F. Heid

Comparison of the McGrath® Series 5 and GlideScope® Ranger with the Macintosh laryngoscope by paramedics

BackgroundOut-of-hospital endotracheal intubation performed by paramedics using the Macintosh blade for direct laryngoscopy is associated with a high incidence of complications. The novel technique of video laryngoscopy has been shown to improve glottic view and intubation success in the operating room. The aim of this study was to compare glottic view, time of intubation and success rate of the McGrath® Series 5 and GlideScope® Ranger video laryngoscopes with the Macintosh laryngoscope by paramedics.MethodsThirty paramedics performed six intubations in a randomised order with all three laryngoscopes in an airway simulator with a normal airway. Subsequently, every participant performed one intubation attempt with each device in the same manikin with simulated cervical spine rigidity using a cervical collar. Glottic view, time until visualisation of the glottis and time until first ventilation were evaluated.ResultsTime until first ventilation was equivalent after three intubations in the first scenario. In the scenario with decreased cervical motion, the time until first ventilation was longer using the McGrath® compared to the GlideScope® and AMacintosh (p < 0.01). The success rate for endotracheal intubation was similar for all three devices. Glottic view was only improved using the McGrath® device (p < 0.001) compared to using the Macintosh blade.ConclusionsThe learning curve for video laryngoscopy in paramedics was steep in this study. However, these data do not support prehospital use of the McGrath® and GlideScope® devices by paramedics.

Postoperative analgesic efficacy of peripheral levobupivacaine and ropivacaine: a prospective, randomized double-blind trial in patients after total knee arthroplasty.

BACKGROUND:Several previous trials have characterized the intra- and postoperative effects of the recently introduced local anesthetics, levobupivacaine and ropivacaine, for a variety of continuous peripheral nerve blocks. METHODS:We compared the analgesic efficacy of levobupivacaine 0.125% versus ropivacaine 0.2% via patient-controlled femoral nerve analgesia after total knee arthroplasty. In a double-blind, randomized, prospective design, 60 patients received femoral infusion with either substance. We analyzed postoperative local anesthetic consumption, pain scores, motor block, and opioid requirements over 72 h. RESULTS:Pain scores, motor block incidence, and opioid requirements were low and not different between the groups. Ropivacaine consumption in milligrams was 67% higher than that of levobupivacaine. CONCLUSIONS:Both levobupivacaine 0.125% and ropivacaine 0.2% provide similar analgesia after total knee arthroplasty with the latter being less potent.

A case control study of statin and magnesium administration in patients after aneurysmal subarachnoid hemorrhage: incidence of delayed cerebral ischemia and mortality

Abstract Objective: To analyse the effect of the implementation of statin and magnesium treatment on delayed cerebral ischemia (DCI) and 14 day mortality in patients with subarachnoid hemorrhage (SAH). Methods: Retrospective, single-center, observational case control study. One hundred SAH patients received either simvastatin and magnesium, solely statin or no treatment. Results: Eighteen percent (n=5) of patients receiving statin and magnesium treatment developed a DCI whereas 24% (n=5) in the statin group and 16% (n=8) in the control group had DCI. Dead by day 14 was registered in 18% (n=5) of patients in the statin and magnesium group, in 10% (n=2) in the statin group and in 27% (n=14) in the control group. None of the results reached a statistical significance level of 0.05. Conclusion: A trend towards a lower mortality within 14 days in patients receiving solely simvastatin and those receiving statin and magnesium as compared with the control group was found. A higher incidence for DCI was found in the statin group, whereas patients without statin and magnesium tended to have less often DCI. None of the results was statistically significant.

Efficacy of vertical infraclavicular plexus block vs. modified axillary plexus block: a prospective, randomized, observer-blinded study

Background:  Despite containing severe risks, infraclavicular approaches to the brachial plexus gained increasing popularity. Likewise, the vertical infraclavicular plexus block improved anesthesia compared to the standard axillary approach but contains the risk of pneumothorax. Therefore we modified the standard axillary technique by inserting a proximal directed catheter, referred to as a high axillary plexus block. We prospectively compared quality and onset of neural blockade after vertical infraclavicular plexus block (VIP) and high axillary plexus block (HAP) in two randomized groups (30 patients in each).

Medikamente zur postoperativen Schmerztherapie: Bewährtes und Neues

In part 1 of this review the perioperative aspects of the use of non-opioids (acetaminophen, dipyrone, traditional NSAR, coxibs) and in part 2 of opioids (weak opioids: tramadol, tilidine with naloxone, strong opioids: morphine, piritramide, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and coanalgesics (gabapentinoids, ketamine) will be discussed. The main aim is to describe the relationship between analgesic efficacy and side effects to make clinical decisions easier in patients with preoperative renal, gastrointestinal, cardiovascular and other diseases. Some new aspects concerning perioperative administration of gabapentinoids and ketamine in patients with perioperative neuropathic pain are discussed.

A German network for regional anaesthesia of the scientific working group regional anaesthesia within DGAI and BDA

Regional anaesthesia generally is considered to be safe. However, reports of complications with different severities are also well known. The scientific working group of regional anaesthesia of the DGAI has founded a network in conjunction with the BDA. With the aid of a registry, we are now able to describe risk profiles and associations in case of a complication. Moreover, a benchmark has been implemented in order to continuously improve complication rates.

Infektionsinzidenz von Katheterverfahren zur Regionalanästhesie

BACKGROUND To analyze safety issues of regional anaesthesia and analgesia in Germany only a few single center studies are available. Therefore, the German Society for Anaesthesiology and Intensive Care Medicine (Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) and the Professional Association of German Anaesthetists (Berufsverband Deutscher Anästhesisten, BDA) initiated a network for safety in regional anaesthesia. From this the first results on infectious complications will be reported. MATERIALS AND METHODS In a Delphi process the documentation of the setup and maintenance of regional anaesthesia and analgesia was agreed with the participants in a working group from the DGAI. After approval by the officially authorized representative for patient data privacy protection a registry was programmed to collect anonymous data. Up to October 2008 data from 6 centers could be analyzed. RESULTS After testing for plausibility 8,781 regional anaesthesia procedures (22,112 catheter days) could be analyzed. The 5,057 neuraxial and 3,724 peripheral catheter-based procedures were in place for a median of 2.48 days (range 1.0-3.0 days) and 4 severe, 15 moderate and 128 mild infections were recorded. Diabetics were not found to show a statistically significant increase in risk (2.6% compared to 1.9% for non-diabetics: n.s.). Neuraxial procedures seem to have a higher rate of infections than peripheral procedures (2.7% vs. 1.3%, p<0.0001). Multiple punctures of the skin also seem to be associated with a higher infection rate than single skin punctures (4.1% vs. 1.6%, p<0.0001). CONCLUSIONS Infectious complications of catheter-based regional anaesthesia are common. Strict hygienic standards must therefore be complied with. More data are necessary to calculate risk factors. The registry provided can also be used as a benchmark to reduce these rates further.

Incidence of infection from catheter procedures for regional anesthesia: first results from the network of DGAI and BDA.

BACKGROUND To analyze safety issues of regional anaesthesia and analgesia in Germany only a few single center studies are available. Therefore, the German Society for Anaesthesiology and Intensive Care Medicine (Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) and the Professional Association of German Anaesthetists (Berufsverband Deutscher Anästhesisten, BDA) initiated a network for safety in regional anaesthesia. From this the first results on infectious complications will be reported. MATERIALS AND METHODS In a Delphi process the documentation of the setup and maintenance of regional anaesthesia and analgesia was agreed with the participants in a working group from the DGAI. After approval by the officially authorized representative for patient data privacy protection a registry was programmed to collect anonymous data. Up to October 2008 data from 6 centers could be analyzed. RESULTS After testing for plausibility 8,781 regional anaesthesia procedures (22,112 catheter days) could be analyzed. The 5,057 neuraxial and 3,724 peripheral catheter-based procedures were in place for a median of 2.48 days (range 1.0-3.0 days) and 4 severe, 15 moderate and 128 mild infections were recorded. Diabetics were not found to show a statistically significant increase in risk (2.6% compared to 1.9% for non-diabetics: n.s.). Neuraxial procedures seem to have a higher rate of infections than peripheral procedures (2.7% vs. 1.3%, p<0.0001). Multiple punctures of the skin also seem to be associated with a higher infection rate than single skin punctures (4.1% vs. 1.6%, p<0.0001). CONCLUSIONS Infectious complications of catheter-based regional anaesthesia are common. Strict hygienic standards must therefore be complied with. More data are necessary to calculate risk factors. The registry provided can also be used as a benchmark to reduce these rates further.

Intraoperative tramadol reduces shivering but not pain after remifentanil-isoflurane general anaesthesia. A placebo-controlled, double-blind trial.

Background and objective Postoperative shivering and pain are frequent problems in patients recovering from anaesthesia with particularly high incidences being observed after remifentanil–isoflurane‐based general anaesthesia. The opioid tramadol is generally effective in preventing shivering and treating pain, but its effects are not characterized after remifentanil‐based general anaesthesia. This randomized, placebo‐controlled, double‐blind study evaluated the effects of intraoperative intravenous tramadol on postoperative shivering and pain after remifentanil‐based general anaesthesia. Methods After Ethics Committee approval, 60 patients scheduled for lumbar disc surgery were included. Surgery was performed under general anaesthesia (remifentanil, isoflurane). Patients were randomly assigned to receive 2 mg kg−1 tramadol in 30 mL 0.9% saline infused intravenously (n = 30) or 30 mL saline (n = 30) 45–30 min before skin closure. The following parameters were assessed every 10 min for 2 h: shivering, pain, postoperative nausea and vomiting, sedation, heart rate, non‐invasive blood pressure and peripheral oxygen saturation. The primary outcome variable was the incidence of shivering during the first 2 postoperative hours. Secondary variables were: shivering intensity, pain, postoperative nausea and vomiting, sedation, heart rate, non‐invasive blood pressure and peripheral oxygen saturation. Results Shivering was less frequent in patients treated with tramadol (20% vs. 70%, P = 0.0009) and was of lower intensity (severe shivering: 10% vs. 46.7%, P = 0.003). Pain scores were similar between the groups and all other secondary outcome variables failed to reveal significant differences. Conclusions Compared with placebo, intraoperative intravenous administration of 2 mg kg−1 tramadol reduces the incidence and extent of postoperative shivering without alterations in pain perception after lumbar disc surgery under remifentanil–isoflurane‐based general anaesthesia.

Präklinisches Management des Patienten mit Schlaganfall

ZusammenfassungIn industrialisierten Ländern ist der Schlaganfall die dritthäufigste Todesursache und gleichsam die häufigste Ursache für erworbene Behinderungen überhaupt. Untersuchungen zur Pathophysiologie des akuten ischämischen Insultes haben gezeigt, daß optimale Behandlungsbedingungen dann bestehen, wenn die Frühsymptome des Schlaganfalls schnell erkannt werden und die Behandlung innerhalb von 3 Stunden nach Einsetzen der Erstsymptome eingeleitet wird. Daraus ergibt sich die Forderung nach neuen Konzepten zur Früherkennung, rascher präklinischer Versorgung, strukturierter Diagnostik, unmittelbar einsetzender Akuttherapie und frühem Beginn der Rehabilitation. Zwischen dem Auftreten der Erstsymptome und dem Einsetzen der Therapie geht häufig wertvolle Zeit verloren. Häufig werden die Symptome von den Patienten, ihren Verwandtenn oder auch von Zeugen gar nicht bemerkt oder bagatellisiert. Im Unterschied zum Trauma und Herzinfarkt wird dem Schlaganfall auch von dem rettungsdienstlichen und medizinischen Personal zu wenig Priorität beigemessen. Nur eine geringe Anzahl von Schlaganfallpatienten wird bereits notfallmäßig behandelt und innerhalb des schmalen therapeutischen Zeitfensters notfallmedizinisch versorgt. Eine Verbesserung dieser Situation ist durch intensivierte Ausbildungsmaßnahmen, die sowohl die Öffentlichkeit als auch notfallmedizinisches Personal berücksichtigen, zu erreichen. Der gültige Behandlungsstandard in der Akuttherapie umfasst die adäquate zerebrale Oxygenierung, die Behandlung von Herzrhythmusstörungen, das Blutdruck-Management sowie die Therapie von Hyperglykämie und Hyperthermie. Es ist zu hoffen, daß Therapien, die auf die ersten Stunden nach Einsetzen der Symptomatik limitiert sind, zukünftig von dem Rettungsdienst angeboten werden können. Der Schlaganfallpatient sollte frühzeitig bei der aufnehmenden Klinik angemeldet werden, um die Anwesenheit eines speziellen Stroke-Teams bei Aufnahme zu ermöglichen.AbstractStroke is the third leading cause of death and number one cause of disability in industrialised countries. Studies into the pathophysiology of acute ischaemic stroke have indicated that treatment options are likely to be optimized when early signs of stroke are recognized and treatment is initiated within 3 hours from symptom onset. Therefore, new conceptions heading towards early diagnosis, fast preclinical treatment, structured diagnostics, immediate initiation of acute therapy as well as early initiation of rehabilitation are required. It is well known that, for most patients, there is a long delay between the onset of symptoms and the start of therapy. Many factors are responsible for the time delay: signs and symptoms often go unrecognized and/or minimized by patients, relatives and bystanders. Unlike trauma or myocardial infarction, stroke is not given a high priority by medical staff and/or emergency medical services (EMS). Although a small number of strike patients is treated as emergency and attended to by the emergency medical services within this time window, this number could easily be increased by intensified public and emergency personnel education. At present the standard of care by the EMS personnel includes adequate cerebral oxygenation, treatment of cardiac arrhythmia, management of hypertension as well as therapy of hyperglycemia and hyperthermia. For the future, we hope that emergency medical services will be able to initiate therapies which must be administered within the first few hours of acute stroke after onset of symptoms. Early notification of hospitals would enable a particular stroke team to be present at the patients admission.