Gottfried Mitterschiffthaler

Ultrasound guidance for the psoas compartment block: an imaging study.

We conducted this study to develop an ultrasound-guided approach to the psoas compartment and to assess its feasibility and accuracy by means of computed tomography (CT). Two examiners performed ultrasound-guided approaches at three levels (L2-3, L3-4, and L4-5) on 10 embalmed cadavers, which were seated prone. After each needle had been advanced into the psoas compartment under ultrasound guidance, the positions of their tips were computed by using two coordinates (A and B). Subsequently, axial transverse CT scans were made to verify the ultrasound measurements by using the same coordinates. In total, 48 approaches were performed (Examiner 1, n = 20; Examiner 2, n = 28). CT revealed that 47 of 48 ultrasound-guided approaches were performed exactly. In 1 of 48 approaches (L3-4), the tip of the needle was located posterior to the psoas muscle. The median differences between ultrasound and CT coordinates were 0.3 ± 0.3 cm for A and 0.2 ± 0.3 for B. Kendall’s coefficient of concordance was 0.9 (P < 0.001) between ultrasound and CT measurements for both coordinates. These results indicate that ultrasound enables exact needle placement, as proved by CT. We conclude that ultrasound guidance might be a useful adjunct to increase the safety and efficacy of the psoas compartment block at these levels.

A study of the paravertebral anatomy for ultrasound-guided posterior lumbar plexus block.

IMPLICATIONS We investigated the feasibility of posterior paravertebral sonography as a basis for ultrasound-guided posterior lumbar plexus blockades. Posterior paravertebral sonography proved to be a reliable as well as accurate imaging procedure for visualization of the lumbar paravertebral region except the lumbar plexus.

Lumbar plexus in children. A sonographic study and its relevance to pediatric regional anesthesia.

Background:Pediatric regional anesthesia has gained increasing interest over the past decades. The current study was conducted to investigate the lumbar paravertebral region and the lumbar plexus at L3–L4 and L4–L5 by means of sonography to obtain fundamentals for the performance of ultrasound-guided posterior lumbar plexus blocks. Methods:Thirty-two children (12 boys, 20 girls) with American Society of Anesthesiologists physical status I or II were enrolled in the current study. The lumbar paravertebral region was visualized at L3–L4 and L4–L5 on two corresponding posterior sonograms (longitudinal, transverse). The lumbar plexus had to be delineated, and skin-plexus distances were measured. In a series of five pediatric patients undergoing inguinal herniotomy, ultrasound-guided posterior lumbar plexus blocks at L4–L5 were performed. Results:The children were stratified into three age groups (group 1: > 3 yr and ≤ 5 yr; group 2: > 5 yr and ≤ 8 yr; group 3: > 8 yr and ≤ 12 yr). The lumbar plexus could be delineated at L3–L4 and L4–L5 in 19 of 20 cases in group 1, in 17 of 20 cases in group 2, in 22 of 24 cases at L3–L4 in group 3, and in 16 of 24 cases at L4–L5 in group 3. In all patients, the lumbar plexus was situated within the posterior part of the psoas major muscle. Skin-plexus distances showed statistical significant differences between groups 1 and 3 and between groups 2 and 3. The strongest positive correlation existed between skin-plexus distances and the children’s weight. Ultrasound guidance enabled safe und successful posterior approaches to the lumbar plexus, thus resulting in effective anesthesia and analgesia of the inguinal region. Conclusions:Sonography of the lumbar plexus in children proved to be feasible. Skin-plexus distances correlated with the children’s weight rather than with their age. The sonographic findings were fundamental for the performance of successful ultrasound-guided posterior approaches in a small group of pediatric patients.

Korean hand acupressure reduces postoperative nausea and vomiting after gynecological laparoscopic surgery.

To investigate the effectiveness of prophylactic Korean hand acupressure in the prevention of postoperative vomiting in women scheduled for minor gynecological laparoscopic surgery, we conducted a double-blinded, randomized, placebo-controlled study. In one group (n = 40), acupressure was performed 30 min before the induction of anesthesia by using special acupressure seeds, which were fixed onto the Korean hand acupuncture point K-K9 and remained there for at least 24 h. The second group (n = 40) functioned as the Placebo group. The treatment groups did not differ with regard to demographics, surgical procedure, or anesthetic administered. In the Acupressure group, the incidence of nausea and vomiting was significantly less (40% and 22.5%) than in the Placebo group (70% and 50%). We conclude that Korean hand acupressure of the acupuncture point K-K9 is an effective method for reducing postoperative nausea and vomiting in women after minor gynecological laparoscopic surgery.

Lumbar Plexus and Psoas Major Muscle: Not Always as Expected

Background and Objectives: Conflicting definitions concerning the exact location of the lumbar plexus have been proposed. The present study was carried out to detect anatomical variants regarding the topographical relation between the lumbar plexus and the psoas major muscle as well as lumbar plexus anatomy at the L4‐L5 level. Methods: Sixty‐three lumbar plexuses from 32 embalmed cadavers were dissected to determine the topographical relation between lumbar plexus and psoas major muscle. At the L4‐L5 levels variability in the course of the femoral as well as obturator nerve were described. Results: The lumbar plexus was situated within the psoas major muscle in 61 of 63 cases. In 2 of 63 cases the entire plexus was localized posterior to the psoas major muscle. In the 61 of 63 cases in which the lumbar plexus was situated within the psoas major muscle, emergence of the individual nerves most often occurred on the posterior or posterolateral surface. Conclusions: Our results synthesize contrasting assumptions in previous literature, by demonstrating that both locations of the lumbar plexus may be encountered in clinical practice: within and posterior to the psoas major muscle. However, the latter situation represents a minor variant. At the level of L4‐L5 the femoral nerve, showing a remarkable degree of branching, as well as the obturator nerve, were found within the psoas major muscle in the vast majority of specimens.

Verifying correct endotracheal intubation by measurement of end-tidal carbon dioxide during an ex utero intrapartum treatment procedure

The ex utero intrapartum treatment (EXIT) procedure provides time to secure the airway of the fetus while utero-placental circulation supplies the fetus with oxygen. We report the anesthetic management of a fetus with a large neck mass during an EXIT procedure in which the confirmation of correct endotracheal intubation was hampered by parts of the mass, blood, and other fluids. The use of a standard end-tidal carbon dioxide probe provided a reliable signal and proved the endotracheal position of the tube while utero-placental circulation was still intact.

Bewertung eines Anatomieworkshops für die Regionalanästhesieausbildung

BACKGROUND The aim of the present investigation was to survey former participants (n=869) of a cadaver workshop using a mail questionnaire to assess the demographic data and the impact of these courses on daily practice. METHODS The deadline for acceptance of return mail was 60 days. Descriptive statistics were employed for analysis of results. RESULTS The response rate was 36.7% and the course was judged to be recommendable by 98.2%. The average course attendant was board certified and had spent a mean time of 9+/-6 years in anesthesiology. The highest quality and degree of subsequent practicability in daily routine was attributed to peripheral nerve block training on cadavers. Of the course participants two-thirds performed regional anesthesia procedures more often following attendance. The majority of course attendants had to defray at least a part of the course fee themselves, and one-third was required to invest leisure time to attend. CONCLUSION Attendance of a cadaver workshop increased knowledge of clinical anatomy and enhanced performance of regional anesthesia procedures. Courses of this format constitute a currently underestimated adjunct to contemporary regional anesthesia education.

Evaluation of a cadaver workshop for education in regional anesthesia

BACKGROUND The aim of the present investigation was to survey former participants (n=869) of a cadaver workshop using a mail questionnaire to assess the demographic data and the impact of these courses on daily practice. METHODS The deadline for acceptance of return mail was 60 days. Descriptive statistics were employed for analysis of results. RESULTS The response rate was 36.7% and the course was judged to be recommendable by 98.2%. The average course attendant was board certified and had spent a mean time of 9+/-6 years in anesthesiology. The highest quality and degree of subsequent practicability in daily routine was attributed to peripheral nerve block training on cadavers. Of the course participants two-thirds performed regional anesthesia procedures more often following attendance. The majority of course attendants had to defray at least a part of the course fee themselves, and one-third was required to invest leisure time to attend. CONCLUSION Attendance of a cadaver workshop increased knowledge of clinical anatomy and enhanced performance of regional anesthesia procedures. Courses of this format constitute a currently underestimated adjunct to contemporary regional anesthesia education.

Pulmonary effects of bupivacaine, ropivacaine, and levobupivacaine in parturients undergoing spinal anaesthesia for elective caesarean delivery: A randomised controlled study

BACKGROUND Spinal anaesthesia is the method of choice for elective caesarean delivery, but has been reported to worsen dynamic pulmonary function when using bupivacaine. Similar investigations are lacking for ropivacaine and levobupivacaine. We have therefore compared the pulmonary effects of intrathecal bupivacaine, ropivacaine and levobupivacaine used for caesarean delivery. METHODS Forced vital capacity, forced expiratory volume in the first second, and peak expiratory flow rate were measured in 48 parturients before and after onset of spinal anaesthesia using either 0.5% bupivacaine 10 mg, 1% ropivacaine 20 mg, or 0.5% levobupivacaine 10 mg. Apgar scores and umbilical arterial pH were recorded. RESULTS The final level of sensory blockade was not different between groups. Forced vital capacity was significantly decreased with bupivacaine (3.6+/-0.5 L to 3.5+/-0.4 L, P<0.05) and ropivacaine (3.2+/-0.4 L to 3.1+/-0.5 L, P<0.05), but not with levobupivacaine (3.6+/-0.5 L to 3.4+/-0.6 L). Forced expiratory volume during the first second was not decreased in any group. Peak expiratory flow rate was significantly decreased with ropivacaine (5.5+/-1.5 L/s to 5.0+/-1.1 L/s, P<0.05) and levobupivacaine (from 6.0+/-1.1 L/s to 5.2+/-0.9 L/s, P<0.01). Neonatal vital parameters did not differ between the three groups. CONCLUSIONS Decreases in maternal pulmonary function tests were similar following spinal anaesthesia with bupivacaine, ropivacaine, or levobupivacaine for caesarean delivery. The clinical maternal and neonatal effects of these alterations appeared negligible.

Management of hepatic echinococcosis in pregnancy.

A 29-year-old woman presented with left flank pain at 20 weeks of pregnancy. She had lived in Turkey during her childhood. Ultrasound and magnetic resonance imaging revealed 3 partially calcified hepatic cysts with a maximum diameter of 9.6 cm and echinococcus multilocularis was confirmed serologically. Pharmacological treatment with albendazole (Eskazole; GlaxoSmithKline, Vienna, Austria) was started, but the cysts continued to enlarge. Vaginal delivery was discussed, but deemed too risky owing to potential rupture of the hepatic cysts during labor. An elective cesarean delivery under spinal anesthesia was performed in the 34th week of pregnancy without complications. Cyst enlargement continued despite albendazole therapy, and an extended right hepatectomy was performed 3 months later. Histology revealed multiple cysts without viable protoscolices. The patient had an uncomplicated recovery and was discharged on the seventh postoperative day. Follow-up 6 months after delivery was uneventful. Echinococcosis is endemic in the Mediterranean region, Middle and Far East, Africa, and South America, with an incidence of approximately 200 per 100 000 [1]. In North America and Europe its incidence is lower (for instance approximately 0.4 per 100 000 in Switzerland [1]), but probably increasing because of immigration from endemic countries. During pregnancy, a physiological decrease in cellular immunity may facilitate echinococcus growth [2]. Cyst rupture can cause potentially life-threatening anaphylaxis and peritoneal infection during labor [3]. Thus, we decided to deliver the baby by cesarean delivery. To mitigate the severity of potential anaphylaxis, we administered an H1-receptor antagonist (diphenhydramine 30 mg; Dibondrin, Montavit, Absam, Austria) and an H2-receptor antagonist (famotidine 20 mg; Ulcusan, Kwizda Pharma, Vienna, Austria), as well as methylprednisolone 250 mg (Urbason; Sanofi-Aventis, Vienna, Austria) before cesarean delivery. Albendazole may be used after the first trimester of pregnancy without teratogenic effects, and may eradicate echinococcus but may not alter cyst size [3]. With medical treatment, an expectant policy may be justified in small (b5 cm) asymptomatic, or totally calcified cysts. In our case, the cysts were large and continued to grow despite albendazole, but enabled us to delay cesarean delivery. Definite treatment—hepatic resection—was performed later. In conclusion, one should be aware of the potential hazards of hepatic echinococcosis during labor. Albendazole may be employed to prevent cyst growth. Cesarean delivery under spinal anesthesia, with prophylaxis against anaphylaxis, should be considered in patients with large echinococcus hepatic cysts to prevent potentially lifethreatening cyst rupture during labor. If postnatal hepatic cysts are large and growing despite albendazole, surgical treatment may be indicated [4].