["Relaxant" awake but still relaxed]. / Relaxiert wach und trotzdem "relaxed"

We report on a 23-year-old female patient who underwent removal of the implants after maxillary surgery. At the end of surgery the administration of anaesthetic agents was discontinued. During the following 30 min several attempts were made to wake the patient, but she did not respond to verbal or pain stimuli. No changes in heart rate, blood pressure vegetative reactions such as sweating, lacrimation, or mydriasis were noted. Protective reflexes like coughing could not be elicited. After 30 min neuromuscular monitoring was applied and indicated residual muscle paralysis after the use of mivacurium. The patient was again sedated and transferred to the ICU, where she was mechanically ventilated for an additional 9 h. An atypical cholinesterase was determined as the underlying reason for the prolonged action of mivacurium. Retrospectively, the patient remembered the attempted wake-up period in detail. However, she reported no feelings of fear or helplessness because she had faith in the anaesthesiologist, a close friend of the patient's family for many years, who kept her calm and comfortable by talking to her during the entire period. Several months after the incident, the patient reported having neither increased fear of surgery nor any negative psychological effects on her life following this incident of awareness.

Controlled-release oxycodone is better tolerated than intravenous tramadol/metamizol for postoperative analgesia after retinal-surgery.

PURPOSE: We assessed the clinical efficacy and tolerance of controlled-release oxycodone (CRO), comparing it with intravenous tramadol/metamizol combination in this prospective, randomised, double-blind study of 35 ASA physical status I-III patients undergoing retinal-surgery. METHODS: General anaesthesia using remifentanil and propofol was performed for surgery. On arrival in the recovery room patients were randomly allocated to two groups. The controlled-release oxycodone group (CRO Group) received 10 mg CRO. 12 h after the initial dose another 10 mg CRO were administered. Simultaneously with the initial CRO dose, and every 4 h up to 24 h postoperatively, the CRO Group received intravenous isotonic saline infusion. On arrival in the recovery room the tramadol/metamizol group (TM Group) received a placebo tablet, and 12 h later a second placebo. Simultaneously 100 mg tramadol combined with 1 g metamizol were administered intravenously every 4 h until 24 h postoperatively. All patients had access to intravenous opioid rescue medication. RESULTS: The AUC for quality of analgesia was significantly higher in the CRO Group than in the TM Group (p = 0.0023). Patient rated quality of analgesia significantly higher in the CRO Group than in the TM Group 8 h (p = 0.048), 16 h (p = 0.009) and 24 h (p = 0.001) postoperatively. There was no statistical difference in AUC for pain scores between groups (p = 0.205). The CRO Group experienced significantly less nausea than the TM Group (p = 0.012). Six patients in the TM Group in contrast to none in the CRO Group interrupted the study before finishing the study protocol (p = 0.022). CONCLUSIONS: We conclude that CRO administered twice in the first 24 h postoperatively is superior to intravenous tramadol/metamizol for postoperative analgesia after retinal surgery, with fewer adverse events and greater patient satisfaction.

Anaphylactoid reactions after cisatracurium administration in six patients.

IMPLICATIONS: We report six cases of anaphylactoid reaction after the administration of the muscle relaxant cisatracurium. They include two first-time documented anaphylactoid reactions after a precurarising dose. These incidents challenge existing views of a substantially reduced anaphylactoid potential of cisatracurium relative to other muscle relaxants.

[Accuracy and dose dependency of the train-of-four count]. / Zuverlässigkeit und Dosisabhängigkeit des Train-of-Four count.

UNLABELLED: The estimation of a nondepolarizing neuromuscular block using the train-of-four (TOF) count shows wide differences compared to the mechanomyographic measurement. The purpose of this study was to evaluate the clinical significance of these differences. METHODS: 89 patients (ASA I-II) in 6 groups received general anesthesia with fentanyl, propofol and a single dose atracurium (150, 200, 250, 300, 450 and 600 microg/kg). Neuromuscular transmission was monitored by stimulation of the ulnar nerve at the wrist with supramaximal TOF stimuli repeated every 15 s using a peripheral nerve stimulator. The isometric force contraction of the m. adductor pollicis was recorded. The height of T1 at reappearance of the second (T2) and fourth (T4) twitch was noted. Also noted was the time difference between the first reappearance of T4 and the 25% recovery of T1. Statistical significance of the results was calculated by the h-test of Kruskal and Wallis. Testing the reliability of the TOF count, a 95% interval of confidence was calculated RESULTS: There were no significant differences between the mean ages, heights and weights of the six groups. T2 and T4 re-appeared at 11+/-2% and 24+/-6% recovery of T1, respectively. Again, there were no significant differences between the six dose groups (Fig. 1). The time difference between the re-appearance of T4 and the 25% recovery was -1.0+/-2 (range: -5-3) minutes. The calculation of a 95% interval of confidence indicated a recovery between 14% and 33% at reappearance of T4, 25% recovery can be expected 5 min before to 3 min after reappearance of T4, respectively. CONCLUSIONS: At reappearance of T4, a recovery of neuromuscular block of 25% is missed only by 3 to 5 min during relaxation with atracurium. We consider this margin of error as unimportant for clinical use. More-over we were able to show that the TOF-count is not dose dependent.