[Outpatient treatment of acute injuries of upper extremities with axillary plexus anesthesia in the emergency department-Is that possible without continuous anesthesia attendance?] / Ambulante Versorgung akuter Verletzungen der oberen Extremität in der Notfallambulanz in axillärer Plexusanästhesie ­ Ist das ohne durchgehende Anästhesiebegleitung machbar?

BACKGROUND: The incorporation into the routine operating procedure of patients with small but acute hand and forearm injuries requiring surgery who present in the emergency admission department, represents a challenge due to limited resources. The prompt treatment in the emergency admission department represents an alternative. This article retrospectively reports the authors' experiences with a treatment algorithm in which emergency patients were treated by ultrasound-guided axillary brachial plexus blocks (ABPB) and surgery carried out in the emergency department without further anesthesia attendance. METHODS: Patients were preselected by the surgeon if they were suitable for a standardized treatment without anesthesia attendance during surgery. If there were no anesthesiological or surgical contraindications patients received an ABPB in the holding area of the operating room (OR) under standard monitoring. Blocks were performed as a multi-injection, ultrasound-guided technique which is anatomically described in detail. Patients >60 kg received a total volume of 30 ml of a mixture of 10 ml 1% ropivacaine (100 mg) and 20 ml 2% prilocaine (400 mg). Patients <60 kg received the same mixture with a reduced volume of 25 ml corresponding to 82.5 mg ropivacaine and 332.5 mg prilocaine. After controlling for block success patients were admitted to the emergency department and the surgical procedure was carried out under supervision by the surgeon without further anesthesia attendance. At discharge patients were explicitly instructed that in the case of any complications or a continuation of the block for more than 24 h they should contact the emergency department. RESULTS: Between January 2013 and November 2017 a total of 566 patients (46.4 years, range 11-88 years, 174.9 cm, range 140-211cm, 80.8 kg, range 42-178kg, ASA 1/2/3, 190/338/38, respectively) were treated according to a standardized protocol. The ABPBs were performed by 74 anesthetists. In 5% of the patients the initial block was incomplete and rescue blocks were performed with a maximum of 2­3ml 1% prilocaine per corresponding nerve. After completion the block was ensured and all patients underwent surgery without further analgesics or local anesthetic infiltration by the surgeon. Complications related to the ABPB and readmissions were not observed. CONCLUSION: It could be demonstrated that minor surgery could be carried out safely and effectively with a defined algorithm using ABPB in selected patients outside the OR without permanent anesthesia attendance: however, indispensable prerequisites for such procedures are careful patient selection, patient compliance, the safe and effective performance of the ABPB and reliable agreement with the surgeon.

[Schwannoma of the inferior gluteal nerve as a rare cause of gluteal radiating chronic low back pain]. / Schwannom des Nervus gluteus inferior als seltene Ursache von nach gluteal einstrahlenden chronischen Rückenschmerzen.

This is the first report of a schwannoma of the inferior gluteal nerve (IGN) as a cause of chronic low back pain in a 43-year-old man. The patient suffered from severe pain radiating to the gluteal region. He was treated for months without pain relief and was on long-term disability. Only a targeted sonographic exam revealed a hypoechoic intrapelvic mass along the course of the IGN. By tumor resection, a schwannoma was histologically confirmed. After tumor removal the patient is free of pain with all medication discontinued. He has been fully reintegrated into his professional life.

Ultrasound-guided anterior approach to the axillary and intercostobrachial nerves in the axillary fossa: an anatomical investigation.

BACKGROUND: The posterolateral and medial aspect of the arm is supplied by the axillary (AXN) and intercostobrachial nerves (ICBN), which are not anaesthetised by an axillary brachial plexus block (ABPB). Blockade of the AXN and the ICBN has been reported in the quadrangular space (QS) posteriorly or by serratus plane block, respectively. An anterior ultrasound-guided approach to block the AXN and ICBN would be desirable to complete an ABPB at a single insertion site. METHODS: After a preliminary dissection study in six cadavers, ultrasound-guided AXN and ICBN injection was performed in 46 Thiel embalmed cadavers bilaterally. Key sonographic landmarks to identify the AXN in the QS are the humerus, teres major muscle, and subscapular muscle. With the same probe position, the ICBN was identified in the subfascial axillary space. Then, 2 ml latex was injected at each nerve and confirmed by dissection. RESULTS: Muscular and bony landmarks were identified in all cadavers. The AXN was seen in 99% in the QS or at the inferolateral margin of the subscapular muscle and surrounded by latex in 96% of cases. Latex spread to the axillary fossa, within the subscapular muscle, or to the radial nerve was noted in 8% of the injections. The ICBN was seen and surrounded by latex in 100% of cases. CONCLUSIONS: We describe a reliable ultrasonographic approach to visualise the AXN and ICBN anteriorly from the conventional ABPB approach as confirmed in this cadaver study.

[Anesthesiological approach for patients with spinal cord injuries]. / Anästhesiologisches Vorgehen bei Patienten mit spinalem Querschnitt.

Spinal cord injuries (SCI) are serious medical conditions, which are associated with severe and potentially fatal risks and complications depending on the location and extent of injury. Traffic accidents, falls and recreational activities are the leading causes for traumatic SCI (TSCI) worldwide whereas non-traumatic spinal cord injuries (NTSCI) are mostly due to tumors and congenital diseases. As chronification of the injuries progresses other organ systems are affected including anatomical changes, the respiratory and cardiovascular systems and endocrinological pathways. All these effects have to be considered in the anesthesiological management of patients with SCI. Autonomic dysreflexia (AD) is the most dangerous and life-threatening complication in patients with chronic SCI above T6 that results from an overstimulation of sympathetic reflex circuits in the upper thoracic spine and can be fatal. This article summarizes the specific pathophysiology of SCI and how AD can be avoided as well as also providing anesthetists with strategies for perioperative and intensive care management of patients with SCI.

Ultrasound-guided catheterisation of the subclavian vein: freehand vs needle-guided technique.

The objective of this prospective, randomised study was to examine the impact of a multi-angle needle guide for ultrasound-guided, in-plane, central venous catheter placement in the subclavian vein. One hundred and sixty patients were randomly allocated to two groups, freehand or needle-guided, and then 159 catheterisations were analysed. Cannulation of the first examined access site was successful in 96.9% of cases with no significant difference between groups. There were three arterial punctures and no other severe injuries. Catheter misplacements did not differ between the groups. Higher success rates within the first and second attempts in the needle-guided group were observed (p = 0.041 and p = 0.019, respectively). Use of the needle guide reduced the access time from a median (IQR [range]) of 30 (18-76 [6-1409]) s to 16 (10-30 [4-295]) s; p = 0.0001, and increased needle visibility from 31.8% (9.7%-52.2% [0-96.67]) to 86.2% (62.5%-100% [0-100]); p < 0.0001. A multi-angle needle guide significantly improved aligning the needle and ultrasound plane compared with the freehand technique when cannulating the subclavian vein. Use of the guide resulted in faster access times and increased success at the first and second attempts.

Isolated aneurysm of the internal jugular vein.

True venous aneurysms are rare. We report the case of a 70-year-old male with the extremely uncommon finding of an aneurysm of the internal jugular vein. Due to their rarity, no general guidelines for the treatment of these aneurysms have been established. Upon surgical exclusion of the aneurysm, a progressive swelling of the right side of the face was noted in this patient leading to the decision to interpose a thin-walled ePTFE prosthesis for want of a suitable vein graft. Upon follow-up three years later, the patient is completely asymptomatic and the prosthesis is patent in Doppler sonography.

[Anesthesia for carotid artery surgery. Is there a gold standard?]. / Anästhesie zur Karotischirurgie. Gibt es einen Goldstandard?

Carotid endarterectomy (CEA) has remained the first choice of treatment in preventing ischemic stroke due to symptomatic stenosis of the internal carotid artery despite other new available options. During CEA patients are first and foremost at risk of cerebral as well as myocardial ischemia, therefore, maintenance of the oxygen supply to the brain and the myocardium is of outstanding importance requiring reliable monitoring of cerebral and cardiac function. The regional versus general anesthesia debate is an age-old one that has brought few definite answers regarding the impact on postoperative outcome of either anesthetic technique. Up to now, there is little evidence from only a few randomized clinical trials to demonstrate the superiority of either anesthetic technique with respect to outcome parameters. Because the level of evidence in favor of regional anesthesia during CEA can at least be rated between 1(-) and 2(+) the resulting recommendation is grade C. The purpose of the review is to highlight the characteristics and goals of anesthetic management during CEA.

Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion.

Ropivacaine 1% 40 ml was mistakenly injected as part of an axillary plexus block in an 84-year-old woman. After 15 min the patient complained of dizziness and drowsiness and developed a generalised tonic-clonic seizure followed by an asystolic cardiac arrest. After 10 min of unsuccessful cardiopulmonary resuscitation, a bolus of 100 ml of Intralipid 20% (2 ml.kg(-1)) was administered followed by a continuous infusion of 10 ml.min(-1). After a total dose of 200 ml of Intralipid 20% had been given spontaneous electrical activity and cardiac output was restored. The patient recovered completely. We believe the cardiovascular collapse was secondary to ropivacaine absorption following the accidental overdose. This case shows that lipid infusion may have a beneficial role in cases of local anaesthetic toxicity when conventional resuscitation has been unsuccessful.

[Impact of thoracic epidural analgesia on revenue for G-DRG M01B, OPS-301 5-604.0 (radical retropubic prostatectomy)]. / Betriebswirtschaftliche Auswirkungen der thorakalen Epiduralanästhesie bei urologischen Operationen. Dargestellt am Beispiel der G-DRG M01B, OPS-301 5-604.0 (radikale retropubische Prostatektomie).

INTRODUCTION: Using the surgical procedure OPS 5-604.0 (radical retropubic prostatectomy) as an example, our study identifies revenue-relevant patient characteristics and describes the impact of the perioperative application of thoracic epidural analgesia (TEA). METHODS: Factors affecting duration of stay were determined in 460 patients undergoing OPS 5-604.0 in the year 2001 and 2002 using multifactorial regression analysis. Preoperative parameters served as factors for matched-pair analysis of the effects of TEA. RESULTS: Characteristics significantly affecting length of postoperative hospital stay were ASA status, age, preoperative haemoglobin concentration, postoperative tachycardia, number of transfused packed red cells, wound infection and surgical revision. Based on identical matching criteria 27 pairs (with/without TEA) could be formed. While the induction time in the TEA group was 8+/-18 min longer (p=0.04), emergence was briefer by 3+/-9 min (p=0.045). Neither anaesthesia presence time nor anaesthesia costs or total costs of surgery differed significantly between the pairs. However, duration of epidural postoperative pain therapy was longer with TEA but in contrast, the postoperative length of hospital stay after TEA was reduced. Assuming a continuous demand for OPS 5-604.0 procedures, TEA enables 32 more procedures to be carried out per year with an increased yield on turnover of 2.7%. CONCLUSION: At first sight combined anaesthesia procedures require more human resources and material, however, as a result of shortened hospital stay and optimized pain therapy patient satisfaction increases and a substantial potential for increased revenue is gained.

A fine balance--one-lung ventilation in a patient with Eisenmenger syndrome.

A 38-yr-old woman with an atrial septum defect and Eisenmenger syndrome was scheduled for a lung biopsy via thoracoscopy during one-lung ventilation. Fluids were given to increase central venous pressure to 8 mm Hg, an epidural catheter was inserted at the sixth thoracic intervertebral space and ropivacaine 0.3%, 6 ml were given. Careful balance of systemic and pulmonary vascular resistance is crucial in Eisenmenger syndrome, so norepinephrine (0.14 mg kg(-1) min(-1)) was infused before general anaesthesia was started with fentanyl 4 mg kg(-1), ketamine 2 mg kg(-1), pancuronium 1 mg and succinylcholine 2 mg kg(-1). Anaesthesia was maintained with propofol 4-8 mg kg(-1) h(-1). To control pulmonary artery pressure, ventilation was performed with oxygen 100% and nitric oxide 20 ppm. Surgery and anaesthesia course were uneventful and the patient was extubated. However, pleural haemorrhage required treatment with blood components, re-intubation on the second postoperative day and removal of the haematoma by mini-thoracotomy. A step-by-step approach using a balanced combination of regional and general anaesthesia, controlled fluid administration, norepinephrine and inhaled nitric oxide preserved a stable circulation even during one-lung ventilation. The diagnostic value of lung biopsy must be weighed against the possibility of life-threatening haemorrhage.

[Thoracotomy and scoliosis surgery in a patient with a univentricular heart]. / Thorakotomie und Skoliosekorrektur bei univentrikulärem Herzen.

We report the case of a 15-year-old boy with a single left ventricle who underwent total cavopulmonary connection (Fontan circulation). Due to a progredient idiopathic scoliosis he had to undergo two surgical correction procedures of the vertebral column. Fontan circulation is characterized by the functional absence of the right ventricle. Blood from the systemic circulation passively flows directly into the pulmonary artery. Therefore, central venous preload as well as pulmonary vascular resistance gain essential significance for cardiac output. After volume preload, in both procedures anaesthesia was induced with etomidate and maintained intravenously with propofol and fentanyl but without N(2)O. Increases of the systemic and pulmonary vascular resistance were avoided. A central venous pressure of 20 mmHg was clinically associated with the most stable haemodynamics. In view of the elective nature of the present surgical procedures and with regard to an individual advantage vs risk estimation, tactical algorithms of action must be predefined on the basis of the individual physiology/pathophysiology to keep reaction times for necessary interventions brief.

[Secondary cranial extension after spinal anesthesia with isobaric 0.5% bupivacaine following postural change]. / Hohe sekundäre Ausbreitung einer Spinalanästhesie mit isobarem 0,5%igem Bupivacain nach spätem Lagewechsel.

Inadvertent cranial extension of sympathetic and sensory block following posture change during spinal anaesthesia has been reported for isobaric as well as for hyperbaric local anaesthetics. We present the case of a patient who underwent surgical repair of a refracture of the tibia under spinal anaesthesia with 17.5 mg of isobaric 0.5% bupivacaine. The maximum level of sensory block (MLSB) reached T8 after 15 min. Following posture change into a 15 degrees anti-Trendelenburg position 35 min after lumbar puncture, the MLSB increased cranially for 10 segments and reached the C6 level after 10 min of anti-Trendelenburg position. The patient suffered from severe bradycardia and arterial hypotension which were treated with 6% hydroxyethyl starch, atropine and Akrinor. In addition, the patient developed respiratory insufficiency and was therefore intubated and the lungs were mechanically ventilated. The operation was performed uneventfully with the patient under general anaesthesia. At the end of surgery the trachea was extubated, and the patient was awake with stable hemodynamics, sufficient spontaneous ventilation and free of pain. MLSB reached the second lumbar dermatome. This case shows that after assumed fixation of the local anaesthetic an inadvertent extension of the MLSB following posture change is possible. Close surveillance is recommended for patients with central neuraxial blocks until the block is in complete remission. The mechanisms for inadvertent high extension of the MLSB following posture change are discussed.

Relationship of comorbidity, age and perioperative complications in patients undergoing radical prostatectomy.

OBJECTIVES: To investigate the prevalence and distribution of comorbidity and its association with perioperative complications in patients undergoing radical prostatectomy (RPE). METHODS: In 431 unselected RPE patients, the American Society of Anesthesiologists Physical Status classification (ASA-PS), the New York Heart Association classification of cardiac insufficiency (NYHA), the classification of angina pectoris of the Canadian Cardiovascular Society (CCS), height, weight, the body mass index (BMI), and the number of concomitant diseases (NCD) were assessed and related to perioperative cardiovascular complications. RESULTS: In RPE patients less than 70 years old, comorbidity rose nearly continuously with increasing age. However, after reaching an age of 70 years, the proportion of NYHA-0 patients increased (60-64 years, 86%; 65-69 years, 85%; >or=70 years, 87%). Furthermore, the severe comorbidities decreased in patients selected for RPE aged 70 or more years. There was a nonsignificant trend towards higher comorbidity in patients with perioperative cardiovascular complications. CONCLUSIONS: These data suggest that documentation of the distribution of ASA-PS, CCS, NYHA and of concomitant diseases might be helpful to characterize the general health status and the degree of selection of prostate cancer treatment populations especially in series with a high portion of patients aged 70 or more years. Concerning perioperative complications, the individual predictive value of comorbidity seems to be poor in the radical prostatectomy setting.