Comparison of tissue distribution, phrenic nerve involvement, and epidural spread in standard- vs low-volume ultrasound-guided interscalene plexus block using contrast magnetic resonance imaging: a randomized, controlled trial.

BACKGROUND: Ultrasound guidance allows for the use of much lower volumes of local anaesthetics for nerve blocks, which may be associated with less aberrant spread and fewer complications. This randomized, controlled study used contrast magnetic resonance imaging to view the differential-volume local anaesthetic distribution, and compared analgesic efficacy and respiratory impairment. METHODS: Thirty patients undergoing shoulder surgery were randomized to receive ultrasound-guided interscalene block by a single, blinded operator with injection of ropivacaine 0.75% (either 20 or 5 ml) plus the contrast dye gadopentetate dimeglumine, followed by magnetic resonance imaging. The primary outcome was epidural spread. Secondary outcomes were central non-epidural spread, contralateral epidural spread, spread to the phrenic nerve, spirometry, ultrasound investigation of the diaphragm, block duration, pain scores during the first 24 h, time to first analgesic consumption, and total analgesic consumption. RESULTS: All blocks provided fast onset and adequate intra- and postoperative analgesia, with no significant differences in pain scores at any time point. Epidural spread occurred in two subjects of each group (13.3%); however, spread to the intervertebral foramen and phrenic nerve and extensive i.m. local anaesthetic deposition were significantly more frequent in the 20 ml group. Diaphragmatic paralysis occurred twice as frequently (n=8 vs 4), and changes from baseline peak respiratory flow rate were larger [Δ=-2.66 (1.99 sd) vs -1.69 (2.0 sd) l min(-1)] in the 20 ml group. CONCLUSIONS: This study demonstrates that interscalene block is associated with epidural spread irrespective of injection volume; however, less central (foraminal) and aberrant spread after low-volume injection may be associated with a more favourable risk profile. CLINICAL TRIAL REGISTRATION: This study was registered with the European Medicines Agency (Eudra-CT number 2013-004219-36) and with the US National Institutes' of Health registry and results base, clinicaltrials.gov (identifier NCT02175069).

Regional anesthesia in patients with significant comorbid disease.

An increasing body of evidence suggests that regional anesthesia does not only provide better pain control compared to systemic analgesic and anesthetic techniques but that it is associated with improved perioperative outcomes. As these benefits may be especially prominent in the patient population suffering from high comorbidity burden, anesthesiologists have to be familiar with associated factors that may complicate the decision to use regional anesthetics. This manuscript is intended to provide a brief overview of the recent literature regarding beneficial outcomes associated with the use of regional versus general anesthesia, before focusing on the discussion of the implications of specific comorbid states on the performance of regional anesthetic techniques.

Prothrombin complex concentrate and recombinant prothrombin alone or in combination with recombinant factor X and FVIIa in dilutional coagulopathy: a porcine model.

BACKGROUND: This study was conducted to assess whether newly developed recombinant clotting factor concentrates enable the reversal of dilutional coagulopathy. METHODS: In 50 anesthetized pigs, ~60% of the blood volume was withdrawn and replaced with hydroxyethyl starch. Pigs were randomized to receive either 200 mg kg(-1) fibrinogen (n = 10), fibrinogen and 35 IU kg(-1) prothrombin complex concentrate (PCC) (n = 10), fibrinogen and 4 mg kg(-1) recombinant human factor II (rhFII) concentrate (n = 10), fibrinogen and a three-factor combination (3F) of 4 mg kg(-1) rhFII, 0.006 mg kg(-1) recombinant human FVIIa and 0.32 mg kg(-1) recombinant human FX (n = 10), or saline (n = 10). Thereafter, a standardized liver laceration was performed to induce uncontrolled hemorrhage. Survival time and blood loss were determined, and standard coagulation tests and thrombelastometry were performed. RESULTS: Fibrinogen combined with rhFII or PCC improved survival. Blood loss was significantly decreased in all groups as compared with the animals receiving saline. Clotting time was significantly shortened in the animals treated with fibrinogen and PCC, as well as in those treated with fibrinogen and 3F. One animal died after administration of fibrinogen and PCC. CONCLUSION: Following hemodilution, a combination of fibrinogen and PCC, rhFII or 3F enhances coagulation and final clot strength. Mortality was reduced statistically significantly only in the animals treated with fibrinogen and rhFII or PCC, whereas administration of the combination of fibrinogen and PCC caused a fatal thromboembolic complication. The combination of fibrinogen and rhFII might be effective in reversing dilutional coagulopathy and may reduce blood loss in cases of dilutional coagulopathy.

Immunologic changes in healthy probands and HIV infected patients after oral administration of Staphylococcus aureus 12c: a pilot study.

The tumoricidal and antiviral effects of Staphylococcal toxins are well documented. In a preliminary study we investigated the immune modulating properties of these toxins by administering single oral doses of a 12c potency of a lysate of Staphylococcus aureus Cowan I, to 4 healthy probands and 12 HIV infected patients with clinical symptoms. We observed a decrease of circulating immune complexes in the healthy probands as well as in the HIV positive patients, accompanied in the latter by a significant increase of CD4 lymphocytes, CD4/CD8-ratio and an improvement of the HIV related symptoms. None of the dose dependent toxic effects commonly found in Staphylococcal sepsis were noticed. Further research on the immune modulating effects of potencies of bacterial superantigens is suggested, especially in view of a possible treatment for HIV infected and other immune compromised patients.

Immunologic changes in healthy probands and HIV infected patients after oral administration of Staphylococcus aureus 12c: a pilot study

The tumoricidal and antiviral effects of Staphylococcal toxins are well documented. In a preliminary study we investigated the immune modulating properties of these toxins by administering single oral doses of a 12c potency of a lysate of Staphylococcus aureus Cowan I, to 4 healthy probands and 12 HIV infected patients with clinical symptoms. We observed a decrease of circulating immune complexes in the healthy probands as CD4 lymphocytes... (AU)

[The dysuria syndrome. Significance of urethral diameter for recurrent bacterial cystitis in the female]. / Das Dysurie-Syndrom. Die Bedeutung der Harnröhrenweite für die rekurrierende bakterielle Zystitis der Frau.

Internal urethrotomy is still used in female patients for the prophylactic treatment of recurrent bacterial cystitis as well as for sterile dysuric voiding disorders. 72% of the bacterial cystitis group (n = 18) remained uninfected during the 1st year after the treatment. 60% of the women with sterile dysuria complaints reported a significant improvement after the surgical procedure. The success is most possibly due to improved urodynamic conditions. The necessity of urethrotomy in patients with recurrent bacterial cystitis is discussed. The etiology of sterile dysuric voiding disorders however remains unclear.