[The addicted patient in anaesthesia - benzodiazepine dependence]. / Der suchtkranke Patient in der Anästhesie - Postoperative Überwachung und Behandlung.

As a result of the demographic change, the proportions of elderly patients undergoing operations and anesthesia are increasingly important. The consumption of benzodiazepines evidently rises with increasing age. Associated with the increasing consumption in the elderly is the risk of cognitive impairment, delirium, falls and fractures. Also long-term benzodiazepine use in low-dose may induce perioperative withdrawal syndrome. The following article will present characteristics and complications accompanied by critical benzodiazepine use especially in the elderly patients.

[Management of anaesthesia and intensive care for acute ischemic insult]. / Ischämischer Insult - Anästhesiologisches und intensivmedizinisches Management.

The acute ischemic stroke (AIS) is a major cause of death and disability in Germany. The treatment of patients with AIS focuses on rapid recanalization of close brain vessels. Anaesthesiologists are likely to encounter patients with AIS and must be aware of the anaesthetic considerations for these patients. The advantage and risk of general anaesthesia during a neuroradiology procedure is shown. We make recommendations for blood pressure, blood glucose and temperature management.

Impact of thoracic epidural analgesia on blood loss in radical retropubic prostatectomy.

INTRODUCTION: Radical retropubic prostatectomy (RRP) is associated with an increased risk of intraoperative blood loss and the necessity of transfusions. This prospective randomised clinical study evaluates the influence of thoracic epidural analgesia (TEA) on blood loss in RRP. MATERIALS AND METHODS: 235 patients were randomised: TEA in group 1 (n = 116; general anaesthesia + TEA) comprised continuous administration of 0.25% bupivacaine, while group 2 (n = 119; general anaesthesia alone) received intravenous analgesia with fentanyl (intubation: 2 µg/kg; maintenance: 0.1-0.3 mg). A restrictive infusion regimen (<1,000 ml until specimen removal) was administered in both groups. Blood loss, infusion rates and anaesthesiological parameters were recorded and analysed using regression models and analyses of variance. RESULTS: Haemoglobin difference between the pre- and the first postoperative day (group 1: 3.35 ± 1.16 g/dl; group 2: 3.56 ± 1.42 g/dl; p = 0.19), overall blood loss (group 1: 665 ± 431.5 ml; group 2: 705 ± 881 ml; p = 0.73) and transfusion rates (0.4% intraoperatively; 2.55% postoperatively; p = 1.0) did not show group differences. In regression analysis blood loss was influenced by preoperative haemoglobin levels (p < 0.0001), patients' weight (p = 0.018) and duration of the operation (p = 0.017). CONCLUSIONS: This study did not demonstrate a direct impact of TEA on intraoperative blood loss and transfusion rates in RRP. Further randomised clinical trials are needed to evaluate an impact of the different anaesthetic procedures presented alone or in combination on blood loss.

[Current strategies to minimize of blood loss during radical prostatectomy]. / Anästhesie in der Urologie - Aktuelle Strategien zur Minimierung von Blutverlusten bei radikaler Prostatektomie.

Prostate cancer is a frequently diagnosed cancer in men with a high incidence. Despite enhancements of surgical techniques in prostatectomyperioperative blood loss is still the most frequent complication. Controlled hypotension (MAP 60-70mmHg) consisting of thoracal epidural anaesthesia und restrictive fluid management is a safe method to minimize blood loss. 25 degrees Trendelenburg position supports the multimodal treatment of controlled hypotension. Tranexamic acid is a safe drug to treat hyperfibrinolysis during prostate resection.

Urinary tract effects after multifocal nonthermal irreversible electroporation of the kidney: acute and chronic monitoring by magnetic resonance imaging, intravenous urography and urinary cytology.

PURPOSE: The nonthermal irreversible electroporation (NTIRE) is a novel potential ablation modality for renal masses. The aim of this study was the first evaluation of NTIRE's effects on the renal urine-collecting system using intravenous urography (IVU) and urinary cytology in addition to histology and magnetic resonance imaging (MRI). METHODS: Eight percutaneous NTIRE ablations of the renal parenchyma, including the calyxes or pelvis, were performed in three male swine. MRI, IVU, histology, and urinary cytology follow-ups were performed within the first 28 days after treatment. RESULTS: MRI and histological analysis demonstrated a localized necrosis 7 days and a localized scarification of the renal parenchyma with complete destruction 28 days after NTIRE. The urine-collecting system was preserved and showed urothelial regeneration. IVU and MRI showed an unaltered normal morphology of the renal calyxes, pelvis, and ureter. A new urinary cytology phenomenon featured a temporary degeneration by individual vacuolization of detached transitional epithelium cells within the first 3 days after NTIRE. CONCLUSIONS: This first urographical, urine-cytological, and MRI evaluation after porcine kidney NTIRE shows multifocal parenchyma destruction while protecting the involved urine-collecting system with regenerated urothelial tissue. NTIRE could be used as a targeted ablation method of centrally located renal masses.

Irreversible electroporation of renal cell carcinoma: a first-in-man phase I clinical study.

PURPOSE: Irreversible electroporation (IRE) is a newly developed nonthermal tissue-ablation technique in which high-voltage electrical pulses of microsecond duration are applied to induce irreversible permeabilisation of the cell membrane, presumably through nanoscale defects in the lipid bilayer, leading to apoptosis. The purpose of this study was to assess the feasibility and safety of ablating renal cell carcinoma (RCC) tissue by IRE. METHODS: Six patients scheduled for curative resection of RCC were included. IRE was performed during anaesthesia immediately before the resection with electrographic synchronisation. Central haemodynamics were recorded before and 5 min after electroporation. Five-channel electrocardiography (ECG) was used for detailed analysis of ST waveforms. Blood sampling and 12-lead ECG were performed before, during, and at scheduled intervals after the intervention. RESULTS: Analysis of ST waveforms and axis deviations showed no relevant changes during the entire study period. No changes in central haemodynamics were seen 5 min after IRE. Similarly, haematological, serum biochemical, and ECG variables showed no relevant differences during the investigation period. No changes in cardiac function after IRE therapy were found. One case of supraventricular extrasystole was encountered. Initial histopathologic examination showed no immediate adverse effects of IRE (observation of delayed effects will require a different study design). CONCLUSION: IRE seems to offer a feasible and safe technique by which to treat patients with kidney tumours and could offer some potential advantages over current thermal ablative techniques.

Effects of dopexamine, dobutamine or dopamine on prolactin and thyreotropin serum concentrations in high-risk surgical patients.

OBJECTIVES: Catecholamines are often used for optimisation of cardiac index and oxygen delivery in high-risk surgical patients; however, infusions of dopamine and dopexamine are associated with dose-dependent hypophysiotropic and thyreotropic properties. The objective was to compare endocrine effects of equipotent inotropic doses of dopexamine, dobutamine and dopamine on prolactin and thyreotropin release perioperatively. DESIGN: A prospective, randomised, blinded clinical trial. SETTING: Adult surgical intensive care unit in a university hospital. PATIENTS: Thirty male patients (ASA III) undergoing elective major abdominal surgery. INTERVENTIONS: Patients were randomised to receive dopexamine (DX, n=10), dobutamine (DO, n=10) or dopamine (DA, n=10) on the first postoperative day for 8 h. MEASUREMENTS AND RESULTS: All patients received a catecholamine infusion in doses adjusted to increase cardiac index by 35% within the first hour. Blood samples were obtained and prolactin and thyreotropin serum concentrations were determined by radioimmunoassays. Mean doses of dopexamine, dobutamine and dopamine used were 0.73+/-0.27, 4.06+/-1.95 and 5.0+/-1.84 micro g kg(-1)min(-1), respectively. Cardiac index was increased by 36% (DX group), 38% (DO group) and 38% (DA group). Alterations of oxygen delivery and oxygen consumption were not significantly different between the study groups. Dopexamine and dobutamine had no hypophysiotropic effects. In contrast, dopamine suppressed prolactin and thyreotropin secretion with a maximal effect after 4 h. After dopamine withdrawal, a rebound release of prolactin and thyreotropin was observed. CONCLUSIONS: In high-risk surgical patients dopexamine or dobutamine produced fewer effects on prolactin and thyreotropin serum concentrations in comparison with DA when used in equivalent dosages.