[New oral anticoagulants in perioperative medicine]. / Neue orale Antikoagulanzien in der perioperativen Medizin.

New oral anticoagulants (NOAC) inhibit factor Xa (Stuart-Prower factor) or factor IIa (thrombin) and are alternatives to vitamin K antagonists. Perioperative indications are deep vein thrombosis prophylaxis for prosthetic hip and knee replacement, therapeutic anticoagulation for deep vein thrombosis as well as the prophylaxis of stroke for patients with atrial fibrillation. Patients on NOACs pose multiple perioperative challenges for all medical disciplines involved. For non-emergency surgery, patients should be evaluated by an anesthesiolgist as early as possible to assess an optimal appointment for surgery and bridging strategy. Management of emergency procedures for patients on NOACs requires an interdisciplinary approach. The individual risk for uncontrolled bleeding versus the urgency for surgery needs to be evaluated on an individual basis. The determination of drug serum levels enables a rough estimation of anticoagulant activity. Emergency procedures in coagulopathy due to active bleeding are treated with the unspecific administration of blood products and coagulation factor concentrates.

[Awake fiberoptic intubation]. / Fiberoptische Wachintubation.

Airway management is a core task for anesthesiologists. Deficiencies in training or equipment as well as fateful complications in this field are responsible for a significant proportion of anesthesia-associated morbidity and mortality. Nowadays there are a variety of advanced technical aids on the market to overcome the difficult airway. Nevertheless, the "cannot intubate cannot ventilate scenario" still occurs and regularly results in poor outcome, such as permanent neurological deficits or even death. Therefore, awake fiberoptic intubation remains the gold standard in the expected difficult airway because when applied correctly this technique never leads to a point where a patient's respiration is compromised as a result of medical measures before a secure airway has been established.

[Heparin-induced thrombocytopenia]. / Heparininduzierte Thrombozytopenie.

Heparins are in widespread use as anticoagulants for the prophylaxis and therapy of thromboembolisms. A dangerous side-effect is heparin-induced thrombocytopenia type II (HIT type II) with the paradox of thromboembolic venous and arterial vascular occlusions. HIT type II is an immunological disease which results in activation of platelets and plasma coagulation. The main symptom is an acute onset of thrombocytopenia with a fall in thrombocytes to less than 50% of the initial value with or without newly arising thromboembolic complications between days 5 and 14 after the start of heparin therapy. Surgery patients are more often affected by subclinical antibody formation as well as by symptomatic HIT type II than clinical patients. In this review we will discuss the difficult diagnosis and the differential diagnosis with special emphasis on postoperative intensive care patients, as well as preventive measures and management on occurrence of HIT type II and associated thrombotic complications.

Correlation of MMSE, SKT and clock test scores in patients with mild and moderate dementia.

The objective of our study was to assess the correlation of routine neuropsychological test results in elderly patients referred to a gerontopsychiatric ward. MMSEs, Clocktests (CT) and SKTs were performed in 94 patients (Age: Median = 74 ys, Range = 54-89 ys; 64 f, 30 m; MMSE < 25:45 and MMSE > 25:37) with mild to moderate dementia and evaluated retrospectively. Linear and multiple regression was used. The scores of all 3 tests used were reciprocally correlated (p < 0.05). Multiple regression analysis showed a maximum correlation of 0.87 and marked standardized beta values, if SKT was chosen as dependent variable. In conclusion, results of SKT, CT or MMSE in patients with dementia showed marked pairwise or multiple correlations and therefore it is not necessary to include more than two reliable tests in clinical psychogeriatric studies.

[Malignant hypertension in a single kidney with doubled blood vessel supply]. / Maligne Hypertonie bei Einzelniere mit doppelter Gefässversorgung.

HISTORY: A 72-year-old male in acute renal failure, intubated and ventilated, was transferred to our hospital. He had a 30-years history of severe hypertension and signs of general atherosclerosis. 25 years ago, the left kidney had been removed because of an ischaemic renal infarction due to a renal artery stenosis. Blood pressure-monitoring showed excessive high systolic (up to 250 mmHg) and diastolic (up to 160 mmHg) blood pressure. INVESTIGATIONS: The MRI-scan revealed a single right kidney with a main artery and an accessory one, both with a severe ostial stenosis. The resistance index (RI) value, measured by duplex ultrasonography was 44. DIAGNOSIS AND TREATMENT: In two interventional procedures both stenosed arteries were dilated a stent was applied. Afterwards blood pressure and renal function improved. CONCLUSIONS: Severe hypertension can be caused by a renal artery stenosis. It can be diagnosed by duplex ultrasonographic studies, which has the advantage of determining the RI and therefore identifying patients with no improvement of blood pressure or renal function after resolving the stenosis. The angioplasty with or without a stent is as successful as an operation but has less complications.

[Psychometric diagnosis of dementia in clinical gerontopsychiatry practice]. / Psychometrische Demenzdiagnostik in der klinischen Praxis der Gerontopsychiatrie.

An extensive battery of cognitive tests is conducted to detect dementia in geriatric patients. Based on the ICD-10 diagnostic criteria for dementia the diagnosis includes cognitive deficits such as memory impairment and other cognitive disturbances in various stages. To establish a profile of cognitive deficits and to detect early stages of dementia a combination of psychometric tests has proven to be effective and valid (MMSE, SKT, SIDAM, GDS/BCRS, clock drawing). To evaluate interrelations between these tests, correlations of total scores among 40 randomly chosen geriatric patients were calculated for all tests using the Spearman rank-order correlation. The cognitive test battery appears to be a reliable instrument for diagnosing people with dementia. Due to advantages and shortcomings of each test in evaluating various stages of dementia adequately, a combination of tests should be used.

[Dose-response relationship of clonidine with epidural administration of ropivacaine in orthopedic procedures of the lower extremities]. / Dosis-Wirkungsbeziehung von Clonidin zu epidural appliziertem Ropivacain bei orthopädischen Eingriffen der unteren Extremität.

OBJECTIVE: The aim of this study was to investigate preliminarydose-range effects of clonidine added to ropivacaine for epidural analgesia in elective orthopedic surgery of the lower limbs with doses, causing a minimum of cardiovascular side effects. METHODS: 60 patients were randomly assigned to receive in a double-blind fashion a mixture of 1 mg/cm height ropivacaine plus saline or 1 mg/cm ropivacaine plus 25 micrograms, 50 micrograms, 75 micrograms, 100 micrograms or 150 micrograms clonidine for epidural analgesia. The sensory and motor function were determined at defined time intervals for 30 minutes. Heart rate and blood pressure were controlled and sedation score was judged. The postoperative 2-segment-regression of pin-prick and the onset of pain were recorded. RESULTS: The six groups were comparable in demographic data and in term of onset time. The prolongation of analgesia reached 513 +/- 92 min (p = 0.002) for 150 micrograms clonidine, 460 +/- 148 min (p = 0.073) for 100 micrograms clonidine, 440 +/- 86 min (p = 0.057) for 75 micrograms clonidine compared with 347 +/- 114 min for saline. In an equal manner, 2-segment-regression for pin-prick was extended to 251 +/- 47 min (p = 0.018) for 150 micrograms clonidine, 238 +/- 33 min (p = 0.034) for 100 micrograms clonidine, 229 +/- 29 min (p = 0.027) for 75 micrograms clonidine and 178 +/- 43 min for saline. Heart rate dropped down in all groups. Mean arterial pressure decreased significantly in the groups with 75, 100 and 150 micrograms clonidine. Sedation score increased continuously from 0.6 +/- 0.5 (saline) to 1.8 +/- 0.8 (150 micrograms clonidine). CONCLUSION: We conclude that 150 micrograms clonidine significantly enhances the duration of analgesia of epidurally administered ropivacaine in a mean of 171 mg. This time interval is longer than the one with 200 mg ropivacaine alone. But, there are side effects in form of decrease of arterial pressure. Cardiovascular monitoring seems to be essential. Because of the enhanced analgesia duration, the time interval for reloading epidural anaesthesia are increased.

[Diagnosis of poly-orchidism]. / Zur Diagnostik der Polyorchie.

In a patient referred for sclerotherapy of a varicocele, three testicles and focal atrophy in one testicle were additionally diagnosed by ultrasound and MR. In the literature other diseases are occasionally described accompanying this rare benign congenital anomaly.

[Comparison of x-ray plain films, x-ray tomograms and computed tomograms in lung nodules in children and adolescents]. / Vergleich von Röntgenübersichtsaufnahmen, Röntgenschichtaufnahmen und Computer-tomogrammen bei pulmonalen Rundherden im Kindes- und Jugendalter.

A comparison was carried out of the value of plain radiographs, tomography and CT in 37 patients aged between five and 24 years. The majority of these patients had an osteosarcoma. Thirty-five CT examinations were performed on 16 patients and about 300 foci were demonstrated. Plain radiographs only showed 50%, and tomograms only 70% of these lesions. Surgery was carried out in 34 patients and there was agreement between the findings at thoracotomy and radiology in about half the cases. Frequently, more metastases were found at operation than could be demonstrated radiologically, in a few cases there were fewer.