Caroline Kratz

Postoperative Analgesia and Functional Recovery After Total-Knee Replacement: Comparison of a Continuous Posterior Lumbar Plexus (Psoas Compartment) Block, a Continuous Femoral Nerve Block, and the Combination of a Continuous Femoral and Sciatic Nerve Block

Background and Objectives Continuous femoral nerve block is a well-accepted technique for regional analgesia after total-knee replacement. However, many patients still experience considerable pain at the popliteal space and at the medial aspect of the knee. The goal of this study is to evaluate whether a psoas compartment catheter provides better postoperative analgesia than a femoral nerve catheter does and whether it is as effective as the combination of a femoral and a sciatic nerve catheter and, thus, improves functional outcome. Methods Ninety patients who underwent total-knee replacement under standardized general anesthesia participated in this prospective randomized study. Group FEM received a continuous femoral nerve block, group FEM/SCI received a combination of a femoral and a sciatic continuous nerve block, and group PSOAS received a continuous psoas compartment block. Patient-controlled analgesia with piritramide was available for 48 hours. Maximal bending and extending of the knee and walking distance was assessed during the first 7 days. A standardized telephone survey was conducted after 9 to12 months to evaluate residual pain and functional outcome. Results Postoperative opioid consumption during 48 hours was significantly less in the FEM/SCI group (median: 18 mg; 25th/75th percentile: 6/40) compared with the FEM group (49 mg; 25/66) and the PSOAS group (44 mg; 30/62) (P =.002). Postoperative pain scores were not different, and no differences occurred with respect to short-term or long-term functional outcome. Conclusion The FEM/SCI catheter is superior to FEM and PSOAS catheter with respect to reduced analgesic requirements after total-knee replacement, but functional outcome does not differ with those 3 continuous regional analgesia techniques.

Pharmakologische Besonderheiten und Probleme des älteren Patienten

Because of demographic developments, the fraction of the German population over 65 years of age in the year 2025 will have risen to 20% and will continue to rise so that in 2030 this number will have doubled compared to todays numbers. This has a huge impact on the requirements for anaesthesiologic procedures. In addition to the frequent multi-morbidity in this age group, physiologic changes also occur in the elderly which have to be taken into consideration during the entire perioperative management of these patients. Renal, cardiovascular and hepatic function are impaired in many elderly patients. A major concern in addition to cardiovascular and operative complications is the postoperative cognitive dysfunction (POCD), not only because of its implications for the patient but also because of economical consequences. Regional anaesthesia has some benefits when compared to general anaesthesia as it leads to a reduction in thromboembolic and respiratory complications.

Implementation and effects of pulse-contour- automated SVV/CI guided goal directed fluid therapy algorithm for the routine management of pancreatic surgery patients

BACKGROUND Goal directed fluid management in major abdominal surgery has shown to reduce perioperative complications. The approach aims to optimize the intravascular fluid volume by use of minimally invasive devices which calculate flow-directed variables such as stroke volume (SV) and stroke volume variation (SVV). OBJECTIVE We aimed to show the feasibility of routinely implementing this type of hemodynamic monitoring during pancreatic surgery, and to evaluate its effects in terms of perioperative fluid management and postoperative outcomes. METHODS All patients undergoing pancreatic surgery at a university hospital during two successive 12 months periods were included in this retrospective cohort analysis. Twelve months after the implementation of a standard operating procedure for a goal directed therapy (GDT, N = 45) using a pulse contour automated hemodynamic device were compared with a similar period before its use (control, N = 31) regarding mortality, length of hospital and ICU stay, postoperative complications and the use of fluids and vasopressors. RESULTS Overall, 76 patients were analysed. Significantly less crystalloids were used in the GDT group. Patients receiving GDT showed significantly fewer severe complications (insufficiency of intestinal anastomosis: 0 vs. 5 (P = 0.0053) and renal failure: 0 vs. 4 (P = 0.0133). Mortality for pancreatic surgery was 1 vs. 3 patients, (P = 0.142), and length of stay (LOS) in the intensive care unit (ICU) was 4.38 ± 3.63 vs. 6.87 ± 10.02 (P= 0.0964) days. Use of blood products was significantly less within the GDT group. CONCLUSIONS Implementation of a SOP for a GDT in the daily routine using flow-related parameters is feasible and is associated with better outcomes in pancreatic surgery.

Pharmacoeconomic considerations of tropisetron for prophylaxis and treatment of CINV and PONV

Postoperative nausea and vomiting has been described as the big little problem in anesthesia, with the overall incidence after anesthesia using volatile anesthetics remaining between 20 and 30%. In patients who receive ambulatory surgery, postoperative nausea and vomiting may lead to delayed discharge or unplanned overnight admission to hospital which is counterproductive to the primary goal of saving costs in healthcare by undergoing day-surgery. The same economic factors apply to patients who experience nausea and vomiting after chemotherapy. Drugs today are judged by their ability to cure a condition with as few adverse reactions as possible. There remains the question of whether a certain medication meets expectations from a pharmacoeconomic point of view. 5-HT3 antagonists are a comparatively new class of drugs that seem to perform satisfactory in the treatment of different forms of nausea and vomiting with few adverse reactions. However, these drugs are comparatively expensive. Studies on the efficacy and pharmacoeconomic comparisons have been conducted. Tropisetron is one of the newest 5-HT3 antagonists. While its efficacy has been shown in several studies, there are few studies on its pharmacoeconomic benefits. There are several antiemetic measures, such as total intravenous anesthesia, using antiemetic prophylaxis or omitting the nitrous oxide with proven effectiveness. Most are roughly equivalent but differ with respect to costs and side effects Routine antiemetic prophylaxis is not indicated due to economic and medical reasons (potential side effects of antiemetics). Patients at high risk can be identified using validated risk scores and should receive antiemetic drugs.

Impact of Focused Intraoperative Transthoracic Echocardiography by Anesthesiologists on Management in Hemodynamically Unstable High-Risk Noncardiac Surgery Patients.

OBJECTIVES Focused transthoracic echocardiography (TTE) is used perioperatively for surgical patients. Intraoperative application of TTE is feasible, but its benefits remain unclear. The intention of this study was to investigate the effect of intraoperative TTE on the management of high-risk noncardiac surgery patients. DESIGN A prospective interventional study. SETTING Single-center university hospital. PARTICIPANTS Fifty consecutive hemodynamically unstable high-risk patients anesthetized for noncardiac surgery. INTERVENTIONS Focused TTE was performed on hemodynamically unstable anesthetized patients whenever circulatory instability (defined as hypotension or low cardiac output) occurred intraoperatively. A cardiac output monitoring system using pulse contour analysis was established before induction of anesthesia. The intended therapy for stabilizing the patient was documented; however, the management actually administered was guided by the results of the TTE. Differences between the 2 lines of management were documented and analyzed. MEASUREMENTS AND MAIN RESULTS Intraoperative TTE was applied successfully in all 50 unstable patients. In 33 patients (66%, 95% confidence interval, 52.11-77.61) TTE led to a change of management. Altogether, 82 episodes of hemodynamic instability were recorded, including 38 episodes (46.34%, 95% confidence interval, 35.95-57.06) in which TTE led to a change of treatment. The most common pathologic finding was hypovolemia (66%); in contrast, in 22%, right-heart overload or right-heart failure (4%) was detected. CONCLUSIONS Focused TTE by anesthesiologists can provide new information that may alter the hemodynamic management of unstable high-risk noncardiac surgery patients in the operating room.

Feasibility and Impact of Focused Intraoperative Transthoracic Echocardiography on Management in Thoracic Surgery Patients: An Observational Study

OBJECTIVES Intraoperative focused transthoracic echocardiography (TTE) is feasible and has an effect on the management of hemodynamically unstable surgical patients. Furthermore, in noncardiac thoracic surgery, TTE might provide additional information for hemodynamic treatment. Transthoracic accessibility during thoracic surgical interventions is assumed to be difficult. For patients positioned on their right side, a modified subcostal transthoracic view might be helpful. DESIGN A prospective observational study. SETTING Single-center university hospital. PARTICIPANTS The study comprised 105 consecutive patients undergoing noncardiac thoracic surgery. INTERVENTIONS Focused TTE was performed during anesthetic induction after intubation for mechanical ventilation. Intraoperative focused TTE, after positioning and draping for surgery, was attempted again for all 105 patients. Changes in patient management due to the results of the TTE were documented and analyzed. MEASUREMENTS AND MAIN RESULTS Presurgical TTE with mechanical ventilation was applied successfully in 98.1% of 105 patients. Intraoperative imaging was successful in 90 patients (85.7%). Results of intraoperative TTE led to the modification of perioperative management in 39 patients (37.1%), 20 (22.0%) of these during surgery. CONCLUSIONS TTE in noncardiac thoracic surgery is feasible using a modified subcostal view and has an effect on hemodynamic management in a considerable number of patients.

Pre‐operative fluid bolus for improved haemodynamic stability during minor surgery: A prospectively randomized clinical trial

Haemodynamic instability during the induction of anaesthesia and surgery is common and may be related to hypovolaemia caused by pre‐operative fasting or chronic diuretic therapy. The aim of our prospective, controlled, randomized study was to test the hypothesis that a predefined fluid bolus given prior to general anaesthesia for minor surgery would increase haemodynamic stability during anaesthetic induction.

Pharmacological peculiarities and problems with older patients

Because of demographic developments, the fraction of the German population over 65 years of age in the year 2025 will have risen to 20% and will continue to rise so that in 2030 this number will have doubled compared to todays numbers. This has a huge impact on the requirements for anaesthesiologic procedures. In addition to the frequent multi-morbidity in this age group, physiologic changes also occur in the elderly which have to be taken into consideration during the entire perioperative management of these patients. Renal, cardiovascular and hepatic function are impaired in many elderly patients. A major concern in addition to cardiovascular and operative complications is the postoperative cognitive dysfunction (POCD), not only because of its implications for the patient but also because of economical consequences. Regional anaesthesia has some benefits when compared to general anaesthesia as it leads to a reduction in thromboembolic and respiratory complications.

Pharmakologische Besonderheiten und Probleme des älteren Patienten@@@Pharmacological peculiarities and problems with older patients

Because of demographic developments, the fraction of the German population over 65 years of age in the year 2025 will have risen to 20% and will continue to rise so that in 2030 this number will have doubled compared to todays numbers. This has a huge impact on the requirements for anaesthesiologic procedures. In addition to the frequent multi-morbidity in this age group, physiologic changes also occur in the elderly which have to be taken into consideration during the entire perioperative management of these patients. Renal, cardiovascular and hepatic function are impaired in many elderly patients. A major concern in addition to cardiovascular and operative complications is the postoperative cognitive dysfunction (POCD), not only because of its implications for the patient but also because of economical consequences. Regional anaesthesia has some benefits when compared to general anaesthesia as it leads to a reduction in thromboembolic and respiratory complications.