Abstract Background The perioperative antibiotic prophylaxis with 1st or 2nd generation cephalosporins is evidence-based in orthopedic surgery. There are, however, situations with a high risk of prophylaxis-resistant surgical site infections (SSI). Methods We perform a superiority randomized controlled trial with a 10% margin and a power of 90% in favor of the broad-spectrum prophylaxis. We will randomize orthopedic interventions with a high risk for SSI due to selection of resistant pathogens (open fractures, surgery under therapeutic antibiotics, orthopedic tumor surgery, spine surgery with American Society of Anesthesiologists (ASA) score ≥ 3 points) in a prospective-alternating scheme (1:1, standard prophylaxis with cefuroxime versus a broad-spectrum prophylaxis of a combined single-shot of vancomycin 1 g and gentamicin 5 mg/kg parenterally). The primary outcome is “remission” at 6 weeks for most orthopedic surgeries or at 1 year for surgeries with implant. Secondary outcomes are the risk for prophylaxis-resistant SSI pathogens, revision surgery for any reason, change of antibiotic therapy during the treatment of infection, adverse events, and the postoperative healthcare-associated infections other than SSI within 6 weeks (e.g., urine infections or pneumonia). With event-free surgeries to 95% in the broad-spectrum versus 85% in the standard prophylaxis arm, we need 2 × 207 orthopedic surgeries. Discussion In selected patients with a high risk for infections due to selection of prophylaxis-resistant SSI, a broad-spectrum combination with vancomycin and gentamycin might prevent SSIs (and other postoperative infections) better than the prophylaxis with cefuroxime. Trial registration ClinicalTrial.gov NCT05502380. Registered on 12 August 2022. Protocol version: 2 (3 June 2022)

This report addresses the dilemma of continuing lithium prophylaxis and antidepressant therapy in view of cardiovascular adverse effects under electroconvulsive therapy (ECT) in patients with a long history of recurrent affective disorders. A severely depressed 48-year-old woman who had been treated with lithium for 18 years developed a ventricular tachycardia during ECT. Possible interaction with succinylcholine was taken into account, and rocuronium was used as an alternative muscle relaxant. Electroconvulsive therapy was continued without adverse effects after reduction of lithium and withdrawal from duloxetine. Systemic studies on cardiac adverse effects of serotonin and norepinephrine reuptake inhibitors and serotonin and norepinephrine reuptake inhibitor-lithium combinations during ECT are needed.

To the Editor: The recent article by March et al. (1) comparing single and double injection techniques of the sciatic nerve at the popliteal level raises several issues. First, the puncture point is not clearly defined and the time between the two injections in the two stimulation groups is not given. Second, stimulation of the two branches of the sciatic nerve at the popliteal level using a posterior approach and a fixed defined point, (10 cm from the popliteal skin crease) does not take into consideration the anatomical variation between patients. It has been shown in 500 consecutive patients scheduled for a popliteal block, that the distance between the knee crease to the apex of the popliteal fossa—the apex being the ideal puncture point for performing this block because it is the most proximal point from the knee crease (which allows a puncture without interfering with the muscle structure), varies from 6 to 13 cm (2). Third, when the two parts of the sciatic nerve (peroneal and tibial) are still together, the procedure used by the authors is not without risk. In other words, if the second stimulation occurs on a nerve, that is already partially anesthetized, the risk of inadvertent intraneural injection is increased. Finally, we disagree with the author's conclusion, because one stimulation at the apex of the popliteal fossa which elicits inversion (almost) always successfully blocks both components of the sciatic nerve (2). A double stimulation may be indicated, only when inversion is, for any reason, impossible to elicit, meaning that the peroneal and tibial parts of the sciatic nerve are already well separated (3). Markus Risch, MD Stephan Blumenthal, MD Alain Borgeat, MD Department of Anesthesia Balgrist University Hospital Zurich, Switzerland [email protected]