Low-dose spinal anesthesia for cesarean section to prevent spinal-induced hypotension.

PURPOSE OF REVIEW: Low-dose combined spinal epidural (CSE) anesthesia is a common technique to anesthetize women for cesarean section. It is used to reduce the incidence of hypotension while providing excellent anesthetic conditions. RECENT FINDINGS: Low spinal doses produce effective anesthesia but of limited duration. Therefore, an epidural catheter (and thus CSE) is required to guarantee pain-free surgery. Recent work confirmed that lower spinal doses can reduce significantly hypotension. SUMMARY: Low-dose CSE is a valuable strategy to anesthetize pregnant women for cesarean section but requires attention and training.

Horner's syndrome and paresthesia in the trigeminal nerve territory secondary to epidural analgesia for labor / Síndrome de Horner e parestesia do território do nervo trigêmeo secundário a analgesia peridural para trabalho de parto

Abstract Currently, epidural analgesia is a common procedure for labor analgesia. Although it is considered a safe technique, it is not without complications. Horner's syndrome and paresthesia within the trigeminal nerve distribution are rare complications of epidural analgesia. We report a case of a pregnant woman who developed Horner's syndrome and paresthesia within the distribution of the trigeminal nerve following epidural analgesia for the relief of labor pain.

Resumo A analgesia peridural é hoje em dia um procedimento comum para analgesia do trabalho de parto. Embora seja considerada uma técnica segura, não está isenta de complicações. A síndrome de Horner e a parestesia do território do nervo trigêmeo são complicações raras da analgesia peridural. Relatamos um caso de uma grávida que desenvolveu a síndrome de Horner e parestesia do território do nervo trigêmeo após analgesia peridural para o alívio da dor do trabalho de parto.

Dural sinus thrombosis following epidural analgesia for delivery: a clinical case / Trombose de seios durais após analgesia peridural para parto: caso clínico

Abstract Background and objectives: Neurological complications of spinal anesthesia are rare conditions. Headache caused by low pressure of the cerebrospinal fluid is one of the most frequent, which occurs after post-dural puncture. A comprehensive history and physical exam must be carried out before making the diagnosis of Post-Dural Puncture Headache (PDPH) and additional tests are necessary to exclude the possibility of developing serious neurological complications such as Dural Sinus Thrombosis (DST). According to the Case Report a differential diagnosis between Dural Sinus Thrombosis with PDPH is discussed. Case report: A 22 year-old lady, ASA Physical Status Class I was admitted at 39 weeks of gestation for delivery. For labor pain relief she requested epidural for analgesia, but unfortunately accidental dural puncture occurred. She developed an occipital headache and neck pain in the second day postpartum which was relieved by both lying down and supporting treatment such as rehydration, analgesics and caffeine. On day third postpartum she was discharged without complaints. On day fifth postpartum the pain returned and became more intense and less responsive to oral analgesics. She was admitted to the hospital to do a complete neurological and image investigation that showed a lesion consistent with the diagnosis of cortical vein thrombosis and Dural Sinus Thrombosis (DST). She was treated with oral anticoagulants. After two days, a repeated magnetic resonance image (MRI) showed partial canalization of the central sinus thrombus. The patient was discharged from hospital five days after her admission without any of the initial symptoms. Conclusion: The report describes a patient who developed severe headache following continuous epidural analgesia for delivery. Initially it was diagnosed as PDPH, however with the aid of MRI the diagnosis of DST was later established and treated. DST is a rare condition and is often underdiagnosed. Because of its potentially lethal complications, it should always be considered in acute headache differential diagnosis.

Resumo Justificativa e objetivos: As complicações neurológicas da raquianestesia são condições raras. A cefaleia causada pela baixa pressão do fluido cerebrospinal é uma das mais frequentes e ocorre após a punção dural. Anamnese completa e exame físico geral devem ser feitos antes de fazer o diagnóstico de cefaleia pós-punção dural (CPPD) e testes adicionais são necessários para excluir a possibilidade de complicações neurológicas graves, como trombose de seios durais (TSD). De acordo com o relato do caso, discutiremos o diagnóstico diferencial entre TSD e CPPD. Relato de caso: Paciente de 22 anos, estado físico ASA I, foi admitida com 39 semanas de gestação para o parto. Para alívio da dor do trabalho de parto, a paciente solicitou analgesia peridural, mas infelizmente ocorreu uma punção dural acidental. A paciente desenvolveu cefaleia occipital e dor cervical no segundo dia pós-parto - ambas aliviadas com repouso e terapia de suporte, como reidratação, analgésicos e cafeína. No terceiro dia pós-parto, a paciente recebeu alta sem queixas. No quinto dia pós-parto, a dor retornou e ficou mais intensa e com pouca resposta aos analgésicos orais. Ela foi admitida no hospital para uma completa investigação neurológica e de imagem que mostrou uma lesão compatível com o diagnóstico de trombose venosa cortical e TSD. A paciente foi tratada com anticoagulantes orais. Após dois dias, a repetição de ressonância nuclear magnética (RM) mostrou canalização parcial de trombo do seio central. A paciente recebeu alta hospitalar cinco dias após a admissão, sem quaisquer dos sintomas iniciais. Conclusão: O caso descreve uma paciente que desenvolveu cefaleia grave após epidural contínua para o parto. Inicialmente ela foi diagnosticada como CPPD, contudo com o auxílio da RNM foi estabelecido o diagnóstico tardio de TSD. TSD é uma condição rara e frequentemente subdiagnosticada. Ela deve sempre ser considerada como diagnóstico diferencial de cefaleia aguda em decorrência de suas complicações potencialmente letais.

Signal attenuation maps for needle enhancement and localization in 2D ultrasound.

PURPOSE: We propose a novel framework for enhancement and localization of steeply inserted hand-held needles under in-plane 2D ultrasound guidance. METHODS: Depth-dependent attenuation and non-axial specular reflection hinder visibility of steeply inserted needles. Here, we model signal transmission maps representative of the attenuation probability within the image domain. The maps are employed in a contextual regularization framework to recover needle shaft and tip information. The needle tip is automatically localized by line-fitting along the local-phase-directed trajectory, followed by statistical optimization. RESULTS: The proposed method was tested on 300 ex vivo ultrasound scans collected during insertion of an epidural needle into freshly excised porcine and bovine tissue. A tip localization accuracy of [Formula: see text] was achieved. CONCLUSION: The proposed method could be useful in challenging procedures where needle shaft and tip are inconspicuous. Improved needle localization results compared to previously proposed methods suggest that the proposed method is promising for further clinical evaluation.

Intra- versus postoperative initiation of pain control via a thoracic epidural catheter for lumbar spinal fusion surgery.

BACKGROUND: Thoracic epidural anesthesia (TEA) is one of the pillars of perioperative pain care. Particularly for spine surgery which causes significant postoperative pain TEA seems like an appealing option. However, beneficial effects of a TEA are questionable when the catheter is not used intraoperatively, a decision that is usually based on the surgeon's wish to perform immediate neurological examination postoperatively. METHODS: Forty patients undergoing transforaminal lumbar interbody fusion surgery (TLIF) were randomized into two groups. Patients received preoperative insertion of a TEA. For patients in the intraoperative group an epidural infusion was started preoperatively and maintained throughout. For patients in the postoperative group the epidural infusion was started once neurological examination had been performed. The primary outcome measure in this study was postoperative requirements of piritramide during the first two postoperative hours. Secondary outcomes involved postoperative pain numeric rating scale (NRS) scores, intraoperative opioid requirements, side effects and ability to perform direct postoperative neurological examination. RESULTS: Postoperative group patients required significantly more opioids both intra- and postoperatively (P=0.036 and P=0.039) and NRS scores were significantly higher on admission to recovery, at 30 and 60 min as compared to patients in the intraoperative group (P=0.013; P=0.004 and P=0.012). Early postoperative neurological examination was feasible in all patients in both groups. CONCLUSIONS: Epidural catheters used intraoperatively during TLIF are feasible, significantly reduce pain, intra- and postoperative use of opioids and do not influence the quality of neurological tests directly after the surgical procedure.

Comparison of Epidrum, Epi-Jet, and Loss of Resistance syringe techniques for identifying the epidural space in obstetric patients.

BACKGROUND: Identifying the epidural space is essential during epidural anesthesia (EA). Pressure of the epidural space in pregnancy is higher than that in nonpregnant woman. Loss of resistance (LOR) method is the most commonly preferred method for identifying the epidural space. Epidrum and Epi-Jet are recently innovated supporting devices that facilitate identifying process for epidural space. In this study we aimed to compare Epidrum, Epi-Jet, and LOR methods in identifying the epidural space, feasibility of technique. METHODS: Two hundred and forty pregnant women who were scheduled for caesarian section surgery under lumbar EA or combined spinal epidural anesthesia (CSEA) were randomized into three groups (Group I Epidrum, n = 80), Group II (Epi-Jet, n = 80), and Group III (LOR, n = 80). We recorded the time required to identify the epidural space and deflation of Epidrum balloon and Epi-Jet syringe, number of attempts, additional methods used to identify epidural space, usefulness of methods, accuracy of identification of epidural space, and outcomes of epidural catheterization. RESULTS: There were no significant differences between the groups with respect to demographic data, duration of deflation of Epidrum balloon and Epi-Jet syringe and distance between skin and epidural space. The mean time required to enter epidural space in Group I was shorter than that in Group II (P = 0.031). Feasibility of Epi-Jet was easier than that of Epidrum (P = 0.015). Number of uncertainties of epidural space identification was higher in Group I than that in Group II (P = 0.009). Also, the requirement for LOR to confirm epidural space and failure rates was higher in Group I than Group II (P < 0.001). CONCLUSION: We suggest that Epi-Jet is superior to Epidrum in pregnant patients in terms of clarity of epidural space identification, usefulness, and success rates of EA or CSEA.

Does ultrasound guidance add accuracy to continuous caudal-epidural catheter placements in neonates and infants?

BACKGROUND: Caudo-lumbar and caudo-thoracic epidural anesthesia is an established technique that carries a low risk of dural puncture or spinal cord trauma in infants. Traditionally catheter advancement is based on external measurements. However, malpositioning of catheters are known to occur. We hypothesized that caudal-epidural catheters inserted under real-time ultrasound guidance may be more accurate than the accuracy of the measurements traditionally used for their placement. METHODS: We studied 25 patients, aged 2 days to 5 months, posted for abdominal or thoracic surgery, receiving general anesthesia followed by caudo-epidural continuous block. External measurement defined as the distance from the caudal space and the surgically congruent vertebral level was measured in centimeters with the back gently flexed. Subsequently, a caudo-epidural block was performed in the same position. The epidural catheter insertion was followed under real-time ultrasound guidance till the predetermined vertebral level was reached. The actual length placed under real-time ultrasound scan was defined as the actual length. The high-frequency probe was placed longitudinal and paramedian to the spine. The vertebral level was determined by identifying the lumbosacral junction in longitudinal saggital view and counting the vertebrae up from L5. The catheter length at the skin was compared with the length recorded by external measurement. RESULTS: The actual length placed under real-time ultrasound scan were consistently longer than the external distance between the caudal space and selected vertebral level. The mean values of ultrasound were higher than the mean values of external measurement with a difference of 4.28 cm. Accuracy was not affected by age or affected by the selected vertebral level in the age group we studied. CONCLUSION: We conclude that catheters placed under ultrasound guidance are more accurate than the traditional method developed before the advent of ultrasound in young infants.

Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery.

BACKGROUND AND OBJECTIVES: Venous thromboembolism (VTE) is a common cause of preventable harm. Perioperative thoracic epidural analgesia (TEA) presents a challenge to optimal VTE prophylaxis. Our primary aim was to characterize missed doses of VTE prophylaxis associated with epidural catheter placement and removal. Our secondary aim was to measure the effect of an enhanced recovery after surgery (ERAS) pathway on the rate of TEA-associated missed VTE prophylaxis. METHODS: We retrospectively reviewed a prospectively collected database of 1264 colorectal surgery patients at a single academic center. Missed preoperative doses between TEA patients and non-TEA patients were compared. Missed postoperative unfractionated heparin (UFH) doses associated with epidural removal were compared before and after implementation of an ERAS program. Other data collected included demographic data, surgical indication, and thrombohemorrhagic complications. RESULTS: Of the 445 TEA patients, 12.6% missed their preoperative heparin doses compared with 8.4% of patients without epidurals (P = 0.017). Of the TEA patients prescribed 3 times daily UFH, 22.5% missed one or more doses associated with epidural removal. The percent of patients missing at least one dose of UFH on epidural removal dropped from 28.1% before ERAS to 17.9% after the ERAS program (P = 0.023). Seven patients developed VTEs. There were zero epidural hematomas. CONCLUSIONS: Thoracic epidural analgesia was associated with a 1.5-fold increased risk of missed dose of preoperative VTE prophylaxis, which was not affected by implementation of an ERAS program. The implementation of an ERAS program reduced missed doses associated with epidural removal. This study highlights the challenge posed by providing VTE prophylaxis in the setting of perioperative neuraxial analgesia.

Epidural anesthesia and analgesia in liver resection: Safety and effectiveness. / Anestesia y analgesia epidural en la resección hepática: seguridad y efectividad.

OBJECTIVES: Perioperative epidural analgesia in liver resection provides optimal dynamic pain relief. Coagulation disorders occurring in the postoperative period can lead to greater risk of complications during epidural catheter removal. The aim of this study is to evaluate the effectiveness and complications of epidural analgesia and delayed epidural catheter removal due to postoperative coagulopathy. METHODS: A retrospective study of 114 patients undergoing open liver resection and epidural analgesia, from March 2012 to February 2015. Postoperative course of pain intensity, coagulation parameters and delayed catheter removal was analyzed RESULTS: Of the 114 operated patients, 73 met the inclusion criteria. 59% of patients received major hepatectomy (resection ≥ 3 segments) and 15% had Child's Class A cirrhosis (11/73). 96% of catheters functioned properly. 89% of patients had controlled pain (numerical rate scale <3) at rest and 8.2% (6 patients) had severe pain (numerical rate scale > 6) with movement. The INR peaked on postoperative day 2, 1.41 [0.99-2.30], and gradually returned to normal values in most patients by postoperative day 4, 1.26 [0.90 - 2.20]. The catheters were left in place 3.6 (± 1.1) days. In 6 patients (8%), catheter removal was postponed due to coagulation disorders. CONCLUSIONS: Epidural analgesia for liver resection was a safe practice, which produced optimal control of postoperative pain. The percentage of delayed catheter removal due to postoperative coagulopathy was low, not requiring transfusion of blood products.

The influence of patient position on withdrawal force of lumbar epidural catheters after total knee arthroplasty: A randomized trial.

STUDY OBJECTIVE: Elderly patients with degenerative knee disease may have accompanying degenerative spine conditions. There are no studies on lumbar epidural catheter withdrawal forces in these patients. The aim of this study was to investigate withdrawal forces and possible associated risk factors in patients undergoing total knee arthroplasty (TKA). DESIGN: Prospective randomized trial. SETTING: Operating room and ward in a university hospital. PATIENTS: Seventy-eight patients aged 65 to 80years who were undergoing TKA and combined spinal epidural anesthesia were enrolled. INTERVENTIONS: Lumbar epidural catheterization was performed in a lateral position before surgery and the patients were randomly allocated to one of 3 positions for removal: flexed lateral (L), prone (P), and sitting (S). On the third postoperative day, the lumbar epidural catheters were removed by a single investigator with the patient in the assigned position. MEASUREMENTS: We measured the peak tension during catheter withdrawal and evaluated the factors affecting peak tension. MAIN RESULTS: The forces required to remove the catheters were considerably greater in the sitting and prone than in the flexed lateral position: group P (3.9N [0.28-10.36]), group S (4.1N [0.04-11.57]), and group L (1.3N [0.07-3.65]) (P<.001). There was a positive correlation between the length of catheter in the epidural space and peak tension (P=.0026, ß coefficient=.223). CONCLUSIONS: For ease of removal of catheters from the lumbar epidural space, the flexed lateral position is recommended for elderly patients undergoing TKA. When placing the epidural catheter, the physician should be careful not to insert a catheter that is excessively long.

Utility of transesophageal echocardiography in identifying spinal canal structures and epidural catheter position: a prospective observational study of intraoperative hemodynamics and postoperative analgesia.

PURPOSE: The aims of this study were to determine the utility of transesophageal echocardiography (TEE) for identifying spinal canal structures and epidural catheter position and to assess the effect of catheter position on intraoperative hemodynamics and quality of postoperative analgesia. METHODS: Twenty-six adult patients undergoing thoracic surgery were included in this prospective, observational study. An epidural catheter was inserted 7.5 cm or more into the thoracic epidural space using a midline approach and a loss-of-resistance technique. A pediatric TEE probe was inserted after induction of general anesthesia. It was used to identify the spinal canal structures, the catheter tip position in the epidural space, and the spread of injected local anesthetic. Intraoperative hemodynamics, postoperative visual analogue scale (VAS) pain scores, and the need for rescue epidural doses were recorded and compared between groups determined by their catheter position. RESULTS: Two subjects were excluded from the study because of an intrathecally positioned epidural catheter. The remaining 24 subjects were divided into two groups based on TEE-determined epidural catheter position: posterior (Gr-P) or lateral (Gr-L). Spinal canal structures and the epidural catheter was successfully identified in all patients. The epidural catheter was located posteriorly in 20 (83%) patients and laterally in four (17%) patients. The spread of the local anesthetic was bilateral in all Gr-P patients, whereas it was unilateral in all but one of the Gr-L patients. Compared to Gr-P patients, Gr-L patients had higher heart rates and blood pressures at various time points after local anesthetic administration until the end of surgery (P = 0.02 to < 0.001). Postoperative VAS scores (P = 0.02) and the median number of rescue analgesic doses required during the intraoperative and postoperative periods were also higher in Gr-L patients (P < 0.001). CONCLUSION: Transesophageal echocardiography reliably identified spinal canal structures and the position of epidural catheters in the epidural space in adult patients. Posteriorly located epidural catheters appear to provide better epidural analgesia than laterally situated catheters.

Thromboelastometry versus free-oscillation rheometry and enoxaparin versus tinzaparin: an in-vitro study comparing two viscoelastic haemostatic tests' dose-responses to two low molecular weight heparins at the time of withdrawing epidural catheters from ten patients after major surgery.

BACKGROUND: Monitoring low molecular weight heparins (LMWH's) in the perioperative period is prudent in patients at high risk of coagulative complications, especially when the patient has an epidural catheter requiring withdrawal, which is associated with the risk of spinal haematoma. The aim of this study was to evaluate the in vitro dose-responses of two different LMWH's on two different viscoelastic haemostatic tests, using blood sampled from patients with normal routine coagulation parameters, on the day after major surgery when their epidural catheters were due to be withdrawn. METHODS: Enoxaparin or tinzaparin were added in vitro to blood from ten patients who had undergone oesophageal resection, to obtain plasma concentrations of approximately 0, 0.5, 1.0 and 1.5 IU/mL. Coagulation was monitored using thromboelastometry (ROTEM®) using the InTEM® activating reagent; and free oscillation rheometry (FOR: ReoRox®), activated using thromboplastin. Clot initiation was measured using ROTEM-CT, ReoRox-COT1 and ReoRox-COT2. Clot propagation was measured using ROTEM-CFT, ROTEM-Alpha Angle and ReoRox-Slope. Clot stability was measured using ROTEM-MCF and ReoRox-G'max, and clot lysis was measured using ROTEM-ML and ReoRox-ClotSR. RESULTS: Clot initiation time assessed by thromboelastometry and FOR was prolonged by increasing concentrations of both LMWH's (P < 0.01). Equivalent doses of tinzaparin in international units (anti-FXa units) per millilitre prolonged clot initiation more than enoxaparin (P < 0.05). There was significant inter-individual variation - the ranges of CT and COT1 at LMWH-concentrations of 0 and 1.5 IU/mL overlapped. None of the tests reflecting clot formation rate or stability showed a dose-response to either LMWH but clot lysis showed a tentative negative dose-response to the LMWH's. CONCLUSIONS: Clot initiation time's dose-dependent prolongation by LMWH's in this study agrees with previous research, as does tinzaparin's stronger anti-coagulative effect than enoxaparin at equivalent levels of anti-FXa activity. This casts doubt on the validity of using anti-FXa assays alone to guide dosage of LMWH's. The significant inter-individual variation in dose-response suggests that the relationship between dose and effect in the postoperative period is complicated. While both ROTEM and FOR may have some role in postoperative monitoring, more research is needed before any conclusion can be made about their clinical usefulness.

Panorama Ultrasound for Navigation and Guidance of Epidural Anesthesia.

Despite the common use of epidural anesthesia in obstetrics and surgery, the procedure can be challenging, especially for obese patients. We propose the use of an ultrasound guidance system employing a transducer-mounted camera to create 3-D panorama ultrasound volumes of the spine, thereby allowing identification of vertebrae and selection of puncture site, needle trajectory and depth of insertion. The camera achieves absolute position estimation of the transducer with respect to the patient using a specialized marker strip attached to the skin surface. The guidance system is validated first on a phantom against a commercial optical tracking system and then in vivo by comparing panorama images from human subjects against independent measurements by an experienced sonographer. The results for measuring depth to the epidural space, intervertebral spacing and registration of interspinous gaps to the skin prove the potential of the system for improving guidance of epidural anesthesia. The tracking and visualization are implemented in real time using the 3D Slicer software package.

Effects of ketamine and midazolam on emergence agitation after sevoflurane anaesthesia in children receiving caudal block: a randomized trial / Efeitos de cetamina e midazolam sobre a incidência de agitação pós-anestesia com sevoflurano em crianças submetidas ao bloqueio caudal: estudo randomizado / Efectos de la ketamina y el midazolam sobre la incidencia de agitación postanestesia con sevoflurano en niños sometidos al bloqueo caudal: estudio aleatorizado

Background and objectives: Emergence agitation is a common postanaesthetic problem in children after sevoflurane anaesthesia. We aimed to compare the effects of ketamine and midazolam administered intravenously, before the end of surgery, for prevention of emergence agitation in children who received caudal block for pain relief under sevoflurane anaesthesia. Methods: 62 American Society of Anesthesiologists patient classification status I children, aged 2–7 years, scheduled for inguinal hernia repair, circumcision or orchidopexy were enrolled to the study. Anaesthesia was induced with sevoflurane 8% in a mixture of 50% oxygen and nitrous oxide. After achieving adequate depth of anaesthesia, a laryngeal mask was placed and then caudal block was performed with 0.75 mL kg−1, 0.25% bupivacaine. At the end of the surgery, ketamine 0.25 mg kg−1, midazolam 0.03 mg kg−1 and saline were given to ketamine, midazolam and control groups, respectively. Agitation was assessed using Paediatric Anaesthesia Emergence Delirium scale and postoperative pain was evaluated with modified Children's Hospital of Eastern Ontario Pain Scale. Results and conclusions: Modified Children's Hospital of Eastern Ontario Pain Scale scores were found higher in control group than in ketamine and midazolam groups. Paediatric Anaesthesia Emergence Delirium scores were similar between groups. Modified Children's Hospital of Eastern Ontario Pain Scale and Paediatric Anaesthesia Emergence Delirium scores showed a significant decrease by time in all groups during follow-up in postanaesthesia care unit. The present study resulted in satisfactory Paediatric Anaesthesia Emergence Delirium scores which are below 10 in all groups. As a conclusion, neither ketamine nor midazolam added to caudal block under sevoflurane anaesthesia did show further effect on emergence agitation. In addition, pain relief still seems to be the major factor in preventing emergence ...

Justificativa e objetivos: A incidência de agitação é um problema pós-anestésico comum em crianças após a anestesia com sevoflurano. Nosso objetivo foi comparar os efeitos de cetamina e midazolam administrados por via intravenosa, antes do término da cirurgia, para prevenir a incidência de agitação em crianças submetidas ao bloqueio caudal para alívio da dor sob anestesia com sevoflurano. Métodos: Foram inscritos no estudo 62 pacientes pediátricos, entre 2-7 anos, estado físico classificado de acordo com a Sociedade Americana de Anestesiologistas (ASA: I), programados para correção de hérnia inguinal, circuncisão ou orquidopexia. A anestesia foi induzida com sevoflurano a 8% em uma mistura de oxigênio (50%) e óxido nitroso (50%). Depois de atingir a profundidade adequada da anestesia, uma máscara laríngea foi colocada e, em seguida, o bloqueio caudal foi feito com bupivacaína a 0,25% (0,75 mL kg−1). No fim da cirurgia, cetamina (0,25 mg kg−1), midazolam (0,03 mg kg−1) e solução salina foram administrados aos grupos cetamina, midazolam e controle, respectivamente. A incidência de agitaçio foi avaliada com a escala Paediatric Anaesthesia Emergence Delirium (PAED) e a dor no período pós-operatório avaliada com a escala modificada Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS). Resultados e conclusões: Os escores de dor da escala modificada mCHEOPS foram maiores no grupo controle do que nos grupos cetamina e midazolam. Os escores PAED foram semelhantes entre os grupos. Os escores dessas duas escalas mostraram uma diminuição significativa do tempo em todos os grupos durante o acompanhamento em sala de recuperação pós-anestesia. O presente estudo resultou em escores satisfatórios da escala PAED, que ficaram abaixo ...

Introducción y objetivos La incidencia de agitación es un problema postanestésico frecuente en niños después de la anestesia con sevoflurano. Nuestro objetivo fue comparar los efectos de la ketamina y del midazolam administrados por vía intravenosa antes del término de la cirugía para prevenir la incidencia de agitación en niños sometidos al bloqueo caudal para alivio del dolor bajo anestesia con sevoflurano. Métodos 62 pacientes pediátricos, con edades entre 2 y 7 años, estado físico clasificado de acuerdo con la Sociedad Norteamericana de Anestesiólogos (ASA I), programados para la corrección de hernia inguinal, circuncisión o orquidopexia fueron inscritos en el estudio. La anestesia se indujo con sevoflurano al 8% en una mezcla de oxígeno al 50% y óxido nitroso al 50%. Después de alcanzar la profundidad adecuada de la anestesia, una mascarilla laríngea se colocó y enseguida el bloqueo caudal se realizó con bupivacaína al 0,25% (0,75 ml kg−1). Al final de la cirugía, la ketamina (0,25 mg kg−1), el midazolam (0,03 mg kg−1) y la solución salina fueron administrados a los grupos ketamina, midazolam y control, respectivamente. La incidencia de agitación se evaluó usando la escala Paediatric Anaesthesia Emergence Delirium y el dolor en el período postoperatorio se calculó con la escala modificada Children's Hospital of Eastern Ontario Pain Scale. Resultados y conclusiones Las puntuaciones de dolor de la escala modificada Children's Hospital of Eastern Ontario Pain Scale fueron más elevadas en el grupo control que en los grupos ketamina y midazolam. Las puntuaciones de la Paediatric Anaesthesia Emergence Delirium fueron parecidas entre los grupos. Las puntuaciones de esas 2 escalas arrojaron una reducción significativa del tiempo en todos los grupos durante el ...

Air versus saline in the loss of resistance technique for identification of the epidural space.

BACKGROUND: The success of epidural anaesthesia depends on correct identification of the epidural space. For several decades, the decision of whether to use air or physiological saline during the loss of resistance technique for identification of the epidural space has been governed by the personal experience of the anaesthesiologist. Epidural block remains one of the main regional anaesthesia techniques. It is used for surgical anaesthesia, obstetrical analgesia, postoperative analgesia and treatment of chronic pain and as a complement to general anaesthesia. The sensation felt by the anaesthesiologist from the syringe plunger with loss of resistance is different when air is compared with saline (fluid). Frequently fluid allows a rapid change from resistance to non-resistance and increased movement of the plunger. However, the ideal technique for identification of the epidural space remains unclear. OBJECTIVES: • To evaluate the efficacy and safety of both air and saline in the loss of resistance technique for identification of the epidural space.• To evaluate complications related to the air or saline injected. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), MEDLINE, EMBASE and the Latin American and Caribbean Health Science Information Database (LILACS) (from inception to September 2013). We applied no language restrictions. The date of the most recent search was 7 September 2013. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and quasi-randomized controlled trials (quasi-RCTs) on air and saline in the loss of resistance technique for identification of the epidural space. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: We included in the review seven studies with a total of 852 participants. The methodological quality of the included studies was generally ranked as showing low risk of bias in most domains, with the exception of one study, which did not mask participants. We were able to include data from 838 participants in the meta-analysis. We found no statistically significant differences between participants receiving air and those given saline in any of the outcomes evaluated: inability to locate the epidural space (three trials, 619 participants) (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.33 to 2.31, low-quality evidence); accidental intravascular catheter placement (two trials, 223 participants) (RR 0.90, 95% CI 0.33 to 2.45, low-quality evidence); accidental subarachnoid catheter placement (four trials, 682 participants) (RR 2.95, 95% CI 0.12 to 71.90, low-quality evidence); combined spinal epidural failure (two trials, 400 participants) (RR 0.98, 95% CI 0.44 to 2.18, low-quality evidence); unblocked segments (five studies, 423 participants) (RR 1.66, 95% CI 0.72 to 3.85); and pain measured by VAS (two studies, 395 participants) (mean difference (MD) -0.09, 95% CI -0.37 to 0.18). With regard to adverse effects, we found no statistically significant differences between participants receiving air and those given saline in the occurrence of paraesthesias (three trials, 572 participants) (RR 0.89, 95% CI 0.69 to 1.15); difficulty in advancing the catheter (two trials, 227 participants) (RR 0.91, 95% CI 0.32 to 2.56); catheter replacement (two trials, 501 participants) (RR 0.69, 95% CI 0.26 to 1.83); and postdural puncture headache (one trial, 110 participants) (RR 0.83, 95% CI 0.12 to 5.71). AUTHORS' CONCLUSIONS: Low-quality evidence shows that results do not differ between air and saline in terms of the loss of resistance technique for identification of the epidural space and reduction of complications. Applicability might be compromised, as most of the results described in this review were obtained from parturient patients. This review underlines the need to conduct well-designed trials in this field.