[History and Technique of Epidural Anaesthesia]. / Epiduralanästhesie - Geschichte und Technik der Epiduralanästhesie.

In 1901, the first Epidural anesthesia via a caudal approach was independently described by two FrenchmanJean-Anthanase Sicard and Fernand Cathelin.. The Spanish military surgeon, Fidel Pagés Miravé, completed the lumbar approach successfully in 1921. The two possibilities for identification of the epidural space the "loss of resistance" technique and the technique of the "hanging drop" were developed by Achille Mario Dogliotti, an Italian, and Alberto Gutierrez, an Argentinean physician, at the same time. In 1956 John J. Bonica published the paramedian approach to the epidural space. As early as 1931 Eugene Aburel, a Romanian obstetrician, injected local anaesthetics via a silk catheter to perform lumbar obstetric Epidural analgesia. In 1949 the first successful continuous lumbar Epidural anaesthesia was reported by Manuel Martinez Curbelo, a Cuban. Epidural anaesthesia can be performed in sitting or lateral position in all segments of the spinal column via the median or paramedian approach. Different off-axis angles pose the challenge in learning the technique.

Simulation-based medical education is no better than problem-based discussions and induces misjudgment in self-assessment.

Simulation-based teaching (SBT) is increasingly used in medical education. As an alternative to other teaching methods there is a lack of evidence concerning its efficacy. The aim of this study was to evaluate the potency of SBT in anesthesia in comparison to problem-based discussion (PBD) with students in a randomized controlled setting. Thirty-three fourth-year medical students attending a curricular anesthesiology course were randomly allocated to either a session of SBT or a session of PBD on an emergency induction method. Ten days later all students underwent examination in a simulator. The performance of each student was evaluated by weighted tasks, established according to a modified Delphi process. Confidence and a multiple-choice questionnaire were additionally performed pre- and post-intervention. A total of 32 students completed the study. Participants in the SBT group presented with significantly higher self-assessment scores after the intervention than students in the PBD group. However, students in the SBT group achieved only slightly and statistically insignificantly higher scores in the theoretical and simulator examination (p > 0.05) with only a moderate effect size of d = 0.52. The current study demonstrates that both PBD and SBT lead to comparable short-term outcomes in theoretical knowledge and clinical skills. However, undesirably, SBT students overrated their anticipated clinical abilities and knowledge improvement.

Nicotinamide increases systemic vascular resistance in ovine endotoxemia.

OBJECTIVE: The nuclear enzyme Poly(ADP-Ribose)-Polymerase (PARP) has been hypothesized as playing a major role in various forms of inflammation. PARP activation is induced by DNA strand breakage and can result in intracellular energy depletion and, ultimately, cell death. Further, it is thought to influence cardiovascular function and organ failure in endotoxemia. Here, we investigated the effect of the PARP inhibitor nicotinamide on cardiovascular and liver function in healthy and chronically endotoxemic sheep. DESIGN: Prospective controlled trial. SETTING: University research laboratory. SUBJECTS: 12 female adult sheep. INTERVENTIONS: Six healthy sheep, instrumented for chronic study, received nicotinamide intravenously as a bolus of 40 mg/kg followed by a continuous infusion of 10 mg.kg(-1).h(-1); six animals received the vehicle. One hour after bolus application, a continuous infusion of endotoxin ( Salmonella typhosa, 10 ng.kg(-1).min(-1)) was started. Hemodynamic parameters were determined before and during endotoxemia. MEASUREMENTS AND RESULTS: Treatment with nicotinamide resulted in a significantly higher systemic vascular resistance index and lower cardiac index in endotoxemic animals, but not in controls. It also attenuated endotoxin-induced increase in gamma-glutamyl transferase. CONCLUSIONS: The PARP inhibitor nicotinamide attenuates impairment of cardiovascular function during endotoxemia. In addition, PARP activation may be involved in endotoxin-induced liver injury.

The European Working Time Directive: effect on education and clinical care.

PURPOSE OF THE REVIEW: In 2009 the European Working Time Directive limits the weekly working hours to an average of 48 in all European Union member states. The recent published effects on education and patient care are discussed. RECENT FINDINGS: In European Union member states with traditional long working hours for hospital doctors the reduced working hours led to a decrease in trainee case loads. A negative effect on patients care is only suspected, but not yet measured. In particular, British anesthetists started a discussion about the required changes in training and assessment to counterbalance the lack of practice. European Surgical Disciplines demand for 48 h working time and 12 h teaching and education time per week for trainees. So far many member states have delayed the implementation of European laws in national laws. SUMMARY: There are less measured clinical facts than political statements published. The actual working time directives in the European Union member states are inconsistent and further political development on this topic across the European Union remains unclear.

Therapeutic administration of thoracic epidural anesthesia reduces cardiopulmonary deterioration in ovine pulmonary embolism.

OBJECTIVE: It was hypothesized that sympathetic blockade restricted to the thoracic levels and achieved by thoracic epidural anesthesia might be capable of reducing hemodynamic deterioration after pulmonary artery embolism and that this might represent a potential method of treatment in patients with pulmonary embolism. Cardiopulmonary function after pulmonary embolism was therefore studied in sheep, either without a sympathetic blockade (the control group) or with sympathetic blockade. DESIGN: Prospective, randomized laboratory investigation. SETTING: University research laboratory. SUBJECTS: Twelve adult, chronically instrumented Blackhead ewes. INTERVENTIONS: Pulmonary embolization was achieved by injecting autologous blood clots (0.75 mL/kg) intravenously into an external jugular vein. The treatment group (n = 6) received 6 mL of 0.175% bupivacaine and the control group (n = 6) received 6 mL of 0.9% NaCl 90 mins after the embolization procedure. The injections were made via an epidural catheter (at the level of T3). Results were considered to be statistically significant (with analysis of variance) at p < .05. MEASUREMENTS AND MAIN RESULTS: After epidural administration of bupivacaine in the thoracic epidural anesthesia group, the mean pulmonary artery pressure and heart rate were significantly reduced and the stroke volume index was significantly higher in comparison with the control group, in which the animals received epidural injections of saline. CONCLUSIONS: Thoracic epidural anesthesia administered after the occurrence of pulmonary artery embolism thus significantly reduces hemodynamic deterioration in awake, spontaneously breathing sheep and may represent an additional option in the treatment of pulmonary embolism.

How to teach regional anesthesia.

PURPOSE OF REVIEW: The demand for peripheral nerve blocks and neuroaxial blocks from both patients and surgeons has increased over the last few years. This change in attitude towards regional anesthesia is prompted by the insight that adequate perioperative pain management leads to earlier ambulation, shorter hospital stay, reduced cost and increased patient satisfaction. To avoid serious complications of these techniques structured residency programs need to be available. RECENT FINDINGS: Until 2004, the Residency Review Committee for Anesthesiology in the United States required a minimum of 50 epidurals, 40 spinals and 40 peripheral nerve blocks during residency. Similarly, the German Society for Anesthesia and Intensive Care required 100 neuroaxial blocks and 50 peripheral nerve blocks. In 2004 the American Society of Regional Anesthesia and Pain Medicine endorsed standardized guidelines for regional anesthesia fellowships which regulate the administrative, equipment and educational demands. SUMMARY: This review introduces the reader to the different teaching methods available, including cadaver workshops, three-dimensional videoclips, video filming, ultrasound guidance and acoustic assist devices as well as demonstrating their advantages and disadvantages. Moreover, an overview is given of future residency training programs, which integrate administrative, material and educative demands as well as the teaching means into the daily clinical routine.