Ilioinguinal and iliohypogastric nerves cannot be selectively blocked by using ultrasound guidance: a volunteer study.

BACKGROUND: Ilioinguinal (IL) and iliohypogastric (IH) nerve blocks are used in patients with chronic postherniorrhaphy pain. The present study tested the hypothesis that our method, previously developed in cadavers, blocks the nerves separately and selectively in human volunteers. METHODS: We blocked the IL and the IH nerves in 16 volunteers in a single-blinded randomized cross-over setting under direct ultrasound visualization, by injecting two times the ED95 volume of 1% mepivacaine needed to block a peripheral nerve. The anaesthetized skin areas were tested by pinprick and marked on the skin. A digital photo was taken. For further analysis, the parameterized picture data were transformed into a standardized and unified coordinate system to compare and calculate the overlap of the anaesthetized skin areas of the two nerves on each side. An overlap <25% was defined as selective block. RESULTS: Fifty nerve blocks could be analysed. The mean volume injected to block a single nerve was 0.9 ml. Using ultrasound, we observed spread from one nerve to the other in 12% of cases. The overlap of the anaesthetized skin areas of the nerves was 60.3% and did not differ after exclusion of the cases with visible spread of local anaesthetic from one nerve to the other. CONCLUSIONS: The IL and IH nerves cannot be selectively blocked even if volumes below 1 ml are used. The most likely explanation is the spread of local anaesthetic from one nerve to the other, although this could not be directly observed in most cases.

Pharmacokinetic parameter sets of alfentanil revisited: optimal parameters for use in target controlled infusion and anaesthesia display systems.

BACKGROUND: In open TCI and anaesthesia display systems, the choice of pharmacokinetic (PK) parameter sets of opioids is clinically relevant. Accuracy and bias of the PK models may be affected by administration mode and the co-administered hypnotic drug. We retrospectively evaluated the performance of eight PK parameter sets for alfentanil in two data sets (infusion and bolus application). METHODS: With the dosing history from two studies in orthopaedic patients anaesthetized with propofol or inhalation anaesthetics the alfentanil plasma concentration over time was calculated with eight PK parameter sets. Median absolute performance error (MDAPE), log accuracy, median performance error (MDPE), log bias, Wobble, and Divergence were computed. Mann-Whitney rank test with Bonferroni correction was used for comparison between bolus and infusion data, repeated measures analysis of variance on ranks was used for comparison among parameter sets. RESULTS: The parameters by Scott (original and weight adjusted) and Fragen had a MDAPE ≤30% and a median log accuracy <0.15 independent of the administration mode, while MDPE was within ±20% and log bias nearly within ±0.1, respectively. The sets by Maitre and Lemmens were within these limits only in the bolus data. All other parameter sets were outside these limits. CONCLUSIONS: In healthy orthopaedic patients, the PK parameters by Scott and by Maitre were equally valid when alfentanil was given as repeated boluses. When given as infusion, the Maitre parameters were less accurate and subject to a significant bias. We cannot exclude that the difference between bolus and infusion is partially because of the different hypnotics used.

Evaluation of a novel needle guide for ultrasound-guided phantom vessel cannulation.

We evaluated a novel, sled-mounted needle guide for ultrasound-guided vessel cannulation. Fifty medical students were randomly assigned to use ultrasound with the sled (sled group, n = 23) or ultrasound without the sled (control group, n = 27) for vessel cannulation in a phantom. For each of 15 attempts we recorded cannulation time and designated a successful cannulation as 1 and a failure as 0. Our primary outcome was the mean overall success rate. The median (IQR [range]) number of successes in the sled group and control group were 15.0 (13.0-15.0 [11.0-15.0]) and 11.0 (9.0-13.0 [6.0-15.0]), respectively (p < 0.001). Cannulation time decreased from the first to the last attempt in the sled group from 7.0 s (6.0-10.0 [4.0-16]) s to 4.0 s (3.0-4.0 [1.0-6.0]) s and in the control group from 35.0 s (27.0-35.0 [11.0-35.0]) s to 7.0 s (5.0-10.0 [3.0-25.0]) s. The sled group demonstrated a shorter cannulation time at each attempt (p < 0.001). The novel sled improved the success rate and efficiency of ultrasound-guided phantom vessel cannulation.

Model-based control of neuromuscular block using mivacurium: design and clinical verification.

BACKGROUND: Short-acting agents for neuromuscular block (NMB) require frequent dosing adjustments for individual patient's needs. In this study, we verified a new closed-loop controller for mivacurium dosing in clinical trials. METHODS: Fifteen patients were studied. T1% measured with electromyography was used as input signal for the model-based controller. After induction of propofol/opiate anaesthesia, stabilization of baseline electromyography signal was awaited and a bolus of 0.3 mg kg-1 mivacurium was then administered to facilitate endotracheal intubation. Closed-loop infusion was started thereafter, targeting a neuromuscular block of 90%. Setpoint deviation, the number of manual interventions and surgeon's complaints were recorded. Drug use and its variability between and within patients were evaluated. RESULTS: Median time of closed-loop control for the 11 patients included in the data processing was 135 [89-336] min (median [range]). Four patients had to be excluded because of sensor problems. Mean absolute deviation from setpoint was 1.8 +/- 0.9 T1%. Neither manual interventions nor complaints from the surgeons were recorded. Mean necessary mivacurium infusion rate was 7.0 +/- 2.2 microg kg-1 min-1. Intrapatient variability of mean infusion rates over 30-min interval showed high differences up to a factor of 1.8 between highest and lowest requirement in the same patient. CONCLUSIONS: Neuromuscular block can precisely be controlled with mivacurium using our model-based controller. The amount of mivacurium needed to maintain T1% at defined constant levels differed largely between and within patients. Closed-loop control seems therefore advantageous to automatically maintain neuromuscular block at constant levels.

[Effect compartment equilibration and time-to-peak effect. Importance of a pharmacokinetic-pharmacodynamic principle for the daily clinical practice]. / Wirkortäquilibration, Anschlagzeit, "time to peak effect". Bedeutung pharmakokinetisch-dynamischer Prinzipien für die tägliche klinische Praxis.

Contrary to the situation in "classical" clinical pharmacology, non-steady state phenomena play a fundamental role for clinical pharmacology in anesthesia. Their understanding is of tantamount importance for the safe and efficient application of drugs relevant to anesthesia. Concepts like optimised target-controlled infusion (TCI), effect compartment targeting and the small margin of error tolerable during maintained spontaneous ventilation, force the anesthesiologist to acquire a firm understanding of the difference between the concentration time course at the effect side vs. time course of the plasma concentration. The underlying concepts, their application for the rational use of muscle relaxants, propofol with TCI systems, volatile anaesthetics and opioids will be discussed.

Model-based control of mechanical ventilation: design and clinical validation.

BACKGROUND: We developed a model-based control system using end-tidal carbon dioxide fraction (FE'(CO(2))) to adjust a ventilator during clinical anaesthesia. METHODS: We studied 16 ASA I-II patients (mean age 38 (range 20-59) yr; weight 67 (54-87) kg) during i.v. anaesthesia for elective surgery. After periods of normal ventilation the patients were either hyper- or hypoventilated to assess precision and dynamic behaviour of the control system. These data were compared with a previous group where a fuzzy-logic controller had been used. Responses to different clinical events (invalid carbon dioxide measurement, limb tourniquet release, tube cuff leak, exhaustion of carbon dioxide absorbent, simulation of pulmonary embolism) were also noted. RESULTS: The model-based controller correctly maintained the setpoint. No significant difference was found for the static performance between the two controllers. The dynamic response of the model-based controller was more rapid (P<0.05). The mean rise time after a setpoint increase of 1 vol% was 313 (sd 90) s and 142 (17) s for fuzzy-logic and model-based control, respectively, and after a 1 vol% decrease was 355 (127) s and 177 (36) s, respectively. The new model-based controller had a consistent response to clinical artefacts. CONCLUSION: A model-based FE'(CO(2)) controller can be used in a clinical setting. It reacts appropriately to artefacts, and has a better dynamic response to setpoint changes than a previously described fuzzy-logic controller.

Subtraction procedure for the registration of tissue perfusion with Doppler ultrasound.

Tissue perfusion, i.e., in muscles or parenchymatous organs, is of both physiological and pathophysiological interest. The measurement of tissue perfusion is an unsolved problem. The Doppler ultrasound method is well suited to this purpose. However, measurements using this technique may be disturbed by movements or vibrations such as heart motion, muscle trembling or vibration of the subsoil (i.e. the examination table). These interfering movements produce Doppler frequencies in the same frequency range as slowly flowing erythrocytes, causing artifacts to appear in the measured data. The goal of this project was to suppress such artifacts with the help of a subtraction procedure. The mathematical theory of this subtraction procedure and its implementation in a newly developed two channel Doppler system are presented. This system was successfully tested on a phantom which is able to generate flow and movement artifacts. Preliminary measurements in the forearms of volunteers showed that movement artifacts can be at least partially suppressed.

[Weaning of young smokers using a transdermal nicotine patch]. / Entwöhnung junger Raucher mit Hilfe eines transdermalen Nikotinpflasters.

To assess efficacy and tolerance of a transdermal nicotine system (TNS) as adjuvant to tobacco withdrawal, 112 young, nicotine-dependent cigarette smokers were treated for nine weeks with TNS (n = 56) or placebo (n = 56). Initial doses of nicotine (21 or 14 mg/24 h) were based on previous smoking habits and stepwise reduced to 7 mg/24 h if abstinence was achieved during medication. After treatment, 39.3% of the TNS users were abstinent versus 19.6% on placebo (p less than 0.05). The craving for cigarettes diminished steadily, but not more significantly on TNS medication. Tenseness, difficulty in concentration and feelings of hunger were consistently and in part significantly lessened in the TNS group. The other withdrawal symptoms were not influenced by TNS treatment. Nine-month follow-up cotinine-verified abstinence rates were 12.5% in the TNS and 3.6% in the placebo group (n. s.). Transient mild or moderate erythema at the application site appeared in 20% of the TNS and 6.3% of the placebo group, and 7.1% of the TNS users dropped out because of severe localized erythema. Other mild, transient, systemic side effects reported by 33.9% of the TNS and 26.8% of the placebo users (n. s.) did not lead to drop-outs.