Electrostimulation with or without ultrasound-guidance in interscalene brachial plexus block for shoulder surgery.

In a prospective controlled trial to compare conventional interscalene brachial plexus block (ISBPB) using anatomic landmarks and electro-stimulation with a combined technique of ultrasound guidance followed by nerve stimulation, 60 patients were randomized into 2 matched equal groups: Group A using nerve stimulation (NS) alone and Group B using the combination of ultrasound and NS. The time to detect the plexus (3.9 ± 4 min in Group A and 3.3 ± 1.4 min in Group B) was not significantly different. We needed to reposition the needle once (n = 13) or twice (n = 4) in Group B. First-shot motor response was achieved in all but one patient in Group A; here we were only able to locate the plexus by use of ultrasound. None of the patients needed general anaesthesia. There were no significant differences between postoperative pain, motor power, or patient's satisfaction. ISBPB seems similarly effective using electro-stimulation and ultrasound if performed by experienced anesthesiologists.

Large volume autologous plasma predonation and retransfusion in orthopedic surgical patients.

BACKGROUND: Intraoperative washed autologous transfusion of the scavenged blood can reduce the deterioration of anemia, even during the operation with a comparatively large blood loss. On the other hand, plasma level can not be collected by this system. The preoperative donation and perioperative retransfusion of autologous plasma may reduce the plasma dilution. PURPOSE: The influence of a large volume plasma predonation and perioperative retransfusion on the plasma protein level was investigated. METHODS: Thirteen patients (63.2 +/- 13.2 yr, 70.3 +/- 12.1 kg) were examined regarding their serum protein (SP), IgG, coagulation systems, colloid osmotic pressure (COP), blood cell count before, just after, 2 h after and 7 days after the donation of 900 ml plasma by plasmapheresis with a simultaneous volume replacement. Twenty surgical patients (52.8 +/- 17.3 yr, 72.6 +/- 16.6 kg, the mean predonated autologous plasma: 2100 ml) with intra- and postoperative retransfusion of autologous plasma were examined perioperatively for SP, IgG, coagulation systems and COP. These parameters were compared with that of the predonated plasma. RESULTS: All data including SP, coagulation and COP, with the exception of IgG, completely recovered within 7 days after preoperative plasmapheresis. Perioperatively, autologous washed blood transfusion system was used. The retransfused volume of autologous predonated plasma was 1740 ml on average. Although about 41 of blood on average was lost perioperatively, only one patient out of 20 patients had to be administered homologous red blood cell transfusion. The levels of most parameters, except for COP, constantly recovered in accordance with the autologous plasma transfusion. Differences in the patterns of improvement were also observed between the parameters. CONCLUSION: A 900 ml plasma predonation can therefore be safely performed with an interval of not less than a week between the last donation and the operation. Autologous plasma retransfusion is thus considered to improve the protein levels.

Efficacy and cost effectiveness of harmonic scalpel compared with electrocautery in posterior instrumentation of the spine.

Different methods to reduce blood loss during spinal surgery have been described already. Although the use of the harmonic scalpel (HS), an ultrasonically activated coagulator, has been described in endoscopic spinal surgery, its efficacy in posterior instrumentation of the spine remains unclear. The aim of this study was to determine if blood loss was lower using the HS than electrocauterization (EC) and to evaluate the cost effectiveness of the HS in reducing the need for transfusion in patients undergoing posterior instrumentation of the spine. The two groups were matched in a blinded manner, without knowledge of blood loss and were similar with respect to mean age, diagnosis and operation data. All instrumentations were done by the same surgeon. After matching was completed (HS group n = 50, EC group n = 50) blood loss and overall costs for blood products were analyzed by independent observers. The following were significantly lower with the HS than with EC: (1) blood loss (1106+/-985 ml vs 2176+/-1764 ml, P < 0.001), (2) frequency of cell saver use (13 vs 28 patients, P = 0.001), (3) average cost of blood products (Euro 72 vs Euro 219, P < 0.001), (4) predonation of autologous fresh frozen plasma (2.58+/-2.78 vs 4.5+/-2.2 U, P = 0.002) and red blood cells (0.38+/-0.75 vs 0.88+/-1.1 U, P = 0.009). The overall costs, including the costs for the HS, remained neutral. The use of the HS in posterior spinal surgery leads to significantly lower blood loss, and less need for and cost of blood products, compared to EC in cases with major anticipated blood loss.