A randomized, controlled, blinded evaluation of augmenting point-of-care ultrasound and remote telementored ultrasound in inexperienced operators.

BACKGROUND: Handheld ultrasound devices present an opportunity for prehospital sonographic assessment of trauma, even in the hands of novice operators commonly found in military, maritime, or other austere environments. However, the reliability of such point-of-care ultrasound (POCUS) examinations by novices is rightly questioned. A common strategy being examined to mitigate this reliability gap is remote mentoring by an expert. OBJECTIVES: To assess the feasibility of utilizing POCUS in the hands of novice military or civilian emergency medicine service (EMS) providers, with and without the use of telementoring. To assess the mitigating or exacerbating effect telementoring may have on operator stress. METHODS: Thirty-seven inexperienced physicians and EMTs serving as first responders in military or civilian EMS were randomized to receive or not receive telementoring during three POCUS trials: live model, Simbionix trainer, and jugular phantom. Salivary cortisol was obtained before and after the trial. Heart rate variability monitoring was performed throughout the trial. RESULTS: There were no significant differences in clinical performance between the two groups. Iatrogenic complications of jugular venous catheterization were reduced by 26% in the telementored group (P < 0.001). Salivary cortisol levels dropped by 39% (P < 0.001) in the telementored group. Heart rate variability data also suggested mitigation of stress. CONCLUSIONS: Telementoring of POCUS tasks was not found to improve performance by novices, but findings suggest that it may mitigate caregiver stress.

Continuous lumbar/thoracic epidural analgesia in low-weight paediatric surgical patients: practical aspects and pitfalls.

PURPOSE: Continuous epidural anaesthesia attenuates perioperative stress and avoids the need for systemic opioids. In addition, it may prevent the need for postoperative mechanical ventilation. The aim of the study was to prospectively follow the perioperative course of young infants treated with continuous thoracic/lumbar epidural anaesthesia for major surgery. METHODS: Data were collected prospectively from 44 epidural anaesthetics in 40 infants (18 premature or former premature) weighing 1,400-4,300 g who underwent major abdominal surgery (33 cases), thoracic surgery (5), or both (1), or ano-rectal surgery (5) at our centre. RESULTS: Epidural placement was achieved easily in all cases, with high quality analgesia for 24-96 h. Tracheal extubation was delayed after 4 anaesthetics due to muscle relaxant overdose (n = 1), surgeon's request (n = 2), and systemic opioid administration before epidural anaesthesia was considered (n = 1). Intraoperative complications included haemodynamic instability (n = 1) and vascular catheter placement (n = 5). Postoperative complications included meningitis (n = 1), insertion site erythema (n = 7), apnoea (n = 6; 4 premature and 2 full-term infants) and tracheal re-intubation (n = 6). CONCLUSIONS: Continuous epidural analgesia is effective in low-weight infants undergoing major surgery. The trachea may be extubated immediately after surgery. Attention should be paid to the unique anatomical, physiological, and pharmacological aspects. The patients should be monitored carefully for pain, respiratory failure, and meningitis (an extremely rare complication).

The effects of general vs spinal anesthesia on frontal cerebral oxygen saturation in geriatric patients undergoing emergency surgical fixation of the neck of femur.

STUDY OBJECTIVE: To assess the effect of regional vs general anesthesia on transcranial cerebral oxygen saturation (rSo2). DESIGN: Prospective, randomized, open-label study. SETTING: Large referral hospital. PATIENTS: Sixty American Society of Anesthesiologists physical status I, II, and III geriatric patients at least 60 years of age, undergoing surgical fixation of the neck of femur. INTERVENTIONS: Patients were randomized to receive either general (group GA) or spinal (group S) anesthesia. In all cases, frontal rSo2 was measured for a 10-minute preoperative control period, throughout the surgical procedure, and for 10 minutes postoperatively. MEASUREMENT AND MAIN RESULTS: The frequency of a decrease in rSo2 below baseline preoperative levels was significantly (P < .0001) higher in group S. However, the number of patients in whom at least one dip below baseline was recorded was similar between the groups. By contrast, general anesthesia was associated with a significantly higher rSo2 when compared with spinal anesthesia. Logistic regression revealed no correlation between changes in blood pressure, heart rate, or peripheral oxygen saturation and the frequency of rSo2 dips below baseline. CONCLUSION: Cerebral oxygen saturation is likely patient specific and independent of the anesthetic technique administered. Spinal anesthesia is associated with a higher incidence of cerebral desaturation. However, the number of patients in whom at least one dip below baseline was recorded was similar between the groups.

The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine.

STUDY OBJECTIVE: To describe the frequency and timing of intravenous patient-controlled analgesia (IV-PCA) or neuraxial morphine-induced postoperative respiratory depression. DESIGN: Audit of data captured by routine quality assurance of the acute pain protocols that were implemented by nurses performing routine postoperative care. SETTING: The surgical wards of a university-affiliated, 700-bed, tertiary hospital. PATIENTS AND INTERVENTIONS: In real time, the data of all patients enrolled into our Acute Pain Service (APS) were entered and stored in the APS database. Thereafter, patients who had received IV morphine via a PCA device or neuraxial morphine between January 1999 and December 2002 were isolated. From this subset, all patients in whom a respiratory rate (RR) less than 10 breaths per minute was recorded were retrieved. MEASUREMENTS AND MAIN RESULTS: From a total of 4500 patients, IV or neuraxial morphine was administered to 1524 patients. Eighteen (1.2%) cases of an RR less than 10 breaths per minute were recorded (13 patients, 4 patients, and 1 patient in the IV-PCA, daily epidural morphine, and single-dose intrathecal morphine groups, respectively). A direct correlation between intraoperative fentanyl administration and postoperative respiratory depression was demonstrated between the IV-PCA (P = 0.03) and epidural groups (P = 0.05). The time from IV-PCA initiation or last neuraxial morphine administration until the diagnosis of respiratory depression ranged between 2 hours and 31.26 hours and 2 hours and 12.15 hours, respectively. Ten (55.6%) patients received naloxone. CONCLUSION: Morphine-induced respiratory depression may occur at any time during the APS admission. However, the optimal frequency of intermittent RR monitoring is unknown. Furthermore, because multiple variables (age, sex, prior opioid administration, site of operation) may affect morphine-induced respiratory depression, further investigation must be performed to determine the ideal monitoring protocol.

Naval casualty management training using human patient simulators.

BACKGROUND: Extended-evacuation or austere environments (e.g. naval, immature or depleted combat zones) are characterized by the lack of resources to facilitate medical evacuation in the "Golden Hour" from moment of injury. This may require the primary caregiver, often a relatively inexperienced general physician or EMT, to administer extended medical care in the field. We describe the Shipboard and Underwater Casualty Care and Sedation Simulation (SUCCeSS) program in the Israeli Navy, intended to train caregivers for extended prehospital intensive casualty care using high fidelity life-size simulation mannequins set up onboard corvettes or submarines during maneuvers, in maximally realistic conditions. Twenty two general physicians and EMTs in 12 teams were enrolled in the program in the years 2011-2013. Two to three hour long training sessions were headed by senior surgeons and anesthesiologists using flexible scripts enabling the mannequin operators to react to caregivers' actions and their consequences. Trainee evaluation was performed by the preceptors using semi-structured forms taking into account both critical treatment decisions and observation on the effects of actions taken. Trainees also completed self-report CRM (Crisis Resource Management) questionnaires before and after the sessions. RESULTS: Success of the trainees correlated with an evaluation score above 72%. The mean overall CRM score for team leaders post exercise was 74.64%, an improvement of 10% over pre-exercise scores (p < 0.0001). CONCLUSION: Caregiver self-perceived competence and self-sufficiency in treating casualties at sea was improved via high fidelity simulation in theatre using realistic naval casualty care situations. We discuss the relative strengths and weaknesses of our training program for the teaching of "NCM", or Naval Casualty Management, as well as the emergent concepts of the military extended evacuation environment.

Sedation methods for intra-articular corticosteroid injections in Juvenile Idiopathic Arthritis: a review.

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. Intra-articular corticosteroid injection (IASI), one of the cornerstones of treatment for this disease, is usually associated with anxiety and pain. IASI in JIA may be performed under general anesthesia, conscious sedation, or local anesthesia alone. Currently, there is no widely accepted standard of care regarding the sedation method for IASI. This review discusses the different methods of anesthesia and sedation in this procedure, emphasizing the advantages and shortcomings of each method.

The postoperative analgesic efficacy of wound instillation with ropivacaine 0.1% versus ropivacaine 0.2%.

STUDY OBJECTIVES: To assess the influence of ropivacaine concentration on wound instillation-induced postoperative analgesia following total abdominal hysterectomy with bilateral salpingo-oophorectomy. DESIGN: Prospective, randomized, double-blind study. SETTING: Large referral hospital. PATIENTS: 40 ASA physical status I and II patients undergoing total abdominal hysterectomy with bilateral salpingo-oophorectomy. INTERVENTIONS: A standard general anesthetic was administered. In all cases surgery was performed via a Pfannenstiel incision. On completion of the surgery, a multi-orifice, 20-gauge epidural catheter was placed above the fascia such that the tip was sited at the point that demarcated 50% of the length of the surgical wound. Thereafter, the catheter was connected to an electronic patient-controlled analgesia (PCA) device programmed to deliver 9 mL of drug, with a lockout time of 60 minutes and no basal infusion. Patients were randomized to receive PCA with ropivacaine 0.1% (Group 0.1) or ropivacaine 0.2% (Group 0.2). During the first 6 postoperative hours, a co-investigator administered "rescue" morphine (2 mg IV). Thereafter, "rescue" meperidine 1 mg/kg was administered on patient request. MEASUREMENTS AND MAIN RESULTS: The number of attempts to activate the PCA device and actual PCA instillations during the 24 hour study period were similar between the groups. The number of 2 mg "rescue" morphine dosages administered was 4.3 +/- 1.7 versus 4.4 +/- 2.5 for the Group 0.1 and Group 0.2, respectively. For Group 0.1 and Group 0.2, the total dose of "rescue" morphine administered during the first 6 postoperative hours was 8.7 mg +/- 3.6 versus 9.1 mg +/- 5, respectively. "Rescue" meperidine administration during the subsequent 18 hours was similar between the groups. Throughout the study period, pain scores were similar between the groups. CONCLUSION: With a pre-set volume, varying the concentration of ropivacaine (0.1% versus 0.2%) does not affect the analgesic efficacy of wound instillation following total abdominal hysterectomy with bilateral salpingo-oophorectomy.

A comparison of three techniques for acute postoperative pain control following major abdominal surgery.

STUDY OBJECTIVES: To compare the analgesic efficacy of a nonsteroidal antiinflammatory drug (NSAID) alone (basic pain treatment) with that of NSAID in conjunction with either intravenous (IV) patient-controlled analgesia (IV-PCA) or intermittent epidural morphine (epidural morphine), among patients recovering from major intraabdominal surgery; and to assess the fixed and variable costs of providing the respective acute pain treatment modalities. DESIGN: Prospective, nonrandomized study. SETTING: Postanesthesia care unit (PACU) and surgical departments of a large referral hospital. PATIENTS: All patients (n = 358) treated by our Acute Pain Service (APS) who were recovering from major intraabdominal surgery (colectomy, cholecystectomy, colostomy, gastrectomy, splenectomy). MEASUREMENTS AND MAIN RESULTS: The structure of our APS, analgesic regimens, and the associated patient monitoring and event-response algorithms are detailed. Data of 358 patients recovering from major intraabdominal surgery and treated according to one of the three treatment protocols were collected and analyzed. The cost of providing our APS and the nursing time required to monitor and treat patients in each treatment group were also calculated. The median visual analog scale (VAS) scores were low in all three treatment groups (23.5 mm vs. 6 mm vs. 4, for the basic pain treatment, IV-PCA, and epidural morphine groups, respectively). However, the median VAS was significantly (p < 0.04) lower among patients who received epidural morphine than either the IV-PCA or basic pain treatment groups. Similarly, the number of patients who had at least one episode of a pain VAS >30 mm was significantly (p < 0.04) lower in the epidural morphine group than either of the other two groups. The frequency of nausea and vomiting was similar among the groups. However, the frequency of postoperative pruritus was significantly (p < 0.001) higher in the epidural morphine group than the other two groups. Patient satisfaction was unaffected by group allocation. Institutional costs per patient and the nursing time required to provide the APS were lowest in the basic pain treatment group. CONCLUSIONS: Considering the respective pain profiles, complication rates, and institutional costs associated with the three analgesic regimens analyzed, the basic pain Treatment alone constitutes a useful alternative to the other two analgesic regimens assessed.

[Lumbar epidural anesthesia in a very-low-birth-weight infant].

In this case study two combined, light-general and lumbar epidural anesthetics were administered to a premature neonate for the repair of gastroschisis. The female infant's body weight was 1400 grams (first operation) and 1700 grams (second operation). The epidural catheter was inserted between the low-lumbar vertebrae using the "loss of resistance" for saline technique. Intra- and postoperative analgesia were based on epidural administration of bupivacaine and fentanyl. No systemic opioids were administered. The infant recovered from general anesthesia at the end of both operations. Excellent analgesia was accomplished throughout the peri-operative course except for short periods during and after the second operation that resolved after the epidural catheter was withdrawn by a few centimeters. Neither respiratory or hemodynamic depression, nor bupivacaine toxicity were observed. The anesthetic and analgesic management is presented in the article. Technical aspects of lumbar epidural anesthesia, it's advantages over the caudal approach and dosages of epidural anesthetics in small infants, as well as complications and risks are emphasized.

Preoperative ultrasound and intraoperative findings of inguinal hernias in children: A prospective study of 642 children.

BACKGROUND/PURPOSE: Preoperative sonographic studies of the groins have become a routine evaluation of inguinal hernia in children. Its value is not only to confirm the clinical diagnosis, but also to accurately assess the opposite side and to prevent an unnecessary exploration or additional operation at a later stage. The purpose of this study is to report more definitive criteria of inguinal hernias (IH) and patent process vaginalis (PPV) established from 1,284 groin examinations. METHODS: From January 1999 to October 2000 the authors compared prospectively the sonographic dimensions of the inguinal canal to the operative findings as reported by the surgeons (blinded to the results) for 642 pediatric patients (ages 1 to 176 months) undergoing inguinal hernia repairs. RESULTS: A normal inguinal canal was found at operation when a preoperative sonographic groin width of 3.6 +/- 0.8 mm, on average, was detected. A PPV was found when a groin width of 4.9 +/- 1.1 mm was detected. A full hernia was found when a groin width of 7.2 +/- 2.0 mm was detected. A large hernia was found when a groin width of 12.8 +/- 3.6 mm was detected, and a hydrocele was found along with a groin width of 4.8 +/- 2.2 mm. CONCLUSIONS: Establishing accurate sonographic criteria for inguinal hernia and patent processus vaginalis is an important tool for the pediatric surgeon to plan the approach before groin surgery.

The distance from the skin to the subarachnoid space can be predicted in premature and former-premature infants.

PURPOSE: Spinal anesthesia can be technically challenging in young infants. We studied whether the distance between the skin and the lumbar subarachnoid space in premature and former-premature young infants could be predicted prior to lumbar puncture. METHODS: The distance from skin entry point to tip of the spinal needle was measured using a caliper after lumbar spinal anesthesia at the L4-5 interspace. This distance was correlated to the patient's weight, postconceptual age and lumbar ultrasonographic measurement of the skin-to-subarachnoid space and predictive statistical models were sought. RESULTS: Thirty-five premature or former-premature infants were studied. Three models were examined: all three independent variables, weight and postconceptual age only, and weight only. The model selected contained the weight and postconceptual age, because it had the highest value for adjusted R squared, as well as the lowest value for the mean squared error. Adding the ultrasonic measurement to the model worsened the results. The statistical model that described the depth of the subarachnoid space at the L4-5 level was Y = 13.19 + 0.0026 x W - 0.12 x PCA, where Y is the distance (mm) from the skin to the subarachnoid space, W is the patient's weight (g) and PCA is the postconceptual age (weeks). Adjusted R squared was 0.72, mean square error was 2.63 and P < 10(-9). CONCLUSION: The distance between the skin and the subarachnoid space at the level of L4-5 interspace can be predicted using a statistical model based on the infant's weight and postconceptual age. Spinal ultrasound has no value in L4-5 subarachnoid space depth prediction.

Spinal anesthesia in 62 premature, former-premature or young infants--technical aspects and pitfalls.

PURPOSE: To highlight technical aspects and pitfalls of spinal anesthesia (SA) in infants. METHODS: The medical history and perioperative course of all infants who underwent SA over a 28-month period were collected (retrospectively in the first 20). RESULTS: Sixty-two infants underwent surgery under SA. Fifty-five were premature and former-premature, postconceptional age 43.3 +/- 5.0 weeks, weight 3261 +/- 1243 g. Of these, 21 had co-existing disease: cerebral (six), cardiac (nine), pulmonary (11) and urological (six). Hyperbaric tetracaine or bupivacaine 1 mg x kg(-1) with adrenaline was administered. Four infants (three premature) required N(2)O supplementation and three needed general anesthesia. The supplementation rate was similar or lower than in previous studies. Postoperatively, all seven were shown to have lower limb motor and sensory blockade. Complications in premature patients included intraoperative hypoxemia (two), apnea (two) and bradycardia (one). Postoperative complications included bradycardia (three), hypoxemia (one) and apnea and hypoxemia (one). The postoperative complication rate was similar to previous studies. CONCLUSION: Successful SA in infants depends on close attention to preoperative assessment, appropriate patient positioning during and after lumbar puncture, drug dosing and intra- and postoperative cardiorespiratory monitoring. A relatively high dose of hyperbaric solution of tetracaine or bupivacaine with adrenaline should be administered.