[Results of autologous blood donation in orthopedic hip and knee joint replacement]. / Ergebnisse der Eigenblutspende bei orthopädischem Hüft- und Kniegelenkersatz.

OBJECTIVE: This study was undertaken to investigate the efficiency of autologous blood donation (ABD) with regard to saving of homologous transfusion, to determine the reasons for exclusion from donations and the rate of incidents during the procedure, and to investigate the quality of autologous fresh frozen plasma (AFFP). METHODS: During an observation period of 4.5 years, all patients scheduled for elective orthopaedic hip and knee replacement were included. A period of 4 years was evaluated retrospectively, and the last half year was evaluated prospectively. RESULTS: Among a collective of 710 patients, 55 (8%) non-donors and 655 (92%) donors with a total number of 1592 ABD were found. Mean age of non-donors with hip surgery was significantly higher than that of donors (72 vs. 64 years), the same was observed in patients with knee surgery (71 vs. 68 years). In the hip surgery group, 11 of 338 patients were non-donors (3%), compared with 44 of 372 patients with knee surgery (12%). In the prospective part of the study, 7% of 121 patients were non-donors. Reasons for exclusion from donation were 5 times of medical and 4 times of organisational nature. In donors for hip surgery, a mean of 3.0 units was collected, compared with 1.9 units in donors for knee surgery. On the day before operation, mean haemoglobin concentrations were similar in donors and non-donors. During ABD, 11 incidents were observed, representing 0.69% of all ABD, 83.5% of 327 donors with hip surgery left the hospital without any transfusion of homologous blood, 16.5 of donors with hip surgery received one or more homologous transfusions, compared with 100% of non-donors (p < 0.001). In knee surgery, 93.3% of donors and 63.6% of non-donors required no homologous blood, whereas 6.7% of donors and 36.4% of non-donors received one or more homologous transfusions (p < 0.001). 529 of 2850 autologous blood units (19%) were not transfused, and 19 of these units were rejected due to technical or organisational problems. In 97 patients with 240 ABD and 240 AFFP, prothrombine time, fibrinogen concentration and AT III in defrosted AFFP exceeded 70% of the values determined before ABD. CONCLUSION: ABD is a safe procedure in almost all, even elderly, patients scheduled for elective orthopaedic hip or knee replacement in both types of operations, ABD reduces the risk of homologous transfusion significantly. A number of 3-4 units is necessary for total hip replacement, whereas 2 units are sufficient for partial or total knee replacement. Haemostatic quality of AFFP meets the requirements of fresh frozen homologous plasma.

[Total intravenous anesthesia (TIVA) in geriatric surgery. S-(+)-ketamine versus alfentanil]. / Totale intravenöse Anästhesie (TIVA) in der Alterschirurgie. S-(+)-Ketamin versus Alfentanil.

In this prospective, randomized study, two regimens of total intravenous anaesthesia (TIVA), with propofol and S(+)-ketamine (S-ketamine) and with propofol and alfentanil, were compared with reference to endocrine stress response, circulatory effects and recovery. METHODS. The investigation was conducted in two groups of 20 ASA I-III patients over 60 years of age who were scheduled for endoprothetic orthopaedic surgery. After oral premedication with midazolam, patients received a TIVA with body-weight-adjusted doses of propofol, and S-ketamine or alfentanil as the analgesic component. For CPPV (PEEP 5 mbar), air and oxygen (FiO2 33%) were used. For muscle relaxation, patients of both groups received vecuronium in body-weight-adjusted doses. Blood samples were taken through a central venous line at seven time points before induction of anaesthesia and on the first morning after the operation also for analysis of epinephrine, norepinephrine (by HPLC/ECD), and ADH, ACTH and cortisol (by RIA). In addition, SAP, HR, arterial oxygen saturation, recovery from anaesthesia and side effects were observed. RESULTS. The two groups had comparable group mean values for age (S-ketamine group 71 years, alfentanil-group 70 years), other biometric data, and duration of anaesthesia and operation (Table 1). Plasma levels of epinephrine, norepinephrine (Table 2, Fig. 1), ADH (Table 2, Fig. 2) ACTH and cortisol (Table 2, Fig. 3) were higher in the S-ketamine-group (P < 0.05) owing to the intraoperative course of these endocrine parameters. Before induction, and on the first morning after the operation, levels were comparable between the groups. 5 min after the induction of anaesthesia, SAP and HR (Table 3) were significantly lower in the alfentanilgroup (P = 0.001). Recovery from anaesthesia (orientation with respect to person and location) was faster in the alfentanilgroup (16 vs 39 min, P = 0.001). An arterial oxygen saturation below 90% was observed in 7 patients in the S-ketamine- and 13 patients in the alfentanilgroup (P = 0.03). Four patients with S-ketamine reported dreams, and 1 dream was judged negative. Postoperative emesis was found in 6 patients in the S-ketaminegroup and 12 patients in the alfentanilgroup (P = 0.03). All patients said they would agree to undergo the same anaesthetic technique again. CONCLUSIONS. Considerable differences were found in the endocrine stress response of the two groups. With respect to endocrine response and circulation, TIVA with propofol and S-ketamine had sympathomimetic properties with positive circulatory effects and led to moderate endocrine stimulation. This should be kept in mind in patients with hypotension, hypothyrosis, or adrenocortical insufficiency; because "eustress" might be beneficial in this group of patients. On the other hand, TIVA with propofol and alfentanil showed sympatholytic properties, with negative circulatory effects and a remarkable reduction of endocrine stress response. This might be beneficial in patients with hypertension and states of endocrine hyperfunction. Both regimens were accompanied by such typical side effects as dreams, delayed recovery, reduced ventilation, and emesis, which should also be considered.

[Endocrine stress reaction, hemodynamics and recovery in total intravenous and inhalation anesthesia. Propofol versus isoflurane]. / Endokrine Stressbreaktion, Kreislauf- und Aufwachverhalten bei totaler intravenöser und Inhalationsanästhesie. Propofol versus Isofluran.

This prospective, randomised study compared total intravenous anaesthesia (TIVA) and inhalation anaesthesia with respect to endocrine stress response, haemodynamic reactions, and recovery. METHODS. The investigation included two groups of 20 ASA I-II patients 18-60 years of age scheduled for orthopaedic surgery. For premedication of both groups, 0.1 mg/kg midazolam was injected IM. Patients in the propofol group received TIVA (CPPV, PEEP 5 mbar, air with oxygen FiO2 33%) with propofol (2 mg/kg for induction followed by an infusion of 12-6 mg/kg.h) and fentanyl (0.1 mg before intubation, total dose 0.005 mg/kg before surgery, repetition doses 0.1 mg). For induction of patients in the isoflurane-group, 5 mg/kg thiopentone and 0.1 mg fentanyl was administered. Inhalation anaesthesia was maintained with 1.2-2.4 vol.% isoflurane in nitrous oxide and oxygen at a ratio of 2:1 (CPPV, PEEP 5 mbar). For intubation of both groups, 2 mg vecuronium and 1.5 mg/kg suxamethonium were injected, followed by a total dose of 0.1 mg/kg vecuronium. Blood samples were taken through a central venous line at eight time points from before induction until 60 min after extubation for analysis of adrenaline, noradrenaline (by HPLC/ECD), antidiuretic hormone (ADH), adrenocorticotropic hormone (ACTH), and cortisol (by RIA). In addition, systolic arterial pressure (SAP) heart rate (HR), arterial oxygen saturation (SpO2), and recovery from anaesthesia were observed. RESULTS. Group mean values are reported; biometric data from both collectives were comparable (Table 1). Plasma levels of adrenaline (52 vs. 79 pg/ml), noradrenaline 146 vs. 217 pg/ml), and cortisol (82 vs. 165 ng/ml) were significantly lower in the propofol group (Table 2, Figs. 1 and 3). Plasma levels of ADH (4.8 vs. 6.1 pg/ml) and ACTH (20 vs. 28 pg/ml) did not differ between the groups (Table 2, Figs 2 and 3). SAP (128 vs. 131 mmHg) was comparable in both groups, HR (68/min vs. 83/min) was significantly lower in the propofol group, and SpO2 (97.1 vs 97.4%) showed no significant difference (Table 3). Recovery from anaesthesia was slightly faster in the propofol group (following of simple orders 1.9 vs. 2.4 min, orientation with respect to person 2.4 vs. 3.4 min, orientation with respect to time and space 2.8 vs. 3.7 min), but differences failed to reach statistical significance. CONCLUSIONS. When compared with isoflurane inhalation anaesthesia, moderation of the endocrine stress response was significantly improved during and after TIVA with propofol and fentanyl. Slightly shorter recovery times did not lead to an increased stress response. With respect to intra- and postoperative stress reduction, significant attenuation of sympatho-adrenergic reaction comparable SAP and reduced HR, sympatholytic and hypodynamic anaesthesia with propofol and fentanyl seems to be advantageous for patients with cardiovascular and metabolic disorders. For this aim, careful induction and application of individual doses is essential.

[Total i.v. anesthesia with S-(+)-ketamine in orthopedic geriatric surgery. Endocrine stress reaction, hemodynamics and recovery]. / TIVA mit S-(+)-Ketamin in der orthopädischen Alterschirurgie. Endokrine Stressreaktion, Kreislauf- und Aufwachverhalten.

UNLABELLED: Clinically-used ketamine is a racemic mixture of two isomers, S-(+)- and R-(-)-ketamine. Previous investigations showed the anaesthetic potency of S(+)-ketamine to be three times higher than that of R-(-)-ketamine. It was the aim of this study to compare the effects of S-(+)-ketamine and racemic ketamine on endocrine and cardiovascular parameters, recovery, and side effects in geriatric patients during total intravenous anaesthesia (TIVA) for orthopaedic surgery. METHODS: Forty patients over 60 years of age scheduled for elective hip or knee replacement were investigated in a double-blind, randomised design. For induction of TIVA, patients received 0.1 mg midazolam, 0.5 mg atropine, 1 mg/kg S(+)-ketamine or 2 mg/kg racemic ketamine, respectively, 2 mg vecuronium, and 1.5 mg/kg suxamethonium. After intubation and relaxation with a total dose of 0.1 mg/kg vecuronium, a continuous infusion of 2 mg/kg per hour S-(+)- or 4 mg/kg per hour racemic ketamine was administered throughout surgery. Blood samples were taken through a central venous catheter at seven time-points, before induction as well during and after surgery, until the 1st postoperative morning for analysis of adrenaline, noradrenaline (by high-pressure liquid chromatography with electrochemical detection), anti-diuretic hormone (ADH), adrenocorticotropic hormone (ACTH), cortisol (by radioimmunoassay), glucose, and lactate. In addition, systolic arterial pressure (SAP), heart rate (HR), and arterial oxygen saturation were measured, and the time intervals between the end of ketamine infusion and the return of consciousness and orientation were protocolled. The incidence and assessment of dreams and other side effects were reported by the patients. RESULTS: Biometric data of the groups were comparable, the mean age of both groups being 68 years. Plasma adrenaline, noradrenaline, ADH, ACTH, cortisol, and glucose as well as SAP and HR increased significantly (P < 0.05) during the course of anaesthesia. The influence on lactate levels was not significant. There were no differences between S(+)- and racemic ketamine with respect to these parameters. Three patients in the ketamine-racemate group showed severe arterial hypertension and were withdrawn from the study. Recovery clearly improved after administration of S(+)-ketamine compared to the racemate. Simple orders were followed after 2.0 +/- 3.4 versus 4.9 +/- 6.8 min (P = 0.07), orientation with respect to person returned after 5.7 +/- 4.0 versus 14.6 +/- 10.0 min (P < 0.001) and spatial orientation after 8.2 +/- 5.4 versus 17.4 +/- 9.7 min (P < 0.001). After racemic ketamine, 1 patient remembered a negative dream and 1 patient a positive dream. In the S(+)-group, 1 positive dream was reported. No intraoperative awareness was reported, and all patients would accept the same anaesthesia again. CONCLUSIONS: Increases in cardiovascular parameters and insufficient reduction of the stress response with respect to ADH, ACTH, and cortisol seem to require a more potent hypnotic element during TIVA with ketamine. With regard to endocrine and cardiovascular parameters, the pharmacodynamic effects of racemic and S-(+)-ketamine were comparable. Because of the significant improvement in recovery and the reduced quantitative drug load, S-(+)-ketamine offers a clinical advantage compared with currently used racemic ketamine.

Developmental and personality correlates of adrenocortical activity as indexed by salivary cortisol: observations in the age range of 35 to 65 years.

Unstimulated salivary cortisol concentrations were measured in 767 adults aged 35-65 yr over the course of one day. Interindividual differences in early morning cortisol concentrations showed consistent and significant relationships with demographic and psychological variables. Socioeconomic status was positively associated with cortisol levels. Relationships of cortisol levels with age were moderated by gender: for women, a negative regression of cortisol level on age was observed while no significant age effects were obtained for men. In bivariate and multivariate regression analyses, a positive association between cortisol levels and indicators of successful development and personal well-being was observed; these relationships were more pronounced for the male sample. Intradyadic correlations further revealed a slight but significant association of morning cortisol levels within married couples. The findings are discussed with respect to mediating developmental mechanisms and pathophysiological implications.