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Innervation of the thumb and radial part of the dorsum of the hand is achieved primarily by the radial nerve, which is usually blocked for hand surgery. Inefficient blocks occur because the lateral antebrachial cutaneous nerve also extends into this area. The question then arises, whether skin innervation and peripheral blocking techniques should be directed at from the innervation by these nerves or more by the dermatome and its spinal segments.In 68 human upper limbs embalmed with Thiel's method, the topography of the lateral antebrachial cutaneous nerve (LACN), the superficial branch of the radial nerve (sbRN) and communicating branch (CB) were investigated by meticulous dissection from the cubital fossa to the most distal macroscopically dissectible branch, and the areas reached by these nerves were compared to the described dermatome.In 52.9% of all specimens, the LACN was found proximal to the rascetta, in 35.3% it extended to the base of the thumb, and in 8 cases (11.8%) it extended distally to the base of the thumb. In 50%, the LACN was anterolateral to the brachioradialis muscle, and in 38.2%, strictly lateral. Only in 8 cases (11.8%) the LACN presented itself running more dorsally and laterally. A CB was observed in 28 specimens (41.2%). Both investigated nerves were found to innervate the dermatomes of C6 and C7.The LACN should be considered for individual targeted blocks for surgical procedures and pain therapy within the wrist and thumb region as all nerves that might contribute to innervation of a targeted dermatome should be blocked.

To the Editor:We read with interest the work by Perez et al. (1), concluding that omega-3 fatty acids may have an effect on the development of neuropathic pain in a sciatic nerve ligation model. The methodology may be compromised because a thorough analysis of key constituents of fatty acid emulsion

A 91-yr-old man (57 kg, 156 cm, ASA III) received an infraclavicular brachial plexus block for surgery of bursitis of the olecranon. Twenty minutes after infraclavicular injection of 30 mL of mepivacaine 1% (Scandicain®) and 5 min after supplementation of 10 mL of prilocaine 1% (Xylonest®) using an

BACKGROUND The postoperative beneficial effects of thoracic epidural analgesia (TEA) within various clinical pathways are well documented. However, intraoperative data are lacking on the effect of different epidurally administered concentrations of local anesthetics on inhaled anesthetic, fluid and vasopressor requirement, and hemodynamic changes. We performed this study among patients undergoing major upper abdominal surgery under combined TEA and general anesthesia. METHODS Forty-five patients undergoing major upper abdominal surgery were randomly assigned to one of three treatment groups receiving intraoperative TEA with either 10 mL of 0.5% (Group 1) or 0.2% (Group 2) ropivacaine (both with 0.5 microg/mL sufentanil supplement), or 10 mL saline (Group 3) every 60 min. Anesthesia was maintained with desflurane in nitrous oxide (60%) initiated at an age-adapted 1 minimum alveolar concentration (MAC) until incision. Desflurane administration was then titrated to maintain an anesthetic level between 50 and 55, as assessed by continuous Bispectral Index monitoring and the common clinical signs (PRST score). Lack of intraoperative analgesia, as defined by an increase in pulse rate, sweating, and tearing (PRST) score >2 or an increase of mean arterial blood pressure (MAP) >20% of baseline, was treated by readjusting the end-tidal concentration of desflurane toward 1 MAC, and above this level by additional rescue i.v. remifentanil infusion. Hypotension, as defined as a decrease in MAP >20% of baseline, was treated by reducing the end-tidal desflurane concentration to a Bispectral Index level of 50-55 and below that with crystalloid or norepinephrine infusion, depending on central venous pressure. RESULTS End-tidal desflurane concentration could be significantly reduced in Group 1 to 0.7 +/- 0.1 MAC (P < 0.001) and to 0.8 +/- 0.1 MAC (P < 0.001) in Group 2, but not in Group 3. Significant hypotension occurred within 20 min in all patients of Groups 1 and 2 (MAP from 80 +/- 10 to 56 +/- 5) (Group 1), 78 +/- 18 to 58 +/- 7 mm Hg (Group 2), P < 0.01, whereas MAP remained unchanged in Group 3 (74 +/- 12 to 83 +/- 15 mm Hg, P = 0.42). Heart rate did not change significantly over time within any of the groups. Furthermore, groups did not differ significantly regarding i.v. fluid and norepinephrine requirement. Patients in Group 3 received more remifentanil throughout the surgical procedure (7.2 +/- 4.9 mg x kg(-1) x h(-1)) when compared with Group 2 (1.6 +/- 2.2 mg x kg(-1) x h(-1)), P < 0.01. Remifentanil infusion among patients receiving ropivacaine 0.5% was not necessary at any time. CONCLUSION Epidural administration of 0.5% ropivacaine leads to a more pronounced sparing effect on desflurane concentration for an adequate anesthetic depth when compared with a 0.2% concentration of ropivacaine at comparable levels of vasopressor support and i.v. fluid requirement.

Objective To test a novel and easy-to-use mortality index developed and validated in a nationally representative US sample of older adults in patients selected for radical prostatectomy. Methods The sample comprised 2205 consecutive patients who underwent radical prostatectomy in the years 1992-2005. The median age was 64 years and the median follow-up was 9.7 years. A slightly modified Lee mortality index was calculated based on information obtained by chart review. The 10-year competing mortality rates were compared with overall mortality rates previously reported in a US population-based cohort using the given confidence intervals with the 2-tailed Wald test. Cox proportional hazard models were calculated to analyze the combined effects of variables using overall mortality as study endpoint. Results The modified Lee mortality index provided a clear dose-response pattern in the radical prostatectomy cohort with 10-year competing mortality rates between 2.5% and 50%. Overall, the competing mortality rates reached only narrowly two-thirds of the values predicted by the modified Lee mortality index, reflecting selection for healthy operative candidates (chi-square homogeneity test; P = .0043). In the multivariate analysis considering the modified Lee mortality index, age, and tumor-related variables, the Lee mortality index was identified as an independent predictor of overall survival. Comorbidity measures delivering similar prognostic information as the modified Lee mortality index, however, largely replaced this index in the multivariate models. Conclusion The modified Lee mortality index could be suited as comorbidity measure in men with prostate cancer. Practical use would require adjustment for selection effects.

Study Type – Outcomes (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Several comorbidity classifications have been investigated for their suitability to assist treatment decision-making in men with early prostate cancer. In unselected patients, some serious comorbidities have been shown to be associated with a 10-year competing mortality rate clearly superseding the 50% level. The present study shows that it is hardly possible to discern meaningful subsets of patients with a 10-year risk of competing mortality of >50% by using comorbidity classifications. This finding suggests that the selecting clinicians did well in estimating the medium-term survival probability in men referred for radical prostatectomy. OBJECTIVE • To identify subsets of patients who are most likely to die from competing causes ≤10 years after radical prostatectomy (RP). PATIENTS AND METHODS • In all, 2205 consecutive patients who underwent RP for clinically localized prostate cancer between 1992 and 2005 were studied. The 10-year cumulative competing mortality rates were determined in several worst-case scenarios formed by using comorbidity classifications and combinations of them. RESULTS • In this sample of men selected for RP, even those with the most severe comorbidity level had a competing mortality risk of

To externally review a nomogram developed to predict the 10-year survival probability of men selected for radical prostatectomy.A total of 1910 consecutive patients who underwent radical prostatectomy from 1992 to 2004 were studied. The mean age was 64.2 years; the mean follow-up for the surviving patients was 6.3 years. The patients were classified according to age and the Charlson comorbidity score. The 10-year survival probability was estimated for each individual patient, applying a recently published nomogram incorporating these 2 variables. The survival rates estimated by the Kaplan-Meier method and the mean values of the nomogram-predicted survival probabilities were compared using 1-sample Wald tests. Subgroup analyses were done after stratification by age and Charlson score.Even including the prostate cancer-related mortality (accounting for 5.1% at 10 years), the 10-year overall survival rate in our sample was somewhat greater than predicted by the nomogram (84.9% vs 81.9%, P = .0222). Subgroup analyses revealed that this difference was attributable to a greater than predicted survival in patients with a Charlson score of 0 and agedor = 70 years (87.9% vs 74.7%, P.0001). In contrast, in the other subgroups, the predicted and Kaplan-Meier estimated survival rates did not differ meaningfully.Clinicians using this nomogram should be aware of a possible underestimation of survival in healthy men agedor = 70 years selected for radical prostatectomy.

We identified an age range in which comorbidity is most closely associated with premature mortality after radical prostatectomy.A total of 1,302 patients selected for radical prostatectomy were stratified according to the Charlson score, the American Society of Anesthesiologists physical status classification, the New York Heart Association classification of heart insufficiency and the classification of angina pectoris of the Canadian Cardiovascular Society. Furthermore, patients were subdivided into several age groups. Comorbid mortality and overall mortality were the study end points. The prognostic relevance of the comorbidity classifications was assessed by comparing Mantel-Haenszel HRs, p values and 10-year overall survival rates.The discriminative capacity of all 4 investigated comorbidity classifications decreased when patients 70.0 years or older were included with decreasing HRs and increasing p values. Except for the American Society of Anesthesiologists classification HRs for comparing the high vs low risk groups tended to decrease and p values simultaneously tended to increase when patients younger than 63.0 years were included. In the age range of between 63.0 and 69.9 years 10-year overall survival rates differed by 14% to 28% between patients with a high vs low comorbid risk compared with 6% to 13% in the whole sample.The discriminative capacity of the investigated comorbidity classifications was greatest in the age group that was 63.0 to 69.9 years old. In patients younger than 63.0 or older than 70.0 years comorbidity classification seemed to contribute little to the prediction of comorbid mortality.

Perimortem caesarean section is very rare, mostly resulting in high mortality of mother and/or fetus. We report a case of successful resuscitation of both mother and newborn following maternal cardiac arrest prior to delivery. Postoperative outcome was complicated by severe bleeding and coagulopathy following fibrinolysis and subcapsular hepatic haematoma. We consider a fast reaction time based on a special in-hospital emergency team for immediate caesarean section and an aggressive management of coagulopathy as major factors that led to both patients recovery without neurological sequelae.

To investigate the consistency of several comorbidity classifications and concomitant diseases at radical prostatectomy (RP) during a 10-year period.In 1,297 patients who underwent RP between 1993 and 2002, age and several comorbidity classifications were derived from patient records and assigned to the year of surgery. Trends were evaluated using the Cochran-Armitage trend test.Parallel to an increasing frequency of RPs and a shift toward more organ-confined tumors (P = 0.0094), the proportion of patients agedor =70 years increased (P = 0.0077). The proportion of the American Society of Anesthesiologists (ASA) Physical Status class 3 increased (P0.0001), whereas that of ASA class 1 decreased (P0.0001). A Charlson scoreor =1 has been assigned with an increasing frequency (P = 0.0008), whereas the trend with a Charlson score ofor =2 did not reach statistical significance (P = 0.07). In contrast to the latter 2 classifications, no significant trends were observed with classifications related to diabetes mellitus and heart disease.This study shows that the application of the ASA classification may change significantly over time, whereas cardiac and diabetes-related conditions, as well as the Charlson score were apparently less sensitive to changing classification standards in the RP setting.

Objectives To investigate several comorbidity classifications as possible predictors of mortality, because the value of comorbidity as a prognostic factor is uncertain in patients older than 70 years of age and radical prostatectomy in patients older than 70 years is controversial. Methods A total of 214 consecutive patients aged 70 years or older who underwent radical prostatectomy from December 1992 to December 2002 were stratified according to the Charlson score, American Society of Anesthesiologists physical status classification, New York Heart Association classification of cardiac insufficiency, classification of angina pectoris from the Canadian Cardiovascular Society, and age (70 to 72 versus 73 to 74 versus 75 years or older). The mean follow-up in the surviving patients was 5.1 years (range 1.3 to 12.5). A sample of 240 consecutive patients aged 67.0 to 69.9 years treated during the same period was used for comparison. The overall and comorbid mortality were the study endpoints. Mantel-Haenszel hazard ratios were calculated. Comparisons were made using the log-rank test. Results Unlike for patients aged 67.0 to 69.9 years, for those 70 years old or older, only one of the investigated stratifications reached significance as a predictor of mortality. A New York Heart Association classification of 2+ versus 0 was significant for overall mortality (hazard ratio 5.8, P = 0.021) and comorbid mortality (hazard ratio 15.9, P = 0.046). Conclusions Comorbidity is of limited prognostic value in patients selected for radical prostatectomy and 70 years old or older.

Background Although local anesthetics (LAs) are hyperbaric at room temperature, density drops within minutes after administration into the subarachnoid space. LAs become hypobaric and therefore may cranially ascend during spinal anesthesia in an uncontrolled manner. The authors hypothesized that temperature and density of LA solutions have a nonlinear relation that may be described by a polynomial equation, and that conversion of this equation may provide the temperature at which individual LAs are isobaric. Methods Density of cerebrospinal fluid was measured using a vibrating tube densitometer. Temperature-dependent density data were obtained from all LAs commonly used for spinal anesthesia, at least in triplicate at 5 degrees, 20 degrees, 30 degrees, and 37 degrees C. The hypothesis was tested by fitting the obtained data into polynomial mathematical models allowing calculations of substance-specific isobaric temperatures. Results Cerebrospinal fluid at 37 degrees C had a density of 1.000646 +/- 0.000086 g/ml. Three groups of local anesthetics with similar temperature (T, degrees C)-dependent density (rho) characteristics were identified: articaine and mepivacaine, rho1(T) = 1.008-5.36 E-06 T2 (heavy LAs, isobaric at body temperature); L-bupivacaine, rho2(T) = 1.007-5.46 E-06 T2 (intermediate LA, less hypobaric than saline); bupivacaine, ropivacaine, prilocaine, and lidocaine, rho3(T) = 1.0063-5.0 E-06 T (light LAs, more hypobaric than saline). Isobaric temperatures (degrees C) were as follows: 5 mg/ml bupivacaine, 35.1; 5 mg/ml L-bupivacaine, 37.0; 5 mg/ml ropivacaine, 35.1; 20 mg/ml articaine, 39.4. Conclusion Sophisticated measurements and mathematic models now allow calculation of the ideal injection temperature of LAs and, thus, even better control of LA distribution within the cerebrospinal fluid. The given formulae allow the adaptation on subpopulations with varying cerebrospinal fluid density.

Supplementation of clinical nutrition with omega-3 fatty acid in fish oil exerts immune-modulating and organ-protective effects, even after short-term application. The aim of this study was to evaluate dose-dependent effects of parenteral supplementation of a 10% fish oil emulsion (Omegaven, Fresenius-Kabi, Bad Homburg, Germany) on diagnosis- and organ failure-related outcome.Prospective, open label, multiple-center trial.A total of 661 patients from 82 German hospitals receiving total parenteral nutrition foror =3 days were enrolled in this study. The sample included 255 patients after major abdominal surgery, 276 with peritonitis and abdominal sepsis, 16 with nonabdominal sepsis, 59 after multiple trauma, 18 with severe head injury, and 37 with other diagnoses. The primary study end point was survival; secondary end points were length of hospital stay and use of antibiotics with respect to the primary diagnosis and the extent of organ failure. Multiple quasi-linear and logistic regression models were used for calculating diagnosis-related fish oil doses associated with best outcome.The patients enrolled in this survey were (mean +/- sd) 62.8 +/- 16.5 yrs old, with a body mass index of 25.1 +/- 4.2 and Simplified Acute Physiology Score (SAPS) II score of 32.2 +/- 13.6. Length of hospital stay was 29.1 +/- 18.7 days (12.5 +/- 14.8 days in the intensive care unit). Total parenteral nutrition, including fish oil (mean, 0.11 g.kg(-1).day(-1)), was administered for 8.7 +/- 7.5 days and lowered hospital mortality as predicted by Simplified Acute Physiology Score II from 18.9% (95% confidence interval, 17.4-20.4%) to 12.0% (p.001). The fish oil dose.kg.day did correlate with beneficial outcome (intensive care unit stay, hospital stay, mortality). Fish oil had the most favorable effects on survival, infection rates, and length of stay when administered in doses between 0.1 and 0.2 g.kg(-1).day(-1). Lower antibiotic demand by 26% was observed when doses of 0.15-0.2 g.kg(-1).day(-1) were infused as compared with doses of0.05 g.kg(-1).day(-1). After peritonitis and abdominal sepsis, multiple quasi-linear regression models revealed a fish oil dose for minimizing intensive care unit stay of 0.23 g.kg(-1).day(-1) and an inverse linear relationship between dosage and intensive care unit stay in major abdominal surgery.Administration of omega-3 fatty acid may reduce mortality, antibiotic use, and length of hospital stay in different diseases. Effects and effect sizes related to fish oil doses are diagnosis dependent. In view of the lack of substantial study literature concerning diagnosis-related nutritional single-substrate intervention in the critically ill, the present data can be used in formulating hypotheses and may serve as reference doses for randomized, controlled studies, which may, for instance, confirm the value of omega-3 fatty acid in the adjunctive therapy of peritonitis and abdominal sepsis.

Epidemiologic studies have indicated that high intake of saturated fat and/or animal fat increases the risk of colon and breast cancer. Omega-3 PUFAs in fish oil (FO) can inhibit the growth of human cancer cells in vitro and in vivo. These effects are related to the uptake of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) into the cellular substrate pool and their competitive metabolism with arachidonic acid (AA) at the cyclooxygenase and 5-lipoxygenase levels. The metabolites of EPA and DHA have less inflammatory and immunosuppressant potency than the substances derived from AA. Based on previous experimental data, we hypothesized that FO supplementation after major abdominal cancer surgery would improve hepatic and pancreatic function. Ours was a prospective, randomized, double-blinded clinical trial on 44 patients undergoing elective major abdominal surgery, randomly assigned to receive total parenteral nutrition (TPN) supplemented with either soybean oil (SO 1.0 g/kg body weight daily, n = 20) for 5 days or a combination of FO and SO (FO 0.2 + SO 0.8 g/kg body weight daily, n = 24). Compared to pure SO supplementation in the postoperative period, FO significantly reduced ASAT [0.8 +/- 0.1 vs. 0.5 +/- 0.1 mmol/(l. sec)], ALAT [0.9 +/- 0.1 vs. 0.6 +/- 0.1 mmol/(l. sec)], bilirubin (16.1 +/- 5.3 vs. 6.9 +/- 0.6 mmol/l), LDH (7.7 +/- 0.4 vs. 6.7 +/- 0.4 mmol/(l. sec) and lipase (0.6 +/- 0.1 vs. 0.4 +/- 0.1 micromol/(l. sec) in the postoperative course. Moreover, patients with increased risk of sepsis (IL-6/IL-10 ratio >8) showed a tendency to shorter ICU stay (18 hr) under omega-3 PUFA treatment. Weight loss as encountered after the SO emulsion of 1.1 +/- 2.2 kg was absent in the FO group. After major abdominal tumor surgery, FO supplementation improved liver and pancreas function, which might have contributed to the faster recovery of patients.

Im Rahmen von Spinalanasthesien (SPA) kann die Ausbreitung der sensorischen und sympathischen Blockade durch Lagewechsel sowohl nach der Anwendung von isobaren wie auch hyperbaren Lokalanasthetika (LA) unvorhersehbar zunehmen. Wir berichten in diesem Zusammenhang uber einen 50-jahrigen adiposen Patienten, bei dem zur Versorgung einer Unterschenkelfraktur eine SPA mit 17,5 mg 0,5%igem isobarem Bupivacain durchgefuhrt wurde. Nach 15 min erreichte die Ausbreitung der sensorischen Blockade ihr Maximum bei Th8. Nach 15° Oberkorperhochlagerung, 35 min nach der intrathekalen Injektion des LA, kam es innerhalb der nachsten 10 min zu einer unbeabsichtigten Zunahme der kranialen Ausbreitung um 10 Segmente bis C6. Der Patient wurde bradykard, hypoton, respiratorisch insuffizient und musste intubiert und beatmet werden. Die Hamodynamik wurde durch die intravenose Applikation von Akrinor®, Atropin und kolloidalen Volumenersatzmitteln rasch stabilisiert. Die anschliesende Operation erfolgte ohne Besonderheiten in Intubationsnarkose. Bei Operationsende wurde der Patient bei stabiler Hamodynamik und suffizienter Spontanatmung problemlos extubiert. Unmittelbar nach Extubation erreichte die kraniale sensorische Ausbreitung L2. Die Kasuistik zeigt, dass es auch nach vermeintlicher Fixierung des LA zu einer unerwarteten Zunahme der Blockade nach Lagewechsel kommen kann, und dass Patienten nach SPA bis zur Remission der Blockade sorgfaltig uberwacht werden mussen. Die der unbeabsichtigten kranialen Ausbreitung von sensorischer und sympathischer Blockade zugrunde liegenden Pathomechanismen werden diskutiert.

The extent of lymph node dissection in radical cystectomy is a subject of controversy. A more extended dissection has been reported to be associated with superior survival. We analyzed the relationship between the lymph node count and different causes of death in a sample of 735 patients who underwent radical cystectomy for recurrent or muscle-invasive urothelial or undifferentiated carcinoma of the bladder. The median follow-up was 7.8 yr. The median lymph node count was 17, and the median age was 67 yr. Although there was a clear association between lymph node count and overall survival (≥21 vs.10 lymph nodes: 10-yr rates: 59% vs. 32%, respectively; hazard ratio: 0.63; 95% confidence interval, 0.46-0.87; log-rank test: p=0.0056), there was no detectable relationship between bladder cancer mortality and lymph node count (narrowly congruent cumulative mortality curves, Pepe-Mori test, p values ranging between 0.40 and 0.93). The differences were virtually entirely attributable to differences in competing mortality. These observations indicate that serious bias may occur when the lymph node count is used to stratify patients undergoing radical cystectomy. The results of the ongoing randomized trials should be awaited to reliably answer the question of the degree to which more extensive dissection may improve outcome.Survival differences in patients stratified by lymph node count may be attributed to competing mortality. The results of ongoing randomized trials should be awaited to answer the question of the degree to which more extensive lymph node dissection may improve outcome.

The focus of this paper is to identify and quantify risk factors for early hemorrhagic progression of brain contusions (HPC) in patients with traumatic brain injury (TBI) and to evaluate their impact on patients' outcome. Further, based on abnormal values in routine blood tests, the role of trauma-induced coagulopathy is analyzed in detail. Therefore, a prospective study of 153 TBI patients was completed at one institution between January 2008 and June 2012. The collected data included demographics, initial Glasgow Coma Scale pupillary response, initial and 6 h follow-up computed tomography scan findings, coagulation parameters (international normalized ratio, partial thromboplastin time, platelet count, fibrinogen, D-dimer and factor XIII), as well as outcome data using the modified Rankin score at discharge and after one year. The overall rate of early HPC within the first 6 h was 43.5%. The frequency of coagulopathy was 47.1%. When analyzing for risk factors that independently influenced outcome in the form of mRS ≥4 at both points, the following variables appeared: elevated D-dimer level (≥10,000 μg/L), HPC, and initial brain contusions ≥3 cm. Patients sustaining early HPC had a hazard ratio of 5.4 for unfavorable outcome at discharge (p=0.002) and of 3.9 after one year (p=0.006). Overall, patients who developed early HPC were significantly more likely to be gravely disabled or to die. Unfavorable neurological outcome after an isolated TBI is determined largely by early HPC and coagulopathy, which seem to occur very frequently in TBI patients, irrespective of the severity of the trauma.

We report a patient to whom ropivacaine 1.1 mg kg(-1) was administered for brachial plexus blockade and who developed grand mal convulsions because of inadvertent i.v. injection. No symptoms of cardiovascular toxicity occurred. Venous blood samples were taken 15, 45, 75 and 155 min after the injection. The measured total plasma concentrations of ropivacaine were 3.3, 1.6, 1.2 and 1.0 mg litre(-1) respectively. Initial plasma concentration after the end of the injection period was estimated at 5.75 mg litre(-1) using a two-compartment pharmacokinetic model.

Objectives: To investigate the prevalence and distribution of comorbidity and its association with perioperative complications in patients undergoing radical prostatectomy (RPE). Methods: In 431 unselected RPE patients, the American Society of Anesthesiologists Physical Status classification (ASA-PS), the New York Heart Association classification of cardiac insufficiency (NYHA), the classification of angina pectoris of the Canadian Cardiovascular Society (CCS), height, weight, the body mass index (BMI), and the number of concomitant diseases (NCD) were assessed and related to perioperative cardiovascular complications. Results: In RPE patients less than 70 years old, comorbidity rose nearly continuously with increasing age. However, after reaching an age of 70 years, the proportion of NYHA-0 patients increased (60–64 years, 86%; 65–69 years, 85%; ≧70 years, 87%). Furthermore, the severe comorbidities decreased in patients selected for RPE aged 70 or more years. There was a nonsignificant trend towards higher comorbidity in patients with perioperative cardiovascular complications. Conclusions: These data suggest that documentation of the distribution of ASA-PS, CCS, NYHA and of concomitant diseases might be helpful to characterize the general health status and the degree of selection of prostate cancer treatment populations especially in series with a high portion of patients aged 70 or more years. Concerning perioperative complications, the individual predictive value of comorbidity seems to be poor in the radical prostatectomy setting.

Patienten, die sich einer radikalen Prostatektomie (rPE) einschlieslich retroperitonealer Lymphadenektomie (rLA) unterziehen, haben aufgrund ihres Alters und ihrer Begleiterkrankungen ein erhohtes perioperativen Risiko. Ziel dieser Untersuchung war es, den intra- und postoperativen Verlauf der standardisierten Operation rPE+rLA unter verschiedenen Anasthesieregimen zu analysieren. Krankenakten von 433 Patienten, die sich zwischen 1994 und 1999 in unserer Einrichtung einer rPE+rLA unterzogen, wurden retrospektiv ausgewertet. Die Patienten wurden nach dem durchgefuhrten Anasthesieverfahren eingeteilt: 1. Allgemeinanasthesie (AA), 2. Kombination lumbale Epiduralanasthesie (LEA)+AA, 3. thorakale Epiduralanasthesie (TEA)+AA. Fur die intra- und postoperative Katheteranalgesie wurden Bupivacain 0,25% oder Ropivacain 0,2%, 8–12 ml/h verwendet. Die Allgemeinanasthesie wurde als balancierte Anasthesie durchgefuhrt. Diese retrospektive Erhebung zeigt unter epiduraler Analgesie, gemessen an Tachykardien und hypertensiven Episoden, eine reduzierte intra- und postoperative Stressantwort, kurzere Extubationszeiten, fruheres Wiedereinsetzen der gastrointestinalen Motilitat ([h] AA: 50,6±11,1/ LEA: 39,3±13,6/ TEA:33,8±13,0), tendenziell selteneres Erbrechen und eine um einen Tag verkurzte Krankenhausverweildauer ([d] AA: 12,4±5,8/ LEA: 11,1±3,1/ TEA: 11,5±3,8). Dabei war unter TEA die Dauer der Anasthesieprasenz im OP-Bereich vergleichbar mit AA ([min] AA: 222,9±43,5/ LEA: 238,2±41,8/ TEA: 227,0±46,2), und der Wachstationsaufenthalt verkurzt. Daneben war unter TEA die Anzahl der auffalligen postoperativen Thoraxrontgenbefunde reduziert. Zum Erreichen einer der TEA vergleichbaren Analgesie mussten unter LEA haufiger sensomotorische Blockaden, saO2-Abfalle und tendenziell eine hohere Anzahl kardialer Komplikationen in Kauf genommen werden. Gemessen an den von uns erhobenen Parametern stellt damit die Kombination einer Allgemeinanasthesie, insbesondere mit thorakaler Epiduralanalgesie ein sicheres und auch betriebswirtschaftlich effizientes anasthesiologisches Vorgehen bei radikalen Prostatektomien dar.

A 45-year-old man with cryptorchism, who was known to suffer from generalized myasthenia gravis, was admitted to hospital for surgical treatment using laparoscopy. Such minimally invasive surgery requires good muscle relaxation. However, the use of neuromuscular blocking agents in patients with myasthenia gravis may lead to prolonged apnoea after operation, thus necessitating mechanical ventilation of the lungs. We used a combination of general anaesthesia (with desflurane), and epidural anaesthesia (with the amide local anaesthetic ropivacaine) to obtain excellent abdominal relaxation during surgery. Tracheal extubation was possible immediately after the operation and no adverse effects were observed. The patient was discharged from hospital on the second day after operation. The combination of regional and general anaesthesia for minimally invasive surgery in this patient permitted safe anaesthetic management.

Study Type - Outcomes (cohort). Level of Evidence 2b. What's known on the subject? and What does the study add? Several comorbidity classifications have been investigated for their suitability to assist treatment decision-making in men with early prostate cancer. In unselected patients, some serious comorbidities have been shown to be associated with a 10-year competing mortality rate clearly superseding the 50% level. The present study shows that it is hardly possible to discern meaningful subsets of patients with a 10-year risk of competing mortality of50% by using comorbidity classifications. This finding suggests that the selecting clinicians did well in estimating the medium-term survival probability in men referred for radical prostatectomy.• To identify subsets of patients who are most likely to die from competing causes ≤ 10 years after radical prostatectomy (RP).• In all, 2205 consecutive patients who underwent RP for clinically localized prostate cancer between 1992 and 2005 were studied. The 10-year cumulative competing mortality rates were determined in several worst-case scenarios formed by using comorbidity classifications and combinations of them.• In this sample of men selected for RP, even those with the most severe comorbidity level had a competing mortality risk of50% ≤ 10 years after RP. • Depending on the comorbidity classification used, the 10-year cumulative competing mortality rates differed between 16 and 39% in the whole sample and between 18 and 48% in men aged ≥ 65 years.• Clinicians do well in estimating the further life span in candidates for RP. Comorbidity classifications may assist treatment choice in this population but are not able to discern meaningful subsets to be excluded from curative treatment because of a life expectancy falling below a limit of 10 years.

Traditional methods for approaching the lumbar plexus from the posterior rely on finding the intersection of lines that are drawn based on surface landmarks. These methods may be inaccurate in many cases. The aim of this study was to determine the accuracy of these traditional approaches and determine if modifications could increase their accuracy.The lumbar plexus region of 48 cadavers (78 +/- 7 yr; 167 +/- 6 cm; 60 +/- 13 kg; men/women: 29/19) was dissected, and relevant anatomic structures were marked. Needle proximity curves were obtained by triangulation for the five traditional approaches and for vectors from the posterior superior iliac spine directed towards the lumbar spinous processes of L3 and towards L4.Proximity curves (mean +/- SD) showed that except Pandin's approach (13 +/- 5 mm too medial), all others were too lateral: Winnie (17 +/- 8 mm), Chayen (8 +/- 5 mm), Capdevila (6 +/- 4 mm), and Dekrey (17 +/- 6 mm). Further, the curves had a narrow parabolic shape and thus a narrow margin of error. Both diagonal vectors had a significantly higher proximity to the lumbar plexus as compared with traditional approaches with a wide parabola, indicating more error tolerance. Using the vector posterior superior iliac spine-L3 with a length between 1/6-1/3 (= 16-22 mm) of the distance posterior superior iliac spine-L3, a proximity to the lumbar plexus5.0 +/- 0.3 mm was reached.Improvement of both the proximity and the margin of error is possible by using diagonal landmark vectors. Relying on the position of the posterior superior iliac spine eliminates the sex and sided differences and individual body size, which can be problematic if firm metric distances are used in determining the entry point.

Objectives To compare comorbidity measures and to analyze survival rates in men undergoing radical prostatectomy at age 70 years or older. Materials and methods A total of 329 consecutive patients aged 70 or more years who underwent radical prostatectomy between 1992 and 2004 were studied. The patients were stratified by 5 comorbidity classifications, tumor stage, Gleason score, and PSA value. Mortality was subdivided into overall, comorbid, competing, prostate cancer-specific, and second cancer-specific mortality. Competing risk and Kaplan-Meier survival curves as well as Mantel-Haenszel hazard ratios were calculated. Comparisons were made with the log-rank test. Cox proportional hazard models were used to determine the independent significance of prognostic variables. Results Considering the dose-response relationship, P values and the discrimination of 2 risk groups, the Charlson score was the best of the tested comorbidity classifications in men selected for radical prostatectomy at age 70 years or older. Beside the tumor-related factors Gleason score 8–10 (hazard ratio 2.61, P = 0.0234) and lymph node involvement (hazard ratio 2.89, P = 0.0145), a Charlson score of 1 or greater was identified as an independent predictor of overall mortality (hazard ratio 2.16, P = 0.0441). Without comorbidity or adverse tumor-related risk factors, elderly men had an excellent 10-year overall survival probability (77% to 100%, depending on the classification used), whereas 10-year overall survival was distinctly poor in the presence of lymph node metastases (30%) or Gleason score 8–10 disease (33%). Conclusions The Charlson comorbidity score may be used to stratify men selected for radical prostatectomy at age 70 years or older and to estimate long-term survival probability. In the absence of adverse tumor-related parameters or serious comorbidity, long-term survival probability is excellent in this subgroup.

Background and Objectives High-resolution ultrasound imaging (HRUI) allows real-time visualization of peripheral nerves, needle insertion, and the spread of local-anesthetic (LA) solution. We evaluated the feasibility of performing a high interscalene brachial-plexus block for carotid endarterectomy by means of HRUI, thereby limiting the amount of LA to the dose required to sufficiently surround the relevant nerve structures. Methods The interscalene brachial plexus was localized in the interscalene groove at its most cephalad point in 14 patients undergoing carotid endarterectomy by use of an ultrasound device with a 17.5 MHz transducer. Up to 20 mL of ropivacaine 0.5% was injected. Results In all patients, HRUI allowed clear delineation of the upper part of the interscalene brachial plexus at the level of the 4th cervical vertebra appearing as 1 hypoechoic, roundish, hypodense node located in a distance of 1.5 ± 0.3 cm to the skin, 1.5 ± 0.2 cm lateral to the common carotid artery, and 0.6 ± 0.2 cm from the transverse process of the spine. Likewise HRUI allowed a clear delineation of minor blood vessels and adjacent anatomic structures, as well as accurate placement of the needle close to the nerves. Real-time observation of LA spread during injection was possible, even in increments of less than 1 mL. Conclusions High-resolution ultrasonic imaging allows clear depiction of the target tissues and facilitates accurate needle placement during high interscalene brachial-plexus blocks. This technique may minimize the risk of direct puncture-related complications, as well as accidental intravascular injection of LA. The observation of LA spread in all patients, even in small increments of less than 1 mL might enhance safety by limiting the injected LA to the actual demand. Well-placed LA spread could potentially avoid central nervous toxicity caused by intravascular injection or resorption of inadequately high dosages, in particular in nerve blocks of the highly vascularized neck region.

Although local anesthetics (LAs) are hyperbaric at room temperature, density drops within minutes after administration into the subarachnoid space. LAs become hypobaric and therefore may cranially ascend during spinal anesthesia in an uncontrolled manner. The authors hypothesized that temperature and density of LA solutions have a nonlinear relation that may be described by a polynomial equation, and that conversion of this equation may provide the temperature at which individual LAs are isobaric.Density of cerebrospinal fluid was measured using a vibrating tube densitometer. Temperature-dependent density data were obtained from all LAs commonly used for spinal anesthesia, at least in triplicate at 5 degrees, 20 degrees, 30 degrees, and 37 degrees C. The hypothesis was tested by fitting the obtained data into polynomial mathematical models allowing calculations of substance-specific isobaric temperatures.Cerebrospinal fluid at 37 degrees C had a density of 1.000646 +/- 0.000086 g/ml. Three groups of local anesthetics with similar temperature (T, degrees C)-dependent density (rho) characteristics were identified: articaine and mepivacaine, rho1(T) = 1.008-5.36 E-06 T2 (heavy LAs, isobaric at body temperature); L-bupivacaine, rho2(T) = 1.007-5.46 E-06 T2 (intermediate LA, less hypobaric than saline); bupivacaine, ropivacaine, prilocaine, and lidocaine, rho3(T) = 1.0063-5.0 E-06 T (light LAs, more hypobaric than saline). Isobaric temperatures (degrees C) were as follows: 5 mg/ml bupivacaine, 35.1; 5 mg/ml L-bupivacaine, 37.0; 5 mg/ml ropivacaine, 35.1; 20 mg/ml articaine, 39.4.Sophisticated measurements and mathematic models now allow calculation of the ideal injection temperature of LAs and, thus, even better control of LA distribution within the cerebrospinal fluid. The given formulae allow the adaptation on subpopulations with varying cerebrospinal fluid density.

Ropivacaine 1% 40 ml was mistakenly injected as part of an axillary plexus block in an 84-year-old woman. After 15 min the patient complained of dizziness and drowsiness and developed a generalised tonic-clonic seizure followed by an asystolic cardiac arrest. After 10 min of unsuccessful cardiopulmonary resuscitation, a bolus of 100 ml of Intralipid 20% (2 ml.kg(-1)) was administered followed by a continuous infusion of 10 ml.min(-1). After a total dose of 200 ml of Intralipid 20% had been given spontaneous electrical activity and cardiac output was restored. The patient recovered completely. We believe the cardiovascular collapse was secondary to ropivacaine absorption following the accidental overdose. This case shows that lipid infusion may have a beneficial role in cases of local anaesthetic toxicity when conventional resuscitation has been unsuccessful.

Objectives Radical cystectomy is the preferred standard treatment for patients with muscle-invasive bladder cancer. With improvements in intra- and perioperative care lower complication rates have been reported. We retrospectively evaluated our series of patients who underwent radical cystectomy for advanced bladder cancer for perioperative complications as well as operative time, postoperative hospital stay and transfusion rates. Patients and methods Between April 1993 and August 2005, 516 radical cystectomies were performed for muscle infiltrating transitional cell carcinoma and other types of neoplastic diseases of the bladder at our institution. The average age was 66.3 yr (31–89). Results The perioperative mortality rate was 0.8%. A total of 141 patients (27.3%) developed at least one perioperative complication. The most frequent medical complications were subileus in 20 (3.9%) patients, deep venous thrombosis in 24 (4.7%), and enterocolitis in 10 (1.9%). Surgical complications included pelvic lymphoceles in 42 (8.1%) patients, wound dehiscence in 46 (8.9%), pelvic hematoma in 4 (0.8%), peritonitis in 4 (0.8%) and small bowel obstruction in 4 (0.8%). The total early reoperation rate was 6.2%. Operative time, postoperative hospital stay and average number of blood units transfused decreased over the period 1993–2005. Conclusions Radical cystectomy today is a procedure with an acceptable rate of perioperative morbidity and mortality. Improvements in surgical technique and anaesthesia as well as increased quality of perioperative care in recent years have resulted in reduced morbidity and shorter hospital stay.

To identify and compare tumor- and non-tumor-related predictors of survival after radical prostatectomy and to incorporate the latter into the tumor node metastasis classification of prostate cancer.A total of 402 patients who underwent radical prostatectomy (mean follow-up period 6.9 years) were stratified according to postoperative tumor stage, Gleason score, prostate-specific antigen level, age and five comorbidity classifications. Cox proportional hazard models were used to identify independent prognostic factors predicting overall survival.Comorbidity (American Society of Anesthesiologists Physical Status classification), Gleason score and age, but not tumor stage, were independent predictors of overall survival. Based on tumor stage and the identified independent prognostic factors, an easily applicable prognostic score was developed to predict overall mortality.A prognostic classification of radical prostatectomy patients based on Gleason score, comorbidity and age and supplementary to a coarsened variant of the tumor node metastasis classification may be of clinical value.

INTRODUCTION Using the surgical procedure OPS 5-604.0 (radical retropubic prostatectomy) as an example, our study identifies revenue-relevant patient characteristics and describes the impact of the perioperative application of thoracic epidural analgesia (TEA). METHODS Factors affecting duration of stay were determined in 460 patients undergoing OPS 5-604.0 in the year 2001 and 2002 using multifactorial regression analysis. Preoperative parameters served as factors for matched-pair analysis of the effects of TEA. RESULTS Characteristics significantly affecting length of postoperative hospital stay were ASA status, age, preoperative haemoglobin concentration, postoperative tachycardia, number of transfused packed red cells, wound infection and surgical revision. Based on identical matching criteria 27 pairs (with/without TEA) could be formed. While the induction time in the TEA group was 8+/-18 min longer (p=0.04), emergence was briefer by 3+/-9 min (p=0.045). Neither anaesthesia presence time nor anaesthesia costs or total costs of surgery differed significantly between the pairs. However, duration of epidural postoperative pain therapy was longer with TEA but in contrast, the postoperative length of hospital stay after TEA was reduced. Assuming a continuous demand for OPS 5-604.0 procedures, TEA enables 32 more procedures to be carried out per year with an increased yield on turnover of 2.7%. CONCLUSION At first sight combined anaesthesia procedures require more human resources and material, however, as a result of shortened hospital stay and optimized pain therapy patient satisfaction increases and a substantial potential for increased revenue is gained.