PURPOSE:Calcifying tendinitis is a common condition of the shoulder. In many cases, arthroscopic reduction in the deposit is indicated. The localization of the deposit is sometimes challenging and time-consuming. Pre-operative ultrasound (US)-guided needle placement in the deposit and pre-operative US marking of the deposit at the skin with a ballpoint are described and recommended methods to alleviate the procedure without using ionizing radiation by fluoroscopy.METHODS:Intra-operative sonography of the shoulder is introduced as a new method to localize the calcific deposit with high accuracy. After standard arthroscopic buresectomy, the surgeon performs an ultrasound examination under sterile conditions to localize the deposits. A ventral longitudinal US section is recommended, and the upper arm is rotated until the deposit is visible. Subsequently, perpendicular to the skin at the position of the transducer, a needle is introduced under arthroscopic and ultrasound visualization to puncture the deposit.RESULTS:The presence of snow-white crystals at the tip of the needle proves the exact localization. Consecutively, the curettage can be accomplished. Another intra-operative sonography evaluates possible calcific remnants and the tendon structure.CONCLUSION:This new technique may alleviate arthroscopic calcific deposit curettage by visualizing the deposit without using ionizing radiation. Additionally, soft tissue damage due to decreased number of punctures to detect the deposit may be achieved. Both factors may contribute to reduced operation time.

Aim. Anxiety is an important perioperative issue, especially in patients undergoing spinal anesthesia. Intraoperative noise is potentially harmful to staff and patients and hinders continuous sedation. The primary goal was to test the hypothesis that patients wearing single-use paraffin wax earplugs while undergoing spinal anesthesia in an extremely noisy environment show a reduction in the amount of propofol necessary for bispectral guided sedation compared to patients without earplugs. The secondary goal was to evaluate whether earplugs could reduce the incidence of intraoperative awareness with recall.Methods. In this prospective, randomized study, 50 patients undergoing orthopedic surgery were included. After achieving a target sedation depth of bispectral score 70 using a propofol bolus followed by a continuous infusion, an independent investigator either placed or did not place earplugs into the patients' ears (PLUG or noPLUG groups, respectively). Propofol requirements for stable sedation guided by the bispectral index and incidence of postoperative recall of intraoperative events were assessed in a double-blinded fashion.Results. We found high but comparable propofol requirements in both groups (PLUG 4.4 +/- 1.2 vs. noPLUG 4.2 +/- 1.0 mg kg(-1) h(-1), p-NS). The incidence of intraoperative awareness was lower in the PLUG compared to the noPLUG group (16 vs. 56%; P<0.001).Conclusion. Although no sedative-sparing effect could be found in patients who wore earplugs during elective orthopedic surgery under spinal anesthesia, we nevertheless recommend using single-use paraffin wax earplugs. Beside their beneficial effect against potential harmful intraoperative noise, they reduce the incidence of intraoperative awareness with recall. (Minerva Anestesiol 2010;76:504-8)

BACKGROUND:This study investigated the cost-effectiveness of ultrasonographic-guided interscalene brachial plexus blockade (ISB) in comparison with general anaesthesia (GA) for arthroscopic shoulder surgery.METHODS:Forty patients undergoing arthroscopic shoulder surgery received either an ultrasonographic-guided ISB or GA. ISB was performed outside the operation room (OR) and patients were transferred in the OR at the earliest 20 min after block performance. All drugs and disposables were recorded to evaluate the costs for both techniques. The following anaesthesia-related times were defined: ready for surgical preparation (from arrival in the OR until end of anaesthesia induction), OR emergence time (from end of dressing until leaving the OR), anaesthesia control time (from patient's arrival in the OR until readiness for positioning plus time from the end of surgery to patient's discharge from the OR), and post-anaesthesia care unit (PACU) time (from patient's arrival in the PACU to the eligibility for discharge to normal ward). Personnel costs were excluded from statistical analysis.RESULTS:The total costs were [mean (sd)] 33 (9)euro for patients with ISB and 41 (7)euro for those who received GA (P<0.01). The anaesthesia-related workflow was improved in the ISB group when compared with the GA group [ready for surgical preparation 8 (3) vs 13 (5) min, P<0.001; OR emergence time 4 (3) vs 10 (5), P<0.001; anaesthesia control time 12 (4) vs 23 (6), P<0.001; and PACU time 45 (17) vs 70 (20), P<0.001].CONCLUSIONS:Ultrasonographic-guided ISB is a cost-effective method for arthroscopic shoulder surgery.

Preoperative anxiety can increase postoperative pain and is therefore important to avoid. Different approaches have already been tested for preoperative anxiolysis. Gabapentinoids might be a useful alternative to benzodiazepines. Pregabalin is used for treating generalized anxiety disorders and shows a favourable pharmacokinetic profile after oral administration; however, its anxiolytic effect preoperatively in healthy outpatients is still unclear. In this randomised, double-blind, placebo-controlled trial the anxiolytic effect of pregabalin in 40 outpatients undergoing standardised general anaesthesia and postoperative pain therapy for minor orthopaedic surgery was analysed. Patients received preoperatively either 300 mg pregabalin or placebo orally. The primary outcome was anxiety before anaesthesia induction, the secondary outcome the postoperative pain, both assessed using a visual analogue scale from 0 to 100. Without any side effects pregabalin reduced preoperative anxiety compared with the control group (23 ± 10 vs. 38 ± 17; p = 0.003). Pain scores did not differ between groups; however, need of piritramide in the postanaesthesia care unit was reduced to half by pregabalin compared with the control group. A single preoperative dose of 300 mg pregabalin reduces anxiety in patients undergoing minor orthopaedic surgery without any side effects like dizziness or persisting sedation resulting in a prolonged stay in the postanaesthesia care unit.

SummaryWe assessed the minimal remifentanil dosage required for tracheal tube tolerance in awake and spontaneously breathing patients after major abdominal surgery. Forty postoperative patients received remifentanil 0.1 μg.kg−1.min−1, which was reduced in steps of 0.025 μg.kg−1.min−1 every 30 min. Respiratory response subscore of comfort scale (CSRR), Ramsay sedation scale (RSS), visual analogue scale (VAS), respiratory rate, and minute ventilation were recorded. Spontaneous respiration with no or little response to ventilation (CSRR 2) in co‐operative, oriented and tranquil patients (RSS 2) was defined as the main outcome and study endpoint. Thirty‐one patients (77.5%) reached a CSRR 2 and RSS 2 with remifentanil 0.025 μg.kg−1.min−1 and nine patients (22.5%) required remifentanil 0.05 μg.kg−1.min−1. Analgesia was sufficient in all patients (VAS = 30). Remifentanil 0.025−0.05 μg.kg−1.min−1 achieves satisfactory tracheal tube tolerance in awake and spontaneously breathing patients.

INTRODUCTION:Sepsis activates the coagulation system and frequently causes hypercoagulability, which is not detected by routine coagulation tests. A reliable method to evaluate hypercoagulability is thromboelastography (TEG), but this has not so far been used to investigate sepsis-induced hypercoagulability. Antithrombin (AT) in plasma of septic patients is decreased, and administration of AT may therefore reduce the acquired hypercoagulability. Not clear, however, is to what extent supraphysiologic plasma levels of AT decrease the acute hypercoagulability in septic patients. The present study investigates the coagulation profile of septic patients before and during four day high-dose AT therapy.METHODS:Patients with severe sepsis were randomly assigned to receive either 6,000 IU AT as a bolus infusion followed by a maintenance dose of 250 IU/hour over four days (n = 17) or placebo (n = 16). TEG, platelet count, plasma fibrinogen levels, prothrombin time and activated partial thromboplastin time were assessed at baseline and daily during AT therapy.RESULTS:TEG showed a hypercoagulability in both groups at baseline, which was neither reversed by bolus or by maintenance doses of AT. The hypercoagulability was mainly caused by increased plasma fibrinogen, and to a lesser extent by platelets. Plasmatic coagulation as assessed by the prothrombin time and activated partial thromboplastin time was similar in both groups, and did not change during the study period.CONCLUSION:The current study shows a distinct hypercoagulability in patients suffering from severe sepsis, which was not reversed by high-dose AT treatment over four days. This finding supports recent data showing that modulation of coagulatory activation in septic patients by AT does not occur before one week of therapy.

Total hip or knee replacement surgeries are common orthopedic interventions that can be performed with spinal anesthesia (SA) or general anesthesia (GA). No study has investigated the economic aspects associated with the two anesthetic techniques for this common surgery. We randomized 40 patients to receive either SA or GA and analyzed the drug and supply costs for anesthesia und recovery. Anesthesia-related times, hemodynamic variables, and pain scores were also recorded. Total costs per case without personnel costs were almost half in the SA group compared with the GA group; this was a result of less cost for anesthesia (P < 0.01) and for recovery (P < 0.05). This finding was supported by a sensitivity analysis. There were no relevant differences regarding anesthesia-related times. Patients in the GA group were admitted to the postanesthesia care unit with a higher pain score and needed more analgesics than patients in the SA group (both P < 0.01). We conclude that SA is a more cost-effective alternative to GA in patients undergoing hip or knee replacement, as it is associated with lower fixed and variable costs. Moreover, SA seems to be more effective, as patients in the SA group showed lower postoperative pain scores during their stay in the postanesthesia care unit.

From the Departments of Anesthesiology and General Intensive Care (A.M.M., C.G., M.Z., C.K.S.) and Surgery (T.B.), General Hospital, University of Vienna, Vienna, Austria; and the Ludwig-Boltzmann-Institute for Anesthesiology and Intensive Care (C.G., M.Z.), Vienna, Austria. Submitted for publication January 8, 2004. Accepted for publication April 20, 2004. Address for reprints: Anette-Marie Machata, MD, Department of Anesthesiology and General Intensive Care, General Hospital Vienna, University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria; email: [email protected].

Newer anaesthetic agents, such as remifentanil and sevoflurane, are more expensive than conventional anaesthetics, such as isoflurane and fentanyl. However, newer anaesthetics might outweigh their higher acquisition costs by reducing length of stay in the postanaesthesia care unit and thereby reducing personnel costs. We retrospectively investigated the influence of newer anaesthetics on time to eligibility for discharge from the postanaesthesia care unit in consecutive patients undergoing major abdominal surgery. Using a chart review, patients undergoing major abdominal surgery with three different anaesthetic regimens (isoflurane/fentanyl (n=80), sevoflurane/fentanyl (n=40), and sevoflurane/remifentanil (n=42)) were compared regarding duration of anaesthesia, surgery, time till extubation, and time to eligibility for discharge from the post-anaesthesia care unit. Extubation times were shorter in patients in the sevoflurane/fentanyl and the sevoflurane/remifentanil groups compared to patients in the isoflurane/fentanyl group. Time to eligibility to discharge from the postanaesthesia care unit was similar in isoflurane/fentanyl and sevoflurane/fentanyl group. In the sevoflurane/fentanyl group, time to eligibility for discharge from the unit showed a tendency to be increased (P=0.08), however these patients were significantly older compared to the other groups. Sevoflurane and remifentanil did not appear to reduce time to eligibility to discharge from the postanaesthesia care unit in our patients undergoing major abdominal surgery compared to isoflurane and fentanyl. This study highlighted the necessity for carefully planned transition from remifentanil to other longer-acting analgesia in our patients.

Department of Anesthesiology and General Intensive Care, Medical University of Vienna, Vienna, Austria

SOCIETY OF CRITICAL CARE MEDICINE 34TH CRITICAL CARE CONGRESS PHOENIX, ARIZONA, USA JANUARY 15-19, 2005: Oral Presentation: GI From Bench to Bedside

UNLABELLED:Diagnostic blood loss is a recognized issue during the delivery of intensive care services. We designed this study to compare the effects of educational versus organizational approaches to reduce daily diagnostic blood loss in intensive care patients. First, as an educational approach, physicians on two wards were repeatedly informed about the importance of diagnostic blood loss and that 1.0-1.5 mL is sufficient for blood gas analysis. Second, as an organizational approach, 3-mL syringes were replaced by 2-mL syringes. Measurements after both periods were compared with a control group. The amount of drawn/discarded blood of 320 samples was measured in each group after the 2 interventions. Compared with the control group, the educational program reduced the amount of drawn/discarded blood in one ward, but not the other. After the organizational change, the amount of drawn/discarded blood was reduced in both wards. Additionally, because of the smaller costs of 2-mL syringes, implementation of 2-mL syringes saved US dollars 30800/yr in our hospital. In conclusion, our study shows that an educational program seems less effective in influencing physician behavior than organizational changes. Therefore, organizational changes should be favored over educational approaches whenever possible. IMPLICATIONS:Organizational change is more effective than educational programs to reduce diagnostic blood loss. Organizational implementation of smaller syringes reduces the amount of discarded blood and can save money.

Awake nasotracheal fiberoptic intubation requires an anesthetic management that provides sufficient patient comfort, adequate intubating conditions, and stable hemodynamics. Short-acting and easily titratable analgesics are excellent choices for this maneuver. In this study, our aim was to determine an appropriate dosage regimen of remifentanil for awake nasotracheal fiberoptic intubation. For that reason, we compared two different dosage regimens. Twenty-four patients were randomly assigned to receive remifentanil 0.75 micro g/kg in bolus, followed by a continuous infusion of 0.075 micro g x kg(-1) x min(-1) (Group L), or remifentanil 1.5 micro g/kg in bolus, followed by a continuous infusion of 0.15 micro g x kg(-1) x min(-1) (Group H). All patients were premedicated with midazolam 0.05 mg/kg IV and glycopyrrolate 0.2 mg IV. Both dosage regimens ensured patient comfort and sedation. Discomfort did not differ between groups. Patients in Group H were sedated more profoundly. Hemodynamic stability was maintained with both remifentanil doses. Intubating conditions were adequate in all patients and comparable between the groups. The large dosage regimen did not result in any additional benefit compared with the small dosage. For awake nasotracheal fiberoptic intubation, we therefore recommend remifentanil 0.75 micro g/kg in bolus followed by continuous infusion of 0.075 micro g x kg(-1) x min(-1), supplemented with midazolam 0.05 mg/kg.

The share of older individuals is the fastest growing sector in our population. It is widely accepted that there are enormous differences between chronological and biological age. The elderly patient is characterized by an ongoing decrease of general and reserve functional capacity of each organ system. These changes might be tolerable and not decreasing quality of daily life, but become obvious during an exceptional situation, e.g. a surgical intervention or an infection. Interacting comorbidities and changes in the cardiovascular, pulmonary, hepatorenal or neuromuscular state require an exact treatment strategy, ranging from the preoperative risk assessment and optimization to optimal intraoperative treatment in view of a decreased reserve functional capability. Tachycardia, excessive changes in blood pressure and blood glucose levels, hypothermia, and of course hypoxia should be avoided in all cases. Postoperative continuation of careful blood and fluid substitution, pain therapy, and above all a careful contact with the elderly patient help to guarantee a perfect result - an early reintegration into their earlier surrounding. The necessity of modern intensive care should be evaluated and organized in advance. Medical progress, short acting, well controllable drugs for general and regional anesthesia as well as modern less invasive monitoring and treatment facilities enable physicians to treat the steadily ageing population. Clinical experience as well as scientific results show clearly that advanced age is associated with an increased perioperative morbidity and mortality risk. Aware of the physiological changes and mastering modern diagnostic and therapeutic facilities, we are proudly to say that advanced chronological age per se is no longer a contrainclication for a surgical intervention.