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Der Schmerz 12/2012; 26(6):724-5. · 0.88 Impact Factor
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ABSTRACT: A severe hepatopathy constitutes a serious threat during pregnancy and poses considerable challenges to the treating physicians. A broad spectrum of pregnancy-dependent or independent diseases like HELLP-syndrome, liver infection or acute fatty liver of pregnancy (AFLP) is characterized by these affections of the liver. In this study, we present a series of 3 cases with life-threatening hepatopathies and discuss the current state of the literature. A special focus is placed on pathogenesis and differential diagnosis.Pathological, radiological and gynaecological/surgical procedures were performed according to the current German guidelines. Laboratory tests were conducted in the clinics' routine diagnostics section. The existing literature was reviewed via the US National Library of Medicine database "PubMed.gov".The first patient had been afflicted by a fulminant HELLP syndrome causing delivery after 32 weeks of pregnancy. Consecutively, she suffered a sub-total liver infarction followed by a severe coagulopathy and septic peritonitis. The second patient was diagnosed with HELLP syndrome at 36 weeks of pregnancy. The initially mild syndrome exacerbated after delivery leading to haemorrhagic shock and acute renal failure. In the third case, a woman with asymptomatic hepatitis B delivered in the 36th week of pregnancy. Post partum, her pre-existing condition worsened fulminantly resulting in sub-acute liver dystrophy and massive coagulopathy.Whenever a hepatopathy occurs during pregnancy, several divergent diagnoses with severe implications and different aetiopathologies have to be considered. Diagnostic and therapeutic strategies have to be weighed quickly to enable a fast, interdisciplinary cooperation in order to prevent fatal outcomes.
Zeitschrift für Geburtshilfe und Neonatologie 12/2012; 216(6):277-84.
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ABSTRACT: D-116883 (Aeterna Zentaris GmbH, Frankfurt, Germany) is an orally effective drug that acts via inhibition of phosphatidylinositol 3-kinase (PI3K). The PI3K/AKT signal transduction pathway is involved in ovarian cancer tumorigenesis. Phosphatase and Tensin homolog (PTEN) loss and other activating mutations frequently contribute to the activation of this pathway. We tested whether D-116883 exerts cytostatic effects in in vitro models of ovarian cancer and analyzed the induced programmed cell death.
We evaluated the potency of D-116883 in four ovarian carcinoma cell lines with different cellular assays. The effects of D-116883 on cell proliferation was analysed by crystal-violet staining and tetrazolium salt [(3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide; MTT] assay. The capacity for anchorage-independent growth was analyzed in two ovarian carcinoma cell lines without and with D-116883 addition by using the soft agar assay. Fluorescence activated cell sorting (FACS) cell cycle analyses were performed. Cells were incubated with multicaspase inhibitor benzyloxycarbonyl-val-ala-asp(OMe)-fluoromethylketone (zVAD) and inhibitor of necroptosis necrostatin.
Growth inhibition occurred in all ovarian carcinoma cell lines studied (A2780, A2780cis, OAW42 and SKOV3) in a micromolar range (IC(50)<1 μM). By using soft agar assay, a reduced capacity for anchorage-independent growth, a hallmark of tumor cells, caused by D-116883 was demonstrated. Cell cycle analyses showed that D-116883 dose-dependently increased apoptotic cells. Multicaspase inhibitor zVAD and inhibitor of necroptosis necrostatin did not abrogate the growth-inhibiting effect of the compound.
PI3K inhibitor D-116883 showed substantial cytotoxic effects in various in vitro models of ovarian cancer. Our results make D-116883 a good candidate for further ovarian cancer research including in vivo experiments.
Anticancer research 05/2012; 32(5):2035-41. · 1.73 Impact Factor
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C.C. Apfel, P. Kranke,
S. Piper,
D. Rüsch,
H. Kerger,
M. Steinfath,
K. Stöcklein,
D.R. Spahn,
T. Möllhoff,
K. Danner,
A. Biedler,
M. Hohenhaus,
B. Zwissler,
O. Danzeisen,
H. Gerber,
F.-J. Kretz
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ABSTRACT: Bislang existieren für den deutschen Sprachraum keine expertenbasierten Handlungsempfehlungen zur Vermeidung oder Therapie
von „postoperative nausea and vomiting“ (postoperative Übelkeit und Erbrechen, PONV). Ziel war daher die Entwicklung von Empfehlungen,
aus denen im klinikspezifischen Kontext „standard operating procedures“ (SOPs) abgeleitet werden können. Ein anästhesiologisch
besetztes Expertengremium bearbeitete relevante Schlüsselthemen in Arbeitsgruppen, die anschließend im Plenum diskutiert wurden.
Die Empfehlungen sollten sich auf Erkenntnisse stützen, zu denen umfassende und vertrauenswürdige Daten vorliegen. Einzelne
Risikofaktoren, wie z.B. die Anamnese des Patienten, besitzen, isoliert betrachtet, keine ausreichende Sensitivität und Spezifität,
um anhand dessen klinisch rationale Entscheidungen zu treffen. Im Gegensatz dazu berücksichtigen vereinfachte Risikoscores
mehrere Faktoren und ermöglichen folglich eine zuverlässigere Risikoeinschätzung. Einzelne antiemetische Interventionen zur
Vermeidung von PONV sind mit einer relativen Risikoreduktion von ca. 30% im Allgemeinen vergleichbar effektiv. Dieses scheint
für die total intravenöse Anästhesie (TIVA) ebenso wie für Dexamethason und andere Antiemetika (Dimenhydrinat, Droperidol,
Serotoninantagonisten, transdermales Scopolamin) zu gelten. Eine adäquate, hinreichend hohe Dosierung ist dabei Voraussetzung,
die bei Kindern natürlich gewichtsadaptiert erfolgen sollte. Während die relative Risikoreduktion weitgehend unabhängig vom
Kontext ist, sind die absolute Risikoreduktion und somit die „number needed totreat“ (NNT) einer Prophylaxe vor allem vom
Patientenrisiko abhängig. Bei einem niedrigen Risiko erscheint eine Prophylaxe nicht sinnvoll. Bei mittlerem Risiko sollte
eine Prophylaxe nicht vorenthalten werden. Ein hohes Risiko erfordert ein multimodales Vorgehen, das im Einzelfall angepasst
werden sollte (medizinisches Risiko, Patientenpräferenz). Die Therapie von PONV sollte prompt, vorzugsweise mit zuvor noch
nicht verwendeten Antiemetika erfolgen. Das Gremium schlägt Algorithmen vor, bei denen die Indikation und das Ausmaß einer
Prophylaxe vor allem vom Patientenrisiko abhängig sind. Unter Berücksichtigung lokaler Gegebenheiten sollten diese eine evidenzbasierte
Erstellung von SOPs erleichtern.
There are no consensus guidelines for the management of postoperative nausea and vomiting (PONV) in German speaking countries.
This meeting was intended to develop such guidelines on which individual health care facilities can derive their specific
standard operating procedures (SOPs). Anesthesiologists reviewed published literature on key topics which were subsequently
discussed during two meetings. It was emphasized that recommendations were based on the best available evidence. The clinical
relevance of individual risk factors should be viewed with caution since even well proven risk factors, such as the history
of PONV, do not allow the identification of patients at risk for PONV with a satisfactory sensitivity or specificity. A more
useful approach is the use of simplified risk scores which consider the presence of several risk factors simultaneously. Most
individual antiemetic interventions for the prevention of PONV have comparable efficacy with a relative risk reduction of
about 30%. This appears to be true for total intravenous anesthesia (TIVA) as well as for dexamethasone and other antiemetics;
assuming a sufficiently high, adequate and equipotent dosage which should be weight-adjusted in children. As the relative
risk reduction is context independent and similar between the interventions, the absolute risk reduction of prophylactic interventions
is mainly dependent on the patient’s individual baseline risk. Prophylaxis is thus rarely warranted in patients at low risk,
generally needed in patients with a moderate risk and should include a multimodal approach in patients at high risk for PONV.
Therapeutic interventions of PONV should be administered promptly using an antiemetic which has not been used before. The
group suggests algorithms where prophylactic interventions are mainly dependent on the patient’s risk for PONV. These algorithms
should provide evidence-based guidelines allowing the development of SOPs/policies which take local circumstances into account.
Der Anaesthesist 04/2012; 56(11):1170-1180. · 0.99 Impact Factor
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ABSTRACT: Fragestellung. Ziel der Untersuchung war die systematische Aufarbeitung randomisierter, kontrollierter Studien, in denen Tropisetron im
Placebovergleich zur Prophylaxe von Übelkeit (PÜ) und Erbrechen (PE) in der postoperativen Phase untersucht wurde.
Methodik. Nach systematischer Literatursuche (Cochrane-Library, MEDLINE, EMBASE, Literaturverzeichnisse; bis Dezember 2001) wurden
die Inzidenzen für PÜ, PE bzw. PÜ und/oder PE (PÜ&E) extrahiert. Zudem wurden der Bedarf an zusätzlicher antiemetischer Medikation
und unerwünschte Arzneimittelwirkungen erfasst.
Ergebnisse. In 19 Studien und 22 Vergleichen erhielten 1.012 Patienten Placebo und 1.267 Patienten Tropisetron. Bei statistisch nicht
zu sichernder Dosis-Wirkung-Beziehung zwischen 2 mg iv.-Gabe (4 Vergleiche) und 5 mg iv.-Gabe (12 Vergleiche) sind die zusammengefassten
Effektdaten angegeben. Das relative Risiko (RR) für PÜ, PE und PÜ&E unter Prophylaxe mit Tropisetron lag bei 0,72 (95%-CI:
0,62–0,83), 0,59 (95%-CI: 0,47–0,73) und 0,70 (95%-CI: 0,62–0,79). Das RR für den Bedarf an antiemetischer Medikation lag
bei 0,63 (95%-CI: 0,54–0,74); die hierfür berechnete NNT bei 5,6 (95%-CI: 4,0–9,1). Das RR bei Kindern für Dosierungen von
0,1–0,2 mg×kg−1 lag bei 0,49 (95%-CI: 0,38–0,63), 0,49 (95%-CI: 0,38–0,63) und 0,32 (95%-CI: 0,15–0,70) für PE, PÜ&E und Bedarfsmedikation.
Für Erwachsene mit erhöhtem Risiko (Placeboinzidenz 40–80%) lag die NNT für PÜ bei 6,7 (95%-CI: 4,8–11,1). Unter gleicher
Prämisse lag die NNT für PE bei 5,0 (95%-CI: 3,6–8,3), für PÜ&E bei 4,6 (95%-CI: 3,6–6,3). Bei erheblicher Differenz der Inzidenzen
für unerwünschte Wirkungen innerhalb der untersuchten Studien, ergaben sich für keines der untersuchten Symptome signifikante
Unterschiede zur Kontrollgruppe.
Schlussfolgerungen. Die prophylaktische iv.-Gabe von mindestens 2 mg Tropisetron reduziert PÜ&E signifikant und klinisch relevant. Sie scheint
außerdem gut verträglich zu sein. Für die 2-mg-Dosierung liegen allerdings nur wenige Untersuchungen vor. Bei Kindern ist
eine Dosierung von 0,1 mg×kg−1 Körpergewicht effektiv. Für eine orale Applikation von Tropisetron fehlen Daten.
Objective. A quantitative systematic review of randomised controlled trials investigating the efficacy of tropisetron versus placebo
to prevent postoperative nausea (PN) and vomiting (PV) as well as PN and/or PV (PONV).
Methods. The relevant results for the 24 h postoperative period were extracted from systematically searched studies (MEDLINE, EMBASE,
Cochrane-Library, reference lists; last update December 2001).
Results. In 19 studies and 22 comparisons, 1,012 patients received a placebo and 1,267 patients tropisetron and the pooled analyses
(2–5 mg iv) are presented. The relative risks (RR) for PN, PV and PONV with tropisetron prophylaxis were 0.72 (95%-CI: 0.62–0.83),
0.59 (95%-CI: 0.47–0.73) and 0.70 (95%-CI: 0.62–0.79), respectively. The RR for rescue treatment was 0.63 (95%-CI: 0.54–0.74).
The RR in children for a variable dose of 0.1-0.2 mg×kg−1 was 0.49 (95%-CI: 0.38–0.63), 0.49 (95%-CI: 0.38–0.63) and 0.32 (95%-CI: 0.15–0.70) for PV, PONV and rescue treatment, respectively.
Restricting the analysis to a predefined control event rate of 40–80% revealed that about 6–7 patients need to be treated
with tropisetron for PN to be prevented in 1 patient who would have had PN if all had received a placebo (NNT=6.7; 95%-CI:
4.8–11.1). The corresponding NNT for preventing PV and PONV was 5.0 (95%-CI: 3.6–8.3) and 4.6 (95%-CI: 3.6–6.3), respectively.
Conclusion. Tropisetron significantly reduced the incidence of PONV. There is no clear evidence for a dose response between 2 and 5 mg
iv. For children a dose of 0.1 mg×kg−1 of body weight is effective. Sufficient data for the oral application of tropisetron are lacking.
Der Anaesthesist 04/2012; 51(10):805-814. · 0.99 Impact Factor
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ABSTRACT: Studies conducted shortly after the implementation of pulse oximetry (PO) into clinical practice 20-25 years ago revealed that many patients breathing room air during transfer from the operating room (OR) to the post-anesthesia care unit (PACU) directly after general anesthesia (GA) had a peripheral oxygen saturation (S(p)O(2)) below 90%. Moreover, it was shown that the detection of hypoxemia by clinical criteria is extremely unreliable. Meanwhile, the use of PO has become part of the obligatory standard monitoring during GA in Germany and many other countries. Likewise, the use of PO is standard care in the PACU although there are no official recommendations. However, for the time period in between, i.e. immediately after GA during transportation of patients from the OR to the PACU, monitoring of the S(p)O(2) in patients breathing room air is neither obligatory in Germany nor are there any official recommendations or guidelines in this respect. Given the introduction of shorter acting anesthetic agents within the last 25 years, the main goal of this study was to explore whether the incidence of hypoxemia in the immediate period after GA is still so high. Additional aims of this study were to examine whether the detection of hypoxemia based on clinical criteria can be confirmed to be very unreliable, what the risk factors for hypoxemia following GA are and how common it is in Germany to transport patients from the OR to the PACU without PO and supplemental oxygen.
In a prospective observational study 970 patients who underwent a broad spectrum of elective surgery under GA in a university hospital setting were included. The S(p)O(2) was measured at the end of the transfer from the OR to the PACU immediately after the anesthetist who had taken care of the patient during the operation had estimated the S(p)O(2). The association between biometric, surgical and anesthesiological variables on the one hand and hypoxemia as well as a decrease of S(p)O(2) on the other hand were studied using multivariate methods. Finally, a survey including all university hospitals was carried out to find out about the use of PO and oxygen during patient transfer from the OR to the PACU.
Of the 959 patients who were eligible for analysis 17% had a S(p)O(2) < 90% and 6.6% a S(p)O(2) < 85%. Hypoxemia was not recognized in 82% of the patients in whom an assessment based on clinical grounds was carried out. Variables with an independent influence on hypoxemia and decrease of S(p)O(2) were as follows: saturation before induction of GA, body mass index, age, American Society of Anesthesiologists (ASA) physical status, difference between maximum and minimum inspiratory pressure, mode of ventilation, the choice of opioid and muscle relaxant as well as the use of nitrous oxide. Patient-dependent risk factors had the strongest impact on hypoxemia. In about 80% of the university hospitals neither PO nor supplemental oxygen is used during transportation of the patient from the OR to the PACU.
The use of opioids and relaxants with short duration of action may have favorable effects on preventing hypoxemia and decreases of S(p)O(2). These measures will, however, not be sufficient to solve this problem because the highest risk factors for hypoxemia are patient-related. Despite knowing risk factors for oxygen desaturation, it is currently not possible to reliably predict which patients will become hypoxemic or have a decrease of S(p)O(2). Therefore, transportation of patients breathing room air from the OR to the PACU directly after GA without use of PO or supplemental oxygen seems to be questionable in terms of patient safety.
Der Anaesthesist 04/2012; 61(4):299-309. · 0.99 Impact Factor
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ABSTRACT: Tapentadol is a new centrally acting analgesic with a dual mode of action as an agonist of the µ-opioid receptor and as a norepinephrine reuptake inhibitor. The aim of the present study was to evaluate the results from randomized controlled trials investigating the relative amount of adverse effects using tapentadol or oxycodone for the treatment of pain.
A quantitative systematic review was carried out according to the PRISMA recommendations on randomized controlled trials comparing tapentadol and oxycodone in pain treatment. The incidences of typical adverse side effects of opioid-based analgesic therapy (e.g. nausea, vomiting, obstipation or pruritus) were extracted and the pooled relative risks (RR) with corresponding 95% confidence intervals (CI) were calculated.
A total of 9 trials involving 7,948 patients were included and of these 2,810 patients were treated with oxycodone and 5,138 were treated with tapentadol in equivalent analgesic dosages as documented by an equivalent analgesic effect. The risk of typical opioid-based adverse effects, such as nausea (RR 0.61; 95% CI 0.57-0.66), vomiting (RR 0.50, 95% CI: 0.41-0.60), obstipation (RR 0.47, 95%-CI 0.40-0.56), dizziness (RR 0.86, 95% CI 0.78-0.95), somnolence (RR 0.76, 95% CI 0.67-0.86) and pruritus (RR 0.46, 95% CI 0.37-0.58) was reduced when tapentadol was used for analgesic treatment. These adverse effects were investigated in all nine trials. The risk for dryness of the mouth (6 trials, 6,218 patients, RR 1.79, 95% CI 1.40-2.29) and dyspepsia (1 trial, 646 patients, RR 2.75, 95% CI 1.09-6.94) was increased when tapentadol was used instead of oxycodone. There were no significant differences in the relative risk for any other investigated adverse effect such as dysentery, headache or fatigue.
The results show that using tapentadol significantly reduces the risk of the typical opioid-based adverse effects compared with oxycodone while providing equivalent analgesic treatment.
Der Schmerz 02/2012; 26(1):16-26. · 0.88 Impact Factor
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ABSTRACT: Acute myocardial infarction during pregnancy is a rare event that is often associated with a very high maternal mortality, estimated to be from 19 to 37%. During the last decades the incidence of myocardial infarction during pregnancy has increased . The main contributing factor could be a higher prevalence of the metabolic syndrome. The strongest predictors correlated with a myocardial infarction are hypertension, diabetes mellitus and advanced maternal age. In addition, improved diagnostic tools could explain the elevated incidence of myocardial infarction during pregnancy. In general gestation is not considered a risk factor for myocardial infarction but gravidity is accompanied by an increase in oestrogen and progesterone levels. It is generally accepted that oral contraceptives increase the risk of coronary heart disease. We present a case where a 37-year-old gravida was admitted to hospital with diffuse thoracic pain. In the patient's history, we found several putative reasons for the thoracic pain that pointed to a musculoskeletal cause. Based on an elevation of ischaemic heart markers and continuous non-specific thoracic pain we performed a primary Cesarean section. In the coronary angiography procedure that followed, a thrombotic occlusion of the ramus diagonalis was diagnosed. We here describe the differential diagnosis as well as the problems associated with diagnosing myocardial infarction in the third trimester of pregnancy.
Zeitschrift für Geburtshilfe und Neonatologie 10/2011; 215(5):209-11.
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ABSTRACT: Epidural regional analgesia is still recommended as the gold standard for obstetric analgesia due to its high efficacy and less depressing effects to the central nervous system. However, if absolute or relative contraindications for a regional anesthetic technique are present, there is a need for an effective and safe alternative. This survey investigates the current use of intravenous opioids, with a focus on remifentanil as patient-controlled intravenous analgesia (PCIA), in obstetrics in German hospitals.
A questionnaire was sent to 930 anesthesia units. Data were collected and analyzed using SPSS statistical package (PASW Statistics 18.0). The questionnaire requested statistics on births, the existing alternative labor analgesic techniques, intramuscular or intravenous opioids, PCIA or other options. Furthermore, the questions focused on details regarding the use of intravenous opioids in conjunction with PCIA techniques.
Replies were received from 343 anesthetic departments (response rate 37%) and 281 clinics had an obstetric department and were included for further analysis. All clinics provided a 24 h epidural service and the most commonly used opioids were pethidine (19%), meptazinol (17%) and piritramide (16%) for intermittent intravenous/intramuscular administration. Only 0.9% of the clinics offered nitrous oxide as an alternative analgesic technique and 22 (8%) of the responding anesthetic departments offered PCIA. Remifentanil was the most popular choice in conjunction with PCIA (68%) for labor analgesia. Most hospitals offering PCIA continuously monitor oxygen saturation (91%) and the blood pressure (95%), whereas continuous electrocardiograms (18%) and clinical observation of the respiratory frequency (19%) were less commonly reported. However, most clinics offered one-to-one nursing for the parturient using an opioid PCIA.
This survey revealed that pethidine, meptazinol and piritramide are the most common opioids for opioid-based systemic labor pain relief in Germany. If PCIA is offered, remifentanil is the most popular opioid. However, only a few clinics are routinely using PCIA for obstetric analgesia. Furthermore the study showed that the current monitoring standards seem to have room for improvement with respect to safe administration of an opioid PCIA. The safety standards require continuous observation of the oxygen saturation, the possibility for oxygen supply, one-to-one nursing for a close clinical observation of the mother and the presence of an anesthetist during the initial titration phase to safely apply this technique. Applying these safety standards PCIA may prove a useful alternative for central neuraxial labor analgesia in those women who either do not want, cannot have or do not need epidural analgesia.
Der Anaesthesist 09/2011; 60(11):995-1001. · 0.99 Impact Factor
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ABSTRACT: The aim of this quantitative systematic review was to assess the efficacy and adverse effects of ketamine added to caudal local anaesthetics in comparison with local anaesthetics alone in children undergoing urological, lower abdominal, or lower limb surgery.
The systematic search, data extraction, critical appraisal, and pooled data analysis were performed according to the PRISMA statement. All randomized controlled trials (RCTs) were included in this meta-analysis and relative risk (RR), mean difference (MD), and the corresponding 95% confidence intervals (CIs) were calculated using the Revman(®) statistical software for dichotomous and continuous outcomes.
Thirteen RCTs (published between 1991 and 2008) including 584 patients met the inclusion criteria. There was a significant longer time to first analgesic requirements in patients receiving ketamine in addition to a local anaesthetic compared with a local anaesthetic alone (MD: 5.60 h; 95% CI: 5.45-5.76; P<0.00001). There was a lower RR for the need of rescue analgesia in children receiving a caudal regional anaesthesia with ketamine in addition to local anaesthetics (RR: 0.71; 95% CI: 0.44-1.15; P=0.16).
Caudally administered ketamine, in addition to a local anaesthetic, provides prolonged postoperative analgesia with few adverse effects compared with local anaesthetics alone. There is a clear benefit of caudal ketamine, but the uncertainties about neurotoxicity relating to the dose of ketamine, single vs repeated doses and the child's age, still need to be clarified for use in clinical practice.
BJA British Journal of Anaesthesia 08/2011; 107(4):601-11. · 4.24 Impact Factor
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ABSTRACT: The aim of the present study was to conduct a meta-analysis of the results from randomized controlled trials investigating the relative efficacy of droperidol versus metoclopramide for the prevention of postoperative nausea and vomiting (PONV).
A systematic literature search for randomized controlled trials comparing droperidol and metoclopramide for the prevention of PONV was performed according to the PRISMA recommendations. The incidence of PONV within the early (0-6 h) and cumulative postoperative periods (0-48 h) was collated and the pooled relative risk (RR) with the corresponding 95% confidence interval (CI) was calculated. Results from a subgroup analysis are presented excluding the data of a Japanese group (Fujii et al.) which are given in parentheses.
A total of 41 (30) trials with a total number of 3,491 (2,721) patients were included and of these 12 (8) trials with 1,403 (1,083) patients reported data of the early period and 32 (21) studies with 2,656 (1,836) patients comprised data of the cumulative period. A total of 1,797 (1,309) patients were treated with droperidol (0.25-5 mg) and 1,694 (1,412) with metoclopramide (5-50 mg). In the early period the risk for PONV after metoclopramide was 35% (95%-CI: 17-57%) higher than after prophylaxis with droperidol (without Fujii data: 46%; 23-73%). During the cumulative period the risk for PONV after metoclopramide was increased by 20% (95%-CI: 7-37%) compared to droperidol (without Fujii data: 25%; 4-50%). Due to heterogenous dosing of both drugs subgroup analyses with distinct dose intervals were performed with increments of 0.75 mg for droperidol and 7 mg for metoclopramide. Droperidol was superior in 17 (12) out of 19 (14) subgroup analyses. Comparing recommended doses of droperidol (0.75-1.5 mg) with low doses of metoclopramide (7-14 mg) and medium metoclopramide doses (14-21 mg) PONV was increased by 12% (95%-CI: -11% to 42%) and 32% (95%-CI: 4%-66%), respectively when metoclopramide instead of droperidol was used. When higher doses of metoclopramide (>20 mg) were used the superiority of droperidol was less pronounced and did not reach statistical significance due to the limited numbers of trials included in this analysis (3 studies, 662 patients). The risk for PONV after high-dose metoclopramide was increased by 13% (95%-CI: -21% to +61%) for the early period and by 19% (95%-CI: -11% to +57%) for the cumulative observation period.
For the prevention of postoperative nausea and vomiting droperidol is significantly superior to metoclopramide doses below 20 mg. There was no obvious positive dose response with respect to increasing doses of metoclopramide. There was also a trend towards higher efficacy of droperidol compared to higher doses of metoclopramide (≥20 mg). However, there were not enough comparative studies to show a statistically significant result in this subgroup analysis. These data support the notion that droperidol in low doses may represent the more effective D(2)-antagonist for a pharmacological armamentarium to cope with PONV.
Der Anaesthesist 12/2010; 60(5):432-40, 442-5. · 0.99 Impact Factor
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ABSTRACT: PURPOSE: The aim of this quantitative systematic review was to assess the efficacy and safety of ultrasound-guided neuraxial blocks in obstetric analgesia and anesthesia. MATERIALS AND METHODS: A systematic search for clinical trials investigating the efficacy and safety of ultrasound-assisted neuraxial blocks in comparison to any other technique was performed in MEDLINE, EMBASE, CINAHL and CENTRAL. Relative risks (RR) were calculated for dichotomous data (e. g. number of patients with vascular punctures), and mean differences (MD) were calculated for continuous outcomes (e. g. number puncture attempts), along with the respective 95 % confidence intervals (95 % CI). RESULTS: Six clinical trials (published between 2001 and 2009) including the data of 659 patients satisfied the inclusion criteria. Ultrasound-facilitated neuraxial blocks required a lower number of puncture attempts (MD: -0.92; 95 % CI: -1.11 to -0.74; p < 0.00001) and fewer puncture levels (MD: -0.2; 95 % CI: -0.31 to -0.1; p = 0.0002) in comparison with the more conventional loss of resistance. The success rate with the first attempt under ultrasound guidance in supposedly difficult patients was 71 % in comparison to 20 % using a conventional technique. Patients receiving ultrasound-assisted neuraxial blocks had a lower rate of procedure-related complications (post-dural puncture headache, spinal or vascular puncture). CONCLUSION: There is some evidence that ultrasound guidance may improve the efficacy and safety of neuraxial blocks in obstetrics. If technical difficulties are anticipated, ultrasound may lower the rate of procedure-related adverse events.
Ultraschall in der Medizin 11/2010; · 2.40 Impact Factor
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ABSTRACT: Thoracic paravertebral blocks (PVBs) are successfully performed for pain management after breast surgery. The aim of the present quantitative systematic review was to assess the efficacy and adverse events of PVB in women undergoing breast surgery.
The systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the PRISMA statement. The relative risk (RR), mean difference (MD), and their corresponding 95% confidence intervals (CIs) were calculated using the RevMan statistical software for dichotomous and continuous outcomes, respectively. Pain scores were converted to a scale ranging from 0 (no pain) to 10 (worst pain).
Fifteen randomized controlled trials (published between 1999 and 2009) including 877 patients met the inclusion criteria. There was a significant difference in worst postoperative pain scores between PVB and general anaesthesia (GA) at <2 h (MD: -2.68; 95% CI: -3.33 to -2.02; P<0.00001), 2-24 h (MD: -2.34; 95% CI: -2.42 to -1.12; P<0.00001), and 24-48 h (MD: -1.75; 95% CI: -3.19 to 0.31; P=0.02). Accordingly, lower pain scores were observed for combined PVB with GA compared with GA alone for <2 h (MD: -1.87; 95% CI: -2.53 to -1.21; P<0.00001), 2-24 h (MD: -2.21; 95% CI: -3.07 to -1.35; P<0.00001), and 24-48 h (MD: -1.80; 95% CI: -2.92 to 0.68; P=0.002). The RR for the reported adverse events (e.g. pneumothorax) was low.
There is considerable evidence that PVB in addition to GA or alone provide a better postoperative pain control with little adverse effects compared with other analgesic treatment strategies.
BJA British Journal of Anaesthesia 10/2010; 105(6):842-52. · 4.24 Impact Factor
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ABSTRACT: Epidural analgesia is considered as the standard method for labor analgesia by inducing a minimal negative impact on labor while providing effective analgesia. Labor analgesia in the absence of epidural analgesia is difficult to achieve with the commonly used analgesic interventions. If epidural analgesia is not feasible due to coagulation disorders, anticoagulation, inability to insert an epidural catheter or due to the mother''s refusal to accept neuraxial analgesia, there is a need for interventions to cope with labor pain. So far, pethidine, diamorphine, meptazinol and spasmolytics remain the most widely used substances for IM and IV use. Unfortunately, in addition to not being very effective, these interventions may be associated with undesirable side effects for the parturient and the newborn. For a decade, anaesthesiologists have experienced the unique properties of remifentanil in the settings of surgical anaesthesia and conscious sedation since it was introduced for labor analgesia. Unfortunately, remifentanil is not licensed for administration to the pregnant patient, and it is unlikely that the manufacturers would consider the cost justified.
Therefore, relevant concerns, legal issues and precautions are discussed based on the presentation of case series and a protocol is presented on how the use of remifentanil can be safely implemented for labor analgesia in selected situations.
Proper informed consent, appropriate monitoring for the mother and the newborn, one-to-one nursing or midwifery care as well as the availability of an attending physician experienced in neonatal resuscitation and an anaesthesiologist with experience regarding the use of remifentanil are important to ensure that this method retains its good reputation for obstetric analgesia.
Zeitschrift für Geburtshilfe und Neonatologie 08/2010; 214(4):145-50.
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ABSTRACT: Droperidol is commonly noted to be more effective at preventing postoperative nausea (PON) than vomiting (POV) and it is assumed to have a short duration of action. This may be relevant for clinical decisions, especially for designing multiple-drug antiemetic regimens.
We conducted a post hoc analysis of a large multicentre trial. Within this trial, 1734 patients underwent inhalation anaesthesia and were randomly stratified to receive several antiemetic interventions according to a factorial design, one of which was droperidol 1.25 mg vs placebo. We considered differences to be significant when: (i) point estimates of one outcome are not within the limits of the confidence interval (CI) of the other outcome; and (ii) differences in risk ratio (also known as relative risks, RR) are at least 20%.
Over 24 h, nausea was reduced from 42.9% in the control to 32.0% in the droperidol group, corresponding to a relative risk (RR) of 0.75 (95% CI from 0.66 to 0.84). Vomiting was reduced from 15.6% to 11.8%, and therefore associated with a similar RR of 0.76 (0.59-0.96). In the early postoperative period (0-2 h), droperidol prevented nausea and vomiting similarly, with an RR of 0.57 (0.46-0.69) for nausea and 0.56 (0.37-0.85) for vomiting. In the late postoperative period (2-24 h), the RR was again similar with 0.83 (0.72-0.96) for nausea compared with 0.89 (0.66-1.18) for vomiting but significantly less compared with the early postoperative period.
We conclude that droperidol prevents PON and POV equally well, yet its duration of action is short-lived.
BJA British Journal of Anaesthesia 07/2009; 103(3):359-63. · 4.24 Impact Factor
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ABSTRACT: The classic Laryngeal Mask Airway (cLMA), ProSeal Laryngeal Mask Airway (PLMA), Intubating Laryngeal Mask Airway (ILMA), Combitube (CT), Laryngeal Tube (LT) and tracheal intubation (TI) were compared in a manikin study. Nurses, anaesthetic nurses, paramedics, physicians and anaesthetists inserted the devices three times in a randomised sequence. Time taken for successful insertion, success rates and ease of insertion were evaluated. Anaesthetists performed tracheal intubation significantly faster than other healthcare professionals (p < 0.05). Insertion times for the cLMA, PLMA, LT and CT were not significantly different between the groups. Insertion of the CT, ILMA and TI was associated with a significant learning effect in all groups. This was not observed with the cLMA, PLMA or LT. All non-anaesthetists were able to insert the cLMA, PLMA and LT within two attempts with a > 90% success rate on the first attempt. The ILMA and TI were the only devices where more than one subject experienced some difficulty in insertion. The cLMA, PLMA and LT should be evaluated for use in situations where only limited airway training is possible.
Anaesthesia 05/2009; 64(5):549-54. · 2.96 Impact Factor
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ABSTRACT: Optical laryngoscopes have been developed to facilitate difficult airway management. The Airtraq is a single-use device and the GlideScope is reusable. In this study, the Airtraq and the Glidescope were compared in 60 ASA I-III patients with tumours of the upper airway undergoing direct endoscopic microlaryngoscopy. Patients were randomly assigned to the Airtraq or the Glidescope group and the Cormack and Lehane grade was assessed by Macintosh laryngoscopy prior to tracheal intubation. There were no differences in tracheal intubation success rates or duration of intubation attempts between both devices. The Cormack and Lehane grade was improved in 77% and 82% of cases in the Airtraq and Glidescope group, respectively. Blood traces on the device and traumatic pharyngeal lesions were found more frequently in the Airtraq group. The Airtraq and Glidescope laryngoscopes are valuable tools for the management of patients with potentially difficult airways with the Glidescope appearing to be less traumatic.
Anaesthesia 04/2009; 64(3):323-8. · 2.96 Impact Factor
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R M Jokela,
O S Cakmakkaya,
O Danzeisen,
K T Korttila, P Kranke,
A Malhotra,
A Paura,
O C Radke,
D I Sessler,
A Soikkeli,
N Roewer,
C C Apfel
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ABSTRACT: Ondansetron is widely believed to prevent postoperative vomiting more effectively than nausea. We analysed data from 5161 patients undergoing general anaesthesia who were randomly stratified to receive a combination of six interventions, one of which was 4 mg ondansetron vs placebo. For the purpose of this study a 20% difference in the relative risks for the two outcomes was considered clinically relevant. Nausea was reduced from 38% (969/2585) in the control to 28% (715/2576) in the ondansetron group, corresponding to a relative risk of 0.74, or a relative risk reduction of 26%. Vomiting was reduced from 17% (441/2585) to 11% (293/2576), corresponding to a relative risk of 0.67, or a relative risk reduction of 33%. The relative risks of 0.67 and 0.74 were clinically similar and the difference between them did not reach statistical significance. We thus conclude that ondansetron prevents postoperative nausea and postoperative vomiting equally well.
Anaesthesia 03/2009; 64(2):147-51. · 2.96 Impact Factor
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ABSTRACT: In the present study, we compared patient-controlled (PCS) and anesthesiologist-controlled sedation (ACS) with respect to adverse effects and patient centered outcomes.
A total of 100 patients undergoing elective knee- or hip-replacement under spinal anesthesia were randomly allocated to either a PCS (bolus: 0.25 mg kg(-1); no lockout interval; n = 50) or a continuous infusion of propofol 1% (3 mg kg(-1) h(-1); n = 50), following an initial bolus of 0.25 mg kg(-1). Safety parameters and patient satisfaction were evaluated and calculated propofol plasma concentrations were analyzed.
Baseline characteristics were comparable between the groups. Patient satisfaction did not differ between the investigated groups. Memory of the operation was more pronounced in the PCS group. Mean propofol plasma levels were significantly higher in the ACS group and the individual variation was more pronounced in the PCS group. Episodes of respiratory depression occurred in one PCS and in three ACS patients.
PCS using propofol boluses of 0.25 mg kg(-1), without a lockout interval, appeared to be safe for sedation during knee- and hip replacements, with a high degree of patient satisfaction. PCS and ACS provided comparable satisfaction levels but PCS was associated with lower mean calculated plasma concentrations. Individual propofol consumption and associated plasma levels to obtain satisfactory levels of sedation are highly variable.
Expert Opinion on Pharmacotherapy 12/2008; 9(16):2733-9. · 3.20 Impact Factor
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ABSTRACT: The aim of this systematic review was to assess the benefits and harms of supplemental oxygen (HBOT/NBOT) for treating and preventing migraine and cluster headaches.
All randomized trials comparing the effect of supplemental oxygen on migraine or cluster headache with those that exclude supplemental oxygen were included in this review. The systematic search included all relevant sources according to the paradigms of the Cochrane Collaboration. Data were analyzed with RevMan 4.2.
Nine trials involving 201 participants satisfied the inclusion criteria. HBOT was effective in relieving an acute migraine and seemed to be sufficient in the treatment of an acute cluster attack. NBOT was effective in terminating acute cluster headache compared to sham treatment, but not in comparison to sublingual ergotamine. There was no evidence for any prophylactic effects. Serious adverse effects were not noted in the trials investigated.
There is some evidence that HBOT is effective for termination of acute migraine. NBOT was similarly effective in cluster headache, however with sparse data. Because of costs and poor availability HBOT cannot be regarded as a routine therapy. Further indications in the case of treatment failure using standard therapy need to be defined based on data of future clinical trials.
Der Schmerz 05/2008; 22(2):129-32, 134-6. · 0.88 Impact Factor
