Oral piercing: risk of aspiration.
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Adult↗
Biomedical subjects
C A Greim
Publications and source records attributed to C A Greim.
Sonographic imaging of the sciatic nerve division in the popliteal fossa.
BACKGROUND: We studied the anatomy of the sciatic nerve and its division into the tibial and peroneal part using handheld ultrasound in adults. We wanted to evaluate the feasibility of ultrasound-guided identification of the sciatic nerve in the popliteal fossa and the correlation of the findings by ultrasound with patients' characteristics. METHODS: 74 volunteers were randomly selected. Using a handheld ultrasound system with a 5-10 MHz linear array probe the popliteal fossa and the back of the thigh were examined and measured. Using a caliper the distance of the joint line to the nerve division was measured. The sciatic nerve and its division were depicted by ultrasound. RESULTS: We could depict the sciatic nerve in all volunteers and its division in 53 of 74 (72%) volunteers. The position of nerve division showed large anatomic variation. A significant correlation between the width of the knee-joint line and the depth of the nerve division could be demonstrated. We conclude that handheld ultrasound is able to depict the sciatic nerves division. To block the nerve by one injection a more proximal access or visualization by mobile ultrasound is recommended. In addition the surrounding anatomic structures can be depicted as well.
Adolescent↗
[Pain management in shoulder surgery].
Surgical procedures in the region of the shoulder joint are among the most painful interventions in orthopedic practice. For this reason, in addition to intravenous pain therapy with opioids, blockade of the brachial plexus has become established as an effective method to provide analgesia.High-resolution ultrasound offers the possibility of performing nerve blockades under visual monitoring. Studies on interscalene blockade performed under sonographic control provide evidence for both the high efficacy and safety of the procedure. Clinically manifest signs of nerve damage have not appeared with use of this method. Smaller operations can usually be adequately managed with perioperative single-shot blockade. More extensive operations for which severe pain lasting for several days can be expected and surgical interventions involving preexistent shoulder stiffness necessitate catheterization for uninterrupted pain therapy. Successful rehabilitation after shoulder surgery requires diligent perioperative pain blockade, which can primarily be provided by interscalene plexus blockade.
Humans↗
Treatment of hiccup during general anaesthesia or sedation: a qualitative systematic review.
BACKGROUND AND OBJECTIVE: Acute hiccup is a minor complication that can occur during sedation or general anaesthesia. The disorder can disturb the surgical field, might interfere with lung ventilation or could hamper diagnostic procedures. The objective was to perform a systematic search for interventions aimed at treating hiccup occurring during anaesthesia or sedation. METHODS: A systematic search for reports describing interventions to treat hiccup in conjunction with anaesthesia was carried out (MEDLINE, EMBASE, Cochrane-Library, manual screening of reference lists and review articles, up to December 2001). Search terms were 'hiccup', 'singultus' or 'hiccough'. RESULTS: Twenty-six reports involving approximately 581 patients focused on hiccup remedies in the anaesthesia setting. Only one report was substantiated by a randomized controlled trial. This investigated methylphenidate 10 mg intravenously in 51 patients, which did not show a beneficial effect compared with placebo. Hiccup was a self-limiting phenomenon. Case series and case reports focused on various systemically applied drugs in 12 reports, stimulating techniques (e.g. pharyngeal stimulation) in seven, topical applied remedies (e.g. intranasal ice-cold water) in four, and ventilation techniques (e.g. continuous positive pressure ventilation) in two. CONCLUSIONS: A large variety of interventions have been proposed for the treatment of hiccup during anaesthesia and sedation. However, perioperative treatment is still based on empirical findings and no treatment is 'evidence-based'. Thus, no valid recommendations for the treatment of hiccup can be derived. Uncontrolled observations are inadequate to establish treatment efficacy.
Anesthesia, General↗
Effects of intra-abdominal CO2-insufflation on normal and impaired myocardial function: an experimental study.
BACKGROUND: Intra-abdominal pressure (IAP) elevation during CO2-pneumoperitoneum increases cardiac afterload and may enhance dysfunction of the already compromised heart. This study focused on the effects of acute IAP increases on left and right ventricular loadings and contractility in the heart with impaired global function. METHODS: Impairment of myocardial function (IMF) was pharmacologically induced in 16 pigs by administration of halothane and propranolol, while baseline arterial pressure was maintained by intravenous phenylephrine. Intra-abdominal pressure was gradually increased by 10 mmHg up to 30 mmHg in the supine position (IMF group 1, n = 8) or in a head-down tilted position (IMF group 2, n = 8). In two control groups with normal myocardial function, IAP was also increased in the supine position or the head-down tilted position. Cardiac function in all groups was assessed by epicardial echocardiography, intraventricular pressure measurements and pulmonary artery catheterization. RESULTS: The increase in IAP was accompanied by a transient rise in LV end-systolic wall stress and reduced cardiac output significantly by 16-24% in all groups. In the IMF groups, LV end-diastolic transmural pressure increased by 34-60% to peak values of 24 mmHg, while cross-sectional LV end-diastolic areas remained unchanged. Increases in right ventricular end-diastolic volume and decreases in right ventricular ejection fraction as well as in cardiac output were most pronounced at IAP 20 mmHg and significantly stronger in both IMF groups than in the control groups (P < 0.001). CONCLUSION: Following the acute elevation of IAP, the right ventricular volume load shifted more extensively in the IMF groups than in the animals with normal myocardial function. Myocardial function in the impaired heart may worsen during IAP elevation due to right ventricular load alterations rather than a LV afterload increase.
Abdomen↗
Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: a randomized controlled trial of factorial design.
BACKGROUND: Despite intensive research, the main causes of postoperative nausea and vomiting (PONV) remain unclear. We sought to quantify the relative importance of operative, anaesthetic and patient-specific risk factors to the development of PONV. METHODS: We conducted a randomized controlled trial of 1180 children and adults at high risk for PONV scheduled for elective surgery. Using a five-way factorial design, we randomly assigned subjects by gender who were undergoing specific operative procedures, to receive various combinations of anaesthetics, opioids, and prophylactic antiemetics. RESULTS: Of the 1180 patients, 355 (30.1% 95% CI (27.5-32.7%)) had at least one episode of postoperative vomiting (PV) within 24 h post-anaesthesia. In the early postoperative period (0-2 h), the leading risk factor for vomiting was the use of volatile anaesthetics, with similar odds ratios (OR (95% CI)) being found for isoflurane (19.8 (7.7-51.2)), enflurane (16.1 (6.2-41.8)) and sevoflurane (14.5 (5.6-37.4)). A dose-response relationship was present for the use of volatile anaesthetics. In contrast, no dose response existed for propofol anaesthesia. In the delayed postoperative period (2-24 h), the main predictors were being a child (5.7 (3.0-10.9)), PONV in the early period (3.4 (2.4-4.7)) and the use of postoperative opioids (2.5 (1.7-3.7)). The influence of the antiemetics was considerably smaller and did not interact with anaesthetic or surgical variables. CONCLUSION: Volatile anaesthetics were the leading cause of early postoperative vomiting. The pro-emetic effect was larger than other risk factors. In patients at high risk for PONV, it would therefore make better sense to avoid inhalational anaesthesia rather than simply to add an antiemetic, which may still be needed to prevent or treat delayed vomiting.
Adolescent↗
Vertical infraclavicular brachial plexus block in a child with cystic fibrosis.
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Brachial Plexus↗
What can be expected from risk scores for predicting postoperative nausea and vomiting?
Several risk scores have been developed to calculate the probability of postoperative nausea and vomiting (PONV). However, the power to discriminate which individual will suffer from PONV is still limited. Thus, we wondered how the number of predictors in a score affects the discriminating power and how the characteristics of a population--which is needed to measure the power of a score--may affect the results. For ethical reasons and to be independent from centre specific populations, we developed a computer model to simulate virtual populations. Four populations were created according to number, frequency, and odds ratio of predictors. Population I: parameters were derived from a previously published paper to verify whether calculated and reported values are in accordance. Population II: a gynaecological population was created to investigate the impact of the study setting. Populations III and IV: to meet ideal assumptions a model with up to seven predictors with an odds ratio of 2 and 3 was tested, respectively. The discriminating power of a risk score was measured by the area under a receiver operating characteristic curve (AUC) and an increase of more than 0.025 per predictor was considered to be clinically relevant. The AUC of population I was similar to those reported in clinical investigations (0.72). The study setting had a considerable impact on the discriminating power since the AUC decreased to 0.65 in a gynaecological setting. The AUC with the 'idealized' populations III and IV was at best in the range of 0.7-0.8. The inclusion of more than five predictors did not lead to a clinically relevant improvement. The currently available simplified risk scores (with four or five predictors) are useful both as a method to estimate individual risk of PONV and as a method for comparing groups of patients for antiemetic trials. They are also superior to single predictor models which are just using the patients' history of PONV or female gender alone. However, our analysis suggests that the power to discriminate which indvidual will suffer from PONV will remain imperfect, even when more predictors are considered.
Area Under Curve↗
The detection of interatrial flow patency in awake and anesthetized patients: a comparative study using transnasal transesophageal echocardiography.
UNLABELLED: The Valsalva maneuver in the awake patient and the ventilation maneuver in the tracheally intubated anesthetized patient are two provocation methods to detect a patent foramen ovale (PFO) by means of contrast transesophageal echocardiography. In 60 patients undergoing posterior fossa surgery, a contrast agent was administered via a peripheral vein during a Valsalva maneuver immediately before anesthesia induction, followed by central venous administration during a ventilation maneuver in the same patients when anesthetized and endotracheally intubated. We evaluated both maneuvers with a 32-element monoplane transnasal transesophageal echocardiography probe to trace the atrial flow of the contrast agent in a 90 degrees bicaval view. A maneuver was rated positive when more than four bubbles appeared in the left atrium during the first three cardiac cycles after intrathoracic pressure release. The right atrial cross-sectional area before pressure release, and the peak septal excursion during atrial contrast opacification, were measured. McNemar's test was used to assess a paired dichotomous response on the two maneuvers for a significant difference. In 56 patients, the ventilation maneuver was significantly (P < 0.037) more often positive for PFO (n = 14) than the Valsalva maneuver (n = 7). Although there was no difference in the methods regarding the peak septal excursion, the mean right atrial area before pressure release was significantly smaller during the ventilation maneuver than during the Valsalva maneuver (11.2 +/- 3.1 cm(2) vs 14.4 +/- 3.3 cm(2), n = 42, P < 0.05). In the patients with a positive ventilation, but a negative Valsalva maneuver, the discrepancy was even larger (10.9 +/- 4.4 cm(2) vs 16.3 +/- 4.2 cm(2), n = 7, P < 0.001). We conclude that the ventilation maneuver is superior to the Valsalva maneuver in detecting PFO. Our data suggest that a peak pressure of 30 cm H(2)O during the ventilation maneuver achieves a more pronounced reduction in right atrial load and allows right atrial pressure to exceed left atrial pressure when intrathoracic pressure is released. IMPLICATIONS: A controlled ventilation maneuver in anesthetized patients immediately before posterior fossa surgery may be superior to the preoperative Valsalva maneuver in detecting a patent foramen ovale by contrast transesophageal echocardiography. This approach identifies patients at high risk for paradoxic embolism, but it is not practical for preoperative identification of patients who might benefit from patent foramen ovale closure before surgery.
Anesthesia↗
Facilitation of pulmonary artery catheter placement by transesophageal echocardiography after tricuspid valve surgery.
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Aged↗
An increased body mass index is no risk factor for postoperative nausea and vomiting. A systematic review and results of original data.
BACKGROUND: An increased Body Mass Index (BMI) is almost always mentioned as a fundamental risk factor for postoperative nausea (PN), vomiting (PV) or both (PONV). However, multivariate analyses were unable to detect any correlation. Therefore, we asked whether an increased BMI is really a risk factor for PONV. METHODS: For the systematic review, a search of electronic databases and a detailed manual search of reviews were carried out. For the analysis of the original data, 587 adult patients from a randomised controlled antiemetic trial (RCT) who underwent general anaesthesia were allocated to four weight groups: Underweight (BMI < 20), Normal Weight (BMI 20-25), Overweight (BMI 25-30) and Obesity (BMI > or = 30). RESULTS: Four publications with original data were found. Two described a positive relationship, although not clearly supported by the data. Despite this, most narrative reviews claimed a positive correlation between obesity and PONV by quoting again narrative reviews or misquoting originals. In the RCT, the calculated underlying risk profile for PONV was comparable between all groups. Incidences (95% confidence intervals) of PONV were 45.8% (34.0; 57.6), 41.7 (36.5; 46.9), 47.8 (38.4; 57.1) and 44.1 (31.0; 57.1), for the groups Underweight, Normal Weight, Overweight and Obesity, respectively (P=0.69). The incidences of PN and PV also did not differ with P=0.76 and P=0.36, respectively. CONCLUSION: Systematic search of the literature provides no evidence for a positive relationship. Furthermore, our data confirm that an increased BMI is not a risk factor for PONV. This negative finding is important as focussing on the relevant risk factors is needed to allow for an objective risk assessment of PONV.
Body Mass Index↗
Intracavitary contrast intensity after transpulmonary transmission of a second-generation contrast agent at normal and reduced myocardial contractility.
In this closed-chest preparation in 10 anesthetized pigs, we determined the effects of left ventricular (LV) contractility changes on the echocardiographic contrast intensity variation of a second-generation contrast agent within the LV cavity. The peak positive rate of change in LV pressure (dP/dt(max)), as an index of the isovolumetric phase, was gradually reduced by administration of halothane and propranolol, and the velocity of circumferential fiber shortening (Vcfs) was referenced as an index for the LV ejection phase. Contrast intensity-time curves of the LV cavity were obtained after transpulmonary transmission of the contrast agent. An off-line densitometric method was performed to determine peak maximum and minimum intensities (I(max), I(min)) and their difference (I(amp)). Compared with baseline values, at reductions in dP/dt(max) of 50% and 75%, the contrast intensity parameters I(max), I(min), and I(amp) were decreased by 23% +/- 6% and 44% +/- 5%, 24% +/- 5% and 44% +/- 3%, and 31% +/- 6% and 45% +/- 3%, respectively (P <.05). Significant correlations were observed between I(amp) and dp/dt(max) (r = 0.82, P <.003, n = 30) and their changes (r = 0.59, P <.03, n = 20), but correlations between contrast indexes and Vcfs were only moderate. The sensitivity of I(amp) to indicate changes in dP/dt(max) and Vcfs was 0.95 and 0.83, respectively. The cyclic variation of LV intracavitary contrast intensity reflects the isovolumetric contraction phase better than the ejection phase. The results suggest that measurements of cyclic intensity changes may contribute to the assessment of myocardial contractility changes. Underlying biophysical mechanisms and load dependency of this phenomenon require further investigation.
Animals↗
Methodological problems arising from 'serial publishing' on the effectiveness of granisetron in PONV.
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Antiemetics↗
Transnasal transesophageal echocardiography: a modified application mode for cardiac examination in ventilated patients.
UNLABELLED: In 42 endotracheally intubated patients, we examined the utility of a miniaturized monoplane probe for transnasal transesophageal echocardiography (TEE). Transnasal TEE was prospectively evaluated in 26 deeply and 16 mildly sedated patients receiving topical anesthesia with lidocaine jelly 2%. The patients with deep sedation were additionally examined with transoral monoplane and multiplane TEE. Transnasal esophageal insertion of the TEE probe was successfully performed in 90% of patients. Endotracheal malpositioning was corrected in two patients. Nasal bleeding required treatment in another patient. Topical anesthesia was adequate in 82% of mildly sedated patients. Left ventricular short- and four-chamber long-axis views of good quality were obtained with transnasal (transoral) monoplane TEE in 76% (81%) and 92% (96%) of patients (differences not significant). Compared with conventional multiplane TEE, transnasal monoplane TEE missed diagnoses in 19% of patients. The relative error (mean +/- SEM) of quantification with transnasal TEE was <9% +/- 2% for ventricular diameters and <7% +/- 2% for cross-sectional area measurements, with a bias of 0.5 +/- 3.8 cm2 and 0.1 +/- 2.4 cm2 (mean +/- 2 SD) for left ventricular end-diastolic and end-systolic short-axis areas. The relative error in measuring intracardiac flow velocities was >40%, but systolic to diastolic peak velocity ratios at the valvular site were determined with an error <4% +/- 3%. Transnasal monoplane TEE can be performed even in mildly sedated patients with an endotracheal tube without further need for analgesia or sedation. The technique is as useful as conventional transoral TEE to image standard tomographic planes for quantification, but it is less suited for comprehensive echocardiographic diagnosing. IMPLICATIONS: Transnasal insertion of a miniaturized monoplane transesophageal echocardiography (TEE) probe was studied in endotracheally intubated patients. Nasal passage was well tolerated even by patients with only mild sedation. Imaging quality was similar to conventional transoral monoplane TEE with larger transducers, but technical restraints cause a deficit in complete cardiac diagnosing obtained with multiplane TEE.
Anatomy, Cross-Sectional↗
A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers.
BACKGROUND: Recently, two centers have independently developed a risk score for predicting postoperative nausea and vomiting (PONV). This study investigated (1) whether risk scores are valid across centers and (2) whether risk scores based on logistic regression coefficients can be simplified without loss of discriminating power. METHODS: Adult patients from two centers (Oulu, Finland: n = 520, and Wuerzburg, Germany: n = 2202) received inhalational anesthesia (without antiemetic prophylaxis) for various types of surgery. PONV was defined as nausea or vomiting within 24 h of surgery. Risk scores to estimate the probability of PONV were obtained by fitting logistic regression models. Simplified risk scores were constructed based on the number of risk factors that were found significant in the logistic regression analyses. Original and simplified scores were cross-validated. A combined data set was created to estimate a potential center effect and to construct a final risk score. The discriminating power of each score was assessed using the area under the receiver operating characteristic curves. RESULTS: Risk scores derived from one center were able to predict PONV from the other center (area under the curve = 0.65-0.75). Simplification did not essentially weaken the discriminating power (area under the curve = 0.63-0.73). No center effect could be detected in a combined data set (odds ratio = 1.06, 95% confidence interval = 0.71-1.59). The final score consisted of four predictors: female gender, history of motion sickness (MS) or PONV, nonsmoking, and the use of postoperative opioids. If none, one, two, three, or four of these risk factors were present, the incidences of PONV were 10%, 21%, 39%, 61% and 79%. CONCLUSIONS: The risk scores derived from one center proved valid in the other and could be simplified without significant loss of discriminating power. Therefore, it appears that this risk score has broad applicability in predicting PONV in adult patients undergoing inhalational anesthesia for various types of surgery. For patients with at least two out of these four identified predictors a prophylactic antiemetic strategy should be considered.
Adult↗
Non-systematic serial publishing is not appropriate and ethically questionable.
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Antiemetics↗
[Early clinical results with transnasal esophageal echocardiography].
UNLABELLED: Currently undergoing a clinical trial a new miniaturized monoplane ultrasound probe potentially enhances the practicability of perioperative transesophageal echocardiography (TEE) without loss of echocardiographic quality. METHODS: In the present prospective study, the nasally inserted miniaturized TEE probe was tested in 12 ventilated patients and compared with a conventional TEE probe. Echocardiographic quality was tested by two independent investigators by analyzing the percentage of the endocardium contour detection (< 50%, 50-75%, 75-100%) in the left ventricular short- and long-axis views. RESULTS: In 11 patients, more than 50% of endocardium were visualized continuously with both probes. Although the nasal TEE probe was inferior to conventional TEE in detecting lateral endocardium, automated endocardium detection compared well with both methods. Inter- and intraobserver variability in manual measurements of the left ventricular cross-sectional area was below 5% on average and differed non-significantly with regard to the method. In 2 patients, continuous monitoring was aggravated by repeated loss of contact between the miniaturized TEE probe and mucosa. CONCLUSIONS: In comparison with conventional TEE, the miniaturized TEE probe provides practicability advantages without significant loss of information for cardiovascular monitoring.
Adult↗
[Postoperative vomiting. A score for prediction of vomiting risk following inhalation anesthesia].
UNLABELLED: Despite numerous factors are thought to affect postoperative vomiting (PV) recent studies demonstrated that the risk of PV can be predicted by considering just the most important ones. Therefore, the aim of this study was to present the clinically most relevant factors, a risk score based upon those factors and its clinical applicability for other types of surgery. METHODS: In a prospective study 2220 adult inpatients scheduled for elective surgery were monitored for PV after inhalational anaesthesia over 24 hours. None of the patients received prophylactic antiemetic treatment. Multivariate analyses were performed with data of patients who underwent otolaryngological procedures to identify the major risk factors and to derive a risk score. The applicability of the score in surgical and ophthalmological procedures was tested by linear regression analysis of expected and observed incidences. RESULTS: In the multivariate model, clinically most important risk factors for PV were female gender, young age, a positive history of postoperative nausea and vomiting or motion sickness, non-smoking and a long duration of anaesthesia, whereas the relative impact of the "type of operation itself" was small. Expected and observed incidences in patients undergoing other types of surgery were strongly correlated (R2 = 0.99, P < 0.001). CONCLUSION: The risk for PV after inhalational anaesthesia in adults can be predicted using a score which is based on individual risk factors and the duration of anaesthesia only.
Adolescent↗