Υπερηχογραφικά κατευθυνόμενος αποκλεισμός του βραχιονίου πλέγματος κάτωθεν της κλείδας.

Ο αποκλεισμός του βραχιονίου πλέγματος αναφέρεται για πρώτη φορά από τους William Halsted και Richard Hall (1884). Από τότε έχουν χρησιμοποιηθεί αρκετές μέθοδοι για να επιτευχθεί αναισθησία του άνω άκρου μέσω αποκλεισμού του βραχιονίου πλέγματος. Από τις τέσσερις κλασικές προσεγγίσεις, δηλ. διακαλινική, υπερκλείδια, υποκλείδια και μασχαλιαία, στην παρούσα μελέτη θα ασχοληθούμε με τις τρεις τελευταίες. Οι μέθοδοι για τον αποκλεισμό ήταν η έκλυση παραισθησίας, η ψηλάφηση της συνοδού αρτηρίας, η νευροδιέγερση και πιο πρόσφατα ο εντοπισμός με υπερηχογραφική καθοδήγηση. Ο υπερηχογραφικά καθοδηγούμενος αποκλεισμός πλεονεκτεί λόγω του μη επεμβατικού και δυναμικού χαρακτήρα της τεχνικής και έχει μεγαλύτερη αποτελεσματικότητα από τις άλλες μεθόδους. Το βραχιόνιο πλέγμα σχηματίζεται από τους πρόσθιους κλάδους των αυχενικών νεύρων Α5 έως Α8 και από το πρώτο θωρακικό νεύρο (Θ1). Στη συνέχεια σχηματίζονται τα τρία πρωτεύοντα στελέχη του πλέγματος, το άνω, το μέσω και το κάτω, ανάμεσα στον πρόσθιο και τον μέσο σκαληνό μυ. Τα πρωτεύοντα στελέχη περνούν πίσω από την κλείδα, διακλαδίζονται και στη συνέχεια σχηματίζονται τα δευτερεύοντα στελέχη: το έξω, το έσω και το οπίσθιο. Τέλος, στο έξω όριο του ελάσσονος θωρακικού μυός, τα δευτερεύοντα στελέχη δίνουν τους τελικούς κλάδους του βραχιονίου πλέγματος: το μυοδερματικό νεύρο, το μασχαλιαίο νεύρο, το κερκιδικό νεύρο, το μέσο νεύρο και το ωλένιο νεύρο. Ο υποκλείδιος αποκλεισμός του βραχιονίου πλέγματος παρέχει αναισθησία στα άπω 2/3 του βραχίονα και είναι ιδανικός για τοποθέτηση καθετήρα μετεγχειρητικής αναλγησίας. Μπορεί να γίνει σε δύο διαφορετικές θέσεις: στον έξω υποκλείδιο βόθρο ή στον πλευροκλειδικό χώρο. Τα δευτερεύοντα στελέχη του βραχιονίου πλέγματος περιβάλλουν τη μασχαλιαία αρτηρία. Ο κίνδυνος για πνευμοθώρακα είναι μικρός αλλά οι διαταραχές πηκτικότητας είναι σχετική αντένδειξη για την επιτέλεσή του. Ο μασχαλιαίος αποκλεισμός βραχιονίου πλέγματος είναι ο πιο δημοφιλής αποκλεισμός και παρέχει αναισθησία κάτω από τον αγκώνα.. Οι τελικοί κλάδοι του βραχιονίου πλέγματος εντοπίζονται μέσα στο μασχαλιαίο βόθρο, περιμετρικά της μασχαλιαίας αρτηρίας. Υπάρχουν αρκετές ανατομικές παραλλαγές ως προς τη θέση των τελικών κλάδων του βραχιονίου πλέγματος στο έδαφος της μασχάλης. Τέλος, το κερκιδικό, το ωλένιο, το μέσο και το μυοδερματικό νεύρο μπορούν να αποκλειστούν και σε περιφερικότερα σημεία της διαδρομής τους με τη βοήθεια του υπερήχου. Με αυτόν τον τρόπο μπορούμε να βελτιώσουμε έναν κεντρικότερο αποκλεισμό, να τον επιταχύνουμε και να τον παρατείνουμε. Οι αποκλεισμοί των νεύρων αυτών μπορούν να γίνουν είτε πάνω από τον αγκώνα ή κάτω από αυτόν. Με τη βοήθεια του υπερήχου οι αποκλεισμοί έχουν γίνει πιο ασφαλείς, αποτελεσματικοί και ακριβείς. Χρειάζεται, όμως, γνώση της νέας τεχνικής και των οδηγών ανατομικών σημείων. Αντικείμενο της παρούσας μελέτης είναι η παρουσίαση της ανατομίας, της ηχοανατομίας και των τρόπων εκτέλεσης των περιφερικών αποκλεισμών του άνω άκρου κάτω από το επίπεδο της κλείδας με υπερηχογραφική καθοδήγηση. Για το σκοπό αυτό ανατρέξαμε κυρίως στην σχετική βιβλιογραφία των τελευταίων δέκα χρόνων. Τα περισσότερα είναι άρθρα ανασκόπησης. Πρόκειται για ένα σχετικά νέο πεδίο επιστημονικής τεχνικής και το συνολικό συμπέρασμα είναι ότι η χρήση του υπερήχου στους περιφερικούς αποκλεισμούς συμβάλλει αποφασιστικά στην αποτελεσματικότητα, την ασφάλεια και την ακρίβειά τους.Brachial plexus blockade was firstly introduced by William Halsted and Richard Hall in 1884.There are four main approaches from which the brachial plexus can be blocked: interscalene, supraclavicular, infraclavicular and axillary. In this thesis, the three last approaches will be dealt with. There are several techniques used to localise the brachial plexus nerves: eliciting paraesthesias, palpation of accompanying artery, electrical nerve stimulation and most recently, ultrasound guidance. Ultrasound guided blockade has a noninvasive and dynamic nature that leads to higher success rates and less complications. The brachial plexus is derived from the anterior primary rami of C5-C8 and T1 nerves. These roots form the three trunks (superior, middle and inferior) between the anterior and middle scalene muscles. The three trunks separate into anterior and posterior divisions behind the clavicle and subsequently the divisions join to form the three cords: lateral, medial and posterior in relation with the axillary artery. At the lateral border of the pectoralis minor muscle, the cords give rise to their terminal branches: the musculocutaneous, radial, ulnar, median and axillary nerves. Infraclavicular blockade of the brachial plexus provides anaesthesia of the distal two thirds of the arm and is ideal for the placement of an indwelling catheter. It can be performed either in the lateral infraclavicular fossa or in the costoclavicular space. Risk of pneumothorax is small but it should perhaps be avoided in patients receiving anticoagulants in case of inadvertent vascular puncture. Axillary brachial plexus block is the most popular block and provides anaesthesia of the upper limb distal to the elbow. The final branches of the brachial plexus are located in the axillary fossa around the axillary artery. There are several anatomical variations of these nerves and ultrasound guidance is vital for their localization. Finally, the musculocutaneous, radial, ulnar and median nerves can be blocked further down their course under ultrasound guidance. In this way, a proximal brachial plexus block can be hastened, improved and prolonged. Distal nerve blocks of the upper extremity can be performed above or below the elbow. Under ultrasound guidance, brachial plexus blockade has become safer, more efficient and accurate. However, the use of ultrasound is dependent on the operator’s experience as well as his/her knowledge of the relevant anatomy

The Use of the Hypotension Prediction Index Integrated in an Algorithm of Goal Directed Hemodynamic Treatment during Moderate and High-Risk Surgery

(1) Background: The Hypotension Prediction Index (HPI) is an algorithm that predicts hypotension, defined as mean arterial pressure (MAP) less than 65 mmHg for at least 1 min, based on arterial waveform features. We tested the hypothesis that the use of this index reduces the duration and severity of hypotension during noncardiac surgery. (2) Methods: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized 1:1 to standard of care or hemodynamic management with HPI guidance with a goal directed hemodynamic treatment protocol. The trigger to initiate treatment (with fluids, vasopressors, or inotropes) was a value of HPI of 85 (range, 0–100) or higher in the intervention group. Primary outcome was the amount of hypotension, defined as time-weighted average (TWA) MAP less than 65 mmHg. Secondary outcomes were time spent in hypertension defined as MAP more than 100 mmHg for at least 1 min; medication and fluids administered and postoperative complications. (3) Results: We obtained data from 99 patients. The median (IQR) TWA of hypotension was 0.16 mmHg (IQR, 0.01–0.32 mmHg) in the intervention group versus 0.50 mmHg (IQR, 0.11–0.97 mmHg) in the control group, for a median difference of −0.28 (95% CI, −0.48 to −0.09 mmHg; p = 0.0003). We also observed an increase in hypertension in the intervention group as well as a higher weight-adjusted administration of phenylephrine in the intervention group. (4) Conclusions: In this single-center prospective study of patients undergoing elective noncardiac surgery, the use of this prediction model resulted in less intraoperative hypotension compared with standard care. An increase in the time spent in hypertension in the treatment group was also observed, probably as a result of overtreatment. This should provide an insight for refining the use of this prediction index in future studies to avoid excessive correction of blood pressure

Ketamine Versus Tramadol As an Adjunct To PCA Morphine for Postoperative Analgesia After Major Upper Abdominal Surgery: a Prospective, Comparative, Randomized Trial.

BACKGROUND AND AIMS: Patient-controlled analgesia (PCA) with morphine is commonly used to provide analgesia following major surgery, but is not sufficient as a monotherapy strategy. This study aimed to compare the adjunctive analgesic effect of ketamine versus tramadol on postoperative analgesia provided via PCA-morphine in patients undergoing major upper abdominal surgeries. METHODS: Forty-two patients undergoing elective major upper abdominal surgery under general anesthesia were allocated to receive either ketamine (load dose of 0.5 mg kg(-1) followed by a continuous infusion of 0.12 mg kg(-1) h(-1) up to 48 postoperative hours; ketamine group, n = 21) or tramadol (load dose of 1 mg kg(-1) followed by a continuous infusion of 0.2 mg kg(-1) h(-1) up to 48 postoperative hours; tramadol group, n = 21) in addition to their standard postoperative analgesia with PCA-morphine. Postoperative data included morphine consumption, visual analog scale (VAS) scores, and side effects during the first 48 postoperative hours after PCA-morphine initiation. RESULTS: There were no significant differences in patient demographic and intraoperative data between the two groups. Tramadol group had significantly less total morphine consumption during the first 48 postoperative hours (28.905 [16.504] vs 54.524 [20.846] mg [p < 0.001]) and presented significantly lower VAS scores at rest and mobilization (p < 0.05) than the ketamine group. No statistical difference was recorded between the two groups (p > 0.05) regarding postoperative cough, sedation, hallucinations, pruritus, urine retention, and postoperative nausea and vomiting. However, patients in the ketamine group reported dry mouth more frequently than patients in the tramadol group (p = 0.032). CONCLUSIONS: Postoperative administration of tramadol was superior to ketamine due to significantly reduced opioid consumption and better pain scores in patients receiving PCA-morphine after major upper abdominal surgery

Intraoperative transfusion practices in Europe

Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl and increased to 9.8 (1.8) g dl after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold

Intraoperative transfusion practices in Europe

© 2016 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.Background: Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. Methods: We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. Results: The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl-1 and increased to 9.8 (1.8) g dl-1 after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Conclusions: Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl-1), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold

Intraoperative transfusion practices and perioperative outcome in the European elderly: A secondary analysis of the observational ETPOS study

The demographic development suggests a dramatic growth in the number of elderly patients undergoing surgery in Europe. Most red blood cell transfusions (RBCT) are administered to older people, but little is known about perioperative transfusion practices in this population. In this secondary analysis of the prospective observational multicentre European Transfusion Practice and Outcome Study (ETPOS), we specifically evaluated intraoperative transfusion practices and the related outcomes of 3149 patients aged 65 years and older. Enrolled patients underwent elective surgery in 123 European hospitals, received at least one RBCT intraoperatively and were followed up for 30 days maximum. The mean haemoglobin value at the beginning of surgery was 108 (21) g/l, 84 (15) g/l before transfusion and 101 (16) g/l at the end of surgery. A median of 2 [1–2] units of RBCT were administered. Mostly, more than one transfusion trigger was present, with physiological triggers being preeminent. We revealed a descriptive association between each intraoperatively administered RBCT and mortality and discharge respectively, within the first 10 postoperative days but not thereafter. In our unadjusted model the hazard ratio (HR) for mortality was 1.11 (95% CI: 1.08–1.15) and the HR for discharge was 0.78 (95% CI: 0.74–0.83). After adjustment for several variables, such as age, preoperative haemoglobin and blood loss, the HR for mortality was 1.10 (95% CI: 1.05–1.15) and HR for discharge was 0.82 (95% CI: 0.78–0.87). Preoperative anaemia in European elderly surgical patients is undertreated. Various triggers seem to support the decision for RBCT. A closer monitoring of elderly patients receiving intraoperative RBCT for the first 10 postoperative days might be justifiable. Further research on the causal relationship between RBCT and outcomes and on optimal transfusion strategies in the elderly population is warranted. A thorough analysis of different time periods within the first 30 postoperative days is recommended

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Background Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. Methods We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients’ preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. Findings Between June 16, 2014, and April 29, 2015, data from 22803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21694); ORadj 1·86, 95% CI 1·53–2·26; ARRadj –4·4%, 95% CI –5·5 to –3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15–1·49; ARRadj –2·6%, 95% CI –3·9 to –1·4) and the administration of reversal agents (1·23, 1·07–1·41; –1·9%, –3·2 to –0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85–1·25; ARRadj –0·3%, 95% CI –2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82–1·31; –0·4%, –3·5 to 2·2) was associated with better pulmonary outcomes. Interpretation We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications