Live stream of prehospital point-of-care ultrasound during cardiopulmonary resuscitation - A feasibility trial.

BACKGROUND: Current resuscitation guidelines recommend that skilled persons could use ultrasound to detect reversible causes during cardiopulmonary resuscitation (CPR) where the examination can be safely integrated into the Advanced Life Support (ALS) algorithm. However, in a prehospital setting performing and rapidly interpreting ultrasound can be challenging for physicians. Implementing remote, expert-guided, and real-time transmissions of ultrasound examinations offers the opportunity for tele-support, even during an out-of-hospital cardiac arrest (OHCA). The aim of this feasibility study was to evaluate the impact of tele-supported ultrasound in ALS on hands-off time during an OHCA. METHODS: In an urban setting, physicians performed point-of-care ultrasound (POCUS) on patients during OHCA using a portable device, either with tele-support (n = 30) or without tele-support (n = 12). Where tele-support was used, the ultrasound image was transmitted via a remote real-time connection to an on-call specialist in anaesthesia and intensive care medicine with an advanced level of critical care ultrasound expertise. The primary safety endpoint of this study was to evaluate whether POCUS can be safely integrated into the algorithm, and to provide an analysis of hands-off time before, during, and after POCUS during OHCA. RESULTS: In all 42 cases it was possible to perform POCUS during regular rhythm analyses, and no additional hands-off time was required. In 40 of these 42 cases, the physicians were able to perform POCUS during a single regular rhythm analysis, with two periods required only in two cases. The median hands-off time during these rhythm analyses for POCUS with tele-support was 10 (8-13) seconds, and 11 (9-14) seconds for POCUS without tele-support. Furthermore, as a result of POCUS, in a quarter of all cases the physician on scene altered their diagnosis of the primary suspected cause of cardiac arrest, leading to a change in treatment strategy. CONCLUSIONS: This feasibility study demonstrated that POCUS with tele-support can be safely performed during OHCA in an urban environment. Trial Registration (before patient enrolment): ClinicalTrials.gov, NCT04817475.

Ultrasound-guided cannulation of the great saphenous vein at the ankle in infants.

BACKGROUND: The establishment of peripheral venous access in infants is the most common invasive technique in paediatric anaesthesia. Venous puncture can be challenging due to the small size of vessels in this patient population. The present study was designed to investigate the practicability of ultrasound-guided vascular access to the great saphenous vein (GSV) at the level of the medial malleolus in infants ≤ 12 months. METHODS: Ninety consecutive infants ≤ 12 months undergoing elective surgery were included in this prospective study and divided into two age groups (0-6 and 7-12 months). After anaesthesia induction with sevoflurane, an ultrasound investigation of both GSVs at the level of the medial malleoli was performed. Subsequently, venous access in one GSV was established under direct ultrasound control. Anatomical ultrasound data and success rates of venous accesses were analysed. RESULTS: While not deeper relative to the skin, the GSV was significantly larger in older infants. The success rate in infants ≤ 6 months was 96%, whereas in older infants, the success rate was 100%. The overall success rate in all infants was 98%. CONCLUSIONS: Ultrasound facilitates venous puncture of the GSV in the vast majority of infants ≤ 12 months. Direct visualization via ultrasound is a promising technique for the establishment of venous access in the GSV at the level of the medial malleolus in infants.

Ultrasound assessment of cranial spread during caudal blockade in children: effect of the speed of injection of local anaesthetics.

BACKGROUND: Despite caudal blockade being the most widely used regional anaesthetic procedure for infants and children undergoing subumbilical surgery, the question whether the injection velocity of the local anaesthetic itself affects its spread in the epidural space has not yet been investigated. Thus, the aim of the present study was to measure the cranial spread of caudally administered local anaesthetics in infants and children by means of real-time ultrasonography, with a special focus on comparing the effect of using two different speeds of injection. METHODS: Fifty ASA I-II infants and children, aged up to 6 yr, weighing up to 25 kg, undergoing subumbilical surgery, were enrolled in this prospective, randomized, observer-blinded study. Caudal blockade was performed under ultrasound observation using ropivacaine 1 ml kg(-1) 0.2% or 0.35% and an injection given at either 0.25 ml s(-1) or 0.5 ml s(-1), respectively. RESULTS: Ultrasound observation of the local anaesthetic flow and the extent of cranial spread was possible in all patients. All caudal blocks were considered successful, and all surgical procedures could be completed without any indications of insufficient analgesia. No statistically significant difference could be observed between the two injection speeds regarding the cranial spread of the local anaesthetic in the epidural space. CONCLUSIONS: The main finding of the present study is that the speed of injection of the local anaesthetic does not affect its cranial spread during caudal blockade in infants and children. Therefore, the prediction of the cranial spread of the local anaesthetic, depending on the injection speed, is not possible.

Tell Us! A survey of public opinion on how to deal with COVID-19 risks and subsequent harm.

SETTING: The COVID-19 pandemic has impacted all of us in many areas of life due to mitigation measures, delays in medical care, or the disease itself. When it concerns issues as complex and universal as COVID-19, the public should also have a say in how to deal with managing its impact. DESIGN: In a widely distributed online questionnaire, members of the Austrian public were invited to contribute experiences, ideas and opinions on the level of risk they were willing to accept regarding COVID-19. The huge variety of responses were categorised by social scientists into groups used in a workshop to draw up recommendations for responding to future challenges to the healthcare system from an interdisciplinary point of view. RESULTS: The results of the survey indicated that while members of the public are primarily afraid of illnesses caused by COVID-19, they also fear the psychological burden and effects at the societal level. CONCLUSION: Our study has shown that there is a significant public desire to have a say in issues which directly impact citizens.

CONTEXTE: La pandémie de COVID-19 a eu un impact sur chacun d'entre nous dans de nombreux domaines de la vie en raison des mesures d'atténuation, des retards dans les soins médicaux ou de la maladie elle-même. Lorsqu'il s'agit de questions aussi complexes et universelles que la COVID-19, le public devrait également avoir son mot à dire sur la façon de gérer son impact. MÉTHODE: Dans un questionnaire en ligne largement diffusé, les membres du public autrichien ont été invités à faire part de leurs expériences, idées et opinions sur le niveau de risque qu'ils étaient prêts à accepter concernant le COVID-19. La grande variété des réponses a été classée par des spécialistes en sciences sociales dans des groupes utilisés lors d'un atelier pour élaborer des recommandations visant à répondre aux futurs défis du système de santé d'un point de vue interdisciplinaire. RÉSULTATS: Les résultats de l'enquête ont indiqué que si les membres du public craignent avant tout les maladies causées par le COVID-19, ils craignent également le fardeau psychologique et les effets au niveau de la société. CONCLUSION: Notre étude a montré qu'il existe un désir significatif du public d'avoir son mot à dire sur les questions qui ont un impact direct sur les citoyens.

Does regional anaesthesia really improve outcome?

In recent decades, a number of studies have attempted to determine whether regional anaesthesia offers convincing benefits over general anaesthesia. However, today we interpret meta-analyses more carefully, and it remains unclear whether regional anaesthesia reduces mortality. However, regional anaesthesia offers superior analgesia over opioid-based analgesia, and a significant reduction in postoperative pain is still a worthwhile outcome. Recent developments in technical aspects of regional anaesthesia have the potential to provide significant advantages for many patients in all age groups. Moreover, studies focusing on specific outcomes have shown benefits for regional anaesthesia used for surgery and postoperative analgesia.

Ultrasound assessment of cranial spread during caudal blockade in children: the effect of different volumes of local anaesthetics.

BACKGROUND: Despite the large amount of literature on caudal anaesthesia in children, the issue of volume of local anaesthetics and cranial spread is still not settled. Thus, the aim of the present prospective randomized study was to evaluate the cranial spread of caudally administered local anaesthetics in children by means of real-time ultrasound, with a special focus on the effects of using different volumes of local anaesthetics. METHODS: Seventy-five children, 1 month to 6 yr, undergoing inguinal hernia repair or more distal surgery were randomized to receive a caudal block with 0.7, 1.0, or 1.3 ml kg(-1) ropivacaine. The cranial spread of the local anaesthetic within the spinal canal was assessed by real-time ultrasound scanning; the absolute cranial segmental level and the cranial level relative to the conus medullaris were determined. RESULTS: All the blocks were judged to be clinically successful. A significant correlation was found between the injected volume and the cranial level reached by the local anaesthetic both with regards to the absolute cranial segmental level and the cranial level relative to the conus medullaris. CONCLUSIONS: The main finding of the present study was positive, but numerically small correlation between injected volumes of local anaesthetic and the cranial spread of caudally administered local anaesthetics. Therefore, the prediction of the cranial spread of local anaesthetic, depending on the injected volume of the local anaesthetic, was not possible. EudraCT Number: 2008-007627-40.

Fifteen years of ultrasound guidance in regional anaesthesia: Part 2-recent developments in block techniques.

The use of ultrasound guidance for regional anaesthesia has gained enormous popularity in the last 10 yr. The first part of this review article provided information on safety, technical developments, economic aspects, education, advantages, needle guidance techniques, and future developments in ultrasound. The second part focuses on practical and technical details of individual ultrasound-guided nerve blocks in adults. We present a comprehensive review of the relevant literature of the last 5 yr with a commentary based on our own clinical experience in order to provide information relevant to patient management. Upper limb blocks, including interscalene, supra- and infraclavicular, and axillary approaches, are described and discussed. For the lower limb, psoas compartment, femoral, obturator, sciatic, and lateral cutaneous nerve blocks are described, as are some abdominal wall blocks. The potential role of ultrasound guidance for neuraxial block is addressed. The need for further large-scale studies of the role of ultrasound is emphasized.

Caudal anaesthesia under sedation: a prospective analysis of 512 infants and children.

BACKGROUND: Caudal anaesthesia is a common procedure for infants and children undergoing subumbilical surgery, mostly performed in conjunction with general anaesthesia. Even if complications are rare, the risk of postoperative apnoea is significant, especially in infants born preterm or operated upon before 46 weeks of post-conceptual age. Caudal block in sedated, spontaneously breathing patients might be a safe alternative. METHODS: We investigated 512 infants and children. Premedication consisted of midazolam, sedation was induced with i.v. nalbuphine 0.1 mg kg(-1) and propofol 1 mg kg(-1), and maintained with propofol 5 mg kg(-1) h(-1) in children, if necessary. Caudal block was performed with ropivacaine 1 ml kg(-1) (0.2% or 0.35%). RESULTS: Data were obtained from 228 infants and 284 children. Median (IQR) age was 1.3 (0.2, 3.4) yr; median body weight was 10.0 (4.8, 15.3) kg. Two hundred and thirty-three (45.51%) were born preterm and 47 (9.18%) were operated upon before 46 weeks of post-conceptual age. Caudal block was successful in 98.05% and adverse events occurred in 7.03% patients. The incidence of adverse events was not higher in born preterm or operated upon before 46 weeks of post-conceptual age than in term born infants (P=0.35 and 0.35, respectively), or in infants vs children (P=0.61). There was no correlation between the incidence of adverse events and continuous sedation (P=0.07), coexisting diseases (P=0.11), or ASA classification (P=0.33). CONCLUSIONS: Caudal anaesthesia under sedation is associated with high success rates and a low incidence of adverse events, but requires careful and anticipatory perioperative management.

Current trends in paediatric regional anaesthesia.

Regional anaesthesia is a cornerstone in paediatric anaesthesia today. Many paediatric anaesthetists include regional anaesthetic techniques in their daily clinical practice to provide superior and long-lasting analgesia without the risk of respiratory depression. The first part this article reviews new scientific findings in the field of paediatric regional anaesthesia. The second part focuses on safety aspects and on the impact of ultrasound on paediatric regional anaesthesia.

Effect of brain magnetic resonance imaging on body core temperature in sedated infants and children.

BACKGROUND: Children undergoing magnetic resonance imaging (MRI) under sedation are at risk of hypo- or hyperthermia. The effect of brain MRI at differing magnetic field strengths on body core temperature in sedated infants and young children has not been reported previously. METHODS: Two groups of 38 infants and children (aged 1 month to 6 yr 5 months) underwent brain MRI for different indications related to cerebral diseases, at 1.5 Tesla (T) and 3 T MRI units, respectively. All patients received deep sedation comprising midazolam, nalbuphine, and propofol. Pre-scan and post-scan temperatures were measured at the right tympanic and at rectal sites. No active warming devices were used during the procedures. RESULTS: Body core temperature measurements were similar between right tympanic and rectal site before and after the scans. After 1.5 T scans, the median (IQR) increase from pre-scan to post-scan tympanic temperature was 0.2 degrees C (0.1-0.3), and the median (IQR) rectal temperature increase was 0.2 degrees C (0-0.3) (P<0.001). After 3 T scans, the median (IQR) tympanic temperature increase was 0.5 degrees C (0.4-0.7), and the median (IQR) rectal temperature increase was 0.5 degrees C (0.3-0.6) (P<0.001). CONCLUSIONS: Body core temperature increased significantly during 1.5 and 3 T examinations; this increase was more profound during 3 T MRI. Patient heating occurred despite minimal efforts to reduce passive heat loss under sedation and without the use of warming devices.

A new instrument for pain assessment in the immediate postoperative period.

Perceptual-cognitive impairment after general anaesthesia may affect the ability to reliably report pain severity with the standard visual analog scale (VAS). To minimise these limitations, we developed 'PAULA the PAIN-METER' (PAULA): it has five coloured emoticon faces on the forefront, it is twice as long as a standard VAS scale, and patients use a slider to mark their pain experience. Forty-eight postoperative patients rated descriptive pain terms on PAULA and on a standard VAS immediately after admission and before discharge from the postanaesthesia care unit. Visual acuity was determined before both assessments. The values obtained with PAULA showed less variance than those obtained with the standard VAS, even at the first assessment, where only 23% of the patients had regained their visual acuity. Furthermore, the deviations of the absolute VAS values in individual patients for each descriptive pain term were significantly smaller with PAULA than with the standard VAS.

Propofol-based sedation regimen for infants and children undergoing ambulatory magnetic resonance imaging.

BACKGROUND: Propofol is widely used for infants and children requiring sedation for magnetic resonance imaging. However, increased doses of propofol may quickly lead to an unintended deep sedation and respiratory depression. Thus, an appropriate low dosage, which nevertheless ensures sufficient sleep for successful magnetic resonance imaging (MRI) completion, would probably minimize respiratory adverse events. We investigated the safety and efficacy of a low-dose propofol-based sedation regimen in a broad age range of children. METHODS: We investigated 500 infants and children, prospectively. Premedication consisted of i.v. midazolam 0.1 mg kg(-1). Sedation was induced with i.v. nalbuphine 0.1 mg kg(-1) and propofol 1 mg kg(-1), and maintained with propofol 5 mg kg(-1) h(-1). Outcome measures were induction time, sedation time, recovery time, need for additional sedation, respiratory events, cardiovascular events, paradoxical reactions, and sedation failure. RESULTS: Data were obtained from 53 infants and 447 children. Median (IQR) age was 5.3 (4.5, 6.1) yr and body weight was 19.3 (16.5, 24.7) kg. The induction time was 2 (1, 2) min, sedation time 55 (45, 65) min, and recovery time 8 (8, 9) min. Additional sedation was necessary in 11 patients (2.2%), mild respiratory events occurred in five patients (1%). All MRI examinations could be completed without paradoxical reaction or sedation failure. CONCLUSION: This sedation regimen provides the shortest induction time so far described, a rare demand for additional sedation, a low incidence of respiratory events, and a rapid recovery.

Ultrasonographic-guided ilioinguinal/iliohypogastric nerve block in pediatric anesthesia: what is the optimal volume?

Recently, our study group demonstrated the usefulness of ultrasonographic guidance in ilioinguinal/iliohypogastric nerve blocks in children. As a consequence, we designed a follow-up study to evaluate the optimal volume of local anesthetic for this regional anesthetic technique. Using a modified step-up-step-down approach, with 10 children in each study group, a starting dose of 0.2 mL/kg of 0.25% levobupivacaine was administered to perform an ilioinguinal/iliohypogastric nerve block under ultrasonographic guidance. After each group of 10 patients, the results were analyzed, and if all blocks were successful, the volume of local anesthetic was decreased by 50%, and a further 10 patients were enrolled into the study. Failure to achieve a 100% success rate within a group subjected patients to an automatic increase of half the previous volume reduction to be used in the subsequent group. Using 0.2 and 0.1 mL/kg of 0.25% levobupivacaine, the success rate was 100%. With a volume of 0.05 mL/kg of 0.25% levobupivacaine, 4 of 10 children received additional analgesia because of an inadequate block. Therefore, according to the protocol, the amount was increased to 0.075 mL/kg of 0.25% levobupivacaine, where the success rate was again 100%. We conclude that ultrasonographic guidance for ilioinguinal/iliohypogastric nerve blocks in children allowed a reduction of the volume of local anesthetic to 0.075 mL/kg.

Ultrasonographic guidance for sciatic and femoral nerve blocks in children.

BACKGROUND: Recent studies have shown that ultrasound guidance for paediatric regional anaesthesia can improve the quality of upper extremity and neuraxial blocks. We therefore investigated whether ultrasound guidance for sciatic and femoral nerve blocks prolongs sensory blockade in comparison with nerve stimulator guidance in children. METHODS: Forty-six children scheduled for surgery of one lower extremity were randomized to receive a sciatic and femoral nerve block under either ultrasound or nerve stimulator guidance. After induction of general anaesthesia, the blocks were performed using an ultrasound-guided multiple injection technique until the nerves were surrounded by levobupivacaine, or by nerve stimulator guidance using a predefined dose of 0.3 ml kg(-1) of levobupivacaine. An increase in heart rate of more than 15% of baseline during surgery defined a failed block. The duration of the block was determined from the injection of local anaesthetic to the time when the patient received the first postoperative analgesic. RESULTS: Two blocks in the nerve stimulator group failed. There were no failures in the ultrasound group. The duration of analgesia was longer in the ultrasound group mean (sd) 508 (178) vs 335 (169) min (P < 0.05). The volume of local anaesthetic in sciatic and femoral nerve blocks was reduced with ultrasound compared with nerve stimulator guidance [0.2 (0.06) vs 0.3 ml kg(-1) (P < 0.001) and 0.15 (0.04) vs 0.3 ml kg(-1) (P < 0.001), respectively]. CONCLUSIONS: Ultrasound guidance for sciatic and femoral nerve blocks in children increased the duration of sensory blockade in comparison with nerve stimulator guidance. Prolonged sensory blockade was achieved with smaller volumes of local anaesthetic when using ultrasound guidance.

Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss-of-resistance technique.

BACKGROUND: We report a prospective, randomized study to evaluate ultrasound guidance for epidural catheter placement in children 0-6 yr of age. METHODS: Epidural catheters were placed at lumbar or thoracic cord levels in 64 children undergoing major surgery, using either ultrasonography or loss-of-resistance (LOR) for guidance. Using a 5-10 MHz linear ultrasound probe, the neuraxial structures were identified, the skin-epidural depth and epidural space was measured, the advancing epidural catheter visualized, and the spread of local anaesthetic verifying catheter position was confirmed. Epidural placement procedures were analysed for bone contacts and speed of execution. Children under 6 months were analysed separately. RESULTS: Epidural placement involved bone contacts in 17% of children in the ultrasound group and 71% of children in the LOR group (P<0.0001). Epidurals were executed more swiftly in the ultrasound group [162 (75) s vs 234 (138) s; P<0.01]. Children under 6 months revealed a 0.9 correlation between skin-epidural depth and body weight. CONCLUSIONS: Ultrasonography is a useful aid to verify epidural placement of local anaesthetic agents and epidural catheters in children. Advantages include a reduction in bone contacts, faster epidural placement, direct visualization of neuraxial structures and the spread of local anaesthetic inside the epidural space. Ultrasound guidance requires additional training and good manual skills, and should only be used once experience in ultrasound-guided techniques of regional anaesthesia has been acquired.

Ultrasonography-guided rectus sheath block in paediatric anaesthesia--a new approach to an old technique.

BACKGROUND: The purpose of this study was an anatomical and clinical evaluation of ultrasonography-guided rectus sheath blocks in children. METHOD: A total of 30 children were included in the sono-anatomical part of the study. The depth of the anterior and posterior rectus sheath was evaluated with a portable SonSite 180 plus ultrasound machine and a 5-10 MHz linear probe. In total, 20 consecutive children undergoing umbilical hernia repair were included in the clinical part of this study. After induction of general anaesthesia children received a rectus sheath block under real-time ultrasonographic guidance by placing 0.1 ml kg(-1) bilaterally in the space between the posterior aspect of the sheath and the rectus abdominis muscle. RESULTS: Ultrasonographic visualization of the posterior rectus sheath was possible in all children. The correlation between the depth of the posterior rectus sheath and weight (adjusted r(2)=0.175), height (adjusted r(2)=0.314) and body surface area (adjusted r(2)=0.241) was poor. The ultrasound-guided rectus sheath blockade provided sufficient analgesia in all children with no need for additional analgesia in the perioperative period. CONCLUSION: The bilateral placement of levobupivacaine 0.25% 0.1 ml kg(-1) in the space between the posterior aspect of the rectus sheath and the rectus abdominis muscle under real-time ultrasonographic guidance provides sufficient analgesia for umbilical hernia repair. The unpredictable depth of the posterior rectus sheath in children is a good argument for the use of ultrasonography in this regional anaesthetic technique in children.

Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children.

BACKGROUND: The ilioinguinal/iliohypogastric nerve block is a popular regional anaesthetic technique for children undergoing inguinal surgery. The success rate is only 70-80% and complications may occur. A prospective randomized double-blinded study was designed to compare the use of ultrasonography with the conventional ilioinguinal/iliohypogastric nerve block technique. METHODS: One hundred children (age range, 1 month-8 years) scheduled for inguinal hernia repair, orchidopexy or hydrocele repair were included in the study. Following induction of general anaesthesia, the children received an ilioinguinal/iliohypogastric block performed either under ultrasound guidance using levobupivacaine 0.25% until both nerves were surrounded by the local anaesthetic or by the conventional 'fascial click' method using levobupivacaine 0.25% (0.3 ml kg(-1)). Additional intra- and postoperative analgesic requirements were recorded. RESULTS: Ultrasonographic visualization of the ilioinguinal/iliohypogastric nerves was possible in all cases. The amount of local anaesthetic used in the ultrasound group was significantly lower than in the 'fascial click' group (0.19 (SD 0.05) ml kg(-1) vs 0.3 ml kg(-1), P<0.0001). During the intraoperative period 4% of the children in the ultrasound group received additional analgesics compared with 26% in the fascial click group (P=0.004). Only three children (6%) in the ultrasound-guided group needed postoperative rectal acetaminophen compared with 20 children (40%) in the fascial click group (P<0.0001). CONCLUSIONS: Ultrasound-guided ilioinguinal/iliohypogastric nerve blocks can be achieved with significantly smaller volumes of local anaesthetics. The intra- and postoperative requirements for additional analgesia are significantly lower than with the conventional method.

The effect of hydroxyethyl starch 200 kD on platelet function.

We evaluated the effects of hydroxyethyl starch with a molecular weight of 200 kD (HES 200 kD) on platelets to gain insight into the potential mechanisms involved in the anticoagulant effects of HES 200 kD. Blood was obtained before and after an IV infusion (10 mL/kg) of either saline (n = 15) or HES 200 kD (n = 15) in otherwise healthy patients scheduled for minor elective surgery. Flow cytometry was used to assess the expression of glycoprotein (GP) IIb-IIIa, GP Ib, and P-selectin on agonist-activated platelets. Overall platelet function was evaluated by assessing thromboelastographic maximum amplitude (MA) in celite-activated blood and platelet function analyzer-closure times by using collagen/adenosine diphosphate cartridges. Saline infusion had no effects on platelet variables, whereas HES 200 kD reduced GP IIb-IIIa expression and MA and prolonged platelet function analyzer-closure times, without affecting the expression of P-selectin and GP Ib. In vitro experiments extended these observations by a concentration-related inhibiting effect of HES 200 kD on GP IIb-IIIa expression. This study demonstrates that cellular abnormalities with decreased availability of platelet GP IIb-IIIa are involved in the anticoagulant effects of HES 200 kD.