Der geriatrische Patient aus chirurgischer Sicht — Hernienchirurgie und Lebensqualität

Zusammenfassung   Grundlagen: über die subjektive Lebensqualit?t nach Hernienoperation bei geriatrischen Patienten ist wenig bekannt. Die Indikationsstellung und die Operation selbst werden in dieser Altersgruppe sehr unterschiedlich gehandhabt. Methodik: 90 über 75j?hrige Patienten wurden in Lokalan?sthesie mittels anteriorer Patch-Plastik (Lichtenstein) operiert und 2–26 Monate postoperativ zur Lebensqualit?t und Zufriedenheit mit der Operation befragt. Ergebnisse: Bei 83 Elektiveingriffen verlief die Operation in Lokalan?sthesie problemlos. Probleme mit der Operation ergaben sich bei 7 F?llen mit Inkarzeration u.a. durch Fehleinsch?tzung der Situation. 97% der Patienten beurteilten das Operationsergebnis retrospektiv mit der bestm?glichen Note auf einer 5teiligen Skala. Bei 2 Patienten stellte sich als Ursache geringerer Zufriedenheit eine als mangelhaft empfundene postoperative Nachbetreuung heraus. Schlu?folgerungen: Für ein subjektiv positiv empfundenes Ergebnis der Leistenhernienchirurgie im hohen Alter sind folgende Faktoren ausschlaggebend: zurückhaltende Indikationsstellung, Lokalan?sthesie, optimale und schonende chirurgische Technik, pers?nliche perioperative Betreuung durch den Operateur.      

Ist die Spinalanästhesie bei Eingriffen in Bauchlage ein empfehlenswertes Verfahren?

There is still controversy on the usefulness of spinal anesthesia for operations performed in the prone or jackknife position. There is about the risk of inadvertent increase of the sensomotory blockade with the patient in the prone position and the difficulty of managing consecutive cardiorespiratory complications or inducing general anesthesia in case of failures. This article reviews the current literature in terms of safety and effectiveness of spinal anesthesia for such operations. For lower-limb or perianal operations with limited extension and blood loss, performed in the prone position, spinal anesthesia seems to be a safe, effective and economic technique in patients without severe a cardiac history. Substantial knowledge about the onset time, fixation time, duration of sensomotory block and baricity of the applied local anesthetic is crucial in this setting. Obese patients are at risk for sudden extension of the block when turned into the prone position. Additional narcotics and sedatives should be avoided and continuous monitoring of hemodynamic and respiratory parameters, of the level of the blockade and vigilance of the patient is mandatory.     

Kapselruptur bei Kataraktoperationen mit Sponge-Oberflächen- und intrakameraler Anästhesie

Background. Combined topical and intracameral anaesthesia has become increasingly popular in cataract surgery. The purpose of this study was to determine the risk of capsular lesions with an intact motility during surgery. Patients and methods. In a prospective clinical study, we analyzed 2000 phacoemulsifications with IOL implantation performed by an experienced surgeon with combined sponge and intracameral lidocain anaesthesia. Preoperatively two grades of difficulty of the surgical proceduce were defined. Results. Operations were carried out on 1,658 patients with a (grade 1) low degree and 342 patients (grade 2) with a high degree of difficulty (17.1%). Capsular lesions occurred in 17 operations (0.85%),15 in cases with a high degree of difficulty (88%). In 12 of these, an anterior vitrectomy was necessary and in 1 operation a pars plana vitrectomy after application of additional retrobulbar anaesthesia was performed. Conclusions. In this study the incidence of capsular lesions was not increased compared to other methods of anaesthesia. Anterior vitrectomy with the patient under combined sponge and intracameral anaesthesia, was possible without retrobulbar anaesthesia.     

PNPLA6基因复合杂合突变引起的Boucher-Neuhäuser综合征一例并文献分析

目的 结合相关文献探讨Boucher-Neuhäuser综合征(Boucher-Neuhäuser syndrome,BNS)患者的临床特征和基因检测结果,以助于临床诊断。 方法 对1例BNS患者采集临床表型,进行相关实验室检验、神经影像学检查与基因检测,同时结合文献分析BNS特点。 结果 本例患者为青年男性,以震颤、共济失调、第二性征发育不良、癫痫为主要表现,呈缓慢进展性病程。头颅MRI提示小脑重度萎缩,基因检测发现为编码神经靶酯酶的PNPLA6基因复合杂合突变,即18号外显子c.1811C>T(p.A604V)和28号外显子c.2990C>T(p.S997L),分别来自其父母。其中c.1811C>T突变未见文献报道,c．2990C>T突变已报道为与BNS相关的致病突变。 结论 以青少年起病,表现为震颤、共济失调合并第二性征发育不良、癫痫等症状时,需考虑PNPLA6基因相关的BNS可能。     

Peribulbäranästhesie versus topische Anästhesie bei der Kataraktoperation Vergleich des postoperativen Verlaufes

Hintergrund: Die intrakamerale Gabe von Konservierungsstoff-freien Lokalan?sthetika (z.B. Lidocain) zur Lokalan?sthesie bei der Kataraktoperation wird von immer mehr Operateuren als alternatives Verfahren neben der herk?mmlichen retro- oder peribulb?ren Injektion propagiert. Wir haben den postoperativen Verlauf nach peribulb?rer An?sthesie und nach intraokularer Gabe von Lidocain 1%ig untersucht und verglichen. Patienten und Methoden: Es wurden insgesamt 186 Kataraktpatienten in je zwei Gruppen in diese Studie aufgenommen. Die Lokalan?sthesie erfolgte in der ersten Gruppe mittels Peribulb?rinjektion (6 ml Xylonest?2%), in der zweiten Gruppe mittels Sponge-An?sthesie plus intrakameraler Applikation von 0,15 ml Lidocain 1%. Am ersten postoperativen Tag wurde die Hornhaut hinsichtlich Epithelstippung, Deszemetfalten, sowie der Vorderkammerreizzustand an der Spaltlampe beurteilt. Der bestkorrigierte Visus wurde festgehalten, der postoperative Schmerzverlauf dokumentiert. Ergebnisse: Der 30 min postoperativ gemessene Visus war in der Lidocaingruppe signifikant besser. Es zeigten sich signifikant st?rkere frühpostoperative Schmerzen in der Lidocaingruppe, sowie statistisch signifikant mehr Deszemetfalten am ersten postoperativen Tag. Schlussfolgerung: Die topische An?sthesie mittels intrakameraler Lidocaingabe ist eine Alternative zu der Peribulb?rinjektion. Sie bietet dem Patienten eine schnelle postoperative visuelle Rehabilitation.      

Intracameral anesthesia with lidocaine in cornea guttata

Background. Combined topical and intracameral anesthesia has become increasingly popular in cataract surgery. We analyzed the use of intracameral anesthesia in patients with corneal dystrophy who had undergone cataract surgery. Patients and methods. We measured the number of endothelial cells in 40 eyes with Fuchs' corneal endothelial dystrophy preoperatively as well as three times postoperatively (after 1 day, 4 weeks, and 3 months). Performing sponge anesthesia, the additional application of 0.15 ml lidocaine 1% was randomized. Results. The lidocaine group showed the following loss of endothelial cells in the central cornea: 1 day postoperatively 9.2%, 4 weeks later 9.7%, and 3 months after surgery 10.7%. The other group had a postoperative loss of endothelial cells in the central cornea of 8.8% (1 day), 9.3% (4 weeks), and 10.5% (3 months). No significant differences between the two groups were observed. Conclusions. Cornea guttata is not a contraindication for the use of intraocular lidocaine.     

Gefahren und Komplikationen bei rückenmarknahen Katheterverfahren

Pain therapy with epidural or intrathecal catheters is an invasive method. These techniques have specific indications in both acute and chronic pain therapy. However, complications can occur. Thus, the potential complications and the therapy necessary must be known.Drugs: Complications resulting from acute local anesthetic intoxication's are rare. High plasma levels during chronic therapy may lead to confusion. Respiratory depression can occur in opioid naive patients up to 12 (-24) h after injection. Adequate monitoring is a prerequisite for this therapy. After application of clonidine, hypotension is frequent in hypertonic and hypovolemic patients. Epidural or intrathecalcatheter placement can result in therapeutic failure, trauma by punction and inability to place the catheter. During chronic therapy, technical problems can occur, e.g., dislocation, occlusion. To exclude intrathecal and intravascular placement, application of a test dosage of a local anesthetic with adrenaline is recommended.Neurological complications can result in nerve root deficit or "simple" post-spinal headache, but cauda equina syndromes, paralyses, intracranial bleeding, sinus thrombosis and central neurological deficits have been reported. Skininfection at the insertion site of the catheter has been observed with an incidence of 1.9 to 7.7%. A spinal infection with neurological deficit is rare. Spinal infections are often associated with other diseases. Spinalhematomas are rare. Coagulation disorders and anticoagulants can lead to bleeding. Intravenous heparin should be avoided, because this is frequently associated with spinal bleeding. Therapy with cumarines is a contraindication for insertion of spinal catheters.Monitoring: During treatment with spinal catheters, adequate monitoring increases safety for the patients. Efficacy of the injections, puncture site and the neurological status should be documented daily. Neurological deficits must be diagnosed without losing time and adequate therapy must be initiated.     

PRNP基因P102L突变致非典型Gerstmann-Sträussler-Scheinker综合征一例并文献复习

目的 提高临床医生对Gerstmann-Sträussler-Scheinker综合征（Gerstmann-Sträussler- Scheinker syndrome,GSS）的识别水平。方法 分析了1例2018年10月于首都医科大学宣武医院就诊、临床表现酷似克雅病（Creutzfeldt-Jakob disease）、最终经基因检测确诊的GSS患者的临床信息、神经心理学检查、脑脊液检查、头颅磁共振成像、¹⁸F氟代脱氧葡萄糖正电子发射断层摄影术、脑电图及基因等资料,并结合文献报道复习两种不同朊蛋白病之间的差别。结果 本例患者为62岁女性,首发症状为小脑性共济失调,随后出现快速进展性痴呆,并伴有锥体束和锥体外系损害,头颅磁共振成像提示\"花边征\",14-3-3蛋白阴性,PRNP基因分析显示P102L基因突变。结论 对临床首发表现为遗传性共济失调,随后出现不同程度认知功能减退的患者,应当考虑GSS。PRNP基因检查对诊断有决定性意义。     

Anästhesieverfahren zur Sectio caesarea in Deutschland Eine Umfrage

Aim of study: Goal of this survey is to give an overview of anaesthesia for caesarean section in Germany. Method: In 1994 and 1995, we sent a questionnaire to the chief-anaesthetists of all German hospitals with departments of gynaecology/obstetrics to find out the routine anaesthetic procedures for caesarean section. Results: We obtained data from 409 hospitals (response rate 46.4%) with 321,816 births – 50,123 of which were sections (mean caesarean section rate 16.6%). The mean general anaesthesia rate for elective caesarean sections was 66,5%, for non-elective sections 90,8%. The mean epidural anaesthesia rate for caesarean section was 22,6% and the mean spinal anaesthesia rate was 9,8%. For general anaesthesia most hospitals used antacids and/or histamine₂-receptor antagonists (64,6% of responding hospitals). Anaesthesia was induced with intravenous barbiturates (82%), succinylcholine for intubation (98,2%) and no opioids before clamping of the cord (94,8%). For regional anaesthesia bupivacaine was the most common local anaesthetic (spinal 84,0%, epidural 96,8%). Opioids were added to local anaesthetics for epidural anaesthesia at 21,4% of the hospitals. Conclusions: General anaesthesia is the commonest practice for caesarean sections at German hospitals. Nowadays regional anaesthesia gains more importance compared to previous German surveys and in agreement with foreign data.