Target-controlled infusion of propofol for fibreoptic intubation.

BACKGROUND AND OBJECTIVE: In a retrospective study, we examined the suitability of a departmental clinical protocol for anaesthesia induction with target-controlled infusion of propofol developed for fibreoptic intubation in spontaneously breathing patients scheduled for outpatient oral surgery at the dental clinic of the Vienna University Hospital. METHODS: Propofol was administered using target-controlled infusion (Diprifusor) at increasing target plasma concentrations starting at 2.5 microg mL(-1). After 10 min, an intravenous dose of alfentanil (5-10 microg kg(-1)) was given for pain reduction. After a further 2 min, the patient was evaluated for response to auditory stimulation. If unresponsive, fibreoptic intubation was performed, otherwise the target concentration was increased by 0.2 microg mL(-1) every 2 min until non-responsiveness was attained. RESULTS: Tracheal intubation was successful in all patients without any haemodynamic instability. However, one patient required facemask ventilation for 2 min. No patient was aware of intubation. The plasma concentration required for non-responsiveness was 2.8 +/- 0.4 microg mL(-1) (mean +/- SD). CONCLUSIONS: When using a target-controlled infusion of propofol, fibreoptic intubation can be performed with complete amnesia of the procedure for the patient. However, assisted ventilation of the lungs may be necessary as spontaneous ventilation may cease.

Recollection of dreams after short general anaesthesia: influence on patient anxiety and satisfaction.

BACKGROUND AND OBJECTIVE: We ascertained whether dreams during short general anaesthesia influence subsequent patient satisfaction and anxiety. METHODS: Fifty female patients were randomized into two groups to test for a difference between intravenous and inhalational anaesthesias. In Group Propo, anaesthesia was induced and maintained with propofol; in Group Metho-Iso, anaesthesia was induced with methohexital and maintained with isoflurane. Satisfaction and anxiety with anaesthesia were evaluated using a visual analogue scale from 0 to 100. Dream incidence rate, satisfaction and anxiety were assessed from immediately after waking until 3 months later. RESULTS: Seventeen patients (34%) dreamed during anaesthesia. There were no significant differences in satisfaction or anxiety after anaesthesia between the dreaming and non-dreaming patients (satisfaction, 92.3 +/- 21.6 versus 92.1 +/- 21.6; anxiety, 21.1 +/- 21.1 versus 30.3 +/- 32.1), or between Group Propo and Group Metho-Iso (satisfaction, 94.4 +/- 19.3 versus 90.0 +/- 23.4; anxiety, 26.0 +/- 27.6 versus 28.4 +/- 30.7). There was no significant difference in the incidence rate of dreaming with the type of anaesthesia used (Group Propo, 11 patients; Group Metho-Iso, 6 patients). CONCLUSIONS: Dreaming during general anaesthesia is common but does not influence satisfaction or anxiety after anaesthesia.

Postoperative pain and subcutaneous oxygen tension.

Surgical patients randomly assigned to standard pain control had postoperative subcutaneous oxygen partial pressures that were significantly less than patients given better pain treatment. Our data suggest that control of postoperative pain is a major determinant of surgical-wound infection and should be given the same consideration as maintaining adequate vascular volume and normothermia.

Severe pneumothorax after intercostal nerve blockade. A case report.

BACKGROUND: Intercostal nerve blockade is recognized as an efficient and safe regional anesthetic technique. Although an appropriate technique was applied, we report a severe pneumothorax associated with this type of regional anesthesia. METHODS: A 57-year-old female patient underwent block of intercostal nerves 3 to 8 for interstitial radiotherapy of the left breast in the sitting position. Calcified residual foci in the right upper lobe from a previous primary infection of tuberculosis were diagnosed by preoperative x-ray. After completion of the blocks in the midline of the axilla, the patient complained of pain between the scapulas, developed severe dyspnea and panic, and felt as if her life was in jeopardy. A severe pneumothorax was diagnosed and a chest tube was placed. After the application of the chest tube, the patient recovered quickly. CONCLUSION: Extra caution should be used in applying this procedure to patients with underlying chronic lung disease, especially on the opposite side. Our case demonstrates that in all patients undergoing intercostal nerve blockade preference should be given to the approach at the dorsal angulation of the rib in the lateral or prone position due to its lower risk of pneumothorax.

[Risk and procedure education in anesthesiology. Overview of Austrian and German legal regulations]. / Risko- und Verlaufsaufklärung in der Anäthesiologie. Ubersicht über die Osterreichische und Deutsche Judikatur.

Informed consent is currently an ethical, medical and legal requirement. An increase in public discussion of real or supposed malpractice has led to critical attitude in patients and increased demands on informed consent by the courts. Unfortunately, the legal requirements of informed consent have developed from atypical situations involving dissatisfied and injured patients rather than from the more usual occurrences of physicians helping patients with subsequent patient satisfaction. In addition, laws have not set forth clear guidelines for physicians to follow. We review the elements of informed consent based on current Austrian and German jurisdiction in the particular field of anesthesiology and summarize the legal and medical realities in order to point out specific criteria for decision making.

Arterial blood pressure after human cardiac arrest and neurological recovery.

BACKGROUND AND PURPOSE: In animal cardiac arrest studies, outcome has been improved by inducing arterial hypertension early after return of spontaneous circulation. The aim of our study was to evaluate whether arterial blood pressure within the first minutes and hours after return of spontaneous circulation influences neurological recovery in human cardiac arrest survivors. METHODS: Of 136 retrospectively evaluated patients after sudden cardiac death, two groups were defined: group 1, mean arterial blood pressure (MABP) within 5 minutes after return of spontaneous circulation above 100 mm Hg; group 2, MABP of 100 mm Hg or less. Thereafter MABP was measured every 5 minutes until 2 hours after return of spontaneous circulation. The groups were compared in regard to age, sex, in/out of hospital, witnessed/not witnessed, first electrocardiographic rhythm, time from cardiac arrest to beginning of life support and to return of spontaneous circulation, cumulative epinephrine dose administered, and best neurological outcome within 6 months. RESULTS: In group 1 (n = 54) good neurological recovery was observed in 63% and in group 2 (n = 82) in 55% (chi 2 = 0.87, P = NS). Both groups exhibited comparable baseline values except that time intervals from beginning of life support to return of spontaneous circulation were shorter in group 1. After we controlled for this difference with Spearman's partial rank correlation (rs), there was no association between MABP measured within the first 5 minutes and outcome (rs = -.023; P = NS). Good neurological recovery was independently and directly related to MABP measured during 2 hours after return of spontaneous circulation (rs = .26; P < .01). CONCLUSIONS: In human cardiac arrest survivors, good functional neurological recovery was independently and positively associated with arterial blood pressure during the first 2 hours after human cardiac arrest but not with hypertensive reperfusion within the first minutes after return of spontaneous circulation.