[Correlation of the epidural space measured intraoperatively and estimated by MRI or US: an observational study]. / Correlação entre a profundidade do espaço peridural medida no intraoperatório e a estimada por RM ou US: estudo observacional.

BACKGROUND AND OBJECTIVES: To assess the agreement between the epidural depth measured from the surgical site with the epidural depths estimated with magnetic resonance imaging (MRI) and ultrasound scanning. METHODS: Fifty patients of either sex, scheduled for L4-5 lumbar disc surgery under general anesthesia were enrolled in this prospective observational study, and the results of 49 patients were analyzed. The actual epidural depth was measured from the surgical site with a sterile surgical scale. The MRI-derived epidural depth was measured from the MRI scan. The ultrasound estimated epidural depth was measured from the ultrasound image obtained just before surgery. RESULTS: The mean epidural depth measured from the surgical site was 53.80 ± 7.67mm, the mean MRI-derived epidural depth was 54.06 ± 7.36mm, and the ultrasound-estimated epidural depth was 53.77 ± 7.94mm. The correlation between the epidural depth measured from the surgical site and MRI-derived epidural depth was 0.989 (r2 = 0.979, p < 0.001), and the corresponding correlation with the ultrasound-estimated epidural depth was 0.990 (r2 = 0.980, p < 0.001). CONCLUSIONS: Both ultrasound-estimated epidural depth and MRI-derived epidural depth have a strong correlation with the epidural depth measured from the surgical site. Preprocedural MRI-derived estimates of epidural depth are slightly deeper than the epidural depth measured from the surgical site, and the ultrasound estimated epidural depths are somewhat shallower. Although both radiologic imaging techniques provided reliable preprocedural estimates of the actual epidural depth, the loss of resistance technique cannot be discarded while inserting epidural needles.

Correlation of the epidural space measured intraoperatively and estimated by MRI or US: an observational study / Correlação entre a profundidade do espaço peridural medida no intraoperatório e a estimada por RM ou US: estudo observacional

Abstract Background and objectives: To assess the agreement between the epidural depth measured from the surgical site with the epidural depths estimated with magnetic resonance imaging (MRI) and ultrasound scanning. Methods: Fifty patients of either sex, scheduled for L4‒5 lumbar disc surgery under general anesthesia were enrolled in this prospective observational study, and the results of 49 patients were analyzed. The actual epidural depth was measured from the surgical site with a sterile surgical scale. The MRI-derived epidural depth was measured from the MRI scan. The ultrasound estimated epidural depth was measured from the ultrasound image obtained just before surgery. Results: The mean epidural depth measured from the surgical site was 53.80 ± 7.67 mm, the mean MRI-derived epidural depth was 54.06 ± 7.36 mm, and the ultrasound-estimated epidural depth was 53.77 ± 7.94 mm. The correlation between the epidural depth measured from the surgical site and MRI-derived epidural depth was 0.989 (r2 = 0.979, p < 0.001), and the corresponding correlation with the ultrasound-estimated epidural depth was 0.990 (r2 = 0.980, p < 0.001). Conclusions: Both ultrasound-estimated epidural depth and MRI-derived epidural depth have a strong correlation with the epidural depth measured from the surgical site. Preprocedural MRI-derived estimates of epidural depth are slightly deeper than the epidural depth measured from the surgical site, and the ultrasound estimated epidural depths are somewhat shallower. Although both radiologic imaging techniques provided reliable preprocedural estimates of the actual epidural depth, the loss of resistance technique cannot be discarded while inserting epidural needles.

Resumo Justificativa e objetivos: Avaliar a concordância entre a profundidade peridural medida no campo cirúrgico com a profundidade peridural estimada pela Ressonância Magnética (RM) e ultrassonografia. Métodos: Cinquenta pacientes de ambos os sexos agendados para cirurgia de disco lombar L4-5 sob anestesia geral foram incluídos neste estudo observacional prospectivo, e os resultados de 49 pacientes foram analisados. A profundidade peridural real foi medida no campo cirúrgico com uma régua cirúrgica estéril. A profundidade peridural obtida pela Ressonância Magnética (RM) foi medida a partir das imagens do exame de RM. A profundidade peridural estimada pelo ultrassom foi medida a partir da imagem do ultrassom obtida imediatamente antes da cirurgia. Resultados: A profundidade peridural média medida no campo cirúrgico foi de 53,80 ± 7,67 mm; a profundidade peridural média da RM foi de 54,06 ± 7,36 mm; e a profundidade peridural estimada por ultrassom foi de 53,77 ± 7,94 mm. A correlação entre a profundidade peridural medida no campo cirúrgico e a profundidade peridural derivada da RM foi de 0,989 (r2 = 0,979; p < 0,001); e a correlação correspondente com a profundidade peridural estimada por ultrassom foi de 0,990 (r2 = 0,980; p < 0,001). Conclusões: Tanto a profundidade peridural estimada por ultrassom quanto a profundidade peridural derivada da RM mostram forte correlação com a profundidade peridural medida no campo cirúrgico. As estimativas pré-operatórias da profundidade peridural derivadas da RM são um pouco mais profundas do que a profundidade peridural medida no campo cirúrgico, e as profundidades peridurais estimadas por ultrassom são um pouco mais rasas. Embora ambas as técnicas de imagem radiológica tenham fornecido estimativas pré-operatórias confiáveis da profundidade peridural real, a técnica de perda de resistência não pode ser descartada durante a inserção da agulha peridural.

Preprocedural Ultrasound Estimates of Epidural Depth: Transverse Median Plane is Comparable to Paramedian Sagittal Oblique Plane in Non-Pregnant Patients.

OBJECTIVE: The aim of this study was to assess the accuracy and precision of the actual epidural depth (ND) and ultrasound (US) estimates of the distance from the skin to the epidural space in the transverse median plane (ED/TM) and paramedian sagittal oblique plane (ED/PSO) in patients who were not pregnant and who were undergoing unilateral inguinal hernia repair surgery under combined spinal epidural anaesthesia. METHODS: A total of 100 patients with the American Society of Anaesthesiology status I-III of either gender were recruited. All epidurals were inserted at the L3-4 intervertebral space, and the epidural needle was marked with a sterile marker. The ND was measured between the marker and the tip of the needle. The ED/TM and ED/PSO were assessed with a 2-5 MHz curved array probe at the L3-4 intervertebral space. The Pearson correlation coefficient and Lin's concordance correlation coefficient were used to assess the precision and the Bland-Altman test was used to assess the 95% limit of agreement. RESULTS: The ND was 48.98±6.91 mm, the ED/PSO was 48.92±6.91 mm and the ED/TM was 48.90±6.91 mm. The Pearson correlation coefficient between ND and ED/PSO was 0.995 (p<0.001) and 0.994 (p<0.001) with ED/TM. Lin's concordance correlation coefficient for ND and ED/PSO was 0.995 (95%CI [confidence interval]: 0.992-0.997), and 0.993 for ND and ED/TM (95% CI: 0.990-0.996). The 95% limit of agreement between ND and ED/PSO was 0.70-1.37, and for ND and ED/TM, it was 0.79-1.54. CONCLUSION: Preprocedural ultrasound (US) scanning in both planes provides reliable estimates for actual epidural depth in non-pregnant patient population.

Effects of Isothermic Irrigation on Core Body Temperature During Endoscopic Urethral Stone Treatment Surgery Under Spinal Anesthesia: A Randomized Controlled Trial.

Purpose? Isothermic irrigation decreases the reduction in core temperature and shivering in patients undergoing transurethral resection of prostate gland but this effect has not been studied in patients undergoing endoscopic urethral stone treatment surgery. The current study is designed to study the effect of isothermic hydration on core temperature in patients scheduled for endoscopic urethral stone treatment surgery under spinal anesthesia. Materials and Methods? Sixty patients allocated randomly into two groups. In GroupW (n = 30) irrigation fluid at 37°C was used whereas at room temperature in GroupRT (n = 30). Spinal anesthesia was performed at L3-L4 interspace with 15mg of hyperbaric bupivacaine. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and five minute intervals until the end of operation. Shivering and surgeon comfort was also recorded. The primary outcome was the core temperature at the end of surgery. Frequencies, means, standard deviations, percentages, chi-square tests, independent samples t-test, and Mann Whitney U tests were used where eligible for the statistical analysis.Results? Baseline core temperature was 36.6 ± 0.4°C in GroupW and 36.6 ± 0.5°C in GroupRT (P = .097) which decreased to 36.0 ± 0.5°C and 35.2 ± 0.7°C respectively (P = .018) at the end of operation.  Shivering was observed in 36.7% (n = 11) in GroupRT and 6.7% (n = 2) in GroupW (P = .012). Hemodynamic parameter changes and demographic data were not significant between groups.Conclusion? Isothermic irrigation decreases both the reduction in core temperature and the incidence of shivering while increasing the surgeon comfort.

Abdominal girth has a strong correlation with actual and ultrasound estimated epidural depth

Background/aim/AIM: This study aimed to assess the correlations of actual epidural depth (ND) and ultrasound estimated epidural depth in the paramedian sagittal oblique plane (ED/PSO) and transverse median plane (ED/TM) with the abdominal girth (AG), body mass index (BMI), and weight of patients. Materials and methods: One hundred and thirty patients of either sex scheduled for unilateral inguinal hernia repair were enrolled. ED/PSO and ED/TM were assessed with a 2­5 MHz curved array probe at the L3­4 intervertebral space. The epidural needle was marked with a sterile marker upon locating the epidural space. The ND was assessed by measuring the distance from the sterile marker to the tip of the epidural needle with a linear scale. Anthropometric measures of the patients were recorded. Results: ED/PSO was 49.6 ± 7.9 mm, ED/TM was 49.5 ± 7.9 mm, and ND was 50.0 ± 8.0 mm. AG was 99.8 ± 12.9 cm. The Pearson correlation coefficient between ND and ED/PSO was 0.997 and with ED/TM was 0.996 (P < 0.001 for both). Pearson correlation coefficients for ND with AG, BMI, and weight were 0.757, 0.547, and 0.638, respectively (P < 0.001 for all). Conclusion: AG, weight, and BMI have strong correlations with ND.

Effects of isothermic crystalloid coload on maternal hypotension and fetal outcomes during spinal anesthesia for cesarean section: A randomized controlled trial.

OBJECTIVE: Spinal anesthesia induced hypotension (SAIH) is a common occurrence during spinal anesthesia for cesarean section resulting in perturbing effects on maternal and fetal outcomes. Previous studies conducted to attenuate SAIH focused on the timing of intravenous fluid infusion and demonstrated the superiority of coload strategy on traditional preload strategy but neither of them focused on the effect of the temperature of crystalloid infused on SAIH and fetal outcomes. The current study aimed to assess the effect of the temperature of the crystalloid infused with coload strategy on the incidence of SAIH and fetal outcomes. MATERIALS AND METHODS: Seventy-six parturients were enrolled into the study and data of 60 parturients were analyzed. Patients were randomly assigned to receive crystalloid coload at room temperature (Group RT, n = 30) or warmed at 37 °C (Group W, n = 30). The incidence of hypotension, cumulative hypotension episodes, heart rate, core body temperature, ephedrine dose, and fetal outcomes were recorded. RESULTS: There was no significant difference in the incidence of maternal hypotension, cumulative hypotension episodes, and ephedrine dose (p = 0,625, p = 0,871, p = 0,460 respectively). Umbilical arterial pH and fetal Apgar scores at first and fifth minutes were higher in Group W than in Group RT (p = 0.013, p = 0.006 and p = 0.045 respectively). One fetus in Group RT but none in Group W had umbilical arterial pH lower than seven. Fetal birth weight and rectal temperature measurements were comparable in both groups (p = 0.639 and p = 0.675 respectively). Demographic data, patient characteristics, and surgery data were comparable between groups. CONCLUSIONS: Isothermic crystalloid coload strategy results in higher umbilical pH values and Apgar scores in parturients scheduled for cesarean section under spinal anesthesia.

Abdominal girth has a strong correlation with ultrasound-estimated epidural depth in parturients: a prospective observational study.

BACKGROUND: Preprocedural ultrasound examination of vertebral column guides to locate desired intervertebral space and provides a prevision of needle trajectory and estimated needle depth in parturients. The objective of this study was to assess the correlation between ultrasound-estimated epidural depth (ED) with abdominal girth (AG), body mass index (BMI), weight, height, and age. METHODS: In this prospective, observational study, ultrasound imaging was done at L3-4 interspace in transverse median plane (TP) and paramedian sagittal oblique plane (PSO) to obtain ultrasound estimates of skin to epidural space depth. Combined spinal epidural anesthesia was performed at L3-4 interspace. AG, BMI, age, height, and weight were recorded for every parturient. RESULTS: Data from 130 parturients were analyzed. Estimated ED was 56.5 ± 9.5 mm in TP, 57.5 ± 9.3 mm in PSO, and actual epidural depth was 57.9 ± 9.4 mm. Correlation coefficients between ED and AG were 0.797 in TP (95% CI 0.727-0.854, p < 0.001) and 0.803 in PSO (95% CI 0.733-0.857, p < 0.001). Correlation coefficients between ED and BMI were 0.543 in TP (95% CI 0.405-0.661, p < 0.001) and 0.566 in PSO (95% CI 0.428-0.680, p < 0.001). Correlation coefficients between ED and weight were 0.593 in TP (CI = 0.466-0.695, p < 0.001) and 0.615 in PSO (CI = 0.500-0.716, p < 0.001). Height and age had no significant correlation with ED. CONCLUSIONS: Abdominal girth has a strong correlation with ultrasound-estimated epidural depth in parturients.

The effects of crystalloid warming on maternal body temperature and fetal outcomes: a randomized controlled trial / Os efeitos do aquecimento de cristaloides sobre a temperatura corporal materna e nas condições fetais: ensaio clínico randômico

Abstract Background and objectives: Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia. Methods: In this prospective randomized controlled trial, sixty parturients scheduled for elective cesarean section with spinal anesthesia were randomly allocated to receive crystalloid at room temperature or warmed at 37 °C. Spinal anesthesia was performed at L3-L4 interspace with 10 mg of hyperbaric bupivacaine without adding opioids. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and 5-min intervals until the end of operation. The primary outcome was maternal core temperature at the end of cesarean section. Results: There was no difference for baseline tympanic temperature measurements but the difference was significant at the end of the operation (p = 0.004). Core temperature was 36.8 ± 0.5 °C at baseline and decreased to 36.3 ± 0.5 °C for isothermic warmed crystalloid group and baseline tympanic core temperature was 36.9 ± 0.4 °C and decreased to 35.8 ± 0.7 °C for room temperature group at the end of the operation. Shivering was observed in 43.3% in the control group. Hemodynamic parameter changes and demographic data were not significant between groups. Conclusions: Isothermic warming crystalloid prevents the decrease in core temperature during cesarean section with spinal anesthesia in full-term parturients. Fetal Apgar scores at first and fifth minute are higher with isothermic warming.

Resumo Justificativa e objetivos: A hipotermia ocorre em cerca de 60% dos pacientes sob anestesia e geralmente não é tratada adequadamente durante procedimentos cirúrgicos de curta duração. A hipotermia está associada a desfechos clínicos adversos. O presente estudo teve como objetivo avaliar os efeitos do aquecimento de cristaloides nas condições maternas e fetais em pacientes submetidas à cesariana eletiva com raquianestesia. Métodos: Neste estudo prospectivo, randômico e controlado, 60 parturientes agendadas para cesárea eletiva com raquianestesia foram distribuídas aleatoriamente para receber cristaloides à temperatura ambiente ou aquecidos a 37 °C. A raquianestesia foi realizada no interespaço L3-L4 com 10 mg de bupivacaína hiperbárica sem adição de opioides. Temperatura central, tremores e parâmetros hemodinâmicos foram medidos a cada minuto até o décimo minuto e em intervalos de 5 min até o fim da operação. O desfecho primário foi a temperatura central materna ao final da cesárea. Resultados: Não houve diferença nas mensurações basais da temperatura timpânica, mas a diferença foi significativa no fim da operação (p = 0,004). A temperatura central foi de 36,8 ± 0,5 °C na fase basal e diminuiu para 36,3 ± 0,5 °C no grupo com aquecimento isotérmico de cristaloides e a temperatura basal timpânica foi de 36,9 ± 0,4 °C e diminuiu para 35,8 ± 0,7 °C no grupo sem aquecimento das soluções no fim da operação. Tremores foram observados em 43,3% no grupo controle. Alterações nos parâmetros hemodinâmicos e dados demográficos não foram significantes entre os grupos. Conclusões: O aquecimento isotérmico de cristaloides previne a redução da temperatura central durante a cesariana com raquianestesia em parturientes a termo. Os escores de Apgar para os fetos no primeiro e quinto minutos são maiores com o aquecimento isotérmico.

[The effects of crystalloid warming on maternal body temperature and fetal outcomes: a randomized controlled trial]. / Os efeitos do aquecimento de cristaloides sobre a temperatura corporal materna e nas condições fetais: ensaio clínico randômico.

BACKGROUND AND OBJECTIVES: Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia. METHODS: In this prospective randomized controlled trial, sixty parturients scheduled for elective cesarean section with spinal anesthesia were randomly allocated to receive crystalloid at room temperature or warmed at 37°C. Spinal anesthesia was performed at L3-L4 interspace with 10mg of hyperbaric bupivacaine without adding opioids. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and 5-min intervals until the end of operation. The primary outcome was maternal core temperature at the end of cesarean section. RESULTS: There was no difference for baseline tympanic temperature measurements but the difference was significant at the end of the operation (p=0.004). Core temperature was 36.8±0.5°C at baseline and decreased to 36.3±0.5°C for isothermic warmed crystalloid group and baseline tympanic core temperature was 36.9±0.4°C and decreased to 35.8±0.7°C for room temperature group at the end of the operation. Shivering was observed in 43.3% in the control group. Hemodynamic parameter changes and demographic data were not significant between groups. CONCLUSIONS: Isothermic warming crystalloid prevents the decrease in core temperature during cesarean section with spinal anesthesia in full-term parturients. Fetal Apgar scores at first and fifth minute are higher with isothermic warming.

The role of videolaryngoscope in endotracheal intubation training programs / O papel do videolaringoscópio em programas de treinamento de intubação endotraqueal

Abstract Background Macintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education. Methods Endotracheal intubation was performed on a human manikin owing a standard respiratory tract by Macintosh laryngoscopes and C-MAC® videolaryngoscope (Karl Storz, Tuttligen, Germany). Eighty paramedic students were randomly allocated to four groups. At the first week of the study 10 endotracheal intubation trials were performed where, Group-MM and Group-MV used Macintosh laryngoscopes; Group-VV and Group-VM used videolaryngoscopes. Four weeks later all groups performed another 10 endotracheal intubation trial where Macintosh laryngoscopes was used in Group-MM and Group-VM and videolaryngoscopes used in Group-VV and Group-MV. Results Success rates increased in the last 10 endotracheal intubation attempt in groups MM, VV and MV (p = 0.011; p = 0.021, p = 0.290 respectively) whereas a decrease was observed in group-VM (p = 0.008). Conclusions The success rate of endotracheal intubation decreases in paramedic students who used VL during endotracheal intubation education and had to use Macintosh laryngoscopes later. Therefore we believe that solely videolaryngoscopes is not enough in endotracheal intubation training programs.

Resumo Justificativa Os laringoscópios Macintosh são amplamente utilizados para o treinamento de estudantes de medicina e paramédicos em intubação endotraqueal; contudo, há mais estudos na literatura que apoiam os videolaringoscópios no treinamento de intubação endotraqueal. Nosso objetivo foi comparar o tempo de intubação endotraqueal e as taxas de sucesso de videolaringoscópios e laringoscópios Macintosh durante o treinamento de intubação endotraqueal e determinar o desempenho da intubação endotraqueal dos alunos quando precisam usar um dispositivo de intubação endotraqueal diferente daquele que usaram durante seu treinamento. Métodos A intubação endotraqueal foi realizada em modelo humano com trato respiratório padrão usando laringoscópios Macintosh e videolaringoscópio C-MAC® (Karl Storz, Tuttligen, Alemanha). Oitenta estudantes paramédicos foram randomicamente alocados em quatro grupos. Na primeira semana do estudo, 10 tentativas de intubação endotraqueal foram realizadas, nas quais o Grupo-MM e Grupo-MV utilizaram laringoscópios Macintosh e o Grupo-VV e Grupo-VM utilizaram videolaringoscópios. Quatro semanas depois, todos os grupos realizaram mais 10 tentativas de intubação endotraqueal, nas quais laringoscópios Macintosh foram utilizados pelo Grupo-MM e Grupo-VM e videolaringoscópios pelo Grupo VV e Grupo-MV. Resultados As taxas de sucesso aumentaram nas últimas 10 tentativas de intubação endotraqueal nos grupos MM, VV e MV (p = 0,011; p = 0,021, p = 0,290, respectivamente), enquanto uma redução foi observada no Grupo-VM (p = 0,008). Conclusões A taxa de sucesso da intubação endotraqueal diminuiu nos estudantes paramédicos que utilizaram VL durante o treinamento em intubação endotraqueal e precisaram usar laringoscópios Macintosh posteriormente. Portanto, acreditamos que o uso isolado de videolaringoscópios não é suficiente em programas de treinamento de intubação endotraqueal.

[The role of videolaryngoscope in endotracheal intubation training programs]. / O papel do videolaringoscópio em programas de treinamento de intubação endotraqueal.

BACKGROUND: Macintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education. METHODS: Endotracheal intubation was performed on a human manikin owing a standard respiratory tract by Macintosh laryngoscopes and C-MAC® videolaryngoscope (Karl Storz, Tuttligen, Germany). Eighty paramedic students were randomly allocated to four groups. At the first week of the study 10 endotracheal intubation trials were performed where, Group-MM and Group-MV used Macintosh laryngoscopes; Group-VV and Group-VM used videolaryngoscopes. Four weeks later all groups performed another 10 endotracheal intubation trial where Macintosh laryngoscopes was used in Group-MM and Group-VM and videolaryngoscopes used in Group-VV and Group-MV. RESULTS: Success rates increased in the last 10 endotracheal intubation attempt in groups MM, VV and MV (p=0.011; p=0.021, p=0.290 respectively) whereas a decrease was observed in group-VM (p=0.008). CONCLUSIONS: The success rate of endotracheal intubation decreases in paramedic students who used VL during endotracheal intubation education and had to use Macintosh laryngoscopes later. Therefore we believe that solely videolaryngoscopes is not enough in endotracheal intubation training programs.