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1.
BJU Int ; 132(5): 554-559, 2023 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-37259473

RESUMO

OBJECTIVE: To evaluate whether rectus sheath catheter (RSC) insertion may be an alternative to thoracic epidural (TE). PATIENTS AND METHODS: In a non-blinded, single-centre, non-inferiority study, patients undergoing open radical cystectomy were randomized 1:1 to receive either a TE or surgically placed RSC. The primary endpoint was cumulative opiate use (median oral morphine equivalent [OME]) in the first 72 h postoperatively. Secondary outcomes included visual analogue scale pain scores, measures of postoperative recovery including mobility and time to regular diet, and complications. RESULTS: Ninety-seven patients were randomized (51 TE, 46 RSC). The median OME was 103 (77.5-132.5) mg in the TE arm and 161.75 (117.5-187.5) mg in the RSC arm. A Mann-Whitney U-test confirmed non-inferiority of RSC to TE at a threshold of 15 mg OME (P = 0.002). When comparing pain scores for the first three postoperative days, an early difference was observed that favoured the TE group during post-anaesthesia care unit stay, which was lost after postoperative day 1. Patient satisfaction with analgesia on the third postoperative day was similar in the two arms (P = 0.47). There were no statistically significant differences between arms with respect to the other secondary outcomes. CONCLUSIONS: The outcomes from this prospective randomized trial demonstrated non-inferiority of RSC insertion compared to TE with respect to 72-h opiate use. Patient satisfaction with pain control on postoperative day 3 was the same for each group.

2.
Can J Anaesth ; 67(8): 936-941, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32385824

RESUMO

PURPOSE: Catheter-based adductor canal blocks are an effective pain management strategy for total knee arthroplasty. Nevertheless, catheter-based techniques may fail if the tip migrates because of leg movement. This observational study used ultrasound to measure the distance from the skin to the adductor canal (SAC). We tested the hypothesis that leg movements mimicking those occurring during postoperative physiotherapy change the SAC distance. METHODS: Following total knee arthroplasty under spinal anesthesia, the SAC distance was measured using ultrasound in 40 patients. The leg was passively moved into five standardized positions: neutral, neutral position with manual lateral displacement of the skin, 30° external rotation, straight leg raised to 30°, and knee and hip flexed to 90°. RESULTS: The mean (standard deviation) SAC distance change from the neutral position was +1.0 (0.6) cm with manual displacement, +0.3 (0.4) cm with external rotation, +0.4 (0.4) cm with straight leg raise, and +0.6 (0.5) cm with leg flexion (P < 0.001 for all positions). SAC distance changes did not correlate with height, body mass index, or leg circumference. CONCLUSION: Passive leg movements in five standardized positions increase the SAC distance. We speculate that the altered SAC distance associated with passive leg movement may contribute to catheter tip dislodgement and adductor canal block failure. TRIAL REGISTRATION: www.clinicaltrials.gov , NCT03562559; registered 19 June, 2018.


RéSUMé: OBJECTIF: Les blocs du canal des adducteurs utilisant un cathéter constituent une stratégie efficace du contrôle de la douleur pour l'arthroplastie totale de genou. Néanmoins, les techniques reposant sur des cathéters peuvent échouer si leur extrémité migre du fait d'un mouvement de la jambe. Cette étude observationnelle a utilisé l'échographie pour mesurer la distance séparant la peau du canal des adducteurs (P-CA). Nous avons testé l'hypothèse que des mouvements de la jambe imitant ceux qui surviennent au cours de la physiothérapie postopératoire modifient la distance P-CA. MéTHODES: Après une arthroplastie totale de genou sous rachianesthésie, la distance P-CA a été mesurée par échographie chez 40 patients. La jambe a été mobilisée passivement dans cinq positions standardisées : position neutre, position neutre avec déplacement latéral manuel de la peau, rotation latérale de 30°, jambe tendue soulevée à 30° et, enfin, genou et hanche fléchis à 90°. RéSULTATS: La modification de la distance P-CA moyenne (écart-type) à partir de la position neutre a été +1,0 (0,6) cm avec le déplacement manuel, +0,3 (0,4) cm avec la rotation latérale, +0,4 (0,4) cm avec la jambe tendue soulevée et +0,6 (0,5) cm avec la jambe fléchie (P < 0,001 pour toutes les positions). Les modifications de la distance P-CA n'étaient pas corrélées à la taille, l'indice de masse corporelle ou la circonférence de la jambe du patient. CONCLUSION: Les mouvements passifs de la jambe dans cinq positions standardisées augmentent la distance P-CA. Nous pensons que la modification de la distance P-CA associée à un mouvement passif de la jambe peut contribuer au déplacement de l'extrémité du cathéter et à l'échec du bloc du canal des adducteurs. ENREGISTREMENT DE L'ESSAI CLINIQUE: www.clinicaltrials.gov, NCT 03562559; Enregistré le 19 juin 2018.


Assuntos
Perna (Membro) , Anestésicos Locais , Catéteres , Humanos , Perna (Membro)/diagnóstico por imagem , Bloqueio Nervoso , Dor Pós-Operatória
3.
Can J Anaesth ; 67(9): 1152-1161, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32500513

RESUMO

PURPOSE: Optimizing patient position and needle puncture site are important factors for successful neuraxial anesthesia. Two paramedian approaches are commonly utilized and we sought to determine whether variations of the seated position would increase the chance of puncture success. METHODS: We simulated paramedian needle passes on three-dimensional lumbar spine models registered to volumetric ultrasound data acquired from ten healthy volunteers in three different positions: 1) prone; 2) seated with thoracic and lumbar flexion; and 3) seated as in position 2, but with a 10° dorsal tilt. Simulated paramedian needle passes from the right side performed on validated models were used to determine L2-3 and L3-4 neuraxial target size and success. We selected two paramedian puncture sites according to standard anesthesia textbook descriptions: 10 mm lateral and 10 mm caudal from inferior edge of the superior spinous process as described by Miller, and 10 mm lateral from the superior edge of the inferior spinous process as described by Barash. RESULTS: A significant increase in the area available for dural puncture was found in the L2-3 (61-62 mm2) and L3-4 (76-79 mm2) vertebral levels for all seated positions relative to the prone position (P < 0.001). Similarly, a significant increase in the total number of successful punctures was found in the L2-3 (77-79) and L3-4 (119-120) vertebral levels for all seated positions relative to the prone position (P < 0.001). No differences were found between seated positions. The Barash puncture site achieved a higher number of successful punctures than the Miller puncture site in both the L2-3 (19) and L3-4 (84) vertebral levels (P < 0.001). CONCLUSION: An added dorsal table tilt did not increase puncture success in the seated position. The landmarks for puncture site described by Barash resulted in significantly more successful punctures compared with those described by Miller in all positions.


RéSUMé: OBJECTIF: L'optimisation de la position du patient et celle du site de ponction de l'aiguille sont des facteurs importants pour la réussite d'une anesthésie neuraxiale. Deux approches paramédianes sont fréquemment utilisées et nous avons tenté de déterminer si des variations de la position assise augmenteraient la probabilité de réussite de la ponction. MéTHODE: Nous avons simulé les passages paramédians de l'aiguille sur des modèles tridimensionnels de la colonne lombaire adaptés à partir de données d'échographie volumétriques acquises auprès de dix volontaires sains placés dans trois positions différentes : 1) couché sur le ventre; 2) assis en flexion thoraco-lombaire; et 3) assis comme en position 2, mais avec une inclinaison dorsale de 10°. Les passages paramédians simulés de l'aiguille du côté droit réalisés sur des modèles validés ont été utilisés pour déterminer la taille des cibles neuraxiales L2­3 et L3­4 ainsi que la réussite de la ponction. Nous avons sélectionné deux sites de ponction paramédians selon les descriptions de deux manuels d'anesthésie standard, soit 10 mm en latéral et 10 mm en caudal depuis le bord inférieur de l'apophyse épineuse supérieure tel que décrit par celui de Miller, et 10 mm en latéral depuis le bord supérieur de l'apophyse épineuse inférieure, tel que décrit par celui de Barash. RéSULTATS: Une augmentation significative de la surface disponible pour la ponction durale a été observée aux niveaux vertébraux L2­3 (61­62 mm2) et L3­4 (76­79 mm2) dans les deux positions assises par rapport à la position ventrale (P < 0,001). De la même manière, nous avons observé une augmentation significative du nombre total de ponctions durales réussies aux niveaux vertébraux L2­3 (77­79) et L3­4 (119­120) dans les deux positions assises par rapport à la position ventrale (P < 0,001). Aucune différence n'a été observée entre les deux positions assises. Le site de ponction selon le manuel de Barash a permis la réalisation d'un nombre plus élevé de ponctions réussies que le site de ponction selon celui de Miller, tant au niveau vertébral L2­3 (19) qu'au niveau L3­4 (84) (P < 0,001). CONCLUSION: L'ajout d'une inclinaison du plan dorsal n'a pas augmenté le taux de réussite de la ponction en position assise. Les repères utilisés pour le site de ponction décrits par le manuel de Barash ont entraîné un nombre significativement plus élevé de ponctions réussies que ceux décrits par celui de Miller, toutes positions confondues.


Assuntos
Raquianestesia , Voluntários Saudáveis , Humanos , Vértebras Lombares/diagnóstico por imagem , Região Lombossacral/diagnóstico por imagem , Sistema de Registros , Ultrassonografia
4.
J Arthroplasty ; 33(4): 1045-1051, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29198872

RESUMO

BACKGROUND: Adductor canal blocks (ACBs) provide effective analgesia following total knee arthroplasty. We hypothesized that ACB single injection plus intravenous (IV) dexamethasone (Dex) shows non-inferiority to catheter, while ACB single injection does not. METHODS: One hundred eighty patients were randomized and 177 analyzed from among 1 of 3 ACB interventions: (1) 0.5% ropivacaine 20 mL; (2) 0.5% ropivacaine 20 mL plus IV Dex 8 mg; (3) 0.5% ropivacaine 20 mL followed by continuous infusion of 0.2% ropivacaine at 5 mL/h for 48 hours. The primary endpoint was cumulative opioid consumption at 24 hours in oral morphine equivalents, with a non-inferiority limit of 30 mg. Secondary endpoints included opioid consumption at 12 and 48 hours, rest pain scores, quality of recovery survey, length of stay, and anti-emetic usage. RESULTS: For 24-hour opioid consumption, single injection ACB with and without IV Dex had a mean difference of -24.2 mg (confidence interval [CI] 0.5 to -48.9, P < .001) and -21 mg (CI 3.2 to -45.1, P < .001) relative to catheter, demonstrating non-inferiority. Non-inferiority was also shown at 12 hours by Dex and single injection over catheter with mean difference of -20.4 mg (CI -6.8 to -33.9, P < .001) and -15.1 mg (CI -2.1 to -28.2, P < .001), respectively. No intergroup difference was found for 48-hour opioid consumption. No differences in other secondary outcomes were observed across the 3 groups. CONCLUSION: Single injection ACB, with and without IV Dex, is non-inferior to ACB catheters in 24-hour opioid consumption, and may be attractive options for early-discharge, fast-track total knee arthroplasty.


Assuntos
Analgesia/métodos , Artroplastia do Joelho/métodos , Cateterismo , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Idoso , Analgésicos Opioides/uso terapêutico , Feminino , Nervo Femoral/efeitos dos fármacos , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Morfina/uso terapêutico , Músculo Esquelético , Manejo da Dor/métodos , Estudos Prospectivos , Coxa da Perna , Resultado do Tratamento
5.
Can J Surg ; 61(5): 357-360, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-30247856

RESUMO

Summary: Multidisciplinary simulation has been used to successfully teach crisis resource management in operating room and emergency department settings. This article describes a "Mega-Sim" approach using an in-situ simulation that moves among multiple hospital departments to enhance multidisciplinary training and assess institutional response to a rare but high-risk event: trauma in a pregnant patient. It appears that a Mega-Sim can be used to identify systems issues, increase medical knowledge and improve perceptions of teamwork and communication within and among hospital departments.


Assuntos
Equipe de Assistência ao Paciente/normas , Recursos Humanos em Hospital/normas , Guias de Prática Clínica como Assunto/normas , Complicações na Gravidez/terapia , Garantia da Qualidade dos Cuidados de Saúde/normas , Treinamento por Simulação/métodos , Centros de Traumatologia/normas , Ferimentos e Lesões/terapia , Adulto , Emergências , Feminino , Humanos , Gravidez
6.
Can J Anaesth ; 64(4): 370-375, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28078544

RESUMO

PURPOSE: Nasotracheal intubation is a widely performed technique to facilitate anesthesia induction during oral, dental, and maxillofacial surgeries. The technique poses several risks not encountered with oropharyngeal intubation, most commonly epistaxis due to nasal mucosal abrasion. The purpose of this study was to test whether the use of the Parker Flex-Tip™ (PFT) nasal endotracheal tube (ETT) with a posterior facing bevel reduces epistaxis when compared with the standard nasal RAE ETT with a leftward facing bevel. METHODS: Sixty American Society of Anesthesiologists physical status I and II patients undergoing oral or maxillofacial surgery with nasotracheal intubation were recruited. Patients were randomized to either a standard nasal RAE ETT or a PFT nasal ETT. The ETT was thermosoftened and lubricated for both study groups prior to insertion, and the size of the tube was chosen at the discretion of the attending anesthesiologist. The primary outcome was the incidence of epistaxis, with a secondary outcome of epistaxis severity (scored as none, mild, moderate, or severe). An investigator measured both outcomes five minutes after intubation was completed. RESULTS: Mild or moderate epistaxis was experienced by 22 of 30 (73%) patients in the PFT group compared with 21 of 30 (70%) patients in the standard nasal RAE ETT group (absolute risk reduction, 3%; 95% confidence interval, -19 to 25; P = 0.78). There were no occurrences of severe epistaxis in either group. CONCLUSION: There was no difference in the incidence or severity of epistaxis following nasal intubation using the Parker Flex-Tip nasal ETT when compared with a standard nasal RAE ETT. This trial was registered at ClinicalTrials.gov, identifier: NCT02315677.


Assuntos
Epistaxe/etiologia , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/instrumentação , Adulto , Desenho de Equipamento , Feminino , Humanos , Intubação Intratraqueal/métodos , Masculino , Cavidade Nasal , Método Simples-Cego
7.
J Vasc Surg ; 58(3): 735-41, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23683378

RESUMO

OBJECTIVE: Ultrasound-guided percutaneous vascular access for endovascular procedures is well established in surgical practice. Despite this, rates of complications from venous and arterial access procedures remain a significant cause of morbidity. We hypothesized that the use of a new technique of vascular access using an ultrasound with a novel needle-guidance positioning system (GPS) would lead to improved success rates of vascular puncture for both in-plane and out-of-plane techniques compared with traditional ultrasound. METHODS: A prospective, randomized crossover study of medical students from all years of medical school was conducted using a phantom gel model. Each medical student performed three ultrasound-guided punctures with each of the four modalities (in-plane no GPS, in-plane with GPS, out-of-plane no GPS, out-of-plane with GPS) for a total of 12 attempts. The success or failure was judged by the ability to aspirate a simulated blood solution from the model. The time to successful puncture was also recorded. A poststudy validated NASA Task Load Index workload questionnaire was conducted to assess the student's perceptions of the two different techniques. RESULTS: A total of 30 students completed the study. There was no significant difference seen in the mean times of vascular access for each of the modalities. Higher success rates for vascular access using the GPS for both the in-plane (94% vs 91%) and the out-of-plane (86% vs 70%) views were observed; however, this was not statistically significant. The students perceived the mental demand (median 12.0 vs 14.00; P = .035) and effort to be lower (mean 11.25 vs 14.00; P = .044) as well as the performance to be higher (mean 15.50 vs 14.00; P = .041) for the GPS vs the traditional ultrasound-guided technique. Students also perceived their ability to access vessels increased with the aid of the GPS (7.00 vs 6.50; P = .007). The majority of students expressed a preference for GPS (26/30, 87%) as opposed to the traditional counterpart. CONCLUSIONS: Use of the novel SonixGPS needle-tracking ultrasound system (UltraSonix, Richmond, BC, Canada) was not associated with a higher success rate of vascular puncture compared with the traditional ultrasound-guided technique. Assessment of mental task load significantly favored the use of the ultrasound GPS over the traditional ultrasound technique.


Assuntos
Cateterismo Periférico/instrumentação , Competência Clínica , Imagens de Fantasmas , Estudantes de Medicina , Ultrassonografia de Intervenção/instrumentação , Atitude do Pessoal de Saúde , Colúmbia Britânica , Cateterismo Periférico/efeitos adversos , Distribuição de Qui-Quadrado , Estudos Cross-Over , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Agulhas , Percepção , Estudos Prospectivos , Punções , Estudantes de Medicina/psicologia , Inquéritos e Questionários , Fatores de Tempo , Carga de Trabalho
8.
Can J Anaesth ; 60(9): 896-901, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23780883

RESUMO

PURPOSE: The SonixGPS™ is a novel needle tracking system that has recently been approved in Canada for ultrasound-guided needle interventions. It allows optimization of needle-beam alignment by providing a real-time display of current and predicted needle tip position. Currently, there is limited evidence on the effectiveness of this technique for performance of real-time spinal anesthesia. This case series reports performance of the SonixGPS system for real-time ultrasound-guided spinal anesthesia in elective patients scheduled for joint arthroplasty. METHODS: In this single-centre case series, 20 American Society of Anesthesiologists' class I-II patients scheduled for lower limb joint arthroplasty were recruited to undergo real-time ultrasound-guided spinal anesthesia with the SonixGPS after written informed consent. The primary outcome for this clinical cases series was the success rate of spinal anesthesia, and the main secondary outcome was time required to perform spinal anesthesia. RESULTS: Successful spinal anesthesia for joint arthroplasty was achieved in 18/20 patients, and 17 of these required only a single skin puncture. In 7/20 (35%) patients, dural puncture was achieved on the first needle pass, and in 11/20 (55%) patients, dural puncture was achieved with two or three needle redirections. Median (range) time taken to perform the block was 8 (5-14) min. The study procedure was aborted in two cases because our clinical protocol dictated using a standard approach if spinal anesthesia was unsuccessful after three ultrasound-guided insertion attempts. These two cases were classified as failures. No complications, including paresthesia, were observed during the procedure. All patients with successful spinal anesthesia found the technique acceptable and were willing to undergo a repeat procedure if deemed necessary. CONCLUSIONS: This case series shows that real-time ultrasound-guided spinal anesthesia with the SonixGPS system is possible within an acceptable time frame. It proved effective with a low rate of failure and a low rate of complications. Our clinical experience suggests that a randomized trial is warranted to compare the SonixGPS with a standard block technique.


Assuntos
Raquianestesia/métodos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Ultrassonografia de Intervenção/métodos , Canadá , Aprovação de Equipamentos , Feminino , Humanos , Masculino , Satisfação do Paciente , Estudos Prospectivos , Fatores de Tempo , Falha de Tratamento , Resultado do Tratamento , Ultrassonografia de Intervenção/instrumentação
11.
Anesth Analg ; 115(5): 1242-5, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22822197

RESUMO

Superior laryngeal nerve block is a valuable technique for provision of upper airway anesthesia. In bilateral scans of 20 volunteers, we developed a technique for ultrasonographic visualization of the superior laryngeal nerve and key anatomical structures using a hockey stick-shaped 8 to 15 MHz transducer (HST15 to 8/20 linear probe, Ultrasonix, Richmond, BC, Canada). Subsequently, we simulated superior laryngeal nerve scanning and injection in bilateral injections in 2 cadavers. Ultrasound-guided in-plane advancement of a needle toward the superior laryngeal nerve and injection of 1 mL of green dye was achieved in all 4 attempts and confirmed by a postprocedural dissection performed by an anatomist. We conclude that ultrasound-guided superior laryngeal nerve block in humans may be feasible.


Assuntos
Experimentação Humana , Nervos Laríngeos/diagnóstico por imagem , Ultrassonografia de Intervenção/métodos , Adulto , Idoso , Cadáver , Feminino , Corantes Fluorescentes/administração & dosagem , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Ultrassonografia de Intervenção/instrumentação
14.
Anesth Analg ; 112(5): 1236-8, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-21372276

RESUMO

The role of ultrasound scanning in spinal anesthesia is principally limited to preprocedure imaging and identification of anatomical structures. We describe our experience with a real-time ultrasound technique for visualization and performance of spinal anesthesia. An initial cadaver study was performed in 5 unembalmed cadavers to develop a technique for real-time performance of ultrasound-guided spinal anesthesia via Taylor's approach (paramedian approach to the L5-S1 interspace). Subsequently, 10 patients scheduled for joint arthroplasty underwent real-time ultrasound-guided spinal anesthesia in the prone position. The relevant anatomy and the needletip were visualized easily and all spinals were effective for joint arthroplasty.


Assuntos
Raquianestesia/métodos , Vértebras Lombares/diagnóstico por imagem , Sacro/diagnóstico por imagem , Ultrassonografia de Intervenção , Idoso , Idoso de 80 Anos ou mais , Artroplastia , Colúmbia Britânica , Cadáver , Feminino , Humanos , Injeções Espinhais , Masculino , Pessoa de Meia-Idade , Posicionamento do Paciente , Decúbito Ventral , Fatores de Tempo
19.
Ultrasound Med Biol ; 45(1): 255-263, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30292460

RESUMO

Patient positioning and needle puncture site are important for lumbar neuraxial anesthesia. We sought to identify optimal patient positioning and puncture sites with a novel ultrasound registration. We registered a statistical model to volumetric ultrasound data acquired from volunteers (n = 10) in three positions: (i) prone; (ii) seated with thoracic and lumbar flexion; and (iii) seated as in position ii, with a 10° dorsal tilt. We determined injection target size and penetration success by simulating lumbar injections on validated registered models. Injection window and target area sizes in seated positions were significantly larger than those in prone positions by 65% in L2-3 and 130% in L3-4; a 10° tilt had no significant effect on target sizes between seated positions. In agreement with computed tomography studies, simulated L2-3 and L3-4 injections had the highest success at the 50% and 75% midline puncture sites, respectively, measured from superior to inferior spinous process. We conclude that our registration to ultrasound technique is a potential tool for tolerable determination of puncture site success in vivo.


Assuntos
Raquianestesia/instrumentação , Posicionamento do Paciente/métodos , Postura , Ultrassonografia de Intervenção/métodos , Raquianestesia/métodos , Espaço Epidural/diagnóstico por imagem , Humanos , Vértebras Lombares/diagnóstico por imagem , Região Lombossacral/diagnóstico por imagem , Reprodutibilidade dos Testes
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