[Guidance of axillary multiple injection technique for plexus anesthesia. Ultrasound versus nerve stimulation]. / Steuerung der axillären Multiinjektionstechnik zur Plexusanästhesie. Ultraschall vs. Nervenstimulation.

BACKGROUND: Ultrasound guidance is still a young method in regional anesthesia when compared to nerve stimulation and only a few studies exist comparing these two techniques in an axillary multiple injection approach. AIM: This prospective, randomized, observer-blinded study compared an ultrasound-guided (SONO) quadruple injection axillary block (out of plane, perineural) with a nerve stimulation-guided (STIM) triple injection axillary block for upper limb surgery. MATERIAL AND METHODS: A total of 60 patients were randomized to either the SONO (n = 30) or STIM (n = 30) group. For the block 40-50 ml mepivacaine 1.5 % (plexus) and 5-10 ml mepivacaine 0.5 % (subcutaneous in the medial skin of the arm) was used. Anesthesia time was recorded as the primary end point. After evaluation of block-related pain using a visual analog scale (VAS) a blinded observer tested sensory and motor function of the median nerve (MED), ulnar nerve (ULN), radial nerve (RAD), musculocutaneous nerve of the upper limb (MUC) and medial cutaneous nerve of the forearm (CAM) at defined times. The main outcome variable was onset time (defined loss of sensory/motor function). RESULTS: No differences were observed between the groups in terms of onset time (single nerves 10-20 min, plexus 20-25 min) and success rate (SONO 90 %, STIM 89 %). Patient satisfaction as measured by block-related pain score (VAS 2 cm), complications (vascular puncture SONO 7 %, STIM 11 %; paresthesia SONO 21 %, STIM 22 %) and patient acceptance (SONO 92 %, STIM 91 %) showed no differences. Performance time was shorter in the SONO group (6.68 ± 1.72 min vs. 8.05 ± 2.58, p = 0.02). CONCLUSION: Nerve stimulation-guided axillary plexus blocks performed by trained anesthesiologists may result in similar onset times and success rates compared to ultrasound-guided blocks.

Fractional carbon dioxide laser resurfacing of rhytides and photoageing: a prospective study using profilometric analysis.

BACKGROUND: Results of profilometric skin analyses after fractional ablative skin resurfacing are not only important for evaluating the efficacy of this therapy but are also relevant for physicians practising laser and aesthetic skin therapy. Currently, objective measurements of wrinkle reduction after fractional CO2 laser resurfacing are scarce, and it remains unclear whether the various facial areas respond differently to this therapy. OBJECTIVES: To measure wrinkle parameters, the homogeneity of melanin distribution and skin roughness in four facial areas (periorbital, perioral, forehead, cheeks) before and after three fractional CO2 laser treatments. METHODS: Twenty-five women were analysed with regard to wrinkle parameters and mottled pigmentation on the face. We measured wrinkle size, depth and width and the homogeneity of melanin distribution and skin roughness in four facial areas before and after three fractional CO2 laser treatments. Additionally, the investigators rated clinical improvement using five-point grading scales. RESULTS: Wrinkles were significantly reduced in all facial areas, and the best results for wrinkle size and depth were found for the cheeks (-58·3%, P = 0·018 and -51·3%, P = 0·018) and the periorbital area (-35·1%, P < 0·001 and -31·1%, P = 0·001, respectively). The percentage improvements of rhytides evaluated by the investigators were mostly similar to those found from in vivo measurements. The homogeneity of melanin distribution in the skin was improved by 21·4% on the cheeks (P = 0·012) and by 24·0% in the periorbital area (P < 0·001). Clinical investigators rated the improvement of mottled pigmentation considerably higher (51-75%). CONCLUSIONS: After a serial treatment with the fractional CO2 laser, we measured considerably varying wrinkle reduction depending on the area of the face, and the best results were found for the cheeks.

[Operation room management in quality control certification of a mainstream hospital]. / OP-Management im KTQ-Zertifizierungsprozess eines Schwerpunktkrankenhauses.

We report the results of our study concerning the organisation of operating room (OR) capacity planned 1 year in advance. The use of OR is controlled using 2 global controlling numbers: a) the actual time difference between the expected optimal and previously calculated OR running time and b) the punctuality of starting the first operation in each OR. The focal point of the presented OR management concept is a consensus-oriented decision-making and steering process led by a coordinator who achieves a high degree of acceptance by means of comprehensive transparency. Based on the accepted running time, the optimal productivity of OR's (OP_A(%) can be calculated. In this way an increase of the overall capacity (actual running time) of ORs was from 40% to over 55% was achieved. Nevertheless, enthusiasm and teamwork from all persons involved in the system are vital for success as well as a completely independent operating theatre manager. Using this concept over 90% of the requirements for the new certification catalogue for hospitals in Germany was achieved.

[Recombinant activated factor VIIa for treatment of traumatic liver rupture]. / Einsatz von rekombinantem aktiviertem Faktor VIIa zur Behandlung der traumatischen Leberruptur.

Hepatic rupture after blunt abdominal trauma may lead to severe bleeding, depletion and consumption of clotting factors, with the risk of packing to defer the definitive operation. We report two cases of hepatic rupture after blunt trauma with intrahepatic hematoma and severe intraabdominal bleeding. In both cases the bleeding could be stopped by early intervention with recombinant activated factor VIIa (rFVIIa). In neither case was surgical intervention necessary and after 3 weeks both patients were released without complications. These cases demonstrate that the early therapy with a single dose of rFVIIa before the development of a hemostatic crisis is a therapeutic option in selected cases where surgical therapy of the bleeding is difficult and risky.

Remifentanil for analgesia during retrobulbar nerve block placement.

BACKGROUND AND OBJECTIVES: Patients undergoing eye surgery under regional anaesthesia often require concomitant medication for analgesia and comfort. Remifentanil, with its ultra-short acting-profile, may be useful to reduce pain during retrobulbar nerve block for cataract surgery. METHODS: We performed a prospective, randomized, double-blind study to compare the efficacy of remifentanil for analgesia during retrobulbar nerve block placement. Ninety patients undergoing cataract surgery were randomly divided to receive either remifentanil 0.3 microg kg(-1) (n = 45) or an equivalent volume of saline (n = 45). The injection was administered within 30 s in both groups. Patients rated their amount of pain on a 10 cm visual analogue scale. Respiratory frequency, oxygen saturation, cardiac rhythm and postoperative nausea and vomiting (PONV) were recorded. RESULTS: The mean visual analogue score in the Remifentanil group was 2.56; it was 5.51 in the Saline group (P = 0.001, U-test). Three patients developed bradycardia and three had PONV in the Remifentanil group. Two patients developed tachycardia and one had PONV in the Saline group. No patient developed respiratory depression. CONCLUSION: In patients undergoing retrobulbar block placement for eye surgery, 0.3 microg kg(-1) remifentanil over 30 s significantly reduced their reported pain. In addition, remifentanil did not increase the risk of untoward side-effects.

[Unusual complication after combined spinal/epidural anaesthesia]. / Ein ungewöhnlicher Befund nach kombinierter Spinal- und Epiduralanästhesie zur Sectio caesarea.

An 31-year-old women with a long history of back pain without neurological symptoms underwent a caesarean section during the 36th week of pregnancy with combined spinal-epidural anaesthesia. Indication was the increasingly severe back pain. She delivered a normal healthy boy. On the 3rd day after surgery she developed a discrete sensory cauda equina syndrome on the left side. The interpretation of the magnetic resonance imaging (MRI) was a tumor in the thecal sac extending from the middle of the vertebral body of L-1 to the the superior vertebral plate of L-3. A few days later she underwent a laminectomy under general anaesthesia with resection of an intradural mass adherent to the cauda equina. Pathological review of the surgical specimen revealed a myxopapillary ependymoma WHO grade I. The postoperative course was uncomplicated with preservation of bladder dysfunction but after 4 weeks the bladder function was normalised.

[Reduction of severe cardiac complications during implantation of cemented total hip endoprostheses in femoral neck fractures]. / Verminderung von schweren kardialen Komplikationen während der Implantation von zementierten Hüfttotalendoprothesen bei Oberschenkelhalsfrakturen.

Intraoperative circulatory and pulmonary problems occuring during the repair of femoral neck fractures with cemented hip arthroplasty are a common problem, that cannot be ultimately explained. As a possible reason for this problem is air embolism during the polymerisation of the methylmethacrylat discussed. We started a prospective randomised clinical examination with 72 patients to prove the efficiency of palacos mixed in vacuum, with respect to the reduction of severe cardiovascular complication during endoprosthetic repair of femoral neck fractures. In the control group with 36 patients, surgical repair was performed with palacos mixed conventionally. In the second group (vacuum group), also consisting of 36 patients, surgical repair was performed with palacos mixed in vacuum. Invasive hemodynamic monitoring and transesophageal echocardiography was performed in all cases. In the control group pulmonary embolism occurred echocardiographically in 86% of the cases vs. 14% in the vacuum group. 53% of the control patients--vs. 11% of the vacuum patients--showed clinical complications in form of significant decrease of arterial oxygenation and circulatory insufficiency with the need of catecholamines. Clinical complications occurred in the control group in 80% of the patients--vs. 13.7% in the vacuum group--whose pulmonal arterial pressure was higher than 30 mmHg preoperatively and only in 18.8% of the cases--vs. 7.1% in the vacuum group--with a normal pulmonal arterial pressure. Mortality in the control group amounted to 13.8% in the vacuum group to 2.8%. Through the use of methylmethacrylate mixed in vacuum for surgical repair of femoral neck fractures with cemented hip arthroplasty, the incidence of severe cardiac complications could be reduced significantly. Patients with increased pulmonal arterial pressure have the highest risk for cardiac complications.

[Prolapse of the small intestine through a surgically closed introitus vaginae after vaginal hysterectomy followed by subsequent colpectomy]. / Dünndarmprolaps durch einen nach vaginaler Hysterektomie und späterer Kolpektomie verschlossenen Introitus vaginae.

We report on an unusual case of small bowel prolapse through a hiatus in the closed introitus vaginae after previous total colpectomy. The interval between colpectomy and present prolapse was nearly 4 years. The intestinum was reponated by abdominal approach, but a partial resection of the small bowel was not to avoid. The possible complications after vaginal hysterectomy resp. colpectomy are discussed. According to literature we didn't find a similar case.

[Prenatal diagnosis of a severe heart defect (author's transl)]. / Pränatale Ultraschalldiagnostik eines schweren Herzvitiums.

Report of the case of a 22 year old primigravida. At 37 weeks gestation an ultra-sound examination was carried out because of fetal bradycardia. An atrial septal defect was found with a complete atrial ventricle canal. (AV canal). These findings were corroberated at autopsy in addition a polyspienic syndrome with multiple thoracic and abdominal malformations was found. The antepartum diagnosis permitted a team approach to the case. The infant was immediately transferred to the cardiac centre where a pace maker was placed and angiography carried out. Ante-partum ultra-sound diagnosis of congenital heart disease permits optimal neonatal treatment.