Point-of-care ultrasonography in Ukraine: a survey of anesthesiologists-intensivists participating in ultrasonography courses.

PURPOSE: Despite the potential value of point-of-care ultrasonography (POCUS) in resource-limited environments, it is not widely used in low- and middle-income countries compared with high-income countries. We sought to evaluate the current POCUS practice of Ukrainian anesthesiologists who attended POCUS courses to guide future POCUS training in Ukraine. METHODS: We conducted a 25-question web-based survey. It was distributed to 255 participants of POCUS courses held in Ukraine in 2023. The survey sections described current POCUS practice, perception of POCUS value, POCUS skills self-assessment, and perceived barriers to implementing POCUS in clinical practice. RESULTS: Two hundred and forty-four out of 255 course participants completed the survey, representing 214 unique respondents. Those who self-rated their skills identified themselves as either novices or beginners in areas of POCUS knowledge (118/157, 75%), image acquisition (110/158, 70%), image interpretation (117/158, 74%), and integration into clinical decision-making (105/155, 68%). Among all survey responders, 55% (118/214) reported using POCUS for vascular access procedures, 45% (97/214) for trauma assessment, and 44% (93/214) for regional anesthesia. Reported barriers to POCUS implementation included lack of ultrasound devices (101/214, 47%) and lack of trained faculty (112/214, 52%). CONCLUSION: Among anesthesiologists who participated in POCUS courses in Ukraine, the majority were in early stages of ultrasound practice. Respondents identified POCUS applications not currently practiced and evaluated barriers to POCUS use. Based upon these survey findings, we propose the following measures in Ukraine: 1) developing a standardized national POCUS curriculum; 2) increasing the number of experienced instructors of POCUS; and 3) acquiring ultrasound devices to support clinical applications of POCUS, especially in the Central, Southern, and Eastern regions.

RéSUMé: OBJECTIF: Malgré la valeur potentielle de l'échographie ciblée (POCUS) dans les environnements à ressources limitées, cette modalité n'est pas très répandue dans les pays à revenu faible et intermédiaire par rapport aux pays à revenu élevé. Nous avons cherché à évaluer la pratique actuelle des anesthésiologistes en Ukraine qui ont suivi des cours d'échographie ciblée afin d'orienter la future formation en POCUS dans ce pays. MéTHODE: Nous avons mené un sondage en ligne de 25 questions. Il a été distribué à 255 personnes ayant suivi des cours de POCUS organisés en Ukraine en 2023. Les sections de l'enquête décrivaient la pratique actuelle en échographie ciblée, la perception de sa valeur, l'auto-évaluation des compétences en POCUS et les obstacles perçus à sa mise en œuvre dans la pratique clinique. RéSULTATS: Deux cent quarante-quatre des 255 personnes ayant pris part au cours ont répondu au sondage, représentant 214 répondant·es uniques. Les personnes ayant auto-évalué leurs compétences se sont identifiées comme novices ou débutantes dans les domaines de la connaissance de l'échographie ciblée (118/157, 75 %), de l'acquisition d'images (110/158, 70 %), de l'interprétation d'images (117/158, 74 %) et de l'intégration dans la prise de décision clinique (105/155, 68 %). Parmi toutes les personnes ayant répondu à l'enquête, 55 % (118/214) ont déclaré utiliser l'échographie ciblée pour les procédures d'accès vasculaire, 45 % (97/214) pour l'évaluation des traumatismes et 44 % (93/214) pour l'anesthésie régionale. Les obstacles signalés à la mise en œuvre de l'échographie ciblée comprenaient le manque d'appareils d'échographie (101/214, 47 %) et le manque de professeur·es formé·es (112/214, 52 %). CONCLUSION: Parmi les anesthésiologistes qui ont participé aux cours d'échographie ciblée en Ukraine, la majorité en étaient aux premiers stades de la pratique de l'échographie. Les répondant·es ont identifié les applications de l'échographie ciblée qui ne sont pas actuellement pratiquées et ont évalué les obstacles à son utilisation. Sur la base des résultats de cette enquête, nous proposons les mesures suivantes en Ukraine : 1) la création d'un programme national normalisé d'échographie ciblée; 2) l'augmentation du nombre d'instructrices et instructeurs expérimenté·es en échographie ciblée; et 3) l'acquisition d'appareils d'échographie pour soutenir les applications cliniques de cette modalité, en particulier dans les régions du Centre, du Sud et de l'Est du pays.

Misuse of Tourniquets in Ukraine may be Costing More Lives and Limbs than they Save.

Hands-on training and social media sites have heavily emphasized the use of tourniquets to treat limb injuries during the Ukraine war. Tourniquet overuse or misuse can lead to significant tragedy-limb loss, physiologic complications, and even death. Casualty evacuation in Ukraine often exceeds 6 hours, and the liberal use of limb tourniquets may have unintentionally increased morbidity. Tourniquet application was appropriate in 24.6% of the wounded with tourniquets in one recent publication by a Ukrainian vascular surgeon. The longer a limb tourniquet is in place raises the risk of compartment syndrome, vascular thrombosis, rhabdomyolysis, and irreversible myonecrosis resulting in major tissue loss and often necessitating limb amputation. If bleeding is controlled with a tourniquet, attempts to remove the tourniquet as early as possible to avoid the negative consequences are essential. Training in tourniquet use without explaining possible limb loss and other complications resulting from tourniquets left in situ more than 2 hours makes use risky. Tourniquets should be loosened at one hour if the tactical situation allows, and the injury assessed to determine if major bleeding persists or to determine if other methods of hemostasis would be effective. Ukraine must improve the training so that everyone becomes aware of the risks of prolonged or improper tourniquet use. This tourniquet training information must be transmitted to military medical leaders, Ukrainian military medics, civilian volunteers, volunteers in Ukraine, and NATO trainers in allied countries conducting medical training for Ukrainian soldiers. A trauma registry and tracking through echelons of care can enhance performance improvement through timely feedback.

Effective Humanitarian Work: Teaching Medical Skill Sets in Ukraine.

The senior authors traveled to Ukraine to teach specific skills to Ukrainian physicians and other medical professionals, utilizing a 2-day ATLS course, workshops in point-of-care ultrasonography (POCUS), lectures and webinars on damage control resuscitation, damage control surgery, and transfusion of whole blood. The authors have focused on providing skill sets that Ukrainian doctors can utilize within their existing system to improve immediate patient care for casualties resulting from the unanticipated Russian invasion and improve outcomes. Given the resource limitations and differences of the Ukrainian healthcare systems, the authors believe Western-based professionals who come to Ukraine to help for short periods should resist the temptation to offer western solutions that may not work in Ukraine. Major improvements in Ukrainian health care will require long-term efforts in teaching but also need to include increased efforts to improve hospitals, clinics, staffing, education, supplies, and equipment. Those who travel to help in Ukraine can still teach short courses that provide skills that Ukrainian doctors and nurses can use within their existing healthcare system to improve the quality of patient care in the immediate period of crisis and hopefully improve outcomes in the near term. It is not a reasonable expectation to think that the delivery of 2-day courses such as ATLS or POCUS will significantly change the country-wide delivery of healthcare. This sort of practice change requires the engagement of medical and political leaders and a sustained reform effort over years, not days or weeks. Supportive countries and non-governmental organizations need to prepare for a long and extensive investment in improving Ukrainian healthcare.

Clinical Report: Schistosomiasis Exposure in U.S. Service Personnel During Whitewater Rafting on the Nile River in Jinja, Uganda.

Schistosomiasis is a known risk after exposure to freshwater in tropical parts of the world. In March 2014, 28 off-duty U.S. service members went on a water adventure in the Nile River in Jinja, Uganda. In April 2014, 10 of the 28 service members returned for a second water adventure. Twelve weeks after freshwater exposure, schistosomiasis enzyme-linked immunosorbent assay testing was performed. Twenty-five percent had elevated Schistosomiasis mansoni immunoglobulin G (7 positive of 28 exposed); all had negative pre-exposure serology. The serology-positive service members were treated with oral praziquantel 60 mg/kg in divided doses. Our report is the first schistosomiasis report among U.S. service members deployed to Africa since World War II. The absence of reports among U.S. service members and several reports among deployed foreign military units and tourists in sub-Saharan Africa suggest a lack of postexposure testing. We recommend schistosomiasis testing of prior and future U.S. military units deployed to sub-Saharan Africa with fresh water exposure. Unit commanders and medical personnel should discourage unnecessary fresh water contact in sub-Saharan Africa.

The U.S. Navy's forward resuscitative surgery system during Operation Iraqi Freedom.

The forward resuscitative surgery system (FRSS) is the Navy's most forward-deployed echelon II medical unit. Between March and August 2003, six FRSS teams were deployed in support of Operation Iraqi Freedom (OIF). During the combat phase of OIF (March 21 to May 1, 2003), a total of 34 Marine Corps and 62 Iraqi patients underwent treatment at a FRSS. FRSS teams were assigned two distinct missions; "forward" FRSS teams operated with combat service support elements in direct support of regimental combat teams, and "jump" FRSS teams served as a forward element of a surgical company. This article presents the experiences of the FRSS teams in OIF, including a discussion of time to presentation from wounding, time to operation, time to evacuation, and lessons learned from the deployment of the FRSS.

Intrathecal neurolytic blocks for the relief of cancer pain.

Intrathecal neurolytic blocks for the treatment of chronic pain were first described by Dogliotti in 1931. Since then, many authors have described the intrathecal injection of various neurolytic substances for the treatment of oncologic pain. In recent years, alcohol and phenol have been the substances most commonly used for this purpose. There are no controlled studies, so the literature consists of observations, reports and book chapters reflecting the opinions of experienced clinicians. This chapter describes the indications, contraindications, potential complications, and expected benefits of intrathecal injection of alcohol and phenol in the treatment of cancer pain. Four cases of cancer patients whose intractable pain was treated by the authors using intrathecal neurolysis are presented. Pertinent literature is reviewed. In this account, the emphasis is on proper selection of patients and techniques.

Post-dural puncture headache: pathophysiology, prevention and treatment.

Post-dural puncture headache (PDPHA) has been a vexing problem for patients undergoing dural puncture for spinal anaesthesia, as a complication of epidural anaesthesia, and after diagnostic lumbar puncture since Bier reported the first case in 1898. This Chapter discusses the pathophysiology of low-pressure headache resulting from leakage of cerebrospinal fluid (CSF) from the subarachnoid to the epidural spaces. Clinical and laboratory research over the last 30 years has shown that use of small-gauge needles, particularly of the pencil-point design, is associated with a lower risk of PDPHA than traditional cutting point needle tips (Quincke-point needles). A careful history can rule out other causes of headache. A positional component of headache is the sine qua non of PDPHA. In high-risk patients (e.g. age < 50 years, post-partum, large-gauge-needle puncture), patients should be offered early (within 24-48 h of dural puncture) epidural blood patch. The optimum volume of blood has been shown to be 12-20 ml for adult patients. Complications of autologous epidural blood patch are rare.

Anestesia y analgesia peridural torácica para cirugía oncológica: ­La técnica anestésica es importante! / Thoracic epidural anesthesia and analgesia for cancer surgery: the anesthetic technique is important!

La cirugía oncológica mayor paliativa o curativa puede asociarse a morbilidad cardíaca o pulmonar significativa y a severo dolor postoperatorio. Actualmente existen evidencias que justifican el uso de anestesia peridural y general combinadas para pacientes que son sometidos a estos prolongados procedimientos de tórax y/o abdomen. El manejo intraoperatorio de ambos componentes de la anestesia, que provea un bloqueo sensorial adecuado y continuo con anestésicos locales mientras se limita el uso de anestésicos inhalatorios y endovenosos a un mínimo necesario para el confort del paciente, puede ser tan importante como la elección de la técnica anestésica per se. Aunque son necesarios estudios clínicos bien diseñados para confirmar esta hipótesis, un estudio piloto reciente ha demostrado que esta opción anestésica permite una hospitalización más corta, sin aumentar la incidencia de complicaciones ni arriesgar el confort del paciente.

Anestesia y analgesia peridural torácica para cirugía oncológica: íLa técnica anestésica es importante! / Thoracic epidural anesthesia and analgesia for cancer surgery: the anesthetic technique is important!

La cirugía oncológica mayor paliativa o curativa puede asociarse a morbilidad cardíaca o pulmonar significativa y a severo dolor postoperatorio. Actualmente existen evidencias que justifican el uso de anestesia peridural y general combinadas para pacientes que son sometidos a estos prolongados procedimientos de tórax y/o abdomen. El manejo intraoperatorio de ambos componentes de la anestesia, que provea un bloqueo sensorial adecuado y continuo con anestésicos locales mientras se limita el uso de anestésicos inhalatorios y endovenosos a un mínimo necesario para el confort del paciente, puede ser tan importante como la elección de la técnica anestésica per se. Aunque son necesarios estudios clínicos bien diseñados para confirmar esta hipótesis, un estudio piloto reciente ha demostrado que esta opción anestésica permite una hospitalización más corta, sin aumentar la incidencia de complicaciones ni arriesgar el confort del paciente. (AU)