Pleural bupivacaine for pain treatment after nephrectomy.

UNLABELLED: The efficacy of pleural analgesia after nephrectomy is controversial. We therefore evaluated i.v. opioid requirements in patients with and without pleural bupivacaine. Patients undergoing elective nephrectomy were randomly assigned to receive postoperative i.v. piritramid alone (n = 18) or piritramid combined with pleural bupivacaine (n = 19). In the patients assigned to receive pleural analgesia, boluses of 20 mL of 0.25% bupivacaine were given at 6-h intervals via an pleural catheter that was inserted in the medial axillary line at the sixth intercostal space. Pain scores (10-cm visual analog scale) and opioid requirements were recorded over the first 2 postoperative days. One hour after pleural puncture, a chest radiograph was performed. The catheter was removed 48 h after insertion. Patient characteristics were similar in each group, as was the duration of surgery. Pain scores were similar in each group: 3.0 +/- 2.5 in those given pleural bupivacaine and 3.1 +/- 2.7 in those given piritramid alone. However, the piritramid requirement was significantly less in those given pleural bupivacaine (23 +/- 3 mg) than in those given piritramid alone (45 +/- 6 mg). Furthermore, the time from completion of surgery until the first opioid request was significantly longer in the patients who received bupivacaine (4.7 +/- 1.0 vs 2.8 +/- 1.0 h). One patient had a small pneumothorax that resolved without treatment. These data indicate that pleural analgesia is effective and provides a significant opioid-sparing effect. IMPLICATIONS: We conclude that pleural analgesia significantly prolongs the time until postoperative opioid was first requested and halves the total required dose. These data indicate that pleural analgesia is effective and provides a significant opioid-sparing effect.

[Definition and evaluation of a documentation standard for intensive care medicine: the ASDI(Working Group for Standardization of a documentation system for Intensive care medicine) pilot project]. / Definition und Evaluation eines Dokumentationsstandards für Intensivmedizin: Das ASDI-Pilotprojekt.

OBJECTIVES: A comparison of data from different intensive care units (ICUs) needs standardized documentation. In this study the ASDI documentation standard for intensive care was tested in clinical practice. Goal of the study was to evaluate parameters and functionality required for a national, interdisciplinary documentation system for intensive care. DESIGN: 13 ICUs participated in a 4-week trial using the provided program for documentation of all admitted patients during the observation period. In addition, a questionnaire was distributed to the unit coordinators. RESULTS: 376 patients were documented in 1591 patient days. Valid SAPS II scores were found in only 29% of the discharged patients (39.1 +/- 15.5 points). Time needed for data entry exceeded preset limits (ten minutes per patient and day) in 38% of the cases. All participants affirmed the necessity of a documentation standard for intensive care, giving quality control and cost analysis as the most important reasons. CONCLUSION: The ASDI data set fitted existing needs very closely. Only 7 out of 122 parameters (5.7%) were found to be superfluous and thus removed. Measures to reduce documentation effort to the default limits were a) a new, date orientated concept for manual recording, b) rede-sign of the user interface with new, user friendly data entry possibilities, and c) the integration of statistical analysis and reports in the documentation system. The revised data set represents a broad-based consensus, which seems to be well-suited as foundation for the national quality assurance program.

Isoflurane narcotherapy in depressive patients refractory to conventional antidepressant drug treatment. A double-blind comparison with electroconvulsive treatment.

This is the first report on a controlled study comparing the therapeutic and non-therapeutic (side) effects of electroconvulsive treatment (ECT) and isoflurane narcotherapy (ISONAR; deep anesthesias with the inhalation of anesthetic isoflurane) in drug-refractory, severely depressed women, who had been randomly allocated either to ECT (n = 10) or ISONAR (n = 10). Patients from each group were subjected to a total of six treatment sessions (two sessions per week) and maintained on a fixed antidepressant drug dose. The antidepressant efficacy of either treatment was evaluated for each treatment session (in search of a 'rapid antidepressant effect') and at weekly intervals. Cognitive functions or signs of an organic brain syndrome were evaluated by means of psychological tests and extensive EEG analyses. Rapid antidepressant effects of the first treatment session were only significant in patients on ISONAR; in the subsequent treatment sessions, ECT also induced rapid antidepressant effects. Antidepressant effects during the treatment period were comparable, and patients on ISONAR improved further during follow-up, whereas patients on ECT tended to relapse. ISONAR-treated patients improved in most psychometric variables, whereas patients on ECT deteriorated. Finally, the EEG patterns of the ISONAR-treated patients remained normal or augmented (dominant alpha power), whereas patients on ECT developed an increase in abnormalities in EEG patterns and theta/delta power. This indicates an organic brain syndrome in patients on ECT.

[Remote artificial respiration and anesthesia in nuclear magnetic resonance imaging]. / Patientenferne Beatmung und Narkose bei der Kernspintomographie.

Ferromagnetic equipment and equipment driven by alternate current cannot be used close to patients undergoing magnetic resonance imaging. Therefore, we tested a ventilator (Siemens Servo 900-D) that was placed more than 7 m away from the patient (outside the magnetic influence of 1.5 teslas) using tubing measuring 9 m in length. Tubing for children above the age of 8 and adults had a width of 22 mm; for neonates and children up to the age of 8 the width was 10 mm. Since the compressed air in such long tubes must be taken into consideration, we plotted nomograms for children and adults that helped to estimate respiratory minute volume including the compressed volume and a table to read the volume of compressed air that has to be added to respiratory volumes already established for ventilated patients from the ICU. In eight patients aged 7 weeks to 56 years (4 to 75 kg body wt.), capnography and blood gases showed that the nomograms were sufficiently accurate to allow safe ventilation. To improve safety, remote monitoring is recommended using long tubing or lines for oscillometric blood pressure measurement, capnography, and pulse oximetry as well as telemetric ECG.

Fetal kidney volume and urine production in cases of fetal growth retardation.

The amount of amniotic fluid has a close correlation to the function of the fetal renal system. In many cases of fetal growth retardation oligohydramnios is obvious. The aim of this study is the investigation of the hourly fetal urine production rate (HFUPR) and the growth of fetal kidneys during pregnancy in cases of fetal growth retardation and to evaluate the renal participation in the origin of oligohydramnios in cases of growth retardation. In 52 healthy pregnancies and 27 cases with known fetal growth retardation, the volume of the fetal kidneys was measured sonographically and the hourly rate of fetal urine production was determined. Two third of the patients with fetal growth retardation had obvious oligohydramnios. In cases of fetal growth retardation the volume of the fetal kidneys was significantly smaller when compared to the control group, and the volume of fetal urine production was significantly lower. The reduced perfusion of the fetal kidneys in those cases with fetal growth retardation may be the reason for the reduction of the HFUPR. Due to the fact that HFUPR is a dynamical parameter and in close relationship to the perfusion of the fetal kidneys, the identification and measurement of this parameter may help to detect subacute and imminent fetal distress in cases of sonographically proven fetal growth retardation.

Prostaglandin metabolism in umbilical vessels of smoking and non-smoking mothers.

Arachidonic acid (AA) and its metabolites are responsible for the regulation of the umbilical blood flow. We investigated the prostaglandin (PG) synthesis in umbilical arteries and veins of 16 smoking and 17 non-smoking mothers. AA and PGs were analyzed after extraction of samples by means of thin layer chromatography (TLC). Of all the AA metabolites in umbilical arteries and veins, prostacyclin reached the highest concentration. In non-smoking mothers the conversion rate of AA in arteries and veins was similar. The only exception was PGE2 which showed a significantly lower concentration in umbilical veins of smoking mothers. However, the influence of PGE2 on the blood flow of umbilical arteries and veins seems to be of minor importance compared to other vessels.

Pregnancy-specific parameters in early pregnancies after in vitro fertilization: prediction of the course of pregnancy.

The plasma concentrations of the beta subunit of human chorionic gonadotropin (beta-hCG), pregnancy-specific glycoprotein, and progesterone were measured in 37 pregnancies after in vitro fertilization. Twenty-one pregnancies ended with delivery, 9 as clinical abortions, and 7 as biochemical abortions. To predict the pregnancy outcome as early as possible, we designed a prediction graph by calculating a "cutoff line" using discriminant analysis and prediction bands up to 95% probability. This prediction graph can help in the estimation of the probability of pregnancy outcome with satisfactory reliability by determination of beta-hCG only.

Effects of epidural analgesia on plasma catecholamines and cortisol in parturition.

To assess the effect of epidural block on plasma catecholamines and cortisol during labour and delivery, plasma epinephrine, norepinephrine and cortisol levels were determined in 26 healthy parturients, all of whom delivered vaginally (18 received an epidural block, eight had meperidine 50 mg intramuscularly). We found a significant drop of plasma epinephrine and cortisol and no significant reduction of plasma norepinephrine 1 h after administration of epidural block compared to preblock values. Observing the data during the whole course of labour in correlation with cervical dilatation, in the control group, where the parturients received meperidine, all hormones rose progressively up to the moment of delivery. One hour after delivery the catecholamines returned to normal levels; cortisol returned more slowly. In the epidural group the increase of plasma epinephrine and cortisol was significantly inhibited but not that of norepinephrine.

Rapid psychotherapeutic effects of anesthesia with isoflurane (ES narcotherapy) in treatment-refractory depressed patients.

Treatment-refractory depressed patients who objected to electroconvulsive therapy (ECT) were given a series of anesthesias with isoflurane (Forane), a modern and established inhalation anesthetic. According to our hypothesis to be tested, the brief period of electrocerebral silence (ES), which can be observed shortly after the grand mal seizure in ECT, may be in itself a crucial biological determinant for the therapeutic effects of ECT. Isoflurane is the only drug known to effect an ES in the EEG in nontoxic concentrations, which does not result in adverse effects on any body organ including the brain; no seizure activity can be observed. Eleven depressed patients received a total of 36 anesthesias with isoflurane (ES narcotherapy). Rapid antidepressant effects were observed in 9 patients (p less than 0.0001). Effects were reproducible and lasted up to several weeks. No adverse effects of anesthesia were noticed.

[Correlation of psychological changes and spermiogram improvements following acupuncture]. / Korrelation psychischer Veränderungen und Spermiogrammverbesserungen nch Akupunktur.

The purpose of the study was to find the correlation between the effect of acupuncture on fertility and psychological effects. To investigate its influence on male subfertility, 28 patients received acupuncture treatment after informed consent. We evaluated subjective parameters by written psychological tests, while objective parameters consisted of measuring concentration, volume and motility in the spermiogram before and after acupuncture. There was a significant increase in sperm quality in all parameters but volume. The psychological test showed no change caused by acupuncture. Hence, we believe, that the effect of acupuncture on sperm quality is not caused by placebo-mechanisms.

[Modification of semen quality by acupuncture in subfertile males]. / Die Beeinflussbarkeit der Samenqualität durch Akupunktur bei subfertilen Männern.

Our first attempt in treating subfertility by acupuncture was carried out on 28 males. The results obtained from the experiences in veterinary medicine encouraged us to attempt this type of therapy. Each patient received a total of 10 treatments for a period of three weeks. Several spermiograms were made after diagnosis subfertility. We checked spermiograms and hormone levels before and after acupuncture. Total count, concentration and motility were evaluated. In all cases we observed a statistically significant improvement of sperm quality. Having obtained these good results in our first studies, we now intend to continue acupuncture therapy in subfertile males for insemination or intercourse at the time of the ovulation of their female partners.

[The RACZ-epidural catheter. First clinical experiences]. / Der RACZ-Epiduralkatheter. Erste klinische Erfahrungen.

We tested a new epidural catheter, which is made of a stainless steel spiral (similar to an anode endotracheal tube) covered with a fluorpolymer. This catheter was tested in 15 patients who were administered lumbar epidural anaesthesia for pain relief during labor. We also have information on the evaluation of this catheter in about 100 patients from the obstetric anesthesia service, Stanford-University Medical Center. The main advantage of this catheter is, that it does not kink. The disadvantages are: 1. catheter leakage either at the skin interface or just below the injection port particular after prolonged usage, 2. difficult or impossible injection if the catheter injection port is screwed on too tight which requires cutting the catheter (not recommended by the manufacturer), 3. a 17 gauge rather than a 18 gauge epidural needle is recommended and 4. the high price of the catheter.

[Problems of anesthesia for cesarean section in myasthenia gravis]. / Probleme der Sectionarkose bei Myasthenia gravis.

The case of a 27 year old female, being pregnant the second time and suffering from myasthenia gravis since 1974 is reported. The patient was admitted to the hospital for repeat caesarian section. Anaesthesia of the preoxygenated patient during caesarian section was induced with 0.5% halothane and ketamine (2 mg/kg b.w.) intravenously. Muscle relaxing drugs (competitive and depolarizing inhibitors) as well as morphine derivates (e.g. fentanyl) and barbiturates are contraindicated. Therefore anaesthesia was maintained with 0.2:N2O = 1:1 combined with 0.5% halothane up to the point of ligation of the umbilical cord, and up to 1.5% halothane thereafter. Intubation was performed without muscle relaxation. The postoperative somnolence frequently seen after the combined use of ketamine and halothane was antagonized with physostigmine salicylate. The newborn showed all signs of neonatal myasthenia.

Influence of laparoscopic follicular aspiration under general anaesthesia on corpus luteum progesterone secretion in normal and clomiphene-stimulated cycles.

In 32 patients with unstimulated normal cycles and 24 with cycles stimulated with clomiphene and human chorionic gonadotrophin (hCG) all visible follicles were punctured laparoscopically under general anaesthesia for the purpose of in vitro fertilization. In unstimulated cycles the time of surgery was between 24 and 32 h after the first luteinizing hormone (LH) increase in the urine; in the cycles stimulated with hCG (5000 i.u.) laparoscopy was between 35 and 37 h after injection. Blood samples for progesterone determination were taken about 7 days later. Progesterone levels were compared with those in a control group not subjected to surgery, in which the progesterone levels were determined 7 days after the LH increase. There was no statistically significant difference in the progesterone levels in the unstimulated subjects after laparoscopy compared with those in the control subjects but progesterone levels in the stimulated subjects were significantly higher (p less than 0.01). Durations of the luteal phases showed no significant differences thus laparoscopy under general anaesthesia does not impair luteal function.

[Physostigmine and reversal of anticholinergic effects of neurolept-anaesthesia (author's transl)]. / Physostigmin als Antagonist der anticholinergen Depression nach Neuroleptanästhesie.

After 486 gynaecological procedures performed under neuroleptanaesthesia 32 patients remained irresponsive despite naloxone reversal of possible fentanyl overdose and exclusion by peripheral nerve stimulation of prolonged neuromuscular blockade. By random selection 18 of these (group A) received physostigmine 2 mg, 14 patients (group B) served as controls. Groups were comparable concerning age, technique and duration of anaesthesia, total doses of anaesthetics and muscle relaxants. Patients in group A were fully responsive within 9 +/- 4,6 min. after physostigmine, patients without this drug (group B) however within 49 +/- 19 min. This difference was highly significant (P less than 0,001).

[The influence of oxygen and bicarbonate administration to the parturient on maternal and fetal blood gases and acid base balance (author's transl)]. / Der Einfluss der Verabreichung von Sauerstoff und Natriumbikarbonat an Gebärende auf die Blutgas- und pH-Werte von Mutter und Fetus.

The effects of oxygen and bicarbonate administration to parturients were studied by analysis of maternal and fetal blood gas parameters. Oxygen inhalation resulted in a significant increase of the fetal pO2 and appears to be a practicable mean of intrauterine reanimation of hypoxic fetuses. Intravenous bicarbonate was unable to raise the fetal pH. Simultaneous bicarbonate and oxygen administration had no desirable effects on the fetal acid-base-balance.