Armin Rieger

Intercurrent complications in chronic alcoholic men admitted to the intensive care unit following trauma

ObjectiveA chronic alcoholic group following trauma was investigated to determine whether their ICU stay was longer than that of a non-alcoholic group and whether their intercurrent complication rate was increasedDesignProspective study.SettingAn intensive care unit.PatientsA total of 102 polytraumatized patients were transferred to the ICU after admission to the emergency room and after surgical treatment. Of these patients 69 were chronic alcoholics and 33 were allocated to the non-alcoholic group. The chronic-alcoholic group met the DSM-III-R and ICD-10 criteria for alcohol dependence or chronic alcohol abuse/harmful use. The daily ethanol intake in these patients was ≥60 g. Diagnostic indicators included an alcoholismrelated questionnaire (CAGE), conventional laboratory markers and carbohydrate-deficient transferrin.Measurement and resultsMajor intercurrent complications such as alcohol withdrawal syndrome (AWS), pneumonia, cardiac complications and bleeding disorders were documented and defined according to internationally accepted criteria. Patients did not differ significantly between groups regarding age, TRISS and APACHE score on admission. The rate of major intercurrent complications was 196% in the chronic alcoholic vs 70% in the non-alcoholic group (P=0.0001). Because of the increased intercurrent complication rate, the ICU stay was significantly prolonged in the chronic-alcoholic group by a median period of 9 days.ConclusionsChronic alcoholics are reported to have an increased risk of morbidity and mortality. However, to our knowledge, nothing is known about the morbidity and mortality of chronic alcoholics in intensive care units following trauma. Since chronic alcoholics in the ICU develop mor major complications with a significantly prolonged ICU stay following trauma than non-alcoholics, it seems reasonable to intensify research to identify chronic alcoholics and to prevent alcohol-related complications.

Laryngo-pharyngeal complaints following laryngeal mask airway and endotracheal intubation

Study Objective To investigate the incidence and severity of laryngo-pharyngeal complaints following anesthesia with the use of a laryngeal mask airway (LMA) compared with endotracheal intubation in adults. Design Prospective study with randomized patient selection. Setting University medical center. Patients 202 adult ASA physical status I, II, and III patients scheduled for elective surgery of either an extremity or breast, or a transurethral resection. Interventions Following intravenous induction of anesthesia, a standard LMA size #3, #4, or #5 corresponding to the patients body weight, was inserted in 103 patients; 99 patients were intubated with a polyvinylchloride endotracheal tube [7.5 mm inner diameter (ID) in women and 8.0 mm ID in men]. Cuff pressures in the LMA group were initially reduced to a minimum pressure at which an air-tight seal between the LMA and the laryngeal inlet was provided at a positive pressure of 20 cm H 2 O during manual bag ventilation. Cuffs of endotracheal tubes were inflated and controlled to a volume needed to prevent gas leak at 35 cm H 2 O pressure. Measurements and Main Results Cuff pressures were continuously monitored in both groups. Patients assessed their laryngo-pharyngeal complaints on a 101-point numerical rating scale on the evening after surgery and the following two days. No difference was found in the incidence and severity of sore throat on the evening following surgery or on the two following days. Dysphonia was more frequent following intubation than following LMA insertion on the day of surgery (46.8% vs. 25.3%) and on the first postoperative day (28.1% vs. 11.6%) ( p Conclusions There is a distinct pattern of laryngo-pharyngeal complaints following the use of the LMA and endotracheal intubation. With regard to minor laryngo-pharyngeal morbidity, the advantage of the LMA to endotracheal intubation is questionable.

Patient-controlled intranasal analgesia : A method for noninvasive postoperative pain management

Recently, a new device for patient-controlled intranasal analgesia (PCINA) was described, and a pilot study demonstrated promising results with respect to efficacy and patient satisfaction. The present study compares PCINA with intravenous (IV) patient-controlled analgesia (PCA). Fifty orthopedic patients were prospectively studied over an 8-h period on the first day after surgery. The patients were randomly allocated to PCINA group (n = 25) or to an IV PCA group (n = 25). Pain intensity was evaluated at 30-min intervals using a 101-point numerical rating scale. With respect to initial pain intensity, there was no significant intergroup difference. At the 30- to 480-min measurement points pain intensity in the PCINA group (P < 0.0001) and the IV PCA group (P < 0.0001) was significantly less as compared to the initial value. There was no significant intergroup difference in pain intensity. No patient had problems using the PCINA device. The present study demonstrates, that PCINA provides relief of postoperative pain as effectively as IV PCA. (Anesth Analg 1996;83:548-51)

Intracuff Pressures Do Not Predict Laryngopharyngeal Discomfort after Use of the Laryngeal Mask Airway

Background:The laryngeal mask airway (LMA) is a large foreign body that exerts pressure on the pharyngeal mucosa, which may lead to throat discomfort. To determine whether intracuff pressures are associated with such discomfort, a randomized, double-blind study was performed to determine the effect

Relevance of Carbohydrate-deficient Transferrin as a Predictor of Alcoholism in Intensive Care Patients following Trauma

Every second traumatized patient is a chronic alcoholic. Chronic alcoholics are at risk due to an increased morbidity and mortality. Reliable and precise diagnostic methods for detecting alcoholism are mandatory to prevent posttraumatic complications by adequate prophylaxis. The patients history, however, is often not reliable, and conventional laboratory markers are not sensitive or specific enough. The aim of this study was to investigate whether carbohydrate-deficient transferrin (CDT) is a sensitive and specific marker to detect alcoholism in traumatized patients. One hundred and five male traumatized patients or their relatives gave their written informed consent to participate in this institutionally approved study. All patients were transferred to the intensive care unit after admission to the emergency room, followed by surgical treatment. Diagnostics included an alcoholism-related questionnaire, conventional laboratory markers (mean corpuscular volume, gamma-glutamyltransferase, aspartate aminotransferase, and alanine aminotransferase), and CDT sampling (microanion-exchange chromatography, turbidimetry, and radioimmunoassay, respectively). Only patients in whom a reliable history could be obtained were included. Alcoholism was diagnosed if the patients met the Diagnostic and Statistical Manual of Mental Disorders criteria for chronic alcohol abuse or dependence. The administration of fluids before CDT sampling was carefully documented. Patients did not differ significantly regarding age, Trauma and Injury Severity Score, and Acute Physiology and Chronic Health Evaluation score. The sensitivity of the CDT research kit was 70% and of the commercially available kit CDTect was 65%. Early sampling in the emergency room and before administration of large volumes of fluid increased the sensitivity to 83% for the CDT research kit and 74% for CDTect, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Intranasales Fentanyl zur Therapie akuter Schmerzspitzen bei Karzinompatienten

ZusammenfassungEin hoher Prozentsatz der Patienten mit chronischen Tumorschmerzen klagt trotz regelmäßiger Analgetikagabe über intermittierend auftretende akute Schmerzspitzen. Wegen solcher Schmerzspitzen muß bei Patienten mit chronischen Karzinomschmerzen neben einer Basisanalgesie (mit z.B. retardiertem Morphin oder Buprenorphin) zusätzlich eine Bedarfsmedikation verordnet werden. In der vorliegenden Studie wurde bei fünf Patienten zur Therapie einer akuten Schmerzspitze eine intranasale, bedarfsadaptierte Fentanyltitration durchgeführt. Bei allen Patienten konnte damit eine schnell einsetzende und deutliche Schmerzreduktion erzeilt werden. Klinisch relevante Veränderungen von arterieller Sauerstoffsättigung, Herzfrequenz, Blutdruck oder Atemfrequenz traten nicht auf. Alle Patienten beurteilten die erzielte Schmerzlinderung als gut oder sehr gut. Schmerzen oder Brennen im Bereich der Nase wurden von keinem Patienten angegeben.AbstractBackground and aim of the studyDespite regular administration of analgesics, a high percentage of patients with chronic malignant pain experience break-through cancer pain or incident pain. Such pain peaks in patients with chronic malignant pain require “rescue” medication in addition to basic analgesia with for example slow-release morphine or buprenorphine. For rescue medication a fast acting and powerful analgesic should be available to the patient. Recent studies have shown that intranasal fentanyl provides rapid onset of pain relief.Patients and methodsIn this open pilot study five patients with chronic cancer pain (age: 42–62 years; weight: 55–80 kg) received demand-adapted intranasal fentanyl titration for treatment of acute breakthrough cancer pain. Intranasal fentanyl doses (0.027 mg) were repeated at 5-min intervals until the patients experienced marked pain relief. Pain intensity was evaluated (0–30 min: 5-min intervals; 30–120 min: 10-min intervals) with the aid of a numerical rating scale (0 = no pain; 100 worst pain possible).Results and discussionThe patients received 2, 4, 6, 7 or 8 fentanyl boluses (totalling 0.054 mg, 0.108 mg, 0.162 mg, 0.189 mg or 0.216 mg, respectively). Rapid onset and marked reduction of pain intensity was achieved in all five patients. There were no clinically relevant changes in arterial haemoglobin oxygen saturation, heart rate, arterial blood pressure or respiratory rate. All five patients scored the pain relief obtained as good or very good. There were no reports of pain or burning sensations in the nose or other side-effects.

A comparison of sevoflurane with halothane in outpatient adenotomy in children with mild upper respiratory tract infections

STUDY OBJECTIVE To investigate the efficacy and safety of sevoflurane compared with halothane in pediatric outpatient ear-nose-throat (ENT) surgery during the induction, maintenance, emergence, and recovery of anesthesia. DESIGN Prospective, randomized, comparative, open-label study. SETTING ENT operating room and postoperative recovery room at a university medical center. PATIENTS 41 ASA status I and II children between the ages of 2 to 10 years, with mild upper respiratory tract infection (URI). INTERVENTIONS Induction and maintenance of anesthesia with either sevoflurane or halothane for outpatient adenotomy, otomicroscopy, and myringotomy. MEASUREMENTS AND MAIN RESULTS Induction (means +/- SEM) was significantly shorter in the sevoflurane group (2.6 +/- 0.2 minutes) than in the halothane group (3.2 +/- 0.2 minutes). There was no difference between the two groups with regard to complications that occurred during the induction and maintenance period. The time to emergence and recovery was significantly shorter with sevoflurane than with halothane (means +/- SEM; time to extubation 9.9 +/- 0.98 minutes vs. 13.4 +/- 1.06 minutes, time to eye opening 12.9 +/- 1.6 minutes vs. 24.5 +/- 1.8 minutes, command response time 20.7 +/- 2.5 minutes vs. 36.4 +/- 2.8 minutes). No difference in the incidence of complications during emergence and recovery was found. Evaluation of recovery as assessed by a modified Aldrete score showed that children who had received sevoflurane reached higher scores in the first 30 minutes following the discontinuation of the anesthetic. The Pain/Discomfort Scale demonstrated a difference in the sevoflurane group, with more children being agitated and restless. CONCLUSION Sevoflurane provides a safe and rapid anesthetic induction with no differences in complications during the induction, maintenance, and emergence period. With sevoflurane, the time of emergence and recovery was significantly shorter. The characteristics of sevoflurane as evaluated in the present study make it a suitable anesthetic in pediatric outpatient surgery even in the presence of mild URI.

Intranasal fentanyl for breakthrough cancer pain. A pilot study.

ZusammenfassungEin hoher Prozentsatz der Patienten mit chronischen Tumorschmerzen klagt trotz regelmäßiger Analgetikagabe über intermittierend auftretende akute Schmerzspitzen. Wegen solcher Schmerzspitzen muß bei Patienten mit chronischen Karzinomschmerzen neben einer Basisanalgesie (mit z.B. retardiertem Morphin oder Buprenorphin) zusätzlich eine Bedarfsmedikation verordnet werden. In der vorliegenden Studie wurde bei fünf Patienten zur Therapie einer akuten Schmerzspitze eine intranasale, bedarfsadaptierte Fentanyltitration durchgeführt. Bei allen Patienten konnte damit eine schnell einsetzende und deutliche Schmerzreduktion erzeilt werden. Klinisch relevante Veränderungen von arterieller Sauerstoffsättigung, Herzfrequenz, Blutdruck oder Atemfrequenz traten nicht auf. Alle Patienten beurteilten die erzielte Schmerzlinderung als gut oder sehr gut. Schmerzen oder Brennen im Bereich der Nase wurden von keinem Patienten angegeben.AbstractBackground and aim of the studyDespite regular administration of analgesics, a high percentage of patients with chronic malignant pain experience break-through cancer pain or incident pain. Such pain peaks in patients with chronic malignant pain require “rescue” medication in addition to basic analgesia with for example slow-release morphine or buprenorphine. For rescue medication a fast acting and powerful analgesic should be available to the patient. Recent studies have shown that intranasal fentanyl provides rapid onset of pain relief.Patients and methodsIn this open pilot study five patients with chronic cancer pain (age: 42–62 years; weight: 55–80 kg) received demand-adapted intranasal fentanyl titration for treatment of acute breakthrough cancer pain. Intranasal fentanyl doses (0.027 mg) were repeated at 5-min intervals until the patients experienced marked pain relief. Pain intensity was evaluated (0–30 min: 5-min intervals; 30–120 min: 10-min intervals) with the aid of a numerical rating scale (0 = no pain; 100 worst pain possible).Results and discussionThe patients received 2, 4, 6, 7 or 8 fentanyl boluses (totalling 0.054 mg, 0.108 mg, 0.162 mg, 0.189 mg or 0.216 mg, respectively). Rapid onset and marked reduction of pain intensity was achieved in all five patients. There were no clinically relevant changes in arterial haemoglobin oxygen saturation, heart rate, arterial blood pressure or respiratory rate. All five patients scored the pain relief obtained as good or very good. There were no reports of pain or burning sensations in the nose or other side-effects.

Safe and normothermic massive transfusions by modification of an infusion warming and pressure device.

A fluid-warming pressure infusion device (H-500/H25i, Level 1) was modified to meet the demands for safe, normothermic, and effective massive transfusions. By incorporating an autoventing 40 microns filter (Pall AV-SP), which was originally manufactured for use in an extracorporal circulation, the risk of accidental air embolism can be eliminated. Feasibility and efficiency of this model were tested in ten patients. The mean volume transfused and infused (packed red cells and colloids) was 6750 mL (SD +/- 2519) during a mean period of acute volume resuscitation of 55 minutes (SD +/- 30). Calculated flow rates averaged 140 mL/min, which were sufficient to stabilize all but one patient. This patient subsequently died because of uncontrollable surgical bleeding. Body temperature remained stable with a minimal mean drop of -0.3 degrees C. Supplying the Level 1 warming and pressure device with a Pall AV-SP filter allows for safe, effective, and demand-adapted massive transfusions in a large number of trauma patients at a reasonable cost.

Intraoperative Atemwegsobstruktion bei Anwendung der Larynxmaske Fallbericht und fiberoptische Befunde

ZusammenfassungDie Atemwegsobstruktion im Bereich des Larynx kann bei Maskennarkosen und bei Narkosen mit der Larynxmaske zu einer bedrohlichen Gefährdung des Patienten führen. Da mit der Larynxmaske ein Fremdkörper in den Hypopharynx und prälaryngeal eingebracht wird, gilt es zu unterscheiden, ob diese Atemwegsobstruktion durch die Larynxmaske selbst oder durch andere Faktoren verursacht wird. Verständnis der pathophysiologischen Abläufe und Erfahrung im Umgang mit der Larynxmaske sind Voraussetzung für die richtigen therapeutischen Maßnahmen. Nicht das Entfernen einer korrekt plazierten Larynxmaske, sondern die Vertiefung der Narkose ist die vordringlichste erste Maßnahme bei einer intraoperativen Atemwegsobstruktion.AbstractLaryngeal obstruction is a challenging complication during anaesthesia with a face mask or laryngeal mask and is due to insufficient analgesia in most cases. However, with a laryngeal mask in place it must be differentiated whether the airway obstruction is caused by the laryngeal mask itself or by other factors. Knowledge of the pathophysiology of the laryngeal closure and experience with the use of the laryngeal mask are essential for adequate treatment. Not the removal of a correctly inserted laryngeal mask which initially provided a satisfying airway, but the relaxation of laryngeal muscle activity by adequate anaesthesia is the first mandatory treatment if intraoperative airway obstruction occurs.