Recurrent Laryngeal Nerve Monitoring and Rocuronium: A Selective Sugammadex Reversal Protocol

Background

The use of neuromuscular blocking agents may affect intraoperative neuromonitoring during thyroid surgery. A selective neuromuscular recovery protocol was evaluated in a retrospective cohort study during human thyroid neural monitoring surgery.

Methods

One hundred and twenty-five consecutive patients undergoing thyroidectomy with intraoperative neuromonitoring followed a selective neuromuscular block recovery protocol—single intubating dose of rocuronium followed by sugammadex if needed at the first vagal stimulation (V1).

Results

Data from 120 of 125 patients could be analysed. Fifteen (12.5%) patients needed sugammadex reversal to obtain an EMG response at the first vagal stimulation (V1). In the remaining 105 patients, spontaneous recovery of rocuronium-induced neuromuscular block was sufficient for a successful first vagal stimulation (V1).

Conclusions

In patients undergoing thyroid surgery, routine reversal of rocuronium block with sugammadex is not mandatory for reliable intraoperative neuromonitoring. A selective neuromuscular block recovery approach may be a valuable and more cost-efficient alternative to routine reversal.

     

Why surgeons need to know about anaesthesia

Background

During laparoscopic surgery, it is important to secure adequate surgical workspace. This can be obtained by improved neuromuscular blockade during the procedure. However, there are a lack of knowledge about neuromuscular blockade in anaesthesia in general among surgeons and a lack of knowledge about surgical technical issues among anaesthesiologists.

Methods

The issues are discussed based on the available literature.

Results

Knowledge between the two specialities is highly relevant and is typically lacking. There are data to support the fact that the abdomen may be tense although there are clear signs of neuromuscular blockade on the TOF-watch. This situation can be easily explained by the pharmacodynamics of the neuromuscular blocking agents, and it means that the anaesthesiologist is overestimating the level of blockade.

Conclusions

There are potential problems during laparoscopic surgery where a better communication and collaboration between surgeon and anaesthesiologist may be beneficial for patient outcome.

     

Serial elongation,derotation and flexion (EDF) casting under general anesthesia and neuromuscular blocking drugs improve outcome in patients with juvenile scoliosis: preliminary results

Purpose

Juvenile scoliosis (JS), among different types of spinal deformity, remains still a challenge for orthopedic surgeons. Elongation, derotation and flexion (EDF) casting technique is a custom-made thoracolumbar cast based on a three-dimensional correction concept. The primary objective of the present study was to measure changes on plain radiographs of patients with JS treated with EDF plaster technique. The second aim was to evaluate the effectiveness of the EDF plaster technique realized under general anesthesia (GA) and neuromuscular blocking drugs, i.e. curare, on the radiological curve correction.

Methods

A retrospective comparative case series study was performed in which were included forty-four skeletally immature patients. Three patient groups were selected. Group 1: EDF cast applied with patients awaken and no anesthesia; Group 2: EDF cast applied under GA without neuromuscular blocking drugs; Group 3: EDF cast applied under GA with neuromuscular blocking drugs. All the patients were treated with two serial EDF casts by 2 months and a half each. All measurements were taken from the radiographic exams. Cobb’s angle; RVAD and Nash and Moe grade of rotation were assessed before and after applying the cast. Thirty-four (77.3 %) patients were followed up at least 24 months after removal of last EDF cast.

Results

Eighteen patients (3 males, 15 females) were included in Group 1, 12 (2 males, 10 females) in Group 2 and 14 (5 males, 9 females) in Group 3. Serial EDF casting was more effective at initial curve reduction and in preventing curve progression when applied under GA with neuromuscular blocking drugs, i.e. curare. RVAD and Nash and Moe score improved significantly in all groups of patients treated according to principles of EDF technique. During follow-up period, six patients required surgery in Group 1 (6/18; 33.3 %), 3 patients required surgery in Group 2 (3/12; 25 %) and 2 patients underwent surgery in Group 3 (2/14; 15 %).

Conclusions

Preliminary results show EDF casting is effective in controlling the curve in both frontal (Cobb’s angle) and transverse plane (rib vertebral angle and apical vertebral rotation degree).

     

Task Shifting: The Use of Laypersons for Acquisition of Vital Signs Data for Clinical Decision Making in the Emergency Room Following Traumatic Injury

Importance

In resource-limited settings, identification of successful and sustainable task-shifting interventions is important for improving care.

Objective

To determine whether the training of lay people to take vital signs as trauma clerks is an effective and sustainable method to increase availability of vital signs in the initial evaluation of trauma patients.

Design

We conducted a quasi-experimental study of patients presenting with traumatic injury pre- and post-intervention.

Setting

The study was conducted at Kamuzu Central Hospital, a tertiary care referral hospital, in Lilongwe, Malawi.

Participants

All adult (age ≥ 18 years) trauma patients presenting to emergency department over a six-month period from January to June prior to intervention (2011), immediately post-intervention (2012), 1 year post-intervention (2013) and 2 years post-intervention (2014).

Intervention

Lay people were trained to take and record vital signs.

Main outcomes and measures

The number of patients with recorded vital signs pre- and post-intervention and sustainability of the intervention as determined by time-series analysis.

Results

Availability of vital signs on initial evaluation of trauma patients increased significantly post-intervention. The percentage of patients with at least one vital sign recorded increased from 23.5 to 92.1%, and the percentage of patients with all vital signs recorded increased from 4.1 to 91.4%. Availability of Glasgow Coma Scale also increased from 40.3 to 88.6%. Increased documentation of vital signs continued at 1 year and 2 years post-intervention. However, the percentage of documented vital signs did decrease slightly after the US-trained medical student and surgeon who trained the trauma clerks were no longer available in country, except for Glasgow Coma Scale. Patients who died during emergency department evaluation were significantly less likely to have vital signs recorded.

Conclusions and relevance

The training of lay people to collect vital signs and Glasgow Coma Scale is an effective and sustainable method of task shifting in a resource-limited setting.

     

First-Pass Intubation Success

Background

Airway management is a central skill for every physician working in emergency medicine. Endotracheal intubation in the prehospital setting has been proven to be more difficult and complicated as compared to the in-hospital setting.

Method

Therefore, on the basis of the existing literature the importance of the first-pass intubation success (FPS) and the possibilities for its optimization are addressed and discussed.

Results

Several studies have shown a 4 to 7 times higher rate of complications (e.g., hypoxia, aspiration, cardiac arrest) after 2 or more intubation attempts. Current literature demonstrates that education and frequent training is a major prerequisite for a maximum FPS and patient safety. Induction of anesthesia should be standardized and after careful pre-oxygenation. The relevance of neuromuscular blocking agents and video laryngoscopy for FPS is discussed.

     

Alcohol acute intoxication before sepsis impairs the wound healing of intestinal anastomosis: rat model of the abdominal trauma patient

Introduction

Most trauma patients are drunk at the time of injury. Up to 2% of traumatized patients develop sepsis, which considerably increases their mortality. Inadequate wound healing of the colonic repair can lead to postoperative complications such as leakage and sepsis.

Objective

To assess the effects of acute alcohol intoxication on colonic anastomosis wound healing in septic rats.

Methods

Thirty six Wistar rats were allocated into two groups: S (induction of sepsis) and AS (alcohol intake before sepsis induction). A colonic anastomosis was performed in all groups. After 1, 3 or 7 days the animals were killed. Weight variations, mortality rate, histopathology and tensile breaking strength of the colonic anastomosis were evaluated.

Results

There was an overall mortality of 4 animals (11.1%), three in the group AS (16.6%) and one in the S group (5.5%). Weight loss occurred in all groups. The colon anastomosis of the AS group didn’t gain strength from the first to the seventh postoperative day. On the histopathological analysis there were no differences in the deposition of collagen or fibroblasts between the groups AS and S.

Conclusion

Alcohol intake increased the mortality rate three times in septic animals. Acute alcohol intoxication delays the acquisition of tensile strength of colonic anastomosis in septic rats. Therefore, acute alcohol intoxication before sepsis leads to worse prognosis in animal models of the abdominal trauma patients.

     

Algorithm for activation of coagulation support treatment in multiple injured patients––cohort study

Background

Early recognition and management of trauma related coagulopathy improves the outcome. Trauma facilities should implement an algorithm to identify the bleeding trauma patient with coagulopathy.

Objective

The scope of the paper is to identify the indicators of early coagulopathy and to optimize the indications for thromboelastometry and coagulation support.

Design

Cohort study based on data from trauma registry.

Setting

Data of 493 major trauma patients treated in GH Celje from 2006 to 2014 were included into The TraumaRegister DGU^® (TR-DGU).

Patients

Patients were selected for inclusion into TR-DGU according to the following criteria: polytraumatized patients with Injury severity score (ISS) ≥ 18, patients with injuries to single region with AIS 5, patients with major injuries to a single region and abnormal vital signs. All patients that were dead on arrival to hospital, patients presented to hospital >24 h after the injury, and head injuries that occurred with a low energy mechanism in patients on anticoagulation drugs were excluded.

Measurements

Two groups were formed (with or without coagulopathy). Mortality, morbidity, length of mechanical ventilation, ICU and hospital stay were used as outcome and compared between the groups. A coagulopathy prediction model (CPM) was developed to identify the patients who were at high risk of coagulopathy.

Results

Coagulopathy was present in 51 % of patients. Severe injuries to the torso and limbs, infusion of >1000 ml of fluids in the prehospital settings, and hypotension were included into CPM. If all three criteria were present, the sensitivity of the model to predict coagulopathy was 93 %. By adding the blood gas analysis (BE ≤ ?5), the specificity increased to 81.7 %.

Limitations

Shortcomings of our analysis are mainly related to the quality of data in the registry that may not be comparable to a clinical trial where data are collected specifically to address a given issue.

Conclusions

The Criteria for activation of coagulation support treatment remain centre dependent. In our settings the CPM is the tool to select patients for ROTEM^® analysis. By adding data from blood gas analysis, treatment of coagulopathy is justifiable before complete test results are available.

     

Durchführung einer prähospitalen Notfallnarkose und Atemwegssicherung

Background

The goal of rapid sequence induction (RSI) in cases of emergency situations is to secure the airway as quickly as possible to prevent pulmonary aspiration of gastric contents; however, the technique itself is not standardized. For example, the choice of drugs, application of cricoid pressure and the patient position remain controversial. A survey of emergency medical services (EMS) physicians throughout Germany was carried out to assess the different RSI techniques used and with respect to complying with the national guidelines for emergency airway management anesthesia and local standard operating procedures (SOP).

Material and methods

Between 1 April 2017 and 31 May 2017, EMS medical directors in Germany were contacted and asked to distribute a 28-question online questionnaire to local EMS physicians. Of the questions 26 were multiple choice and 2 with plain text. After 6 weeks an e?mail reminder was sent. In addition, the survey was distributed via social media to EMS physicians.

Results

In total the survey was opened 2314 times and 1074 completed responses were received (completion rate 46%). Most of the participants were male (78%) and anesthesiologists (70%) and only one quarter had a local SOP for RSI. The most frequently used muscle relaxant was succinylcholine (62%) and over half of the participants reported using cricoid pressure (57%). There was a distinction between the specialist disciplines in the selection of drugs. Propofol was used most by anesthesiologists, while the others still used etomidate on a larger scale. Nearly 100% could fall back on supraglottic devices (one third laryngeal mask, two thirds laryngeal tube) but only 32.8% with the recommended esophageal drainage. A video laryngoscope was available to 51% of all EMS physicians surveyed.

Conclusion

The results of the survey demonstrate heterogeneity in RSI techniques used by EMS physicians in Germany. Medical equipment and safe care practices, such as labeling of syringes varied considerably between different service areas. The recommendations of the S1 national guidelines on emergency airway management and anesthesia should be adhered to together with the implementation of local SOPs.

     

A small case series of aortic balloon occlusion in trauma: lessons learned from its use in ruptured abdominal aortic aneurysms and a brief review

Background

EndoVascular and Hybrid Trauma Management (EVTM) is an emerging concept for the early treatment of trauma patients using aortic balloon occlusion (ABO), embolization agents and stent grafts to stop ongoing traumatic bleeding. These techniques have previously been implemented successfully in the treatment of ruptured aortic aneurysm.

Aims

We describe our very recent experience of EVTM using ABO in bleeding patients and lessons learned over the last 20 years from the endovascular treatment of ruptured abdominal aortic aneurysms (rAAA). We also briefly describe current knowledge of ABO usage in trauma.

Methods

A small series of educational cases in our hospital is described, where endovascular techniques were used to gain temporary hemorrhage control. The methods used for rAAA and their applicability to EVTM with a multidisciplinary approach are presented.

Results

Establishing femoral arterial access immediately on arrival at the emergency room and use of an angiography table in the surgical suite may facilitate EVTM at an early stage. ABO may be an effective method for the temporary stabilization of severely hemodynamically unstable patients with hemorrhagic shock, and may be useful as a bridge to definitive treatment of the bleeding patients.

Conclusion

EVTM, including the usage of ABO, can be initiated on patient arrival and is feasible. Further data need to be collected to investigate proper indications for ABO, best clinical usage, results and potential complications. Accordingly, the ABOTrauma Registry has recently been set up. Existing experiences of EVTM and lessons from the endovascular treatment of rAAA may be useful in trauma management.

     

Pancreas sparing duodenectomy for duodenal trauma

Background

Although blunt abdominal trauma is frequently encountered, isolated duodenal injury is relatively uncommon. The management of such patients is challenging and various surgical procedures are described for their management.

Methods

Two patients presented to our emergency department with isolated duodenal injuries (transection and devascularisation) secondary to blunt abdominal trauma.

Results

Both patients underwent exploratory laparotomy, revealing transection of the duodenum along with proximal devascularization and detachment of mesentery at duodeno-jejunal junction without any other intra-abdominal injury (especially pancreas, colon, vena cava) for which pancreas-sparing duodenectomy (infra-ampullary) was performed.

Conclusion

Pancreas-sparing duodenectomy is a valuable tool in the management of duodenal trauma, allowing the surgeon (and the patient) to avoid the complications of major surgical resections.

     

Update on the role of endothelial cells in trauma

Purpose

This review gives an overview of physiological processes, mainly regarding vascular endothelial cells and their important role in hemostasis, information processing, and communication during trauma. An insight is given into molecules and cells involved in the first innate immune response through to the behavior of endothelial cells in developing trauma. The goal of this review is to show the overlap of crucial factors related to the endothelium and the development of trauma.

Methods

A systemic literature search was performed using Google scholar and PubMed.

Results

The results of the literature search showed that the endothelium, especially the vascular endothelium, is involved in various cellular and subcellular pathways of activation, suppression, and transfer of information. A variety of molecules and cells are orchestrated, subsequently the endothelium gets in contact with a traumatizing event.

Conclusion

The endothelium is one of the first barriers that comes into contact with exo- and endogenous trauma-related signals and is a pivotal point in activating subsequent pathways and cascades by transfer of information.

     

Biologika und weitere neue Medikamente in der Rheumatologie seit 2000

Background

Rheumatoid arthritis (RA), psoriatic arthritis and axial spondyloarthritis are severe diseases, which without adequate treatment lead to extremely reduced mobility, functional status and quality of life.

Objective

The effects of biologics and further new antirheumatic drugs on the burden of disease.

Methods

Evaluation of study results and register data dealing with the efficacy and safety of these drugs.

Results

Biologics have been proven to dramatically improve the outcome of all three diseases and contributed to the fact that remission is a realistic target today. In addition, the cardiovascular risk and mortality in RA have been reduced and structural damage is considerably blocked by biologics. Recently Janus kinase (JAK) inhibitors contributed to the treatment possibilities in the same way. Biologics as well as JAK inhibitors offer an excellent safety profile and tolerability with infections being the most important risk.

Conclusion

With the availability of biologics and additional new drugs all three diseases have lost the status of difficult to treat diseases. Their usage according to the guidelines ensures that the burden of disease can been minimalized in most cases. The benefit-risk profile of these drugs has been shown to be excellent.

     

Paediatric trauma resuscitation: an update

Purpose

Paediatric trauma is the leading cause of mortality in children. Paediatric trauma resuscitation is the first and foremost step towards a successful treatment and subsequent recovery. Significant advances have taken place in the last years in relation to this field of trauma care.

Methods

In this narrative review, we attempt to summarise the recent development in the concepts of fluid resuscitation, massive transfusion, permissive resuscitation, management of coagulopathy and use of tranexamic acid, literature pertaining to implementation of transfusion protocols in the paediatric population and education related to the paediatric trauma resuscitation.

Results/Conclusions

The current evidence although emerging is still sparse and high-quality studies are needed to shed more light on most of the above domains of resuscitation.

     

Do obstetric risk factors truly influence the etiopathogenesis of congenital muscular torticollis?

Background

Congenital muscular torticollis (CMT) is seen in childhood and presents within months after birth. The etiology remains unknown; however, medical textbooks suggest trauma at birth as a main reason. The aim of this study was to systematically describe obstetric and perinatal outcomes in a population of children with a confirmed congenital muscular torticollis diagnosis.

Materials and methods

Children with a validated diagnosis of congenital muscular torticollis born at Aarhus University Hospital from 2000 to 2014 were included in the study. Information on perinatal, intrapartum and neonatal characteristics were obtained from databases and from medical records, and systematically described.

Results

In this study, there were no differences in birth characteristics in children with left- and right-sided torticollis, between boys and girls or between the conservatively treated and the children who needed surgery. Most of the children with congenital muscular torticollis in this study were delivered at term without signs of birth complications or trauma. None experienced moderate or severe asphyxia.

Conclusions

The results of the present study suggests that complicated birth or birth trauma may not be the main cause of congenital muscular torticollis and point towards intrauterine and prenatal reasons for its development.

Level of evidence according to OCEBM levels of evidence working group

3

     

Early results in the treatment of proximal humeral fractures with a polyaxial locking plate

Objectives

We report early results using a second generation locking plate, non-contact bridging plate (NCB PH^®, Zimmer Inc. Warsaw, IN, USA), for the treatment of proximal humeral fractures. The NCB PH^® combines conventional plating technique with polyaxial screw placement and angular stability.

Design

Prospective case series.

Setting

A single level-1 trauma center.

Patients

A total of 50 patients with proximal humeral fractures were treated from May 2004 to December 2005.

Intervention

Surgery was performed in open technique in all cases.

Main outcome measures

Implant-related complications, clinical parameters (duration of surgery, range of motion, Constant–Murley Score, subjective patient satisfaction, complications) and radiographic evaluation [union, implant loosening, implant-related complications and avascular necrosis (AVN) of the humeral head] at 6, 12 and 24 weeks.

Results

All fractures available to follow-up (48 of 50) went to union within the follow-up period of 6 months. One patient was lost to follow-up, one patient died of a cause unrelated to the trauma, four patients developed AVN with cutout, one patient had implant loosening, three patients experienced cutout and one patient had an axillary nerve lesion (onset unknown). The average age- and gender-related Constant Score (n = 35) was 76.

Conclusions

The NCB PH^® combines conventional plating technique with polyaxial screw placement and angular stability. Although the complication rate was 19%, with a reoperation rate of 12%, the early results show that the NCB PH^® is a safe implant for the treatment of proximal humeral fractures.

     

Pancreatic fracture: a rare complication following scoliosis surgery

Open image in new window

Study design

Grand Round case report.

Objective

We report a pancreatic fracture associated with Wirsung duct disruption, following a scoliosis surgery in a cerebral palsy adolescent.

Summary of background data

Spinal fusion surgery is the standard treatment for severe neuromuscular scoliosis. Many complications such as digestive ones account for its complexity. Postoperative acute pancreatitis is well described, although its pathophysiology remains unclear. To our knowledge, pancreatic fracture following scoliosis correction has never been described to date. Clinical presentation is not specific, and management is not consensual.

Case report

A 14-year-old adolescent had posterior spinal fusion for neuromuscular scoliosis due to cerebral palsy. During the postoperative course, she developed progressive nonspecific abdominal symptoms. The abdominal CT scan demonstrated a pancreatic fracture and a surgical exploration was decided as perforations of the bowel were highly suspected. Drains were placed around the pancreatic area as the retrogastric region was out of reach due to local inflammation. Conservative management led to the occurrence of a pseudocyst in the following weeks as the pancreatic leakage progressively dropped.

Discussion

Two hypotheses have been proposed: direct iatrogenic trauma from lumbar pedicle screws and pancreatic rupture related to the correction of the spinal deformity. As the latter seems the most likely, spinal surgeons should be aware of this occurrence following severe scoliosis correction.

Conclusion

Spinal fusion for severe neuromuscular scoliosis is a difficult procedure, with a high rate of complications. Among them, pancreatic fracture should be considered when abdominal pain persists in the postoperative period. Conservative management is advocated especially in case of a poor general condition.

     

Eponymous terms in daily practice: a survey among Dutch orthopedic surgeons

Introduction

With a survey among Dutch orthopedic surgeons, we try to assess whether eponymous terms are still in use in daily practice. We also tried to find out whether younger generations tend to use them less than our older colleagues.

Materials and methods

In a survey consisting of 57 eponymous terms, 67 participants were asked to mark the eponyms they knew and whether they used them in daily practice.

Results

No correlation was observed in known/used eponyms or years of experience in 58 completed surveys. Respondents who classified themselves as trauma or general orthopedic surgeons knew or used a significantly higher number of eponyms in daily practice than orthopedic surgeons who classified themselves as spine, upper limb, lower limb, sports or pediatric surgeons.

Discussion

Eponymous terms are used frequently in daily practice. Super-specialization might eradicate the general orthopedic surgeon, and the number of eponyms known and used might become smaller and more focused on the super-specialty.

Conclusion

Our survey showed that eponymous terms are still used frequently in daily practice among both young and more senior orthopedic surgeons in The Netherlands.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.