Should a percutaneous dilational tracheostomy be guided with a bronchoscope?

OBJECTIVE: The aim was to evaluate the complications and practicability of percutaneous dilational tracheostomy (PDT) with and without video endoscopic guidance in critically ill patients. METHODS: In a retrospective review of patients admitted to a multidisciplinary ICU, PDT was performed under bronchoscopic control in 74 patients and without bronchoscopic control in 113 patients. Both groups were evaluated in similar technical conditions. RESULTS: Complications in both groups were mostly minor. Bleeding or difficult tracheal cannulation occurred in 8 patients in each group. In patients without bronchoscopy, one major bleeding necessitated a switch to open revision, the Murphy eye was punctured (n = 2) and there was one pneumothorax. Furthermore, similar levels of cuff leaks, loss of airway and minor stoma infections were noted in both groups. All tracheostomies were performed bedside with similar manpower. Operation times were shorter in patients without bronchoscopy. CONCLUSION: Our data about PDT in critically ill patients do not indicate any clear-cut difference in complication rates or practicability in the absence of bronchoscopic guidance when adequate skills and experience have been acquired and simple but effective precautions at each step are adopted. However, randomisation and long-term laryngotracheal followup should be considered in future studies.

A randomized, double-blind, controlled trial on non-opioid analgesics and opioid consumption for postoperative pain relief after laparoscopic cholecystectomy.

BACKGROUND: Following laparoscopic cholecystectomy, an effective post-operative pain control is necessary, at least during the first 24 hours. We present a randomized, double-blind trial on the effect of the combined use of intravenous parecoxib, and metamizol or paracetamol on piritramide consumption using a patient-controlled analgesia (PCA) pump in patients recovering from laparoscopic cholecystectomy. METHODS: 120 patients were randomly allocated to four patient groups treated with normal saline or one of non-opioid analgesics (parecoxib 40 mg twice daily, metamizol 1 g three times daily, paracetamol 1 g three times daily) in addition to piritramide using the PCA pump. Beginning in the post-anesthesia care unit (PACU), patients were asked every 2 h for 6 hours and afterwards once every 6 h to quantify their pain experience at rest while piritramide consumption was recorded. RESULTS: In all groups, piritramide consumption was high in PACU. Only metamizol significantly reduced piritramide consumption compared to the others upon discharge from PACU. Overall, cumulative piritramide consumption was slightly lower in the metamizol group and higher in the NaCl group; however, these findings were statistically not significant. VAS scores were highest upon arrival in PACU and dropped almost continuously after surgery. A significantly lower postoperative pain intensity was only found in the parecoxib group at 24 h after surgery compared to the metamizol group. CONCLUSION: The efficacy of tested additive medications on piritramide consumption and pain relief is weak and there is no clear-cut difference between the non-opioid drugs used.

Case report. Successful use of tenecteplase in massive pulmonary embolism with cardiopulmonary resuscitation immediately following tracheostomy.

The use of thrombolytics for the treatment of massive pulmonary embolism with cardiopulmonary resuscitation is being controversially discussed. This is one of the first reports on the successful use of tenecteplase in a 59-year-old man who survived a massive pulmonary embolism after tracheostomy followed by a 30-minute cardiopulmonary resuscitation without cerebral damage. In such a dramatic clinical event, the immediate and simple use of this modern thrombolytic appears to be a justifiable last-resort treatment option until controlled studies in sufficiently sized patient populations will have proven or refuted its efficacy and safety.

The synergistic effect of two different nondepolarizing muscle relaxants on intraocular pressure.

STUDY OBJECTIVES: To evaluate the synergistic effect of neuromuscular blockade, produced by administering a priming dose of d-tubocurarine before or after pancuronium bromide, on endotracheal intubating conditions, intraocular pressure (IOP), and hemodynamic changes 1 minute following injection of intubating doses. To compare the results with equipotent doses of the individual muscle relaxants administered as a single bolus dose or in divided doses. DESIGN: Randomized study. SETTING: University medical center. PATIENTS: Ninety ASA physical status I and II inpatients (45 males, 45 females) assigned to one of six comparable groups (A-F). INTERVENTIONS: One hour after premedication, either normal saline (Groups A and B) or a priming dose of either d-tubocurarine (Groups C and F) or pancuronium (Groups D and E) was given intravenously (IV). Three minutes later, anesthesia was induced with 6 mg/kg of 2.5% thiopentone i.v. Then an intubating dose of pancuronium (Groups A, C, and E) or d-tubocurarine (Groups B, D, and F) was administered. The total dose given was equal to d-tubocurarine 0.4 mg/kg or pancuronium 0.07 mg/kg. Patients were intubated 1 minute after injection of an intubating dose of either relaxant. MEASUREMENTS AND MAIN RESULTS: IOP was measured with a Perkins applanation tonometer and blood pressure (BP) by a sphygmomanometer. Heart rate was derived from the electrocardiogram. Intubating conditions were scored according to given intubation criteria. Measurements were obtained at different times before and after intubation. In those patients given only one muscle relaxant for intubation either divided into priming and intubating doses or preceded by normal saline (Groups A, B, E, and F), there was a significant increase in IOP in response to intubation as compared with baseline (p < 0.05). In contrast, when d-tubocurarine was used as the priming drug for pancuronium blockade (Group C), IOP was significantly reduced in response to intubation, despite a concomitant increase in BP (p < 0.05). No significant change in IOP was observed when pancuronium was used as the priming drug for d-tubocurarine blockade (Group D). Although good to excellent intubating conditions were reported in Groups C and D, poor intubating conditions were reported when the priming muscle relaxant was the same as the relaxant used to intubate. CONCLUSIONS: A smooth, rapid-sequence intubation with a concomitant reduction in IOP as required for open-eye, full-stomach patients can be achieved with a judicious mixture of nondepolarizing muscle relaxants as described for d-tubocurarine and pancuronium in Groups C and D.

A new approach to intravenous regional anesthesia.

In an attempt to reduce the dose of local anesthetic during intravenous (IV) regional anesthesia of the upper limb, we combined 100 mg of lidocaine with 0.05 mg of fentanyl and 0.5 mg of pancuronium. The study was designed in a randomized, double-blind fashion to determine the efficacy of this approach in providing analgesia and relaxation during surgery and to evaluate its safety after immediate deflation of the tourniquet following IV drug injection. Eighty unpremedicated patients, ASA physical status I or II, were assigned to the following groups: group A (n = 15) received 100 mg of lidocaine diluted in 40 mL of NaCl IV; groups B-D (n = 15 in each group) received 100 mg of lidocaine diluted in NaCl, with the addition of 0.05 mg of fentanyl (group B) or 0.5 mg of pancuronium (group C), or both (group D) to a total volume in all groups of 40 mL. Patients in groups A-D underwent elective operations on the forearm, wrist, and hand; for evaluation of safety, in 20 volunteers (group E) the tourniquet was immediately released after IV injection of the three drugs at the previously described doses. The analgesic effect was more profound in group D compared with groups A-C. In group D, 9 of 15 patients had excellent analgesia. In six patients, pain was experienced at the beginning of surgery, but 5 min thereafter patients remained pain free.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraocular pressure changes in response to endotracheal intubation facilitated by atracurium or succinylcholine with or without lidocaine.

Changes in intraocular pressure (IOP) and hemodynamics (SP, DP and HR) were measured in 105 patients ASA I and II randomly assigned into seven equal and comparable groups (A to G) during induction of anesthesia and endotracheal intubation facilitated either by succinylcholine or atracurium with or without lidocaine. IOP decreased significantly (p less than 0.01) after induction of anesthesia with thiopentone in all the groups. While atracurium with or without lidocaine did not affect IOP following complete suppression of train-of-four (groups A, B, and C), succinylcholine per se or in combination with lidocaine (groups F and G) significantly (p less than 0.01) increased IOP after induction with thiopentone but not exceeding the baseline IOP level. IOP was significantly elevated (p less than 0.01) immediately after endotracheal intubation in all the groups when compared to IOP following thiopentone administration. In those patients given atracurium (groups A to E), IOP increased (p less than 0.05) in response to endotracheal intubation above the baseline level only in group B where atracurium was divided into a priming and intubating doses. However, the priming dose did not have any significant effect on the onset time of complete twitch suppression of train-of-four and did not affect the intubation conditions compared with the uniformly excellent conditions found with atracurium over an equivalent bolus dose of the relaxant. In patients who received succinylcholine only (group F), IOP immediately after endotracheal intubation was significantly greater (p less than 0.01) as compared to the baseline and did not return to the baseline level until 3 minutes after endotracheal intubation. The use of lidocaine in combination with atracurium (group D) or succinylcholine (group G) for a rapid sequence intubation did not affect IOP following endotracheal intubation. However, atracurium when used in a rapid sequence intubation could not produce similar intubation conditions when compared with succinylcholine. Consequently, we cannot endorse atracurium as an alternative to succinylcholine for patients with penetrated eye injuries and full stomach requiring rapid sequence intubations. In this context, the role of IV lidocaine in mitigating or preventing the systemic and ocular reactions and especially the acute increase in IOP associated with endotracheal intubation should be emphasized.

The effect of various administration routes of lidocaine on hemodynamics and ECG rhythm during endotracheal intubation.

Observations of arterial blood pressure, heart rate and cardiac rhythm during endotracheal intubation and within a five minute period thereafter were made in 80 patients randomly assigned into four groups. The aim was to study the cardiovascular changes following endotracheal intubation using a standard anesthesia technique and to compare the efficacy of lidocaine in controlling cardiovascular changes using different administration techniques. Anesthesia was induced with thiopentone and succinylcholine followed by endotracheal intubation. In group A, the control group, no lidocaine was given. In groups B, C, and D, lidocaine as laryngotracheal spray, transtracheal injection or intravenous injection in a dosage of 1 mg/kg BW was administered prior to endotracheal intubation. In the control group, laryngoscopy and endotracheal intubation caused a significant rise in blood pressure and heart rate with a high percentage (60%) of cardiac dysrhythmias including serious types. In the lidocaine groups, we observed significantly lower values of blood pressure and cardiac dysrhythmias as compared to the control group. Only 20-25% of the cases showed sinus tachycardia. No significant differences were noticed between the lidocaine groups. We conclude from our study that those patients who had received lidocaine prior to endotracheal intubation showed minimal cardiovascular changes. Lidocaine should therefore routinely be used prior to endotracheal intubation.

[Hormone and metabolism behavior in distress without physical stress]. / Hormon- und Stoffwechselverhalten bei Stresssituationen ohne körperliche Belastung.

The psychological effects on cortisol, human growth hormone (HGH), free fatty acids and lactate were investigated in 10 healthy students using a one hour television game. To insure that only the psychological aspects of the game were being measured, hematocrit, creatininkinase, CK-MB and myoglobin were used as controls. The game began 60 minutes after venapuncture of a lower arm vein with an indwelling catheter. Blood samples were taken 30 and 60 minutes after venapuncture, at intervals of 20 minutes during the game and 30, 60 and 120 minutes after the end of the game. After an initial rise, plasma cortisol levels sank steadily and significantly (alpha = 1%). The HGH level initially fell, but as the game progressed, rose and remained at a high level for a considerable period after the game had ended. These variations however were not statistically significant. The three free fatty acids under investigations, myristinic acid (C14), palmitic acid (C16), and stearic acid (C18), all showed similar levels over the course of the experiment. During the first 20 minutes of the play, free fatty acid levels rose, with stearic acid levels rising the most (52%). The free fatty acid levels then sank as the game progressed, with the palmitinic acid level showing a significant decline (alpha = 1%). The other parameters remained relatively constant during the experiment, with the exception of the CK-MB level, which showed severe, hard-to-interpret variations.

[Ketamine anesthesia in strabismus surgery--hormone and cardiovascular tests]. / Ketaminnarkose bei Schieloperationen - hormonund Kreislaufuntersuchungen.

The effects of ketamine anesthesia on the sympathoadrenal and adrenocortical system, on plasma concentrations of somatotropine and insulin and the circulatory system were investigated in eight patients undergoing strabismus surgery. Therefore blood concentrations of adrenalin, noradrenalin, ACTH, cortisol, somatotropin and insulin as well as arterial blood pressure and heart rate were measured 30 min after premedication (I), 5 min after the initial injection of ketamine (II) and in steady state during the operation (III). Plasma adrenalin and noradrenalin levels were determined fluorimetrically by a modified trihydroxyindole technic; plasma cortisol, somatrotropin and insulin were determined by radioimmunoassay. All examined parameters--except insulin--showed significant changes after induced of anesthesia and during surgery compared to the respective pre-anesthetic values.

[Electrostimulation anesthesia in surgery of the retina and vitreous body]. / Elektrostimulationsanästhesie in der Netzhaut- und Glaskörperchirurgie.

Needling of acupuncture points combined with mechanical or electrical stimulation is insufficient for analgesia for surgical interventions. Therefore a new concept of anesthesia was developed: Electrostimulation has been combined with induction of anesthesia, relaxation and controlled ventilation with a mixture of N2O/O2. We have used this method of anesthesia in patients undergoing retinal and vitreous surgery. Our stimulation has been done by self-adhesive electrodes placed bilaterally in the area of trigeminal nerve and cervical plexus. The aim of this study was to investigate the stress response under electrostimulation anesthesia compared with neurolept anesthesia. Therefore the plasma concentrations of adrenaline, noradrenaline, cortisol and some metabolic parameters (glucose, glycerol, NEFA, ketone bodies) as well as heart rate and arterial blood pressure were measured before, during and after surgery. The changes in the parameters under surgery showed that ESA induces a higher stress reaction than NLA. The differences between the two groups are not significant.

[Chronic alcohol consumption and use of anesthetics - retrospective study of laryngectomies]. / Chronischer Alkoholkonsum und Narkosemittelverbrauch - Eine retrospektive Studie bei Kehlkopfresektionen.

It was the purpose of this clinical retrospective study, which was conducted under homogeneous conditions, to find out whether there is a connection between chronic alcoholism and the consumption of narcotics. We examined a group of tumour patients who had to undergo partial laryngectomy in anaesthesia with neuroleptics. We examined 161 reports with regard to their statistical valuation. 21 patients were selected from group A in whom anaesthesia with neuroleptics had been induced with Thiopental, Droperidol and Fentanyl, and 48 patients from group B in whom anaesthesia with neuroleptics was induced with Flunitrazepam and Fentanyl. The patients of both groups were divided into three groups according to their previous alcohol history: Daily consumption of alcohol group I less than 20 ml, group II 20-100 ml, group III greater than 100 ml. Group A turned out to be too small for statistical valuation. But the mean values of Fentanyl consumption indicated dependence on the quantity of alcohol consumed. Group B was analysed statistically. In spite of the fact that there was a lack of statistical significance, the mean values for the consumption of Fentanyl (in group II higher by 7.8% and in group III higher by 16.9% than in group I) did show a dependence on alcohol abuse, the more so since signs of insufficient anaesthesia were reported by such patients only in whom severe abuse of alcohol had been established.

[Sympathetic activity and blood pressure in normotensive and hypertensive patients undergoing ophthalmic surgery under electrostimulation anaesthesia (author's transl)]. / Sympathikusaktivität und Blutdruckverhalten bei normo- und hypertensiven Patienten unter Elektrostimulationsanaesthesie und Operation.

Plasma adrenaline, noradrenaline, blood pressure and heart rate were determined in 10 normotensive and 10 hypertensive patients undergoing ophthalmic surgery under electrostimulation anaesthesia. Venous blood samples for the determination of the catecholamines by a spectrofluorometric method were taken 30 min after premedication and 45 min after surgical incision. The catecholamine concentrations showed no significant differences neither by comparing the normotensive patients with the hypertensive patients nor by comparing the values during operation with them after premedication in each group. However, in the hypertensive patients blood pressure showed a higher increase during operation than in the normotensive patients.

[The effect of enflurane anaesthesia and operation on the sympathoadrenal and adrenocortical system (author's transl)]. / Verhalten der sympathoadrenalen und adrenocorticalen Aktivität bei Enflurannarkose und Operation.

The effect of enflurane anaesthesia on the sympathoadrenal system, the hypothalamic-hypophyseal-adrenocortical system, and on the circulatory system was investigated in patients undergoing ophthalmic surgery. Blood concentrations of adrenaline, noradrenaline, ACTH, cortisol, and arterial blood pressure and heart rate were measured in 10 patients 30 min after premedication (I), 3-5 min after surgical incision (II), 20 or 45 min after surgical incision (III) and in 7 of 10 patients 10-15 min after extubation (IV). After conventional induction anaesthesia was maintained with enflurane (1.5-2.0%), combined with N2O/O2 2:1, and intermittent relaxation. Plasma adrenaline, ACTH, cortisol and heart rate increased significantly during operation, while plasma noradrenaline and blood pressure did not change significantly. Thus enflurane anaesthesia could not completely inhibit the increased activity of sympathoadrenal and hypothalamic-hypophyseal-adrenocortical system caused by surgical stress.

[Circulatory pattern under electro-stimulation-analgesia and neurolept-anaesthesia in the same patient. A comparative study during retinal and vitreous body operations (author's transl)]. / Kreislaufverhalten unter Elektrostimulations- und Neuroleptanasthesie beim selben Patienten. Eine vergleichende Studie bei Netzhaut- und Glaskörperoperationen.

The present paper reports a comparative study on circulatory conditions of patients who underwent both electro-stimulation- and neurolept anaesthesia. Investigations were carried out in 20 patients who had operations on the retina or vitreous body, either under neurolept or electro-stimulation anaesthesia, and who had to undergo a second of those, so that both types of anaesthesia were administered in each patient. 50% of the patients were showing polymorbidity which is often observed in elderly persons; 5 of the cases were patients suffering from hypertonia which had previously been treated unsatisfactory. As measure for judging the circulatory conditions under either anaesthetic method, the plain measurable values of systolic and diastolic pressure and heart rate were registered. A statistical evaluation of the anaesthetic records was carried out with special consideration of circulatory stability and each method of anaesthesia in the individual group of patients. Concerning circulatory changes, significant variations on 1%- level were found.

[The influence of electro-stimulation anaesthesia on the intraocular pressure (author's transl)]. / Beeinflussung des Augeninnendruckes durch Elektrostimulationsanaesthesie.

The effect of electrostimulation anaesthesia was studied in 23 patients undergoing ophthalmic surgery. Intraocular pressure (IOP) was measured 30 minutes after premedication (I), immediately after intubation (II), after the start of stimulation and relaxation (III) and after the establishment of full relaxation and achievement of full stimulation (IV). After intubation IOP increased from 16.4 +/- 3.3 mm Hg to 19.4 +/- 5.6 mm Hg (p less than 0.05), but decreased at reading IV statistically significantly compared with reading I to 12.7 +/- 2.8 mm Hg. To investigate the effect of electrostimulation alone on IOP, we performed tonometry on 10 control persons, in whom we observed a rise in IOP which can be attributed to current induced contractions of the extraocular muscles. The results demonstrate that there is a direct relation between electrostimulation and extraocular muscles, and we find it essential to relax the patients sufficiently to avoid hazards of IOP elevation.

[Metabolic investigations under electro-stimulation and neurolept anaesthesia (author's transl)]. / Vergleichende Stoffwechseluntersuchungen unter Elektrostimulatins- und Neuroleptanästhesie. Eine klinisch-experimentelle Studie bei Netzhaut- und Glaskörperoperationen.

During ophthalmic operations the effects of electrostimulation anaesthesia on metabolites, as glucose, glycerol, ketone bodies, and on blood gas and acid base parameters, were investigated in 10 patients with normal circulation and metabolism. They were compared with those of a group operated under neuroleptanesthesia. Both groups of patients were treated with muscle relaxation and controlled normoventilation by a N2O/O2 (1:1) mixture. As the determined parameters gave no evidence of significant differences between the two groups, it is concluded that electrostimulation anaesthesia and neuroleptanaesthesia produce comparable analgesia.

[The effect of premedication with thalamonal on the plasma catecholamine levels (author's transl)]. / Wirkung der Prämedikation mit Thalamonal auf den Katecholaminspiegel im Plasma.

The sympathetic suppressant properties of Thalamonal as a premedication is reported in both normotensive and hypertensive patients. The investigations were carried out in 27 patients altogether, of whom 7 were previously treated hypertensives. The plasma catecholamines noradrenaline and adrenaline, the blood pressure and heart rate were monitored before and after premedication.

[Recommendations for transfusion therapy. Volume substitution, raising oxygen transport capacity and replacement of clotting factors (author's transl)]. / Empfehlungen zur Transfusionstherapie. Volumensubstitution, Erhöhung der Sauerstofftransportkapazität und Ersatz von Gerinnungsfaktoren.

The principal aims of whole blood transfusion therapy are simultaneous volume substitution, raising the oxygen transport capacity and the replacement of clotting factors. The necessary control factors for volume substitution are described. It must be borne in mind that the blood undergoes changes during storage which among other things affects the ability of the blood to transport oxygen and the clotting potential. Not only the destruction of thrombocytes must be considered but also the loss of activity of the proaccelerin and the antihemophilic globulin A. For this reason for massive blood transfusions using older blood conserves it is recommended that the loss of activity be compensated by antihemophilic cryoprecipitate.