[Anesthesiological care of trauma patients in orthogeriatric co-management]. / Anästhesiologische Betreuung von Traumapatienten im orthogeriatrischen Co­Management.

Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.

[Anesthesiological care in orthogeriatric co-management. Perioperative treatment of geriatric trauma patients]. / Anästhesiologische Betreuung im orthogeriatrischen Co­Management. Perioperative Versorgung des geriatrischen Traumapatienten.

Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.

Fragility fractures requiring special consideration: vertebral fractures.

The treatment of osteoporotic vertebral fractures is complicated because of the comorbid conditions of the elderly patient. Underlying osteoporosis leads to malalignment of the weakened bone and impedes fracture fixation. The treatment of osteoporotic vertebral fractures is widely empirical, because standardized and accepted treatment evidence-based concepts are missing for certain fracture types. As in other osteoporotic fractures in the elderly, the key for good outcome may be a combination of interdisciplinary treatment approaches and adapted surgical procedures. This article gives an overview of the underlying problems and possible treatment strategies for treatment of osteoporotic vertebral fractures in geriatric patients.

Predictors of Postoperative Cognitive Decline in Very Old Patients With Hip Fracture: A Retrospective Analysis.

BACKGROUND: To investigate incidence and predictors of the various postoperative cognitive declines in old patients with hip fracture. METHODS: This retrospective chart study evaluated 411 patients (age ≥80 years, follow-up 5 years). After exclusion of 82 patients (preexisting dementia or delirium), 70 patients showing either diagnosed postoperative delirium (POD; group 1; N = 18, 5.5%) or an unspecified cognitive dysfunction and behavior (group 2; N = 52, 15.8%) were analyzed and compared with those without any acute postoperative cerebral impairment (control group; N = 259, 78.7%). Medical history, anesthesiological, orthopedic, and rehabilitation data were assessed using the medical database of the hospital information system. Relative ratio was calculated with Fisher exact test: P value Bonferroni corrected ≤.003. RESULTS: Acute cognitive complications were observed in 70 (21.3%) patients. Our data in group 1 showed that patients with a medical history of stroke (relative risk [RR] = 16.2, P = .0001) or nicotine abuse (RR = 14.4, P = .001) and perioperative surgical bleeding (RR = 6.54, P = .002) are more likely to develop POD. Unspecified cognitive dysfunction and behavior (group 2) was significantly associated with a medical history of stroke (RR = 12.5, P = .0001) and postoperatively with depression (RR = 3.32, P = .001). In the follow-up, significantly more patients in group 1 (55.6%, RR = 21.8, P = .0001) and group 2 (13.5%, RR = 3.88, P = .001) developed dementia as compared to controls (1.9%). Mortality did not differ significantly between the groups (group 1: RR = 1.75, P = .5 and group 2: RR = 0.66, P = 1.0). CONCLUSION: These data show that various predictors can identify a greater likelihood of developing postoperative cognitive decline in very old patients with hip fracture. Not identifying or labeling of POD limits the opportunity for evaluation, treatment, and planning. Thus, routine cognitive assessments need to be performed in the scope of multidisciplinary orthogeriatric comanagement.

Peridural Anesthesia or Ultrasound-Guided Continuous 3-in-1 Block: Which Is Indicated for Analgesia in Very Elderly Patients With Hip Fracture in the Emergency Department?

PURPOSE: The aim of our study was to investigate the clinical relevance of preoperative acute pain management and cardiovascular stability by ultrasound-guided continuous 3-in-1 nerve block in very elderly patients with hip fracture when compared to epidural anesthesia (PDA). METHODS: To study the analgesic effect, we enrolled 37 very elderly patients with hip fractures, of whom 3 patients with dementia had to be excluded. Thus, 34 patients were randomized to 1 of the 3 groups: group A (ultrasound-guided continuous 3-in-1 block, bupivacaine; n = 10, dropout rate: 0), group B (PDA, bupivacaine; n = 14, dropout rate: 8), and group C (systemic pain therapy, piritramide/paracetamol; n = 10, dropout rate: 0). Pain intensity was assessed preoperatively and up to 24 hours postoperatively using a visual analog scale, verbal rating scale, analgesic consumption, scale of well-being, and cardiocirculatory parameters (eg, serum troponin T). RESULTS: Our data show that in the preoperative period both regional anesthesia (RA) procedures (analgesia responders after 1 hour: 86.7% and 100%; P = .001) were superior to systemic analgesia (analgesia responders: 46.7%), and the rescue medication requirement in the 2 RA groups was significantly lower (P = .02). Serum troponin T level increased only in the systemic analgesia group (P = .04). In the emergency department, the disadvantage of PDA in geriatric patients with hip fracture was the fact that procedures were more complex, resulting in a high dropout rate (57.1%). The use of PDA has to be critically discussed for ethical concerns. CONCLUSION: In the specific situation of acute hospital admission, the ultrasound-guided continuous 3-in-1 block appears to be indicated as a stress-free means of providing adequate preoperative pain relief in very elderly patients with hip fracture. However, these findings should be corroborated by studies involving larger numbers of patients.

Ultrasound-Guided Regional Anesthesia in a Glucose-6-Phosphate Dehydrogenase (G6PD)-Deficient Geriatric Trauma Patient.

OBJECTIVE: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a genetic enzymatic disorder causing hemolytic anemia. Exposure to drugs is considered to be the most common cause of acute hemolysis in patients with G6PD deficiency. Experience with regional anesthesia, in particular peripheral nerve blocks, is rarely described in patients with G6PD deficiency, but is of great clinical interest. For this reason, we now report on the successful management of ultrasound-guided axillary brachial plexus block in a patient with geriatric G6PD deficiency. CASE REPORT: A female, 75-year-old geriatric trauma patient with G6PD deficiency and a fracture of the left forearm, was scheduled for osteosynthesis of the left forearm. For surgery regional anesthesia with ultrasound-guided axillary brachial plexus block with 30 mL bupivacaine 0.5% was established. Surgical operation und postoperative course were uneventful and with no signs of hemolysis. CONCLUSION: Ultrasound-guided axillary brachial plexus block with bupivacaine was a safe and effective technique in this patient with G6PD deficiency. Peripheral nerve block is a major analgesic approach and of great value for anesthesiologists and surgeons, especially in our aging and multimorbid society.

Multidisciplinary Approach to Lifesaving Measures in the Elderly Individuals With Flail Chest Injury With ORIF of Rib Fractures: A Report of 2 Cases.

In this case report, we present 2 cases of flail chest in geriatric patients after severe blunt chest trauma, which were treated at the University Hospital Innsbruck (Level I Trauma Center and Tyrolean Geriatric Fracture Center) by a multidisciplinary team of physicians from anesthesia, intensive care, trauma surgery, and acute geriatrics. We want to point out the benefit of a multidisciplinary approach in geriatric patients with flail chest.

Long-term functional outcome in geriatric hip fracture patients.

BACKGROUND: Fragility fractures are a major health care problem worldwide. The proportion of the geriatric population and the overall life expectancy will increase. Hip fractures are the most common fragility fractures needing surgery and nowadays treatment concepts are changing. We studied the long-term functional outcome and their influencing factors in patients treated without any interdisciplinary aspects. DESIGN AND SETTING: A retrospective cohort study with functional long-term follow-up examination was carried out in a level one trauma centre on hip fracture patients 80 years old and above treated without any formalized interdisciplinary aspects ("usual care"). PATIENTS: Of 281 consecutive patients who were treated 2005 and 2006 with usual care, 246 patients with a mean age of 86.8 years met our inclusion criteria. 69.1% died within the study period of 4.9 years. On the remaining patients, the residential status, the Barthel Index and the Parker Score were assessed. RESULTS: The mean Barthel Index was 49.6 and the mean Parker Score was 2.7. More than one-fourth of the survivors were found to be bedridden and 45% were not able to walk outside. 88% are bound to one floor and only 8% are able to walk unaided. Patients with more comorbidities and patients with subsequent fractures had significant higher mortality rates. Patients with trochanteric fractures had significant better functional outcome scores compared to patients with femoral neck fractures. Nursing home residents showed significant higher mortality rates and lower functional outcome scores. Patients who were transferred to a nearby acute geriatric hospital for further treatment had significantly higher functional outcome scores. CONCLUSION: This paper shows the frustrating long-term outcome of geriatric hip fracture patients but it also suggests that an early geriatric intervention may lead to better function.

Unilateral anesthesia does not affect the incidence of urinary retention after low-dose spinal anesthesia for knee surgery.

We evaluated whether unilateral low-dose spinal anesthesia may reduce the likelihood of postoperative urinary retention. Forty patients scheduled for knee arthroscopy randomly received bilateral (n = 20) or unilateral (n = 20) spinal anesthesia with 6-mg hyperbaric bupivacaine 0.5%. The incidence of urinary retention (>500 mL) assessed with an ultrasound device (Bladderscan) and subsequent temporary catherization was 7/20 patients in the bilateral versus 6/20 in the unilateral group (not significant). We concluded that unilateral low-dose spinal anesthesia does not further decrease the likelihood of urinary retention. Our results demonstrate the value and necessity of monitoring bladder volume postoperatively.

Management of temporary urinary retention after arthroscopic knee surgery in low-dose spinal anesthesia: development of a simple algorithm.

INTRODUCTION: In practice, trauma and orthopedic surgery during spinal anesthesia are often performed with routine urethral catheterization of the bladder to prevent an overdistention of the bladder. However, use of a catheter has inherent risks. Ultrasound examination of the bladder (Bladderscan) can precisely determine the bladder volume. Thus, the aim of this study was to identify parameters indicative of urinary retention after low-dose spinal anesthesia and to develop a simple algorithm for patient care. MATERIALS AND METHODS: This prospective pilot study approved by the Ethics Committee enrolled 45 patients after obtaining their written informed consent. Patients who underwent arthroscopic knee surgery received low-dose spinal anesthesia with 1.4 ml 0.5% bupivacaine at level L3/L4. Bladder volume was measured by urinary bladder scanning at baseline, at the end of surgery and up to 4 h later. The incidence of spontaneous urination versus catheterization was assessed and the relative risk for catheterization was calculated. Mann-Whitney test, chi(2) test with Fischer Exact test and the relative odds ratio were performed as appropriate. *P < 0.05. RESULTS: Seventy percent of the patients were able to void spontaneously; in 30%, a Foley catheter had to be inserted because bladder volume exceeded 500 ml and/or urination was insufficient (P < 0.01). Bladder volume differed independently of the fluid infused. Additionally, patients with a bladder volume >300 ml postoperatively had a 6.5-fold greater likelihood for urinary retention. CONCLUSION: In the management of patients with short-lasting spinal anesthesia for arthroscopic knee surgery we recommend monitoring bladder volume by Bladderscan instead of routine catheterization. Anesthesiologists or nurses under protocol should assess bladder volume preoperatively and at the end of surgery. If bladder volume is >300 ml, catheterization should be performed in the OR. Patients with a bladder volume of <300 ml at the end of surgery may be transferred to the ward or recovery room. In these patients, bladder volume must be checked at least every 60 min for a maximum of 3 h or until spontaneous voiding is possible or bladder volume is >500 ml.

Effects of face mask ventilation in apneic patients with a resuscitation ventilator in comparison with a bag-valve-mask.

Bag-valve-mask ventilation in an unprotected airway is often applied with a high flow rate or a short inflation time and, therefore, a high peak airway pressure, which may increase the risk of stomach inflation and subsequent pulmonary aspiration. Strategies to provide more patient safety may be a reduction in inspiratory flow and, therefore, peak airway pressure. The purpose of this study was to evaluate the effects of bag-valve-mask ventilation vs. a resuscitation ventilator on tidal volume, peak airway pressure, and peak inspiratory flow rate in apneic patients. In a crossover design, 40 adults were ventilated during induction of anesthesia with either a bag-valve-mask device with room air, or an oxygen-powered, flow-limited resuscitation ventilator. The study endpoints of expired tidal volume, minute volume, respiratory rate, peak airway pressure, delta airway pressure, peak inspiratory flow rate and inspiratory time fraction were measured using a pulmonary monitor. When compared with the resuscitation ventilator, the bag-valve-mask resulted in significantly higher (mean+/-SD) peak airway pressure (15.3+/-3 vs. 14.1+/-3 cm H2O, respectively; p=0.001) and delta airway pressure (14+/-3 vs. 12+/-3 cm H2O, respectively; p<0.001), but significantly lower oxygen saturation (95+/-3 vs. 98+/-1%, respectively; p<0.001). No patient in either group had clinically detectable stomach inflation. We conclude that the resuscitation ventilator is at least as effective as traditional bag-valve-mask or face mask resuscitation in this population of very controlled elective surgery patients.

The effect of ciprofloxacin and gentamicin on spinal morphine-induced antinociception in rats.

This paper investigates the possible antinociceptive effect of systemically administered ciprofloxacin and gentamicin and its influence on intrathecal morphine-induced antinociception. Using thermal nociceptive tests (hot-plate test and tail-flick test) and a motor function test (catalepsy test) in male Sprague-Dawley rats (n=5-9/dose), the following observations were made: ciprofloxacin administered intraperitoneally in the dose range 4-64 mg/kg demonstrated a modest antinociceptive effect in both nociceptive tests. Solvent of ciprofloxacin (intraperitoneally) and saline (intraperitoneally), given as a control, showed no effect. Gentamicin, administered at a dose of 0.1-4 mg/kg intraperitoneally, demonstrated a significant (P<0.05) antinociceptive effect in the tail-flick test but not in the hot-plate test. However, opioid antagonists caused no significant change in the antibiotics. Furthermore, ciprofloxacin intraperitoneally produced a significant left-shift in the hot-plate test (ED50 saline-morphine=2.86 [CI 95%: 2.2, 4.32]microg; ED50 ciprofloxacin-morphine=0.87 (CI 95% 0.68, 1.21) microg, P<0.05) and in the tail-flick test (ED50 saline-morphine=1.98 (CI 95%: 1.21, 2.84) microg; ED50 ciprofloxacin-morphine=0.37 (CI 95%: 0.23, 0.44) microg; P<0.05) for intrathecal morphine-induced antinociception. From a comparison of these data with the predicted ciprofloxacin-morphine value (hot-plate test: 1.61 (CI 95%: 1.18, 2.51]microg; tail-flick test: 0.82 (CI 95%: 0.52, 1.92) microg) we estimate that ciprofloxacin and morphine produce at least additive effects (P>0.05). This was reversed with intraperitoneal naloxone (P<0.05). Gentamicin intraperitoneally did not influence the antinociception achieved with intrathecal administration of morphine (hot-plate test: ED50 gentamicin-morphine=2.71 (CI 95%: 2.35; 3.2) microg; tail-flick test: ED50 gentamicin-morphine=2.43 (CI 95%: 1.58; 5.22]microg; P>0.05). These data show that intraperitoneal administration of ciprofloxacin and gentamicin produces a modest antinociceptive effect in the hot-plate test and tail-flick test. Ciprofloxacin, but not gentamicin, can interact at least additively to increased naloxone-reversible morphine intrathecal antinociception. Differences in the ability to penetrate the blood-brain barrier between the two antibiotics could explain the lack of effect from gentamicin in the hot plate and on morphine-induced antinociception.

Acute pain is underassessed in out-of-hospital emergencies.

OBJECTIVES: To evaluate the quality of pain assessment by emergency medical services (EMS) in out-of-hospital emergencies. METHODS: A prospective study was conducted on a convenience sample of patients during a one-year observation period. Pain ratings assessed by emergency patients were documented at three different intervals during the emergency call, and compared with concomitant assessments by EMS providers. A visual analog scale (VAS) and a verbal pain scale (VPS) were used for pain assessment. Repeated-measures ANOVA and Dunnett's t-test were used for data analysis. RESULTS: Fifty-one out of 70 eligible patients met inclusion criteria. In most emergency patients the intensity of pain was underestimated by EMS, especially when pain was severe (p = 0.0001). During the course of transport, both pain and pain assessment by EMS improved significantly (p = 0.0001). The VAS and VPS were significantly correlated (p = 0.0001). CONCLUSIONS: EMS providers significantly underestimate their patients' pain severity. EMS providers should be more attentive to their patients' complaints and comfort.

Enhancement of morphine analgesia by fenfluramine in subjects receiving tailored opioid infusions.

We evaluated the ability of fenfluramine, a serotonin releaser, to increase the analgesic potency of morphine administered by tailored i.v. infusion. Ten normal volunteers participated in 4 test sessions, involving different treatments on different days: (1) oral placebo/saline infusion, (2) oral placebo/morphine infusion, (3) oral fenfluramine (60 mg)/saline infusion, and (4) oral fenfluramine/morphine infusion. Subjects experienced repetitive painful dental electrical stimuli at strong but tolerable intensities during testing. On the 2 test days involving morphine, the opioid was administered by a computer-pump system that used individual pharmacokinetic parameters to achieve consecutive, steady plasma concentrations near target values of 16, 32 and 64 ng morphine/ml; each morphine concentration plateau was maintained for 45 min. On the saline infusion days, our procedures were identical to morphine test days except that the infused fluid contained no drug. For all sessions outcome measures included subject ratings of pain intensity, dental evoked potential (EP) amplitude, and visual analog scale (VAS) ratings of subjective side-effect intensities (nausea, alertness, dizziness, itching, mood). We obtained these measures during baseline and at each morphine concentration plateau or at corresponding times during saline infusions. Fenfluramine significantly increased the analgesic potency of morphine during the opioid infusion, while fenfluramine alone produced borderline analgesic effects. Fenfluramine alone decreased alertness slightly, but did not significantly increase morphine side effects. Thus, we conclude that fenfluramine enhances the analgesic potency of morphine without a parallel increase in opioid side-effect potency.