[Pegfilgrastim vs filgrastim in primary prophylaxis of febrile neutropenia in patients with breast cancer after chemotherapy: a cost-effectiveness analysis for Germany]. / Pegfilgrastim vs. Filgrastim zur Primärprophylaxe der febrilen Neutropenie bei Brustkrebspatientinnen nach Chemotherapie: Eine Kosten-Effektivitäts-Analyse für Deutschland.

OBJECTIVE: Febrile neutropenia (FN) is a common toxic side effect of myelosuppressive chemotherapy. The cost-effectiveness of primary prophylaxis (PP) of FN with granulocyte colony stimulating growth factor (G-CSF) filgrastim for six or eleven days was compared to single dose pegfilgrastim in patients with early breast cancer receiving chemotherapy (>or= 20 % FN risk) as simulated in a model. METHODS: Based on a decision-analytical model we conducted a cost-effectiveness analysis (CEA) and a cost-utility analysis (CUA) from the perspective of the Statutory Health Insurance (SHI) in Germany. The model simulated three clinical alternatives being built on each other, that pegfilgrastim and filgrastim had differential impact on (1) the risk of FN, (2) on FN-related mortality, and (3) on the achieved chemotherapy relative dose intensity (RDI) leading to gain in long-term survival. RESULTS: Assuming a 5.5 % lower risk of FN for PP with pegfilgrastim than an 11-day course of filgrastim provided - from the perspective of the SHI - a cost saving of Euro 2,229. A gain of 0.039 quality-adjusted life-years (QALY) resulted when the third alternative was used. Assuming a 10.5 % lower risk of FN for PP with pegfilgrastim than a 6-day filgrastim course, the third alternative showed an incremental cost-effectiveness ratio (ICER) of Euro 17.165 per life-year gained (LYG) and Euro 18.324 per QALY with 0.074 QALYs gained. CONCLUSION: These results indicate that PP with pegfilgrastim is cost saving compared to 11-day use of filgrastim and cost-effective compared to 6-day use of filgrastim in patients with breast cancer treated in Germany.

[Catabolic stress response during and after abdominal surgery. Comparison between two anaesthesia procedures]. / Katabole Stressantwort während und nach abdominalchirurgischen Eingriffen. Ein Vergleich zwischen zwei Anästhesieverfahren.

BACKGROUND: The purpose of the study was to investigate the effect of modified neuroleptanesthesia (NLA) with fentanyl/midazolam on the catabolic responses during and after abdominal surgery. METHODS: A total of 13 patients undergoing cystoprostatectomy received either modified NLA ( n=7) or inhaled anesthesia with isoflurane (ISO, n=6). Glucose and urea production rates were assessed before, during and 1 day after the operation. Plasma concentrations of glucose, urea, lactate, insulin, glucagon and cortisol were also determined. RESULTS: In contrast to isoflurane anesthesia, modified NLA prevented an increase in plasma glucose concentration and glucose production during ( P<0.05), but not after surgery. There were no differences in perioperative urea production rates or plasma concentrations of urea, insulin, glucagon and lactate between the two groups. Modified NLA suppressed the intraoperative increase in plasma cortisol concentration as observed in the ISO group ( P<0.05). CONCLUSION: Modified NLA inhibits the increase in plasma glucose concentration and glucose production as seen during isoflurane anesthesia. However, NLA does not influence the catabolic response on the first postoperative day.

The cost-effectiveness of routine childhood varicella vaccination in Germany.

This study explores the economic value of a routine varicella vaccination program for Germany. An age-structured decision analytic model was used to assess the benefits, costs and cost-effectiveness of an immunization program for a period of 30 years. Three interventions were compared with no vaccination: universal vaccination of around 15 months old healthy children, vaccination of susceptible adolescents (11-12 years of age), and the combined strategy. The analysis was conducted from both the societal perspective and the payers', i.e. sickness funds, perspective. Input data were mainly derived from a retrospective survey (analyzed were 1334 patient records) and from a seroprevalence study (n = 4602 sera). Using a coverage rate of 85% and a vaccine efficacy rate of 86% routine children vaccination could prevent around 611,000 varicella cases and over 4700 major complications per year. Average yearly cost savings for the society are 51.3 million Euro. The benefit-cost ratio (BCR) is 4.12. From the third-party payer's perspective, the BCR is 1.75 which is a consequence of significant reimbursement of parent's lost earnings by German sickness funds. The adolescent vaccination strategy has a favorable BCR ratio of 8.44 from the societal perspective, but clearly inferior medical effects. The combined vaccination strategy showed similar results as the children strategy. Routine childhood varicella vaccination appears to be a highly efficient strategy to reduce the burden of varicella and results in significant savings for both the society and the payers.

[Using epidural anesthesia in patients with acute pancreatitis--prospective study of 121 patients]. / Anwendung der Epiduralanästhesie bei Patienten mit akuter Pankreatitis--Prospektive Untersuchung an 121 Patienten.

According to a previous study, an excellent level of analgesia can be expected when using epidural anaesthesia in patients with acute pancreatitis. In the present investigation, the effectiveness and safety of epidural anaesthesia is demonstrated in a large group of patients with severe acute pancreatitis, who were admitted to an intensive care unit. Epidural anaesthesia alone produced excellent analgesia on 1,083 of 1,496 observation days (72%) without the systemic use of other analgesic substances. Even in patients with marginal cardiovascular stability, epidural injection of local anaesthetic solution was tolerated well. Only 8% of all local anaesthetic injections were associated with a haemodynamic reaction that required pharmacological intervention. There was no case of a septic or neurological complication of epidural anaesthesia. Initially elevated serum amylase and lipase were normalized after 17.4 days (minimum one day, maximum 19 days). Surgical intervention was necessary for 36 patients, with a total of 64 surgeries having to be performed, including cholecystectomy. Sixteen patients required artificial ventilation for an average time of 12.3 days (minimum two days, maximum 48 days). Lethality was 2.5% (three patients), with all three patients suffering from an acute stage III pancreatitis. The average duration of ICU treatment was 12.4 days (minimum two days, maximum 101 days).

Complications, co-morbidity, and blood glucose control in type 2 diabetes mellitus patients in Germany--results from the CODE-2 study.

In this study, prevalence and incidence of complications as well as co-morbidity in type 2 diabetes patients in Germany were evaluated as part of a cost-of-illness study (CODE-2(TM), Costs of Diabetes in Europe - Type 2)In a pre-study, 197 general practitioners and diabetes specialists all over Germany provided data on the complication status of 2701 randomly selected patients with type 2 diabetes. The patients were grouped into five mutually exclusive strata. This pre-study was performed to generate a general overview on complication status to select proper patients for the main study. The main study was performed on stratified samples derived from the pre-study. Irrespective of the real prevalence of the five strata, an equal number of 160 were randomly selected from each stratum. Thus, rare complications were also covered in the study. Data from 809 patients were collected retrospectively on the basis of medical files during interviews with the physician. To achieve representative estimates of absolute prevalence and incidence of diabetes-related complications in Germany, results were weighted using frequencies of the strata. Severe complications were diagnosed in 50% of these patients. Prevalences were: 10.56% myocardial infarction, 6.66% stroke, 3.97% foot ulcer, 2.30% amputations and 1.34% blindness. Overall incidences in the diabetes population were estimated at 0.78% myocardial infarction, 1.28% stroke and 0.80% amputations. 23% of the diabetes patients suffered from 2 or more complications. The complication status became considerably worse with increasing time since the diagnosis of diabetes. The mean HbA1c level was 7.51% (i.e. 122% of the upper limit of the respective normal ranges). The presence of complications and co-morbidity in type 2 diabetes patients was a frequent finding. This underlines the importance of complications in diabetes patients and the necessity to increase any means of prevention in order to relieve the personal and economic burden of type 2 diabetes.

Intraoperative epidural blockade prevents the increase in protein breakdown after abdominal surgery.

BACKGROUND: The aim of this study was to investigate the effect of epidural blockade with bupivacaine, restricted to the intraoperative period, on protein catabolism after major abdominal surgery. METHODS: Fourteen patients undergoing cystoprostatectomy were randomly assigned to receive either general anaesthesia with isoflurane (control group, n=7) or a combination of general anaesthesia and epidural blockade with bupivacaine from segment T4 to S5 (epidural group, n=7). Rates of urea (Ra urea) and glucose production (Ra glucose) were measured three days before and three days after the operation using stable isotope tracers ([15N2]urea, [6,6-2H2]glucose). Protein breakdown was calculated from the urea production rate. Plasma concentrations of metabolic substrates (urea, glucose, lactate, glycerol, amino acids) and hormones (insulin, glucagon, cortisol, adrenaline, noradrenaline) were also determined. RESULTS: Protein breakdown significantly increased after surgery in the control group (P<0.05), while it remained unaltered in the epidural group (control; 66 (54-76), epidural; 43 (29-58) mg x kg(-1) x h(-1), P<0.05, median (range)). Glucose plasma concentration and Ra glucose increased in both groups to a similar extent (P<0.05). Plasma concentration of branched chain amino acids decreased after epidural analgesia to a value significantly lower than in the control group (P<0.05). Glutamine plasma concentration decreased in the control group (P<0.05), but did not change in the epidural group. There were no differences in plasma concentrations of insulin, cortisol and catecholamines between the two groups. Glucagon plasma concentration in the epidural group was significantly lower than in the control group (P<0.05). CONCLUSION: Intraoperative epidural blockade inhibits the increase in protein breakdown after abdominal surgery.

Understanding the mechanisms by which isoflurane modifies the hyperglycemic response to surgery.

UNLABELLED: We studied the effect of anesthesia on the kinetics of perioperative glucose metabolism by using stable isotope tracers. Twenty-three patients undergoing cystoprostatectomy were randomly assigned to receive epidural analgesia combined with general anesthesia (n = 8), fentanyl and midazolam anesthesia (n = 8), or inhaled anesthesia with isoflurane (n = 7). Whole-body glucose production and glucose clearance were measured before and during surgery. Glucose clearance significantly decreased during surgery independent of the type of anesthesia. Epidural analgesia caused a significant decrease in glucose production from 10.2 +/- 0.4 to 9.0 +/- 0.4 micromol. kg(-1). min(-1) (P < 0.05), whereas the plasma glucose concentration was not altered (before surgery, 5.0 +/- 0.2 mmol/L; during surgery, 5.2 +/- 0.1 mmol/L). Glucose production did not significantly change during fentanyl/midazolam anesthesia (before surgery, 10.5 +/- 0.5 micromol. kg(-1). min(-1); during surgery, 10.1 +/- 0.5 micromol. kg(-1). min(-1)), but plasma glucose concentration significantly increased from 4.8 +/- 0.1 mmol/L to 5.3 +/- 0.2 mmol/L during surgery (P < 0.05). Isoflurane anesthesia caused a significant increase in plasma glucose concentration (from 5.2 +/- 0.1 mmol/L to 7.2 +/- 0.5 mmol/L) and glucose production (from 10.8 +/- 0.5 micromol. kg(-1). min(-1) to 12.4 +/- 1.0 micromol. kg(-1). min(-1)) (P < 0.05). Epidural analgesia prevented the hyperglycemic response to surgery by a decrease in glucose production. The increased glucose plasma concentration during fentanyl/midazolam anesthesia was caused by a decrease in whole-body glucose clearance. The hyperglycemic response observed during isoflurane anesthesia was a consequence of both impaired glucose clearance and increased glucose production. IMPLICATIONS: Epidural analgesia combined with general anesthesia prevented the hyperglycemic response to surgery by decreasing endogenous glucose production. The increased glucose plasma concentration in patients receiving fentanyl/midazolam anesthesia was caused by a decrease in whole-body glucose clearance. The hyperglycemic response observed during inhaled anesthesia with isoflurane was a consequence of both impaired glucose clearance and increased glucose production.

[The effect of total intravenous anesthesia with propofol, alfentanil and vecuronium (TIVA) on bronchial mucosal transport]. / Effekt einer total intravenösen Anästhesie mit Propofol, Alfentanil und Vecuronium (TIVA) auf den bronchialen Schleimtransport.

PURPOSE: The mucociliary escalator of the lung is an important protective transport system by means of which inhaled particles and microorganisms are removed from the tracheobronchial system. In the present prospective study the effect of total intravenous anaesthesia with propofol, alfentanil, vecuronium, and oxygen-air ventilation on bronchial mucus transport velocity (BTV) was investigated. METHOD: 10 patients undergoing major abdominal surgery were included in the study. In all patients anaesthesia was induced and maintained with propofol, alfentanil, and vecuronium. Ventilation was assisted with a mixture of air and oxygen (FiO2:0.35). The BTV was measured preoperatively in the conscious patients one day before surgery while they received local anaesthesia with 10 ml of 1 percent lidocaine and after the end of the operation during intubation anaesthesia. BTV was determined with a small volume of albumin microspheres labelled with technetium -99m, which was deposited on the dorsal surface at the lower ends of the right and left main bronches via a catheter placed in the inner channel of a fibre-optic bronchoscope [7]. The study was approved by the ethics committee of our hospital. RESULTS: The administered dose of propofol was 3.0 g (1.8-5.5), of alfentanil 26 mg (20-50), and of vecuronium 20 mg (16-34) (median with range). The duration of mechanical ventilation up to the time of measurement was 5 h (3.0-9.5). TIVA produced a decrease of BTV in the right (9.7 vs 4.9 mm/min) and left main bronchus (11.3 mm/min vs 5.3 mm/min). CONCLUSIONS: Total intravenous anaesthesia with propofol, alfentanil, and vecuronium depressed mucociliary flow in patients with healthy lungs. The period for recovery of mucociliary clearance and the possible disadvantage in patients with increased pulmonary risk (e.g. patients with chronic bronchitis and abdominal surgery) should be clarified in further studies.

Cardiac function in patients with treated hypertension during aortic aneurysm repair.

OBJECTIVES: To investigate the impact of arterial hypertension on cardiac function during aortic cross-clamping and declamping. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Twenty treated hypertensive males with slight left ventricular hypertrophy and 10 normotensive controls undergoing elective repair of an abdominal aortic aneurysm. INTERVENTIONS: Using transesophageal echocardiography, the mitral inflow profile was evaluated during aortic cross-clamping and declamping. MEASUREMENTS AND MAIN RESULTS: During the clamping period, the ratio of peak atrial to peak early filling velocity (PA/PE) was significantly higher in the hypertensive patients. One minute after aortic cross-clamping, mean arterial pressure (MAP) and pulmonary artery occlusion pressure significantly increased in the hypertensive patients, whereas they did not change in the normotensive group. Cardiac index and heart rate significantly decreased after cross-clamping, and increased after clamp release in both groups. PA/PE significantly dropped in both groups after aortic declamping, and returned to baseline values thereafter. MAP also decreased significantly in both groups after clamp release, but the fall of MAP tended to be more pronounced in the hypertensive patients. CONCLUSIONS: In the treated hypertensive patients, more pronounced hemodynamic and echocardiographic responses to aortic cross-clamping probably mirror the altered diastolic left ventricular function in these patients. With respect to intraoperative management, however, the treated hypertensive patients did not react grossly differently from the normotensive controls.

Comparison of therapies with torasemide or furosemide in patients with congestive heart failure from a pharmacoeconomic viewpoint.

This observational study compared patients suffering from congestive heart failure (CHF) who were treated with loop diuretics torasemide or furosemide. Data documenting the course of the disease and its associated costs over a period of one year were collected retrospectively. A total of 400 CHF patients, 200 in each treatment group, were included in the analysis. Concomitant ACE inhibitor therapy was received by 46% of patients in both groups. More torasemide-treated patients (38.0%) than furosemide-treated patients (24.5%) achieved an improvement in NYHA class in the one-year period. The main difference between the two groups was the number of CHF-related hospitalisations: 62 vs 324 hospital days due to CHF were necessary among torasemide- and furosemide-treated patients, respectively. Thus torasemide treatment was associated with an 80% reduction in hospital days compared with furosemide. Furthermore, about 30% fewer working days were lost in the torasemide group than in the furosemide group (441 days vs 617 days, respectively). Direct and indirect costs were evaluated, resulting in overall annual costs of DEM 1502 per torasemide-treated patient and DEM 1863 per furosemide-treated patient. A cost-effectiveness analysis showed a difference between the therapies of DEM 3651 in favour of torasemide. In conclusion, treatment with torasemide improved clinical outcome and was more cost-effective than with furosemide.

[Effectiveness, side effects and costs of postoperative pain therapy: intravenous and epidural patient-controlled analgesia (PCA)]. / Wirksamkeit, Nebenwirkungen und Kosten postoperativer Schmerztherapie: Intravenöse und epidurale patientenkontrollierte Analgesie (PCA).

PURPOSE: Improvement of the quality of analgesia, reduction of side effects and costs by application of epidural (PCEA) in comparison to intravenous patient-controlled analgesia (PCA) in postoperative pain treatment. METHODS: 62 patients with upper abdominal surgery took part in this randomised prospective study which was approved by the local ethics committee. Epidural catheters were inserted at T 8/9 (group PCEA). General anaesthesia was performed with propofol, sufentanil 2 micrograms/kg, pancuronium, enflurane and O2:N2O = 1:2. Postoperative analgesia consisted of epidural bupivacaine 0.25% + sufentanil 2 micrograms/ml (BS). (bolus 0.05 ml/kg, lockout 10 min) in group PCEA, or of intravenous morphine (bolus 2 mg. lockout 10 min) in group PCA. The following parameters were recorded until the evening of postoperative day 4: pain intensity at rest (VASR, 1-10) and on coughing (VASH, 1-10), blood pressure, heart rate, blood gas analysis, ability to ambulate, pruritus, nausea/vomiting (PONV), patient satisfaction (0-4), time and expenses for postoperative pain treatment. RESULTS: Median VASR (1 vs 2) and VASH (3 vs 4.5) were lower, cough intensity (2 vs 1) and patient satisfaction score (4 vs 3) were higher in PCEA compared to PCA. Ability to ambulate, pruritus, PONV, haemodynamics, paO2 and paCO2 were comparable. Postoperative pain treatment with PCEA was more time-consuming (407 vs 299 min) and expensive (71 vs 40 S/day) than PCA. CONCLUSION: PCEA in comparison to PCA after major abdominal surgery provides superior analgesia with comparable side effects at approximately 80% higher costs.

Assessment of perioperative glycerol metabolism by stable isotope tracer technique.

The aim of this study was to investigate metabolic changes during and after abdominal hysterectomy with specific regard to glycerol metabolism. Seven otherwise healthy patients with benign uterine myoma were enrolled in this study. Glycerol turnover and hepatic glucose production were measured before and after the operation by using stable-isotope technique ([1,1,2,3,3-2H5]-glycerol, [6,6-2H2]-glucose). Metabolic substrates (glycerol, nonesterified fatty acids, beta-hydroxybutyrate, glucose, lactate) and hormones (insulin, glucagon, cortisol, catecholamines) were determined pre-, intra- and postoperatively. Hysterectomy was associated with an increase of postoperative glycerol turnover from 3.56 +/- 1.28 to 6.46 +/- 2.44 mumol.kg-1.min-1 (P < 0.05). This increment was inversely related to the age of the patients (r = 0.872, P < 0.05). Glycerol concentration tended to increase perioperatively. These changes, however, were not of statistical significance. Hepatic glucose production and glucose plasma levels increased postoperatively from 9.75 +/- 1.61 to 12.79 +/- 1.45 mumol.kg-1.min-1 (P < 0.05) and 4.6 +/- 0.9 to 6.2 +/- 0.9 mmol/L (P < 0.05), respectively. Cortisol and catecholamine levels rose during and after surgery, while insulin and glucagon remained unchanged. The enhanced rate of lipolysis after hysterectomy was not detectable from plasma glycerol levels alone. The results of this study showed that using stable isotope technique allowed a more differentiated look at metabolic pathways than static plasma substrate concentrations, especially under perioperative conditions.

Effects on haemodynamics and catecholamine release of xenon anaesthesia compared with total i.v. anaesthesia in the pig.

In order to investigate haemodynamic response and catecholamine release during anaesthesia with xenon, we conducted a study on 28 pigs which were allocated randomly to one of four groups: total i.v. anaesthesia with pentobarbitone and buprenorphine, and xenon anaesthesia with inspiratory concentrations of 30%, 50% or 70%, respectively, supplemented with pentobarbitone. Haemodynamic variables were measured using arterial and Swan Ganz catheters. Depth of anaesthesia was monitored using spectral edge frequency analysis. Plasma concentrations of dopamine, noradrenaline and adrenaline were measured by high pressure liquid chromatography. All haemodynamic variables and plasma concentrations of dopamine and noradrenaline remained within normal limits. Adrenaline concentrations were reduced significantly in all groups. Xenon anaesthesia was associated with a high degree of cardiovascular stability. Significant reduction in adrenaline concentrations at inspiratory xenon concentrations of 30% and 50% can be explained by analgesic effects of xenon below its MAC value.

Shed mediastinal blood in 500 elective cardiac surgery patients: is there enough for retransfusion routinely?

OBJECTIVE: Since an increased use of several blood salvaging measures has contributed to a reduction in perioperative blood loss and the requirement for banked blood in recent years, the aim of this study was to establish current postoperative drainage losses in order to evaluate whether homologous retransfusion may be a useful measure to reduce autologous transfusion in elective cardiac surgery. DESIGN/SETTING: This prospective clinical investigation was performed at a University Intensive Care Unit during the first six hours following cardiac surgery. PATIENTS: 373 men and 127 women undergoing elective cardiac surgery were investigated. MEASURES: The amount of shed blood was measured four and six hours postoperatively. RESULTS: The average blood loss was higher in men than in women both in all operations as a whole (men, four hours: 223+/-73 ml, six hours 270+/-95 ml; women, four hours: 156+/-25 ml, six hours 195+/-22 ml), in valve replacement (men, four hours: 299+/-87 ml, six hours 350+/-101 ml; women, four hours: 187+/-30 ml, six hours: 219+/-31 ml) and in coronary artery bypass grafting (men, four hours: 197+/-69 ml, six hours: 242+/-83 ml; women, four hours: 128+/-15 ml, six hours: 173+/-18 ml). A blood loss of 400 ml was exceeded in 13% of men after valve replacement four and six hours postoperatively. In all other groups, less than 8% of patients had a loss of more than 400 ml both after four and after six hours. CONCLUSIONS: Postoperative drainage losses in elective cardiac surgery patients are small and a measurable advantage from retransfusion seems to be unlikely. We therefore endorse the routine use of shed mediastinal blood retransfusion in these patients.

Influence of vaginal versus abdominal hysterectomy on perioperative glucose metabolism.

The aim of this study was to investigate the metabolic effects of abdominal versus vaginal hysterectomy with specific regard to perioperative glucose metabolism. Fourteen patients received either abdominal (AH, n = 7) or vaginal hysterectomy (VH, n = 7). Hepatic glucose production was measured before and 2.5 h after the operation by stable isotope technique ([6,6-2H2]-glucose). Metabolic substrates (glucose, lactate, nonesterified fatty acids [NEFA], beta-hydroxybutyrate) and hormones (insulin, glucagon, cortisol, catecholamines) were determined pre-, intra-, and postoperatively. VH induced a higher postoperative glucose concentration than the abdominal approach (VH, 148 +/- 25 mg/dL; AH, 111 +/- 16 mg/dL; P < 0.05). Since postoperative enhancement of hepatic glucose production was comparable in both groups, glucose clearance was lower after the vaginal procedure (VH, 1.7 +/- 0.3 mL.kg-1.min-1; AH, 2.1 +/- 0.3 mL.kg-1.min-1; P < 0.05). NEFA, beta-hydroxybutyrate, and catecholamines similarily increased after surgery. Cortisol levels were more increased after VH (VH, 80 +/- 26 micrograms/dL; AH, 37 +/- 14 micrograms/dL; P < 0.001). Lactate, glucagon, and insulin concentrations did not change perioperatively. The more pronounced hyperglycemic response to VH was due to lower peripheral glucose use caused by higher postoperative cortisol values. The mechanisms responsible for this marked cortisol enhancement after the vaginal operation as well as the clinical significance for patients with preexisting impaired carbohydrate tolerance, however, remained unclear and warrant further investigation.

[The effect of a heat and moisture exchanger (HME) on bronchial mucus transport in a closed inhalation anesthesia system]. / Einfluss eines Wärme- und Feuchtigkeitsaustauschers (HME) auf den bronchialen Schleimtransport im Rückatemnarkosesystem.

UNLABELLED: The administration of dry anaesthetic gases for ventilation leads to morphological changes of the tracheobronchial epithelium that may cause postoperative pulmonary complications. Therefore, additional humidification with a heat and moisture exchanger (HME) is suggested for ventilation during anaesthesia, particularly when using semi-open breathing systems. Recommendations concerning the use of a HME in the semi-closed system are controversial. There are no data in the literature as to whether a HME improves mucociliary transport under these conditions. We therefore studied bronchial mucus transport velocity (BTV) with and without the use of a HME in the semi-closed circle system in humans. PATIENTS AND METHODS: The study was approved by the ethics committee of our hospital. In a prospective, randomised trial a total of 22 patients undergoing major abdominal surgery were investigated. In all patients anaesthesia was induced and maintained with midazolam, fentanyl, and vecuronium. After intubation, a HME (BACT/VIRAL HME, Pharma Systems AB, Sweden) was inserted between the endotracheal tube and ventilation tubing in 11 patients; the other 11 were ventilated without a HME and served as controls. Ventilation was assisted with a fresh flow of 3 in a semi-closed system (Dräger Sulla 808 V with an 8 ISO circle system and Ventilog 2 ventilator, Drägerwek AG, Germany) and a 2:1 mixture of nitrous oxide and oxygen. The fresh gas passed through the soda lime canister. At the end of the operation BTV was measured with a small volume of albumin microspheres labeled with technetium Tc99m, which was deposited on the dorsal surface at the lower ends of the right and left main bronchi via a catheter placed in the inner channel of a fibre-optic bronchoscope. RESULTS: The two groups were comparable with regard to age, sex, preoperative lung function, duration of mechanical ventilation, and dose of anaesthetics. There were no statistically significant differences in the BTVs. DISCUSSION: BTV does not improve with the use of a HME in the semi-closed circle system with a fresh gas flow of 31. With modern anaesthesia machines lower fresh gas flows should be administered, whereby the humidity and temperature of the inspired gases are further increased.

Effect of 7.2% hypertonic saline/6% hetastarch on left ventricular contractility in anesthetized humans.

BACKGROUND: Although a positive inotropic effect of hypertonic saline has been demonstrated in isolated cardiac tissue as well as in animal preparations, no information exists about a possible positive inotropic action of hypertonic saline in humans. The aim of this investigation was to determine whether a clinically relevant positive inotropic effect can be demonstrated in humans. METHODS: Twenty-six patients without cardiovascular disease were randomized to receive 4 ml/kg of either 7.2% hypertonic saline/6% hetastarch or 6% hetastarch (control) at a rate of 1 ml.kg-1.min-1 while under general endotracheal anesthesia. Transesophageal echocardiography was used to evaluate left ventricular function. Arterial pressure, heart rate, and left ventricular end-systolic and end-diastolic diameter, area, and wall thickness were measured immediately before and after administration of either solution. Fractional area change, end-systolic wall stress, and the area under the end-systolic pressure-length relationship curve (ESPLRarea) were calculated. ESPLRarea was used to assess left ventricular contractility. RESULTS: Administration of hypertonic saline/hetastarch resulted in a significant decrease of mean arterial pressure and end-systolic wall stress from 77 +/- 14 (mean +/- SD) to 64 +/- 17 mmHg (P < 0.01) and from 52 +/- 14 to 32 +/- 11 10(3) dyne/cm2 (P > 0.01), respectively. End-diastolic area and fractional area change increased from 16.5 +/- 2.9 to 21.7 +/- 3.3 cm2 (P < 0.01) and from 0.53 +/- 0.07 to 0.70 +/- 0.06 (P < 0.01), respectively, whereas there was only a minor change of ESPLRarea from 38 +/- 13 to 44 +/- 13 mmHg.cm (P < 0.05). CONCLUSIONS: The apparent improvement of left ventricular systolic function in response to hypertonic saline/hetastarch is caused mainly by the combined effect of increased left ventricular preload and reduced left ventricular afterload. A possible positive inotropic action of hypertonic saline/hetastarch is not likely to be clinically relevant.

Analgesic and hemodynamic effects of epidural clonidine, clonidine/morphine, and morphine after pancreatic surgery--a double-blind study.

This study characterizes analgesia an hemodynamics after epidural clonidine 8 micrograms/kg (Group C) or clonidine 4 micrograms/kg+morphine 2 mg (Group CM) in comparison to epidural morphine 50 micrograms/kg (Group M). Forty-five patients scheduled for pancreatectomy in combined general/epidural anesthesia were studied. The study drugs were administered 75 min postoperatively and for 10 h pain intensity (visual analog scale [VAS]), heart rate (HR), mean arterial pressure (MAP), and cardiac output (CO) were measured; filling pressures were kept > 5 mm Hg. Adequate analgesia could be achieved within 1 h in all patients of Groups C and CM, but only in six patients of Group M (P < 0.001). Quality of analgesia was comparable in all groups (VAS reduction 82% +/- 20%, mean +/- SD) but duration of analgesic action was longer in Groups CM (586 +/- 217 min) and M (775 +/- 378 min) compared to Group C (336 +/- 119 min) (P < 0.001). In Group M, no hemodynamic alterations occurred. In Groups C and CM, HR, CO, and MAP were reduced significantly compared to baseline within the first 15-90 min, while stroke volume and systemic vascular resistance remained stable. We conclude, that hemodynamic alteration after epidural clonidine under conditions of stable filling pressures is caused mainly by a decrease in HR. It is not an effect of analgesia but of the intrinsic antihypertensive action of clonidine.

[Quality control in anesthesiology. Results of a prospective study following the recommendations of the German Society of Anesthesiology and Intensive Care]. / Prozessqualität in der Anästhesiologie. Ergebnisse einer prospektiven Erhebung nach den Empfehlungen der DGAI.

The German Social Law has required quality assurance (QA) procedures since 1989. The measures must be suitable to allow "comparing investigations". In 1992 the German Society of Anaesthesiology and Intensive Care Medicine published recommendations for QA in anaesthesia: most problems during an anaesthetic should be documented in a standardised manner, and thus, a list of 63 pitfalls, events, and complications (PECs) and five degrees of severity were defined. The goal of this study was to determine the frequency of PECs in anaesthesia and to correlate PECs with procedures and preoperative health status. MATERIALS AND METHODS. Demographic data, preoperative findings, type and duration of anaesthesia and operation, and kind and severity of PECs were integrated in an automatically readable anaesthetic data record (ARADR). During 12 months all anaesthetics in our department were documented by the ARADR; the records were read by a reading device and the data stored in a modern SQL database (Informix). Degrees of severity: I. PEC leads to reaction of anaesthetist, no impact for recovery room (RR); II. impact for RR, no impact on transfer to ward; III. significant prolongation of RR stay or additional monitoring on ward; IV. PEC leads to intensive care unit admission; V. disabling damage or death. RESULTS. In all, 18350 anaesthetics were recorded (9055 male, 9295 female); the median age was 41 years (1 day-99 years). In 4251 (23.2%) anaesthetics 5927 PECs occurred, 3412 of them involving the cardiovascular and 949 the respiratory system, the latter with a tendency to higher degrees of severity. PECs caused by technical equipment (126) or lesions caused by anaesthesists (342) had no fatal outcomes and were less severe. Patients in ASA class I had 12.3% anaesthetics with PECs, ASA II 23.3%, ASA III 33.8%, ASA IV 34.9%, and ASA V 58.5%. PECs of degrees IV and V showed a higher incidence in the higher ASA classes. There was no fatal PEC in an ASA class I patient and only one (of 13615) in an elective procedure. Emergency cases had more frequent and more severe PECs: 16 of 19 PECs of degree V were in ASA class IV and V patients and 15 in emergency situations, all of them in surgical patients. Patients with cardiovascular disease had a more frequent incidence of PECs by a factor of 1.39 to 5.93 than those without such disease. CONCLUSIONS. Standardised incident reporting by defined PECs seems a good way to describe problems in anaesthesia. The types of PECs in our study had a similar distribution to those in other investigations, but there was a tendency to less frequent fatal PECs in ASA classes I to IV and more frequent ones in ASA class V. We expect better comparability when multicenter studies are done using identical methods in the next few years. Perhaps different patients collectives with special risks will be detected; efforts in quality improvement could focus on these patients.