Der Anaesthesist
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Timely establishment of venous access in infants and toddlers can prove a particularly challenging task. Since the 1940s the technique of intraosseous infusion has established itself as a valuable alternative means for rapid, efficient and safe delivery of drugs and fluids to critically ill children. Whereas international guidelines for paediatric emergency medical care have assigned intraosseous infusion a high priority, most anaesthetists utilize this well-proven technique with great reluctance. ⋯ In particular, children with acutely life-threatening conditions, such as circulatory arrest, laryngospasm, acute airway haemorrhage, hypovolaemic shock or hypothermia secondary to extensive burns, should receive an intraosseous cannula if intravenous access cannot be rapidly established. Future discussion may reveal whether a transiently inserted intraosseous infusion would also be indicated if the child with difficult or impossible venous access presents without acute life-threatening conditions for anaesthesia. Successful application of the intraosseous infusion technique requires immediate access to the necessary equipment, intensive education, continuous training and clear guidelines for its application in an anaesthesia department.
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Increased intra-operative and postoperative blood loss might be caused by acquired platelet function disorders. In particular because conventional coagulation analyses and platelet count fail to detect impaired platelet function, implementation of bedside-tests for platelet function in the peri-operative period is desirable according to the results of retrospective studies. Following adequate adjustment of basic conditions of haemostasis (e.g. temperature, pH, Ca2+-concentration, haematocrit) a pharmacological approach with desmopressin (1-desamino-8-d-arginine vasopressin; DDAVP) or tranexamic acid potentially represents a low cost alternative to platelet transfusions with minor side effects.
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In neonates, infants and young children central venous catheters are of vital importance during surgery as well as postoperative care. The benefit of ultrasonography seems to be very important for vascular access of the internal jugular (IJV), subclavian (SCV), femoral and even peripheral veins. Ultrasound-guided cannulation of the IJV increases the success rate, reduces the time to the successful puncture and decreases the inadvertent puncture of the carotid artery in children in comparison to the landmark-guided technique. ⋯ After catheterization of the SCV the homolateral IJV is screened by the use of ultrasound to detect wrong guide wire migration. A clear and rapid visualization of visceral pleura movement against the parietal pleura during respiration via ultrasound indicates the absence of pneumothorax after cannulation. In the case of haemodynamic instability, ultrasound should be used to exclude pericardial effusion.
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Review
[Scalp blocks. A useful technique for neurosurgery, dermatology, plastic surgery and pain therapy].
Safe and effective cranial analgesia can be achieved by blocking the sensitive nerves of that region. These include the supraorbital nerve, the supratrochlear nerve, the zygomaticotemporal nerve, the auriculotemporal nerve and the greater and lesser occipital nerves which are accessible at typical and most proximal points. ⋯ Scalp blocks are useful for intraoperative neurologic testing of the patient during awake craniotomy or for supplementation of general anesthesia for other forms of craniotomy. Other applications are minimally invasive and stereotactic neurosurgery including deep brain stimulation, photodynamic therapy of actinic ceratosis, cranial plastic surgery and pain therapy.
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Despite numerous publications, new guidelines for the treatment of acute pain and efforts from a number of initiatives, there is still a tremendous need for improvement in postoperative pain therapy. One of the reasons for the shortcomings in the care of patients with postoperative pain is the lack of applicability of guidelines in daily clinical practice. Therefore, simple but effective and easy to implement concepts need to be developed. ⋯ The pros and cons will be discussed and ideas on how to deal with balanced analgesia in daily practice will be given. Another pain concept of "procedure-specific postoperative pain therapy", is an appealing idea of an international initiative from surgeons and anaesthesiologists and an essential part of the German S3 guidelines for acute pain released last year. Critical evaluation of the available recommendations for procedure-specific analgesia together with the presentation of relatively simple but evidence-based algorithms for specific procedures may help to implement this concept in clinical routine.