We have previously shown, that a therapeutic platelet transfusion strategy is safe in patients after autologous peripheral stem cell transplantation(ASCT) and can reduce the number of platelet transfusions to about 50% compared with the prophylactic strategy (Wandt et al, BMT 2006, 37, 387–392). To confirm these results, we started a randomised multicenter study in 2005 and present the results of the first planned interim analysis.

This randomised, placebo-controlled, patient and observer blinded trial was conducted to determine whether acupuncture at the acupuncture point P6 is effective in preventing postoperative nausea and vomiting (PONV) compared to placebo acupuncture. Female patients (n = 220) scheduled for gynaecological or breast surgery were randomly assigned to two groups receiving either acupuncture (n = 109) or placebo acupuncture (n = 111). Each group was stratified for type of surgery and included two subgroups receiving intervention either before or after induction of anaesthesia. The incidence of PONV and/or antiemetic rescue medication within 24 h after surgery was the main outcome measure which showed no statistically significant difference between groups (43.7% acupuncture, 50.9% placebo, p = 0.27). The differences were more pronounced for patients having gynaecological surgery (48.9% acupuncture, 67.6% placebo, p = 0.07) than for those having breast surgery (38.7% acupuncture, 40.3% placebo, p = 0.86). The secondary outcome, vomiting, was significantly reduced by acupuncture from 39.6% to 24.8% (p = 0.03). Subgroup analysis showed no difference between applications of acupuncture before compared to after induction of anaesthesia.

The use of ultrasound as a diagnostic tool for the visualisation of the epidural space has effects on the quality and the performance of epidural anesthesia. This work presents an overview of the recent experiences with ultrasound for epidural anesthesia and on the possibilities for ultrasound imaging techniques. The results of visualisation of the epidural space and its limiting structures obtained by various working groups are presented. We review all presently available data on the prediction of the puncture depth. The various working groups found correlations between predicted and effective puncture depth between 0.79 and 0.98 and the precision of the measurement was 57-7.7 mm. Regarding the prediction of the puncture angle there was a poor correlation ranging between 0.07 and 0.31. The precision between the measured and the punctured angles was found to be 10-13.4 degrees. In all available prospective randomised studies on the puncture effects in the lumbar epidural space, the influence of ultrasound showed a significant reduction ( p<0.03) of the puncture attempts,and we found a significant ( p<0.05) reduction in the number of puncture levels. The ultrasound-guided puncture allowed an ideal needle trajectory and a more precise application of the catheter. A significant improvement of analgesia quality ( p<0.035) and patient satisfaction ( p<0.006) could be achieved. The metaanalysis of the different studies regarding puncture quality by ultrasound-guided peridural anaesthesia showed a clear advantage for the use of imaging techniques.

Zusammenfassung Die diagnostische Anwendung von Ultraschall mit der Darstellung der Punktionsebene und des Epiduralraumes hat Auswirkungen auf den Ablauf und die Qualität einer Periduralanästhesie.Die vorliegende Arbeit zeigt einen Überblick über die bisherigen Erfahrungen mit Ultraschall im Rahmen der Periduralanästhesie und gibt einen Ausblick auf die Möglichkeiten bildgebender Verfahren in der Regionalanästhesie.Die verschiedenen Arbeitsgruppen, die sich mit Ultraschall und Periduralanästhesie beschäftigen, fanden Korrelationen von 0,79–0,98 zwischen der vorhergesagten und der effektiv gemessenen Punktionstiefe; die Präzision lag zwischen 5,7 mm und 7,7 mm.Die Bestimmung des erwarteten Punktionswinkels ergab eine nur geringe Korrelation zwischen 0,07 und 0,31; die Präzision der gemessenen Werte lag zwischen 10° und 13,4°. In allen Studien konnte eine positive Beeinflussung der Periduralanästhesie durch die Anwendung von Ultraschall im Sinne einer signifikanten Erniedrigung ( p <0,03) der Punktionsversuche gezeigt werden.Darüber hinaus konnte durch dieses Verfahren die Anzahl notwendiger Punktionsebenen signifikant ( p <0,05) reduziert werden.Die ultraschallunterstützte Punktion ermöglicht einen idealeren Punktionsablauf und eine exaktere Applikation des Periduralkatheters.In Untersuchungen konnte eine signifikante Verbesserung der Analgesie ( p <0,035) und der Patientenzufriedenheit ( p <0,006) gezeigt werden.Die Metaanalyse der verschiedenen Untersuchungen zur Punktionsqualität bei ultraschallunterstützter Periduralanästhesie ergab einen deutlichen Vorteil zugunsten der Anwendung bildgebender Methoden.

The postdural puncture headache (PDPH) is a possible complication after spinal or epidural puncture. The therapeutic concept is usually organised step by step, but the epidural blood patch is the most reliable and effective therapy. In earlier studies myelographie, epidurographie and MRT were used, to visualise the localisation of the dural defect and to describe the effects of patching the epidural space. Our working group focused on the utilisation of ultrasound and we decided to use this technique for the visualisation of bloodpatches. With agreement of the local ethics committee we monitored the performance of 4 epidural bloodpatches in pregnant women, who suffered from PDPH. We used a General Electric LQ 400 ultrasonograph with a 7-MHz-probe. To ensure sterile conditions we used sterile ultrasound sleeves and sterile ultrasound gel. In 3 of 4 cases a continuity loss could be represented in the doppel layer signal of the dura. It had the size of the diameter of a Tuohy needle. In one case the defect of the dura was larger than in the preliminary investigations (2,5 - 3 mm). The ultrasonography of the epidural space was performed in the paramedian scan. All patches were placed by using the conventional loss of resistance technique with using online ultrasound support. The epidural puncture and the application of the blood patches were visualised simultaneously in all cases. With the injection of blood a brief expansion of the epidural space was seen. The patients recieved a mean injection volume of 17 ml sterile blood. 10 to 40 seconds after the injection of blood the disconituity of the dura doppel layer signal was no longer provable. Within a short time we could detect the increase of cerebrospinal fluid and the patients headache was treated sucessfully. The clinical use of this diagnostic technique can be found in the simultaneous presentation of the dura leakage and the intervention while performing an epidural bloodpatch. Since these informations are relevant for further clinical practice further investigations are warranted.

The postdural puncture headache (PDPH) is a possible complication after spinal or epidural puncture. The therapeutic concept is usually organised step by step, but the epidural blood patch is the most reliable and effective therapy. In earlier studies myelographie, epidurographie and MRT were used, to visualise the localisation of the dural defect and to describe the effects of patching the epidural space. Our working group focused on the utilisation of ultrasound and we decided to use this technique for the visualisation of bloodpatches. With agreement of the local ethics committee we monitored the performance of 4 epidural bloodpatches in pregnant women, who suffered from PDPH. We used a General Electric LQ 400 ultrasonograph with a 7-MHz-probe. To ensure sterile conditions we used sterile ultrasound sleeves and sterile ultrasound gel. In 3 of 4 cases a continuity loss could be represented in the doppel layer signal of the dura. It had the size of the diameter of a Tuohy needle. In one case the defect of the dura was larger than in the preliminary investigations (2,5 - 3 mm). The ultrasonography of the epidural space was performed in the paramedian scan. All patches were placed by using the conventional loss of resistance technique with using online ultrasound support. The epidural puncture and the application of the blood patches were visualised simultaneously in all cases. With the injection of blood a brief expansion of the epidural space was seen. The patients recieved a mean injection volume of 17 ml sterile blood. 10 to 40 seconds after the injection of blood the disconituity of the dura doppel layer signal was no longer provable. Within a short time we could detect the increase of cerebrospinal fluid and the patients headache was treated sucessfully. The clinical use of this diagnostic technique can be found in the simultaneous presentation of the dura leakage and the intervention while performing an epidural bloodpatch. Since these informations are relevant for further clinical practice further investigations are warranted.

BACKGROUND:The efficacy of epidural anaesthesia depends on the accurate identification of the epidural space (ES). Abnormal anatomical conditions may make the procedure difficult or impossible. The aim of this study was to investigate whether pre-puncture ultrasound examination of the spinal anatomy might be beneficial in expected cases of difficult epidural anaesthesia.METHODS:We used digital ultrasound equipment with a 5-MHz transducer to assess the anatomy of the ES and the posterior parts of the spinal column. We examined 72 parturients with abnormal anatomical conditions who were scheduled for epidural anaesthesia. The women were randomised into two equal groups. In all patients, the standard loss of resistance technique was used. In the ultrasound group, an ultrasound examination of the appropriate spinal region was conducted prior to epidural puncture. ES depth seen on the ultrasound images was compared to the ES depth measured by the needle. We compared the number of puncture attempts with the standard method (control group) to the number of attempts under ultrasound guidance.RESULTS:Ultrasonography significantly improved operating conditions for epidural anaesthesia. The maximum VAS scores and patient acceptance were significantly better.CONCLUSIONS:With ultrasound measurement of the ES depth, the quality of epidural anaesthesia was enhanced.

Epidural anaesthesia (EA) is the most important analgesia technique in obstetrics for delivery. In pregnancy, hormonal adjustments lead to an alteration of tissue consistency, which often causes an early, untimely loss of resistance. Apart from mere inspection and palpation, no useful diagnostic method prior to EA performance has been established yet. In this prospective study, we examined 100 pregnant women, who had been admitted for childbirth and were undergoing epidural block (level L3-L4) for delivery. Sonotopography of the lumbar epidural structures was performed directly before epidural puncture and childbirth. We evaluated the visibility of all anatomical structures and compared all distances measured by ultrasonography and during puncture. The correlation between distances measured by ultrasound and by puncture needle was high (r2 = 0.79). No obvious dependency was found between ultrasonic and puncture angle (r2 = 0.19). The temporal distance from ultrasonic examination and puncture causes unavoidable differences: each deviation between ultrasound and puncture conditions causes a modification of the puncture depth. The patient acceptance of the procedure was very good. Ultrasonography offers the possibility to determine site and direction of epidural puncture and distance of the epidural space to the skin even before the puncture attempt. The ultrasound controlled EA for delivery can easily be inserted into the clinical routine. Ultrasonography can fill an important diagnostic gap in regional anaesthesia.

Combined spinal and epidural analgesia (CSE) is widely used to provide analgesia for cesarean delivery. The success and quality of analgesia depend on correct cannulation of the epidural space (ES). Epidural puncture is traditionally guided using surface landmarks and the loss-of-resistance (LOR) technique. However, difficulty in identifying surface landmarks (e.g., the obese patient) and deviation of the needle trajectory from midline may lead to failed or asymmetric epidural block. To facilitate ES cannulation, additional information regarding puncture depth and axis from the skin’s surface would be desirable. Diagnostic imaging including plain radiography, computed tomography, and magnetic resonance imaging (MRI) can provide accurate anatomic information regarding the location of the epidural space, but their use is impractical in most clinical settings where epidural analgesia is used. In contrast, the safety and feasibility of bedside ultrasonography during pregnancy are well established. In the present study, we used ultrasonography to measure the ES depth (i.e., the distance from the skin to the ligamentum flavum) and to gain additional information on neighboring anatomical structures before performing the epidural block. We assessed the usefulness of ultrasonography in facilitating successful localization of the epidural space compared with the LOR technique alone in a group of parturients undergoing CSE for elective cesarean delivery. Methods

Epidural anaesthesia is an important analgesia technique for obstetric delivery. During pregnancy, however, obesity and oedema frequently obscure anatomical landmarks. Using ultrasonography, we investigated the influence of these changes on spinal and epidural anatomy. We examined 53 pregnant women who were to receive epidural block for vaginal delivery or Caesarean section. The first ultrasound imaging was performed immediately before epidural puncture; the follow-up scan was done 9 months later. The ultrasound scan of the spinal column was performed at the L3/4 interspace in transverse and longitudinal planes, using a Sonoace 6000 ultrasonograph (Kretz, Marl, Germany) equipped with a 5.0-MHz curved array probe. We measured two distances from the skin to the epidural space: the minimum (perpendicular) and the maximum (oblique) needle trajectory. The quality of ultrasonic depiction was analysed by a numerical scoring system. An average weight reduction of 12.5 kg had occurred by the follow-up examination. During pregnancy, the optimum puncture site available on the skin for epidural space cannulation was smaller, the soft-tissue channel between the spinal processes was narrower, and the skin-epidural space distance was greater. The epidural space was narrower and deformed by the tissue changes. The visibility of the ligamentum flavum, of the dura mater and of the epidural space decreased significantly during pregnancy. Nevertheless, ultrasonography offered useful pre-puncture information. Thus far, palpation has been the only available technique to facilitate epidural puncture. Ultrasound imaging enabled us to assess the structures to be perforated. We anticipate that this technique will become valuable clinically.

Zusammenfassung Die Periduralanästhesie (PDA) ist heute das wichtigste geburtshilfliche Analgesieverfahren. Sie wird durch schwangerschaftsbedingte Bindegewebsveränderungen erschwert, die u. a. einen verfrühten “loss of resistance” vortäuschen können. Diagnostische Maßnahmen vor der PDA beschränken sich derzeit auf Inspektion und Palpation. Eine Etablierung diagnostischer Hilfsmittel ist anzustreben. Vor der Anlage einer geburtshilflichen Periduralanästhesie wurde bei 100 Schwangeren prospektiv eine Ultraschalluntersuchung der lumbalen Wirbelsäule durchgeführt. Die Erkennbarkeit aller anatomischen Strukturen wurde bewertet, und die sonographisch gefundenen Entfernungen wurden mit den bei der Punktion vorgefundenen Werten verglichen. Die Korrelation zwischen vor bzw. bei der Punktion gemessenen Werten war mit r 2 =0,79 hoch. Zwischen Ultraschall- und Punktionswinkel ergab sich jedoch nur eine geringe Abhängigkeit (r 2 =0,19). Der zeitliche Abstand von Ultraschalluntersuchung und Punktion bedingt eine unvermeidbare Unschärfe: jede Abweichung zwischen Schall- und Punktionsgegebenheiten verursacht Veränderungen der Punktionstiefe. Die Patientenakzeptanz des Verfahrens war sehr gut. Die Ultraschalldiagnostik bietet eine Möglichkeit, Punktionsrichtung und Abstand des Epiduralraums zur Haut noch vor dem Punktionsversuch festzulegen. Die ultraschallgesteuerte PDA für Schwangere lässt sich problemlos in den klinischen Alltag einfügen. Ultraschall kann damit eine wichtige diagnostische Lücke in der Regionalanästhesie füllen.

Bone sialoprotein (BSP) is a noncoflagenous bone matrix protein that is important for both mineralization and cell-cell interactions. Tissue studies in primary breast cancers have shown that immunohistochemical expression of BSP is associated with a high incidence of bone metastases in the course of the disease. We used a RIA to investigate the importance of serum BSP as a marker for subsequent bone metastases. Between 1994 and 1996, preoperative blood samples were collected from 388 consecutive patients with nonmetastatic breast cancer and from 30 control patients with benign breast disease. Serum BSP concentrations were measured in a blinded fashion by RIA. The cutoff for elevated serum BSP values was 24 ng/ml, ie., two SDs above the normal mean value. Serum BSP was correlated with the risk of metastasis and analyzed with regard to its prognostic value. After a median follow-up period of only 20 months, 28 patients had developed metastases. Fourteen patients had bone metastases only, 9 visceral metastases only, and 5 a combination of osseous and visceral metastases. Of the 19 women with skeletal metastases, 17 had preoperative serum BSP values in excess of 24 ng/ml (median BSP values: 48.3 ng/ml for isolated metastatic bone disease, 30.6 ng/ml for combined metastases), whereas none of the women with visceral metastases only had elevated serum BSP concentrations (median BSP value: 12.3 ng/ml). The median serum BSP value in the control group (benign breast disease) was 8.8 ng/ml serum BSP; levels correlated with the size of the primary tumor, but not with any other prognostic factors. Using a multivariate regression analysis, serum BSP was found to be the most important independent prognostic factor for the development of skeletal metastasis (P < 0.001; relative risk, 94); its specificity was 96.7%, and its sensitivity was 89.5%. Our study shows that patients with preoperatively elevated serum BSP levels are at high risk of subsequent bone metastases in the first years after primary surgery. The mechanism of BSP in the pathogenesis of skeletal metastases is unclear. Because BSP contains an integrin recognition sequence, its expression in tumor cells may facilitate their adhesion to the bone surface. However, it is possible that a proportion of circulation BSP is derived from normal or tumor-induced bone turnover. Breast cancer patients with elevated serum BSP levels may benefit from osteoprotective adjuvant therapy with bisphosphonates.

The management of anaesthesia in patients suffering preeclampsia has to be selected individually. There is a high rate of caesarean sections in patients with preeclampsia. Intubation anaesthesia or regional anaesthesia are commonly used methods and can be considered comparable and equally useful. In our opinion, the application of regional anaesthesia should be preferred, if the initial criteria, such as normal neurologic status and blood coagulation, are fulfilled. We believe in a considerable reduction of vital risks when using regional anaesthesia. Our aim was to figure out the risk-factors of preeclampsia and preterm maturity regarding anaesthesia management. Preeclampsia is a severe illness in pregnancy with a frequency of 5-10%. In 1997, we experienced 73 patients with praeeclampsia according to the definition of ISSPH. Mode of delivery was conventional in 10 patients, 2 patients had a vacuum extraction and 61 patients needed a caesarean section. The rate of epidural anesthesia for delivery was 51%. We used epidural anaesthesia in 6 spontaneous deliveries, in 2 vacuum extractions and in 30 caesarean sections. There were no problems with epidural anaesthesia and the outcome of mother and child was also considered to be excellent. We suggest to use regional anesthesia techniques whenever possible.

For answering the question at which hysteroscopical procedures an intraoperative screening method is necessary to avoid a fluid overload and whether a beginning fluid absorption can be diagnosed early by adding ethanol to the distension medium, a prospectively randomised comparative study of ablative versus non-ablative operative hysteroscopy with differing ethanol concentrations was performed (n=120), Purisole (a mannit/sorbit solution) was used a distension medium, The measuring parameters (breath alcohol, amount of absorbed fluid, haematocrit and haemoglobin values, central venous pressure, heart frequency) were intraoperatively determined at 5-minute intervals. The results of the study show that with those hysteroscopical procedures during which the endometrium is not or only minimally injured (e.g. syneciolysis, hysteroscopic proximal tubal catheterisation), intraoperative screening is not: necessary due to the low absorbing amounts. With hysteroscopical procedures such as resection of myoma, endometrium ablation and septum resection, however, an addition of ethanol of 2% to the distension medium has proved useful, because with this method absorption amounts of 400 ml and more can be detected by positive values of breath alcohol. As the result of a further absorption of fluid, delayed in time compared to the first positive value of breath alcohol, there is an increase in central venous pressure and hyponatraemia. Intraoperative ethanol monitoring is a non-invasive procedure which can be performed during ablative-operative hysteroscopies and has no negative influence on the course of the intervention and the general condition of the patients.

OBJECTIVE:This study compared the two short-acting intravenous anaesthetic agents, etomidate in lipid emulsion and propofol, for anaesthesia during elective outpatient cardioversion.METHODS:After institutional approval and informed consent, 40 patients (ASA II/III) scheduled for cardioversion were studied. Patients with a left ventricular ejection fraction < 30% were excluded. The anti-arrhythmic medication was not discontinued, and no patient was given pharmacological premedication. Anaesthesia was induced either with etomidate (in lipid emulsion) 0.25 mg/kg or propofol 1.5 mg/kg. Both agents were administered over 30 seconds. Subsequent increments were given until the patients no longer followed verbal commands and the lid reflex was absent. Patients were allowed to breathe 40% oxygen via face mask. Artificial ventilation was performed if a patient became apnoeic for more than 20 seconds. The blood pressure was monitored continuously with the Finapres noninvasive blood pressure monitor, and the heart rate was recorded simultaneously. All data were collected electronically. The duration of anaesthesia was taken as the period from the start of induction until the opening of the eyes on command. For assessment of recovery from anaesthesia, patients were asked to perform a series of psychomotor tests.RESULTS:The two groups were similar in their demographic and haemodynamic baseline data. In both groups, a significant decrease in blood pressure occurred 120 seconds after anaesthesia induction, which was due to the performance of the cardioversion. Five minutes after induction, the blood pressure returned to baseline in the etomidate group, while it remained below baseline in the propofol group. Propofol caused a significant decrease in heart rate. Significantly more patients needed artificial ventilation after propofol administration because of apnoea. Involuntary muscle movements occurred only in patients receiving etomidate. The immediate emergence from anaesthesia was faster after propofol. However, 15 minutes after awakening there was no difference in psychomotor skills between the two groups. No residual psychomotor impairment was evident 60 minutes after anaesthesia in any patient. All patients were discharged four hours after the cardioversion.CONCLUSIONS:Because the recovery characteristics were similar in both groups, the occurrence of side effects may be a major factor when choosing between etomidate and propofol for outpatient cardioversion.

This paper reports on an open explorative study on the absorption of the electrolytfree distension medium Purisole (Mannitol-Sorbitol solution) during hysteroscopic procedures and its effects on laboratory and cardiovascular parameters. Intra- and postoperative levels of mannitol and sorbitol in urine were also measured to determine elimination of both components. The study population consisted of 84 patients aged 22-62 years. 54 women underwent ablative (resection of submucous fibroids, endometrial ablation, septum resection), 30 patients non-ablative operative hysteroscopic procedures (synechiolysis, hysteroscopic proximal tubal catheterisation). The duration of operations was between 23-48 minutes. Ethanol was added to the Purisole solution for determination of resorption. In 57 cases 1% ethanol in Purisole was used as irrigating fluid. In 27 cases 2% ethanol was added to the distension fluid. A median slight encrease of central venous pressure was noted during the procedures. 18 women had an intraoperative hyponatriaemia (only 4 patients < 130 mmmol/1). For the 15 patients, in which ethanol absorption was noted, fluid resorption was calculated on the basis of blood alcohol concentration (median 850 ml). Resorption was below the determination threshold in the other 69 women. Urine examination showed intra- and postoperatively increased concentrations of sorbitol and mannitol. Fluid overload and intraoperative cardiovascular complications did not occur in our patients.

For answering the question at which hysteroscopical procedures an intraoperative screening method is necessary to avoid a fluid overload and whether a beginning fluid absorption can be diagnosed early by adding ethanol to the distension medium, a prospectively randomised comparative study of ablative versus non-ablative operative hysteroscopy with differing ethanol concentrations was performed (n = 120). Purisole (a mannit/sorbit solution) was used a distension medium. The measuring parameters (breath alcohol, amount of absorbed fluid, haematocrit and haemoglobin values, central venous pressure, heart frequency) were intraoperatively determined at 5-minute intervals. The results of the study show that with those hysteroscopical procedures during which the endometrium is not or only minimally injured (e.g. syneciolysis, hysteroscopic proximal tubal catheterisation). Intraoperative screening is not necessary due to the low absorbing amounts. With hysteroscopical procedures such as resection of myoma, endometrium ablation and septum resection, however, an addition of ethanol of 2% to the distension medium has proved useful, because with this method absorption amounts of 400 ml and more can be detected by positive values of breath alcohol. As the result of a further absorption of fluid, delayed in time compared to the first positive value of breath alcohol, there is an increase in central venous pressure and hyponatraemia. Intraoperative ethanol monitoring is a non-invasive procedure which can be performed during ablative-operative hysteroscopies and has no negative influence on the course of the intervention and the general condition of the patients.