Safety and feasibility of nasopharyngeal evaporative cooling in the emergency department setting in survivors of cardiac arrest.

AIM: Mild therapeutic hypothermia improves survival and neurologic recovery in primary comatose survivors of cardiac arrest. Cooling effectivity, safety and feasibility of nasopharyngeal cooling with the RhinoChill device (BeneChill Inc., San Diego, USA) were determined for induction of therapeutic hypothermia. METHODS: Eleven emergency departments and intensive care units participated in this multi-centre, single-arm descriptive study. Eighty-four patients after successful resuscitation from cardiac arrest were cooled with nasopharyngeal delivery of an evaporative coolant for 1h. Subsequently, temperature was controlled with systemic cooling at 33 degrees C. Cooling rates, adverse events and neurologic outcome at hospital discharge using cerebral performance categories (CPC; CPC 1=normal to CPC 5=dead) were documented. Temperatures are presented as median and the range from the first to the third quartile. RESULTS: Nasopharyngeal cooling for 1h reduced tympanic temperature by median 2.3 (1.6; 3.0) degrees C, core temperature by 1.1 (0.7; 1.5) degrees C. Nasal discoloration occurred during the procedure in 10 (12%) patients, resolved in 9, and was persistent in 1 (1%). Epistaxis was observed in 2 (2%) patients. Periorbital gas emphysema occurred in 1 (1%) patient and resolved spontaneously. Thirty-four of 84 patients (40%) patients survived, 26/34 with favorable neurological outcome (CPC of 1-2) at discharge. CONCLUSIONS: Nasopharyngeal evaporative cooling used for 1h in primary cardiac arrest survivors is feasible and safe at flow rates of 40-50L/min in a hospital setting.

Pre-emptive analgesia: comparison of preoperative with postoperative caudal block on postoperative pain in children.

We have compared in 25 children the effect of preoperative with postoperative caudal block on pain after circumcision in a double-blind, randomized study. After induction of anaesthesia, patients were allocated randomly to receive a caudal block either before (n = 14) or immediately after (n = 11) surgery. Postoperative pain was rated on a paediatric pain scale. If pain occurred, children received paracetamol in a dose related to body weight. Using the Mann-Whitney U test (significance < or = 0.05) there was no significant difference in cumulative postoperative analgesic requirements within the first 48 h and in times to first analgesic administration between the groups. Cumulative pain score, assessed every 30 min for the first 8 h after operation, was significantly lower for those patients who received caudal anaesthesia after operation. Thus we could not demonstrate any advantage in performing caudal block before compared with after surgery.

How noisy are anaesthesia and intensive care medicine? Quantification of the patients' stress.

The minimum and maximum sound pressure levels (Lmin, Lmax) were measured, and the energy equivalent sound pressure level (Leq) and the impulse rated Leq (LAlm) were ascertained in the surgical intensive care unit and the anaesthetic and recovery room. Frequency analyses were also made of the noise from various pieces of equipment. The LAlm was never below 60 dB(A)--the wake-up threshold in man--comprising strong narrow-band impulses with Lmax more than 100 dB(A) primarily from instrument alarms. When several instruments were alerted at the same time, a broad-band noise resulted which was based on their various spectral peaks. Whilst the maximum sound level of the technical equipment was high, it was surpassed by avoidable background noise caused by the staff (e.g. falling bucket lid: 94.7 dB(A)). No relationship was found between acoustic parameters and intended type of anaesthesia or surgery. Sound level was low in dangerous situations and high during routine work.

[Preoperative treatment with beta-receptor blockers and isoflurane anesthesia. Hemodynamic interactions in patients with coronary disease]. / Präoperative Therapie mit beta-Rezeptorenblockern und Isoflurananaesthesie. Hämodynamische Interaktionen bei Patienten mit koronarer Herzkrankheit.

Although many patients undergoing general anesthesia and surgery are pretreated with beta-adrenoceptor blocking drugs, hemodynamic interactions of beta-blockers and volatile anesthetics have so far only been studied in animals. We therefore designed a clinical study to evaluate the relationship between the extent of preoperative beta-adrenoceptor blockade and the hemodynamic effects of isoflurane anesthesia. Sixty-one patients with coronary artery disease (CAD) and normal global left ventricular function scheduled for elective myocardial revascularization were studied immediately prior to surgery. One group of patients (n = 39) had been treated with beta-adrenoceptor blocking agents for at least 3 weeks up to and including the day of surgery. The degree of clinical beta-adrenoceptor blockade was quantified using the isoproterenol sensitivity test. The dose of isoproterenol required to increase heart rate by 25 beats/min was defined as the chronotropic dose 25 (CD25), representing the degree of beta-adrenoceptor blockade. Hemodynamic data were collected before and during isoflurane anesthesia (0.5%-0.6% end-tidal) plus 50% nitrous oxide. Twenty-two patients without preoperative beta-blocker therapy served as a control group. Preanesthetic values of cardiac index (CI), heart rate (HR) and mean arterial pressure (MAP) were lower in patients pretreated with beta-blocking drugs, but statistically these differences were not significant when compared to data obtained in unblocked patients. Isoflurane anesthesia caused significant reductions of CI and arterial blood pressure. However, there were no significant differences in the absolute values or the percentage changes compared to baseline data obtained in awake patients between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Muscular obstruction of the right ventricular outflow tract. Subvalvular pulmonary stenosis or hypertrophic cardiomyopathy?]. / Muskuläre Obstruktion der rechtsventrikulären Ausflussbahn. Subvalvuläre Pulmonalstenose oder hypertrophische Kardiomyopathie?

A case is reported of right ventricular outflow obstruction caused by hypertrophic cardiomyopathy. The pressure gradient between the inflow tract and the outflow tract of the right ventricle was 84 mm Hg. Resection of the hypertrophic muscle bundles practically eliminated the obstruction leaving only an insignificant subvalvular gradient of 2 mm Hg. Histologic examination revealed cardiac muscle cell hypertrophy and disorganization.