Der Anaesthesist
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Case Reports
[Intra-abdominal bleeding after myocardial infarction with cardiopulmonary resuscitation and thrombolytic therapy].
Adverse effects of resuscitation due to closed-chest cardiac massage are common, and the incidence is increased when an incorrect technique is used. Nevertheless, thrombolytic therapy of a myocardial infarction can become necessary even after cardiopulmonary resuscitation (CPR). In these patients, the risk of thrombolytic therapy-induced bleeding is immanent. ⋯ In patients with thrombolytic therapy after CPR and persisting cardio-vascular instability, a resuscitation injury with consequent haemorrhagic shock should be suspected. For diagnosis, chest X-ray films and abdominal and thoracic sonography are useful and practicable, even at the bedside. Anaesthetic management should focus on adequate monitoring, replacement of volume and oxygen carriers, fast restoration of plasma coagulation, and careful, blood pressure-adjusted maintenance of anaesthesia.
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Randomized Controlled Trial Comparative Study Clinical Trial
[Tamm-Horsfall protein, alpha-1- and beta-2-microglobulin as kidney function markers in heart surgery].
After cardiac surgery, transient renal dysfunction often occurs. Regional differentiation of these processes is possible only using invasive techniques, including renal biopsy. Approximately 30 different plasma protein components have been identified in the urine of healthy individuals by means of qualitative and quantitative immunochemical methods. ⋯ Measurement of the excretion of THp and alpha-1 and beta-2 MG is a useful addition to present clinical standards for recognising early changes in renal function. The increases in the postoperative period after cardiac surgery showed tubular damage even in patients without predictive risk factors or clinical signs. In patients with renal dysfunction open heart surgery and extracorporeal circulation led to significant tubular damage.
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High-frequency ventilation techniques have been applied for a number of years for laryngeal surgery in order to ventilate patients without endotracheal tubes or catheters. A further development of high-frequency jet ventilation (HFJV) is the technique of superimposed HFJV (SHFJV), which was achieved by combining low- and high-frequency jet streams. Although good clinical results were observed, which have been published in the past, the clinical details of development of SHFJV have not been previously published. ⋯ The pulsations of the high-frequency jet stream induce continuous alveolar ventilation. The positioning of the jet nozzles in the jet laryngoscopy has the result that the velocities are already decreased at the tip of the laryngoscope and decrease further with distance from the nozzles. This prevents possible damage to the laryngeal mucosa.
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Randomized Controlled Trial Clinical Trial
[Analgesia-sedation for maxillo-facial surgery with midazolam-pentazocine and miazolam-ketamine. Clinical double-blind study of anxiety, analgesia, sedation and amnesia].
Ketamine and midazolam, applied as intravenous medication for conscious sedation in day-case maxillo-facial surgery, has been proven to be superior to pentazocine and midazolam concerning cardiovascular parameters and respiratory depression. The aim of this study was to evaluate the effects of low-dose ketamine/midazolam on anxiety, analgesia, amnesia and subjective feelings. METHODS. 140 out-patients (ASA I) were randomly divided into four groups. The double-blind study was prospective. ⋯ Local anaesthesia (LA), articaine 4% plus epinephrine 1:200,000 (n = 35); test group P/M: LA, additional pentazocine 0.40 mg/kg bw and midazolam 0.075 mg/kg bw i.v. (n = 35); test group K25/M: LA, additionally ketamine 0.25 mg/kg bw and midazolam 0.075 mg/kg bw i.v. (n = 35), test group K50/M: LA, additionally ketamine 0.5 mg/kg bw and midazolam 0.075 mg/kg bw i.v. (n = 35). LA was injected 3 min after application of the systemic medication in the test groups or application of a placebo (saline 0.9%) in the control group. Three further minutes later, operation was started. For evaluation questionnaires, visual analogue scales (VAS) and the state-trait anxiety inventory (STAI) were used. For testing retrograde and anterograde amnesia, acoustic sensations were delivered before application of the systemic medication (a Christmas carol) and during operation (the German national anthem). RESULTS. The control group and the test groups were comparable with regard to biological data, duration of operation, applied dosage of local anaesthetics and actual anxiety before operation. The patients in all test groups rated intraoperative anxiety as mild, in contrast to the control group. Nearly no pain sensation during the operation was remembered in all test groups. Retrograde amnesia was not found in any group. Complete anterograde amnesia was observed in all test groups with respect to the intraoperative sensation, but even in the control group 50% of the patients did not remember having heard the national anthem. As subjective feelings negative criteria were mainly reported in the control group, where as in all test groups positive sensations dominated. Dreams were reported mostly after the higher dosage of ketamine, but no patient experienced any unpleasant dreams. The clinical assessment of the different regimes were excellent for test groups P/M and K50/M, modest for the control group and test group K25/M. Postoperatively, patients of test group P/M were remarkably sedated, but no clinically relevant sedation or motor weakness were observed in the other groups. Postoperative pain sensations were rated more intense in all test groups than in the control group. In test groups P/M and K25/M an increasing pain level was recorded during the postoperative period, with the consequence of a higher demand rate for analgesics. CONCLUSIONS. Dental surgery can be performed safely with low-dose ketamine/midazolam. Compared to pentazocine/midazolam, the higher dosage of ketamine (0.5 mg/kg bw) showed identical results intraoperatively, but was superior during the postoperative period (vigilance), and thus may represent a suitable dosage. The lower dosage of ketamine resulted in worse operating conditions, but a dosage higher than 0.5 mg/kg bw might lead to unconscious sedation and might increase the frequency of unpleasant dreams.