The Influence of Different Treatment Combinations on Skin Laxity and Dimpling.

OBJECTIVE: The aim of the study was to identify the effectiveness of the combination of tissue stabilized guided subcision, microfocused ultrasound, and minimally invasive calcium hydroxylapatite injections in various sequences for treating skin surface irregularities of the buttocks and thighs. MATERIAL AND METHODS: 61 females (body mass index: 22.6 ± 2.4 kg/m², age: 37.2 ± 6.8 years) were enrolled in this randomized interventional prospective study. Treatment arms included a variable combination and sequence of three treatment modalities: (1) Tissue-stabilized guided subcision, (2) microfocused ultrasound, and (3) calcium hydroxylapatite injections. Six months after the final intervention skin laxity and skin dimpling severity scores were assessed by the study participants, the treating physicians and by eleven blinded independent board-certified experts. RESULTS: No adverse events were observed during the study that required intervention outside the standard of care treatment protocol. The combination of three treatment modalities was shown to provide greater improvement in skin laxity 1.88 (95% CI, 0.66–5.37) and skin dimpling 1.31 (95% CI, 0.61–2.81) scores as compared to any combination of two modalities. The combination of concomitant microfocused ultrasound and calcium hydroxylapatite injections followed three months later by tissue stabilized guided subcision yielded the greatest improvement in skin laxity 2.23 (95% CI, 0.51–9.82) and skin dimpling 1.79 (95% CI, 0.67–4.78) at 9-month follow-up. CONCLUSION: This study provides evidence for the effectiveness of combination therapies for the improvement of skin surface irregularities on the buttocks and thighs. J Drugs Dermatol. 2020;19(11): 1030-1038. doi:10.36849/JDD.2020.5117.

Extracorporeal CO2 removal as bridge to lung transplantation in life-threatening hypercapnia.

In patients awaiting lung transplantation (LTX), adequate gas exchange may not be sufficiently achieved by mechanical ventilation alone if acute respiratory decompensation arises. We report on 20 patients with life-threatening hypercapnia who received extracorporeal CO2 removal (ECCO2-R) by means of the interventional lung assist (ILA®, Novalung) as bridge to LTX. The most common underlying diagnoses were bronchiolitis obliterans syndrome, cystic fibrosis, and idiopathic pulmonary fibrosis, respectively. The type of ILA was pumpless arteriovenous or pump-driven venovenous (ILA activve®, Novalung) in 10 patients each. ILA bridging was initiated in 15 invasively ventilated and five noninvasively ventilated patients, of whom one had to be intubated prior to LTX. Hypercapnia and acidosis were effectively corrected in all patients within the first 12 h of ILA therapy: PaCO2 declined from 109 (70-146) to 57 (45-64) mmHg, P < 0.0001; pH increased from 7.20 (7.06-7.28) to 7.39 (7.35-7.49), P < 0.0001. Four patients were switched to extracorporeal membrane oxygenation due to progressive hypoxia or circulatory failure. Nineteen patients (95%) were successfully transplanted. Hospital and 1-year survival was 75 and 72%, respectively. Bridging to LTX with ECCO2-R delivered by arteriovenous pumpless or venovenous pump-driven ILA is feasible and associated with high transplantation and survival rates.

Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial.

OBJECTIVE: To determine which bedside method of detecting inadvertent endobronchial intubation in adults has the highest sensitivity and specificity. DESIGN: Prospective randomised blinded study. SETTING: Department of anaesthesia in tertiary academic hospital. PARTICIPANTS: 160 consecutive patients (American Society of Anesthesiologists category I or II) aged 19-75 scheduled for elective gynaecological or urological surgery. INTERVENTIONS: Patients were randomly assigned to eight study groups. In four groups, an endotracheal tube was fibreoptically positioned 2.5-4.0 cm above the carina, whereas in the other four groups the tube was positioned in the right mainstem bronchus. The four groups differed in the bedside test used to verify the position of the endotracheal tube. To determine whether the tube was properly positioned in the trachea, in each patient first year residents and experienced anaesthetists were randomly assigned to independently perform bilateral auscultation of the chest (auscultation); observation and palpation of symmetrical chest movements (observation); estimation of the position of the tube by the insertion depth (tube depth); or a combination of all three (all three). MAIN OUTCOME MEASURES: Correct and incorrect judgments of endotracheal tube position. RESULTS: 160 patients underwent 320 observations by experienced and inexperienced anaesthetists. First year residents missed endobronchial intubation by auscultation in 55% of cases and performed significantly worse than experienced anaesthetists with this bedside test (odds ratio 10.0, 95% confidence interval 1.4 to 434). With a sensitivity of 88% (95% confidence interval 75% to 100%) and 100%, respectively, tube depth and the three tests combined were significantly more sensitive for detecting endobronchial intubation than auscultation (65%, 49% to 81%) or observation(43%, 25% to 60%) (P<0.001). The four tested methods had the same specificity for ruling out endobronchial intubation (that is, confirming correct tracheal intubation). The average correct tube insertion depth was 21 cm in women and 23 cm in men. By inserting the tube to these distances, however, the distal tip of the tube was less than 2.5 cm away from the carina (the recommended safety distance, to prevent inadvertent endobronchial intubation with changes in the position of the head in intubated patients) in 20% (24/118) of women and 18% (7/42) of men. Therefore optimal tube insertion depth was considered to be 20 cm in women and 22 cm in men. CONCLUSION: Less experienced clinicians should rely more on tube insertion depth than on auscultation to detect inadvertent endobronchial intubation. But even experienced physicians will benefit from inserting tubes to 20-21 cm in women and 22-23 cm in men, especially when high ambient noise precludes accurate auscultation (such as in emergency situations or helicopter transport). The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements. TRIAL REGISTRATION: NCT01232166.

Spinal versus general anesthesia for orthopedic surgery: anesthesia drug and supply costs.

Total hip or knee replacement surgeries are common orthopedic interventions that can be performed with spinal anesthesia (SA) or general anesthesia (GA). No study has investigated the economic aspects associated with the two anesthetic techniques for this common surgery. We randomized 40 patients to receive either SA or GA and analyzed the drug and supply costs for anesthesia und recovery. Anesthesia-related times, hemodynamic variables, and pain scores were also recorded. Total costs per case without personnel costs were almost half in the SA group compared with the GA group; this was a result of less cost for anesthesia (P < 0.01) and for recovery (P < 0.05). This finding was supported by a sensitivity analysis. There were no relevant differences regarding anesthesia-related times. Patients in the GA group were admitted to the postanesthesia care unit with a higher pain score and needed more analgesics than patients in the SA group (both P < 0.01). We conclude that SA is a more cost-effective alternative to GA in patients undergoing hip or knee replacement, as it is associated with lower fixed and variable costs. Moreover, SA seems to be more effective, as patients in the SA group showed lower postoperative pain scores during their stay in the postanesthesia care unit.

Pilot study of neuraxial imaging by ultrasound in infants and children.

BACKGROUND: Ultrasonography is becoming an important adjunct in regional anesthesia. Epidural anesthesia may pose significant challenges in infants and children because of difficulties in identifying the epidural space. In addition, epidural catheters are sometimes difficult to advance. The present study was performed to evaluate an optimal ultrasound technique for direct visualization of neuraxial structures in children. METHODS: A total of 32 infants and children scheduled for minor surgery were prospectively included in a high-resolution ultrasound study. Scans were performed using either a sector or linear probe and views from a longitudinal paramedian, median and transversal angle at lumbar and thoracic levels of the spinal cord were analyzed. RESULTS: In all children investigated, the linear probe generated better images than the sector probe. Of the various scanning perspectives, the paramedian longitudinal approach offered the best views at both cord levels. Broken down by age groups, the best visibility was clearly obtained in neonates up to 3 months of age (P < 0.0001 Vs all other age groups). In older children, the quality of ultrasound decreased in an age-dependent manner. CONCLUSIONS: Paramedian longitudinal scans with linear probes are the most favorable method of imaging neuraxial anatomy at lumbar and thoracic cord levels in infants and children, with the best results in neonates up to 3 months of age. Based on these results, and using real time imaging, a practical technique for ultrasound-guided epidural anesthesia for neonates and infants at lumbar and thoracic levels of the spinal cord is planned.

Caudal clonidine prolongs analgesia from caudal S(+)-ketamine in children.

UNLABELLED: We performed a prospective randomized double-blinded study to test preservative-free S(+)-ketamine alone or in combination with clonidine for intra- and postoperative caudal blockade in pediatric surgery over a 24-h period. Fifty-three children (1-72 mo) scheduled for inguinal hernia repair were caudally injected with either S(+)-ketamine 1 mg/kg alone (Group K) or with additional clonidine (Group C1 = 1 microg/kg; Group C2 = 2 microg/kg) during sevoflurane anesthesia via a laryngeal mask. Intraoperative monitoring included heart rate, blood pressure, and pulse oximetry; postoperative monitoring included a pain discomfort scale and a sedation score. No additional analgesic drugs were required during surgery. The mean duration of postoperative analgesia was 13.3 +/- 9.2 h in Group K, 22.7 +/- 3.5 h in Group C1, and 21.8 +/- 5.2 h in Group C2 (P < 0.0001, Group K versus other groups). Groups C1 and C2 received significantly fewer analgesics in the postoperative period than Group K (15% and 18% vs 63%; P < 0.01). The three groups had similar postoperative sedation scores. We conclude that the combination of S(+)-ketamine 1 mg/kg with clonidine 1 or 2 microg/kg for caudal blockade in children provides excellent analgesia without side effects over a 24-h period. IMPLICATIONS: Caudally administered preservative-free S(+)-ketamine combined with 1 or 2 microg/kg clonidine provides excellent perioperative analgesia in children and has minimal side effects.