Threshold current for an insulated epidural needle in pediatric patients

We designed this study to determine the threshold current for nerve stimulation of an insulated needle in the epidural space. The intended dermatome was identified using the bony landmarks of the spine. An 18-gauge insulated Tuohy needle was inserted perpendicularly to the skin and advanced until "loss of resistance" was felt. A nerve stimulator was then connected to the insulated needle. Twenty patients were studied using an insulated Tuohy needle and one patient was studied using a noninsulated Tuohy needle. Muscle twitch was elicited with a current of 11.1 +/- 3.1 mA (mean +/- sd) in all patients in which an insulated needle was used. Muscle twitches were within 2 myotomes of the intended level (based on bony landmarks). Muscle twitch was not elicited with a noninsulated needle. After catheter threading, positive stimulation tests were elicited via epidural catheters in all patients (4.9 +/- 2.3 mA). Postoperative radiograph confirmed all catheter placements within 2 myotomes of the muscle twitches. Electrical stimulation may be a useful adjuvant tool to loss of resistance for confirming proper thoracic epidural needle placement. The threshold current criteria for an insulated needle (6-17 mA) would be higher than the original Tsui test criteria described for an epidural catheter (1-10 mA) in the epidural space.     

Evaluation of an insulated Tuohy needle system for the placement of interscalene brachial plexus catheters

Major shoulder surgery can be extremely painful. Interscalene brachial plexus catheters provide excellent postoperative analgesia but are technically difficult to place. A new insulated Tuohy needle system for plexus catheterisation is now available. This prospective study examined its ease of use and the postoperative analgesia produced by patient-controlled interscalene analgesia with ropivacaine 0.2%. Nineteen patients undergoing major shoulder surgery were studied. Interscalene brachial plexus blocks were performed using a modified Winnie technique with the insulated Tuohy needle and a nerve stimulator. After injection of ropivacaine 0.75% 30-40 ml into the plexus, a catheter was inserted. Block and catheter insertion times were recorded. All 19 patients had successful blocks and had catheters successfully threaded. Catheter infusions provided successful analgesia (visual analogue pain score < 5/10) in 18 patients, with one failure, giving a 95% success rate. Mean [range] catheter insertion time was 3.6 [1-10] min. Decreased block and catheter insertion times were associated with experience with the equipment when comparing the mean (SD) times for the first seven catheters and the last seven catheters inserted (12.1 (4.2) min vs. 7.9 (2.4) min), p < 0.05). It is concluded that the insulated Tuohy needle system for interscalene catheterisation proved easy to use in the hands of someone who had not used it before, and can be recommended.     

腹腔镜卵巢打孔术治疗难治性多囊卵巢综合征合并不孕

目的:探讨腹腔镜卵巢打孔术治疗难治性多囊卵巢综合征(PCOS)合并不孕的临床价值、适应证及机理。方法:对符合PCOS标准的不孕症47例采用腹腔镜电针双侧卵巢打孔术,观测术后排卵、妊娠、流产情况,比较手术前后血FSH,LH和T值的变化及月经情况的改变。结果:术后血清雄激素(T)及黄体生成激素(LH)明显下降,术后排卵率为85.1%。妊娠率为61.7%,早期流产率为10.3%,无1例发生卵巢过度刺激综合征(OHSS)。结论:腹腔镜卵巢打孔术可提高PCOS合并不孕患者的自然排卵率及对克罗米芬的敏感性,从而提高妊娠率,是PCOS不孕症特别是难治性PCOS患者恢复卵巢生理功能的有效手段,但应掌握手术时机和手术指征。术后3个月未妊娠者尽早采用促排卵药物以提高妊娠率。     

Safety of the Veress needle in pediatric laparoscopy

PURPOSE: To better establish the complication rate with the Veress needle technique for establishing a pneumoperitoneum in pediatric laparoscopy. PATIENTS AND METHODS: We reviewed all pediatric laparoscopy cases performed by a single surgeon from 1996 to 2003. There were 257 patients ranging in age from 4 months to 19 years. Infraumbilical placement of the Veress needle was used to create a pneumoperitoneum. All instances of preperitoneal insufflation, vessel/viscus injury, and forced conversion to open surgery were recorded. The length of time required to establish pneumoperitoneum was reported in the last 139 patients. RESULTS: The average length of time required to gain access to the peritoneum was <2 minutes. Of these procedures, 138 were performed for nonpalpable undescended testicles, 101 for varicoceles, 13 for duplication anomalies, and 5 for intersex disorders. There were 18 cases (7.0%) of preperitoneal insufflation. No cases resulted in vessel/visceral injury, conversion to open surgery, conversion to use of the Hassan trocar technique, or inability to complete the procedure because of complications in establishing a pneumoperitoneum. In all cases of preperitoneal insufflation, proper access was achieved by pulling the needle out and reinserting it at a different angle, with pneumoperitoneum being achieved easily in each case. CONCLUSION: The use of the Veress needle to establish pneumoperitoneum in children of all ages is safe, fast, and efficacious.     

The threshold current in the intrathecal space to elicit motor response is lower and does not overlap that in the epidural space: a porcine model

Purpose

Using electrical epidural stimulation, a current of 1 to 10 mA is required to confirm the presence of the tip of an epidural catheter in the epidural space. The purpose of this study was to examine the hypothesis that the threshold current required to elicit a motor response in the intrathecal space is significantly lower than that in the epidural space in a porcine model.

Methods

Four 20-kg pigs were used in this experiment. Eighteen gauge, insulated, Tuohy needles were advanced into the epidural space using the loss of resistance technique at five different spinal levels in each pig. When the epidural space was entered, an electrical current was applied to the needle and increased progressively until a motor response was elicited. The needle was then further advanced until cerebrospinal fluid (CSF) was observed or until the needle had been advanced a maximum of 1 cm. At this point, the current was reapplied and increased until motor activity was evident.

Results

A total of 20 needles were inserted in four pigs. The current required to produce a motor response in the epidural space was 3.45 ± 0.73 mA (mean ± SD). The current required to produce a motor response in the intrathecal space (entry confirmed by the presence of CSF) was 0.38 ± 0.19 mA (mean ± SD). Two needles were advanced 1 cm without obtaining CSF but the current thresholds were similar to those obtained when CSF was evident (0.4 mA and 0.3 mA, respectively).

Conclusion

The threshold current of an insulated needle required to elicit a motor response in the intrathecal space, was significantly (P < 0.01) lower than that in the epidural space in a porcine model.     

Diabetic kidney disease in pediatric patients: A current review

In the last decades, a significant increase in the incidence of diabetic kidney disease (DKD) was observed concomitant with rising diabetes mellitus (DM) incidence. Kidney disease associated with DM in children and adolescents is represented by persistent albuminuria, arterial hypertension, progressive decline in estimated glomerular filtration rate to end-stage renal disease and increased cardiovascular and all-cause morbidity and mortality of these conditions. In medical practice, the common and still the “gold standard” marker for prediction and detection of diabetic kidney involvement in pediatric diabetes is represented by microalbuminuria screening even if it has low specificity to detect early stages of DKD. There are some known limitations in albuminuria value as a predictor biomarker for DKD, as not all diabetic children with microalbuminuria or macroalbuminuria will develop end-stage renal disease. As tubular damage occurs before the glomerular injury, tubular biomarkers are superior to the glomerular ones. Therefore, they may serve for early detection of DKD in both type 1 DM and type 2 DM. Conventional and new biomarkers to identify diabetic children and adolescents at risk of renal complications at an early stage as well as renoprotective strategies are necessary to delay the progression of kidney disease to end-stage kidney disease. New biomarkers and therapeutic strategies are discussed as timely diagnosis and therapy are critical in the pediatric diabetic population.     

钳式针辅助单孔腹腔镜治疗儿童腹股沟疝微创分析

目的分析钳式针辅助单孔腹腔镜治疗儿童腹股沟疝的微创效果与可行性。方法回顾性分析2013年7～11月,首都医科大学附属北京朝阳医院京西院区采用钳式针辅助单孔腹腔镜治疗儿童腹股沟斜疝106例。结果本组患儿均在腹腔镜下顺利完成疝囊高位结扎术,单侧手术时间为5～11min,平均7．8min,双侧手术时间为9～15min,平均11．3min,麻醉清醒后即可离床活动,术后当日出院。随访1～4个月,无阴囊水肿、戳孔疝、线结异物瘘等并发症发生,无复发。结论钳式针辅助单孔腹腔镜治疗儿童腹股沟疝,操作简单,创伤小、疼痛轻、恢复快、无瘢痕,更符合微创手术理念,可作为儿童腹股沟疝的首选术式推广应用。     

Computed tomography-guided needle biopsies in pediatric oncology

Background

The use of computed tomography (CT)-guided biopsies facilitate the diagnosis and management in several medical settings. In this study, the authors analyzed how effective cutting and fine-needle biopsies are in pediatric oncology.

Methods

Medical records of 75 patients were analyzed in retrospect allowing the study of 101 biopsy results. The results of these procedures were compared with clinical follow-up or surgical biopsy results and evaluated for how they affected the patient’s treatment.

Results

CT-guided biopsies altered the treatment in 57 of 75 patients. No major complication occurred. Cutting and fine-needle biopsies are comparable in obtaining adequate material, but cutting needle obtains a superior rate of specific diagnosis.

Conclusions

CT-guided biopsies are safe procedures that can alter the management of pediatric oncology patients. Cutting and fine-needle biopsies each have one optimal specific use that must be considered to improve their accuracy.     

Advances and current topics in the study of metabolism and nutrition of pediatric patients

Scientific meetings on surgical metabolism and nutrition in pediatric patients have been held 13 times, once a year since 1971 as an evening session of the annual meetings of Japanese Society of Pediatric Surgeons. The initial meeting was established by several pediatric surgeons who were interested in surgical metabolism and nutrition, for the purpose of making progress and development in this particular field. At these meetings, many papers dealing with different problems on transfusion including total parenteral nutrition, on tube feeding nutrition including elemental diet, and on surgical metabolism related to adrenocortical response to surgical stress have been up to date presented and discussed. Problems on total parenteral nutrition in pediatric patients were picked up 3 times, and its indication, nutritional compositions including minerals and vitamins in addition to carbohydrates, amino acids and fat emulsions, managements and complications were discussed. At present, this method has been proved very important, necessary and safe in treating pediatric patients with disorders in the alimentary tract. Elemental diet is known to be more advantageous, namely more physiological and safer, compared with total parenteral nutrition. Incomplete compositions and high osmotic pressure of this nutrients are, however, disadvantageous to be improved in the future.     

Anesthesia through an intraosseous line using an 18-gauge intravenous needle for emergency pediatric surgery

Study ObjectiveTo describe the success and complication rate of intraosseous (IO) access for delivery of anesthesia with the use of an 18-gauge (G) intravenous (IV) needle.DesignProspective study.SettingChildren’s Welfare Teaching Hospital, Baghdad, Iraq.Patients300 critically ill infants and toddlers, age 3 weeks to 16 months, requiring emergency surgery for intra-abdominal or pelvic conditions, in whom peripheral or central access was not obtainable. Patients presented for surgery between 2007 and 2010.InterventionsIn 26 patients, the IO catheter was established when peripheral access was not obtained at the outset of surgery; in 4 patients standard peripheral vascular access failed during the surgical procedure and IO access was obtained. An 18-G IV needle was placed into the proximal tibia and attached to an extension set with a 3-way stopcock to deliver anesthesia.Main ResultsFor 26 critically ill children and 4 other children, IV access failed during delivery of anesthesia; vascular access was successfully obtained within minutes in all 30 infants (100%) using the intraosseous route. Ninety percent (27/30) of patients awoke immediately postoperatively in good condition; 10% (3/30) went to the pediatric intensive care unit (PICU) for further care due to their critical preoperative condition. Complications associated with use of the IO route were considered minor (3/30 pts [10%]) and included extravasation of fluid in two cases and cellulitis in one.ConclusionThe IO route provided for rapid delivery of anesthesia, induction, and maintenance in this series of critically ill infants undergoing emergency surgery when other vascular access routes failed. Few complications were noted. Intraosseous access was achieved through a simple technique using an 18-gauge IV needle.     

Microsurgical catheterization of the intrathecal space in the rat for chronic infusion of drugs

An original technique for placement of intrathecal catheters suitable for drug administration is described. For implantation a microsurgical laminectomy is carried out, opening the dura mater and placing the catheter under surgical microscope control. Only a few instrumentation is mandatory. The mean time for this surgery was between 15 and 20 minutes. A 10% of the animals operated on developed neurological deficits and must be dropped. The mortality rate was a 5%. No catheter malfunctions were found.     

超声引导下患儿肋锁间隙臂丛神经阻滞的研究进展

肋锁间隙(CCS)臂丛神经阻滞是一种锁骨下臂丛神经阻滞方式。臂丛内侧束、外侧束、后束在CCS集中于腋动脉外侧,位置关系固定,使用较少的局麻药即可达到良好的阻滞效果。近年来,CCS臂丛神经阻滞逐渐应用于患儿区域麻醉。患儿CCS臂丛神经解剖位置表浅,易于超声定位,但血管、神经、胸膜等结构距离较近,超声引导增加了患儿CCS臂丛神经阻滞的有效性和安全性。本文就CCS臂丛神经阻滞的解剖基础及超声定位、阻滞方法及药物用量、患儿临床应用和相关并发症进行综述,以期为患儿CCS臂丛神经阻滞的应用提供参考。     

Feasibility of adding magnesium to intrathecal fentanyl in pediatric cardiac surgery

Background

Magnesium is (NMDA) receptor antagonist used as an adjuvant for postoperative analgesia. There are several studies comparing the efficacy of the different routes of administration of magnesium. We aimed to study the effects of adding magnesium to IT fentanyl on peri-operative analgesic requirements after elective pediatric cardiac surgery.

Methods

This prospective double controlled randomized study (closed envelop method) included eighty pediatric patients subjected to elective open cardiac surgery. They were randomly allocated into four equal groups (20 patients each): (A) control group (i.v. fentanyl), (B) intrathecal fentanyl group (ITF) (received IT 1 μg/kg of fentanyl), (C) intrathecal fentanyl and magnesium (0.5 mg/kg) group (received IT 1 μg/kg of fentanyl citrate and 0.5 mg/kg magnesium sulfate), and (D) intrathecal fentanyl magnesium (1 mg) group (received IT 1 μg/kg of fentanyl citrate, and 1 mg/kg magnesium sulphate). The perioperative anesthetic management was standardized.

Results

The results of this study demonstrated that the analgesic profile tended to be better with ITF, ITF-Mg 0.5 mg/kg and ITF-Mg 1 mg/kg groups than the control group. Also, intraoperative fentanyl used in ITF-Mg (1 mg) was statistically less as compared with ITF and ITF-Mg (0.5 mg) groups. Time to extubation (h) was surprisingly, shorter in ITF-Mg (1 mg) as compared with ITF and control groups. Also, postoperative intravenous fentanyl consumption μg/kg/24 h was more in control group as compared with other groups.

Conclusion

In conclusion, the use of intrathecal fentanyl-magnesium (1 mg/kg) in pediatric patients subjected to open cardiac surgery reduced intra and postoperative analgesic consumption, prolonged the time to first analgesic requirement and allowed early tracheal extubation when compared with intravenous fentanyl, intrathecal fentanyl or intrathecal fentanyl-magnesium (0.5 mg/kg).     

Fracture of the astragalus in pediatric patients,an unusual entity

Introduction and importanceThe fracture of the astragalus is an unusual bone fracture (Ladero and Concejero, 2004) and is even more unusual in pediatric patients. The astragalus is a bone surrounded by cartilage and other structures making it difficult to appreciate on an X-ray which can lead to misdiagnosis (Ladero and Concejero, 2004; Inal and Inal, 2014) and could lead to not applying the right treatment and risk avascular necrosis or other sequelae.Case presentation3-year-old male with foot pain and edema+++, unable to walk or stand up since a fall 2 days before, had a doubtful diagnosis after an x-ray showed no apparent bone injury. A CT scan confirmed astragulus fracture; it was then treated adequately, thus avoiding complications that could have occurred had the fracture not been diagnosed and treated correctly.Clinical findings and interventions and outcomeThe limb was immobilized with a suropodalic cast for 5 weeks. No surgery was performed because of the patient's age and because the fracture was not displaced (Hawkins type 1) (Jasqui-Remba and Rodriguez-Corlay, 2016; Urrutia et al., 1999).Relevance and impactThere is a risk of misdiagnosis in these cases since the astragulus fracture might not show up in an X-ray, as in the case presented. A CT scan can detect the fracture and thus help consolidate the bone correctly. The correct differential diagnosis also reduces the risk of avascular necrosis, which increases due to poor blood supply to the astragalus.     

Percutaneous electrode guidance using the insulated needle for prelocation of peripheral nerves during axillary plexus blocks

BACKGROUND AND OBJECTIVES: Short reports have noted that percutaneous prelocation is helpful in determining the anatomic course of a peripheral nerve, and, thereby, may serve as a guide for block needle insertion. We prospectively studied percutaneous electrode guidance to assist axillary brachial plexus blocks. METHODS: In 131 consecutive patients, the tip of an insulated needle emitting 5 mA was placed on the skin above and below the axillary artery to obtain a hand motor response characteristic of the median, ulnar, and radial nerves in succession. The current was reduced until all movement had ceased. The needle was then inserted toward the nerve to be blocked, decreasing the intensity from 2 mA to 0.5 mA, so that the same selected motor response was still obtained. The length of the needle inserted was noted, and 1.5% lidocaine was injected. Pain verbal analogic score (VAS) values were noted during both procedures. Complete sensory blockade was evaluated at 30 min. RESULTS: Rates of successful percutaneous electrode guidance were 94.6% for the median nerve, 89.4% for the radial nerve, 88.5% for the ulnar nerve, and 85.5% for all 3 nerves together. A significant correlation was found between the lowest percutaneous current applied and the depth of the nerve stimulated at 0.5 mA. Pain VAS values were significantly lower during percutaneous stimulation than during needle insertion (P <.05). Sensory block for all 3 nerves was noted in 92% of patients. CONCLUSIONS: Percutaneous electrode guidance using the insulated needle enabled clinicians to locate the terminal branches of the plexus in the axilla and appreciate their depth. This method could, therefore, minimize patient discomfort and perhaps the risk of nerve trauma.