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OBJECTIVE: To assess stress hormone response in traumatised patients studied at the site of injury and on their way to hospital. METHODS: The study was prospective. Blood samples were taken from 77 patients immediately after the arrival of the emergency physician at the site of the accident (t1) and shortly before patients' admission to hospital (t2). Plasma concentrations of beta endorphin, cortisol, adrenocorticotrophic hormone (ACTH), prolactin, and growth hormone were measured. RESULTS: Trauma in out-of-hospital patients resulted in remarkably increased concentration of growth hormone within minutes. ACTH, cortisol, and prolactin were only moderately increased. No significant correlations were found between hormone levels and blood pressure or heart rate. The plasma ACTH concentration was significantly lower before admission to hospital than immediately after the accident. Plasma cortisol, prolactin, and growth hormone concentrations were not significantly different between the two points of observation. In samples taken immediately after the accident (t1), there was a positive correlation between both beta endorphin and prolactin and the injury severity score, whereas cortisol levels were negatively correlated with injury severity score, suggesting impaired cortisol release from the adrenal cortex after severe injury. At t1 ACTH was correlated with cortisol and beta endorphin. Patients with head injuries had hormone concentrations similar to those without head injuries but with a similar injury severity score from injuries in other parts of the body. CONCLUSIONS: Lower cortisol concentrations in the very severely injured might be due to failure of the adrenal cortex to respond normally to ACTH stimulation. Growth hormone seems to play a major role in the response to trauma, reflecting an immediate stress response.

Pyrazolopyrimidinediones are a novel series of compounds that inhibit growth of Helicobacter pylori specifically. Using a variety of methods, advanced analogues were shown to suppress the growth of H. pylori through the inhibition of glutamate racemase, an essential enzyme in peptidoglycan biosynthesis. The high degree of selectivity of the series for H. pylori makes these compounds attractive candidates for novel H. pylori -selective therapy.

Die meisten Patienten auf Intensivstationen leiden an einer respiratorischen Insuffizienz und werden einer respiratorischen Therapie unterzogen, wobei eine Atemwegsverbindung zwischen dem Respirationstrakt des Patienten und dem Beatmungsgerat geschaffen werden mus.

Changes in the EEG power spectrum were studied in 50 patients (ASA status I or II), receiving either 2 mg.kg-1 of racemic ketamine or 1 mg.kg-1 of S-(+) ketamine in a randomized and double-blind manner after prior administration of 0.1 mg.kg-1 of midazolam. The patients receiving intramuscular premedication with midazolam about 45 minutes prior to induction of anaesthesia showed, in a deliberately quiet environment and mostly in the early morning, a delta dominated EEG (56% delta power) with a reduced alpha peak (17% alpha power) and an average median of 4 Hz as the baseline findings of the EEG power spectrum. The intravenous administration of midazolam led to activation of the lower beta range (13-18 Hz) and the subsequent injection of ketamine caused an increase in activity in the fast beta range (21-30 Hz), both being accompanied by a reduction of delta power from 56% to 40%. Correspondingly, an increase in the median frequency was noted. Causing nearly the same changes in EEG, S-(+) ketamine was confirmed to be twice as potent as racemic ketamine.

Die Durchfuhrung einer Narkose ist heute wie kaum eine andere arztliche Tatigkeit durch die unmittelbare Anwendung einer Vielzahl hochkomplizierter technischer Gerate gekennzeichnet. Mit diesen konnen wir sowohl eine geradezu unubersehbare Zahl von Vitalparametern und Geratefunktionen fortlaufend aufzeichnen und uberwachen, als auch unsere therapeutischen Masnahmen, wie die Beatmung oder die Zufuhr von Anasthetika, subtil dosieren.

Lachgas (N2O, Stickoxydul) nimmt unter den Anasthetika eine Sonderstellung ein. Es ist das alteste und das auch heute noch am weitesten verbreitete Anasthetikum. Dies verdankte es in der Vergangenheit v. a. seiner analgetischen Wirkung und seiner Nichtentflammbarkeit. Heute werden als Vorteile in erster Linie seine gunstigen physikalischen Eigenschaften mit der daraus resultierenden guten Steuerbarkeit sowie die vermeintlich fehlende Toxizitat und fehlende Kreislaufbeeintrachtigung genannt. Gerade die letzten 3 Aspekte fuhrten dabei zu der weitverbreiteten Ansicht, Lachgas entsprache - bis auf seine Schwache bzgl. der hypnotischen Wirksamkeit - am ehesten den Vorstellungen von einem idealen Anasthetikum.

In a randomized, double-blind study, we have examined the stereoselective disposition and pharmacodynamic characteristics of ketamine in surgical patients after i.v. administration of S(+)-ketamine 1 mg/kg body weight (25 patients) or racemic ketamine 2 mg/kg body weight (25 patients). S(+)-Ketamine was not inverted to R(-)-ketamine. After racemate administration we observed statistically significant (P < 0.01) smaller clearance and volume of distribution for R(-)-ketamine compared with S(+)-ketamine. In contrast, the pharmacokinetic variables of S(+)-ketamine were not significantly different between treatment groups. Systolic and diastolic arterial pressure and heart rate increased significantly (P < 0.005) in both groups. At 1, 3 and 15 min after S(+)-ketamine administration, significantly greater increase in systolic and diastolic pressures were observed compared with the racemate group. There was no correlation between the changes in haemodynamic variables and plasma catecholamine concentrations, which remained unaffected after administration of the medications.

Lachgas (N2O, Stickoxydul) nimmt unter den Anasthetika eine Sonderstellung ein. Es ist das alteste und am weitesten verbreitete Anasthetikum. Dies verdankte es in der Vergangenheit v. a. seiner analgetischen Wirkung und seiner Nichtentflammbarkeit. In jungerer Zeit wurden in erster Linie seine gunstigen physikalischen Eigenschaften mit der daraus resultierenden guten Steuerbarkeit sowie die vermeintlich fehlende Toxizitat und fehlende Kreislaufbeeintrachtigung geschatzt. Gerade die letzten 3 Aspekte fuhrten dabei zu der weitverbreiteten Ansicht, Lachgas entsprache ’ bis auf eine Schwache bezuglich der hypnotischen Wirksamkeit ’ am ehesten den Vorstellungen von einem idealen Anasthetikum.

Ketamin ist ein Allgemeinanasthetikum, dessen Wirkungsspektrum sowohl anasthetisch-hypnotische als auch analgetische Eigenschaften umfast. Die klinische Wirkung des Ketamins wurde von Anfang an als „dissoziative Anasthesie“ bezeichnet, womit sein charakteristischer narkotisch-kataleptischer Effekt umschrieben wird, der aus einer Koordinationsunterbrechung zwischen neokortikal-thalamischen und limbisch-retikularen Hirnstrukturen resultiert [13, 10, 46].

A prospective study was undertaken to determine the efficacy of monitoring somatosensory-evoked potentials (SEP) during carotid artery surgery in predicting a new ischemic neurologic deficit. Three hundred seventy-six patients underwent 400 reconstructions of the internal carotid artery. The mortality rate of the entire series was 0.8%. In 383 procedures, SEP amplitudes were always present during cross-clamping of the internal carotid artery. In spite of that, three neurologic deficits occurred, but all were associated with technical failures and not related to clamping ischemia. Complete loss of SEP amplitudes was noted in 17 procedures. Five of seven patients without an indwelling shunt showed a neurologic deficit after surgery, whereas shunt insertion in 10 resulted in three neurologic deficits. It is concluded that at present SEP recording is an accurate monitoring method in detecting clamping-related cerebral ischemia during carotid artery surgery.

Discussion of paranasal sinusitis as a nosocomial infection in the mechanically ventilated intensive care (ICU) patient has recently been intensified. Some authors have emphasized nasotracheal intubation as a possible pathogenetic pathway. The aim of this study was to investigate the impact of nasotracheal or orotracheal intubation on the development of sinusitis in ICU patients.In a prospective study, we followed 44 patients who required mechanical ventilation (greater than 24 h) in the ICU because of prolonged recovery from abdominal, thoracic, or posttraumatic surgery. Twenty patients were intubated nasotracheally and 24 orotracheally. Assignment to the groups was random. All were provided with a nasogastric tube and initially treated with systemic antibiotics. They received local antimicrobial prophylaxis of the nose, oropharynx, and stomach. Daily a-scan examinations of the maxillary sinuses were performed from the day of admission to the ICU until extubation, tracheotomy, death, or transfer. The average observation period was 6.9 days in the oral group and 7.1 days in the nasal group. In the case of a pathologic finding, aspiration of the antral sinus was carried out. In this study sinusitis indicated a sonographic finding; it did not necessarily imply a bacterial infection.At the beginning of the observation period, 6 patients in the oral group and 4 in the nasal group already had a pathologic maxillary sinus finding. At the end, in 15 of 24 in the oral group and 19 of 20 in the nasal group unilateral or bilateral sinusitis could be demonstrated. Development of bilateral sinusitis (13/20 in the nasotracheal group, 8/24 in the orotracheal group) was mainly observed after the appearance of unilateral sinusitis. The site corresponded to the site of the nasal tube in 65%. Unilateral paranasal infection was observed in nasotracheally and orotracheally intubated patients after an average of 2.8 and 2.6 days, respectively, whereas bilateral sinusitis had an average time delay of 4.5 and 5.7 days. Aspiration of the maxillary sinus was performed in 22 of 34 cases with sinusitis. Pathogenic organisms could be demonstrated in 7 of 13 nasotracheally intubated patients but only 2 of 9 with orotracheal tubes.We found that patients intubated orotracheally developed significantly less sinusitis than those intubated nasotracheally. Edema, local infection of the nasal mucosa, or mechanical obstruction of sinus drainage pathways by the tube are possible explanations. The fact that 63% of orally intubated patients had a pathologic maxillary sinus finding as well suggests that in addition to other reasons, an increased central venous pressure, positive pressure ventilation, and the supine position must be regarded as predisposing factors that increase the incidence of sinusitis. We conclude that the conditions of critically ill patients predispose to the development of sinusitis. Nasotracheal intubation is to be regarded as an additional risk, and therefore oral intubation should be preferred.

In order to test the hypothesis that halothane is more effective and safer than enflurane and isoflurane in patients with reactive airway disease, a clinical trial was performed to compare these three agents in patients with asthma or chronic obstructive pulmonary disease (COPD). METHODS. After obtaining institutional approval and informed consent, 31 patients with bronchial asthma or COPD were studied (FEV1 less than 65% of FVC); all patients underwent extensive surgery of the paranasal sinuses. Premedication consisted of i.m. atropine and promethazine; anesthesia was induced with diazepam, fentanyl, etomidate, and succinylcholine and maintained with pancuronium and 50% N2O in O2 together with one of the volatile agents, halothane, enflurane, or isoflurane, selected at random. Patients were mechanically ventilated. On the basis of respiratory pressures, volumes, and flows, inspiratory (Rin) and expiratory (Rex) resistance and compliance (C) were calculated after induction (control), 15 min after the addition of the volatile agent (1.25 MAC), every 15 min during the surgical procedure, and at the end of the operation. RESULTS. In 1 case, airway resistance increased markedly a few minutes after administration of isoflurane. The results obtained in this patient were not included in the evaluation of the data. There were no statistically significant differences in the preoperative data or control values of Rin, Rex, and C among the three groups (n = 10 each). With the respective inhalational agents, Rin increased maximally between 3% (halothane) or 8% (enflurane) and 21% (isoflurane), Rex between 16% (halothane, enflurane) and 29% (isoflurane). For the most part, however, these changes were not statistically significant as compared with controls. Intergroup comparisons failed to reveal any statistically significant differences either. In all groups C decreased continuously to about 90% of control. DISCUSSION. The results show that in patients with asthma or COPD, airway resistance remains virtually unchanged during surgery and anesthesia under halothane or enflurane anesthesia. With isoflurane, however, the resistance may rise by a slight but not statistically significant extent. Furthermore, marked bronchospastic reactions occurred in 2 patients in the isoflurane group. Thus, the three volatile anesthetics studied were not found to be unequivocally safe and effective in preventing increases in bronchomotor tone. However, pharmacodynamic effects other than those on respiration (e.g., cardiovascular actions, arrhythmogenic threshold, metabolism, toxicity) must additionally be taken into consideration.

During carotid surgery a monitoring device that will identify patients with inadequate cerebral perfusion and impending cerebral damage after carotid clamping is desirable. Such patients may benefit from cerebral protective measures, which should be applied selectively as their use can also lead to complications. METHODS. In order to evaluate the reliability of somatosensory evoked responses as a means of detecting patients with insufficient collateral perfusion after carotid cross clamping, a prospective study involving 482 operations for reconstruction of supraaortic vessels was performed. Somatosensory evoked potentials (SEPs) were recorded from a cervical (C2-Fz) and a parietal (C3'/C4'-Fz) electrode above the ipsilateral hemisphere following stimulation of the contralateral median nerve. RESULTS. In 22 procedures (4.6%) complete flattening of the cortical SEP occurred after carotid cross clamping. In 7 of 9 cases in which no indwelling shunt was used despite electrical silence neurological deficits were found postoperatively. The SEP amplitude was restored in 12 of the remaining 13 patients with complete loss of the SEP after shunt insertion. Only 3 of these patients demonstrated neurological impairment. During 460 operations evoked potentials were always present. Nevertheless, 5 neurological sequelae were noticed despite unchanged SEP after carotid artery clamping. All deficits, however, were caused by embolization and were unrelated to reduced blood flow after carotid cross clamping. CONCLUSIONS. Our results confirm the reliability of SEP monitoring for the detection of significant cerebral ischemia after carotid clamping. In absence of the cortical SEP immediate shunt placement is necessary to avoid neurological deficits. On the other hand, the risks attendant on indiscriminate cerebral support (embolism after shunt placement, cardiac ischemia due to induced hypertension) can be avoided in the presence of cortical potentials. This allows protection of the heart and the brain by anesthetic management and enables the surgeon to perform endarterectomy with no hurry, to avoid technical failure. SEP data may also be helpful in decision making on reoperation to look for sources of embolization. In conclusion, advanced monitoring by somatosensory evoked responses may help to improve the outcome of carotid surgery.

Kardiale und neurologische Komplikationen sind die Hauptursachen der peri-operativen Morbiditat und Mortalitat nach operativen Eingriffen an der A. carotis. Bleibende neurologische Schaden und Myokardinfarkte treten in einer Haufigkeit von je 1–3% auf [11, 29]. Die hohe Rate kardialer Zwischenfalle ist dadurch begrundet, das die Arteriosklerose der hirnversorgenden Arterien, derentwegen eine Karotisendarterektomie durchgefuhrt wird, in der Regel keine isolierte Erkrankung, sondern nur eine Erscheinungsform einer Systemerkrankung aller Gefase ist. Dementsprechend haufig finden sich unter den Patienten solche mit einem fortgeschrittenen Alter und einer Reihe von Begleiterkrankungen, insbesondere des Herz-Kreislauf-Systems.

Die Einfuhrung der Intubation in die Anasthesietechnik war vermutlich der wichtigste Fortschritt fur die Narkose. Erst die Intubation schuf die Voraussetzung fur eine Vielzahl heute durchgefuhrter operativer Eingriffe, sie wurde dabei fur den Kranken der wesentlichste Beitrag fur seine Sicherheit, nicht zuletzt durch die Ermoglichung besonderer Narkoseverfahren mit minimaler Belastung fur den Patienten. Vor allem durch die Intubation sind Komplikationen der Narkose so selten, das ein groser Anteil an der verbleibenden Narkosemorbiditat und -mortalitat durch die Intubation selbst hervorgerufen wird. Damit kommt der Verminderung intubationsbedingter Risiken ein besonders hoher Stellenwert zu. Insbesondere geht es darum, Schaden zu vermeiden, die aus einem lokalen Trauma, aus reflektorischen Reaktionen des Herz-Kreislauf-Systems oder einer Hypoxie — meist als Folge einer schwierigen Intubation — entstehen.

Multimodal EPs and heartratevariability-measurements in comatose patients have been performed for few years at the university hospitals of Graz and Erlangen.The following data and parameters are analysed and discussed: brainstem auditory evoked potentials, mechanical evoked long-latency SEP, VEP recorded over the central and occipital region and heartratevariability (HRV). The method of data acquisition and processing is described and normative data are introduced. For the long-latency EP-components a signal-to-noise-ratio (SNR) is calculated. SNR is defined as ratio of the largest EP peak-to-peak amplitude and the mean amplitude (standard deviation) of a period prior to the stimulation. An unmeasureable or questionable EP is defined when SNR < 2,6. For the vertex-SEP the following mean + standard deviation was obtained: SNR = 10,6 ± 4,6; the vertex VEP was calculated with SNR = 7,0 ± 3,0. The SNR of the bipolar recorded occipitally VEP was 3,9 ± 2,0. Heartratevariability measurements in normal persons revealed the following mean ± standard deviation at a heartrate of 67,8/min ± 10,8/min: HRV = 7,8 % ± 2,5 %. Seit einigen Jahren werden multimodale EP-Untersuchungen und Messungen der Herzratenvariabilitat an komatosen Patienten der Universitatskliniken in Graz und Erlangen durchgefuhrt. Dabei werden im einzelnen bewertet: akustische Hirnstammpotentiale, durch mechanische Vibrationsreize ausgeloste spate SEP, zentrale und okzipitale VEP und Herzratenvariabilitat. In dieser Arbeit sind die Mesmethoden beschrieben und werden die Normbereiche der einzelnen Signale bzw. Parameter definiert. Fur die Bewertung spater EP-Komponenten wird ein Signal-Storverhaltnis verwendet, das sich aus dem Quotienten aus maximaler Peak-to-peak Amplitude und der mittleren Streuung vor der Stimulation ergibt. Bei einem Signal-Storverhaltnis < 2,6 wird das EP als fraglich bzw. nicht vorhanden klassifiziert. Fur das Vertex-SEP wurde ein Signal-Storverhaltnis = 10,6 ± 4,6 (Mittelwert ± Streuung) und fur das Vertex-VEP ein Signal-Storverhaltnis = 7,0 ± 3,0 errechnet. Das bipolar okzipitale VEP ergab ein Signal-Storverhaltnis = 3,9 ± 2,0. Die Herzratenvariabilitat an Normalpersonen liegt im Bereich von 7,8 % ± 2,5 % bei einer Herzrate von 67,8/min ± 10,8/min.

The depressant effects of continuous positive-pressure ventilation (CPPV) on circulatory and renal functions, and their reversal by dopamine (5 μg/kg/min), dobutamine (7.5 μg/kg/min), or a combination of the two drugs (dopamine 2.5 and dobutamine 5 μg/kg/min) were studied in 10 patients with acute respiratory distress syndrome (ARDS) requiring treatment with positive end-expiratory pressure (PEEP). In comparison with a control period of intermittent positive-pressure ventilation (IPPV), CPPV increased arterial oxygen tension (PaO2) by 11%, but decreased the cardiac index (CI) by 21% and systemic oxygen transport (TO2) by 14%. The additional administration of catecholamines resulted in an increase both in CI — by 38% (dopamine), 33% (dobutamine), and 47% (combination) — and in TO2 —by 34% (dopamine), 28% (dobutamine) and 46% (combination). The observed changes in PaO2 were negligible. The changeover from IPPV to CPPV resulted in a marked decrease in urinary output (42%), sodium excretion (52%), and in creatinine clearance (36%). Under dopamine or the combination of dopamine and dobutamine there was a two- to threefold improvement in these parameters as compared with the CPPV figures, while under dobutamine alone, the increases were virtually of the same order as the increase in CI. It may be concluded that both dopamine and dobutamine are suitable for correcting impaired circulatory and renal functions induced by CPPV. Their beneficial effects on circulatory and respiratory parameters are virtually identical. In the presence of renal failure, the use of dopamine or a combination of the two drugs is recommended.

Pain-management in pediatric-oncological patients is an interdisciplinary task. The working group pain--therapy of GPO tries to work up an analgesic concept for this group of patients. Pre-existing experience in the therapy with sustained release Morphine and Metamizol should be considered. The documentation-system is just worked up, we ask all pediatric oncological groups to cooperate.

Gewebsbeschadigung und Gewebszerstorung sind die adaquaten Reize der Sinnesmodalitat Schmerz. Qualvolle Schmerzempfindung ist deshalb die unausweichliche Begleiterscheinung jeder schweren Verletzung. Zunachst beherrschen sensorische und affektiv-emotionale Komponenten der Nozizeption das Erscheinungsbild: Stohnende und schreiende Schwerverletzte, agitierte, konfusionierte, aber auch stuporose Patienten gehoren zum Bild jeder chirurgischen Erstbehandlungseinheit. Dementsprechend ist die Linderung akuter Schmerzen meist das dringlichste Anliegen des Verletzten an seinen Arzt, humanitare Aspekte veranlassen zunachst unser therapeutisches Handeln.

Multimodal EPs and heart rate variability-measurements in comatose patients have been performed for few years at the university hospitals of Graz and Erlangen. The following data and parameters are analysed and discussed: brainstem auditory evoked potentials, mechanical evoked long-latency SEP, VEP recorded over the central and occipital region and heart rate variability (HRV). The method of data acquisition and processing is described and normative data are introduced. For the long-latency EP-components a signal-to-noise-ratio (SNR) is calculated. SNR is defined as ratio of the largest EP peak-to-peak amplitude and the mean amplitude (standard deviation) of a period prior to the stimulation. An unmeasurable or questionable EP is defined when SNR less than 2.6. For the vertex-SEP the following mean +/- standard deviation was obtained: SNR = 10.6 +/- 4.6; the vertex VEP was calculated with SNR = 7.0 +/- 3.0. The SNR of the bipolar recorded occipitally VEP was 3.9 +/- 2.0. Heart rate variability measurements in normal persons revealed the following mean +/- standard deviation at a heart rate of 67.8/min +/- 10.8/min: HRV = 7.8% +/- 2.5%.

Alle Formen der Allgemeinanasthesie beeintrachtigen die ausere Atmung. Angriffspunkte sind die neurale Steuerung, die neuro-muskulare Ubertragung, der pulmonale Gasaustausch und die pul-monale Hamodynamik. Die in der analgetischen Anasthesie verwendeten Opioide beschranken sich dabei im wesentlichen auf die Reduktion des zentralen Atemantriebs. Diese zentrale Atemdepression der Opioide ist lange bekannt; bei sachgemaser Anwendung als Schmerzmittel spielte sie jedoch nie eine bedeutsame Rolle. In der analgetischen Anasthesie, insbesondere der Neuro-leptanasthesie (NLA) mit Fentanyl, war dies bis vor wenigen Jahren offensichtlich hochstens wahrend der Narkose ein Problem. Lange Zeit wurde der Einsatz der NLA sogar fur Narkosen bei erhaltener Spontanatmung empfohlen oder diskutiert. Inzwischen ist jedoch die kunstliche Beatmung als Conditio sine qua non wahrend der NLA allgemein anerkannt; eine Atemdepression wahrend der Narkose hat damit keine Bedeutung. Fur die postoperative Atmung wurde nach Neuroleptanasthesien im Gegensatz zur Inhalationsnarkose sogar ein positiver Nettoeffekt auf die Blutgaswerte als Folge einer lang dauernden postoperativen Analge-sie nachgewiesen (6).

Die Vorteile der Neuroleptanaesthesie bei Einleitung und Aufrechterhaltung einer Narkose sind anerkannt. Zunehmende Unsicherheit verursachen jedoch Berichte uber postoperativ aufgetretene Atemdepressionen, die gelegentlich im Atemstillstand gipfeln sollen. Hierfur wird ein biphasischer Verlauf der Atemdepression nach Gabe von Fentanyl verantwortlich gemacht [1,2].

Die Bestimmung der Narkosetiefe mit Hilfe neurophysiologischer Methoden scheint sich in zunehmendem Mase als sinnvolle Erganzung eines Narkose-Monitorings anzubieten. Die Analyse des EEGs und die Ableitung sensorisch evozierter Potentiale stehen dabei im Vordergrund (siehe dazu G. Pfurtscheller: Kombiniertes EEG-EP-Moni-toring, S. 34 ff.).

Starke (narkotische) Analgetika bzw. Opioide werden seit langer Zeit zur medikamentosen Anasthesievorbereitung im Rahmen einer unmittelbar praoperativen Pramedikation verwendet

Die Langzeitsedierung gehort zu den aktuellen Themengebieten, mit denen sich Anasthesisten auseinandersetzen. Der relativ neue Begriff der „Langzeitsedierung“ definiert dabei in Analogie zur „Langzeitbeatmung“ Verfahren zur psychovegetativen Dampfung und motorischen Ruhigstellung beatmungspflichtiger Patienten auf Intensivstationen mit Hilfe zentralwirksamer Pharmaka. Die Aktualitat der Langzeitsedierung ruhrt wohl v. a. aus der Erkenntnis, das sie einem Patienten nicht immer nutzt und auch keine harmlose Begleitmasnahme ist, sondern das — wie die Untersuchungen von Ledingham mit Etomidate eindrucksvoll demonstrierten — ein ungunstiges Sedierungsregime sogar die Mortalitat von Intensivpatienten steigern kann.

Plasma concentrations of mepivacaine were determined after retrobulbar anesthesia. The measured maximal blood levels that can produce systemic side effects range from 1.23 to 4.88 micrograms/ml. We therefore recommend preoperative and intraoperative monitoring of arterial blood pressure and ECG.

Pramedikation heist fur den Anasthesisten, zum einen einen ersten personlichen Kontakt zum Patienten wahrend der Abendvisite herzustellen und zum anderen die Verordnung gewisser Medikamente und Masnahmen zur praoperativen Vorbereitung des Patienten. Das bedeutet letzlich eine psyehomedikamentose Fuhrung des Patienten und den Aufbau eines stabilen Vertrauensverhaltnisses [34].

The influence of anesthetics on respiratory mechanics is of considerable clinical relevance. During anesthesia an increase in total respiratory resistance can complicate ventilation, particularly in cases with preexisting obstructive bronchial disease. Reduced compliance and a deterioration of resistance can favour or induce postoperative respiratory complications. It is also desirable that anesthetic drugs have as little influence as possible on compliance and resistance. In patients with primarily increase airways resistance, a bronchospasmolytic effect and an inhibition of respiratory secretion are positive.

Pain-management in pediatric-oncological patients is an interdisciplinary task. The working group pain--therapy of GPO tries to work up an analgesic concept for this group of patients. Pre-existing experience in the therapy with sustained release Morphine and Metamizol should be considered. The documentation-system is just worked up, we ask all pediatric oncological groups to cooperate.

Bei der Komplexitat der Atmungsregulation liefert die Messung globaler respiratorischer Parameter (Frequenz und Atemminutenvolumen) oft keine zuverlassigen Hinweise fur die Beurteilung atemdepressiver Wirkungen von Pharmaka. Darum wird haufig im Rahmen von solchen Fragestellungen die CO2-Antwort verwendet, die einen einzelnen ruckgekoppelten Atemantrieb beschreibt. Fur die Interpretation von Messungen der CO2-Antwort mus die Variationsbreite der Methode bekannt sein, besonders wenn Aussagen zum Vorliegen diskreter individueller Veranderungen (z. B. fur das Erkennen von „Rebound-Phanomenen“ nach Narkosen) gemacht werden sollen.

The effects of the inhalational anaesthetic, isoflurane, on two major parameters of respiratory mechanics--resistance and compliance--were studied in a total of 30 patients. With increasing inspiratory concentrations of isoflurane, resistance was measured in 5 spontaneously breathing patients using the oscillation method. In 16 mechanically ventilated patients resistance and compliance were calculated from airway pressure, gas flow, and tidal volume. In 9 patients with asthma or COPD the course of resistance and compliance was recorded intraoperatively. An increase in resistance of up to 117% of the initial volume occurred during spontaneous respiration, and was caused by a decrease in tidal volume. During mechanical ventilation with constant tidal volume, no definite changes in resistance or compliance were seen with increasing isoflurane concentrations. In the patients with elevated airway resistance there were only minor, statistically non-significant changes in resistance and compliance. The results show that the effects of isoflurane on respiratory mechanics do not differ from those of halothane or enflurane. Therefore, isoflurane may be considered appropriate for use in patients with impaired airway resistance.

Von allen postoperativen Komplikationen besitzen die typisch chirurgischen Komplikationen zweifellos den hochsten Stellenwert. Wahrend sich jedoch solche Ereignisse oft geradezu erwartet einstellen oder eine statistisch zu erfassende Zahl als operationsimmanent akzeptiert wird, gelten andere Storungen des postoperativen Verlaufes, wie thromboembolische oder bronchopulmonale Zwischenfalle, eher als unerwartete Argernisse. Dies trifft in besonderem Mase fur die bronchopulmonale Komplikation zu, wobei die Haufigkeit jedoch hier nicht nur von pulmonalen Vorerkrankungen, sondern auch deutlich von den chirurgischen Erfordernissen einer langen Operationszeit und der Grose sowie Lokalisation des Eingriffes abhangt.

Berichte uber postoperative Atemdepressionen nach Opioidanasthesien mit Fentanyl haben den Verdacht auf eine biphasische Atemdepression aufkommen lassen [1]. Eigene Messungen der CO2-Antwort bis 3,5 h nach Narkoseende konnten jedoch eine solche Wirkung auf die Atmung nicht beweisen, jedoch auch nicht zweifelsfrei widerlegen, zum Teil allerdings deswegen, weil Verlaufsmessungen der CO2-Antwort nach Narkosen nur auserst schwierig interpretiert werden konnen [6]. Klinisch erkennbare Atemstorungen nach Opioidanasthesien treten am ehesten in der ersten halben Stunde nach Narkoseende auf [5]. Ziel der vorliegenden Untersuchung sollte es darum sein: 1. Unabhangig von der CO2-Antwort durch eine kontinuierliche Registrierung mehrerer atemregulationsabhangiger Grosen wahrend einer Zeitdauer von 30 min im Anschlus an eine Opioidanasthesie zusatzliche Erkenntnisse hinsichtlich einer moglichen phasischen Atemdepression nach Einsatz von Fentanyl zu gewinnen und 2. im gleichen Untersuchungsgang Unterschiede zwischen der Standardneuroleptanasthesie und einer Benzodiazepin-(Diazepam-)Fentanyl-Kombination in bezug auf die postoperative Atmung zu quantifizieren.

In 40 patients who underwent large abdominal or thoraco-abdominal operations, the efficacy of intentional coughing was determined by recording the peak expiratory flow rate (PEFR) of two consecutive coughs. The measurements were made preoperatively and then 1, 2, 24, and 36 hrs. postoperatively. They consisted of two series, the first one completely uninfluenced, the second one following detailed instruction and manual assistance by the therapist. Before instruction, PEFR of the first cough averaged 5070 ml/s. and statistically significantly increased to 7100 ml/s. after instruction. The postoperative values decreased to about 30% of those found preoperatively. It was not before the first postoperative day that the values began to improve to above 40%. In all instances, the absolute PEFR-values of the first cough were significantly higher by 16 to 60% than those of the second one. From the results it is concluded that, after abdominal or thoraco-abdominal surgery, continuous instruction and assistance by the personnel are crucial for the efficacy of coughing.

Plasma concentrations of mepivacaine were determined after retrobulbar anesthesia. The measured maximal blood levels that can produce systemic side effects range from 1.23 to 4.88 µg/ml. We therefore recommend preoperative and intraoperative monitoring of arterial blood pressure and ECG.

Ein Thoraxtrauma wird oft zu spat erkannt, zu spat behandelt und hat daher eine zu hohe Letalitat. Die Unterlagen von 570 stationaren Patienten (1. 1. 1978 bis 30. 9. 1982) wurden statistisch ausgewertet. Haufigste Ursache ist ein Verkehrsunfall (58,4%). Extrathorakale Begleitverletzungen lagen in 50,2 % vor. Haufigste Verletzungsfolge sind Rippenfrakturen (72 %) in Kombination mit Hamato-Pneumothorax. Durch Verbesserung des Rettungswesens mit kurzen Transportzeiten und konsequenter Atemtherapie konnte die Letalitat beim kombinierten Thoraxtrauma von 34 auf 17 % gesenkt werden. Das isolierte Thoraxtrauma hat dagegen eine gleichbleibende Letalitat von 6 bis 9 %.