Systematic Review on Pain-Related Outcome Domains After Sternotomy: A First Step Toward the Development of a Core Outcome Set.

OBJECTIVES: Pain after surgery has a major impact on acute and long-term recovery and quality of life, but its management is often insufficient. To enhance the quality of research and to allow for better comparability between studies, it is important to harmonize outcomes for assessing the efficacy and effectiveness of pain management interventions after surgery. As a first step in developing a core outcome set, this study aimed to systematically search for outcome domains assessed in research regarding acute pain management after sternotomy as an example of a typically painful surgical procedure. METHODS: A systematic literature review was performed using MEDLINE, Embase, and CENTRAL. Eligibility criteria consisted of randomized controlled trials and observational trials targeting pain management after sternotomy in adults in the acute postoperative setting (≤2 weeks). After duplicate removal and title and abstract screening by 2 independent reviewers, study characteristics and outcome domains were identified, which were extracted from full texts and summarized qualitatively. RESULTS: Of 1350 studies retrieved by database searching, 156 studies were included for full-text extraction. A total of 80 different outcome domains were identified: pain intensity, analgesic consumption, physiological function, and adverse events were the most frequent ones. Outcome domains were often not explicitly reported, and the combination of domains and assessment tools was heterogeneous. The choice of outcomes is commonly made within clinicians; patients' perspectives are not considered. CONCLUSIONS: The wide variety of commonly applied outcome domains, the nonexplicit wording, and the heterogeneous combination of the domains indicating treatment benefit demonstrate the need for harmonization of outcomes assessing perioperative pain management after surgery.

[Outpatient treatment of acute injuries of upper extremities with axillary plexus anesthesia in the emergency department-Is that possible without continuous anesthesia attendance?] / Ambulante Versorgung akuter Verletzungen der oberen Extremität in der Notfallambulanz in axillärer Plexusanästhesie ­ Ist das ohne durchgehende Anästhesiebegleitung machbar?

BACKGROUND: The incorporation into the routine operating procedure of patients with small but acute hand and forearm injuries requiring surgery who present in the emergency admission department, represents a challenge due to limited resources. The prompt treatment in the emergency admission department represents an alternative. This article retrospectively reports the authors' experiences with a treatment algorithm in which emergency patients were treated by ultrasound-guided axillary brachial plexus blocks (ABPB) and surgery carried out in the emergency department without further anesthesia attendance. METHODS: Patients were preselected by the surgeon if they were suitable for a standardized treatment without anesthesia attendance during surgery. If there were no anesthesiological or surgical contraindications patients received an ABPB in the holding area of the operating room (OR) under standard monitoring. Blocks were performed as a multi-injection, ultrasound-guided technique which is anatomically described in detail. Patients >60 kg received a total volume of 30 ml of a mixture of 10 ml 1% ropivacaine (100 mg) and 20 ml 2% prilocaine (400 mg). Patients <60 kg received the same mixture with a reduced volume of 25 ml corresponding to 82.5 mg ropivacaine and 332.5 mg prilocaine. After controlling for block success patients were admitted to the emergency department and the surgical procedure was carried out under supervision by the surgeon without further anesthesia attendance. At discharge patients were explicitly instructed that in the case of any complications or a continuation of the block for more than 24 h they should contact the emergency department. RESULTS: Between January 2013 and November 2017 a total of 566 patients (46.4 years, range 11-88 years, 174.9 cm, range 140-211cm, 80.8 kg, range 42-178kg, ASA 1/2/3, 190/338/38, respectively) were treated according to a standardized protocol. The ABPBs were performed by 74 anesthetists. In 5% of the patients the initial block was incomplete and rescue blocks were performed with a maximum of 2­3ml 1% prilocaine per corresponding nerve. After completion the block was ensured and all patients underwent surgery without further analgesics or local anesthetic infiltration by the surgeon. Complications related to the ABPB and readmissions were not observed. CONCLUSION: It could be demonstrated that minor surgery could be carried out safely and effectively with a defined algorithm using ABPB in selected patients outside the OR without permanent anesthesia attendance: however, indispensable prerequisites for such procedures are careful patient selection, patient compliance, the safe and effective performance of the ABPB and reliable agreement with the surgeon.

[Algorithm for flexible decision-making in the intra-hospital management of patients with the changing requirements of the SARS-CoV-2 pandemic]. / Flexibler Entscheidungsalgorithmus zum innerklinischen stationären Patient*innen-Management unter wechselnden Anforderungen der SARS-CoV-2-Pandemie.

After the initial fulminant outbreak, the SARS-CoV­2 pandemic has now taken a more protracted course which, nevertheless, challenges hospitals in returning to a "normal" mode and in preparing for a worst-case scenario of a second wave. Not only the organization of the first contact with the patient and the admission in the emergency department but also the admission as an in-patient and the subsequent management requires both flexibility and clear directions of action for the medical personnel involved. The aim of the algorithm was to develop a structured, easy to implement and easy to follow guideline while simultaneously preserving resources. The algorithm covers some key points of decision making such as clinical signs, first contact, admission for in-patient treatment, consequences of swab and computed tomography (CT) results, and allocation and isolation measures within the hospital. The algorithm is not intended to guide diagnostics, decisions and treatment in the narrower medical sense but to provide more general instructions for the management of in-patients considering specific aspects of SARS-CoV­2.

[Changes in age distribution and frequency of comorbidities in patients in the occupational insurance association treatment process]. / Veränderung der Altersstruktur und Häufigkeit von Komorbiditäten bei Patienten im bg-lichen Heilverfahren.

BACKGROUND: Due to the demographic development the proportion of older patients has increased. These show at least a higher rate of comorbidities, which affects the length of inpatient hospital stay. Until now no uniform recording exists for such comorbidities within the occupational insurance association system even if the clinical relevance is beyond dispute. Adaptations within the system with increased interdisciplinary treatment are necessary. OBJECTIVE: The aim of this study was to analyze changes in the age distribution and the frequency of comorbidities in patients in the occupational insurance association system. METHODS: The study was a retrospective analysis of age distribution and comorbidities of all operatively treated occupational insurance association patients in 2005 (n = 631), 2010 (n = 1180) and 2015/2016 (n = 2315). A comparison of the age groups ≤29 years, 30-49 years, 50-65 years and ≥66 years was performed. RESULTS: The proportion of patients aged 50-65 years showed a significant increase: 2005 (26.5%), 2010 (30.5%) and 2015/2016 (37.3%) (p < 0.001) and an increased proportion of patients with at least 1 comorbidity: 2005 (38.7%), 2010 (52.5%) and 2015/2016 (52.9%) (p = 0.01). This was statistically significant (p < 0.001, p = 0.005) within the age group 30-49 years (2005: 31.1%, 2015/2016: 49.0%) and the age group 50-65 years (2005: 55.7%, 2015/2016: 67.1%). Significant changes were found for arterial hypertension, morbid obesity, thyroid and respiratory diseases. In addition, there was an increase in multimorbid patients. DISCUSSION: A changing age distribution with a tendency to an increased number of older patients and an increased frequency of comorbidities could be determined. In the present documentation system of the occupational insurance association treatment procedure these comorbidities are insufficiently recorded and considered, even though their clinical relevance is indisputable. Adaptations with respect to intensified interdisciplinary cooperation are necessary.

Ultrasound-guided anterior approach to the axillary and intercostobrachial nerves in the axillary fossa: an anatomical investigation.

BACKGROUND: The posterolateral and medial aspect of the arm is supplied by the axillary (AXN) and intercostobrachial nerves (ICBN), which are not anaesthetised by an axillary brachial plexus block (ABPB). Blockade of the AXN and the ICBN has been reported in the quadrangular space (QS) posteriorly or by serratus plane block, respectively. An anterior ultrasound-guided approach to block the AXN and ICBN would be desirable to complete an ABPB at a single insertion site. METHODS: After a preliminary dissection study in six cadavers, ultrasound-guided AXN and ICBN injection was performed in 46 Thiel embalmed cadavers bilaterally. Key sonographic landmarks to identify the AXN in the QS are the humerus, teres major muscle, and subscapular muscle. With the same probe position, the ICBN was identified in the subfascial axillary space. Then, 2 ml latex was injected at each nerve and confirmed by dissection. RESULTS: Muscular and bony landmarks were identified in all cadavers. The AXN was seen in 99% in the QS or at the inferolateral margin of the subscapular muscle and surrounded by latex in 96% of cases. Latex spread to the axillary fossa, within the subscapular muscle, or to the radial nerve was noted in 8% of the injections. The ICBN was seen and surrounded by latex in 100% of cases. CONCLUSIONS: We describe a reliable ultrasonographic approach to visualise the AXN and ICBN anteriorly from the conventional ABPB approach as confirmed in this cadaver study.

[Anesthesia management in microsurgical reconstructions]. / Anästhesiologisches Management bei mikrochirurgischen Rekonstruktionen.

Microsurgical procedures for construction of anastomoses present new challenges for anesthetists in the perioperative setting. Despite their increasing importance, so far no perioperative management guidelines for these patients existed. Anesthetists can influence the success of surgery (e. g. successful perfusion of a flap) via an optimal preoperative, intraoperative and postoperative approach. Patients should be carefully evaluated preoperatively for increased risks to avoid poor postoperative outcomes. Perioperatively, the choice of anesthetic procedure as well as the management of fluid infusion, blood glucose, temperature and blood transfusion are of great importance. Adequate analgesia as well as strict control should be performed as soon as possible postoperatively, preferably in a surveillance unit to detect and treat any complications as early as possible.

[Survey of pain after ambulatory surgery: An internet-based instrument]. / Erhebung von Schmerzen nach ambulanten Operationen : Ein internetbasiertes Instrument.

BACKGROUND AND AIM: Pain after surgery continues to be undermanaged. Studies and initiatives aiming to improve the management of postoperative pain are growing; however, most studies focus on inpatients and pain on the first day after surgery. The management of postoperative pain after ambulatory surgery and for several days thereafter is not yet a major focus. One reason is the low return rate of the questionnaires in the ambulatory sector. This article reports the development and feasibility of a web-based electronic data collection system to examine pain and pain-related outcome on predefined postoperative days after ambulatory surgery. MATERIAL AND METHODS: In this prospective pilot study 127 patients scheduled for ambulatory surgery were asked to participate in a survey to evaluate aspects related to pain after ambulatory surgery. The data survey was divided in (1) a preoperative, intraoperative and postoperative part and (2) a postoperative internet-based electronic questionnaire which was sent via e-mail link to the patient on days 1, 3 and 7 after surgery. A software was developed using a PHP-based platform to send e-mails and retrieve the data after web-based entries via a local browser. Feasibility, internet-based hitches and compliance were assessed by an additional telephone call after day 7. RESULTS: A total of 100 patients (50 female) between 18 and 71 years (mean 39.1 ± 12.7 years) were included in the pilot study. Return rates of the electronic questionnaires were 86% (days 3 and 7) and 91% (day 1 after surgery). All 3 electronic questionnaires were answered by 82% of patients. Aspects influencing the return rate of questionnaires were work status but not age, gender, education level and preoperative pain. Telephone interviews were performed with 81 patients and revealed high operability of the internet-based survey without any major problems. CONCLUSION: The user-friendly feasibility and operability of this internet-based electronic data survey system explain the high compliance and return rate of electronic questionnaires by patients at home after ambulatory surgery. This survey tool therefore provides unique opportunities to evaluate and improve postoperative pain management after ambulatory surgery.

[Anesthesiological approach for patients with spinal cord injuries]. / Anästhesiologisches Vorgehen bei Patienten mit spinalem Querschnitt.

Spinal cord injuries (SCI) are serious medical conditions, which are associated with severe and potentially fatal risks and complications depending on the location and extent of injury. Traffic accidents, falls and recreational activities are the leading causes for traumatic SCI (TSCI) worldwide whereas non-traumatic spinal cord injuries (NTSCI) are mostly due to tumors and congenital diseases. As chronification of the injuries progresses other organ systems are affected including anatomical changes, the respiratory and cardiovascular systems and endocrinological pathways. All these effects have to be considered in the anesthesiological management of patients with SCI. Autonomic dysreflexia (AD) is the most dangerous and life-threatening complication in patients with chronic SCI above T6 that results from an overstimulation of sympathetic reflex circuits in the upper thoracic spine and can be fatal. This article summarizes the specific pathophysiology of SCI and how AD can be avoided as well as also providing anesthetists with strategies for perioperative and intensive care management of patients with SCI.

[Effects of Vibrax (Mechanical Vibrations) on the Arterial Blood Gases of Patients in the Intensive Care Unit after Cardiac Surgery]. / Effekte der Vibraxanwendung (mechanische Vibration) auf die Blutgaswerte von Patienten auf der Intensivstation nach einem kardiochirurgischen Eingriff.

OBJECTIVE: Respiratory physiotherapy is an integral part of the care of patients in intensive care units (ICU) after cardiac surgery. One of the most commonly used techniques in ICU to prevent pulmonary complications are mechanical vibrations, which can be applied with a tool called Vibrax.The aim of this study was to investigate the effects of Vibrax (mechanical vibrations) on the arterial blood gases of patients in ICU during the 1. or 2. day after cardiac surgery. METHODS: A randomized controlled pilot study was conducted with 23 patients. The participants of the control group (CG) received a cardiovascular training with mobilization to the edge of the bed and active breathing exercises. On the patients of the intervention group (IG) additionally Vibrax was applied for 5 minutes. As primary outcome parameter the PaO2/FiO2 ratio was measured. RESULTS: In the CG no significant changes over time were observed (p ≥ 0.06). The IG showed a significant (p = 0.009) increase in the PaO2/FiO2 ratio from before the physiotherapy intervention (M = 296.52, SE = 34.94 mmHg) to 60 minutes after completion of the physiotherapy intervention (M = 331.39, SE = 48.14 mmHg). There was no significant difference between the CG and IG at any measuring time (p ≥ 0.09). CONCLUSION: The results of this pilot study indicate that the application of Vibrax has positive effects on the arterial blood gases of patients in ICU on the 1. or 2. day after cardiac surgery. But whether the effects are clinically relevant could not be clarified.

Ultrasound-guided catheterisation of the subclavian vein: freehand vs needle-guided technique.

The objective of this prospective, randomised study was to examine the impact of a multi-angle needle guide for ultrasound-guided, in-plane, central venous catheter placement in the subclavian vein. One hundred and sixty patients were randomly allocated to two groups, freehand or needle-guided, and then 159 catheterisations were analysed. Cannulation of the first examined access site was successful in 96.9% of cases with no significant difference between groups. There were three arterial punctures and no other severe injuries. Catheter misplacements did not differ between the groups. Higher success rates within the first and second attempts in the needle-guided group were observed (p = 0.041 and p = 0.019, respectively). Use of the needle guide reduced the access time from a median (IQR [range]) of 30 (18-76 [6-1409]) s to 16 (10-30 [4-295]) s; p = 0.0001, and increased needle visibility from 31.8% (9.7%-52.2% [0-96.67]) to 86.2% (62.5%-100% [0-100]); p < 0.0001. A multi-angle needle guide significantly improved aligning the needle and ultrasound plane compared with the freehand technique when cannulating the subclavian vein. Use of the guide resulted in faster access times and increased success at the first and second attempts.

[Prediction of further hospital treatment for emergency patients by emergency medical service physicians]. / Notärztliche Einschätzung der klinischen Weiterversorgung von Notfallpatienten.

INTRODUCTION: Prehospital assessment of illness and injury severity with the National Advisory Committee for Aeronautics (NACA) score and hospital pre-arrival notification of a patient who is likely to need intensive care unit (ICU) or intermediate care unit (IMC) admission are both common in Germany's physician-staffed emergency medical services (EMS) system. AIM: This study aimed at comparing the prehospital evaluation of severity of disease or injuries by EMS physicians and the subsequent clinical treatment in unselected emergency department (ED) patients. MATERIAL AND METHODS: This study involved a prospective observational analysis of patients transported to the ED of an academic level I hospital escorted by an EMS physician over a period of 6 months (February-July 2011). The physician's qualification and the patient's NACA score were documented and the EMS physician was asked to predict whether the patient would need hospital admission and, if so, to the general ward, IMC or ICU. After the ED treatment, discharge or admission, outcome and length of hospital and ICU or IMC stay were documented. RESULTS: A total of 378 mostly non-trauma patients (88 %) treated by experienced EMS physicians could be enrolled. The number of patients discharged from the ED decreased, while the number of patients admitted to the ICU increased with higher NACA scores. Prehospital prediction of discharge or admission, IMC or ICU treatment by EMS physicians was accurate in 47 % of the patients. In 40 % of patients a lower level of care was sufficient while 12 % needed treatment on a higher level of care than that predicted by EMS physicians. Of the patients 39 % who were predicted to be discharged after ED treatment, were admitted to hospital and 48 % of patients predicted to be admitted to the IMC were admitted to the general ward. Patients predicted to be admitted to the ICU were admitted to the ICU in 75 %. Higher NACA scores were associated with increased mortality and a longer hospital IMC or ICU length of stay, but significant differences were only found between patients with NACA V versus VI scores or patients predicted to be treated on the IMC versus the ICU. CONCLUSIONS: Prehospital NACA scores indicate the need for inpatient treatment, but neither hospital discharge or admission nor need of IMC or ICU admission after initial ED treatment could be sufficiently predicted by EMS physicians. Thus, hospital prenotification in order to predispose IMC or ICU capacities does not seem to be useful in cases where an ED can reassess admitted EMS patients.

[Differences of analgesic efficacy and complication rates between ultrasound and nervestimulator guided peripheral nerve catheters : Database analysis on patient-relevant target parameters]. / Vergleich der Analgesiequalität und Komplikationen von ultraschall- und nervenstimulatorgesteuerten peripheren Nervenkathetern : Datenbankanalyse zu patientenrelevanten Zielparametern.

BACKGROUND: Peripheral nerve catheters (PNC) play an important role in postoperative pain treatment following major extremity surgery. There are several trials reported in the literature which investigated the efficacy and safety of ultrasound (US) and nerve stimulator (NS) guided PNC placement; however, most of these trials were only small and focused mainly on anesthesiologist-related indicators of block success (e.g. block onset time and procedure time) but not primarily on patient-related outcome data including postoperative pain during movement. AIM: This retrospective analysis compared the analgesic efficacy and safety of US versus NS guided peripheral nerve catheters (PNC) for postoperative pain therapy in a large cohort of patients. MATERIAL AND METHODS: Data of patients (June 2006-December 2010) treated with US (nus = 368 June 2008-December 2010) and NS (nns = 574, June 2006-May 2008) guided PNC were systematically analyzed. Apart from demographic data, postoperative pain scores [numeric rating scale (NRS): 0-10] on each treatment day, the number of patients with need for additional opioids, cumulative local anesthetic consumption and catheter-related complications were compared. RESULTS: On the day of surgery patients treated with US-guided PNC reported lower NRS at rest (p = 0.034) and during movement (p < 0.001). Additionally, the number of patients requiring additional opioids on the day of surgery was lower in the US group (absolute difference 12.4 %, p = 0.001). Furthermore, the number of multiple puncture attempts (absolute difference 5.6 %, p < 0.001) and failed catheter placements (absolute difference 3.4 %, p = 0.06) were lower in the US group. There were no patients in both groups with long-lasting neurological impairment. CONCLUSION: This database analysis demonstrated that patients treated with US-guided PNC reported significantly lower postoperative pain scores and the number of patients requiring additional opioids was significantly lower on the day of surgery. The numbers of multiple punctures and failed catheter placements were reduced in the US group, which might be seen as an advantage of US-guided regional anaesthesia.

Ultrasound compared with nerve stimulation guidance for peripheral nerve catheter placement: a meta-analysis of randomized controlled trials.

BACKGROUND: The aim of this meta-analysis was to compare the efficacy and safety of ultrasound (US) vs nerve stimulation (NS) guidance for peripheral nerve catheter placement. METHODS: This meta-analysis was performed according to the PRISMA statement and the recommendations of the Cochrane Collaboration. For dichotomous outcomes relative risks [RRs; 95% confidence intervals (CIs)] were calculated, while for continuous outcomes, mean differences (MDs; 95% CI) were calculated. All statistical analyses were performed using the Revman® statistical software (Version 5.1). RESULTS: Fifteen randomized controlled trials including 977 patients satisfied the inclusion criteria. Peripheral nerve catheters placed under US guidance showed a higher RR of 1.14 (95% CI: 1.02-1.27; P=0.02) for an overall successful block in comparison with NS. However, postoperative pain scales at movement (numeric rating scale: 0-10) were comparable between US- vs NS-guided peripheral nerve catheters 24 (MD: 0.08; 95% CI: -0.77 to 0.94; P=0.85) and 48 (MD: 1.0; 95% CI: -0.3 to 2.3; P=0.13) h after surgery. Patients receiving a US-guided peripheral nerve catheter had a lower RR of 0.13 (95% CI: 0.04-0.38; P=0.0002) for an accidental vascular puncture. CONCLUSIONS: There is evidence that US-guided peripheral nerve catheters show a higher success rate and a lower risk for an accidental vascular puncture compared with NS guidance. However, this difference resulted only in marginally lower postoperative pain scores at rest. Nevertheless, these results were influenced by heterogeneity and should be interpreted with caution.

[Oral therapy algorithm for the treatment of postoperative pain. A prospective observational study]. / Oraler Therapiealgorithmus bei akuten postoperativen Schmerzen. Eine prospektive Beobachtungsstudie.

BACKGROUND: Postoperative pain continues to be undermanaged, at least in part, due to inadequate organization and lack of use of opioids. Especially patients who do not receive consultation from an acute pain service and are therefore not eligible to receive regional anesthesia techniques or patient-controlled devices suffer from severe pain after surgery. The aim of the present prospective observational study was to assess the efficacy and feasibility of an analgesia algorithm for this subgroup of patients. METHODS: An oral opioid concept including controlled-release (cr) oxycodone, immediate-release (ir) hydromorphone and a non-opioid analgesic was implemented at three different departments at the University Clinic of Muenster, Germany. Briefly, cr-oxycodon was administered preoperatively to patients undergoing ear nose and throat (ENT), general or elective trauma surgery on the day of surgery and every 12 h for a maximum of 4 days postoperatively. Inadequately managed pain above 3 on a visual analog scale (VAS 0-10) at rest and above 5 during movement was treated with ir-hydromorphone on patient request. After written informed consent, patients were assessed prospectively for up to 5 days perioperatively using a standardized questionnaire preoperatively, for 4 days postoperatively as well as 6 and 12 months after surgery. RESULTS: A total of 275 patients were included in the present prospective observational study: (ENT surgery: 163, trauma surgery 82 and general surgery 30). Median resting and evoked numeric rating scale (NRS) pain scores were equal or less than 3 and 5, respectively. Less patients received cr-oxycodone after ENT and general surgery compared to trauma surgery (p < 0.001). Constipation was more frequent after general and trauma surgery compared to ENT surgery. Vomiting decreased from 20 %-30 % on the day of surgery to 10 % or less regardless of the type of operation. No severe adverse events were observed. Additionally, patients with an increased depression score before surgery reported greater immediate postoperative pain than non-depressed patients. Of the patients 11 (15.7 %) and 7 (14.9 %) complained about persistent postoperative pain 6 and 12 months after surgery, respectively and these patients had increased acute pain ratings during the first postoperative days. CONCLUSIONS: The present study has demonstrated that the implementation of an oral opioid algorithm for patients without patient-controlled intravenous or regional analgesia is effective and feasible on surgical wards. Patients who underwent trauma surgery needed more cr-oxycodone. Side effects were similar regardless of the operation with the exception of obstipation which was more frequent after trauma and general surgery compared to ENT surgery.

[Validity of admission diagnoses as process-driving criteria : influence on length of stay and consultation rate in emergency departments]. / Validität von Einweisungsdiagnosen als Prozesssteuerungskriterium : Einfluss auf Verweildauer und Konsilrate in der zentralen Notaufnahme.

BACKGROUND: Primary care physicians and specialists often refer patients to the emergency department with a specific diagnosis and request for admission. Such an external diagnosis frequently influences the initial evaluation in the emergency department. The present study aimed to evaluate the accuracy of such external diagnoses and to assess the consequences of incorrect diagnoses on length of stay and number of specialty consultations in the emergency department. MATERIAL AND METHODS: This was a prospective observational study over the course of 3 months in the emergency department of a tertiary care center. External admission diagnoses made by primary care physicians and specialists were categorized as "accurate", "partially accurate" and "inaccurate". A special analysis of the external admission diagnosed was performed for patients admitted directly to an intermediary care unit and intensive care unit or patients who were transferred directly from the emergency department to the operating room. RESULTS: Data for 784 patients were analyzed. Patients were on average 63.1 ± 19.5 years old (minimum-maximum 18-97 years, median 68 years) and 54 % were male. After emergency department evaluation and treatment 57.8 % of external diagnoses were categorized as accurate, 23.6 % as partially accurate and 18.6 % as inaccurate. Patients with partially accurate and inaccurate diagnoses had a 3 and 6.5 times higher rate of specialty consultations in the emergency department, respectively, when compared with patients with an accurate diagnosis (number of specialty consultations n = 0: 77.3 % vs. 54.1 % vs. 92.9 %, p < 0.05; n = 1: 20.0 % vs. 40.4 % vs. 6.2 %, p < 0.05; n = 2: 2.7 % vs. 5.5 % vs. 0.9 %, p < 0.05, respectively. Patients with an accurate diagnosis had a shorter total length of stay than patients with a partially accurate or inaccurate diagnosis [mean ± SD (min-max; median): 192 ± 108 min (10-707 min; 181 min) vs. 246 ± 126 min (27-1,026 min; 214 min) vs. 258 ± 138 min (22-700 min; 232 min), p < 0.001], respectively. Out of 85 patients admitted directly to an intermediary care unit, intensive care unit and patients who were transferred directly from the emergency department to the operating room the diagnosis was accurate, partially accurate and inaccurate in 56.5 %, 24.7 % and 18.8 %, respectively. CONCLUSIONS: Admission diagnoses made by primary care physicians and specialists who subsequently refer patients to the emergency department are subject to certain inaccuracies. Inaccurate admission diagnoses are associated with an increased length of stay and a considerably higher rate of specialty consultation in the emergency department. Standardized operating procedures, treatment algorithms and triage systems are important to identify such incorrect diagnoses so that these patients can undergo appropriate diagnostic investigation and treatment.

Spinal GABA transporter 1 contributes to evoked-pain related behavior but not resting pain after incision injury.

The inhibitory function of GABA at the spinal level and its central modulation in the brain are essential for pain perception. However, in post-surgical pain, the exact mechanism and modes of action of GABAergic transmission have been poorly studied. This work aimed to investigate GABA synthesis and uptake in the incisional pain model in a time-dependent manner. Here, we combined assays for mechanical and heat stimuli-induced withdrawal reflexes with video-based assessments and assays for non-evoked (NEP, guarding of affected hind paw) and movement-evoked (MEP, gait pattern) pain-related behaviors in a plantar incision model in male rats to phenotype the effects of the inhibition of the GABA transporter (GAT-1), using a specific antagonist (NO711). Further, we determined the expression profile of spinal dorsal horn GAT-1 and glutamate decarboxylase 65/67 (GAD65/67) by protein expression analyses at four time points post-incision. Four hours after incision, we detected an evoked pain phenotype (mechanical, heat and movement), which transiently ameliorated dose-dependently following spinal inhibition of GAT-1. However, the NEP-phenotype was not affected. Four hours after incision, GAT-1 expression was significantly increased, whereas GAD67 expression was significantly reduced. Our data suggest that GAT-1 plays a role in balancing spinal GABAergic signaling in the spinal dorsal horn shortly after incision, resulting in the evoked pain phenotype. Increased GAT-1 expression leads to increased GABA uptake from the synaptic cleft and reduces tonic GABAergic inhibition at the post-synapse. Inhibition of GAT-1 transiently reversed this imbalance and ameliorated the evoked pain phenotype.

Switching magnetization by 180° with an electric field.

Magnetoelectric coupling allows for manipulating the magnetization by an external electric field or the electrical polarization by an external magnetic field. Here, we propose a mechanism to electrically induce 180° magnetization switching combining two effects: the magnetoelectric coupling at a multiferroic interface and magnetic interlayer exchange coupling. By means of first-principles methods, we investigate a ferroelectric layer in contact with a Fe/Au/Fe trilayer. The calculations show that the interface magnetism is strongly coupled to the ferroelectric layer. Furthermore, under certain conditions a reversal of polarization causes a sign reversal of the interlayer exchange coupling which is results in a 180° switching of the free layer magnetization. We argue that this magnetoelectric coupling mechanism is very robust and can find applications in magnetic data storage.

Efficacy and adverse effects of ketamine as an additive for paediatric caudal anaesthesia: a quantitative systematic review of randomized controlled trials.

BACKGROUND: The aim of this quantitative systematic review was to assess the efficacy and adverse effects of ketamine added to caudal local anaesthetics in comparison with local anaesthetics alone in children undergoing urological, lower abdominal, or lower limb surgery. METHODS: The systematic search, data extraction, critical appraisal, and pooled data analysis were performed according to the PRISMA statement. All randomized controlled trials (RCTs) were included in this meta-analysis and relative risk (RR), mean difference (MD), and the corresponding 95% confidence intervals (CIs) were calculated using the Revman(®) statistical software for dichotomous and continuous outcomes. RESULTS: Thirteen RCTs (published between 1991 and 2008) including 584 patients met the inclusion criteria. There was a significant longer time to first analgesic requirements in patients receiving ketamine in addition to a local anaesthetic compared with a local anaesthetic alone (MD: 5.60 h; 95% CI: 5.45-5.76; P<0.00001). There was a lower RR for the need of rescue analgesia in children receiving a caudal regional anaesthesia with ketamine in addition to local anaesthetics (RR: 0.71; 95% CI: 0.44-1.15; P=0.16). CONCLUSIONS: Caudally administered ketamine, in addition to a local anaesthetic, provides prolonged postoperative analgesia with few adverse effects compared with local anaesthetics alone. There is a clear benefit of caudal ketamine, but the uncertainties about neurotoxicity relating to the dose of ketamine, single vs repeated doses and the child's age, still need to be clarified for use in clinical practice.

[Spinal and epidural anesthesia in patients with hemorrhagic diathesis : decisions on the brink of minimum evidence?]. / Rückenmarknahe Regionalanästhesie bei Patienten mit hämorrhagischen Diathesen : Entscheidungen am Rande des Evidenzminimums?

Neuraxial anesthesia is an established and safe procedure in perioperative pain therapy which can help to minimize complications and to improve perioperative outcome. In patients with acquired bleeding disorders by comorbidities or concomitant antithrombotic medication an individual decision should be made based on risks and benefits. A large number of literature references and guidelines help making a decision, for example the recently updated evidence-based guidelines of the American Society of Regional Anesthesia and Pain Medicine for patients receiving antithrombotic or thrombolytic therapy. However, no explicit recommendations or guidelines exist for patients with hemorrhagic diatheses, such as von Willebrand disease (vWD), hemophilia A and B and idiopathic thrombocytopenic purpura (ITP). Published data regarding the safety of neuraxial techniques in these patients is scarce. Neuraxial anesthesia in patients with vWD is only acceptable when coagulation is optimized (substitution of factor concentrates or hemostatic agents depending on the type of vWD) and monitored frequently during the procedure. The only exception might be obstetric patients with vWD type I as coagulation frequently normalizes at the end of pregnancy. In these patients neuraxial anesthesia can often be performed without supplementation of clotting factors.Neuraxial techniques in patients with hemophilia A or B are usually contraindicated. The procedure may only be acceptable if serious reasons exist against general anesthesia. Supplementation of the missing factor to normal levels and monitoring during procedure is essential if neuraxial block is performed.Patients with ITP often present with low platelet counts. Normally, spinal or epidural anesthesia is considered safe if the platelet count is over 80,000/µl. However, the consistently low platelet counts in ITP seem to be less problematic than rapidly falling values due to other diseases, because this is often accompanied by platelet dysfunction or coagulopathy. In several studies neuraxial anesthesia was successfully performed with platelet counts between 50,000 and 80,000/µl. Nevertheless, the minimum safe platelet count for neuraxial blockade remains undefined in these patients.Evidence-based recommendations for neuraxial anaesthesia in patients with hemophilia, vWD or ITP cannot be offered. Each patient has to be treated individually with appropriate caution. This overview is intended to assist in the decision for or against neuraxial anesthesia in these patients, with emphasis on the pathophysiological background, blood investigations and case reports from the literature.

Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials.

BACKGROUND: Thoracic paravertebral blocks (PVBs) are successfully performed for pain management after breast surgery. The aim of the present quantitative systematic review was to assess the efficacy and adverse events of PVB in women undergoing breast surgery. METHODS: The systematic search, data extraction, critical appraisal, and pooled analysis were performed according to the PRISMA statement. The relative risk (RR), mean difference (MD), and their corresponding 95% confidence intervals (CIs) were calculated using the RevMan statistical software for dichotomous and continuous outcomes, respectively. Pain scores were converted to a scale ranging from 0 (no pain) to 10 (worst pain). RESULTS: Fifteen randomized controlled trials (published between 1999 and 2009) including 877 patients met the inclusion criteria. There was a significant difference in worst postoperative pain scores between PVB and general anaesthesia (GA) at <2 h (MD: -2.68; 95% CI: -3.33 to -2.02; P<0.00001), 2-24 h (MD: -2.34; 95% CI: -2.42 to -1.12; P<0.00001), and 24-48 h (MD: -1.75; 95% CI: -3.19 to 0.31; P=0.02). Accordingly, lower pain scores were observed for combined PVB with GA compared with GA alone for <2 h (MD: -1.87; 95% CI: -2.53 to -1.21; P<0.00001), 2-24 h (MD: -2.21; 95% CI: -3.07 to -1.35; P<0.00001), and 24-48 h (MD: -1.80; 95% CI: -2.92 to 0.68; P=0.002). The RR for the reported adverse events (e.g. pneumothorax) was low. CONCLUSIONS: There is considerable evidence that PVB in addition to GA or alone provide a better postoperative pain control with little adverse effects compared with other analgesic treatment strategies.