Neuraxial blockade in children

Epidural blockade in children has become more popular for postoperative analgesia in recent years owing to increased experience, greater confidence and the development of appropriate equipment. In the UK, approximately 2000 lumbar epidural and continuous caudal blocks are performed each year. Spinal anaesthesia remains popular for babies at risk of postoperative apnoea, but is being superseded by light general anaesthesia with desflurane or sevoflurane combined with caudal blockade. Contraindications to neuraxial blockade include patient or parental refusal, coagulation abnormalities, septicaemia, raised intracranial pressure, meningitis, infection at the entry site, allergy to local anaesthetics, myelomeningocele (spina bifida) and abnormal sacral anatomy for a caudal epidural.     

Mapping scores onto stages: mini-mental state examination and clinical dementia rating.

OBJECTIVE: Although the clinical course of Alzheimer disease (AD) is gradual, it is useful for a number of reasons to distinguish between different levels of severity. The Clinical Dementia Rating (CDR) has demonstrated high validity and reliability for this purpose, but it requires a considerable amount of data to be collected both from the patient and from an informant. In the present study, the authors mapped Mini-Mental State Examination (MMSE) scores onto CDR categories to determine how well the MMSE performs as a surrogate of the CDR as a timesaving method of staging dementia. METHOD: Eight hundred sixty-three probands, including 524 patients with probable AD, 92 patients with questionable dementia, and 247 with memory complaints but no objective cognitive impairment, were included. Cutoff scores were identified on one-half of the sample using a receiver operating characteristic analysis. The cutoff values were then applied to the other half of the sample, and the agreement between MMSE score ranges and CDR stages was determined by calculating Cohen's kappa. RESULTS: The MMSE discriminated well between CDR stages 0.5, 1, 2, and 3 but performed poorly in the separation between CDR stages zero and 0.5. The MMSE ranges were 30 for no, 26-29 for questionable, 21-25 for mild, 11-20 for moderate, and 0-10 for severe dementia. Substantial agreement between the two instruments was obtained for the categories mild (kappa=0.62, p<0.001, N=115), moderate (kappa=0.69, p<0.001, N=114), and severe dementia (kappa=0.76, p<0.001, N=39), whereas the agreement was moderate for no (kappa=0.44, p<0.001, N=120) and only fair for questionable dementia (kappa=0.28, p<0.001, N=42). CONCLUSION: The MMSE can be used as a surrogate measure for the CDR for the staging of dementia in AD.     

Anaesthesia for vascular emergencies

Patients undergoing emergent vascular surgery, such as ruptured abdominal aortic aneurysm, acute ischaemic limb revascularization, and postoperative evacuation of haematoma after carotid surgery have significantly higher morbidity and mortality than for the equivalent elective procedures. This is partly caused by the high risk of the procedures. In addition, these patients have significant co-morbidity, and are usually under-assessed and under-prepared for such surgery, and often present out of normal working hours. Careful selection and application of anaesthetic techniques is important to minimize this morbidity, but also experienced anaesthetists and surgeons should be involved from the outset in managing these patients.