Randomised clinical trial of pilonidal sinus operations performed in the prone position under spinal anaesthesia with hyperbaric bupivacaine 0.5 % versus total intravenous anaesthesia.

PURPOSE: The aim of this randomised clinical trial was to determine whether spinal anaesthesia (SPA) is superior to total intravenous anaesthesia (TIVA) in patients undergoing pilonidal sinus (PS) operations in the prone position. METHODS: After approval of the local ethics committee, suitable patients aged 19-49 years were randomised to SPA (7.5 mg hyperbaric bupivacaine) or TIVA (Propofol and Fentanyl). Cumulative consumption of analgesics, postoperative recovery, complications and patient satisfaction were evaluated. RESULTS: A total of 50 patients were randomised within a 24-month period. Median monitoring time in the recovery room was 0 (0-11) min for SPA versus 40 (5-145) min for TIVA (p < 0.0001). Patients in the SPA group were able to drink (40.5 (0-327) min versus TIVA 171 (72-280) min, p < 0.0001) and eat (55 (0-333) min versus TIVA 220 (85-358), p < 0.0001) earlier. More patients with a TIVA needed analgesics in the recovery room (SPA n = 0 versus TIVA n = 6, p = 0.0023) and suffered more frequently from a sore throat (SPA n = 0 versus TIVA n = 11, p = 0.0001). Two patients with a TIVA suffered from nausea and vomiting. Patients of both groups were equally satisfied with the anaesthesia technique offered. CONCLUSIONS: SPA with 7.5 mg hyperbaric bupivacaine is superior to TIVA in patients undergoing PS operations in the prone position in terms of analgesia consumption in the recovery room, recovery times and postoperative complications.

Influence of the pre-operative time in upright sitting position and the needle type on the incidence of post-dural puncture headache (PDPH) in patients receiving a spinal saddle block for anorectal surgery.

BACKGROUND: A spinal saddle block can be a safe method for anorectal surgery with a low rate of complications when performed with the right technique. A dreaded complication is the post-dural puncture headache (PDPH), which can be decreased by the use of non-cutting spinal needles. Regrettably, cutting Quincke (Q)-type needles are still widely used for economic reasons. Besides size and design of a spinal needle, the pre-operative time in upright sitting position may also influence the incidence of PDPH after spinal saddle block. METHODS: Within 4 months, 363 patients undergoing anorectal surgery in saddle block technique were randomised to receive either a 27-gauge (G) pencil-point (PP) or a 27-G Q spinal needle and were pre-operatively left in upright sitting position for 10 or 30 min, respectively. The incidence of PDPH was assessed 1 week after the operation via a telephone interview. RESULTS: Three hundred sixty three patients (219 males/144 females) were analysed. Fifteen patients (4.1%) developed PDPH. Patients receiving spinal anaesthesia with a Q needle suffered significantly more frequently from PDPH [Q: n = 12 (6.6%) vs. PP: n = 3 (1.7%), p = 0.02], but there was no association between PDPH and pre-operative time in the upright position (p = 0.20). CONCLUSIONS: These data prove that using 27-G PP needles is the method with the fewest side effects caused by spinal saddle block, and suggest that the time spent sitting in the upright position is not clinically relevant.

High incidence of post-dural puncture headache in patients with spinal saddle block induced with Quincke needles for anorectal surgery: a randomised clinical trial.

PURPOSE: Spinal saddle block represents nearly the ideal anaesthesia technique for anorectal surgery. Post-dural puncture headache (PDPH) is a dreaded complication but can be decreased by the use of non-cutting spinal needles to rates less than 1%. Though, cutting Quincke type needles are still widely used for economic reasons, leading to a higher rate of PDPH. We performed this study to demonstrate a reduction of PDPH by the use of very small 29-G compared with commonly used 25-G Quincke type spinal needles. METHODS: Two hundred sixteen adult patients (male/female, 19-83 years, ASA status I-III) were randomised 1:1 to groups, in which either a 25-G or a 29-G Quincke type spinal needle was used for a spinal saddle block. The incidence of PDPH was assessed during 1 week after surgery. RESULTS: Thirty-nine of 216 patients developed PDPH but there was no difference between the two needle sizes (25-G, n = 18/106 vs. 29-G, n = 21/110, p = 0.6870). Women suffered significantly more from PDPH than men (23/86 vs. 16/130, p = 0.0069). Ambulatory patients had a later onset of PDPH than in-patients (24 h [0.5-72] vs. 2 h [0.2-96], p = 0.0002) and the headache was more severe in these patients (NRS 7 [2-10] vs. NRS 3 [1-8], p = 0.0009). CONCLUSIONS: The use of 29-G compared with 25-G Quincke needles led to no reduction of PDPH and is considerably higher compared with data from pencil-point needles. The use of non-cutting or pencil-point spinal needles should become the standard for performing spinal saddle block.

Influence of early defibrillation on the survival rate and quality of life after CPR in prehospital emergency medical service in a German metropolitan area.

Early defibrillation by emergency medical personnel has been shown to improve survival in patients suffering from out-of-hospital cardiac arrest with ventricular fibrillation. Due to organisational differences it is difficult to compare results in various studies. Comparison of studies has been simplified by introduction of the Utstein template. After introduction of an early defibrillation program in Hamburg, we compared the patients being treated with early defibrillation by emergency medical technicians (EMTs) with patients being defibrillated by physicians in an out-of-hospital emergency service in a prospective study. All patients suffered from non EMT-witnessed ventricular fibrillation of cardiac origin. During 1 year, 103 patients were analyzed with respect to survival rate and quality of life. Of the 53 patients in the early defibrillation group (G1) 11 regained a palpable pulse at physicians' arrival, whereas all patients of the control group (G2) showed ventricular fibrillation. More patients treated with early defibrillation regained sinus rhythm without antiarrhythmics in the prehospital phase (G1: n=43 (86%); G2: n=32 (60%); P<0.05) and had a shorter in-hospital stay (G1: median, 23 days; range 5-51 days; G2: median 39, range 15-88 days; P<0.05). Twelve patients in G1 and 16 in G2 were discharged from hospital. The survival rate was similar in both groups (after 6 months G1: n=12; G2: n=14, after 12 months G1: n=10; G2: n=13 and after 24 months G1: n=9; G2: n=10), and the quality of life according to Glasgow-Pittsburgh Cerebral Performance Category (CPC) and Overall Performance Category (OPC) scores also was comparable between groups. We conclude that early defibrillation provides a higher incidence of return of a spontaneous circulation, a reduced need for antiarrhythmics and shorter in-hospital treatment times in patients with out-of-hospital ventricular fibrillation.

Cachexia and pancreatic cancer: are there treatment options?

Cachexia is frequently described in patients with pancreatic ductal adenocarcinoma (PDAC) and is associated with reduced survival and quality of life. Unfortunately, the therapeutic options of this multi-factorial and complex syndrome are limited. This is due to the fact that, despite extensive preclinical and clinical research, the underlying pathological mechanisms leading to PDAC-associated cachexia are still not fully understood. Furthermore, there is still a lack of consensus on the definition of cachexia, which complicates the standardization of diagnosis and treatment as well as the analysis of the current literature. In order to provide an efficient therapy for cachexia, an early and reliable diagnosis and consistent monitoring is required, which can be challenging especially in obese patients. Although many substances have been tested in clinical and preclinical settings, so far none of them have been proven to have a long-term effect in ameliorating cancer-associated cachexia. However, recent studies have demonstrated that multidimensional therapeutic modalities are able to alleviate pancreatic cancer-associated cachexia and ultimately improve patients' outcome. In this current review, we propose a stepwise and pragmatic approach to facilitate and standardize the treatment of cachexia in pancreatic cancer patients. This strategy consists of nutritional, dietary, pharmacological, physical and psychological methods.

Enhanced central organ oxygenation after application of bovine cell-free hemoglobin HBOC-201.

PURPOSE: While the effects of dilutional anemia or isovolemic hemodilution (IHD) on the oxygen extraction and tissue oxygenation in peripheral organs after application of hemoglobin-based oxygen carriers like HBOC-201 have been studied intensively, little is known about tissue oxygenation properties of hemoglobin solutions in central organs like the liver. METHODS: Twelve Foxhounds were anesthetized and then randomized to either a control group without hemodilution (Group 1) or underwent first step isovolemic hemodilution (pulmonary artery occlusion pressure constant) with Ringer's solution (Group 2) to a hematocrit of 25% with second step infusion of HBOC-201 until a hemoglobin concentration of +0.6 g.dL(-1) was reached. Tissue oxygen tensions (tpO2) were measured in the gastrocnemius muscle using a polarographic needle probe, and in the liver using a flexible polarographic electrode. RESULTS: While arterial oxygen content and oxygen delivery decreased with hemodilution in Group 2, global liver and muscle oxygen extraction ratio increased after hemodilution and additional application of HBOC-201. Hemodilution and application of HBOC-201 provided augmentation of the mean liver tpO2 (baseline: 48 +/- 9, 20 min: 53 +/- 10, 60 min: 67 +/- 11*, 100 min: 68 +/- 7*; *P < 0.05 vs baseline and Group 1), while oxygen tensions in Group 1 remained unchanged. Oxygen tension in the skeletal muscle increased after hemodilution and additionally after application of HBOC-201 in comparison to baseline and to the control group (P < 0.05). CONCLUSION: In the present animal model, IHD with Ringer's solution and additional application of HBOC-201 increased oxygen extraction and tpO(2) in the liver and skeletal muscle, in parallel and in comparison with baseline values and a control group.

Pre- and intraoperative epidural ropivacaine have no early preemptive analgesic effect in major gynecological tumour surgery.

PURPOSE: Thoracic epidural analgesia (TEA) is an established technique for postoperative pain relief after major abdominal surgery. However it is still under discussion whether pre-incisional TEA can reduce postoperative pain perception or postoperative analgesic consumption. METHODS: The present prospective, randomized, double-blind study was performed to investigate the effects of intra- and postoperative TEA vs only postoperative TEA using ropivacaine 0.375% in 30 women scheduled for major abdominal tumour surgery. Prior to induction of general anesthesia patients received an epidural bolus of 10 mL saline in Group I (GI) and 10 mL ropivacaine 0.375% in Group II (GII) followed by an infusion of 6 mL x hr(-1) of the respective solution during surgery. Postoperatively all patients received an epidural infusion of 6 mL x hr(-1) ropivacaine 0.375% during 24 hr followed by patient controlled epidural analgesia for the next 72 hr. Operative data, dynamic pain scores, consumption of local anesthetics and standardized supplemental analgesics were analyzed. RESULTS: No difference was seen between groups with respect to the amount of required postoperative local anesthetics and supplemental analgesics, pain scores and side effects during the first 96 hr following surgery except a reduction of intraoperative sufentanil consumption (GI: 143.2 +/- 52.6 vs GII: 73.3 +/- 32.6 microg, P < 0.001). CONCLUSION: Intraoperative TEA with ropivacaine 0.375% did not significantly reduce the amount of analgesics required after major abdominal gynecological tumour surgery.