The Abdominal Hernia-Q: a critical analysis of the components that impact quality-of-life.

PURPOSE: Ventral hernias (VH) are a common surgical problem associated with significant morbidity. While assessment tools have examined quality-of-life (QoL), the relative change in specific domains of hernia-related QoL measures from pre- to post-operative period has yet to be comprehensively examined. Using the Abdominal Hernia-Q (AHQ), this study aims to assess the impact of ventral hernia repair (VHR) on key components of QoL. METHODS: A retrospective chart review was conducted of patients undergoing VHR between September 2017 and September 2019 who had completed at least one pre- and post-operative AHQ. Post-operative intervals were created to capture AHQ responses around standard follow-up visits (< 1.5 months, 1.5-4.5 months, 4.5-11 months, and 11 + months) and scores were statistically analyzed. RESULTS: A total of 136 patients were included, with an average age of 54.8 years at the time of VHR. Compared to the pre-operative period, the appearance score increased significantly (p < 0.05). The physical domain score increased from < 1.5 month to the 1.5-4.5 month period (p = 0.03) and remained significantly higher in later time period. The appearance score decreased from the 1.5-4.5 month to 4.5-11 month period (p = 0.05). CONCLUSIONS: VHR leads to a sustained multi-dimensional increase in hernia-specific QoL measures during the post-operative course driven by early positive changes in appearance and sustained physical functioning. The initial increase in QoL is mainly driven by an improvement in appearance, while the sustained increase may be due to restored physical function.

The incisional hernia epidemic: evaluation of outcomes, recurrence, and expenses using the healthcare cost and utilization project (HCUP) datasets.

BACKGROUND: Incisional hernias (IH) following abdominal surgery persist as morbid, costly, and multi-disciplinary surgical challenges. Using longitudinal, multi-state, administrative claims data (HCUP State Inpatient Databases (SID)); (HCUP State Ambulatory Surgery and Services Databases (SASD)), we aimed to characterize the epidemiology, outcomes, recurrence, and costs of IH. STUDY DESIGN: 529,108 patients undergoing abdominal surgery in 2010 across six specialties (colorectal, general/bariatric, hepatobiliary, obstetrics/gynecology, urology, and vascular) were identified within inpatient and ambulatory databases for Florida (FL), Iowa (IA), Nebraska (NE), New York (NY), and Utah (UT). IH repairs, complications, and expenditures were assessed through 2014. Predictive regression modeling was validated using a training set of 1000 bootstrapped repetitions. RESULTS: 16,169 (3.1%) patients developed hernias requiring repair (4.3-year mean follow-up), 3176 (20%) underwent recurrent repair, and 731 (23%) underwent re-recurrent repair. Patients with IH had increased readmissions (6.6 vs. 2.4), morbidity (39 vs. 8% surgical and 22 vs. 7% medical), and costs ($46,000 vs. $25,000) when compared to patients without IH (p < 0.001). IH expenditures totaled $875 million: initial ($687 million), recurrent ($155 million), and re-recurrent hernias ($33 million). IH predominated in colorectal (10%), hepatobiliary (8%), and vascular (5%) procedures. Of 31 significant independent IH risk factors (p < 0.001), obesity, age, smoking, open surgery, and prior surgery were pervasive across surgical specialties. CONCLUSION: IH represents an unremitting surgical epidemic associated with considerable morbidity, costs, and features consistent with a chronic disease state. We define critical pervasive risk factors (obesity, age, smoking open surgery, and prior surgery) independently associated with IH across surgical disciplines. With failed repairs, subsequent success becomes less likely, increasing morbidity and costs-underscoring the critical importance of optimal treatment and prevention.

Cutting through the fat: a retrospective analysis of clinical outcomes, cost, and quality of life with the addition of panniculectomy to ventral hernia repair in overweight patients.

BACKGROUND: Due to the increased prevalence of overweight patients with ventral hernia, abdominal wall reconstruction combining ventral hernia repair (VHR) with panniculectomy (VHR-PAN) in overweight patients is increasingly considered. We present a retrospective comparison between VHR-PAN and VHR alone in overweight patients by examining costs, clinical outcomes, and quality of life (QoL). METHODS: Patients with body mass index (BMI) > 25.0 kg/m2 underwent VHR-PAN or VHR alone between September 2015 and May 2017 with a single surgeon and were matched into cohorts by BMI and age (n = 24 in each cohort). QoL was assessed using the Hernia-related Quality of Life Survey (HerQLes). Cost was assessed using billing data. Statistical analyses were performed using Fisher's exact tests, Mann-Whitney U tests, and regression modeling. RESULTS: Hernia defect size (p = 0.127), operative time (p = 0.140), mesh placement (p = 0.357), and recurrence rates (p = 0.156) did not vary significantly between cohorts at average follow up of one year. 60% of patients completed QoL surveys, with 61% net improvement in VHR-PAN postoperatively (p = 0.042) vs 36% in VHR alone (p = 0.054). Mean total hospitalization costs were higher for VHR alone (p = 0.019). Regression modeling showed no significant independent contribution of procedure performed due to differences in cost, wound complications, or hernia recurrence. CONCLUSIONS: At mean follow up of 2 years, VHR-PAN patients reported a comparable increase in QoL to those who received VHR alone without significantly different cost and complication rates. Concurrent VHR-PAN may therefore be a safe approach for overweight patients presenting with hernia and excess abdominal skin.

Review of the Imaging Features of Benign Osteoporotic and Malignant Vertebral Compression Fractures.

Vertebral compression fractures are very common, especially in the elderly. Benign osteoporotic and malignant vertebral compression fractures have extremely different management and prognostic implications. Although there is an overlap in appearances, characteristic imaging features can aid in the distinction between these 2 types of compression fractures. The aim of this review is to characterize the imaging features of benign and malignant vertebral compression fractures seen with CT, PET, SPECT, and MR imaging.

Application of Benford's law: a valuable tool for detecting scientific papers with fabricated data? : A case study using proven falsified articles against a comparison group.

BACKGROUND: In naturally occurring numbers the frequencies of digits 1-9 in the leading position are counterintuitively distributed because the frequencies of occurrence are unequal. Benford-Newcomb's law describes the expected distribution of these frequencies. It was previously shown that known fraudulent articles consistently violated this law. OBJECTIVE: To compare the features of 12 known fraudulent articles from a single Japanese author to the features of 13 articles in the same research field from other Japanese authors, published during the same time period and identified with a Medline database search. RESULTS: All 25 articles were assessed to determine whether the data violated the law. Formulas provided by the law were used to determine the frequencies of occurrence for the first two leading digits in manually extracted numbers. It was found that all the known fraudulent papers violated the law and 6 of the 13 articles used for comparison followed the law. Assuming that the articles in the comparison group were not falsified or fabricated, the sensitivity of assessing articles with Benford-Newcomb's law was 100% (95% confidence interval CI: 73.54-100%) but the specificity was only 46.15% (95% CI: 19.22-74.87%) and the positive predictive value was 63.16% (95% CI: 38.36-83.71%). CONCLUSION: All 12 of the known falsified articles violated Benford-Newcomb's law, which indicated that this analysis had a high sensitivity. The low specificity of the assessment may be explained by the assumptions made about the articles identified for comparison. Violations of Benford-Newcomb's law about the frequencies of the leading digits cannot serve as proof of falsification but they may provide a basis for deeper discussions between the editor and author about a submitted work.

Fentanyl bolus induces muscle tremors in sevoflurane-anaesthetized piglets.

Intravenous fentanyl (10 mcg/kg) or saline (control) was randomly administered to 10 healthy sevoflurane-mono-anaesthetized piglets. Trembling was assessed by two blinded observers using a visual analogue scale (VAS) and a simple ordinal scale at baseline and 5 min (T5) after drug administration. If no trembling was observed at that time point, the opposite treatment was administered and piglets were re-evaluated after another 5 min (T10). Four out of five piglets showed trembling after fentanyl (T5), while none given saline showed any trembling. With fentanyl the VAS scores were significantly higher at T5 compared either with baseline or with the control treatment. Control animals received fentanyl after the 5 min evaluation and all piglets showed clear trembling afterwards. The median time after fentanyl administration until first muscle tremors was 51 (20-840) s. In summary, nine out of 10 sevoflurane-anaesthetized piglets showed muscle tremors after intravenous fentanyl. Tremors subsided over time and no specific treatment was necessary.

Blood glucose, acid-base and electrolyte changes during loading doses of alpha2-adrenergic agonists followed by constant rate infusions in horses.

The aim of the present study was to investigate changes in blood glucose concentration ([Glu]B), acid-base status and electrolyte concentrations during constant rate infusions (CRI) of two alpha2-adrenergic agonists in seven horses treated in a blinded, randomised, crossover design with xylazine or romifidine. An intravenous (IV) bolus of xylazine (1mg/kg) or romifidine (80 µg/kg) was administered followed by an IV CRI of xylazine (0.69 mg/kg/h) or romifidine (30 µg/kg/h) for 2h. Blood samples were collected from the pulmonary artery before and after loading doses, during the CRI, and for 1h after discontinuing drugs. Blood glucose, base excess (BE), pH, partial pressure of carbon dioxide (Pv¯CO2), strong ion difference (SIDest) and bicarbonate concentration ( [Formula: see text] ) increased significantly during the CRI with both alpha2-adrenergic agonists. Chloride concentration ([Cl(-)]B) and anion-gap (AG) decreased significantly compared to baseline. The decrease in sodium concentration ([Na(+)]B) was only significant with xylazine. From 1h after starting the CRI onwards, [Glu]B was significantly higher with romifidine compared to xylazine. Except [Glu]B, SIDest, and Pv¯CO2, all variables returned to normal values 1h after discontinuing xylazine. After stopping romifidine, all variables except pH remained altered for at least 1h. It was concluded that loading doses of alpha2-adrenergic agonists followed by CRIs produce [Glu]B, acid-base and electrolyte changes. The clinical significance of the reported changes remains to be investigated and absolute values should be interpreted with caution, as fluid boli were used for cardiac output measurements, but may become important during prolonged infusion and in critically ill patients.

[Pediatric anesthesia for proton radiotherapy : medicine remote from the medical centre]. / Kinderanästhesie zur protonenbestrahlung : medizin fernab der klinik.

Anesthesia care for infants and young children for proton beam radiotherapy demands great technical and vocational skills from the anesthesia team and also a high degree of competence in soft skills. The anesthesia team should be experienced and regularly trained in pediatric anesthesia, especially as the children are often in a reduced general condition. The infrastructure should be established according to the current standards in anesthesiology. Monitoring of vital data, thorax excursions and inadvertent movements of the remotely positioned and sedated patient need to be under constant technical and optical surveillance. Propofol is an ideal hypnotic for the sedation of children under spontaneous breathing for proton beam radiation therapy. It is well tolerated even when given on a daily basis over several weeks. A close cooperation between the pediatric oncologist, radiation oncologist and anesthetist is important in order to manage additional medical problems in an optimal way. The special needs of oncology patients must be taken into consideration when planning anesthesia care.

[Pediatric caudal anesthesia: importance and aspects of safety concerns]. / Kaudalanästhesie bei Kindern : Stellenwert und Aspekte zur Sicherheit.

Caudal block is a safe procedure commonly used for pediatric perioperative analgesia. Complications are extremely rare but nevertheless local and systemic contraindications must be excluded. Optimal safety and quality result when strict attention is paid to technical details. A local anesthetic (LA) containing epinephrine allows early detection of inadvertent intravascular LA administration; therefore an epinephrine/LA mixture is recommended at least for the test dose. In terms of safety the choice of LA itself is probably of secondary importance. Clonidine as an adjuvant has an excellent risk/benefit profile with minimal side effects. Inadvertent systemic LA intoxication is a rare but potentially fatal complication of regional anesthesia and measures for prevention and early detection are essential. Should circulatory arrest occur, immediate resuscitation following standard guidelines is to be initiated including the use of epinephrine as the first line drug. Intravenous administration of lipid solutions may be beneficial as a secondary adjunct to stabilize hemodynamics but is not an alternative to epinephrine.

[Pediatric caudal anesthesia : importance and aspects of safety concerns]. / Kaudalanästhesie bei Kindern : Stellenwert und Aspekte zur Sicherheit.

Caudal block is a safe procedure commonly used for pediatric perioperative analgesia. Complications are extremely rare but nevertheless local and systemic contraindications must be excluded. Optimal safety and quality result when strict attention is paid to technical details. These are discussed in detail in this review. A local anesthetic (LA) containing epinephrine allows early detection of inadvertent intravascular LA administration; therefore an epinephrine/LA mixture is recommended at least for the test dose. In terms of safety the choice of LA itself is probably of secondary importance. Clonidine as an adjuvant has an excellent risk/benefit profile with minimal side effects. Inadvertent systemic LA intoxication is a rare but potentially fatal complication of regional anesthesia and measures for prevention and early detection are essential. Should circulatory arrest occur, immediate resuscitation following standard guidelines is to be initiated including the use of epinephrine as the first line drug. Intravenous administration of lipid solutions may be beneficial as a secondary adjunct to stabilize hemodynamics but is not an alternative to epinephrine.

[Distance from the laryngeal mask grip to endotracheal tube tip. A crucial point during fiberoptic intubation in children]. / Längenverhältnis von Trachealtubus zur Larynxmaske. Kritischer Punkt bei der fiberoptischen Intubation im Kindesalter.

BACKGROUND: Management of difficult airways and difficult intubation differs in pediatric and in adult patients. In conscious children, fiberoptic intubation is not feasible because of limited compliance. The specially designed laryngeal mask for blind tracheal intubation, LMA Fastrach™, is available for adolescents and adults only. Therefore, fiberoptic-guided intubation through a supraglottic airway device (SAD) is a standard technique for the management of difficult intubation in children. While performing the procedure, stabile positioning of the endotracheal tube (ETT) and prevention of dislodgement are critical issues. The relationship between the length of the ETT and the SAD is highly important and was investigated in this in vitro study. MATERIALS AND METHODS: In this study 6 different brands of SAD in the pediatric sizes 1-3 and 2 different ETT brands (cuffed, Microcuff(®), uncuffed, Sheridan PED-SOFT™) were investigated. Using pediatric growth tables, the recommended patient weight for each SAD size was correlated to patient age and then to appropriately sized cuffed and uncuffed ETTs. The ETT size was chosen according to the manufacturer's recommendations (cuffed ETT) and according to the literature (uncuffed ETT). The various SAD-ETT pairs were assessed with regard to differences in their length. After lubrication with silicone the ETT with a firmly attached 15 mm tube adapter was maximally inserted into the SAD and the ETT tip overlapping the SAD cuff was measured. Secondarily, an adapter for fiberoptic procedures was interposed and the measurements repeated. RESULTS: For a defined patient uncuffed ETTs were usually selected with a larger internal diameter (ID) compared to cuffed ETTs. Therefore, the uncuffed ETT is the longer one and will overlap the SAD by a longer tip. Comparing the curved SAD brands AuraOnce™ and Aura-i™, the Aura-i™ devices generally showed shorter tubes resulting in a longer protruding ETT tip (median 1.5 cm, minimum-maximum 1.0-2.4 cm). The straight brands LMA classic™, AuraStraight™ and LMA Unique™ showed similarity in tube length. In comparison with i-gel(®), for the SAD sizes 1-2.5 the former provide a longer projecting ETT tip. Only i-gel(®) together with AuraStraight™ showed the longest overlapping ETT tip for SAD size 3. If a swivel adapter was used during the fiberoptic intubation procedure, the length of the ETT could be critically reduced in relation to the length of the SAD. Using a swivel adapter from VBM Medizintechnik, (Sulz a. N., Germany) a relative reduction in ETT length of 2.3 or 3.2 cm has to be taken into account. CONCLUSIONS: For fiberoptic-guided endotracheal intubation through an SAD, sufficient length of the ETT in relation to the SAD is mandatory. Differences in geometry between SAD and ETT brands have to be considered. The selection of a relatively small SAD in combination with an uncuffed ETT might be advantageous. Redesigned extra long ETTs would be desirable to decrease the risk for ETT dislocation and to increase the safety of the technique. Restrictive use of a swivel adapter during the procedure is important because of further and potentially critical decreases in ETT length. In addition, after successful intubation of the trachea, removal of the SAD via an airway exchange catheter and replacement of the cuffed ETT of choice in the correct position is recommended to secure the airway and provide unimpaired ventilation and oxygenation.

Comparison of thromboelastometry (ROTEM®) with standard plasmatic coagulation testing in paediatric surgery.

BACKGROUND: Thromboelastometry (ROTEM(®)) might be useful to detect intraoperative coagulation disorders early in major paediatric surgery. This observational trial compares this technique to standard coagulation tests. METHODS: Intraoperative blood sampling was obtained in children undergoing elective major surgery. At each time point, standard coagulation tests [activated partial thromboplastin time (aPTT), prothrombin time (PT), and fibrinogen level] and ROTEM(®) analyses (InTEM, ExTEM, and FibTEM) were performed simultaneously by trained hospital laboratory staff. RESULTS: A total of 288 blood samples from 50 subjects were analysed. While there was a poor correlation between PT and aPTT to ExTEM clotting time (CT) and InTEM CT, respectively, a good correlation was detected between PT and aPTT to clot formation time, and a very good correlation between fibrinogen level and FibTEM assay (r=0.882, P<0.001). Notably, 64% of PT and 94% of aPTT measurements were outside the reference range, while impaired CT was observed in 13% and 6.3%, respectively. Standard coagulation test results were available after a median of 53 min [inter-quartile range (IQR): 45-63 min], whereas 10 min values of ROTEM(®) results were available online after 23 min (IQR: 21-24 min). CONCLUSIONS: PT and aPTT cannot be interchangeably used with ROTEM(®) CT. Based on the results of ROTEM(®), recommended thresholds for PT and aPTT might overestimate the need for coagulation therapy. A good correlation was found between the fibrinogen level and the FibTEM assay. In addition, ROTEM(®) offered faster turnaround times.

Comparison of air-sealing characteristics of tapered- vs. cylindrical-shaped high-volume, low-pressure tube cuffs.

BACKGROUND: This study aimed at comparing air-sealing characteristics of the new tapered-shaped tracheal tube cuffs with cylindrical tube cuffs. METHODS: Tracheal tubes with tapered-shaped polyurethane (PU) and polyvinyl chloride (PVC) cuffs as well as standard cylindrical-shaped cuffs made of PU and PVC (Covidien, Athlone, Ireland) were investigated. A tracheal model attached to a test lung was intubated, and cuffs were inflated to 10, 15, 20, 25 and 30 cm H(2)O. The test lung was ventilated with intermittent positive pressure ventilation at peak inspiratory pressures (PIPs) of 20 and 25 cm H(2)O. Air leakage was assessed by spirometry and measurement of sevoflurane concentration passing the cuff at the upper cuff border using an anaesthetic gas analyser. Experiments were repeated four times with new tracheal tubes for each run. Statistical comparisons were done using Mann-Whitney U-test with level of significance at P < 0.05. RESULTS: The tapered-shaped PVC tube cuff demonstrated a significantly lower air leakage determined by spirometry than the cylindrical-shaped cuff at both PIPs (20 and 25 cm H(2)O). Similarly, sevoflurane leakage was less with the tapered PVC cuff particularly at higher cuff pressures. With the PU cuff, reduction in air leakage by a tapered-shaped compared with a cylindrical-shaped tube cuff was not significant. CONCLUSIONS: A tapered-shaped tube cuff considerably improves air-sealing characteristics of PVC tube cuffs and allows thereby reducing cuff pressure required for sufficient ventilation. In tube cuffs made of PU that exhibits superior sealing characteristics compared with PVC, a tapered shape failed to result in a further reduction of air leakage.

Accuracy and precision of hemoglobin point-of-care testing during major pediatric surgery.

INTRODUCTION: The aim of the study was to compare accuracy and reproducibility of four point-of-care testing (POCT) devices (GEM® Premier 3000, ABL 800 flex, GEM® OPL™, HemoCue® B-Hemoglobin) for hemoglobin (Hb) analyzes as compared with the reference laboratory method (Sysmex XE 2100) in children undergoing major surgery. METHODS: Pediatric patients undergoing craniofacial, spine, hip, or cancer surgery were included. Blood samples for Hb testing were taken at several intraoperative time points and generally withdrawn from the arterial catheter, if accessible. RESULTS: A total of 256 blood samples were taken intraoperatively from 71 pediatric patients. All POCT devices showed very small bias (maximum -0.46 g/dL) to reference method as well as very good reproducibility (maximum coefficient of variation of 0.99%). However, in two cases (HemoCue), potential clinical relevant differences were observed beyond a range of 2 g/dL. CONCLUSION: All POCT devices tested and operated by trained staff for hemoglobinometry showed reliable test results. They all allow for simple, fast, and precise bedside determination of hemoglobin concentration in the intraoperative setting.

Electrocardiographic and haemodynamic alterations caused by three different test solutions of local anaesthetics to detect accidental intravascular injection in children.

BACKGROUND: The aim of this study was to investigate ECG and haemodynamic alterations provoked by a test dose of bupivacaine, epinephrine, and their combination. METHODS: Paediatric patients undergoing general anaesthesia were randomized into three groups. After anaesthesia induction and tracheal intubation, 0.2 ml kg(-1) (max. 3 ml) of the corresponding test solution was i.v. injected: bupivacaine 0.125% (Group B), bupivacaine 0.125% plus epinephrine 1:200 000 (Group BE), or epinephrine 1:200 000 (Group E). ECG was printed and analysed post hoc. Non-invasive arterial pressure (AP) was measured at 1 and 2 min after test dose injection. Increases in T-wave of ≥ 25%, in heart rate (HR) of ≥ 10 beats min(-1), and in systolic AP of ≥ 15 mm Hg above baseline value were considered a positive result. RESULTS: A total of 105 children aged 0.2-16 (median 6.8) yr were enrolled. Test dose injection provoked T-wave elevation in 0%, 85%, and 89% of patients in Groups B, BE, and E, respectively. A positive increase in HR was found in 0%, 68%, and 76%. A positive increase in AP at 1 min was found in 0%, 88%, and 94% and at 2 min in 0%, 42%, and 59%. A decrease in HR of ≥ 10 beats min(-1) was observed in 6%, 76%, and 69%. Alterations in T-wave and HR were significantly influenced by age. CONCLUSIONS: ECG and haemodynamic alterations after i.v. injection of a local anaesthetic test dose were significantly influenced by epinephrine. T-wave elevation, increase in AP, and changes in HR are highly reliable variables, particularly when age is taken into account.

[Bupivacaine toxicity and propofol anesthesia : animal study on intravascular bupivacaine injection]. / Bupivacaintoxizität und Propofolanästhesie : Tierstudie zur intravasalen Bupivacaininjektion.

BACKGROUND: Several reports have confirmed the efficacy of Intralipid® (containing soya bean oil, egg phospholipids, glycerin and water) in the therapy of systemic local anesthetic intoxication. Pretreatment with Intralipid® shifted the dose-response to bupivacaine-induced asystole in rats. Whether intravenous anesthesia with propofol in the widely used medium chain triglyceride lipid emulsion increases the therapeutic range of systemically administered bupivacaine or not is unknown and was investigated in this study. METHODS: A total of 30 piglets aged 2-6 weeks and weighing 4.5-6.5 kg were randomized into 2 groups and anesthetized with sevoflurane (group S) alone or with propofol 10 mg/kg body weight (BW)/h plus sevoflurane (group PS). After 60 min of steady state anesthesia arterial blood was sampled for assessment of blood gases, acid-base state and triglyceride plasma concentrations. Thereafter bupivacaine 0.125% was continuously infused by an infusion syringe pump through a central venous line at a rate of 4 mg/kg BW/min until invasively measured mean arterial pressure (MAP) was reduced by 50% of initial value. The bupivacaine infusion was stopped, blood for assessment of bupivacaine plasma concentration was drawn and the spontaneous hemodynamic course was observed. Resuscitation was not attempted. Results are presented as median and range. The Mann-Whitney U-test was used to assess differences between the two groups for triglyceride as well as for bupivacaine plasma concentrations measured at MAP 50%. A p-value≤0.05 was considered to be significant. RESULTS: Baseline conditions (arterial blood pH, plasma protein and triglyceride plasma concentrations) did not differ significantly between the two groups. After 1 h of anesthesia, triglyceride plasma concentrations were significantly increased in group PS (median 0.69 mmol/l) compared to the corresponding baseline values (median 0.14 mmol/l; p<0.001) and to the 1 h values of group S (median 0.16 mmol/l; p<0.001). The total amount of bupivacaine administered was 9 mg/kg BW in both groups (6-13 mg/kg BW in group S, 5-13 mg/kg BW in group PS). Resulting bupivacaine plasma concentrations were 180 µmol/l (83-686 µmol/l) in group S and 185 µmol/l (130-465 µmol/l) in group PS. However, the total amount of bupivacaine administered and bupivacaine plasma concentrations at MAP 50% did not reveal statistically significant differences between the two groups but a huge variability of both parameters within each group was observed. None of the 30 piglets spontaneously recovered and they died from pulseless electrical activity or from asystolic cardiac arrest. The time from MAP 50% until cardiac arrest demonstrated a large variability but did not reveal significant differences between the two groups. The time to cardiac arrest was similar in both groups. CONCLUSION: Medium/long chain triglyceride lipid emulsion (50:50) as widely used in propofol solutions did not increase therapeutic safety in cases of intravascular bupivacaine administration in this piglet model.

Electrocardiographic changes during continuous intravenous application of bupivacaine in neonatal pigs.

BACKGROUND: It is controversial as to whether T-wave elevation is caused by local anaesthetics, epinephrine, or their combination. It has been shown that T-elevation after intravascular injection of a small bupivacaine test dose is caused by epinephrine and not by bupivacaine. The aim of this study was to investigate ECG changes with higher doses of i.v. bupivacaine. METHODS: Thirty neonatal pigs were anaesthetized with sevoflurane and their tracheas intubated and artificially ventilated. Under steady-state conditions, bupivacaine was continuously infused (flow rate 3.2 ml kg(-1) min(-1)) by a syringe infusion pump through a central venous catheter. Group 1 received bupivacaine 0.125%, Group 2 bupivacaine 0.5%. The ECG was continuously printed and subsequently analysed for alterations in heart rate, ventricular de- and repolarization, and arrhythmias at 1.25, 2.5, and 5 mg kg(-1) bupivacaine infused. RESULTS: Sinus rhythm persisted in all pigs. Heart rate decreased progressively in both groups, but this was significantly more pronounced in Group 1. T-wave elevation occurred in 40% and 0% (Groups 1 and 2) at 1.25 mg kg(-1), in 80% and 0% at 2.5 mg kg(-1), and in 93% and 80% at 5 mg kg(-1) bupivacaine infused. There were significant differences between the two groups at 1.25 and 2.5 mg kg(-1) infused. CONCLUSIONS: Higher doses of i.v. infused bupivacaine can cause T-elevation. With slower injection technique, T-elevation can already be detected at lower bupivacaine doses administered.

Electrocardiographic alterations during intravascular application of three different test doses of bupivacaine and epinephrine: experimental study in neonatal pigs.

BACKGROUND: Origin of electrocardiographic (ECG) alterations during intravascular injection of local anaesthetic solutions is controversial. The aim of this study was to elucidate whether epinephrine, bupivacaine or their combination is responsible for ECG alteration. METHODS: Forty-five piglets were randomized into three groups. After induction of general anaesthesia using sevoflurane and peripheral venous cannulation, the trachea was intubated, the lungs were artificially ventilated, and anaesthesia was maintained by sevoflurane. Under steady state 0.2 ml kg(-1) and after 10 min 0.4 ml kg(-1) of one of the following three test solutions was administered i.v.: bupivacaine 0.125% (Group 1), bupivacaine 0.125%+epinephrine 1:200 000 (Group 2), and plain epinephrine 1:200,000 (Group 3). The ECG was analysed for alterations in heart rate and T-elevation. RESULTS: After injection of 0.2 or 0.4 ml kg(-1) test solution, an increase in heart rate of at least 10% was found in none of Group 1 and in all of Groups 2 and 3. After application of 0.2 ml kg(-1) test solution, T-elevation was found in 7% of Group 1 and in 93% of Groups 2 and 3. The injection of 0.4 ml kg(-1) revealed a T-elevation in 27%, 100%, and 100%, respectively, in Groups 1, 2, and 3. CONCLUSIONS: This animal model demonstrated that increases in heart rate and T-elevation in the ECG during i.v. application of a common test dose (0.2 ml kg(-1)) of bupivacaine are caused by epinephrine addition. Whether higher doses of bupivacaine alone can cause similar ECG changes or not requires further studies.

[Fibre optic-assisted endotracheal intubation through the laryngeal mask in children]. / Fiberoptisch unterstützte endotracheale Intubation durch die Larynxmaske im Kindesalter.

Fibre optic-assisted tracheal intubation through the laryngeal mask airway is a simple and safe procedure for securing the airway in the paediatric patient with unexpected and known difficult tracheal intubation. Therefore, fibre optic-assisted tracheal intubation through the laryngeal mask airway represents a standard airway technique and must be part of clinical education and also regular training. However, the removal of the laryngeal mask airway over the tracheal tube is impaired by the short length of the tracheal tube, easily resulting in tube dislocation from the trachea. Among several techniques to overcome this problem, the Cook airway exchange catheter offers a reliable method not only for safe removal of the laryngeal mask over the tracheal tube but also for insertion of an adequate tracheal tube, particularly in paediatric patients. This is particularly important for cuffed tubes as the pilot balloon of the cuffed tube is too large to pass through laryngeal mask airway tubes size 2.5 and smaller. This presentation demonstrates fibre optic-assisted tracheal intubation through the laryngeal mask airway in children step-by-step and discusses its clinical implications. A list with compatible sizes of laryngeal mask airways, tracheal tubes and airway exchange catheters is also provided.