Hans-Christian Jeske

Management of hemorrhage in severe pelvic injuries.

BACKGROUND Major pelvic trauma results in high mortality. No standard technique to control pelvic hemorrhage has been identified. METHODS In this retrospective study, the clinical course of hemodynamically instable trauma patients with pelvic fractures treated according to an institutional algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was evaluated. Study variables included demographics, data on the type and extent of injury, achievement of time from admission to hemorrhage control, complications of angiography, red blood cell needs, and outcome. Standard statistical tests were used. RESULTS Of 1,476 pelvic fracture patients, 45 fulfilled the inclusion criteria. Two patients presented with severe intra-abdominal hemorrhage and underwent emergency laparotomy with pelvic packing. Forty-two patients underwent angiographic embolization before (n = 24) or after (n = 18) a computed tomography scan. Applying the clinical algorithm, pelvic hemorrhage was controlled in all but one patient who died before any intervention could be initiated (97.8%). The hourly need for red blood cell transfusions decreased during 24 hours after angiographic embolization when compared with before the procedure (3.7 +/- 3.5 vs. 0.1 +/- 0.1 U/h; p < 0.001). In patients undergoing angiographic embolization, the mean time to hemorrhage control was 163 minutes +/- 83 minutes. Hospital mortality was 26.2%. Two patients required reembolization because of hemorrhage from other than the primary bleeding site. One patient developed gluteal necrosis, and nine subsequently required renal replacement therapy. CONCLUSION Application of a clinical algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was effective and safe to rapidly control hemorrhage in hemodynamically instable trauma patients with pelvic fractures.

Pressure support ventilation versus continuous positive airway pressure ventilation with the ProSeal laryngeal mask airway: A randomized crossover study of anesthetized pediatric patients

Continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) improve gas exchange in adults, but there are little published data regarding children. We compared the efficacy of PSV with CPAP in anesthetized children managed with the ProSeal™ laryngeal mask airway. Patients were randomized into two equal-sized crossover groups and data were collected before surgery. In Group 1, patients underwent CPAP, PSV, and CPAP in sequence. In Group 2, patients underwent PSV, CPAP, and PSV in sequence. PSV comprised positive end-expiratory pressure set at 3 cm H2O and inspiratory pressure support set at 10 cm H2O above positive end-expiratory pressure. CPAP was set at 3 cm H2O. Each ventilatory mode was maintained for 5 min. The following data were recorded at each ventilatory mode: ETco2, Spo2, expired tidal volume, peak airway pressure, work of breathing patient (WOB), &dgr; esophageal pressure, pressure time product, respiratory drive, inspiratory time fraction, respiratory rate, noninvasive mean arterial blood pressure, and heart rate. In Group 1, measurements for CPAP were similar before and after PSV. In Group 2, measurements for PSV were similar before and after CPAP. When compared with CPAP, PSV had lower ETco2 (46 ± 6 versus 52 ± 7 mm Hg; P < 0.001), slower respiratory rate (24 ± 6 versus 30 ± 6 min−1; P < 0.001), lower WOB (0.54 ± 0.54 versus 0.95 ± 0.72 JL−1; P < 0.05), lower pressure time product (94 ± 88 versus 150 ± 90 cm H2O s−1min−1; P < 0.001), lower &dgr; esophageal pressure (10.6 ± 7.4 versus 14.1 ± 8.9 cm H2O; P < 0.05), lower inspiratory time fraction (29% ± 3% versus 34% ± 5%; P < 0.001), and higher expired tidal volume (179 ± 50 versus 129 ± 44 mL; P < 0.001). There were no differences in Spo2, respiratory drive, mean arterial blood pressure, and heart rate. We conclude that PSV improves gas exchange and reduces WOB during ProSeal™ laryngeal mask airway anesthesia compared with CPAP in ASA physical status I children aged 1–7 yr.

A Randomized Study of the Effectiveness of Suprascapular Nerve Block in Patient Satisfaction and Outcome After Arthroscopic Subacromial Decompression

PURPOSE The purpose of this study was to evaluate the efficiency of the suprascapular nerve (SSN) block in pain reduction after arthroscopic subacromial decompression operations and its influence on patient satisfaction. Furthermore, we wanted to evaluate whether better perioperative pain management could positively influence postoperative shoulder function. METHODS In this prospective, randomized, double-blinded clinical trial, 3 groups of patients--each with 15 participants--were treated with SSN block (10 mL of 1% ropivacaine), placebo, or a subacromial infiltration of local anesthesia (20 mL of 1% ropivacaine). Preoperative and postoperative pain was evaluated with a visual analog scale. Functional outcome was measured by the Constant-Murley score, and patient satisfaction was measured anecdotally by interview 2 days, 2 weeks, and 6 weeks after surgery. RESULTS The SSN group reported significantly lower levels of postoperative pain, required significantly less analgesia, had better range of motion, and had higher levels of postoperative satisfaction in comparison to the subacromial infiltration group and placebo group. CONCLUSIONS Patients treated with SSN blocks had less pain overall, which led to a decreased need for analgesics in comparison to the subacromial infiltration and placebo groups. Furthermore, patients in the SSN-blocked group achieved better postoperative ROM and were significantly more satisfied after surgery.

The Impact of Business Cards on Physician Recognition After General Anesthesia

Despite their contribution to overall perioperative treatment of patients, anesthesiologists often remain in anonymity. We evaluated the impact of business cards on physician recognition after general anesthesia. Using a questionnaire, 441 patients were interviewed for recall of the anesthesiologist’s name, the surgeon’s name, and their overall satisfaction with anesthetic care 6 wk after undergoing surgery during general anesthesia. Of these patients, 155 had and 137 had not randomly received a business card during the preoperative visit, with another 149 patients serving as a control group. Business card recipients responded significantly more frequently than did nonrecipients or patients from the control group (65.8% vs 54.7% vs 53%), with recall of the anesthesiologist’s name being significantly more frequent in the Business Card Recipient group (51.5% vs 14.3% vs 11.4%). Patient satisfaction with anesthetic care and recall of the surgeon’s name were similar in all groups. The use of a simple tool such as a business card can indeed produce a measurable positive change in physician recognition on the part of the patient.

The influence of postural changes on gastroesophageal reflux and barrier pressure in nonfasting individuals.

There is controversy regarding optimal body positioning (i.e., head-up, head-down) in awake nonfasting individuals to minimize the risk for pulmonary aspiration of gastric contents as the result of gastroesophageal reflux (GER). In the present study, we investigated GER and intragastric-esophageal barrier pressure by means of multichannel intraluminal impedance measurement and intragastric-esophageal manometry in awake, nonfasting volunteers randomly positioned in a 20° head-up position, the supine position, and a 20° head-down position. No significant difference among positions was found with respect to number of GER episodes per person (0/1/1) or intragastric-esophageal barrier pressure (15.6/19.6/19.4 mm Hg). We conclude that specific body positioning is useless in the prophylaxis of GER in awake nonfasting individuals.

Preoperative administration of esomeprazole has no influence on frequency of refluxes

STUDY OBJECTIVE To examine the effect of esomeprazole in a fixed time setting on gastric content volume, gastric acidity, gastric barrier pressure, and reflux propensity. DESIGN Randomized, controlled, double-blind trial. SUBJECTS 21 healthy, ASA I physical status volunteers. INTERVENTION Esomeprazole was given 12 hours and one hour before investigation. Before the study, a multichannel intraluminal impedance catheter, pH monitoring data logger (PHmetry) catheter, and an intragastric-esophageal manometry catheter were placed nasally after topical anesthesia. MEASUREMENTS Gastric acidity and gastric content volume were determined by PHmetry after aspiration of gastric contents over a nasogastric tube. Gastroesophageal reflux and intragastric-esophageal barrier pressure were investigated by multichannel intraluminal impedance measurement, PHmetry, and intragastric-esophageal manometry. MAIN RESULTS The pH of gastric contents was significantly (P < 0.001) higher after esomeprazole (mean [25th-75th percentile], 4.2 [3.9-4.8] vs 2.0 [1.9-2.7]), and gastric content volume was significantly (P < 0.001) lower (5.0 mL [3.0-12.0] vs 15 mL [10.0-25.0]) in comparison to placebo. No significant difference between esomeprazole and placebo was found with respect to number of refluxes per person, duration of reflux, or barrier pressure. CONCLUSION Esomeprazole in a fixed time setting can markedly increase the pH of gastric contents and decrease gastric content volume, but has no influence on the frequency, duration of refluxes, or gastroesophageal barrier pressure.