Ralf Gebhard - Academia.edu (original) (raw)

Papers by Ralf Gebhard

Current opinion in anaesthesiology, 2015

Ultrasound guidance is frequently utilized for needle placement and observation of local anesthet... more Ultrasound guidance is frequently utilized for needle placement and observation of local anesthetic spread when performing peripheral nerve blocks. Although there is evidence that ultrasound technology can reduce complications, there are limitations to 2-dimensional (2-D) ultrasound. Three-dimensional (3-D) and especially real-time 3-D (4-D) ultrasound may allow for optimized and well tolerated needle positioning and enhanced observation of local anesthetic spread around the target structure. This article reviewed the current literature regarding the use of 3-D and 4-D ultrasound technology in a regional anesthesia setting. Several investigations have utilized 3-D ultrasound as a tool to study anatomical spatial relationships, evaluate local anesthetic spread, or optimize nerve block needle or catheter positioning. However, this was mostly achieved by retrospectively generating a 3-D image after the performance of the actual nerve blocks or studying anatomy on volunteers. There are ...

Introduction In response to voluntary and federally required performance improvement (PI) initiat... more Introduction In response to voluntary and federally required performance improvement (PI) initiatives, the anesthesiology community, already at the forefront of patient safety efforts, is responding at national and local levels. We describe an initiative to accomplish quality assurance (QA) together with resident education and a potential method to evaluate the practice-based learning and improvement competency. Discussion Measurement of performance parameters leads to improved quality of anesthesia care (1), is required by regulatory agencies such as the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) (2), and may be useful as an evaluation tool for the practice-based learning and improvement competency. In response to a request for more visible QA (than morbidity and mortality case conferences) from our institution, and incorporating the broadly defined American Council for Graduate Medical Education (ACGME) requirement for an 'academic project' to b...

Prehospital and disaster medicine

The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thous... more The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thousands of injuries requiring immediate surgical interventions, and 1.5 million internally displaced survivors. The earthquake destroyed or disabled most medical facilities in the city, seriously hampering the ability to deliver immediate life- and limb-saving surgical care. A Project Medishare/University of Miami Miller School of Medicine trauma team deployed to Haiti from Miami within 24 hours of the earthquake. The team began work at a pre-existing tent facility in the United Nations (UN) compound based at the airport, where they encountered 225 critically injured patients. However, non-sterile conditions, no means to administer oxygen, the lack of surgical equipment and supplies, and no anesthetics precluded the immediate delivery of general anesthesia. Despite these limitations, resuscitative care was administered, and during the first 72 hours following the event, some amputations wer...

Minerva anestesiologica, 2001

The constant search for increased efficiency and reduction of hospital length of stay has led to ... more The constant search for increased efficiency and reduction of hospital length of stay has led to an increase number of major orthopedic procedures performed as outpatients and the increase in the associated intensity and duration of acute postoperative pain. Although, it is well established that single peripheral blocks provide adequate anesthesia and excellent immediate postoperative analgesia in patients undergoing minor ambulatory orthopedic surgery, the postoperative acute pain benefit is limited to less than 24 hours. However, many patients required over 24 hours of intensive postoperative analgesia. Furthermore the need for immediate postoperative physical therapy in orthopedics dictates that local anesthetics be chosen on the basis of their safety and ability to produce preferential sensory blocks. As early as 1946, Ansbro proposed the use of continuous nerve blocks to prolong the duration of analgesia of nerve block technique during anesthesia. Continuous nerve blocks have a...

Anesthesia and analgesia, 2002

Carpal tunnel release is often performed as an outpatient procedure. We designed this retrospecti... more Carpal tunnel release is often performed as an outpatient procedure. We designed this retrospective study to assess the effect of different anesthesia techniques on intraoperative cardiovascular stability and discharge time. According to the anesthesia technique received, 62 consecutive patients were categorized in Group BIER (IV regional anesthesia), Group BLOCK (distal nerve blocks), and Group GENERAL (general anesthesia). Incidences of intraoperative periods of tachycardia or bradycardia and hyper- or hypotension were studied, as were tourniquet, surgical, operating room, and discharge times. Cardiovascular stability was better achieved in Group BLOCK, as indicated by a significantly smaller incidence of periods of hypertension compared with Group BIER (5% vs 25%) and a significantly less frequent incidence of periods of hypotension compared with Group GENERAL (14% vs 42%). Patients in Group BLOCK spent significantly less time in the hospital after surgery than patients in Group ...

Regional Anesthesia and Pain Medicine, 2009

The prevalence of obesity and diabetes mellitus continues to rise in industrialized countries. Th... more The prevalence of obesity and diabetes mellitus continues to rise in industrialized countries. The impact of diabetes on the practice of peripheral nerve block anesthesia, however, has not been fully elucidated. The authors retrospectively evaluated the influence of diabetes, body mass index (BMI), age, and sex on the success of supraclavicular block (SCB) placed with a landmark-based paresthesia technique. The anesthetic records of 1858 consecutive patients who received an SCB were analyzed. Block success was documented solely on the day of surgery, without additional follow-up. Patients were categorized as diabetic (group D, n = 262) or nondiabetic (group ND, n = 1596). Block "success rate" (ie, general anesthesia not required to produce surgical conditions) was analyzed using multiple regression (multivariable linear and logistic) to assess the associations of diabetes and/or body mass index on successful surgical anesthesia. Patients in group D were more likely (odds ratio, 3.3) to have a "successful" SCB for surgical anesthesia than were patients in group ND (P < 0.0001). Body mass index, age, and sex were not associated predictors of SCB "success." We speculate that the "higher success" of SCB in patients with diabetes may be explained by: (i) higher sensitivity of diabetic nerve fibers to local anesthetics, (ii) possible unknown intraneural penetration before injection, and/or (iii) preexisting neuropathy with accompanying decreased sensation. In the absence of additional follow-up on these patients, these data should generate outcomes research addressing dose-response curves for patients with diabetes or at risk for diabetes.

Journal of Clinical Anesthesia, 2014

Evidence supports the concept that patients undergoing major orthopedic surgery benefit from eith... more Evidence supports the concept that patients undergoing major orthopedic surgery benefit from either thromboprophylaxis or peripheral nerve blocks, especially continuous techniques. A group of anesthesiologists with significant experience in orthopedic anesthesia and peripheral nerve blocks reviewed the literature related to thromboprophylaxis and peripheral nerve blocks and their combination in orthopedics. Major bleeding, including retroperitoneal hematoma, is an established complication of thromboprophylaxis. Major bleeding, including retroperitoneal hematoma, is also an established complication of peripheral nerve blocks. Between 1997 and 2012, only 4 case reports of major bleeding were reported in patients receiving thromboprophylaxis and peripheral nerve blocks. Evidence supports the safety of the combination of thromboprophylaxis and peripheral nerve blocks. This group of experts concluded that currently there is no evidence that the combination of thromboprophylaxis and peripheral nerve block increases the risk of major bleeding compared to either of the treatments alone.

Journal of Clinical Anesthesia, 2002

To survey American anesthesiology residency program directors to determine the availability and e... more To survey American anesthesiology residency program directors to determine the availability and extent of training in peripheral nerve block techniques. Survey questionnaire was mailed and faxed to 132 American anesthesiology residency program directors and followed up 4 weeks later with another mailing to nonresponders. University medical center. Of the 132 American anesthesiology residency program directors surveyed, 69 (52%) responded. Of the responders, 40 (58%) offered a specific peripheral nerve block rotation. The rotation was of 1 month's duration in 61% of these programs. Formal instruction was administered during the rotation in 69%. The regional instruction approach consisted of a nerve stimulator (98%), paresthesia (75%), and transarterial (85%). Multimedia, mannequins, and cadaver dissection were used infrequently (13-25%). During the rotation, residents performed a variety of blocks, but the number of each block varied from 2 (supraclavicular) to 10 (axillary). These blocks were performed in the operating room in 48% of programs. Finally, in the programs with a specific peripheral nerve block rotation, residents were evaluated. Specific peripheral nerve block rotations are not always included in anesthesiology residents' curriculum. In addition, residents in programs with a specific nerve block rotation are exposed to a greater number of peripheral nerve block techniques than those who do not have such a rotation included in their curriculum.

European Journal of Anaesthesiology, 2001

European Journal of Anaesthesiology, 2006

European Journal of Anaesthesiology, 2004

Current Opinion in Anaesthesiology, 2008

NSAIDs have served as analgesic, antiinflammatory, and antipyretic medicines for over a century. ... more NSAIDs have served as analgesic, antiinflammatory, and antipyretic medicines for over a century. A novel class of NSAIDs, cyclooxygenase-2 inhibitors, was introduced in 1999. All NSAIDs and aspirin inhibit active sites of cyclooxygenase-1 and cyclooxygenase-2. Recent studies have demonstrated an important role of cyclooxygenase-2 inhibitors in the management of acute pain processes. There have been many reports related to an 'imbalance theory' suggesting that cyclooxygenase-2 inhibitors create an 'imbalance' between thromboxane and prostacyclin (reduction of prostacyclin), resulting in a prothrombic state; however, these drugs were designed to have improved gastrointestinal safety profiles by being more selective of the cyclooxygenase-2 pathway. Although balance and regulation of hemostasis is influenced in part by the balance of prostacyclin and thromboxane A2, many other substances are involved in thrombosis and include the coagulation cascade, fibrinogen and plasminogen pathways, numerous endogenous substances such as adenosine, nitric oxide, and serotonin. On the basis of many human studies, one may conclude that perioperative cyclooxygenase-2 inhibitors, in standard doses, decrease opioid consumption. Future investigations that include different multimodal techniques, for example combining cyclooxygenase-2 inhibitors with regional blocks, may help elucidate and clarify the true benefits of perioperative cyclooxygenase-2 inhibitors in acute pain management strategies.

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2003

Annals of Internal Medicine, 2010

Anesthesiology, 2002

Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... Skip Navigation Links Home > July ...

Anesthesiology, 2003

... Jacques E. Chelly, MD, Ph.D., MBA,* Jennifer R. Greger, MD, Andrea Casati, MD, Ralf Gebhard, ... more ... Jacques E. Chelly, MD, Ph.D., MBA,* Jennifer R. Greger, MD, Andrea Casati, MD, Ralf Gebhard, MD, Bruce Ben-David, MD *University of Pittsburgh ... Douglas Gourlay, MD, FRCPC University of Toronto, Wasser Pain Management Centre, Mount Sinai Hospital, Toronto, Ontario. ...

Current opinion in anaesthesiology, 2015

Ultrasound guidance is frequently utilized for needle placement and observation of local anesthet... more Ultrasound guidance is frequently utilized for needle placement and observation of local anesthetic spread when performing peripheral nerve blocks. Although there is evidence that ultrasound technology can reduce complications, there are limitations to 2-dimensional (2-D) ultrasound. Three-dimensional (3-D) and especially real-time 3-D (4-D) ultrasound may allow for optimized and well tolerated needle positioning and enhanced observation of local anesthetic spread around the target structure. This article reviewed the current literature regarding the use of 3-D and 4-D ultrasound technology in a regional anesthesia setting. Several investigations have utilized 3-D ultrasound as a tool to study anatomical spatial relationships, evaluate local anesthetic spread, or optimize nerve block needle or catheter positioning. However, this was mostly achieved by retrospectively generating a 3-D image after the performance of the actual nerve blocks or studying anatomy on volunteers. There are ...

Introduction In response to voluntary and federally required performance improvement (PI) initiat... more Introduction In response to voluntary and federally required performance improvement (PI) initiatives, the anesthesiology community, already at the forefront of patient safety efforts, is responding at national and local levels. We describe an initiative to accomplish quality assurance (QA) together with resident education and a potential method to evaluate the practice-based learning and improvement competency. Discussion Measurement of performance parameters leads to improved quality of anesthesia care (1), is required by regulatory agencies such as the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) (2), and may be useful as an evaluation tool for the practice-based learning and improvement competency. In response to a request for more visible QA (than morbidity and mortality case conferences) from our institution, and incorporating the broadly defined American Council for Graduate Medical Education (ACGME) requirement for an 'academic project' to b...

Prehospital and disaster medicine

The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thous... more The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thousands of injuries requiring immediate surgical interventions, and 1.5 million internally displaced survivors. The earthquake destroyed or disabled most medical facilities in the city, seriously hampering the ability to deliver immediate life- and limb-saving surgical care. A Project Medishare/University of Miami Miller School of Medicine trauma team deployed to Haiti from Miami within 24 hours of the earthquake. The team began work at a pre-existing tent facility in the United Nations (UN) compound based at the airport, where they encountered 225 critically injured patients. However, non-sterile conditions, no means to administer oxygen, the lack of surgical equipment and supplies, and no anesthetics precluded the immediate delivery of general anesthesia. Despite these limitations, resuscitative care was administered, and during the first 72 hours following the event, some amputations wer...

Minerva anestesiologica, 2001

The constant search for increased efficiency and reduction of hospital length of stay has led to ... more The constant search for increased efficiency and reduction of hospital length of stay has led to an increase number of major orthopedic procedures performed as outpatients and the increase in the associated intensity and duration of acute postoperative pain. Although, it is well established that single peripheral blocks provide adequate anesthesia and excellent immediate postoperative analgesia in patients undergoing minor ambulatory orthopedic surgery, the postoperative acute pain benefit is limited to less than 24 hours. However, many patients required over 24 hours of intensive postoperative analgesia. Furthermore the need for immediate postoperative physical therapy in orthopedics dictates that local anesthetics be chosen on the basis of their safety and ability to produce preferential sensory blocks. As early as 1946, Ansbro proposed the use of continuous nerve blocks to prolong the duration of analgesia of nerve block technique during anesthesia. Continuous nerve blocks have a...

Anesthesia and analgesia, 2002

Carpal tunnel release is often performed as an outpatient procedure. We designed this retrospecti... more Carpal tunnel release is often performed as an outpatient procedure. We designed this retrospective study to assess the effect of different anesthesia techniques on intraoperative cardiovascular stability and discharge time. According to the anesthesia technique received, 62 consecutive patients were categorized in Group BIER (IV regional anesthesia), Group BLOCK (distal nerve blocks), and Group GENERAL (general anesthesia). Incidences of intraoperative periods of tachycardia or bradycardia and hyper- or hypotension were studied, as were tourniquet, surgical, operating room, and discharge times. Cardiovascular stability was better achieved in Group BLOCK, as indicated by a significantly smaller incidence of periods of hypertension compared with Group BIER (5% vs 25%) and a significantly less frequent incidence of periods of hypotension compared with Group GENERAL (14% vs 42%). Patients in Group BLOCK spent significantly less time in the hospital after surgery than patients in Group ...

Regional Anesthesia and Pain Medicine, 2009

The prevalence of obesity and diabetes mellitus continues to rise in industrialized countries. Th... more The prevalence of obesity and diabetes mellitus continues to rise in industrialized countries. The impact of diabetes on the practice of peripheral nerve block anesthesia, however, has not been fully elucidated. The authors retrospectively evaluated the influence of diabetes, body mass index (BMI), age, and sex on the success of supraclavicular block (SCB) placed with a landmark-based paresthesia technique. The anesthetic records of 1858 consecutive patients who received an SCB were analyzed. Block success was documented solely on the day of surgery, without additional follow-up. Patients were categorized as diabetic (group D, n = 262) or nondiabetic (group ND, n = 1596). Block "success rate" (ie, general anesthesia not required to produce surgical conditions) was analyzed using multiple regression (multivariable linear and logistic) to assess the associations of diabetes and/or body mass index on successful surgical anesthesia. Patients in group D were more likely (odds ratio, 3.3) to have a "successful" SCB for surgical anesthesia than were patients in group ND (P < 0.0001). Body mass index, age, and sex were not associated predictors of SCB "success." We speculate that the "higher success" of SCB in patients with diabetes may be explained by: (i) higher sensitivity of diabetic nerve fibers to local anesthetics, (ii) possible unknown intraneural penetration before injection, and/or (iii) preexisting neuropathy with accompanying decreased sensation. In the absence of additional follow-up on these patients, these data should generate outcomes research addressing dose-response curves for patients with diabetes or at risk for diabetes.

Journal of Clinical Anesthesia, 2014

Evidence supports the concept that patients undergoing major orthopedic surgery benefit from eith... more Evidence supports the concept that patients undergoing major orthopedic surgery benefit from either thromboprophylaxis or peripheral nerve blocks, especially continuous techniques. A group of anesthesiologists with significant experience in orthopedic anesthesia and peripheral nerve blocks reviewed the literature related to thromboprophylaxis and peripheral nerve blocks and their combination in orthopedics. Major bleeding, including retroperitoneal hematoma, is an established complication of thromboprophylaxis. Major bleeding, including retroperitoneal hematoma, is also an established complication of peripheral nerve blocks. Between 1997 and 2012, only 4 case reports of major bleeding were reported in patients receiving thromboprophylaxis and peripheral nerve blocks. Evidence supports the safety of the combination of thromboprophylaxis and peripheral nerve blocks. This group of experts concluded that currently there is no evidence that the combination of thromboprophylaxis and peripheral nerve block increases the risk of major bleeding compared to either of the treatments alone.

Journal of Clinical Anesthesia, 2002

To survey American anesthesiology residency program directors to determine the availability and e... more To survey American anesthesiology residency program directors to determine the availability and extent of training in peripheral nerve block techniques. Survey questionnaire was mailed and faxed to 132 American anesthesiology residency program directors and followed up 4 weeks later with another mailing to nonresponders. University medical center. Of the 132 American anesthesiology residency program directors surveyed, 69 (52%) responded. Of the responders, 40 (58%) offered a specific peripheral nerve block rotation. The rotation was of 1 month's duration in 61% of these programs. Formal instruction was administered during the rotation in 69%. The regional instruction approach consisted of a nerve stimulator (98%), paresthesia (75%), and transarterial (85%). Multimedia, mannequins, and cadaver dissection were used infrequently (13-25%). During the rotation, residents performed a variety of blocks, but the number of each block varied from 2 (supraclavicular) to 10 (axillary). These blocks were performed in the operating room in 48% of programs. Finally, in the programs with a specific peripheral nerve block rotation, residents were evaluated. Specific peripheral nerve block rotations are not always included in anesthesiology residents' curriculum. In addition, residents in programs with a specific nerve block rotation are exposed to a greater number of peripheral nerve block techniques than those who do not have such a rotation included in their curriculum.

European Journal of Anaesthesiology, 2001

European Journal of Anaesthesiology, 2006

European Journal of Anaesthesiology, 2004

Current Opinion in Anaesthesiology, 2008

NSAIDs have served as analgesic, antiinflammatory, and antipyretic medicines for over a century. ... more NSAIDs have served as analgesic, antiinflammatory, and antipyretic medicines for over a century. A novel class of NSAIDs, cyclooxygenase-2 inhibitors, was introduced in 1999. All NSAIDs and aspirin inhibit active sites of cyclooxygenase-1 and cyclooxygenase-2. Recent studies have demonstrated an important role of cyclooxygenase-2 inhibitors in the management of acute pain processes. There have been many reports related to an 'imbalance theory' suggesting that cyclooxygenase-2 inhibitors create an 'imbalance' between thromboxane and prostacyclin (reduction of prostacyclin), resulting in a prothrombic state; however, these drugs were designed to have improved gastrointestinal safety profiles by being more selective of the cyclooxygenase-2 pathway. Although balance and regulation of hemostasis is influenced in part by the balance of prostacyclin and thromboxane A2, many other substances are involved in thrombosis and include the coagulation cascade, fibrinogen and plasminogen pathways, numerous endogenous substances such as adenosine, nitric oxide, and serotonin. On the basis of many human studies, one may conclude that perioperative cyclooxygenase-2 inhibitors, in standard doses, decrease opioid consumption. Future investigations that include different multimodal techniques, for example combining cyclooxygenase-2 inhibitors with regional blocks, may help elucidate and clarify the true benefits of perioperative cyclooxygenase-2 inhibitors in acute pain management strategies.

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2003

Annals of Internal Medicine, 2010

Anesthesiology, 2002

Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... Skip Navigation Links Home > July ...

Anesthesiology, 2003

... Jacques E. Chelly, MD, Ph.D., MBA,* Jennifer R. Greger, MD, Andrea Casati, MD, Ralf Gebhard, ... more ... Jacques E. Chelly, MD, Ph.D., MBA,* Jennifer R. Greger, MD, Andrea Casati, MD, Ralf Gebhard, MD, Bruce Ben-David, MD *University of Pittsburgh ... Douglas Gourlay, MD, FRCPC University of Toronto, Wasser Pain Management Centre, Mount Sinai Hospital, Toronto, Ontario. ...