Pressure monitoring devices may undetect epidural space: a report on the use of Compuflo® system for epidural injection.

Lumbar epidural infiltration (EI) is a feasible procedure performed in pain therapy. Even though epidural analgesia is widely applied, it remains a blind technique, based on the operator's hand sensations, and it is associated with significant failure rate and several potential complications. Compuflo® (Compuflo, Milestone Scientific, Livingston, NJ) is a computerized injection pump which precisely detects the real time pressure at the tip of a Tuohy needle when placed in human tissues, thanks to a continuous fluid path. In our institution, we usually perform EI for chronic back pain guided by the Compuflo device, especially for expected difficult procedures. However, we report 6 false negative cases on a total number of 60 procedures in which the Compuflo system didn't meet the criteria of epidural space entry, even though the epidural space was actually reached. A mild pressure decrease (less than 50%) which lasted for more than 5 s was reported on the monitor, and the acoustic signal changed in a little bit lower sound, without a clear indication on stopping or not the needle advancement. This unspecific drop in monitored pressure gives false negatives using the Compuflo® system and may lead to excessive advancing of the needle. In conclusion, we consider the epidural pressure monitoring device Compuflo as a tool which may be able to ease the correct positioning of an epidural needle. The percentage of 10% false negative identifications of the epidural space in our case series however suggests more investigations on adequate or specific settings for this epidural system. In the meantime, in chronic pain patients, this anesthetic technique should only be used by experienced hands.

Impact of Ethnicity on the Prevalence of Early Repolarization Pattern in Children: Comparison Between Caucasian and African Populations.

The patterns and prevalence of early repolarization pattern (ER) in pediatric populations from ethnic backgrounds other than Caucasian have not been determined. Black African children (ages 4-12) from north-west Madagascar were prospectively recruited and their ECGs compared with those of age- and sex-matched Caucasian ethnicity individuals. ER was defined by ≥ 0.1 mV J-point elevation in at least two contiguous inferior and/or lateral ECG leads. A total of 616 children were included. There was a trend toward a higher frequency of ER in the Africans compared to the Caucasians (23.3% vs. 17.1%, respectively, p = 0.053). The subtype (slurred vs. notched) and location of ER (lateral, inferior, or inferior-lateral) were significantly different in the two groups (p < 0.001 and p = 0.020, respectively). There was no significant difference in the number of high-risk ECG features of ERP (i.e., horizontal/descendent pattern, inferior or inferior-lateral location or J-waves ≥ 2 mm) between African and Caucasian children. On the multivariate analysis, African ethnicity was an independent predictive factor of ER (OR 3.57, 95% CI 2.04-6.25, p < 0.001). African children have an increased risk of ER compared to Caucasian counterparts. Future studies should clarify the clinical and prognostic significance of ER in the pediatric population, and whether ethnicity has an impact on the outcomes.

The VL3 videolaryngoscope for tracheal intubation in adults: A prospective pilot study.

BACKGROUND: Videolaryngoscopy (VLS) is recommended by international guidelines for the management of difficult airways. We conducted an observational prospective pilot study to assess the efficacy of the new VL3 videolaryngoscope for routine tracheal intubation (TI) in adults; in terms of success rate, the number of attempts, and maneuver duration, including both normal and difficult airways. METHODS: This prospective observational pilot study comprised a sample of 56 adult patients undergoing elective general anesthesia. For each patient, we performed VLS by VL3 recording the following data: successful TI rate, number of attempts, time of intubation, time to glottis visualization, Cormack-Lehane grade (CL), need for external laryngeal pressure, and presence of post-laryngoscopy side effects. RESULTS: TI was successfully carried out in the totality of patients. In only 4 out of 56 cases, the VL3 offered a CL II. The first attempt intubation was achieved in 48 patients (85.7%). In one case, external laryngeal pressure was needed. No CL III or CL IV were observed. We did not find any significant difference between the predicted difficult airways sample and the rest of the population. CONCLUSION: VL3 videolaryngoscope showed to be an effective and safe device for routine TI, even in those patients with predicted difficult airway. More studies are needed to confirm our findings and verify its efficacy even in other settings.

Effects of Malnutrition on Left Ventricular Mass in a North-Malagasy Children Population.

BACKGROUND: Malnutrition among children population of less developed countries is a major health problem. Inadequate food intake and infectious diseases are combined to increase further the prevalence. Malnourishment brings to muscle cells loss with development of cardiac complications, like arrhythmias, cardiomyopathy and sudden death. In developed countries, malnutrition has generally a different etiology, like chronic diseases. The aim of our study was to investigate the correlation between malnutrition and left ventricular mass in an African children population. METHODS: 313 children were studied, in the region of Antsiranana, Madagascar, with age ranging from 4 to 16 years old (mean 7,8 ± 3 years). A clinical and echocardiographic evaluation was performed with annotation of anthropometric and left ventricle parameters. Malnutrition was defined as a body mass index (BMI) value age- and sex-specific of 16, 17 and 18,5 at the age of 18, or under the 15th percentile. Left ventricle mass was indexed by height2.7 (LVMI). RESULTS: We identified a very high prevalence of children malnutrition: 124 children, according to BMI values, and 100 children under the 15th percentile. LVMI values have shown to be increased in proportion to BMI percentiles ranging from 29,8 ± 10,8 g/m2.7 in the malnutrition group to 45 ± 15,1 g/m2.7 in >95th percentile group. LVMI values in children < 15th BMI percentile were significantly lower compared to normal nutritional status (29,8 ± 10,8 g/m2,7 vs. 32,9 ± 12,1 g/m2,7, p = 0.02). Also with BMI values evaluation, malnourished children showed statistically lower values of LVMI (29,3 ± 10,1 g/m2,7 vs. 33,6 ± 12,5 g/m2,7, p = 0.001). CONCLUSION: In African children population, the malnourishment status is correlated with cardiac muscle mass decrease, which appears to be reduced in proportion to the decrease in body size.

ECG is an inefficient screening-tool for left ventricular hypertrophy in normotensive African children population.

BACKGROUND: Left ventricular hypertrophy (LVH) is a marker of pediatric hypertension and predicts development of cardiovascular events. Electrocardiography (ECG) screening is used in pediatrics to detect LVH thanks to major accessibility, reproducibility and easy to use compared to transthoracic echocardiography (TTE), that remains the standard technique. Several diseases were previously investigated, but no data exists regarding our study population. The aim of our study was to evaluate the relationship between electrocardiographic and echocardiographic criteria of LVH in normotensive African children. METHODS: We studied 313 children (mean age 7,8 ± 3 yo), in north-Madagascar. They underwent ECG and TTE. Sokolow-Lyon index was calculated to identify ECG-LVH (>35 mm). Left ventricle mass (LVM) with TTE was calculated and indexed by height(2.7) (LVMI(2.7)) and weight (LVMI(w)). We report the prevalence of TTE-LVH using three methods: (1) calculating percentiles age- and sex- specific with values >95th percentile identifying LVH; (2) LVMI(2.7) >51 g/m(2.7); (3) LVMI(w) >3.4 g/weight. RESULTS: 40 (13%) children showed LVMI values >95th percentile, 24 children (8%) an LVMI(2.7) >51 g/m(2.7) while 19 children (6%) an LVMI(w) >3.4 g/kg. LVH-ECG by Sokolow-Lyon index was present in five, three and three children respectively, with poor values of sensitivity (ranging from 13 to 16%), positive predictive value (from 11 to 18%) and high values of specificity (up to 92%). The effects of anthropometrics parameters on Sokolow-Lyon were analyzed and showed poor correlation. CONCLUSION: ECG is a poor screening test for detecting LVH in children. In clinical practice, TTE remains the only tool to be used to exclude LVH.