[Anesthesia, ventilation and pain treatment in thoracic trauma]. / Narkose, Beatmung und Schmerztherapie beim Thoraxtrauma.

The management of anesthesia plays a central role in the treatment of thoracic trauma, both in the initial phase when safeguarding the difficult airway and in the intensive care unit. A rapid transfer to a trauma center should be considered in order to recognize and treat organ dysfunction in time. Development of atelectasis, pneumonia and acute lung failure are common pulmonary complications. Non-invasive ventilation combined with physiotherapy and respiratory training can help to minimize these pulmonary complications. If single lung ventilation is necessary as part of the operative patient care, a double-lumen tube, a bronchial blocker and the Univent®-Tubus (Fuji Systems Corporation, Tokyo, Japan) can be used. Special attention should be paid to the hypoxic pulmonary vasoconstriction that occurs in this maneuver. Pain therapy is ideally carried out patient-adapted with epidural anesthesia. In addition, intraoperatively inserted catheters in the sense of a continuous intercostal block or serratus plane block are good alternatives. The aim of these therapies should be early mobilization and transfer of the patient to rehabilitation.

Chloroprocaine 10 mg/ml for low-dose spinal anaesthesia in perianal surgery - a randomised dose finding study.

BACKGROUND: Low-dose spinal anaesthesia is a safe and reliable anaesthesia technique in outpatient perianal surgery. Regarding its short duration of action and its trend to hyperbaric characteristics, plain chloroprocaine 10 mg/ml seems to be ideal to perform low-dose spinal anaesthesia. The aim of this trial was to determine the optimal dosage of chloroprocaine for this indication. METHODS: Hundred and twenty patients undergoing perianal surgery were enrolled and randomly allocated to receive 10, 20 or 30 mg of chloroprocaine 10 mg/ml intrathecally. Patients had to sit upright for at least 10 min after injection. We measured the expansion of sensory and motor block and the times until voiding, walking without assistance and home discharge. RESULTS: The expansion of the sensory (P ≤ 0.0059) and the motor block (P ≤ 0.0086) gained with increasing doses. At a dose of 30 mg the incidence of a profound, clinically relevant motor block was significantly higher compared to 10 and 20 mg (P ≤ 0.0004). In the 10 mg group two patients suffered from nociceptive pain due to an incomplete block and five patients announced discomfort during procedure. Doses of 10 and 20 mg led to a significantly earlier discharge compared to 30 mg (P = 0.0003; P = 0.0406). CONCLUSION: Plain chloroprocaine 10 mg/ml can successfully be used for low-dose spinal anaesthesia in perianal outpatient surgery. Regarding the unfavourable motor block and later discharge-times in the 30 mg group on the one hand and the block-failures in the 10 mg group on the other, 20 mg can be recommended as the optimal dose.

[Active muscle extension testing of the hamstrings: reference values and impacting factors]. / Aktive Muskeldehntestung der ischiocruralen Muskulatur: Referenzwerte und Einflussfaktoren.

INTRODUCTION: Less muscle elasticity of the hamstrings increases the risk of muscle strain. Muscle balance is the purpose of muscle stretching. The active knee-extension test (AKE) represents an established test of muscle elasticity. For evaluating the test results standard values are necessary. The aim of this study is to measure standard values of the AKE test in a collective of healthy male and female fitness athletes and to determine factors of muscle elasticity. MATERIAL AND METHODS: We performed the AKE test in 119 healthy fitness athletes (56 women, 63 men) evaluated biometric and anthropometric data, examined joint function in knee and hip activity scores (WOMAC, Lysholm score, Tegner score, UCLA-acitivity scale), psychological score (HADS scale) and clinical evidence of rheumatoid criteria (ACR). Unpaired t-test and multiple regressions were calculated. RESULTS: The average knee extension deficit was as measured 31.6 ± 12.6° (men: 35.6 ± 10.4°; women 27.1 ± 13.5°, p = 0.0002), factors like "female gender", "physical work", "sports activities for many years", "hip flexion" and "body fat content" influence the muscle elasticity. DISCUSSION: For the first time, standard values for the AKE test are available, allowing an estimation of muscle elasticity of the hamstrings. Factors like "female gender", "physical work" and "sports activities for many years" affect the muscle elasticity, while "body fat content" and "hip flexion" are combined to female gender and are considered as indirect factors of hamstring flexibility.

Dosage finding for low-dose spinal anaesthesia using hyperbaric prilocaine in patients undergoing perianal outpatient surgery.

BACKGROUND: Hyperbaric prilocaine 20 mg/ml may be preferable for perianal outpatient surgery. The aim of this prospective, single-centre, randomised, single-blinded, controlled clinical trial was to determine the optimal dosage of hyperbaric prilocaine 20 mg/ml for a spinal anaesthesia (SPA) in patients undergoing perianal outpatient surgery. METHODS: One hundred and twenty patients (18-80 years/American Society of Anesthesiologists grade I-III) were enrolled in this study. The patients were randomised to receive 10, 20 or 30 mg of prilocaine for SPA. We measured expansion of the sensory and motor block, evaluated times to walk, void and being eligible for discharge, and determined the demand of analgesics. RESULTS: 116/120 patients were available for analysis. The expansion of the sensory block gained with an increasing dosage: 10 mg: 3(1-6) dermatomes; 20 mg: 4(2-6) dermatomes; 30 mg: 5(3-7) dermatomes (P < 0.0001). Dermatomes were counted upwards beginning with S(5). Also, the motor block gained with an increased dosage (Bromage score 1-3: 10 mg: n = 3, 20 mg: n = 8 and 30 mg: n = 18, P = 0.0002). Patients receiving 10 mg were ready for discharge earlier compared with both other groups (10 mg: 199 ± 39 min; 20 mg: 219 ± 47 min; 30 mg: 229 ± 32 min, P = 0.0039). Pain occurred earlier in the 10 mg group than in the 30 mg group (10 mg: 168 ± 36 min; 30 mg: 205 ± 33 min, P = 0.0427). The demand of additional analgesics was comparable in all dosage groups. CONCLUSION: Hyperbaric prilocaine 20 mg/ml can be applied in dosages of 10, 20 and 30 mg for SPA in perianal surgery. Because of sufficient analgesia, missing motor block and shorter recovery times, 10 mg of hyperbaric prilocaine 20 mg/ml can be recommended for perianal outpatient surgery.

Influence of high dose tumescent local anaesthesia with prilocaine on systemic interleukin (IL)-6, IL-8 and tumour necrosis factor-α.

BACKGROUND AND OBJECTIVE: Tumescent local anaesthesia (TLA) with high prilocaine doses leads to formation of methemoglobin (MHb) which is known to be a potent activator of pro-inflammatory endothelial cell response in vitro. As TLA is widely used for large dermatological resections, the aim of this study was to investigate the effects of high prilocaine doses on the systemic inflammatory response in vivo and its clinical relevance. METHODS: This prospective study examines the influence of MHb on serum interleukin (IL)-6, IL-8 and tumour necrosis tumour necrosis (TNF)-α levels up to 72 h after application of TLA with prilocaine in doses higher than 600 mg. RESULTS: A total of 30 patients received prilocaine in a median dose of 1500 mg (range: 880-4160 mg) for large resections. Peak prilocaine serum concentration was reached 4 h (0.72 ± 0.07 µg/mL), the maximum concentration of MHb (7.43 ± 0.87%) and IL-6 (28.4 ± 4.1 U/L) 12 h after TLA application. TNF-α and IL-8 release were not found significantly increased. Three patients developed MHb concentrations >15%. CONCLUSIONS: This clinical study shows for the first time that a high prilocaine serum concentration leads in vivo to elevated systemic levels of IL-6 but not of IL-8 and TNF-α because of initial high MHb levels. Because of possible and unpredictable high MHb concentrations, TLA should only be performed with prilocaine in doses of 2.5 mg/kg. In general, new solutions of TLA are necessary to achieve adequate anaesthesia for large dermatological resections to decrease the risk of methemoglobinaemia.

Randomized clinical trial of perianal surgery performed under spinal saddle block versus total intravenous anaesthesia.

BACKGROUND: The aim of this randomized clinical trial was to determine whether spinal saddle block (SSB) is superior to total intravenous anaesthesia (TIVA) in perianal surgery. METHODS: Suitable patients aged 18-75 years (American Society of Anesthesiologists grade I or II) scheduled to undergo perianal surgery were randomized to SSB (1.0 ml 0.5 per cent hyperbaric bupivacaine) or TIVA with propofol and fentanyl by means of a laryngeal mask. Cumulative consumption of analgesics within 24 h after surgery was recorded, and postoperative recovery and patient satisfaction were evaluated. RESULTS: A total of 201 patients were randomized. Supplemental analgesia within 24 h after surgery was required by 31 of 101 patients having SSB and 58 of 100 who had TIVA (P < 0.001). Median monitoring time in the recovery room was 5 (range 1-45) min for SSB versus 44 (4-148) min for TIVA (P < 0.001). Patients in the SSB group were able to eat and drink more quickly, although times to mobilization and micturition were not significantly different. Patients having SSB were more likely to describe the anaesthesia as 'better than expected'. CONCLUSION: SSB is superior to TIVA in patients undergoing perianal surgery in terms of analgesic consumption within 24 h after surgery and aspects of postoperative recovery. REGISTRATION NUMBER: ISRCTN41981381 (http://www.controlled-trials.com).