Outbreak of carbapenem-resistant Acinetobacter baumannii in the intensive care unit: a multi-level strategic management approach.

An outbreak of carbapenem-resistant Acinetobacter baumannii (CRAb) occurred in an interdisciplinary intensive care unit, affecting 10 patients. Within hours of recognition of the spread of CRAb an intervention team was instituted for collection of available data, decision-making, communication and monitoring of all interventions performed, including cohorting, temporary stop of admissions, staff education, and enforcement of infection control measures. An area was defined for cohortation of patients colonized with CRAb, with a separate nursing team and a second set of mobile equipment. New transmissions were no longer observed after only four days into the institution of enhanced infection control measures.

[Topical anesthesia before vascular access in children. Comparison of a warmth-producing lidocaine-tetracaine patch with a lidocaine-prilocaine patch]. / Topische Anästhesie vor Venenpunktion bei Kindern. Vergleich eines wärmenden Lidocain-Tetracain- mit einem Lidocain-Prilocain-Pflaster.

BACKGROUND: Venepuncture is one of the most stressful situations for children during induction of general anesthesia. Therefore, many clinicians use a local anesthesia patch (EMLA) containing a mixture of lidocaine and prilocaine in order to reduce the stress for pediatric patients. This study compared the effect of a new heated topical anesthesia delivery system containing lidocaine and tetracaine (Rapydan) with the lidocaine/prilocaine patch EMLA. METHODS: The study design was prospective, randomized, single-blinded and monocenter. A total of 200 children aged from 3 to 13 years were randomized into group E (EMLA) or group R (Rapydan). The primary endpoint of the study was the overall incidence of pain. Additionally, the intensity of pain during venous puncture was evaluated by means of an investigator-based 4 point pain score: 0 no reaction, 1 gentle movement/grimacing, 2 moderate withdrawal of the arm/crying and 3 strong withdrawal/screaming. Furthermore, erythema of the skin, visibility of the veins and success rate of the punctures were assessed. RESULTS: Mean contact time of the patch with the skin was 35 min in both groups. The overall incidence of pain was 46% in group E and 12% in group R (p<0.001). The intensity of pain also differed significantly between the groups. A pain score of 1 was observed in 24% (group E) versus 10% (group R), a score of 2 was documented in 13% (group E) versus 1% (group R) and a score of 3 was observed in 9% (group E) versus 1% (group R; p<0.001). Erythema of the skin was observed more frequently in group R (p<0.001). Visibility of the veins and success rate of venous puncture did not differ significantly. CONCLUSIONS: After a contact time of 35 min the Rapydan patch led to superior analgesia during venous puncture than the EMLA patch. With regard to visibility of the veins and success rate of the punctures, differences between the two patches were not observed.

Attenuation of a rocuronium-induced neuromuscular block in patients receiving prednisolone.

BACKGROUND: This study tested the influence of continuous medication (more than 4 weeks) with prednisolone on a rocuronium-induced neuromuscular block. METHODS: The time course of a rocuronium-induced neuromuscular blockade (0.3 mg/kg) was investigated in 40 patients with chronic inflammatory bowel disease undergoing elective abdominal surgery. The primary end point was the time from the start of injection of rocuronium until recovery of the TOF ratio to 0.9. Twenty patients received continuous medication with prednisolone (group A), and 20 were without glucocorticoid medication (group B). Additionally, another 20 patients without inflammatory bowel disease and without glucocorticoid medication served as control (group C). RESULTS: The onset time was prolonged in group A [253 (51.2) s] compared with group B [187 (61.3) s]. Twitch height at the onset of the block was higher in group A [16.5 (0-61)%] than that in group B [5.0 (0-33)%]. The duration to 25% twitch height was shorter in group A [12.6 (0-20.7) min] compared with group B [16.7 (0-25.3) min] and group C [16.9 (0-29.3) min]. The recovery to a train-of-four ratio of 0.9 was reduced in group A [25.7 (23-34.3) min] compared with group B [34.7 (32.7-44.2) min] and group C [36.5 (31.7-42.3) min]. CONCLUSIONS: Prednisolone treatment in patients with inflammatory bowel disease is associated with a delayed onset and a shorter duration of action of rocuronium. The presence of an inflammatory bowel disease did not influence the neuromuscular block.

Influence of a continuous prednisolone medication on the time course of neuromuscular block of atracurium in patients with chronic inflammatory bowel disease.

BACKGROUND: Corticosteroids interact with neuromuscular blocking agents. However, experimental data are contradictory: enhancement and attenuation of the neuromuscular block has been observed. This study tested the influence of long-term medication with prednisolone on atracurium-induced neuromuscular block. METHODS: Sixty patients with chronic inflammatory bowel disease undergoing elective abdominal surgery were investigated. Thirty patients received a long-term medication with prednisolone (Group A) and 30 were without corticoid medication (Group B). Additionally, another 30 patients without inflammatory bowel disease and without corticoid medication served as control (Group C). The following parameters of an atracurium-induced neuromuscular block (0.25 mg kg(-1)) were measured: onset time, maximum block, recovery to 25% first twitch height, recovery index (time from 25% until 75% recovery of first twitch), duration to recovery to a train-of-four (TOF) rate of 0.7 and 0.9. RESULTS: The groups did not differ with regard to onset time, maximum block, and recovery index. The duration to 25% twitch height was significantly lower in Group A [18.1 (0-30.7) min] compared with Group B [23.5 (0-36.7) min; P<0.05]. Duration to a TOF rate of 0.7 and 0.9, respectively, were significantly reduced in Group A [36.1 (7.9) and 40.9 (9.0 min)] compared with Group B [47.9 (7.6) and 53.4 (9.2) min; P<0.001]. CONCLUSIONS: Long-term medication with prednisolone resulted in a shorter duration of an atracurium-induced neuromuscular block in patients with Crohn's disease or ulcerative colitis. The presence of the inflammatory bowel disease did not influence the time course of the neuromuscular block.

Effects of hyperoncotic or hypertonic-hyperoncotic solutions on polymorphonuclear neutrophil count, elastase- and superoxide-anion production: a randomized controlled clinical trial in patients undergoing elective coronary artery bypass grafting.

BACKGROUND: Hypertonic-hyperoncotic solutions may be an effective treatment for systemic inflammatory response syndrome (SIRS). With regard to the immunomodulatory effects of these drugs, previous studies demonstrated controversial results. Therefore, the present study investigated the influence of different hyperoncotic and hypertonic-hyperoncotic solutions on polymorphonuclear neutrophil leukocyte (PMNL) count, elastase and superoxide-anion production in patients undergoing elective coronary artery bypass grafting (CABG) with cardiopulmonary bypass. METHODS: Fifty patients scheduled for elective CABG with cardiopulmonary bypass were randomly assigned to five groups: (i) NaCl 0.9%, 750 ml/m(2) body surface area (BSA); (ii) hydroxyethylic starch 10%, 250 ml/m(2) BSA and NaCl 0.9%, 400 ml/m(2) BSA; (iii) dextran 10%, 250 ml/m(2) BSA and NaCl 0.9%, 300 ml/m(2) BSA; (iv) hypertonic sodium chloride 7.2%/hyperoncotic hydroxyethylic starch 10%, 150 ml/m(2) BSA; and (v) hypertonic sodium chloride 7.2%/hyperoncotic dextran 10%, 150 ml/m(2) BSA. Blood samples were drawn from arterial, central venous and coronary artery sinus catheters peri-operatively. PMNL count, superoxide-anion production and elastase were recorded. RESULTS: PMNL counts and elastase activity increased in all groups after reperfusion. Superoxide-anion production showed only minor changes. Between groups, no significant differences were demonstrated. CONCLUSIONS: Infusion of clinically relevant doses of hypertonic-hyperoncotic solution did not affect PMNL count, elastase- or superoxide-anion production during elective CABG with cardiopulmonary bypass.

[Haemodynamic effects following preoperative hypervolemic haemodilution with hypertonic hyperoncotic colloid solutions in coronary artery bypass graft surgery]. / Hämodynamische Reaktionen nach präoperativer hypervolämischer Hämodilution mit hyperton-hyperonkotischen Kolloiden bei Koronarbypassoperationen.

OBJECTIVE: Using hyperoncotic colloids as volume replacement to provide haemodynamic stability appears to be a suitable approach to diminish fluid overload and subsequent interstitial edema during cardiac surgery. The aim of the present study was to investigate for the first time the haemodynamic effects following preoperative haemodilution with different hypertonic hyperoncotic colloid solutions in patients undergoing coronary artery bypass grafting. METHODS: A total of 43 patients with normal left ventricular ejection fraction, undergoing elective coronary artery bypass grafting received preoperatively after induction of anaesthesia according to randomisation the following solutions: 1: 750 ml/m(2) (body surface area) NaCl 0.9% ( n=10, control group, NACL), 2: 250 ml/m(2) 10% HES 200/0.5 plus 400 ml/m(2) NaCl 0.9% ( n=9, HES), 3: 250 ml/m(2) 10% dextran 40 plus 300 ml/m(2) NaCl 0.9% ( n=8, DEX), 4: 150 ml/m(2) hypertonic NaCl (7.2%) 10% HES 200/0.5 (n=8, HYPER-HES), 5: 150 ml/m(2) hypertonic NaCl (7.2%) 10% dextran 60 ( n=8, HYPER-DEX). Haemodynamic measurements were performed immediately before and 15 min after haemodilution and up to 60 min after termination of extracorporeal circulation in 10 min intervals. Fluid balances were calculated separately, during the time period of surgery, postoperatively up to 24 h after termination of surgery, and during the course of extracorporeal circulation. RESULTS: After haemodilution with colloid solutions, a marked increase was observed in all patients and with HYPER-HES and HYPER-DEX a statistically significant increase in cardiac index (CI: +38%, +54%), stroke volume index (SVI: +42%, +40%), and oxygen availability (DO2: +34%; +41%), respectively, was observed during the pre-bypass period. At the same time right and left ventricular filling pressures increased slightly in all patients but these changes did not differ among the treatment groups. Heart rate and mean arterial pressure remained almost unchanged in all groups. The amount of crystalloid solutions required by the patients during surgery was markedly decreased with HES and DEX and significantly decreased with HYPER-HES and HYPER-DEX (1,013+/-341 ml/m(2), 1,096+/-234 ml/m(2)) compared to the control group NACL (1629+/-426 ml/m(2)). Serum sodium concentrations increased with HYPER-HES and HYPER-DEX to maximal values of 150+/-3 mmol/l and 149+/-4 mmol/l, respectively (baseline 141+/-3 mmol/l, 141+/-1 mmol/l) CONCLUSIONS: Compared to isotonic saline solution, preoperative volume replacement with hyperoncotic colloids improves haemodynamic conditions during the pre-bypass period in patients with normal left ventricular function undergoing coronary artery bypass grafting. Additionally intraoperative crystalloid solution requirements are reduced. The volume saving effects are increased with administration of hyperoncotic colloids in a preparation with hypertonic saline solution, whereas the choice of the colloid, either hydroxyethyl starch or dextran seems to be of minor importance.

[Procalcitonin plasma concentrations and systemic inflammatory response following different types of surgery]. / Procalcitoninplasmakonzentration und systemische inflammatorische Antwort nach verschiedenen operativen Eingriffen.

OBJECTIVE: Procalcitonin (PCT) is currently recommended as a suitable parameter to detect and to evaluate the course of bacterial, fungal or parasitic infections. However, recent studies provide evidence that surgical trauma and humoral mediators of inflammation, respectively,may induce PCT synthesis, thereby reducing the validity and reliability of PCT as an "infection-monitoring" parameter. The aim of the present study was to assess and to compare PCT and CRP (C-reactive protein) plasma concentrations in patients presenting without infection following different types of surgery in the absence or presence of a systemic inflammatory response syndrome (SIRS). METHODS: PCT and CRP plasma concentrations were assessed daily on postoperative days 1-5 and maximal values were determined in 94 patients. The patients were allocated to four groups of different types of surgery as follows: A: minor, primarily aseptic surgery, B: major abdominal surgery, C: major vascular surgery and D: thoracic surgery including esophagectomy. All categories were divided into two subgroups representing patients with and without SIRS, respectively. RESULTS. PCT plasma concentrations increased moderately compared to normal values in 21% of patients after minor and aseptic surgery (A), in 27% and 41% after major vascular (C) and thoracic (D) surgery, respectively, and in 65% of patients after major abdominal (B) surgery. The difference between PCT concentrations in patients undergoing major abdominal surgery and the patients after minor, aseptic surgery was significant ( p<0,05: A vs. B). Comparing the patients presenting with or without systemic inflammatory response (SIRS), no significant differences in PCT concentrations between groups could be observed. In the majority of patients PCT values rose to peak levels on the first and second postoperative days, followed by a rapid decline based on the plasma half-life of PCT. In contrast, postoperative CRP plasma concentrations were markedly elevated above normal values in all investigated patients during the whole observation period. Between-categories statistical analysis revealed significant differences comparing patients undergoing minor and aseptic surgery with patients after major vascular, and thoracic surgery, respectively ( p<0,05,A vs.C, D). CRP concentrations were significantly increased in patients with systemic inflammatory response compared to patients with normal postoperative course in surgical categories B, C, and D, respectively ( p<0,05). CONCLUSIONS: Postoperative PCT plasma concentrations in patients presenting without signs of infection are largely influenced by the type of surgical procedure. During the first and second postoperative day PCT concentrations are more frequently elevated in patients after major abdominal, major vascular and thoracic surgery compared to patients undergoing minor, aseptic operations. Thus an "infection monitoring" considering PCT value analysis during the postoperative course may transiently be impeded after major and particularly after intestinal surgery during the first 2 days postoperatively, whereas it appears not to be substantially affected by the presence or absence of systemic inflammatory response.

[Narcotrend stages and end-tidal desflurane concentrations. An investigation during recovery from desflurane/remifentanil anaesthesia]. / Narcotrend-Stadien und endexspiratorische Desflurankonzentrationen Eine Untersuchung bei Ausleitung von Desfluran-Remifentanil-Anästhesien.

OBJECTIVE: [corrected] As indicated by the manufacturer the EEG monitor Narcotrend trade mark (MonitorTechnik, Bad Bramstedt) can be used to analyse EEG effects of volatile anaesthetics, however, published data are missing. This study evaluated the emergence from a desflurane/remifentanil anaesthetic and was designed to investigate the relationship between Narcotrend stages (version 2.0 AF) and end-tidal desflurane concentrations and to identify the pattern of changes of the Narcotrend stages during recovery. METHODS: Adult patients scheduled for orthopaedic surgery were premedicated with 0.15 mg/kg diazepam orally in the evening and on the morning before surgery. Narcotrend EEG electrodes were positioned on the patient's forehead as recommended by the manufacturer. For induction of anaesthesia, remifentanil was infused at 0.4 microgram/kg/min and propofol 2 mg/kg was given for hypnosis. After neuromuscular blockade and orotracheal intubation, remifentanil was reduced to 0.2 microgram/kg/min, and desflurane in O(2)/air was added according to clinical needs. After termination of surgery, administration of anaesthetics was discontinued and simultaneously, the fresh gas flow was increased to 10 l/min of O(2) while the respirator pattern was left unchanged. Narcotrend stages and end-tidal desflurane concentrations were recorded as data pairs at intervals of 1 min during emergence from anaesthesia; data evaluation included the last 7 min before extubation. RESULTS: A total of 50 patients (mean age +/-SD 44.4+/-13.0 years) were studied and 400 data pairs were obtained. A decreasing depth of anaesthesia as indicated by the Narcotrend was associated with significantly lower end-tidal desflurane concentrations: for E (general anaesthesia with deep hypnosis) 3.6+/-1.0 vol%, for D (general anaesthesia) 1.7+/-0.8 vol%, for C (light anaesthesia) 0.7+/-0.3 vol% and for A and B (awake or sedated) 0.5 vol%. A reduction of end-tidal desflurane concentrations was accompanied by a shift of Narcotrend stages from C/D/E to A/B/C. CONCLUSION: During emergence from desflurane/remifentanil anaesthesia, a reduction of end-tidal desflurane concentrations was detected by the EEG monitor Narcotrend and classified as a typical change of distribution of Narcotrend stages.

Recovery after remifentanil and sufentanil for analgesia and sedation of mechanically ventilated patients after trauma or major surgery.

We investigated the analgesic effect and the neurological recovery time after administration of remifentanil in mechanically ventilated patients in an intensive care unit. Twenty patients, after trauma or major surgery with no intracranial pathology, were randomized to receive either remifentanil/propofol (n=10) or sufentanil/propofol (n=10). A sedation score and a simplified pain score were used to assess adequate sedation and analgesia. Medication was temporarily stopped after 24 h. Immediately before and 10 and 30 min after, the degree of sedation and pain score were evaluated. Adequate analgesia and sedation was achieved with remifentanil 10.6 microg kg(-1) h(-1) and propofol 2.1 mg kg(-1) h(-1), or sufentanil 0.5 microg kg(-1) h(-1) and propofol 1.3 mg kg(-1) h(-1). The difference in propofol dose between groups was significant. Ten minutes after terminating the medication, the degree of sedation decreased significantly after remifentanil and all patients could follow simple commands. During the following 20 min, all patients with remifentanil emerged from sedation and complained of considerable pain. By contrast, in the sufentanil group, only six (7) responded to commands after 10 (30) min and their pain score remained essentially unchanged during the 30-min observation period. We conclude that, in contrast to sufentanil, remifentanil facilitates rapid emergence from analgesia and sedation, allowing a clinical neurological examination within 10-30 min in mechanically ventilated patients with no intracranial pathology.

[Gamma-hydroxybutyric acid-ethanolamide (LK 544). The suitability of LK 544 for sedation of patients in intensive care in comparison with midazolam]. / Gammahydroxybuttersäure-Ethanolamid (LK 544). Die Eignung von LK 544 zur Sedierung von Intensivpatienten im Vergleich mit Midazolam.

OBJECTIVE: In this phase 2 study gammahydroxybutyric acid-ethanolamide (GHB-ethanolamide) was compared with midazolam for sedation of patients in the intensive care unit (ICU). GHB-ethanolamide is a new derivative of gammahydroxybutyric acid, a drug commonly used for sedation in intensive care patients. METHODS: A total of 29 non-intubated, spontaneously breathing patients following major surgery, were randomly assigned to 2 groups: group A (n = 14) received 150 mg/kg GHB-ethanolamide i.v. followed by 150 mg/kg/h. Group B (n = 15) received 0.025 mg/kg midazolam i.v. followed by 0.025 mg/kg/h. The degree of sedation was assessed over a 3-5 h period both clinically by the Ramsay Score and by the spectral frequency index (SFx), derived by continuous computerized EEG recording (CATEEM). RESULTS: EEG: the SFx showed a significantly deeper sedation compared to baseline values, 10, 60 and 120 min after start of sedation in the GHB-ethanolamide group. By contrast, no difference could be observed compared to baseline values in the midazolam group. A comparison between both groups showed a deeper sedation in the GHB group 60 and 120 min after start of sedation. The Ramsay Score increased from baseline values of 2.0 (2.0/2.0) to 3.0 (2.0/3.0) during sedation (Median (25th/75th percentile) and no significant differences could be observed between groups. In the Midazolam group the sedation of two patients had to be terminated because of side effects (Ramsay Score 6 and paradoxical, agitated reaction). CONCLUSIONS: GHB-ethanolamide produces adequate sedation for extubated and spontaneously breathing ICU patients. The drug might be safer than midazolam with regards to side effects such as respiratory depression.

Interpleural analgesia does not influence postthoracotomy pain.

UNLABELLED: The management of postthoracotomy pain is a problem and may contribute to atelectasis, leading to hypoxemia, pulmonary infection, and permanent alveolar damage. We sought to determine the efficacy of interpleural analgesia for pain control and to evaluate independent predictors for postoperative pain intensity. Eighty-three patients undergoing elective anterolateral (n = 37) and posterolateral (n = 46) thoracotomy were included in a prospective, randomized, double-blinded trial. Patients were assigned to receive either 0.5% bupivacaine or saline solution interpleurally every 4 h for 10 doses postoperatively. All patients also received patient-controlled analgesics (PCA) with piritramide as the opioid for additional pain control. Pain was assessed on the basis of PCA requirements and by using a visual analog scale. Visual analog scale scores and PCA requirements were not different between groups. Both interpleural bupivacaine and saline significantly reduced pain scores 30 min after the administration. We concluded that pain reduction by interpleural instillation of bupivacaine reflects a placebo-like effect; however, interpleural analgesia is not effective in patients undergoing lateral thoracotomy. Sex and surgical approach were shown to influence postoperative pain intensity at rest, but not during coughing. The female patients, and those undergoing posterolateral thoracotomy, exhibited higher pain scores. This observation appears to be of only marginal clinical significance. The efficacy of interpleural analgesia to reduce postoperative pain intensity in patients after lateral thoracotomy is controversial. In this study we demonstrated a lack of efficacy of interpleural analgesia. IMPLICATIONS: The efficacy of interpleural analgesia to reduce postoperative pain intensity in patients after lateral thoracotomy is controversial. In this study, we demonstrated a lack of efficacy of interpleural analgesia.

[Bioavailability of sotalol in short bowel syndrome]. / Bioverfügbarkeit von Sotalol bei verkürzter gastrointestinaler Passage.

BACKGROUND: The individual bioavailability of enterally administered drugs is usually uncertain in case of reduced bowel length. Routine measurements of plasma concentrations are available only for a small number of drugs. The daily dose recommended by the manufacturers may result in subtherapeutic plasma concentrations when given to such patients. CASE REPORT: In 2 patients with hemodynamically relevant atrial fibrillation and reduced gut length application of increasing sotalol doses was initiated. For the assessment of the individual bioavailability plasma concentrations were measured via HPLC immediately before and 2 hours after enteral application of sotalol. Judging by clinical criteria both patients were treated successfully. Even in the patient with severe short bowel syndrome (stomach, duodenum and 50 cm jejunal remnant) doubling of the daily dose led to a substantial increase in plasma concentrations. CONCLUSION: Effective enteral medication with sotalol in patients with short residual bowel is possible. Normal plasma concentrations can be achieved by administering doses according to the manufacturers' instructions. In case of severe short bowel syndrome, the measurements of plasma concentrations may be beneficial in supervising dose-adjustment.

[Puerperal sepsis due to infected episiotomy wound]. / Puerperalsepsis durch infizierte Episiotomienaht.

A healthy 31-year-old woman showed a severe septic shock syndrome a few days after vaginal delivery. In the episiotomy wound were found Group A Streptococci and E. coli. Although an antibiotic therapy was instituted immediately, the condition of the patient worsened. Platelet counts fell below 5000/microliter and she developed respiratory, cardiocirculatory and renal insufficiency, so that mechanical ventilation, high-dose-catecholamine therapy and continuous venovenous hemodiafiltration had to be performed. In the course of the disease the patient showed a reversible cardiomegaly with pulmonary hypertension and an extensive desquamation of the skin. Fever persisted in spite of the fact that in all following clinical and laboratory examinations no septic focus could be revealed any longer. She recovered slowly and could not be weaned from the respirator for four weeks because of a severe critical illness polyneuromyopathy.

[Successful thrombolysis of a fulminant lung embolism during cardiopulmonary resuscitation]. / Erfolgreiche Thrombolyse einer fulminanten Lungenembolie unter kardiopulmonaler Reanimation.

A healthy 38-year-old woman suffered a sudden cardiac arrest 2 days after a vaginal hysterectomy. Although standard cardiac life support (CPR) was instituted immediately after the event, it was not possible to re-establish a spontaneous circulation for about 40 min. Systemic intravenous thrombolytic therapy with slow injection of 1.5 million IU urokinase was performed as a final life-maintaining measure because of the high probability that the underlying cause was a pulmonary embolus; 10 min later (after 60 min of ongoing CPR) the patient regained a stable circulation. She survived without neurological deficit in spite of the long duration of CPR.

The Bland-White-Garland syndrome. Clinical picture and anaesthesiological management.

We report a five-month-old infant with an impaired left ventricular ejection fraction as a result of Bland-White-Garland-syndrome (BWGS). Total intravenous anaesthesia with fentanyl and midazolam was used as the anaesthetic technique. After aortic reimplantation of the left coronary artery, weaning from cardiopulmonary bypass (CPB) was prolonged and was only successfully managed with high dose noradrenaline, dopamine and dobutamine. Persistent myocardial dysfunction led to prolonged intensive care treatment. Seven months after surgery, left ventricular function and clinical condition have improved significantly.

[Spinal anesthesia in infancy using bupivacaine 0.5%. The effect of an adrenaline addition on duration and hemodynamics]. / Spinalanästhesie im Säuglingsalter mit Bupivacain 0.5%. Der Einfluss eines Adrenalinzusatzes auf Wirkdauer und Hämodynamik.

The duration of spinal anaesthesia in infants is short compared to adult patients. When tetracaine is used, the addition of epinephrine significantly prolongs the duration. For bupivacaine, however, the influence of epinephrine on the duration is not clear. We investigated the effects of epinephrine 1:200,000 added to bupivacaine 0.5% on duration and haemodynamics. PATIENTS AND METHODS. Ten former pre-term infants with postnatal respiratory problems, scheduled for bilateral inguinal hernia repair, were enrolled in the study after informed parental consent had been obtained. The infants were fasted at least 4 h prior to surgery. If they did not receive i.v. infusions before surgery, a bolus of 10 ml/kg Ringer's acetate was injected after inserting the i.v. cannula, followed by a continuous infusion of 8 ml/kg 2/3 N NaCl with 5% dextrose. Spinal anaesthesia was performed in a sitting position with 0.6 ml bupivacaine 0.5%. Five patients received plain bupivacaine (group I) and five bupivacaine with epinephrine 1:200,000 (group II). Heart rate registered by ECG and non-invasive blood pressure were recorded prior to positioning the baby for lumbar puncture and 2, 5, 10, and 20 min after injection of bupivacaine. The duration of spinal anaesthesia was defined as the time from injection to the time when the first movements of the legs were observed after stimulation. For testing statistical differences the U test was used between the groups and the Wilcoxon and Wilcox test within the groups. RESULTS. (expressed as median and range). Additional epinephrine significantly prolonged the duration of spinal anaesthesia (group II: 95 min [60-120] vs group I: 50 min [37-85]). Haemodynamic parameters did not differ at any time between or within the groups. In group I, one infant had high spinal anaesthesia with impaired respiration but without cardiovascular effects; after 10 min of assisted ventilation by mask, sufficient respiration as judged by pulse oximetry and clinical observation had returned. The duration of spinal anaesthesia in this child was 60 min. CONCLUSIONS. Epinephrine 1:200,000 significantly prolongs the duration of spinal anaesthesia in former preterm infants. Haemodynamic parameters in this age group remain unchanged during spinal anaesthesia and are not influenced by the addition of epinephrine.

[Pharmacodynamic effects of the phosphodiesterase inhibitor enoximone during exposure to the volatile anesthetics halothane and isoflurane in coronary surgery patients]. / Pharmakodynamische Effekte des Phosphodiesterase-hemmers Enoximon unter dem Einfluss der volatilen Anästhetika Halothan und Isofluran beim koronar-chirurgischen Patienten.

AIM OF THE STUDY: We investigated the pharmacodynamic effects of the phosphodiesterae inhibitor enoximone in the presence of halothane and isoflurane in 20 patients, ASA class III, aged 45-75 years, undergoing coronary artery bypass grafting. The study was approved by the local Medical Ethics Committee and patients' informed written consent was obtained. METHODS: After induction of anaesthesia (midazolam, fentanyl, etomidate and pancuronium) all patients received either halothane 1 MAC (group I, n = 10) or isoflurane 1 MAC (group II, n = 10), followed 20 min later by enoximone 0.5 mg/kg. Haemodynamic variables were measured and blood samples (arterial, mixed venous) were obtained before the administration of the volatile anaesthetics (control, t0), immediately (t1) and 5 (t2) min after steady state conditions with halothane or isoflurane, as verified by the end-expiratory concentration and 5 (t3) and 10 (t4) min after the injection of enoximone. Heart rate (HR), mean arterial pressure (MAP), mean pulmonary artery pressure, pulmonary capillary wedge pressure and right atrial pressure were recorded. Cardiac (CI) and stroke volume indices, systemic (SVR) and pulmonary vascular resistance, oxygen availability (AO2) oxygen consumption and oxygen extraction rate were calculated using standard formulae. RESULTS: In both groups HR remained essentially unchanged throughout the investigation period. MAP decreased significantly in both groups under steady state conditions with the volatile anaesthetics (group I: 19%; group II: 30%) but remained unchanged after subsequent injection of enoximone. After administration of halothane SVR remained essentially unchanged, whereas isoflurane decreased SVR significantly by 20%. After enoximone, there was a significant decrease in SVR in both groups (group I: 26%; group II: 25% compared with the values obtained after halothane and isoflurane respectively). Halothane and isoflurane decreased CI significantly and to a similar degree (group I: 17%; group II: 17%). After the injection of enoximone CI increased significantly and reached control values in both groups. AO2 decreased significantly after administration of the volatile anaesthetics (group I: 19%; group II: 21%) and increased significantly after administration of enoximone, returning to control values. Halothane (7%) and isoflurane (13%) produced a significant increase in oxygen extraction. After bolus injection of enoximone oxygen extraction decreased significantly and returned to control value in group II. In group I enoximone decreased oxygen extraction significantly compared with control. CONCLUSION: Our results suggest that in the presence of halothane or isoflurane the phosphodiesterase inhibitor enoximone produces a comparable increase in cardiac output and decrease in systemic vascular resistance in patients with coronary artery disease.

[Patient-controlled administration of alfentanil during interventional measures--an alternative to general anesthesia]. / Patientengesteuerte Applikation von Alfentanil bei interventionellen Massnahmen--eine Alternative zur Allgemeinanästhesie.

OBJECTIVE: In 360 patients undergoing extracorporal shock wave lithotripsy (ESWL) the effects of an opioid analgesia with alfentanil (Rapifen) were investigated. METHODS: Starting with an intravenous bolus injection of 30 micrograms/kg repetitive injections of 15 micrograms/kg were administered when pain recurred. In 12 patients arterial blood samples were taken to determine alfentanil serum concentrations and blood gases. The pharmacokinetics of alfentanil were described by an open two-compartment model. RESULTS: In spite of multiple applications of the opioid no relevant cumulation could be seen. Although the patients received 3 l/min of oxygen via nasal tube, a significant decrease in paO2 was observed. pH was decreased and there was a significantly increased paCO2. No significant changes in arterial blood pressure were observed. Two patients developed rigidity of the chest wall. CONCLUSION: For short operations with only mild noxious stimuli opioid analgesia with alfentanil is a suitable procedure if applied by an experienced anaesthesiologist.