Landmark Technique Research Articles

A comparative study of ultrasound assisted versus landmark technique for combined spinal-epidural anaesthesia in patients undergoing lower limb orthopaedic surgery.

Background and Aims:Spinal anatomy is better visualised in the para sagittal oblique view with the aid of ultrasonography. The present study was undertaken to investigate whether preprocedural ultrasonography can facilitate the ease of establishing combined spinal epidural (CSE) via paramedian approach versus landmark approach in patients undergoing lower limb orthopaedic surgery.Methods:This prospective randomised study was conducted in 100 American Society of Anesthesiologists (ASA) grade I-II patients, aged 18-60 years requiring CSE and randomly divided into two groups: Ultrasound-assisted (USG) group (n = 50) and Surface landmark (SLG) group (n = 50). The primary outcome was to compare the first pass needle success rate to establish CSE and the secondary outcomes were to compare the number of needle puncture attempts, time to establish landmarks (t1), time to accomplish CSE (t2) and complications.Results:First pass needle success rate in USG group was 43 (86.0%) versus 36 (60.0%) in SLG group (P = 0.001). Number of attempts taken to establish CSE was lower in USG group as compared to SLG group (P = 0.023). t1 was greater in USG group (1.45 ± 0.47) minutes as compared to (0.79 ± 0.34) minutes in SLG group (P = 0.003). t2 was reduced in USG group (1.47 ± 0.55) minutes versus (2.73 ± 1.36) minutes in SLG group (P = 0.005).Conclusion:Preprocedural USG for CSE via paramedian approach increases first pass needle success rate and reduces needle puncture attempts in patients undergoing lower limb orthopaedic surgery.

Comparison of landmark guided and ultrasound guided percutaneous dilatational tracheostomy: Efficiency, efficacy and accuracy in critically ill patients.

Background and Aims:To overcome the procedure-related complications associated with landmark-guided percutaneous dilatational tracheostomy (PDT) ultrasound is emerging as a promising tool. Present study was designed to compare landmark-guided PDT and ultrasound-guided PDT in terms of efficiency, efficacy, and accuracy.Material and Methods:Hundred intensive care unit patients requiring prolonged mechanical ventilation were prospectively randomized into 2 groups of 50 patients each. In land mark guided (LMG) group, patients underwent landmark-guided PDT, whereas in ultrasound guided (USG) group, patients underwent ultrasound-guided PDT.Results:Both the groups were comparable in terms of demographic data, sequential organ failure assessment score, ventilator settings, and mean days on mechanical ventilation prior to PDT. The mean assessment time in the ultrasound-guided group (1.56 ± 1 min) was significantly more (P-value = 0.000) than in the landmark-guided group (0.84 ± 0.72 min). The mean total procedure time for the USG group (5.98 ± 10.23 min) was more than that for the LMG group (4.86 ± 8.03 min) (P-value 0.542). Deviation of puncture site from the midline was seen in two patients in group A as compared to none in the USG group (P-value = 0.153). The number of patients requiring more than one attempt for successful needle insertion was more (P-value = 0.148) in the LMG group (20%) as compared to USG group (8%). Incidence of complications, like bleeding and desaturation was more in the LMG group as compared to the USG group.Conclusion:Ultrasound-guided PDT is associated with reduction in periprocedural complications as compared to landmark technique, although it takes slightly longer time.

Development of object detection and classification with YOLOv4 for similar and structural deformed fish

Food scarcity is an issue of concern due to the continued growth of the human population and the threat of global warming and climate change. Increasing food production is expected to meet the challenges of food needs that will continue to increase in the future. Automation is one of the solutions to increase food productivity, including in the aquaculture industry, where fish recognition is essential to support it. This paper presents fish recognition using YOLO version 4 (YOLOv4) on the "Fish-Pak" dataset, which contains six species of identical and structurally damaged fish, both of which are characteristics of fish processed in the aquaculture industry. Data augmentation was generated to meet the validation criteria and improve the data balance between classes. For fish images on a conveyor, flip, rotation, and translation augmentation techniques are appropriate. YOLOv4 was applied to the whole fish body and then combined with several techniques to determine the impact on the accuracy of the results. These techniques include landmarking, subclassing, adding scale data, adding head data, and class elimination. Performance for each model was evaluated with a confusion matrix, and analysis of the impact of the combination of these techniques was also reviewed. From the experimental test results, the accuracy of YOLOv4 for the whole fish body is only 43.01 %. The result rose to 72.65 % with the landmarking technique, then rose to 76.64 % with the subclassing technique, and finally rose to 77.42 % by adding scale data. The accuracy did not improve to 76.47 % by adding head data, and the accuracy rose to 98.75 % with the class elimination technique. The final result was excellent and acceptable

Ultrasound-Guided Transversus Abdominis Plane Block versus Land Mark Technique in Lower Abdominal Surgery

Ultrasound-Guided Transversus Abdominis Plane Block versus Land Mark Technique in Lower Abdominal Surgery

6: Pre-procedural ultrasonography as an adjunct to landmark technique for identification of epidural space in parturients coming for labour analgesia- a prospective randomised controlled trial.

Background and Aims:Pregnancy-induced softening of tissues and ligaments, may increase the false-positive rate when identifying the epidural space by the loss of resistance ( LOR ) technique. Ultrasonography (USG), which has now become the EYE of anesthesiologists, can be used as a reliable tool to facilitate epidural needle placement in parturients. The objectives of the study included finding out the correlation between USG guided estimated depth versus actual depth of epidural space in parturients.Number of attempts taken and incidence of dural punctures by landmark technique versus USG guided technique were the secondary objectivesMethods:After the approval from the institutional ethics committee and Clinical Trials Registry of India registration, 62 parturients of American Society of Anesthesiologists(ASA) II requesting labor analgesia were randomised into two groups of 31 each- GROUP-L (conventional landmark technique) and GROUP-U (preprocedural ultrasound scan done before epidural).In group-U, Tuohy needle was introduced through the USG pre-determined insertion point and epidural space was located using LOR technique.Results:Ultrasound increased the success rate of epidural at first attempt from 51.6% in group “L” to 87% in group “U” Fewer needle attempts (P value - 0.001) were required in group “U” as compared to group “L”.No accidental dural punctures in group U, compared to 6 in group-L.Mean depth of epidural space (cm)-UD= 3.89 ± 0.45 cm and ND=4.05±0.37 cm. Conclusion:Pre-procedural ultrasonography is a simple, safe and accurate tool to determine the needle insertion site, decrease the incidence of accidental dural punctures and helps to assess epidural space depth in parturients.Group LGroup U P Mean of total no. of attempts1.73±0.891.13±0.590.001No. of attempts First attempt16 (51.6%)27 (87%)0.002 Second attempt10 (32.2%)4 (12.9%) >2 attempts5 (16.1%)0Accidental dural puncture60

Abstract No.: ABS2471: Comparison of landmark versus ECG-guided technique for correct insertion of central venous catheter in paediatric patients undergoing cardiothoracic surgery

Background & Aims:Central venous catheters (CVC), commonly indicated in paediatric patients during cardiac surgeries can cause various complications if not correctly positioned. Objective of this study was to compare correct placement of the CVC tip using anatomical landmark technique with ECG-guided technique.Methods:A prospective, randomised interventional study was conducted on 72 patients of <12 years age, randomly allotted to two groups of 36 patients each (landmark and ECG). After induction, central venous cannulation was performed in right IJV in all patients using either of the techniques. Post operative chest X rays were obtained in all patients and correct position of CVC was checked. CVC tip position within 0.5cm above/ below or at carina was considered as correct position. Analyses were performed using Student’s t-tests and Chi square-tests.Results:It was found that 22 (61.11%) in the landmark group were positioned correctly as compared to 33 (91.67%) in the ECG group (p = 0.006). The mean depth of CVC insertion was 9.05±1.66 in landmark group and 8.26±1.41 in the ECG group (p= 0.032). The landmark group had 12 (33.33%) participants with complications during the procedure, compared to 3 (8.33%) in the ECG-guided group (p = 0.020).Conclusion:ECG-guided technique was found to be more accurate for CVC tip placement than the anatomical landmark technique. ECG-guided technique had less complications than the anatomical landmark technique. Hence, ECG-guided CVC placement is relatively accurate, efficient, and safe.ParameterLandmark Group (n=36)ECG Group (n=36) P Age (in years)6.56±3.646.50±3.480.947Sex (M/F)21/1520/161.00Height (cm)114.04±22.95112.79±22.580.816Weight (kg)19.33±9.4019.83±8.480.810

54 A Novel, Cost-Effective and Easily Reproducible Simulation Method for Teaching Fascia Iliaca Blocks Significantly Improves Peri-Operative Administration Rates in Neck of Femur Fracture Patients

Despite high-level evidence supporting early fascia iliaca block (FIB) administration in patients sustaining neck of femur (NOF) fractures, administration remains suboptimal, restricted primarily by limited training opportunities. We present a novel, cost-effective and easily reproducible simulation session designed to teach the landmark technique during the Covid-19 pandemic.A simulation mannequin was used with four absorbent swabs, two banana skins and a clear dressing were applied to the inguinal region to recreate the “two-pop” texture of the landmark technique. Ten participants attended, limited by social distancing. A 1 (poor) to 5 (excellent) feedback sheet was handed to all participants for the five domains of content, delivery, interaction, usefulness, and quality of the practical skills session, with opportunities for qualitative feedback. The FIB administration rates in all NOF fracture patients between August -October 2019, before the simulation session, were statistically compared to November-December 2020, following it.All participants gave a 5/5 (excellent) rating for all five domains, confirming good acceptability amongst practitioners. In the time period before the session, 9/29 NOF fracture patients received a FIB, improving to 18/31 patients following it (p = 0.042; two-tailed Fisher’s exact test), a statistically significant increase in administration. The average cost per participant for the single-use materials in the session was £1.56, whereas the multiple-use items costed £7.88 per participant.Adoption of this novel, cost-effective and widely reproducible simulation method is deemed highly useful and acceptable by a diverse range of healthcare professionals, resulting in a statistically significant increase in FIB administration in NOF fracture patients.

Reliability of dual inclinometer for lumbar range of motion using two different Landmarking techniques.

To measure the intra-rater and inter-rater reliability of active lumbar extension and flexion movements using dual inclinometer with two different landmarking techniques. The reliability study was conducted at the Physical Therapy Department of the University Teaching Hospital, The University of Lahore, Pakistan, in January 2020, and comprised patients of either gender aged >18 years with mild or symptomatic lower back pain, and healthy subjects s controls. Repeated measurements with dual inclinometer were taken by two examiners and data was recorded by two separate observers. A set of three active lumbar extension and flexion movements were performed for an initial warm-up. The examiners repeated a palpation of bony landmarks prior to each trial. The two different landmarking techniques were applied on the lumbar spine to identify the start and end points. Both the examiners measured each participant thrice. For each examiner and each landmarking technique, the three data sets were acquired for active lumbar extension and flexion for a total of 120 sets per session per examiner per landmarking. Each set comprised three alternating active lumbar extension and flexion movements. Data was analysed using SPSS version 26. Of the 40 subjects with mean age 27.8+11.0 years, 19(48%) were males and 21(52%) were females. There were 15(38%) cases; 6(40%) males and 9(60%) females. The remaining 25(62%) were controls. The two landmarking techniques with dual inclinometer produced a high to very high intra-rater reliability (intraclass correlation coefficient:0.73-0.91) for both lumbar extension and flexion movements with moderate to low standard error of measurement values (0.36-1.31), while a high inter-rater reliability (intraclass correlation coefficient: 0.72-0.76; standard error of measurement: 0.52-0.63) for extension measurements and only moderate inter-rater reliability (intraclass correlation coefficient: 0.59-0.65; standard error of measurement: 1.36-1.49) for flexion measurements. Dual inclinometer along with skilled examiners and accurate landmarking methodology provided clinically reliable measurements.

Effectiveness of Ultrasound Guided Trans-versus Abdominis Plane (TAP) Block with Landmark Technique Guided TAP Block for Open Appendectomy

Objective: To compare the analgesic efficacy of ultrasound (US) guided TAP block with landmark technique guided TAP block for management of post-op pain after open appendectomy in patients of acute appendicitis. Methods: In this study, we include 80 patients of acute appendicitis who were planned for open appendectomy were included. The study was conducted from June-2021 to Jan-2022 in Nishtar Hospital Multan. In Landmark TAP group; TAP block was given using bupivacaine (0.25%) after completion of surgical procedure using blind landmark technique. In US TAP group; TAP block was administered under US supervision. VAS Score and time of first rescue analgesia were main study outcomes. Results: Mean age was 33.5±9.9 years in landmark TAP group and 32.8±10.4 years in US TAP group (p-value 0.75). There was no significant difference in mean VAS score at 1, 6, 12 and 18 hours after surgery between the groups, However, after 24 hours of surgery mean VAS score was higher in landmark TAP group; 3.5±1.2 versus 2.9±1.0 in TAP group (p-value 0.02). Time of first rescue analgesia was significantly prolonged in US TAP group; 1320.7±275.9 minutes versus 1180.4±320.7 minutes in landmark TAP group (p-value 0.04). Conclusion: Ultrasound guided TAP block is superior to landmark guided TAP block, as it provides better analgesic outcomes in comparison of landmark guided TAP block. Keywords: Ultrasonography, landmark technique, transversus abdominus plane block.

Comparative Study of the Efficacy and Safety of Ultrasound-guided and Landmark-based Paravertebral Block Technique in Patients undergoing Elective Unilateral Breast Surgery

Introduction: Identifying the Paravertebral Space (PVS) by its anatomical landmarks is associated with high failure rates and complications. With the advent of Ultrasonography (USG), failure rate has decreased leading to an increased interest in performing USG guided Thoracic Paravertebral Block (TPVB). Aim: To assess the efficacy and safety of ultrasound guided TPVB and its comparison with the landmark-based technique, in patients undergoing elective unilateral breast surgery. Materials and Methods: This cross-sectional study was carried out at Command Hospital, Pune from July 2014 to December 2015, on females between 18-70 years, accepted in American Society of Anaesthesiology (ASA) I-III for unilateral breast surgeries. Patients were divided into two groups with 40 subjects in each group. Group A subjects were treated with anatomical landmark technique and group B subjects with USG guided technique. The p-value &lt;0.05 was considered to be statistically significant. Results: Demographic parameters (age, height, weight and Body Mass Index (BMI) and the scheduled surgery were comparable in between the groups. In group A, success rate of the block was 82.5%, compared to 95% in group B (p-value &gt;0.05 using Fisher’s-exact test). Mean (SD) time taken for performing the block in group A was 371.10 (10.37) seconds while it was 613.73 (37.15) seconds in group B (p-value &lt;0.05 by two independent sample t-tests). No statistically significant difference was seen in haemodynamic parameters, except for the Heart Rate (HR) at 70, 80, 90 minutes after administering the block and at the end of surgery. Correlation analysis for quantitative variables with PVS depth (dependent variable), measured sonologically, showed very good linear correlation of PVS depth with weight (Pearson correlation coefficient, r=0.819, p-value &lt;0.001). BMI (r=0.884; p-value &lt;0.001). Conclusion: The success rate is higher with ultrasound guided TPVB compared to the landmark technique though statistically insignificant. But it is recommended to use ultrasound-guided TPVB for advantages such as lesser requirement of opioid supplementation, real time visualisation of the spread of drugs in PVS with lesser complication rates.

Accuracy of Different Complete-Arch Digital Scanning Techniques with a Combined Healing Abutment-Scan Body System.

Investigate the effects of three different complete-arch digital implant scanning techniques used with a combined healing abutment-scan body (CHA-SB) system on the accuracy (trueness and precision) and scan time. A poly(methyl methacrylate) master model simulating an edentulous maxilla was fabricated with four parallelly inserted dental implants. A CHA-SB system was attached to each implant. The model surface was scanned using a structured blue light industrial extraoral scanner to achieve a reference model standard tessellation language file (MRM-STL). Three different scanning techniques-(1) conventional technique with unmodified master model, (2) scan body splinting technique using orthodontic elastic ligatures and plastic splint materials, and (3) land-marking technique using pyramid-shaped glass-ceramic markers-were performed. Fourteen consecutive digital scans were made by using an intraoral scanner (IOS) for each technique, converted to an STL file, and superimposed on the MRM-STL. Trueness and precision were calculated for each technique. The scan time was also recorded. The data were analyzed with one-way analysis of variance (ANOVA) and Tukey honest significant difference (HSD) tests (α = .05). Effects of different scanning techniques on the trueness (distance and angular deviations; P < .001) and scan time (P = .002) were statistically significant. For precision, different scanning techniques had only a significant effect on the distance deviation (P < .001). Regarding trueness and precision, none of the scanning techniques was superior to others. The scan body splinting technique led to significantly less scan time.

Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery

Dear Editor, Our case was an 18 yrs/m, weighing 54 kg without co morbidities presented with pain in right elbow and was posted for screw fixation of fracture capitulum. His routine blood work and airway examination were normal to undergo the surgery under supraclavicular block (SCB). On arrival, patient’s PR was 84/min, BP- 118/72 mm Hg, SpO2- 98% on room air. For right sided SCB, patient was placed supine, head turned to left side with shoulder depressed and needle was inserted lateral to subclavian artery pulsation just above the clavicle, posterolaterally. There was inadvertent puncture of subclavian artery each time, despite using standard techniques. Hence we decided to abandon standard SCB and proceed with lower interscalene block (LISB).Using modified Winnie’s approach interscalene groove was palpated and needle was inserted 2-3 cm below the classical interscalene block (ISB) site. Paresthesia was attained over whole upper limb and then Inj. Lignocaine + Adrenaline (2%) 10 ml along with inj. Bupivacaine 0.5% 10 ml was injected after repeated negative aspirations. A satisfactory sensory and motor blockade was obtained after 15 minutes of injection. Throughout the procedure, patient was continuously monitored and surgery was completed within 1.5h without any adverse event. The patient was shifted to ward. The block weaned off in 6 hrs and his vitals were stable throughout his course of stay in the hospital. Traditionally, the subclavian artery is an important relation of the brachial plexus for landmark guided SCB. However, anatomical variation may be present in as much as 50% of the population. [1] T1 nerve root supplies skin both above and below the elbow. Some authors have suggested a combined ISB + axillary block to get profound anaesthesia for elbow surgery. [2,3] Axillary nerve block was not contemplated in our case as optimal arm positioning was precluded due to severe pain at elbow. The advantages of LISB over SCB and ISB or ISB + axillary block are that it significantly reduces the risk of pneumothorax , inadvertent arterial puncture, ulnar sparing (as lower trunks of brachial plexus are more superficial in LISB) and avoids multiple injections. LISB also provides adequate anaesthesia and analgesia to whole upper limb which could be due to the relative proximity of the inferior trunks to the other components of brachial plexus as they become tightly bundled between the clavicle and first rib at this level.[2] Performing an LISB is easier due to its accessibility and shallow location of the brachial plexus, which may be favourable to those who disfavour or may not be comfortable with the supraclavicular approach. [4] Our case exemplifies that in those centres where ultrasound machine is unavailable and access to the brachial plexus for SCB by landmark technique remains elusive despite troubleshooting, lower interscalene block can be safely used to provide similar quality and extent of surgical anaesthesia.

ULTRASOUND GUIDED CENTRAL VENOUS CANNULATION BY ANESTHESIA TRAINEE: NEED OF THE HOUR DURING COVID PANDEMIC

Covid pandemic has created deciency of doctors needed to administer skilled procedures in ICUs and operating rooms. Post graduate trainees need to acquire skills fast and perform it safely on patients. Ultrasound (USG)-guided central venous cannulation (CVC) is one such. The study aimed at nding the feasibility of training USG-guided CVC cannulation to anesthesia trainee as opposed to landmark method in terms of ease, speed and safety. Patients needing CVC were divided into 2 groups of 50 each, where Group 1 was subjected to Landmark method and Group 2 to USG-guided method. Continuous variables were compared using unpaired t test and categorical variables using either the Chi square test. Access time (in seconds) was signicantly less in the USG group (258.78 ± 11.17) as opposed to Landmark technique (301.60 ± 14.03) (p 0.03). Accidental carotid artery puncture was seen in 9 patients in Landmark group as opposed to none in the USG group. No patient in any group developed pneumothorax. USG-guided technique is superior and safer than the traditional landmark technique in hands of anaesthesia trainee in terms of a shorter access time, and less incidence of arterial puncture which is desirable in COVID patients to shorten the exposure time. USG-guided method needs an assistant to focus the probe. Nonetheless, this training should be imparted to the trainee to ll the gap created by skilled doctors falling sick during COVID pandemic.

Evaluating the Anatomic Spread of Selective Nerve Scalp Blocks Using Methylene Blue: A Cadaveric Analysis.

The modern scalp block consists of local anesthesia injections that target the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, and greater and lesser occipital nerves. Limited data exist on the local anesthetic spread that occurs with this technique. This study examines the extent of the spread of a scalp block using methylene blue in a cadaveric model. A traditional landmark-based scalp block was performed on 6 unembalmed human cadavers using 25-G, 1.5-inch needles to inject 1 to 2 mL of methylene blue 0.1% at each nerve bilaterally; a total volume of 20 mL was injected. The cadavers were then dissected, and the spread of injectate was measured and recorded. All the nerves required for analgesic coverage were appropriately stained by the injections, except for in 2 specimens where the lesser occipital nerve could not be identified. The zygomatic (stained in 2 of 8 specimens) and temporal (stained in 5 of 8 specimens) branches of the facial nerve were stained as a result of the zygomaticotemporal and/or auriculotemporal injections. Tracking from the zygomatic injection site was noted as far inferior as the temporalis muscle attachments on the mandible. This cadaveric study confirms that the landmark-based technique for scalp blocks consistently stained all 6 nerves involved in scalp innervation. There was significant unintentional spread to the branches of the facial nerve when using the landmark technique.

Unintentional common carotid artery cannulation during attempted internal jugular venous catheter insertion

Purpose: Insertion of a central venous catheter is a common procedure, performed by anesthesiologists and other medical professionals. The preferred site for central venous cannulation is the right internal jugular vein.&#x0D; Case Report: We present the case of a male patient who underwent renal transplantation for end-stage renal disease. During preparation for surgery, the right common carotid artery was cannulated instead of the right internal jugular vein. The situation was immediately recognized and managed by a vascular surgeon. The patient recovered completely without neurological deficit.&#x0D; Conclusion: Central venous cannulation is usually performed using the landmark technique. Incidental cannulation of the common carotid artery is a rare complication that can have serious consequences if not immediately recognized and properly managed.

Preprocedural ultrasound for neuraxial blockade in nonobstetric patients. Should it be considered as a standard of care?

Preprocedural ultrasound for neuraxial blockade in nonobstetric patients. Should it be considered as a standard of care?

Effect of additional reference objects on accuracy of five intraoral scanners in partially and completely edentulous jaws: An in vitro study

Statement of problemThe effect of additional reference objects on the accuracy of different intraoral scanners for partially and completely edentulous patients has not been investigated sufficiently. PurposeThe purpose of this in vitro study was to evaluate the effect of an additional reference object in the form of additional artificial landmarks on the trueness and precision of different intraoral scanners in partially and completely edentulous areas. Material and methodsPartially and completely edentulous models with 2 and 4 implants (BLT, RC, Institut Straumann AG), respectively, were used in the study. For the digital scan, scan bodies (CARES Mono Scanbody) were attached, and reference data obtained by using industrial scanners. Ten digital scans of the same model were made with each intraoral scanner: PRIMESCAN, TRIOS 3, TRIOS 4, Carestream 3600, and Medit. Then, additional artificial landmarks were attached, and 10 more intraoral scans were made with each device. Computer-aided design files of the scan bodies were aligned to obtain 3-dimensional surfaces with reference and test scanners. Trueness and precision of distance, angulations, and vertical shift between scan bodies were estimated. The Mann-Whitney Wilcoxon or Student 2-sample t test was applied to estimate statistically significant differences between groups (α=.05). ResultsIn the partially edentulous model, distance trueness mean ±standard deviation values ranged from −46.7 ±15.4 μm (TRIOS 3) to 392.1 ±314.3 μm (Medit) in models without additional artificial landmarks. When additional artificial landmarks were applied, trueness of distance mean ±standard deviation values ranged between −35 ±13 μm (TRIOS 4) and 117.7 ±232.3 μm (CARESTREAM). Trueness mean ±standard deviation values of angulation varied from −0.0 ±0.5 degrees (CARESTREAM) to 0.2 ±0.0 degrees (PRIMESCAN) without additional artificial landmarks and from 0.0 ±0.2 degrees (TRIOS 3) to 0.4 ±0.5 degrees (CARESTREAM) with additional artificial landmarks. Vertical shift trueness measurements varied from −108 ±47.1 μm (TRIOS 4) to 107.2 ±103.5 μm (Medit) without additional artificial landmarks and from −15.0 ±45.0 μm (CARESTREAM) to −86.9 ±42.1 μm (TRIOS 4) with additional artificial landmarks. The additional artificial landmark technique improved the trueness of all measured parameters for the 5 tested intraoral scanners. No statistically significant differences were found among models with or without additional artificial landmarks, except for Medit in all parameters and PRIMESCAN in angle measurements (P<.05). The best precision for distance was found with TRIOS 3 and with PRIMESCAN for angulation and vertical shift. Larger deviations were observed in the completely edentulous situation. The effect of additional artificial landmarks was limited when the accuracy parameters of digital scans were considered. ConclusionsScans with and without additional artificial landmarks of partially edentulous conditions scanned by any of the intraoral scanners tested did not influence precision and trueness, except for Medit i500 in the distance and vertical shift parameters and CARESTREAM3600 in vertical shift. Precision and trueness of digital scans of completely edentulous areas were affected, except for Medit i500 for distance, PRIMESCAN and TRIOS 4 for angle, and all systems except TRIOS 4 for vertical shift precision.

Comparative evaluation of landmark technique and ultrasound-guided caudal epidural injection in pediatric population: A systematic review and meta-analysis.

Caudal block is a common regional anesthesia technique in pediatrics with landmark method predominantly being practiced. Ultrasound-guided technique provides real-time visualization of the structures and injection while performing caudal block. We performed this meta-analysis to determine the utility of ultrasound in caudal blocks in children over the landmark-based technique. Randomized controlled trials comparing ultrasound-guided caudal blocks and landmark technique in pediatrics were searched from databases-PubMed, Embase, Scopus, and CENTRAL from inception until August 2020. The primary objective was success rate between the two techniques and secondary objectives included time to perform the block, first puncture success, and complications. Five trials with 904 participants were included for this meta-analysis. There was no difference in success rate between the two techniques (Risk ratio-1.07; 95% CI [0.97, 1.18]; p=.15). Time to perform the block was similar (Mean difference-8.88s; 95% CI [-21.64, 39.40; p=.57) while first puncture success was higher with ultrasound-guided technique (Risk ratio-1.31; 95% CI [1.15, 1.49]; p=.0001). Complications like vascular puncture and needle misplacement were lower in the ultrasound group, and no serious complications were seen in any patient. Needle visualization and sacral canal distension were seen in 82% and 97.5% of the cases, respectively, in ultrasound group. Ultrasound-guided caudal injection does not improve the success rate or time to perform the block but results in higher first puncture success and lower incidence of complications compared to landmark technique.

Avoiding harm: central venous access in Kartagener syndrome and other vascular anomalies

Placement of internal jugular catheters is more likely to be complicated if a left-sided approach is used, assuming normal anatomy. Kartagener syndrome is the sine qua non of sidedness confusion and results in cognitive challenges that increase the risk of adverse patient outcomes. The altered anatomy can cause profound disorientation from our usual processes. In normal circumstances the right-sided approach is used for placement of internal jugular catheters, but in Kartagener syndrome the left-sided approach should be preferred. Surgical volume and use of ultrasound guided techniques are positively correlated with better outcomes. Clinical experience may be a detriment to performance. Knowledge of these issues will help clinicians maintain vigilance and avoid error. &#x0D; &#x0D; Keywords: Kartagener syndrome, central venous access, superior vena cava, landmark technique, internal jugular vein catheterization cognitive bias

Transversus abdominis plane block by landmark technique with ropivacaine versus bupivacaine for post-operative analgesia in patients undergoing lower segment caesarean section deliveries

Transversus Abdominis Plane (TAP) Block is an efficacious abdominal field block which is widely used component of multimodal analgesia. Compare the efficacy of Inj. Ropivacaine 0.2% and Inj. Bupivacaine 0.2% when used in TAP block for post-operative analgesia in lower segment caesarean section deliveries(LSCS) done under spinal anaesthesia. Randomized double blinded prospective study conducted after institutional ethics committee in our institute. We have recruited sixty patients scheduled for an elective LSCS which were enrolled into two groups to receive TAP block with bupivacaine 0.2% 15ml Group B (n=30) versus ropivacaine 0.2% 15ml Group R (n=30) + dexamethasone 2mg bilaterally. TAP block was administered on completion of surgery. Primary objective was to compare time to rescue analgesia in postoperative period. Secondary Objectives wereto compare hemodynamic response during postoperative period, measure the intensity of pain using visual analogue scale (VAS), number of analgesic doses in first 24 hours, patient satisfaction with pain management and complications if any.SPSS software 16 version. Time for rescue analgesia was shorter in Group B (6.7 hour) than in Group R (9.47 hour) (p = 0.00). VAS was lower in Group R. Higher dose of analgesics was required in Group B (p=0.008). All this led to higher patient satisfaction score in Group R. This study concludes that 0.2% ropivacaine provided a longer duration of analgesia compared to 0.2% bupivacaine when used in TAP block for post-operative analgesia in LSCS deliveries.