Made available in DSpace on 2014-06-11T19:28:19Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-12-16Bitstream added on 2014-06-13T18:57:20Z : No. of bitstreams: 1 nunes_crm_me_botfm.pdf: 392435 bytes, checksum: 70391dbf289d0130b47bfb5d3d2df41b (MD5) / Secretaria de Saúde do Estado de São Paulo / Dentre as malformações associadas à fissura labiopalatal, a Sequência de Robin (SR) é a que apresenta maior frequência, exigindo maiores cuidados e, dentre as síndromes associadas a SR, a mais freqüente é a Sequência de Robin Isolada (SRI). Caracteriza-se por anomalias como micrognatia, glossoptose e fissura palatina. O tratamento destes pacientes exige que se realize a palatoplastia primária a partir dos 12 meses de vida, de acordo com determinações do Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo (HRAC-USP). Tais pacientes apresentam maior índice de complicações na Sala de Recuperação Anestésica (SRA). Neste período crítico a enfermagem deve permanecer atenta às complicações, promovendo as intervenções mais rápidas e eficazes possíveis. Este trabalho, prospectivo não exploratório, tem como objetivo avaliar as complicações no pós-operatório imediato em pacientes com SRI após palatoplastia primária e propor um instrumento específico para aplicá-lo na SRA do HRAC-USP, bem como descrever os tipos de complicações mais frequentes e indicar as principais intervenções realizadas pela equipe de enfermagem. Para isto, propôs-se um instrumento, baseado no modelo de Biazon, o qual foi submetido à avaliação de juízes, que atestaram sua objetividade e clareza. Este instrumento contem parâmetros clínicos e sintomas indicativos de complicações e intervenções, relacionados à Respiração, Sangramento, Hipotermia e Dor. Fezse um estudo piloto com dez pacientes, calculando-se o Valor α de Cronbach para avaliar sua consistência e coerência. Depois o instrumento foi aplicado em mais 25 pacientes. Os resultados obtidos após avaliação evidenciam que a idade média dos pacientes com SRI submetidos a palatoplastia primária é superior à Resumo dos pacientes com fissura de palato... / Among all malformations associated to cleft lip and palate, the Robin Sequence (RS) is the most frequent, demanding more care than any other associated syndrome. And, among all the syndromes associated to the RS, the most common is the Isolated Robin Sequence (IRS). It is characterized by three abnormalities: Micrognathism, Glossoptosis and cleft palate. The treatment requires to perform a first plastic surgery, identified as primary palatoplasty, only after the age of 12 months, according to a determination of the Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo (HRAC-USP). Such patients have a higher rate of complications at the Post-Anaesthetic Recovery Room (PARR). In this critical period, nursing must keep focus observing the possible complications in order to promote the most effective and imediate interventions. This prospective, non-exploratory research aims to evaluate the complications at the imediate post-operatory of IRS patients after a primary palatoplasty and propose a specific instrument to be applied at the HRAC-USP`s PARR, as well as describe the most frequent complications and indicate the main interventions by the nurse staff team. In order to achieve it, it was proposed an instrument, based on Biazon`s model, wich was submitted to judges evaluation, whom testified its clearness and objectivity. This instrument contains clinical parameters, indicative symptoms of complications and interventions, related to breathing, bleeding, hipothermy and pain. There has been made a pilot study with tem patients, calculating the value of the coefficient of Cronbach`s α, measuring the reliability and consistency of this study. Later the same instrument was applied to more 25 patients. The results, obtained after the evaluation, demonstrated that the average age of patients with IRS undergoing primary palatoplasty is higher Abstract than that... (Complete abstract click electronic access below)

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The efficacy of immersion anaesthesia with tricaine methanesulfonate or propofol on silver catfish Rhamdia quelen was assessed through induction and recovery times and observation of mortality. Two types of comparisons were conducted: one contrasting grey silver catfish of three size ranges and another comparing two strains of the species, albino and grey. For tricaine methanesulfonate, there was no uniform relationship between the induction and recovery times and the size of the grey silver catfish. The grey animals were more sensitive to the anaesthetic than the albinos were, and recovery was also faster in the grey fish group. Induction of propofol anaesthesia had a direct relationship with size, with the small animals reaching anaesthesia stage earlier. No uniform pattern was observed for recovery among the three different sizes. Propofol promoted faster anaesthesia in the grey animals than in the albinos, but no direct relationship was observed for recovery between the strains. No mortality was detected throughout the experiment. This study reports a novel, efficient and practical use of propofol as an immersion anaesthetic for fish and notes the first time that silver catfish have been anesthetised with such an agent. The best outcomes with propofol were registered in the size range comparison, indicating that 12 mg.L-1 is the most efficient concentration to anesthetise the small fish and that 10 mg.L-1 is a more appropriate concentration for anaesthesia of the medium and large animals. With regard to tricaine methanesulfonate, 300 mg.L-1 promoted satisfactory results for anaesthesia of the large fish in the size range comparison and the albino in the strain comparison. The grey fish responded better to 100 mg.L-1 of the anaesthetic in the latter evaluation. These findings show that it is essential to consider size and strain when anesthetising silver catfish with tricaine methanesulfonate or propofol bath solution. / A eficácia da anestesia em banho de imersão com metanosulfonato de tricaína ou propofol em jundiá Rhamdia quelen foi avaliada através de tempos de indução e recuperação anestésica e observação de mortalidade. Foram realizados dois tipos de comparações: um contrastando jundiás cinzas de três tamanhos e outro comparando duas variedades da espécie, albina e cinza. Para metanosulfonato de tricaína, não houve relação uniforme entre tempos de indução e recuperação e tamanho dos jundiás. Os peixes cinzas foram mais sensíveis ao anestésico do que os albinos e a recuperação também ocorreu mais rapidamente nos animais cinzas. Indução anestésica com propofol apresentou relação direta com o tamanho dos peixes, sendo os pequenos os primeiros a atingirem o estágio de anestesia. Não foi observado padrão uniforme entre os diferentes tamanhos de peixe na recuperação. Propofol induziu anestesia mais rapidamente nos peixes cinzas do que nos albinos, mas não foi observada relação direta entre as duas variedades na recuperação. Não houve mortalidade ao longo do experimento. Este estudo descreve um uso novo, eficiente e prático de propofol como anestésico para banho de imersão em peixes, bem como o primeiro relato de anestesia de jundiá com este agente. Os melhores resultados com propofol foram registrados na comparação entre jundiás cinzas de diferentes tamanhos, indicando 12 mg.L-1 como a concentração mais eficaz para anestesia dos peixes pequenos e 10 mg.L-1 como a mais eficiente para os peixes médios e grandes. Com relação ao metanosulfonato de tricaína, 300 mg.L-1 promoveu resultados satisfatórios para anestesia dos peixes grandes na comparação entre tamanhos e para anestesia dos albinos na comparação entre variedades. Nesta última, os jundiás cinzas responderam melhor a concentração de 100 mg.L-1. Estes resultados demonstram ser essencial considerar tamanho e variação genética quando opta-se por anestesiar jundiás em banho de imersão com metanosulfonato de tricaína ou propofol.

Orientador: José Eduardo Corrente / Banca: Maria Irene Bachega / Banca: Wilza Carla Spiri / Resumo: Dentre as malformações associadas à fissura labiopalatal, a Sequência de Robin (SR) é a que apresenta maior frequência, exigindo maiores cuidados e, dentre as síndromes associadas a SR, a mais freqüente é a Sequência de Robin Isolada (SRI). Caracteriza-se por anomalias como micrognatia, glossoptose e fissura palatina. O tratamento destes pacientes exige que se realize a palatoplastia primária a partir dos 12 meses de vida, de acordo com determinações do Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo (HRAC-USP). Tais pacientes apresentam maior índice de complicações na Sala de Recuperação Anestésica (SRA). Neste período crítico a enfermagem deve permanecer atenta às complicações, promovendo as intervenções mais rápidas e eficazes possíveis. Este trabalho, prospectivo não exploratório, tem como objetivo avaliar as complicações no pós-operatório imediato em pacientes com SRI após palatoplastia primária e propor um instrumento específico para aplicá-lo na SRA do HRAC-USP, bem como descrever os tipos de complicações mais frequentes e indicar as principais intervenções realizadas pela equipe de enfermagem. Para isto, propôs-se um instrumento, baseado no modelo de Biazon, o qual foi submetido à avaliação de juízes, que atestaram sua objetividade e clareza. Este instrumento contem parâmetros clínicos e sintomas indicativos de complicações e intervenções, relacionados à Respiração, Sangramento, Hipotermia e Dor. Fezse um estudo piloto com dez pacientes, calculando-se o Valor α de Cronbach para avaliar sua consistência e coerência. Depois o instrumento foi aplicado em mais 25 pacientes. Os resultados obtidos após avaliação evidenciam que a idade média dos pacientes com SRI submetidos a palatoplastia primária é superior à Resumo dos pacientes com fissura de palato... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Among all malformations associated to cleft lip and palate, the Robin Sequence (RS) is the most frequent, demanding more care than any other associated syndrome. And, among all the syndromes associated to the RS, the most common is the Isolated Robin Sequence (IRS). It is characterized by three abnormalities: Micrognathism, Glossoptosis and cleft palate. The treatment requires to perform a first plastic surgery, identified as primary palatoplasty, only after the age of 12 months, according to a determination of the Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo (HRAC-USP). Such patients have a higher rate of complications at the Post-Anaesthetic Recovery Room (PARR). In this critical period, nursing must keep focus observing the possible complications in order to promote the most effective and imediate interventions. This prospective, non-exploratory research aims to evaluate the complications at the imediate post-operatory of IRS patients after a primary palatoplasty and propose a specific instrument to be applied at the HRAC-USP's PARR, as well as describe the most frequent complications and indicate the main interventions by the nurse staff team. In order to achieve it, it was proposed an instrument, based on Biazon's model, wich was submitted to judges evaluation, whom testified its clearness and objectivity. This instrument contains clinical parameters, indicative symptoms of complications and interventions, related to breathing, bleeding, hipothermy and pain. There has been made a pilot study with tem patients, calculating the value of the coefficient of Cronbach's α, measuring the reliability and consistency of this study. Later the same instrument was applied to more 25 patients. The results, obtained after the evaluation, demonstrated that the average age of patients with IRS undergoing primary palatoplasty is higher Abstract than that... (Complete abstract click electronic access below) / Mestre

La fibrilación auricular es la arritmia más frecuente en la práctica clínica, con una prevalencia que alcanza el 10% en la población mayor de 70 años, y unas perspectivas de incremento en consonancia con el aumento de la esperanza de vida. No obstante, a pesar de ser la arritmia más frecuente, los mecanismos causantes de su generación y persistencia no se conocen con exactitud. Por esta razón, los estudios cuyo objetivo sea profundizar en los mecanismos que envuelven la citada arritmia son de gran ayuda para el desarrollo de protocolos clínicos que mejoren el diagnóstico, y permitan seleccionar los tratamientos más apropiados. Numerosos estudios científicos han indagado en cuáles son los factores que afectan al estado electrofisiológico de las aurículas, responsables de la iniciación y mantenimiento de la fibrilación, así como en los que gobiernan la transmisión de los impulsos eléctricos entre la aurícula y el ventrículo, donde el sistema nervioso autónomo se ha apuntado como uno de los factores responsables. En esta tesis doctoral se ha estudiado el efecto sobre la actividad auricular y ventricular, del anestésico más comúnmente usado en terapias destinadas a restablecer el ritmo sinusal en pacientes con episodios de fibrilación auricular. Este anestésico es el propofol (2,6-diisopropylphenol), que es un rápido anestésico intravenoso. La rápida redistribución y metabolismo del propofol resultan en una rápida eliminación de aproximadamente 1 hora, haciéndolo útil para sedaciones de corta duración. La hipótesis de este estudio es si el propofol puede alterar la actividad auricular durante la fibrilación auricular. Simultáneamente a la realización de los procedimientos de ablación, se realizan registros electrocardiográficos y electrogramas auriculares. Los electrogramas permiten extraer información local de las aurículas, muy útil para reflejar los procesos electrofisiológicos que ocurren durante la fibrilación auricular. Habitualmente, los registros internos de epi / Cervigón Abad, R. (2009). Signal processing of intracardiac recordings for the evaluation of propofol effects during atrial fibrillation [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/5766 / Palancia

Introduction The neuropsychological deterioration after cardiac surgery involving cardiopulmonary bypass (CPB), is ascribed to brain ischaemia caused by, amongst others, hypotension, cerebral hyperthermia, cerebral embolism, interaction between pharmacological methods and hypothermia during ischaemia, and the directly neurotoxic of anaesthetic drugs. AimTo investigate the effect of the anaesthetic techniques midazolam plus ketamine (MK) or sufentanil (S) on the quantitative EEG (QEEG), reaction time (RT), serum neuron specific enolase (NSE), and serum S-100<font face="symbol">b</font> protein after cardiac surgery involving CPB in humans. Patients and methodsThe sample consisted of a total of 42 patients scheduled for elective coronary artery bypass (CABG) or valve replacement (VR). All patients were not available for all the postoperative tests. Patients were allocated randomly to group MK or S. Anaesthetic technique: S or MK. Isoflurane was administered when necessary. CPB technique: 30°C, membrane oxygenation, a 40 <font face="symbol">m</font>m filter in the arterial cannula and <font face="symbol">a</font>-stat-blood gas management, blood pressure of 50 to 70 mm Hg and a haematocrit <font face="symbol">></font> 22%. Patients were weaned from CPB when nasopharyngeal temperature reached a maximum of 37,5°C. QEEG and RT was performed 1 to 2 days preoperatively and 5 to 6 days postoperatively.Serum-NSE and -S-100<font face="symbol">b</font> protein were measured preoperatively, 2 minutes after going on CPB, after rewarming to 37°C, just before the end of CPB and 2, 4, 10, 20, 30, and 48 hours after CPB. ResultsQEEG: The most noticable finding was an increase in slow wave activity (relative <font face="symbol">q</font> and <font face="symbol">s</font>). The QEEG outcome was better after CABG than after VR (p < 0,001), but not different between MK and S (p = 0,5000). <font face="symbol">Dq</font>% was better with MK than S (p = 0,0120). <font face="symbol">Dq</font>% (p = 0,0010), <font face="symbol">Da/q</font>% (p = 0,0090) and <font face="symbol">D</font>PS% (p = 0,0025) was better after CABG than VR. Reaction time: There was a significant deterioration in 5/18 (27,78%) of MK and 12/18 (66,67%) of S (p = 0,0220). The change in accuracy in sequential reation time 1 (p = 0,0100), and sequential reation time 2 (p = 0,0970) and the cumulative accuracy was better with MK than S(p = 0,0020). Chemical markers: Over groups 14,8% of patients had a poor NSE and 61,9% a poor S-100<font face="symbol">b</font> outcome. Within groups a poor NSE outcome was found in 14,8% of MK and 14,8% of S (p = 1,0000), and 4,8% of CABG but 23,8% of VR (p = 0,1840). Within groups as adverse S-100<font face="symbol">b</font> outcome was found in 42,9% of MK but 81,0% van S (p = 0,0250; Fisher's exact test), and 66,7% of CABG and 57,1% of KV (p = 0,7510. According to area under the curve of corrected NSE, CABG had a better outcome than VR (p = 0,0040). According to both maximum S-100<font face="symbol">b</font> level and the area under the curve of S-100<font face="symbol">b</font>, an interaction occurred between the anaesthetic technique and the procedure, with VR doing better with MK while CABG did significantly better with S (p = 0,0180 en 0,0040 respectively). Conclusion, shortcomings, significance and contribution This study has shown that, in as far as brain damage is concerned, the outcome was probably better with MK than with S, and CABG better than VR. An interaction was found between the anaesthetic technique and the type of operation. / Thesis (MD)--University of Pretoria, 2003. / Anaesthesiology / unrestricted

Bakgrund: Varje år drabbas omkring 100 000 patienter av vårdskador inom somatisk sjukvård i Sverige, förutom det lidande som det innebär för den enskilda individen medför det även ökade kostnader på både individ- och samhällsnivå. Det dominerande sättet att arbeta med patientsäkerhet inom hälso- och sjukvård är genom avvikelserapportering och analysering av negativa händelser. Specialistsjuksköterskan inom anestesisjukvård är precis som all annan hälso- och sjukvårdspersonal skyldig att rapportera när en avvikelse observerats. En strategi som kan användas för att koppla avvikelserapportering till förbättrad patientsäkerhet är att analysera avvikelser och koda händelserna till specifika områden. Genom att identifiera ett specifikt problem kan ett tvärvetenskapligt team därefter skapas för att granska de negativa händelserna kopplat till en specifik kategori, för att utifrån det resultatet utveckla förbättringar.  Syfte: Syftet var att beskriva och kartlägga innehållet i perioperativa avvikelserapporter på operationsavdelningen som berör patientsäkerheten, relaterade till anestesisjuksköterskans profession. Metod: En retrospektiv registerstudie med induktiv ansats. Datamaterialet analyserades med kvalitativ manifest innehållsanalys. Resultat: Fyra kategorier och fjorton underkategorier framkom under analysförfarandet. I kategorin patientomhändertagande identifierades flest avvikelserapporter, följt av kommunikation, teknik och organisation. Slutsats: Studiens resultat visar att de avvikelserapporter på operationsavdelningen, som berört patientsäkerhet relaterade till anestesisjuksköterskans profession, som var vanligast förekommande, var relaterade till patientomhändertagande eller kommunikation. I patientomhändertagande var läkemedelsrelaterade avvikelserapporter en av de vanligast förekommande och i kategorin kommunikation var det kommunikationen mellan vårdpersonal som genererade flest avvikelserapporter. Utifrån resultatet ses att mer forskning och fler förbättringsåtgärder behöver göras för att öka patientsäkerheten. / Background: Every year around 100,000 patients suffer from care injuries in somatic health care in Sweden, in addition to the suffering it entails for the individual, it also entails increased costs at both individual and societal level. The dominant way of working with patient safety in healthcare is through incident reporting and analysis of negative events. The anesthetic care nurse, just like all other personnel is obliged to report when an incident is observed. One strategy that can be used to link incident reporting to improve patient safety is to analyze incidents and code the events to specific areas. By identifying a specific problem, a multidisciplinary team can then be created to review the negative events linked to a specific category, in order to develop improvements based on that result. Aim: The aim was to describe and map out the content of perioperative incident reports in the operating department that affect patient safety, related to the nurse anesthetist´s profession. Method: A retrospective registry study with an inductive approach. The data was analyzed using qualitative manifest content analysis. Results: Four categories and fourteen subcategories emerged during the analysis procedure. Most incident reports were identified in the category patient care, followed by communication, technology and organization. Conclusion: The results of this study show that the incident reports in the operating department, which affected patient safety related to the nurse anesthetist's profession, which were most common, were related to patient care or communication. In patient care, medication-related incident reports were among the most frequently occurring, and in the communication category, it was communication between healthcare staff that generated the most incident reports.

It is possible that interruption of nociceptive input from intervertebral discs can be modulated through bilateral L1 and L2 dorsal root ganglia (DRG) blockade. In order to test this hypothesis, we prospectively collected data from patients with low-lumbar pain, accurately diagnosed as discogenic using provocation discography. Methods Twelve patients were recruited with a mean (SD) symptom duration of 13.7 (8.2) years. Bilateral DRG blocks of L1 and L2 were performed using methylprednisolone 80 mg, clonidine 75 µg and 0.5% bupivacaine 4 ml in each patient. Results Analysis of Brief Pain Inventories showed no significant change in pain scores. Conclusion We conclude that blocks of this nociceptive pathway in humans using bilateral DRG blocks has no therapeutic value.

Various techniques and drug regimes for thoracic paravertebral block (PVB) have been evaluated for post-thoracotomy analgesia, but there is no consensus on which technique or drug regime is best. We have systematically reviewed the efficacy and safety of different techniques for PVB. Our primary aim was to determine whether local anaesthetic (LA) dose influences the quality of analgesia from PVB. Secondary aims were to determine whether choice of LA agent, continuous infusion, adjuvants, pre-emptive PVB, or addition of patient-controlled opioids improve analgesia. Indirect comparisons between treatment arms of different trials were made using metaregression. Twenty-five trials suitable for metaregression were identified, with a total of 763 patients. The use of higher doses of bupivacaine (890¿990 mg per 24 h compared with 325¿472.5 mg per 24 h) was found to predict lower pain scores at all time points up to 48 h after operation (P=0.006 at 8 h, P=0.001 at 24 h, and P<0.001 at 48 h). The effect-size estimates amount to around a 50% decrease in postoperative pain scores. Higher dose bupivacaine PVB was also predictive of faster recovery of pulmonary function by 72 h (effect-size estimate 20.1% more improvement in FEV1, 95% CI 2.08%¿38.07%, P=0.029). Continuous infusions of LA predicted lower pain scores compared with intermittent boluses (P=0.04 at 8 h, P=0.003 at 24 h, and P<0.001 at 48 h). The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. Further well-designed trials of different PVB dosage and drug regimes are needed.

Sammanfattning Bakgrund: Det är fortsatt förekommande med komplikationer relaterat till medelsvår och svår postoperativ smärta. Anestesisjuksköterskan har det samlade omvårdnadsansvaret för patienten perioperativt. En helhetsbedömning av patienten avgör postoperativt smärtlindringsbehov. Den Perioperativa dialogen skapar mening i arbetet och trygghet för patienten. Författarna identifierade avsaknad av riktlinjer vid genomförandet av en individuell helhetsbedömning vid handläggning av postoperativ smärtlindring. Syfte: Syftet var att belysa hur anestesisjuksköterskor planerar, genomför och utvärderar postoperativ smärtlindring i generell anestesi utefter tidsfaserna pre-, intra- och postoperativt samt inverkan av den perioperativa dialogen. Metod: En kvalitativ studie genomfördes med tio semistrukturerade intervjuer. Data analyserades med kvalitativ innehållsanalys med en induktiv ansats. Resultat: I resultatet framkom fyra huvudkategorier med totalt elva underkategorier som berör informanternas handläggning. Preoperativa åtagande - Planeringsprocess Känna ansvar för planering, Skapa vårdrelation, Beakta patientens känslotillstånd. Intraoperativa vårdmoment - Konstant utvärdering av behandling, Anpassa behandling fortlöpande, Självständigt ansvarsområde. Postoperativa förhoppningar - Eftersträva återkoppling, Undvika smärtgenombrott. Perioperativa organisatoriska aspekter - Anpassa utefter arbetsförhållanden, Avsaknad av den Perioperativa dialogen. Slutsats: Handläggningen av postoperativ smärtlindring är ett komplext område vilket kräver beaktning av flera faktorer för ett gott utfall. Den perioperativa dialogen är inte prioriterad. Det saknas konsensus för anestesisjuksköterskans handläggning av postoperativ smärta. Det krävs utveckling och ett utökat samarbete av hela vårdkedjan för att kunna möta den postoperativa smärtproblematiken. / Abstract Background: Complications still occur in connection to moderate and severe postoperative pain. The nurse anaesthetic´s is completely responsible for the patient care perioperative. An overall assessment of the patient all together determine the postoperative need of analgesic. The perioperative dialogue is a method which gives the nurse anaesthetic´s a sense of meaningfulness of the work and creates a perception of safety for the patient. The authors identified the absence of guidelines to make an individual overall assessment when managing postoperative pain. Aim: The aim of the study was to elucidate the nurse anaesthetic´s planning, implement and evaluate postoperative analgesic during total anaesthesia along the time-phases pre-, intra and postoperative and the impact of the perioperative dialogue. Method: A qualitative study was conducted with ten semistructured interviews. A qualitative content analysis was made with an inductive approach. Result: The result is presented in four head categories and eleven sub-categories that illuminate the informants’ experiences. Preoperative undertakings - Feeling responsibility for planning, Create a care-relation, Respect the patients emotional state. Intraoperative steps – Constant evaluation of treatment, Adapt the treatment continuously, Independent responsibility. Postoperative expectations – trying to obtain feedback, Avoid outbreak of pain. Perioperative organizational aspects – Adjustment along work situation, Absence of the perioperative dialogue.    Conclusion: The postoperative pain management is a complex matter that demand consideration of several aspects to achieve a good outcome. The perioperative dialogue is not prioritised. There is a lack of consensus among nurse anaesthetic´s managing postoperative pain. Developing and increasing cooperation along the entire chain of care is necessary to manage the issue of postoperative pain.

Einleitung: Für die Messung der "Narkosetiefe" werden vorwiegend Parameter des Elektroenzephalogramms (EEG) untersucht, welche offenbar keine Aussage zur Unterdrückung von Bewegungen auf Schmerzreize treffen können. Dies ist auch wenig verwunderlich, da Untersuchungen an Tieren die Ausschaltung einer Bewegung auf Schmerzreiz durch Anästhetika auf der spinalen Ebene erwarten lassen. Der spinale H-Reflex, ein elektrisch ausgelöster, monosynaptischer Reflex, wurde bereits zur Überwachung der Unterdrückung von Bewegungen während der Narkose vorgeschlagen. Diese Arbeit diente der vergleichenden Untersuchung der H-Reflex-Amplitude mit EEG-Parametern unter Sevofluran-Narkosen. Es wurden Konzentrations-Wirkungs-Kurven ermittelt, sowie die Eignung als Parameter zur Vorhersage von Bewegungen auf schmerzhafte Reize überprüft. Weiterhin sollte der Effekt des schmerzhaften Reizes auf die H-Reflex-Amplitude selbst aufgeklärt werden. Methodik: Nach Zustimmung der Ethikkommission und schriftlicher Einwilligung wurden 28 Patientinnen in die Studie eingeschlossen. Sie wurden präoperativ untersucht. Nach anfänglicher Vertiefung bis zur Toleranz einer Larynxmaske, wurde die Narkose mit Hilfe der "up-and-down"-Methode auf einen Wert nahe der minimalen alveolären Konzentration (MAC) eingestellt. Nach mindestens 15 Minuten konstanter Konzentration wurde von einem "steady-state" ausgegangen und am volaren Unterarm ein elektrisch ausgelöster Schmerzreiz (Tetanus-Reiz, 60 mA) appliziert. Für die Ermittlung der Konzentrations-Wirkungs-Kurve diente ein pharmakokinetisch-pharmadynamisches Modell, welches auf einem sigmoidalen Emax-Modell beruht. Die Eignung eine Bewegung vorherzusagen wurde anhand der "Prediction Probability" (PK-Wert) überprüft. Ergebnisse: Bei 14 Patientinnen konnte der H-Reflex kontinuierlich über die gesamte Messperiode ausgelöst werden. Die Wachwerte betrugen für die H-Reflex-Amplituden 6,5 (+/- 4,1 SD) mV. Sevofluran unterdrückt die H-Reflex-Amplituden konzentrationsabhängig. Die Unterdrückung konnte gut durch das sigmoidale Modell dargestellt werden (Median - r^2 = 0,96). Die Unterdrückung der H-Reflex-Amplitude unterliegt einer signifikant steileren Konzentrations-Wirkungs-Beziehung als die der EEG-Parameter spektrale Eckfrequenz 95 (SEF95) und bispektraler Index (BIS). Die H-Reflex-Amplitude konnte Bewegungen auf einen Schmerzreiz mit einer PK von 0,74 vorhersagen, während mittels der EEG-Parameter SEF95 und BIS lediglich zufällige Aussagen bezüglich stattfindender Bewegungen getroffen werden können. Der Schmerzreiz veränderte die H-Reflex-Amplitude, das spontane frontale Elektromyogramm und die Herzfrequenz, nicht jedoch die kortikal abgeleiteten Parameter BIS und SEF95. Schlussfolgerung: Aus dieser Arbeit ergeben sich Hinweise, dass die Unterdrückung von Bewegungen auf schmerzhafte Reize und die Unterdrückung der H-Reflex-Amplitude durch Sevofluran eng verknüpft sind. Auch wenn kein kausaler Zusammenhang besteht, so würde dies die hohe Vorhersagekraft der H-Reflex-Amplituden für Bewegungen auf Schmerzreiz erklären. Sie ist zur Überwachung der Unterdrückung von groben gezielten Bewegungen während einer Narkose geeignet. Mittels H-Reflex-Amplituden können Aktivierungen des Rückenmarkes registriert werden, welche auf kortikaler Ebene nicht sichtbar werden. Zukünftige auf dem H-Reflex basierende Studien können weitere Einsichten in die Mechanismen der Anästhesie liefern und behilflich an der Erarbeitung von Richtlinien zur optimalen Medikamentendosierung sein. / Introduction: The measurement of "depth of anesthesia" is mostly done by parameters of the electroencephalogram (EEG), which can not make a statement about the suppression of movement due to painful stimulation. This is not surprising, looking at recent animal studies that assume the anesthetic induced unresponsiveness to noxious stimulation at the side of the spinal cord. The spinal H-reflex, an electric induced, monosynaptical reflex has been proposed to monitor the suppression of movements during anesthesia. This dissertation shows a comparative examination of the H-reflex-amplitude and parameters of the EEG under anesthesia with sevoflurane. Concentration-response functions have been determined, the prediction of movement to painful stimulation has been tested. Also the effect of the painful stimulus itself on the H-reflex-amplitude has been discovered. Methods: After approval of the institutional review board and informed consent were obtained, 28 patients were included into this study. The examination has been done prior to surgery. After induction of anesthesia until a laryngeal mask was tolerated, sevoflurane was decreased to a level close to minimum alveolar concentration (MAC) using the "up-and-down" method. After at least 15 minutes of constant sevoflurane concentration a "steady-state" was assumed and a painful electrical stimulation (tetanic stimulus of 60mA) was applied. The concentration-response functions were determined using pharmacokinetic and pharmacodynamic modeling, based on a sigmoid Emax model. To estimate and compare the predictive value of the parameters, prediction probability Pk was calculated. Results: On 14 patients the H-reflex could been measured continuously throughout the study period. At awake level, H-reflexes had a mean amplitude of 6,5 (+/- 4,1 SD) mV. Sevoflurane depresses the H-reflex-amplitude in a concentration dependent way, which was well modeled by the sigmoid Emax model (median r^2 = 0,96). The depression of the H-reflex-amplitude underlies a significant steeper concentration-response function as the EEG-parameters spectral edge frequency (SEF95) and bispectral index (BIS). H-reflex-amplitude could predict movement on to painful stimulation with a Pk value of 0,74, whereas EEG-parameters could only make statements, concering upcoming movements, by chance. The painful stimulation changed H-reflex-amplitude, frontal recorded electromyogram and heart-frequency but not the cortical recorded parameters BIS and SEF95. Conclusions: Results indicate that the suppression of movement and the suppression of the H-reflex-amplitude caused by sevoflurane are close connected. Although it does not imply a causual connection, it would explain the high predictive value of the H-reflex-amplitude for motor responses to noxious stimuli. H-reflex-amplitude can be used to monitor the suppression of gross purposeful movements during sevoflurane anesthesia. Using H-reflex-amplitude spinal activation can be registered, which are not seen on cortical level. Coming up studies based on the H-reflex can help to get more insights into the mechanisms of anesthesia and help to develop guidelines for optimal drug dosing.