Υπερηχογραφικά καθοδηγούμενοι αποκλεισμοί θωρακικού τοιχώματος

Οι νεότερες υπερηχογραφικά καθοδηγούμενες τεχνικές του αποκλεισμού στο επίπεδο του μείζονος θωρακικού μυός (PECS 1), του ελάσσονος θωρακικού (PECS 2), του πρόσθιου οδοντωτού (Serratus Anterior Plane-SAP) και του ανελκτήρα τη ράχη μυός (Erector Spinae Plane-ESP) έχουν πρόσφατα εισαχθεί στην κλινική πράξη, ως λιγότερο επεμβατικές, με ελάχιστες επιπλοκές και εύκολη εκμάθηση τεχνικές, εναλλακτικές του επισκληρίδιου και του παρασπονδυλικού αποκλεισμού. Για την κατανόηση και εκτέλεση των αποκλεισμών αυτών είναι απαραίτητη η λεπτομερής γνώση της ανατομίας των μυών και των περιτονιών που τους περιβάλλουν, αλλά και της ακριβούς πορείας των νεύρων του θωρακικού τοιχώματος, από την έκφυσή τους μέχρι τις τελικές νευρικές απολήξεις. Στόχος στους αποκλεισμούς αυτούς είναι ο εντοπισμός και η διήθηση με όγκο τοπικού αναισθητικού των χώρων απ’ όπου περνάνε τα νεύρα που πρόκειται να αποκλειστούν. Με τον τρόπο αυτό οι αποκλεισμοί στο επίπεδο του μείζονος και του ελάσσονος θωρακικού μυός αφορούν επεμβάσεις κυρίως στο πρόσθιο ημιθωράκιο. Ο αποκλεισμός στο επίπεδο του πρόσθιου οδοντωτού, συμπληρωματικά στους προηγούμενους θα αποκλείσει το πλάγιο θωρακικό τοίχωμα. Τέλος, ο αποκλεισμός στο επίπεδο του ανελκτήρα μυ της ράχης, συγκριτικά με τους προηγούμενους, πραγματοποιείται κεντρικότερα στην πορεία των νωτιαίων νεύρων, και μπορεί να συνδράμει στην αναλγησία και του οπίσθιου θωρακικού τοιχώματος.In recent years, the newer ultrasound guided techniques of the thoracic region such as the pectoralis major plane block (PECS 1), pectoralis minor plane block (PECS 2), serratus anterior plane block (SAP Block) and erector spinae plane block (ESP block) have been introduced in clinical practice as less invasive, with few complications and contraindications, easy to learn and, also, as an alternative to the traditionally used epidural or paravertebral block. To thoroughly understand and safely perform these plane blocks, a detailed knowledge of the anatomy of the muscles, the fasciae that surround them and the exact course of the spinal nerves through them, is necessary. The aim of these blocks is to –under ultrasound guidancelocate the myofascial plane where the nerves to be blocked are situated, and infuse a volume of local anesthetic. In that way, the PECS 1 and PECS block aim to block mostly the anterior hemithorax and the SAP block can provide analgesia to the lateral wall of the thorax. Finally, the ESP block, which is performed more centrally in comparison to the other blocks, can provide analgesia to the posterior aspect of the thoracic wall

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

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