[Cis-atracurium--an equivalent substitution for atracurium in pediatric anesthesia?]. / Cis-Atracurium--Ein gleichwertiger Ersatz für Atracurium in der Kinderanästhesie?

Cis-atracurium is a stereoisomer of atracurium, about five times more potent than the racemate. Whereas cis-atracurium is routinely used in adults, its effects on children are still poorly defined. We compared equipotent doses of atracurium and cis-atracurium in children aged between 2 and 12 years regarding the quality of neuromuscular blockade, the intubation conditions and the occurrence of side-effects. After approval by the ethics committee and with informed parental consent, 84 children (ASA I or ASA II) were randomly allocated to receive either 0.5 mg/kg atracurium (group A, n = 42) or 0.1 mg/kg cis-atracurium (group C, n = 42). In both groups anaesthesia was induced with 15 micrograms/kg alfentanil and 5-7 mg/kg thiopentone. We assessed the intubation conditions according to the Krieg Scale. Anaesthesia was maintained with a nitrous oxide/oxygen mixture of 2:1 and isoflurane in an endexpiratory concentration of approximately 0.6 Vol.%. Neuromuscular blockade was controlled acceleromyographically in response to supramaximal stimulation of the ulnar nerve. We measured the onset time (T1 = 5%), duration of effect (T1 = 25%), recovery index (T1 = 25%-75%) and the recovery time at a train-of-four-ratio (T4/T1) of 0.7. These parameters did not show any significant differences between group A and group C: onset time: 3.1 +/- 1.5 min (group A) versus 3.4 +/- 1.1 min (group C), duration of effect: 34.1 +/- 5.5 min (group A) versus 34.1 +/- 6.5 min (group C), recovery index: 9.3 +/- 3.3 min (group A) versus 9.6 +/- 2.5 min (group C), recovery time at a TOF-ratio of 0.7:49.3 +/- 8.4 min (group A) versus 52.3 +/- 6.6 min (group C). In group A, the intubation conditions were "excellent" or "good" in 98% of the patients, whereas in group C the figure was only 69%. Regarding side-effects, we found significantly more frequent urticaria in group A (6 of the 42 patients) (p < or = 0.05) than in group C, in which no patient showed urticaria. Flush and tachycardia occurred much less frequently and there were no significant differences in the two groups: two patients in group A and only one in group C. The authors conclude that atracurium and cis-atracurium lead to comparable neuromuscular effects in children aged between 2 and 12 years. Only the intubation conditions were better after atracurium, but atracurium was followed by urticaria more often than cis-atracurium.

[Postoperative epidural analgesia--current status, indications and management]. / Postoperative Epiduralanalgesie--Stellenwert, Indikationen und Management.

We are reporting on postoperative pain treatment using epidural analgesia in 1,822 patients, performed between 1995 to 2000, following continuous epidural anaesthesia combined with general anaesthesia for operations in various specialized areas (general or visceral surgery, vascular and thoraxic surgery, gynaecology, urology and orthopaedics). A total of 1,727 of these postoperative epidurals were included in a detailed evaluation. The postoperative epidural analgesia consisted of a continuous application of 0.25% bupivacain or 0.2% ropivacain. These local anaesthetics were administered epidurally in an hourly perfusion rate of 7.5 ml. We found "good" pain relief through continuous epidural administering of the local anaesthetics in 1,292 patients (74.8%). "Moderate" pain relief was achieved in 392 patients (22.7%). Sufentanil had to be epidurally administered in addition to local anaesthetics in 262 patients (15.2%) in the wake-up room. The sufentanil doses lay between 5 and a maximum 10 micrograms per hour. An additional epidural application of morphine-boli in a dose of 3 mg every 8-12 hours was necessary in 384 patients (22.2%) in the surgical wake-up stations. In 392 patients (22.7%), the additional systemic administering of antipyretic analgesics such as metamizol or paracetamol or spasmolytica was sufficient. In 43 cases (2.5%), sufficient pain relief could not be achieved with epidural analgesia even with additive applications of systemic functioning pharmaceuticals, so that the postoperative pain therapy had to be completely switched to a PCA. The lying time of the epidural catheter was 2-5 days. It was shortest with the gynaecological patients and longest with patients from general, visceral, thoraxic and vascular surgery areas. An important factor for a sufficient epidural analgesia is the exact epidural positioning of the catheter tip in the area of the spinal cord segments, which are affected by the operation. This reveals the required puncture height. The following side-effects resulting from the epidural analgesia were found: blood pressure loss of more than 20% of the starting value (21%), temporary bladder voiding disorders (8%), temporary sensory disorders of the lower extremities (6.5%), seldom nausea (2.4%) and post-puncture headaches (1.2%). The most important prerequisites for successful postoperative epidural analgesia and thus for increased patient satisfaction are correct selection of the insertion height in relation to the planned operation, constantly available medical pain service, the inclusion of trained care personnel and unequivocal written instructions.

[Direct autotransfusion systems deliver blood of inadequate quality]. / Direkte Autotransfusionssysteme liefern Blut unzureichender Qualität.

OBJECTIVE: Systems for direct retransfusion of blood salvaged from the surgical field and in drainage systems (direct autotransfusion) have been in use for many years. The quality of the blood obtained with such systems, however, has not been systemically assessed in a comparative manner. The aim of our study was the analysis of the quality of the blood, obtained with three commercially available direct autotransfusion systems (drainage systems with filters). METHODS: With ethics committee approval and informed consent, 30 patients receiving knee arthroplasty were randomly allocated to three groups. Each group of 10 patients received treatment with one drainage system (Consta Vac, Solcotrans, Haem-o-Trans). In the salvaged blood, we measured cellular elements, variables of coagulation and fibrinolysis, complement activation and cellular elements, both before and after passage of the autotransfusion system. RESULTS: Analysis revealed a low haematokrit (< 30%) and platelet count (< 80 Gpt/l). The salvaged blood proved uncoagulable and defibrinised with no measurable clotting and fibrinogen; clotting activity, fibrinolysis and complement reaction were grossly induced (TAT, PAP and FDP high, C3 low). The blood was contaminated with cellular debris reflected by concentration of enzymes usually confined to the intracellular space (LDH, elastase, beta-thromboglobulin). CONCLUSION: The systems/filters assessed in this study do not improve quality of blood drained from the surgical field. Retransfusion of such blood can not be recommended.

Blood separation with two different autotransfusion devices: effects on blood cell quality and coagulation variables.

The quality of blood products obtained from two different autotransfusion devices (CATS- Fresenius and Sequestra 1000 - Medtronic) was tested in 27 patients undergoing elective orthopaedic surgery. Blood products provided from our institutional blood bank (n = 16) served as controls. Hemodiluted blood was separated into platelet poor plasma (PPP), platelet rich plasma (PRP), and packed red cells (PRC) and analysed for blood cell count, fibrinogen concentration, thromboplastin time, partial thromboplastin time, platelet aggregation and platelet recovery rate. Coagulation variables showed no differences between the CATS-group (n = 14) and the Sequestra 1000-group (n = 13). The volume of PRP was lower in the Sequestra 1000-group (45+/-3 ml vs. 89+/-1 ml, p<0.05), but hematocrit was higher (14.4+/-7.8% vs. 8.5+/-2.8%, p<0.05). PPP produced with CATS contained a higher concentration of white blood cells (0.6+/-0.2 Gpt/l vs. 0.1+/-0.01 Gpt/l, p<0.05) and thrombocytes (163+/-74 Gpt/l vs. 11+/-12 Gpt/l, p<0.05). Hematocrit of PRC was significantly higher in the CATS-group (73.8+/-2.0% vs. 69.0+/-6.5%, p<0.05). Blood products were of high quality in both groups and comparable to or superior than blood products provided from our institutional blood bank.

[Opioid peptides in hemorrhagic shock]. / Opioidpeptide im hämorrhagischen Schock.

Regarding the treatment of vitally endangered intensive care patients the neuroendocrine regulation of the post-aggression metabolism is important. The role of opioid peptides in this system is investigated in the animal experiment "Haemorrhagic Shock in the Dog". It was shown that the opioid peptide beta-endorphin and metenkephalin rise grossly in connection with pathological and endocrinological alterations in shock. Based on the literature the role of increased concentration of opioids in haemorrhagic shock is discussed and conclusions for therapeutic measures are presented.

Argyrophil and beta-endorphin immunoreactive cells in focal islet-cell adenomatosis and insulin-producing islet-cell adenomata.

Pancreatic tissue from 3 cases of hyperinsulinemic hypoglycemia was examined using histochemical and immunoperoxidase staining techniques. The insular lesions present were adenomatosis and insulin-producing islet-cell adenomata. The great majority of the islet parenchymal cells in these lesions were reactive with antibodies to pro-insulin, C-peptide, and insulin. A variable number of islet cells was found to react with beta-endorphin antiserum in all 3 cases, while the reaction with antiserum against the neural tissue marker antigen, S-100, was restricted to the cases with islet-cell adenoma. Argyrophil parenchymal cells were present in focal adenomatosis but almost absent in insulomata. These results suggest that various lesions of the endocrine pancreas causing hypoglycemia can be distinguished by means of specific histo- and immunocytochemical methods because of differences in the distribution of characteristic cellular antigens.