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Patients with central apnoea may use electro ventilation, provided their phrenic nerves and diaphragm muscles are normal. A tendency towards better survival has been found, and both an improved quality of life and facilitated nursing have been claimed with electro ventilation compared to mechanical ventilation. The high investment for the device may form a hurdle for fund providers like our hospital administration board. We, therefore, from our first patient onwards, collected clinically meaningful data in a special register of all patients using electro ventilation and their controls on mechanical ventilation. Since 1988 172 patients left our institution dependent on a respiratory device. Of these, all 48 patients with preserved phrenic nerves chose phrenic nerve stimulation. A patient on mechanical ventilation who agreed to participate was chosen as a control (n = 44). All patients were seen at least once a year. 90 patients suffered high tetraplegia, and 2 suffered central apnoea for other reasons. There is a tendency towards better survival, and there is a lower frequency of decubital ulcers (0.02) and respiratory tract infections (p0.000) with electro than with mechanical ventilation. The frequency of respiratory infections turned out to be a better measure of the quality of respiratory care than survival. The resulting decrease in the need for airway nursing, and the reduced incidence of respiratory infections repaid the high investment in electro ventilation within one year in our setting. Informed patients prefer electro to mechanical ventilation; fund providers might also agree with this preference.

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Traumatic spinal cord injury is most common among men between 16 and 30 years. Prevention should be targeted both on traffic safety and individual behaviour Key issues in patient care are safe transfer from the place of injury to a hospital, diagnostic imaging (primarily CT, MRI if needed) and assessment of neurological injury by AIS-questionnaire, early surgical decompression and stabilisation for most cases, and treatment and rehabilitation starting from the emergency room and extending to life-long care carried out by a multi-professional team.

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BACKGROUND: Stability of threshold currents during long-term use of phrenic nerve stimulation has been questioned. METHODS AND RESULTS: Between January 5, 1988, and March 5, 2008, 49 patients with functional C2-tetraplegia received an Atrostim PNS (Atrotech Ltd., Tampere, Finland) as treatment of their respiratory insufficiency; a follow-up of 35 of such patients was carried out exclusively in our institution for 6.3 (4.44) 0.04-15.75 years (mean [standard deviation (SD)] range). The device employed four-pole sequential nerve stimulation, which provided four threshold currents subsequently evaluated for each phrenic nerve. Stimulation data were prospectively recorded. The differences between threshold currents recorded 1 year after implantation and the last recorded values were 0.33-0.43 (0.44-0.63) 0-2.9 mA. After having excluded the data of eight patients with values >1 mA (= mean + SD), we registered the differences for the remaining patients of 0.15-0.24 (0.14-0.24) 0-0.95 mA, which is just twice the adjustment accuracy of the device. Out of the eight problem cases one had, and two were suspected to have, surgical trauma; all three nerves recovered. In two cases the values steadily increasing over years might have been caused by unspecific foreign body reaction. Two cases with values >1 mA for different durations at different electrodes might be caused by biofilm, and one patient displaying steadily increasing values lived, unwilling to live, only 2 years after the implantation. CONCLUSION: Thus, there was no permanent nerve injury and in 77% of the presented cases threshold currents remained stable.

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BACKGROUND: No simple method exists to distinguish children in need for premedication. The present study was planned to detect preoperative anxiety levels of children by rating their drawings. METHODS: Sixty ASA I children aged 4-7 years undergoing adenoidectomy were divided into AGIT and CALM groups according to agitation level observed during venous cannulation. All children drew a picture at three different times: (i) just after arrival in the day-case unit, (ii) 10 min before operation and, (iii) prior to leaving for home. The children were also randomized to three premedication groups: group D, rectal diazepam 0.5 mg x kg(-1); group P, 0.9% NaCl 0.1 ml x kg(-1) rectally; group NT, no premedication. Five features (size of the drawing, form of the drawing line, colors used, mark of the pen and clarity of the picture) from the children's drawings were rated with a 3-point scale. The ratings of each feature were made to form a sum score of anxiety ranging from 0 to 10. In the analysis of variance for repeated measures both the premedication group and agitation score were taken into the model as factors. RESULTS: The anxiety score of the drawings of the agitated children (during venous cannulation) was significantly higher already after arrival in the hospital [AGIT 4.76 (95% CI: 3.56-5.96) Vs CALM 3.67 (95% CI: 2.97-4.37) P = 0.029], but there were no statistical differences between the different premedication groups. CONCLUSIONS: When routine sedative premedication is not used the drawings of the children might detect the children needing sedative premedication.

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UNLABELLED: The electroencephalographic burst suppression pattern (BSP) might indicate the brain's effect-site concentration of anesthetics more precisely than clinical signs and thus eliminate bias from studies on the reaction to tracheal intubation after different induction drugs. To test this hypothesis, we compared the catecholamine and cardiovascular responses and their variances to tracheal intubation when either BSP was induced by infusion of propofol (30 mg x kg(-1) x h(-1); n = 14) or thiopental (75 mg x kg(-1) x h(-1); n = 14) or anesthesia by repeated bolus doses until loss of reflexes (LR), initially of propofol 2.5 mg/kg (n = 15) or thiopental 5 mg/kg (n = 15). The standard deviations were more often smaller in the BSP than in the LR groups, but the results of Levene's test for differences of variance were insignificant. At the LR level, propofol attenuated catecholamine, arterial blood pressure, and heart rate responses to intubation better than thiopental, but at the BSP level, only the norepinephrine response was better attenuated. Cp50 concentrations of propofol and thiopental at the onset of BSP were 9.65 and 31.60 micro g/mL, respectively. IMPLICATIONS: Our results did not support the hypothesis that the responses to tracheal intubation can be more accurately predicted when unconsciousness is controlled with the aid of an electroencephalographic burst suppression pattern. Significant differences were found in the reactions between propofol and thiopental. At the burst suppression level, the catecholamine response was abolished with propofol.

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The clinical effectiveness of locally administered opioids is still under discussion; in particular, the potency of morphine in settings other than intra-articular arthroscopy has been questioned. We developed another pain model, postpartum resection of the fallopian tubes for sterilisation, in which each patient serves as her own control when one side is infiltrated with the active drug (in this study sufentanil 5 mg) and the contralateral side with normal saline. In the control group both sides are infiltrated with plain saline. After 30 min from the end of anaesthesia onwards, 26 out of 30 patients observed significant pain relief on the side of the sufentanil infiltration, which in 11 patients lasted until the end of the observation period 24 h postoperatively; no difference was observed in the control group. In our pain model with a high assay sensitivity, the infiltration of one side with the lipophilic test drug, sufentanil, caused local analgesia in primarily non-inflamed tissue. The use of each patient as her own control excluded inter-subject bias.

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