Agents and Actions

, Volume 36, Supplement 2, pp C213–C218 | Cite as

Problem solving strategies with biomedical and clinimetric components: The case of perioperative H1-+H2-prophylaxis

  • W. Lorenz
  • B. Stinner
  • W. Dietz
  • M. Koller
  • M. Rothmund
  • W. Dick
Plenary Lecture Symposium on Histamine and Antihistamine in Anaesthesia and Surgery (iii) Prophylaxis and Treatment of Histamine-Involved Anaphylactoid Reactions in Anaesthesia and Surgery


A formal (objective) problem solving strategy was developed for the question whether a perioperative histamine H1-+H2-prophylaxis should be applied to patients at risk for a histamine release reaction or for a special severity of such a reaction even in the case of a minor histamine release.

The problem solving strategy followed a four-step procedure: defining the problem, gathering information, stepwise decision making by means of a heuristic decision tree and a selection of biomedical and clinimetric trials for answering the questions in this decision tree and finally drawing conclusions.

An antihistamine H1-+H2-propylaxis was rationally, not definitely recommended for patients at risk (previous reactions to i.v. agents, atopy, multimorbidity or age >70 years) on the basis of drawing conclusions after passing stepwise the heuristic decision tree. Definitive answers can be expected from two randomized trials in Mainz and Frankfurt, the conduct of which is finished and which are at present in the phase of data analysis. They investigate the effectiveness of the H1-+H2-prophylaxis in high risk patients as identified in our problem solving strategy.


Data Analysis High Risk Histamine Decision Tree High Risk Patient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. [1]
    T. S. Kuhn, The structure of scientific revolutions, pp. 1–210, University of Chicago Press, Chicago 1962.Google Scholar
  2. [2]
    W. Lorenz,Hypersensitivity reactions induced by anaesthetic drugs and plasma substitutes: Influence of paradigms on incidence and mechanisms. InImmunotoxicology (Ed. G. G. Gibson, R. Hubbard and D. V. Parke), pp. 283–305, Academic Press, London 1983.Google Scholar
  3. [3]
    W. Lorenz, M. Ennis, A. Doenicke and W. Dick,Perioperative uses of histamine antagonists. J. Clin. Anesth.2, 345–360 (1990).CrossRefPubMedGoogle Scholar
  4. [4]
    A. S. Elstein, L. S. Shulman and S. A. Sprafka,Medical Problem Solving. Evaluation & The Health Professions13, 3–34 (1990).Google Scholar
  5. [5]
    W. Lorenz, R. Gross and M. Rothmund,Is clinical intuition a useful, practical term or a conglomeration of informal (soft) thinking and decision making? Discussion (not a reply) about the hypothesis: intuition in surgery as a strategy of medical decision making. Theor. Surg.6, 108–109 (1990).Google Scholar
  6. [6]
    E. Neugebauer, W. Lorenz, W. Oettinger, D. B. Carr, L. B. Hinshaw, J. P. Green, T. C. Chalmers, J. Hilden und H. R. Wulff,Discussion about an example of meta-analysis in basic surgical research: The role of mediators in septic/endotoxic shock. Theor. Surg.4, 79–105 (1989).Google Scholar
  7. [7]
    G. Jameson,Definitions: data, facts, information, knowledge, artificial intelligence, expert systems. Theor. Surg.5, 97–98 (1990).Google Scholar
  8. [8]
    B. Kleinmuntz, Formal representation of human judgement, pp. 149–186, John Wiley & Sons, New York, London, Sydney 1968.Google Scholar
  9. [9]
    L. B. Lusted, Introduction to medical decision making, pp. 70–175, Charles C. Thomas, Springfield USA 1968.Google Scholar

References in the metaanalysis indicated by a specific prefix (m 1, m 2 ... etc)

  1. [m 1]
    D. Duda, H. Menke, W. Lorenz, M. S. Rugelis, B. Stinner, D. Weber, B. Kapp, Th. Junginger and W. Dick,Histamine release during induction of anaesthesia and preparation for operation in patients undergoing general surgery: incidence and clinically severe cases. Agents and Actions (in press).Google Scholar
  2. [m 2]
    J. Sattler, W. Lorenz, D. Schröder, A. Klingler, J. Klag, K. Glaser and R. Dennhard,Histamine release in the course of elective conventional cholecystectomy in aged patients: problems in defining release in relation to specific intraoperative events. Agents and Actions (in press).Google Scholar
  3. [m 3]
    F. W. Ahnefeld, A. Doenicke and W. Lorenz,Histamine and antihistamines in anaesthesia and surgery. Klin. Wochenschrift.60, 871–1062 (1982).CrossRefGoogle Scholar
  4. [m 4]
    M. C. Laxenaire,Prévention des réactions anaphylactoides peranesthésiques. Ann. Fr. Anaesth. Reanim.4, 99–244 (1985).Google Scholar
  5. [m 5]
    M. C. Laxenaire and D. A. Moneret-Vautrin, Le risque allergique en anesthésie-réanimation, pp. 1–151, Masson, Paris 1990.Google Scholar
  6. [m 6]
    J. Watkins and C. J. Levy, Guide to immediate anaesthetic reactions, pp. 1–128, Butterworths, London 1988.Google Scholar
  7. [m 7]
    W. Dietz, H. Lennartz, I. Köpf, A. Schmal, U. Kaiser and W. Lorenz,Lebensbedrohliche anaphylaktoide Reaktionen im perioperativen Zeitraum: Blockade durch Histamine H 1-+H 2-Antagonisten oder Methylprednisolon? Langenbecks Arch. Chir. Suppl. Chir. Forum 333–337 (1987).Google Scholar
  8. [m 8]
    W. Lorenz, A. Doenicke, K. Messmer, H.-J. Reiman, M. Thermann, W. Lahn, J. Berr, A. Schmal, P. Dormann, P. Regenfuss and H. Hamelmann,Histamine release in human subjects by modified gelatin (Haemaccel (R)) and dextran: An explanation for anaphylactoid reactions observed under clinical conditions? Brit. J. Anaesth.48, 151–165 (1976).PubMedGoogle Scholar
  9. [m 9]
    A. Doenicke, M. Ennis, and W. Lorenz,Histamine release in anaesthesia and surgery: a systematic approach to risk in the perioperative period. InAnaphylactoid Reactions in Anesthesia. International Anesthesiology Clinics, vol. 23 (Ed. D. J. Sage), pp. 41–66, 1985.Google Scholar
  10. [m 10]
    J. Moss, M. F. Roizen, E. J. Nordby, R. Thisted, J. L. Apfelbaum and D. J. McDermott,Decreased incidence and mortality of anaphylaxis to chymopapain. Anesth. Analg.64, 1197–1201 (1985).PubMedGoogle Scholar
  11. [m 11]
    V. V. Kakkar and M. D. Stringer,Prophylaxis of venous thromboembolism. World J. Surg.14, 670–678 (1990).CrossRefPubMedGoogle Scholar
  12. [m 12]
    J. Kusche and C.-D. Stahlknecht,Antibioticaprophylaxe bei colorectalen Operationen: Gibt es ein Mittel der Wahl? Chirurg52, 577–585 (1981).PubMedGoogle Scholar
  13. [m 13]
    W. Lorenz, M. Fischer, E. Neugebauer and H. Rohde,Akute gastroduodenale Läsionen: Gedanken über eine Begleiterkrankung verschiedener pathophysiologischer Zustände und Streßsituationen. InMagen und Magenkrankheiten, (Ed. W. Domschke and K. G. Wormsley) pp. 123–130, Georg Thieme, Stuttgart 1981.Google Scholar
  14. [m 14]
    M. Tryba,Der Einfluß präventiver Maßnahmen auf Morbidität und Mortalität von Intensivpatienten. InDer Gastrointestinaltrakt als Quelle systemischer Infektionen. Anästhesiologie und Intensivmedizin Suppl.I (Ed. M. Tryba) pp. 42–53, Perimed, Erlangen 1991.Google Scholar
  15. [m 15]
    W. Lorenz and M. Rothmund,Grundlagen der Technologiebewertung in der chirurgischen Diagnostik. Langenbecks Arch. Chir. Suppl.II, 369–376 (1988).Google Scholar
  16. [m 16]
    W. Lorenz and A. Doenicke,Histamine release in clinical conditions. Mount Sinai J. Med.45, 357–386 (1978).Google Scholar
  17. [m 17]
    R. D. Hull, J. Hirsh, D. L. Sackett and G. L. Stoddart,Cost-effectiveness of primary and secondary prevention of fatal pulmonary embolish in high-risk surgical patients. CMA J.127, 990–995 (1982).Google Scholar

Copyright information

© Birkhäuser Verlag 1992

Authors and Affiliations

  • W. Lorenz
    • 1
  • B. Stinner
    • 2
  • W. Dietz
    • 2
  • M. Koller
    • 1
  • M. Rothmund
    • 2
  • W. Dick
    • 3
  1. 1.Institute of Theoretical SurgeryUniversity of MarburgGermany
  2. 2.Department of Surgery, Centre of Operative Medicine 1University of MarburgGermany
  3. 3.Department of AnaesthesiologyUniversity of MainzGermany

Personalised recommendations