[Pain in children and adolescents in Germany: the prevalence and usage of medical services. Results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS)]. / Schmerzen bei Kindern und Jugendlichen in Deutschland: Prävalenz und Inanspruchnahme medizinischer Leistungen. Ergebnisse des Kinder- und Jugendgesundheitssurveys (KiGGS).

As part of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), representative data were collected on pain in 14,959 children and adolescents aged 3 to 17 years in Germany. The results are reported separately for 11-17-year olds, who were asked themselves, and 3-10 year olds, whose parents reported on their pain. Among the 3-10 year olds, the prevalence of pain over three months was 64.5% and among the 11-17 year olds it was 77.6% (71.1% altogether for the 3-17 year old children). Pain prevalence increased significantly with age; in all age groups girls reported pain significantly more often than boys of the same age. In the 3-10 year olds the most common pain localisation was stomach pains, followed by pain in the head and throat. Children and adolescents aged 11 to 17 most often reported headaches, followed by pains in the stomach and back. Pain occurring at least once a week in the last three months was reported by 24.3% of the 11-17 year old children and adolescents and by 9.9% of the 3-10 year old children suffering from pain. More than half (54.1%) of the 3-10 year olds and more than one third of the 11-17 year olds (35.9%) who reported recurrent principal pain consulted a doctor for this reason; 36.7% and 46.7% respectively took medicine. These results show that pain is a relevant problem in children and adolescents in Germany.

[Risk factors for back pain in children and adolescents]. / Risikofaktoren für Rückenschmerzen bei Kindern und Jugendlichen in Industrienationen.

Factors that have led to the increasing prevalence of back pain amongst children and adolescents living in industrialized nations are mostly unknown. The following literature review was aimed at determining the risk factors for back pain amongst children and adolescents. We searched both PUBMED and MEDLINE between the years 1985 and 2003 for the keywords "children or adolescents" and "back pain". Only data published in original articles were used. The risk for suffering back pain is influenced by physical, behavioural, emotional and social factors. The effects of physical activity, sitting, muscle status, weight of schoolbags, exercise, television and computer use, as well as age and gender on the development of back pain in children and adolescents were examined. Associations between continuous or recurring back pain and psychosocial factors (lifestyle, emotional factors, social relationships) could be demonstrated. There was no relationship between changes of the spine seen by radiological tests and the development of chronic back pain. Longitudinal epidemiological studies are urgently needed to delineate the risk factors for the development as well as the natural history of chronic back pain in the young.

Reports of pain among German children and adolescents: an epidemiological study.

AIM: The aim of this study was to investigate the prevalence of pain and characteristics of pain (frequency, duration, intensity) among children and adolescents and to compare them across different age and gender groups. METHODS: 735 children and adolescents aged 10-18 y from schools in the Luebeck region of Germany were surveyed using a modified German version of the self-completion pain questionnaire of Perquin and co-workers. RESULTS: 715 out of 735 questionnaires (97.3%) were returned completed. Pain during the preceding 3 mo was reported by 85.3% (n = 610) of the respondent children and adolescents. The prevalence of pain increased with age. The most common complaints were headache (65.6%), abdominal pain (47.7%), limb pain (46.4%) and back pain (38.6%). A pain duration of longer than 3 mo was reported by 45.5% (35.4% for longer than 6 mo). Pain once a week or more frequently was reported by 33.7% of children and adolescents. CONCLUSION: Almost half of the surveyed children and adolescents had suffered complaints for longer than 3 mo. The experience of pain in general and especially pain with a duration of longer than 3 mo is very common in children and adolescents, and requires further attention. Further studies are necessary to investigate the natural course, functional implications and prognosis due to pain complaints in children and adolescents.

[Pain in children and adolescents--results of an exploratory epidemiological study]. / Schmerzen bei Kindern und Jugendlichen--Ergebnisse einer explorativen epidemiologischen Studie.

AIM OF THE STUDY: The objective of this exploratory study was to examine the prevalence of overall pain generally and combinations of different pain locations, as well as their location, intensity, and duration in children and adolescents. METHODS: After consent was granted by the local ethical committee and the Ministry for Education, Research, Science and Culture, modified versions of the structured pain questionnaire of Perquin et al. were submitted to 1077 parents, children,and adolescents in the Lübeck region of Germany. Of the 1077 questionnaires distributed, 1030 were returned (95.6%), and 991 of the 1030 questionnaires (96.2%) could be included in the analysis. RESULTS: The prevalence of overall pain during the preceding 3 months was 80.1%, while the prevalence of pain in more than one region of the body during the preceding 3 months was 66.3%. Of the children and adolescents, 57% had headaches, 43.2% suffered from abdominal pain, 41.6% had limb pain, 32.9% had back pain, and 30% suffered from sore throats during the previous 3 months. A total of 30.7% of the children and adolescents with pain reported that the pain had already lasted for more than 6 months. CONCLUSIONS: Pain in general is very frequent in children and adolescents. Further studies are required to investigate chronic pain in children and adolescents.

Development and evaluation of a video program for presentation prior to elective cardiac surgery.

BACKGROUND: : The objective of the present study was to develop and evaluate the effects of a preparatory videotape on endocrine stress responses of patients prior to cardiac surgery and to analyze patient acceptance of this video for preoperative preparation. METHODS: : 101 male patients prior to elective cardiac surgery were enrolled into the study. On the day before surgery, patients were assigned to one of the following groups: group 1 (n = 51) saw a video with realistic information about the upcoming perioperative procedure, and group 2 (n = 50) saw a video of the same length without surgery-related information. Venous blood was sampled before and 15 min after the video presentation. On the second postoperative day, patients filled in a questionnaire concerning their experiences of having preoperatively watched the video. RESULTS: : After viewing the video, blood levels of cortisol, adrenocorticotropic hormone (ACTH), beta-endorphin, prolactin, epinephrine and norepinephrine in patients of group 1 were not significantly different compared to values measured before the video presentation. In patients of group 2, blood levels of cortisol, ACTH, prolactin and norepinephrine were significantly lower after video presentation compared to values obtained before the video. Patients of group 1 (compared to group 2) were significantly more often of the opinion that the video had helped in the preparation for surgery, and that they would like to repeat this adjunct preoperative video preparation in another similar situation. CONCLUSION: : We conclude from our results that (i); cardiac surgical patients prefer preoperatively an adjunct surgery-related video preparation to a non-specific video presentation, and that (ii); preoperative preparation with realistic information about the upcoming medical procedure in patients undergoing cardiac surgery does not lead to an increase in endocrine stress hormone levels.

[Assessment of pain in The Child and Adolescent Health Survey]. / Die Erfassung von Schmerz in einem Kinder- und Jugendgesundheitssurvey.

Until now, there have been no nation-wide studies allowing a reliable estimation of the prevalence of pain in children and adolescents in Germany. In addition, data regarding the limitations and use of health care measures were also not available for children and adolescents, as well as data on influential factors that might provide valuable information on the occurrence and persistence of pain in the same epidemiological group. In the part of the survey entitled "Pain", the prevalence of pain generally as well as the features of persistent and/or recurring pain will be studied. An important result of this study shall be the first nation-wide representative figures on the prevalence of pain in general, as well as combinations of various types of pain in children and adolescents. In this way it should provide an up-to-date and representative data source to answer the following questions: How frequent is pain in children and adolescents? To what extent does pain in afflicted individuals lead to limitations? What kinds of health care measure does the individual who suffers such pain seek (medical consultation, medication)? According to the children (or their parents) or adolescents, what factors are involved in causing pain and allowing it to persist?

Inter-individual differences in cytokine release in patients undergoing cardiac surgery with cardiopulmonary bypass.

Cardiac surgery with cardiopulmonary bypass (CPB) leads to a systemic inflammatory response with secretion of cytokines (e.g. IL-6, TNF-alpha, IL-1 beta and sIL-2R). The objective of the following study was to investigate in vitro and in vivo cytokine responses and white blood cell counts (WBC) of patients with high versus low cytokine secretion after a coronary artery bypass grafting (CABG) procedure. Twenty male patients undergoing elective CABG surgery with CPB under general anaesthesia were enrolled in the study. On the day of surgery (postoperatively), serum levels of TNF-alpha and IL-1 beta were significantly higher in patients of the high IL-6 level group compared to the respective values in the patient group with low IL-6 levels. The inter-individual differences in IL-6 release in patients undergoing CABG surgery with CPB were accompanied by differences in the release of other cytokines, such as TNF-alpha, IL-1 beta and sIL-2R. To understand whether genetic background plays a role in influencing cytokine plasma levels under surgical stress, we examined the distribution of polymorphic elements within the promoter regions of the TNF-alpha and IL-6 genes, and determined their genotype regarding the BAT2 gene and TNF-beta intron polymorphisms. Our preliminary data suggests that regulatory polymorphisms in or near the TNF locus, more precisely the allele set 140/150 of the BAT2 microsatellite marker combined with the G allele at -308 of the TNF-alpha gene, could be one of the genetic constructions providing for a less sensitive response to various stimuli. Our results suggest: (1) close relationships between cytokine release in the postoperative period, and (2) inter-individually varying patterns of cytokine release in patients undergoing CABG surgery with CPB.

Blood levels of atrial natriuretic peptide, endothelin, cortisol and ACTH in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass.

Previous studies demonstrated a biphasic time course with post-operative dissociation of blood levels of cortisol and ACTH in patients undergoing major surgery and critically ill patients. A possible role of endothelin and atrial natriuretic peptide (ANP) in the dissociation of concentrations of cortisol and ACTH in critically ill patients has been suggested. In the present study, we investigated the perioperative course of blood levels of endothelin, ANP, ACTH, and cortisol in 13 male patients undergoing cardiac surgery with cardiopulmonary bypass (CPB): group 1 consisted of 7 patients with an uneventful perioperative period and group 2 consisted of 6 patients with perioperative complications. Blood samples were taken pre-[T1], intra-[T2], post-operatively (on the day of surgery) [T3], as well as on the first [T4] and second [T5] post-operative days. Blood samples of endothelin, ANP, cortisol, and ACTH were measured using commercially available immunoassays. Perioperatively, a biphasic time course with post-operative dissociation of ACTH and cortisol concentrations was observed in all patients studied. Intraoperatively, during CPB, the highest levels of endothelin were found. Perioperatively, ANP and endothelin levels were elevated compared to pre-operative values up to the second post-operative day. On the second post-operative day, ANP concentrations were significantly higher in patients with complications in the perioperative period compared to those with an uneventful perioperative period. Our results suggest that: 1) plasma levels of ANP increased in patients with perioperative complications; 2) plasma levels of ANP may have prognostic value for patients undergoing cardiac surgery; and 3) the dissociation of ACTH and cortisol cannot solely be explained by the increase in endothelin-1 and ANP concentrations observed in patients undergoing major surgery.

Blood levels of corticosteroid-binding globulin, total cortisol and unbound cortisol in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass.

Previous studies have demonstrated a persistent rise in serum cortisol concentrations after cardiac surgery. To further investigate this finding and to evaluate the effect of hemodilution that occurs with the onset of cardiopulmonary bypass (CPB), concentrations of cortisol-binding globulin (CBG), total and unbound cortisol, and packed cell volume (PCV) were studied in 28 patients undergoing coronary artery bypass graft surgery. All patients received a standardized general anesthetic using a balanced technique with sufentanil, isoflurane, and midazolam. Blood was collected preoperatively, intraoperatively during CPB, and postoperatively in the evenings on the day of surgery and on the first and second postoperative day. Cortisol and CBG concentrations were measured by radioimmunoassay and were used to calculate the fraction of unbound cortisol. Serum CBG and cortisol concentrations corrected for hemodilution were significantly higher than non-corrected values. Perioperatively, CBG measurements were significantly intercorrelated. Intraoperatively, total and unbound cortisol concentrations were not significantly increased compared to preoperative values. Postoperatively up to the end of the study period serum concentrations of total and unbound cortisol were significantly increased compared to baseline values. Our results suggest that hemodilution occurs in all patients during cardiac surgery and continues up to the second postoperative day. This may lead to an underestimation of serum cortisol and CBG concentrations in patients undergoing heart surgery with CPB. Intraoperatively, concentrations of total and unbound cortisol were not significantly elevated. The postoperative rise in serum total cortisol concentration was accompanied by an increase in unbound cortisol concentration. The postoperative increase of unbound cortisol concentrations in patients undergoing cardiac surgery with CPB was largely due to an increase in cortisol secretion.

The immune-endocrine interaction varies with the duration of the inflammatory process in cardiac surgery patients.

The present study investigated the perioperative course of cytokine release and hypothalamic-pituitary-adrenal (HPA) axis activation in relation to the duration of the inflammatory response in cardiac surgery patients. Twelve male patients scheduled for elective coronary artery bypass grafting surgery with cardiopulmonary bypass and general anaesthesia were divided into two study groups: group 1 (n=6) underwent surgery at 13.00 h+/-30 min, group 2 (n=6) at 08.30 h+/-50 min. Blood samples were collected preoperatively and up to the first postoperative day. Postoperatively, on the day of surgery, serum concentrations of the proinflammatory cytokines interleukin (IL)-6, IL-1beta and tumour necrosis factor (TNF)-alpha were not significantly different between the two groups, while blood concentrations of cortisol, adrenocorticotrophic hormone (ACTH) and beta-endorphin in group 2 patients were significantly higher than in group 1 patients. Postoperatively, on the day of surgery, ACTH and cortisol concentrations in group 1 patients were positively correlated to the blood concentrations of IL-1beta, IL-6 and TNF-alpha. By contrast, group 2 patients showed no significant relationship between cytokine release and activation of HPA axis at this time. Our results suggest that in patients undergoing cardiac surgery, the cytokine response is initiated before the HPA axis is fully activated. In the early postoperative period, cytokines appear to be involved in the activation of the HPA axis, while in the later postoperative period, high cortisol concentrations may inhibit the release of IL-6.

Perioperative serum levels of tumour-necrosis-factor alpha (TNF-alpha), IL-1 beta, IL-6, IL-10 and soluble IL-2 receptor in patients undergoing cardiac surgery with cardiopulmonary bypass without and with correction for haemodilution.

Cardiac surgery with cardiopulmonary bypass (CPB) leads to a systemic inflammatory response with secretion of cytokines. Alterations in the serum concentrations of cytokines have important prognostic significance. Reports on cytokine release during cardiac surgery with CPB have yielded conflicting results. Haemodilution occurs with the onset of CPB resulting in large fluid shifts during the perioperative course of cardiac procedures. In the present study we compare the perioperative course of serum concentrations of TNF-alpha, IL-1beta, IL-6, IL-10 and sIL-2R with and without correction for haemodilution in patients undergoing coronary artery bypass grafting (CABG) surgery. Twenty male patients undergoing elective CABG surgery with CPB and general anaesthesia using a balanced technique with sufentanil, isoflurane and midazolam were enrolled into the study. Serum levels of TNF-alpha, IL-1beta, IL-6, IL-10 and sIL-2R were measured using commercially available ELISA kits. Simultaneous haematocrit values were obtained at all sample times. Statistical analysis was performed by non-parametric analysis of variance and t-tests for data corrected for haemodilution and data that were not corrected for haemodilution. Adjusted significance level was P < 0.01. Intra-operatively, up to the second post-operative day PCV values were significantly decreased compared with preoperative values. Cytokine measurements not corrected for haemodilution were significantly lower than the corrected values. The perioperative haemodilution and decrease in PCV may lead to an underestimation of the cytokine secretion in post-operative patients. We conclude that cytokine measurements were significantly influenced by the perioperative haemodilution and the subsequent decrease in PCV and may in part account for the varying results reported in the literature regarding cytokine release in patients undergoing CABG surgery.

Irrigation fluid absorption during transurethral resection of the prostate: spinal vs. general anaesthesia.

BACKGROUND: The absorption of irrigation fluid during transurethral resection of the prostate (TURP) is determined primarily by hydrostatic pressure in the bladder and prostatic venous pressure. In comparison to spontaneously breathing patients, patients undergoing mechanical ventilation with positive pressure have a raised central venous pressure and a reduced venous return, both of which can influence intravascular absorption. The purpose of the prospective study was to compare the effects of general (GA) and spinal anaesthetic (SA) techniques on the perioperative absorption of irrigating fluid in patients undergoing TURP. METHODS: Forty patients undergoing TURP were randomised and assigned either to group GA or SA. Irrigating fluid absorption was traced by adding 1.5% (w/v) ethanol to the irrigating fluid. Perioperative blood ethanol concentration (BEC), haemoglobin concentration, haematocrit, serum sodium concentration and central venous pressure (CVP) were measured at 10-min intervals during TURP and at 30-min intervals while patients were recovering. Absorption routes were indexed by the BEC and changes in serum sodium concentrations. Where the BEC was greater than 0.05 mg.mL-1, absorption of irrigating fluid was assumed. For assessing the volume of irrigating fluid absorbed, the maximum BEC, the absorption rate, the area under the BEC curve (AUC), and the volumes calculated according to the Hahn nomogram (Volin) for each patient were taken into consideration. RESULTS: There were 15 cases of irrigating fluid absorption in patients receiving GA (75%), and 11 in those receiving SA (55%). CVP was significantly lower in spontaneously breathing patients with SA as compared to those with GA (P < 0.05). In patients with irrigating fluid absorption the maximum BEC (P < 0.02), as well as the rate of irrigant fluid absorption (P < 0.01), were significantly higher amongst patients receiving SA. In this group, the calculated area under the curve and the absorbed fluid volumes determined with the nomogram were significantly increased (P < 0.05). CONCLUSION: The absorption of irrigation fluid during the TURP is significantly more marked amongst spontaneously breathing patients with regional anaesthesia in comparison to patients undergoing general anaesthesia with positive pressure ventilation. The markedly lower central venous pressure before the start of irrigation should be considered as a possible cause of this effect.

Perioperative cytokine release during coronary artery bypass grafting in patients of different ages.

Surgical interventions and cardiopulmonary bypass (CPB) induce a systemic inflammatory response with cytokine release. Ageing is perceived as a process of impaired immune functions: IL-1beta, IL-6 and tumour necrosis factor-alpha (TNF-alpha) secretion are increased while IL-2 release is reduced in advanced age. At present, little information is available about perioperative immune reactions at different stages of ageing. The aim of the present study was to compare IL-6, IL-1beta, TNF-alpha, IL-10 and soluble IL-2 receptor (sIL-2R) in younger and older patients undergoing cardiac surgery. Male patients (n = 14) undergoing elective coronary artery bypass grafting (CABG) surgery employing CPB with moderate hypothermia were divided into two groups according to their age: group 1 included seven patients < 50 years old, group 2 included seven patients > 65 years old. All patients received general anaesthesia using a balanced technique with sufentanil, isoflurane and midazolam. Blood samples were collected pre-operatively (T1); intra-operatively during CPB (T2); post-operatively on the day of surgery (T3); on the first post-operative day (T4). Blood concentrations of IL-6, IL-1beta, IL-10, TNF-alpha and sIL-2R were measured using commercially available ELISA kits and corrected for plasma cell volume. Statistical analysis was performed by non-parametric analysis of variance and Mann-Whitney U-test. Significance level was set to P<0.05. There were no statistically significant differences in the perioperative release of TNF-alpha, IL-6, IL-1beta, IL-10 and sIL-2R among the two groups. We conclude that the perioperative course of cytokine release in patients undergoing CABG surgery with CPB and comparable perioperative management does not significantly differ in the two age groups.

Persistent endocrine stress response in patients undergoing cardiac surgery.

To investigate the endocrine stress response in patients undergoing major surgery with general anesthesia using a balanced technique with sufentanil, isoflurane and midazolam up to the second postoperative day, blood levels of cortisol, epinephrine, norepinephrine, prolactin and growth hormone were determined in 68 males for elective coronary artery bypass grafting (CABG) surgery. Intraoperatively, during extracorporeal circulation none of the measured parameters were significantly increased compared to preoperative values. The endocrine response of patients with perioperative epinephrine medication (n = 32) was not significant different to patients that did not receive exogenous epinephrine (n = 36). On the evening of the day of surgery, levels of cortisol (3 fold), epinephrine (4.7 fold), norepinephrine (1.7 fold) and growth hormone (16.5 fold) were significantly increased. Compared to preoperative values levels of cortisol (3.3 fold), growth hormone (5.5 fold) and norepinephrine (1.8 fold) remained elevated up to the evening of the second postoperative day. In conclusion, the endocrine stress response in patients undergoing CABG-surgery under general anesthesia with sufentanil, midazolam, isoflurane is intraoperatively prevented by anesthesia. Although hemodilution or hormone degradation might be responsible for the lack of an increase in endocrine parameters during CPB, this study indicates that a balanced technique with isoflurane, sufentanil and midazolam is more effective in blocking the endocrine stress response than previously described anesthetic techniques. In the early postoperative period, a sharp increase in cortisol, epinephrine, norepinephrine and growth hormone occurred suggesting that the predominant endocrine stress response begins in the intensive care unit with end of anesthesia. The postoperative elevated levels of cortisol, growth hormone and norepinephrine indicate a persisting stress-response for more than two days after surgical trauma.

Effects of propofol vs isoflurane on respiratory gas exchange during laparoscopic cholecystectomy.

BACKGROUND: Respiratory function and pulmonary gas exchange are affected in laparoscopic procedures where a pneumoperitoneum is introduced using CO2. Previous studies have shown differing results concerning pulmonary gas exchange during laparoscopic procedures: Whereas in patients undergoing isoflurane anaesthesia decreases in PaO2 are demonstrated, this factor remains unchanged in patients undergoing propofol anaesthesia. In the present study, the effects of propofol on pulmonary gas exchange were compared with those of isoflurane in patients undergoing elective laparoscopic cholecystectomy in a prospective randomised manner. METHODS: Twenty ASA patients with physical status I and II were divided randomly between isoflurane (IG) and propofol groups (PG). After induction of anaesthesia patients were moderately hyperventilated. Respirator settings remained unchanged during pneumoperitoneum (PP) until 10 min after deflation of the peritoneal cavity. Blood gas analyses were performed at 5 time points: 15 min after induction of anaesthesia (giving pre-PP values), immediately before carbon dioxide insufflation (0 min PP), after both 30 and 60 min of PP and 10 min post PP. Inspiration plateau pressure (Pplat), compliance of the respiratory system, and both ins- and expiratory gas concentrations were continuously recorded by an Ultima V monitor (Datex Corp., Helsinki, Finland). The difference between arterial and end-tidal CO2 partial pressure (P(a-et)CO2) was calculated so as to allow assessment of physiological dead space by the modified Bohr equation. RESULTS: Pulmonary gas exchange differed significantly after 30 min of PP between the IG and the PG. At this time, PaO2 was 19.5 +/- 2.9 kPa (mean +/- SD) in the IG and 23.1 +/- 1.8 kPa in the PG (P < 0.01), whereas PaCO2 was 5.5 +/- 0.37 kPa in the IG and 4.9 +/- 0.27 kPa in the PG (P < 0.01). These discrepancies remained until after carbon dioxide desufflation. At 10 min post PP, PaO2 was 18.3 +/- 2.6 kPa in the isoflurane group and 21.9 +/- 2.2 kPa in the propofol group (P < 0.01), whereas PaCO2 was 5.4 +/- 0.46 kPa in the IG and 4.8 +/- 0.22 kPa in the PG (P < 0.01). During carbon dioxide insufflation the P(a-et)CO2 increased significantly in the IG from 0.47 +/- 0.13 kPa to 0.76 +/- 0.37 kPa (P < 0.05), while the values in the PG remained constant. CONCLUSION: This study demonstrates that pulmonary gas exchange in patients with laparoscopic cholecystectomy is affected by the choice of anaesthetic procedure. During and after laparoscopic cholecystectomy using isoflurane as the anaesthetic, the PaCO2 is significantly higher and the PaO2 significantly lower than they are with propofol.

Postoperative dissociation of blood levels of cortisol and adrenocorticotropin after coronary artery bypass grafting surgery.

The regulation of the hypothalamo-pituitary-adrenal (HPA) axis in the operative and perioperative period of major surgical procedures is necessary for successful adaption to surgical stress. We report evidence on an altered response of HPA axis regulation in patients who underwent coronary artery bypass grafting (CABG) surgery. Plasma levels of adrenocorticotropin (ACTH), beta-endorphin, and cortisol were determined with radio-immune assay in 50 males for elective CABG surgery. The patients received general anesthesia using a balanced technique with sufentanil, isoflurane, and midazolam. Pre- and intraoperatively, there was no significant increase in plasma cortisol, ACTH, and beta-endorphin levels. On the evening of surgery, all plasma hormone levels were increased. On the evening of the first and second postoperative day, plasma ACTH and beta-endorphin levels returned to the preoperative baseline values. During the same time interval, plasma cortisol levels were significantly elevated and remained high until the end of the study period (p < 0.001). Our results indicate an altered regulation of the HPA axis in the postoperative period of patients after CABG surgery, as they are compatible with similar results in patients after major abdominal surgery, burned patients, and critically ill patients. Therefore, it is assumed that the finding of a postoperative dissociation between ACTH and cortisol is a result of the severity of perioperative adaptive mechanisms rather than of the specific conditions related to cardiac surgery.

[The preparation for elective interventions--the spectrum and dissemination of somatic and psychological measures in Germany]. / Vorbereitung auf elektive Eingriffe--Spektrum und Verbreitung somatischer und psychologischer Massnahmen in Deutschland.

INTRODUCTION: The positive effects of preoperative preparation on postoperative recovery in patients undergoing elective surgery have been demonstrated. On that account, we surveyed the practice procedures of preoperative preparation for elective surgery patients at German hospitals. METHODS: During November 1994, we sent 1500 questionnaires to the directors of anaesthesiology departments in Germany. A total of 590 questionnaires (39.3%) were completed and returned. The participating hospitals range in size from 20 to 2600 beds (mean = 364; s = 334,97), totalling together more than 1.7 million surgical operations per year. RESULTS: The surveyed hospitals used one or more of the following procedures for pre-operative preparation: 573 (98.6%) of the replying hospitals used medical anxiolysis, 415 (71.3%) applied preoperative respiratory therapy. Furthermore, 222 (38.5%) of the studied hospitals trained their patients in postoperative relevant behaviour (respiratory therapy n = 167; physiotherapy n = 63 and patient-controlled analgesia n = 41). 74 (13%) offered psychological counselling, 29 (5%) made use of other psychological techniques (muscle relaxation; autogenic training, biofeedback) and 26 (4%) used other preparatory methods like video tapes (n = 13), music (n = 5), acupuncture (n = 4). DISCUSSION: Nearly all hospitals prepared their patients for surgery with a pre-op visit and anxiolytic medications. Further preparatory methods in most surveyed hospitals are only used on a case-by-case basis. At present psychological methods of preoperative preparation are not routinely used in clinical practice in Germany. CONCLUSIONS: Existing possibilities for optimising preoperative preparation in patients undergoing elective surgery are not used regularly. Preoperative preparation needs to be improved, especially in patients undergoing major surgery. Standardisation of management procedures and integration of several professional groups and regular application of known procedures for preoperative preparation may lead to cost-saving optimisation of the duration of hospital stay.