Preoperative portal vein or portal and hepatic vein embolization: DRAGON collaborative group analysis.

BACKGROUND: The extent of liver resection for tumours is limited by the expected functional reserve of the future liver remnant (FRL), so hypertrophy may be induced by portal vein embolization (PVE), taking 6 weeks or longer for growth. This study assessed the hypothesis that simultaneous embolization of portal and hepatic veins (PVE/HVE) accelerates hypertrophy and improves resectability. METHODS: All centres of the international DRAGON trials study collaborative were asked to provide data on patients who had PVE/HVE or PVE on 2016-2019 (more than 5 PVE/HVE procedures was a requirement). Liver volumetry was performed using OsiriX MD software. Multivariable analysis was performed for the endpoints of resectability rate, FLR hypertrophy and major complications using receiver operating characteristic (ROC) statistics, regression, and Kaplan-Meier analysis. RESULTS: In total, 39 patients had undergone PVE/HVE and 160 had PVE alone. The PVE/HVE group had better hypertrophy than the PVE group (59 versus 48 per cent respectively; P = 0.020) and resectability (90 versus 68 per cent; P = 0.007). Major complications (26 versus 34 per cent; P = 0.550) and 90-day mortality (3 versus 16 per cent respectively, P = 0.065) were comparable. Multivariable analysis confirmed that these effects were independent of confounders. CONCLUSION: PVE/HVE achieved better FLR hypertrophy and resectability than PVE in this collaborative experience.

[Patient-centered perioperative vigilance: perioperative process quality, effectiveness of pain treatment and mobilization progress after implementation of a treatment bundle for total knee endoprosthesis]. / Patient*innenzentrierte perioperative Versorgung: perioperative Prozessqualität, Effektivität von Schmerztherapie und Mobilisationsfortschritt nach Implementation eines Maßnahmenbündels bei Knietotalendoprothese.

BACKGROUND: The perioperative surgical home is a patient-centered, team-based model of care developed in the USA to coordinate diagnosis, treatment and follow-up; however, due to different healthcare systems, scientific findings in the USA cannot be simply transferred to Germany. OBJECTIVE: This preliminary study was carried out to evaluate the effects of a new interdisciplinary treatment bundle (patient-centered perioperative vigilance, PPV) in a German university hospital. MATERIAL AND METHODS: After IRB approval and written informed consent, 34 patients (PPV group) undergoing elective endoprosthetic surgery were enrolled after introduction of the PPV bundle (1. preoperative patient education, 2. specific surgical technique, 3. specific anesthesia technique, 4. start of mobilization on day of operation) and compared to historic matched pairs (HMP) for age cohort, ASA-PS, body mass index, and sex. We hypothesized that PPV shortens induction time (primary outcome). Secondary outcomes were length of hospital stay (LOS), resting pain and pain with movement on postoperative day 1 and mobilization progress on postoperative days 1, 3 and 6. Groups were compared with Wilcoxon-Mann-Whitney test for noninferiority. In the case of noninferiority, a Wilcoxon-Whitney-Mann test for superiority was additionally applied. RESULTS: The median anesthesia induction time was 13.5 min for PPV and 60 min for HMP (p < 0.0001). The LOS was 8 days for PPV and 12 days for HMP (p < 0.0001). Resting pain on postoperative day 1 was 20 for PPV (30 for HMP). Pain with movement was identical (median 40). Mobilization progress was better for PPV on days 1, 3 and 6 (p < 0.0001 for each day). CONCLUSION: The concept of patient-centered perioperative vigilance (PPV) shortens induction time and hospital length of stay. Mobilization improves with PPV on day 1. Higher pain scores in PPV seem to be clinically insignificant, which warrants further study.

Impact of inhalation vs. intravenous anaesthesia on autonomic nerves and internal anal sphincter tone.

BACKGROUND: Pelvic intraoperative neuromonitoring (pIONM) aims to identify and spare the autonomic nerves and maintain patients' quality of life. The effect of anaesthetic agents on the pIONM signal is unknown; therefore, the aim of the present study was to compare the influences of inhalation anaesthesia (IA) and total intravenous anaesthesia (TIVA). METHODS: Twenty rectal cancer patients undergoing open nerve-sparing total mesorectal excision (TME) were assigned to pIONM under either IA or TIVA (n = 10 per group). IA was maintained with sevoflurane and TIVA with propofol. During surgery, pelvic autonomic nerves were electrically stimulated under electromyography (EMG) of the internal anal sphincter (IAS). These triggered EMG signals were analysed. RESULTS: The absolute EMG amplitude during pIONM increased to 1.20 µV (interquartile range (IQR): 0.94-1.6) for IA and 1.49 µV (IQR: 0.84-2.75) for TIVA (P = 0.002). The relative EMG amplitude increase also was significantly lower for IA (0.59; IQR: 0.30-0.81; TIVA: 0.99; IQR: 0.62-2.5), (P = 0.001). CONCLUSIONS: This is the first study to compare the influences of IA and TIVA on the autonomic nervous system. While both anaesthetic regimens proved useful for pIONM, TIVA with propofol may provide better signal quality than IA with sevoflurane.

[Minimally invasive abdominothoracic esophagus resection by transoral esophagogastrostomy: interdisciplinary challenge]. / Minimalinvasive abdominothorakale Ösophagusresektion mit transoraler Ösophagogastrostomie : Interdisziplinäre Herausforderung.

BACKGROUND: Resection of the esophagus is an invasive 2-cavitiy procedure which requires special anesthesiological expertise during perioperative care. Furthermore, in surgery new minimally invasive techniques are continually being established which place special challenges on the treatment team because the anesthesiologist is decisively involved in the course of surgery. AIM: The aim of this article is to present the development of surgical treatment options for esophageal cancer starting from classical open resection up to the minimally invasive technique of esophagectomy (MIE). Previous experience with MIE on a cohort of patients is presented and the special anesthesiological characteristics of this innovative technique are illustrated. MATERIAL AND METHODS: In the department for general, visceral and transplantation surgery of the University Medical Center of Mainz, minimally invasive abdominothoracic esophageal resection has been carried out since 2010. High thoracic anastomization was performed using the EEA™-OrVil™ system operated by the anesthesiologist. Currently 17 highly selected patients have been surgically treated using this technique. RESULTS: Esophagogastric anastomosis with the EEA™-OrVil™ system was feasible in all patients. Transoral introduction of the gastric probe with the connecting sheath and the angled anvil led to minor dislocation of the double lumen tube in only one patient and could immediately be corrected. Further intraoperative complications did not occur. Four of the 17 patients developed pneumonia which could be controlled by intravenous antibiotics. None of the patients had to be reintubated. One patient developed gastric tube necrosis and died 51 days postoperatively due to massive intracerebral hemorrhage. There were no complications of anastomoses following OrVil™ anastomization. In all patients an R0 resection could be achieved. CONCLUSION: Minimally invasive esophagectomy with transoral anastomization appears to be an enrichment of the minimally invasive spectrum as interdisciplinary cooperation leads to reduced operation time and a more efficient process of anastomization. This also results in decreased one-lung ventilation time which is directly correlated to postoperative pulmonary complications. In particular, the interdisciplinary character of this technique and the necessity for targeted communication proved to be of assistance also in other situations.

Performance of the C-MAC video laryngoscope in patients after a limited glottic view using Macintosh laryngoscopy.

We applied the C-MAC videolaryngoscope in 52 consecutive patients who were found to have an unexpected Cormack and Lehane grade-3 (n = 49) and grade-4 (n = 3) laryngeal view with the Macintosh laryngoscope. The glottic view improved in 49 (94%) patients using the C-MAC. Tracheal intubation was successful in 49 of 52 patients (94%). In one patient, tracheal intubation failed using the C-MAC despite the presence of a Cormack and Lehane grade-2. These results suggest that the C-MAC videolaryngoscope has a role as a rescue device in cases of an initially difficult laryngeal view.

Evaluation of the McGrath Series 5 videolaryngoscope after failed direct laryngoscopy.

SUMMARY: Unanticipated difficulties during tracheal intubation and failure to intubate are among the leading causes of anaesthesia-related morbidity and mortality. Using the technique of video laryngoscopy, the alignment of the oral and pharyngeal axes to facilitate tracheal intubation is unnecessary. In this study we evaluated the McGrath Series 5 videolaryngoscope for tracheal intubation in 61 patients who exhibited Cormack and Lehane grade 3 or 4 laryngoscopies with a Macintosh laryngoscope. Using the McGrath resulted in an improved glottic view, compared to Macintosh laryngoscope. Laryngoscopy was improved by one grade in 10%, by two grades in 80% and by three grades in 10% of cases (p < 0.0001). The success rate for intubation was 95% with the McGrath. These results suggest that the McGrath videolaryngoscope can be used with a high success rate to facilitate tracheal intubation in difficult intubation situations.

[Incidence of infection from catheter procedures for regional anesthesia: first results from the network of DGAI and BDA]. / Infektionsinzidenz von Katheterverfahren zur Regionalanästhesie : Erste Ergebnisse aus dem Netzwerk von DGAI und BDA.

BACKGROUND: To analyze safety issues of regional anaesthesia and analgesia in Germany only a few single center studies are available. Therefore, the German Society for Anaesthesiology and Intensive Care Medicine (Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) and the Professional Association of German Anaesthetists (Berufsverband Deutscher Anästhesisten, BDA) initiated a network for safety in regional anaesthesia. From this the first results on infectious complications will be reported. MATERIALS AND METHODS: In a Delphi process the documentation of the setup and maintenance of regional anaesthesia and analgesia was agreed with the participants in a working group from the DGAI. After approval by the officially authorized representative for patient data privacy protection a registry was programmed to collect anonymous data. Up to October 2008 data from 6 centers could be analyzed. RESULTS: After testing for plausibility 8,781 regional anaesthesia procedures (22,112 catheter days) could be analyzed. The 5,057 neuraxial and 3,724 peripheral catheter-based procedures were in place for a median of 2.48 days (range 1.0-3.0 days) and 4 severe, 15 moderate and 128 mild infections were recorded. Diabetics were not found to show a statistically significant increase in risk (2.6% compared to 1.9% for non-diabetics: n.s.). Neuraxial procedures seem to have a higher rate of infections than peripheral procedures (2.7% vs. 1.3%, p<0.0001). Multiple punctures of the skin also seem to be associated with a higher infection rate than single skin punctures (4.1% vs. 1.6%, p<0.0001). CONCLUSIONS: Infectious complications of catheter-based regional anaesthesia are common. Strict hygienic standards must therefore be complied with. More data are necessary to calculate risk factors. The registry provided can also be used as a benchmark to reduce these rates further.

Intraoperative tramadol reduces shivering but not pain after remifentanil-isoflurane general anaesthesia. A placebo-controlled, double-blind trial.

BACKGROUND AND OBJECTIVE: Postoperative shivering and pain are frequent problems in patients recovering from anaesthesia with particularly high incidences being observed after remifentanil-isoflurane-based general anaesthesia. The opioid tramadol is generally effective in preventing shivering and treating pain, but its effects are not characterized after remifentanil-based general anaesthesia. This randomized, placebo-controlled, double-blind study evaluated the effects of intraoperative intravenous tramadol on postoperative shivering and pain after remifentanil-based general anaesthesia. METHODS: After Ethics Committee approval, 60 patients scheduled for lumbar disc surgery were included. Surgery was performed under general anaesthesia (remifentanil, isoflurane). Patients were randomly assigned to receive 2 mg kg(-1) tramadol in 30 mL 0.9% saline infused intravenously (n = 30) or 30 mL saline (n = 30) 45-30 min before skin closure. The following parameters were assessed every 10 min for 2 h: shivering, pain, postoperative nausea and vomiting, sedation, heart rate, non-invasive blood pressure and peripheral oxygen saturation. The primary outcome variable was the incidence of shivering during the first 2 postoperative hours. Secondary variables were: shivering intensity, pain, postoperative nausea and vomiting, sedation, heart rate, non-invasive blood pressure and peripheral oxygen saturation. RESULTS: Shivering was less frequent in patients treated with tramadol (20% vs. 70%, P = 0.0009) and was of lower intensity (severe shivering: 10% vs. 46.7%, P = 0.003). Pain scores were similar between the groups and all other secondary outcome variables failed to reveal significant differences. CONCLUSIONS: Compared with placebo, intraoperative intravenous administration of 2 mg kg(-1) tramadol reduces the incidence and extent of postoperative shivering without alterations in pain perception after lumbar disc surgery under remifentanil-isoflurane-based general anaesthesia.

[Procedural analgesia : concepts and practice]. / Prozedurale Analgesie : Begriff und Praxis.

The effect of severe pain and its hazardous stress-related cardiocirculatory consequences have been well documented for the perisurgical setting. Independently of surgical intervention however, even short and simple measures (e.g. thorax drain removal, repositioning a limb fracture) and longer diagnostic procedures such as MRI are potentially very painful or stressful to the patient. Though longer diagnostic procedures are frequently supported by systemic medication, short interventions regularly lack this aspect. Specific challenges result from the need to counteract sometimes great changes in pain intensity. Moreover procedural analgesia represents a multidisciplinary measure not restricted to anaesthesiology, as most of these measures are performed without anaesthesia. To avoid endangering the patient, the choice of drugs and patient monitoring have to meet certain professional and technical standards. Competence in respiratory management is of paramount importance. This paper outlines these requirements and serves as an orientation outside the anaesthesiological speciality.

Establishing PNB-qPCR for quantifying minimal ctDNA concentrations during tumour resection.

The analysis of blood plasma or serum as a non-invasive alternative to tissue biopsies is a much-pursued goal in cancer research. Various methods and approaches have been presented to determine a patient's tumour status, chances of survival, and response to therapy from serum or plasma samples. We established PNB-qPCR (Pooled, Nested, WT-Blocking qPCR), a highly specific nested qPCR with various modifications to detect and quantify minute amounts of circulating tumour DNA (ctDNA) from very limited blood plasma samples. PNB-qPCR is a nested qPCR technique combining ARMS primers, blocking primers, LNA probes, and pooling of multiple first round products for sensitive quantification of the seven most frequent point mutations in KRAS exon 2. Using this approach, we were able to characterize ctDNA and total cell-free DNA (cfDNA) kinetics by selective amplification of KRAS mutated DNA fragments in the blood plasma over the course of tumour resection and the surrounding days. Whereas total cfDNA concentrations increased over the surgical and regenerative process, ctDNA levels showed a different scheme, rising only directly after tumour resection and about three days after the surgery. For the first time, we present insights into the impact of surgery on the release of ctDNA and total cfDNA.

[Drugs for postoperative analgesia: routine and new aspects. Part 1: non-opioids]. / Medikamente zur postoperativen Schmerztherapie: Bewährtes und Neues. Teil 1: Nichtopioide.

In part 1 of this review the perioperative aspects of the use of non-opioids (acetaminophen, dipyrone, traditional NSAR, coxibs) and in part 2 of opioids (weak opioids: tramadol, tilidine with naloxone, strong opioids: morphine, piritramide, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and coanalgesics (gabapentinoids, ketamine) will be discussed. The main aim is to describe the relationship between analgesic efficacy and side effects to make clinical decisions easier in patients with preoperative renal, gastrointestinal, cardiovascular and other diseases. Some new aspects concerning perioperative administration of gabapentinoids and ketamine in patients with perioperative neuropathic pain are discussed.

[Drugs for postoperative analgesia: routine and new aspects: Part 2: opioids, ketamine and gabapentinoids]. / Medikamente zur postoperativen schmerztherapie: bewährtes und neues : Teil 2: Opioide, ketamin und gabapentinoide.

In part 1 of this review, perioperative aspects of the use of non-opioids (acetaminophene, dipyrone, traditional NSAR, coxibs) were discussed. In part 2 the perioperative aspects of opioids (weak opioids: tramadol, tilidine with naloxone, strong opioids: morphine, piritramide, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and coanalgesics (gabapentinoids; ketamine) will now be presented. The main aim of the review is to describe the use, risks and cost of some substances to facilitate the differential indication. New aspects concerning the use of gabapentinoids and ketamine are discussed.

Epidural ropivacaine -- where are the benefits? A prospective, randomized, double-blind trial in patients with retropubic prostatectomy.

BACKGROUND: In comparison with bupivacaine, ropivacaine exhibits comparable anaesthetic effects but with less motor impairment and systemic toxicity. However, the analgesic potency may differ. For example, ropivacaine during obstetric epidural analgesia provides an approximately 40% lower analgesic potency than bupivacaine. Equal visual analogue pain scores require significantly higher dosages of ropivacaine, and general statements about a favourable benefit-risk profile relative to that of bupivacaine may therefore have limited clinical impact. We addressed this topic in a male pain model by evaluating the analgesic efficacy of epidural ropivacaine 0.2% vs. bupivacaine 0.125% after retropubic prostatectomy. METHODS: Forty patients scheduled for retropubic prostatectomy were randomly assigned to two groups (20 patients per group). In a double-blind prospective design, patient-controlled lumbar epidural analgesia was provided by ropivacaine 0.2% in the ropivacaine group and by bupivacaine 0.125% in the bupivacaine group. The primary endpoint was the total amount of local anaesthetic consumption. The secondary endpoints were the numeric rating scale scores for rest and dynamic pain and the degree of motor impairment. RESULTS: Ropivacaine consumption was 60% higher (mean +/- standard deviation, 1372.5 +/- 108.3 mg) than that of bupivacaine (852 +/- 75.2 mg) (P < 0.001). There were no significant differences in the numeric rating scale scores and motor impairment. CONCLUSIONS: In male patients, lumbar epidural administration of ropivacaine 0.2% after retropubic prostatectomy does not appear to provide benefits over bupivacaine 0.125%. Moreover, in view of the significantly higher drug requirements, general statements focusing on the favourable therapeutic index of ropivacaine may require critical analysis, at least during epidural administration.

Management of incomplete regional anaesthesia in Germany: results of a nation-wide survey.

BACKGROUND: Regional anaesthesia (RA) provides well-defined benefits with known attendant risks. However, incomplete blockade may introduce unanticipated risks depending on the compensatory measures employed. Until now, no data were available characterizing the pattern of response of German anaesthesiologists in this situation. This study analyses interventions in response to incomplete RA in a nation-wide setting. METHODS: A questionnaire was sent to every German anaesthesia department (n= 1381). Questions focused on interventions coping with an incomplete RA and differentiated between a pre- and a peri-surgical setting and measures to face pain outside the surgical field. If systemic supplementation was administered, we analysed the substances and characterized their influence on subsequent patient care. RESULTS: Six hundred and sixty-seven questionnaires were returned anonymously, representing a return rate of 48.3%. If RA was incomplete before surgery, 56.8% of anaesthesiologists repeated peripheral blocks, 48.5% repeated epidural (EDA) and 60.4% repeated spinal anaesthesia (SPA). 56.9% of clinicians preferred an early switch to general anesthesia (GA). If RA was incomplete during surgery, 49.5% tended to switch early to GA, 13.9% made attempts to avoid this by intensive systemic supplementation. Benzodiazepines and opioids were the most commonly used substances. Pain or discomfort outside the surgical field was widely managed by intravenous supplementation (67.7%) and only 10.6% were willing to switch to general anaesthesia. CONCLUSIONS: In Germany, anaesthesiologists manage incomplete RA using a widespread spectrum of measures. Some might introduce specific risks, which potentially outweigh the benefits of RA in comparison to GA techniques.

[Acute pain management after orthopaedic surgery]. / Akutschmerztherapie nach orthopädisch-traumatologischen Eingriffen.

Provision of sufficient post-operative pain therapy is an obligation in the clinical management of patients. A wide range of medical, technical and organizational options is used to improve post-operative pain management in orthopaedic surgery. Measurement of pain is as important as the correct use of analgesics and application techniques. Standardized pain therapy algorithms should facilitate autonomous treatment of patients. Additional procedures like patient-controlled analgesia or local catheter for pain are necessary for individualized or operation-specific pain therapy. The balanced combination in postoperative pain therapy could reduce side effects and complication rates, increase mobility and enhance patient satisfaction.

[Anesthesia and analgesia in addicts: basis for establishing a standard operating procedure]. / Anästhesie und Analgesie bei Suchtpatienten: Grundlagen zur Erstellung einer "standard operating procedure".

Addicts have an exaggerated organic and psychological comorbidity and in cases of major operations or polytrauma they are classified as high-risk patients. Additional perioperative problems are a higher analgetics requirement, craving, physical and/or psychological withdrawal symptoms, hyperalgesia and tolerance. However, the clinical expression depends on the substance abused. For a better understanding of the necessary perioperative measures, it is helpful to classify the substances into central nervous system depressors (e.g. heroin, alcohol, sedatives, hypnotics), stimulants (e.g. cocaine, amphetamines, designer drugs) and other psychotropic substances (e.g. cannabis, hallucinogens, inhalants). The perioperative therapy should not be a therapy for the addiction, as this is senseless. On the contrary, the characteristics of this chronic disease must be accepted. Anesthesia and analgesia must be generously stress protective and sufficiently analgesically effective. Equally important perioperative treatment principles are stabilization of physical dependence by substitution with methadone (for heroin addicts) or benzodiazepines/clonidine (for alcohol, sedatives and hypnotics addiction), avoidance of stress and craving, thorough intraoperative and postoperative stress relief by using regional techniques or systematically higher than normal dosages of anesthetics and opioids, strict avoidance of inadequate dosage of analgetics, postoperative optimization of regional or systemic analgesia by non-opioids and coanalgetics and consideration of the complex physical and psychological characteristics and comorbidities. Even in cases of abstinence (clean) an inadequate dosage must be avoided as this, and not an adequate pain therapy sometimes even with strong opioids, can potentially activate addiction. A protracted abstinence syndrome after withdrawal of opioids can lead to increased response to administered opioids (e.g. analgesia, side-effects).

Current practice in regional anaesthesia in Germany.

BACKGROUND AND OBJECTIVE: Several new techniques and agents (e.g. ropivacaine) have been introduced in regional anaesthesia to improve patients outcome and safety. The beneficial effects on patient outcome are clear with these techniques, however, no information is available about their pattern and frequency of use in clinical practice. This study presents data concerning the current practice of regional anaesthesia in Germany. METHODS: A questionnaire was sent to every German anaesthesia department (n = 1381). Questions focused on the frequency and range of regional anaesthetic procedures employed, with attention also to the organizational structural of the individual institution. RESULTS: Six hundred and sixty-seven questionnaires were returned anonymously, representing a return rate of 48.3%. In hospitals with less than 200 beds, the number of regional anaesthetics was markedly higher compared to large hospitals with more than 400 beds. In contrast, small hospitals tended to provide only basic techniques of regional anaesthesia, whereas larger hospitals implemented more advanced techniques. Bupivacaine remains the most commonly used long-lasting local anaesthetic. Staff structure was also different in small departments - patient care was performed by board certified anaesthesiologists while residents were responsible for the patients in larger departments. CONCLUSIONS: In small hospitals a majority of board certified anaesthesiologists rely on basic regional anaesthesia techniques. In large departments some consultants provide the entire spectrum of regional anaesthesia, with the majority of cases transferred to the residents responsibility. These results indicate the strong need to improve residency programs with regard to regional anaesthesia.

Efficacy of vertical infraclavicular plexus block vs. modified axillary plexus block: a prospective, randomized, observer-blinded study.

BACKGROUND: Despite containing severe risks, infraclavicular approaches to the brachial plexus gained increasing popularity. Likewise, the vertical infraclavicular plexus block improved anesthesia compared to the standard axillary approach but contains the risk of pneumothorax. Therefore we modified the standard axillary technique by inserting a proximal directed catheter, referred to as a high axillary plexus block. We prospectively compared quality and onset of neural blockade after vertical infraclavicular plexus block (VIP) and high axillary plexus block (HAP) in two randomized groups (30 patients in each). METHODS: In group VIP the insulated needle was inserted midway between the ventral process of the acromion and the jugular notch. In group HAP, first an axillary needle was placed. Through this a stimulating catheter was inserted in a proximal direction (10-15 cm); correct placement was confirmed by nerve stimulation. All patients received 40 ml ropivacaine 0.75% (300 mg). Discriminating between analgesia and anesthesia, a blinded observer assessed progression of neural blockade every 5 min for 60 min by pin prick. Incomplete blocks were supplemented 60 min after initial injection. RESULTS: All patients in both groups demonstrated sufficient surgical anesthesia. No patient needed systemic supplementation or general anesthesia. However, vertical infraclavicular plexus block indicated superior anesthesia compared to high axillary plexus block, regarding musculocutaneous, axillary and radial nerve, which were completely blocked with a higher success rate and in a shorter time interval (P < 0.05). CONCLUSIONS: While both techniques provide sufficient surgical anesthesia, vertical infraclavicular plexus block demonstrated a partially higher success rate and a faster onset than high axillary plexus block.

The treatment of pain in urology.

Contemporary medicine is characterized by sophisticated specialization of the individual physician. The specialist in urological surgery may undertake one of the most important and primary medical tasks, the mitigation and therapy of pain. This review aims to provide an overview of the concepts of pain therapy in urology. Most patients benefit from basic concepts of analgesia, including measuring and documenting pain scores at the bedside by the nursing staff. Patients undergoing very painful operative procedures require more potent techniques of analgesia, e.g. intravenous patient-controlled analgesia and epidural analgesia. These techniques need adequate supervision by an acute pain service, but their implementation improves the outcome in some situations. Pain in acute renal obstruction varies in intensity and duration; hence, analgesic therapy has to be tailored to the individual patient. Pain syndromes from cancer can be more complex than those after surgery. Neuropathic pain is probably the most difficult to manage and requires consultation with a pain-management specialist. In the case of neuropathic pain, treatment only with opioids is of limited efficacy and combination with co-analgesics is necessary. In addition, invasive analgesic therapies should sometimes be considered.

[Clinical experience with ipsilateral impedance audiometry (author's transl)]. / Uber die Bedeutung des ipsilateralen Stapediusreflexes bei Normalhörigkeit.

Most of the commercial impedance measuring devices for ipsilateral stimulus still apply probe tone and stimulus at the same time, thus eliciting artefacts and a great variety of answers. Results of ipsilateral reaction using the impedance apparatus of Grason and Stadler with an intermittent stimulus generator are shown and discussed. The diagnostic value appears improved.