[First Results of the German consulting center for infection control outbreak registry]. / Infektionen und Kolonisationen: Was können wir verbessern?

BACKGROUND: Outbreaks of infectious diseases and / or colonization pose an increasing burden on hospitals and the health system in general and can be a threat to patient safety. METHODS: At the end of 2013 we implemented a quality assurance registry of outbreak investigations performed by the Deutsches Beratungszentrum für Hygiene (German Consulting Center for Infection Control and prevention) in Freiburg. Now we analyzed the registered outbreaks until January 2015. RESULTS: Norovirus was the leading causative organism and gram negative bacteria dominated the group of bacterial outbreaks. Outbreaks lasted between 6 and 185 days. 24 % of outbreaks were related to colonization only. Within 29 outbreaks we had 187 infected patients, 50 colonized patients und 92 infected health care workers (64 x norovirus, 20 x influenza, 8 x scabies). No deaths were recorded. Several risk factors and improvement potentials for future outbreaks could be identified. CONCLUSION: Lack of staff compliance with vaccination or prophylactic therapy, misuse of personal protective equipment and lapses in absence from work for the required time can play an important role for prolonged outbreak situations esp. with viral outbreaks and scabies. A structured and goal directed outbreak management especially in the initial phase of an outbreak seems to be important for an efficient and fast termination of an outbreak.

[Colonization-outbreak of two clonally different strains of Serratia marcescens in a neonatal intensive care unit]. / Kolonisationsausbruch mit zwei klonal unterschiedlichen Stämmen von Serratia marcescens auf einer neonatologischen Intensivstation.

We describe an outbreak of two clonally different strains of Serratia marcescens in a neonatal intensive care unit. Three colonization cases in the first outbreak phase were related to contact transmission from an index patient during emergency respiratory treatment while eight colonizations in the second phase were caused by contaminated bathing lotion. All transmissions resulted in colonization only and no infections were recorded. Based on our experience and the literature review sufficient staffing levels, basic hygiene and a goal-directed investigation of the environment are the cornerstones of a rapid outbreak termination. The epidemiological search for parallels in cases should be assisted by sophisticated electronic records.

[Infection prevention by the anesthesia team]. / Infektionsprävention durch das anästhesieteam.

The anesthesia team acts every day in a highly complex and high risk environment for the transmission of pathogenic organisms and the induction of infectious complications. With strict adherence to standard precautions and infection control practices in particular regular hand disinfection before and after direct patient contact and before performance of aseptic tasks during anesthesia and an optimized perioperative process the members of the anesthesia team can become infection control pioneers within the hospital. In order to be successful, structural and organizational resources in the form of training, personnel, materials and time, need to be adequate for the situation. This review summarizes the infection control recommendations for anesthesia practice based on the most recent literature and guidelines and offers practical advice for commonly observed mistakes.

[Quality management in regional anesthesia using the example of a Regional Anesthesia Surveillance System (RASS)]. / Qualitätsmanagement in der Regionalanästhesie am Beispiel des Regionalanästhesie Surveillance Systems (RASS).

Regional anesthesia and regional analgesia techniques with or without a continuous catheter are frequently utilized in all areas of modern anesthesiology. There are individual and economic benefits but also risks involved with those techniques. While the incidence of severe complications is rare and preventive action not always possible, the consequences can be detrimental especially with hematoma or abscess formation associated with central neuraxial blocks. Therefore, it is important to create national and international databases with large case numbers utilizing standardized definitions of complications in order to allow realistic risk assessment and early discovery of potential dangers and preventive actions. This article shows the integration of standardized codes from the Regional Anesthesia Surveillance System with a software tool to allow high-quality data acquisition and the building of a foundation for national and international data collection and analysis as well as for feedback of institutional data for individual process optimization as part of a quality management system.

Nosocomial infections and infection control in regional anesthesia.

BACKGROUND: Although rare, infectious complications from regional anesthesia and analgesia can be devastating. The literature on this topic consists primarily of surveys, case reports, case series, and studies in which used supplies were cultured. We derived infection control recommendations from the existing literature and compared these recommendations with existing guidelines. METHODS: Structured literature search of the Cochrane Central Register of Controlled Trials, MEDLINE, including old MEDLINE and EMBASE until 2005. Descriptive statistics were cited when applicable. MAIN RESULTS: Incidence rates for infectious complications vary substantially between studies and range from 3.7 to 7.2/100,000 for spinal anesthesia-associated meningitis and from 0.2 to 83/100,000 for epidural anesthesia-associated epidural abscesses. Few comprehensive prospective trials have been conducted and most case reports do not provide complete information about infection control practices. CONCLUSION: Studies using more robust methods are necessary to define the rates of infection after different regional anesthesia procedures and to identify risk factors for infections. Data on risk factors would allow anesthesiologists to develop evidence-based guidelines for placement and care of catheters used for regional anesthesia. A multicenter surveillance system may help anesthesiologists address some of the unanswered questions and to develop evidence-based infection control recommendations.

Regional Anesthesia Surveillance System: first experiences with a quality assessment tool for regional anesthesia and analgesia.

BACKGROUND: The incidence of complications related to regional anesthesia and analgesia is hardly known and estimates are based on extrapolation from controlled trials, insurance registries and retrospective chart reviews and only a few attempts of prospective data collection have been made. We designed a surveillance system for regional anesthesia for easy and reliable data acquisition. METHODS: A list of definitions of complications and quality indicators of interest was created and introduced in a single institution. Data are collected within the hospital information system and by individual reports of complications from trained reporters in the Acute Pain Service. A data cross-check is performed by the Surveillance coordinator. RESULTS: We present complications rates for 9790 catheter days and 4547 punctures for continuous neuraxial and peripheral nerve blocks between October 2003 and January 2006. Most complications were related to catheter dislocation and 'wet taps'. Serious complications such as neurologic deficits, bleeding complications and infections were rare. Data quality reached 98% reliability of complication coding. DISCUSSION: This is the description of a prospective regional anesthesia surveillance system, which currently allows longitudinal analysis of performance parameters at a single institution and will provide data about the incidences of complications related to regional anesthesia and analgesia in the future.

[Safety and effectiveness of the cervical paravertebral approach to the brachial plexus--data from the Regional Anesthesia Surveillance System (RASS)]. / Sicherheit und Effektivität des zervikal posterioren Zugangs zum Plexus brachialis--Daten des Regionalanästhesie Surveillance Systems (RASS).

BACKGROUND: This is the first report of the Regional Anesthesia Surveillance System (RASS) analyzing complication data of the relatively new cervical posterior approach to the brachial plexus. MATERIAL AND METHODS: The Regional Anesthesia Surveillance System (RASS) was introduced in October 2003. All regional anesthesia punctures and continuous catheters in place are recorded as part of the midnight-statistic and forwarded to the RASS databank. Complications are registered and coded according to standardized definitions ( www.UIRASS.com ) by the acute pain service. Plausibility of coding is checked against the medical record by the RASS-coordinator for data quality assurance. RESULTS: From October 2003-October 2005 there have been 360 cervical posterior punctures and 547 catheterdays. The utilization ratio of the cervical posterior brachial plexus block is 1.42 %. A pneumothorax occurred in 2.7/1000 punctures, local anesthetic toxicity and short term neurologic deficits were also observed in 2.7/1000 punctures. Catheter dislocation occurred in 5.4/1000 catheterdays and severe neck pain was noticed in 16.3/1000 punctures. There were no catheter associated long term neurological deficits, bleeding or infectious complications. CONCLUSION: The cervical posterior approach to the brachial plexus is an alternative to the interscalene approach with the advantages of high success rate and secure catheter placement. Neck pain can be a disadvantage of the technique and acute complications like pneumothorax and local anesthetic toxicity seem to be similar to those reported with interscalene blocks in the literature.

[Cuff pressure monitoring and regulation in adults]. / Cuffdruckmessung und Regelung im Erwachsenenalter.

OBJECTIVES: In adults the use of cuffed endotracheal tubes is the standard technique. Nitrous oxide increases the cuff pressure secondary to diffusion through the cuff membrane. The aim of the study was to verify a newly designed cuff pressure regulating device and comparison of postoperative complications. METHODS: In a prospective, randomized, open trial the cuff pressure and the incidence of postoperative complications (e.g., hoarseness, coughing and pain while swallowing) were measured using the newly designed automatic pressure monitoring and regulating device Cuff Pressure Control (Tracoe) and a conventional handheld manometer. A total of 40 patients were assigned to the automatic group with a goal of 25.5 cmH(2)O and 40 patients to the conventional group where the pressures were kept between 20 cmH(2)0 and 40 cmH(2)0 with intermittent measurements and manual pressure release. RESULTS: The automatic device reliably maintained the pressure at the chosen constant level within +/-2 cmH(2)O. In the control group increases in cuff pressure to 40 cmH(2)O were common. The incidence of postoperative complications in both groups was not significantly different. CONCLUSIONS: In conclusion our data demonstrate that the automatic cuff pressure and regulation device was useful and reliable in an adult population of intubated patients in the studied pressure range.

[Propofol-LCT versus propofol-MCT/LCT with or without lidocaine - a comparison on pain on injection]. / Propofol-LCT versus Propofol-MCT/LCT mit oder ohne Lidocain - Vergleichende Untersuchung zum Injektionsschmerz.

OBJECTIVE: A disadvantage of Propofol (commercial preparation containing long-chain triglycerides; Propofol-LCT) is pain on injection, which is reported by 54 - 100 % of the patients. Many different approaches have been used in an attempt to decrease the pain on injection of propofol. The currently most efficacious treatment is lidocaine given intravenously with a tourniquet prior to Propofol injection. In previous studies, larger concentrations of free propofol in the aqueous phase of an emulsion were associated with more pain on injection. A new formulation of propofol (a mixture of long-chain and medium-chain triglycerides in the carrier emulsion; Propofol-MCT/LCT) reduces the incidence of pain on bolus injection. This study was designed to investigate, whether the use of Propofol-MCT/LCT alleviates pain on injection to a similar degree as pretreatment with lidocaine. METHODS: Eighty patients (ASA I - III) were randomly assigned to four groups according to a double-blinded protocol, to receive either lidocaine 2 % or normal saline given iv. with a 60 seconds tourniquet time before the injection of Propofol-LCT or Propofol-MCT/LCT. (group 1: 2 ml NaCl 0,9 %, Propofol-LCT; group 2: 2 ml NaCl 0,9 %, Propofol-MCT/LCT; group 3: 2 ml lidocaine 2 %, Propofol-LCT; group 4: 2 ml lidocaine 2 %, Propofol-MCT/LCT). Assessment of pain on injection was performed after 30 % of the induction dose was given. RESULTS: Pain on injection caused by Propofol-LCT with pre-treatment of lidocaine and Propofol-MCT/LCT alone is shown to be equivalent. Comparison of Propofol-MCT/LCT with pre-treatment of lidocaine and Propofol-LCT alone shows a statistical noticeable p-value of 0.035. Propofol-MCT/LCT with pre-treatment of lidocaine suggests a tendency of causing less pain compared to Propofol-MCT/LCT. Analysis of the postoperative questionnaire supplies no significant difference. CONCLUSION: The results suggest that pain on injection is reduced equivalent using either Propofol-MCT/LCT alone or Propofol-LCT with pre-treatment of lidocaine. Pre-treatment with lidocaine before Propofol-MCT/LCT seems to have an additional effect.

Bilateral occipital neuropathy as a rare complication of positioning for thyroid surgery in a morbidly obese patient.

BACKGROUND: Peripheral neuropathies in various locations are described as complications after anesthesia and surgery. This is the first case report of temporary bilateral occipital neuropathy from positioning for thyroid surgery in a morbidly obese patient. METHODS: A 48-year-old women with a history of depression, fibro-myalgia, asthma, sleep apnea, diabetes mellitus and morbid obesity (127 kg, 165 cm) underwent 4 hours anesthesia with propofol/remifentanil without muscle relaxation for thyroid surgery. The neck with a very low range of motion secondary to fat tissue needed to be extended to facilitate surgery as much as possible. The head was carefully padded and there were no episodes of hypotension or hypoxemia throughout the case or in the PACU. At post op day 1 she complained of bilateral numbness in the distribution area of both greater occipital nerves. On post op day 2 tingling sensations and improvement of numbness was noticed. The patient recovered without residual symptoms after 6 weeks. CONCLUSION: Pressure or shear stress to the nerve, hypoperfusion or metabolic disturbances are discussed as the leading etiology of nerve damage during surgery in the literature. Pressure from fat tissue during prolonged head extension for surgery seems to be the cause in this case and should therefore be avoided whenever possible in morbidly obese patients, especially when other risk factors for neuropathy like diabetes are present.

[Brachial plexus. Anesthesia and analgesia]. / Plexus brachialis. Anästhesie und Analgesie.

This review explains the different approaches to the brachial plexus (posterior cervical, interscalene, supra- and infraclavicular, and axillary) and their advantages and disadvantages (indications, contraindications, and complications) for surgery and postoperative or chronic pain management. One of the focussed areas of this review is the use of continuous catheter techniques. Information about the most commonly used local anesthetics as well as adjuncts suggested in the literature is summarized. As essential components for the success of those techniques, organizational and documentation requirements are described. In summary, regional techniques for single shot or continuous block of the brachial plexus are an efficient and safe way of providing anesthesia and analgesia for surgery or pain in the region of the shoulder, arm, or hand.

[Epiglottic abscess as a rare reason for airway obstruction in adults]. / Epiglottisabszess als seltene Ursache einer Atemwegsverlegung beim Erwachsenen.

Acute epiglottitis in adults is a potentially life-threatening disease of increasing incidence. Although pharyngitis is the most common cause of sore throat in the adult, acute epiglottitis must be considered in the differential diagnosis when there is unrelenting throat pain and minimal objective signs of pharyngitis. We report the case of a 45-year old man with acute epiglottitis and occlusion of the upper airways due to an epiglottic abscess. A brief discussion of the diagnosis and treatment of adult epiglottitis is presented. Patients with acute painful dysphagia should be considered to have epiglottitis until the diagnosis is proven. Early diagnosis and aggressive airway management can be life saving.

Comparison between nasal and intravenous desmopressin for the treatment of aminosalicylic acid-induced platelet dysfunction.

BACKGROUND AND OBJECTIVE: The study was conducted to compare the standard intravenous route with the intranasal route of desmopressin application and to establish the best time for initiating treatment with desmopressin with the use of the Born test and the PFA 100-Analyzer for monitoring the therapeutic effect. METHODS: Thirty healthy volunteers (ASA I) with no known bleeding disorder were randomly assigned to an intravenous or an intranasal group in a cross-over design fashion. After obtaining baseline values, the volunteers were given 500 mg aminosalicylic acid for 3 days. On day 4, platelet function tests were performed and desmopressin (0.3 microg kg(-1) body weight) was administered either intravenously or intranasally. Born tests (aggregation after stimulation with epinephrine and collagen) were conducted at 30 and 240 min, and PFA 100 bleeding time measurements were conducted at 30, 120 and 240 min after desmopressin administration. Wilcoxon signed rank sum tests or non-parametric ANOVA for repeated measures were used for statistical evaluation. RESULTS: All volunteers showed a marked decreased platelet function in the Born test (especially if stimulation with epinephrine was used) and an increased PFA 100 bleeding time after treatment with aminosalicylic acid. Platelet function was improved by intravenous as well as intranasal application of desmopressin (P < 0.001) after 30 min. The effect diminished after 4 h in both groups. CONCLUSIONS: Intravenous as well as intranasal desmopressin improved platelet function in healthy volunteers with aminosalicylic acid-induced platelet dysfunction at least 30 min after application. The effect lasts up to 4 h.

[Analysis of the anesthesiologist's vigilance with an eye-tracking device. A pilot study for evaluation of the method under the conditions of a modern operating theatre]. / Analyse der Aufmerksamkeitsverteilung des Anästhesisten mit Hilfe der Blickbewegungsmessung. Pilotstudie zur Methodenevaluation unter den Bedingungen eines modernen Operationsbetriebes.

INTRODUCTION: With the inclusion of new monitoring devices over the last two decades, the distribution of the anesthesiologists vigilance has changed which might influence the ergonomic profile of an optimal anesthesia workstation. The aim of this pilot study was the evaluation of an eyetracking device to analyze the vigilance distribution of an anesthesiologist during routine cases in an operating theatre of the 21st century. MATERIAL AND METHODS: Five anesthesiologist with different levels of training were followed during different types of surgery using a video camera-based eye-tracking system. The films were analyzed by an independent observer and rated according to defined regions of interest (ROI). Then typical scan-paths were identified and quantitatively analyzed. RESULTS: The eye-tracking studies proved to be technically of high quality but were time-consuming. Only few disturbances to the operating room (OR) personnel were recorded according to their subjective impressions but bias of behaviour due to the measurement procedure itself cannot be completely excluded. The vigilance of the anesthesiologist towards different factors was dependent on the level of professional training, the type of anesthesia and the type of surgery. Certain factors such as documentation (10-15%) or external disturbances (approximately 20%) proved to be relatively constant. Typical scan-paths could also be identified. CONCLUSION: Eye-tracking studies proved to be a suitable way to analyze the distribution of vigilance of anesthesiologists in a modern operating theatre. For further studies examining the influence of detailed modifications of the OR environment, a standardized study design with the same level of education, the same anesthesia technique and the same surgical procedure needs to be chosen.

Vibration sense testing with a 128-Hz tuning fork as a tool to determine recovery from epidural neuraxial block.

BACKGROUND AND OBJECTIVES: Vibration sense testing using a 128-Hz tuning fork is a commonly used test in the diagnosis of dorsal horn dysfunction and polyneuropathy. In this open, prospective study, we tested the hypothesis that vibration sense testing is a sensitive and specific method to assess recovery from epidural block. METHODS: Recovery from epidural block was evaluated in 81 patients undergoing cesarean delivery or vein stripping by comparing the use of a 128-Hz tuning fork with the results of conventional evaluation of block recovery. Conventional block recovery testing included Bromage-Score, formal muscle power testing according to the British Medical Research Council, pinprick testing, and warm/cold testing. Epidural blocks were performed by the same anesthesiologist using ropivacaine and sufentanil via an epidural catheter. After obtaining baseline values, an epidural anesthetic was performed and patients were tested every 30 minutes until complete recovery from the block was documented with all examined methods. Statistical analysis was performed to compare the results of the different methods to the time at which baseline values of vibration sense were reached. RESULTS: At the time vibration sense testing returned to baseline, there was no residual motor block according to the Bromage Score in 100% of the patients and no residual block for foot flexion and extension. Twelve percent of the patients showed a minimal lack of strength in the quadriceps muscle and 11% had residual sensory anesthesia to pinprick below L5/S1. CONCLUSIONS: Based on our observations, recovery of vibration sense corresponds with recovery of motor block after epidural anesthesia and may serve as an easy means of documenting recovery with a single test before discharge.