Hyperoxic cardiopulmonary bypass during cardiac operations in adults results in oxidative myocardial damage related to oxygen-derived free radicals and nitric oxide. These adverse effects can be markedly limited by reduced oxygen tension management. The concept of normoxic cardiopulmonary bypass may be applied to surgical advantage during cardiac operations.

Acetaminophen is widely used prophylactically for postoperative analgesia in children and is thought to have an opioid-sparing effect. We showed that rectal acetaminophen up to 40 mg/kg administered at anesthesia induction lacked proof of efficacy, whereas IV opioid boluses resulted in reliable pain relief in children undergoing cleft palate repair.

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These data demonstrate the feasibility and safety of various surgical coronary revascularization techniques without general anesthesia. Continuation of thoracic epidural analgesia provides good pain control and fast mobilization postoperatively. Surprisingly, the awake coronary artery bypass grafting procedure was well accepted by the patients.

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The last survey addressing postoperative pain management in Germany was published in 1987, special data concerning postoperative pain management in pediatric patients had not been presented previously. The goal of this survey is to present the standard of postoperative pain management in pediatric patients in Germany. A detailed questionnaire was mailed to all German anaesthesia departments and interdisciplinary intensive care units (n = 1,500) to determine the current management of postoperative pain management in pediatric patients. After eight weeks, 42.6% of the survey had been returned. Rectally administered acetaminophen is the standard drug regimen for postoperative analgesia in children. Compared to previous surveys, the use of opioids has increased in popularity. The routine use of non-steroid antiinflammatory drugs (NSAIDs) and spasmolytics as well as the application of regional anaesthesia techniques is uncommon in pediatric postoperative pain management. Compared to other European countries, patient- or parent-controlled analgesia is more popular in Germany. Despite modern concepts of organization and a great variety of drugs available today, 71.1% of the responding anesthesiologists in this survey still believe that pediatric postoperative pain management needs to be improved.

Our combination of remifentanil and propofol was shown to be a safe sedation regimen for fiberoptic intubation. Monitoring ventilation via nasal capnography and arterial oxygen saturation via pulse oximetry provided sufficient patient safety.

Recent developments in coronary artery bypass graft surgery (CABG) without cardiopulmonary bypass made the sole use of high thoracic epidural anesthesia (TEA) in conscious patients feasible. Previously, TEA has been reported only for single-vessel CABG via lateral thoracotomy. We investigated the feasibility and complications of sole TEA in 20 patients undergoing beating-heart arterial revascularization via partial lower sternotomy for single-vessel disease (minimally invasive direct coronary artery bypass grafting [MIDCAB] technique; n = 10) or complete median sternotomy for multivessel disease (off-pump coronary artery bypass grafting [OPCAB] technique; n = 10). An epidural catheter was inserted at the T1-2 or T2-3 interspace. An epidural infusion of ropivacaine 0.5% and sufentanil 1.66 micro g/mL was started to establish anesthetic levels at C5-6 for OPCAB and at T1-2 for MIDCAB. Nine OPCAB and eight MIDCAB procedures were completed while patients were awake and spontaneously breathing during the entire procedure. Because of surgical pneumothorax (OPCAB), insufficient anesthesia, or phrenic nerve palsy (both MIDCAB), three patients required intraoperative conversion to general anesthesia. The heart rate decreased significantly (P < 0.05) by 10%-15% in both groups during the procedure. Compared with baseline (B), mean arterial blood pressure (mm Hg) was decreased significantly only during coronary anastomosis (CA) (B(OPCAB), 95 +/- 11; CA(OPCAB), 68 +/- 9; B(MIDCAB), 86 +/- 10; CA(MIDCAB), 73 +/- 10; P not significant between groups). PaCO(2) increased from 42 +/- 2 mm Hg to 46 +/- 7 mm Hg (P < 0.05) throughout the perioperative course during OPCAB, whereas it remained almost unaltered during MIDCAB procedures. All patients rated TEA as "good" or "excellent." In conclusion, we demonstrated that the sole use of TEA for MIDCAB and OPCAB procedures was feasible and provided a high degree of patient satisfaction in our small and highly selected cohorts. IMPLICATIONS. The sole use of high thoracic epidural anesthesia was studied in 20 patients who underwent beating-heart coronary artery bypass grafting using either median or partial lower sternotomy while awake.