[Specific aspects of pediatric emergencies in the prehospital setting]. / Spezielle pädiatrische Notfälle in der Prähospitalphase.

Life-threatening pediatric emergencies are relatively rare in the prehospital setting; therefore, the treating emergency physician may not always be familiar with and well trained in these situations. However, pediatric emergencies require early recognition and initiation of specific diagnostic and therapeutic interventions to prevent further complications. Treatment of pediatric emergencies follows current recommendations as detailed in published international guidelines. The aim of this review is to provide specific information with regard to respiratory, cardiac and neurological medical emergencies commnly encountered in children in the prehospital setting. It is not the aim of this review article to provide specific guidance with regard to a variety of surgical emergencies. Due to improved treatment modalities the emergency medical team may also be confronted with acutely ill children with very severe and complex underlying clinical syndromes (e.g. complex cardiac malformations and syndromic genetic disorders). This article also provides specific information with regard to treatment of this susceptible and vulnerable patient cohort.

[Pediatric emergencies: Knowledge of basic measures for the emergency physician]. / Notfälle im Kindesalter: Vom Notarzt zu beherrschende Basismaßnahmen.

Life-threatening pediatric emergencies are relatively rare in the prehospital setting. Thus, the treating emergency physician may not always be familiar with and well trained in these situations. However, pediatric emergencies require early recognition and initiation of specific diagnostic and therapeutic interventions to prevent further damage. The treatment of pediatric emergencies follows current recommendations as detailed in published international guidelines. The aim of this review is to familiarize the emergency physician with general aspects pertinent to this topic-most importantly anatomical and physiological characteristics in this cohort. Also, specific information with regard to analgesia and sedation, which may be warranted in the prehospital setting, will be provided.

Selective gelatinase inhibition reduces apoptosis and pro-inflammatory immune cell responses in Campylobacter jejuni-infected gnotobiotic IL-10 deficient mice.

Increased levels of the matrix metalloproteinases-2 and -9 (also referred to gelatinase-A and -B, respectively) can be detected in intestinal inflammation. We have recently shown that selective gelatinase blockage by the synthetic compound RO28-2653 ameliorates acute murine ileitis and colitis. We here investigated whether RO28-2653 exerts anti-inflammatory effects in acute Campylobacter jejuni-induced enterocolitis of gnotobiotic IL-10(-/-) mice generated following antibiotic treatment. Mice were perorally infected with C. jejuni (day 0) and either treated with RO28-2653 (75 mg/kg body weight/day) or placebo from day 1 until day 6 post infection (p.i.) by gavage. Irrespective of the treatment, infected mice displayed comparable pathogen loads within the gastrointestinal tract. Following RO28-2653 administration, however, infected mice exhibited less severe symptoms such as bloody diarrhea as compared to placebo controls. Furthermore, less distinct apoptosis but higher numbers of proliferating cells could be detected in the colon of RO28-2653-treated as compared to placebo-treated mice at day 7 p.i. Remarkably, gelatinase blockage resulted in lower numbers of T- and B-lymphocytes as well as macrophages and monocytes in the colonic mucosa of C. jejuni-infected gnotobiotic IL-10(-/-) mice. Taken together, synthetic gelatinase inhibition exerts anti-inflammatory effects in experimental campylobacteriosis.

[Anesthesia for electroconvulsive therapy]. / Narkose zur Elektrokrampftherapie.

Electroconvulsive therapy is a well-established form of treatment for a broad spectrum of severe psychiatric disorders. The treatment, in which a generalized epileptic seizure is provoked by electrical stimulation of the brain, is performed with the patient under anesthesia and muscle relaxation. Therefore, sufficient knowledge of the physiological and pharmacological characteristics is an essential requirement for safe anesthesia. The following review is intended to provide some new aspects of the procedure and management of anesthesia.

Campylobacter jejuni infection of infant mice: acute enterocolitis is followed by asymptomatic intestinal and extra-intestinal immune responses.

Campylobacter (C.) jejuni is among the leading bacterial agents causing enterocolitis worldwide. Despite the high prevalence of C. jejuni infections and its significant medical and economical consequences, intestinal pathogenesis is poorly understood. This is mainly due to the lack of appropriate animal models. In the age of 3 months, adult mice display strong colonization resistance (CR) against C. jejuni. Previous studies underlined the substantial role of the murine intestinal microbiota in maintaining CR. Due to the fact that the host-specific gut flora establishes after weaning, we investigated CR against C. jejuni in 3-week-old mice and studied intestinal and extra-intestinal immunopathogenesis as well as age dependent differences of the murine colon microbiota. In infant animals infected orally immediately after weaning C. jejuni strain B2 could stably colonize the gastrointestinal tract for more than 100 days. Within six days following infection, infant mice developed acute enterocolitis as indicated by bloody diarrhea, colonic shortening, and increased apoptotic cell numbers in the colon mucosa. Similar to human campylobacteriosis clinical disease manifestations were self-limited and disappeared within two weeks. Interestingly, long-term C. jejuni infection was accompanied by distinct intestinal immune and inflammatory responses as indicated by increased numbers of T- and B-lymphocytes, regulatory T-cells, neutrophils, as well as apoptotic cells in the colon mucosa. Strikingly, C. jejuni infection also induced a pronounced influx of immune cells into extra-intestinal sites such as liver, lung, and kidney. Furthermore, C. jejuni susceptible weaned mice harbored a different microbiota as compared to resistant adult animals. These results support the essential role of the microflora composition in CR against C. jejuni and demonstrate that infant mouse models resemble C. jejuni mediated immunopathogenesis including the characteristic self-limited enterocolitis in human campylobacteriosis. Furthermore, potential clinical and immunological sequelae of chronic C. jejuni carriers in humans can be further elucidated by investigation of long-term infected infant mice. The observed extraintestinal disease manifestations might help to unravel the mechanisms causing complications such as reactive arthritis or Guillain-Barré syndrome.

[Placenta praevia totalis et increta. Cause of life-threatening haemorrhaging during a caesarean section]. / Placenta praevia totalis et increta. Ursache einer lebensbedrohlichen Blutung während einer Sectio caesarea.

Placenta increta is a rare but potentially life-threatening risk constellation after a previous caesarean section. We present the case of a 29-year-old gravida 2 para 1 patient, who developed dramatic haemorrhaging caused by this abnormal placentation, which could only be resolved by a postpartal hysterectomy. This demonstrates that in the case of a combination of the two most common predisposing factors, repeat caesarean section and placenta praevia, the possibility of a placenta increta should be considered and suitable precautions should be taken.

[Anaesthesiological aspects of electroconvulsive therapy]. / Anästhesiologische Aspekte bei Elektrokrampftherapie.

Electroconvulsive therapy (ECT) is used in the therapy of severe psychiatric disorders. The treatment, in which a generalized epileptic seizure is provoked by electrical stimulation of the brain, is performed under anaesthesia and muscle relaxation. Considering careful previous clinical examination and anaesthesiological and internal contraindications, ECT is a safe form of treatment. The following review is intended to familiarize with ECT and to provide advice for the anaesthesiological management.

[Remifentanil-propofol versus fentanyl-midazolam combinations for intracranial surgery: influence of anaesthesia technique and intensive sedation on ventilation times and duration of stay in the ICU]. / Remifentanil-Propofol versus Fentanyl-Midazolam-Kombination bei intrakraniellen Eingriffen: Einfluss von Anästhesietechnik und Intensivanalgosedierung auf Beatmungszeiten und Dauer des Intensivaufenthalts.

INTRODUCTION: After neurosurgery patients often need to be sedated and ventilated in the intensive care unit (ICU). However, rapid postoperative recovery and neurological examination are particularly important for the early recognition of complications. In this retrospective study two different strategies of anaesthesia technique and ICU sedation (fentanyl-midazolam versus remifentanil-propofol) were compared. METHODS: Intraoperatively, patients received continuous infusions of either fentanyl (0.2-1.0 mg/h) and midazolam (2-10 mg/h) or remifentanil (0.2-0.5 microg/kg body weight/min) and propofol (3-6 mg/kg body weight/h). After arrival in the ICU fentanyl (0.03-0.2 mg/h) and midazolam (2-12 mg/h) or remifentanil (0.1-0.2 microg/kg body weight/min) and propofol (0.5-3 mg/kg body weight/h) were infused to reach a Ramsay score of 4. The times between termination of infusion and extubation and the length of stay in the ICU were examined. RESULTS: A total of 60 patients (n=30 each group) undergoing supratentorial brain tumour surgery were enrolled. The groups were comparable for age, weight, ASA status (American Society of Anesthesiologists) and duration of drug administration (remifentanil-propofol 528+/-382 min versus fentanyl-midazolam 548+/-360 min). Extubation times were significantly shorter after remifentanil-propofol (47 min) than after fentanyl-midazolam (481 min), and the length of stay in the ICU was also significantly reduced (1.8 days versus 3.7 days). As a result of prolonged unconsciousness and impaired neurological assessability, a brain CT scan was necessary in 3 patients after fentanyl-midazolam to exclude neurosurgical complications. CONCLUSION: This retrospective study demonstrates that remifentanil-propofol anaesthesia and ICU sedation are superior to the combination of fentanyl and midazolam in terms of ventilation time and length of ICU stay. Moreover, the use of fentanyl-midazolam may lead to unnecessary CT scans.

Effect of propofol on seizure-like phenomena and electroencephalographic activity in children with epilepsy vs children with learning difficulties.

There is an ongoing debate as to whether propofol exhibits pro- or anticonvulsant effects, and whether it should be used in patients with epilepsy. We prospectively assessed the occurrence of seizure-like phenomena and the effects of intravenous propofol on the electroencephalogram (EEG) in 25 children with epilepsy (mean (SD) age: 101 (49) months) and 25 children with learning difficulties (mean (SD) age: 52 (40) months) undergoing elective sedation for MRI studies of the brain. No child demonstrated seizure-like phenomena of epileptic origin during and after propofol sedation. Immediately after stopping propofol, characteristic EEG changes in the epilepsy group consisted of increased beta wave activity (23/25 children), and suppression of pre-existing theta rhythms (11/16 children). In addition, 16 of 18 children with epilepsy and documented EEG seizure activity demonstrated suppression of spike-wave patterns after propofol sedation. In all 25 children with learning difficulties an increase in beta wave activity was seen. Suppression of theta rhythms occurred in 11 of 12 children at the end of the MRI study. In no child of either group was a primary occurrence or an increase in spike-wave patterns seen following propofol administration. The occurrence of beta wave activity (children with learning difficulties and epilepsy group) and suppression of spike-wave patterns (epilepsy group) were transient, and disappeared after 4 h. This study demonstrates characteristic, time-dependent EEG patterns induced by propofol in children with epilepsy and learning difficulties. Our data support the concept of propofol being a sedative-hypnotic agent with anticonvulsant properties as shown by depression of spike-wave patterns in children with epilepsy and by the absence of seizure-like phenomena of epileptic origin.

[Acute aortic dissection. Differential diagnosis of a thoracic emergency]. / Akute Aortendissektion. Differenzialdiagnose des thorakalen Notfalls.

Acute aortic dissection is an infrequent but important differential diagnosis of acute chest pain. The variability of presenting symptoms makes it difficult to diagnose correctly. Important clinical indicators - besides chest pain - are symptoms related to acute aortic insufficiency and/or pericardial tamponade, variable acute neurologic alterations, or signs of peripheral or visceral malperfusion. The spontaneous prognosis depends on the location and extent of the dissection, and left untreated dissection carries a high mortality. The key goal of preclinical treatment is stabilization with analgesia, mild sedation (opioids, benzodiazepines) and treatment of hypertension (beta-blockers) or hypotension (fluid administration). If the patient presents with a high probability of dissection, early transfer to a specialized center appears advisable. Initial clinical diagnostic studies include transthoracic echocardiogram and computed tomography. If the ascending aorta is involved (Stanford type A) immediate replacement of the proximal aorta is necessary. Isolated dissections of the descending aorta (type B) require aggressive blood pressure control, but can be managed conservatively in most cases. A high level of vigilance is necessary in all patients to detect and treat visceral ischemia.

[Myocardial preconditioning with volatile anesthetics. General anesthesia as protective intervention?]. / Myokardiale Präkonditionierung durch volatile Anästhetika. Narkose als protektive Intervention?

Reduction of the perioperative cardiovascular risk with pharmacological interventions plays a prominent role in routine anesthesia practice. For example, perioperative beta-blockade is well established in anesthesiological treatment of patients. There is a growing body of evidence supporting the cardioprotective effects of volatile anesthetics known as anesthetic-induced preconditioning. There are numerous and complex data from animal studies. The mechanisms of anesthetic-induced preconditioning have been extensively studied but have still not been clearly identified. Initial clinical data show the cardioprotective effects of volatile agents by looking at parameters of myocardial function and laboratory values and therefore, the question of the relevance of these data for routine clinical practice has been raised. This review gives a summary of the currently available data focusing on the mechanisms of anesthesiological preconditioning and clinical studies.

[Influence of gender on the intubation conditions with rocuronium]. / Einfluss des Geschlechts auf die Intubationsbedingungen nach Rocuronium.

PURPOSE: There is increasing evidence for gender differences in the pharmacokinetics and pharmacodynamics of anaesthetic drugs and neuromuscular blocking agents, e.g. rocuronium (Roc). Females require 30% less Roc than males to achieve the same degree of neuromuscular block and onset times are shorter. However, whether this leads to an improvement of the intubation conditions in females is unclear. METHODS: After approval of the ethics committee 60 female and 60 male patients were each randomised into 2 groups to receive 0.6 mg/kg body weight Roc or 1.0 mg/kg succinylcholine (Sux; control group). Induction: thiopentone (5 mg/kg), fentanyl (3 microg/kg) then Roc (Roc groups) or Sux (Sux groups) and tracheal intubation after 60 s. Time to intubation, glottic exposure and intubating conditions were assessed. RESULTS: Men were significantly larger and heavier (p<0.001) than women, but the body mass index was comparable (ns). Number of attempts, time to intubation, and Cormack grades were comparable (ns). However, the rate of clinically acceptable intubation conditions was significantly higher in the female compared to the male Roc group: 80% vs 47%, p<0.05. The incidence of clinically acceptable intubation conditions in the female Roc and Sux groups were similar (80%). CONCLUSION: The intubation conditions after Roc were significantly better in women than in men. The differences were Roc-related and did not occur in the control groups.

[Intracranial haemorrhage. A reason for delayed awakening after general anaesthesia]. / Intrakranielle Massenblutung. Ein Grund für verzögertes Erwachen nach Allgemeinanästhesie.

Delayed awakening after general anaesthesia is in the majority of cases due to prolonged effects of anaesthetic drugs. However, intracerebral processes are also associated with disturbances of consciousness. Here, we report a case of a female patient who developed an intracerebral haemorrhage because of an arteriovenous malformation during routine surgery. This shows that in the case of delayed awakening after general anaesthesia the possibility of an intracerebral process should be considered early even after routine surgery.

[Selective cyclooxygenase-2 inhibitors for postoperative pain therapy. Analgesic efficacy and adverse effects]. / Selektive Zyklooxygenase-2-Inhibitoren zur postoperativen Schmerztherapie. Wirksamkeit und Nebenwirkungsprofil.

Systemic administration of analgesics is still the most widely used method for postoperative pain therapy. In the concept of balanced or multimodal analgesia non-steroidal anti-inflammatory drugs (NSAIDs) play an important role besides opioids. Their analgesic effect is based on a diminished prostaglandin synthesis by inhibition of the cyclooxygenase (COX) enzyme in the arachidonic acid metabolism. The discovery of at least two COX isoenzymes led to the development of selective COX-2 inhibitors that were hypothesized to have an improved risk-benefit-ratio compared with conventional NSAIDs. In this context the analgesic efficacy and adverse effects of selective COX-2 inhibitors for postoperative pain therapy were evaluated by reviewing the pertinent literature.

[Iloprost. Pharmacology and clinical application during surgery]. / Iloprost. Pharmakologie und klinischer Einsatz bei Operationen.

Iloprost is a long-acting prostacyclin analogue with potent vasodilating properties. When applied per inhalation, iloprost rapidly and remarkably reduces pulmonary vascular resistance and thereby pulmonary artery pressure for approximately 60-120 min. In addition, if iloprost is inhaled and not infused, major systemic side-effects such as a significant reduction of the systemic arterial pressure can mostly be circumvented. Inhaled iloprost can be applied by means of ultrasound or by oxygen flow with both techniques being available for intensive care ventilators. For use in the anaesthesia circuit a special construction was built.

[Laryngeal tube versus laryngeal mask airway in anaesthetised non-paralysed patientsA comparison of handling and postoperative morbidity]. / Der LarynxtubusEine Alternative zur Larynxmaske?

BACKGROUND: The purpose of this study was to compare the classical laryngeal mask airway (LMA) with the laryngeal tube (LT) in anaesthetised non-paralysed patients. PATIENTS AND METHODS: A total of 100 patients scheduled for minor elective surgery were included. After standardised induction and maintenance of anaesthesia with propofol and remifentanil, patients were randomly allocated to receive either a LMA or LT; muscle relaxants were not applied. Selection of the appropriate size and the initial inflation volume were chosen according to the manufacturers instructions. Ease of insertion, initial intra-cuff pressure, oropharyngeal leak pressure at an intra-cuff pressure of 60 cm H(2)O and incidence and severity of complications during and after anaesthesia were compared. RESULTS: The LT was inserted significantly quicker than the LMA (35.1+/-15.9 s vs. 56.6+/-42.5 s; mean+/-SD). Insertion of the LT was successful within 1 attempt in 90% and within 2 or 3 attempts in another 4% of patients for the LT compared with 68% and 20% of patients for the LMA, respectively. For the LT the initial cuff pressure was significantly lower (75.1+/-16.2 cm H(2)O) and the oropharyngeal leak pressure after adjustment of the intra-cuff pressure to 60 cm H(2)O was significantly higher (27.2+/-6.9 mbar) compared with the LMA (109.5+/-25.7 cm H(2)O and 19.9+/-4.0 mbar, respectively). Incidence of postoperative laryngeal complications in the LT group (31%) was lower compared with the LMA group (54%). CONCLUSION: In anaesthetised non-paralysed patients the LT compares favourably to the LMA in terms of ease of insertion and postoperative morbidity.

[Life-threatening displacement of a tracheostomy tube in a patient with severe angiotensin-converting enzyme inhibitor-induced angioedema]. / Lebensbedrohliche Dislokation einer Trachealkanüle bei einer Patientin mit oropharyngealem Angioödem.

Angioedema of the lips and the tongue with pharyngeal and laryngeal involvement caused by angiotensin-converting enzyme inhibitors (ACEI) is rare but can cause severe airway compromise and even death due to suffocation. We present the case of a 83-year-old woman with a life-threatening displacement of a tracheostomy tube followed by tension pneumothorax after initial successful treatment of such an airway obstruction by emergency tracheostomy. This case highlights the hazards of tracheostomy tube displacement and is a reminder that where concern of tube dislodgement exists and especially when the possibility of orotracheal intubation is lacking due to upper airway obstruction or difficult airway, permanent epithelized tracheostomy should be performed early to ensure safe and fast tube replacement at any time.

Modulation of the inflammatory response to cardiopulmonary bypass by dopexamine and epidural anesthesia.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction. Microcirculation-dependent alteration of the gut mucosal barrier with subsequent translocation of endotoxins is a postulated mechanism for this inflammatory response. This study was designed to elucidate whether two different approaches to modulate splanchnic perfusion may influence systemic inflammation to CPB. METHODS: We examined 40 patients scheduled for elective coronary bypass surgery in a prospective, randomized study. One group (DPX) received dopexamine (1 micro g. kg-1. min-1) continuously after induction of anesthesia until 18 h after CPB. The control group (CON) received equal volumes of NaCl 0.9% in a time-matched fashion. In a third group (EPI) a continuous epidural infusion of bupivacaine 0.25% [(body height (cm) - 100). 10-1=ml.h-1] was administered for the whole study period. Procalcitonin (PCT), tumor necrosis factor (TNF-alpha), soluble TNF receptor, human soluble intercellular adhesion molecule-1, C-reactive protein (CRP) and leukocyte count were measured as parameters of inflammation. RESULTS: All parameters significantly increased following CPB. Increases of PCT, TNF-alpha and leukocyte count were significantly attenuated in the DPX and EPI groups at different time points. However, neither splanchnic blood flow nor oxygen delivery and consumption were different when compared with the CON-group. CONCLUSION: These results do suggest that mechanisms other than an improved splanchnic blood flow by DPX and EPI treatment have to be considered for the anti-inflammatory effects.

Recovery profile and side effects of remifentanil-based anaesthesia with desflurane or propofol for laparoscopic cholecystectomy.

BACKGROUND: Nitrous oxide (N2O) has been suggested to contribute to bowel distension, resulting in worsened operating conditions for laparoscopic surgery, and to increase incidence of postoperative nausea and vomiting. Therefore, our objective was to assess the feasibility of two remifentanil-based anaesthetic regimens free from N2O with special regard to recovery profile, postoperative analgesic demand and side effects in patients undergoing laparoscopic cholecystectomy. METHODS: Fifty patients (ASA I-II, 23-65 yr) were randomly assigned to receive remifentanil-based anaesthesia in conjunction with propofol (group R/P) or desflurane (group R/D). After standardised induction of anaesthesia, analgesia was continued with remifentanil in all patients. For maintenance of hypnosis, propofol or desflurane were used in concentrations to ensure loss of consciousness, lack of awareness, and maintenance of heart rate and blood pressure within +/- 25% of initial values. At the end of surgery all anaesthetics were discontinued without tapering and early emergence and recovery were recorded. Pain scores were assessed by using a visual analogue scale. Patient-controlled analgesia with i.v. piritramide was used for treatment of postoperative pain and recorded for 90 min in the postanaesthesia care unit (PACU). In addition, side effects were noted. RESULTS: Early emergence from anaesthesia did not differ between the groups. In group R/P, time to eye opening, spontaneous respiration and extubation was 4.4 +/- 2.9 min, 5.2 +/- 3.4 min and 5.5 +/- 3.3 min respectively, compared with 4.7 +/- 2.7 min, 5.3 +/- 2.4 min and 5.7 +/- 2.5 min in group R/D. While pain scores did not differ between both groups on admission to the PACU, patients receiving desflurane required more i.v. piritramide as compared to those receiving propofol, 22.0 +/- 6.5 mg and 17.9 +/- 7.0 mg, respectively (P<0.05). Nausea was less frequent after propofol (16% vs. 48%, P<0.05). CONCLUSION: In patients undergoing laparoscopic cholecystectomy, remifentanil-based anaesthetic regimens in conjunction with propofol or desflurane are suitable and allow for rapid recovery from anaesthesia. However, the use of propofol results in less postoperative analgesic consumption and nausea as compared to desflurane.