[Balloon dilation oft the Eustachian tube in tympanic membrane retraction]. / Stellenwert der Tubendilatation bei Mittelohradhäsivprozess.

OBJECTIVE: A tube dysfunction is a common medical issue and can promote chronic otitis media. With the implementation of the Balloon dilation a treatment of the chronic tube dysfunction was set. In the present study significance of this method was assessed, especially questioning the success in practical terms of tympanic membrane retraction. MATERIAL AND METHODS: In a retrospective study, in a period of assessment from 2011 until 2016, the data of 81 patients, who underwent Balloon dilation of the Eustachian tube due to chronic tube dysfunction with regard to a preoperative presence of tympanic membrane retraction were evaluated. The success of the Balloon dilation was judged due to the capability of a postoperative SVT- Test and the patients' self-assessment. With an average postoperative period of four months, the data of 13 patients were analyzed based on presence of pre- and postoperative tympanic membrane retraction. RESULTS: The treatment occurred at all cases without complications. In patients with chronic tube dysfunction the method revealed an improvement of 46 %, while 31 % of the patients with tympanic membrane retraction showed an improvement of the middle ear ventilation. Subjectively perceived 54 % of the patients marked an improvement of their clinical symptoms. CONCLUSION: In spite of a self-assessed improvement in 54 % only 31 % of the patients with chronic membrane retraction showed an objectively measurable success. To evaluate the question if combination with other middle ear surgeries shows better results, further studies, including more patients and data, are required.

Awake, sedated or anaesthetised for regional anaesthesia block placements?: A retrospective registry analysis of acute complications and patient satisfaction in adults.

BACKGROUND: Whether adults should be awake, sedated or anaesthetised during establishment of regional anaesthesia is still debated and there is little information on the relative safety of each. In paediatric practice, there is often little choice but to use sedation or anaesthesia as otherwise the procedures would be too distressing and patient movement would be hazardous. OBJECTIVE(S): The objective of this study was to evaluate complications related to central and peripheral regional block and patient satisfaction in awake, sedated and anaesthetised adult patients. DESIGN: A retrospective registry analysis. SETTING: The German Network of Regional Anaesthesia database was analysed between 2007 and 2012. PATIENTS: We included data of 42 654 patients and defined three groups: group I awake (n = 25 004), group II sedated (n = 15 121) and group III anaesthetised (n = 2529) for block placement. MAIN OUTCOME MEASURES: Odds ratios [OR; 95% confidence interval (CI)] were calculated with logistic regression analysis and adjusted for relevant confounders to determine the risk of block-related complications in sedated or anaesthetised patients compared with awake patients. RESULTS: Rates of local anaesthetic systemic toxicity were comparable between the groups [awake 0.02% (95% CI: 0.002 to 0.0375), sedated 0.02% (0.003 to 0.042) and anaesthetised 0% (0 to 0.12%)], as were the rates of pneumothorax [awake 0.035% (0 to 0.074), sedated 0% (0 to 0.002) and anaesthetised 0.2% (0 to 0.56)]. Considering peripheral nerve blocks, sedated patients had a decreased risk for multiple skin puncture [adjusted OR: 0.78 (95% CI: 0.71 to 0.85), premature termination [0.45 (0.22 to 0.91)], primary failure [0.58 (0.40 to 0.83)] and postoperative paraesthesia [0.35 (0.28 to 0.45)], but an increased risk for a bloody tap [1.82 (1.50 to 2.21)]. General anaesthesia increased the risk of a bloody tap [adjusted OR: 1.33 (95% CI: 1.01 to 1.78)] and multiple skin puncture [1.28 (1.12 to 1.46)], but decreased the risk for postoperative paraesthesia [0.16 (0.06 to 0.38)]. In neuraxial sites, sedation increased the risk for multiple skin puncture [adjusted OR: 1.18 (95% CI: 1.09 to 1.29)], whereas block placement under general anaesthesia decreased the risk for multiple skin puncture [0.53 (0.39 to 0.72)] and bloody tap but significantly increased the risk for postoperative paraesthesia related to a catheter [2.45 (1.19 to 5.02)]. Sedation was associated with a significant improvement in patient satisfaction. CONCLUSION: Sedation may improve safety and success of peripheral nerve block placement. Block placement under general anaesthesia in adults should be reserved for experienced anaesthesiologists and special situations.

Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial.

Importance: Adjunctive hydrocortisone therapy is suggested by the Surviving Sepsis Campaign in refractory septic shock only. The efficacy of hydrocortisone in patients with severe sepsis without shock remains controversial. Objective: To determine whether hydrocortisone therapy in patients with severe sepsis prevents the development of septic shock. Design, Setting, and Participants: Double-blind, randomized clinical trial conducted from January 13, 2009, to August 27, 2013, with a follow-up of 180 days until February 23, 2014. The trial was performed in 34 intermediate or intensive care units of university and community hospitals in Germany, and it included 380 adult patients with severe sepsis who were not in septic shock. Interventions: Patients were randomly allocated 1:1 either to receive a continuous infusion of 200 mg of hydrocortisone for 5 days followed by dose tapering until day 11 (n = 190) or to receive placebo (n = 190). Main Outcomes and Measures: The primary outcome was development of septic shock within 14 days. Secondary outcomes were time until septic shock, mortality in the intensive care unit or hospital, survival up to 180 days, and assessment of secondary infections, weaning failure, muscle weakness, and hyperglycemia (blood glucose level >150 mg/dL [to convert to millimoles per liter, multiply by 0.0555]). Results: The intention-to-treat population consisted of 353 patients (64.9% male; mean [SD] age, 65.0 [14.4] years). Septic shock occurred in 36 of 170 patients (21.2%) in the hydrocortisone group and 39 of 170 patients (22.9%) in the placebo group (difference, -1.8%; 95% CI, -10.7% to 7.2%; P = .70). No significant differences were observed between the hydrocortisone and placebo groups for time until septic shock; mortality in the intensive care unit or in the hospital; or mortality at 28 days (15 of 171 patients [8.8%] vs 14 of 170 patients [8.2%], respectively; difference, 0.5%; 95% CI, -5.6% to 6.7%; P = .86), 90 days (34 of 171 patients [19.9%] vs 28 of 168 patients [16.7%]; difference, 3.2%; 95% CI, -5.1% to 11.4%; P = .44), and 180 days (45 of 168 patients [26.8%] vs 37 of 167 patients [22.2%], respectively; difference, 4.6%; 95% CI, -4.6% to 13.7%; P = .32). In the hydrocortisone vs placebo groups, 21.5% vs 16.9% had secondary infections, 8.6% vs 8.5% had weaning failure, 30.7% vs 23.8% had muscle weakness, and 90.9% vs 81.5% had hyperglycemia. Conclusions and Relevance: Among adults with severe sepsis not in septic shock, use of hydrocortisone compared with placebo did not reduce the risk of septic shock within 14 days. These findings do not support the use of hydrocortisone in these patients. Trial Registration: clinicaltrials.gov Identifier: NCT00670254.

Diabetes: a risk factor for catheter-associated infections.

BACKGROUND AND OBJECTIVES: The incidence of infectious complications associated with continuous regional anesthesia techniques is a matter of concern. Our objective was to determine whether patients suffering from diabetes are at an increased risk of catheter-related infectious complications. METHODS: The German Network for Regional Anaesthesia database was analyzed between 2007 and 2012. After proof of plausibility, data of 36,881 patients undergoing continuous regional anesthesia were grouped in I: no diabetes (n = 32,891) and II: any diabetes (n = 3990). The analysis focused on catheter-related infections after strict definition. Differences among the groups were tested with t and χ tests. Odds ratios were calculated with logistic regression and adjusted for potential confounders. RESULTS: Patients with a diagnosis of diabetes had an increased incidence of catheter-related infections (no diabetes 3.0% vs any diabetes 4.2%; P < 0.001). Among all patients, diabetes remained an independent risk factor for infections for all sites after the adjustment for potential confounders (odds ratio [OR] = 1.26; 95% confidence interval [95% CI], 1.02-1.55; P = 0.036). The risk of infection was significantly increased in peripheral catheters only in the lower limb (adjusted OR = 2.42; 95% CI, 1.05-5.57; P = 0.039). If neuraxial catheters were used, the risk was significantly increased only in lumbar epidural (adjusted OR = 2.09; 95% CI, 1.18-3.73; P = 0.012) for diabetic patients compared with nondiabetic patients. CONCLUSIONS: The presence of diabetes is associated with an increased risk for catheter-related infections in lower limb and lumbar epidural. Specific care should be taken to avoid and detect infections in this population.

Temporary right heart support with percutaneous jugular access.

PURPOSE: Temporary right heart bypass has shown to improve hemodynamic stability and safety in beating heart revascularization. We sought to evaluate feasibility and safety of a right ventricular assist device percutaneously implanted in the right jugular vein. DESCRIPTION: The A-Med jugular coaxial cannula (A-Med Systems Inc, West Sacramento, CA) is designed for percutaneous implantation. Blood from the right heart is drained through the outer tube of this two-cannula device to a microcentrifugal pump and returned into the pulmonary artery through the inner tube. EVALUATION: In 10 patients scheduled for elective coronary bypass grafting without cardiopulmonary bypass, a total of 27 coronary anastomoses were performed with right heart support. Arterial pressure was significantly higher with right heart support when the heart was dislocated to access posterior and posterolateral anastomosis sites. Implantation through the right internal jugular vein was feasible without complications in all patients and facilitated the procedure. CONCLUSIONS: This initial study suggests safety and feasibility of temporary right heart support using percutaneous jugular access for posterior and posterolateral coronary bypass grafting.

The effect of high thoracic epidural anesthesia on systolic and diastolic left ventricular function in patients with coronary artery disease.

In patients with coronary artery disease, vasoconstriction is induced through activation of the sympathetic nervous system. Both alpha1- and alpha2-adrenergic epicardial and microvascular constriction are potent initiators of myocardial ischemia. Attenuation of ischemia has been observed when sympathetic nervous system activity is inhibited by high thoracic epidural anesthesia (HTEA). However, it is still a matter of controversy whether establishing HTEA may correspondingly translate into an improvement of left ventricular (LV) function. To clarify this issue, LV function was quantified serially before and after HTEA using a new combined systolic/diastolic variable of global LV function (myocardial performance index [MPI]) and additional variables that more specifically address systolic (e.g., fractional area change) or diastolic function (e.g., intraventricular flow propagation velocity [Vp]). High thoracic epidural catheters were inserted in 37 patients scheduled for coronary artery surgery, and HTEA was administered in the awake patients. Echocardiographic and hemodynamic measures were recorded before and after institution of HTEA. HTEA induced a significant improvement in diastolic LV function (e.g., Vp changed from 45.1 +/- 16.1 to 53.8 +/- 18.8 cm/s; P < 0.001), whereas indices of systolic function did not change. The change in the diastolic characteristics caused the MPI to improve from 0.51 +/- 0.13 to 0.35 +/- 0.13 (P < 0.001). We conclude that an improvement in cardiac function was due to improved diastolic characteristics.

Crossing atrial thrombus in a patient with recurrent pulmonary embolism.

OBJECTIVES: To report the detection of a thrombus entrapped in a patent foramen ovale by echocardiography in a patient with recurrent pulmonary embolism. DESIGN: Case report. SETTING: Intensive care unit of a university hospital. PATIENT: A 62-yr-old man with initial deep venous thrombosis and recurrent minor pulmonary embolism followed by a severe embolic event with transitory hemiparesis 10 days after prostatectomy. INTERVENTION: Systemic anticoagulation, surgical removal of a crossing atrial thrombus, closure of a patent foramen ovale, and venous thrombectomy. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiography revealed a large thrombus entrapped in a patent foramen ovale with portions in all four heart chambers. Intraoperatively, a 19-cm-long thrombus, shaped like the pelvic veins, was found. The patient was successfully weaned from cardiopulmonary bypass, requiring temporary positive inotropic support because of right ventricular dysfunction. Within 24 hrs of the operation, the patient was discharged to the intermediate care unit. CONCLUSIONS: Recurrent pulmonary embolism can potentially result in paradoxic embolism in patients with a patent foramen ovale. In such patients, it may be crucial to monitor right ventricular function and exclude right-to-left shunts by transesophageal echocardiography, regardless of clinical symptoms. The patent foramen ovale should be closed. This case emphasizes an important indication for transesophageal echocardiography in critically ill patients.