BACKGROUND:The Trendelenburg and Duchenne signs are commonly used to clinically assess hip abductor function. Previous studies, however, have shown only a partial reduction of functional abduction force after paralyzing the gluteus medius and minimus. This study aimed to investigate the effects of experimentally induced sequential paralysis of the tensor fasciae latae, gluteus medius and minimus, and gluteus maximus on the Trendelenburg and Duchenne signs. METHODS:Ten healthy adults received sequential nerve blocks of the branch of the superior gluteal nerve to the tensor fasciae latae, the branch of the superior gluteal nerve to the gluteus medius and minimus, and the inferior gluteal nerve supplying the gluteus maximus. After each block, participants performed a ten-second single-leg stance recorded with 56 skin markers and 27 cameras. Pelvic drop and spinal obliquity were analyzed to determine the presence of a Trendelenburg or Duchenne sign. FINDINGS:Paralysis of the tensor fasciae latae resulted in compensatory mechanisms in 2 of 10 participants. Following paralysis of the gluteus medius and minimus, 5 of 10 could not maintain single-leg stance for ten seconds and one exhibited a Trendelenburg sign. Gluteus maximus paralysis led to failure in 5 of 10 participants, with two showing a Duchenne sign. INTERPRETATION:Our study demonstrates that the Trendelenburg and Duchenne signs lack both sensitivity and specificity and should not be solely attributed to gluteus medius and minimus weakness. Importantly, impairment of the gluteus maximus may also produce similar compensatory patterns or mask abductor deficits.

Inguinal nerve blocks are useful for postoperative pain control after inguinal hernia repair in adults and children. The benefits of diagnostic and therapeutic inguinal nerve blocks in chronic pain patients after hernia repair are discussed controversial. The ilioinguinal and ilihypogastric nerves are best visible by ultrasound about 5 cm cephalad and slightly lateral to the anterior superior iliac spine. Because the transducer must be tilted slightly caudal and the medial transducer edge has to be pressed dorsal for best visualization of the nerves, an out-of-plane approach from caudal to cranial is recommended.

BACKGROUND:Effective postoperative pain control remains a major challenge in spine surgery. Local wound infiltration with anesthetics is a simple component of multimodal analgesia, yet high-quality comparative data between different infiltration regimens are limited. PURPOSE:To evaluate the analgesic efficacy and safety of ropivacaine and levobupivacaine/tramadol wound infiltration compared with placebo in lumbar spine surgery. STUDY DESIGN/SETTING:Prospective, randomized, double-blind, controlled clinical trial. PATIENT SAMPLE:A total of 125 patients undergoing elective primary or revision lumbar spine surgery. OUTCOME MEASURES:Postoperative pain intensity (VAS 2-12 hours), opioid consumption (24 hours), length of hospital stay, sick leave, and adverse events. METHODS:Patients were randomized to receive intraoperative epifascial and subcutaneous wound infiltration with either 0.9% saline (placebo), 0.75% ropivacaine, or 0.5% levobupivacaine+tramadol (100 mg). Outcomes were analyzed using mixed-effects linear models and nonparametric tests. RESULTS:There were no significant differences in postoperative pain scores or opioid consumption between treatment groups at any time point. Hospital stay and functional recovery were comparable. Sick leave duration was shorter in the ropivacaine group compared with placebo (p=.021). No infiltration-related adverse events occurred. CONCLUSIONS:Local wound infiltration with ropivacaine or levobupivacaine/tramadol is safe but does not provide a clinically meaningful benefit in early postoperative pain control or opioid reduction after lumbar spine surgery. Broader multimodal strategies may be required to achieve optimal postoperative recovery.

While limited data on the impact of implementing guidelines in airway management on outcomes exist, there is a consensus that the implementation and the adherence to guidelines enhance patient safety. Recently, the Swiss Society for Anesthesiology and Perioperative Medicine (SSAPM) endorsed the guidelines of The Fondation Latine des Voies Aériennes (FLAVA) as the official guidelines for airway management in Switzerland. This study aimed to determine current practice of airway management in Switzerland. To determine the available equipment, the differences between institutions and between specialists and residents in dealing with airway management. In collaboration with the SSAPM, a covering letter with a survey link to the questionnaire used in the online airway management survey among German anesthesiologists was sent to all heads of departments of anesthesia and members of the SSAPM in August 2023. The participants (residents and specialists) were asked about their personal and institutional backgrounds, access to airway management devices, awareness of recognized airway management guidelines and the importance and application of airway management techniques. Overall, 555 anesthesiologists participated in the survey (response rate 21

Clinical practice in patients at risk of pulmonary aspiration varies widely. However, data on actual management, decision-driving factors and controversial issues remain elusive. We aimed to comprehensively review the management of patients at risk of pulmonary aspiration and identify controversies among anaesthesia professionals. National interprofessional survey. All anaesthesia departments in Switzerland. The survey was distributed electronically to all members of the Swiss Society of Anaesthesiology and Perioperative Medicine, members of the Swiss Interest Group for Anaesthesia Nursing and all department heads in Switzerland. None. Consensus and controversies in clinical practice and management of patients at risk of pulmonary aspiration. A total of 684 respondents were included in the final analysis (59 department heads, 366 consultants, 99 registrars, 160 nurse anaesthetists). The response rate from physicians was 47%. Consensus (>80% agreement or disagreement) was reached on 9/12 (75%) questions regarding preparation for rapid sequence induction (RSI), 6/13 (46%) regarding RSI practice and 3/8 (38%) regarding management of aspiration incidents. Major controversies included high-flow pre-oxygenation (55% agreement), the validity of modified RSI in adults (52% agreement), the primary use of video-laryngoscope (76% agreement) and management of apparent regurgitation. Subjective factors such as clinical presentation were considered more important than objective factors such as medical history, comorbidities or gastric ultrasound. Across a wide range of experience and professional groups, we found a strong consensus on the indication and performance of ’traditional’ RSI. However, clinical decision-making still relies heavily on subjective impressions, while newer risk stratification and management techniques remain controversial.

International survey. Thromboprophylaxis after thoraco-lumbar spine surgery has been a source of controversy for decades. Clear evidence-based guidelines for the best prophylaxis modality are still missing. In this international survey, we asked spine surgeons about their clinical practices. A survey was distributed electronically to global members of the AO Spine community. The survey consisted of 27 questions of which 14 were analyzed in this study. Twelve questions addressed general information and two the way in which thromboprophylaxis was performed in patients with or without heightened risk of venous thromboembolism by using LMWH, UFH or other methods. We defined consensus for binary (yes/no) questions at > 80

Introduction Lunges are commonly used in resistance training and rehabilitation as functional closed kinetic chain exercises. The gluteal muscles play a critical role in stabilizing the hip and pelvis during such movements. Research question How does selective experimentally-induced gluteal muscle paralysis affect joint kinematics, joint reaction forces (JRFs), and dynamic balance during lunge performance? Methods Ten healthy adults underwent sequential blocks of 1) branch of the superior gluteal nerve to the tensor fasciae latae (SGNtfl) muscle, 2) superior gluteal nerve (SGN), and 3) inferior gluteal nerve (IGN) on the dominant right leg. Participants performed forward lunges under control and post-block conditions. Kinematic data were recorded using a 3D motion capture system, ground reaction forces were collected via dual force plates, and joint reaction forces were estimated using musculoskeletal modeling. Results For the affected right leg leading the lunge, SGN and IGN blocks resulted in a significantly higher lunge position (SGN: + 45 mm; IGN: + 33 mm), driven by reduced right knee and ankle flexion and diminished left hip extension. Following the SGN block, pelvic flexion and rotation toward the affected (right) side were observed. JRFs were significantly reduced in the right hip, knee, and ankle (average maximum difference hip: 100 % BW, knee: 200 % BW, ankle: 50 % BW). Conclusion Despite altered mechanics and reduced joint loading following selective gluteal paralysis, participants were able to complete the lunge task, even if the lunge position was higher, and compensatory pelvic flexion and rotation towards the affected side occurred.

BACKGROUND:Clinical practice in patients at risk of pulmonary aspiration varies widely. However, data on actual management, decision-driving factors and controversial issues remain elusive. OBJECTIVE:We aimed to comprehensively review the management of patients at risk of pulmonary aspiration and identify controversies among anaesthesia professionals. DESIGN:National interprofessional survey. SETTING:All anaesthesia departments in Switzerland. PARTICIPANTS:The survey was distributed electronically to all members of the Swiss Society of Anaesthesiology and Perioperative Medicine, members of the Swiss Interest Group for Anaesthesia Nursing and all department heads in Switzerland. INTERVENTION:None. MAIN OUTCOME MEASURES:Consensus and controversies in clinical practice and management of patients at risk of pulmonary aspiration. RESULTS:A total of 684 respondents were included in the final analysis (59 department heads, 366 consultants, 99 registrars, 160 nurse anaesthetists). The response rate from physicians was 47%. Consensus (>80% agreement or disagreement) was reached on 9/12 (75%) questions regarding preparation for rapid sequence induction (RSI), 6/13 (46%) regarding RSI practice and 3/8 (38%) regarding management of aspiration incidents. Major controversies included high-flow pre-oxygenation (55% agreement), the validity of modified RSI in adults (52% agreement), the primary use of video-laryngoscope (76% agreement) and management of apparent regurgitation. Subjective factors such as clinical presentation were considered more important than objective factors such as medical history, comorbidities or gastric ultrasound. CONCLUSION:Across a wide range of experience and professional groups, we found a strong consensus on the indication and performance of 'traditional' RSI. However, clinical decision-making still relies heavily on subjective impressions, while newer risk stratification and management techniques remain controversial.

BACKGROUND:While limited data on the impact of implementing guidelines in airway management on outcomes exist, there is a consensus that the implementation and the adherence to guidelines enhance patient safety. Recently, the Swiss Society for Anesthesiology and Perioperative Medicine (SSAPM) endorsed the guidelines of The Fondation Latine des Voies Aériennes (FLAVA) as the official guidelines for airway management in Switzerland. This study aimed to determine current practice of airway management in Switzerland. OBJECTIVE:To determine the available equipment, the differences between institutions and between specialists and residents in dealing with airway management. METHODS:In collaboration with the SSAPM, a covering letter with a survey link to the questionnaire used in the online airway management survey among German anesthesiologists was sent to all heads of departments of anesthesia and members of the SSAPM in August 2023. The participants (residents and specialists) were asked about their personal and institutional backgrounds, access to airway management devices, awareness of recognized airway management guidelines and the importance and application of airway management techniques. RESULTS:Overall, 555 anesthesiologists participated in the survey (response rate 21%). The main findings were: in general, Swiss anesthesia departments are well-equipped and adhere to airway management guidelines. The guidelines of FLAVA are only known by just over 50%. The vast majority used the traditional screening tests to identify an airway that might be potentially difficult to manage. Of the respondents, 25% still adhere to the myth that a mask ventilation check is necessary before the administration of a muscle relaxant and 14% said that their institution used video laryngoscopy as the primary intubation device. More than 80% think that the expertise to perform awake fiberoptic intubation is important for their daily practice; however, 31% consider their expertise in this technique to be insufficient. In other words, there is a big safety gap. CONCLUSION:Swiss anesthesia departments are well-equipped and adhere to airway management guidelines. The need for regular training to gain and maintain expertise in managing difficult airways, especially to future specialists, still prevails. Thus, developing and establishing a nationwide educational program in airway management and its continuous evaluation would be a milestone for patient safety.

Hip abductors are essential for hip function. To understand abduction weakness, it is important to know which muscles contribute to abduction force. Our aim was to investigate the effects of an experimentally induced weakness of the different muscles (tensor fasciae latae [TFL], gluteus medius and minimus (Gmed/min), gluteus maximus [Gmax]) on the abduction force. Ten participants received sequential nerve blocks of the TFL, the Gmed/min, and the Gmax. Subsequently, abduction force was measured in the lateral decubitus position in three sagittal positions of the hip (30° flexion, neutral, 30° extension). In 30° flexion, the average abduction force was 220 N without block, 187 N with block of the TFL, 83 N with block of the Gmed/min, and 97 N with block of the Gmax, respectively. In neutral position, average abduction force was 213 N without block, 200 N with block of the TFL, 82 N with block of the Gmed/min, and 115 N with block of the Gmax, respectively. In 30° extension, average abduction force was 116 N without block, 146 N with block of TFL, 61 N with block of the Gmed/min, and 94 N with block of the Gmax, respectively. An induced weakness of the TFL reduces abduction force only in 30° of hip flexion by 15%. It is not highly relevant as an abductor. An induced weakness of the Gmax reduces abduction force in flexion by 43%-56%, depending on the position. It is, therefore, highly relevant as an abductor of the hip.

PURPOSE:The radial nerve may be painfully irritated or damaged by open reduction and internal fixation (ORIF) of humeral fractures. Secondary radial nerve lesions after ORIF of humeral shaft fractures are described in up to 16%. Not only peripheral nerves but also orthopaedic instruments and osteosynthesis material are well visible by ultrasound. The aim of this study was to evaluate the accuracy of ultrasound in assessing the relation between the bone overlapping screw tips and the radial nerve close to the humeral bone. METHODS:Ultrasound-guided drilling was used to place screws as close as possible to the radial nerve in 8 humeral bones of four cadavers. The relation between the radial nerve and the screw tips was assessed by high-resolution ultrasound, and the overlap of all screw tips over the bone was measured by ultrasound and fluoroscopy. Thereafter, the findings were validated by anatomical dissection. RESULTS:We could correctly identify all screw tips and their relation to the radial nerve by ultrasound. In 7 of 8 cases, the screw tip had direct contact with the radial nerve. The overlaying length of the screw tip was accurately measured by using ultrasound in all cases. In contrast fluoroscopy underestimated this length in 50% of cases. CONCLUSION:With this study, we show that ultrasound can reliable visualize the screw tips and its relation to the radial nerve. Ultrasound is a promising diagnostic tool to evaluate patients with radial nerve irritations or lesions after ORIF of humeral fractures. Furthermore, ultrasound could be an adequate tool to guide drilling.

Deuxième liste Top 5 Anesthésiologie et médecine périopératoireRecommandations smarter medicine publie une deuxième liste Top 5 en collaboration avec la Société Suisse d' Anesthésiologie et de Médecine Périopératoire (SSAPM).Celle-ci énumère cinq autres traitements inutiles auxquels il est possible de renoncer, de façon à apporter une contribution importante à l'initiative «smarter medicine».

BACKGROUND:Previous studies have shown that dexamethasone has a positive effect on postoperative pain control, opioid consumption, nausea, and vomiting and length of hospital stay after arthroplasty surgery.PURPOSE/HYPOTHESIS:The purpose of this study was to assess whether adding perioperative dexamethasone to our current pain regimen after hip arthroscopy is more effective than a placebo. It was hypothesized that dexamethasone would reduce postoperative pain, reduce opioid consumption, improve subjective pain and nausea scores, and reduce the number of vomiting events.STUDY DESIGN:Randomized controlled trial; Level of evidence, 1.METHODS:A total of 50 patients requiring unilateral elective hip arthroscopy were randomized to receive intravenous dexamethasone immediately before induction of anesthesia and at 8 am on the first postoperative day (2 ×12 mg) or a placebo (sodium chloride 0.9%). The patient, the surgeons, the treating anesthesiologist, and the involved nursing and physical therapy personnel were blinded to group assignment. The primary outcome was postoperative pain, and secondary outcomes were opioid consumption and nausea scores-assessed using a translated revised version of the American Pain Society Patient Outcome Questionnaire 6 hours postoperatively and on days 1 and 2-and vomiting events. A clinical follow-up was performed 12 weeks postoperatively to assess adverse events.RESULTS:The mean age at inclusion was 29 years in both groups. Postoperative pain levels did not differ significantly in most instances. Opioid requirements during the hospitalization in the dexamethasone group were significantly lower than those in the placebo group (31.96 ± 20.56 mg vs 51.43 ± 38 mg; P = .014). Significantly fewer vomiting events were noted in the dexamethasone group (0.15 ± 0.59 vs 0.65 ± 0.91; P = .034). Descriptive data and surgical parameters did not differ significantly.CONCLUSION:Perioperative intravenous dexamethasone significantly reduced postoperative opioid consumption by 40% without compromising pain level and safety, as no corticosteroid-related side effects were observed. Dexamethasone may be a valuable adjuvant to a multimodal systemic pain regimen after hip arthroscopy.REGISTRATION:NCT04610398 (ClinicalTrials.gov identifier).

Heart rate (HR) is closely related to heart rhythm patterns, and its irregularity can imply serious health problems. Therefore, HR is used in the diagnosis of many health conditions. Traditionally, HR has been measured through an electrocardiograph (ECG), which is subject to several practical limitations when applied in everyday settings. In recent years, the emergence of smartphones and microelectromechanical systems has allowed innovative solutions for conveniently measuring HR, such as smartphone ECG, smartphone photoplethysmography (PPG), and seismocardiography (SCG). However, these measurements generally rely on external sensor hardware or are highly susceptible to inaccuracies due to the presence of significant levels of motion artifact. Data from gyrocardiography (GCG), however, while largely overlooked for this application, has the potential to overcome the limitations of other forms of measurements. For this scoping review, we performed a literature search on HR measurement using smartphone gyroscope data. In this review, from among the 114 articles that we identified, we include seven relevant articles from the last decade (December 2012 to January 2023) for further analysis of their respective methods for data collection, signal pre-processing, and HR estimation. The seven selected articles' sample sizes varied from 11 to 435 participants. Two articles used a sample size of less than 40, and three articles used a sample size of 300 or more. We provide elaborations about the algorithms used in the studies and discuss the advantages and disadvantages of these methods. Across the articles, we noticed an inconsistency in the algorithms used and a lack of established standardization for performance evaluation for HR estimation using smartphone GCG data. Among the seven articles included, five did not perform any performance evaluation, while the other two used different reference signals (HR and PPG respectively) and metrics for accuracy evaluation. We conclude the review with a discussion of challenges and future directions for the application of GCG technology.

Application for ESRA Abstract Prizes: I apply as an Anesthesiologist (Aged 35 years old or less) Background and Aims This study compares perioperative complications of patients undergoing general anaesthesia (GA), spinal anaesthesia (SA) or isolated peripheral triple nerve blocks (NB) for total knee replacement surgery in high risk patients. Methods In this retrospective single center study, 329 patients (ASA≥III), scheduled for elective total knee replacement between 2014 and 2020 were included. All patients received a femoral catheter and a proximal sciatica nerve block for perioperative analgesia. Patients in the NB group received an additional obturator nerve block. Due to failure resulting from insufficient block or patients expressing their wish for a general anaesthesia, patients were assigned according to the definitive anaesthesia method. There were 22 individuals in the NB-, 171 patients in the SA – and 136 patients in the GA group. Perioperative parameters, events and costs were compared. Differences between groups were compared using the chi- square test. Results The NB group showed a significantly better haemodynamic stability intraoperatively with less vasopressor consumption, respectively less relevant hypotension. In 73% of patients in the NB group a PACU-Bypass was achieved (vs 34% in SA group vs 13%in GA group). This influenced the overall costs positively. Remarkably, during the initial 24 hours, no episodes with severe pain (visual analog scale score > 30) were observed in the NB group. Regarding other postoperative complications we could not observe a statistically significant difference. Conclusions In summary, the use of triple block as an isolated technique for total knee replacement surgery in specific high-risk patients appears to be a safe option with less haemodynamic complications.

Background and Aims This study compares the perioperative complication rates of interscalene brachial plexus catheters (ISC) alone compared to the combination with general anaesthesia (GA) for total shoulder replacement in high risk patients. Methods 196 patients (ASA≥III), undergoing elective total shoulder replacement between 2014 and 2020 were included retrospectively. The data of 107 patients scheduled for isolated ISC were compared to those of 89 patients with planned GA in addition to ISC. Cardiovascular complications are defined as a decrease in MAP >20% of preoperative MAP, hypertension and tachycardia requiring therapy. Logistic regression analysis was used to calculate univariable and multivariable odds ratios (OR; 95% confidence interval). Results The ISC group showed a significantly better hemodynamic stability during surgery with less vasopressor consumption (Ephedrine-Bolus:31% vs. 73% p<0.001, Norepinephrine/Phenylephrine Bolus: 7% vs. 35% p< 0.001) and less volume supplementation (1069 ml ±463 vs 1308 ±501 p<0.001). Relevant hypotension occurred less frequently (35% vs 82% p < 0.001). (1) Regarding postoperative complications, we found a decreased risk of respiratory (4% vs. 12% p < 0.02) as well as cardiovascular complications (15% vs. 38% p < 0.001) in the ISC group. (3) General anaesthesia remained an independent risk factor for cardiovascular complications after the adjustment for potential confounders (OR: 5.9; 95% CI 2.4- 14.1). Conclusions Isolated ISC can be considered as superior to combined anaesthesia for total shoulder replacement (2) even in cardiovascular high-risk patients.