High molecular weight hydroxyethyl starch solutions are not more effective than a low wmolecular weight hydroxyethyl starch solution in a porcine model of septic shock.

BACKGROUND: There is evidence that suggests that early fluid resuscitation is beneficial in the treatment of sepsis. We previously demonstrated that hydroxyethyl starch (HES) 130/0.42 attenuated capillary leakage better than HES 200/0.5. Using a similar porcine fecal sepsis model, we tested the effects of two new synthetic high molecular weight (700 kDa) hydroxyethyl starches with the same molar substitution of 0.42 but with a different C2/C6 ratio compared to 6% HES 130/0.42 on plasma volume (PV), systemic and tissue oxygenation. METHODS: This was a prospective, randomized, controlled animal study. Twenty-five anesthetized and mechanically ventilated pigs (28.4±2.3 kg) were observed over 8 h. Septic shock was induced with fecal peritonitis. Animals were randomized for volume-replacement therapy with HES 700/0.42 C2/C6/2.5:1 (N.=5), HES 700/0.42 C2/C6/6:1 (N.=5), HES 130/0.42 C2/C6/5:1 (N.=5) or Ringer's Solution (RS, N.=5), and compared to non-septic controls receiving RS (N.=5). The albumin escape rate (AER) was calculated and plasma volume was determined at the end of the study. Tissue Oxygen Saturation was measured with the InSpectra™ Device (InSpectra Tissue Spectrometer, Hutchinson Technology Inc., Hutchinson, MN, USA). RESULTS: The AER increased in all groups compared to control. All colloids (HES 700/6:1 68±15; HES 130 67±4; HES 700/2.5:1 71±12; P<0.05) but not RS (44±7) stabilized PV (mL/kg BW) after eight hours of sepsis. Systemic oxygenation was significantly lower in the RS group (44±17%; P<0.05) compared to all other groups at study end (P<0.05). CONCLUSION: In this porcine fecal peritonitis model, the high molecular weight artificial colloids HES 700/2.5:1 and HES 700/6:1 were not more effective in maintaining plasma volume and systemic and tissue oxygenation than HES 130. In comparison to crystalloid RS, all HES solutions were more effective at maintaining plasma volume, mean arterial pressure (MAP), and systemic and tissue oxygenation.

Regulation of glucose kinetics during exercise by the glucagon-like peptide-1 receptor.

In response to oral glucose, glucagon-like peptide-1 receptor (Glp1r) knockout (Glp1r−/−) mice become hyperglycaemic due to impaired insulin secretion. Exercise also induces hyperglycaemia in Glp1r−/− mice. In contrast to oral glucose, exercise decreases insulin secretion. This implies that exercise-induced hyperglycaemia in Glp1r−/− mice results from the loss of a non-insulinotropic effect mediated by the Glp1r. Muscle glucose uptake (MGU) is normal in exercising Glp1r−/− mice. Thus, we hypothesize that exercise-induced hyperglycaemia in Glp1r−/− mice is due to excessive hepatic glucose production (HGP). Wild-type (Glp1r+/+) and Glp1r−/− mice implanted with venous and arterial catheters underwent treadmill exercise or remained sedentary for 30 min. [3-3H]glucose was used to estimate rates of glucose appearance (Ra), an index of HGP, and disappearance (Rd). 2[14C]deoxyglucose was used to assess MGU. Glp1r−/− mice displayed exercise-induced hyperglycaemia due to an excessive increase in Ra but normal Rd and MGU. Exercise-induced glucagon levels were ∼2-fold higher in Glp1r−/− mice, resulting in a ∼2-fold higher glucagon:insulin ratio. Since inhibition of the central Glp1r stimulates HGP, we tested whether intracerebroventricular (ICV) infusion of the Glp1r antagonist exendin(9­39) (Ex9) in Glp1r+/+ mice would result in exercise-induced hyperglycaemia. ICV Ex9 did not enhance glucose levels or HGP during exercise, suggesting that glucoregulatory effects of Glp1 during exercise are mediated via the pancreatic Glp1r. In conclusion, functional disruption of the Glp1r results in exercise-induced hyperglycaemia associated with an excessive increase in glucagon secretion and HGP. These results suggest an essential role for basal Glp1r signalling in the suppression of alpha cell secretion during exercise.

Administration of bovine polymerized haemoglobin before and during coronary occlusion reduces infarct size in rabbits.

BACKGROUND: Haemoglobin-based oxygen carriers (HBOC) seem to increase the risk of mortality and myocardial infarction in clinical trials. Therefore, we designed this randomized placebo-controlled animal study to evaluate the effects of prophylactic and therapeutic administration of HBOC in a myocardial ischaemia-reperfusion model with respect to infarct size and areas of impaired perfusion (no reflow, NR). METHODS: Thirty-two anaesthetized, mechanically ventilated rabbits were randomized to one of the four groups. Group G1 received 0.4 g kg(-1) i.v. HBOC-200 25 min before coronary artery occlusion, G2 received the same dose i.v. 10 min after occlusion, and G3 and 4 received i.v. saline. G1, 2, and 3 were subjected to 30 min occlusion of left coronary artery followed by 240 min of reperfusion. G4 was treated without ischaemia-reperfusion. Measurement included assessment of the area at risk and infarct size using triphenyltetrazolium chloride stain and areas of NR using thioflavin stain. Ischaemia-reperfusion was confirmed by microspheres technique. RESULTS: Infarct size as a percentage of the area at risk was significantly reduced in G1 [25 (sd 13)%, P=0.026] and G2 [22 (20)%, P=0.009] compared with G3 [48 (17)%]. The areas of NR in percentage of the area at risk [G1, 26 (15)%; G2, 34 (22)%; G3, 36 (12)%; G4, 5 (3)%] did not differ between the groups of animals undergoing coronary occlusion and reperfusion. CONCLUSIONS: Prophylactic and therapeutic administration of HBOC-200 reduces infarct size in myocardial ischaemia and reperfusion in rabbits. This reduction of infarct size is not accompanied by an improvement of areas of NR.

Effects of a prophylactic or therapeutic application of perflubron emulsion on myocardial ischaemia-reperfusion injury in rats.

BACKGROUND AND OBJECTIVE: The efficacy of administering a perfluorochemical-based oxygen therapeutic such as perflubron emulsion (Oxygen) prior to ischaemia is currently unknown, although there is evidence for potential beneficial effects for the perioperative treatment in cardiac risk patients. This experimental study investigated the efficacy of perflubron emulsion in preventing reperfusion injury and myocardial infarction size after coronary ischaemia and reperfusion. The perflubron emulsion was given either in a prophylactic manner, prior to induction of myocardial ischaemia, or as a therapeutic agent given during ischaemia. METHODS: Thirty-two anaesthetized and mechanically ventilated rats were subjected to 25 min occlusion of the left coronary artery followed by 120 min reperfusion. Animals were randomized to one of four groups:Group 1 was treated with administration of 6 g kg (-1) intravenous perflubron emulsion 25 min before occlusion; Group 2 received the same dose 10 min after occlusion; and Groups 3 and 4 received no perflubron emulsion. Inspired O2 (FiO2) concentration was maintained at 1.0 in Groups 1, 2 and 3 and at 0.35 in Group 4. RESULTS: Neither prophylactic nor therapeutic perflubron emulsion treatment reduced infarct size measurements by triphenyltetrazolium-chloride staining or severity of cardiac arrhythmias in comparison to the hyperoxic control group. However, prophylactic application of perflubron emulsion reduced areas of impaired perfusion vs. Group 3 assessed by in vivo staining with Thioflavin-S while no significant effect was seen in Groups 2 and 4 vs. 3. Density of DNA single-strand breaks in the ventricle was increased in all groups ventilated with 100% oxygen. CONCLUSION: Although administration of perflubron emulsion did not reduce infarct size, areas of impaired perfusion were significantly mitigated when perflubron emulsion was administered prior to coronary occlusion. However, a high oxygen concentration may provoke DNA strand breaks during reperfusion after ischaemia. Further studies must clarify whether enhanced oxidative stress outweighs the advantage of improved areas of impaired perfusion following perflubron emulsion.

Intraoperative anisocoria in a child during renal transplantation.

Anisocoria during anaesthesia may indicate a serious neurological condition. Assessment by physical examination and diagnostic imaging is limited during surgery and anaesthesia. We report a case of a boy undergoing renal transplantation, who suffered from anisocoria during general anaesthesia. A transcranial sonography was performed, showing no intracranial pathology. However, retinal hypoperfusion detected with orbital doppler sonography was a plausible explanation for anisocoria.

HES 130/0.42 shows less alteration of pharmacokinetics than HES 200/0.5 when dosed repeatedly.

BACKGROUND: Hydroxyethyl starches (HES) accumulate in the circulation when administered repeatedly. Accumulation is thought to be partly responsible for undesirable effects (tissue storage, blood coagulation impairment, and itching). HES 130/0.42 with low molecular weight and a low level of substitution has recently been developed in order to reduce those risks. METHODS: In healthy volunteers, the pharmacokinetics of HES 130/0.42/6:1 were investigated using a crossover design with HES 200/0.5 serving as control. Fifty grams of either HES were administered in 4 h day-1 for a period of five consecutive days. HES serum concentrations were used for computation of pharmacokinetic coefficients. Change between the first and fifth infusion in the area under the concentration curve (AUC) served as the primary measurement. RESULTS: Although the circulation was freed from the load with HES 130/0.42 within 20 h after end of the previous infusion, the amount of HES 200/0.5 increased continuously from one administration to the other. AUC and elimination half-life (t1/2) were significantly lower with HES 130/0.42. AUC and t1/2 of HES 200/0.5 showed an increase between the first and the fifth administration whereas only a minimal shift was present with HES 130/0.42. Haemodilution via HES 200/0.5 did not change over time. CONCLUSIONS: Repeated administration of HES 130/0.42 shows no accumulation and fewer tendencies to time-dependent changes in pharmacokinetic parameters than HES 200/0.5. The improved reproducibility may improve drug safety, particularly as the accumulation of residual starch with HES 200/0.5 does not contribute to the colloid's volume effect, but may rather increase the risk of undesired reactions.

Molar substitution and C2/C6 ratio of hydroxyethyl starch: influence on blood coagulation.

BACKGROUND: Development of hydroxyethyl starches (HES) with a low impact on blood coagulation but a long intravascular persistence is of clinical interest. A previous in vitro study showed that low substituted high molecular weight HES does not compromise blood coagulation more than medium molecular weight HES. In the present study we assessed the individual effects on blood coagulation of molar substitution and C2/C6 ratio of a high molecular weight HES. METHODS: Blood was obtained from 30 healthy patients undergoing elective surgery and mixed with six high molecular weight (700 kDa) HES solutions differing in their molar substitution (0.42 and 0.51) and C2/C6 ratio (2.7, 7 and 14) to achieve 20, 40 and 60% dilution. Blood coagulation was assessed by Thrombelastograph analysis (TEG) and plasma coagulation tests. Data were compared using a three-way analysis of variance model with repeated measures on the three factors. RESULTS: Higher molar substitution compromised blood coagulation most (for all TEG parameters, P<0.05). The lowest C2/C6 ratio was associated with the lowest effect on blood coagulation; r (P<0.001), angle alpha (P=0.003) and coagulation index (P<0.001). No effect on k and maximum amplitude was observed (P for both >0.50). The higher molar substitution was associated with a lesser increase in PT (P=0.007) and a greater decrease in factor VIII (P=0.010). PTT, functional and antigenic von Willebrand factors were not significantly influenced by molar substitution (P for all >0.20). No significant differences between solutions with the same molar substitution but different C2/C6 ratios were found in plasma coagulation parameters (P for all >0.05). CONCLUSIONS: TEG analysis indicates that high molecular HES with a molar substitution of 0.42 and a C2/C6 ratio of 2.7 has the lowest effect on in vitro human blood coagulation.

Effects of prophylactic or therapeutic application of bovine haemoglobin HBOC-200 on ischaemia-reperfusion injury following acute coronary ligature in rats.

BACKGROUND: Haemoglobin-based oxygen carriers (HBOCs) are assessed as blood substitutes in patients with perioperative anaemia including patients at risk for perioperative cardiac ischaemia. There is controversy as to whether HBOCs are beneficial or deleterious during ischaemia-reperfusion (I-R). Therefore the effects of HBOC-200 on I-R injury were evaluated in a randomized placebo-controlled animal trial. METHODS: Animals were randomized to receive either placebo i.v. without I-R (sham group, n=9), placebo i.v. with I-R (control group, n=10), HBOC-200 0.4 g kg(-1) i.v. prior to I-R (prophylaxis group, n=12) or HBOC-200 0.4 g kg(-1) i.v. during I-R (therapy group, n=15). I-R consisted of 25 min of acute ligature of the left coronary artery followed by 120 min of reperfusion. Measurements included assessment of the area at risk and infarct size using triphenyl tetrazolium chloride (TTC) stain, DNA single-strand breaks (in situ nick translation with autoradiography/densitometry) and cardiac arrhythmias. RESULTS: Infarct size within the area at risk was 62 (sd 15)% (control), 46 (10)% (prophylaxis, P<0.025 vs control) and 61 (9)% (therapy, P<0.85 vs control). The frequency of DNA single-strand breaks was reduced vs control in the sham (P<0.01) and prophylaxis (P<0.04) groups and was almost the same in the therapy group (P<0.75). The severity of cardiac arrhythmias during ischaemia was lower compared with control in the sham (P<0.001) and prophylaxis (P<0.039) groups, but there was no difference in the therapy group. CONCLUSION: This study demonstrates that neither prophylactic nor therapeutic application of the cell-free haemoglobin solution HBOC-200 aggravates cardiac I-R injury. Furthermore, the prophylactic approach may offer a new opportunity for pretreatment of patients at risk for perioperative ischaemic cardiac events.

Effects of isovolaemic haemodilution on oxygenation of liver and skeletal muscle.

BACKGROUND AND OBJECTIVE: Hydroxyethyl starch is frequently used for volume substitution during surgical procedures and for isovolaemic haemodilution. Haemodilution has also been shown to improve tissue oxygen tension in skeletal muscle: However, effects of this volume substitute on tissue oxygen tension of the liver during haemodilution remains unknown. METHODS: Fourteen foxhounds were anaesthetized with fentanyl/midazolam and mechanically ventilated with 30% oxygen. Following splenectomy animals were randomly assigned to a control group without haemodilution but fluid substitution with Ringer's lactate (Group C) or underwent isovolaemic haemodilution to a haematocrit of 25% with hydroxyethyl starch 70/0.5 (Group H). Haemodynamic parameters and oxygen transport during 100 min following isovolaemic haemodilution were measured. Liver oxygen tension was recorded using a flexible polarographic electrode tonometer, whereas in the muscle a polarographic needle probe was used. RESULTS: Animal characteristics and baseline haematocrit were similar in both groups. At baseline the tissue oxygen tension of liver and skeletal muscle were not different between groups. Haemodilution with hydroxyethyl starch 70/0.5 provided augmentation of mean liver tissue oxygen tension (baseline: 46 +/- 13 mmHg; 20 min: 60.3 +/- 12 mmHg; 60 min: 60 +/- 16 mmHg; 100 min: 63 +/- 16 mmHg; P < 0.05 vs. baseline), while oxygen tensions in Group C remained unchanged (baseline: 48 +/- 16 mmHg; 20 min: 52 +/- 19 mmHg; 60 min: 49 +/- 12 mmHg; 100 min: 52 +/- 16 mmHg) and no differences could be detected between groups. Oxygen tension in skeletal muscle changed as follows: Group H - baseline: 24 +/- 32 mmHg; 20 min: 32 +/- 3 mmHg; 60 min: 33 +/- 7 mmHg; 100 min: 33 +/- 11 mmHg. Group C - baseline: 22 +/- 6 mmHg; 20 min: 21 +/- 3 mmHg; 60 min: 24 +/- 4 mmHg; 100 min: 18 +/- 4 mmHg (P < 0.05 vs. baseline, p < 0.05 vs. Group C). CONCLUSION: In this animal model, isovolaemic haemodilution with hydroxyethyl starch 70/0.5 increased tissue oxygen tension in liver and skeletal muscle in comparison with baseline values. However, when compared between groups haemodilution only resulted in an increase of tissue oxygen tension in the muscle but not in the liver.

[Plasma levels of ropivacaine and bupivacaine during postoperative patient controlled thoracic epidural analgesia]. / Plasmakonzentrationen von Ropivacain und Bupivacain während postoperativer Patienten-kontrollierter thorakaler Epiduralanalgesie.

BACKGROUND: The postoperative continuous epidural application of local anesthetics can cause side effects like motor blockade and systemic intoxication. The study was performed to evaluate the plasma levels of two local anesthetics and their analgesic and side effects in continuous postoperative epidural analgesia. METHODS: In a prospective, randomized and double-blind study we have compared side effects of ropivacaine 0.375% (group R) vs. bupivacaine 0.125% in combination with sufentanil 0.5 microg ml(-1) (group B/S) via thoracic epidural catheters for a duration of 96 hours after major abdominal surgery in 30 gynaecological tumor patients. Analgesic effects, side effects and plasma levels of the respective local anesthetic were measured 24, 48, 72 and 96 h after start of epidural infusion. RESULTS: No differences were seen in demographics, perioperative data and analgesic effects. The following cumulative doses of local anesthetics were applied (Group R vs. B/S (median/minimum-maximum ml)): 24 h: 151/121-225 vs. 141/83-171; 48 h: 311/237-424 vs. 299/184-497; 72 h: 454/366-566 vs. 440/256-598; 96 h: 572/399-859 vs. 568/284-711. Plasma levels of local anesthetics remained far below the toxic threshold of 0.6 micro g/ml (Group R vs. B/S (median/minimum-maximum micro g/ml): 24 h: 0.05/0.03-0.24 vs. 0.0/0.0-0.02; 48 h: 0.06/0.02-0.15 vs. 0.006/0.0-0.02; 72 h: 0.05/0.0-0.11 vs. 0.0/0.0-0.02; 96 h: 0.02/0.01-0.32 vs. 0.0/0.0-0.01). The incidence and intensity of motor block (Bromage scale) and other side effects did also not differ between groups. CONCLUSION: The present study shows that thoracic epidural infusion with bupivacaine 0.125% and with a higher concentration of ropivacaine 0.375% during 96 h provides plasma levels of unbound local anesthetic far below the toxic threshold.

Acute heart failure during spinal surgery in a boy with Duchenne muscular dystrophy.

Patients with Duchenne muscular dystrophy (DMD) are at high risk of perioperative complications. DMD may be accompanied by heart failure resulting from dystrophic involvement of the myocardium, which can be subclinical in the early stages of the disease. This case demonstrates that a normal preoperative ECG and echocardiograph cannot exclude the development of heart failure during anaesthesia in DMD patients undergoing major surgery.

Hemoglobin-based oxygen carrier HBOC-201 provides higher and faster increase in oxygen tension in skeletal muscle of anemic dogs than do stored red blood cells.

BACKGROUND: Increasing need for and potential shortage of blood products have intensified the search for alternative oxygen carriers. A solution to this problem could be use of the bovine hemoglobin-based oxygen carrier HBOC-201. While hemodynamic reactions to cell-free hemoglobin have been studied, little knowledge exists about tissue oxygenation properties of hemoglobin solutions, especially in comparison with red blood cells (RBCs). STUDY DESIGN AND METHODS: Tissue oxygenation in skeletal muscle of 12 anesthetized dogs was examined after decrease of hemoglobin concentrations by means of hemodilution to hematocrit 10% and subsequent transfusion with either HBOC-201 or autologous banked RBCs. In addition to hemodynamic parameters, blood gas concentrations and oxygen content in arterial and muscular venous blood, tissue oxygen tension (tPO(2)) were measured in the gastrocnemius muscle with a polarographic needle probe. RESULTS: Hemodilution increased muscular blood flow and oxygen extraction and decreased tPO(2). Transfusion decreased muscular oxygen extraction in the RBC group but not in the HBOC-201 group (P <.01). The 10th percentile of tPO(2) increased by 400% after the first dose of HBOC-201 (P <.001 vs posthemodilution) but only by 33% after equivalent RBC transfusion (P <.01 vs HBOC-201). Increases in the 50th (120%, P <.05) and 90th (31%) percentiles and all percentiles of tPO(2) after the second and third HBOC-201 dose were less pronounced but higher than in the RBC group. CONCLUSION: Compared with RBC transfusion, infusion of low doses of HBOC-201 maintain enhanced oxygen extraction after extended hemodilution and provide faster and higher increase in muscular tissue PO(2).

[Anaesthesia tomorrow. Looking to the future]. / Anästhesie morgen. Ein Blick in die Zukunft.

As in past and present times anaesthesiology will remain the central and original part in the spectrum of anaesthesiology, emergency, pain and intensive-care medicine also in the future. Nevertheless, profound changes will take place within the next few years promoting the anaesthesiologist to the manager of the perioperative workflow. Soft and hard skills like qualification in organisation, team-leading, costing and overall quality management will be mandatory. On the other hand, medical and scientific visions should also remain in scope. Improvements in selectivity of pharmacology and monitoring in anaesthesiology and reduction of perioperative morbidity should also be actively promoted. To provide independence from commercial goals of industrial companies and to enable developments from basic research up to evidence-based clinical applications, concentration of knowledge and financial resources in centres of excellence will be imperative.

Dolasetron prophylaxis reduces nausea and postanaesthesia recovery time after remifentanil infusion during monitored anaesthesia care for extracorporeal shock wave lithotripsy.

BACKGROUND: Remifentanil is used as an analgesic for different procedures performed during monitored anaesthesia care. Opioid-induced nausea and vomiting can be troublesome. METHODS: This prospective, randomized, double-blind study was performed to evaluate the efficacy of prophylaxis with dolasetron in reducing the frequency of postoperative nausea and duration of discharge time. Forty urological patients, undergoing elective ambulatory extracorporeal shock wave lithotripsy (ESWL) received randomly either dolasetron 12.5 mg i.v. (Group 1) or placebo (Group 2) 10 min before a patient-adapted continuous infusion of remifentanil 0.15-0.4 micro g kg(-1) min(-1) was administered. Frequency and intensity (VAS 0-100 mm) of nausea, retching, and vomiting were assessed by patients and blinded investigators during and after the procedure. RESULTS: Patient characteristics, baseline values, duration of ESWL, and total dose of remifentanil did not differ between groups. The frequency (Group 1/Group 2; 20/55%; P<0.05) and mean (SD) maximal intensity [15 (9)/45 (14) mm; P<0.05] of nausea during 24 h was significantly reduced after dolasetron and discharge times in Group 1 were less than Group 2 [22 (14)/45 (28) min; P<0.05].

[Rupture of the trachea after emergency endotracheal intubation]. / Trachealruptur nach notfallmässiger endotrachealer Intubation.

The rupture of the trachea is a rare but serious complication after endotracheal intubation. We report the case of a 77-year-old severely diseased woman with emergency intubation after development of acute respiratory distress. Four days after the emergency intubation a laceration of the membraneous part of the trachea was diagnosed. The patients general condition and the infaust prognosis resulted in the lack of therapeutic options and the death of the patient. According to the forensic autopsy the secondary perforation is probably a consequence of intubation or a pressure lesion of the tube in combination with a weakness of the membraneous part of the trachea due to impaired microperfusion. Every physician performing an intubation has to be aware of the risk and the consequences of a tracheal rupture.

A comparison of anaesthetic techniques for shock wave lithotripsy: the use of a remifentanil infusion alone compared to intermittent fentanyl boluses combined with a low dose propofol infusion.

This study examined the intra-operative and postoperative characteristics of a remifentanil infusion alone, or intermittent fentanyl bolus admistration combined with a propofol infusion, for the anaesthetic management of patients undergoing shock wave lithotripsy. One of the key parameters investigated was the time to discharge. Fifty patients scheduled for extracorporeal shock wavelithotripsy (ESWL) were randomly allocated to receive either a continuous infusion of 0.2-0.4 micro g.kg-1.min-1 of remifentanil (Group 1) or a bolus of 3 micro g.kg-1 fentanyl followed by a continuous infusion of propofol at a rate of 2 mg.kg-1.h-1 with additional boluses of 0.05 mg fentanyl administered as required (Group 2). Both anaesthetic techniques were found to provide satisfactory analgesia and intra-operative conditions for ESWL. However, patients in the remifentanil Group 1 showed a higher incidence of nausea (52% vs. 0%, p < 0.01) and retching (36% vs. 0%, p < 0.01) 120 min following ESWL compared to Group 2. This resulted in prolonged discharge times (p < 0.01) in this group. We found that remifentanil used as the sole agent failed to demonstrate any advantage over the combination of fentanyl/propofol with regard to rapid recovery and discharge following anaesthesia for extracorporal shock wave lithotripsy.

[Severe mediastinal emphysema after temporal gunshot with a gas revolver]. / Ausgedehntes Mediastinalemphysem nach temporaler Schussverletzung mit einem Gasrevolver.

Injuries after a close contact gunshot with clear or tear gas cartridges can lead to severe and life threatening complications. The high pressure of the gas may damage soft tissue, bones and organs. This mechanism is able to cause mediastinal emphysema, rupture of upper and lower pharyngeal, esophageal and tracheal structures far away from the initial trauma with diagnostic findings which are may be difficult to interpret. This case report presents a mediastinal emphysema in a 17 year old man following a temporal shot with a gas revolver. The diagnostics, focussed on CT and X-ray imaging, and the therapeutic concept of such cases will be discussed.

[Analgosedation, analgesia with remifentanil in incontinence surgery via tension-free vaginal tape]. / Analgosedierung bzw. Analgesie mit Remifentanil bei Inkontinenz-Operationen mittels Urethraschlingenplastik (TVT).

OBJECTIVE: The tension-free vaginal tape operation (TVT) is a new surgical treatment of stress urinary incontinence in women. The tape has to be placed at the level of midurethra in the left and right paraurethral canal and has to be brought up to the abdominal wall in close contact with the back of the pubic bone with a special needle instrument. The performed anesthesia is decisive for the operative success, because a sufficient analgesia is demanded and, on the other hand, the correct placement and tension of the urethral tape has to be controlled by the patient performing a stress test by coughing and pressing. In this context the opioid remifentanil seems to be specially suitable because of its pharmacologic characteristics. METHODS: In this retrospective analysis the anesthesia related data of a total of 70 patients undergoing TVT surgery with remifentanil analgesia within one year were reviewed according to their anesthesia protocols. RESULTS: All patients underwent remifentanil analgesia in combination with local anesthesia. In no case the performed procedure had to be changed. In 7 cases a temporary decrease of the pulsoximetrically measured oxygen saturation to less-than-or-equal 92 % occurred, which could be treated by reduction of the infusion rate of remifentanil or by assisted ventilation. All patients were adequately able to perform the intraoperatively required stress test. 16 patients suffered from nausea and/or vomiting postoperatively. CONCLUSION: Continuous infusion of remifentanil is suitable for the short time profound analgesia needed for the TVT operation because of the pharmacologic characteristics of remifentanil. A antiemetic prophylaxis should be performed with this analgetic regime.