenous metastases will influence disease progression only marginally. Based on these considerations, the follow-up of penile cancer should be risk adapted but close as suggested by our algorithm. With a reduced, but close follow-up we can offer our patients aftercare with the consequence of improved prognosis.     

Niedrigflußnarkosen mit Desfluran

Objectives: Due to its low solubility and negligible metabolism, desflurane is assumed to be especially suitable for application by low-flow anaesthetic techniques. The aim of this clinical investigation was the development of a standardised dosing scheme for low-flow and minimal-flow desflurane anaesthesia. Methods: One hundred six ASA status I–II patients were assigned to six groups according to the duration of the initial high-flow phase, fresh gas flow, and fresh-gas desflurane concentration. The median age, height, body weight, and constitution of the groups was comparable. After an initial high-flow phase using 4.4?l/min, the fresh gas flow was reduced to 0.5?l/min (minimal-flow anaesthesia) or 1.0?l/min (low-flow anaesthesia). Inspired nitrous oxide concentrations were maintained at 60% to 70%. Using different standardised schemes of vaporizer settings, inspired desflurane concentrations were applied in the range from 3.4% to 8.7%, i.e., between 1 and 1.5 MAC. Inspired and expired desflurane concentrations were measured continuously by the side-stream technique and recorded on-line. Venous blood samples were taken immediately prior to induction and 45?min after flow reduction for measurement of carboxyhaemoglobin (COHb) concentration). Results: In the 10- to 15-min initial phase during which a high fresh gas flow of 4.4?l/min was used, the inspired desflurane concentration reached values in the range of 90%–95% of the fresh gas concentration. In low-flow anaesthesia this concentration could be maintained without any alteration of the vaporizer setting, whereas in minimal-flow anaesthesia with flow reduction the fresh gas concentration had to be increased by 1% to 2%: The quotient calculated by division of the inspired desflurane concentration by its fresh gas concentration (Q=C_I/C_F) ranges between 0.65 and 0.75 in minimal-flow and between 0.80 and 0.85 in low-flow anaesthesia. If use was made of the wide output range of the desflurane vaporizer, the inspired concentration could be increased rapidly by about 5% in 8?min, although the flow was kept constant at 0.5?l/min. Compared with its value prior to induction (2.13±1.05%), the COHb concentration decreased statistically significantly by about 0.7% during the 1st hour of minimal-flow anaesthesia (1.42±1.01%). In no case was a COHb concentration observed that exceeded threatening or even toxic values, although the soda lime was changed routinely only once a week. Conclusions: The pharmacokinetic properties of desflurane, resulting in especially low individual uptake, and the wide output range of the vaporizer facilitate the use of low-flow anaesthetic techniques in routine clinical practice. Even in minimal-flow anaesthesia, the duration of the initial high-flow phase can be shortened to?min. If the flow is reduced to 1?l/min, the inspired desflurane concentration achieved in the initial high-flow phase can be maintained without any alteration of the vaporizer setting. In minimal-flow anaesthesia, however, with flow reduction to 0.5?l/min, the fresh gas concentration has to be increased to a value 1%–2% higher than the inspired nominal value. Due to the wide dialling range of the desflurane vaporizer, the amount of vapour delivered into the breathing system can be increased to about 110?ml/min even at a flow of 0.5?l/min. The large amount of agent that can be delivered into the system even under low-flow conditions, together with the very low individual uptake, results in a time-constant that is sufficiently short for the clinically required rapid increase in inspired desflurane concentrations. The short time-constant of low-flow desflurane anaesthesia improves the control of the anaesthetic concentration. If all measures are taken to safely avoid inadvertent drying out of the soda lime, there is no evidence that low-flow anaesthesia with desflurane is liable to increase the risk of accidental carbon monoxide poisoning. As the use of desflurane with high-flow anaesthetic techniques becomes wasteful, its routine clinical use from an economic and ecologic standpoint will only be justified if consistently applied with low-flow or minimal-flow anaesthesia.     

Plastik des vorderen Kreuzbandes mit freiem Transplantat mit Hilfe eines neuen Zielgerätes

Zusammenfassung Es wird eine Zusammenfassung der derzeit üblichen Methoden zum Ersatz des vorderen Kreuzbandes gegeben und bezüglich der Haltbarkeit und Biomechanik des Kniegelenkes diskutiert. Vom Autor wird dabei das bei der Brücknerplastik verwandte Ligamentum patellae als Kreuzbandersatz empfohlen, wobei er jedoch wegen der relativen Kürze des Kniescheibenbandes die Verwendung desselben als freies Transplantat angibt. Es wird ausführlich die genaue topographische Lage des vorderen Kreuzbandes im Kniegelenk beschrieben und ein Zielgerät zur korrekten Implantation des proximalen Kreuzbandersatzes am lateralen Femurcondylus vorgestellt.

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A new drill guide for plastic repair of the anterior cruciate ligament by a free ligamenteous graft

Summary A report of the most widely used grafts for the replacement of the anterior cruciate ligament shows the difficulties of plastic repair. The author recommends the patella ligament used by Brückner but, because of the relative shortness of this ligament, not as a distally based ligamenteous graft but as a free one. The exact topography of the anterior cruciate ligament is given. A new drill guide for repair of this ligament is described and the technique of implantation by making use of that drill guide is explained.

     

Die Behandlung komplexer Ellbogenverletzungen mit einem gelenküberbrückenden Fixateur mit Bewegungsachse

Biomechanical investigations in eight specimen elbow joints to test articulated external fixation showed correct extension-flexion joint position between 0 and 120 degrees. The central axis through the radial and ulnar condyles varies less than 3 degrees in total. X-ray cinematography showed correct articulation in all cases without subluxation. In six patients with persistent subluxation and complex fracture of the proximal ulna external fixation with an additional articulation was placed. All patients began with physiotherapy on the 3rd day after operation, the range of joint motion was 0-30-95 degrees in all cases, after 6 weeks 0-30-110 degrees. Additional articulated external fixation at the elbow joint can be an alternative treatment to long-term transfixation of the elbow in cases of complex injury.     

Aortenklappenersatz mit gerüstlosen Bioprothesen

Stentless valves were designed to improve postoperative hemodynamics in comparison to stented bioprosthesis. The implantation technique of stentless valves is very different from conventional bioprostheses: a stented bioprosthesis maintains its form, due to the rigid stent, whereas the form of a stentless valve depends on the surgical suture lines. The general goal is to snugly fit a stentless valve into the aortic root and, thereby, to ensure optimal hemodynamic results. Insufficient coaptation of the cusps and bulging of the prosthesis into the outflow tract are the results of suboptimal implantation techniques. Residual gradients after stentless valve implantation impede postoperative quality of life and long-term survival. The present paper aims to describe the principles of implantation of stentless valves and to standardize the procedure using the Freestyle prosthesis as an example. The standardization of surgical technique and the identification of common pitfalls are mandatory to avoid unfavorable learning curves and to improve quality of life and long-term survival.     

Operation mit verzögerter Dringlichkeit

Ohne ZusammenfassungMit 3 Abbildungen     

Kombination von β-Blockern mit Dobutamin

Ohne Zusammenfassung     

Retrospektive Analyse des differentialtherapeutischen Vorgehens bei Kindern mit Doppelnieren mit Ureter duplex und Harntransportstörung

In this study, we analyzed the findings of 79 duplex kidneys in 64 children treated at our institution between 1987 and 1999. Several reasons for impaired urine transport in a duplex kidney were clarified. A total of 55% of all patients manifested a variety of abnormal findings during prenatal screening. In the course of postnatal diagnostic work-up, renal units were classified according to their leading pathomorphological features: 44% showed a ureterocele, 29% nonfunctioning units at first diagnosis, and 27% vesicoureteric reflux. Nonfunctioning moieties had been heminephrectomized in most cases. In such nonfunctioning cases in the presence of associated ureteroceles, relief drainage was unsuccessful in our study. Reflux rarely matures. Ureterocystoneostomy is successful in 80% of our cases. In functioning units with a ureterocele, endoscopic therapy may be the one and only intervention needed. However, they commonly require secondary reconstructive measures.     

Kombinierte Anästhesie mit Epiduralkatheter Eine retrospektive Analyse des perioperativen Verlaufs bei Patienten mit radikalen Prostatektomien

Patients requiring radical prostatectomy (rPE), including retroperitoneal lymphadenectomy are often aged and have coexisting cardiopulmonary diseases, increasing the risk of perioperative complications. The aim of the present study was to evaluate our perioperative anaesthesiologic regimen over the last five years, in terms of safety and patients comfort. Records of 433 patients who underwent rPE between 1994 and 1999 in our hospital were retrospectively reviewed. Patients were divided in those who received: 1. general anaesthesia (GA) alone, 2. a combination of lumbar epidural anaesthesia (LEA) + GA or, 3. thoracic epidural anaesthesia (TEA) + GA. General anaesthesia was performed as balanced anaesthesia, and epidural administered local anaesthetics were bupivacaine 0.25% or ropivacaine 0.2%, 8-12 ml/h. In terms of intra- and postoperative numbers of tachycardiac and hypertensive episodes, a reduced stress response was observed under epidural anaesthesia (EA). Moreover, the weaning duration was shorter under EA and onset of gastrointestinal motility was found earlier ([h] GA: 50.6 +/- 11.1/LEA: 39.3 +/- 13.6/TEA: 33.8 +/- 13.0). Furthermore, a trend to rarer phases of postoperative vomiting and a significant decrease of in hospital stay of about one day ([d] GA: 12.4 +/- 5.8/LEA: 11.1 +/- 3.1/TEA: 11.5 +/- 3.8) was observed. The duration of personnel binding in the OR did not differ significantly between GA and TEA ([min] GA: 222.9 +/- 43.5/LEA: 238.2 +/- 41.8/TEA: 227.0 +/- 46.2), but ICU stay was shortened under TEA. Besides this, TEA reduced the number of pathologic postoperative thorax-x-rays. Senso-motor blockades, decreases of SaO2 and cardiac complications were experienced more frequent under LEA as compared with TEA. Combination of GA and EA, especially TEA, appears to improve perioperative care of patients undergoing rPE, in terms of patients safety and comfort.     

Atemgasklimatisierung mit dem Narkosegerät Physioflex

The PhysioFlex anaesthesia machine is designed to operate as a quantitative closed system. The gas in the system is circulated at 70 litres per minute. With its small soda lime canister and the integration of all components in a thermal insulating case it fulfils all prerequisites for excellent climatisation of the anaesthetic gases. The extent of warming and humidifying of the anaesthetic gases was monitored during extended neurosurgical operations using long tubes to the patient (3?m each) in an cold operating room (17–18?°C). Material and Methods: The time course of the temperature and the humidity of the inspired gases was analysed in six patients undergoing intracranial surgery [three male, three female; age 58,8±9.5 years; body weight 78.8±11.5?kg; duration 247.5±63.38?min (mean±SD)]. A capacitive humidity sensor (Vaisala, type HMM?30D) and a very small platinum resistor (Sensycon, type GR42105) were used to measure, at 5-min intervals, the relative humidity (rH) and temperature (T) of the gases in the inspiratory limb close to the Y-piece. At that position in the continuous gas stream, humidity and temperature are not dependent on the single breath but change gradually. With the temperature-dependent humidity content of 100% rH absolute humidity was calculated [6]. Results: Within 10?min 100% rH was achieved. Then humidity changes were only temperature dependent. Figure?1 shows the time course of mean inspiratory temperature and mean absolute humidity (mean±SD). After 30?min an average of 20?mg H₂O/l gas was achieved. Analysing the single recordings, 20?mg/l was achieved between the 15th and 80th min. Steady state was reached after about 150?min at a level of more than 24?°C or more than 21.7?mg H₂O/l. As demonstrated in the figure, a change of the soda lime canister (285th min) caused a marked decrease of inspiratory temperature and humidity. Conclusions: The climatisation of anaesthetic gases was faster and reached a higher level with the PhysioFlex than has been reported with conventional anaesthesia machines. Even under these environmental conditions – a cold operating room and long tubing allowing great heat loss to the environment – minimal climatisation of 20?mgH₂O/l was reached within 30?min. The fast climatisation seems to be due to the operating principle, revolving the system volume with 70?l/min. This causes optimal usage of the heat and humidity generated by CO₂ absorption in the soda lime, documented by the strong influence on climatisation of soda lime changes.