[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.

Isolation, culture and regeneration of avocado (Persea americana Mill.) protoplasts.

Protoplasts were isolated from embryogenic suspension cultures derived from avocado (Persea americana Mill.) zygotic embryos and nucellus in an enzyme digestion solution consisting of 1% cellulase Onozuka RS, 1% Macerase R10, 0.2% Pectolyase Y-23, 0.7 M mannitol. 24.5 mM CaCl2, 0.92 mM NaH2PO4 and 6.25 2-[N-morpholino]ethanesulfonic acid (1.5 ml) mixed with 0.7 M MS-8P (2.5 ml). MS-8P medium consisted of Murashige and Skoog salts without NH4NO3, 1 mg l-1 thiamine HCl, 100 mg l-1 myo-inositol, 3.1 g l-1 glutamine and 8P organic addenda. Medium osmolarity was adjusted with 0.15 M sucrose and 0-0.55 M mannitol. Protoplast yields of 3.5×106 protoplasts g-1 were obtained. Growth and development of the protoplasts were significantly affected by osmolarity, nitrogen source, plating density and culture medium dilution. Under optimum conditions, proembryos developed directly from embryogenic protoplasts and subsequently into somatic embryos. Optimum conditions for somatic embryo development included the culture of protoplasts at a density of 0.8-1.6×105 ml-1 in 0.4 M MS-8P for 2-3 weeks, followed by subculture in 0.15 M MS-8P at a diluted density of 20-40× for 1 month in darkness to obtain somatic embryos. Mature somatic embryos were recovered on semisolid medium; however, a low frequency of plantlet recovery (≤1%) from protoplast-derived somatic embryos was observed.

Agrobacterium tumefaciens- mediated transformation of embryogenic avocado cultures and regeneration of somatic embryos.

Embryogenic avocado cultures were genetically transformed with the uidA (GUS) and nptII genes, and transformed somatic embryos were recovered from these cultures. Embryogenic avocado cultures derived from zygotic embryos of `Thomas' and consisting of proembryonic masses were gently separated and co-cultivated with disarmed, acetosyringone-activated Agrobacterium tumefaciens strain A208, which contained the cointegrative vector pTiT37-ASE::pMON9749 (9749 ASE). Kanamycin-resistant embryogenic suspension cultures were selected in two steps: (1) initial selection in maintenance medium, consisting of MS basal medium, supplemented with 0.1 mg l-1 picloram and 50 mg l-1 kanamycin sulfate for 2-4 months and (2) subsequent selection in maintenance medium with 100 mg/ml kanamycin sulfate for 2 months in order to eliminate chimeras. Somatic embryo maturation was initiated by subculture onto semisolid maturation medium (without picloram) followed by transfer to maturation medium with 100 mg l-1 kanamycin sulfate. Genetic transformation of embryogenic cultures and somatic embryos was confirmed by the X-gluc reaction, and integration of nptII and uidA into the avocado genome was confirmed by PCR and Southern hybridization, respectively.

Regeneration of Ceratozamia euryphyllidia (Cycadales, Gymnospermae) plants from embryogenic leaf cultures derived from mature-phase trees.

Embryogenic cultures were induced from pinnae removed from young leaf flushes of mature-phase trees of the endangered cycad species, Ceratozamia euryphyllidia. Induction media consisted of B5 major salts, Murashige and Skoog minor salts and organics, 400 mg l-1 glutamine, 100 mg l-1 asparagine, 100 mg l-1 arginine, 60 g l-1 sucrose, 2 g l-1 gellan gum, 4.65-13.94 µM kinetin and 4.52-9.05 µM 2,4-dichlorophenoxyacetic acid. Cultures were maintained in darkness. Embryogenic cultures were comprised of precotyledonary somatic embryos that proliferated by somatic polyembryogenesis following subculture onto medium without plant growth regulators. Somatic embryo development and maturation occurred spontaneously from proliferating cultures on medium without plant growth regulators. Somatic embryos were monocotyledonous and mature somatic embryos germinated on semisolid medium without growth regulators. Subsequent development, which included the elongation of the first leaves, occurred only after subculture onto semisolid medium without plant growth regulators containing 0.5% (wt/vol) activated charcoal and under low light intensity. The time period from explanting to plant recovery was approximately 3 years.

Germplasm modification and its potential for finding new sources of resistance to diseases.

In vitro procedures are playing a major role in plant breeding. Embryo rescue, either through the culture of excised embryos derived from incompatible crosses or by means of ovule culture, has been a standard procedure for the introgression of genes conferring disease resistance into economically important plants. Somatic hybridization (i.e., protoplast fusion) has also been demonstrated to have some potential in obtaining hybrids that result from very wide interspecific and intergeneric crosses. Wide crosses have also been achieved by means of in vitro pollination of excised ovaries or ovules. Tissue culture-induced variability in regenerated plant (i.e., somaclonal variation) appears to be an effective way of obtaining undirected genetic change that can enhance disease resistance and yield and alter the growth habit of crops that are normally propagated vegetatively (e.g., potato) or by seed (e.g., tomato). In the near future, the isolation and sequencing of genes that confer resistance to specific plant pathogens will be possible, and transfer of this information between species will become a reality.

[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.

Somatic embryogenesis for agricultural improvement.

Many important food and fibre crops have attained close to their maximum yields as a result of conventional breeding approaches and advances in agronomic and horticultural practices. The manipulation of cell and tissue cultures to produce somatic embryos efficiently is one of the keystones of the new technologies that will greatly alter the way crops are planted (as synthetic seed) and genetically altered in the future. Gene transfer into embryogenic plant cells is already challenging conventional plant breeding, and has become an indispensable tool for crop improvement. This review provides a current assessment of the impact of somatic embryogenesis in agriculture.

[Treatment of postoperative shivering with nalbuphine]. / Die Behandlung postoperativen Shiverings mit Nalbuphin.

OBJECTIVE: Postoperative shivering is common and has potentially adverse side effects in high-risk patients. Meperidine, which binds to both mu- and kappa-opioid receptors, is reported to be more effective in treating shivering than morphine or fentanyl. Recent data indicate that much of meperidine's special antishivering effect may be mediated by its kappa-opioid receptor activity. Nalbuphine, an opioid agonist/antagonist also has a potent affinity for kappa-receptors. The aim of this study was to evaluate the antishivering effect of nalbuphine in comparison to meperidine. METHODS: 100 ASA physical status I-II patients shivering after elective surgery were included in the study. General anaesthesia was performed with thiopentone, low-dose fentanyl and enflurane in N2O/O2. After arrival in the recovery room patients shivering within 5 min received either meperidine 25 mg or nalbupine 10 mg in a double-blind, randomised manner. The duration and severity of shivering, heart rate, respiratory rate, blood pressure, end-tidal CO2 concentration, O2-saturation and awareness were documented until 20 min after injection. Patients in need of a second injection were excluded from the study. RESULTS: Demographic variables, duration of operation and temperature decreases were not significantly different between treatment groups. The suppression of shivering was achieved within 4.0 +/- 3.5 or 4.6 +/- 4.1 min following the injection of meperidine or nalbuphine, respectively (p = NS). Vital signs and postoperative vigilance showed no significant differences. No adverse side effects were observed. DISCUSSION: The data indicated that nalbuphine suppressed postoperative shivering as effectively and timely as meperidine in equianalgesic doses. The observation is consistent with the hypothesis that stimulation of kappa-opioid receptors is a likely explanation for much of meperidine's antishivering action.

[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.

Substance loss caused by scaling with different sonic scaler inserts--an in vitro study.

BACKGROUND, AIMS: Depending on the phase of periodontal treatment, power-driven inserts with different power levels are necessary: during initial treatment and flap operations, it must be possible to remove calculus which firmly adheres to the root surface with great efficiency; in contrast, gentle root-surface instrumentation has a high priority during maintenance treatment. Recently, modified sonic scaler inserts have been introduced: diamond-coated inserts for open flap operations and slim probe-shaped sonic scaler inserts for deplaqueing during maintenance. METHOD: We compared the substance removal by these inserts to that of a conventional insert. In a bench system which allows application force, stroke height, and width and frequency of instrumentation to be monitored and also permits assessment of the topography before and after instrumentation (yielding depth removal and removed volume), we instrumented aluminum rods in triplicate and bovine roots in a 5-fold repetition. RESULTS: With high application forces (1.0 N), the diamond-coated inserts removed 30 to 50% more substance than the conventional one. Except for the slim inserts, there was a significant linear relationship between increasing force and removed volume. Probe-shaped inserts do not remove considerable substance even with increasing pressures. CONCLUSIONS: Diamond-coated inserts remove tooth substance very effectively and must thus be handled with care: more pressure effects more removal. Probe-shaped inserts can be used without risk during maintenance visits.

Combination of balanced and regional anaesthesia for minimally invasive surgery in a patient with myasthenia gravis.

A 45-year-old man with cryptorchism, who was known to suffer from generalized myasthenia gravis, was admitted to hospital for surgical treatment using laparoscopy. Such minimally invasive surgery requires good muscle relaxation. However, the use of neuromuscular blocking agents in patients with myasthenia gravis may lead to prolonged apnoea after operation, thus necessitating mechanical ventilation of the lungs. We used a combination of general anaesthesia (with desflurane), and epidural anaesthesia (with the amide local anaesthetic ropivacaine) to obtain excellent abdominal relaxation during surgery. Tracheal extubation was possible immediately after the operation and no adverse effects were observed. The patient was discharged from hospital on the second day after operation. The combination of regional and general anaesthesia for minimally invasive surgery in this patient permitted safe anaesthetic management.