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We describe a case of Q-fever endocarditis with severe destruction of the aortic valve with perivalvular abscess formation and cardiac failure. The patient needed urgent operative treatment and postoperative critical care. All specimens sent for microbiological examination were negative. Molecular analysis, including fluorescence in situ hybridization of aortic valve tissue combined with PCR and sequencing, led to the correct diagnosis and to appropriate anti-infective treatment. The patient subsequently recovered from complex cardiovascular surgery. This is the first report on Q-fever endocarditis that was rapidly diagnosed using these methods.

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The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy.

Introduction In contrast to ultrasound technology (US), peripheral nerve stimulation (PNS) for regional anesthesia was little improved in recent years. When using the combination of both techniques, PNS can give additional information for nerve localization to improve safety and success of regional anesthesia. There are influencing factors on the success rate of stimulation in PNS remaining uninvestigated in a clinical setting to date. This randomized controlled pilot trial evaluates the impact of shape and size of stimulation needles electrodes under dual guidance conditions. Methods In a randomized controlled clinical trial 35 participants undergoing lower limb surgery received a preoperative proximal sciatic nerve block in dual guidance technique. Use of facet needles with point shaped electrodes (N=19, facet group) were compared with tuohy needles with large electroconductive tips (N=16, touhy group). Stimulation success at minimal distance between needle tip and nerve was recorded. Block success and complications of regional anesthesia were assessed. Results In 87% of successful stimulation (20 of 23) an ultrasound-proven contact of needle tip and sciatic nerve was necessary to elicit a motor response. More successful stimulations could performed using facet needles (84%, 16/19) compared to tuohy needles (44%, 7/16, p=0.03). If stimulation was successful the number of successful sensory blockades was increased (78%, 18/23, p=0.02). No serious complications of regional anesthesia were recorded. Discussion This pilot trial suggests that stimulation needles with small electrodes may be more reliable in indicating a contact of needle and nerve, which may improve safety and success of proximal sciatic nerve blocks.

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