Preferred display size and visual distance for ultrasound-guided radial artery cannulation / Tamaño preferido de la imagen en pantalla y distancia visual para la canalización de la arteria radial guiada por ecografía

Abstract Introduction: In-line positioning of an ultrasound image provides higher success rates and less time to completion for radial arterial cannulation. But preferable size and distance of ultrasound display has not been previously discussed. Objective: To assess the ideal visual distance and display size when using a smart phone or tablet as the ultrasound image display. Methods: Four smart phones or tablets were used as ultrasound displays in six different configurations in a simulated radial artery puncture. In a questionnaire, 116 anaesthesiologists working in Ibaraki Prefecture, Japan, were asked which of the six configurations was preferable for radial artery cannulation. Results: Sixty anaesthesiologists answered the questionnaire. About half (53%) preferred the smaller display (4- or 5.5-inch) fixed at a distance of 30 to 40 cm, and most of the rest (44%) preferred the larger display (7.9- or 9.7-inch) placed posterior to the probe with a visual distance of 45 to 60 cm. Conclusions: Among the anaesthesiologists, the preferable size and visual distance for ultrasound-guided radial artery cannulation varied using a smart phone or tablet for in-line display.

Resumen Introducción: El posicionamiento en línea con una imagen ecográfica permite mayores tasas de éxito y reduce el tiempo para realizar la canalización de la arteria radial. Sin embargo, no se ha hablado sobre cuál es el tamaño y la distancia preferibles para la imagen en pantalla. Objetivo: Evaluar la distancia visual y el tamaño de la imagen en pantalla cuando se utiliza un teléfono inteligente o una tableta para visualizar la imagen ecográfica. Métodos: Se utilizaron cuatro teléfonos inteligentes o tabletas como pantalla para visualizar las imágenes ecográficas en seis configuraciones distintas, en una simulación de la canalización de la arteria radial. Mediante un cuestionario se preguntó a 116 anestesiólogos que trabajan para la Prefectura de Ibaraki, Japón, cuál de las seis configuraciones era preferible para la canalización de la arteria radial. Resultados: Sesenta anestesiólogos respondieron el cuestionario. Aproximadamente la mitad (53%) prefirieron la imagen más pequeña (4 o 5,5 pulgadas), fija a una distancia de 30 a 40 cm, y la mayoría de los otros (44%) prefirieron la imagen más grande (7,9- o 9,7 pulgadas), colocada en la parte posterior al transductor, con una distancia visual de 45 a 60 cm. Conclusiones: Entre los anestesiólogos, el tamaño preferido y la distancia visual para la canalización de la arteria radial guiada por ecografía, varió utilizando un teléfono inteligente o una tableta para su visualización en línea.

Hidrodisección guiada por ultrasonido para el tratamiento de pacientes con sindrome del tunel carpiano / Ultrasound-Guided hydrodissection for treatment of Patients with Carpal Tunnel Syndrome

El estudio tuvo como objetivo comparar el grupo de hidrodisección de solución salina normal guiada por ultrasonido más esteroides y el grupo de hidrodisección de solución salina normal guiada por ultrasonido sola en pacientes con síndrome del túnel carpiano (STC), y determinar su relevancia clínica en relación con los resultados del tratamiento. Realizamos 60 hidrodisecciones guiadas por ecografía con solución salina normal con y sin inyecciones de corticosteroides en 51 pacientes con STC y evaluamos los resultados de la ecografía antes y después 21. Evers S, Thoreson AR, Smith J, Zhao C, Geske JR, Amadio PC. Ultrasound-guided hydrodissection decreases gliding resistance of the median nerve within the carpal tunnel. Muscle Nerve 2017 June 16. doi: 10.1002/mus.25723. 22. Smith J, Wisniewski S, J, Finnoff JT, Payne JM. Sonographically Guided Carpal Tunnel Injections. J Ultrasound Med 2008;27:1485-1490. 23. Trescott AME. Peripheral Nerve Entrapments: Clinical Diagnosis and Management. Switzerland: Springer International Publishing; 2016 24. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev 2002(4). 25. Atroshi I, Flondell M, Hofer M, Ranstam J. Methyprednisolone Injections for the Carpal Tunnel Syndrome: A randomized Placebo-Controlled Trial. Ann Int Med 2013;159:309-317. 26. Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-de Jong B. Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice. BMC family practice 2010;11:54. 27. Wu YT, Ho TY, Chou YC, Ke MJ, Li TY, Tsai CK, et al. Six-month efficacy of perineural dextrose for carpal tunnel syndrome: A prospective, randomized, double-blind, controlledtrial. Mayo Clinic proceedings 2017;92:1179-1189. 28. Kirwan J. Is there a place for intra-articular hyaluronate in osteoarthritis of the knee? The Knee 2001;8:93-101. 29. Saltzman BM, Leroux T, Meyer MA, Basques BA, Chahal J, Bach BR, Jr., et al. The therapeutic effect of intra-articular normal saline injections for knee osteoarthritis: Ameta-analysis of evidence level 1 studies. The American journal of sports medicine 2017;45:2647-2653. 30. Padua L, Padua R, Aprile I, Pasqualetti P, Tonali P. Multiperspective follow-up of untreated carpal tunnel syndrome: a multicenter study. Neurology. 2001;56(11):1459­ 66 31. Ortiz-Corredor F, Enriquez F, Diaz-Ruiz J, Calambas N. Natural evolution of carpal tunnel syndrome in untreated patients. Clinical neurophysiology: official journal of the International Federation of Clinical Neurophysiology 2008;119:1373-1378 32. Gordon T, Brushart TM, Chan KM. Augmenting nerve regeneration with electrical stimulation. Neurol Res 2008; 30:1012- 1022. 33. Aulisa L, Tamburrelli F, Padua R, Romanini E, Lo Monaco M, Padua L. Carpal tunnel syndrome: Indication for surgical treatment based on electrophysiologic study. J Hand Surg Am 1998; 23:687-691. 34. Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom- de Jong B. Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice. BMC Fam Pract. 2010;11:54. 35. Girlanda P, Dattola R, Venuto C, Mangiapane R, Nicolosi C, Messina C. Local steroid treatment in idiopathic carpal tunnel syndrome: short- and longterm efficacy. J Neurol. 1993; 240(3):187- 190. 36. Karadas¸ Ö, Tok F, Ulas¸ UH, Odabas¸i Z. The effectiveness of triamcinolone acetonide vs. procaine hydrochloride injection in the management of carpal tunnel syndrome: a double blind randomized clinical trial. Am J Phys Med Rehabil. 2011; 90(4):287-292. 128 LA PRENSA MÉDICA ARGENTINA Ultrasound-Guided hydrodissection for treatment of Patients with Carpal Tunnel Syndrome V.107/Nº 2 de la inyección. Clasificamos estas inyecciones en dos grupos según la solución salina normal más corticosteroide (grupo de esteroides). solución salina normal (grupo de control) y también registramos datos clínicos que incluyen el sexo, la edad, el lado de la inyección, el peso corporal y la duración de las molestias relacionadas con el STC antes de la inyección. Los resultados se midieron mediante la escala analógica visual que se asignó para evaluar el resultado primario. Los resultados secundarios se evaluaron mediante el cuestionario del síndrome del túnel carpiano de Boston, el área transversal del nervio mediano y estudios electrofisiológicos. La evaluación se realizó antes de la inyección y 1, 3 y 6 meses después de la inyección, y se comparó el alivio de los síntomas de los pacientes que recibieron la inyección de solución salina normal y de esteroides. Comparamos las hidrodisecciones con la solución salina normal y las inyecciones de corticosteroides; los datos clínicos, la preinyección de CSA-MN en la entrada del túnel carpiano y las puntuaciones de BCTQ antes de la inyección no mostraron diferencias significativas entre los grupos (p> 0,05). Todos los pacientes (datos de 30 muñecas en cada grupo) completaron el estudio. En comparación con el grupo de control, en todos los momentos posteriores a la inyección, ambos grupos tuvieron una reducción significativa del dolor y la discapacidad, una mejoría en las medidas de respuesta electrofisiológica y una disminución del área transversal del nervio mediano. Nuestro estudio revela que la solución salina normal guiada por ecografía con y sin hidrodisección de corticosteroides tiene un efecto terapéutico en los pacientes con STC. Se demostró que la hidrodisección nerviosa es potencialmente beneficiosa para los pacientes con STC antes de la cirugía. La hidrodisección es un procedimiento simple y mínimamente invasivo que se puede realizar utilizando únicamente NS. Además, en comparación con la inyección a ciegas, la hidrodisección bajo guía ecográfica puede reducir las posibilidades de lesión nerviosa.

The study aimed to compare Ultrasound-Guided Normal saline plus steroid hydrodissection group and Ultrasound-Guided normal saline alone hydrodissection group in patients with carpal tunnel syndrome (CTS), and to determine their clinical relevance in relation to treatment outcomes. We performed 60 US-guided hydrodissections Normal saline with and without corticosteroid injections in 51 patients with CTS and evaluated their pre- and post-injection US findings. We categorized these injections into two groups based on the normal saline plus corticosteroid (steroid group). normal saline (control group) and we also recorded clinical data including gender, age, side of injection, BW, and the duration of pre-injection CTS related discomfort. The outcomes were measured using the visual analog scale was assigned to assess the primary outcome. The secondary outcomes were assessed using the Boston Carpal Tunnel Syndrome Questionnaire, cross-sectional area of the median nerve, and electrophysiological studies. The assessment was performed prior to injection, and 1, 3, and 6 months' post-injection, and the symptom relief for the patients receiving normal saline and steroid injection were compared. We compared hydrodissections with normal saline and corticosteroid injections the clinical data, pre injection CSA-MN at the inlet of the carpal tunnel, and pre-injection BCTQ scores showed no significant intergroup differences (p > 0.05). All patients (data from 30 wrists in each group) completed the study. Compared both the control group, at all post-injection time points, both groups had a significant reduction in pain and disability, improvement on electrophysiological response measures, and decreased cross-sectional area of the median nerve. Our study reveals that ultrasound-guided Normal saline with and without corticosteroid hydrodissection has therapeutic effect in patients CTS. Nerve hydrodissection was shown to be potentially beneficial for CTS patients' pre-surgery. Hydrodissection is a simple, minimally invasive procedure that can be performed using only NS. In addition, compared to blind injection, hydrodissection under ultrasound guidance can lower the chances of nerve injury.

Minimum anesthetic volume in regional anesthesia by using ultrasound-guidance / Volume mínimo de anestésico em anestesia regional guiada por ultrassom

Abstract The ultrasound guidance in regional anesthesia ensures the visualization of needle placement and the spread of Local Anesthetics. Over the past few years there was a substantial interest in determining the Minimum Effective Anesthetic Volume necessary to accomplish surgical anesthesia. The precise and real-time visualization of Local Anesthetics spread under ultrasound guidance block may represent the best requisite for reducing Local Anesthetics dose and Local Anesthetics-related effects. We will report a series of studies that have demonstrated the efficacy of ultrasound guidance blocks to reduce Local Anesthetics and obtain surgical anesthesia as compared to block performed under blind or electrical nerve stimulation technique. Unfortunately, the results of studies are widely divergent and not seem to indicate a dose considered effective, for each block, in a definitive way; but it is true that, through the use of ultrasound guidance, it is possible to reduce the dose of anesthetic in the performance of anesthetic blocks.

Resumo O uso de ultrassom em anestesia regional permite visualizar a colocação da agulha e a propagação dos anestésicos locais. Nos últimos anos houve um grande interesse em determinar o volume mínimo eficaz de anestésico necessário para fazer a anestesia cirúrgica. A visualização precisa e em tempo real da difusão dos anestésicos locais com o uso de ultrassom pode ser o melhor requisito para reduzir a dose e os efeitos relacionados aos anestésicos locais. Revisamos uma série de estudos que relataram a eficácia de bloqueios guiados por ultrassom para reduzir o uso de anestésicos locais e obter anestesia cirúrgica, em comparação com bloqueios feitos com a técnica às cegas e de estimulação elétrica de nervos. Infelizmente, os resultados dos estudos são muito divergentes e não parecem indicar uma dose considerada eficaz para cada bloqueio de modo definitivo, mas é verdade que, com o auxílio do ultrassom, é possível reduzir a dose dos anestésicos em bloqueios.

Minimum anesthetic volume in regional anesthesia by using ultrasound-guidance.

The ultrasound guidance in regional anesthesia ensures the visualization of needle placement and the spread of Local Anesthetics. Over the past few years there was a substantial interest in determining the Minimum Effective Anesthetic Volume necessary to accomplish surgical anesthesia. The precise and real-time visualization of Local Anesthetics spread under ultrasound guidance block may represent the best requisite for reducing Local Anesthetics dose and Local Anesthetics-related effects. We will report a series of studies that have demonstrated the efficacy of ultrasound guidance blocks to reduce Local Anesthetics and obtain surgical anesthesia as compared to block performed under blind or electrical nerve stimulation technique. Unfortunately, the results of studies are widely divergent and not seem to indicate a dose considered effective, for each block, in a definitive way; but it is true that, through the use of ultrasound guidance, it is possible to reduce the dose of anesthetic in the performance of anesthetic blocks.

EUS-guided drainage of pancreatic pseudocysts offers similar success and complications compared to surgical treatment but with a lower cost.

BACKGROUND AND AIM: Pancreatic pseudocysts (PPC) are a complication that occurs in acute and chronic pancreatitis. They comprise 75% of cystic lesions of the pancreas. There are scarce data about surgical versus endoscopic treatment on PPC. The aim of this study was to compare both treatment modalities regarding clinical success, complication rate, recurrence, hospital stay and cost. METHODS: Retrospectively, data obtained prospectively from 2000 to 2012 were analyzed. A PPC was defined as a fluid collection in the pancreatic or peripancreatic area that had a well-defined wall and contained no solid debris or recognizable parenchymal necrosis. Clinical success was defined as complete resolution or a decrease in size of the PPC to 2 cm or smaller. RESULTS: Overall, 64 procedures in 61 patients were included: 21 (33%) cases were drained endoscopically guided by EUS and 43 (67%) cases were drained surgically. The clinical success of the endoscopic group was 90.5 versus 90.7% for the surgical group (P = 0.7), with a complication rate of 23.8 and 25.6%, respectively (P = 0.8), and a mortality rate of 0 and 2.3% for each group, respectively (P = 0.4). The hospital stay was lower for the endoscopic group: 0 (0-10) days compared with 7 (2-42) days in the surgical group (P < 0.0001). Likewise, the cost was lower in the endoscopic group (P < 0.001). The recurrence rate was similar in both groups: 9.5 and 4.5% respectively (P = 0.59). The two recurrences found in the endoscopic group were associated with stent migration, and the recurrence in the surgical group was due to the type of surgery performed (open drainage). CONCLUSION: Endoscopic treatment of PPC offers the same clinical success, recurrence, complication and mortality rate as surgical treatment but with a shorter hospital stay and lower costs.

Utilidad de la ecografia en manos del cirujano para el drenaje percutáneo de los abscesos abdominales y pélvicos / Utility of ultrasound in the hands of the surgeon in percutaneous drainage of abdominal and pelvic abscess

Antecedentes: los abscesos o colecciones abdominopélvicas sintomáticas se caracterizan por ser una entidad clínico-quirúrgica de origen multifactorial, aunque casi siempre su etología es posoperatoria. Objetivo: describir la aplicabilidad y eficacia del drenaje percutáneo de colecciones abdominales y pelvianas, bajo guía ecográfica, en un servicio de cirugía. Material y métodos: en un período de 9 años se incluyeron todos los pacientes con colecciones ab-dominopelvianas tratados en forma consecutiva con drenaje percutáneo bajo guía ecográfica, en el Hospital Italiano de Bahía Blanca. Resultados: desde junio de 2003 hasta junio de 2012 se trataron 87 pacientes con colecciones abdomi-nopelvianas sintomáticas; en 79 de ellos el tratamiento fue realizado bajo guía ecográfica; 4 pacientes no fueron incluidos en el estudio debido a que el tratamiento se realizó bajo guía tomográfica, y los restantes 4 fueron descartados porque eran pacientes pediátricos. En 51 (64,5%) de ellos, el origen fue posoperatorio. Treinta y ocho (48,1%) pertenecían al sexo femenino. El promedio de edad fue 55 años (rango 18-92). El drenaje se realizó bajo guía ecográfica y radioscópica en 78 pacientes (98,7%) y en uno el abordaje fue ecográfico y laparoscópico. En 15 pacientes (18,9%) se presentaron complicaciones inherentes al procedimiento: 7 pacientes cursaron con febre, 3 refrieron dolor luego de la intervención (abordaje intercostal), en 3 se constataron equivalentes febriles, en una, celulits, y en otra, fistula de colon. De acuerdo con la Clasificación de Dindo-Clavien: 14 puntos Grado I (93,3%) y 1 punto Grado III B (6,7%). No hubo mortalidad asociada al procedimiento; 7 pacientes (8,8%) fallecieron por causas no relacionadas con este. La técnica fue resolutiva en 70 pacientes (88,6%) y satsfactoria en 74 (94%). Conclusiones: el drenaje percutáneo de las colecciones abdominales y pélvicas bajo guía ecográfica en manos del cirujano fue factble y eficaz, lo que la convierte en una técnica segura con baja morbilidad y nula mortalidad.

Background: abscesses or symptomatic abdominal collectons have multifactorial origin, although in more than 65% of the cases, the etology is postoperative. Objective: to describe the applicability and utility of abdominal and pelvic percutaneous drainage guided by ultrasound in a surgical team. Methods: a series of consecutive patents with ultrasound guided percutaneous drainage of abdominal or pelvic collecton performed during in a 9 year period. Results: from June 2003 to June 2012, 87 procedures were performed, 79 of them guided with ultrasound.The etology was postoperative in 51 patents (64.5%). Thirty eight (48.1 %) were female. Average age was 55 (range 18-92). Drainage was performed under ultrasound and radiology guide in 78 patents (98.7%) and by laparoscopic and ultrasound guide in one patent. Fifeen patents (18.9%) presented morbidity related to the procedure: fever in 7 patents, unusual pain in 3 (all with intercostal drainage), chills and sweating in 3, cellulits in one, and a colonic leak in one. All patents were included into of Dindo-Clavien Classificaton of Surgical Complicatons and the results were: Grade I: 14 patents, Grade IIIb: one patent. There was no mortality related to the procedure; seven patents (8.8%) died because of other causes. The overall success rate was 88.6 % (70 cases), and satsfactory in 94% (74 cases). Conclusions: in surgeons hands, ultrasound guided percutaneous drainage of abdominal and pelvic collectons was a feasible, efective and safe procedure with low morbidity.

Subcostal transversus abdominis plane phenol injection for abdominal wall cancer pain.

A subcostal transversus abdominis plane (TAP) phenol injection was performed on a patient with refractory cancer pain due a metastatic involvement of the abdominal wall. A diagnostic block with local anesthetic was performed under ultrasound guidance (USG), resulting in a decrease of 80% and 100% in dynamic and static visual analog scale (VAS) for pain, respectively, for 20 hours. A phenol injection was then performed under USG. The patient reported 70% and 100% reduction in the dynamic and static VAS for pain and had a 50% decrease in the opioid requirement that was maintained for 2 months. TAP blocks offer an interesting tool for either diagnosis or therapeutic purpose in chronic pain management. USG provides an optimal approach to soft-tissue lesions where fluoroscopy techniques are not useful.

Hemodialysis catheter implantation in the axillary vein by ultrasound guidance versus palpation or anatomical reference.

BACKGROUND: WE COMPARED THE RESULTS OF FOUR DIFFERENT METHODS OF HEMODIALYSIS CATHETER INSERTION IN THE MEDIAL SEGMENT OF THE AXILLARY VEIN: ultrasound guidance, palpation, anatomical reference, and prior transient catheter. METHODS: All patients that required acute or chronic hemodialysis and for whom it was determined impossible or not recommended either to place a catheter in the internal jugular vein (for instance, those patients with a tracheostomy), or to practice arteriovenous fistula or graft; it was then essential to obtain an alternative vascular access. When the procedure of axillary vein catheter insertion was performed in the Renal Care Facility (RCF), ultrasound guidance was used, but in the intensive care unit (ICU), this resource was unavailable, so the palpation or anatomical reference technique was used. RESULTS: Two nephrologists with experience in the technique performed 83 procedures during a period lasting 15 years and 8 months (from January 1997-August 2012): 41 by ultrasound guidance; 19 by anatomical references; 15 by palpation of the contiguous axillary artery; and 8 through a temporary axillary catheter previously placed. The ultrasound-guided patients had fewer punctures than other groups, but the value was not statistically significant. Arterial punctures were infrequent in all techniques. Analyzing all the procedure-related complications, such as hematoma, pneumothorax, brachial-plexus injury, as well as the reasons for catheter removal, no differences were observed among the groups. The functioning time was longer in the ultrasound-guided and previous catheter groups. In 15 years and 8 months of surveillance, no clinical or image evidence for axillary vein stenosis was found. CONCLUSION: The ultrasound guide makes the procedure of inserting catheters in the axillary veins easier, but knowledge of the anatomy of the midaxillary region and the ability to feel the axillary artery pulse (for the palpation method) also allow relatively easy successful implant of catheters in the axillary veins.