Lateral Recumbent Position Research Articles

Lung Ultrasonography to Diagnose Transient Tachypnea of the Newborn.

This study explored the sensitivity and specificity of ultrasound for diagnosing transient tachypnea of the newborn (TTN). Ultrasound was performed by one export. Patients were placed in a supine, lateral recumbent, or prone position. The probe was placed perpendicular or parallel to the ribs, and each region of the lung was scanned. The scan results were compared with conventional chest radiographic results. A total of 1,358 infants were included in this study. We identified 412 cases without pulmonary diseases, 228 TTN cases, 358 respiratory distress syndrome (RDS) cases, 85 meconium aspiration syndrome (MAS) cases, 215 infectious pneumonia cases, and 60 other cases. The primary ultrasonic characteristic of TTN was pulmonary edema. "White lung" or a "compact B-line" were only observed in severe cases, whereas TTN primarily presented as pulmonary interstitial syndrome or "double lung point." Furthermore, double lung point could appear during the recovery period of severe TTN or RDS, MAS, and pneumonia. Lung consolidation with air bronchograms was not observed in TTN patients. The results showed that white lung or a compact B-line exhibited a sensitivity of 33.8%and a specificity of 91.3%in diagnosing TTN, whereas double lung point exhibited a sensitivity of 45.6%and a specificity of 94.8%in diagnosing severe TTN. Pulmonary edema, alveolar-interstitial syndrome, double lung point, white lung, and compact B-line are the primary ultrasound characteristics of TTN. Ultrasonic diagnosis of TTN based on these findings is accurate and reliable. TTN can be ruled out in the presence of lung consolidation with air bronchograms.

Challenges in the Caesarean Section of a Severely Kyphotic Parturient.

Caesarean section in a severely kyphotic patient presents with unique challenges. We report a case of obstructed labor in case of a pregnant lady with severe kyphosis of spine that was managed by caesarean section. Lateral recumbent position with adequate assistance and paramedian or vertical skin incision was used and found to provide good exposure. Baby was delivered by lower segment uterine incision by reverse breech extraction. Postpartum hemorrhage was managed with uterotonics and bilateral uterine artery ligation. Tubal ligation though advised was refused by the patient. Prolonged catheterization was done in view of obstructed labor. Postoperative period was uneventful.

Entrenamiento en punción lumbar utilizando estrategias educativas de simulación. Experiencia en una residencia de clínica pediátrica

Pediatricians should acquire multiple skills during their professional training, including procedural skills. Skill acquisition requires knowledge on theoretical bases, direct observation and, lastly, supervised repetitive practice. Training using simulators allows to learn procedures in a controlled setting, ensuring patients' safety, integrating this as a learning stage prior to the actual contact with patients. Here we report on the teaching experience of a simulated lumbar puncture procedure. Training was provided to 112 first year pediatric residents who entered Hospital Prof. Dr. Juan P. Garrahan in the 2013-2014 period. Educational contents included communication with parents regarding the procedure, material preparation, compliance with biosafety standards, sepsis and general patient care, puncture and subsequent cerebrospinal fluid collection, and specimen collection. Strategies included, in a sequential order, the introduction of theoretical aspects using the bibliography and audiovisual resources available at the hospital's online campus and subsequent practice of lumbar puncture in a 3-month-old infant phantom on a lateral recumbent position that allowed to make a puncture and collect cerebrospinal fluid. At each training session, the level of confidence was measured before and after the procedure, and a checklist was developed to verify an adequate compliance with each step of the procedure. The simulated lumbar puncture training model has been introduced as an educational strategy of our Pediatric Residency Program.

O62. Use of diuretics in the management of late-onset preeclampsia

Introduction Hemodynamic examinations revealed high cardiac output (CO) in a portion of preeclamptic patients. These cases in our study population met the criteria for late-onset subtype of the disease as hypertension and proteinuria appeared beyond the 33rd gestational week. Objectives To decrease enormously high blood volume, as the possible reason for hypertension and edema, diuretics were applied in preeclamptic women with high CO, and edema. Methods After a short rest on the left lateral recumbent position, blood pressure (BP), and, by the use of impedance cardiography, CO and systemic vascular resistance (SVR) were determined. In the absence of relative hemoconcentration (hematocrit 37 l/l) 40 mg of furosemide was administrated orally in 10 cases. Examinations were repeated after 60 minutes of rest. Looking for the effects of the diuretics identical data (before and after furosemide medication) were compared by paired t -test. Significant difference was determined as p 0.05. Results In most of cases furosemide administration resulted in a lowering of CO and also BP. Heart rate and SVR remained stable, therefore change of CO was due to blood volume decrease. Download : Download full-size image Conclusion Our preliminary data draw attention to the possible use of diuretics in the management of late-onset preeclampsia and support the presumption that increased water retention may play a role in the development of hypertension in late-onset gestational hypertension or preeclampsia. Our data also suggest that the pathogenesis of late-onset preeclampsia is basically different from “classical” preeclampsia characterized by low CO. *The study was supported by TAMOP 4.2.2.D-15/1/KONV-2015-0004

Selective unilateral spinal anaesthesia for outpatient knee arthroscopy using real-time monitoring of lower limb sympathetic tone.

Selective unilateral spinal anaesthesia is a useful approach for ambulatory lower limb surgery because it allows more rapid home discharge compared to bilateral block. Infrequent use is due to the fact that obtaining selective unilateral block can be difficult, requiring attention to technique. We present a method with a high success rate that uses real-time monitoring of the sympathetic activity of the legs. In this prospective study, 56 patients scheduled for ambulatory knee arthroscopy had spinal anaesthesia in the lateral recumbent position, with hyperbaric bupivacaine 0.5% injected at 0.33 ml/min up to a maximum dose of 5 mg. Sympathetic tone of the legs was monitored by plantar electrical dermal resistance. The clinical effect was assessed by loss of sensation and muscle strength. The haemodynamic course and adverse events were monitored. The motor block was strictly unilateral in 55 patients (98%) and the sensory block was strictly unilateral in 53 patients (94%). The median decrease in systolic blood pressure was 6 mmHg. The time from subarachnoid puncture to arrival in the recovery room was 73±23 minutes; the duration of stay in the recovery room was 70±30 minutes. Three patients with a well-established block of adequate extent required conversion to general anaesthesia because of tourniquet pain. Urinary retention only occurred in the sole patient with bilateral block. This method of performing selective unilateral spinal anaesthesia using real-time monitoring of sympathetic tone of the legs has a high success rate and is associated with rapid eligibility for home discharge.

Comparison of changes in tidal volume associated with expiratory rib cage compression and expiratory abdominal compression in patients on prolonged mechanical ventilation.

[Purpose] This study was designed to compare and clarify the relationship between expiratory rib cage compression and expiratory abdominal compression in patients on prolonged mechanical ventilation, with a focus on tidal volume. [Subjects and Methods] The subjects were 18 patients on prolonged mechanical ventilation, who had undergone tracheostomy. Each patient received expiratory rib cage compression and expiratory abdominal compression; the order of implementation was randomized. Subjects were positioned in a 30° lateral recumbent position, and a 2-kgf compression was applied. For expiratory rib cage compression, the rib cage was compressed unilaterally; for expiratory abdominal compression, the area directly above the navel was compressed. Tidal volume values were the actual measured values divided by body weight. [Results] Tidal volume values were as follows: at rest, 7.2 ± 1.7 mL/kg; during expiratory rib cage compression, 8.3 ± 2.1 mL/kg; during expiratory abdominal compression, 9.1 ± 2.2 mL/kg. There was a significant difference between the tidal volume during expiratory abdominal compression and that at rest. The tidal volume in expiratory rib cage compression was strongly correlated with that in expiratory abdominal compression. [Conclusion] These results indicate that expiratory abdominal compression may be an effective alternative to the manual breathing assist procedure.

The effect of body position on postprandial perceptions, gastric emptying, and intragastric meal distribution: An ultrasonographic study in reclining healthy subjects

Objective. Postprandial dyspepsia is common and may be associated with abnormal intragastric distribution of food. We aimed to determine the effect of body position on gastric emptying, meal distribution, and postprandial perceptions in healthy subjects. Material and methods. Eight adolescents (4 females and 4 males aged 14 years) were investigated using three-dimensional ultrasonography. The subjects were studied twice in a random order: once in the right lateral recumbent (RLR) position and once in the left lateral recumbent (LLR) position. Postprandial perceptions, gastric volumes, and antral areas were recorded immediately after the ingestion of 500 ml of a low-caloric meat soup over 4 min, and at 10 and 20 min following the meal. Results. Postprandial perceptions (epigastric pain, nausea, and fullness) were more pronounced in the RLR position compared to the LLR position, particularly at the end of the meal ingestion (p < 0.01). Gastric volumes were significantly smaller in the RLR position compared to the LLR position at 10 min (p < 0.01) and 20 min (p < 0.05). Antral areas were significantly wider in the RLR position compared to the LLR position at 10 min (p < 0.05) and 20 min (p < 0.01). Conclusion. Postprandial perceptions are more pronounced, gastric emptying is faster, and antral area is wider in the RLR position compared to the LLR position. The results suggest that lying on the left side after a meal may be a measure to reduce postprandial dyspeptic sensations.

Dynamic clinical measurements of voluntary vaginal contractions and autonomic vaginal reflexes.

The vaginal canal is an active and responsive canal. It has pressure variations along its length and shows reflex activity. At present, the prevailing idea is that the vaginal canal does not have a sphincter mechanism. It is hypothesized that an active vaginal muscular mechanism exists and might be involved in the pathophysiology of genito-pelvic pain/penetration disorder. The aim of this study was to detect the presence of a canalicular vaginal "sphincter mechanism" by measuring intravaginal pressure at different levels of the vaginal canal during voluntary pelvic floor contractions and during induced reflexive contractions. Sixteen nulliparous women, without sexual dysfunction and pelvic floor trauma, were included in the study. High-resolution solid-state circumferential catheters were used to measure intravaginal pressures and vaginal contractions at different levels in the vaginal canal. Voluntary intravaginal pressure measurements were performed in the left lateral recumbent position only, while reflexive intravaginal pressure measurements during slow inflation of a vaginal balloon were performed in the left lateral recumbent position and in the sitting position. Intravaginal pressures and vaginal contractions were the main outcome measures. In addition, a general demographic and medical history questionnaire was administered to gain insight into the characteristics of the study population. Fifteen out of the sixteen women had deep and superficial vaginal high-pressure zones. In one woman, no superficial high-pressure zone was found. The basal and maximum pressures, as well as the duration of the autonomic reflexive contractions significantly exceeded the pressures and the duration of the voluntary contractions. There were no significant differences between the reflexive measurements obtained in the left lateral recumbent and the sitting position. The two high-pressure zones found in this study, as a result of voluntary contractions and, even more pronounced, as a result of reflexive contractions on intravaginal stimulation, support the hypothesis that the vaginal canal has an active and passive canalicular sphincter mechanism. Further investigation of this sphincter mechanism is required to identify its role in the sexual response and genito-pelvic pain/penetration disorder.

자기공명검사에서 통증제어가 불가능한 급성 요통 환자의 옆으로 누운 자세에 대한 영상평가

본 연구에서는 통증제어가 거의 불가능한 급성요통 환자를 대상으로 바로 누운 자세를 할 수 없는 환자에게 불가피하게 자기공명검사를 받아야할 환자를 위해 기존촬영방법인 정상 체위 바로 누운 자세 대신 변형된 옆으로 누운 자세를 취하게 하여 기존 척추 전용 코일과 복부 전용 코일을 이용하여 요통을 경감시키고 불안정한 자세 보정과 움직임에 의한 인공물을 줄여 장시간 검사를 받는 환자에게 피로감을 감소시켜 자기공명검사의 성공률을 높이고자 한다. 평가방법으로는 영상의 질을 정성적 평가로 하였으며 결과로는 정상인 연구대상자 기존촬영방법인 바로 누운 자세의 평균 점수는 4.64점, 정상인 연구대상자 옆으로 누운 자세(A군)는 3.44점, 극심한 요통을 호소하는 비정상인 연구대상자 옆으로 누운 자세(B군)는 3.40점으로 나타났다. 결론적으로 정상인 연구대상자의 기존촬영방법인 바로 누운 자세에서 검사한 정성적인 평가는 예상대로 높게 나타났으나 정상인 연구대상자 옆으로 누운 자세와 극심한 요통을 호소하는 비정상인 연구대상자 옆으로 누운 자세로 검사한 영상의 정성적 평가는 거의 비슷하게 나타났다. 또한 극심한 요통을 호소하는 비정상인 연구대상자 옆으로 누운 자세(B군)의 영상평가에서 영상의학과 전문의의 영상판독에도 문제가 없는 것으로 나타났다. 이에 바로 누운 자세에서 검사를 진행함에 불편을 겪는 환자에게 이러한 기법이 보편화 된다면 임상에서 많이 활용될 것으로 사료된다. The acute lumbar pain patients who were unavoidable to take MRI examination were made to take altered lateral recumbent position. they were also not able to control their painfulness and to be in supine position. In this study, it is supposed to increase success rate of the MRI examination through taking the altered lateral recumbent position in using spine and body matrix coil. This altered position made relaxing lumber pain and fatigue for the patients who suffered from sever lumber pain. In these reasons, it decreases the motion artifacts through correcting uncomfortable posture. As a result, qualitative analysis for the image quality was estimated to have average points of supine position A group(lateral recumbent position) of normal candidates and B group(lateral recumbent position) of the abnormal candidates who have sever pain at 4.64, 3.44, and 3.40, respectively. In conclusion, while qualitative analysis in the examination with supine position of the normal patients had significantly high points, the qualitative analysis in the examination with lateral recumbent position of the normal patients and abnormal patients who had sever lumbar pain was almost same. In addition, it was judged that radiologists' imagery interpretation had no other problems in the image evaluation of B group who had acute lumbar pain of abnormal patients. Hereupon, if this technique becomes generalized for the patients who suffer from supine position in the examination, it is supposed to be useful in medical field.

Effects of body position and extension of the neck and extremities on lung volume measured via computed tomography in red-eared slider turtles (Trachemys scripta elegans)

To determine the effects of body position and extension of the neck and extremities on CT measurements of ventilated lung volume in red-eared slider turtles (Trachemys scripta elegans). Prospective crossover-design study. 14 adult red-eared slider turtles. CT was performed on turtles in horizontal ventral recumbent and vertical left lateral recumbent, right lateral recumbent, and caudal recumbent body positions. In sedated turtles, evaluations were performed in horizontal ventral recumbent body position with and without extension of the neck and extremities. Lung volumes were estimated from helical CT images with commercial software. Effects of body position, extremity and neck extension, sedation, body weight, and sex on lung volume were analyzed. Mean ± SD volume of dependent lung tissue was significantly decreased in vertical left lateral (18.97 ± 14.65 mL), right lateral (24.59 ± 19.16 mL), and caudal (9.23 ± 12.13 mL) recumbent positions, compared with the same region for turtles in horizontal ventral recumbency (48.52 ± 20.08 mL, 50.66 ± 18.08 mL, and 31.95 ± 15.69 mL, respectively). Total lung volume did not differ among positions because of compensatory increases in nondependent lung tissue. Extension of the extremities and neck significantly increased total lung volume (127.94 ± 35.53 mL), compared with that in turtles with the head, neck, and extremities withdrawn into the shell (103.24 ± 40.13 mL). Vertical positioning of red-eared sliders significantly affected lung volumes and could potentially affect interpretation of radiographs obtained in these positions. Extension of the extremities and neck resulted in the greatest total lung volume.

3D Computer graphics simulation to obtain optimal surgical exposure during microvascular decompression of the glossopharyngeal nerve

The affected artery in glossopharyngeal neuralgia (GPN) is most often the posterior inferior cerebellar artery (PICA) from the caudal side or the anterior inferior cerebellar artery (AICA) from the rostral side. This technical report describes two representative cases of GPN, one with PICA as the affected artery and the other with AICA, and demonstrates the optimal approach for each affected artery. We used 3D computer graphics (3D CG) simulation to consider the ideal transposition of the affected artery in any position and approach. Subsequently, we performed microvascular decompression (MVD) surgery based on this simulation. For PICA, we used the transcondylar fossa approach in the lateral recumbent position, very close to the prone position, with the patient's head tilted anteriorly for caudal transposition of PICA. In contrast, for AICA, we adopted a lateral suboccipital approach with opening of the lateral cerebellomedullary fissure, to visualize better the root entry zone of the glossopharyngeal nerve and to obtain a wide working space in the cerebellomedullary cistern, for rostral transposition of AICA. Both procedures were performed successfully. The best surgical approach for MVD in patients with GPN is contingent on the affected artery--PICA or AICA. 3D CG simulation provides tailored approach for MVD of the glossopharyngeal nerve, thereby ensuring optimal surgical exposure.

Lead II Electrocardiography in Standing and Right Lateral Recumbency in Dogs with Normal Echocardiographic Heart Chamber Values

Abstract The electrocardiographic (ECG) exam has been routinely used in veterinary cardiology with reference values available for the right lateral recumbent position. Many situations require the exam to be performed in the standing position. The study presents that the quality of the ECG recording is comparable for the standing and right lateral recumbent positions, as well as significant differences of the P, S and T waves recorded in two positions.

G134(P) Lumbar Punctures in Children: A Survey of Current Practise

AimsLumbar puncture (LP) is a common procedure in children used to diagnose infection and various neurologic processes. We want to survey current clinical practises, in terms of positioning and use...

Ultrasound-guided pleural puncture in supine or recumbent lateral position: feasibility study

Background: The aim of this study is to evaluate feasibility, safety and efficacy of accessing the pleural space with the patient supine or in lateral recumbent position, under constant ultrasonic guidance along the costophrenic sinus.&#x0D; Methods: All patients with pleural effusion, referred to thoracentesis or pleural drainage from February 2010 to January 2011 in two institutions, were drained either supine or in lateral recumbent position through an echomonitored cannulation of the costophrenic sinus. The technique is described in detail and an analysis of safety and feasibility is carried out.&#x0D; Results: One hundred and one thoracenteses were performed on 76 patients and 30 pigtail catheters were inserted in 30 patients (for a total of 131 pleural procedures in 106 patients enrolled). The feasibility of the procedures was 100% and in every case it was possible to follow real time needle tip passage in the pleural space. Ninety eight thoracenteses (97%) and all catheter drainages were successfully completed. Four thoracenteses were stopped because of the appearance of complications while no pigtail drainage procedure was stopped. After 24 hour follow up, one chest pain syndrome (1.3% of completed thoracenteses) and two pneumothoraces (1.4%) occurred. The mean acquisition time of pleural space was 76 ± 9 seconds for thoracentesis and 185 ± 46 seconds for drainage insertion (p &lt; 0.05).&#x0D; Conclusions: This study highlights the safety and efficacy of this technique of real time echo-monitored pleural space puncture, that offers a more comfortable patient position, an easier approach for the operator, a very low rate of complications with short acquisition time of pleural space.

Effect of two posture fixing in pediatric muscle injection

Objective To discuss the posture of fixing method to reduce the rate of amyxis,subcutaneous scleroma,olisthy needles,subcutaneous passive congestion and spill solution in pediatric muscle injection,so as to prevent and reduce accident injuries and complications.Methods Totals of 800 children within the age of 1 to 7 were randomly divided into the experimental group and the control group,each with 400 cases.The experimental group used embracing posture fixing while the control group used lateral recumbent posture fixing.Two groups' rates of amyxis,subcutaneous scleroma,olisthy needles,subcutaneous passive congestion and spill solution were compared.Results There were 2 cases of amyxis,0 cases of subcutaneous scleroma,1 case of otisthy needles,2 cases of subcutaneous passive congestion and l case of spill solution in the experimental group,while there were 11 cases of amyxis,7 cases of subcutaneous scleroma,9 cases of olisthy needles,11 cases of subcutaneous passive congestion and 9 cases of spill solution in the control group,and the differences were statistically significant (x2 =5.811,5.905,5.712,5.811,5.712,respectively; P ＜ 0.05).Conclusions Embracing posture has better fixing effect than traditional lateral recumbent posture in pediatric muscle injection. Key words: Children ; Posture; Muscle injection ; Fixing

Ultrasound-guided pleural puncture in supine or recumbent lateral position - feasibility study

BackgroundThe aim of this study is to evaluate feasibility, safety and efficacy of accessing the pleural space with the patient supine or in lateral recumbent position, under constant ultrasonic guidance along the costophrenic sinus.MethodsAll patients with pleural effusion, referred to thoracentesis or pleural drainage from February 2010 to January 2011 in two institutions, were drained either supine or in lateral recumbent position through an echomonitored cannulation of the costophrenic sinus. The technique is described in detail and an analysis of safety and feasibility is carried out.ResultsOne hundred and one thoracenteses were performed on 76 patients and 30 pigtail catheters were inserted in 30 patients (for a total of 131 pleural procedures in 106 patients enrolled). The feasibility of the procedures was 100% and in every case it was possible to follow real time needle tip passage in the pleural space.Ninety eight thoracenteses (97%) and all catheter drainages were successfully completed. Four thoracenteses were stopped because of the appearance of complications while no pigtail drainage procedure was stopped. After 24 hour follow up, one chest pain syndrome (1.3% of completed thoracenteses) and two pneumothoraces (1.4%) occurred. The mean acquisition time of pleural space was 76 ± 9 seconds for thoracentesis and 185 ± 46 seconds for drainage insertion (p < 0.05).ConclusionsThis study highlights the safety and efficacy of this technique of real time echo-monitored pleural space puncture, that offers a more comfortable patient position, an easier approach for the operator, a very low rate of complications with short acquisition time of pleural space.

Poor correlation between intracranial pressure and intraocular pressure by hand-held tonometry

PurposeThe aim of this study is to provide data on the controversial issue of whether handheld measurements of intraocular pressure (IOP) are capable of accurately predicting elevated intracranial pressure (ICP) in patients undergoing lumbar puncture (LP).MethodsAll patients over the age of 18 years who underwent an LP in the emergency or neurological departments at the Tel Aviv Medical Center for any reason between October 2007 and July 2010 were eligible to participate in this prospective observational pilot study. IOP was measured with the Tono-Pen XL while patients were in the supine position before undergoing LP. ICP was measured in the lateral recumbent position. ICP and bilateral IOP were measured, and the mean and maximum values of IOP were calculated. The association between ICP and each one of the four IOP measures was evaluated by the Pearson correlation coefficient.ResultsTwenty-four patients (mean age 37.8 ± 15.8 years, ten males and 14 females) were enrolled. The reasons for their requiring an LP were headache (19/24 patients), evaluation for hemiparesis (2/24), cognitive deterioration (1/24), and seizures (2/24). Nine had elevated mean opening pressure (>20 cm H2O), six had an elevated mean IOP (>20 mmHg), and four of these six also had an elevated opening pressure. There was no significant correlation between the ICP measurements and any of the IOP measurements.ConclusionHandheld ocular tonometry has poor sensitivity and specificity for the prediction of increased ICP and is not an effective tool for screening for ICP in the ED or in the neurology department.

The intravenously administered palonosetron does not affect the spinal anesthesia

The 5-hydroxytryptamine Type 3 (5-HT3) antagonists are a class of drugs frequently used to prevent and treat nausea and vomiting. It has been shown that a 5-HT3 receptor exists in the spinal nerves and affects pain control in animals [1]. In one study, ondansetron administered to prevent nausea and vomiting interrupted sensory deprivation in spinal anesthesia performed with lidocain [2]. Another study showed that other 5-HT3 antagonists such as granisetron enhanced recovery of the sensory nerves during spinal anesthesia [3]. Palonosetron, a second-generation 5-HT3 receptor antagonist approved in 2003, is known to have the strongest affinity to the 5-HT3 receptor, with a receptor binding affinity about 30 times stronger than that of ondansetron and granisetron. In addition, its elimination half-life is about 40 hours, far longer than that of other 5-HT3 antagonists. Therefore, a small dose, generally 0.075 mg, is rec ommended to prevent nausea and vomiting after general opera tions [4]. However, as the effect of palonosetron on spinal anes thesia has not been studied, it is unclear whether preoperative administration of palonosetron interrupts the anesthetic effect. In this study, we investigated the effect of palonosetron on spinal anesthesia by examining the level of sensory block, the timing of sensory recovery, and the timing of motor recovery in spinal anesthesia performed with bupivacaine 8 mg when palonosetron 0.075 mg or normal saline solution 1.5 ml was intravenously injected preoperatively. This study was conducted with the approval of the Institutional Review Board at our hospital. The subjects were 80 American Society of Anesthesiologists (ASA) class I-II patients who were scheduled to undergo transurethral surgery under spinal anesthesia. The objective and methods of the study were explained to them before the operation, and informed consent was obtained from each patient. The subjects were randomly assigned either to a group in which normal saline solution 1.5 ml was injected 15 minutes before the operation (Group C) or to a group in which palonosetron 0.075 mg (1.5 ml) was intravenously injected 15 minutes before the operation (Group P). Patients who had undergone lumbar surgery or those who had been administered drugs that could affect spinal anesthesia, such as an analgesic, a calcium channel blocking agent, or an alpha 2 agonist, were excluded from the study. An anesthetist performed anesthesia without knowledge of the intravenously injected drug, and the same anesthetist observed the patients in the operating room and the recovery room. Vital signs such as electrocardiography, blood pressure, and oxygen saturation were monitored in the operating room. Before the induction of anesthesia, normal saline solution 300 ml was intravenously injected in all patients. Anesthesia was performed by having the patient lie in the lateral recumbent position and inserting a 25 G Whitacre needle (Becton-Dickinson, Franklin Lakes, NJ, USA) through the midline of the L4-5 intervertebral space. After checking the outflow of the cerebrospinal fluid, 0.5% hyperbaric bupivacaine 8 mg was injected for 10 seconds. After the injection, the patient adopted the supine posi tion. After the sensory block was checked, the patient adopted the lithotomy position. With respect to the sensory block, the level at which the pinprick sensation disappeared was recorded every 10 minutes, and the highest sensory block level was also recorded. The time to

EComment. Cardiopulmonary bypass and pregnancy

We read with great interest the article by Sepehripour et al. regarding the safety of performing cardiac surgery on cardiopulmonary bypass (CPB) during pregnancy [1]. They included in the results of their research three retrospective literature reviews (published in 1996 and 1998), three retrospective observational studies and eight case reports describing 10 parturients undergoing CPB. However, we found three additional relevant articles investigating the outcome of pregnancy after CBP. In order to be exhaustive, we will summarize the relevant results of the omitted papers. Thalmann et al. [2] performed a population-based study covering a period of 10 years in Austria and found 2 pregnant patients (at 36 and 32 weeks of pregnancy) with acute aortic dissection. Emergent surgery was successful for both patients and their offspring. The relevant result of the study is that pregnancy may not be a risk factor for acute aortic dissection and hence contradicts the findings of previous studies. Guo et al. [3] reported two cases of acute aortic dissection during the third trimester. The first was a 33-year old parturient with Marfan syndrome who underwent a successful Bentall procedure at 28 weeks of gestation, and the second was a 30-year old pregnant patient at 32 weeks of pregnancy who underwent an uneventful aortic root replacement. Both patients underwent a caesarean section immediately before CBP. We recently reported a successful surgical pulmonary embolectomy under CBP [4]. The patient was a 39-year old at 25 weeks of pregnancy who underwent an emergent surgery due to a massive pulmonary embolism with haemodynamic compromise. In this case of heparin-induced thrombocytopenia, we chose to carry out a surgical embolectomy because we were familiar with performing this procedure when fibrinolytic therapy is contraindicated. On the basis of accumulating evidence of encouraging results, we believe it is reasonably safe to perform cardiac surgery during pregnancy at tertiary centres with expertise using additional strategies to minimize maternal and foetal risks (normothermic CBP with high flow rate and left lateral recumbent position) [5]. The maternal mortality rate is reported to be comparable to that of CPB in non-pregnant women, except in the emergent cases. In the other hand, the foetal mortality rate decreases when cardiac surgery is postponed and the foetus is allowed to mature. Conflict of interest: none declared

Positioning of infants in the neonatal intensive care unit for lumbar puncture as determined by bedside ultrasonography

Realising the paucity of data in the standardisation of the optimal position for lumbar puncture (LP) in hospitalised neonates, we have designed an observational study to measure the interspinous distance...