RESUMO
BACKGROUND: Local infiltration anaesthesia (LIA) was introduced as an innovative analgesic procedure for enhanced recovery after primary total knee arthroplasty (TKA). However, LIA has never been compared with analgesia based on an adductor canal catheter and a single-shot sciatic nerve block. OBJECTIVE: To evaluate two analgesic regimens for TKA comparing mobility, postoperative pain and patient satisfaction. DESIGN: Two-group randomised, controlled clinical trial. SETTING: Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Germany between April and August 2017. PATIENTS: Adults undergoing primary TKA under general anaesthesia were eligible for study participation. Exclusion criteria were heart insufficiency (New York Heart Association class >2), liver insufficiency (Child Pugh Score >B), evidence of diabetic polyneuropathy, severe obesity (BMIâ>â40âkgâm), chronic opioid therapy for more than 3 months before scheduled surgery and allergy to local anaesthetics. INTERVENTIONS: Nerve block patients group (n=20) underwent surgery with two ultrasound-guided regional anaesthesia blocks: a single-shot sciatic nerve block with 20âml of ropivacaine 0.75% combined with an adductor canal block with a catheter placed for less than 4 days with an infusion of ropivacaine 0.2% at a rate of 6âmlâh. LIA patients (LIA group, n=20) received LIA of the knee capsule at the end of surgery with 150âml of ropivacaine 0.2%. MAIN OUTCOME MEASURES: The primary endpoint was postoperative time to patient mobilisation (ability to walk) on the ward. RESULTS: Baseline characteristics were similar in each study group. Patients in both groups were mobilised to walk after TKA in similar time frames (LIA 24.0âh versus nerve block 27.1âh, 95% CI of difference -9.6 to 3.3âh). Maximum postoperative pain scores on exertion were higher in LIA patients with a mean 1.3 of 10 numerical rating scale points (95% CI 0.3 to 2.3, Pâ=â0.010) as were intra-operative opioid requirements (LIA median 107 [IQR 100 to 268]âmg versus nerve block median 78 [60 to 98]âmg, Pâ<â0.001). Patient satisfaction, postoperative oral morphine-equivalents and resting pain levels were comparable between groups. Anaesthesia induction time was reduced in LIA patients (LIA 10âmin versus nerve block 35âmin, 95% CI of difference 13 to 38âmin, Pâ<â0.001). CONCLUSION: Both analgesic regimens allow early mobilisation after TKA with high patient satisfaction. LIA shortened peri-operative time. Further research is required to optimise especially pain control during the later postoperative period with LIA. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT03114306.
Assuntos
Anestesia Local , Artroplastia do Joelho/efeitos adversos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Satisfação do Paciente , Idoso , Anestésicos Locais/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Nervo Isquiático/diagnóstico por imagem , Nervo Isquiático/efeitos dos fármacos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
We describe a case of Q-fever endocarditis with severe destruction of the aortic valve with perivalvular abscess formation and cardiac failure. The patient needed urgent operative treatment and postoperative critical care. All specimens sent for microbiological examination were negative. Molecular analysis, including fluorescence in situ hybridization of aortic valve tissue combined with PCR and sequencing, led to the correct diagnosis and to appropriate anti-infective treatment. The patient subsequently recovered from complex cardiovascular surgery. This is the first report on Q-fever endocarditis that was rapidly diagnosed using these methods.
Assuntos
Valva Aórtica , Coxiella burnetii , Endocardite Bacteriana , Doenças das Valvas Cardíacas , Técnicas de Diagnóstico Molecular/métodos , Febre Q , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/microbiologia , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/diagnóstico por imagem , Endocardite Bacteriana/microbiologia , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/microbiologia , Humanos , Hibridização in Situ Fluorescente , Masculino , Pessoa de Meia-Idade , Febre Q/diagnóstico , Febre Q/microbiologiaRESUMO
BACKGROUND: To identify anatomical structures using sonography can be challenging, yet it is a basic requirement for effective and safe ultrasound guided nerve blocks. In clinical routine, we find a wide variety in the visibility of anatomical structures. Aim of this study was to evaluate the feasibility of a newly developed visibility score for anatomical structures in ultrasound guided regional anesthesia. METHODS: We retrospectively evaluated the blockades from the routine documentation of ultrasound-guided regional anesthesia over an arbitrary period of 15 months at a university hospital with a Visibility Score (VIS) of one (best) to five (worst visibility). RESULTS: The study analyzed 983 blockades (femoral, saphenous, infragluteal and popliteal sciatic, transversus abdominis plane, interscalene, supraclavicular, axillary and suprascapular blockades). The following VIS were found: 1: 80.6%; 2: 14.0%; 3: 4.0%; 4: 1.2%; 5: 0.2%. The mean Body Mass Index (BMI) was 27.9 kg/m2. The best cut-off for poor VIS was a BMI of 28.9 kg/m2
Assuntos
Anestesia por Condução , Bloqueio Nervoso , Humanos , Estudos Retrospectivos , Ultrassonografia , Ultrassonografia de IntervençãoRESUMO
BACKGROUND: In patients with hemodynamic instability echocardiography has been recommended as the preferred modality to evaluate the underlying pathophysiology. However, due to the fact that recent scientific data on the utilization of echocardiography in German Intensive Care Units (ICU) are scarce, we sought to investigate current practice. METHODS: A structured, web-based, anonymized survey was performed from May until July 2015 among members of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) consisting of 14 questions. Descriptive data analysis was performed. RESULTS: One hundred four intensivists participated in the survey. Two-thirds of participants (66%) used echocardiography regularly for hemodynamic monitoring and stated that it changed the therapy in 26-50% of the cases irrespective of the time performed after ordering the examination. Transthoracic (TTE) were more frequently used than transesophageal (TEE) examinations. Twenty-six percent of the participants held an echocardiography certificate with a formal examination, 27% completed a structured training without an examination and almost half of the questioned ICU personnel (47%) did not complete a comprehensive training. CONCLUSIONS: The results of this survey demonstrate a widespread utilization of echocardiography as part of routine diagnostic on frequent number of operative ICUs. However, there might be a lack of structured echocardiographic training especially for anesthesiologists.
Assuntos
Cuidados Críticos , Ecocardiografia/estatística & dados numéricos , Medicina de Emergência , Padrões de Prática Médica , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Cuidados Críticos/métodos , Alemanha , Pesquisas sobre Atenção à Saúde , Humanos , Unidades de Terapia Intensiva , InternetRESUMO
Regional plexus and nerve blocks are a common technique in modern anesthesia. Since ultrasound machines are available in many departments, the role of nerve stimulation is highly discussed and different approaches to perform the blocks are taken into account. Common technique for electrical nerve stimulation is searching for a stimulating threshold of 0.4-0.5mA using an impulse width of 0.1ms. We present our hypothesis of using all possible information with a new concept of protective nerve stimulation together with first data supporting our theory. In protective nerve stimulation during ultrasound guided nerve blocks a fixed current of 1.0mA (0.1ms) is used without any change during block performance. The aim is no muscular twitches before and during injection. If this way of neuro-axial blocking brings suitable effects, we should consider new currency settings to perform safer blockades with a lower risk of nerve injuries and a high patient comfort, especially in bad visibility block situations.