[Sacroiliac joint blockage caused by bedding after spinal anaesthesia can simulate a neurological complication]. / Lagerungsbedingte Blockierungen des Sakroiliakalgelenkes nach Spinalanästhesien können neurologische Komplikationen vortäuschen - 2 Fallberichte -

Back pain after spinal anaesthesia is often attributed to the spinal anaesthesia and the accompanying puncture. We demonstrate two cases where this problem was not caused by spinal anaesthesia but was due to sacroiliac joint blockage caused by bedding. As far as we know, this complication has not been described yet. When taken into account, it can be treated easily and with success.

[The early axial traction of the cervical spine after anaesthesia with intubation and extreme reclination of the head]. / Die frühe axiale HWS-Traktion bei Gelenkfunktionsstörungen nach extremer Kopfreklination in Intubationsnarkose.

OBJECTIVE: Patients who have an operation under general anaesthesia with muscle relaxation often complain about neck pain if the head needs to be placed in extreme reclination to facilitate surgical access. Patients complain about vertigo, light muscle tenseness but also about severe joint blockages in the neck region. Due to this complication the standard practise in some hospitals is to refer these patients routinely to a physiotherapist postoperatively. This study investigated the influence of an axial traction - a treatment which can easily be learned by anaesthesiologists - on blockages of the cervical spine in those patients. METHODS: In two randomised groups (n = 15 each) of preoperative inconspicuous patients the following directions of motion were investigated: Ante- and retroflexion of C0/1, side inclination C0/1, side nodding and side movement C2/3 to C6/T1, dorsal movement C5/Th2. The examinations took place at the preoperative anaesthetic round, shortly before extubation, two hours after extubation and the next day. Additionally the patients were asked about their discomfort. An axial traction of the cervical spine was performed in one group after extubation. The number of new blockages and the subjective discomfort of the patients was compared with the Chi-Square test. RESULTS: An axial traction of the cervical spine reduces the frequency and the intensity of symptoms significantly. CONCLUSION: It was investigated whether an axial traction of the cervical spine - a treatment that can easily be learned by anaesthesiologists - could improve patients' comfort. The study showed that an axial traction of the cervical spine immediately after extubation reduces the frequency and intensity of symptoms significantly. This treatment is highly effective, not very time consuming and, if done correctly, without any risk for the patient. By using this treatment routinely, additional expenses for physiotherapeutic interventions could be reduced.

The influence of phonological context on the sound errors of a speaker with Wernicke's aphasia.

A corpus of phonological errors produced in narrative speech by a Wernicke's aphasic speaker (R.W.B.) was tested for context effects using two new methods for establishing chance baselines. A reliable anticipatory effect was found using the second method, which estimated chance from the distance between phoneme repeats in the speech sample containing the errors. Relative to this baseline, error-source distances were shorter than expected for anticipations, but not perseverations. R.W.B.'s anticipation/perseveration ratio measured intermediate between a nonaphasic error corpus and that of a more severe aphasic speaker (both reported in Schwartz et al., 1994), supporting the view that the anticipatory bias correlates to severity. Finally, R.W.B's anticipations favored word-initial segments, although errors and sources did not consistently share word or syllable position.

[The continuous monitoring of hepatic venous oxygen saturation in patient monitoring following hemihepatectomy]. / Die kontinuierliche Uberwachung der lebervenösen Sauerstoffsättigung als erweitertes Monitoring während einer Hemihepatektomie.

UNLABELLED: Increasing numbers of liver tumours and liver metastases from other tumours are treated by liver resection. During resection the ligamentum hepatoduodenale is occluded and the liver is exposed to warm ischemia. Duration and intensity of resulting liver ischemia can not be evaluated without special monitoring devices. A fiberoptic catheter placed in a liver vein facilitates continuous recording of the hepatic-venous oxygen saturation (ShvO2). CASE REPORT: We present a case where such a catheter was placed perioperatively in a patient undergoing hemihepatectomy. The liver venous catheter was positioned by guidance of the saturation curve and X-ray. The preoperative oxygen saturation in this liver vein was 80%. During the whole operation, the ShvO2 was continuously monitored. Blood for blood gas analyses was drawn before, during and after the occlusion of the ligamentum hepatoduodenale. Hemodynamic parameters were documented at the same time. The ShvO2 already decreased in the preparation period before the actual occlusion of the ligamentum hepatoduodenale. During the occlusion the ShvO2 dropped to an average of 30% with the lowest value being 13%. After reopening of the hepatic hilus the ShvO2 increased rapidly but did not reach preoperative values which were recorded not earlier than at the end of the operation. CONCLUSION: Duration and intensity of the decreased ShvO2 were recognized early by the liver venous catheter. It was demonstrated that desaturation of the hepatico-splanchnic region already occurred during the period of liver preparation before the ligamentum hepatoduodenale was occluded. Interventions to protect the liver from ischemia should therefore be applied some time before occlusion of the liver hilus. However, clearly defined indications for this invasive monitoring cannot be given at this time. In situations of extended liver resection or in cases of expected technical difficulties a continuous monitoring of the liver-venous oxygen saturation might be beneficial.

[Is quinidine an outmoded drug?]. / Je chinidin zastaralý lék?

In a group of 273 patients with a recently developed atrial fibrillation the authors compared the success of cardioversion in a group of 141 patients using quinidine and a group of 132 patients where for cardioversion different preparations were used. The results of the investigation confirmed the advantages of quinidine as an antiarrhythmic drug used for pharmacological cardioversion of atrial fibrillation.

[Effect of lidocaine administration mode on decreasing injection pain caused by propofol]. / Einfluss der Applikationsart von Lidocain auf die Verminderung des Injektionsschmerzes durch Propofol.

Pain is a well known complication of propofol injection. Many methods are described to reduce it but often empirical ways are used. In this study we attempt to determine the effects of premixing propofol with lidocaine or to preinjecting lidocaine in a hand vein in combination with using a tourniquet before we applicated propofol. Our study shows that both ways are able to reduce the injection pain but premixing with lidocaine 0.05% is less effective than giving a bolus of lidocaine before the propofol injection.

Cardiopulmonary effects of lying position in anesthetized and mechanically ventilated dogs.

Cardiopulmonary effects of right-lateral and supine (on back) lying position were investigated in 8 anesthetized and mechanically ventilated dogs. Complete hemodynamic and respiratory monitoring were obtained. Heart rate was significantly higher, blood pressure, systemic vascular resistance and left and right ventricular stroke work were significantly lower in supine in comparison to right-lateral position. Arterial and mixed-venous oxygen tensions and mixed-venous oxygen saturation were significantly higher in right-lateral position. Compliance was significantly higher and peak ventilation pressure significantly lower in supine position. Arterio-to-mixed-venous-oxygen content difference, oxygen consumption and utilization were significantly higher and respiratory quotient was significantly lower in supine position in comparison to right-lateral position. All other obtained parameters were not be influenced by posture.

[Intraoperative EEG monitoring in hemihepatectomies]. / Intraoperatives EEG-Monitoring bei Hemihepatektomien.

End-stage liver diseases are correlated with specific EEG changes. In chronic liver diseases normal EEG excludes hepatic encephalopathy. To date, it is not known at what time EEG changes appear in liver dysfunction and whether they are to be seen during the unhepatic phase in hemihepatectomies. To clarify this, we analyzed EEGs in 10 patients during hemihepatectomies with the CATEEM system. During the hemihepatectomies an occlusion of the liver hilus for 20-38 minutes (on average 28 minutes) was necessary. During and after the occlusion we found no changes in EEG. We conclude that brief failure of liver function under general anaesthesia is tolerated without danger to the central nervous system.

[The value of serum endotoxin determination after gastrointestinal interventions]. / Die Wertigkeit von Serum-Endotoxin-Bestimmungen nach gastrointestinalen Eingriffen.

Serumendotoxins were measured in 11 patients after gut surgery and compared with healthy people as a standard. In cases of uncomplicated course 3 to 4-fold raised serumendotoxin levels were observed in a typical two-peak pattern. It was not before the fifth day following operation that serum levels declined constantly. In contrast to these findings, patients suffering from septic complications showed a permanently raised endotoxin level, which correlated well with their clinical course. Therefore single peaks of serumendotoxin measured after operation should not be overvalued. Constantly raised levels following operation, however, may indicate some kind of septic complication.

Code teams and the review of cardiac arrests.

A new system for responding to Codes, or resuscitations of patients with cardiopulmonary arrest, was implemented at St Luke's Medical Center, Milwaukee. A teaching program was begun to establish the Advanced Cardiac Life Support (ACLS) guidelines as the standard of care. A task force defined the composition of the Code team and was then designated the Code Review Committee, meeting monthly to review all Codes. Indicators for review were established. Code review is followed by a letter to the physician Code team leader and/or registered nurse. Data for 18 months, still preliminary, show improved compliance with indicators for documentation and for adherence to ACLS guidelines.

[Plasma and tissue concentrations of biphenylacetic acid following 1 week oral fenbufen medication and topical administration of Felbinac gel on the knee joint]. / Plasma- und Gewebekonzentrationen von Biphenylessigsäure nach einwöchiger oraler Fenbufenmedikation bzw. topischer Anwendung von Felbinac-Gel am Kniegelenk.

In an randomised study 30 patients were treated during one week before undergoing an elective surgery of the knee joint with 1 or 2 g respectively of 3% Felbinac gel (biphenylacetic acid gel) or oral 300 mg Fenbufen thrice daily. Biphenylacetic acid (BPAA) is the therapeutically active metabolite of the non-steroid anti-inflammatory drug Fenbufen. Plasma concentrations were measured before, during therapy and at the time of the operation. During the surgery of the knee joint specimens of synovial fluid and -membrane, of cartilage, muscle and tendons as well as of the skin and the subcutaneous fatty tissue were obtained and the BPAA concentrations measured. There was a large variance of the obtained values in all groups. It seems that mainly methodical problems are responsible for this. At the time of surgery, the plasma concentrations following oral administration were with 10,080 ng/ml 20 to 50 times higher than those after topical administration. The tissue concentrations reached 1/8 to 1/2 of the plasma concentrations. The relation of tissue concentrations to plasma concentrations of BPAA was smaller in patients treated with oral administration than in patients treated with topical administration. Therefore a partial direct penetration of Felbinac into the deeper tissue compartments can be assumed. There was no significant difference in plasma-, synovial- or tissue concentrations between the two groups treated with the topical administration. The tissue concentrations were 1 to 2 orders of magnitude lower than those after oral administration. Only in the skin the concentrations were with 9160 respectively 3830 ng/g higher than those obtained after oral application (2110 ng/g).

Adjunct hyperbaric oxygen therapy in periorbital reconstruction.

The abundant blood supply normally found in the periorbital region grants the reconstructive surgeon many options for repair. When this blood supply is altered by such factors as thermal damage or scar formation, classic methods of lid reconstruction may not suffice. In such situations, treatment with hyperbaric oxygen accelerates the process of primary revascularization of full-thickness skin grafts and large composite grafts. Augmentation of capillary budding occurs because hyperbaric oxygen therapy raises the tissue oxygen tension in hypoxic areas to the level needed for extracellular deposition of collagen, which is needed for support of endothelial cells. Hyperbaric oxygen also appears to improve the survival of ischemic skin flaps of the face, although the exact mechanism of this action is unclear. Since 1982, a total of six patients needing periorbital reconstruction has been treated postoperatively with adjunct hyperbaric oxygen. Although the results have been uniformly favorable, a matched series comparing the results with and without hyperbaric oxygen therapy will be required to prove the efficacy of this treatment regimen.

Adrenocortical function after acute carbon monoxide exposure in humans.

The effect of acute carbon monoxide (CO) exposure on plasma adrenocorticotrophic hormone (ACTH), renin activity (PRA), aldosterone, and cortisol levels was studied in patients approximately 80-90 min after removal from the scene of exposure. Nine patients had carboxyhemoglobin (COHb) levels below 15%. Seven patients had COHb levels that exceeded 15% (Group II). Plasma ACTH, cortisol, and aldosterone levels were significantly higher in Group II (elevated COHb). Plasma cortisol and aldosterone levels were appropriate for the levels of ACTH and PRA achieved. We concluded that (a) acute carbon monoxide poisoning leads to elevated plasma corticosteroid levels, and (b) the adrenal gland appears to function normally acutely after exposure to carbon monoxide.