Percutaneous central venous catheterization in small infants: axillary block can facilitate the insertion rate.

Central venous cannulation through a peripheral vein is the technique of choice in awake nonsedated critically ill infants. Such a technique has a high failure rate. We undertook a retrospective study to determine whether a brachial plexus block performed via the axillary approach could improve the success rate for the insertion of a central venous catheter from a peripheral vein of the upper limb in small infants. Data from 128 infants, submitted or not submitted to the axillary block, were analysed. The failure rate for insertion of the central venous catheter was 27% in the group without the use of the axillary block and 9% with the axillary block (P<0.05). The use of brachial plexus block via the axillary route, although evaluated retrospectively, improves the success rate for the insertion of small diameter central venous silicon catheter from a peripheral vein of the upper limb in small infants.

[Percutaneous catheterization of the newborn: control of pain and easy insertion with brachial plexus block]. / Cateterismo percutaneo nel neonato: controllo del dolore e facilità d'esecuzione col blocco del plesso brachiale.

The increasingly prolonged survival of extremely premature infants who required long-term venous access means that this is often a major problem in modern neonatal unit. The insertion of central venous catheters has become an established practice and the development of silastic catheters inserted by newer percutaneous techniques through a peripheral vein is, now, the choice technique in awake non sedated critically-ill infants. Such technique has an high percentage of failure. We have undertaken a retrospective study to determine whether the brachial plexus block performed via the axillary approach could improve the success rate for the insertion of central venous catheter from a peripheral vein of the upper limb in infants minimizing physical and emotional stress to the neonates. Data from 157 low and very low birthweight infants, submitted or not submitted to the axillary block, were examined. The failure rate for the insertion of the central venous catheter was 27% without using the brachial plexus block vs. 9% in the patients that underwent the block. Use of the brachial plexus block via the axillary route, although retrospectively evaluated, improves the success rate and the pain control for the insertion of small diameter central venous silicon catheter from a peripheral vein of the upper limb in low and very low birthweight infants.

Comparison of ropivacaine with bupivacaine for paediatric caudal block.

In a double-blind, multicentre study 245 children aged 1-10 yr undergoing elective minor surgery as inpatients were randomly allocated to receive a single caudal extradural injection of 1 ml kg-1 of either 0.25% bupivacaine or 0.2% ropivacaine after induction of light general anaesthesia. The groups were comparable for age, weight, vital signs and duration of surgery. The onset time was similar for ropivacaine and bupivacaine (9.7 vs 10.4 min). Further analgesia was not required in 40% of children. The mean time to first analgesia in the remainder was 233 min in the bupivacaine group and 271 min in the ropivacaine group. No motor block was measurable in either group. Ropivacaine 2 mg kg-1 was as effective as bupivacaine 2.5 mg kg-1 for caudal analgesia in children.

Comparison of two application techniques of EMLA and pain assessment in pediatric oncology patients.

BACKGROUND AND OBJECTIVES: The study was designed to compare the analgesic efficacy of the local anesthetic EMLA when applied as a patch and as a cream in combination with a Tegaderm dressing to pediatric oncology patients undergoing repeated lumbar punctures. METHODS: The analgesic effect of the two products was assessed by a continuous or discrete visual analog scale in 24 children 3-16 years old, during two lumbar punctures. Distress was rated by use of the Observational Scale of Behavioral Distress. RESULTS: No significant differences were found between the pain and distress scores for the different preparations of EMLA. CONCLUSION: The EMLA patch and the EMLA cream are equally effective in alleviating pain associated with lumbar puncture. The EMLA patch simplifies and speeds up the application of EMLA. It also allows for control of the dose administered per application, thus preventing both over- and underdosing.

[Effects of ondansetron and metoclopramide on postoperative nausea and vomiting after epidural anesthesia in children]. / Effets de l'ondansétron et du métoclopramide sur les nausées et vomissements postopératoires après anesthésie péridurale chez l'enfant.

We studied the preventive effect on postoperative nausea and vomiting (PONV) of ondansetron, metoclopramide and placebo associated with epidural anaesthesia. Sixty children, ASA I or II, 4 to 12 yr old underwent surgery for inguinal hernia repair (n = 30) or orchidopexy (n = 30). Children were randomly assigned to a postinduction intravenous medication group, ondansetron (5 mg.m-2), metoclopramide (0,12 mg.kg-1) or a saline solution placebo. After a general anaesthesia was obtained with halothane, nitrous oxide and oxygen delivered by mask, caudal or lumbar epidural anaesthesia was performed with plain mepivacaine. General performed with plain mepivacaine. General anaesthesia was interrupted and light narcosis maintained with diazepam during surgery. There were no significant differences in age and weight between the three groups. There were no adverse reactions to either ondansetron or metoclopramide. vomiting was not present in ondansetron group. The incidence of postoperative emesis in the metoclopramide group was 25%, whereas that of placebo group was 10%. The administration of ondansetron was associated with a lower (P = 0.017) incidence of postoperative vomiting if compared to the metoclopramide group. In conclusion ondansetron given preoperatively had proven to be an effective treatment for PONV after epidural block for lower abdominal surgery.

[Plasma levels of atriopeptin and hemodynamics during major vascular surgery: comparison between isoflurane and propofol+fentanyl]. / Livelli plasmatici di atriopeptina ed emodinamica in corso di chirurgia vascolare maggiore: confronto fra isoflurano e propofol+fentanyl.

Atrial natriuretic factor (ANF) is a peptide hormone released from atrial cardiocytes in response to atrial stretch. It has potent and selective effects on vascular smooth muscle, fluid and electrolyte balance, and may interact with other vasoactive substances. The influence of anaesthesia and major vascular surgery on the release and circulation of ANF is unknown. Therefore the relationships between haemodynamic variables, volume expansion and plasma ANF were studied in patients undergoing resection of abdominal aortic aneurysm, randomly assigned to receive isoflurane or propofol+fentanyl anaesthesia. The end point of anaesthetic regimens was the stabilization of mean arterial pressure between +/- 33% from baseline. Haemodynamic parameters and plasma ANF levels were measured preoperatively, after intubation, following aortic cross-clamping, 24 and 48 hours postoperatively. Because of well-known large degree in interpatient pharmacodynamic variability, anaesthesia with propofol and fentanyl did not ensure, usually, the established end point in dose ranges that did not produce unacceptable morbidity. ANF plasma levels were elevated during surgery and in the immediate postoperative period in both groups. A significant correlation was found between ANF levels and mean right atrial pressure. We concluded that anaesthetic drugs do not affect ANF release. Volume expansion for prevention of declamping shock increased, ANF from basal values, during surgery. Inadequacy of postoperative analgesia or persisting atrial stretch could explain the finding of high plasma levels during the immediate postoperative period.

Hemodynamic effects of digoxin in acute myocardial infarction in man: a randomized controlled trial.

Hemodynamic effects of digoxin in acute myocardial infarction (AMI) have been acknowledged to depend on the basal cardiocirculatory state. In the present study, the effects of digoxin in patients with AMI were evaluated in four hemodynamic subsets, based on the relationship between mean pulmonary capillary wedge pressure (PCWP, in mm Hg) and left ventricular stroke work index (LVSWI, in g-m/m2): subset 1: normal (less than or equal to 15 mm Hg) PCWP and normal (greater than or equal to 35 g-m/m2) LVSWI; subset 2: elevated (greater than 15 mm Hg) PCWP and normal LVSWI; subset 3: reduced (less than 35 g-m/m2) LVSWI and normal PCWP; and subset 4: elevated PCWP and LVSWI moderately reduced to a range between 16 and 34 g-m/m2. Forty patients were admitted to the study and were randomly assigned to one of two groups in each subset: control group (19 patients) and treated group (21 patients). Five patients were randomized into each of the subsets 2, 3, and 4 in both the control and treated groups, while in subset 1 there were four control and six digoxin-treated patients. Control patients were administered a placebo saline solution and digoxin-treated patients received 0.50 mg of the drug intravenously in 20 minutes. The effects of the placebo and of the drug were evaluated at 30, 60, and 90 minutes from the end of the infusion. Hemodynamic data did not vary in the control group, and digoxin did not exert any relevant effect in subsets 1 and 2. After drug infusion, cardiac index (Cl, in L/min/m2) significantly increased in subset 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anesthesia for outpatient termination of pregnancy: a comparison of anesthetic techniques]. / Valutazione di quattro metodiche di anestesia nell'interruzione volontaria di gravidanza.

PIP: 60 outpatients who submitted to termination of pregnancy at less than 12 weeks gestation (legal abortion) were randomly anesthetized with fentanyl + thiopentone, ketamine + diazepam, thiopentone + halotane, or thiopentone + enflurane. Each patient breathed spontaneously 3 liters/minute of nitrous oxide. The psychomotor recovery time was evaluated by means of the Zazzo test of "deux barrages" and the matrix attentive test. The anesthesia time and the intra- and postoperative side effects were recorded too. There was a greater frequency of nausea, vomiting, headache, and postoperative restlessness in those patients anesthetized with ketamine + diazepam. This anesthetic mixture induced a longer psychomotor recovery time. On the other hand, in patients anesthetized with fentanyl + thipentone, the authors observed a need for intraoperative additional analgesia during dilatation of the cervix. On the contrary, either technique with the volatile anesthetic agents halothane or enflurane is satisfactory for outpatient termination of pregnancy. When compared with the total intravenous anesthetic technique, the use of enflurane resulted in swifter recovery and minimal side effects and proved to be a safe and reliable anesthetic for this procedure. (author's)^ieng

Intra-aortic balloon pumping in the elderly: percutaneous versus surgical catheter insertion.

The feasibility and safety of percutaneous versus intra-aortic balloon pumping (IABP) in the elderly were evaluated in 45 patients who were over 65 years of age (range 65-79). All the patients required counterpulsation for complicated acute myocardial infarction. IABP insertion was attempted by the surgical technique in 22 patients, while the percutaneous approach was performed in 23. A consistent improvement in the incidence rate of successful insertion was attained with the use of the percutaneous technique as compared with the surgical one (91.3% v 59.1%, P is less than 0.05). Furthermore, no major complication was observed with the percutaneous catheter, while a 9.1% (2/22) incidence rate of serious complications was reported with the surgical technique. Thus, percutaneous IABP substantially decreased the unsuccessful insertions and the risk of severe complications in old patients, despite presumably severe aorto-iliac disease. No specifically age-related technical problem seems, therefore, to limit the applicability of intra-aortic counterpulsation to elderly patients, when percutaneous IABP is employed.

Right ventricular infarction: clinical, hemodynamic, mono- and two-dimensional echocardiographic features.

In a series of 75 patients with transmural acute myocardial infarction, a right to left ventricular filling pressure ratio equal to or greater than 0.65 was assumed to be indicative of associated right ventricular infarction. Eleven (24%) out of 45 patients with infero-posterior myocardial infarction had such hemodynamic evidence of right ventricular infarction (Group A). The remaining 34 patients with infero-posterior myocardial infarction (Group B) and the 30 patients with anterior myocardial infarction did not. Two-dimentional echocardiographic examination performed 5 days after admission in the 62 patients who survived, showed right ventricular free wall asynergy in six out of eight Group A patients: in three of them right ventricular enlargement was present. No patient in Group B inferior infarction or with anterior myocardial infarction had abnormal right ventricular motion or dimensions.

[A case of postinfarction spontaneous angina: physiopathological study of the therapeutic effectiveness of intra-aortic balloon pumping]. / Un caso di angina spontanea post-infartuale: inquadramento fisiopatologico dell'efficacia terapeutica della contropulsazione intra-aortica.

A 46-year-old patient showed spontaneous angina with anterior S-T segment depression 30 hours after an inferior acute myocardial infarction. Myocardial ischemia, which was resistant to drug therapy and induced acute left ventricular failure, was promptly reversed by intra-aortic balloon pumping (IABP). Coronary angiography demonstrated diffuse, severe atherosclerotic disease. Efficacy of IABP in this case of spontaneous angina might be ascribed to an increase of the coronary cross-sectional area in response to the increased intraluminal pressure ("passive vasomotion").