[Sciatic nerve block "out-of-plane" distal to the bifurcation: effective and safe]. / Ischiadikusblockade "out-of-plane" distal der Bifurkation: effektiv und sicher.

BACKGROUND: Ultrasound guided distal sciatic nerve block (DSB) at bifurcation level shows fast onset and provides excellent success rates. However, its safe performance might be difficult for the unexperienced physician. Just slightly distal to the bifurcation, the tibial nerve (TN) and common fibular nerve (CFN) can be shown clearly separated from each other. Therefore, we investigated if a block done here would provide similar quality results compared to the DSB proximally to the division, with a potentially lower risk of nerve damage. METHODS: In this randomized, prospective trial, 56 patients per group received either a DSB distal to the bifurcation "out-of-plane" (dist.) or proximally "in-plane" (prox.) with 30 ml of Mepivacaine 1% each. Success was tested by a blinded examiner after 15 and 30 min respectively (sensory and motor block of TN and CFN: 0 = none, 2 = complete, change of skin temperature). Videos of the blocks were inspected by an independent expert retrospectively with regard to the spread of the local anesthetic (LA) and accidental intraneural injection. RESULTS: Cumulative single nerve measurements and temperature changes revealed significant shorter onset and better efficacy (dist/prox: 15 min: 3.13 ± 1.86/1.82 ± 1.62; 30 min: 5.73 ± 1.92/3.21 ± 1.88; T15 min: 30.3 ± 3.48/28.0 ± 3.67, T30 min. 33.0 ± 2.46/30.6 ± 3.86; MV/SD; ANOVA; p < 0.01) combined with a higher rate of subparaneural spread in the dist. group (41/51 vs.12/53; χ2; p < 0,01). Procedure times were similar. There were no complications in either group. DISCUSSION: The subparaneural spread of the LA turned out to be crucial for better results in the distal group. The steep angle using the out-of-plane approach favors needle penetration through the paraneural sheath. The distance between the branches allows the safe application of the LA, so an effective block can be done with just one injection. CONCLUSION: DSB slightly distal to the bifurcation, in an out-of-plane technique between the TN and CFN, can be done fast, effectively and safe.

[Ultrasound-guided thoracic paravertebral block for acute thoracic trauma: continuous analgesia after high speed injury]. / Ultraschallgestützte thorakale Paravertebralblockade beim akuten Thoraxtrauma : Kontinuierliche Analgesie nach Hochrasanztrauma.

Paravertebral blocks have experienced a renaissance because ultrasound-guidance is becoming common practice. The method is often presented as an alternative to thoracic epidural anaesthesia, mainly in the field of elective thoracic surgery. It is also propagated as an opioid-saving analgesic procedure in breast tumor surgery. In this case report it was successfully used as a continuous intervention for acute pain therapy of a severe injury of the left thorax. A transverse probe position in the fifth intercostal space was combined with an in-plane needle technique from lateral to medial. An ultrasound-enhanced needle positioning was used due to the steep angle of puncture. The absolute limit for medial needle advancement is the acoustic shadow of the transverse process. A catheter was placed 2 cm beyond the needle tip and its correct position was verified by hydrolocation. The excellent and continuous analgesia enabled non-invasive patient ventilation to be achieved directly after extubation and was continued for 6 days.

[Peripheral regional anesthesia in patients under general anesthesia: risk assessment with respect to parasthesia, injection pain and nerve damage]. / Periphere Regionalanästhesie beim Patienten in Allgemeinanästhesie : Risikobewertung bezüglich Parästhesie, Injektionsschmerz und Nervenschäden.

Nerve injury after peripheral regional anesthesia is rare and is not usually permanent. Some authors believe that inducing peripheral nerve blocks in patients during general anesthesia or analgosedation adds an additional risk factor for neuronal damage. This is based on published case reports showing that there is a positive correlation between paresthesia experienced during regional anesthesia and subsequent nerve injury. Therefore, many sources recommend that regional nerve blocks should only be performed in awake or lightly sedated patients, at least in adults. However, there is no scientific basis for this recommendation. Furthermore, there is no proof that regional anesthesia performed in patients under general anesthesia or deep sedation bears a greater risk than in awake or lightly sedated patients. Currently anesthesiologists are free to follow personal preferences in this matter as there is no good evidence favoring one approach over the other. The risk of systemic toxicity of local anesthetic agents is not higher in patients who receive regional anesthesia under general anesthesia or deep sedation. Finally, in children and uncooperative adults the administration of peripheral nerve blocks under general anesthesia or deep sedation is widely accepted.

[Successful infection control in regional anesthesia procedures: observational survey after introduction of the DGAI hygiene recommendations]. / Erfolgreiche Infektionskontrolle bei Regionalanästhesieverfahren: Verlaufsbeobachtung nach Einführung der DGAI-Hygieneempfehlungen.

BACKGROUND: In the context of regional anesthesia procedures adverse events rarely occur but are predominantly systemic intoxication due to local anesthetics (0.01-0.035 %), nerve injuries (0.01-1.7 %) and infections (0-3.2 %). MATERIALS AND METHODS: In a level 1 trauma centre data from all continuous peripheral nerve blocks (cPNB) were prospectively acquired over a period of 8 years (2002-2009) in an observational study (n = 10,549). The acquisition of data was carried out in an intranet-based data bank which was accessible for 24 h on every anesthesia workstation. The collected data included type of block, catheter duration and accompanying complications. This study was carried out with special respect to infectious complications (inflammation and infection). RESULTS: In the years 2002-2004 unexpectedly high rates of infectious complications were observed in 3,491 cPNBs with 146 inflammations (4.2 %) and 112 infections (3.2 %). Based on these alarming findings the existing hygiene regime was revised. The innovations were incorporated into the "Hygiene recommendations for the initiation and continued care of regional anaesthetic procedures" of the German Society for Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI). A major change was the extension of skin disinfection to a spray-and-scrub combined procedure lasting 10 min. The introduction of this care bundle was carried out in 2005. Among 7,053 cPNBs that were conducted between 2005 and 2009 inflammation occurred in only 183 procedures (2.6 %) and infection in 61 procedures (0.9 %). This reduction was highly significant in both categories (p < 0.001). The risk factors catheter duration and catheter localization statistically remained unchanged during the observational period CONCLUSION: Using a real-time computer-based tool for data capture makes a veritable detection of adverse events possible. Such a tool also has the power to monitor the effects of changes in clinical procedures (SOP). In this case it was possible to verify the successful introduction of an extended hygiene care bundle. The new regime significantly decreased the rate of infections in cPNB.

[Complications of peripheral regional anesthesia]. / Komplikationen bei peripherer Regionalanästhesie.

Peripheral regional anesthesia is a commonly used and safe procedure and eneral complications or side effects are generally rare. Nerve damage has an incidence <0.1% depending on the definition and the prognosis is good. To avoid bleeding complications the national standards of block performance under antithrombotic therapy should be respected. Intoxication is mainly the result of accidental intravenous administration and is difficult to treat but higher doses of intravenous lipid emulsions can improve the outcome. Potential infectious complications can occur mainly as a result of catheter techniques and require a strict aseptic approach. Further rare complications are allergies, dislocation of catheters and knotting or loops in catheters. Besides the general complications, there are some specific complications depending on the puncture site, such as pneumothorax or renal puncture.

[Sheared catheter in regional anaesthesia : causes and follow-up of an axiallary plexus catheter]. / Durchtrennter Katheter in der Regionalanästhesie : Uraschen und Vorgehen bei einem axillären Plexuskatheter.

In the past years intoxication with local anesthetics, damage to nerves, vessels and other accompanying structures as well as infectiological events have been discussed more and more as complications accompanying peripheral nerve blocks (PNB). The following case report highlights a complication which seems to rarely occur and deals with a sheared continuous PNB, where a fragment of the catheter remained in the patient. The possible causes for the damage are discussed and recommendations on the clinical management of such a case are made.

[Perivascular brachial plexus block. Ultrasound versus nerve stimulator]. / Perivaskuläre axilläre Plexusanästhesie. Ultraschall versus Nervenstimulator.

BACKGROUND: Optimizing the needle position using ultrasound (US) instead of electrical nerve stimulation (NSt) is increasingly common for perivascular brachial plexus block. These two methods were compared in a prospective, randomized, single-blinded controlled trial regarding effectiveness and time of onset of peripheral nerve blockade. METHODS: After puncture (penetration of neurovascular sheath and complete insertion of needle) 56 patients were randomly assigned to either the US group (finding the needle tip in transpectoral section, short axis, correction of needle position if local anesthetic spread was insufficient) or the NSt group (target impulse reaction in median, ulnar or radial nerve of 0.3 mA/0.1 ms, if necessary correction of position before injection of local anesthetic) to verify the needle position. All patients received 500 mg 1% mepivacaine. Sensory and motor blocks were tested by single nerve measurements (SNM) 5, 10 and 20 min after finishing the injection, where 0 represents minimal and 2 maximal success of the block. RESULTS: Single nerve measurements were analyzed using repeated measures ANOVA. The mean results of cumulative SNMs were significantly higher in the US group at all measurement times. Sensitivity US/NSt: 5 min: 3.36±2.32/2.63±1.87; 10 min: 5.45±2.41/4.21±2.45; 20 min: 7.30±2.02/6.43±2.43, p=0.015, motor function US/NSt: 5 min: 3.91±1.81/3.02±1.67; 10 min: 5.27±1.66/4.05±1.70; 20 min: 6.64±1.37/5.50±1.90, p<0.001. At the beginning of surgery complete nerve blockade was achieved in 89% in the US group and 68% in the NSt group (p=0.006), 3 (US) versus 7 (NSt) patients needed supplementation and 3 (US) versus 11 (NSt) patients needed general anesthesia (p=0.022). To achieve the nerve block took approximately 1 min more in the US group (p=0.003). CONCLUSION: The use of ultrasound in perivascular brachial plexus blocks leads to significantly higher success rates and shorter times of onset.

[Infection control in continuous peripheral regional anesthesia. Clinical study on disinfection time and subcutaneous tunneling in interscalene plexus anesthesia]. / Infektionsreduktion bei peripherer Katheterregionalanästhesie: Klinische Studie zur Desinfektionszeit und zur subkutanen Tunnelung bei interskalenärer Plexusanästhesie.

In the present study the efficacy of subcutaneous tunneling and a 10 min disinfection time with a 70% alcoholic solution to reduce the infection rate in continuous interscalene plexus anesthesia were examined. In a prospective study 1,134 continuous interscalene plexus anesthesias were included. In group 1 (473 catheters) a cotton swab was soaked with the alcoholic solution and swabbed 3 times at the puncture site in the classical manner. In group 2 (661 catheters) disinfection was carried out by spray and swab application with a disinfection time of at least 10 min. In group 1, 19% of the catheters were tunneled subcutaneously, whereas in group 2 this occurred in 89%. In group 1 inflammation occurred in 25 cases (5.3%) and an infection in 32 cases (6.8%). In group 2 there were 37 cases of inflammation (5.5%) and 13 infections (2.0%). The difference between the groups in the infection rate is statistically significant (p<0.002). The practicability of the 10 min disinfection time in the clinical routine was excellent. A 10 min disinfection time with a 70% alcoholic solution combined with subcutaneous tunneling led to a significantly lower infection rate in continuous peripheral regional anesthesia in the neck of the patient.

[Hyperbaric oxygen for carbon monoxide poisoning: case report of severe poisoning due to exhaust fumes]. / Hyperbare Oxygenierung bei Kohlenmonoxidintoxikation: Fallbericht einer schweren Intoxikation durch Autoabgase.

After rescue and transport a patient with severe carbon monoxide poisoning (CO-Hb concentration 82%) was treated by hyperbaric oxygen (HBO) therapy in a pressure chamber. During decompression the patient suffered cardiac arrest due to massive acidosis, hyperpotassaemia, haemoconcentration and elevated CO-Hb level. After successful resuscitation and cardiopulmonary diagnostics, HBO therapy was continued for prophylactic treatment of delayed neurological sequelae. Three months after completing treatment and discharge from hospital there were no neurological sequelae.

Heterozygosity for IL23R p.Arg381Gln confers a protective effect not only against Crohn's disease but also ulcerative colitis.

BACKGROUND: A recent study reported that a non-synonymous single nucleotide polymorphism (rs11209026, p.Arg381Gln) located in the IL23R gene is a protective marker for inflammatory bowel disease. AIM: To analyse the frequency of p.Arg381Gln in three independent European inflammatory bowel disease cohorts and to evaluate how this variant influences disease behaviour. METHODS: We assessed a European cohort of 919 inflammatory bowel disease patients and compared the IL23R p.Arg381Gln genotype frequency with 845 healthy controls. Inflammatory bowel disease patients originated from Germany [Crohn's disease (CD): n = 318; ulcerative colitis (UC): n = 178], Hungary (CD: n = 148; UC: n = 118) and the Netherlands (CD: n = 157). Ethnically matched controls were included. We performed subtyping analysis in respect to CARD15 alterations and clinical characteristics. RESULTS: The frequency of the glutamine allele of p.Arg381Gln was significantly lower in inflammatory bowel disease patients compared with controls in a pooled analysis of all three cohorts (P < 0.000001) as well as in the individual cohorts (Germany: P = 0.001, Hungary: P = 0.02 and the Netherlands: P = 0.0002). The p.Arg381Gln genotype distribution was similar between CD and UC. We did not observe either statistical interactions between p.Arg381Gln and CARD15 variants or any significant associations between p.Arg381Gln genotype and subphenotypes. CONCLUSIONS: The p.Arg381Gln IL23R variant confers a protective effect against both CD and UC, but does not determine disease phenotype.

Possible role of MDR1 two-locus genotypes for young-age onset ulcerative colitis but not Crohn's disease.

BACKGROUND: The role of the single nucleotide polymorphisms (SNPs) on positions 2677G>T/A and 3435C>T of the multi-drug-resistance gene 1 (MDR1) in inflammatory bowel disease (IBD) remains unclear. AIMS: To further elucidate the potential impact of MDR1 two-locus genotypes on susceptibility to IBD and disease behaviour. PATIENTS AND METHODS: Three hundred eighty-eight German IBD patients [244 with Crohn's disease (CD), 144 with ulcerative colitis (UC)] and 1,005 German healthy controls were genotyped for the two MDR1 SNPs on positions 2677G>T/A and 3435C>T. Genotype-phenotype analysis was performed with respect to disease susceptibility stratified by age at diagnosis as well as disease localisation and behaviour. RESULTS: Genotype distribution did not differ between all UC or CD patients and controls. Between UC and CD patients, however, we observed a trend of different distribution of the combined genotypes derived from SNPs 2677 and 3435 (chi(2) = 15.997, df = 8, p = 0.054). In subgroup analysis, genotype frequencies between UC patients with early onset of disease and controls showed significant difference for combined positions 2677 and 3435 (chi(2) = 16.054, df = 8, p = 0.034 for age at diagnosis >or=25, lower quartile). Herein the rare genotype 2677GG/3435TT was more frequently observed (odds ratio = 7.0, 95% confidence interval 2.5 - 19.7). In this group severe course of disease behaviour depended on the combined MDR1 SNPs (chi(2) = 16.101, df = 6, p = 0.017 for age at diagnosis >or=25). No association of MDR1 genotypes with disease subgroups in CD was observed. CONCLUSIONS: While overall genotype distribution did not differ, combined MDR1 genotypes derived from positions 2677 and 3435 are possibly associated with young age onset of UC and severe course of disease in this patient group.

Inflammation and infection complications of 2285 perineural catheters: a prospective study.

BACKGROUND: Perineural catheters (PNCs) are increasingly being used. Few data are available on the infectious complications of PNCs. The incidence and localization of local inflammation and infection associated with PNCs were assessed. METHODS: PNCs placed under sterile conditions for regional anesthesia and post-operative analgesia were evaluated prospectively. Local inflammation was defined as redness, swelling or pain on pressure at the catheter insertion site. Infection was defined as purulent material at the catheter insertion site with or without the need for surgical intervention. RESULTS: In total, 2285 PNCs were evaluated: 600 axillary, 303 interscalene, 92 infraclavicular, 65 psoas compartment, 574 femoral, 296 sciatic and 355 popliteal. Local inflammation occurred in 4.2% and infection in 3.2%. The duration of PNC placement was a risk factor (P < 0.05). Surgical intervention was necessary in 0.9%. No late complications occurred in any patient. Interscalene catheters were associated with an increased risk of infection (4.3%; P < 0.05). Anterior proximal sciatic catheters were associated with a lower risk of local inflammation (1.7%; P < 0.05) and infection (0.4%; P < 0.05). Staphylococcus epidermidis and Staphylococcus aureus were isolated in 42% and 58% of catheter tip cultures, respectively. CONCLUSION: In the present study population, infection of PNCs was a rare occurrence, but the incidence increased with the duration of PNC placement, and close clinical monitoring is required.

[Complications and adverse events in continuous peripheral regional anesthesia Results of investigations on 3,491 catheters]. / Komplikationen bei peripherer Katheterregionalanästhesie Untersuchungsergebnisse anhand von 3,491 Kathetern.

INTRODUCTION: Over a period of 36 months we prospectively documented infectious, neurological and other complications or adverse events occurring during 3,491 peripheral regional anesthesias via a catheter using computer-based data recording. METHODS: The investigation included 936 axillar plexus catheters, 473 interscalene plexus catheters, 125 vertical infraclavicular plexus catheters, 74 catheters with psoas compartment blocks, 900 femoral nerve catheters, 964 sciatic nerve catheters and 19 catheters in other localizations. The regional anesthesia catheters were inserted under sterile circumstances (hood, facemask, sterile gloves and coat, surgical disinfection and sterile covering of the placement site) and under peripheral nerve stimulation. RESULTS: 3,070 (87.9%) of the regional anesthesias via catheter, were carried out without any complications. Inflammation (two out of three criteria: redness at insertion site, pain on palpation or swelling) was found in 146 patients (4.2% of all cases). Infections (two out of the criteria: CRP elevation, pus on the insertion site, fever, leucocytosis, necessary antibiotic treatment with exclusion of other possible causes) appeared in 2.4% of all cases (83 patients). In 29 patients (0.8%) we observed severe infections (surgical intervention necessary e.g. abscess incision). Risk factors for inflammation or infections included duration of catheter therapy, cervical localization of the catheter and the experience of the anesthesiologist (p<0.05). Bacterial species most frequently found were Staphylococcus aureus (54%) and Staphylococcus epidermidis (38%). In 0.3% (9 patients) we found short lasting neurological deficits and in 6 patients (0.2%) we recorded a nerve lesion that lasted more than 6 weeks. Other complications occurred in 4.2% of all cases. DISCUSSION: Special complications such as infections in peripheral catheter regional anesthesia are rare but can pose severe problems. A close postoperative supervision of all regional catheters has to be ensured under careful consideration of the risk factors for infections and the accompanying symptoms.

[Lateral approach to blockade of the sciatic nerve. Biometric data using magnetic resonance imaging]. / Laterale Ischiadikusblockaden. Biometrische Daten anhand magnetresonanztomographischer Untersuchungen.

In the present study we examined 41 volunteers using magnetic resonance imaging to obtain biometric data of the thigh used for a planned blockade of the sciatic nerve via the lateral approach. At a needle entry point 12 cm proximal to the gap of the knee joint at the posterior border of the M. vastus lateralis, the sciatic nerve lies on average at a depth of 5.2 cm (39% of the femoral diameter at this site) with an angle of 10.9 degrees to the horizontal in a dorsal direction. Here the popliteal artery lies on average at a depth of 6.4 cm (48% of the femoral diameter) with an angle of 4.7 degrees to the horizontal in a ventral direction. At the marked point in the middle between the gap of the knee joint and the trochanter major at the posterior border of the M. vastus lateralis, the sciatic nerve is at an average depth of 6.2 cm (40% of the femoral diameter at this site) with an angle of 8.2 degrees in a dorsal direction. At a marked point 5 cm distal of the trochanter major at the posterior border of the M. vastus lateralis, the sciatic nerve is at a depth of 9.1 cm at a dorsal angle of 15.5 degrees (49% of the femoral diameter). The lateral blockade of the sciatic nerve at different sites of the thigh is a technique which is easy to plan with the presented biometric data. The popliteal artery could be reached only at the distal puncture point using a deep puncture and an angle in the ventral direction.

[Influence of blockades with local anesthetics on the stimulation ability of a nerve by peripheral nerve stimulation. Results of a randomized study]. / Einfluss der Blockade mit Lokalanästhetika auf die Stimulierbarkeit eines Nerven mit der peripheren Nervenstimulation. Ergebnisse eine randomisierte Studie.

In the present study we examined the influence of local anesthetics on the ability to stimulate a nerve by means of peripheral nerve stimulation. In 35 patients either 5 ml saline (group 1, n=18) or local anesthetics (group 2, n=17) were injected close to the sciatic nerve in a randomized and double-blind manner. The current needed to stimulate the nerve was measured 30 s and 2 min after injection. The results showed that 30 s and 2 min after injection of local anesthetics there is a strong local anesthetic effect. Therefore nerve damage might occur despite the use of peripheral nerve stimulation. Thus, the multiple injection technique in a close anatomical area has to be considered critically, because anesthetized or partially anesthetized nerves have a lower stimulating ability and could be damaged by a second or third puncture.

[Abscess of the psoas muscle caused by a psoas compartment catheter. Case report of a rare complication of peripheral catheter regional anaesthesia]. / Psoasabszess bei Psoaskompartmentkatheter. Fallbericht einer seltenen Komplikation bei peripherer Katheterregionalanästhesie.

A 27-year-old female patient was continuously treated with a psoas compartment catheter for pain therapy. The catheter was placed under strictly aseptic conditions. After 5 days a painful swelling and erythema were observed at the catheter introduction site and the catheter was removed. At the tip of the catheter a staphylococcus aureus infection was detected. A few days after removing the catheter, the patient showed signs of a general infection such as fever and an increase of CRP. An abscess of the psoas muscle was diagnosed via computer tomography. After treatment with antibiotics the abscess was healed and the patient was discharged after 21 days. An abscess of the psoas muscle is a rare complication of psoas compartment catheters. Erythema, pain or swelling at the site of introduction can be a sign of infection and the catheter must be removed immediately. In addition to the case report a review of the literature is given with data on risk management and own infection rates by 2304 peripheral pain catheters.