Rates of lumbosacral transforaminal injections interpreted as intravascular: fluoroscopy alone or with digital subtraction.

We investigated the rate of injections interpreted as intravascular during imaging of lumbosacral transforaminal epidural injections, using fluoroscopy alone or with digital subtraction. We evaluated 732 injections performed on 348 patients: 8.1% (59/732) and 10.5% (77/732) of injections were interpreted as intravascular during fluoroscopy and digital subtraction, respectively, p = 0.13. The odds ratio (95% CI) for interpreting injections as intravascular increased for both fluoroscopy and digital subtraction fluoroscopy, with: each year of age, 1.04 (1.01-1.07) and 1.03 (1.00-1.06), p = 0.011 and 0.024, respectively; sacral compared with lumbar injections, 10 (5-19) and 8 (5-15), p < 0.001 for both. The odds ratio for intravascular injection increased with three other variables during digital subtraction fluoroscopy: spinal stenosis, 5.1 (1.5-17.1), p = 0.009; failed back surgery syndrome, 4.3 (1.2-15.8), p = 0.025; compression fracture, 8.0 (1.6-39.4), p = 0.011.

Anatomical investigations for appropriate needle positioning for thoracic paravertebral blockade in children.

OBJECTIVE: Clinicians hesitate to perform thoracic paravertebral blockade (TPVB) in children due to the potential high risk of adverse effects. No paediatric anatomical guidelines for TPVB exist. This study aimed to estimate the appropriate depth and distance for safe needle positioning in children. METHODS: The depth (D) from the skin to the paravertebral space and the distance (A) from the spinous process to the needle entry point on the skin were measured using chest computed tomography (CT) in children aged between 1 and 9 years. Correlations between age, gender, weight, height, body mass index (BMI) and each of the anatomical measurements were analysed. RESULTS: Each measurement correlated significantly with age, weight and height, but not with BMI (n = 373 children). Measurements A and D could be calculated by: A = 13.56 + (0.33 × age [years]) + (0.06 × weight [kg]) + 0.47 × (gender [female = 0, male = 1]); and D = 17.49 - (0.35 × age [years]) + (0.55 × weight [kg]). CONCLUSION: These anatomical guidelines for TPVB are recommended to help prevent anaesthetic complications such as pneumothorax, when ultrasonography and CT are unavailable.

Epidural naloxone reduces intestinal hypomotility but not analgesia of epidural morphine.

PURPOSE: Epidural morphine is associated with decreased bowel motility and increased transit time. Low doses of intravenous naloxone reduce morphine-induced pruritus without reversing analgesia, but the effect of epidural naloxone on bowel motility has not been studied. Therefore we evaluated bowel motility and analgesia when naloxone was co-administered with morphine into the epidural space. METHODS: Forty-three patients having combined thoracic epidural and general anesthesia for subtotal gastrectomy were randomly assigned to one of two study groups. All received a bolus dose of 3 mg epidural morphine at the beginning of surgery, followed by a continuous epidural infusion containing 3 mg morphine in 100 ml bupivacaine 0.125% with either no naloxone (control group, n = 18) or a calculated dose of 0.208 microg x kg(-1) x hr(-1) of naloxone (experimental group, n = 25) for 48 hr. We measured the time to the first postoperative passage of flatus and feces to evaluate the restoration of bowel function, and visual analog scales (VAS) for pain during rest and movement. Scores were assessed at 2, 4, 8, 16, 24, 36 and 48 hr postoperatively. RESULTS: The experimental group had a shorter time to the first postoperative passage of flatus (5 1.9 +/- 1 6.6 hr vs 87.0 +/- 19.5 hr, P < 0.001 ) and feces (95.3 +/- 25.0 hr vs 132.9 +/- 29.4 hr, P < 0.001). No differences were found in either resting or active VAS between the two groups. CONCLUSION: Epidural naloxone reduces epidural morphine-induced intestinal hypomotility without reversing its analgesic effects.