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H Wulf

Publications and source records attributed to H Wulf.

At least 19 recordsLinked to original sources
PubMed2002

[Plasma cholinesterase variations as a result of prolonged neuromuscular blockade. Review and problems encountered in two cases of prolonged neuromuscular blockade after muscle relaxation with succinylcholine as compared to mivacurium].

Succinylcholine and mivacurium are degraded more slowly in patients with a qualitatively or quantitatively reduced plasma cholinesterase and are therefore known for inducing a prolonged postoperative apnea. Perioperative laboratory screening even including plasma cholinesterase activity testing will not prevent this due to a possible aberration only in the qualitative cholinesterase activity. This is illustrated by introducing two cases reports of prolonged apnea after administration of mivacurium or succinylcholine. The pathophysiology of plasma cholinesterase is reviewed including genetically determined variants and the degradation pathways of mivacurium and succinylcholine. Only extensive laboratory chemical tests are sufficient to prevent this possible complication. Due to the rare incidence there is no evidence for recommending these laboratory investigations in all patients. Once prolonged apnea occurs following the administration of mivacurium or succinylcholine the best choice is ongoing ventilation combined with a sufficient sedation.

Apnea↗
PubMed2002

[Postoperative pain therapy in minimally invasive direct coronary arterial bypass surgery. I.v. opioid patient-controlled analgesia versus intercostal block].

OBJECTIVE: Lately introduced cardiosurgical procedures such as MIDCAB enable an early extubation immediately after surgery. This also requires an adequate anesthesia regime and especially a sufficient postoperative analgesia. Patient controlled analgesia (PCA) and intercostal nerve blockade (ICB) were evaluated for their suitability for postoperative pain relief in patients undergoing a MIDCAB procedure. MATERIAL AND METHODS: After approval by the local ethic committee and obtaining written informed consent 43 patients were included in this study. Anesthesia was induced and maintained in a total intravenous standardised manner with propofol, remifentanil, cisatracurium and additionally glyceroltrinitrate, clonidine and esmolol were given as needed. After revascularisation patients were randomly assigned to one of two groups receiving either 7.5 mg piritramid i.v. before extubation and continuing a PCA with 2 mg boli and a 10 min lockout, or an ICB with ropivacaine 1% (4 times 5 ml). Additionally all patients received 1 g paracetamol rectally before induction of anesthesia and 1 g metamizol i.v. at the end of surgery. A rescue medication of 3.75 mg piritramid i.v. was allowed. A pain score (NRS 0-10), the Aldrete score (AS 0-12) and oxygen saturation were obtained 1, 4, and 8 h after extubation. RESULTS: The ICB group showed a significantly greater pain reduction in the first (5.8 +/- 1.8 vs. 7.3 +/- 1.9; P < 0.02) and fourth h (3.6 +/- 1.3 vs. 4.6 +/- 1.4; P < 0.02), respectively. Transfer to an intermediate care ward one hr after extubation was achieved more often in the ICB group according to the AS (ICB 9.6 +/- 1.5 vs. PCA 8.9 +/- 1.2; P < 0.05), too. There was no difference with respect to the oxygen saturation. The additional piritramid demand was 9.3 mg in the ICP group and 5 mg in the PCA group in the first 8 hours postoperative. CONCLUSION: ICB gives a better pain relief in the early postoperative phase after MIDCAB procedures compared to a PCA. Both regimes are adequate in order to provide a sufficient pain relief and help to avoid prolonged postoperative mechanical ventilation. These will enable an early transfer of patients to an intermediate care station and save ICU capacity.

Adult↗
PubMed2002

[Placental passage of anesthetics and adjuvants].

In obstetric anaesthesia almost all anaesthetic agents are capable of traversing the fetomaternal blood barrier. They all carry potential side-effects putting the unborn or newborn child at risk. Of major relevance is their potential for embryotoxicity, teratogenicity, postpartal cardiorespiratory or neuromuscular depression and the disturbance of thermoregulation. This can possibly lead to fetal malformation, asphyxia or floppy infant syndrome. Furthermore compromisation of uterine blood flow or contractility of the mature uterus plays an important role for the incidence of intrauterine asphyxia and premature labour or birth. Considering the physiological and pathophysiological alterations during pregnancy regarding all organ systems, the overall goal is to find an ideal choice of anaesthetic drugs and techniques in order to minimise an increased anaesthetic risk during pregnancy.

Adjuvants, Anesthesia↗
PubMed2002

[Transient neurologic symptoms after spinal anesthesia. A quantitative systematic overview (meta-analysis) of randomized controlled studies].

BACKGROUND: Transient neurologic symptoms (TNS) after spinal anesthesia (SPA) is defined as back pain with radiation or dysesthesia in the buttocks, thighs, hips and calves, occurring within 24 h after recovery from otherwise uneventful SPA. The symptoms last for about 1-3 days but neurophysiologic evaluation does not show pathologic findings. The type and the preparation of the local anesthetic drug (baricity, concentration, additives or preservatives) are most often discussed as the underlying cause of TNS. METHODS: Randomized controlled comparative studies reporting the incidence of TNS were systematically searched. Descriptive statistics are presented summarizing the identified trials and the pooled relative risk (RR), the number-needed-to-harm (NNH) with their 95% confidence intervals (95%-CI) were calculated using a random effects model. RESULTS: A total of 29 studies with a 2,813 patients fulfilled the inclusion criteria. Summarizing all patients in these trials without further adjustment, the incidence of TNS was 16.9% after lidocaine, 19.1% after mepivacaine, but only 1.1% after bupivacaine and 1.7% after prilocaine. For tetracaine, procaine, and ropivacaine there were too few studies to draw meaningful conclusions. Using meta-analysis techniques these data were confirmed: the pooled relative risk (RR) for suffering from TNS was 6.7-fold higher after lidocaine (95%-CI: 2.5-18) than after SPA with bupivacaine and 5.5-fold higher (95%-CI: 2-15) than after prilocaine. Furthermore, data show that baricity, concentration of the local anesthetic, and addition of vasoconstrictors have no significant influence on the occurrence of TNS. CONCLUSION: Prilocaine and bupivacaine for SPA are associated with less TNS than lidocaine and mepivacaine. For the other local anesthetics there were not enough comparative trials to give conclusive recommendations.

Adjuvants, Anesthesia↗
PubMed2002

Impact of a multimodal anti-emetic prophylaxis on patient satisfaction in high-risk patients for postoperative nausea and vomiting.

Postoperative nausea and vomiting (PONV) are frequent and unpleasant symptoms. This prospective study aimed to assess the efficacy of a multimodal approach to prevent PONV, and patient satisfaction using the willingness-to-pay method. Two validated risk scores were applied to forecast the individual risk for PONV in 900 consecutive patients of whom 108 were identified as high-risk patients (predicted risk: 79-87%). High-risk patients received multimodal anti-emetic prophylaxis: total intravenous anaesthesia with propofol, high fractional inspired oxygen (80%), omission of nitrous oxide, dexamethasone 8 mg, haloperidol 10 microg.kg(-1), and tropisetron 2 mg. Of the remaining patients with low or moderate risk for PONV, a random sample of 71 females received balanced propofol-desflurane anaesthesia without prophylactic anti-emetics. All patients were interviewed 2 and 24 h after surgery for occurrence of nausea and vomiting. Patient satisfaction was measured using the willingness-to-pay method. The incidence of PONV (95%-confidence interval) in the control-group was 41% (29-51%), slightly lower than predicted by the risk scores (53-57%). The multimodal anti-emetic approach reduced the predicted risk (79-87%) in the high risk-group to 7% (3-14%). This was associated with a high willingness-to-pay median (25th/75th percentile) of 84 UK pounds (33-184 UK pounds) in the multimodal anti-emetic group compared to 14 UK pounds (4-30 UK pounds) in the control group. A multimodal anti-emetic approach can considerably reduce the incidence of PONV in high-risk patients and is associated with a high patient satisfaction as measured by the willingness-to-pay method.

Adult↗
PubMed2002

[Prophylaxis of Postoperative Nausea and Vomiting FollowingGynaecological Laparoscopy].

OBJECTIVE: Compared to other procedures, gynaecological laparoscopies are followed rather frequently by postoperative nausea and vomiting (PONV). Therefore, we investigated the prophylactic antiemetic efficacy of metoclopramide and droperidol under general anaesthesia with isoflurane (part 1). Given the rather unsatisfying results of this monoprophylaxis we examined the effects of a quintuple prophylaxis in this setting (part 2). METHODS: Part 1: Following ethical committee approval and written informed consent 120 patients scheduled for elective gynaecological laparoscopy were allocated prospectively, randomly and observer-blinded to the following groups: group P (placebo): 2 ml NaCl 0.9 %, group D: 2.5 mg droperidol, group M: 10 mg metoclopramide. Part 2: Subsequently 50 patients scheduled for elective gynaecological laparoscopy and bearing a minimum risk of 25 % to experience postoperative vomiting were allocated prospectively and blinded to the observers to a quintuple prophylaxis group: group X: 10 mg metoclopramide, 2.5 mg droperidol, 12.5 mg dolasetron, 62.5 mg dimenhydrinate, 8mg dexamethasone. Part 1 and 2: Anaesthesia was induced with fentanyl, etomidate and succinycholine and maintained with isoflurane/N2O, fentanyl and cisatracurium. The antiemetics were applied intravenously 20 min prior to end of surgery. RESULTS: Within the first 24 h postoperatively vomiting occurred more frequently in group P (44 %) compared to group D (21 %, p = 0.046) and group M (33 %, n. s.). Nausea also occurred more frequently in group P (61 %) compared to group D (24 %, p = 0.003) and group M (48 %, n. s.). Intensity of nausea was reduced both in group D and group M compared to group P (p = 0.03). Likewise the requirements for antiemetics as a rescue medication were reduced in group D (p = 0.02) and group M (p = 0.047) compared to group P. In group X no patient suffered from postoperative vomiting, no patient required a rescue antiemetic. CONCLUSIONS: Whereas droperidol provides a reliable antiemetic effect, the prophylactic effect of metoclopramide is rather uncertain. Therefore, further studies regarding a dose response-relationship for metoclopramide are deemed necessary. Since a monoprophylaxis with droperidol or metoclopramide failed to attain a satisfying PONV-prophylaxis in patients at high risk for PONV, the quintuple antiemetic combination might be an effective and safe solution.

Adolescent↗
PubMed2002

[Motor function during patient-controlled analgesia via a lumbar epidural catheter after major abdominal surgery. Ropivacaine-sufentanil vs. bupivacaine-sufentanil].

INTRODUCTION: The aim of the present study was to investigate postoperative motoric impairment during patient-controlled analgesia after major abdominal surgery with ropivacaine-sufentanil and bupivacaine-sufentanil via a lumbar epidural catheter. METHODS: After approval of the local ethics committee, 40 patients scheduled for major lower abdominal surgery were randomly allocated to receive bupivacaine 0.25 % or ropivacaine 0.2 %, both with sufentanil 2 microgram/ml in a double blind manner. General anaesthesia (midazolam, etomidate, fentanyl, vecuronium, and desflurane in N2O/O2) and postoperative management of the patients were standardised. Postoperatively, the motoric function and ability for active early mobilisation was examined clinically (application of the Bromage scale, ability to leave the bed and ability to walk). Reduction of muscular force of the legs was measured postoperatively using a scale and compared with preoperative baseline values. To ensure a similar level of analgesia, a 10-cm visual analogue scale was applied at rest and while coughing. RESULTS: The two groups did not differ with respect to the demographic data and postoperative levels of analgesia. Less reduction of motoric function at rest was observed in the ropivacaine group (p = 0,044). However, this did not lead to an increased ability to get up from bed (p = 0,57) or to walk around (p = 0,17). A high number of patients did not meet the requirements for early ambulation. Almost half of the patients of both groups were unable to leave their beds in the morning of the first postoperative day. On the second postoperative day about 25 - 30 % of the patients could not walk even when support was applied. Furthermore, median reduction (10th/90th percentile) of muscular strength was reduced to 50 % (37 %/76 %) in the ropivacaine group and to 48 % (31 %/61 %) in the bupivacaine group compared with preoperative values. DISCUSSION: While quality of analgesia was similar, mobility of the legs at rest is better preserved with ropivacaine 0.2 % than with bupivacaine 0.25 %. However, despite the fact that high dose sufentanil was added to both local anaesthetics, there was marked motoric impairment in both groups probably due to the lumbar site of the epidural catheter. This was associated with an unacceptable high incidence of patients unsuitable for early postoperative mobilisation.

Amides↗
PubMed2002

[Head and neck cancer surgery in the elderly].

BACKGROUND: The literature on management of advanced head and neck cancer in the elderly is limited. Diagnostic and treatment decisions may be implicated by advanced age itself. METHOD: Treatment outcomes of head and neck cancer in elderly patients were reviewed in the literature. The results should serve as a basis for an individualized treatment strategy. RESULTS: A comparison of data shows that chronologic age alone should not be a contraindication to adequate oncologic surgery. An aggressive approach to head and neck cancer management with curative intention can be also considered in high aged patients with advanced cancer. Surgical therapy of head and neck cancer can be as effective in elderly patients as in younger patients without a significant increase in mortality and complications. CONCLUSIONS: Head and neck cancer patients of all age groups should have a treatment of equal quality regardless of whether the expected outcome is cure or palliation.

Aged↗
PubMed2001

Dose-response relationship of propofol on mid-latency auditory evoked potentials (MLAEP) in cardiac surgery.

BACKGROUND: Propofol-sufentanil anaesthesia has become popular during cardiac surgery for its titrability and short recovery time. Avoidance of awareness is a major goal during cardiac surgery. We therefore investigated the dose-response relationship of propofol and cortical responses (mid-latency auditory evoked potentials, MLAEP). METHODS: One hundred patients undergoing cardiac surgery were investigated. Basic anaesthesia was performed with sufentanil (4.5 microg kg(-1) h(-1)) / flunitrazepam (9 microg kg(-1) h(-1)) infusion (control group); the other groups received in addition a loading dose of propofol 2 mg kg(-1) and a maintainance infusion of 1-3.5 mg kg(-1) h(-1). MLAEP were evaluated by using Pa/Nb-amplitudes and Nb-latencies. Haemodynamics were monitored by ECG, arterial blood pressure and cardiac function with pulmonary artery catheterization. RESULTS: In the control group, median amplitude of MLAEP decreased by 50% with a wide range, but were detectable in >90% of patients throughout surgery. Propofol suppressed amplitude Pa/Nb of MLAEP dose dependently. With 3.5 mg kg(-1) h(-1) amplitudes disappeared in >40% of patients throughout cardiac surgery. Median Nb-latencies increased in the control group from 44 to a range from 50 to 60 ms. In groups with propofol >2 mg kg(-1) h(-1), Nb-latencies, detectable in the patients without complete suppression of MLAEP, increased to median 60 ms. Haemodynamic parameters and cardiac function did not differ among the groups. The use of vasopressors was not increased even with the highest propofol dose used. CONCLUSION: The dose-response effect of propofol on auditory evoked potentials reveals that combining a loading dose of 2 mg kg-1 with a consecutive infusion of 3.5 mg kg(-1) h(-1) significantly suppresses MLAEP during cardiac surgery. Thus, auditory information may not be processed and awareness with recall becomes unlikely.

Adolescent↗
PubMed2001

Minimum local analgesic dose of plain ropivacaine vs. ropivacaine combined with sufentanil during epidural analgesia for labour.

We have used the up-and-down allocation technique to assess the relative analgesic potencies of epidural ropivacaine alone and ropivacaine combined with sufentanil 0.75 microg.ml-1 in 42 women requesting epidural analgesia in the first stage of labour. Parturients were randomly allocated to one of the two epidural solutions in a double-blind manner. The concentration of local anaesthetic was determined by the response of the previous parturient: an effective concentration (pain < or = 10 mm on a 10-cm visual analogue pain score within 30 min) resulted in a 0.01% decrease in the concentration of ropivacaine for the next parturient, an ineffective concentration resulted in a 0.01% increase. Minimum local analgesic concentration of ropivacaine alone was 0.13% (95% CI 0.12-0.13%) compared with 0.09% (95% CI 0.08-0.1%) for ropivacaine with sufentanil (p < 0.00001).

Adult↗
PubMed2001

The influence of fentanyl vs. s-ketamine on intubating conditions during induction of anaesthesia with etomidate and rocuronium.

BACKGROUND AND OBJECTIVE: In the present study, we investigated the combination of etomidate and s-ketamine with regard to its suitability for modified rapid-sequence induction using rocuronium for muscle relaxation. METHODS: In a prospective, randomized and double-blinded study, 90 patients were assigned to one of three groups for induction of anaesthesia in combination with etomidate (0.3 mg kg-1) and muscle relaxation with rocuronium (0.6 mg kg-1). The groups were as follows: (a) control, i.e. placebo; (b) fentanyl, fentanyl (1.5 microg kg-1); (c) ketamine, s-ketamine (0.5 mg kg-1). Tracheal-intubating conditions after 1 min were classified as excellent, good or poor. During the induction of anaesthesia, arterial pressure and heart rate were measured every 60 s. RESULTS: Intubating conditions were best using etomidate and s-ketamine (23 excellent, 7 good, 0 poor) compared with the control (8, 16, 6 respectively) and fentanyl groups (7, 21, 2 respectively) (P < 0.01). While heart rate and arterial pressure remained stable in the control and fentanyl groups during induction, both significantly increased in the ketamine group (P < 0.01). CONCLUSIONS: The combination of etomidate and s-ketamine for anaesthesia induction produces mostly excellent intubating conditions after 60 s using only 0.6 mg kg-1 of rocuronium. This combination of drugs may be a useful alternative, if succinylcholine needs to be avoided, for modified rapid-sequence induction.

Adult↗
PubMed2001

Muscle relaxants suitable for day case surgery.

Neuromuscular blocking agents are used as adjuvants in day case anaesthesia to facilitate tracheal intubation and/or surgery. Although the majority of day case procedures are performed without the use of neuromuscular blocking agents, there are procedures, such as laparoscopic surgery, microsurgery, open eye surgery, some ear, nose and throat procedures and some paediatric procedures, which may require neuromuscular blockade. The characteristics of an ideal neuromuscular blocking agent for day case surgery are a short onset, a short clinical duration and a short recovery time, with or without reversal. It should also lack histamine release, provide haemodynamic stability, and be competitively priced. This paper reviews the neuromuscular blocking agents currently available and used, such as succinylcholine and mivacurium, low doses of an intermediate-acting neuromuscular block, such as rocuronium and the recently introduced rapacuronium. Their advantages and disadvantages are described and discussed, with special reference to the needs of day case surgery. Rapacuronium offers certain benefits compared with the currently available neuromuscular blocking agents for day care anaesthesia.

Ambulatory Surgical Procedures↗
PubMed2000

[Proxy decision in health questions and advance designations by patients. A practice-oriented review of the legal and ethical problems in treating the incompetent patient].

Except in emergencies, the medical treatment of incompetent patients also has to be based upon an informed consent between the physician and a legitimate legal representative (durable power of attorney). Consequently, the German 'Betreuungsrecht' advices persons to designate in advance such a proxy or surrogate. However, an additional court-decision is demanded, if a medical measure poses significant risks for the future health or the life of the incompetent patient. On the base of the available epidemiologic data we illustrate that neither our medical nor our legal system could realistically cope with the practical consequences of this legislation: The vast majority of our present decisions in such cases is not covered by a legally valid informed consent, which implies possible forensic consequences. This article provides relevant clinical and legal advice on how to protect the legitimate interests of all concerned within the present framework, which should urgently be revised.

Animals↗