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Zur Identifizierung des Epiduralraums bei Anlage ruckenmarknaher Regionalverfahren bedienen sich die meisten Anasthesisten der Widerstandsverlustmethode („Loss-of-resistance“-Technik). Diese Technik hat einerseits einen subjektiven Charakter und ist in gewissen Fallen nur bedingt verlasslich, weshalb wiederholt Ansatze zur Objektivierung unternommen worden sind. Die sog. CompuFlo®-Technologie wurde bereits vor einigen Jahren beschrieben und lieferte in ersten Studien vielversprechende Ergebnisse. Anhand dieser Fallserie werden die ersten Anwendungen im deutschsprachigen Raum illustriert.

Anesthesiologists commonly perform the loss of resistance technique in order to identify the epidural space during neuraxial procedures; however, this technique is subjective and lacks reliability in certain cases. The so-called CompuFlo® technology provides objective information about the position of the epidural needle by means of a pressure curve and acoustic signals. The technology was introduced several years ago and was evaluated in several trials, which showed promising results. The purpose of the present publication is to report on the first experiences with the CompuFlo® technology in German-speaking countries. A series of 24 epidural procedures using the CompuFlo® device was carried out in routine daily practice. The epidural space was successfully identified in 23 cases. Conversion to the conventional loss of resistance technique was performed during the initial cases in a prolonged procedure. The CompuFlo® technique is considered to be a promising technology, which might help to reduce complications after epidural anesthesia, e.g. postdural puncture headache.

Die aktuelle Kasuistik berichtet uber die Anwendung der venoarteriellen extrakorporalen Membranoxygenierung (va-ECMO) als „bridge to therapy“ im Fall einer massiven Lungenembolie mit konsekutivem Rechtsherzversagen. Eine 38-jahrige Frau prasentierte sich in einem Krankenhaus der Regelversorgung mit Dyspnoe und zunehmender Kreislaufinsuffizienz. Die Diagnostik zeigte eine massive Lungenembolie. Nach frustraner Thrombolyse und Entwicklung eines kardiogenen Schocks war die Indikation zur Thrombendarteriektomie gegeben. Um einen Transport der hochgradig instabilen Patientin in ein Zentrum der Maximalversorgung zu ermoglichen, wurde ein mobiles ECMO-Team alarmiert. Dies leitete vor Ort eine va-ECMO-Therapie an der wachen Patientin ein. Nach Stabilisierung der kardiopulmonalen Funktion mithilfe der extrakorporalen Unterstutzung erfolgten die sichere Verlegung und anschliesend die erfolgreiche Operation mit Restitutio ad integrum.

Hintergrund Die Therapie des akuten Lungenversagens („acute respiratory distress syndrome“, ARDS) besteht neben der spezifischen Behandlung der auslosenden Ursache aus einer lungenprotektiven Beatmung und einer Reihe von adjuvanten bzw. supportiven Masnahmen.

Die Spinalanasthesie wird als das Standardanasthesieverfahren zur Sectio caesarea angesehen. Zahlreiche Studien befassen sich mit der Dosisfindung der applizierten Lokalanasthestikamenge und -konzentration, um das Auftreten einer haufig assoziierten Hypotonie zu reduzieren. Die am Universitatsklinikum Wurzburg etablierte Technik der „High-volume-low-concentration“-Medikamentenkombination aus bis zu 12 ml isobarem 0,1 %igem Bupivacain (1 mg/ml) mit Sufentanil (1 µg/ml) ist bislang wenig verbreitet und wurde in dieser retrospektiven Studie hinsichtlich Zuverlassigkeit und Nebenwirkungen untersucht. Von 1424 Anasthesieprotokollen aus den Jahren 2001–2007 wurden 1368 ausgewertet. Erfasst wurden demografische Daten sowie Parameter wie Punktionshohe, Dosis und Ausdehnung, Kreislaufstabilitat und Medikamentenbedarf wahrend der Spinalanasthesie. Als Hypotoniegrenze wurde ein Abfall des systolischen Blutdruckwerts auf

Terrorist attacks have become reality in Germany. The aim of this work was, after the Würzburg terrorist attack, to define quality indicators and application characteristics for rescue missions in life-threatening situations. The results can be used to record data from future missions using this template in order to make them comparable with each other.After approval of the local ethic committee, the first step was to designate a group of experts in order to define the template in a consensus process. The next step was to perform the consensus process by defining the template. An independent expert for emergency medicine and disaster management reviewed and approved the results afterwards.The expert group defined 13 categories and 158 parameters that will further serve the systematic evaluation of the rescue mission of the Würzburg terror attack. Preliminary results of this evaluation process are given in this paper; the full evaluation has not yet been completed.In this study we first describe quality indicators and parameters suitable for the German rescue system in order to evaluate rescue operations for violence caused mass casualties. There is similar international documentation, but it does not specifically focus on life-threatening operations and are not adapted to the German context.There is an important need to systematically evaluate rescue missions after mass killing incidents. In this study we report a template of parameters and quality indicators in order to systematically evaluate mass violence events. The presented template is the result of an expert consensus process and may serve as a basis for further development and research.

Auch im Rahmen der Leitlinien des European Resuscitation Council (ERC) ergeben sich gemas unterschiedlichen Rahmenbedingungen Modifikationen der vorgeschlagenen Algorithmen. Hierbei gehen wesentliche fur den Herz-Kreislauf-Stillstand mitverantwortliche Faktoren in die Therapieentscheidung ein. Die vorliegende Kasuistik thematisiert die Spezifikationen im Rahmen der Hypothermie. Der Patient wurde nach Beinahe-Ertrinken mit schwerer Hypothermie (ca. 30 min unter Wasser) initial ohne Spontankreislauf geborgen. Bei rasch erfolgendem Wiedereinsetzen eines spontanen Kreislaufs („return of spontaneous circulation“, ROSC) konnte er an Tag 15 im Anschluss an den Unfall ohne fokal-neurologische Defizite in die Rehabilitation entlassen werden. Die Sektion 8 des ERC hat Erganzungen zu den ERC-Leitlinien bei Reanimation unter besonderen Umstanden formuliert, die im vorliegenden Fall grose Relevanz hatten. Ein wichtiges Kriterium stellte hier die Hypothermie dar, die eine angepasste Pharmakotherapie notwendig machte. Weiterhin war die Wahl des Zielkrankenhauses aus rettungsdienstlicher Sicht masgeblich, um die Hypothermie und die sich daraus ergebenden Komplikationen adaquat mithilfe kontrollierter Wiedererwarmung therapieren zu konnen.

Sonographisch gesteuerte Multiinjektionstechniken sind heute etablierte Standardverfahren bei der axillaren Plexusanasthesie. Bis heute gibt es allerdings nur wenige Studien, die die Nervenstimulation und die Sonographie als Steuerungsinstrument bei einer axillaren Multiinjektionstechnik vergleichen. In der vorliegenden Arbeit wurde eine ultraschallgesteuerte Vierfachinjektionstechnik (perineural, „out-of-plane“) mit einer nervenstimulationsgesteuerten Dreifachinjektionstechnik in einem prospektiven randomisierten und untersucherverblindeten Studiendesign verglichen. Es wurden 60 Patienten in 2 Gruppen (SONO, n = 30, und STIM, n = 30) randomisiert. Die Anlage der Plexusanasthesie erfolgte durch einen von 5 in beiden Methoden versierten Facharzten und in beiden Gruppen mit 40–50 ml 1,5 %igem Mepivacain sowie 5–10 ml 0,5 %igem Mepivacain. Primarer Zielpunkt war die Anasthesiezeit. Als sekundare Ziele wurden Durchfuhrungszeit (DZ) und die Anasthesiezeiten der Einzelnerven sowie die Erfolgsquote untersucht. Ein verblindeter Untersucher testete die Sensibilitat und die Motorik in den Innervationsgebieten der Nn. medianus (MED), radialis (RAD), musculocutaneus (MUC), ulnaris (ULN) und cutaneus antebrachii medialis (CAM) zu definierten Zeitpunkten. Die Patienten erhielten einen Fragebogen zum Patientenkomfort. Die Anasthesiezeiten der Plexusblockaden unterschieden sich nicht. Die Anasthesiezeiten der Einzelnerven und die Erfolgsquoten (90 vs. 89 %) waren ohne Unterschied. Die DZ war in der SONO-Gruppe signifikant kurzer (6,68 ± 1,72 vs. 8,05 ± 2,58 min, p = 0,02). Patientenzufriedenheit (92 % vs. 91 %) und Bewertungen in der visuellen Analogskala (VAS, 2 cm) zeigten jeweils gute Ergebnisse. Bezuglich des Blockadeerfolgs, der Blockadequalitat und der Patientenzufriedenheit sind die Verfahren gleichwertig; die Unterschiede zwischen den Verfahren sind geringer als erwartet.

Die voraussichtliche Eintreffzeit von Schockraumpatienten spielt fur die aufnehmende Klinik eine bedeutende Rolle. An einem uberregionalen Traumazentrum haben wir die Ubereinstimmung von voraussichtlicher und tatsachlicher Eintreffzeit uberpruft. Es wurde eine retrospektive Analyse aller Schockraumeinsatze von September 2010 bis zum Marz 2011 durchgefuhrt und die tatsachliche Eintreffzeit mit der voraussichtlichen Eintreffzeit verglichen. Der Erfolg des Alarmierungsalgorithmus wurde uberpruft. Es wurden 165 Einsatze in die Datenanalyse eingeschlossen. Eine exakte Ubereinstimmung der geschatzten und der tatsachlichen Eintreffzeit gab es in 14 min. Es konnte gezeigt werden, dass ein standardisierter Alarmierungsalgorithmus fur das Schockraumteam (Alarm 10 min vor geschatzter Ankunft des Patienten) in der uberwiegenden Zahl der Falle zu einem akzeptablen Ergebnis fuhrt. Insbesondere sind nur 3 % der Patienten in einem kritischen Zeitfenster zu fruh im Schockraum eingetroffen.

Im Rahmen dieser Studie wurde die aktuelle Verwendung i.v.-verabreichter Opioide – unter besonderer Berucksichtigung von Remifentanil als patientenkontrollierte intravenose Analgesie („patient controlled intravenous analgesia“, PCIA) – in der Geburtshilfe deutscher Kliniken untersucht. Ein Fragebogen wurde an 930 anasthesiologische Kliniken versandt. In dem zweiseitigen Fragebogen wurde nach Geburtenzahl, den alternativ zur Periduralanalgesie (PDA) verwendeten Methoden der geburtshilflichen Analgesie wie z. B. periodisch i.v.-verabreichten Opioiden, PCIA-Techniken bzw. alternativen Verfahren gefragt. Weiterhin zielten die Fragen auf Details bezuglich der Verwendung einer PCIA ab. Die Daten wurden mithilfe der Statistik-Software PASW Statistics 18.0 erfasst und ausgewertet. Es antworteten 343 anasthesiologische Kliniken (Rucklaufquote: 37%). Uber eine Geburtshilfestation verfugten 281 Kliniken. Alle Kliniken boten einen 24-stundigen anasthesiologischen Bereitschaftsdienst zur Durchfuhrung einer PDA an. Die meistverwendeten periodisch i.v.- oder i.m.-verabreichten Opioide waren Pethidin (19%), Meptazinol (17%) und Piritramid (16%). Nur 22 Kliniken (8%) boten eine PCIA als Alternative an; hierbei war Remifentanil (68%) das am haufigsten genutzte Opioid. Fur letzteren Fall gaben die meisten Befragten an, die Sauerstoffsattigung (91%) und den Blutdruck (95%) zu uberwachen, wahrend das EKG (18%) und die Atemfrequenz (19%) der Mutter weitaus seltener kontrolliert wurden. Diese aktuelle Umfrage zeigt, dass Pethidin, Meptazinol und Piritramid die gebrauchlichsten Analgetika fur eine opioidbasierte Therapie des Wehenschmerzes sind. Eine PCIA – in den meisten Fallen mit Remifentanil – bieten hingegen nur sehr wenige Kliniken an. Weiterhin weisen die Ergebnisse darauf hin, dass die aktuellen Uberwachungsstandards in den Kliniken, die eine PCIA im Rahmen der Geburtshilfe an bieten, verbesserungswurdig sind.

Die venovenose extrakorporale Membranoxygenierung (vv-ECMO) kann bei polytraumatisierten Patienten mit „acute respiratory distress syndrome“ (ARDS) zur Sicherung des Gasaustausches bei Versagen von konventionellen Beatmungsstrategien eingesetzt werden. Da eine systemische Antikoagulation zur Vermeidung von thrombembolischen Komplikationen empfohlen wird, ist die ECMO bei Patienten mit intrakraniellen Blutungen kontraindiziert. Es wird uber den mehrtagigen Einsatz einer vv-ECMO ohne systemische Antikoagulation zur Sicherstellung eines suffizienten Gasaustausches bei einem polytraumatisierten ARDS-Patienten mit schwerem Schadel-Hirn-Trauma (SHT) berichtet.

SUMMARY Aims: Statines, HMG-CoA reductase inhibitors, are widely used to treat hypercholesterinemia. These substances are well tolerated, but myotoxic effects have been reported. The exact mechanisms of the induced myotoxicity are unknown but an involvement of intracellular calcium handling is suspected. Individuals susceptible to malignant hyperthermia (MH) have an impaired calcium homeostasis. An in vitro test measuring contracture responses of isolated muscle bundles is used to investigate cellular processes of MH. Aim of this study was to investigate if statins modify the contracture response of isolated muscle bundles from MH susceptible (MHS) and nonsusceptible (MHN) pigs. Methodology: With approval of the local ethics committee muscle biopsies of 18 MH susceptible and 12 nonsusceptible pigs were performed. Muscle bundles were mounted on an isometric force transducer, preloaded, and electrically stimulated. After establishment of a stable baseline, muscle bundles were exposed to simvastatin, atorvastatin, gemfibrocil, and the pure solvent. Baseline tension was measured and analyzed for changes with P < 0.05 considered to be significant. Results: There were no differences in weight, length, and predrug baseline tension between the groups. Both simvastatin and atorvastatin induced significant contractures in muscle bundles from MHS pigs. Gemfibrocil and the solvent methanol showed no effect. In MHN muscle bundles, none of the tested substances induced a contracture. Statines induce contractures only in MHS muscle bundles. Conclusion: We therefore conclude that the underlying mechanism may be a pathologic influence on intracellular calcium handling that is absent in MHN. A preexisting impairment of the calcium homeostasis seems to be necessary for this behavior because muscle bundles of MHN pigs showed no pathologic reaction. A higher muscle cell vulnerability toward statins is assumed in MHS patients. Statins ought to be used with caution in these individuals. Analogous a diagnostic workup for MH should be considered for patients with statin-induced rhabdomyolyis.

Background Epidural analgesia is considered as the standard method for labor analgesia by inducing a minimal negative impact on labor while providing effective analgesia. Labor analgesia in the absence of epidural analgesia is difficult to achieve with the commonly used analgesic interventions. If epidural analgesia is not feasible due to coagulation disorders, anticoagulation, inability to insert an epidural catheter or due to the mother''s refusal to accept neuraxial analgesia, there is a need for interventions to cope with labor pain. So far, pethidine, diamorphine, meptazinol and spasmolytics remain the most widely used substances for IM and IV use. Unfortunately, in addition to not being very effective, these interventions may be associated with undesirable side effects for the parturient and the newborn. For a decade, anaesthesiologists have experienced the unique properties of remifentanil in the settings of surgical anaesthesia and conscious sedation since it was introduced for labor analgesia. Unfortunately, remifentanil is not licensed for administration to the pregnant patient, and it is unlikely that the manufacturers would consider the cost justified. Methods Therefore, relevant concerns, legal issues and precautions are discussed based on the presentation of case series and a protocol is presented on how the use of remifentanil can be safely implemented for labor analgesia in selected situations. Results and conclusions Proper informed consent, appropriate monitoring for the mother and the newborn, one-to-one nursing or midwifery care as well as the availability of an attending physician experienced in neonatal resuscitation and an anaesthesiologist with experience regarding the use of remifentanil are important to ensure that this method retains its good reputation for obstetric analgesia.

Background: Previous studies reported that propofol anesthesia is an effective means of preventing postoperative nausea and vomiting (PONV) after different types of surgeries. The present analysis of a large antiemetic trial is intend to compare propofol versus isoflurane, enflurane or sevoflurane with respect to the incidences of PONV after strabismus surgery. Methods: 238 ASA I - III inpatients, aged 4-65 years were randomly assigned to receive either isoflurane (group I, n = 60), enflurane (group E, n = 59), sevoflurane (group S, n = 59) or propofol (group P, n = 60) for maintenance as a subgroup of a larger trial of factorial design to investigate interventions to reduce PONV. After opioid application, patients in the inhalational groups (group I, E and S) had anesthesia induced with thiopental, those in group P received propofol for induction. Tracheal intubation was facilitated with succinylcholine. Patients were ventilated with N2O/O2 2:1. Incidence and severity of PONV as well as the need for antiemetic rescue treatment were studied during the first 24 hours after anesthesia. Paracetamol and tramadol was given to treat postoperative pain. Results: There were no significant differences between study groups with respect to patient demographics and risk factors for postoperative nausea and vomiting. Nausea was reported by 43%, 41%, 42% and 22% of patients in groups I, E, S and P, respectively (P = 0.043). The incidence of vomiting was 40%, 46%, 34% and 18% in groups I, E, S and P, respectively (P = 0.011). Conclusion: Patients anesthetized with propofol showed a significantly lower incidence of nausea and vomiting compared to volatile anesthetics, while there was no significant differences in emetogenicity between the volatile anesthetics.

Optical laryngoscopes have been developed to facilitate difficult airway management. The Airtraq is a single-use device and the GlideScope is reusable. In this study, the Airtraq and the Glidescope were compared in 60 ASA I-III patients with tumours of the upper airway undergoing direct endoscopic microlaryngoscopy. Patients were randomly assigned to the Airtraq or the Glidescope group and the Cormack and Lehane grade was assessed by Macintosh laryngoscopy prior to tracheal intubation. There were no differences in tracheal intubation success rates or duration of intubation attempts between both devices. The Cormack and Lehane grade was improved in 77% and 82% of cases in the Airtraq and Glidescope group, respectively. Blood traces on the device and traumatic pharyngeal lesions were found more frequently in the Airtraq group. The Airtraq and Glidescope laryngoscopes are valuable tools for the management of patients with potentially difficult airways with the Glidescope appearing to be less traumatic.

BACKGROUND Quality management and the early implementation of whole-body multi-slice spiral computed tomography (whole-body MSCT) are becoming increasingly important in the management of patients with multiple trauma. The aim of this study was to evaluate both components with respect to the time factor for treatment. METHODS The investigation involved a retrospective data analysis of the time needed in the emergency room for the initial stabilization (phase A), completing the diagnosis (phase B) and the emergency room treatment (phase C). The investigation included three groups: trauma patients imaged in the emergency room with conventional imaging procedures (group I), with whole-body MSCT alone (group II) and those who were imaged with whole-body MSCT after the introduction of a quality management system with standard operating procedures (group III). RESULTS The times for resuscitation (phase A), for diagnostic evaluation (phase B) and for total treatment (phase C) were analyzed. The times for phase A were for group I (n=79) 10 min (interquartile range, IQR 8-12 min), group II (n=82) 13 min (IQR 10-17 min) and group III (n=79) 10 min (IQR 8-15 min; p

Background The aim of this systematic review was to assess the benefits and harms of supplemental oxygen (HBOT/NBOT) for treating and preventing migraine and cluster headaches. Material and methods All randomized trials comparing the effect of supplemental oxygen on migraine or cluster headache with those that exclude supplemental oxygen were included in this review. The systematic search included all relevant sources according to the paradigms of the Cochrane Collaboration. Data were analyzed with RevMan 4.2. Results Nine trials involving 201 participants satisfied the inclusion criteria. HBOT was effective in relieving an acute migraine and seemed to be sufficient in the treatment of an acute cluster attack. NBOT was effective in terminating acute cluster headache compared to sham treatment, but not in comparison to sublingual ergotamine. There was no evidence for any prophylactic effects. Serious adverse effects were not noted in the trials investigated. Conclusions There is some evidence that HBOT is effective for termination of acute migraine. NBOT was similarly effective in cluster headache, however with sparse data. Because of costs and poor availability HBOT cannot be regarded as a routine therapy. Further indications in the case of treatment failure using standard therapy need to be defined based on data of future clinical trials.

Despite new concepts and strategies of basic and advanced life support, the outcome of patients with out-of-hospital cardiac arrest (OHCA) remains poor. The main reason accounting for these poor results is a low-flow phase during conventional cardiopulmonary resuscitation (CPR) with insufficient end organ perfusion. The early use of venoarterial extracorporeal membrane oxygenation (vaECMO) during CPR, i.e. extracorporeal resuscitation (ECPR) might improve OHCA survival rates as well as the neurological outcome in resuscitated patients. This article on a case series discusses the management of ECPR in three patients with OHCA. All patients suffered from a witnessed OHCA and received effective bystander CPR. After subsequent advanced cardiac life support could not achieve a return of spontaneous circulation (ROSC), vaECMO support was established as a bridge to therapy on site or after transportation to a primary or tertiary hospital. During the course of therapy two patients died and one patient was discharged after a full recovery. Early ECPR might improve the outcome in patients with prolonged cardiac arrest without ROSC. The use of ECPR should be based on the individual decision of an experienced ECPR team considering defined inclusion and exclusion criteria. As the outcome mainly depends on the duration and quality of conventional CPR, ECPR support should be requested immediately after establishing advanced life support (approximately 10-15 min).

Background. The value oftransesophageal echocardiography (TEE) in non-cardiac critically ill patients has barely been studied. Materials and methods. Over a period of 4 years TEE was used prospectively to evaluate patients with acute hemodynamic instability in non-cardiac critically ill patients in addition to standard care. Results. A total of 363 TEE studies were performed in 339 selected patients. Volume depletion (169/47%) and regional wall motion abnormalities (97/27%) were the most frequent findings followed by global left ventricular dysfunction (79/22%). Ofthe TEE studies, 203 (56%) provided additional information with therapeutic relevance in 164 (45%) cases. Conclusions. Transesophageal echocardiography provides additional information in critically ill non-cardiac patients with unexplained hemodynamic instability. In the majority of cases a clinical diagnosis is confirmed or improvement of volume resuscitation and catecholamine therapy can be achieved. In the minority of patients the results of TEE lead to distinct changes in medical management. Whether this improved diagnostic accuracy favours outcome, still needs to be evaluated.

Unter der Pramisse eines fallbezogenen Entgeltsystems kommt der Analyse von medizinischen Leistungen in zunehmendem Mas Bedeutung zu. Dabei spielen die Qualitat der Behandlung und auch der dafur benotigte Zeitaufwand eine wichtige Rolle. Anasthesieverfahren erfordern ein hohes Mas an Qualitat und Sicherheit, zudem sind sie sehr personalintensiv. Im Bereich der Regionalanasthesie lassen neue Verfahren, wie z. B. der Einsatz von hochauflosendem Ultraschall bei Nervenblockaden, einen moglichen Zeitgewinn bei verbesserter Qualitat erkennen. Ziel der vorliegenden Untersuchung war die Analyse der Zeitablaufe und der Ergebnisse bei der Verwendung der Verfahren Ultraschall und Nervenstimulation bei axillaren Plexusblockaden. Fur einen Zeitraum von 9 Monaten wurden anhand der Anasthesiedokumentation die ultraschallgefuhrte Plexusanasthesie (Sono) und die Neurostimulationsmethode (NStim) bei handchirurgischen Patienten untersucht. Aufgenommen wurden nur die Falle, bei denen axillare Plexusblockaden durchgefuhrt worden waren. Als Medikation wurde 1,5%iges Mepivacain verwendet. Unvollstandige Protokolle wurden ausgeschlossen. Es erfullten 130 handchirurgische Patienten die Kriterien der Untersuchung. Erfasst wurden die Erfolgsraten und alle Zeiten sowie die daraus resultierenden Zeitablaufe. Alle Daten wurden als Excel-Tabelle gespeichert und statistisch ausgewertet. Die Ergebnisse der Untersuchung zeigen eine signifikante Steigerung der Erfolgsrate der Plexusblockaden bei der Patientengruppe mit Ultraschallfuhrung (98,2% Sono vs. 83,1% NStim). Die Freigabe zur Operation erfolgte in der Gruppe Sono 15 min fruher (5 min vs. 20 min; p

UNLABELLED Interscalene plexus blocks are an important part of the peri-operative treatment in shoulder surgery. The nerve stimulation technique uses external landmarks for the definition of the injection site. Patient obesity is, therefore, one causative factor for a reduced success rate of the blockade. AIM This study investigated whether there are differences in visibility of the target nerves and in the success rate of the block between patients of normal weight (nw) and obese patients (ow), when portable sonography is used for guidance of the interscalene nerve blockade (ISB). METHODS We investigated 70 patients routinely scheduled for shoulder surgery (ASA status I-III). The patients were allocated to group nw (body mass index BMI 25). The interscalene part of the brachial plexus was examined using high-frequency portable ultrasound. The blockade was performed under continuous sonographic monitoring. The quality of the ISB was tested post-operatively, and the time required for the procedure was documented. RESULTS Identification of nerve structures in the obese patients did require slightly more time than in patients of normal weight, statistically (ow: 5 +/- 1 min versus nw: 4 +/- 2 min, p = 0.02). While in 33 patients (94 %) of group nw the plexus blockade was complete, in group ow 27 (77 %) of the blocks were sufficient. The difference in success, however, was not significant (p = 0.08). Visualisation of nerves was difficult in 3 patients in ow-group. CONCLUSION Portable ultrasound provides efficient depiction of the interscalene plexus structures in obese patients and, when used for guidance of regional blockade, renders similar results as in patients of normal weight.

ZusammenfassungDer hyperbaren Sauerstofftherapie (HBOT) werden günstige Effekte in der Therapie des akuten ischämischen zerebralen Insultes zugesprochen. Ziel dieser systematischen Übersicht war es, die Effektivität und Sicherheit der HBOT für diese Indikation zu überprüfen. Es erfolgte eine systematische Suche nach randomisierten kontrollierten Studien, die den Effekt der HBOT im Vergleich zu einer Sham-Behandlung untersuchten. Zwei Autoren extrahierten unabhängig voneinander die Daten. Jede Studie wurde auf ihre Validität überprüft. Die Datenanalyse erfolgte mit dem Computerprogramm RevMan 4.2. Drei randomisierte kontrollierte Studien erfüllten die Einschlusskriterien. Nach 6 Monaten fanden sich zwischen den Behandlungsgruppen keine signifikanten Unterschiede in der Mortalitätsrate. Zwei aus 15 Beeinträchtigungsbzw. Funktionsskalen zeigten eine Verbesserung ein Jahr nach HBOT: die mittlere Trouillas Disability Scale war nach HBOT niedriger und die mittlere Orgogozo Scale war nach HBOT höher. Diese Verbesserungen konnten in anderen Untersuchungen und unter Verwendung anderer Skalen nicht nachvollzogen werden. Diese systematische Übersichtsarbeit hat keine überzeugenden Belege dafür ergeben, dass der Krankheitsverlauf durch eine HBOT bei einem akuten ischämischen zerebralen Insult verbessert wird. Zwar erlauben die drei eingeschlossenen Studien keine abschließende Empfehlung, klinisch relevante positive Effekte sind jedoch unwahrscheinlich.

The current report highlights the use of venoarterial extracorporeal membrane oxygenation (va-ECMO) in a case of pulmonary embolism complicated by right ventricular failure. A 38-year-old woman was admitted to a secondary care hospital with dyspnea and systemic hypotension. Diagnostic testing revealed a massive pulmonary embolism. Thrombolytic therapy was unsuccessful necessitating thromboendarterectomy in the presence of cardiogenic shock. To allow the necessary transport of the highly unstable patient to a tertiary care center a mobile ECMO team was called in. The team immediately initiated awake va-ECMO as a bridge to therapy. Extracorporeal support subsequently allowed a safe transportation and successful completion of the surgical procedure with complete recovery.

Background We studied the anatomy of the sciatic nerve and its division into the tibial and peroneal part using handheld ultrasound in adults. We wanted to evaluate the feasibility of ultrasound-guided identification of the sciatic nerve in the popliteal fossa and the correlation of the findings by ultrasound with patients' characteristics. Methods 74 volunteers were randomly selected. Using a handheld ultrasound system with a 5-10 MHz linear array probe the popliteal fossa and the back of the thigh were examined and measured. Using a caliper the distance of the joint line to the nerve division was measured. The sciatic nerve and its division were depicted by ultrasound. Results We could depict the sciatic nerve in all volunteers and its division in 53 of 74 (72%) volunteers. The position of nerve division showed large anatomic variation. A significant correlation between the width of the knee-joint line and the depth of the nerve division could be demonstrated. We conclude that handheld ultrasound is able to depict the sciatic nerves division. To block the nerve by one injection a more proximal access or visualization by mobile ultrasound is recommended. In addition the surrounding anatomic structures can be depicted as well.

Aim High resolution ultrasound is a new method for detecting anatomical structures in the axilla. The visualisation of nerves can improve the quality of nerve blocks. The aim of our study was to investigate the feasibility of hand held ultrasound to perform sonographically guided blockades of the axillary plexus. Method We investigated 46 patients routinely scheduled for forearm and hand surgery (ASA physical status I-IV, age range 19 - 89 years, mean 47). The axilla was examined using a handheld ultrasound system with a 10 MHz linear array probe. The median, ulnar, radial and musculocutaneus nerve were visualised by ultrasound. Selective nerve blockade was performed under sonographic guidance. Real time monitoring of the local anaesthetic spread was performed. Time required to perform the block and onset times of anaesthesia were documented. Results Complete anaesthesia of the brachial plexus was achieved in all cases. The average time to perform the block was 5 minutes (SD 2 min). Onset time for the block was 7 minutes (SD 3 min). Conclusion Performing axillary nerve blockade using ultrasound guidance provides excellent anaesthesia and fast onset times.

Surgical procedures in the region of the shoulder joint are among the most painful interventions in orthopedic practice. For this reason, in addition to intravenous pain therapy with opioids, blockade of the brachial plexus has become established as an effective method to provide analgesia.High-resolution ultrasound offers the possibility of performing nerve blockades under visual monitoring. Studies on interscalene blockade performed under sonographic control provide evidence for both the high efficacy and safety of the procedure. Clinically manifest signs of nerve damage have not appeared with use of this method. Smaller operations can usually be adequately managed with perioperative single-shot blockade. More extensive operations for which severe pain lasting for several days can be expected and surgical interventions involving preexistent shoulder stiffness necessitate catheterization for uninterrupted pain therapy. Successful rehabilitation after shoulder surgery requires diligent perioperative pain blockade, which can primarily be provided by interscalene plexus blockade.

Background: Intra-abdominal pressure (IAP) elevation during CO2-pneumoperitoneum increases cardiac afterload and may enhance dysfunction of the already compromized heart. This study focused on the effects of acute IAP increases on left and right ventricular loadings and contractility in the heart with impaired global function. Methods: Impairment of myocardial function (IMF) was pharmacologically induced in 16 pigs by administration of halothane and propranolol, while baseline arterial pressure was maintained by intravenous phenylephrine. Intra-abdominal pressure was gradually increased by 10 mmHg up to 30 mmHg in the supine position (IMF group 1, n = 8) or in a head-down tilted position (IMF group 2, n = 8). In two control groups with normal myocardial function, IAP was also increased in the supine position or the head-down tilted position. Cardiac function in all groups was assessed by epicardial echocardiography, intraventricular pressure measurements and pulmonary artery catheterization. Results: The increase in IAP was accompanied by a transient rise in LV end-systolic wall stress and reduced cardiac output significantly by 16–24% in all groups. In the IMF groups, LV end-diastolic transmural pressure increased by 34–60% to peak values of 24 mmHg, while cross-sectional LV end-diastolic areas remained unchanged. Increases in right ventricular end-diastolic volume and decreases in right ventricular ejection fraction as well as in cardiac output were most pronounced at IAP 20 mmHg and significantly stronger in both IMF groups than in the control groups (P

In addition to specific treatment of the underlying cause, the therapy of acute respiratory distress syndrome (ARDS) consists of lung protective ventilation and a range of adjuvant and supportive measures.A survey was conducted to determine the current treatment strategies for ARDS in German ARDS centers.The 39 centers listed in the German ARDS network in 2011 were asked to complete a questionnaire collecting data on the clinic, epidemiology as well as diagnostic and therapeutic measures regarding ARDS treatment.Of the centers 25 completed the questionnaire. In 2010 each of these centers treated an median of 31 (25-75 percentile range 20-59) patients. Diagnostic measures at admission were computed tomography of the thorax (60 % of the centers), whole body computed tomography (56 %), chest x-ray (52 %), abdominal computed tomography (32 %) and cranial computed tomography (24 %). Transesophageal echocardiography was performed in 64 %, pulmonary artery pressure was measured in 56 % and cerebral oximetry in 12 %. Sedation was regularly interrupted in 92 % of the centers and in 68 % this was attempted at least once a day. A median minimum tidal volume of 4 ml/kg (range 2-6) and a maximum tidal volume of 6 ml/kg (4-8) were used. Methods to determine the optimal positive end-expiratory pressure (PEEP) were the best PEEP method (60 %), ARDS network table (48 %), empirical (28 %), pressure volume curve (16 %), computed tomography (8 %), electrical impedance tomography (8 %) and others (8 %). Median minimum and maximum PEEPs were 10 cmH2O (range 5-15) and 21 cmH2O (15-25), respectively. Median plateau pressure was limited to 30 cmH2O (range 26-45). The respiratory rate was set below 20/min in 20 % and below 30/min in 44 %. Controlled ventilator modes were generally preferred with 80 % using biphasic positive airway pressure (BIPAP/BiLevel), 20 % pressure controlled ventilation (PCV) and 4 % airway pressure release ventilation (APRV). Assisted modes were only utilized by 8 % of the centers. Recruitment maneuvers were used by 28 %, particularly during the early phase of the ARDS. Muscle relaxants were administered by 32 % during the early phase of the ARDS. Complete prone positioning was used by 60 % of the centers, whereas 88 % utilized incomplete (135°) prone positioning. Continuous axial rotation was utilized by 16 %. Spontaneous breathing tests were used in 88 % of the centers with 60 % performing these at least once a day. Supportive therapies were frequently applied and mainly consisted of nitrous oxide (44 %), prostacycline (48 %) and corticosteroids (52 %). A restrictive fluid therapy was used in 48 % and a special nutrition regimen in 28 % of the centers. Of the participating centers 22 were able to offer extracorporeal membrane oxygenation (ECMO). In this case, respiratory therapy was modified by further reducing tidal volumes (91 %), inspiratory pressures (96 %) as well as using lower respiratory rates (≤ 8/min in 31 %). Only 9 % reduced PEEP during ECMO. Regular recruitment maneuvers were used by 14 %. Positioning maneuvers during ECMO were used by 82 %.Lung protective ventilation with reduced tidal volumes as well as inspiratory pressures represents the current standard of care and was utilized in all network centers. Prone positioning was widely used. Promising adjuvant therapies such as the muscle relaxation during the early phase of the ARDS, fluid restriction and corticosteroids were used less frequently. During ECMO respirator therapy was generally continued with ultraprotective ventilator settings.

Nowadays Caesarean sections are mainly undertaken using spinal anesthesia; therefore, it is important to minimize potential side effects and risks associated with this technique. Currently, many studies have been conducted to optimize the dose of local anesthetics to avoid hypotension, which often occurs during spinal anesthesia.In a retrospective study design the high-volume, low-concentration technique with up to 12 ml isobaric bupivacain 0.1% (1 mg/ml) and sufentanil (1 µg/ml), which has been used at the University Hospital Würzburg for many years was analyzed with respect to reliability and side effects. The use of this technique so far is unique among university hospitals in Germany.Of the 1424 anesthesia protocols from 2001 to 2007 a total of 1368 were analyzed. Demographic data and parameters, such as location of puncture, dose and extent of anesthesia, hemodynamic stability and additional medication were recorded. A decrease of systolic blood pressure of more than 20% of the initial value was defined as hypotension.The median volume used for spinal anesthesia was 9 ml, containing 9 mg bupivacaine and 9 µg sufentanil. The rate of hypotension was 48.8 %. No significant differences in hypotension between lower and higher volumes were detectable. In 0.84% (n=12) of the cases the procedure had to be changed to general anesthesia and additional analgesia was administered in 3 cases (0.22%).The high-volume, low-concentration technique is an effective approach for spinal anesthesia with a small number of cases needing general anesthesia or additional analgesics. The rate of hypotension was moderate compared to other studies; however, because of the retrospective and non-randomized study design the dependence of this rate on dose and given volume should be interpreted with caution.

In the context of the European Resuscitation Council (ERC) guidelines, modifications of the proposed treatment algorithm need to be performed in order to respond to different parameters. In this respect several factors interacting with cardiac arrest are essential and need to be included in the therapy. This case report demonstrates an example of resuscitation in the situation of hypothermia.After a near drowning accident and approximately 30 min underwater, a patient suffering from severe hypothermia initially required resuscitation after the rescue. A return of spontaneous circulation (ROSC) was successfully achieved within a short length of time and after 15 days on the intensive care unit the patient was discharged to a rehabilitation facility without any signs of focal neurological deficits.Section 8 of the ERC guidelines provides additional information for resuscitation under specific conditions. In this case report, hypothermia was one of the main criteria leading to an adjusted pharmacological therapy. Furthermore, selection of the appropriate hospital for an optimal advanced treatment including controlled warming of the patient and management of hypothermia-induced complications had to be evaluated.

Ultrasound guidance is still a young method in regional anesthesia when compared to nerve stimulation and only a few studies exist comparing these two techniques in an axillary multiple injection approach.This prospective, randomized, observer-blinded study compared an ultrasound-guided (SONO) quadruple injection axillary block (out of plane, perineural) with a nerve stimulation-guided (STIM) triple injection axillary block for upper limb surgery.A total of 60 patients were randomized to either the SONO (n = 30) or STIM (n = 30) group. For the block 40-50 ml mepivacaine 1.5 % (plexus) and 5-10 ml mepivacaine 0.5 % (subcutaneous in the medial skin of the arm) was used. Anesthesia time was recorded as the primary end point. After evaluation of block-related pain using a visual analog scale (VAS) a blinded observer tested sensory and motor function of the median nerve (MED), ulnar nerve (ULN), radial nerve (RAD), musculocutaneous nerve of the upper limb (MUC) and medial cutaneous nerve of the forearm (CAM) at defined times. The main outcome variable was onset time (defined loss of sensory/motor function).No differences were observed between the groups in terms of onset time (single nerves 10-20 min, plexus 20-25 min) and success rate (SONO 90 %, STIM 89 %). Patient satisfaction as measured by block-related pain score (VAS 2 cm), complications (vascular puncture SONO 7 %, STIM 11 %; paresthesia SONO 21 %, STIM 22 %) and patient acceptance (SONO 92 %, STIM 91 %) showed no differences. Performance time was shorter in the SONO group (6.68 ± 1.72 min vs. 8.05 ± 2.58, p = 0.02).Nerve stimulation-guided axillary plexus blocks performed by trained anesthesiologists may result in similar onset times and success rates compared to ultrasound-guided blocks.

During early in-hospital management of the arriving trauma patient the timing of the trauma team alert is an important organisational step. To evaluate the accordance of the estimated and the real arriving time we performed a retrospective data analysis at a level I German trauma centre.Retrospective data analysis. Trauma team alerts from September 2010 until March 2011 were analysed. According to the hospitals pre-alert algorithm, trauma team alert took place 10 min before the estimated time of arrival.There were 165 trauma team alerts included in the analysis. The estimated arrival time coincided with the real arrival time in less than 10 % of cases. In 76 % of the cases, the patient arrived in an acceptable time frame with the trauma team waiting less than 14 min. In 3 % of the cases, the patient arrived prior to the trauma team.An exact estimation of the arrival time is rare. With a trauma team alert 10 min prior to the estimated time of arrival, an acceptable waiting time can be achieved. Arrival of the patient prior to the trauma team can be avoided.

Numerous factors have been claimed to influence postoperative nausea and vomiting (PONV). A critical review of the literature reveals, that strong evidence based on original double-blind, randomized, controlled trials or their meta-analyses is only available for very few risk factors. For most other factors, although mentioned in narrative reviews, there is insufficient evidence. Sufficient evidence on original data or meta-analyses is present for female gender, a history of PONV or motion sickness, non-smoking-status, young age, volatile anaesthetics, nitrous oxide and postoperative opioids. Factors with conflicting results are the menstrual cycle, hypnotics for induction, mask ventilation and nasogastric tube, the experience of the anaesthetist, muscle relaxants and their antagonists and laparoscopic procedures. Insufficient evidence is present for the other types of operation, psychological factors including anxiety and pain. No evidence due to lack of data applies to postoperative movement, hemodynamic stability, hypercarbia and acid-base-shifts. For adipositas++ there is not only a lack of evidence for an effect but evidence for a lack of effect based on several multivariate analyses. In conclusion, we have developed the following simplified view: PONV is mainly caused by opioids and volatile anaesthetics when applied to susceptible patients (females, non-smoker, positive history of previous sickness).

(1) The volatile anaesthetics halothane and enflurane released Ca2+ from thapsigargin sensitive stores in rat glioma C6 cells, but only enflurane induced a significant Ca2+ influx. (2) The reason for this can be explained by a different inhibitory effect of the anesthetics on the capacitative Ca2+ influx. (3)Halothane inhibited the capacitative Ca2+ influx with an IC50 of 1.9 vol.%, whereas enflurane only marginally affected the ion flux through the channel.