Der Anaesthesist
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During the last five years several authors have reported largely satisfactory results, using the steroid intravenous anaesthetic eltanolone (pregnanolone) for induction of anaesthesia after administering a bolus dose. Until now, however, no investigations have been undertaken, dealing with the infusion pharmacokinetics of eltanolone after arterial blood sampling and using slow induction to quantify the concentration-effect relationship. Secondary objectives were to assess the haemodynamic and respiratory effects. ⋯ The model-dependent pharmacokinetic parameters of eltanolone were characterized by a high total clearance (1.75 +/- 0.22 l min-1), small volumes of distribution (Vc = 7.7 +/- 3.4 l; Vdss = 92 +/- 22 l and relatively short half-lives (t1/2 alpha = 1.5 +/- 0.6 min; t1/2 beta = 27 +/- 5 min; t1/2 gamma = 184 +/- 32 min). (Table 2). The clinical signs revealed a good hypnotic effect, resulting in burst suppression periods in the EEG after 19 min during the first and 15 min during the second infusion cycle. The slow induction enabled a thorough observation of the induction phase. During the first infusion cycle cessation of counting occurred after 7.7 +/- 1.3 min (mean +/- SD), reaction to verbal contact was lost after 10.4 +/- 1.3 min and the corneal reflex was lost only in about one half of the volunteers after 17.9 +/- 2.8. During recovery, the corneal reflex reappeared 9.4 +/- 2.4 min after stop of infusion, first reactions to loud verbal commands were recorded after 24.2 +/- 4.3 min and full orientation was regained after 34.7 +/- 6.2 min. During the second cycle all signs disappeared faster and were regained later. The correlation between clinical signs and corresponding serum concentrations revealed, that in both cycles the disappearance occurred at clearly higher concentrations than the reappearance. The decrease of the systolic arterial pressure showed a maximum of 31% compared to the baseline values, which was statistically significant (P < 0.05). Diastolic arterial blood pressure decreased of about 10%, while heart rate increased significantly of about 24% (P < 0.05). Oxygen saturation remained stable with values between 96 and 100% with the exception of one volunteer. Apnoea was not recorded during the entire observation period. The median value of all pCO2 analyses was 41 mmHg with a range of 25-60 mmHg. The only serious undesirable effect was a seizure during awakening in one volunteer which coincided with polyspike waves in his raw-EEG recordings. (ABSTRACT TR
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Clinical Trial
[Intraosseous puncture in preclincal emergency medicine. Experiences of an air rescue service].
In prehospital emergency treatment, the timely establishment of a secure vascular access, especially in infants and small children, can be difficult or even impossible. An alternative to the puncture of peripheral or central veins is intraosseous (IO) puncture However, experience with this method in prehospital emergency medicine within the Federal Republic of Germany is extremely limited at present. After intensive theoretical and practical training of our trauma anaesthesiologists, IO puncture was introduced in our rescue helicopter program "Christoph 22" as an alternative to peripheral or central venous puncture in the prehospital treatment of patients up to 6 years of age. IO puncture is indicated after a maximum of three failed peripheral venous puncture attempts. The purpose of this study was to collect data and summarise first-hand experience on the prehospital use of the IO method as well as the practicability of our prescribed IO puncture algorithm in order to subject them to critical review and evaluation. ⋯ The IO infusion technique has proven to be a simple, fast, and safe alternative method of emergent access to the vascular system.
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Although still rare, pregnancy and delivery in women with spinal cord injuries is becoming more frequent (Table 2). In 85%-90% of patients with lesions above T6 symptoms of autonomic hyperreflexia (Table 1), especially paroxysmal and excessive increases in arterial blood pressure, may occur. In anaesthetising a 31-year-old paraplegic primigravida with a complete transverse spinal lesion at T4 for an elective caesarean section, no indication of hypertonic cardiovascular dysregulation either intra- or postoperatively was observed after repeated epidural administration of bupivacaine. Distinct intraoperative spasticity of the abdominal wall muscles was, however, not influenced by the dosages selected.
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Human recombinant interleukin 2 (IL-2), alone or in combination with other cytokines, is currently under investigation for the immunotherapy of metastatic tumours. Objective responses of 20-35% have been reported in patients with disseminated melanoma and renal cell carcinoma who received high-dose intravenous IL-2 in combination with interferon-alpha (IFN alpha). However, treatment with IL-2 is complicated by a syndrome of life-threatening adverse reactions such as disseminated vascular leakage, fluid retention, severe hypotension, and (reversible) multiple organ dysfunction (MODS). A systemic inflammatory reaction (SIRS/sepsis sepsis-like haemodynamic pattern has been described in patients after IL-2 bolus application alone. Our purpose was to study the haemodynamic changes in patients treated with high-dose IL-2 administered as a constant infusion and in combination with IFN alpha. ⋯ After their daily i.m. injections of IFN alpha, patients had short episodes of fever and tachycardia without significant drops in BP. A few hours after transfer to the ICU and continuous infusion of IL-2, they developed a syndrome of fever, tachycardia and tachypnoea. The haemodynamic values after 5 days of IFN alpha therapy remained in the normal range, whereas those during IL-2 infusion strongly resembled SIRS and sepsis, with a decrease in MAP (98 to 28 mm Hg) and systemic vascular resistance (SVR, 1477 to 805 dyn.s.cm-5) and an increase in cardiac output (cardiac index 2.8 to 4.3 l.min-1.m-2). MAP often had to be stablilized with colloids during the last 48 h of therapy; 5 patients had nadir values below 60 mm Hg, or 30% below basic values in hypertensive patients. Catecholamine therapy became mandatory in 1 patient and therapy had to be discontinued. Surprisingly, some patients already had elevated plasma lactate concentrations after IFN alpha therapy. During IL-2 infusion mean plasma lactate levels increased from 2.3 to 3.2 mmol.l-1 and all patients had lactate concentrations above 2.0 mmol.l-1 at the end of therapy. During the last 48 to 72 h of IL-2 infusion, patients suffered from MODS with altered mental state (7 patients), oliogoanuria (all patients), cardiac dysrhythmias (4 patients), congestive heart failure (1 patient, which led to a second case of therapy interruption), elevated bilirubin (4 patients), and pulmonary dysfunction. In 9 patients supplementary oxygen was necessary when psaO2 fell below 92