C. Schneemilch

Effects of different anaesthetic agents on immune cell function in vitro

Background and objective: Anaesthesia may affect the regulatory balance of postoperative immune response. The aim of this study was to investigate the effects of different volatile and non‐volatile anaesthetic agents and particularly of clinically used agent combinations on the proliferation capacity and cytokine production of immune cells. Methods: Peripheral blood mononuclear cells from healthy donors were PHA‐activated in the presence or absence of various concentrations of thiopental, propofol, fentanyl, sufentanil, sevoflurane, nitrous oxide and combinations of these anaesthetics. Cell proliferation was assessed by tritiated thymidine uptake. Interleukin‐2 production and release of the soluble IL‐2 receptor were determined by enzyme immunoassays and used as measures of lymphocyte activation. Results: Thiopental inhibited cell proliferation in a dose dependent manner (P < 0.001) and reduced sIL‐2R release (2090‐970 pg mL−1; P < 0.05). Propofol reduced sIL‐2R release at the high concentration of 10 μg mL−1 (2220 pg mL−1‐1780 μg mL−1; P < 0.05). Fentanyl and sufentanil did not compensate for or enhance the inhibitory effects of thiopental. Nitrous oxide, but not sevoflurane, reduced the proliferation of human peripheral blood mononuclear cells (P < 0.05). In combinations with thiopental or nitrous oxide, sevoflurane compensated the inhibitory effects of these two agents. Fentanyl, sufentanil, sevoflurane and nitrous oxide did not affect PHA‐induced IL‐2 and sIL‐2 receptor release by human peripheral blood mononuclear cells. Conclusion: Thiopental and nitrous oxide have immunosuppressive activity. In contrast, sevoflurane may have a beneficial effect by alleviating the immunosuppressive effects of both substances.

Selective proteolytic cleavage of IL-2 receptor and IL-6 receptor ligand binding chains by neutrophil-derived serine proteases at foci of inflammation.

Traumatic brain injuries induce a strong, locally restricted inflammatory response. Here we demonstrate that activated neutrophils infiltrate the site of tissue destruction and release large amounts of enzymatically active elastase, cathepsin G, and proteinase 3. High intracerebral protease concentrations were found to be accompanied by a reduced inhibitory potential at foci of inflammation. In 39 neurotrauma patients, a temporal correlation between the protease release from neutrophils and the solubilization of interleukin-2 (IL-2) receptor and IL-6 receptor ectodomains at sites of tissue destruction was observed, suggesting that neutrophil-derived proteases may play a crucial role in the cytokine receptor shedding at foci of inflammation. Under in vitro conditions, the cleavage of membrane-bound IL-2Ralpha was found to be predominantly catalyzed by elastase and, to a lesser extent, by proteinase 3. Cathepsin G was found to be incapable of solubilizing this receptor. In contrast, the cleavage of the IL-6R 80 kDa chain was catalyzed by cathepsin G but not by elastase or proteinase 3. The receptor fragments released by the action of these enzymes were found to retain their ligand-binding capacity. These results strongly suggest a pathophysiologic role of neutrophil-derived serine proteases, particularly in regulation of the expression of functional IL-2 and IL-6 receptors at foci of inflammation.

Clonidine decreases stress response in patients undergoing carotid endarterectomy under regional anesthesia: a prospective, randomized, double-blinded, placebo-controlled study.

Inadequate analgesia or anxiety may induce an increased stress response in patients undergoing carotid endarterectomy (CEA) under regional anesthesia (RA). Central &agr;2 adrenoceptor agonists have significant sedative and analgesic properties, which may attenuate sympathoadrenal activation during CEA and improve the quality of RA. We randomly assigned 80 patients to 2 groups receiving either RA plus placebo (n = 40) or RA plus clonidine 1 &mgr;g/kg as the initial loading dose followed by 1 &mgr;g ·kg−1 ·h−1 (n = 40). RA was performed as combined deep and superficial cervical plexus blockade. Hemodynamic and neurological variables were assessed before, during, and after CEA. Arterial blood samples were collected at defined time points for the determination of plasma concentrations of epinephrine, norepinephrine, cortisol, and creatinine kinase and creatinine kinase-MB. Throughout the study, all patients responded easily to neurological evaluations. Before and during clamping mean arterial blood pressure and heart rate were not different between the groups, but mean arterial blood pressure was lower in the clonidine group (P < 0.01) at skin closure and postoperatively in the intensive care unit. In the placebo group, cortisol, epinephrine, and norepinephrine plasma concentrations were increased significantly (P < 0.05) and more patients required antihypertensive treatment (P < 0.01). Postoperatively the incidence of hypertension (P < 0.001) and development of neurological deficits (P < 0.05) was significantly decreased in the clonidine group. We conclude that 1 &mgr;g ·kg−1 ·h−1 clonidine suppresses the hyperadrenergic response to CEA without adverse effects on hemodynamics or clinical neurological monitoring.

Anesthesia in neurologic and psychiatric diseases: is there a 'best anesthesia' for certain diseases?

Purpose of review Patients with diseases affecting the central nervous system present a wide range of clinical manifestations increasing the perioperative risk. The following review focused on recommendations for anaesthesiological management in patients with both neurologic and psychiatric diseases. Recent findings The heterogeneity of disorders affecting the central nervous system and the variability of comorbidities make definition of standards for anaesthesiological management difficult. Anatomical malpositions, pulmonary and cardiac co-morbidities determine the perioperative risk. Patients require a careful preoperative assessment, including interdisciplinary communication between neurologists, psychiatrists or paediatric physicians. Adequate devices and equipment for airway management should be available before induction of general anesthesia. For premedication in patients with limited respiratory function, clonidine, given orally, is a good alternative. The use of short-acting hypnotic and analgesic drugs (e.g. propofol/remifentanil) can be safely administered for induction and maintenance of anesthesia. The use of volatile agents and succinylcholine is strictly avoided in patients with muscular dystrophy and myopathies. Peripheral and neuroaxial regional anesthesia is not contraindicated in patients with neuromuscular diseases unless there is a rapid deterioration of the neurological status. Summary The ‘best’ anesthesia includes adequate preoperative evaluation of the individual risk, optimization of comorbidities before elective surgery, the use of short-acting anesthetic agents for induction and maintenance of general anesthesia, avoidance of volatile agents and succinylcholine in muscular dystrophy and myopathies.

Sexualbezogene Halluzinationen und Träume unter Anästhesie und Sedierung

ZusammenfassungTräume und Halluzinationen unter Sedierung oder Narkose sind seit den Anfängen der Anästhesie ein bekanntes Phänomen. Halluzinationen können zu Vorwürfen der sexuellen Belästigung oder des Missbrauchs durch den Arzt oder das medizinische Pflegepersonal führen. Die sich unter dem Einfluss sedierender Substanzen entwickelnden Halluzinationen werden von den Patienten als real wahrgenommen, und Anschuldigungen, die aus ihnen abgeleitet werden, lassen sich im Nachhinein oft nur schwer widerlegen. Im vorliegenden Beitrag werden die Begriffe Traum und Halluzination unter Sedierung oder Narkose definiert, und die Wahrscheinlichkeit ihrer Entstehung wird dargestellt. Anhand eines geschichtlichen Rückblicks und von Fallbeschreibungen werden medikolegale Konsequenzen aufgezeigt und Handlungsempfehlungen zur Vermeidung von Anschuldigungen sexueller Belästigungen gegeben.AbstractDreams and hallucinations under sedation or anesthesia have been well known phenomena since the introduction of anesthesia. Sexual hallucinations may lead to allegations of sexual molestation or assault by medical doctors or professional nursing staff. Hallucinations under the influence of sedative or hypnotic drugs may be very vivid and as misinterpreted as being real and it is therefore often difficult to disprove the resulting false allegations. In this report the terms drug-induced dreams and hallucinations are defined and the probable mechanism described. By a historical review and case reports the medicolegal consequences are demonstrated and procedures recommended to avoid allegations of sexual assault.Dreams and hallucinations under sedation or anesthesia have been well known phenomena since the introduction of anesthesia. Sexual hallucinations may lead to allegations of sexual molestation or assault by medical doctors or professional nursing staff. Hallucinations under the influence of sedative or hypnotic drugs may be very vivid and as misinterpreted as being real and it is therefore often difficult to disprove the resulting false allegations. In this report the terms drug-induced dreams and hallucinations are defined and the probable mechanism described. By a historical review and case reports the medicolegal consequences are demonstrated and procedures recommended to avoid allegations of sexual assault.

A Single Dose of Recombinant Activated Factor VII (NovoSeven) Did Not Impair the Function of the Coronary Artery Bypass Grafts : Successful Treatment of Critical Bleeding after Cardiac Surgery in Two Cases

Bleeding disorders and hemorrhages cause considerable morbidity and mortality in cardiac surgical patients. Possible thromboembolic complications make the use of recombinant activated factor VII (rFVIIa) in the treatment of bleeding after cardiac surgery controversial. Case Reports: We describe 2 patients who experienced intractable bleeding after open heart surgery with the use of cardiopulmonary bypass. Bleeding was successfully treated by a single dose (90 γg/kg) of rFVIIa without affecting the patency of the grafts. Conclusion: rFVIIa may provide an opportunity for an effective treatment of serious bleeding episodes both during cardiac surgery and in the postoperative course.

Stationäre medikamentöse Schmerztherapie bei Tumorpatienten: Effekte einer manualisierten Leitlinie für den Konsildienst eines Universitätsklinikums

Hintergrund und Fragestellung | Die medikamentose Behandlung spielt in der Therapie von Tumorschmerzen eine wesentliche Rolle. Ziel dieser Studie war es, die Effektivitat eines anasthesiologischen Konsiliardienstes in einem Universitatsklinikum zu untersuchen und die Qualitat dieser Behandlung bei Patienten eines tertiaren Zentrums zu charakterisieren. Die Untersuchung wurde als eine systematische, klinische, unizentrische Observationsstudie zur Reflexion des klinischen Alltags und zur Kontrolle der Behandlungsqualitat angelegt. Patienten und Methodik | Im Rahmen des Konsildienstes der Schmerzambulanz auf den Stationen werden auch Tumorpatienten medikamentos behandelt. Dabei erfolgen nicht nur einmalige Konsile je Patient, sondern Kontrolluntersuchungen, bis die Patienten mit der Schmerztherapie zufrieden sind. Es wurden sowohl die medikamentosen Therapien vor dem Erstkonsil als auch die eigenen Masnahmen in der Folge prospektiv dokumentiert. Fur den Zeitraum zwischen 01.01.2010 und 31.12.2012 wurden die Daten der Konsilscheine retrospektiv ausgewertet. Zur Beurteilung der Qualitat der medikamentosen Schmerztherapie am Universitatsklinikum Magdeburg wurde ein Vorher-Nachher-Vergleich erstellt (Chi2-Test, Exakter Test nach Fisher, McNemar-Test). Die Auswirkungen der Therapie-Umstellungen wurden mithilfe des WHO-Indexes quantifiziert. Dazu wurden als Parameter der erreichten Schmerzreduktion die entsprechenden Schmerz-Werte auf der visuellen Analogskala (VAS) aufgezeichnet. Ergebnisse | Es wurden n = 375 Tumorpatienten stationar behandelt. Die Umstellung der medikamentosen Therapie durch den anasthesiologischen Konsiliardienst fuhrte zu einem signifikanten Anstieg des WHO-Indexes von 6,37 ± 1,83 (Standardabweichung) auf 8,43 ± 1,47 (p Folgerungen | Die konsequente Anwendung bereits etablierter Leitlinien (WHO-Stufenschema) fuhrt zu einer qualitativen und mittels etablierter Indices (WHO-Index) auch objektiv messbaren Verbesserung und Effektivitatssteigerung der medikamentosen Schmerztherapie von Tumorpatienten im klinischen Alltag.

Sexualbezogene Halluzinationen und Träume unter Anästhesie und Sedierung@@@Sexual hallucinations and dreams under anesthesia and sedation: Medizinische und rechtliche Aspekte@@@Medicolegal aspects

ZusammenfassungTräume und Halluzinationen unter Sedierung oder Narkose sind seit den Anfängen der Anästhesie ein bekanntes Phänomen. Halluzinationen können zu Vorwürfen der sexuellen Belästigung oder des Missbrauchs durch den Arzt oder das medizinische Pflegepersonal führen. Die sich unter dem Einfluss sedierender Substanzen entwickelnden Halluzinationen werden von den Patienten als real wahrgenommen, und Anschuldigungen, die aus ihnen abgeleitet werden, lassen sich im Nachhinein oft nur schwer widerlegen. Im vorliegenden Beitrag werden die Begriffe Traum und Halluzination unter Sedierung oder Narkose definiert, und die Wahrscheinlichkeit ihrer Entstehung wird dargestellt. Anhand eines geschichtlichen Rückblicks und von Fallbeschreibungen werden medikolegale Konsequenzen aufgezeigt und Handlungsempfehlungen zur Vermeidung von Anschuldigungen sexueller Belästigungen gegeben.AbstractDreams and hallucinations under sedation or anesthesia have been well known phenomena since the introduction of anesthesia. Sexual hallucinations may lead to allegations of sexual molestation or assault by medical doctors or professional nursing staff. Hallucinations under the influence of sedative or hypnotic drugs may be very vivid and as misinterpreted as being real and it is therefore often difficult to disprove the resulting false allegations. In this report the terms drug-induced dreams and hallucinations are defined and the probable mechanism described. By a historical review and case reports the medicolegal consequences are demonstrated and procedures recommended to avoid allegations of sexual assault.Dreams and hallucinations under sedation or anesthesia have been well known phenomena since the introduction of anesthesia. Sexual hallucinations may lead to allegations of sexual molestation or assault by medical doctors or professional nursing staff. Hallucinations under the influence of sedative or hypnotic drugs may be very vivid and as misinterpreted as being real and it is therefore often difficult to disprove the resulting false allegations. In this report the terms drug-induced dreams and hallucinations are defined and the probable mechanism described. By a historical review and case reports the medicolegal consequences are demonstrated and procedures recommended to avoid allegations of sexual assault.

[Sexual hallucinations and dreams under anesthesia and sedation : medicolegal aspects].

ZusammenfassungTräume und Halluzinationen unter Sedierung oder Narkose sind seit den Anfängen der Anästhesie ein bekanntes Phänomen. Halluzinationen können zu Vorwürfen der sexuellen Belästigung oder des Missbrauchs durch den Arzt oder das medizinische Pflegepersonal führen. Die sich unter dem Einfluss sedierender Substanzen entwickelnden Halluzinationen werden von den Patienten als real wahrgenommen, und Anschuldigungen, die aus ihnen abgeleitet werden, lassen sich im Nachhinein oft nur schwer widerlegen. Im vorliegenden Beitrag werden die Begriffe Traum und Halluzination unter Sedierung oder Narkose definiert, und die Wahrscheinlichkeit ihrer Entstehung wird dargestellt. Anhand eines geschichtlichen Rückblicks und von Fallbeschreibungen werden medikolegale Konsequenzen aufgezeigt und Handlungsempfehlungen zur Vermeidung von Anschuldigungen sexueller Belästigungen gegeben.AbstractDreams and hallucinations under sedation or anesthesia have been well known phenomena since the introduction of anesthesia. Sexual hallucinations may lead to allegations of sexual molestation or assault by medical doctors or professional nursing staff. Hallucinations under the influence of sedative or hypnotic drugs may be very vivid and as misinterpreted as being real and it is therefore often difficult to disprove the resulting false allegations. In this report the terms drug-induced dreams and hallucinations are defined and the probable mechanism described. By a historical review and case reports the medicolegal consequences are demonstrated and procedures recommended to avoid allegations of sexual assault.Dreams and hallucinations under sedation or anesthesia have been well known phenomena since the introduction of anesthesia. Sexual hallucinations may lead to allegations of sexual molestation or assault by medical doctors or professional nursing staff. Hallucinations under the influence of sedative or hypnotic drugs may be very vivid and as misinterpreted as being real and it is therefore often difficult to disprove the resulting false allegations. In this report the terms drug-induced dreams and hallucinations are defined and the probable mechanism described. By a historical review and case reports the medicolegal consequences are demonstrated and procedures recommended to avoid allegations of sexual assault.