Comparison of the Efficacy Between Intradiscal Gelified Ethanol (Discogel) Injection and Intradiscal Combination of Pulsed Radiofrequency and Gelified Ethanol (Discogel) Injection for Chronic Discogenic Low Back Pain Treatment. A Randomized Double-Blind Clinical Study.

OBJECTIVE: The aim of the present study was to compare two new techniques, intradiscal gelified ethanol injection (Discogel) and the combination of intradiscal pulsed radiofrequency and gelified ethanol injection (PRF+Discogel), regarding their efficacy in discogenic low back pain treatment. DESIGN: Randomized, double-blind, clinical study. METHODS: The final sample was randomized into group A (N = 18, D) and group B (N = 18, PRF+D). During the procedure, four patients from group B were excluded from the study. Groups A and B were assessed regarding the pain score (VAS 0-10), before the interventional procedures, and one, three, six, and 12 months after. Secondary objectives of the study were to compare the two groups regarding the results of the Roland Morris Disability Questionnaire, Lanss score, and quality of life score (EQ-5D). RESULTS: There was no significant evidence for an overall difference in pain score between the two groups (analysis of variance, F = 3.24, df = 1, P = 0.084), except for the sixth and 12th months, when group B presented a statistically important difference compared with group A (Wilcoxon test). Group B appeared to be more effective, with a statistically significant difference, compared with group A regarding the secondary objectives of the study. CONCLUSIONS: After rigorous and comprehensive assessment by an independent observer, both Discogel alone and Discogel in combination with pulsed radiofrequency produced tangible improvements in pain, function, quality of life, and consumption of analgesics, which were sustained at 12 months.

CYP2D6 Basic Genotyping of Patients with Chronic Pain Receiving Tramadol or Codeine. A Study in a Greek Cohort.

OBJECTIVE: To assess CYP2D6 genotype prevalence in chronic pain patients treated with tramadol or codeine. DESIGN: Prospective cohort study. SETTING: General hospital, pain management unit. SUBJECTS: Patients with chronic pain, treated with codeine or tramadol. METHODS: Patients' pain was assessed at baseline (numeric rating scale [NRS]; 0-10). Prescription of codeine or tramadol was selected randomly. The assessment of patients' response to the drug in terms of pain relief and adverse effects was performed after 24 hours. Reduction of pain intensity of >50% or an NRS <4 was considered a positive response. Patients' blood samples were collected during the first visit. Genotyping for the common variants CYP2D6 *2, *3, *4, *5, *6, *9, *10, *14, and *17 was performed, and alleles not carrying any polymorphic allele were classified as CYP2D6*1 (wild-type [wt]). RESULTS: Seventy-six consecutive patients were studied (20 males, 56 females), aged 21-85 years. Thirty-four received tramadol and 42 codeine. The main genotypes of CYP2D6 identified were the wt/wt (35.5%), the *4/wt (17.1%), and the *6/wt (10.5%). Adverse effects were common, especially in carriers of *9/*9, *5/*5, *5/*4, and *10/*10, as well as in variants including the 4 allele (*4/*1 [38.4%] and *4/*4 [42.8%]). CONCLUSIONS: Genotyping can facilitate personalized pain management with opioids, as specific alleles are related to decreased efficacy and adverse effects.

Lessons learned from first case of Cesarean delivery in a COVID-19 positive parturient in Greek region.

We report the successful anesthetic management of a 24-year-old patient, with an active COVID-19 viral infection, scheduled for elective Cesarean section at 40th week of pregnancy. This was the first case in Greek region, and we report and discuss the difficulties and safety issues regarding a COVID-19 positive patient during an elective cesarean delivery. Regional anesthesia with full protective equipment for health personnel involved, along with careful planning and adherence to guidelines achieved safe completion of the operation.

The Utility of Echocardiography for the Prediction of Spinal-Induced Hypotension in Elderly Patients: Inferior Vena Cava Assessment Is a Key Player.

OBJECTIVES: To prospectively assess the diagnostic performance of echocardiographic measurements before spinal anesthesia in elderly patients undergoing lower limb surgery. Emphasis was placed on the dIVCmax-to-IVCCI ratio and IVCCI, where dIVCmax was the maximum diameter of inferior vena cava (IVC) at expiration and IVCCI was the collapsibility index of IVC. DESIGN: Open cohort, prospective, single-center study. SETTING: University hospital. INTERVENTIONS: A transthoracic echocardiography examination was performed in 70 patients before spinal anesthesia under standard criteria and protocol. Patients with intraoperative mean arterial pressure ≤65 mmHg or ≥25% reduction of its preoperative baseline were considered hypotensive. MEASUREMENTS AND MAIN RESULTS: Preoperative echocardiographic measurements, including IVCCI, dIVCmax-to-IVCCI, ejection fraction, global longitudinal peak systolic strain, tricuspid annular plane systolic excursion, ratio of peak velocity flow in early diastole and average of peak velocities in early diastole of lateral and septal mitral annulus, stroke volume index, and left ventricle mass index were assessed. Twenty-eight of 70 patients manifested spinal-induced hypotension. Preoperative dIVCmax-to-IVCCI showed the greatest diagnostic performance among the indices. dIVCmax-to-IVCCI <43 had significantly higher diagnostic power than did IVCCI >0.3 (p = 0.032). Multiple logistic regression analysis revealed that the best predictors for spinal-induced hypotension were the dIVCmax-to-IVCCI ratio and age. CONCLUSIONS: The preoperative dIVCmax-to-IVCCI ratio can predict spinal-induced hypotension greater than IVCCI and other echocardiographic measurements in elderly patients. Both dIVCmax-to-IVCCI ratio and patient age can act as predictors of spinal-induced hypotension in elderly patients.

Is there an interaction between dexamethasone and sugammadex in real clinical conditions? A randomized controlled trial in patients undergoing laparoscopic cholecystectomy.

BACKGROUND AND AIMS: There is evidence that sugammadex can encapsulate other substances except rocuronium, such as dexamethasone. The aim of this study was to investigate the possible clinical interaction between dexamethasone and sugammadex, in patients undergoing laparoscopic cholecystectomy. MATERIAL AND METHODS: This was a randomized, double-blind controlled trial, performed in patients aged 18-75 years, American Society of Anesthesiologists (ASA) I-III, who underwent a laparoscopic cholecystectomy under deep neuromuscular blockade with rocuronium. Patients received 5 mg of dexamethasone or placebo (N/S 0.9%) during induction of anesthesia. Sugammadex 4 mg/kg was administered at the end of surgery at post-tetanic count 1-2. The outcome measures assessed were the time from sugammadex administration until train-of-four (TOF) 0.9, and until patient's extubation, postoperative pain (measured by numeric rating scale 0-10), nausea and vomiting, as well as rescue analgesics and antiemetics required during the first 24 hours postoperatively. The total dose of rocuronium required in both groups was also recorded. RESULTS: Overall, 44 patients were studied. No difference was detected regarding the demographic and surgical characteristics of patients. The time from sugammadex administration until TOF 0.9 and until patients' extubation did not differ significantly between the groups (P = 0.21 and 0.17). Operating conditions, pain scores, nausea/vomiting, and rescue analgesics and antiemetics during the first 24 hours postoperatively, did not differ between the groups. The total dose of rocuronium, however, was significantly more in patients who received dexamethasone (P = 0.01). CONCLUSION: No significant clinical interaction was revealed between dexamethasone and sugammadex during reversal of deep neuromuscular blockade in patients undergoing laparoscopic cholecystectomy.

Transient Effects of Anesthesia on Leukocyte Apoptosis and Monocyte Cytokine Stimulation: A Clinical Study.

The effects of anesthetics on immune cell apoptosis and cytokine stimulation were studied in a prospective study. American Society of Anesthesiologists I/II patients underwent elective inguinal hernia repair or varicose veins stripping surgery and were randomized to either epidural anesthesia (n = 14) or general anesthesia with sevoflurane (n = 19) or propofol (n = 15). Blood was sampled before anesthesia induction (T0), at the end of surgery (T1), and 6 h later (T2). Apoptosis was determined by ANNEXIN-V staining of white blood cells; monocytes were isolated and stimulated for cytokine production. Results were compared with 10 healthy volunteers well-matched for age and gender. Apoptosis of lymphocytes and monocytes was increased in the epidural and sevoflurane groups at T2. Propofol group had increased production of interleukin-6 at T1 and sevoflurane and epidural groups had decreased production of tumor necrosis factor-alpha at T2. Results emphasize the modulation of immune function by epidural and sevoflurane but not propofol anesthesia in a clinical setting.

Ultrasound-Guided Interscalene Brachial Plexus Nerve Block With an Ultralow Volume of Local Anesthetic for Post-Thoracotomy Shoulder Girdle Pain.

OBJECTIVES: To evaluate the efficacy of ultrasound-guided interscalene nerve block using an ultralow volume of local anesthetic (5 mL of ropivacaine, 0.75%) for the management of post-thoracotomy shoulder girdle pain. DESIGN: Open-cohort, prospective, single-center study. SETTING: University hospital. INTERVENTIONS: Patients with post-thoracotomy shoulder girdle pain (visual analog scale [VAS] ≥5) received an ultrasound-guided interscalene nerve block. MEASUREMENTS AND MAIN RESULTS: Thirty minutes after block implementation, the VAS was used to quantify pain across the shoulder girdle. The index (I) was calculated to indicate improvement of pain as follows: [Formula: see text] Nerve bocks resulting in I ≥75% were considered excellent. Total tramadol consumption 36 hours after nerve blocks, patients' satisfaction, and complications related to the procedure also were assessed. Patients were segregated in the following 2 groups: group A, which comprised patients with pain in the shoulder area (glenohumeral and acromioclavicular joints) (n = 30), and group B, which comprised patients with pain in the scapula (n = 17). I was significantly greater in group A (88.3% ± 14%) than in group B (43.2% ± 22%). In groups A and B, 90% and 11% of patients, respectively, demonstrated excellent pain control. Total tramadol consumption in group A, 25 (0-100) mg, was significantly less that of group B, 250 (150-500) mg. Patients' satisfaction also was significantly higher in group A compared with group B. No complications were recorded. CONCLUSIONS: Ultrasound-guided interscalene nerve block can substantially alleviate post-thoracotomy pain in the shoulder but not in the scapular area.

Lazaroid U-74389G for cardioplegia-related ischemia-reperfusion injury: an experimental study.

BACKGROUND: The adverse effects of myocardial ischemia and reperfusion during cardiopulmonary bypass (CPB) have been thoroughly described. Lazaroid U-74389G, a 21 aminosteroid, has been shown to attenuate ischemia and reperfusion injury and improve recovery in a variety of experimental models. METHODS: Sixteen male swine were randomly divided in two groups. All animals underwent 45 min of ischemic cardioplegic arrest, with U-74389G addition to the standard cardioplegic solution, whereas controls underwent the same procedure without U-74389G. Creatine kinase-MB isoenzyme (CK-MB) and cardiac troponin T levels were measured immediately before CPB (time point 0), during the ischemic period (time point 1) and 30 (time point 2), 60 (time point 3), and 120 (time point 4) min after reperfusion. Myocardial biopsies were obtained at time points 0 and 4. RESULTS: CK-MB levels (in U/L) at time points 0-4 were 205 (186-235) versus 219 (196-269; P = 0.72), 215 (167-248) versus 253 (193-339; P = 0.23), 234 (198-255) versus 338 (249-441; P = 0.02), 244 (217-272) versus 354 (269-496; P = 0.01), and 285 (230-321) versus 439 (432-530; P < 0.01) in lazaroid-treated animals versus controls, respectively. Cardiac troponin T levels (in ng/L) at time points 0-4 were 58 (26-287) versus 237 (26-395; P = 0.72), 129 (61-405) versus 265 (145-525; P = 0.23), 261 (123-467) versus 474 (427-1604; P = 0.04), 417 (204-750) versus 841 (584-1818; P = 0.11), and 643 (353-1259) versus 1600 (1378-2313; P < 0.01), respectively. Necrosis grades at time point 4 were 0.0 (0.0-1.0) versus 1.5 (1.0-2.0; P < 0.01) in lazaroid-treated animals versus controls, respectively. CONCLUSIONS: The present study, in addition to reconfirming the well-described adverse effects of CPB, demonstrates the efficacy of the newer generation lazaroid U-74389G in alleviating these effects.

Intraoperative TTE inferior vena cava monitoring in elderly orthopaedic patients with cardiac disease and spinal-induced hypotension.

Objective To address the role of transthoracic echocardiography in inferior vena cava (IVC) monitoring in the management of haemodynamically unstable elderly patients subjected to lower limb orthopaedic surgery under spinal anesthesia. Possible implications in the postoperative care unit (PACU) length of stay (LOS) are investigated. Methods 41 elderly patients with cardiac diseases were recruited. Patients experiencing intraoperative haemodynamic instability (diastolic blood pressure ≤ 60 mmHg) were divided into two groups according to right atrial pressure (RAP), (RAP < 5 mmHg and RAP between 5 and 10 mmHg) as measured by inferior vena cava collapsibility index (IVCCI). Haemodynamic instability was treated with normal saline infused at a constant rate supplemented by phenylephrine (PHE) infusions titrated to normal blood pressure values. Intraoperatively comparisons of peak PHE infusion rates and all episodes of hypotension, including in the PACU, were recorded among groups. The patients' PACU LOS and associated factors were assessed. Results The intraoperative peak PHE infusion rate and the incidence of haemodynamic instability in the postoperative period were significantly higher in patients with RAP < 5 mmHg. The total PHE consumption was also higher in patients with RAP < 5 mmHg postoperatively. The primary risk factor for a prolonged stay in PACU, as determined by multiple regression analysis was RAP. Conclusions Patients with high dynamic collapsibility of the IVC may require aggressive treatment to restore their haemodynamic status. Additionally, intraoperative levels of RAP, as measured by IVCCI, can act as a predictor for increased LOS in the PACU.

Factors associated with the presence of postoperative headache in elective surgery patients: a prospective single center cohort study.

PURPOSE: Headache is an important cause of minor postoperative morbidity. In this study we evaluated the association of anesthesia and surgery with the occurrence of postoperative headache in elective surgery patients. METHODS: After obtaining ethical approval, 446 patients were enrolled in this prospective, single-centre cohort study. Participants were interviewed preoperatively, and for five days postoperatively, regarding the appearance of headache, while demographics, lifestyle, type of anesthesia and surgery, the anesthetic drugs administered and intraoperative adverse effects were recorded. Multiple logistic regression analysis was conducted in order to identify independent factors associated with postoperative headache, both in the total sample and in patients without previous history of headache. RESULTS: The observed overall frequency of postoperative headache was 28.3% (N = 126) in the total sample. In patients with previous history of headache, the frequency of postoperative headache was 41% (N = 89), while in those with no history the frequency of postoperative headache was 16.2% (N = 37). Female gender [p = 0.024; odds ratio (OR) = 2.1], sevoflurane administration (p < 0.001; OR = 3.66), intraoperative hypotension (p = 0.008; OR = 2.12) and smoking (p = 0.006; OR = 1.74) were independently associated with postoperative headache. In patients without previous history, female gender (p = 0.005; OR = 4.77), sevoflurane administration (p = 0.001; OR = 6.9), intraoperative hypotension (p = 0.006; OR = 6.7) and caffeine consumption (p = 0.041; OR = 5.28) presented greater likelihood for postoperative headache, while smoking revealed no association. CONCLUSION: Female gender, sevoflurane, smoking and intraoperative hypotension were documented as independent risk factors for postoperative headache. In patients with no previous history of headache, caffeine consumption was an additional independent factor for postoperative headache, while smoking revealed no association.

N-acetylcysteine ameliorates liver injury in a rat model of intestinal ischemia reperfusion.

BACKGROUND: N-acetylcysteine (NAC) is an antioxidant with direct and indirect antioxidant actions used in the clinical setting. Oxidative stress is known to play a pivotal role in the intestinal ischemia reperfusion (IIR). Therefore, we studied the effect of different pretreatment regimens with NAC on the IIR injury in rats. MATERIALS AND METHODS: Thirty-five male Wistar rats were randomly assigned to five groups. In group sham, only laparotomy was performed. Group control underwent IIR without NAC. In the other groups, NAC was administered intraperitoneally with different regimens: 150 mg/kg before ischemia (NAC 150), 300 mg/kg before ischemia (NAC 300), and 150 mg/kg before ischemia plus 150 mg/kg 5 min before reperfusion (NAC 150 + 150). Measurements in tissues and blood were conducted at 4 h of reperfusion following exsanguination. RESULTS: Histological score of the liver was significantly improved in NAC 300 compared with control (1.7 ± 0.5 versus 2.9 ± 1.1, respectively, P = 0.05). In addition, NAC treatment significantly reduced liver transaminases in all groups of treatment, mostly in group NAC 300. Plasma malondialdehyde levels were lower with NAC treatment, although not statistically significant. Lung glutathione peroxidase was significantly increased in group NAC 300 (P = 0.04), while the other oxidation biomarkers showed no significant differences. CONCLUSIONS: NAC exerts a significant protective role in liver injury following IIR, which seems to be independent of an intestinal protective effect. Additional administration of NAC before reperfusion was of no further benefit. The most effective regimen among the compared regimens was that of 300 mg/kg before ischemia.

Cost-Effective Surgical Management of Liver Disease Amidst a Financial Crisis.

BACKGROUND: Intraoperative use of specialized equipment and disposables contributes to the increasing cost of modern liver surgery. As a response to the recent severe financial crisis in our country we have employed a highly standardized protocol of liver resection that minimizes intraoperative and postoperative costs. Our goal is to evaluate cost-effectiveness of this protocol. STUDY DESIGN: We evaluated retrospectively all patients who underwent open hepatic resections for 4 years. All resections were performed by the same surgical team under selective hepatic vascular exclusion, i.e., occlusion of the hepatoduodenal ligament and the major hepatic veins, occasionally combined with extrahepatic ligation of the ipsilateral portal vein. Sharp parenchymal transection was performed with a scalpel and hemostasis was achieved with sutures without the use of energy devices. In each case we performed a detailed analysis of costs and surgical outcomes. RESULTS: Our cohort included 146 patients (median age 63 years). 113 patients were operated for primary or metastatic malignancies and 33 for benign lesions. Operating time was 121 ± 21 min (mean ± SD), estimated blood loss was 310 ± 159 ml (mean ± SD), and hospital stay was 7 ± 5 days (mean ± SD). Six patients required admission in the ICU postoperatively. 90-day mortality was 2.74 %, and 8.9 % of patients developed grade III/IV postoperative complications (Clavien-Dindo classification). Total in-hospital cost excluding physician fees was 6987.63 ± 3838.51 USD (mean ± SD). CONCLUSIONS: Our analysis suggests that, under pressing economic conditions, the proposed surgical protocol can significantly lessen the financial burden of liver surgery without compromising patient outcomes.

Translation, Cultural Adaptation, and Validation of Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) and Self-Complete Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) Questionnaires into the Greek Language.

BACKGROUND: The LANSS and S-LANSS questionnaires represent two widely accepted and validated instruments used to assist the identification of neuropathic pain worldwide. OBJECTIVE: The aim of this study was to translate, culturally adapt, and validate the LANSS and S-LANSS questionnaires into the Greek language. METHODS: Forward and backward translations of both questionnaires were performed from the English to Greek language. The final versions were assessed by a committee of clinical experts, and they were then pilot-tested in 20 patients with chronic pain. Both questionnaires were validated in 200 patients with chronic pain (100 patients for each questionnaire), using as the "gold standard" the diagnosis of a clinical expert in pain management. Sensitivity and specificity of questionnaires were assessed, as well as the internal consistency (using Cronbach's alpha coefficient) and correlation with the "gold standard" diagnosis (using Pearson correlation coefficient). RESULTS: Sensitivity and specificity of the LANSS questionnaire were calculated to be 82.76% and 95.24%, while for the S-LANSS 86.21% and 95.24%, respectively. Positive predictive value for neuropathic pain was 96% for the LANSS and 96.15% for the S-LANSS. Cronbach's alpha was revealed to be acceptable for both questionnaires (0.65 for LANSS and 0.67 for the S-LANSS), while a significant correlation was observed compared to the "gold standard" diagnosis (rLANSS   = 0.79 και tSLANSS   = 0.77, respectively, P = 0.01). CONCLUSIONS: The LANSS and the S-LANSS diagnostic tools have been translated and validated into the Greek language and can be adequately used to assist the identification of neuropathic pain in everyday clinical practice.

REMIFENTANIL VS FENTANYL DURING DAY CASE DENTAL SURGERY IN PEOPLE WITH SPECIAL NEEDS: A COMPARATIVE, PILOT STUDY OF THEIR EFFECT ON STRESS RESPONSE AND POSTOPERATIVE PAIN.

BACKGROUND: People with special needs undergoing dental surgery frequently require general anesthesia. We investigated the effect of remifentanil vs fentanyl on stress response and postoperative pain in people with special needs undergoing day-case dental surgery. METHODS: Forty-six adult patients with cognitive impairment undergoing day-case dental surgery under general anesthesia were allocated to receive intraoperatively either fentanyl 50 µg iv bolus (group F, n = 23) or continuous infusion of remifentanil 0.5-1 µg/kg/min (group R, n = 23). Iintraoperative hemodynamic parameters were recorded and serum inflammatory mediators [tumor necrosis factor-α, substance-P], stress hormons (melatonin, cortisol) and ß-endorphin were measured. Postoperative pain was assessed during the first postoperative 12 hours with the Wong-Baker faces pain-rating scale. RESULTS: Demographics were similar in two groups. The two groups did not differ regarding their effects on inflammatory mediators, stress hormons and postoperative pain scores. However, the use of remifentanil prevented intraoperative increases of arterial blood pressure and heart rate. CONCLUSIONS: Remifentanil and fentanyl did not affect differently stress and inflammatory hormones during day-case dental surgery, although remifentanil may render intraoperative management of hemodynamic responses easier. Both opioids are equally efficient for postoperative pain management following dental surgery in people with special needs.

Ultrasonographic evaluation of abdominal organs after cardiac surgery.

BACKGROUND: Disturbances of the hepatosplanchnic region may occur after cardiac operations. Experimental studies have implicated impairment of splanchnic blood supply in major abdominal organ dysfunction after cardiopulmonary bypass (CPB). We investigated the impact of the cardiac operation and CPB on liver, kidney, and renal perfusion and function by means of ultrasonography and biochemical indices in a selected group of cardiac surgery patients. MATERIALS AND METHODS: Seventy five patients scheduled for a major cardiac operation were prospectively included in the study. Criteria for selection were moderate or good left ventricular ejection fraction and absence of previous hepatic or renal impairment. Ultrasound examination of the hepatic and renal vasculature and examination of biochemical parameters were performed on the day preceding the operation (T0), on the first postoperative day (T1), and on the seventh postoperative day (T2). RESULTS: Portal vein velocity and flow volume increased significantly, whereas hepatic artery velocity and flow volume decreased at T1 in comparison with T0. Hepatic vein indices remained unaffected throughout the observation period. Renal artery velocity and flow decreased, whereas renal pulsatility index and renal resistive index increased at T1 as compared with T0. Aspartate aminotransferase and alanine aminotransferase values were increased as compared with baseline values 24 h postoperatively. All parameters displayed a trend to approach preoperative levels at T2. Strong negative correlations between alanine aminotransferase values at T1 and hepatic artery velocity and flow volume at the same time point were also demonstrated (R = 0.638, P < 0.001 and r = 0.662, P < 0.001, respectively). CONCLUSIONS: The increase in portal vein flow and velocity and the decrease in hepatic artery flow and velocity in the period after CPB might be attributed to the hypothermic bypass technique and the hepatic arterial buffer response, respectively. The decrease in renal blood flow and velocity and the parallel increase in Doppler renal pulsatility index and renal resistive index could be considered as markers of kidney hypoperfusion and intrarenal vasoconstriction. Maintaining a high index of suspicion for the early diagnosis of noncardiac complications in the period after CPB and institution of supportive care in case of compromised splanchnic perfusion are warranted.

The effect of 0.5 L 6% hydroxyethyl starch 130/0.42 versus 1 L Ringer's lactate preload on the hemodynamic status of parturients undergoing spinal anesthesia for elective cesarean delivery using arterial pulse contour analysis.

PURPOSE: Fluid loading attenuates the hypotensive response to spinal anesthesia (SA). This study aimed to compare the preload efficacy of 0.5 L hydroxyethyl starch (HES) versus 1 L Ringer's lactate (R/L) in the prevention of hypotension after SA for elective cesarean delivery (CD). Assessment of maternal hemodynamic variables using FloTrac/Vigileo™ and neonatal outcome constituted secondary outcomes. METHODS: Thirty-two ASA I/II parturients scheduled for elective CD were preloaded with either 1 L R/L (Group R/L, n = 16) or 0.5 L HES 6% 130/0.42 (Group T, n = 16) approximately 25 min before SA. Hypotension, defined as a 20% decrease of systolic arterial pressure (SAP) from baseline or SAP <100 mmHg, was treated with vasopressors according to a predetermined algorithm. The overall duration of hypotensive episodes and the total amount of vasopressors administered determined the severity of the hemodynamic instability. RESULTS: The incidence of hypotension was 73.3% in Group R/L and 46.7% in Group T. HES compared to R/L preload was associated with a shorter overall duration of hypotensive episodes (p < 0.001), a significantly less usage of ephedrine and phenylephrine (p = 0.015 and p = 0.029, respectively) and a greater impact, although not statistically significant, on cardiac index (CI) and stroke volume index (SVI). Although no statistical difference was detected between groups over time, there was a significant drop in CI, SVI and SAP within groups (p < 0.001) up to 14 min after SA. No difference was recorded in neonatal outcome. CONCLUSIONS: Preloading with 0.5 L HES 130/0.42 produced more stable hemodynamics compared to 1 L R/L solution in obstetric patients.

Ultrasound imaging of the musculocutaneous nerve of infants, preschool children, and school children.

The purpose of this imaging study was to investigate whether the musculocutaneous nerve could be visualized ultrasonographically in childhood and to assess how its visualization changes with age. Forty-two children participated in this prospective imaging study. The musculocutaneous nerve was sought both proximally (near the axillary artery) and distally (within the coracobrachialis muscle) by use of an linear ultrasound probe. Location of the musculocutaneous nerve was good (93 %) for all the children, both proximally and distally. For school-aged children, distal visualization of the musculocutaneous nerve reached 100 %. The musculocutaneous nerve is detectable in childhood by use of ultrasonography; success of detection was high for all the age groups examined.