A cross-sectional study on preoperative anxiety in adults.

OBJECTIVE: The main objective of this study was a detailed comparison of the level of anxiety about surgery and anesthesia. Other objectives included the assessment of the prevalence and intensity of preoperative anxiety. METHODS: This cross-sectional single-center survey used the validated Amsterdam anxiety and information scale (APAIS) and a modified numeric rating scale (mNRS) to assess preoperative anxiety, anxiety about surgery and anxiety about anesthesia. Prevalences and intensities of anxieties were predominantly analyzed descriptively. RESULTS: 3200 patients were enrolled and 3087 (57% females) were analyzed. 92.6% reported preoperative anxiety according to APAIS scores. The average total APAIS anxiety score (APAIS-A-T) was 9.9 (SD 3.6). 40.5% reported high anxiety (defined as APAIS-A-T > 10). Mean anxiety about surgery (APAIS-A-Su) was higher than mean anxiety about anesthesia (APAIS-A-An): 5.5 (SD 2.1) vs. 4.3 (SD 1.9), p < 0.0001. Accordingly, more patients were substantially more afraid (score difference > 2) of surgery (642, 20.8%, 95% CI 19.4-22.3) than of anesthesia (48, 1.6%, 95% CI 1.2-2.1). CONCLUSION: Preoperative anxiety is still very common among adult patients scheduled to undergo an elective procedure. Therefore, it should be evaluated routinely. Anxiety about surgery and anxiety about anesthesia differ in many patients. For this reason, anxiety about surgery and anxiety about anesthesia should be assessed separately. This would allow providing a more individualized support of patients to cope with their anxiety and could require particular attention by the surgeon or the anesthetist.

Pre-operative fluid bolus for improved haemodynamic stability during minor surgery: A prospectively randomized clinical trial.

BACKGROUND: Haemodynamic instability during the induction of anaesthesia and surgery is common and may be related to hypovolaemia caused by pre-operative fasting or chronic diuretic therapy. The aim of our prospective, controlled, randomized study was to test the hypothesis that a predefined fluid bolus given prior to general anaesthesia for minor surgery would increase haemodynamic stability during anaesthetic induction. METHODS: Two hundred and nineteen fairly healthy adult patients requiring minor surgery were enrolled. All received standard treatment, including a pulse contour analysing device for non-invasive measurement of cardiac index. Infusion therapy was started in all patients at induction. The intervention group (106 patients) was randomized to receive an additional fluid bolus of 8 mL/kg Ringer's acetate solution before the induction of anaesthesia. The primary endpoint was the incidence of haemodynamic instability, defined as a significant reduction of blood pressure or cardiac index during induction of anaesthesia. RESULTS: The interventional group had a lesser incidence of haemodynamic instability during induction (41.5% vs 56.6%, P = .025). This group also had higher cardiac index, stroke volume index, systolic and mean blood pressure and a greater left ventricular end-diastolic area. CONCLUSIONS: A fluid bolus prior to anaesthesia reduced the incidence of haemodynamic instability during induction of general anaesthesia. The total fluid volume was slightly greater in the intervention group compared to the control group (1370 ± 439 mL vs 1219 ± 483 mL, P = .007). We conclude that a defined fluid bolus can help stabilizing haemodynamics in patients undergoing general anaesthesia.

[Premedication visits in departments of anesthesiology in Hessen. Compilation of organizational and performance portfolios]. / Prämedikationsvisiten der anästhesiologischen Fachabteilungen in Hessen. Statuserfassung des Organisations- und Leistungsportfolios.

BACKGROUND: Many anesthesia departments operate a pre-anesthesia assessment clinic (PAAC). Data regarding organization, equipment and structure of such clinics are not yet available. Information about modern anesthesiology techniques and procedures contributes to a reduction in emotional stress of the patients but such modern techniques often require additional technical hardware and costs and are not equally available. AIM: This survey examined the current structures of PAAC in the state of Hessen, demonstrated current concepts and associated these with the performance and the portfolio of procedures in these departments. MATERIAL AND METHODS: An online survey was carried out. Data on structure, equipment, organization and available methods were compiled. In addition, anesthesia department personnel were asked to give individual subjective attitudes toward the premedication work. RESULTS: Of the anesthesia departments in Hessen 84 % participated in the survey of which 91 % operated a PAAC. A preoperative contact with the anesthesiologist who would perform anesthesia existed in only 19 % of the departments. Multimedia processing concepts for informed consent in a PAAC setting were in general rare. Many modern procedures and anesthesia techniques were broadly established independent of the hospital size. Regarding the individual and subjective attitudes of anesthetists towards the work, the psychological and medical importance of the pre-medication visit was considered to be very high. CONCLUSION: The PAACs are now well established. This may make economic sense but is accompanied by an anonymization of care in anesthesiology. The high quality, safety and availability of modern anesthesiology procedures and monitoring concepts should be communicated to patients all the more as an expression of trust and high patient safety. These factors can be facilitated in particular by multimedia tools which have as yet only been sparsely implemented in PAACs.

[On preoperative risk evaluation of adult patients before elective non-cardiac surgery: results of a survey on clinical practice in the Federal State of Hessen]. / Zur präoperativen Risikoevaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen: Ergebnisse einer Befragung zur klinischen Praxis im Bundesland Hessen.

BACKGROUND: The German Societies of Anesthesiology and Intensive Care Medicine, Internal Medicine and Surgery have recently published for the first time joint recommendations for the evaluation of adult patients prior to elective non-cardiac surgery. In these recommendations indications for preoperative diagnostic procedures were critically revised and updated. It was unclear to what extent these recommendations were known among German anesthesiologists, how the recommendations were perceived and to what extent they were put into practice. The indications of five common diagnostic procedures in the context of the preoperative evaluation were also unknown. METHODS: Three months after publication of the recommendations, all anesthesiologists employed at hospitals in the state of Hessen were requested to take part in an online survey (OS). In the first part of the OS participants were asked about familiarity with the recommendations, opinions concerning the utility of the recommendations and to what extent they were implemented. In the second part of the OS participants were questioned in general and in the context of two common case scenarios about indications for electrocardiograms (ECG), chest radiographs (chest x-ray), echocardiograms, spirometry and extended cardiac diagnostics, such as stress ECG. In addition, participants of the OS were requested to take part in an interview survey (IS) addressing the same topics. The purpose of the IS was to detect any bias caused by the anonymous character of the OS which could lead to an overestimated self-assessment. Answers of the IS were not compared to the results of the corresponding answers given online by the same anesthesiologist but only analyzed together with the other results of the IS for comparison with the results of the OS. RESULTS: Of the contacted anesthesiologists 396 (29 %) took part in the OS of which 100 took part in the IS. According to the OS 30 % were familiar and 34 % were partially familiar with the recommendations, 20 % just knew that recommendations had been published and 16 % did not even know about the publication. The corresponding results of the IS were 16 %, 36 %, 28 % and 20 %, respectively. Of the participants 90 % (OS) and 89 % (IS) considered the recommendations at least to be predominantly reasonable and useful and 66 % (OS) of the participants tried to implement or at least to partially implement the recommendations (IS only 33 %). Concerning the indications for the different diagnostic procedures, the results of the OS showed that hospital guidelines (44 %) and patient age (32 %) were the most frequent indications for a preoperative ECG. Hospital guidelines (40 %) and own judgement (39 %) were the most common indications for a preoperative chest x-ray and patient age still accounted for 18 % of the indications. In contrast, echocardiography (67 %), spirometry (61 %) and extended cardiac diagnostics (70 %) were primarily indicated based on own judgement. However, reasons given in this context were frequently (77 %) not in agreement with the recommendations. Comparing the results of the OS to those of the IS with respect to the indications of the different diagnostic procedures for the common case scenarios showed a varying degree of consistency with the recommendations. In both cases responses to the IS concerning the indications for the different diagnostic procedures were mostly in accordance with the recommendations compared to answers obtained in the OS. Indications for the chest x-ray showed the worst degree of consistency with the recommendations. CONCLUSIONS: Corresponding to the high significance of local standards for the decision of indicating preoperative diagnostic procedures, the development of local standards that are in agreement with the recommendations seems to be a reasonable way to facilitate the implementation of the recommendations.

[Caesarean sections under regional anesthesia: pros and cons of supplementary oxygen]. / Sectio caesarea in Regionalanästhesie : Pro und Kontra der supplementären Sauerstoffgabe.

The routine administration of supplemental oxygen to women undergoing elective caesarean section under regional anesthesia in order to optimize oxygen supply to the fetus is common anesthetic practice in many German hospitals. However, this practice has been controversially discussed in the non-German literature for many years. This review presents and discusses the pros and cons of routinely providing supplemental oxygen to a parturient during caesarean section on the basis of the literature published over the last 30 years. Proponents of routine oxygen administration point to potential and unforeseeable risks of caesarean sections and consider the prophylactic administration of oxygen based on physiological considerations to be advantageous in terms of patient safety. Interestingly, data regarding the effects of an increased maternal FIO2 on improvement of fetal oxygenation are inconsistent, therefore, no unambiguous recommendation concerning which FIO2 to choose can be given. Opponents of routine oxygen supplementation allude above all to an increase in free radical activity in both mother and fetus; however, data in this respect are not consistent either. As supplemental oxygen to patients undergoing elective caesarean section without any risk factors under regional anesthesia is associated with potential risks while no advantage has so far been demonstrated, routine administration of oxygen has to be challenged and is no longer considered to be indicated by many. On the contrary, in cases of emergency with a concomitant risk of hypoxia for mother and fetus, administration of oxygen is indispensable in the light of present data.

[Hypoxemia after general anesthesia]. / Hypoxämie nach Allgemeinanästhesie.

BACKGROUND: Studies conducted shortly after the implementation of pulse oximetry (PO) into clinical practice 20-25 years ago revealed that many patients breathing room air during transfer from the operating room (OR) to the post-anesthesia care unit (PACU) directly after general anesthesia (GA) had a peripheral oxygen saturation (S(p)O(2)) below 90%. Moreover, it was shown that the detection of hypoxemia by clinical criteria is extremely unreliable. Meanwhile, the use of PO has become part of the obligatory standard monitoring during GA in Germany and many other countries. Likewise, the use of PO is standard care in the PACU although there are no official recommendations. However, for the time period in between, i.e. immediately after GA during transportation of patients from the OR to the PACU, monitoring of the S(p)O(2) in patients breathing room air is neither obligatory in Germany nor are there any official recommendations or guidelines in this respect. Given the introduction of shorter acting anesthetic agents within the last 25 years, the main goal of this study was to explore whether the incidence of hypoxemia in the immediate period after GA is still so high. Additional aims of this study were to examine whether the detection of hypoxemia based on clinical criteria can be confirmed to be very unreliable, what the risk factors for hypoxemia following GA are and how common it is in Germany to transport patients from the OR to the PACU without PO and supplemental oxygen. METHODS: In a prospective observational study 970 patients who underwent a broad spectrum of elective surgery under GA in a university hospital setting were included. The S(p)O(2) was measured at the end of the transfer from the OR to the PACU immediately after the anesthetist who had taken care of the patient during the operation had estimated the S(p)O(2). The association between biometric, surgical and anesthesiological variables on the one hand and hypoxemia as well as a decrease of S(p)O(2) on the other hand were studied using multivariate methods. Finally, a survey including all university hospitals was carried out to find out about the use of PO and oxygen during patient transfer from the OR to the PACU. RESULTS: Of the 959 patients who were eligible for analysis 17% had a S(p)O(2) < 90% and 6.6% a S(p)O(2) < 85%. Hypoxemia was not recognized in 82% of the patients in whom an assessment based on clinical grounds was carried out. Variables with an independent influence on hypoxemia and decrease of S(p)O(2) were as follows: saturation before induction of GA, body mass index, age, American Society of Anesthesiologists (ASA) physical status, difference between maximum and minimum inspiratory pressure, mode of ventilation, the choice of opioid and muscle relaxant as well as the use of nitrous oxide. Patient-dependent risk factors had the strongest impact on hypoxemia. In about 80% of the university hospitals neither PO nor supplemental oxygen is used during transportation of the patient from the OR to the PACU. CONCLUSIONS: The use of opioids and relaxants with short duration of action may have favorable effects on preventing hypoxemia and decreases of S(p)O(2). These measures will, however, not be sufficient to solve this problem because the highest risk factors for hypoxemia are patient-related. Despite knowing risk factors for oxygen desaturation, it is currently not possible to reliably predict which patients will become hypoxemic or have a decrease of S(p)O(2). Therefore, transportation of patients breathing room air from the OR to the PACU directly after GA without use of PO or supplemental oxygen seems to be questionable in terms of patient safety.

[Anaesthesiological experience and factoid public information - effects, interactions and possible strategies for perioperative stress reduction]. / Vorinformationen und Vorerfahrungen - ihre Auswirkung, Interaktionen und Prävention.

BACKGROUND: Preoperative stress influences perioperative complications. Their severity is influenced by advanced information and previous experience. This study evaluates the emotional effects of these factors. METHODS: In a prospective observational study we documented existing anaesthesiological pre-information and previous experience of 461 patients (255 w/206 m) individually. In addition, we recorded the affective emotional condition of each patient before and after the premedication visit via a visual analogue scale (VAS) and a test of current stress (KAB). RESULTS: 248 patients had previous anaesthesiological pre-information. Of those 61 were of a negative nature. These patients showed a significantly higher level of stress and anxiety compared to those with positive information. 41 of 388 patients reported bad experiences with increased anxiety and stress. The premedication visits caused a significant attenuation of the overall stress level in patients with negative experience/information. CONCLUSION: During the individual premedication visit, patients should be asked directly about negative pre-information and perioperative experience. Thus the conversation can be customised to the individual stress factors and show empathy as well. Independent of any medical intervention, this approach can be an effective contribution to stress reduction.

[Relevance of five core aspects of the pre-anesthesia visit: results of a patient survey]. / Wertigkeit von 5 Kernaspekten der Prämedikationsvisite : Ergebnisse einer Patientenbefragung.

BACKGROUND: Due to a variety of reasons (e.g. increase in outpatient surgery and legal restrictions related to working hours) it has become increasingly more difficult to have the pre-anesthesia visit and the anesthesia carried out by the same anesthetist. In the light of these organizational changes as well as increasing economical pressure it has become common practice to implement pre-anesthesia assessment clinics. It is unclear, however, if these changes in anesthetic patient care respect patient needs. METHODS: By means of a survey using the willingness to pay method, the relative significance of five quality aspects (location of pre-anesthesia visit, waiting time, patient-physician relationship, use of multimedia and ambience) were studied. Participation during a 12-month study period was on a voluntary basis. RESULTS: Of the 1,058 questionnaires, 1,014 were eligible for analysis. A pre-anesthesia visit performed by the anesthetist who would deliver anesthesia was the most important aspect for almost two thirds (624 out of 1,014) of the patients with on average more than one third of the money available spent on this item. Waiting time was the second most important factor with about one third of the patients rating this item as the most relevant factor and on average approximately one quarter of the total money available spent on it. Location of the pre-anesthesia visit, use of multimedia and ambience were considered least important. The order of these preferences was regardless of age and gender of subjects. However, there was a trend to age and gender-specific differences concerning the amount of money spent on these five items. For instance, with increasing age, patient-physician relationship and location of the pre-anesthesia visit become more important. CONCLUSIONS: These results suggest that the integration of a pre-anesthesia assessment clinic in anesthetic patient care is not favorable from the patients' point of view because getting to know the anesthetist who will deliver anesthesia is of paramount importance to most patients. In cases where a pre-anesthetic assessment clinic is indispensable, other measures to build up confidence compensating for the lack of personal patient-physician relationship should be developed. In this respect, the promotion of a corporate identity of the whole anesthesia department may be beneficial. Furthermore, keeping the waiting time as short as possible should be a high priority as this item was rated the second most important factor.

[Epidural anesthesia in obstetrics: an accidentally placed intrathecal catheter--remove it or use it?]. / Geburtshilfliche PDA: akzidentell intrathekaler Katheter--entfernen oder nutzen?

Epidural anesthesia is an established method in obstetrics. Despite constant practical experiences and established techniques, accidental penetrations of the dura and therefore malpositioning of the catheter in the intrathecal space are still present. This can result in post spinal headaches, a higher dispersion of the local anesthetic followed by life-threatening respiratory insufficiency and loss of overall conscious delivery. In consideration of these risks removal of the misplaced catheter and proper reinsertion in a higher position is standard. Thus significant emotional stress and re-exposure to the risks of the procedure for the parturient is accepted. We report of a 30-year-old primipara with secondary realized intrathecal placement. In due consideration of the current state of labor, we decided to leave the catheter in place and initiate a pain therapy applying bupivacain via this catheter immediately after the motor block had ceased. Within the first stage of labor sufficient pain relief was established. There was no change in tonicity. It resulted in a normal unproblematic vaginal birth. After an initial irritation due to the high dispersion the patient described a noticeable alleviation of pain during the adequate controlled labor.

Comparison between intubation and the laryngeal mask airway in moderately obese adults.

BACKGROUND: Obesity is a well-established risk factor for perioperative pulmonary complications. Anaesthetic drugs and the effect of obesity on respiratory mechanics are responsible for these pathophysiological changes, but tracheal intubation with muscle relaxation may also contribute. This study evaluates the influence of airway management, i.e. intubation vs. laryngeal mask airway (LMA), on postoperative lung volumes and arterial oxygen saturation in the early postoperative period. METHODS: We prospectively studied 134 moderately obese patients (BMI 30) undergoing minor peripheral surgery. They were randomly assigned to orotracheal intubation or LMA during general anaesthesia with mechanical ventilation. Premedication, general anaesthesia and respiratory settings were standardized. While breathing air, we measured arterial oxygen saturation by pulse oximetry. Inspiratory and expiratory lung function was measured preoperatively (baseline) and at 10 min, 0.5, 2 and 24 h after extubation, with the patient supine, in a 30 degrees head-up position. The two groups were compared using repeated-measure analysis of variance (ANOVA) and t-test analysis. Statistical significance was considered to be P<0.05. RESULTS: Postoperative pulmonary mechanical function was significantly reduced in both groups compared with preoperative values. However, within the first 24 h, lung function tests and oxygen saturation were significantly better in the LMA group (P<0.001; ANOVA). CONCLUSIONS: In moderately obese patients undergoing minor surgery, use of the LMA may be preferable to orotracheal intubation with respect to postoperative saturation and lung function.

Control of Erysiphe pisi Causing Powdery Mildew of Pea (Pisum sativum) by Cashewnut (Anacardium occidentale) Shell Extract.

The effect of methanolic extract of cashewnut (Anacardium occidentale) shell extract was seen on conidial germination of Erysiphe pisi and powdery mildew development in pea (Pisum sativum). Maximum conidial germination inhibition of E. pisi on glass slides was observed at 300 ppm. Similar effect on floated pea leaves was observed after 48 h at the same concentration. Conidial germination on intact untreated pea leaves was also assessed on II and IV nodal leaves while IV and II nodal leaves were treated with the extract and vice versa. There was tremendous reduction in conidial germination on all the nodal leaves. The disease intensity of pea powdery mildew was significantly reduced by methanolic extract of cashewnut shells. Maximum reduction was observed with 200 ppm where 39% disease intensity was recorded in comparison to 96.53% in the control. The phenolic acid content of pea leaves following treatments with this extract varied and no definite pattern was observed. Out of several phenolic compounds, namely, gallic, ferulic, chlorogenic, and cinnamic acids, only gallic acid was found to be present consistently in all the treatments with varied amounts.

Zygocactus virus X-based expression vectors and formation of rod-shaped virus-like particles in plants by the expressed coat proteins of Beet necrotic yellow vein virus and Soil-borne cereal mosaic virus.

Expression vectors were constructed from 35S promoter-containing full-length cDNA clones of Zygocactus virus X (ZVX). The expression of foreign genes was driven by the ZVX coat protein (cp) subgenomic promoter. It was successful only when the variable region downstream of the conserved putative promoter region GSTTAAGTT(X(12-13))GAA was retained. Most of the ZVX cp gene, except for a short 3' part, was replaced by the corresponding sequence of the related Schlumbergera virus X (SVX) and its cp subgenomic promoter to enable encapsidation of the transcribed RNA by an SVX/ZVX hybrid cp. Vector-expressed cp of Beet necrotic yellow vein virus (BNYVV) assembled in Chenopodium quinoa, Tetragonia expansa and Beta vulgaris leaves into particles resembling true BNYVV particles. The virus produced from these constructs retained its ability to express BNYVV cp in local infections during successive passages on C. quinoa. This ability was lost, however, in the rarely occurring systemic infections.

Molecular characterisation of potexviruses isolated from three different genera in the family Cactaceae.

The genome properties of three potexviruses which previously had been isolated from different genera in the family Cactaceae and had been found to be only distantly related serologically have been studied. The sequence of the 3040 3' terminal nucleotides of the genomic RNA of isolate K11 from Schlumbergera bridgesii and the complete RNA sequences of isolates B1 and CC10 from Zygocactus sp. and Opuntia sp., respectively, were determined. Starting sequences were obtained by means of immunocapture reverse transcription PCR using primers derived from highly conserved sequences in other potexviral RNAs. The known parts of the sequences were extended by means of random-primed cDNAs and specific primers derived from the known parts of the sequences. The genome structure of the three viruses resembles that of other potexviruses. The conserved motifs typical for replication-associated proteins, triple gene block (TGB) proteins and coat proteins of potexviruses were readily identified in the translation products of the five open reading frames. The 3' untranslated regions of the three RNAs are folded into secondary structures containing three characteristic hairpins. Rather low percentages of amino acid sequence identities ranging from 62% to 76% for the coat proteins and 41% to 49% for TGB proteins 3 suggest that these viruses should be regarded as distinct virus species for which the names Zygocactus virus X, Schlumbergera virus X and Opuntia virus X are proposed. It is also suggested that the name Cactus virus X which originally was coined for all three virus isolates should no longer be used.

Biologically active metabolites from fungi 14 3-chloro-4-hydroxy-5-(3,7,11-trimethyldodeca-2,6,10-trienyl)-benzamide, a new antibacterial agent from a soil fungus.

The antibacterial 3-chloro-4-hydroxy-5-(3,7,11-trimethyldodeca-2,6,10-trienyl)-benzamide, and the antifungal strobilurins B and D were isolated from an unidentified South African soil fungus.

Metabolites from fungi 15. New isocoumarins from an endophytic fungus isolated from the Canadian thistle Cirsium arvense.

One known (1) and five new polyketide metabolites (2-6) were isolated from the culture extract of an endophytic fungus, Mycelia sterila, from the Canadian thistle Cirsium arvense. Compounds 1-4 are members of the isocoumarin family, whereas metabolite 5 is a dihydrobenzofuran and 6 has an open chain structure. All compounds have an unusual methyl group at the aromatic ring that does not fit into the usual polyketide pattern.

Dihydroisocoumarins from fungi: isolation, structure elucidation, circular dichroism and biological activity.

Five known and three new dihydroisocoumarins were isolated from different fungi. The new isocoumarins are 5-chloro-6-hydroxymellein, 5-chloro-4,6-dihydroxymellein and 5,6-dihydroxymellein. The absolute configuration of these secondary metabolites was confirmed by CD measurements and in two cases by X-ray structure analysis.