[Cardiopulmonary resuscitation after heroin intoxication and hypothermia]. / Kardiopulmonale Reanimation nach Heroinintoxikation und Hypothermie.

We present the case of a 21-year-old female drug addict with severe accidental hypothermia (core body temperature 27.5 degrees C) and cardiorespiratory arrest. After successful cardiopulmonary resuscitation the patient was actively internally rewarmed without the use of extracorporal circulation. Although at the first clinical presentation the patient appeared to be dead, an excellent neurological outcome was achieved. This case report reviews the epidemiology, pathophysiology, prognostic markers and the therapeutic approaches of severe hypothermia.

[Spinal epidural abscess after long-term epidural catheterization]. / Spinaler Epiduralabszess nach rückenmarknaher Langzeitanalgesie.

This case report describes a 63-year-old male patient with considerably impaired postoperative wound healing in the region of the lower extremities. After initial drug therapy for the pain was ineffectual, the patient was treated repeatedly through an epidural catheter. In the further course, an extensive spinal epidural abscess was diagnosed as an incidental finding without neurological symptoms. After taking into consideration the patient's age and the risk factors present as well as inclusion of the subspecialties involved for an interdisciplinary assessment, the patient was successfully treated with a conservative approach. Our contribution concludes with a detailed discussion and comparison of the literature.

[Propofol infusion syndrome]. / Propofolinfusionssyndrom.

The propofol infusion syndrome is a rare but potentially lethal complication resulting from a prolonged continuous administration of propofol. It was first described in the beginning of the 1990's and in recent years there have been frequent reports of problems in association with the use of propofol sedation. The cardinal signs and symptoms of the propofol infusion syndrome are metabolic acidosis, rhabdomyolysis, renal failure, cardiac arrhythmias and a progressive, often therapy-resistant cardiac failure. The pathophysiology of this syndrome appears to involve a disturbance of mitochondrial metabolism induced by propofol. Our report involves a case of propofol infusion syndrome in a patient having undergone cardiac surgery.

Can a dose of 2microg.kg(-1) caudal clonidine cause respiratory depression in neonates?

A case of multiple life-threatening postoperative apnoeas in a term neonate undergoing inguinal herniorrhaphy and orchidopexy who received light inhalation anaesthesia combined with caudal block with 1 ml.kg-1 ropivacaine 0.2% plus 2 microg.kg-1 clonidine is reported. The patient showed no apparent risk factors for postanaesthetic apnoea. Oxycardiorespirography five days after surgery only showed minor abnormalities. Clonidine though administered caudally in the usual dose of 2 microg.kg-1 appeared to be the most likely cause for postanaesthetic apnoea in this neonate.

Peripheral morphine analgesia in dental surgery.

The recent identification of opioid receptors on peripheral nerve endings of primary afferent neurons and the expression of their mRNA in dorsal root ganglia support earlier experimental data about peripheral analgesic effects of locally applied opioids. These effects are most prominent under localized inflammatory conditions. The clinical use of such peripheral analgesic effects of opioids was soon investigated in numerous controlled clinical trials. The majority of these have tested the local, intraarticular administration of morphine in knee surgery and have demonstrated potent and long-lasting postoperative analgesia. As the direct application of morphine into the pain-generating site of injury and inflammation appears most promising, we examined direct morphine infiltration of the surgical site in a unique clinical model of inflammatory tooth pain. Forty-four patients undergoing dental surgery entered into this prospective, randomized, double-blind study. Before surgery they received, together with a standard local anesthetic solution (articaine plus epinephrine) a submucous injection of either 1 mg of morphine (group A) or saline (group B). Postoperative pain intensity was assessed using the visual analog scale (VAS) and numeric rating scale (NRS) at 2, 4, 6, 8, 10, 12, 16, 20 and 24 h after surgery. In addition, patients recorded the occurrence of side effects and the supplemental consumption of diclofenac tablets. Results of 27 patients were analyzed (group A: n=14, group B: n=13). Pain scores which were moderate to severe preoperatively were reduced to a similar extent in both groups up to 8 h postoperatively. Thereafter, pain scores in group A were significantly lower than those in group B for up to 24 h, demonstrating the analgesic efficacy of additional morphine. The time to first analgesic intake and the total amount of supplemental diclofenac were less in group A than in group B. No serious side effects were reported. Our results show that 1 mg of morphine added to a local anesthetic for dental surgery results in significant improvement of postoperative analgesia. Since the majority of dental surgeries is accompanied with an inflammatory reaction, supplemental morphine may be of benefit for the relief of postoperative dental pain.

Sitting position for neurosurgery: experience with preoperative contrast echocardiography in 301 patients.

A persisting foramen ovale (PFO) is the most common cause of paradoxical air embolism. To detect right-to-left shunting, transthoracic contrast echocardiography was performed preoperatively in 301 patients scheduled for neurosurgical procedures in the sitting position. Echocardiography yielded evaluable results in 285 patients (94.7%). In 72 of 285 patients (25.2%), a PFO was diagnosed on the basis of contrast echo signals appearing in the left atrium or ventricle within 5 heart cycles after application of contrast medium via a peripheral vein. If echo signals appeared in the left heart after more than 5 heart cycles, an intrapulmonary right-to-left shunt was considered (11 patients, 3.9%). Venous air embolism (VAE) occurred in 27.4% of 226 patients operated on in the sitting position and in none of the 59 patients operated on in a nonsitting position. We conclude that the sitting position during neurosurgery should be avoided in patients with preoperative evidence of a right-to-left shunt at contrast echocardiography to reduce the risk of paradoxical air embolism (PAE).

Brain death: timing of apnea testing in primary brain stem lesion.

In a 73-year-old patient complete areflexia of the cerebral and peripheral nerves following the rupture of an aneurysm of the basilar artery was diagnosed. During apnea testing the spectral analysis of electroencephalography (EEG) revealed an irreversible shift of peak from 6 to 3 Hz within the low-frequency bands. These findings suggest that apnea testing in patients with primary lesion of the brain stem should be carried out only after an isoelectric EEG.

[Deep accidental hypothermia (24 degrees C). A case report]. / Tiefe akzidentelle Hypothermie (24 degrees C). Eine Kasuistik.

A 65 year old female patient was submitted to the ICU in deep accidental hypothermia, due to lying in cold water after intoxication with Melperon. Body temperature after submission was 24 degrees C; therefore rewarming was done by an extracorporal bypass. After successful rewarming, the further posttraumatic course was free of complications and the patient could be discharged 14 days after the event.

Human pial vascular reactions to intravenous Nimodipine-infusion during EC-IC bypass surgery.

In previous experimental work, the Ca-antagonist Nimodipine had shown a predominantly cerebroarterial dilatory effect. In the present double-blind study of 16 patients, pial arterial and venous reaction was investigated during EC-IC bypass surgery, infusing 1 microgram kg-1min-1 of Nimodipine intravenously. In pial arteries with resting diameters between 25 and 70 micrometers, a significant 18% dilatation was observed. Results are considered promising for future trials in the treatment and prevention of cerebral ischemia caused by vasoconstriction or vasospasm, especially vasospasm following subarachnoid hemorrhage.