Ultraschallgesteuerte perivaskuläre axilläre Plexusanästhesie

BACKGROUND: The perivascular axillary plexus block is an easily applicable procedure with a low risk of complications but with a high failure rate. To improve this, the standard procedure was combined with transpectoral sonography to benefit from the advantages of ultrasound, while using a nearly unchanged puncture technique. METHOD: The technique developed by the authors is described in this article and the success rate and the time factor were determined in a sample of 86 patients. The success rates were compared to previous rates without ultrasound and to those in the literature. RESULTS AND CONCLUSIONS: The rate of complete blocks without the use of transpectoral sonography in our clinic and in the literature was approximately 72%, whereas using transpectoral ultrasound it was 96.5%. None of the 86 patients with transpectoral sonography required general anaesthesia. The onset time using transpectoral sonography was approximately 6 min. The perivascular axillary plexus block, combined with transpectoral sonography, is an effective and efficient procedure.     

Patientengefährdung durch Gerätediversität?

Background

The Federal Institute for Drugs and Medical Devices (BfArM) was notified of an event in which it was not possible to sufficiently ventilate a patient suffering a severe asthma attack. It turned out that the ventilation pressures used by the device for pressure-controlled ventilation were below the values set by the user, which the user was not aware of. The ventilation pressures chosen by the user exceeded the preset alarm limits of the ventilator. This pressure and alarm management significantly differed from that of other ventilators used in the hospital. This and similar incident reports suggest that safely operating medical devices for anesthesia and intensive care may be impaired when different models of a device are used within a hospital. If different models are used, more device information needs to be stored in memory. Existing knowledge on human memory suggests that the more individual memory items (e.?g. different operating rules) are stored, the greater the risk of memory interference and hence of impaired retrieval, particularly if the different items are associated with overlapping retrieval cues. This is the case when different devices are used for a single functional purpose under identical or similar circumstances.

Objective

Based on individual incident reports and theoretical knowledge on an association between device diversity and use problems, this study aimed to determine the organizational conditions regarding device diversity that prevail in German hospitals. Additionally, the anesthetists’ perspectives and experiences in defined clinical settings were investigated.

Methods

For selected groups of medical devices, the biomedical engineers of German hospitals were surveyed about the different makes used in their hospital. Additionally, questionnaires were sent to a department of anesthesiology of a large University Hospital to investigate the personal experiences of working with different makes and models of a device.

Results

Using devices by different manufacturers was particularly frequent for ventilators, but there were also a considerable number of hospitals with syringe pumps and patient monitoring systems from different manufacturers. Almost all participants stated that they work or have worked with different models of a device. The majority of respondents had encountered problems or errors, which they ascribed to the requirement to learn a different method of operation for each device; however, they also listed various benefits, for instance the possibility to optimally address the requirements of specific situations or patient groups. Both biomedical engineers and anesthetists suggested a homogeneous device pool within the hospital and regular and repeated training sessions for each device model used.

Discussion

Using different device models for anesthesia and intensive care seems to be common in many German hospitals, particularly for ventilators. An association between device diversity and problems operating a device is plausible, given the functioning of human memory. This topic should be investigated by future studies in order to identify factors that may contribute to such problems and possible solutions for clinical settings. Likewise, the potential benefits of having different device models at one’s disposal should be evaluated. To pinpoint the measures that will be most effective given the specific settings of the individual hospital, all underlying clinical and economic considerations must be carefully balanced against the associated potential risks.

     

Präklinische Kindernotfälle

Background

Out-of-hospital (OOH) pediatric emergencies have a relatively low prevalence. In Germany the vast majority of cases are attended by non-specialized emergency physicians (EPs) for whom these are not routine procedures. This may lead to insecurity and fear. However, it is unknown how EPs perceive and assess pediatric emergencies and how they could be better prepared for them.

Methods

All active EPs (n=50) of the Department of Anaesthesiology, Emergency and Intensive Care Medicine at the University Medical Centre of Göttingen were presented with a structured questionnaire in order to evaluate their perception and assessment of OOH pediatric emergencies.

Results

The 43 participating EPs made highly detailed statements on the expected characteristics of OOH pediatric emergencies. Their confidence level grew with the children’s age (p<0.03) and with their own experience (p<0.01). The EPs felt particular deficits in the fields of cardiopulmonary resuscitation (n=18) and trauma management (n=8). The preferred educational strategies included simulator-based training (n=24) as well as more exposure to pediatric intensive care and pediatric anesthesia (n=12).

Conclusions

Despite their own limited experience EPs can realistically assess the incidence and severity of pediatric emergencies. They felt the greatest deficits were in the care of infrequent but life-threatening emergencies. Three educational groups can be differentiated: knowledge and skills to be gained with children in hospital, clinical experience from adult care also applicable in children and rare diagnoses and interventions to be trained with manikins or simulators.     

Qualitätssicherung Hämotherapie in der Anästhesie

BACKGROUND: The measures for quality assurance in haemotherapy developed at the Charite Campus Mitte according to the transfusion law of 1998 are introduced and discussed. METHODS: In a 3-year study period the submission of transfusion documentation and the expiration of blood products were compared to the year 2001. The potentials for improvement for 2001-2003 were compared based on evaluation of the self-inspection documentation of the transfusion clinics. RESULTS: The submission rate for the transfusion documentation increased from 90% in 2001 to 98.3% in 2002 and 2003. The expiration of blood products decreased from 5.1% in 2001 to 1.7% in 2003 resulting in a cost reduction from 140,000 Euro to 50,000 Euro. Continuous need for improvement was found for the prescribed annual further education of staff on quality management. CONCLUSIONS: The self-inspection procedure in transfusion clinics still revealed potential for improvement, although documentation of transfusions were improved and the expiration of blood products and the resulting costs were substantially reduced.     

Neurogene Wirbelsäulendeformitäten

Sitting is a dynamic process regulated by motor reactions due to endogenic and exogenic influences. Patients with neuromuscular disorders may not continuously adapt their sitting posture but seating devices may improve their quality of life. Prerequisites for the indication of high quality and cost effective seating devices are guidelines for planning and fitting which consider both pathomorphologic mechanisms and the patient's personality. In order to avoid functional problems and pain caused by an insufficient seating device it is necessary to pay attention to the exact indication, time, and combination of technical options. Planning within a seating clinic needs teamwork. First the goal of treatment is defined; it depends on the functional deficit, on the daily living activities of the patient, and on the social environmental factors. Second fitting of the devices follows defined treatment guidelines. By examination of the sensoric and statomotoric system it is possible to classify the patient's sitting or seating ability for simplifying indication: three groups of active sitters who are able to change position of trunk and pelvis actively are differentiated from three groups of passive sitters who have to be seated.     

Hypovolämisch-hämorrhagischer Schock

The term “shock” refers to a life-threatening circulatory failure caused by an imbalance between the supply and demand of cellular oxygen. Hypovolemic shock is characterized by a reduction of intravascular volume and a subsequent reduction in preload. The body compensates the loss of volume by increasing the stroke volume, heart frequency, oxygen extraction rate, and later by an increased concentration of 2,3-diphosphoglycerate with a rightward shift of the oxygen dissociation curve. Hypovolemic hemorrhagic shock impairs the macrocirculation and microcirculation and therefore affects many organ systems (e.g. kidneys, endocrine system and endothelium). For further identification of a state of shock caused by bleeding, vital functions, coagulation tests and hematopoietic procedures are implemented. Every hospital should be in possession of a specific protocol for massive transfusions. The differentiated systemic treatment of bleeding consists of maintenance of an adequate homeostasis and the administration of blood products and coagulation factors.     

Neurogene Wirbelsäulendeformitäten

Neurogenic spinal deformities develop primarily due to insufficient dynamic stabilization against gravity. Unilateral muscle overactivity is another but rare cause. The aim of treatment is to provide stability as well as to prevent deformity. In mild cases, the treatment of choice is a spinal brace because stabilization can be combined with residual mobility and adequate correction of shape. Seating shells are more readily accepted but less appropriate for this purpose. In severe cases, surgery is a good option despite the considerable effort involved and high rate of complications.     

Testikuläre Ischämie

Background

Ischemia and reperfusion (I/R) lead to cellular damage. A disturbance of testicular perfusion occurs during the therapy of cryptorchidism and in cases of testicular torsion. This results in the activation of mediator cells with an increasing synthesis of mediators of infection like TNF-α and the expression of cell adhesion molecules like ICAM (intercellular adhesion molecule) and VCAM (vascular cell adhesion molecule) at the cellular surface.

Methods

The expression of the cytokines IL-10 and TNF-α and the adhesion molecules ICAM and VCAM after defined testicular I/R injury in nine male transsexuals was evaluated with rt-PCR. Furthermore we examined lactate and the diameter of the testicular tubulus under ischemic conditions.

Results

During ischemia ICAM, IL-10, and VCAM do not show significant changes on the side of testicular ischemia and the contralateral side; the same was seen for the tubulus diameter. TNF-α and the testicular lactate values showed a significant change of the expression pattern.

Discussion

The statistical changes of TNF-α and testicular lactate are the expression of leukocyte migration, infectious reaction, and immune response. To what extent the TNF-α expression represents a severe immunological reaction remains undefined. This human study shows primary results for the immunological understanding of and cellular response to testicular ischemia.     

Methämoglobinämie durch Prilocain nach Plexusanästhesien

ZusammenfassungZiel der Studie Die Studie soll die In-vivo- und In-vitro-Kinetik der o-Toluidin-vermittelten Methämoglobin- (MetHb-)Bildung sowie deren Beeinflussbarkeit durch Ascorbinsäure klären. o-Toluidin ist ein Metabolit des Prilocain; Vitamin C wird als Alternative zu Methylenblau zur Therapie der Methämoglobinämie empfohlen.Methodik Die In-vitro-Messungen zur MetHb-Bildung wurden an Vollblutansätzen von 8 Probanden mit verschiedenen o-Toluidin-Konzentrationen (0,5, 5, 50 µg/ml) ohne und mit Vitamin-C-Zusatz (0,5 und 5 mg/ml) durchgeführt. Die MetHb-Bestimmungen erfolgten vor sowie 30, 60 und 360 min nach Zugabe von o-Toluidin und Vitamin C. In der prospektiven, randomisierten klinischen Studie wurden insgesamt 72 chirurgische und orthopädische Patienten der ASA-Klassen I–III eingeschlossen. Je 24 Patienten erhielten zur Operation eine axilläre oder vertikal-infraklavikuläre Plexusanästhesie oder einen kombinierten Ischiadikus- und Femoralisblock. Je 12 Patienten pro Gruppe erhielten vor Anlage der Regionalanästhesie 2.000 mg Vitamin C i.v.. Bei Eingriffen an der oberen Extremität wurden 40 ml 1%iges Prilocain und 10 ml 0,5%iges Bupivacain und an der unteren Extremität 60 ml 1%iges Prilocain mit 0,25 mg Adrenalin appliziert. Die MetHb-Konzentrationen im Blut der Patienten wurden vor sowie 30, 60, 120, 180 und 360 min nach Anlage der Anästhesie gemessen. Ein p<0,05 wurde als statistisch signifikant angesehen.Ergebnisse In vitro zeigt sich nach 360 min ein signifikanter dosisabhängiger Anstieg der o-Toluidin-vermittelten MetHb-Bildung. Mit 0,5 mg/ml Vitamin C nimmt bei 0,5 µg/ml und 5 µg/ml o-Toluidin die MetHb-Bildung weiter zu, nicht jedoch bei 50 µg/ml o-Toluidin. Die Gabe von 5 mg/ml Vitamin C führt dagegen bei 50 µg/ml o-Toluidin zu einer Verringerung der MetHb-Konzentration. Bei den niedrigeren o-Toluidin-Konzentrationen hat Ascorbinsäure keinen Effekt auf die MetHb-Konzentration. In vivo kommt es nach Plexusanästhesie mit Prilocain zu einem Anstieg der im Blut gemessenen MetHb-Konzentrationen mit einem Maximum nach 120–180 min. Der gemessene Maximalwert der MetHb-Konzentration lag bei 11,3%. Nach 360 min lässt sich bereits wieder ein Abfall der MetHb-Konzentrationen nachweisen. Die i.v.-Gabe von 2.000 mg Vitamin C vor Anlage der Plexusanästhesie beeinflusst nicht die resultierenden MetHb-Konzentrationen.Schlussfolgerung In vitro kann mit hohen unphysiologischen Vitamin C-Konzentrationen der o-Toluidin-vermittelte Anstieg der MetHb-Konzentration nach 360 min reduziert werden. Mit der i.v.-Gabe von 2.000 mg Vitamin C vor Anlage einer Plexusanästhesie mit Prilocain lässt sich der Anstieg der MetHb-Konzentration jedoch nicht beeinflussen.     

Pädiatrische Notfälle in der präklinischen Notfallmedizin

BACKGROUND: The aim of this study was to demonstrate differences in structure and severity of pediatric emergencies treated by aeromedical (air rescue) or ground ambulances services. Conclusions for the training of emergency physicians are discussed.PATIENTS AND METHODS: In a 3-year study period, a total of 9,274 pediatric emergencies covered by the ADAC air rescue service are compared to 4,344 pediatric patients of ground ambulance services in Saarland.RESULTS: In aeromedical services pediatric emergencies are more frequent (12.9% vs. 6.4%), trauma predominates (59.9% vs. 35.6%) and severe injuries or diseases occur more frequently (30.5% vs. 15.0%). In both groups pediatric emergency cases are concentrated into very few diagnostic groups: more than one third of the cases involving pre-school children is due to convulsions. Respiratory diseases and intoxication are the next most frequent causes and are more common in ground ambulance patients. Head trauma is the most common diagnosis in cases of pediatric trauma, followed by musculoskeletal and thoracoabdominal trauma. All types of severe trauma are more frequent in pediatric patients of the aeromedical services.CONCLUSIONS: Training of emergency physicians should include pediatric life support and specific information about frequent pediatric emergency situations. For emergency physicians in aeromedical services, an intensive training in pediatric trauma life support is also necessary.     

Die Hämangiome und Osteohämangiome der Schädelknochen

Zusammenfassung Darstellung der Klinik und Pathologie des Hämangioms der Schädelknochen an Hand von sieben Fällen.Diese gutartigen Geschwülste werden meist im mittleren Lebensalter vorwiegend an den Stirn-und Scheitelbeinen und nur sehr selten an der Schädelbasis beobachtet. Sie sind bei Frauen doppelt so häufig wie bei Männern. Die klinischen Erscheinungen sind uncharakteristisch. Der Operateur kann das Knochenhämangiom an der dunkelblau violetten Färbung erkennen. In einem Teil der Fälle ist das Röntgenbild durch einen umschriebenen Aufhellungsherd mit feinnetzig gezeichnetem Grund, etwas schattendichterem Zentrum, gezähntem Rand und lichtstrahlenartigen Spiculae gekennzeichnet. Das Röntgenbild ist aber nicht pathognomonisch, es können ihm in einzelnen Fällen auch Prozesse anderer Genese zugrunde liegen. Manche Schädelhämangiome stellen sich überhaupt nur als völlig uncharakteristische Aufhellungsherde dar.Histologisch handelt es sich in der Mehrzahl der Fälle um einfache, im Knochen gelegene, kavernöse Hämangiome. Seltener sind kavernöse Osteohämangiome, bei denen sich im Grundgewebe der Geschwulst nebem den Bluträumen auch neue Knochenbälkchen entwickeln. Schließlich gibt es am Schädel noch Osteohämangiome mit Ausbildung kavernöser und capillarer Gefäße.Mit 10 Textabbildungen     

Wirbelsäulenverletzungen und Unfallfolgezustände

The aim of computer-assisted navigation procedures is to increase the anatomical orientation intraoperatively, to improve the accuracy, to minimize the invasiveness and to reduce the emission of radiation. In the field of orthopedic surgery navigation has been used for over 15 years and these techniques are particularly widely used in spinal surgery. There are three major applications of navigation: CT-based (computed tomography) navigation which needs a preoperative CT scan, 2D navigation which is based on standard X-ray images of a C-arm during surgery and 3D navigation which requires an intraoperatively performed C-arm based 3D scan. Higher accuracy has been proven for instrumentation of the lumbar and cervical spine and reduced emission of radiation could be demonstrated. Higher accuracy for pedicle screw insertions of the thoracic spine is still not proven in prospective studies with sufficient numbers of pedicle screws. Navigation systems provide additional information for better anatomical orientation in spinal surgery and can reduce intraoperative fluoroscopy time. Intraoperative 3D scan technology with automatic registration is the perfect tool in spinal surgery today. Knowledge of the classical techniques remains crucial for the safety of patients.     

Verlängerungsosteomien bei Beinlängendifferenzen

Callus distraction is the standard procedure for the operative treatment of leg length discrepancy. The deformity is analysed prior to surgery. Clinical assessment and imaging allow precise quantification. The procedure is performed by ring or unilateral frame and or i.m. nail in a continuous mode. The bone cut is performed percutaneously. Associated axial or rotational deformities are corrected simultaneously--acutely or in a continuous mode. Callus distraction is preferably applied during childhood. For good outcome control of the patient is important during the inpatient and outpatient treatment. Physiotherapy and orthotic treatment are mandatory, the same as the management of complications.     

Die stabilitätsgefährdenden Metastasen

Zusammenfassung. Die Behandlung von Tumorpatienten mit oss?rer Metastasierung ist heutzutage eine vorrangig interdisziplin?re Aufgabe mit der Erstellung eines multimodalen Therapiekonzeptes, in dem die operative Therapie bezüglich des Zeitpunktes und des Umfanges des Eingriffs optimal einzuordnen ist. Ein multimodales Therapiekonzept beinhaltet neben der operativen Therapie die systemische Tumorbehandlung (Chemo-, Hormon- und Immuntherapie), die Strahlentherapie und andere medikament?se Therapieverfahren (z. B. Osteoklastenhemmer). Für die operative Therapie stehen neben den klassischen Verfahren wie die Verbundosteosynthese oder intramedull?rer Stabilisierung neue winkelstabile Implantate sowie moderne modulare Tumorendoprothesensysteme, die nach weitestgehender Tumorresektion eine Defektüberbrückung in einem Gro?teil der Skelettlokalisationen erm?glichen, zur Verfügung. Ziel der operativen Behandlung mu? sein, dem Patienten die Stabilit?t und Funktion der betroffenen Regionen und damit seine Mobilit?t wiederzugeben bei gleichzeitiger Schmerzreduktion, damit der noch verbleibende Lebensabschnitt mit einer akzeptabelen Lebensqualit?t verbunden bleibt.      

Anwendungsbeschränkung für Hydroxyäthylstärke

Background

Within the framework of a risk assessment procedure the Committee for Risk Assessment of Pharmacovigilance (PRAC) of the European Medicines Agency (EMA) came to the conclusion that the benefits of hydroxylethyl starch infusion solutions (HES) no longer outweighed the risks and on 14 June 2013 recommended that approval should be suspended. Until the procedure has finally been concluded, which could last several months, the Federal Institute for Drugs and Medical Products (BfArM) has recommended that HES should not be used.

Aim

The aim of this article is to present the data situation in the most objective and compact way and to ultimately give the reader the foundations in order to be able to form a personal opinion. In addition an attempt will be made to describe a concept how infusion therapy can be carried out without using hydroxyethyl starch (HES).

Material and methods

The background to this decision is given based on a review of the literature and the relevance for intensive care, emergency and perioperative medicine is assessed. Furthermore, a concept of infusion therapy without hydroxyethyl starch is formulated also based on the results of current studies.

Results

For infusion regimens without HES it should be noted that gelatin represents a considerable risk for anaphylactic reactions, that transfer of the new variants of Creutzfeldt-Jacob disease (bovine spongiform encephalopathy BSE) cannot fundamentally be excluded and that some evidence has been found that gelatin can cause kidney injury, probably in a similar way to HES. With respect to the cost-benefit analysis of infusion solutions, blood loss in adults of approximately 1-1.5 l can be substituted by balanced crystalloids (basic therapy 4–5 times compared to the amount of blood lost). For larger blood losses small amounts of hyperoncotic albumin solution (20 %) or alternatively 5 % albumin solution can be used. The 20 % albumin solution seems to have some advantages because it has a higher volume effect (approximately 200 %) and can be more favourable for the fluid balance than 5 % albumin solution. Blood losses greater than 2-3 l normally also require administration of blood products (e.g. fresh frozen plasma FFP and erythrocyte concentrates EC).

Conclusions

The third generation HES solutions cannot be completely replaced by other colloids and in future crystalloids will more strongly again broadly form the basis for infusion therapy. In this aspect balanced crystalloids have priority with respect to the acid-base equilibrium. The history of HES has impressively shown that infusion therapy must be adjusted on a scientifically founded basis, whether in intensive care medicine, perioperative or emergency medicine. Large prospective studies with clinically relevant endpoints are urgently needed.     

Videoassistierte anästhesiologische Patientenaufklärung

Background

Video-assisted patient education (VaPE) has in the past been a subject of many studies. Compared to conventional methods, most authors reported a better transfer of information, some found increased patient satisfaction and a time-sparing effect. There was no increase in anxiety caused by VaPE. Some authors even found a reduction of anxiety levels before anesthesia. All publications to date have focused on the patient’s point of view. There have been no reports on how anesthetists as users assess VaPE.

Methods

In this study 22 anesthesia departments using VaPE were contacted. A total of 122 anesthetists were sent questionnaires of which 81 (66%) were completed and returned. The anesthetists were first questioned about the characteristics of the workplace, the frequency of preanesthesia patient contacts, the content of the videos, the technique of video presentation and their own professional experience. After this the anesthetists were asked to assess five statements concerning: usefulness of VaPE, economy of time, transfer of knowledge, induction of anxiety and influence on the quality of the consent interview. In each category there were 4 choices: fully agree, partly agree, partly disagree and fully disagree. The first two choices were evaluated as positive and the second two as negative answers. The anesthetists were also asked to state the most valued characteristics of VaPE. Out of eight given options they were to select the most favored three. A final question was whether in their opinion VaPE could be recommended to non-users.

Results

Of the anesthetists 97.5% stated that disclosure interviews predominantly took place in the preoperative anesthetic clinic and 73% performed 15 or more patient interviews per day. Videos about general anesthesia were applied by 70%, about non-obstetric regional anesthesia by 56% and about obstetric epidural anesthesia by 59%. The videos were presented to groups of patients via large screens by 27%, individually with CD players or tablet computers by 51% or with both methods (22%). Of the anesthetists 69% had 5 years or more professional experience, 97.5% found VaPE useful for patients education, 92.5% observed a time-saving effect for the following interview and 96% stated that after watching the video patients were better informed. An increase of anxiety caused by VaPE was noted by 46% whereas 54% found no such effect. As to the quality of interview 50% reported an advantage in focusing on the patient’s individual risk profile and the other 50% reported no advantage. The ranking of the main advantages was 1) better patient information, 2) time-saving effect, 3) helpful for patient education, followed by 4) increased patient satisfaction, 5) better understanding of anesthesiology, 6) individualization of the interview and 7) helpful in questions of legal liability. The answer option “no advantage” was not chosen at all. Of the participants 82.5% would recommend VaPE unconditionally (fully agree), 17.5% would give a conditional recommendation to colleagues and no one would not recommend VaPE.

Conclusion

This survey among anesthetists confirmed most results obtained from patient-based studies: medical users attributed to VaPE a better information transfer and a time-sparing effect. Furthermore, users regarded VaPE as helpful for the preanesthesia interview. As compared to the patient-based results, however, many anesthetists seem to overrate the anxiety, caused by disclosure videos. From the users’ point of view, VaPE is a highly appreciated method for patient education which can be recommended to colleagues.

     

Hypoglykämie trotz Hyperglykämie

Hypoglycemia represents the most frequent endocrinologic emergency situation in prehospital patient care. As the patients are usually unconscious on arrival of emergency medical personnel, often the only way to establish a diagnosis is by determination of the blood glucose concentration. However, even normoglycemic or hyperglycemic levels cannot definitively exclude the diagnosis of a previous hypoglycemia as the cause of the acute cerebral deficiency. Therefore, and especially in the case of insulin-dependent diabetes mellitus, a differential diagnosis should be considered. We report a case of emergency treatment of a hypoglycemic episode in a female patient with prolonged neuroglycopenia together with cerebrovascular dementia and Alzheimer's disease.