Der Anaesthesist
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The laryngeal mask (LM) was developed by A. Brain to overcome the disadvantages of the face mask (impractical) and the tracheal tube (invasive). Today this new instrument is applied on a broad scale in Great Britain and with growing interest in continental Europe. ⋯ Apart from anaesthesia, the LM can be used for bronchoscopy in children, for difficult intubations and as a preliminary airway in cases of resuscitation. Two studies performed in Great Britain have evaluated the LM for resuscitation. The investigations should be confirmed in German-speaking countries.
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An 81-year-old patient had prolonged competitive neuromuscular blockade with train-of-four ratios of 0.1 and 0.5, respectively, after two successive anaesthesia procedures (enflurane-N2O/O2; vecuronium-succinylcholine-sequence) for transurethral prostate resection. Although antagonism with neostigmine was promptly successful after the first, 65-min period of anaesthesia (1.5 mg vecuronium for precurarization, 100 mg succinylcholine for intubation, 3 mg vecuronium), repetitive and chronologically staggered administration of neostigmine after the second, 30-min period of anaesthesia (1 mg vecuronium for precurarization, 100 mg succinylcholine for intubation) had hardly any effect, so that the patient had to be ventilated mechanically for a total of 4.5 h. Laboratory analysis revealed homozygous, atypical, plasma cholinesterase (790 U/l; dibucaine number 23; genotype E1aE1a). ⋯ It must be assumed that a complete phase II block developed after the first succinylcholine exposure owing to the longer duration of anaesthesia; the purely competitive component (train-of-four ratio 0.1) was easily antagonized by neostigmine. At the time of the attempted antagonism after the second, shorter period of anaesthesia, however, block transformation was still incomplete (train-of-four ratio 0.5). The administration of neostigmine therefore rather intensified the depolarization segment of the mixed block, so that repeated attempts at antagonism then inhibited any further block transformation.
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At Leipzig University, preoperative pulmonary function testing has been performed for about 3 years in order to detect and classify patients at high pulmonary risk. During the postoperative period, the risk of developing pulmonary complications is particularly high due to factors influencing respiratory mechanics such as the supine position, pain, residual effects of narcotic drugs, etc. It has often been emphasised that an underlying ventilatory disturbance such as obstructive lung disease or smoking may enhance the postoperative pulmonary risk, although the extent of the influence of preoperative pulmonary diseases on the postoperative complication rate is still controversial. ⋯ For minimising perioperative pulmonary complications, respiratory care (prophylaxis and therapy) adequate for the functional risk of the patient is necessary. We assume that intensive pre- and postoperative respiratory care and therapy in patients with underlying reductions in ventilatory function can help to avoid or reduce respiratory complications. The modification of Miller's scheme proposed after evaluating the postoperative course of our patients provides a differentiated prognostic model that allows the establishment of an appropriate and economical therapeutic regimen of perioperative pulmonary care.
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Randomized Controlled Trial Comparative Study Clinical Trial
[Total i.v. anesthesia with S-(+)-ketamine in orthopedic geriatric surgery. Endocrine stress reaction, hemodynamics and recovery].
Clinically-used ketamine is a racemic mixture of two isomers, S-(+)- and R-(-)-ketamine. Previous investigations showed the anaesthetic potency of S(+)-ketamine to be three times higher than that of R-(-)-ketamine. It was the aim of this study to compare the effects of S-(+)-ketamine and racemic ketamine on endocrine and cardiovascular parameters, recovery, and side effects in geriatric patients during total intravenous anaesthesia (TIVA) for orthopaedic surgery. ⋯ Increases in cardiovascular parameters and insufficient reduction of the stress response with respect to ADH, ACTH, and cortisol seem to require a more potent hypnotic element during TIVA with ketamine. With regard to endocrine and cardiovascular parameters, the pharmacodynamic effects of racemic and S-(+)-ketamine were comparable. Because of the significant improvement in recovery and the reduced quantitative drug load, S-(+)-ketamine offers a clinical advantage compared with currently used racemic ketamine.
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Randomized Controlled Trial Comparative Study Clinical Trial
[No inhibition of intestinal motility following ketamine-midazolam anesthesia. A comparison of anesthesia with enflurane and fentanyl/midazolam].
Postoperative intestinal atonia is a complication which is likely to occur in patients predisposed for constipation and in patients after intra-abdominal operations. The postoperative delay of bowel movement, however, is often also related to the type of anaesthesia being used. In order to evaluate the magnitude of an anaesthetic-induced postoperative delay of bowel movement, two types of intravenous-based anaesthesia using fentanyl/midazolam (1 mg/25 mg; dosage 0.1 ml/kg/h), and ketamine/midazolam (250 mg/25 mg; dosage 0.1 ml/kg/h) respectively were compared with a volatile anaesthetic technique (enflurane; mean concentration 1.5 vol%). ⋯ When using intravenous anaesthesia with an opioid, gastro-intestinal inhibition, especially in patients prone to have constipation, is likely to develop postoperatively. In classical neuroleptanaesthesia and in analgosedation in the ICU, the simultaneous use of the butyrophenone droperidol seems to counteract the inhibition of opioid-related gastrointestinal motility. In cases of opioid-related gastrointestinal atonia a gastrokinetic compound may be necessary to overcome this effect on intestinal motility.