Can parturients distinguish between intravenous and epidural fentanyl?

We tested the hypothesis that the sedative, euphoric, and analgesic effects of intravenous fentanyl would distinguish intravenous from epidural administration. One hundred ASA I and II labouring parturients received 100 μg fentanyl either iv or via an epidural catheter in a double-blind, randomized, crossover fashion. Nineteen anaesthetists (8 staff and 11 residents) participated and correctly guessed the route of administration of the fentanyl in 61/66 intravenous doses and in 69/75 epidural doses yielding a sensitivity of 92.4%, a specificity of 92.0%, a positive predictive value of 91.0%, and a negative predictive value of 93.2%. Of the 41 patients that were crossed over, 38 (92.7%) were able to detect a difference between the routes of administration. Most patients experienced prompt, short-lived symptoms with iv fentanyl but no important differences in fetal heart rate pattern or in maternal desaturation were seen between the groups. This study suggests that subjective symptoms will accurately distinguish intravenous from epidural fentanyl administration in labouring parturients (P < 0.001), and should serve as a safe and reliable intravenous test dose for epidural anaesthesia in the obstetric population.     

Can the DOQI guidelines be met by peritoneal dialysis alone in pediatric patients?

DOQI guidelines recommend minimal standards for automated peritoneal dialysis (APD), with a weekly Kt/V of 2.1 and creatinine clearance (C _Cr) of 63 l/1.73 m². The purpose of this study was to assess if the DOQI guidelines could be met by dialysis alone in children on PD. Dialysis clearance studies were retrospectively analyzed in 20 pediatric patients on APD, all with a dwell volume of at least 1,000 ml/m². Mean dialytic Kt/V was 2.0; only 45% had a Kt/V above the recommended 2.1. Mean dialytic C _Cr was 43.5 l/week per 1.73 m²; only 10% achieved a C _Cr above the recommended 63 l/week per 1.73 m². Despite the significant correlation between total therapy volume (TTV) and both Kt/V and C _Cr, only 2 of 10 patients with a TTV over 10 l/m² per day reached the target C _Cr. All patients had currently recommended dwell volumes, therapy times, and nocturnal cycles, but DOQI guidelines were difficult to achieve with dialysis alone. Strict adherence to DOQI guidelines in anephric pediatric PD patients may result in changing dialysis modality. However, without evidence of a correlation between delivered dose of dialysis and improved outcome, adequate dialysis should not be assessed by only measuring Kt/V and C _Cr. Received: 24 June 1999 / Revised: 2 November 1999 / Accepted: 2 November 1999     

The electrical properties of epidural catheters: what are the requirements for nerve stimulation guidance?

We designed the present study to investigate the electrical resistance of commercially available epidural catheters and to search for products and procedures suitable for nerve stimulation-guided insertion. Four types of epidural catheters were evaluated: 2 nonwire-reinforced catheters (19-gauge and 20-gauge nylon) and 2 wire-reinforced catheters (19-gauge without stylet and 20-gauge with stylet). The resistance of a catheter was calculated from the voltage level proportional to the fixed resistance in series circuit. In case of physiologic saline, the resistance of nonreinforced catheters was more than 700 kOmega, whereas the wire-reinforced catheter was 14.4 +/- 0.20 kOmega without stylet and 10.1 +/- 0.42 kOmega with stylet. When the stylet was passed through a 20-gauge nylon catheter, the resistance decreased to 49.2 +/- 1.96 kOmega. When catheters were primed with 10% hypertonic saline, the resistance of both nonreinforced catheters decreased by one third compared with physiologic saline. The electrical resistance of the saline-filled epidural catheters significantly differed among products tested. We conclude that epidural catheterization that is guided by electrical stimulation should be performed only with catheters equipped with spiral stainless steel wire reinforcement or with a stainless steel stylet.     

Medulloblastomas in adolescents and adults – Can the pediatric experience be extrapolated?

Adult medulloblastomas are orphan diseases that differ from their pediatric counterpart. Most are classified as classic or desmoplastic and fall in the SHH subgroup, mainly with loss-of-function mutations in PTCH1 and some by TP53-mutation due to underlying germline mutation. Activation of the WNT pathway is sporadic, although underlying Turcot syndrome may be present. One-third of tumors are issued from group 4. Most adult studies are small non-randomized retrospective heterogeneous studies performed at a single center with short follow-up. Standard craniospinal irradiation followed by maintenance chemotherapy (CCNU, cisplatin-vincristine) results in a 4-year event-free survival (EFS) and overall survival (OS) of 68% and 89% respectively in standard-risk adults, and in a 4-year EFS and OS of 50% and 90%, respectively in high-risk adults. Several pooled analyses point out the potential role of chemotherapy in adults. The feasibility of pediatric protocols in adults is sometimes hampered because of blood and peripheral nerve toxicity. In the near future, subgroups of medulloblastomas may be treated by personalized therapies. With prolonged follow-up, adults fare worse. Long-term sequelae and second line treatment are not well defined in adults. Prospective studies are ongoing to define optimal first-line and relapse treatments.     

Can the addition of clonidine improve the analgesic efficacy of low dose intrathecal morphine? A randomised double-blind trial

OBJECTIVE: To evaluate the influence of intrathecal clonidine on spinal morphine analgesia and adverse effects after major orthopaedic surgery. METHODS: The study was approved by the local Ethics Committee.After written informed consent, 45 ASA I-III patients scheduled for hip or knee replacement were included. Patients were randomly allocated to receive either placebo, 0.1 mg morphine or 0.1 mg morphine+50 microg clonidine in addition to 15 mg bupivacaine intrathecally. The primary outcome parameter was the time to first opioid request. Statistical differences were calculated with U-test or Fisher's exact test. RESULTS: Clonidine did not result in a significant improvement of postoperative analgesia. The mean time until first opioid request was for placebo 10.3+/-7.9 h, for 0.1 mg morphine 23.0+/-3.9 h and for 0.1 mg morphine+ 50 microg clonidine 21+/-6.9 h, respectively. Clonidine significantly increased the rate of adverse effects. CONCLUSION: Our trial did not confirm an improved analgesia with the combination of intrathecal morphine and clonidine. Due to increased adverse effects the combination of intrathecal clonidine and morphine does not seem to be a reasonable alternative in the management of postoperative pain after orthopaedic surgery.     

Can single dose preoperative intrathecal morphine sulfate provide cost-effective postoperative analgesia and patient satisfaction during radical prostatectomy in the current era of cost containment?

We retrospectively analyzed the analgesic efficacy and surgical outcomes of a single preoperative intrathecal long-acting morphine sulfate injection (0.25-0.5 mg) and postoperative intravenous (i.v.) ketorolac in 62 patients who underwent radical retropubic prostatectomy (RRP). Total postoperative analgesic requirement was documented along with assessment of length of hospital stay, pain control and time for resumption of normal activity. Postoperatively, 45% of patients required only nonsteroidal agents (ketorolac), whereas 55% needed a mean of 13.3 mg of supplemental i.v. morphine sulfate. Mean hospital stay was 2.3+/-0.3 days. Eighty-two per cent of patients felt the length of hospital stay adequate. Ninety-seven per cent of patients were satisfied with anesthesia selected and 95% of patients considered pain control on postoperative days 1 and 2 as effective. All patients resumed to full physical activity by 5.3+/-0.4 weeks after surgery. We conclude that a single preoperative injection of intrathecal morphine sulfate combined with i.v. ketorolac postoperatively results in effective analgesia, diminished supplemental narcotic requirement and high patient satisfaction during radical retropubic prostatectomy.     

Can the International Index of Erectile Function distinguish between organic and psychogenic erectile function?

OBJECTIVE

To define the ability of the International Index of Erectile Function (IIEF) to differentiate between organic and psychogenic erectile dysfunction (ED).

PATIENTS AND METHODS

Patients presenting for the evaluation and treatment of ED who had penile duplex Doppler ultrasonography (DUS) completed the IIEF questionnaire. Accepted ranges of the IIEF EF domain were used to grade baseline severity (severe, moderate and mild ≤11, 11–17, 18–25, respectively). Accepted criteria were used to define normality on DUS (peak systolic velocity >30 cm/s and end‐diastolic velocity <5 cm/s). Patients with documented Peyronie’s disease, hypogonadism and a history of radical prostatectomy were excluded.

RESULTS

In all, 112 patients were enrolled, with a mean (sd ) age and duration of ED of 56 (16) and 2 (0.6) years, respectively. The vascular risk‐factor profile included diabetes in 15%, hypertension in 26% and hyperlipidaemia in 20%. The baseline severity of ED was mild, moderate and severe in 28%, 41% and 32% men, respectively. All patients had normal testosterone levels. Patients also with a normal DUS were diagnosed with psychogenic ED, in 50%, 13% and 17% of men with mild, moderate and severe ED by the IIEF, respectively. No patient with venous leak had mild ED, and 62% of men with venous leak had severe ED.

CONCLUSIONS

These results indicate that the IIEF is not completely accurate in differentiating between organic and psychogenic ED, and that almost a fifth of men in this study population with severe ED by the IIEF had normal erectile haemodynamics. These data have potential ramifications for evaluating the baseline severity of ED in trials of erectogenic agents.     

Can we predict the response in the treatment of epilepsy with vagus nerve stimulation?

Despite the introduction of new antiepileptic drugs and advances in the surgical treatment of epilepsy, an important group of patients still remains uncontrolled by any of these methods. The relatively recent introduction of vagus nerve stimulation is yet another possible treatment for refractory epilepsy. This safe, simple, and adjustable technique reduces the number of seizures and multiple publications support its increasing efficacy and effectiveness, with few adverse effects. The goal of our study is to determine the efficacy of this procedure and the factors predicting a response, particularly in the presence of a temporal lobe discharge on the video electroencephalogram (video-EEG) and magnetic resonance imaging (MRI) lesions. We undertook a retrospective study of all the patients with refractory epilepsy who underwent implantation of a vagus nerve stimulator between 2003 and 2009, and with a minimum follow-up of 6 months. The statistical analysis was done with SPSS for Windows. The stimulator was implanted in 40 patients, of whom 38 had a minimum follow-up of 6 months. In one patient, the device had to be removed due to infection, so the series comprised 37 patients. These were divided into different groups, according to the epidemiologic, clinical, radiologic, and electroencephalographic data. In addition, an analysis of the response was performed. The efficacy of the procedure was established according to the reduction in the mean seizure frequency. The baseline value of these seizures was 80.97?±?143.59, falling to 37?±?82.51 at the last revision. The response rate (reduction in seizures ≥50 %) at 6 months was 51.4 %, with 62.2 % of the patients showing this reduction at the last evaluation. Significant differences in the response were seen for the variables: baseline frequency of seizures, temporal lobe discharge on VideoEEG and MRI lesions. The mean time to response was 10 months in patients with lower rate of seizures versus 25 months of those with the higher rate (p?=?0.024), and the response at 6 months was higher (p?=?0.05). Patients with temporal lobe discharge alone or in combination with discharges over other regions had a mean time to response of 11 months versus 26 months in those without temporal discharge (p?=?0.037). In the analysis of the MRI, we had seen that at the last revision, 82.4 % of the patients with lesion had achieved response versus 45 % without lesion (p?=?0.02). Vagus nerve stimulation reduces the frequency of seizures. A temporal lobe discharge on the video-EEG is an indicator of an early response and the presence of an MRI lesion indicates a late response. Patients with fewer rates of seizures have a better prognosis.     

Where is the apex of the sacral hiatus for caudal epidural block in the pediatric population? A radio-anatomic study

Purpose

Caudal epidural block (CEB), administered through the sacral hiatus, is a regional anesthetic technique commonly used in children. To facilitate and optimize pediatric CEB, morphometric data that may be important for the sacral hiatus have been obtained using multidetector computed tomography (MDCT).

Methods

This study is the first radio-anatomic study designed to address this topic in children. Images of 79 children (39 girls and 40 boys between 1 and 9 years old) were divided into three groups according to age [group I (ages 1–3), group II (ages 4–6), and group III (ages 7–9)] and were retrospectively examined. Data were gathered via 3D volume-rendered images. Measurements included the height and width of the sacral hiatus, S2–S4 (sacral vertebra) distance, the distances between the poles of the unfused spinous process of each sacral vertebra, and the dimensions of an imaginary triangle formed between the right and left posterior superior iliac spines (PSIS) and the apex of the sacral hiatus.

Results

The most frequently fused spinous process was at S2 level. The mean S2–S4 distance was 1.36 cm for group I, 1.78 cm for group II, and 2.17 cm for group III. There was not the imaginary equilateral triangle used in the method of finding the sacral hiatus for CEB, and the apex of this triangle did not occur at the standard level (S4) in most of the children. It was observed that the apex deriving from the most distal fused spinous process was at the level of S2 in one of two children.

Conclusion

Dural puncture is inevitable for CEB applied at the S2 level. Consequently, CEB should be applied below this level (range, 1.36–2.17 cm) from the midpoint of the interspinous distance between the PSIS (at the same level with S2) in children aged 1–9 years.     

Can anesthesia improve the outcome in high risk obstertric patients?

Obstetric anesthetists should have an infrastructure that allows for referral and assessment of high risk patients. Management plans should be agreed well before delivery. This information must be available to other members of the team. Protocol for common high risk problems should be agreed and introduced. Promoting regional blockade for Cesarean section will reduce maternal anesthetic mortality. Epidural anesthesia preserves fetal biochemistry better than other forms of anesthesia.     

Parent‐assisted or nurse‐assisted epidural analgesia: is this feasible in pediatric patients?

Aim:  The aim of this study was to assess the feasibility of parent-assisted or nurse-assisted epidural analgesia (PNEA) for control of postoperative pain in a pediatric surgical population.
Methods:  After the institutional review board (IRB) approval was obtained, an analysis of our pain treatment services database of pediatric surgical patients with epidural catheters in whom the parent and/or nurse were empowered to activate the epidural demand-dose button was evaluated.
Results:  Over a 10 -year period between 1999 and 2008, 128 procedures in 126 patients were provided parent or nurse assistance of the epidural demand dose. Satisfactory analgesia was obtained in 86% of patients with no or minor adjustments in PNEA parameters. Fourteen percent of patients were converted to intravenous patient-controlled analgesia (PCA) for inadequate analgesia (7%) or side effects (7%). None of the patients in this cohort required treatment for respiratory depression or excessive sedation.
Conclusions:  Parent-assisted or nurse-assisted epidural analgesia can be safely administered to children undergoing surgery who are physically or cognitively unable or unwilling to self-activate a demand dose. Additional studies are needed to compare the efficacy of PNEA with other modalities for postoperative pain control in children.     

Can interepicondylar distance predict joint line position in primary and revision knee arthroplasty?

Restoration of the position of the prosthetic joint line (JL) to the same level as the original JL is a challenging problem in primary adn revision knee arthroplasty, and there is no reliable method for achieving this objective. We hypothesized that there is a constant ratio between the interepicondylar distance (IED) and the perpendicular distance from this interepicondylar line to the JL and analyzed 100 computed tomography scans of the knee to study this relationship. The IED and the perpendicular distance from this interepicondylar line to the JL was measured using both the clinical epicondylar axis (CEA) and the surgical epicondylar axis (SEA). Results showed that the ration between the IED adn the perpendicular distance from the interepicondylar line to the JL was 3.0 using the CEA and 3.3 using the SEA. The ratio was found to be constant, irrespective of the patient's sex or height. We suggest using the CEA because of the ease in localizing epicondyle peaks and conclude that the position of the JL from the interepicondylar line is one-third the IED using the CEA. This will prove to be a valuable aid in restoring the JL position during knee arthroplasty.