Background. There is little information about the anesthesiologic management of lung transplantation. Therefore, we characterized intraoperative variables and their impact on survival in dependence to preoperative characteristics of recipients and donors. Methods. We analyzed 808 lung transplantations performed at our institution between 1987 and 2006, described patients in relation to the use of cardiopulmonary bypass (CPB), and used both recursive-partitioning and multivariate analyses to examine patients, donors, anesthesiologic management (e.g. gas exchange, hemo-dynamics, transfusions), extracorporeal life support (e.g. unplanned/planned CPB), and other variables. Results. Compared with off-pump transplantations (n = 389), unplanned CPB (n = 216) resulted in more transfusions and both doubled duration of postoperative ventilation (7.2 +/- 16.5 vs. 16.5 +/- 23.7 days, p<0.001) and hospital mortality (10 vs. 19%, p = 0.006) ; after planned CPB (n = 88), mortality doubled again (42%, p<0.001). Pulmonary diseases, their severity and comorbidities differed between groups, but pulmonary diseases were similar between patients with unplanned and planned CPB. According to recursive-partitioning analyses postoperative ventilation of < 4 days 10h discriminated best between survivors and non-survivors, and the duration of postoperative ventilation was also predictive for survival (odds ratio (OR), 1.02 ; 1-day increments). Intraoperative independent risk factors were transfusions of packed red blood cells (OR, 1.10 ; 10-unit increments), planned CPB (OR 2.4) and donors at least 20 cm taller than the recipient (OR 6.0). Conclusions. Apart from avoiding CPB, further efforts towards shorter postoperative ventilation and avoiding the intraoperative need for excessive transfusions may have the potential to improve outcomes as these were identified as important risk factors and were associated with CPB use.

Winterhalter, M.1; Brandl, K.1; Rahe-Meyer, N.1; Hagl, C.2; Hecker, H.3; Gras, C.1; Zuk, J.1; Piepenbrock, S.1 Author Information

BACKGROUNDRecently it has been shown that biphasic external shocks are more effective in the treatment of ventricular fibrillation (VF) compared with monophasic external shocks in terms of number of defibrillation attempts and maximal energy used for termination of VF. Biphasic defibrillators apply different biphasic impulse forms, depending on technology. To the authors' knowledge, there are no existing data concerning the effects of rectilinear biphasic internal shocks in patients undergoing cardiac surgery. The purpose of this study was to compare monophasic with rectilinear biphasic internal shock waveforms for termination of VF in patients undergoing cardiac surgery.METHODSOne hundred thirty-four patients scheduled for elective cardiac surgery were prospectively randomized either to monophasic (group A) or biphasic (group B) internal defibrillation. Defibrillation was started with 7 J and increased stepwise to 30 J in each group until successful termination of VF after aortic declamping. The number of defibrillations, as well as the cumulative and maximal energy for termination of VF, were determined. Preoperatively, intraoperatively, and postoperatively troponin T, total creatine phosphokinase (CPK), and CPK- MB isoenzymes were measured.RESULTSIn 64 patients (47%) VF occurred. The groups consisted of 32 patients each. The number of defibrillations (1.3 +/- 0.6 v 1.9+/- 1.2; p = 0.013), maximal energy per patient (7.9 +/- 2.5 v 11.6 +/- 7.32; p = 0.006), and cumulative energy (10.1 +/-6.1 v 21.3 +/- 24.1; p = 0.016) for successful termination of VF were significantly reduced in group B. Troponin T, CPK, and CPK-MB did not differ between groups.CONCLUSIONSResults of this study indicate that rectilinear biphasic internal defibrillation is more effective in the treatment of VF during cardiac surgery than is monophasic defibrillation. However, no significant difference in myocardial damage could be detected between groups.

Fragestellung: Wird bei Überdruckbeatmung abgesaugt oder bronchoskopiert, kommt es zu einer Leckage im Beatmungssystem und Austritt von volatilen Narkotika. Ein neu entwickelter Konnektor mit Ventilschleuse soll bei offenem Verschluss-Stopfen den Druck im Beatmungssystem halten und den Austritt von Anästhesiegasen verhindern können.

Fragestellung: Vergleich der postoperativen Schmerztherapie mit Paracetamol i.v. in Kombination mit einer PCA-Pumpe nach einem klassischen „high-dose opioid“-Narkoseverfahren mit Fentanyl und einem „fast-track“-Verfahren mit Remifentanil bei 42 ACVB-Patienten in einer prospektiv randomisierten Studie. Methodik: Postoperativ wurden die Patienten nach der Qualität der Narkose und dem postoperativen Schmerzaufkommen mithilfe von visuellen Analog-Skalen (VAS) befragt. Die postoperative Schmerztherapie erfolgte über eine PCA-Pumpe mit Piritramid und der festen Gabe von 3×1g/die Paracetamol i.v. auf der Intensivstation. Der perioperative Stress der Patienten wurde über EEG (BIS), und den endokrinen Hormonen (ADH, ACTH, Cortisol, Adrenalin, Noradrenalin) an 6 Messzeitpunkten erfasst. Die Narkoseeinleitung erfolgte in beiden Gruppen mittels Propofol. Zusätzlich wurden initial 8µg Fentanyl/kg KG i.v. und 0,2mg/kg KG Cis-Atracurium i.v. nach Beginn der Maskenbeatmung gegeben. Die Analgetikagabe in der „high-dose opioid“-Gruppe (A) (n=21) erfolgte anschließend mit intermittierenden Fentanyl-Gaben bis max. 50µg/kg KG. In der Remifentanil-Gruppe (B) (n=21) wurde nach der Einleitung die Analgesie kontinuierlich mit Remifentanil aufrechterhalten. In beiden Gruppen wurde vor und nach der extrakorporalen Zirkulation (EKZ) die Narkose mit Sevofluran zwischen einem BIS-Wert von 40–60 gesteuert. Während der EKZ erfolgte die Narkoseführung mit Propofol. Ergebnisse: Es wurden 33 Männer und 7 Frauen im Alter von 63,9±6,9 Jahre (Gruppe A) und 63,1±10,4 Jahre (Gruppe B) untersucht. Die „fast-track“-Gruppe konnte signifikant schneller extubiert werden (240±182 Minuten vs. 418±212 Minuten) und wies signifikant niedrigere endokrine Stresshormonwerte auf. Weiterhin waren die CK-MB-Werte am ersten postoperativen Tag signifikant niedriger. In der „high dose opioid“-Gruppe wurden 14,9±11,4mg Piritramid via PCA-Pumpe verabreicht und in der „fast track“-Gruppe 22,8±21,4mg Piritramid. Hinsichtlich der Beurteilung des postoperativen Schmerzes anhand einer VAS-Scale (von 0 kein Schmerz bis 10 stärkster Schmerz) gab es keine Unterschiede zwischen den beiden Gruppen (0,95±0,87 vs. 0,67±0,79). Schlussfolgerungen: Das hier vorgestellte kombinierte Schmerztherapieverfahren mit Paracetamol i.v. und Piritramid via PCA-Pumpe ist ein für die tägliche Praxis sicheres postoperatives Verfahren für die Kardiochirurgie insbesondere unter „fast track“-Bedingungen.

Winterhalter, M.; Leyh, R. G.; Piepenbrock, T.; Gras, C.; Zuk, J.; Heine, J.; Hagl, C.; Hecker, H.; Piepenbrock, S. Author Information

Cerebral ischemia with consecutive neurological damage is a typical complication in aortic arch surgery. Therefore, intraoperative neuromonitoring is of increasing interest. This paper describes the role of bilateral near-infrared-spectroscopy (NIRS) in detecting cerebral ischemia. In the case of a patient with acute aortic dissection (Daily, type A), an unexpected sudden reduction of perfusion of the right carotid artery could easily be detected with the help of two instruments INVOS 3100A. The decrease in the saturation values from 74% to 54% correlated well with the drop of blood pressure in the right radial artery. Clamping of the aorta with interruption of the blood flow into the innominate artery through the false lumen was the reason for the low cerebral perfusion. After repositioning the aortic clamp NIRS in combination with invasive blood pressure monitoring sufficiently allowed to control the further course of cerebral perfusion. The NIRS is a non-invasive, easy to handle, and easy to interpret method for intraoperative monitoring of the neurological status. Therefore in our opinion it has got some relevant advantages in contrast to other neuromonitoring methods in aortic arch surgery.

Cerebral ischemia with consecutive neurological damage is a typical complication in aortic arch surgery. Therefore, intraoperative neuromonitoring is of increasing interest This paper describes the role of bilateral near-infrared-spectroscopy (NIRS) in detecting cerebral ischemia. In the case of a patient with acute aortic dissection (Daily,, type A), an unexpected sudden reduction of perfusion of the right carotid artery could easily be detected with the help of two instruments INVOS 3100A. The decrease in the saturation values from 74% to 54% correlated well with the drop of blood pressure in the right radial artery. Clamping of the aorta with interruption of the blood flow into the innominate artery through the false lumen was the reason for the low cerebral perfusion. After repositioning the aortic clamp NIRS in combination with invasive blood pressure monitoring sufficiently allowed to control the further course of cerebral perfusion. The NIRS is a non-invasive, easy to handle, and easy to interpret method for intraoperative monitoring of the neurological status. Therefore in our opinion it has got some relevant advantages in contrast to other neuromonitoring methods in aortic arch surgery.