Assessment of recovery, dreaming, hemodynamics, and satisfaction in postcardiac surgery patients receiving supplementary propofol sedation with S(+)-ketamine.

BACKGROUND: S(+)-ketamine is an analgesic and sedative drug with dissociative attributes. When it is used without sedatives, nightmares have been described. The aim of this study was to assess the effects of postoperative analgosedation with propofol and S(+)-ketamine when compared to standard propofol analgosedation in terms of recovery, dreaming, hemodynamics, and patient satisfaction. METHODS: Forty-eight patients were sedated with propofol (1-3 mg/kg/h) after coronary artery bypass grafting and allocated randomly on admission to the intensive care unit to receive either S(+)ketamine (2 mg mg/kg/h; group A) or 0.9% saline as a placebo (group B) in a double-blind fashion. If necessary, boli of 3.75 mg piritramide (an opioid) were given in both groups. RESULTS: Patients receiving S(+)-ketamine had significantly higher satisfaction for pain management (Visual Analog Scale [VAS] = group A: median 10 [range 9-10]; group B: median 9 [range 6-10]) despite their lower piritramide consumption. Patients receiving S(+)ketamine showed significantly faster eye opening (82+/-51 vs 156+/-110 min) but dreamed significantly more often (at 2 h, 67% in group A vs 29% in group B; at 24 h, 43% in group A vs 10% in group B), whereas no significant differences were detected in the incidence of nightmares at 2 h, 14% in group A vs 10% in group B; at 24 h, 5% in group A vs 5% in group B. CONCLUSIONS: Patients receiving S(+)-ketamine showed higher satisfaction for pain management and dreamed more often, but they did not have more nightmares.

Hepatocellular integrity in patients requiring parenteral nutrition: comparison of structured MCT/LCT vs. a standard MCT/LCT emulsion and a LCT emulsion.

BACKGROUND AND OBJECTIVE: The aetiology of parenteral nutrition-associated hepatic injury remains unresolved. The aim of the study was to evaluate the effects of structured triglycerides in parenteral nutrition compared either to a physical medium-chain triglycerides (MCT)/long-chain triglcerides (LCT) mixture or to a LCT emulsion on hepatic integrity. METHODS: In a randomized, double-blinded trial, we studied 45 patients undergoing abdominal surgery, who were expected to receive parenteral nutrition for 5 days. Patients were allocated to one of three nutrition regimens: Group A (n = 15) received structured triglycerides, Group B (n = 15) a MCT/LCT and Group C (n = 15) a LCT lipid emulsion. Before the start of parenteral nutrition (T0), 24 h (T1), 48 h (T2), 72 h (T3) and 120 h (T4) after start of infusion the following parameters were measured: Alpha-glutathione S-transferase (alpha-GST), alanine aminotransferase (ALT), aspartate aminotransferase (AST), glucose and serum triglycerides. RESULTS: At T3 and T4, alpha-GST levels were significantly higher in Group B (T3: 9.4 +/- 9.9; T4: 14.6 +/- 19.5 microg L-1) and Group C (T3: 14.2 +/- 20.8; T4: 22.4 +/- 39.3 microg L-1) compared with the patients receiving structured triglycerides (T3: 1.9 +/- 1.8; T4: 3.2 +/- 2.7 microg L-1). Whereas the mean alpha-GST-levels in structured triglycerides group always remained in the normal range, this was not the case in both other groups at T3 and T4. There were no significant differences concerning ALT, AST and glucose levels. At T3 and T4, triglyceride levels were significantly lower in Group A than in Groups B and C. CONCLUSIONS: Hepatic integrity was well retained with the administration of structured triglycerides, whereas both MCT/LCT emulsion and LCT emulsion caused subclinical hepatic injury.

Inspired oxygen fraction of 0.8 compared with 0.4 does not further reduce postoperative nausea and vomiting in dolasetron-treated patients undergoing laparoscopic cholecystectomy.

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most frequent complications after general anaesthesia. Single-dose antiemetic prophylaxis has limited efficacy in high-risk patients. Adding a simple potential antiemetic approach, such as increasing the inspired oxygen fraction, to the antiemetic portfolio would preserve pharmacological interventions for treatment of symptoms in the postoperative period. However, the antiemetic effect of a high inspired oxygen fraction is still discussed controversially. The aim of the study was to evaluate whether an inspired oxygen fraction of 0.8 decreases PONV in patients receiving the 5-HT3-antagonist dolasetron. METHODS: In a randomized, placebo-controlled, double-blinded trial we studied 377 patients (ASA I-III) undergoing elective laparoscopic cholecystectomy. Induction of anaesthesia was standardized, including thiopental fentanyl and cis-atracurium. For all patients the individual risk for PONV was calculated using the Koivuranta score and all patients received 12.5 mg dolasetron i.v. before surgery. Patients were allocated randomly to one of three groups: Group A (n=125) received 80% oxygen in air, Group B (n=125) 40% oxygen in air and Group C (n=127) 40% oxygen in nitrous oxide. Postoperative nausea, postoperative vomiting (PV), or nausea, vomiting, or both (PONV) was assessed in the early (0-4 h) and overall postoperative period (0-24 h) by an anaesthesiologist unaware of patient allocation. RESULTS: There was a significantly lower incidence of PONV and PV in Groups A (PONV: 11.2%; PV: 3.2%) and B (PONV: 10.4%; PV: 3.2%) compared with Group C (PONV: 26.7%; PV: 13.3%), but there were no significant differences between Groups A and B. CONCLUSIONS: An inspired oxygen fraction of 0.8 does not further decrease PONV or vomiting in dolasetron-treated patients undergoing laparoscopic cholecystectomy. The lower incidence of PONV in Groups A and B compared with Group C is most likely caused by the omission of nitrous oxide.

[Who contributes to research in intensive medicine in Germany? An update]. / Wer betreibt intensivmedizinische Forschung in Deutschland? Eine Aktualisierung.

INTRODUCTION: In today's times of financial short-cut, it is of highest interest to improve quality. Research in intensive care medicine is an important instrument to improve therapeutic strategies. The origin of papers published in the field of intensive care medicine by German universities were evaluated and compared to a previous analysis (1992 - 1997). METHODS: Using a Medline analysis, 10 international journals (Crit Care Med; Intensive Care Med; Resuscitation; J Crit Care; Crit Care Clin; Circulation; Chest; Am Resp Crit Care Med; Stroke; J Inf Dist) that exclusively or often publish intensive care papers were analysed over the past 6 years (1998 to 2003). Only original papers from German universities were included and the publications were listed according to the origin of specialty: anesthesiological, surgical, cardiac surgical, neurosurgical, internal medicine, neurological, pediatric intensive care medicine. RESULTS: The total number of publications has markedly increased (1998 - 2003; n = 1245) compared to a previous analysis (1992 - 1997: n = 621). The number of publication from surgical institutions was still significantly lower than that of other intensive care units (cardiac surgery: n = 44; anesthesia: n = 356; internal medicine: n = 463). Institutions from the formerly eastern part of Germany participated much more to international journals than in the former analysis. DISCUSSION: Scientific research in intensive care medicine is important to develop new strategies for treating the critically ill. Although the total number of publications has increased, it is astonishing that some intensive care units from German universities did almost not publish in the selected intensive care journals.

A comparison of nefopam and clonidine for the prevention of postanaesthetic shivering: a comparative, double-blind and placebo-controlled dose-ranging study.

Postanaesthetic shivering is a frequent complication following general anaesthesia. The aim of this study was to compare the effectiveness of three doses of nefopam with clonidine and placebo in the prevention of postanaesthetic shivering. We studied 371 patients undergoing abdominal or orthopaedic surgery. Patients were allocated to one of five groups: Group A (n = 73) received 0.2 mg x kg(-1) nefopam, Group B (n = 75) 0.1 mg x kg(-1) nefopam, Group C (n = 76) 0.05 mg x kg(-1) nefopam, Group D (n = 73) 1.5 microg x kg(-1) clonidine, and Group E (n = 74) saline 0.9% as placebo. We found a significant reduction in the incidence of shivering in Group A compared to Group C and clonidine as well as to the placebo group. All active treatments reduced the incidence and the severity of shivering compared to placebo. At 5 min postoperatively clonidine-treated patients showed a significant decrease in MAP and a significantly lower Aldrete score compared to all other groups. No haemodynamic or sedative adverse events were observed in the nefopam-treated patients. The results of our study indicate that nefopam (0.2 mg x kg(-1)) is superior to clonidine (1.5 microg x kg(-1)) in the prophylaxis of postanaesthetic shivering and not accompanied by sedative or haemodynamic side-effects.

Do we necessarily need local anaesthetics for venous cannulation? A comparison of different cannula sizes.

BACKGROUND AND OBJECTIVE: This randomized, prospective study was performed to evaluate the efficacy of a subcutaneous local anaesthetic infiltration prior to venepuncture using different cannula sizes. METHODS: Three-hundred-and-one patients were included in the study, 150 received mepivacaine 1% (0.25 mL) subcutaneously, 151 were cannulated without local analgesia. Patients were further allocated to one of five cannula size groups (standard wire gauge (G)): 20-, 18-, 17-, 16- and 14-G. They were asked to quantify the pain experienced using a four-point rating scale. RESULTS: In the group without local anaesthetics, 28.8% complained about pain compared to 12% receiving local analgesia. The incidence of pain for 14-G (10%) and 16-G (12.9%) cannulae was significantly reduced in the local analgesia group (P < 0.01) compared to no local analgesia (77.4% and 45.1%). Other cannula sizes showed no difference in pain whether using local analgesia or not. CONCLUSIONS: Patients profit from a subcutaneous infiltration with mepivacaine 1% prior to intravenous cathetherization only when cannulae of size > or = 16-G are inserted.

[ProSeal-laryngeal mask versus endotracheal intubation in patients undergoing gynaecologic laparoscopy]. / Ein Vergleich der ProSeal(R)-Larynxmaske mit der konventionellen endotrachealen Intubation bei Laparoskopien in der Gynäkologie.

BACKGROUND: The aim of this study was to assess the practicality of the ProSeal laryngeal mask (PS-LMA) airway during laparoscopic surgery with capnoperitoneum compared to endotracheal intubation (ET). METHODS: Prospective, randomized study. 104 patients undergoing gynaecologic, laparoscopic surgery were allocated randomly to two groups: 1. ET-group (n = 50). 2. PS-LMA-group (n = 54). Total intravenous anaesthesia was performed by the same anaesthesiologist. MEASUREMENTS: Mean arterial pressure, heart rate, at 4 and circuit pressure at 2 measurement points, and the incidences of coughing and sore throat. Insertion of the ET and the PS-LMA was scored by using a four-point scale. Ease of placing the gastric tube was judged by measuring the number of attempts at insertion and the insertion times. A p-value of < 0.05 was considered as significant. RESULTS: There were no differences between PS-LMA and ET concerning circuit pressure at any measurement point. At the end of anaesthesia, mean arterial pressure (92 +/- 13 vs. 100 +/- 14 mmHg; p < 0.01) and heart rate (66 +/- 13 vs. 76 +/- 14 beats/min; p < 0.01) were lower in the PS-LMA-group compared to the ET-group. At the end of anaesthesia 25 patients of the ET-group coughed but nobody in the PS-LMA-group (p < 0.00001). There was no difference with regard to postoperative sore throat. The insertion of the PS-LMA was easier compared to ET (p < 0.05), but we found no significant difference concerning insertion times. Fewer attempts at insertion of the gastric tube were necessary in the PS-LMA-group than in the ET-group (p < 0.01), whereas insertion times did not differ. CONCLUSION: The PS-LMA is a convenient and practicable approach for anaesthesia in patients undergoing laparoscopic surgery.

[Injection pain secondary to propofol-MCT/LCT and propofol-LCT--comparison of prophylaxis with lidocaine]. / Injektionsschmerz unter Propofol-MCT/LCT und Propofol-LCT - Vergleich einer Prophylaxe mit Lidocain.

OBJECTIVE: Pain on injection is one of the most described side-effects of the intravenous application of propofol. This study was designed to assess the efficacy of lidocaine 40 mg in preventing incidence and severity of injection pain for two different propofol solvents. METHODS: In a double-blind and prospective study 202 patients were enrolled and randomized to 4 different groups: group A receiving 2 ml NaCl 0.9 % and propofol-LCT (Disoprivan; AstraZeneca), group B 40 mg lidocaine and propofol-LCT, group C received 2 ml NaCl 0.9 % and propofol-MCT/LCT (Propofol-Lipuro, B. Braun Melsungen AG) and group D 40 mg lidocaine and propofol-MCT/LCT. According to the protocol, all patients were cannulated with a 18-G venous cannula at the dorsum of the hand and no other medicament was injected before the study drug. Time interval between test agents and propofol application in a dosage of 2 mg/kg was one minute. Severity of pain was evaluated during propofol injection over 30 seconds until loss of consciousness using a 4-point rating scale. RESULTS: The incidence of injection pain did not differ between propofol-LCT and propofol-MCT/LCT (64 % and 53 %). Propofol-MCT/LCT significantly reduced the severity of pain compared to propofol-LCT (p < 0.05). The application of lidocaine resulted in a significant reduction in incidence (Propofol-MCT/LCT: 16 %; Propofol-LCT: 31 %) and severity of injection pain compared to placebo. CONCLUSION: Propofol-MCT/LCT showed a significant advantage compared to propofol-LCT considering the severity of injection pain, but not in reducing the incidence of pain. The use of lidocaine resulted in a significant reduction of incidence and severity of injection pain for both propofol solvents.