[Is a blockade of the lateral cutaneous nerve of the thigh an alternative to the classical femoral nerve blockade for knee joint arthroscopy? A randomised controlled study]. / Ist die Blockade des N. cutaneus femoris lateralis eine Alternative zu einer klassischen Femoralisblockade bei Kniegelenkarthroskopien? Eine randomisierte, kontrollierte Untersuchung.

BACKGROUND: Gaps in the distribution area of the lateral femoral cutaneous nerve (LFCN) are assumed to be the reason for pain caused by a thigh tourniquet when performing a femoral nerve (FN) block according to Winnie. The aim of the study was to evaluate if a direct single blockade of the LFCN in patients undergoing knee surgery resulted in a better tolerance to the tourniquet with equally good analgesic quality during surgery. METHODS: A total of 40 patients undergoing knee arthroscopy received a proximal blockade of the sciatic nerve and randomly either an FN or an LFCN block. Practicability, onset time, quality of sensory and motor block, and clinical effectiveness during tourniquet and surgery were assessed. RESULTS: Stimulation time was significantly longer in the LFCN than in the FN group. Quality of sensory and motor block was worse in the LFCN than the NF group. Of the LFCN patients 65% indicated troublesome paraesthesia or pain when a tourniquet was placed, compared to 35% of the FN patients. Of the LFCN patients 50% had pain during cutaneous incision, compared to none of the FN group. During the course of surgery, 70% of the LFCN patients needed supplemental systemic analgesia, but this was required by only 30% of the FN group. CONCLUSION: An LFCN block is not a suitable alternative to an FN block for regional anaesthesia. For patients with contraindications for an FN block according to Winnie (e.g. vessel surgery in the groin) other more effective methods are available.

CSF filtration is an effective treatment of Guillain-Barré syndrome: a randomized clinical trial.

OBJECTIVE: To compare CSF filtration (CSFF) and plasma exchange (PE) in the treatment of patients with Guillain-Barré syndrome (GBS). METHODS: In a prospective controlled clinical trial, 37 patients with acute GBS were randomized to receive either CSFF or PE. Inclusion criteria were fulfillment of National Institute of Neurological and Communicative Disorders and Stroke criteria and disability to walk >5 m unassisted. RESULTS: With similar baseline features in both groups (initial disability grades on the six-point grading scale of the GBS Study Group) the primary outcome variable (improvement within 28 days after randomization) was almost identical (test for equivalence p = 0.0014), the mean grade values being 0.82 in the CSFF group and 0.80 in the PE group. After 56 days, 56% (9 of 16 patients) of the CSFF group and 37% (7 of 19 patients) of the PE group had reached grade 2 (i.e., ability of unassisted walking >5 m). After 6 months, the probability to reach grade 2 was about 80% in both groups. In the CSFF group, transient pleocytosis occurred without apparent clinical complications. Clinically relevant complications were higher in the PE-treated group. CONCLUSIONS: Although the number of patients was small, the authors found that the treatment of GBS with CSFF is at least as effective as with PE. CSFF might work by removing from the CSF inflammatory mediators, autoantibodies, or other factors.

Autotransfusion--bacterial contamination during hip arthroplasty and efficacy of cefuroxime prophylaxis. A randomized controlled study of 40 patients.

40 patients undergoing primary hip arthroplasty, given autologous processed blood transfusion, were randomized a receive no antibiotic prophylaxis (group A, n 20) or cefuroxime (1.5 g single injection; group B, n 20). Bacterial contamination at various steps in the autotransfusion procedure was assessed in liquid and solid culture media. The operation field and the wound drainage blood were never contaminated either of the groups but some of the suction tips were. Parts of the Vacufix blood collection bags of group A contained bacteria, but none in group B. Processed red blood cell concentrates in both groups showed bacterial growth. Greater blood loss did not increase the contamination rate in general. Isolated bacteria included the species Staphylococcus epidermidis, coagulase-negative staphylococci and Propionibacteria in both groups, but with different cell counts. In addition, Corynebacterium bovis et minutissimum and Moraxelle were identified in group A. In conclusion, autologous blood transfusion was a safe procedure. If contamination occurred, the bacterial count was low, and the bacteria of low pathogenicity. Antibiotic prophylaxis with cefuroxime reduced this contamination of suction tips and collection bags and limited the transfer of autologous blood products.

[Preoperative risk assessment of children with Duchenne muscular dystrophy and relevance for anesthesia and intra- and postoperative course]. / Präoperative Risikoerfassung bei Kindern mit Muskeldystrophie Typ Duchenne und ihre Relevanz für die Anästhesie sowie den intra- und postoperativen Verlauf.

BACKGROUND: Patients suffering from muscle disorders have an elevated anesthetic risk, i.e. to develop malignant hyperthermia or rhabdomyolysis. In addition serious cardial and pulmonal complications are imminent during anesthesia for surgery. PATIENTS AND METHODS: We investigated retrospectively the preoperative risk factors of 81 Duchenne patients undergoing 101 anesthesia (79 for muscle releasement operations and 23 for spine surgery) and the relation to possible complications due to the anesthesia and the intra- and postoperative course. RESULTS AND DISCUSSION: 83% of the patients showed pathologic ECG, 26% cardiac insufficiency in echocardiography, 31% pathologic X-rays of the thorax and 73% serious pulmonary restriction. Consequently avoiding of anesthetic agents with a high trigger potential for developing malignant hyperthermia (i.e. halothane or muscle relaxants type succinylcholine) prevented severest complications as malignant hyperthermia, rhabdomyolysis or cardiac arrest. Nevertheless other complications (i.e. arrhythmia, cardiac insufficiency) occurred due to the cardiac and pulmonary limitations more pronounced in the older patients of the spine surgery group.

Influence of hemodilution on cefuroxime levels and bacterial contamination of intra- and postoperative processed wound blood during hip replacement.

MATERIALS AND METHODS: In a prospective randomized study we investigated the effect of hemodilution on cefuroxime levels and bacterial contamination of processed shed blood during hip arthroplasty. 10 patients received cefuroxime 1,5 g as single shot prophylaxis before (group A), 10 after hemodilution (15 ml/KG) (group B). Cefuroxime levels in serum 1 h after administration, at the end of operation, after 12 h and in drainage-blood after 12 h were assessed by HPLC. Bacteriological study was performed from collecting bags (Vacufix), wound drainage blood and processed red blood cell concentrates, using pour plate technique and broth culture enrichment. RESULTS AND DISCUSSION: Mean concentrations of cefuroxime were higher in group B than group A, but differed not significantly. No bacterial contamination was found in collecting bags and wound drainages in both groups. Processed red cell concentrates in group B showed no growth. In group A, however, 3/10 were contaminated with < or = CFU/ml of coagulase-negative Staphylococcus, Staphylococcus epidermidis and Propionibacterium acnes. The differences between groups did not reach the level of statistical significance and could not be related to lower cefuroxime levels. No wound infection occurred in either group.

Cerebrospinal fluid and serum from patients with inflammatory polyradiculoneuropathy have opposite effects on sodium channels.

The effects of cerebrospinal fluid (CSF) and serum from patients having Guillain-Barré syndrome (GBS) or chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) on voltage-dependent Na+ channels were compared. Bathing human myoballs in CSF substantially reduced their Na+ currents (by > 40% with 8 of 10 patients) elicited at 1 Hz under whole-cell recording conditions. This was because, at the resting potential, more Na+ channels were inactivated (left-shift of the h infinity curve). CSF from patients with other neurological diseases (OND) produces a similar, but smaller, effect. In contrast, serum samples from the same GBS and OND patients caused an increase of the Na+ currents by reducing the number of Na+ channels inactivated at the resting potential. This right-shift of the h infinity curve is in part explained by the effect of serum albumin. We confirm that the CSF of most GBS and CIDP patients contains factors inhibiting voltage-dependent Na+ currents. There is no indication that such factors are effective in the serum of these patients.

[Infraclavicular vertical brachial plexus blockade. A new method for anesthesia of the upper extremity. An anatomical and clinical study]. / Die vertikale infraklavikuläre Blockade des Plexus brachialis. Eine neue Methode zur Anästhesie der oberen Extremität Eine anatomische und klinische Studie.

Patchy analgesia and incomplete motor blockade sometimes occur during surgery of the upper limb under axillary brachial plexus blockade. To avoid these problems, we sought an alternative approach to the brachial plexus to guarantee reliable anaesthesia. Based on anatomic studies, we undertook a prospective clinical study with 175 patients. METHODS. One hundred seventy-five patients undergoing surgery of the upper limb were anaesthetised using the new technique, based on the results of the anatomic study. We divided the distance between the fossa jugularis and the ventral process of the acromium into two equal parts. An exactly vertical puncture was made using an electrical stimulation cannula and nerve stimulator set at 1.0 mA until muscle contractions were noted in the area to be operated. The current was then progressively reduced to at least 0.3 mA; 400 mg Prilocaine 1% and 50 mg bupivacaine 0.5% were applied in a single injection. RESULTS. Operability was achieved in 94.8% of patients within an average time of 13.5 min after injection (minimum 5 min, maximum 30 min). The tourniquet was tolerated in all cases. For sedation or analgesia, 32.5% required no drugs, 57.1% received low doses of hypnotics (< 5 mg midazolam) as desired, and 5.2% required systemic analgesia due to patchy anaesthesia. In 5.2% of cases the block was insufficient and general anaesthesia was administered. Except in these cases, complete blockades were found after surgery. Postoperative analgesia lasted for 3 to 20 h with an average of 8 h. All patients were satisfied with the anaesthesia and would choose this method another time. Venous puncture occurred in 18 cases without significant problems. In 12 cases we observed Horner's syndrome. No arterial or pleural injury was observed. CONCLUSIONS. Infraclavicular vertical brachial plexus blockade represents a highly successful method compared to other common techniques. Tolerance of the upper arm tourniquet for even longer periods also demonstrates the effective anaesthesia. Other important advantages include a very rapid onset of complete neural blockade and long-lasting postoperative analgesia. The method had low risks and high acceptance by both patients and anaesthesists.

[Effectiveness of home ventilation of young children and infants]. / Effektivität der Heimbeatmung bei Kleinkindern und Säuglingen.

BACKGROUND: The home care ventilation of patients with chronic respiratory insufficiency is a well-established method. In treating infants and newborns a lot of problems arise that deal with indication, prognosis and management. PATIENTS AND METHODS: We investigated 7 newborns and infants with chronic respiratory insufficiency after cervical spine trauma causing "pentaplegia" or due to inherited neuromuscular disorders (spinal muscular atrophy, myopathy) during homecare ventilation. RESULTS AND DISCUSSION: In contrast to experience with adults the management of the children with "pentaplegia" was relatively harmless. All were tracheostomized primarily, but 1 tracheostomy could be closed, because the patient finally achieved to be ventilated only during night-time in the iron lung. The 3 children with neuromuscular diseases were ventilated noninvasively by specially fitted nasal masks. Despite coming to the frontiers of feasibility, and taking into account the psychological stress for patients, relatives, doctors and nurses, satisfactory results were obtained.

Preoperative autologous plasmapheresis--9 years experience in orthopedic surgery.

Since nine years preoperative autologous plasmapheresis (PPH) is an essential part of a comprehensive autologous transfusion program in the Rehabilitation Hospital/Orthopedic University Clinic of Ulm. After v. Finck's recommendation in 1984 we started plasma-predeposit by centrifugation-plasmapheresis (PCSR, Haemonetics Comp.) in all elective orthopedic-surgical patients expecting a blood loss > 1,000 ml. Primarily this procedure was used for intra- and postoperative hemostasis stabilization and for having the ideal component to recomplete the harvested red cells by the Cell SaverR to full blood units. By clinical experience the strategy of routinely combining plasma-predeposit and wound-blood salvaging instead of full blood- or red cell's-predeposit was recognized as not only being highly effective in saving of banked blood but furthermore as being the best way of getting free from all time related problems due to the limited preservation period of red cells because donated platelet poor plasma (PPP) can easily be frozen and stored up to one year at least. In addition there is one more decisive aspect in favour of autologous fresh frozen plasma (AFFP): it may be used for the best and most physiological kind of volume replacement. In combination with a short acting artificial plasma substitute (e.g. Polygelin) for intraoperative replacement AFFP is best suitable for reestablishing and maintaining postoperative normovolemia which is essential for any kind of hemodilution practicing like we routinely do when accepting low hemoglobin concentrations (> 7,0 g/dl) to avoid homologous blood transfusions and to reduce the risk of thromboembolic complications at the same time.(ABSTRACT TRUNCATED AT 250 WORDS)

Filtration of cerebrospinal fluid in acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome).

INTRODUCTION: Acute Guillain-Barré syndrome (GBS) is a disease where cell-mediated and humoural immune reactions play a key role. Breakdown of the blood-nerve barrier, inflammation of the nerve roots and conduction block are leading symptoms. As it is likely that pathological humoural or cellular factors are concentrated in the subarachnoid space and since factors in the cerebrospinal fluid (CSF) of GBS patients were shown to block sodium channels, a direct therapeutic intervention in the intrathecal compartment seemed worthwhile. METHODS: For this purpose, we developed a technique to purify CSF from pathological factors. Filtration was achieved by withdrawal of CSF (through a lumbally inserted 18 G catheter) and reinfusion via specially developed filters. RESULTS: Twenty severely affected GBS patients were treated with 4 to 38 CSF filtrations. This eliminated cells (> 99%) and reduced the protein content. Clinical improvement was achieved probably by improvement of nerve conduction following a reduction of sodium channel blocking factors. The median time to one grade improvement was 19 days, to reach grade 2 (independent walking) was 42 days. Ventilated patients were weaned from the ventilator after 16 days (median). Patients for which CSF filtration was the first kind of treatment improved faster than patients that had not responded to other treatments, such as plasma exchange or intravenous immunoglobulins. DISCUSSION AND CONCLUSION: Severe side effects were not observed, except sometimes transient headache during the withdrawal phase. This therapy seams to shorten treatment time (in comparison to times reported in studies with and without GBS-specific treatment by plasma exchange or immunoglobulins) and to reduce the degree of remaining neurological deficits. An open randomized controlled study is currently being conducted to compare CSF filtration with plasma exchange.

Factors in the cerebrospinal fluid of multiple sclerosis patients interfering with voltage-dependent sodium channels.

The effect of cerebrospinal fluid (CSF) from patients with multiple sclerosis (MS) on voltage-dependent Na+ channels in human myoballs was studied. The transient Na+ currents, elicited by whole-cell depolarization from -85 to -20 mV, were decreased to 75-25% the control value in the presence of CSF from all 7 MS patients investigated. The effect was complete in about 5 s and was fully reversible on admission of standard external fluid. Such decrease was not or only to a minor extent observed with 10 out of 11 control CSFs from patients without inflammatory neurological disease. The origin of the factors interfering with the Na+ channels is unknown. It is suggested that, in addition to demyelination, impaired Na+ channel function might cause the symptoms in MS.