BACKGROUND:Thoracic epidural anesthesia (TEA) is one of the pillars of perioperative pain care. Particularly for spine surgery which causes significant postoperative pain TEA seems like an appealing option. However, beneficial effects of a TEA are questionable when the catheter is not used intraoperatively, a decision that is usually based on the surgeon's wish to perform immediate neurological examination postoperatively.METHODS:Forty patients undergoing transforaminal lumbar interbody fusion surgery (TLIF) were randomized into two groups. Patients received preoperative insertion of a TEA. For patients in the intraoperative group an epidural infusion was started preoperatively and maintained throughout. For patients in the postoperative group the epidural infusion was started once neurological examination had been performed. The primary outcome measure in this study was postoperative requirements of piritramide during the first two postoperative hours. Secondary outcomes involved postoperative pain numeric rating scale (NRS) scores, intraoperative opioid requirements, side effects and ability to perform direct postoperative neurological examination.RESULTS:Postoperative group patients required significantly more opioids both intra- and postoperatively (P=0.036 and P=0.039) and NRS scores were significantly higher on admission to recovery, at 30 and 60 min as compared to patients in the intraoperative group (P=0.013; P=0.004 and P=0.012). Early postoperative neurological examination was feasible in all patients in both groups.CONCLUSIONS:Epidural catheters used intraoperatively during TLIF are feasible, significantly reduce pain, intra- and postoperative use of opioids and do not influence the quality of neurological tests directly after the surgical procedure.

Background: Although spinal anaesthesia has a more favourable risk-profile, patients prefer surgery under general anaesthesia. Besides fear of severe but rare neurological complications, reasons for rejection are fear of backache or anticipated pain during puncture. Providing local anaesthesia before lumbar puncture is not a standard procedure. The aim of this randomized clinical trial was to evaluate the efficacy in pain reduction and the effect on patient satisfaction when using different local anaesthetic treatments before puncture. Methods: 83 patients receiving spinal anaesthesia were randomly allocated to three subgroups: group I (control) did not receive any local anaesthetic pre-treatment of the skin, group II (EMLA) received EMLA patch and group III (Prilocaine) received local skin infiltration using 2 ml of Prilocaine prior to lumbar puncture. Pain during puncture, duration of procedure, comparison of expected versus actual pain as well as future decision for or against spinal anaesthesia was assessed. Results: Pain during puncture was significantly reduced in the EMLA and Prilocaine groups as compared to patients in the control group. No significant differences between the EMLA and Prilocaine groups were detected, though pain scores were slightly lower in the EMLA-group. Duration of procedure was significantly longer in the Prilocaine-group as compared to the EMLA-group. Although pain was significantly higher in the control group, there was no significant difference between the groups regarding future acceptance of spinal anaesthesia. Conclusion: Irrespective of the type (EMLA or Prilocaine), the use of local anaesthetic pre-treatment of the skin was found to significantly reduce pain during puncture. Our data supports the use of local anaesthesia prior to spinal puncture in daily routine. There was a trend towards better pain control in the EMLA-group; however, the actual pain in all groups was not clinically relevant in terms of decision for or against future spinal anaesthesia.

Der Einsatz von Ultraschall bei regionalanästhesiologischen Verfahren erfährt in den letzten Jahren eine zunehmende Verbreitung und Akzeptanz. Prognostisch werden Ultraschallgeräte in wenigen Jahren zur Grundausstattung von Anästhesiearbeitsplätzen gehören.

Modern day general anesthesia has a convincing safety record in any age group presenting with or without severe co-morbidities, hence allowing surgeons to introduce a broad range of patients to surgical procedures.

Background. Effects of perioperative cervical level neuraxial blocks on the dissemination of cancer metastases have become a matter of substantial interest. However, experience with these catheters has been limited and data on feasibility and efficacy is sparse. Methods. Data from 39 patients scheduled to undergo breast cancer surgery while awake with a cervical epidural alone was retrospectively analyzed. Results. In 26 patients (66,7%, 95% CI 51,7–81,7) the cervical epidural catheter was sufficient for surgery. In one patient (2.6%, 95% CI 0–7.6) identification of the epidural space was not possible. Four patients (10.3%, 95% CI 0,7–19,9) had an insufficient sensory block. Seven patients (17.9%, 95% CI 5,7–30,1) had a partially insufficient sensory block. Rates of failed epidural blocks were not significantly different between different insertion levels. 21 patients (80.8%, 95% CI 65,4–96,1) developed hypotension and required an intravenous vasopressor. One patient developed nausea. In one patient the dura was accidentally punctured. No neurological damage was observed. No other major complications were observed. Discussion. Epidural punctures in the cervical region are feasible but do bear potential for major complications. Anesthesiologists should familiarize themselves with high epidural block techniques.

Reproducible SuccessAs mentioned in our colleagues' impressive article, such a concept has been in place at our hospital for years and we have succeeded in permanently integrating interdisciplinary measures into standard care.Prompted by the experiences we had gathered since 2001 and knowing that the awareness of the importance of these measures among all healthcare professionals involved is not given at all times, a "Department of Perioperative Geriatric Medicine" was established (1).The insight that the number of patients experiencing postoperative delirium can be reduced with appropriate measures is not new and the health care professionals working with these patients are familiar with it.However, what is missing is the awareness of how much these measures can contribute to a better quality of life for these patients.If not enough awareness has been raised among the healthcare professionals involved, their acceptance of these measures will be low, and it does not come as a surprise that attempts to establish these essentially simple measures universally in the daily hospital routine often fail.This article shows that our success is by no means a welcome development in just a single hospital, but can definitely be reproduced at other hospitals.Thankfully, the authors mention the fact that delirium prolongs the length of hospital stays.Apart from conflict-ridden hospital courses (patients with delirium are at risk for further complications), delirium is a cost factor in itself-the increased demand on resources is not paid for.There is good evidence to support the cost effectiveness of the measures established at our hospital-maybe this is another incentive to dive deeper into the topic of "delirium".In addition, this topic is increasingly covered by the media, and patients confront us with their concerns about cognitive deficits.This should encourage all healthcare professionals involved in the perioperative management of these high-risk patients to test and rigorously pursue the establishment of such measures where they work.

In the medical treatment of children drugs are frequently used outside the boundaries of the approved licensing and use under the terms of off-label use is possible. However, this requires critical reasoning and experience with the drug involved. With help of a traffic light colored spreadsheet this article illustrates the limitations, problems and possibilities of pharmacotherapy in pediatric emergencies or pediatric anesthesia. Of the 45 emergency drugs listed in this article most can be used in childhood, at least under specific conditions. Licensing restrictions occur especially in the newborn period and infancy resulting in frequent off-label use. Severe pitfalls, such as the propofol infusion syndrome after long-term sedation with propofol under the age of 16 years, emphasize the need for serious reflection on the substances involved. Decisions regarding pharmaceutical therapy should be based on the current standard of medical knowledge. When official recommendations from pharmaceutical companies are missing, treatment decisions for off-label use can be based on guidelines, study and literature databases or recommendations in medical journals.

In der medizinischen Versorgung von Kindern werden Medikamente regelhaft außerhalb ihrer Zulassung eingesetzt. Die Verwendung im Rahmen des „Off label use“ ist möglich, erfordert aber den kritischen Umgang mit der eingesetzten Substanz. Im vorliegenden Beitrag werden Grenzen, Grauzonen und Möglichkeiten der Pharmakotherapie von Kindern in Notfallmedizin und Kinderanästhesie mithilfe eines tabellarischen Ampelschemas dargestellt. Von den 45 aufgezeigten Notfallmedikamenten sind die meisten, zumindest unter Auflagen, im Kindesalter einsetzbar. Im Säuglingsalter und in der Neugeborenenperiode offenbaren sich Lücken hinsichtlich der Zulassung, sodass regelhaft ein Off label use erfolgt. Gravierende Fallstricke, wie das Propofolinfusionssyndrom im Rahmen einer Dauersedierung mit Propofol bei Patienten unter 16 Jahren, verdeutlichen die Notwendigkeit der kritischen Auseinandersetzung mit den eingesetzten Substanzen. Maßgeblich für die medikamentöse Therapie ist der aktuelle Stand des medizinischen Wissens. Bei Fehlen der formalen Zulassung in den Fachinformationen sind Leitlinien, Studienverzeichnisse, Literaturdatenbanken oder Empfehlungen in der Fachliteratur sinnvolle Stützen für die Rechtfertigung einer Off-label-Therapie.

Die Ursachen einer Bewusstlosigkeit, insbesondere bei jungen Patienten, sind vielfältig. Häufig ist es prähospital nicht möglich, die Hintergründe aufzuklären. Dieser Fallbericht beschreibt die Reanimation eines jungen Patienten nach Intoxikation mit einem Gemisch aus Schwefelsäure und Ameisensäure in vermutlich suizidaler Absicht.