Real-time visualization of ultrasound-guided retrobulbar blockade: an imaging study

Background Retrobulbar anaesthesia allows eye surgery in awake patients. Severe complications of the blind techniques are reported. Ultrasound-guided needle introduction and direct visualization of the spread of local anaesthetic may improve quality and safety of retrobulbar anaesthesia. Therefore, we developed a new ultrasound-guided technique using human cadavers. Methods In total, 20 blocks on both sides in 10 embalmed human cadavers were performed. Using a small curved array transducer and a long-axis approach, a 22 G short bevel needle was introduced under ultrasound guidance lateral and caudal of the eyeball until the needle tip was seen 2 mm away from the optic nerve. At this point, 2 ml of contrast dye as a substitute for local anaesthetic was injected. Immediately after the injection, the spread of the contrast dye was documented by means of CT scans performed in each cadaver. Results The CT scans showed the distribution of the contrast dye in the muscle cone and behind the posterior sclera in all but one case. No contrast dye was found inside the optic nerve or inside the eyeball. In one case, there could be an additional trace of contrast dye behind the orbita. Conclusions Our new ultrasound-guided technique has the potential to improve safety and efficacy of the procedure by direct visualization of the needle placement and the distribution of the injected fluid. Furthermore, the precise injection near the optic nerve could lead to a reduction of the amount of the local anaesthetic needed with fewer related complication

Ultrasound-guided spermatic cord block for scrotal surgery

Background Performing spermatic cord block for scrotal surgery avoids the potential risks of neuraxial and general anaesthesia and provides long-lasting postoperative analgesia. A blindly performed block is often inefficient and bears its own potential risks (intravascular injection of local anaesthetics, haematoma formation and perforation of the deferent duct). The use of ultrasound may help to overcome these disadvantages. The aim of this study was to test the feasibility and monitor the success rate of a new ultrasound-guided spermatic cord block. Methods Twenty consecutive patients undergoing urologic surgery (subcapsular orchiectomy or vaso-vasostomy) were included in this prospective study. Using a linear ultrasound probe, the spermatic cord was identified by locating the spermatic artery and the deferent duct. A 23 G Microlance needle was advanced close to the deferent duct by avoiding vessel perforation, and local anaesthetic was deposited around the deferent duct under direct visualization. The primary outcome was the success rate of the block which was defined as surgery without any substitution of opioids, additional local anaesthetics, or sedatives. Results In 20 patients, 40 blocks were performed with a success rate of 95% (n=38). The failure rate was 5% (n=2) and no conversion to general anaesthesia was needed. The mean duration of the block was 14.1 h (sd 6.9). Conclusions The use of ultrasound guidance to perform spermatic cord block is feasible and has a high success rate. Our new approach may become a suitable alternative to neuraxial or general anaesthesia especially in the ambulatory surgical setting. Registry: International Standard Randomised Controlled Trial Number Register; www.controlled-trials.com; Registry Nr.: ISRCTN4464781

Different Learning Curves for Axillary Brachial Plexus Block: Ultrasound Guidance versus Nerve Stimulation

Little is known about the learning of the skills needed to perform ultrasound- or nerve stimulator-guided peripheral nerve blocks. The aim of this study was to compare the learning curves of residents trained in ultrasound guidance versus residents trained in nerve stimulation for axillary brachial plexus block. Ten residents with no previous experience with using ultrasound received ultrasound training and another ten residents with no previous experience with using nerve stimulation received nerve stimulation training. The novices' learning curves were generated by retrospective data analysis out of our electronic anaesthesia database. Individual success rates were pooled, and the institutional learning curve was calculated using a bootstrapping technique in combination with a Monte Carlo simulation procedure. The skills required to perform successful ultrasound-guided axillary brachial plexus block can be learnt faster and lead to a higher final success rate compared to nerve stimulator-guided axillary brachial plexus block

Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study

Background During paravertebral block, the anterolateral limit of the paravertebral space, which consists of the pleura, should preferably not be perforated. Also it is possible that, during the block, the constant superior costotransverse ligament can be missed in the loss-of-resistance technique. We therefore aimed to develop a new technique for an ultrasound-guided puncture of the paravertebral space. Methods We performed 20 punctures and catheter placements in 10 human cadavers. A sonographic view showing the pleura and the superior costotransverse ligament was obtained with a slightly oblique scan using a curved array transducer. After inline approach, injection of 10 ml normal saline confirmed the correct position of the needle tip, distended the space, and enabled catheter insertion. The spread of contrast dye injected through the catheters was assessed by CT scans. Results The superior costotransverse ligament and the paravertebral space were easy to identify. The needle tip reached the paravertebral space without problems under visualization. In contrast, the introduction of the catheter was difficult. The CT scan revealed a correct paravertebral spread of contrast in 11 cases. Out of the remaining, one catheter was found in the pleural space, in six cases there was an epidural, and in two cases there was a prevertebral spread of contrast dye. Conclusions We successfully developed a technique for an accurate ultrasound-guided puncture of the paravertebral space. We also showed that when a catheter is introduced through the needle with the tip lying in the paravertebral space, there is a high probability of catheter misplacement into the epidural, mediastinal, or pleural space

Ultrasound-guided thoracic paravertebral puncture and placement of catheters in human cadavers: where do catheters go?†

Background Paravertebral regional anaesthesia is used to treat pain after several surgical procedures. This study aimed to improve on our first published ultrasound-guided approach to the paravertebral space (PVS) and to investigate a possible discrepancy between the needle, catheter, and contrast dye position. Methods In 10 cadavers, we conducted 26 ultrasound-guided paravertebral approaches combined with loss of resistance (LOR) and after an interim analysis performed 36 novel, pure ultrasound-guided (PUSG) paravertebral approaches. Needle-tip position was controlled by a first computed tomography (CT) scan. After placement of the catheters, the tips were assessed by a second CT and the spread of injected contrast dye was assessed by further CT scans. The part of the PVS near the intervertebral foramen was defined as the primary target to reach. Results The first CT scans assessing 62 needle tips revealed that: 13 (50%) of LOR and 34 (94%) of PUSG approaches were at the target; and two (8%) LOR and no PUSG approaches were outside the PVS. With the second CT scans 60 catheter-tip positions were analysed: three (12%) of LOR and five (14%) of PUSG approaches were at the target, three (12%) of LOR and two (6%) of PUSG approaches were outside the PVS. No catheters were detected in the epidural space. In two cases, insertion of the catheter was not possible. In cases with major epidural contrast, the widest contrast dye spread was 7.7 (3.5) [mean (sd)] vertebral segments. Conclusions Our new PUSG technique has a high success rate for paravertebral needle placement. Although needles were correctly positioned, catheters were usually found distant from the needle-tip positio

Ultrasound-guided percutaneous tracheal puncture: a computer-tomographic controlled study in cadavers

Background Ultrasound-guided techniques are increasingly used in anaesthetic practice to identify tissues beneath the skin and to increase the accuracy of placement of needles close to targeted structures. To examine ultrasound's usefulness for dilatational tracheostomy, we performed ultrasound-guided tracheal punctures in human cadavers followed by computer-tomographic (CT) control. Methods The trachea of nine cadavers was punctured using an in-plane approach with a longitudinal ultrasound visualization of the trachea. As soon as a loss of resistance was felt, or air/fluid could be aspirated into the attached syringe, the syringe was disconnected and the ultrasound transducer set aside. Thereafter, a cricothyroidotomy guidewire was inserted through the needle into the trachea. The needle was then removed, leaving the wire in place and a control CT imaging of the neck and the chest was performed. Primary outcome was successful wire insertion into the trachea. Results Tracheal puncture and wire insertion was successful in eight of nine cadavers at the first attempt and in one at the second attempt (total of 10 puncture attempts, nine successful). In eight of nine successfully inserted wires, the wire was placed on the defined midline. Conclusions Ultrasound guidance can facilitate successful tracheal puncture. However, combining an in-plane approach with a longitudinal ultrasound visualization of the trachea neither guarantees an exact midline puncture nor allows detection of a misplaced guidewir

Energy-dependent photoemission delays from noble metal surfaces by attosecond interferometry

How quanta of energy and charge are transported on both atomic spatial and ultrafast time scales is at the heart of modern technology. Recent progress in ultrafast spectroscopy has allowed us to directly study the dynamical response of an electronic system to interaction with an electromagnetic field. Here, we present energy-dependent photoemission delays from the noble metal surfaces Ag(111) and Au(111). An interferometric technique based on attosecond pulse trains is applied simultaneously in a gas phase and a solid state target to derive surface-specific photoemission delays. Experimental delays on the order of 100 as are in the same time range as those obtained from simulations. The strong variation of measured delays with excitation energy in Ag(111), which cannot be consistently explained invoking solely electron transport or initial state localization as supposed in previous work, indicates that final state effects play a key role in photoemission from solids

Effects of Varying the Three-Body Molecular Hydrogen Formation Rate in Primordial Star Formation

The transformation of atomic hydrogen to molecular hydrogen through three-body reactions is a crucial stage in the collapse of primordial, metal-free halos, where the first generation of stars (Population III stars) in the Universe are formed. However, in the published literature, the rate coefficient for this reaction is uncertain by nearly an order of magnitude. We report on the results of both adaptive mesh refinement (AMR) and smoothed particle hydrodynamics (SPH) simulations of the collapse of metal-free halos as a function of the value of this rate coefficient. For each simulation method, we have simulated a single halo three times, using three different values of the rate coefficient. We find that while variation between halo realizations may be greater than that caused by the three-body rate coefficient being used, both the accretion physics onto Population III protostars as well as the long-term stability of the disk and any potential fragmentation may depend strongly on this rate coefficient.Comment: 29 pages, 7 figures; Accepted for publication in The Astrophysical Journa

Dark Matter Halo Environment for Primordial Star Formation

We study the statistical properties (such as shape and spin) of high-z halos likely hosting the first (PopIII) stars with cosmological simulations including detailed gas physics. In the redshift range considered ($11 < z < 16$) the average sphericity is $= 0.3 \pm 0.1$, and for more than 90% of halos the triaxiality parameter is $T \lesssim 0.4$, showing a clear preference for oblateness over prolateness. Larger halos in the simulation tend to be both more spherical and prolate: we find $s \propto M_h^{\alpha_s}$ and $T \propto M_h^{\alpha_T}$, with $\alpha_s \approx 0.128$ and $\alpha_T= 0.276$ at z = 11. The spin distributions of dark matter and gas are considerably different at $z=16$, with the baryons rotating slower than the dark matter. At lower redshift, instead, the spin distributions of dark matter and gas track each other almost perfectly, as a consequence of a longer time interval available for momentum redistribution between the two components. The spin of both the gas and dark matter follows a lognormal distribution, with a mean value at z=16 of $=0.0184$, virtually independent of halo mass. This is in good agreement with previous studies. Using the results of two feedback models (MT1 and MT2) by McKee & Tan (2008) and mapping our halo spin distribution into a PopIII IMF, we find that at high-$z$ the IMF closely tracks the spin lognormal distribution. Depending on the feedback model, though, the distribution can be centered at $\approx 65 M_\odot$ (MT1) or $\approx 140 M_\odot$ (MT2). At later times, model MT1 evolves into a bimodal distribution with a second prominent peak located at $35-40 M_\odot$ as a result of the non-linear relation between rotation and halo mass. We conclude that the dark matter halo properties might be a key factor shaping the IMF of the first stars.Comment: 10 pages, 6 figures, accepted for publication in MNRA

Logarithmic Corrections in the 2D XY Model

Using two sets of high-precision Monte Carlo data for the two-dimensional XY model in the Villain formulation on square $L \times L$ lattices, the scaling behavior of the susceptibility $\chi$ and correlation length $\xi$ at the Kosterlitz-Thouless phase transition is analyzed with emphasis on multiplicative logarithmic corrections $(ln L)^{-2r}$ in the finite-size scaling region and $(ln \xi)^{-2r}$ in the high-temperature phase near criticality, respectively. By analyzing the susceptibility at criticality on lattices of size up to $512^2$ we obtain $r = -0.0270(10)$, in agreement with recent work of Kenna and Irving on the the finite-size scaling of Lee-Yang zeros in the cosine formulation of the XY model. By studying susceptibilities and correlation lengths up to $\xi \approx 140$ in the high-temperature phase, however, we arrive at quite a different estimate of $r = 0.0560(17)$, which is in good agreement with recent analyses of thermodynamic Monte Carlo data and high-temperature series expansions of the cosine formulation.Comment: 13 pages, LaTeX + 8 postscript figures. See also http://www.cond-mat.physik.uni-mainz.de/~janke/doc/home_janke.htm