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  • 1
    ISSN: 1432-055X
    Keywords: Schlüsselwörter: Endokrine Streßreaktion – Aufwachverhalten – Kreislaufverhalten – Isofluran – Propofol ; Key words: Endocrine stress response – Recovery – Haemodynamic reaction – Isoflurane – Propofol
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract. This prospective, randomised study compared total intravenous anaesthesia (TIVA) and inhalation anaesthesia with respect to endocrine stress response, haemodynamic reactions, and recovery. Methods. The investigation included two groups of 20 ASA I – II patients 18 – 60 years of age scheduled for orthopaedic surgery. For premedication of both groups, 0.1 mg/kg midazolam was injected IM. Patients in the propofol group received TIVA (CPPV, PEEP 5 mbar, air with oxygen, FiO2 33%) with propofol (2 mg/kg for induction followed by an infusion of 12 – 6 mg/kg⋅h) and fentanyl (0.1 mg before intubation, total dose 0.005 mg/kg before surgery, repetition doses 0.1 mg). For induction of patients in the isoflurane-group, 5 mg/kg thiopentone and 0.1 mg fentanyl was administered. Inhalation anaesthesia was maintained with 1.2 – 2.4 vol.% isoflurane in nitrous oxide and oxygen at a ratio of 2:1 (CPPV, PEEP 5 mbar). For intubation of both groups, 2 mg vecuronium and 1.5 mg/kg suxamethonium were injected, followed by a total dose of 0.1 mg/kg vecuronium. Blood samples were taken through a central venous line at eight time points from before induction until 60 min after extubation for analysis of adrenaline, noradrenaline (by HPLC/ECD), antidiuretic hormone (ADH), adrenocorticotropic hormone (ACTH), and cortisol (by RIA). In addition, systolic arterial pressure (SAP), heart rate (HR), arterial oxygen saturation (SpO2), and recovery from anaesthesia were observed. Results. Group mean values are reported; biometric data from both collectives were comparable (Table 1). Plasma levels of adrenaline (52 vs. 79 pg/ml), noradrenaline (146 vs. 217 pg/ml), and cortisol (82 vs. 165 ng/ml) were significantly lower in the propofol group (Table 2, Figs. 1 and 3). Plasma levels of ADH (4.8 vs. 6.1 pg/ml) and ACTH (20 vs. 28 pg/ml) did not differ between the groups (Table 2, Figs. 2 and 3). SAP (128 vs. 131 mm Hg) was comparable in both groups, HR (68/min vs. 83/min) was significantly lower in the propofol group, and SpO2 (97.7 vs. 97.4%) showed no significant difference (Table 3). Recovery from anaesthesia was slightly faster in the propofol group (following of simple orders 1.9 vs. 2.4 min, orientation with respect to person 2.4 vs. 3.4 min, orientation with respect to time and space 2.8 vs. 3.7 min), but differences failed to reach statistical significance. Conclusions. When compared with isoflurane inhalation anaesthesia, moderation of the endocrine stress response was significantly improved during and after TIVA with propofol and fentanyl. Slightly shorter recovery times did not lead to an increased stress response. With respect to intra- and postoperative stress reduction, significant attenuation of sympatho-adrenergic reaction, comparable SAP and reduced HR, sympatholytic and hypodynamic anaesthesia with propofol and fentanyl seems to be advantageous for patients with cardiovascular and metabolic disorders. For this aim, careful induction and application of individual doses is essential.
    Notes: Zusammenfassung. Zum prospektiv-randomisierten Vergleich der endokrinen Streßreaktion sowie des Kreislauf- und Aufwachverhaltens während und nach totaler intravenöser Anästhesie (TIVA) mit Propofol und Fentanyl bzw. Inhalationsanästhesie mit Isofluran und Lachgas nach Thiopentaleinleitung wurden 2 Gruppen zu je 20 chirurgischen bzw. orthopädischen Patienten untersucht. An 8 Meßzeitpunkten vor der Einleitung bis 60 min nach der Extubation wurden die endokrinen Streßparameter und die Kreislaufdaten bestimmt und postoperativ u. a. das Aufwachverhalten bewertet. Die Konzentrationen von Adrenalin, Noradrenalin und Cortisol lagen in der Propofolgruppe im Gruppenmittel jeweils signifikant niedriger als in der Isoflurangruppe; die Konzentrationen von ADH und ACTH blieben vergleichbar. Bei den Kreislaufparametern war der systolische Blutdruck in beiden Kollektiven vergleichbar; die Herzfrequenz lag in der Propofolgruppe signifikant niedriger als in der Isoflurangruppe. Im Aufwachverhalten hatte die TIVA gegenüber der Inhalationsanästhesie nur leichte Vorteile; das Signifikanzniveau wurde verfehlt. Insgesamt war die TIVA mit Propofol der Inhalationsanästhesie mit Isofluran in der Moderation der chirurgischen Streßantwort deutlich überlegen. Das graduell verbesserte Aufwachverhalten in der Propofolgruppe war nicht mit einer verstärkten endokrinen Streßreaktion verbunden. Gerade zu diesen Meßzeitpunkten wies die TIVA eindeutige Vorteile auf. Im Hinblick auf die signifikant verminderte sympathoadrenerge Reaktion bei vergleichbarem systolischen Blutdruck und reduzierter Herzfrequenz sowie die überlegene intra- und postoperative Streßabschirmung scheint eine TIVA mit Propofol bei entsprechend vorsichtiger Einleitung und Narkoseführung für Patienten mit Stoffwechsel- und Kreislauferkrankungen besonders geeignet. In diesem Sinne gehört die TIVA mit Propofol zu den sympatholytischen, hypodynamen Narkoseformen.
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  • 2
    ISSN: 1432-055X
    Keywords: Schlüsselwörter: Ketamin – TIVA – endokrine Streßreaktion – Aufwachverhalten – Kreislaufreaktion ; Key words: Ketamine – Total intravenous anaesthesia – Endocrine stress response – Recovery – Haemodynamic reaction
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract. Clinically-used ketamine is a racemic mixture of two isomers, S-(+)- and R-(−)-ketamine. Previous investigations showed the anaesthetic potency of S-(+)-ketamine to be three times higher than that of R-(−)-ketamine. It was the aim of this study to compare the effects of S-(+)-ketamine and racemic ketamine on endocrine and cardiovascular parameters, recovery, and side effects in geriatric patients during total intravenous anaesthesia (TIVA) for orthopaedic surgery. Methods. Forty patients over 60 years of age scheduled for elective hip or knee replacement were investigated in a double-blind, randomised design. For induction of TIVA, patients received 0.1 mg midazolam, 0.5 mg atropine, 1 mg/kg S(+)-ketamine or 2 mg/kg racemic ketamine, respectively, 2 mg vecuronium, and 1.5 mg/kg suxamethonium. After intubation and relaxation with a total dose of 0.1 mg/kg vecuronium, a continuous infusion of 2 mg/kg per hour S-(+)- or 4 mg/kg per hour racemic ketamine was administered throughout surgery. Blood samples were taken through a central venous catheter at seven time-points, before induction as well during and after surgery, until the 1st postoperative morning for analysis of adrenaline, noradrenaline (by high-pressure liquid chromatography with electrochemical detection), anti-diuretic hormone (ADH), adrenocorticotropic hormone (ACTH), cortisol (by radioimmunoassay), glucose, and lactate. In addition, systolic arterial pressure (SAP), heart rate (HR), and arterial oxygen saturation were measured, and the time intervals between the end of ketamine infusion and the return of consciousness and orientation were protocolled. The incidence and assessment of dreams and other side effects were reported by the patients. Results. Biometric data of the groups were comparable, the mean age of both groups being 68 years. Plasma adrenaline, noradrenaline, ADH, ACTH, cortisol, and glucose as well as SAP and HR increased significantly (P〈0.05) during the course of anaesthesia. The influence on lactate levels was not significant. There were no differences between S-(+)- and racemic ketamine with respect to these parameters. Three patients in the ketamine-racemate group showed severe arterial hypertension and were withdrawn from the study. Recovery clearly improved after administration of S-(+)-ketamine compared to the racemate. Simple orders were followed after 2.0±3.4 versus 4.9±6.8 min (P=0.07), orientation with respect to person returned after 5.7±4.0 versus 14.6±10.0 min (P〈0.001) and spatial orientation after 8.2±5.4 versus 17.4±9.7 min (P〈0.001). After racemic ketamine, 1 patient remembered a negative dream and 1 patient a positive dream. In the S-(+)-group, 1 positive dream was reported. No intraoperative awareness was reported, and all patients would accept the same anaesthesia again. Conclusions. Increases in cardiovascular parameters and insufficient reduction of the stress response with respect to ADH, ACTH, and cortisol seem to require a more potent hypnotic element during TIVA with ketamine. With regard to endocrine and cardiovascular parameters, the pharmacodynamic effects of racemic and S-(+)-ketamine were comparable. Because of the significant improvement in recovery and the reduced quantitative drug load, S-(+)-ketamine offers a clinical advantage compared with currently used racemic ketamine.
    Notes: Zusammenfassung. Zum doppelblind-randomisierten Vergleich der endokrinen Streßreaktion sowie des Kreislauf- und Aufwachverhaltens bei Verwendung von S-(+)-Ketamin und Ketamin-Razemat erhielten 2×20 Patienten über 60 Jahren bei Hüft- und Kniegelenkersatz eine totale intravenöse Anästhesie (TIVA) mit Ketamin, Midazolam und Vecuronium. Die Messungen erfolgten an 7 Zeitpunkten vor Einleitung der Narkose und bis zum ersten postoperativen Tag. Die Kollektive waren statistisch einheitlich (mittleres Alter jeweils 68 Jahre). Die endokrinen Streßparameter Adrenalin, Noradrenalin, ADH, ACTH und Cortisol sowie Glukose und Laktat waren in beiden Gruppen vergleichbar; alle Streßhormone und die Glukose stiegen intraoperativ signifikant an (p〈0,05). Der systolische Blutdruck, die Herzfrequenz und die arterielle Sauerstoffsättigung waren weitgehend vergleichbar. Im Aufwachverhalten war S-(+)-Ketamin dem Razemat eindeutig überlegen (Gruppenmittelwerte): Befolgen einfacher Befehle (Augen öffnen, Kopf heben) nach 2,0±3,4 statt 4,9±6,8 min (p=0,07), Orientierung zur Person nach 5,7±4,0 statt 14,6±10,0 min (p〈0,001), räumliche Orientierung nach 8,2±5,4 statt 17,4±9,7 min (p〈0,001). Intraoperative Wachheitserlebnisse traten nicht auf. Die deutlich ausgeprägte Kreislaufreaktion und die nur unzureichend abgeschwächte Reaktion von ADH, ACTH und Cortisol legen trotz der vollständigen Amnesie und der hervorragenden Akzeptanz die Verwendung einer potenteren hypnotischen Komponente zur TIVA mit Ketamin nahe. Im Aufwachverhalten ist S-(+)-Ketamin dem Razemat auch unter klinischen Bedingungen und bei älteren Patienten eindeutig überlegen und verbessert bei halbierter Substanzbelastung die Einsatzmöglichkeiten von Ketamin zur TIVA.
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