Geert-Jan van Geffen

Different Approaches to Ultrasound-guided Thoracic Paravertebral Block An Illustrated Review

Given the fast development and increasing clinical relevance of ultrasound guidance for thoracic paravertebral blockade, this review article strives (1) to provide comprehensive information on thoracic paravertebral space anatomy, tailored to the needs of a regional anesthesia practitioner, (2) to interpret ultrasound images of the thoracic paravertebral space using cross-sectional anatomical images that are matched in location and plane, and (3) to briefly describe and discuss different ultrasound-guided approaches to thoracic paravertebral blockade. To illustrate the pertinent anatomy, high-resolution photographs of anatomical cross-sections are used. By using voxel anatomy, it is possible to visualize the needle pathway of different approaches in the same human specimen. This offers a unique presentation of this complex anatomical region and is inherently more realistic than anatomical drawings.

Ultrasound-guided proximal and distal sciatic nerve blocks in children.

STUDY OBJECTIVE To present the use of ultrasonography for the performance of proximal subgluteal and distal sciatic nerve blocks in children. DESIGN Prospective descriptive study. SETTING University hospital. PATIENTS 45 ASA physical status I, II, and III patients, aged between 8 months and 16 years, scheduled for lower limb surgery. INTERVENTIONS During general anesthesia, proximal, subgluteal, and distal sciatic nerve blocks using ultrasonography were performed. If severe postoperative pain was expected, a catheter technique was used. MEASUREMENTS The injected amount of local anesthetic was noted. Based on the spread of local anesthetic, prediction for successful block was made. Complications, adverse effects, postoperative pain scores, and parent satisfaction scores were noted. MAIN RESULTS 21 proximal sciatic nerve blocks (12 single-injection and 9 continuous blocks) and 35 distal sciatic nerve blocks (17 single-injection, 6 bilateral single-injection, 4 continuous, and one bilateral continuous block) were performed. A mean initial dose of 0.25 mL.kg(-1) of ropivacaine 0.375% was injected. A successful block was obtained in all children. Excellent postoperative pain relief was obtained. All parents were satisfied with the postoperative pain relief. No complications occurred. CONCLUSION Ultrasonography is useful in the identification of the sciatic nerve and it facilitates needle and catheter placement for proximal and distal nerve blocks in children.

Prospective double blind randomized placebo-controlled clinical trial of the pectoral nerves (Pecs) block type II

STUDY OBJECTIVE The aim of this clinical trial was to test the hypothesis whether adding the pectoral nerves (Pecs) block type II to the anesthetic procedure reduces opioid consumption during and after breast surgery. DESIGN A prospective randomized double blind placebo-controlled study. SETTING A secondary hospital. PATIENTS 140 breast cancer stage 1-3 patients undergoing mastectomy or tumorectomy with sentinel node or axillary node dissection. INTERVENTIONS Patients were randomized to receive either a Pecs block with levobupivacaine 0.25% (n=70) or placebo block with saline (n=70). MEASUREMENTS The pain levels were evaluated by Numeric Rating Scale (NRS) pain scores at 15-minute intervals during the post anesthesia care unit stay time (PACU), at 2-hour intervals for the first 24h on the ward and at 4-hour intervals for the next 24h. Intraoperative and postoperative opioid consumption were recorded during the full stay. Patient satisfaction was evaluated upon discharge using a 10-point scale. MAIN RESULTS Intraoperative sufentanil requirements were comparable for the Pecs and placebo group (8.0±3.5μg and 7.8±3.0μg, P=0.730). Patients in the Pecs group experienced significantly less pain than patients in the control group (P=0.048) during their PACU stay. Furthermore, patients in the Pecs group required significant less postoperative opioids (9.16±10.15mg and 14.97±14.38mg morphine equivalent, P=0.037) and required significant fewer postsurgical opioid administration interventions than patients in the control group (P=0.045). Both patient-groups were very satisfied about their management (9.6±0.6 and 9.1±1.8 on a 10-point scale, P=0.211). CONCLUSIONS The Pecs block reduces postsurgical opioid consumption during the PACU stay time for patients undergoing breast surgery.

Detection of attempted movement from the EEG during neuromuscular block: proof of principle study in awake volunteers

Brain-Computer Interfaces (BCIs) have the potential to detect intraoperative awareness during general anaesthesia. Traditionally, BCI research is aimed at establishing or improving communication and control for patients with permanent paralysis. Patients experiencing intraoperative awareness also lack the means to communicate after administration of a neuromuscular blocker, but may attempt to move. This study evaluates the principle of detecting attempted movements from the electroencephalogram (EEG) during local temporary neuromuscular blockade. EEG was obtained from four healthy volunteers making 3-second hand movements, both before and after local administration of rocuronium in one isolated forearm. Using offline classification analysis we investigated whether the attempted movements the participants made during paralysis could be distinguished from the periods when they did not move or attempt to move. Attempted movement trials were correctly identified in 81 (68–94)% (mean (95% CI)) and 84 (74–93)% of the cases using 30 and 9 EEG channels, respectively. Similar accuracies were obtained when training the classifier on the participants’ actual movements. These results provide proof of the principle that a BCI can detect movement attempts during neuromuscular blockade. Based on this, in the future a BCI may serve as a communication channel between a patient under general anaesthesia and the anaesthesiologist.

The Episure Autodetect syringe, a loss-of-resistance technique for locating the epidural space, used in pediatric patients

The Episure Autodetect syringe, a spring‐loaded syringe, is a loss‐of‐resistance syringe with an internal compression that applies constant pressure on the plunger. As the principle of loss‐of‐resistance is the same for adult and for pediatric patients, the Episure Autodetect syringe should be able to identify correctly the epidural space also in pediatric patients.

Continuous Peripheral Nerve Blocks Safe Practice and Management

Continuous peripheral nerve blocks can be used to provide effective and prolonged analgesia. A variety of needle/catheter assemblies exist, and perineural catheters can be installed using various guidance mechanisms, including nerve stimulation and ultrasound. Complications that may hinder the efficacy of a continuous regional block include inaccurate catheter tip location, catheter dislocation, infection at the catheter insertion site, and difficulty removing the catheter. Neurologic injury with continuous blocks is rare and related to multiple risk factors. Other complications that affect single-injection blocks, such as accidental vascular puncture and systemic local anesthetic toxicity, may also occur with continuous blocks. Complications associated closely with continuous blocks include increased risk of patient falls and problems with the infusion regimen or equipment.

Prehospital Echocardiography During Resuscitation Impacts Treatment in a Physician-Staffed Helicopter Emergency Medical Service: an Observational Study

Abstract Background: Patients in cardiac arrest must receive algorithm-based management such as basic life support and advanced (cardiac) life support. International guidelines dictate diagnosing and treating any factor that may have caused the arrest or may be complicating the resuscitation. Ultrasound may be of potential value in this process and can be used in a prehospital setting. The objective is to evaluate the use of prehospital ultrasound during traumatic and non-traumatic CPR and determine its impact on prehospital treatment decisions in a Dutch helicopter emergency medical service (HEMS). Methods: We conducted an observational study in cardiac arrest patients, of any cause, in whom the Nijmegen HEMS performed CPR with concurrent echocardiography. The participating physicians had to adhere to Advanced Life Support protocols as per standard operating procedure. Simultaneous with the interruptions of chest compressions to allow for heart rhythm analysis, ultrasound-trained HEMS physicians performed echocardiography according to study protocol. The HEMS nurse and physician recorded patient data and data on impacted (supported or altered) patient treatment decisions. Results: From February 2014 through November 2016, we included 56 patients who underwent 102 ultrasound examinations. Sixty-two (61%) ultrasound examinations impacted 78 treatment decisions in 49 patients (88%). The impacted treatment was related to termination of CPR in 32 (57%), fluid management (14%), drugs selection and doses (14%), and choice of destination hospital (5%). Causes of cardiac arrest included trauma (48%), cardiac (21%), medical (14%), asphyxia (9%), and other (7%). Conclusion: Prehospital echocardiography has an impact on patient treatment and may be a useful tool to support decision-making during CPR in a Dutch HEMS.

Optical signature of nerve tissue-Exploratory ex vivo study comparing optical, histological, and molecular characteristics of different adipose and nerve tissues: OPTICAL SIGNATURE OF NERVE TISSUE

During several anesthesiological procedures, needles are inserted through the skin of a patient to target nerves. In most cases, the needle traverses several tissues—skin, subcutaneous adipose tissue, muscles, nerves, and blood vessels—to reach the target nerve. A clear identification of the target nerve can improve the success of the nerve block and reduce the rate of complications. This may be accomplished with diffuse reflectance spectroscopy (DRS) which can provide a quantitative measure of the tissue composition. The goal of the current study was to further explore the morphological, biological, chemical, and optical characteristics of the tissues encountered during needle insertion to improve future DRS classification algorithms.

ABCDE of prehospital ultrasonography: a narrative review

Prehospital point-of-care ultrasound used by nonradiologists in emergency medicine is gaining ground. It is feasible on-scene and during aeromedical transport and allows health-care professionals to detect or rule out potential harmful conditions. Consequently, it impacts decision-making in prioritizing care, selecting the best treatment, and the most suitable transport mode and destination. This increasing relevance of prehospital ultrasonography is due to advancements in ultrasound devices and related technology, and to a growing number of applications. This narrative review aims to present an overview of prehospital ultrasonography literature. The focus is on civilian emergency (trauma and non-trauma) setting. Current and potential future applications are discussed, structured according to the airway, breathing, circulation, disability, and environment/exposure (ABCDE) approach. Aside from diagnostic implementation and specific protocols, procedural guidance, therapeutic ultrasound, and challenges are reviewed.

Erratum zum Beitrag: Vitamin C beim chronischen nicht spezifischen Kreuzschmerz

Erratum zum Beitrag: Vitamin C beim chronischen nicht spezi schen Kreuzschmerz Olaf Buchbinder, Geldern; Geert-Jan van Ge en, Nijmegen/Niederlande; Hagen Maxeiner, Gießen; Gert Jan Sche er, Nijmegen; Jörg Mühling, Nijmegen; Schmerzmedizin 2017;33(1):32–41 DOI: 10.1007/s00940-017-0495-6 Am Ende des Beitrags wurde der Name des Co-Autors Hagen Maxeiner falsch abgedruckt. Die korrekten Autorendaten lauten: PD Dr. Hagen Maxeiner, D.E.S.A., E.D.I.C. Universitätsklinikum Gießen und Marburg Klinik für Anästhesiologie und Operative Intensivmedizin Sektion Schmerztherapie Ga kystraße 14 35392 Gießen