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W Seeling

Publications and source records attributed to W Seeling.

At least 37 records · Page 2Linked to original sources
PubMed1998

[Results of a survey of anesthetists on postoperative nausea and vomiting].

OBJECTIVE: Although an increasing number of studies concerning postoperative nausea and vomiting (PONV) have been performed, we do not know, what anaesthesiologists think about this problem and how they handle it in their daily routine. METHODS: A survey was performed involving anesthesiologists at 30 institutions of different size. 474 out of 1000 questionnaires were returned. RESULTS: When asked what kind of general anaesthesia they prefere in a woman at a very high risk to suffer PONV, the following answers were obtained: anaesthesia induction with propofol (78%), thiopentone (17%), etomidate (5%). Maintenance of anaesthesia with an inhalation anesthetic (44%) or with propofol (44%). The remaining 14% would use a combination of these techniques (6%) or neuroleptanaesthesia with droperidol (5%) or midazolam (1%). Only 10% of the respondants would omit nitrous oxide. There is no consensus about the optimal amount of intraoperative opioids. Fentanyl, alfentanil, and sufentanil are rated to contribute equally to the occurence of PONV, whereas opioids used for postoperative analgesia are thought to have substantial differences: piritramid is rated to be much less emetogenic than tramadol and morphine. 70% advocate routine antiemetic prophylaxis for high-risk patients (most often mentioned risk factors were: female sex: 85%, obesity: 81%, high doses of intraoperative opioids: 72%) and 23% administrate antiemetics even for all patients. Ondansetron and droperidol are suggested to be superior to metoclopramide, triflupromazine, dimenhydrinate, and transdermal scopolamine. However, metoclopramide is the drug of first choice for more than 50% of the respondants followed by droperidol, whereas only 29% use ondansetron as a first line drug. An unexpected high number of anaesthesiologists (13%) have experience with non-pharmacological methods for prophylaxis and treatment of PONV. Acupuncture/acupressure (10%) was most often mentioned. CONCLUSION: A great majority (93%) stated, that PONV is a relevant problem, that still remains unsolved. This proofs the need for further controlled studies.

Anesthesia↗
PubMed1998

Vasopressor hormone response following mesenteric traction during major abdominal surgery.

BACKGROUND: We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI2) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. METHODS: In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGF1 alpha (stabile metabolite of PGI2), TXB2 (stabile metabolite of thromboxane A2) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. RESULTS: Following MT, arterial hypotension occurred along with a substantial PGI2 release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF1 alpha (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P = 0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB2 (164 (87) vs. 58 (1) ng/L, P = 0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P = 0.001), AVP (41 +/- (18) vs. 12 (7) ng/L, P = 0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. CONCLUSION: Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI2 release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A2, presumably contributing to hemodynamic stability within 30 min after MT.

Abdomen↗
PubMed1997

[Postoperative analgesia after endoscopic abdominal operations. A randomized double-blind study of perioperative effectiveness of metamizole].

In comparison to conventional operating technique endoscopic surgery reveals numerous advantages, particular rapid mobilisation and earlier discharge from observation. For a effective utilization of these advantages, it is desirable to have a efficient postoperative analgesic scheme, which can be continued into the period after discharge from hospital. In a randomised, prospective double-blind study we investigated the analgesic efficacy of dipyrone in 40 patients, scheduled for endoscopic abdominal surgery (mainly endoscopic cholecystectomy). Patients received before induction of anesthesia either dipyrone (1 g/100 ml NaCl i.v.) or placebo (100 ml NaCl i.v.). These infusions were repeated 6 h and 12 h after first application. After surgery all patients were allowed to self-administer buprenorphine intravenously from a PCA-pump (Bolus 30 micrograms, lockout 5 min in the recovery room, 30 min on the ward). Every hour for the first 6 h and after 24 h, cumulated doses of buprenorphine, pain scores (0-10), pulse, blood pressure and side effects were recorded. Dipyrone-treated patients had significantly less pain immediately after surgery and used a significantly lower cumulated dose of buprenorphine (-67%; 90 micrograms vs. 270 micrograms buprenorphine) in the first 24 h after surgery.

Adolescent↗
PubMed1997

[Effectiveness, side effects and costs of postoperative pain therapy: intravenous and epidural patient-controlled analgesia (PCA)].

PURPOSE: Improvement of the quality of analgesia, reduction of side effects and costs by application of epidural (PCEA) in comparison to intravenous patient-controlled analgesia (PCA) in postoperative pain treatment. METHODS: 62 patients with upper abdominal surgery took part in this randomised prospective study which was approved by the local ethics committee. Epidural catheters were inserted at T 8/9 (group PCEA). General anaesthesia was performed with propofol, sufentanil 2 micrograms/kg, pancuronium, enflurane and O2:N2O = 1:2. Postoperative analgesia consisted of epidural bupivacaine 0.25% + sufentanil 2 micrograms/ml (BS). (bolus 0.05 ml/kg, lockout 10 min) in group PCEA, or of intravenous morphine (bolus 2 mg. lockout 10 min) in group PCA. The following parameters were recorded until the evening of postoperative day 4: pain intensity at rest (VASR, 1-10) and on coughing (VASH, 1-10), blood pressure, heart rate, blood gas analysis, ability to ambulate, pruritus, nausea/vomiting (PONV), patient satisfaction (0-4), time and expenses for postoperative pain treatment. RESULTS: Median VASR (1 vs 2) and VASH (3 vs 4.5) were lower, cough intensity (2 vs 1) and patient satisfaction score (4 vs 3) were higher in PCEA compared to PCA. Ability to ambulate, pruritus, PONV, haemodynamics, paO2 and paCO2 were comparable. Postoperative pain treatment with PCEA was more time-consuming (407 vs 299 min) and expensive (71 vs 40 S/day) than PCA. CONCLUSION: PCEA in comparison to PCA after major abdominal surgery provides superior analgesia with comparable side effects at approximately 80% higher costs.

Abdomen↗
PubMed1997

[Differential indications for non-opioids for postoperative analgesia III. Analgesic effect of perioperative administration of metamizole plus diclofenac after spinal anesthesia].

PURPOSE: In a previous study we investigated the analgesic efficacy of a combination of metamizol plus diclofenac after general anaesthesia. After minor orthopaedic surgery postoperative opioid requirements were reduced by 73% during the first 24 h after surgery. In the present study, we have investigated the efficacy of this analgesic combination after minor orthopaedic operations performed in spinal anaesthesia. METHODS: Seventy four patients, scheduled for minor orthopaedic surgery, participated in this double-blind, randomised, placebo-controlled study. The setting was comparable to our previous study. Before induction of spinal anaesthesia, verum-treated patients received a diclofenac suppository (100 mg), and metamizol (1 g/100 ml NaCl 0.9% intravenously over 15 min). These infusions were repeated at 6 h and 12 h. In addition to the third infusion, the patients received a further diclofenac suppository (100 mg). Cumulated doses of buprenorphine (PCA, patient-controlled analgesia), pain scores (0-10), blood pressure, heart rate and side effects were recorded during the first 6 h and again at 24 h. RESULTS: After spinal anaesthesia had subsided, all patients required increasing doses of buprenorphine. Verum-treated patients required significantly lower doses during the first 24 h after surgery (median -29%). CONCLUSIONS: The combination of metamizol and diclofenac causes a clinically relevant reduction in opioid requirements after minor orthopaedic surgery in spinal anaesthesia.

Adult↗
PubMed1997

Reduced postoperative analgesic demand after inhaled anesthesia in comparison to combined epidural-inhaled anesthesia in patients undergoing abdominal surgery.

We studied the effect of epidural/general combination anesthesia, in comparison to inhaled anesthesia, on postoperative pain and analgesic consumption in patients undergoing upper abdominal surgery. Anesthesia was induced with propofol and maintained with enflurane in 70% N2O as necessary to maintain arterial blood pressure within 20% of baseline. Group I received bupivacaine 0.25% 0.2 mL/kg and sufentanil 1 microgram/kg 65 +/- 3 min before dermal incision and 0.1 mL/kg bupivacaine 0.25% + sufentanil 2 micrograms/mL (BS) every hour thereafter. Group II received 0.2 mL/kg of BS 316 +/- 15 min after dermal incision in the recovery room. Postoperative patient-controlled epidural analgesia (PCEA) with BS was provided. Pain intensities and consumption of PCEA BS were recorded on postoperative days (PODs) 1 to 5. Inspiratory fraction of enflurane was lower (0.5% +/- 0.01% vs 1.6% +/- 0.04%; P < 0.001) in Group I compared with Group II. Cumulative postoperative consumption of PCEA BS was higher in Group I compared with Group II from the evening of POD 2 until the end of the study (301 +/- 19 mL vs 249 +/- 17 mL; P < 0.001), while pain intensities were comparable at all times. The intraoperative effects of combined BS and enflurane/N2O (inspiratory fraction [Fi] approximately 1 minimum alveolar anesthetic concentration [MAC]) did not preempt postoperative pain in contrast to enflurane/N2O anesthesia (Fi approximately 2.8 MAC).

Abdomen↗
PubMed1997

The impact of prostanoids on pulmonary gas exchange during abdominal surgery with mesenteric traction.

We investigated the effect of intravenous (iv) ibuprofen on prostanoid release and on pulmonary gas exchange after abdominal mesenteric traction (MT) during either abdominal aortic surgery or pancreas resection. In a prospective, randomized, double-blind study, 400 mg ibuprofen (pancreas n = 13, aorta n = 13) or a placebo (pancreas n = 13, aorta n = 13) was administered iv before skin incision. MT was applied uniformly. The prostanoid plasma concentrations, venous admixture (Q(va)/Q(t)), and PaO2/FIO2 ratio were determined at baseline (before MT) and 5, 15, 45, and 90 min after MT. Patients who underwent aortic surgery were older and exhibited a lower preoperative PaO2 than those who underwent pancreas resection. Placebo-treated patients revealed a 30-fold peak increase in 6-keto-prostaglandin F1alpha (stable metabolite of prostacyclin) levels after intentional MT during aortic as well as pancreatic operations. This response was accompanied by an increase in Q(va)/Q(t) (ibuprofen: pancreas 7% +/- 1%, aorta 14% +/- 2%; placebo: pancreas 16% +/- 3%, aorta 26% +/- 3%/15 min after MT [mean +/- SEM, P < 0.05, placebo vs ibuprofen]), which resulted in decreased PaO2/ FIO2 ratio only in the aortic surgery patients (ibuprofen: 310 +/- 19; placebo: 237 +/- 24 15 min after MT, [mean +/- SEM, P < 0.05]). The authors conclude that ibuprofen-pretreated patients demonstrated almost constant prostanoid levels without changes in pulmonary gas exchange after MT.

6-Ketoprostaglandin F1 alpha↗
PubMed1997

Epidural bolus clonidine/morphine versus epidural patient-controlled bupivacaine/sufentanil: quality of postoperative analgesia and cost-identification analysis.

UNLABELLED: We compared the costs, quality of analgesia, and side effects of postoperative patient-controlled epidural analgesia (PCEA) with bupivacaine/sufentanil versus an epidural bolus (BOLUS) of clonidine/morphine in 68 patients with pancreatic surgery. Postoperative pain treatment was performed over 4 days: the PCEA pump was filled with bupivacaine 0.25% and sufentanil 2 micrograms/mL and set to 3-mL bolus and 10-min lockout time. BOLUS patients received injections of clonidine 150 micrograms plus morphine 2 mg on demand. Visual analog scale (VAS) score at rest and during coughing, heart rate (HR), systolic arterial pressure (SAP), incidence of postoperative nausea and vomiting, pruritus, duration of intestinal paralysis, hospital treatment, and costs for personnel and material were recorded. VAS scores during coughing (3 +/- 2.5 vs 5 +/- 3, P < 0.001) was higher, and HR (79 +/- 13 vs 89 +/- 15, P < 0.001), and SAP (110 +/- 18 vs 124 +/- 23, P < 0.001) were lower, in the BOLUS compared with the PCEA group. The incidence of hypotension (SAP < 80 mm Hg) was greater (6 vs 0, P < 0.001) in the BOLUS group. The incidence of all other side effects was comparable. The costs of personnel ($204 +/- $40 vs $166 +/- $38, P < 0.001) were higher in the BOLUS group, but the costs of material ($51 +/- $17 vs $87 +/- $18, P < 0.001) were higher in the PCEA group. Total costs ($62 +/- $9 vs $62 +/- $11 per day, P = 0.9) were comparable. We conclude that because of superior analgesia and reduced side effects at analogous costs, PCEA is preferable to the BOLUS technique for the treatment of postoperative pain. IMPLICATIONS: An epidural clonidine/morphine bolus technique resulted in inferior analgesia, more side effects, and comparable costs compared with a bupivacaine/sufentanil patient-controlled regimen in a randomized controlled trial after abdominal surgery.

Adult↗
PubMed1997

[Epiduritis after long-term pain therapy with an epidural catheter--review of the literature with a current case report].

Patients suffering from vascular disease are often a challenge for the acute pain service. Ischaemia, impaired wound healing, stump and phantom limb pain often require a complex analgesic regimen. Invasive measures such as spinal or epidural catheters can be very helpful but carry the risk of infection, as shown by this case report. A 53-year-old woman with a ten-year history of diabetes developed arterial vascular disease. Her right lower leg had been amputated two years previously. She was now admitted with necroses of the left forefoot. A bypass operation was performed under general anaesthesia. Because of intractable ischaemic pain, she was provided with an epidural catheter by the acute pain service. The bypass occluded, however, and a few days later her left lower leg also had to be amputated, this operation being performed under epidural anaesthesia with bupivacaine. The catheter was subsequently used for postoperative pain control and as a means to prevent phantom limb pain. When signs of superficial catheter infection were noticed days later, the catheter was immediately removed. Intractable pain then developed in the left leg which could not be sufficiently controlled with opioids and NSAIDs, and so a second epidural catheter was inserted one segment rostrally. Several days later the infected vascular prosthesis had to be removed followed by amputation of the thigh, this operation also being performed in epidural anaesthesia. Eleven days after insertion of the first epidural catheter, the patient complained of low back pain and headache. Examination by a neurologist revealed no signs of intraspinal infection. The second epidural catheter dislocated at this point in time and it was decided to introduce a third one, this being the only means to treat the otherwise intractable stump pain. Ten days later meningism, Kernig's sign and leucocytosis developed. NMR tomography detected intraspinal fluid in the epidural space at the dorsal border of the spinal canal. A hemilaminectomy was performed. The spinal epidural space showed signs of inflammation of the adipose tissue, but no pus. A little necrotic material and residues of an old haematoma were removed and the epidural space was lavaged. Specimens taken from the epidural material revealed colonisation with staphylococcus epidermidis, which was sensitive to the broad spectrum antibiotics formerly given to the patient to treat the infection in the left stump. By the next day, all signs of epiduritis had disappeared and the patient recovered completely.

Analgesia, Epidural↗
PubMed1996

[Epidural and intrathecal administration of alpha 2-adreno-ceptor agonists for postoperative pain relief].

Spinal clonidine interacts with pre- and postsynaptic alpha(2)-adrenoceptors on afferent neurons in the superficial dorsal horn of the spinal cord: it causes analgesia by inhibition of the synaptic and electrotonic neurotransmission of nociceptive impulses. Epidural doses higher than 4 microg/kg have an analgesic onset time of less than 30 min, reduce pain by more than 70 %; these effects last for 4-5 h. Epidural clonidine analgesia is accompanied by a reduction in heart rate, cardiac output and blood pressure of approximately 20 % compared with baseline. The haemodynamic side effects mean close supervision is needed during the first hour after epidural application and limit the use of epidural clonidine to patients who are refractory to the analgesic effects of epidural opioid or local anaesthetics. In these patients excellent results can be achieved either with clonidine alone or with a combination of clonidine and an opioid or a local anaesthetic to exploit the additive or supra-additive interactions of these drugs.

English Abstract↗
PubMed1996

[Epidurography: comparison with CT, spiral CT and MR epidurography].

PURPOSE: The purpose of this study was to explain the origin of image patterns demonstrated by conventional epidurography, which is a controversially discussed topic in recent literature. MATERIAL AND METHODS: After introduction of thoracic epidural catheters and iopamidol injection, conventional epidurography and CT-epidurography were performed on 25 preoperative patients. After injection of Gadolinium-DTPA MR-epidurography was performed in two patients treated for chronic pain with already introduced epidural catheters. Three volunteers also underwent identical imaging after introduction of thoracic epidural catheters and in addition helical-CT epidurography using twin-beam technology. RESULTS: 40% of the patients demonstrated the railroad track phenomenon. We were able to prove that it is a sign of a rhythmically variable filling of segments of the lateral epidural space with contrast medium 76% of the patients demonstrated no ventral epidural space at the thoracic level. 56% of the patients showed a medial area of translucence combined with a band-shaped contrasting of the epidural space in the standard ap view. This was proven in all cases to be a plica mediana dorsalis by CT. In all volunteers who underwent helical-CT and MR epidurography we observed the railroad track phenomenon and the filling defect of the anterior thoracic epidural space. CONCLUSION: CT epidurography is well suited for obtaining new insights into the interpretation of findings obtained by conventional epidurography.

Analgesia, Epidural↗
PubMed1996

[Differential administration of non-opioids in postoperative analgesia, I. Quantification of the analgesic effect of metamizole using patient-controlled analgesia].

OBJECTIVE: The aim of this study was to investigate: 1. Whether the perioperative administration of metamizol causes a significant reduction in postoperative opioid requirements within the first 24 h after surgery. 2. The opioid-sparing effect after different types of operations. 3. Whether preoperative application of metamizol causes a significant reduction of the pain-score immediately after operation. METHODS: In a double-blind, randomised, placebo-controlled study, 117 patients, scheduled for minor orthopaedic or laparoscopic surgery or other operations (mainly resection of the thyroid gland and inguinal herniotomies) received either metamizol (1 g/100 ml NaCl 0.9%) or placebo (100 ml NaCl 0.9%) intravenously over 15 min in three separate doses: the first dose was given just before induction and the others 6 h and 12 h later. After surgery all patients were allowed to self-administer buprenorphine from a PCA (patient-controlled analgesia) pump (Bolus: 30 microgram, lockout: 5 min in the recovery room, 30 min on the ward). Every hour for the first 6 h and after 24 h, cumulated doses of buprenorphine, pain scores (0-10), blood pressure, pulse and side effects were recorded. RESULTS: After minor orthopaedic and laparoscopic surgery, metamizol-treated patients had significantly less pain immediately after surgery and used a significantly lower cumulated dose of opioid in the first 24 h after surgery (-20% and -67% respectively) than patients receiving placebo. After the other types of surgery no analgesic effect could be established. CONCLUSIONS: Perioperative administration of metamizol results in better pain relief and significantly lower buprenorphine requirements particularly after laparoscopic operations. To achieve a significant pain reduction immediately after the operation, the first dose should be applied before induction.

Adolescent↗
PubMed1996

[Differential indications of non-opioid drugs for postoperative analgesia II. Quantification of the analgesic effect of a combination of metamizol plus diclofenac via patient-controlled analgesia].

OBJECTIVE: In a previous study we investigated the analgesic efficacy of metamizol. After laparoscopic operations, in particular, the reduction of postoperative opioid requirements within the first 24 h after surgery attained clinical relevance (-67%). In the present study we investigated the analgesic efficacy of supplementary diclofenac. METHODS: 86 patients, scheduled for minor orthopaedic surgery, laparoscopic cholecystectomy or resection of the thyroid gland, participated in a doubleblind, randomised, placebo-controlled study. The setting was comparable to our previous study, apart from the supplementary administration of diclofenac. Before induction of anaesthesia, verum-treated patients received a diclofenac suppository (100 mg), in addition to metamizol (1 g/100 ml NaCl 0.9% intravenous over 15 min). These infusions were repeated at 6h and 12h. In addition to the third infusion, the patients received a further diclofenac suppository (100 mg). Cumulated doses of buprenorphine (PCA, patient-controlled analgesia), pain scores (0-10), blood pressure, pulse and side effects were recorded during the first 6 h and again at 24 h. RESULTS: All verum-treated patients had significantly less pain immediately after surgery and required lower cumulated doses of buprenorphine during the first 24 h after operation (laparoscopic cholecystectomy -33%, minor orthopaedic surgery -73%, resection of thyroid gland -60%). CONCLUSIONS: Combination of metamizol and diclofenac cause a clinically relevant reduction in opioid requirements, in particular after minor orthopaedic surgery and resection of the thyroid gland. There is no need for supplementary diclofenac following laparoscopic surgery.

Adult↗
PubMed1996

Prophylactic use of epidural mepivacaine/morphine, systemic diclofenac, and metamizole reduces postoperative morphine consumption after major abdominal surgery.

BACKGROUND: Surgical trauma induces nociceptive sensitization leading to amplification and prolongation of postoperative pain. While preemptive analgesic treatment with numerous agents has been successful in experimental animals, results of human studies remain conflicting. The authors used a multimodal approach for preemptive analgesia before abdominal surgery: diclofenac and metamizole inhibit prostaglandin synthesis, thus influencing peripheral sensitization; epidural local anesthetics induce conduction block, epidural opioids inhibit nociceptive synaptic transmission, and metamizole induces descending inhibition. The interaction of these drugs might suppress spinal nociceptive sensitization and postoperative analgesic demand. METHODS: One hundred forty-two patients scheduled for major abdominal surgery were randomly assigned to one of three groups and studied prospectively. Epidural catheters in groups 1 and 2 were placed at interspaces T8-T10, the position of the catheter was confirmed by epidurography, and sensory testing after administration of 5 ml mepivacaine 1%. Group 1 received 75 mg intramuscular diclofenac, 1000 mg intravenous metamizole, 5.3 +/- 1 mg epidural morphine, and 15-20 ml mepivacaine 1% 85 +/- 41 min before skin incision. Epidural analgesia was maintained by injections of 0.1 ml.kg-1.h-1 mepivacaine 1%. Group 2 patients received the balanced analgesia regimen before wound closure (221 +/- 86 min after skin incision). Group 3 patients did not receive any study substances. General anesthesia was induced with 5 mg/kg thiopental and 2 micrograms/kg fentanyl and maintained with enflurane and nitrous oxide. Postoperative analgesia consisted of patient-controlled intravenous morphine over 5 days. RESULTS: Median visual analog scale pain intensities were < 3 cm and did not differ among the groups. Morphine consumption per hour on postoperative day 2 was 0.8 +/- 0.1 mg/h (group 1) < 1.2 +/- 0.1 mg/h (group 2) = 1.1 +/- 0.1 mg/h (group 3) and cumulative morphine consumption (in mg) on the morning of day 5 was 95 +/- 9 (group 1) < 111 +/- 11 (group 2) < 137 +/- 10 (group 3). CONCLUSIONS: A significant reduction of patient controlled analgesia requirements could be achieved by our preincisional balanced analgesia regimen compared to application before wound closure. The more distinct difference between patients receiving balanced analgesia and those in the control group is based on the analgesic action of the study substances, which lasted about 14 h.

Abdomen↗
PubMed1996

Perioperative endotoxemia and bacterial translocation during major abdominal surgery: evidence for the protective effect of endogenous prostacyclin?

OBJECTIVE: To investigate the potential role of endogenous prostacyclin (PGI2) released after mesenteric traction during major abdominal surgery on perioperative endotoxemia and bacterial translocation. DESIGN: Prospective, randomized, double-blind clinical study. SETTING: Operating room and surgical intensive care unit in a university hospital. PATIENTS: Fifty consecutive patients scheduled for major abdominal surgery (pancreas resection, abdominal aortic surgery). INTERVENTIONS: Fifteen minutes before skin incision, either 400 mg of ibuprofen or a placebo equivalent were administered intravenously. Immediately after peritoneal incision, eventration and action of the small bowel was intentionally performed in a uniform fashion. MEASUREMENTS AND MAIN RESULTS: Baseline values were obtained before induction of anesthesia. Additional measurements, along with assessments of hemodynamics and gas exchange, were performed before incision of the peritoneum and at 5, 30, and 45 mins and 3, 6, and 24 hrs after mesenteric traction. Arterial plasma concentrations of 6-keto-prostaglandin F1 alpha and thromboxane B2 (stable metabolites of PGI2 and thromboxane A2) were determined by radioimmunoassay. Endotoxin was measured by limulus amebocyte lysate test. Mesenteric lymph nodes were sampled in 31 patients (ibuprofen n = 14, placebo n = 17) and sent for culture under sterile conditions. Transient hypotension and a marked increase of plasma 6-keto-prostaglandin F1 alpha concentrations occurred up to 6 hrs after mesenteric traction in untreated patients with median peak concentrations (2243 vs. 72 ng/L [p < .0001, placebo vs. ibuprofen], observed 5 mins after mesenteric traction). Endotoxemia occurred in both study groups. However, after mesenteric traction, plasma endotoxin concentrations were significantly higher in the ibuprofen group. Median peak concentrations (0.12 vs. 0.27 EU/mL [p < .001, placebo vs. ibuprofen]) were observed 3 hrs after mesenteric traction. Gram-negative bacteria in mesenteric lymph nodes were detected exclusively in the ibuprofen group (n = 5, p < .01). CONCLUSIONS: In ibuprofen-pretreated patients, significantly higher endotoxin concentrations as well as bacterial translocation to mesenteric lymph nodes occurred, despite the absence of a transient decrease in mean arterial pressure that had been associated with PGI2 release. Therefore, we hypothesized that during major abdominal surgery, endogenous PGI2 released in response to mesenteric traction may play a crucial role in maintaining splanchnic microcirculation and thus preserving gut mucosal barrier function.

APACHE↗
PubMed1995

[CT-epidurography. A comparison of conventional and CT-epidurography with contrast medium injection through a thoracic peridural catheter].

Epidurography with contrast medium is used to verify the correct position of an epidural catheter and to detect malpositioning. There is great variability in the distribution of contrast medium according to the individual morphology of the epidural space and the way it is injected. Results of investigations of the anatomy of the spinal canal and epidural space performed with anatomic specimens, epiduroscopy, and conventional and computed tomographic (CT) epidurography are sometimes contradictory. We have performed CT epidurography in approximately 30 patients to date. Insights regarding the distribution of contrast medium in the epidural space can help to interpret conventional epidurographies and to explain special features, such as the "rail-road-track phenomenon" or the plica mediana dorsalis. METHODS. Patients scheduled for major abdominal operations were studied. Catheters were introduced into the thoracic epidural space on the day before the operation. Conventional epidurographies were performed routinely after insertion of the catheters with a mobile X-ray apparatus, usually in the recovery room, using 5 ml iopamidol (Solutrast 250 M). Selected patients (good mental state and stable psychic condition), after written consent and with approval of the local ethical committee, were investigated with CT epidurography using the same contrast medium (partly diluted). From among the CT scans performed until now, five characteristic images are presented and compared to conventional epidurographies. RESULTS. When small volumes (5 ml) of iopamidol were injected slowly, we regularly observed a railroad-track phenomenon in the AP images of conventional epidurographies. After rapid injection of larger volumes (10-15 ml), the spread was more homogeneous and sometimes outline a lighter zone of contrast distribution in the midline. CT epidurography in these cases (5 out of 30 patients) revealed a plica mediana dorsalis. In the majority of the CT scans of the thoracic epidural space its anterior (ventral) compartment was unfilled by contrast medium. According to the findings of several investigators, dura mater and ligamentum longitudinal posterius have grown together, so that an epidural space does not exist in ventral thoracic segments of the spinal canal. In lower thoracic and lumbar segments both structures are separate, and a wide anterior epidural space was present and filled with contrast medium. In other cases the dorsal and dorsolateral epidural space was completely filled, but the contrast medium stopped behind the spinal nerves and surrounding dural sheaths, as if these structures, together with the connective tissue strands between them, formed a membrane that spread in a frontal plane. A railroad-track phenomenon is interpreted in the literature as the X-ray correlate of contrast medium spread in the subdural space, indicating an incorrect catheter position. According to conventional epidurographies and confirmed by CT scans, this feature is also seen regularly in cases with correct catheter position. Small volumes of iopamidol spread preferentially into the wider parts of the epidural space between the gaps of the vertebral arcs, whereas the dura mater and periosteal layers touch at the inner side of the pedicules and laminae, allowing the existence of only a potential epidural space. This rhythmic widening and narrowing of the epidural space is the explanation of the "railroad track" in AP contrast epidurographies. CONCLUSIONS. CT epidurography is a valuable tool to provide better insight into the morphology of the epidural space when filled with fluid (contrast medium, local anaesthetics), complementing findings using epiduroscopy and anatomic specimens. It stands to reason that this time- and cost-expensive method can never replace conventional epidurographies, but can help to interpret them properly.

Adult↗
PubMed1995

[Analgesia with intra-articular morphine following knee joint arthroscopy? A double-blind, randomized study with patient-controlled analgesia].

UNLABELLED: Previous studies investigating the peripheral action of locally instilled morphine after arthroscopic knee surgery found evidence for an analgesic effect. Follow-up studies have lead to conflicting results. We used patient-controlled analgesia (PCA) to test the analgesic potency of intraarticular morphine. METHODS. Patients undergoing arthroscopic knee surgery under general anaesthesia received, after written informed consent and in double-blind and randomised manner, 1 mg morphine diluted in 10 ml saline either intraarticularly or intravenously at the end of the surgical procedure. A control injection of 10 ml saline was given at the other site. The pain intensity on a visual analogue scale (VAS) and the cumulative morphine consumption were recorded at 1, 2, 3, 4, 6, 8 and 24 h after the end of general anaesthesia. STATISTICS: Wilcoxon rank sum test with P < 0.05. RESULTS. A total of 59 patients were included in the study; 29 received morphine intraarticularly (verum group), 30 intravenously (control group). There was no difference in gender, age, duration of arthroscopy or anaesthesia. There were more than 60% diagnostic arthroscopies in both groups; other types of surgery were comparable, with the exception of cruciate band repair procedures only in the control group. We found no difference in morphine consumption or pain intensity between the two groups throughout the study period. Median overall consumption of morphine after 24 h was 14 mg in the verum group and 15 mg in the control group, with wide interindividual variation. Pain intensities were remarkably low. The peak pain intensity of both groups was found at 1 h postoperatively, with median 16/100 on the VAS in both groups. Blinding was robust. CONCLUSION. We found no reduction in postoperative morphine supplementation after 1 mg morphine intraarticularly compared to 1 mg intravenously given at the end of knee arthroscopies. There were also no differences in pain intensities on a VAS. We conclude that titration of postoperative pain with a morphine-filled PCA pump was unable to show a difference in analgesic potency between intraarticular and intravenous morphine.

Adolescent↗