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A Biedler

Publications and source records attributed to A Biedler.

35 records · Page 2Linked to original sources
PubMed2000

Interpleural analgesia does not influence postthoracotomy pain.

UNLABELLED: The management of postthoracotomy pain is a problem and may contribute to atelectasis, leading to hypoxemia, pulmonary infection, and permanent alveolar damage. We sought to determine the efficacy of interpleural analgesia for pain control and to evaluate independent predictors for postoperative pain intensity. Eighty-three patients undergoing elective anterolateral (n = 37) and posterolateral (n = 46) thoracotomy were included in a prospective, randomized, double-blinded trial. Patients were assigned to receive either 0.5% bupivacaine or saline solution interpleurally every 4 h for 10 doses postoperatively. All patients also received patient-controlled analgesics (PCA) with piritramide as the opioid for additional pain control. Pain was assessed on the basis of PCA requirements and by using a visual analog scale. Visual analog scale scores and PCA requirements were not different between groups. Both interpleural bupivacaine and saline significantly reduced pain scores 30 min after the administration. We concluded that pain reduction by interpleural instillation of bupivacaine reflects a placebo-like effect; however, interpleural analgesia is not effective in patients undergoing lateral thoracotomy. Sex and surgical approach were shown to influence postoperative pain intensity at rest, but not during coughing. The female patients, and those undergoing posterolateral thoracotomy, exhibited higher pain scores. This observation appears to be of only marginal clinical significance. The efficacy of interpleural analgesia to reduce postoperative pain intensity in patients after lateral thoracotomy is controversial. In this study we demonstrated a lack of efficacy of interpleural analgesia. IMPLICATIONS: The efficacy of interpleural analgesia to reduce postoperative pain intensity in patients after lateral thoracotomy is controversial. In this study, we demonstrated a lack of efficacy of interpleural analgesia.

Analgesia↗
PubMed1999

[Pre-analytic errors in the determination of arterial O(2)-partial pressure under hyperoxic conditions].

OBJECTIVE: A variety of influences reduce the validity of the measured oxygen partial pressure (paO(2)). Most errors occur when obtaining the blood sample and preparing it for analysis. Unfortunately, there is great controversy concerning the relevance and extent of these pre-analytic errors. Apart from this, the exact estimation of influencing factors under hyperoxic conditions has been neglected. Therefore, the objective of this study was to assess pre-analytic measuring errors for paO(2) under the condition of hyperoxia as completely as possible and to work out solutions to eliminate these errors. METHODS: paO(2) analysis was performed on more than 2000 blood samples. Errors analyzed were the technique of sample taking (direct puncture or from an indwelling catheter), aspirated air bubbles (0.05-0.35 ml), time and temperature of sample storage, and the material, size and manufacturer of the analyzing syringe. RESULTS: The paO(2) was on average 41 mmHg lower in samples taken from the indwelling catheter than by direct puncture. An air bubble size of 0.1-0.25 ml caused a decrease of 17-41 mmHg. Storage time of 2 min accounted for an paO(2) reduction of 6-67 mmHg depending on the type of syringe used. Glass syringes turned out to be more accurate than plastic syringes. The best results were obtained not from commercial "blood gas syringes" but from a simple plastic injection syringe. For all pre-analytic errors correction factors were established. CONCLUSION: All pre-analytic errors investigated caused a significant paO(2) decrease. Even an ideal procedure (almost no air bubble, short storage on ice) contributes a significant error. Only the appropriate correction factors as calculated from this study for routine use lead to the correct results. If they are not taken into account the paO(2) values will be falsely low, potentially leading to misinterpretation and misjudgement of a patient's condition.

Humans↗
PubMed1999

[Remifentanil for oocyte retrieval: A new single-agent monitored anaesthesia care technique].

INTRODUCTION: Transvaginal puncture for oocyte retrieval is a short-lasting but painful procedure. We hypothesized that a sole infusion of the ultra-short acting mu-agonist remifentanil may be a suitable and well-controllable single-agent analgesic technique that can dose-dependently be applied to spontaneously breathing patients. METHODS: Fifty consenting adult women were enrolled in this prospective trial. A sedative premedication was omitted, all patients received 3 L/min of inhaled oxygen, and a sole remifentanil infusion was started with 0.25 microg/kg/min. Remifentanil was adjusted as needed for pain relief (in steps of 0.05 microg/kg/min) and finished after the last puncture. Dosage requirements, vital functions, oxygen saturation (as achieved by pulse oximetry, psO(2)), adverse drug effects and the level of sedation (LOS 1-5; 1 = asleep/unarousable, 4 = calm/awake) were recorded. Remifentanil plasma concentrations were achieved by STANPUMP pharmacokinetic simulation. Data are presented as mean +/- SD. RESULTS: A total of 50 women (31.8 +/- 5.1 yr, 67.3 +/- 14. ASA I or II ) were investigated. Follicular aspiration lasted 10.8+/-5.2 min, and remifentanil was infused for 19.7+/-8.3 min. Dosage requirements were 0.25 microg/kg/min in 70% of all patients, 0.3 microg/kg/min in 22%, 0.2 microg/kg/min in 6%, and 0.4 microg/kg/min in 2% of all cases. Vital signs (baseline, after 1(st) puncture, end of surgery) nearly remained unchanged: heart frequency = 85 +/- 15, 87 +/- 17, 90 +/- 17 bpm, systolic blood pressure = 129 +/- 12, 132 +/- 13, 131 +/- 14 mmHg; respiratory rate = 116 +/- 4, 15 +/- 4 breaths/min; psO(2) = 99 +/- 1, 99 +/- 1, 99 +/- 2%. LOS was 4.0 (all), 3.9 +/- 0.3, 3.9 +/- 0.3. Remifentanil plasma concentrations were 5.0 +/- 1.3 ng/mL at the start, 6.6 +/- 1.3 at the end of surgery and 1.2 +/- 0.5 at PACU arrival. Adverse drug effects: 54% itching, no muscle rigidity. 94% of all women would choose this technique again. CONCLUSIONS: The sole infusion of remifentanil is a suitable and satisfying single-agent monitored anaesthesia care technique for oocyte retrieval. However, close anaesthetic observation - especially of the respiratory function - is mandatory.

Adult↗
PubMed1999

[TIVA with propofol-remifentanil or balanced anesthesia with sevoflurane-fentanyl in laparoscopic operations. Hemodynamics, awakening and adverse effects].

OBJECTIVE: This study was designed to investigate the differences between TIVA with propofol/remifentanil (P/R) and balanced anaesthesia with sevoflurane/fentanyl (S/F) in gynaecological laparoscopic surgery. Emphasis was put on haemodynamic reaction, recovery profile, postoperative side effects and patient satisfaction. METHODS: Sixty patients were randomly assigned to receive either total intravenous anaesthesia with propofol/remifentanil or anaesthesia with sevoflurane/fentanyl. After premedication (midazolam) and induction of anesthesia (propofol, atracurium) in both groups, either 1 microgram/kg fentanyl (S/F) or 1 microgram/kg remifentanil (P/R) was injected. Anaesthesia was maintained with 0.5 microgram/kg/min remifentanil (reduced to 50% after 5 min) and 0.06 microgram/kg/min propofol (P/R) or 1.7 vol % sevoflurane (S/F). Both groups were mechanically ventilated with 30% oxygen in air. The administration of sevoflurane and the infusion of the anaesthetics were adjusted to maintain a surgical depth of anaesthesia. For postoperative analgesia 1 g paracetamol was administered rectally prior to surgery. After recovery 20 mg/kg metamizol was given intravenously. At the end of surgery the anaesthetics were discontinued and haemodynamics, early emergence from anaesthesia, pain level, frequency of analgesic demand, incidence of PONV, shivering and patient satisfaction were assessed. Parameters were recorded for 24 h postoperatively. RESULTS: Recovery time after propofol-remifentanil anaesthesia was significantly shorter than after administration of sevoflurane and fentanyl (spontaneous ventilation 4.1 vs. 6.3 min, extubation 4.3 vs. 9.3 min, eye opening 4.4 vs 8.2 min, stating name 5.3 vs. 13.2 min, stating date of birth 5.4 vs. 13.3 min). There were no significant differences between the groups in shivering, pain score, analgesic demand and PONV. The S/F group responded to tracheal intubation with significantly higher blood pressure than the P/R group. During maintenance of anaesthesia heart rate in patients with S/F was significantly higher (P/R:HR max +16/-10; S/F:HR max +24/-0.). Measured on a scale (S/F 62%). CONCLUSION: Compared with patients given balanced anaesthesia with sevoflurane and fentanyl, TIVA with propofol and remifentanil proved to be particularly suited for gynaecological laparoscopic surgery. Its major advantages are haemodynamic stability, significantly shorter times of emergence, and the exceptional acceptance by the patients.

Adult↗
PubMed1999

[Postoperative cognition disorders in elderly patients. The results of the "International Study of Postoperative Cognitive Dysfunction" ISPOCD 1)].

OBJECTIVE: Cognitive dysfunction is a known problem after operations and may be especially relevant in the elderly. The aim of this international multicentre study was to investigate short- and long-term cognitive dysfunction in elderly patients and to elucidate the relevance of hypoxaemia and hypotension as causative factors. METHODS: 1218 patients aged 60 years and older and scheduled for major non-cardiac surgery under general anaesthesia were investigated. Oxygen saturation was measured by continuous pulse oximetry before surgery and throughout the day of and the first 3 nights after surgery. Blood pressure was recorded every 3 minutes during the operation and every 15-30 min for the rest of that day and night. Cognitive testing was performed before and 1 week and 3 months after the operation. Cognitive dysfunction was identified with neuropsychological tests compared with controls recruited from the UK (n = 176) and the same countries as study centres (n = 145). RESULTS: Postoperative cognitive dysfunction was present in 25.8% of patients 1 week after surgery and in 9.9% 3 months after surgery, compared with 3.4% and 2.8%, respectively, of the UK controls. Increasing age and duration of anaesthesia, little education, a second operation, postoperative infections, and respiratory complications were the risk factors for early postoperative cognitive dysfunction, but only age was a risk factor for long-term postoperative cognitive dysfunction. Hypoxaemia and hypotension were not significant risk factors at any time. CONCLUSION: With this investigation long-term cognitive dysfunction could be proven definitively for elderly patients after major operations under general anaesthesia. No factors with prophylactic or therapeutic influence were detectable so that aetiology and pathophysiology of POCD could not be further determined.

Aged↗
PubMed1999

[Portable capnographs in emergency care: a comparison of equipment].

Recently, transportable capnographs fulfilling the practical demands of emergency medicine have become commercially available (NPB-75, sidestream, Nellcor Puritan Bennett; and Tidal Wave, mainstream, Novametrix). A prerequisite for their use is an accuracy as required for clinical purposes (i.e., pCO2 +/- 2 mmHg). Additionally, environmental conditions in emergency medicine (e.g., changes in ambient temperature) should not have a significant impact on accuracy. The objective of this investigation was to analyse the accuracy of the two capnographs. The accuracy of the pCO2 measurement was evaluated under the following conditions: (1) measurement with three gas mixtures of defined concentrations (gas A: 5% CO2, 95% O2; gas B: 5% CO2, 20% O2, 75% N2; gas C: 10% CO2, 90% N2) related to STPD conditions (STPD = Standard Temperature and Pressure, Dry); and (2) exposure to changes in temperature (from +22 degrees C to -20 degrees C, and from -20 degrees C to +22 degrees C) applying the aforementioned 3 gas mixtures (STPD); and (3) in 20 patients manually ventilated with pure oxygen following endotracheal intubation (i.e., BTPS conditions = body temperature and pressure, saturated). Adequacy of the results was compared to the alveolar gas monitor AGM 1304 (Bruel & Kjaer, Copenhagen, Denmark; sidestream) which served as the reference method (providing an accuracy for the alveolar carbon dioxide partial pressure (pACO2) of +/- 1 mmHg). In the 3 dry gas mixtures, mean inaccuracy proved to be +4.5 +/- 4.1, +2.8 +/- 3.7, and +2.2 +/- 7.0 mmHg (gas A, gas B, gas C; STPD) with the Nellcor sidestream device. Using the Novametrix mainstream capnograph the results were found as follows: (1) -1.1 +/- 0.6, +2.9 +/- 0.6, and +5.6 +/- 2.3 mmHg (oxygen compensation enabled); and (2) +0.2 +/- 1.6, +2.2 +/- 0.6, and +3.2 +/- 4.2 mmHg (oxygen compensation disabled). After changing the environmental temperature (-20 degrees C / +22 degrees C), the resulting deviations (gases A-C, STPD) found with the Nellcor device averaged -12 +/- 4% and +15 +/- 3% (Nellcor); with the Novametrix mainstream device the deviations averaged -1 +/- 2% and +1 +/- 1%, and -2 +/- 1% and +1 +/- 1% (oxygen compensation enabled/disabled). Mean inaccuracy of the pCO2 measurement during ventilation of patients with pure oxygen (BTPS) was found to average -0.9 +/- 0.9 (Nellcor), and either +3.9 +/- 0.8 or +2.1 +/- 0.7 mmHg with the Novametrix (oxygen compensation enabled/disabled). Under BTPS conditions, both devices showed an acceptable deviation of the measurement accuracy up to a maximum of +/- 2 mmHg. The higher deviations of the "NPB-75" (Nellcor Puritan Bennett, sidestream) when using dry gas mixtures (STPD) may be explained by the automatic water vapour correction. Under the conditions of low and changing ambient temperature (-20 degrees C, +22 degrees C), only the "Tidal Wave" (Novametrix; mainstream) remained uninfluenced, whereas deviations of -12% and +15% were found with the "NPB-75".

Capnography↗
PubMed1999

[Puerperal sepsis due to infected episiotomy wound].

A healthy 31-year-old woman showed a severe septic shock syndrome a few days after vaginal delivery. In the episiotomy wound were found Group A Streptococci and E. coli. Although an antibiotic therapy was instituted immediately, the condition of the patient worsened. Platelet counts fell below 5000/microliter and she developed respiratory, cardiocirculatory and renal insufficiency, so that mechanical ventilation, high-dose-catecholamine therapy and continuous venovenous hemodiafiltration had to be performed. In the course of the disease the patient showed a reversible cardiomegaly with pulmonary hypertension and an extensive desquamation of the skin. Fever persisted in spite of the fact that in all following clinical and laboratory examinations no septic focus could be revealed any longer. She recovered slowly and could not be weaned from the respirator for four weeks because of a severe critical illness polyneuromyopathy.

Adult↗
PubMed1998

Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction.

BACKGROUND: Long-term postoperative cognitive dysfunction may occur in the elderly. Age may be a risk factor and hypoxaemia and arterial hypotension causative factors. We investigated these hypotheses in an international multicentre study. METHODS: 1218 patients aged at least 60 years completed neuropsychological tests before and 1 week and 3 months after major non-cardiac surgery. We measured oxygen saturation by continuous pulse oximetry before surgery and throughout the day of and the first 3 nights after surgery. We recorded blood pressure every 3 min by oscillometry during the operation and every 15-30 min for the rest of that day and night. We identified postoperative cognitive dysfunction with neuropsychological tests compared with controls recruited from the UK (n=176) and the same countries as study centres (n=145). FINDINGS: Postoperative cognitive dysfunction was present in 266 (25.8% [95% CI 23.1-28.5]) of patients 1 week after surgery and in 94 (9.9% [8.1-12.0]) 3 months after surgery, compared with 3.4% and 2.8%, respectively, of UK controls (p<0.0001 and p=0.0037, respectively). Increasing age and duration of anaesthesia, little education, a second operation, postoperative infections, and respiratory complications were risk factors for early postoperative cognitive dysfunction, but only age was a risk factor for late postoperative cognitive dysfunction. Hypoxaemia and hypotension were not significant risk factors at any time. INTERPRETATION: Our findings have implications for studies of the causes of cognitive decline and, in clinical practice, for the information given to patients before surgery.

Abdomen↗
PubMed1998

[Ondansetron. Prophylaxis and therapy of nausea and vomiting following major gynecologic procedures. Results of a national multicenter study].

UNLABELLED: This investigation was conducted as a national multicenter study to evaluate effectiveness and safety of prophylactic and therapeutic ondansetron for postoperative nausea and vomiting (PONV) in major gynaecological surgery. METHODS: 387 patients were randomised to receive either ondansetron 8 mg or placebo i.v. prior to anaesthesia induction. Anaesthesia was performed with a volatile anaesthetic, nitrous oxide and opioids. Established PONV was treated with ondansetron 4 mg i.v. Postoperative evaluation included time, duration and severeness of nausea and vomiting in the first 24 h after the operation. RESULTS: In the study period the incidence of emesis was 35% after prophylactic ondansetron and 58% after placebo (p < 0.01). Nausea occurred in 49% and 64% respectively (p < 0.01). 28% after prophylactic ondansetron and 48% after placebo required ondansetron therapy (p < 0.01). The number of adverse events was small in total and comparable for both groups. CONCLUSION: Our investigation proves the efficiency of ondansetron 8 mg prior to induction of anaesthesia in preventing PONV. Furthermore, our results demonstrate the safety of the drug for prophylaxis and therapy.

Antiemetics↗
PubMed1998

[Evaluation of lactate measurement in blood and plasma with biosensor technology: a comparison of methods].

UNLABELLED: The introduction of biosensor technology for near bedside measurement of plasma lactate concentrations has been a promising step for critical care profiling. However, methodological drawbacks and relevant inaccuracy have been reported. With the advent of a new biosensor (Chiron Diagnostics) and a revised NOVA Biomedical device, accuracy was expected to be improved. The goal of the present investigation was to evaluate the accuracy of both methods. METHODS: Two devices (System 860, Chiron Diagnostics; StatProfile 9, NOVA Biomedical) were simultaneously analysed using 9 biosensors in both fresh frozen plasma and citrated whole blood. The results were compared with an established photometric method (Lactat PAP, Analyticon). Measurements were performed as duplicates (n = 1120) before and after the addition of 1 molar sodium lactate solution (2-24 mmol/L). For the estimation of between-day precision commercially available aqueous and serum-based quality controls were analysed daily over a period of 60 days. RESULTS: Reproducibility in blood was 2.6 +/- 2.8% (Chiron), 4.1 +/- 4.0% (NOVA) and 1.5 +/- 2.1% (Analyticon), in plasma respectively 2.1 +/- 2.4%, 2.1 +/- 2.9% and 1.0 +/- 1.1%. Mean inaccuracy in plasma presented to be -0.2 +/- 16.4% (plasma) and +7.2 +/- 13.1% (blood) for Chiron, +9.4 +/- 18.4% and +18.7 +/- 16.7% for NOVA, and -37.8 +/- 18.2% and -27.5 +/- 17.6% for Analyticon. Calculated between-day-precision (variation coefficients mean values) was 11.5 +/- 4.9% (Chiron) and 14.0 +/- 5.9% (NOVA). CONCLUSION: Although accuracy of lactate concentrations obtained with biosensor technology has improved (mean 0-18%), the variability of the results still poses a problem (mean 13-18%). Therefore, from the methodological point of view, interpretation of a single lactate value requires caution when applying to the critically ill, particularly with view to threshold values, and should be considered vis-à-vis other options.

Biosensing Techniques↗
PubMed1998

[Remifentanil in gynecologic laparoscopy. A comparison of consciousness and circulatory effects of a combination with desflurane and propofol].

OBJECTIVES: Rapid post-anaesthetic awakening and low hypnotic potency are two characteristic properties of the new opioid remifentanil. For clinical use remifentanil must be combined with another anaesthetic agent. Propofol is well-established for ambulatory anaesthesia, however, the properties of desflurane (low blood-gas solubility, rapid elimination) suggest this volatile anaesthetic to be a comparable alternative, particularly if rapid awakening is desired. The present study was designed to compare emergence times and haemodynamics for a combination of remifentanil wich hypnotic concentrations of either propofol or desflurane. METHODS: Gynaecological patients, scheduled for elective laparoscopy, were studied at random. After oral premedication with diazepam 0.08-0.12 mg/kg, anaesthesia was induced identically in both groups: remifentanil bolus (1 microgram/kg), start of remifentanil infusion (0.5 microgram/kg/min), followed by propofol (approx. 2 mg/kg) and cisatracurium (0.1 mg/kg). For maintenance of anaesthesia remifentanil (0.25 microgram/kg/min) was combined with either desflurane (0.5 MAC = 3.0 vol%) or propofol (6 mg/kg/h). With termination of surgery anaesthetic delivery was discontinued simultaneously and recovery times were recorded. Heart rate and non-invasive blood pressure were recorded at defined points of interest. RESULTS: In total, 40 patients (desflurane n = 20, propofol n = 20) were studied in comparable groups. For both regimens, emergence after remifentanil-based anaesthesia was remarkably rapid between unconsciousness and complete recovery: In mean only 60 s elapsed from the onset of spontaneous breathing to the moment when patients could clearly state their name. In comparison, recovery times were significantly shorter after remifentanil-desflurane than after remifentanil-propofol: time to spontaneous ventilation 6.4 +/- 2.8 vs. 9.6 +/- 3.9 min (mean +/- SD, p = 0.01); extubation 6.7 +/- 2.8 vs. 9.8 +/- 4.0 min (p = 0.02) and arrival at PACU 11.1 +/- 3.4 vs. 14.7 +/- 4.2 min (p = 0.005). The courses of heart rate (HR) and mean arterial pressure (MAP) were mostly similar in both groups with only minimal or moderate cardiocirculatory reactions during intubation or start of surgery. CONCLUSIONS: Remifentanil in combination with either desflurane or propofol, used for general anaesthesia during gynaecological laparoscopy, will facilitate a smooth haemodynamic course as well as a rapid emergence thereafter. Recovery times after remifentanil-based anaesthesia are significantly shorter with 3.0 vol% of desflurane than with 6 mg/kg/h propofol. Thus, desflurane appears to be a well-suited adjunct to remifentanil and an ideal alternative to propofol, if rapid recovery is required. Differences are best explained by the pharmacological properties of both coanaesthetics and their applied dosages.

Adult↗
PubMed1996

[Accuracy of measurement and overestimation of CO2 of two capnometers intended for potential use in emergency medicine].

UNLABELLED: Capnometry, the noninvasive measurement of end-expiratory CO2 concentration (cCO2, vol%) or calculation of its respective partial pressure (pCO2; mmHg) is an established method. However, for prehospital settings, capnometry is still used very restrictively, mainly owing to the respective devices used. The prerequisite for their use is sufficient accuracy (+/-2 mmHg) and easy handling. Two special capnometers (STAT CAP. Nellcor: mainstream, semiquantitative estimation; Capnocheck 8200, BCI: sidestream, quantitative measurement, numeric display), developed recently for potential use in emergency medicine, are said to fit these criteria. Therefore, the objective of the present investigation was to assess the accuracy and precision of both devices, comparing methods under standardized in vitro (reference gases) and in vivo (intubated and ventilated patients) conditions. METHODS: Both devices ("STAT CAP": pCO2 range, light bars; "Capnocheck 8200") were evaluated regarding the accuracy of pCO2 (Capnocheck) and the precision of the CO2 range (STAT CAP). Tests were performed with four dry gas mixtures (STPD) of defined composition and during ventilation of 20 intubated patients (BTPS). All measurements were compared with the alveolar gas monitor "AGM 1304" (Brüel & Kjaer, Denmark) as a reference method with a proven +/- 1 mmHg accuracy of pCO2 measurement. RESULTS: The "Capnocheck" (BCI) presented an accuracy of the pregiven pCO2 of 0.7-1.4 mmHg (dry gas mixtures, STPD) and an overestimation of 0.2 +/- 4.1 mmHg (BTPS) during ventilation with pure oxygen; inaccuracy during ventilation with 70% N2O in O2 proved to be + 1.2 +/- 1.7 mmHg (BTPS). Nellcor's "STAT CAP" failed to reach the target value in 10% of analyses, as shown by the respective segment bar of the display. CONCLUSION: Evaluation of the accuracy of capnometers must focus on the necessary pH2O correction and the possible effects exercised by O2 (and N2O) as well as the possible dependence on barometric pressure (if pCO2, mmHg, is the desired value). The "Capnocheck" showed an accuracy of more than 2 mmHg in dry gas mixtures as well as in humidified air. Concerning the practical use during constant artificial ventilation, the digital display and accuracy of the sidestream capnometer allow for reliable conclusions on patients' ventilation and circulation (CO2 elimination). The 90% accuracy of the segment bar display of Nellcor's "STAT CAP", per se covering only a rather broad range of 20 mmHg, obviously does not provide more than a rough overview. Therefore, the STAT CAP cannot be recommended for prehospital capnometry in the field. However, both the accuracy of the BCI capnometer (Capnocheck) and its numeric display and easy handling strongly recommend this device also for clinical use.

Blood Gas Analysis↗
PubMed1995

[Apnoeic oxygenation in Boerhaave syndrome].

UNLABELLED: Boerhaave's syndrome (Hermann Boerhaave, 1724 [5]) stands for the atraumatic spontaneous rupture of the oesophagus, and still represents a life-threatening situation. Contrary to the surgical approach, the anaesthesiological management has been largely neglected so far. CASE REPORT: The present case report introduces a patient requiring surgical therapy due to a belatedly diagnosed rupture of the oesophagus. In agreement with the surgeon, endotracheal intubation was performed using a single-lumen oral Woodbridge tube. During left thoracotomy, artificial ventilation sometimes obstructed the surgeons. Following a life-threatening intrathoracic venous bleeding (after additional right thoracotomy), the situation became almost adverse, since the surgeon could not stop the bleeding due to the movement of the lungs. Ventilation was therefore stopped. The oxygen supply was provided 20 min by application of the so-called apnoeic oxygenation, first described in 1908 by the German surgeon Franz Volhard (15). Using the filled 2.5l reservoir bag of the circle circuit as the oxygen source (CPAP 10 cm H2O), oxygenation was maintained by refilling the bag after its volume had been decreased due to the patient's ongoing O2 consumption. Starting with an initial paO2 value of only 400mmHg (despite pAO2 approximately 670 mmHg, i.e. intrapulmonary right-left shunt of approx. 10-15%), the paO2 declined to 100 mmHg during the 20 min of apnoeic oxygenation (i.e. a drop by 15 mmHg per minute), whereas arterial pCO2 increased by 50 mmHg to a value of 90 mmHg, as stated recently in literature [18]). No relevant changes of ECG, heart rate, blood pressure and partial arterial oxygen saturation (pulse oxymeter) occurred. CONCLUSION: During thoracic operations adverse situations may arise from the two antipodes artificial ventilation and acceptable surgical access. Alternative respiratory techniques, e.g. one-lung anaesthesia and/or high-frequency jet ventilation, are not always applicable, although the present case report indicates that a double lumen tube should be recommended. However, the clinical use of oxygenation by apnoeic oxygenation is a useful measure that can be realised in a simple and safe manner. The present case report may help to consider this particular alternative also during thoracic surgery (no influence of FRC size on pAO2 decrease). If applied correctly, apnoeic oxygenation obviously increases both the flexibility of the anaesthesist and patient safety, and additionally provides the ability of safe acting in clinical routine settings as well as during emergencies. In summary, knowledge of this technique of oxygenation seems to be an integral part of serious anaesthesiological education and clinical management.

Esophageal Diseases↗