Lateral Decubitus Position Research Articles

Optimum clear liquid quantification using point of care gastric sonography after ingestion of measured volumes of clear liquid in adult patients posted for elective surgeries: A randomized controlled study

: High mortality and morbidity as a result of gastric content aspiration in the perioperative period is common. Therefore, nature and volume of gastric content can be obtained quantitatively and qualitatively by using ultrasonography. In this study we assessed the quantity and quality of gastric content after giving measured volumes of clear liquid orally depending on the body weight, 2 hours before anaesthesia. 132 patients were randomly assigned into four groups. Patients in group A received 0 mL kg-1, group B received 5 mL kg-1, group C received 8 mL kg-1 and group D received 10 mL kg-1 of clear liquid orally 2 hours prior to anaesthesia. Residual volume and content in the gastric antrum were observed by using ultrasonography after 2 hours in both supine and right lateral decubitus position. In our study, 100% of patients in group A, 97% of patients in group B, 81.8% of patients in group C and 69.7% of patients in group D revealed grade 0 antrum (empty stomach) with P value <0.05. Remaining patients showed grade 1 (empty only in supine) and grade 2 antrum (not empty in both supine and right lateral decubitus) with liquid as their main gastric content respectively. Majority of patients showed empty stomach after administration of clear fluids given orally upto 5 mL kg-1 2 hours prior to anaesthesia.

Safety and technical performance of bilateral decubitus CT myelography using standard versus increased intrathecal iodinated contrast volume.

Lateral decubitus CT myelography (LDCTM) is one of the main studies for the detection of CSF-venous fistulas (CVF), but detection of CVFs is dependent on intrathecal contrast density. The purpose of this investigation was to assess tolerability and technical performance of increased intrathecal doses of myelographic contrast compared to standard doses. Retrospective series of 24 patients who underwent LDCTM following administration of either 10 or 20 ml of intrathecal iodinated contrast media (300 or 320mg/mL iodine content). Patients were scanned in the initial lateral decubitus position, then turned to the contralateral side and re-scanned in the same session. Safety and tolerability of the 20 ml dosage was assessed from clinical records. Technical performance of the studies was compared between groups by measuring attenuation values over the lateral thecal sac at standardized levels. Both the initial scan and the scan after turning to the contralateral side were assessed. No moderate or severe adverse event was recorded in either group. The 20-ml group showed higher attenuation values, which were statistically greater on the second side examined compared to the standard-dose group. Increased volume of intrathecal contrast was well-tolerated and improved technical performance of LDCTM in this limited series. Further assessment of safety and impact on diagnostic yield using larger patient cohorts is warranted. LDCTM = lateral decubitus CT myelography; CVF = CSF-venous fistula; IOCM = iodinated contrast media.

Assessing Full Stomach Prevalence with Ultrasound Following Preoperative Fasting in Diabetic Patients with Dysautonomia: A Comparative Observational Study.

Traditionally, diabetics have been considered patients with a high risk of aspiration due to having delayed gastric emptying; However, the evidence concerning residual gastric volume (GV) in fasting diabetic patients is inconsistent. This study aimed to compare the fasting GV of diabetic patients with or without dysautonomia with control patients scheduled for elective surgery using gastric ultrasound. This bicentric prospective single-blinded case-control study was conducted at 2 university hospitals in Spain. Patients aged over 18 years, classified as American Society of Anesthesiologists (ASA) physical statuses I to III and having similar fasting statuses, were included in the study. The primary outcome was to compare the prevalence of risk stomach using the Perlas gastric content grading scale evaluated by ultrasound in the 3 groups. Secondary outcomes included the measurement of cross-sectional area (CSA) and GV in the right lateral decubitus (RLD) position, as well as the prevalence of solid gastric residue. A total of 289 patients were recruited for the study, comprising 145 diabetic patients (83 of whom had dysautonomia) and 144 patients in the control group. The percentage of patients classified as Perlas grade 2 was 13.2% in the control group, 16.1% in diabetic patients without dysautonomia, and 22.9% in diabetic patients with dysautonomia (P = .31). Antral CSA was significantly higher in diabetic patients with dysautonomia (6.5 [4.8-8.4]) compared to the control group (5.4 [4.0-7.2]; P = .04). However, no significant differences were observed between groups in residual GV. Among diabetic patients with dysautonomia, 12% exhibited solid gastric residue, which was twice the percentage observed in diabetic patients without dysautonomia (4.8%) and 3 times higher than that in the control group (3.5%; P = .03). The presence of dysautonomia was associated with an increased odds ratio of solid gastric residue (odds ratio [OR], 3.37; 95% confidence interval [CI], 1.28-8.87; P = .01) after adjusting for confounding factors. This study offers insights into the relationship between dysautonomia in patients with diabetes mellitus and the presence of full stomach, underscoring the significance of preoperative gastric ultrasound evaluation in managing perioperative risks in this population.

Effect of pericapsular nerve group block on perioperative analgesia characteristics for hip fracture operations

Aims: Pericapsular nerve group (PENG) block is a new regional analgesia technique that has recently been used for perioperative analgesia for hip fracture operations. The purpose of this research was to examine the perioperative analgesic characteristics of PENG block in patients who were going to undergo spinal anesthesia for a hip fracture procedure. Methods: The study was conducted as a prospective randomized controlled study between February 2021 and May 2021 after ethics committee approval. Patients with consent were included in the study. The patients were randomly divided into two groups (Group-I and Group-II). Patients in Group I underwent a PENG block with a 0.25% concentration of 20 cc bupivacaine in the preoperative waiting room 30 minutes before the operation. Afterward, spinal anesthesia was applied in the operating room. The patients in Group II received only spinal anesthesia. Preoperative visual analog scale (VAS) scores were recorded for both groups in the preoperative period. ECG, arterial blood pressure, pulse, and oxygen saturation measurements were performed in all patients preoperatively, intraoperatively, and postoperatively. Pulse, arterial blood pressure, oxygen saturation measurements, and VAS scores were recorded in the lateral decubitus position before and at the 5th minute after spinal anesthesia. In addition, the comfort of the anesthetist who will administer the spinal anesthesia during the application was questioned (0: poor, 1: moderate, 2: good, 3: very good). All patients 5 min after spinal anesthesia It remained in the lateral position for the duration. VAS scores were recorded during the postoperative phase at the 0th, 2nd, 8th, 16th, and 24th hours, along with the time of the first analgesic administration. The total amount of tramadol and paracetamol taken during the first 24 hours following surgery was noted. Results: Patients; gender, age, body weight, height, BMI, and ASA values were statistically similar (p > 0.05). In comparisons between the groups; During position, postoperative 2nd, 8th, 16th, 24th hours, and their sum, VAS values were found to be statistically lower in Group-I (p < 0.05). While it was found that the first analgesic administration time was statistically longer in Group-I patients (p < 0.001), the amounts of paracetamol and tramadol consumed in the first 24 hours were found to be statistically lower (p < 0.001). In addition, the comfort of the anesthetist during spinal anesthesia was found to be better in Group-I (p: 0.014). Conclusion: PENG block can be used effectively as a part of perioperative multimodal analgesia in hip fracture surgery. PENG can reduce the pain levels of patients with hip fractures as well as reduce the need for additional analgesia. It also increases the comfort of the anesthetist who will administer regional anesthesia.

Posterior Malleolus Fracture Fixation In Lateral Decubitus Position: Surgical Technique and Results in 60 Patients

The present study shows how posterior malleolus fractures (PMFs) and distal fibular fractures were fixed using the posterolateral approach with the patient in lateral decubitus position, not previously described in the literature. This technique has been used in 60 consecutive patients (42 women and 18 men; mean age 54.7; range 21-92 years), 33 of which presented as fracture dislocations from March, 2021 to December, 2023. After PMFs fixation in lateral decubitus position, release of the sacral support allowed patients to be placed supine (without de-sterilizing the operative field), in order to proceed with medial malleolus or posteromedial fragment fixation. Fractures were classified according to the Lauge Hansen classification as SER4 (n = 50), PER4 (n = 7), SAD (n = 1), and PAB (n = 2). Fractures were classified according to Rammelt & Bartonicek, as type B (n = 40), C (n = 13), and D (n = 7). During the same period of time 14 fractures involving the PM, classified as type A, were treated with indirect fixation, whilst 6 geriatric and/or poor mobility patients with fracture dislocations were treated with retrograde hindfoot nail fixation. Follow-up period ranged from 4-36 months (mean = 14.4; SD = 8.8). Complications occurred in 5 patients (8.3%; 3 had delayed (medial) wound healing, one developed CRPS and one required implants removal and arthroscopy because of metal irritation and stiffness). No deep infections, thromboembolic events, fracture malreductions or malunions were recorded and all patients returned to the preinjury mobilization status. In conclusion, PM fracture fixation was feasible and safely performed with patients in lateral decubitus position.

Developing novel non-assistant help operation in dual-portal robotic-assisted thoracic surgery (neoDRATS)

ObjectiveTo introduce and evaluate the non-assistant help operation in dual-portal robotic-assisted thoracic surgery (neoDRATS), a novel technique designed to eliminate the need for skilled assistants by using all 4 robotic arms independently during anatomical lung surgery. MethodsPatients were placed in the lateral decubitus position under general anesthesia with single-lung ventilation. The da Vinci Xi Surgical System was used, with specific configurations for right- and left-side operations. The neoDRATS technique used a 4-cm working port and a 1.8-cm secondary port, with detailed guidelines for optimal setup and robotic arm manipulation. ResultsThe neoDRATS approach demonstrated successful surgical outcomes without the need for a skilled assistant. The use of a 0° camera and careful placement of instruments minimized interference within the thoracic cavity. The technique provided smooth operability and minimized postoperative discomfort. Video demonstrations of right and left upper lobectomies are provided to illustrate the approach. ConclusionsNeoDRATS offers a practical, safe, and minimally invasive alternative to conventional multiportal and uniportal robotic-assisted thoracic surgeries. This technique simplifies the surgical process, particularly in settings with limited availability of skilled assistants, and represents a significant advancement in robotic thoracic surgery. Further refinement and clinical integration of neoDRATS are anticipated as robotic innovations continue to evolve.

Arthroscopic Remplissage Before Bankart Repair With All-Suture Anchor Mattress Fixation in the Beach-Chair Position

A common procedure for treatment of Hill-Sachs lesions in the setting of anterior shoulder instability is arthroscopic remplissage. Remplissage consists of using the posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion and convert it into an extra-articular defect. Previous versions of this technique have not specified the timing in which remplissage and Bankart repair occur and have been performed with the patient in the lateral decubitus position. In this Technical Note, we describe our technique where we perform the remplissage before Bankart repair using all-suture anchor mattress fixation with the patient in the beach-chair position. By performing the remplissage before Bankart repair, the shoulder is reduced to allow for easier execution of the remplissage and reduce difficulties that might prevent its completion if done after Bankart repair. Further, by completing remplissage before Bankart repair in the beach-chair position, the humeral head is moved posteriorly with the cuff to allow for better access for the following labral repair and allows for the standardization between arthroscopic and open shoulder instability management.

Surgical management of iSGS in pregnant patients: Survey among North American expertise centers

ObjectiveTo identify, group and document the surgical management of idiopathic subglottic stenosis (iSGS) in pregnant women among North American centers with expertise in the treatment of airway stenosis. BackgroundIdiopathic subglottic stenosis is a rare airway disease that primarily affects women in their third to fifth decade of life. Symptoms of iSGS often worsen during pregnancy and can present as a threat to optimal maternal and fetal health; however there is a lack of evidence addressing the management of iSGS in pregnancy. Study designCross-Sectional Survey Study. MethodsA twenty-four question survey was designed to query the surgical management, ventilation, and perioperative considerations for pregnant patients with iSGS. Twenty-nine North American academic tertiary care centers with airway surgery expertise were identified. A designated surrogate for each center was contacted by email to distribute and obtain results of the survey. Results17 centers responded. Most centers include differences in perioperative assessment such as frequency of consultation with a maternal/fetal medicine specialist. There is occasional use of a tocometer and rarely a non-stress test. Ventilation with intermittent jet ventilation or high-flow nasal cannula is favored. The surgical protocols include positional modifications, with pregnant patients in the left lateral decubitus position. The preferred timing for intervention is in the second or third trimester. ConclusionThis is the first national survey describing surgical and perioperative considerations for the pregnant patient with iSGS among centers with airway expertise in the United States and Canada.

Clinical Outcomes of Prone Transpsoas Lumbar Interbody Fusion: A 1-Year Follow-Up.

Lateral lumbar interbody fusion (LLIF) is commonly used to address various lumbar pathologies. LLIF using the prone transpsoas (PTP) approach has several potential advantages, allowing simultaneous access to the anterior and posterior columns of the spine. The aim of this study was to report the 1-year outcomes of LLIF via PTP. This is a retrospective review of 97 consecutive patients who underwent LLIF via PTP. Radiographic parameters, including lumbar-lordosis, segmental-lordosis, anterior disc height, and posterior disc height, were measured on preoperative, initial-postoperative, and 1-year postoperative imaging. Patient-reported outcomes measures, including Oswestry Disability Index, visual analog scale (VAS), pain EQ5D, and postoperative complications, were reviewed. Ninety-seven consecutive patients underwent 161 levels of LLIF. Fifty-seven percent underwent 1-level LLIF, 30% 2-level LLIF, 6% 3-level LLIF, and 7% 4-level LLIF. The most common level was L4 to L5 (35%), followed by L3 to L4 (33%), L2 to L3 (21%), and L1 to L2 (11%). Significant improvements were noted at initial and 1-year postoperative periods in lumbar-lordosis (2° ± 10°, P = 0.049; 3° ± 9°, P = 0.005), segmental-lordosis (6° ± 5°, P < 0.001; 5° ± 5°, P < 0.001), anterior disc height (8 mm ± 4 mm, P < 0.001; 7 mm ± 4 mm, P < 0.001), and posterior disc height (3 mm ± 2 mm, P < 0.001; 3 mm ± 2 mm, P < 0.001). Significant improvements were seen in Oswestry Disability Index at 6 weeks (P = 0.002), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively; pain EQ5D at 6 weeks (P < 0.001), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively; and leg and back visual analog scale at 2 weeks (P < 0.001), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively. The average length of stay was 2.5 days, and the most common complications were ipsilateral hip flexor pain (46%), weakness (59%), and contralateral hip flexor pain (29%). PTP is a novel way of performing LLIF. These 1-year data support that PTP is an effective, safe, and viable approach with similar patient-reported outcome measures and complications profiles as LLIF performed in the lateral decubitus position.

STUDY TO COMPARE FASTING GASTRIC VOLUME USING ULTRASOUND IN DIABETIC AND NON DIABETIC PATIENTS POSTED FOR ELECTIVE SURGERIES

Objective: To study the comparison of fasting gastric volume using ultrasound in diabetic and nondiabetic patients in elective surgeries. To compare the incidence of delayed gastric emptying in diabetic and nondiabetic after standard fasting guidelines Material and Methods: After institutional ethical committee approval, CTRI registration and patient consent, prospective study was conducted in 30 diabetic and 30 non-diabetic patients aged 30-60years of American society of anesthesiologists- physical status I-III having similar fasting intervals. Pre operatively, quantitative assessments of gastric antrum in supine and right lateral decubitus (RLD) positions were performed using curvilinear probe in accordance to standard gastric scanning. USG grade, cross-sectional area (CSA) of the antrum and gastric volume were calculated. The gastric antrum was classified as Grade 0, 1 or 2, signifying empty antrum, fluid in RLD position only and antral fluid in both supine and RLD positions, respectively. Results:The CSA of 2.35 ± 1.07 cm2 and 3.51 ± 1.4 cm2 in diabetic were significantly higher (P = 0.001) than 1.37 ± 0.32 cm2 and 2.19 ± 1.15 cm2 of control, in supine and RLD positions, respectively. GV was 3.85± 20.06 ml in control group and 6.5±23.51 ml in diabetic group. Conclusion: Diabetic patients have higher gastric antral cross-sectional area and gastric volumes as observed by gastric ultrasound than the non-diabetic patients. Reference - 1. Robinson M, Davidson A. Aspiration under anaesthesia: Risk assessment and decision-making. Contin Edu Anaesth Crit Care Pain. 201314:171–5. 2.Perlas A, Chan VW, Lupu CM, Mitsakakis N, Hanbidge A. Ultrasound assessment of gastric content and volume. Anesthesiology. 2009111:82–9. 3. Smith I, Kranke P, Murat I, Smith A, OSullivan G, Soreide E, et al. Perioperative fasting in adults and children: Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 201128:556–69.

Rapid alleviation of perioperative airway obstruction through positional adjustments in a patient with a giant anterior mediastinal mass: A case report

Rationale: This case describes the rapid resolution of acute airway obstruction after anesthesia induction in a young man with a massive 12.7 × 9 × 12 cm anterior mediastinal tumor. It emphasizes the remarkable effectiveness of positional adjustments in immediately alleviating airway compression caused by large mediastinal masses. The crisis was resolved quickly and without invasive measures through only positional tactics, without the need for emergency invasive interventions. This highlights the decisive role of strategic patient positioning as a primary technique for perioperative management of mediastinal masses, ensuring adequate ventilation and preventing catastrophic outcomes. Patient concerns: Due to the unique anatomical location of mediastinal tumors, the anesthesia risks for patients with mediastinal tumors are very high. These tumors can cause airway compression, leading to severe cardiovascular dysfunction and even mortality during general anesthesia. Diagnoses: Combining the patient’s medical history, symptoms and signs, fiberoptic bronchoscopy and excluding other causes, it was confirmed that the tumor compressed the airway and blocked the airway. Interventions: Ventilation was rapidly improved by adjusting the patient’s position, ultimately to the left lateral decubitus position with head-up tilt. Outcomes: Through positional adjustment, the patient’s airway obstruction symptoms rapidly improved. Airway pressure decreased significantly, end-tidal carbon dioxide returned to 40 mm Hg, and oxygen saturation increased to 95%. The mediastinal tumor was ultimately successfully resected. The surgical procedure went smoothly with successful extubation on the first postoperative day. The patient had a smooth recovery and was discharged on the seventh postoperative day without any lingering postoperative complications. Lessons: This case provides an important educational illustration of how mediastinal mass patients can develop sudden catastrophic airway obstruction after induction despite being asymptomatic preoperatively. It demonstrates an effective crisis rescue technique through positioning that may help inform management of similar high-risk cases.

Effect of patient position on the success rate of placing triple-cuffed double lumen endotracheal tubes: a two-center interventional observational study.

Double-lumen endotracheal tubes (DLT) are essential for one-lung ventilation during thoracic surgery. Bronchoscopy is crucial for correct placement of a DLT to avoid complications such as hypoxemia. This study evaluated the effectiveness of the triple-cuffed DLT (tcDLT) in the supine and lateral positions for correct placement without bronchoscopic guidance. This prospective observational study included 167 patients scheduled for elective thoracic surgery requiring one-lung ventilation. The incidence of successful placement of left-sided tcDLTs was compared between the supine and lateral decubitus positions under bronchoscopic surveillance. Successful tcDLT placement was defined as the placement of the proximal end of the bronchial cuff within 5 mm of the carina. Among 153 patients who completed the study, the successful tcDLT placement rate in the lateral position (70.6%) was significantly higher than that in the supine position (50.3%). The rate of difference was 20.3% (95% confidence interval [CI], 10.6-29.9%). The extended successful placement rate, including slightly deeper placements, showed no significant differences between the positions (88.9%; 95% CI, 83.9‒93.9% in supine, 86.3%; 95% CI, 80.8‒91.7% in lateral). tcDLT facilitates correct tube placement in both the supine and lateral positions, with a higher lateral success rate. This finding supports the idea that tcDLTs offer a reliable alternative for lung separation when bronchoscopy is not feasible.

Effects of starting one lung ventilation and applying individualized PEEP right after patients are placed in lateral decubitus position on intraoperative oxygenation for patients undergoing thoracoscopic pulmonary lobectomy: study protocol for a randomized controlled trial

BackgroundFor patients receiving one lung ventilation in thoracic surgery, numerous studies have proved the superiority of lung protective ventilation of low tidal volume combined with recruitment maneuvers (RM) and individualized PEEP. However, RM may lead to overinflation which aggravates lung injury and intrapulmonary shunt. According to CT results, atelectasis usually forms in gravity dependent lung regions, regardless of body position. So, during anesthesia induction in supine position, atelectasis usually forms in the dorsal parts of lungs, however, when patients are turned into lateral decubitus position, collapsed lung tissue in the dorsal parts would reexpand, while atelectasis would slowly reappear in the lower flank of the lung. We hypothesize that applying sufficient PEEP without RM before the formation of atelectasis in the lower flank of the lung may beas effective to prevent atelectasis and thus improve oxygenation as applying PEEP with RM.MethodsA total of 84 patients scheduled for elective pulmonary lobe resection necessitating one lung ventilation will be recruited and randomized totwo parallel groups. For all patients, one lung ventilation is initiated the right after patients are turned into lateral decubitus position. For patients in the study group, individualized PEEP titration is started the moment one lung ventilation is started, while patients in the control group will receive a recruitment maneuver followed by individualized PEEP titration after initiation of one lung ventilation. The primary endpoint will be oxygenation index measured at T4. Secondary endpoints will include intrapulmonary shunt, respiratory mechanics, PPCs, and hemodynamic indicators.DiscussionNumerous previous studies compared the effects of individualized PEEP applied alone with that applied in combination with RM on oxygenation index, PPCs, intrapulmonary shunt and respiratory mechanics after atelectasis was formed in patients receiving one lung ventilation during thoracoscopic surgery. In this study, we will apply individualized PEEP before the formation of atelectasis while not performing RM in patients allocated to the study group, and then we’re going to observe its effects on the aspects mentioned above. The results of this trial will provide a ventilation strategy that may be conductive to improving intraoperative oxygenation and avoiding the detrimental effects of RM for patients receiving one lung ventilation.Trial registrationwww.Chictr.org.cn ChiCTR2400080682. Registered on February 5, 2024.

Preoperative gastric volume assessment using ultrasound in cerebral palsy pediatric patients: a prospective observational study

BackgroundAlthough cerebral palsy is a risk factor for aspiration, there is insufficient research on residual gastric volume after preoperative fasting in children with cerebral palsy. We evaluated the incidence of a full stomach by ultrasound assessment of the gastric volume in children with cerebral palsy who underwent orthopedic surgery after preoperative fasting. MethodsThe patients fasted for 8 h for solid foods and 2 h for clear liquids. We obtained the gastric antral cross-sectional area using ultrasound in the semi-recumbent and right lateral decubitus positions. A calculated stomach volume > 1.5 mL.kg−1 was considered as full, which poses a high aspiration risk. The primary outcome was the incidence of full stomach, and the secondary outcomes were the qualitative gastric volume, correlation of disease severity categorized according to the Gross Motor Function Classification System with the residual gastric volume, gastric volume per body weight, and qualitative gastric volume. ResultsThirty-seven pediatric patients with cerebral palsy, scheduled for elective orthopedic surgery, were included for analysis. Full-stomach status was observed in none, and the gastric volume per body weight was 0.5 (0.4–0.7) mL.kg−1. No significant differences were observed in the residual gastric volume (p = 0.114), gastric volume per body weight (p = 0.117), or qualitative grade of gastric volume (p = 0.642) in relation to disease severities. ConclusionChildren with cerebral palsy who fasted preoperatively had empty or nearly empty stomachs. Further studies are required to determine the optimal fasting duration for such children.

Relationship between epidural catheter migration beneath the skin and subcutaneous fat thickness assessed using postoperative CT imaging: a retrospective cross-sectional study.

The causes of epidural catheter migration beneath the skin have not been previously investigated. We hypothesized that greater subcutaneous fat thickness might be associated with increased catheter migration beneath the skin. We conducted a retrospective cross-sectional study of patients who had undergone combined general and epidural anesthesia, selecting individuals who received thoracic and abdominal CT scans within the first 5 postoperative days. Needle depth was defined as the distance from the needle tip to the skin surface when the anesthesiologist determined that the needle tip had reached the epidural space. We measured the length of the epidural catheter from the skin surface to the epidural space (catheter length), and subcutaneous fat thickness (fat thickness) using CT imaging. Migration distance was calculated by subtracting needle depth from catheter length. We analyzed 127 patients (72 males), all undergoing epidural catheter insertion in the left lateral decubitus position via a paramedian approach. The median age of the patients was 71years. Epidural catheters were postoperatively found to substantially curve beneath the skin. Regression analysis revealed no significant influence of fat thickness on catheter length (regression coefficient 0.10, 95% confidence interval [CI]: - 0.17, 0.38). However, it indicated a positive correlation between fat thickness and needle depth (regression coefficient 0.50, 95% CI: 0.30, 0.70), and a negative correlation between fat thickness and migration distance (regression coefficient - 0.40, 95% CI: - 0.65, - 0.14). We found a negative correlation between epidural catheter migration beneath the skin and subcutaneous fat thickness. Anesthesiologists should be aware of the possibility of substantial subcutaneous curving of the catheter, especially in patients with scant subcutaneous fat.

Comparison of Post-Operative Analgesia of Caudal versus Dorsal Penile Nerve Blocks for Pediatric Patients Undergoing Hypospadias Repair

Abstract Background Hypospadias is the second most common congenital disorder in males after cryptorchidism, but it is the most common penile congenital malformation. It is an abnormality of anterior urethral and penile development in which the urethral opening is ectopically located on the ventral aspect of the penis proximal to the tip of the glans penis, which, in this condition, is splayed open. The urethral opening may be located as far down as in the scrotum or perineum. The penis is more likely to have associated ventral shortening and curvature, called chordee, with more proximal urethral defects. Aim of the Work The aim of this study is to compare the effectiveness of penile block versus caudal block using bupivacaine on the quality of analgesia after hypospadias repair in pediatrics. Methodology This prospective randomized comparative clinical study was conducted in Ain Shams University Hospitals; Pediatric Surgery Unit. It included 30 male patient aged (1–8) years, ASA I or II patients undergoing hypospadias (distal penile and mid penile) repair. They were divided into two groups: Group P: Penile block (n = 15) received dorsal penile nerve block by using the subpubic approach technique. Group C: Caudal block (n = 15) received caudal epidural block using a 22-G needle in the lateral decubitus position. Results There was statistically high significant difference between the two groups in postoperative MAP and HR (p value &amp;lt;0.001) but no statistically significant difference between them in Spo2. FLACC pain scores were significantly lower in group C compared with group P at PACU and 3 hours postoperative (p value &amp;lt;0.001) but no statistically significant difference between them at 6, 9 and 12 hours postoperative. Also, The time for first rescue analgesia was significantly longer in caudal group compared with penile group (P &amp;lt; 0.001) and the total analgesia consumption was also significantly lower (P &amp;lt; 0.001) in group C compared with group P. Postoperative time of ambulation was significantly lower (P &amp;lt; 0.001) in group P compared with group C. Conclusion The current study revealed that Caudal block provided significantly prolonged postoperative analgesia, reduced the postoperative analgesic requirements and prolonged time of ambulation as compared with Penile block in pediatric patients undergoing hypospadias repair.

Olecranon Osteotomy Exposure for Distal Humeral Fracture Treatment.

Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing1. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques1,2. The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular "bare area" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner. Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate. The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures1-3. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches3. OO has not been associated with triceps weakness, unlike some of the alternative techniques2. The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures4. Osteotomies united in all patients in 2 reported series, totaling 84 cases1,2. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients1,2. Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the OO because of its natural lack of cartilage5,6. This non-articular bare area is located just distal to the deepest portion of the trochlear notch, approximately 2 to 2.5 cm distal to the olecranon tip5,6.An (apex-distal) chevron osteotomy angle of ∼130° will help to keep the osteotomy within the non-articular bare area6.Beginning on the dorsal surface of the ulna, directly posterior to the bare area, an oscillating saw is utilized to create a chevron osteotomy to subchondral bone, perpendicular to the long axis of the ulna5,6.The OO is completed by fracturing through the osteochondral surface, which leaves an irregular chondral cancellous surface that can accurately interdigitate. This facilitates later reduction and stability of the osteotomy.Anatomic articular reduction of the OO is not solely judged on the dorsal cortical bone because of the kerf removed by the saw blade. Instead, examination of the articular surface of the trochlear notch is the primary assessment of reduction.Placement of suture through the proximal portion of the plate aids in the repair of the longitudinal split of the distal triceps.Successful treatment of distal humeral fractures requires accurate reduction and rigid fixation aided by adequate exposure achieved through OO. ORIF = open reduction and internal fixationOT = occupational therapyHWR = hardware removalK-wire = Kirschner wireROM = range of motion.

Application of modified Frosch approach for Schatzker typeⅡtibial plateau fractures with posterolateral column

To explore clnical efficacy of modified Frosch approach for Schatzker typeⅡtibial plateau fracture with posterolateral column. From January 2019 to September 2020, totally 11 patients with Schatzker typeⅡtibial plateau fractures with posterolateral column were treated, including 7 males and 4 females, aged from 21 to 49 years old. Modified Frosch approach was adopted for lateral decubitus position, and posterolateral fractures were fixed with support plates or posterolateral screws. Anterolateral fixation with conventional tibial plateau lateral locking plate. Tibial plateau varus angle and posterior inclination angle were measured by X-ray immediately and 12 months after operation, as well as knee motion at 12 months after operation. Knee function at 12 months after operation was evaluated by knee score of Hospital for Special Surgery(HSS). Eleven patients were followed up for 12 to 15 months. Varus angle and inclination angle at immediately after operation ranged from 76° to 86° and 6° to 10°, respectively, and 79° to 88° and 6° to 10°, respectively at 12 months after operation. The range of extension of knee ranged from 0° to 5°, and flexion was 106° to 137° at 12 months after operation. Postoperative HSS knee score at 12 months ranged from 74 to 94 scores, 8 patients were excellent and 3 good. Modified Frosch approach is an effective surgical method for Schatzker typeⅡtibial plateau fracture with posterolateral column. A single incision is used to complete fracture exposure and fixation at two sites, avoiding use of combined incisions, and could obtain good postoperative knee joint function. During operation, popliteal fossa structure should be familiar, and the common peroneal nerve should be protected to avoid injury.

Prevalence of Aspiration Risk due to a Full Stomach Assessed by Gastric Ultrasonography in Diabetic Patients Undergoing Non-Emergency Surgery

Background: Pulmonary aspiration causes severe complications and high mortality, especially in diabetic patients during the perioperative period. Gastric ultrasonography is able to detect a patient with full stomach that poses high risk of pulmonary aspiration. However, in Thailand, there is no previous prevalence study. Objective: To study the prevalence of aspiration risk resulting from full stomach in diabetic patients during non-emergency surgery and to identify related risk factors using gastric ultrasonography. Materials and Methods: One hundred nineteen diabetic patients were enrolled between July 2021 and January 2022. A preoperative ultrasound examination of gastric content was performed in the right lateral decubitus position. Aspiration risk due to full stomach was defined as having solid contents or fluid volume more than 1.5 mL/kg. The associated risk factors were analyzed using multiple logistic regression models. Results: The prevalence of aspiration risk due to “full stomach” was 18.49% (22 out of 119 patients). Age between 65 and 84 years old (adjusted OR 015, 95% CI 0.04 to 0.54) and blood urea nitrogen (BUN) levels (adjusted OR 1.04, 95% CI 1.00 to 1.08) were statistically significantly associated risk factors (p&lt;0.05). There was no incidence of pulmonary aspiration during the study period. Conclusion: While diabetic patients were advised to follow standard fasting guidelines, the risk of pulmonary aspiration persisted. Implementing an anesthetic plan as though the patient belonged to the “full stomach” group helped ensure the patient’s safety. Additionally, preoperative gastric ultrasound assessment is able to detect “full stomach” condition, thereby, further reducing the incidence of pulmonary aspiration.

A comparative study using gastric ultrasound to evaluate the safety of shortening the fasting time before pediatric echocardiography: a randomized controlled non-inferiority study.

The objective of this study was to demonstrate that the gastric cross-sectional area (CSA) in the right lateral decubitus position (RLDP) during a 2-h fasting period is not larger than that during a conventional 4-h fasting period prior to pediatric echocardiography. 93 patients aged under 3years scheduled for echocardiography under sedation were enrolled and randomly allocated into two groups; 2-h fasting vs 4-h fasting. For group 4h (n = 46), the patients were asked to be fasted for all types of liquid for more than 4h, while group 2h (n = 47) were asked to be fasted for all types of liquid for 2h before echocardiography. Gastric ultrasound was performed before echocardiography, and CSARLDP was measured. We compared CSARLDP, incidence of at-risk stomach, fasting duration, and the incidence of major (pulmonary aspiration, aspiration pneumonia) and minor complications (nausea, retching, and vomiting, apnea, and bradycardia) between two groups. The mean difference of CSARLDP (group 2h-group 4h) was 0.49 (-0.18 to 1.17) cm2, and it was within the non-inferiority margin (Δ = 2.1 cm2). There was no difference in the incidence of at-risk stomach (P = 0.514). There was no significant difference in the incidence of major and minor complications between the two groups. Two-hour fasting in pediatric patients who need an echocardiography did not increase major and minor complications and CSA significantly.