Highly selective motor nerve block and movement analysis for preoperative evaluation of complex spastic gait.

BACKGROUND: Lower-extremity spasticity and impaired gait control after central nervous system injury are challenging to improve, because spasticity limits residual motor control while providing mechanical support. Highly selective partial neurectomies (HSPNs) can substantially reduce spasticity but may have greater risks in patients with complex lower-extremity spastic gait. OBJECTIVE: To examine the potential of ultrasound- and stimulation-guided highly selective motor nerve blocks (HSMNBs) to assess the potential impact of reduced spasticity on gait. METHODS: In this retrospective series, six patients underwent HSMNBs with movement assessment before and after the block. Range of motion, strength, position angles, surface electromyography, lower limb kinematics, and patient satisfaction were assessed. RESULTS: Pre- and post-HSMNB movement analysis yielded dichotomous gait kinematics, which facilitated surgical decisions. Of the 59 metrics evaluated, 82% demonstrated a positive improvement post-block (62% improved more than one standard deviation (SD) of typically developing means, 49% improved > 2 SD) and 16% demonstrated a negative change (2% worsened > 1 SD). CONCLUSION: HSMNB provided clear efficacy in changing clinical, surface electromyography, and gait parameters. Movement analysis provided clear and robust objective and patient-centered evidence for surgical guidance. This protocol may provide utility in evaluation of patients being considered for HSPNs for complex spastic gait patterns.

Spontaneous Fatal Intraoperative Rupture of Great Vessel During Growing Rod Lengthening: Do Children With Ehlers-Danlos Syndrome Require the Availability of Vascular Expertise? A Case Report and Review of the Literature.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a family of inherited connective tissue diseases. Kyphoscoliotic EDS (kEDS) is associated with severe and early spinal deformity. Very little has been reported regarding the orthopaedic surgical care of kEDS likely due to its rare incidence. A more common subtype is the vascular-type EDS (vEDS, previously labeled type IV), which is associated with reports of vascular complications in the literature. METHODS: The case report of a single, fatal complication of spontaneous rupture of the superior vena cava, after extubation, subsequent to revision minimal growing rod lengthening in a child with kEDS. We additionally review prior reported cases of kEDS for pediatric spine surgery and the sentinel event of spontaneous vascular rupture in all EDS patients. RESULTS: The anterior thoracoabdominal approach in children with kEDS has been associated with severe intravascular complications, with no deaths reported to date. Posterior spinal procedures were associated with frequent overall complications, but no events of perioperative or spontaneous vascular injury were identified before our case.Reports of spontaneous vessel rupture (n=39) appear more frequently in vEDS, but have been documented in patients with EDS type I (classic EDS or cEDS) and kEDS disease. The 30-day mortality in these patients was 59%. The majority of the deaths occurred on the day of the vascular event. Surviving patients overwhelmingly received intraoperative consultation and treatment from either general or vascular surgeons at their respective institutions for assistance. CONCLUSIONS: Providers should consider their proximity to available emergent consultation before operating on patients with EDS of any subtype. LEVEL OF EVIDENCE: Level V-expert opinion.

The Fastrach Intubating Laryngeal Mask Airway: an overview and update.

PURPOSE: To provide an evidence-based overview and update on the use of the Fastrach Intubating Laryngeal Mask Airway (FT-LMA) when used within operative and non-operative settings. PRINCIPAL FINDINGS: The FT-LMA is available in three sizes to provide ventilation and the ability to pass an endotracheal tube (ETT) into the trachea blindly, semi-blindly, or with indirect visualization for patients over 30 kg. The Chandy maneuver is recommended routinely; the first maneuver optimizes ventilation, and the second maneuver increases success at endotracheal intubation (ETI). The manufacturer's reinforced tube or a pre-warmed or reversed standard ETT may be utilized. Insertion and ventilation are successful in almost all patients. Blind ETI is highly successful; adjuncts are generally not necessary. The FT-LMA has a proven role in the airway management of anticipated difficult operating room (OR) intubations, unanticipated OR intubations, cervical spine injuries, and limited airway access situations. Literature in the pre-hospital and emergency department settings is limited but favourable. The FT-LMA has compared favourably with fibreoptic intubation, the LMA-Classic, the laryngeal tube, and the CobraPLA. Initially, the more expensive LMA CTrach appeared to be more successful, but overall it is not. The FT-LMA airway seal pressures are excellent; serious complications are uncommon, and the FT-LMA figures prominently in most difficult airway guidelines. CONCLUSIONS: The FT-LMA has proven to be a useful difficult airway device both within and outside of the operating room. Effective ventilation is established in nearly all cases, and blind ETI is possible in the vast majority of cases if the optimal techniques described are used. Serious complications are uncommon.

Intrathecal baclofen for postoperative analgesia after total knee arthroplasty.

STUDY OBJECTIVE: To determine whether intrathecal baclofen is an effective adjunctive agent to decrease acute and chronic postoperative pain after total knee arthroplasty. DESIGN: Prospective, randomized, double-blind controlled trial. SETTING: Operating room and inpatient units of a university hospital. PATIENTS: 60 adult, ASA physical status I, II, and III patients presenting for total knee arthroplasty. INTERVENTIONS: Anesthesia was provided by spinal injection of 15 mg of 0.75% hyperbaric bupivacaine combined with either 100 mcg baclofen or saline. Sedation was provided with intravenous midazolam and propofol. MEASUREMENTS: Data were collected on adverse effects, opioid usage, and verbal pain scale (VPS) from 0 to 10. The study period was divided into six discrete time intervals that included the 1(st) 72-hour postoperative period and a three-month post-discharge follow-up telephone call. MAIN RESULTS: The baclofen group used less morphine in the PACU than the control group (5 mg vs. 9.3 mg; P = 0.04). VPS were lower in the baclofen group than the treatment group, but significant differences could be demonstrated only in the time periods 48-72 hours and three months postoperatively. At three months, fewer patients in the baclofen group reported pain than the control group (8/27 vs. 19/29; P = 0.009). Regression analysis showed that the baclofen group was 4.5 times less likely to report pain at three months (95% CI: 1.5-16.6). CONCLUSIONS: IT baclofen used as an adjuvant to spinal anesthesia for total knee arthroplasty allows for less postoperative opioid usage and less chronic pain at three months.

Detection, frequency and prediction of problems in the use of the proseal laryngeal mask airway in children.

OBJECTIVES: Our objective was to assess the use of several tests of ProSeal LMA (PLMA) position and function that had been previously published but not studied in the pediatric population in a wide variety of clinical cases. BACKGROUND: The PLMA is widely used in pediatric anesthesia practice but complication rates have only been studied in small series while tests of function suggested for adults have not been studied at all. METHODS: We prospectively collected data, after placement of the PLMA by the digital method, on depth of insertion (DOI), 'suprasternal notch' test, 'chest pressure test', leak pressure, maximum minute ventilation (MMV), resting minute ventilation (RMV), success rate of insertion and success rate of passage of a gastric tube. Perioperative complication rates were recorded. RESULTS: A total of 222 cases were analyzed, 47 were laparoscopic or open abdomen, 15 nonsupine. Ages were 2 months to 20 years and weight 5.4-116 kg. Two hundred seven (91%) were placed successfully at first attempt and 100% at third attempt. One hundred fifty-four of 156 (99%) gastric tubes were placed successfully. Four patients had signs of inadequate ventilation. All of these had MMV/RMV ratios <2. A total of nine had MMV/RMV ratio <2. Eight had DOI score < or =2. CONCLUSIONS: The PLMA can be used in a large variety of cases with a high degree of success. Clinical tests described for adults, such as MMV/RMV ratio and DOI are also associated with complications in the pediatric population.

Arterial to endtidal carbon dioxide gradient during pediatric laparoscopic fundoplication.

BACKGROUND: Discrepancies between arterial carbon dioxide (P(a)CO(2)) and endtidal carbon dioxide (ETCO(2)) measures have been demonstrated in ventilated children with cyanotic congenital heart disease, infants with respiratory failure and during visceral and urological laparoscopic surgery. OBJECTIVES: Our objective was to assess the extent of the P(a)CO(2) to ETCO(2) gradient in children during laparoscopic fundoplication. METHODS: We prospectively collected data on patient characteristics, surgical conditions, pH, ETCO(2)and P(a)CO(2) during laparoscopic fundoplication using carbon dioxide insufflation in children age <29 months. RESULTS: Data were collected on nine cases, four cases aged <1 year. A P(a)-ETCO(2) gradient was present during insufflation. The gradient was larger in children age less than 1 year but statistically significantly different from a value of zero, only at t = 30 min (mean = 8 mmHg, sem = 0.81, P = 0.004) and t = 60 min (mean = 5 mmHg, sem = 1, P = 0.014). Minute ventilation was increased from 20% to 100% to control ETCO(2). CONCLUSIONS: ETCO(2) may not accurately represent arterial values during laparoscopic fundoplication, especially in the infant when carbon dioxide insufflation is used. Consideration should be given to placing an arterial line for blood gas measurement in some patients.

Perioperative complications of adenotonsillectomy in children with obstructive sleep apnea syndrome.

We evaluated the rate of complications experienced by children who undergo adenotonsillectomy for obstructive sleep apnea syndrome (OSAS), the safety of a standard anesthetic protocol for these children, and preoperative predictors of complications. Sixty-one children with OSAS, confirmed by polysomnography, and 21 children with recurrent tonsillitis were anesthetized using a standard protocol before adenotonsillectomy (ages 2-16 yr, ASA 1-3). The number of complications and medical interventions in the perioperative period were recorded and correlated with the presence and severity of OSAS. Children with OSAS had more respiratory complications per operation than non-OSAS children (5.7 vs 2.9, P < 0.0001). Supraglottic obstruction, breath holding, and desaturation on anesthetic induction and emergence were the most common complications. Increased severity of OSAS, low weight, and young age are correlated with an increased rate of complications. Medical intervention was necessary in more children with OSAS during recovery and emergence than in the non-OSAS group (17/61 vs 1/21, P < 0.05). Both groups of children had similar opioid requirements and time to discharge from the recovery room. These findings suggest that children with OSAS are at risk for respiratory complications after adenotonsillectomy, but that these complications do not prolong the time to discharge.

A simple technique to reduce epistaxis and nasopharyngeal trauma during nasotracheal intubation in a child with factor IX deficiency having dental restoration.

Epistaxis and airway trauma are often associated with nasotracheal intubation. We describe a patient with Factor IX deficiency who required nasotracheal intubation. An inexpensive, nonproprietary, rapid technique was used to reduce the trauma of intubation.

Lumbar epidural blood patch to treat a large, symptomatic postsurgical cerebrospinal fluid leak of 5 weeks duration in a 3-year-old.

UNLABELLED: A 3-yr-old with B-cell lymphoma presented with a 5-wk history of 400 mL/day cerebrospinal fluid (CSF) leak, which precluded chemotherapy, after placement of an Omaya reservoir and drain. Surgical repair was unsuccessful. Symptoms included irritability, failure to eat and noncommunication. After lumbar epidural blood patch with 7 mL the symptoms resolved immediately, allowing recommencement of chemotherapy. Epidural blood patch should be considered as possible early treatment for CSF leaks. IMPLICATIONS: An epidural blood patch successfully treated a large cerebrospinal fluid leak of long duration in a 3-yr-old. Considering the distress of such a leak to the patient, staff, and parents, epidural blood patch may be considered as an early treatment option.

A comparison of Internet usage between two residency programs in the United Kingdom and the United States.

STUDY OBJECTIVE: To survey the pattern of use and availability of the Internet among anesthesia residents. DESIGN: Survey questionnaire. SETTING: University hospital. MEASUREMENTS: A postal questionnaire of Internet attitudes and usage was sent to trainees in Anesthesiology in two training programs: the University of New Mexico, Albuquerque, NM (UNM) and the North West Regional Health Authority, Manchester, UK (NWR). A repeat questionnaire was sent to nonresponders after 4 weeks. Telephone interviews were conducted with hospital administration to determine availability and cost of the Internet. MAIN RESULTS: Response rates were 67% (82/122) from the NWR and 83% (25/31) from UNM. Compared with NWR, residents at UNM used the Internet longer for general (median 3 vs. 2 yrs; p < 0.001) and medical (median 2 vs. 1.2 yrs; p < 0.001) purposes. All (31/31) UNM trainees and 73% (89/122) of NWR trainees had Internet access. More NWR trainees who had Internet access at work (60/61; 98%) used it for medically related purposes than those without work access (17/21, 81%; p < 0.001). More UNM trainees (19/25; 76%) accessed web sites other than those of official national organizations than did NWR trainees (40/82, 49%; p = 0.046). Approximately 75% of all trainees access web sites of the Association of Anesthetists and Royal College of Anesthetists (in the NWR) the American Society of Anesthesiologists (ASA) and American Board of Anesthesiology (in UNM) and online journals. The most popular sites were GASNET (Global Anesthesiology Server Network; NWR) and ASA (American Society of Anesthesiologists; UNM). Both UNM and NWR trainees perceived the Internet as supplying useful and accurate information. CONCLUSIONS: If the reported survey results are representative of Internet use among anesthesia residents in the United States and UK, Internet access at work is associated with greater Internet use for medical purposes, perhaps in part because residents perceive it to be a convenient and accurate resource.

A Comparison of Internet Usage Between Two Residency Programs in the United Kingdom and the United States.

BACKGROUND: The Internet is a potentially useful tool in medical education. The patterns of its usage and availability among anesthesia residents have not been surveyed. This survey, conducted in 2000, attempts to gain insight into and quantify its usage. METHODS: After ethics committee approval, a postal questionnaire of attitudes and usage was sent to trainees in Anesthesiology in two training programs: the University of New Mexico, USA (UNM) and the North West Regional Health Authority, UK (NWR). A repeat questionnaire was sent to non-responders after four weeks. Telephone interviews were conducted with hospital administration to determine availability and cost of the Internet. RESULTS: Response rates were 67% (82/122) from the NWR and 83% (25/31) from UNM. Compared to UNM, residents at UNM used the Internet longer for general (median 3 vs. 2 years, p<0.001) and medical (median 2 vs. 1.2 years, p<0.001) purposes. All (31/31) UNM trainees and 73 % (89/122) of NWR trainees had Internet access. More NWR trainees who had Internet access at work (98%; 60/61)) used it for medically related purposes than those work access (17/21, 81%) (p<0.001). More UNM trainees (76%; 19/25) accessed web sites other than those of official national organizations than NWR trainees (40/82, 49%) (p=0.046). Approximately 75% of all trainees access web sites of the Association of Anaesthetists and Royal College of Anaesthetists (in the NWR) the American Society of Anesthesiologists and American Board of Anesthesiology (in UNM) and on-line journals. The most favorite sites were GASNET (NWR) and ASA (UNM). Both UNM and NWR trainees perceived the Internet as supplying useful and accurate information. CONCLUSIONS: If the reported survey results are representative of Internet use among anesthesia residents in the USA and UK, access at work is associated with greater Internet use for medical purposes perhaps in part because residents perceive it as a convenient and accurate resource.