Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients

The post-lumbar puncture syndrome (PLPS) can best be explained by prolonged spinal fluid leakage owing to delayed closure of a dural defect. Its incidence after spinal anaesthesia is much lower than after diagnostic lumbar puncture (LP). This difference could be caused by a strand of arachnoid, which might enter the needle with the outflowing cerebrospinal fluid (CSF) during diagnostic LP and upon removal of the needle be threaded back through the dura to produce prolonged CSF leakage. To find a technique that further reduces the incidence of PLPS, this hypothesis was tested by evaluating the effect that reinserting the stylet before removing the needle had on the incidence of PLPS. By reinserting the stylet to the tip of the needle, the hypothesized strand would be pushed out, thereby reducing the frequency of PLPS. Sprotte’s “atraumatic needle” (21 gauge) was used for LP. A total of 600 patients participated in the prospective study. They were randomized into two groups and questioned about their complaints every day for up to 7 days after the LP. All LPs were performed by two experienced neurologists (T.B., M.S.). In 300 patients, the stylet was reinserted to the tip of the needle; in the other 300 it was not reinserted. Whereas 49 of the 300 patients without reinsertion developed PLPS, only 15 of the 300 patients with reinsertion did. This significant difference (16.3 vs 5.0%, P < 0.005, chi square test) supports our hypothesis. On the basis of our results, we recommend reinserting the stylet before removing the needle in order to reduce the incidence of PLPS. Received: 30 September 1997 Received in revised form: 9 March 1998 Accepted: 20 March 1998     

Peritoneal Dialysis for Acute Renal Failure in Infants: A Comparison of Three Types of Peritoneal Access

Peritoneal access for peritoneal dialysis (PD) poses a significant problem in infants due to their small size and can result in considerable morbidity and occasional mortality. This study was carried out to compare the complications associated with three different types of PD catheters for intermittent PD. A total of 79 sessions of PD were given to 51 infants with acute renal failure. Twenty-nine infants received 1, 18 received 2 and 2 infants received 3 and 4 sessions of PD, respectively. For PD access an intravenous cannula was used in 36, stylet catheter in 18, and guide wire inserted femoral vein catheter in 25 procedures. Percentage reduction of serum creatinine per PD session was comparable in infants being dialysed with different types of PD access. Local puncture site and intraperitoneal bleed were associated with the use of a stylet catheter during 4 procedures each (22.2%). Catheter blockade was commonest with the intravenous cannula (22.2%), followed by guide wire inserted femoral vein catheter (16%), and was least with the stylet catheter (5.5%). Total mechanical complications were lower with guide wire inserted femoral vein catheter (16%) as compared to intravenous cannula (25%) and stylet catheter (66%) (p < 0.05). There were 4 episodes of peritonitis (5.0%), 3 bacterial and 1 fungal. Although peritonitis was more common with intravenous cannula (8.3%) than guide wire inserted catheter (4%) and stylet catheter (nil), the difference was not statistically significant. Total complications including mechanical and infective were least with guide wire inserted femoral vein catheter (20%), followed by intravenous cannula (33%) and stylet catheter (66%) (p < 0.05). Of 51 infants, 20 died (39.0%). The PD procedure per se resulted in mortality in 2 cases, 1 because of massive intraperitoneal bleed due to stylet induced injury of an intra abdominal blood vessel and the other due to fungal peritonitis. To conclude, of the three types of access for intermittent PD, complications related to the PD procedure are the least with guide wire inserted femoral vein catheter.     

视可尼喉镜在困难气管插管的应用

目的观察视可尼喉镜（SOS）应用于困难气管插管的成功率及安全性。方法30例术前评估预测为困难气管插管的择期手术患者,随机分为2组（每组n=15）,S组用SOS插管,M组用McCoy喉镜插管。2组病例均采用快速顺序静脉诱导,由同一名麻醉医师完成气管插管操作。记录麻醉诱导前（T1）、气管插管开始时（T2）、气管插管完成时（T3）的平均动脉压（MAP）、心率（HR）、脉搏氧饱和度（SpO2）以及插管时间、次数和并发症。结果2组患者MAP、HR在T1、T2时差异无显著性（P〉0.05）,T3时M组MAP、HR较S组升高（P〈0.05）。与T1时比较,T3时M组MAP、HR升高（P〈0.05）。2组患者SpO2组内、组间差异均无显著性（P〉0.05）。S组插管时间较M组明显缩短（P〈0.01）。S组一次插管成功率明显高于M组（P〈0.05）,2组声音嘶哑发生率差异无显著性（P〉0.05）。结论SOS用于困难气管插管成功率高、插管反应轻、安全性好,插管时间缩短,优于McCoy喉镜。     

ShikaniTM Seeing Optical Stylet-aided tracheal intubation in patients with a large epiglottic cyst

Large epiglottic cysts can block the glottis,leading to serious consequences.This condition presents a challenge in terms of airway management for anesthesiologists during induction of anesthesia.We report the use of a ShikaniTM Seeing Optical Stylet combined with a Macintosh laryngoscope to aid tracheal intubation in seven patients with large epiglottic cysts.Use of this technique can avoid cyst rupture and allow smooth,safe intubation.     

困难气道管理的新方法——可视可塑型硬光纤喉镜的临床应用

困难气道的处理是对麻醉医师的一大挑战，新近出现的可视可塑型硬光纤喉镜不仅是解决困难气道的快速有效手段，而且因其可保护门齿，插管应激反应小，因而也可替代直接喉镜完成常规气管插管。     

插管型喉罩与可视管芯用于全麻气管插管时对心血管反应的影响

目的比较可视管芯(SOS)、插管型喉罩(ILMA)和Macintosh喉镜(MAC)在气管插管过程中对患者心血管各指标的影响。方法选取拟在全麻下行眼眶手术的MallamptiⅠ/Ⅱ级、ASAⅠ级的患者60例,随机分为ILMA组、SOS组、MAC组,分别接受ILMA、SOS、MAC进行气管插管,每组20例,比较入室后5min(TBL)、气管插管前(TBI)、气管插管后即刻(TAI)、气管插管后1～5min(T1～T5)的收缩压、舒张压、心率及脑电双频谱指数(BIS),并比较TBI、T1、T3的血浆去甲肾上腺素(NA)浓度。结果 T1时点SOS组患者血压和心率低于MAC组和ILMA组,差异有统计学意义(P<0.05),而MAC组和ILMA组相比差异无统计学意义(P>0.05)。血浆NA浓度SOS组在插管后1min、3min均低于MAC组和ILMA组(P<0.05),同时ILMA组在上述2个时点的NA浓度均低于MAC组(P<0.05)。结论 SOS相对于MAC和ILMA在气管插管过程中能够减轻患者的心血管应激反应,而ILMA进行气管插管时并不能减轻此反应。     

Effect of stylet removal on neural response telemetry and stapedial reflex thresholds during cochlear implantation

Objective

The purpose of this study was to analyze changes in neural response telemetry (NRT) and electrically evoked stapedial reflex thresholds (ESRT) before and after stylet withdrawal during cochlear implant surgery.

Methods

Thirty children (21–92 months old) who were candidates for cochlear implantation took part in this study. In all of them Nucleus Contour Advance was implanted. NRT and ESRT responses were recorded initially with the stylet in and then when the stylet was taken out during the implant procedure. The recordings were performed in the basal, middle, and apical areas of the electrode array.

Results

The threshold levels required to obtain NRT and ESRT responses after stylet removal were lower. This decrease was observed in all parts of the cochlea. It was statistically significant in all areas with the exception of the basal ESRT measurements.

Conclusion

Withdrawing the stylet results in better NRT and ESRT responses, most probably due to a favorable position change of the electrode array within the scala tympani.     

瑞芬太尼全麻诱导时视可尼喉镜与直接喉镜气管插管的临床观察

目的：观察瑞芬太尼全麻诱导时视可尼喉镜（shikaniopticalstylet,SOS屿直接喉镜气管插管对患者血流动力学变化的影响。方法：非心肺疾病择期手术患者60例,ASAI级,年龄20～40岁,体重40～60kg,随机分为视可尼喉镜组（S）组和直接喉镜组（H）组,每组30例。记录麻醉诱导前（T0）、气管插管前即刻（T1）、气管插管后1min（T2）、插管后2min（T3）及插管后3min（T4）的SBP、DBP、HR变化,记录插管试插例次,气管插管时间。术后随访气管插管的相关并发症。结果：两组均顺利完成气管内插管。S组平均插管时间为（36±12）s,H组平均插管时间为（20±8）s,两组插管时间差异有统计学意义（P〈0．05）。组内比较,与T0相比,两组T1SDB、DBP均明显下降（P〈0．05）,两组HR无明显减慢（P〉0．05）;与T1相比,T2时两组SDB、DBP均明显升高（P〈0．05）,两组HR无明显增快（P〉0．05）;与基础值T0相比,S组T2时SDB降低（P〈0．05）,S组T2、T3、T4时HR增快（P〈0．05）。组间比较,两组血流动力学的改变,差异无统计学意义（P〉0．05）。S组有1例患者拔管后出现暂时性声音嘶哑,2例自诉咽喉疼痛,H组有2例患者诉咽喉疼痛,3例咽喉不适。结论：瑞芬太尼全麻诱导时,与直接喉镜相比,视可尼喉镜气管插管对患者血流动力学变化的影响无明显差异,可作为临床气管插管常规使用。     

普通喉镜与视可尼硬质喉镜联用在外伤性颈椎手术气管插管中的效果

目的 评价视可尼硬质喉镜在颈椎外伤性手术中气管插管的效果及安全性.方法 选取48例颈椎骨折脱位手术患者,随机分成两组,单用视可尼喉镜组(S组),普通喉镜与视可尼喉镜联用组(C组),在麻醉诱导后分别以视可尼喉镜或与普通喉镜联用的方法实施气管插管,观察记录麻醉诱导前(T0)、气管插管开始时(T1),导管插入时(T2)及导管插入后5min(T3)的HR,SBP,DBP值,插管所用时间、次数及并发症发生情况.结果 最终S组有20例,C组有23例患者数据进入统计.所有病例在各时间点的HR,SBP差异未有显著性变化,而DBP呈现为一先上升后下降的进程,且在T2时,组间比较差异具有显著性.插入气管导管时间上C组显著快于S组,1次插管成功率C组显著高于S组.术后所有患者未见明显的插管相关并发症.结论 快速诱导下对颈椎损伤患者使用视可尼硬质喉镜进行插管安全性好、插管迅速、成功率高,在需缩短插管时间情况下,可以采取联用普通喉镜的方法.