Touhy Needle Research Articles

Design and Assessment of a Bimanual Haptic Epidural Needle Insertion Simulator.

The case experience of anesthesiologists is one of the leading causes of accidental dural punctures and failed epidurals-the most common complications of epidural analgesia used for pain relief during delivery. We designed a bimanual haptic simulator to train anesthesiologists and optimize epidural analgesia skill acquisition. We present an assessment study conducted with 22 anesthesiologists of different competency levels from several Israeli hospitals. Our simulator emulates the forces applied to the epidural (Touhy) needle, held by one hand, and those applied to the Loss of Resistance (LOR) syringe, held by the other one. The resistance is calculated based on a model of the epidural region layers parameterized by the weight of the patient. We measured the movements of both haptic devices and quantified the results' rate (success, failed epidurals, and dural punctures), insertion strategies, and the participants' answers to questionnaires about their perception of the simulation realism. We demonstrated good construct validity by showing that the simulator can distinguish between real-life novices and experts. Face and content validity were examined by studying users' impressions regarding the simulator's realism and fulfillment of purpose. We found differences in strategies between different level anesthesiologists, and suggest trainee-based instruction in advanced training stages.

CONTINUOUS SPINAL ANAESTHESIA: A PROMISING TECHNIQUE FOR PROLONGED LOWER LIMB ORTHOPAEDIC SURGERIES

Background: Continuous Spinal Anaesthesia (CSA) is an advancing technique for prolonged lower limb orthopaedic surgeries. It awards prompt anaesthesia and analgesia, controlled sensorimotor blockade along with better haemodynamic stability using titrated and lower doses of Local Anaesthetic (LA) agents. This mode of regional anaesthesia using intrathecal catheter thus demonstrated to be an efcient and safe technique providing lesser incidence of Local Anaesthetic Systemic Toxicity (LAST) and Post Dural Puncture Headache (PDPH). This study integrates our experience with CSA for prolonged lower limb orthopaedic surgeries. Methodology: Our study comprised six cases posted for lower limb orthopaedic surgery belonging to ASA grades I and II. A 20-gauge catheter was threaded in subarachnoid space. The catheter was inserted 3cm intrathecally through 18-Gauge Touhy's needle in L3-L4 interspace. 1ml of hyperbaric Ropivacaine 0.75% with 10µg Dexmedetomidine as an adjuvant was injected. In our case series, we considered aliquots of isobaric Ropivacaine with a concentration of 0.75% for maintenance of anaesthesia wherefore 0.375% for analgesia. All of our patients were Results: hemodynamically stable intraoperatively as well as in the postoperative period. The average duration of analgesia in the postop period was 14-16 hours on the rst top-up. Excellent patient and surgeon satisfaction was experienced. Our case series concludes that CSA is an Conclusion: effective and better option for Single-Shot and Epidural Anaesthesia in lower limb orthopaedic surgeries under skilled expertise

Retrograde nasal intubation for an anticipated difficult intubation

A 58-year-old female patient with recurrence of carcinoma in the angle of the mouth on the left side was posted for composite resection and Pectoralis major myocutaneous flap reconstruction. The patient had carcinoma left buccal mucosa 1 year back and had undergone left partial mandiblectomy and radiotherapy. On airway examination (MPG) could not be assessed; on mouth opening one-and-half finger was admitted.There was a 4 cm × 4 cm ulceroproliferative growth in the left angle of the mouth extending to lower lip, which was bleeding on touch. After shifting to the operating theatre, venous access was secured with a with a wide-bore cannula. Standard monitoring was connected and preoxygenation was done. Under strict aseptic precaution under local anaesthesia, trachea located with Touhy's needle. Epidural catheter passed through the needle into the larynx and taken out through the oral cavity and Ryle's tube, which the patient already had for feeds, was pulled and taken out of the oral cavity. Catheter tip was tied to it and pulled out through the nostril and passed through murphy's eye of 6.5 mm (ID ETT) and lower end pulled, thereby pulling ETT into the trachea, cuff was inflated and tube fixed at 25 cm. General anaesthesia was administered. Thorough airway assessment, preparat ion and counselling of patient help in reducing airway-related morbidity and mortality.

Comparison of Touhy and Quincke needles on intravascular injection rate in lumbar transforaminal epidural block: a randomized prospective trial

BackgroundTransforaminal epidural steroid injection is widely used in clinical practice to effectively deliver injectate into the ventral epidural space. Complications associated with intravascular injection such as spinal cord infarction and...

Video-assisted isolated percutaneous hernia sac suturing in children with inguinal hernia (VIPS)

Background. Inguinal hernias in children are a common problem. They occur in 520 cases of 1000 newborns, with the prevalence in males of about 10 times. Therefore, they present a very important problem in pediatric surgery.
 Materials and methods. This prospective study was performed from 2019 to 2020 and included 30 patients with diagnosed inguinal hernias. Video-assisted percutaneous hernia sac ligation was performed in all patients.
 Results. The mean operating time was 10.3 2.7 min in patients with unilateral inguinal hernias and 14.7 1.6 min in patients with the bilateral variant. No complications or recurrences were observed during the six-month follow-up period. In one case, an additional 3 mm port setting was performed in an eight-month-old child. The main reason for doing this was the fibrous transformation of the parietal peritoneum because of the existence of incarcerations in the anamnesis.
 Conclusion. This technique garners all the advantages of a minimally invasive surgical treatment of inguinal hernias using the Tuohy needle. However, the conductor application allows us to create the same approach using a Touhy needle. This means that we can perform an isolated hernia sac ligation without getting under the preperitoneal tissue ligature, parts of the internal oblique and transverse muscles, aponeurosis of the external oblique muscle, and subcutaneous fat. This presented video-assisted percutaneous hernia sac ligation method seems like a potential minimally invasive way to treat inguinal hernias in children.

Epidural Anesthesia with Xylazine-Lidocaine or Dexmedetomidine-Lidocaine Mixture in Cows

Çalışmada, ayakta abomasum deplasmanı operasyonu uygulanan ineklerde, modifiye dorsolumbar epidural anestezi ile her ikisi de α2-agonisti olan ksilazin ve deksmedetomidin’in etkinliklerinin karşılaştırılması amaçlandı. Çalışmada iki grup oluşturuldu (n=12). Birinci gruptaki ineklerin epidural anestezisi ksilazin-lidokain hidroklorid kombinasyonu, ikinci gruptakilerin ise deksmedetomidin-lidokain hidroklorid kombinasyonu ile gerçekleştirildi. Abomasum deplasmanı operasyonuna alınan ineklerin preoperatif rektal ısı, nabız, solunum sayısı, ruminasyon sayısı kaydedildi. İlk interlumbar aralıktan, 18 G Touhy iğnesi ile orta hattan negatif basınç yöntemiyle epidural boşluğa girildi. Gruplara uygulanan ksilazin (0.025mg/kg)-lidokain hidroklorid (0.1mg/kg) ve deksmedetomidin (0.001mg/kg)-lidokain hidroklorid (0.1mg/kg) karışımları %0.9’ luk serum fizyolojik ile 6 ml’ye tamamlanarak 1 dakika sürede uygulandı. Ensizyona tepki ile cerrahi uygulama sırasında sedasyon, ataksi ve huzursuzluk skorları 10 dk aralıklarla kaydedildi. Postoperatif 3 saat’lik zaman diliminde, 30 dk aralıklarla takibe devam edilerek veriler kaydedildi. İki olguda tekniğin uygulanamaması, 1 olguda ise hayvanın yatması nedeniyle toplam 3 olgu çalışma dışı bırakıldı. Çalışmaya dâhil edilen bütün olgularda, teknik kolaylıkla uygulanabildi. Uygulanan tekniğin operasyon için yeterli düzey ve sürede, analjezi ve sedasyon sağladığı gözlendi. Kolay uygulanabilen bu teknik ile az miktarda ilaç ve doz sarfıyla preemptif analjezi sağlandı. Sonuç olarak; ineklerin abomasum deplasmanı olgularında uygulanan modifiye dorsolumbar epidural anestezi tekniğinin, her iki etken madde için de klinik pratikte uygulanabilir olduğu kanısına varıldı.

Cervical Epidural and Subarachnoid Catheter Placement in Standing Adult Horses.

Horses underwent either cervical epidural space (CES) catheterization or subarachnoid space (SAS) catheterization while restrained in stocks, under deep sedation (detomidine and morphine) and local anesthesia (mepivacaine 2%) block. Catheters were placed under ultrasound guidance with visualization of the dura, SAS, and spinal cord between the first (C1) and second (C2) cervical vertebrae. Following sedation and sterile skin preparation, operator 1 placed under ultrasound guidance, a 6- or 8-inch Tuohy needle with the bevel oriented caudally. For CES, a 6-inch Touhy needle was used with the hanging drop technique to detect negative pressure, and operator 2 then passed the epidural catheter into the CES. For SAS, following puncture of the dura, cerebrospinal fluid (CSF) was aspirated prior to placement of the epidural catheter. Placement into either CES or SAS was confirmed with plain and contrast radiography. Catheters were wrapped for the duration of the study. CSF cytology was assessed up to every 24 h for the study period. Horses were assessed daily for signs of discomfort, neck pain, catheter insertion site swelling, or changes in behavior. A complete postmortem assessment of the spinal tissues was performed at the end of the study period (72 h). Two horses had CES catheters and five horses had SAS catheters placed successfully. All horses tolerated the catheter well for the duration of the study with no signs of discomfort. Ultrasound was essential to assist placement, and radiography confirmed the anatomical location of the catheters. CSF parameters did not change over the study period (P > 0.9). There was evidence of mild meningeal acute inflammation in one horse and hemorrhage in another consistent with mechanical trauma. Placement of an indwelling CES or SAS catheter appears to be safe, technically simple, and well tolerated in standing sedated normal horses.

Bilateral Transversus Abdominis Plane Block versus Epidural analgesia for Postoperative Pain Relief in Lower Abdominal Surgery

Abstract Background epidural and caudal analgesia have been considered the gold-standard techniques after abdominal surgery for adults and children, respectively. The techniques consist of injecting the local anesthetic within the epidural space, between the ligamentumflavum and the dura mater. Depending on the surgical site and the level of injection, cervical, thoracic, or lumbar nerve roots are blocked after their emergence from the neural foramen. Epidural and caudal analgesia have technical drawbacks with epidural local anesthetic associated with hypotension secondary to the sympathetic blockade.In the last decade, a new abdominal truncal block, called the tranversusabdominis plane (TAP) block, was described consisting of local anesthetic injection between the internal oblique and transversusabdominis muscle. This block provides analgesia by blocking the 7th to 11th intercostal nerves (T7–T11), the subcostal nerve (T12), and the ilioinguinal nerve and iliohypogastric nerve (L1–L2). Aim of the Work to compare the analgesic efficacy of epidural analgesia and transverse abdominis plane (TAP) block to provide postoperative analgesia after abdominal surgery. Methods sixty patients undergoingLower Abdominal Surgery were randomly divided into 2 equal groups by Closed Envelope Method. patients scheduled for Lower Abdominal surgery were assessed preoperatively in the form of evaluation of their medical history, their laboratory investigations and for fulfilling the above inclusion criteria.Patients Preparation was done by 2 mg Dormicum IV injection as a sedation preoperatively. After obtaining baseline vital signs, All patients received GA; sevoflurane was used for induction and maintenance of anesthesia, IV cannula was inserted and laryngeal mask airway (LMA) to secure the airway.Patients were divided randomly into two groups, each group consists of 30 patients. Group A: Patients in this group received Epidural analgesia, patients were placed in sitting position, Epidural block was administered under sterile conditions with a 18 G Touhy needle using a standard loss of resistance technique. After negative aspiration, 1ml/kg of 0.25% bupivacaine was injected. Group B: Patients in this group received US guided TAP block on the same side of surgery, patients were placed in supine position, linear US probe (high frequency probe 10–12 MHz) connected to a portable US unit (SonoSite, USA) was placed in the mid-axillary plane midway between the lower costal margin and the highest point of iliac crest. After skin disinfection, a 23-G 50-mm needle with an injection line was inserted in plane with the probe. Once the tip of the needle was placed in the space between the internal oblique abdominal muscle and transverses abdominis muscle, and after negative aspiration, 0.5 ml/kg 0.25% bupivacaine was injected. The following parameterswas assessed and recorded Hemodynamic monitoring, Assessment of postoperative painUsing visual analogue scale score, Any case of failed block was recorded, Doses of analgesics required intraoperatively and during the first 2 hours postoperatively were recorded. In case of failed block, 1 mic/kg Fentanyl IV was given. Complications During and after the procedurewere recorded. Results There was no significant differences regarding Demographic data, Heart Rate, SPO2 and duration of surgerybetween both groups. There were significant difference between both group regarding systolic blood pressure, Diastolic blood pressure, visual analogue score, need of analgesic, mobilization postoperative, pain on coughing and hospital stay Conclusion The current study revealed that Epidural block provided significantly prolonged postoperative analgesia, reduced the postoperative analgesic requirements compared with Ultrasound guided TAP Block in patients undergoing lower abdominal surgery. Both analgesic techniques are safe.

3:36 PM Abstract No. 350 Intrathecal catheter and port placement for nusinersen infusion in patients with spinal muscular atrophy and spinal fusion: Technical note

Spinal muscular atrophy (SMA) is among the most common monogenic causes of spinal motor neuron(SMN) degeneration with severely affected cases having a median survival of less than 2 years of age. Nusinersen (Spinraza) is a novel antisense oligonucleotide administered intrathecally for treatment of SMA. Most of these patients have scoliosis often treated by posterior fusion from T2 to sacrum making lumbar puncture challenging. Building on our prior experience in intrathecal catheter placement, we describe our initial experience with an image-guided approach to implantation of intrathecal catheters and subcutaneous ports in patients with SMA with extensive spinal fusions. IRB-approved retrospective study included 12 patients who underwent intrathecal catheter and port placement from June 2018 to April 2019. Intrathecal access was obtained by an interventional radiologist utilizing iGuide software and Dyna CT. A 14G bone penetration set was used to drill an osseous tunnel through the spinal fusion mass and using Touhy needle, a 3.7 Fr intrathecal catheter was advanced into cervical subarachnoid space. A subcutaneous port was then placed by a neurosurgeon and connected to the intrathecal catheter. Port patency was confirmed by contrast injection. Patient demographics and procedure demographics (table) were collected and analyzed. The Study included 4 males and 8 females, all with spinal fusion. Average radiation dose was 857 mGy, exposure time was 3.3 min to 12 min, EBL was 8.33 mL and mean total procedure time was 1:54 hr. The procedure was technically successful in all cases with no immediate postprocedural complications. 2 patients developed delayed CSF leak which was treated with epidural blood patch successfully. In 2 patients, CSF could not be aspirated prior to drug injection however catheter patency was confirmed by contrast injection study. Our novel technique is safe, effective, negates the requirement for open surgery to gain intrathecal access, and reduces cumulative radiation exposure incurred during repeated fluoroscopy-guided lumbar punctures. Despite initial success, more extensive prospective study to determine the long-term outcome of this novel technique is needed.Tabled 1Procedure DemographicsPatient NumberAccessTip of CatheterRadiation Dose (mGy)Radiation Time (mins)EBL (mL)Total Time (hh:mm)1L3-L4T5-612555.7101:562L3-L4T413477101:533L3-L4T18809101:554L3-L4T1387552:045L3-L4T1447552:076L3-L4T1111111.451:547L3-L4T44955.151:498L4-L5T5-T6136812101:459L3-L4C75553.3201:3210L3-L4T17397.952:1411L4-L5T183110.9101:3512L3-L4T18698.4102:01 Open table in a new tab

Accidental dural puncture and post-dural puncture headache: a retrospective review in an Irish maternity hospital.

Accidental dural puncture (ADP) during epidural catheter insertion and the possible consequent post-dural puncture headache (PDPH) remain challenging complications in obstetric anaesthesia. ADP/PDPH can represent a considerable degree of morbidity for the parturient and require immediate diagnosis and appropriate management to ensure recovery and avoid complications. This retrospective audit was carried out to identify the accidental dural puncture and post-dural puncture headache rates at the Coombe Women and Infant University Hospital in Dublin. Cases of ADP and PDPH were identified retrospectively from a register used to record these cases. Demographic and obstetric data was retrieved using the patients' medical records. Analysis was carried using MS Excel. In 1year (June 1, 2018 to June 1, 2019), there were 25 cases of ADP during epidural catheter insertion and this is 0.78% of epidurals done in this period. Seventeen of these (68%) subsequently developed PDPH. In total, there are 32 cases of PDPH: 27 after epidural analgesia using an 18G Touhy needle and 5 after a spinal anaesthetic using a 25G Whitacre needle. All PDPH cases received first-line conservative treatment and 9 (28.1%) required an epidural blood patch (EBP). No-one required a second EBP. The incidence of ADP at our hospital (0.78%) is within the range quoted in the literature (0.1-1.5%) and below the UK standard of 1%. The incidence of PDPH after recognized ADP (68%) is also consistent with other published reports.

Pitfalls of a Shared Neuraxial Space: Wandering Epidural Catheter.

Children with severe spasticity with indwelling baclofen pumps often present for extensive orthopedic procedures to improve mobility and comfort. Procedural pain can be effectively managed by epidural infusions. Epidurals are sited at surgically congruent levels either above or below the level of insertion of the intrathecal catheter.1,2The three-dimensional reconstructed view demonstrates the course of epidural catheter traveling caudally in the epidural space (image). The catheter travels from the L4 level coursing antero-laterally at the L5 level, “wandering” toward the left L5–S1 foramen to lie anterior to the sacrum.The epidural catheter is placed in the L4–L5 interspace with the bevel of the Touhy needle directed cephalad in a patient with a longstanding intrathecal catheter at the L3 level.Risks of placing an epidural with an existing intrathecal catheter include catheter damage with interruption of baclofen delivery and subsequent baclofen withdrawal syndrome, intrathecal migration of the epidural catheter, and misdirected epidural catheter due to a scarred epidural space. Any one of these scenarios would lead to suboptimal pain control in a patient population that is often nonverbal or cognitively delayed.This image underscores the potential for epidural catheter malposition in a scarred epidural space and make a case for routine postepidural placement epidurogram in patients with intrathecal catheters. A computed tomography scan conspicuously displays small-caliber epidural catheters and may be further augmented by contrast.3The authors declare no competing interests.

Development of a Lumbar Drain Simulator for Instructional Technique and Skill Assessment

Medical simulation for the teaching of procedural skills to health-care providers is an effective method of instruction to improve safety, quality, and procedural efficiency. There are several commercially available simulators for lumbar puncture training; however, there is currently no model available for lumbar drain intrathecal catheter placement. A modular lumbar drain simulator was assembled with the use of a spine model, ballstical gel, and Penrose drain tubing to recreate the procedural steps and tactile feedback of a live lumbar drain insertion. The assembled simulator demonstrated the ability to provide users with manual feeback of a "pop" sensation when intrathecal puncture was achieved with a 14 gauge Touhy needle, as well as spontaneous CSF flow. A silastic catheter was able to be inserted into the simulated subarachnoid space in the same manner as a live procedure. A high-fidelity lumbar drain simulator can be constructed in a cost-effective manner. We have detailed the materials and assembly of our successful design in order to provide a novel educational tool for procedural instruction and practice.

Continuous spinal anaesthesia for caesarean section in a patient with peripartum cardiomyopathy.

Continuous spinal anaesthesia for caesarean section in a patient with peripartum cardiomyopathy.

Effect of Interlaminar Epidural Steroid Injection in Patients with Central Cervical Spinal Stenosis.

To investigate the effect of interlaminar epidural steroid injection (ESI) for management of central cervical spinal stenosis-induced posterior neck pain. This retrospective study recruited 45 patients with posterior neck pain caused by central cervical spinal stenosis. For the ESI procedure, a 21-gauge Touhy needle was inserted into the epidural space between C7 and T1, and 20 mg (40 mg/mL) of dexamethasone with 4 mL of normal saline was injected. The effect of the procedure was evaluated using a numerical rating scale at 1, 2, and 3 months after the procedure. Successful pain relief was defined as reduction in numerical rating scale score of ≥50% compared with before treatment. At 3 months after treatment, patient satisfaction levels were examined; patients who reported very good (score= 7) or good results (score= 6) were considered to be satisfied with the procedure. Posterior neck pain was significantly reduced at follow-up evaluation 1, 2, and 3 months after ESI (P < 0.001, repeated measures 1-factor analysis). At 3 months after the procedure, 58% of the patients achieved a successful response (≥50% pain reduction), and 56% were satisfied with treatment results. Cervical interlaminar ESI appears to be a good treatment method for managing chronic posterior neck pain induced by central cervical spinal stenosis, especially when pain is refractory to oral medication.

The Comparative Study of Epidural Levobupivacaine and Bupivacaine in Major Abdominal Surgeries in Type- 2 Diabetic Patient

Background: Major abdominal surgeries still induce neurohumoral changes responsible for postoperative pain, various organ dysfunctions, prolong hospitalization and convalescence. Insufficient pain therapy prolongs the hospital stay and rises the mortality rates. Epidural analgesia confers excellent pain relief and complete dynamic analgesia leading to a substantial reduction in the surgical stress response. Opioid and local anaesthetic infusion by an epidural catheter is widely used as a postoperative pain management method after major abdominal surgeries. Type-2 Diabetic patient has many comorbidity with cardiovascular complication and they are more vulnerable to pain. Objectives: The purpose of this study was to compare the effect of levobupivacaine and bupivacaine with fentanyl in postoperative analgesia and haemodynamic changes of type-2 Diabetic patients for major abdominal surgeries. Material and method: Sixty (60) patients were selected whose were suffering from Type-2 Diabetes mellitus and were going to be operated for major abdominal surgeries (Whipple’s procedure, FCPD, Gastrectomy, Hemi colectomy). Every patient received an epidural block in the sitting position at the T8- 9 or T9-10 level via 18 G Touhy needle. Each patient in group A received 0.125% levobupivacaine with 2 μgm. fentanyl / ml solution through epidural catheter @ 4 ml / hr. and group B were received 0.125% bupivacaine with 2 μgm. fentanyl / ml solution through epidural catheter@ 4 ml / hr Results: Mean visual analog scale (VAS) values of groups did not differ at all time. They were 6 at the end of the surgery (0.Min, p= 0.06). The VAS scores were not statistically significant in group A &amp; group B (p &gt; 0.05). The frequency of tachycardia was higher in group B that was bupivacaine group. Conclusion: The results of our study suggest same concentration of epidural levobupivacaine and bupivacaine with fentanyl provide stable postoperative analgesia and both were found safe for the patients undergoing major abdominal surgery, but levobupivacaine is less tachycardic and safer for Type-2 Diabetic patient. JBSA 2017; 30(1): 5-13

An Epidural Blood Patch for Spontaneous Intracranial Hypotension - A Case Report

Spontaneous Intracranial Hypotension (SIH) is a potentially serious, rare, pathophysiological entity of diverse origin. Orthostatic headache, low CSF pressure and diffuse meningeal enhancement on brain MRI are the major features. We report a 36 year old nun with an acute onset of severe headache over the vertex of the head becoming holo-cephalic, associated with neck pain, peaking in intensity in 15-on assuming the erect posture and relieved on assuming the recumbent position. Conventional treatment resulted in minimal improvement. MRI of the brain with gadolinium showed cerebellar tonsillar descent and diffuse meningeal enhancement. Lumbar puncture revealed an opening pressure of 60 mm of H2O and the CSF unremarkable on analysis. With the working diagnosis of SIH, she was posted for an epidural blood patch. After a pre-anaesthetic checkup and due consent, the patient was pre-medicated. In the operating room, the patient was positioned and draped in the left lateral position with a 15 degree trendelenburg tilt. At the L2-L3 intervertebral space, the primary anaesthesiologist identified the epidural space with an 18G Touhy needle adopting the loss of resistance to air technique. Simultaneously a 16G needle with extension was secured by the first assistant in the cephalic vein. Blood collected in 10 mL syringes was then introduced into the epidural space. After a volume of 26 mL, significant lower limb parasthesia and pain was complained of. The procedure was halted and the patient placed supine. She was discharged and noted to be symptom free at follow ups.

Physical characteristics of catheters used for subarachnoid drainage

BackgroundCerebrospinal fluid diversion through lumbar drainage catheters is a routine procedure that is used in a variety of clinical applications. Fracture of catheters during insertion or removal may result in...

"Needle-in-needle" epicardial access: Preliminary observations with a modified technique for facilitating epicardial interventional procedures.

to flex over the course of insertion, and tactile assessment of force and perception of cardiac motion was limited. In this report, we describe our initial experience with the “needle-inneedle” (NIN) technique of epicardial access in which a short 18G needle is inserted under the sternum and the long 21G needle is inserted through the 18G needle. It is hoped that this technique improves the stability of the small needle and potential tactile feedback, thus reducing the risk of significant pericardial bleeding. We report preliminary results of its procedural success and acute complications compared with the standard Sosa technique, 1 which uses a 17G or 18G Touhy needle.

Noninvasive cardiac output monitoring during anaesthetic management for caesarean delivery in parturient with severe mitral stenosis: A more relaxed look.

Noninvasive cardiac output monitoring during anaesthetic management for caesarean delivery in parturient with severe mitral stenosis: A more relaxed look.

Combined use of fascia iliaca block, subarachnoid block and dexmedetomidine sedation for patients having fractured femur surgery

To the Editor: Anesthesia for the patient with a fractured hip is frequently encountered and is often very challenging due to advanced age, cardiac and respiratory co-morbidities and dementia/delirium. No guidelines exist as to the best method of anesthesia for hip fracture surgery, however there is general agreement that avoiding polypharmacy, utilizing regional and neuraxial anesthesia and avoiding excessively deep anesthesia is likely optimal. For patients requiring fixation of femoral neck fractures, we present the novel anaesthetic management of dexmedetomidine (DEX) sedation, fascia iliaca regional block (FIB) and subarachnoid block (SAB). Patient characteristics, surgical procedure and anesthetic conduct are presented in Table 1. In the operating theatre a DEX loading dose averaging 0.85 mcg/kg (range 1.3–0.3 mcg/kg) was administered over 10 min. As DEX has few amnestic properties, a small dose of midazolam was also administered. Concurrently, a FIB was carried out by the classic 2-pop technique using a 16 gauge Touhy needle and 0.5 % ropivicaine. DEX was converted to a maintenance infusion averaging 0.85 mcg/kg/h (range 1–0.7 mcg/kg/h) and adjusted to optimize sedation and minimize side effects. The FIB was given 15 min to take effect, and SAB was carried out in the lateral position with the fractured side up. The administration of cardiovascular drugs was not required in three of four patients, and no airway obstruction occurred. The DEX infusion was decreased based on trends of heart rate and blood pressure, and discontinued once closure of fascia had begun. SAB may be preferred over general anesthesia as it is associated with reductions in early mortality, postoperative confusion, myocardial infarctions, pneumonia, deep vein thrombosis, fatal pulmonary embolism and postoperative hypoxia [1]. In non-cardiac surgery DEX is associated with a trend to improved cardiac outcomes and improved allcause mortality, while decreasing non-fatal myocardial infarctions, and myocardial ischemia—a2-receptor agonists attenuate the stress response and may prevent cardiac complications [2]. Hip fracture patients often suffer from delirium and dementia—up to 50 % of patients with hip fractures have delirium accompanying their acute orthopaedic injury [3]. Interventions to decrease delirium include minimizing the use of narcotics and benzodiazepines, effective pain management, use of regional and neuraxial anesthesia, and maintaining a lighter plane of anesthesia [3]. DEX produces sedation and analgesia by acting both peripherally and centrally, is purported to have a role in neuroprotection and improves effectiveness of SAB [4]. FIB is effective in this patient population as it decreases the amount of medication needed for SAB, is performed quickly and easily in the supine position and does not rely on optimal coagulation status. In these patients FIB can be utilized as the main anaesthetic for positioning the patient for SAB, is more efficacious than IV opioids in facilitating the lateral position for SAB and aids postoperative pain control [5]. We utilize 0.5 % ropivacaine in a large volume without complication to allow a relatively quick onset for positioning while maintaining a longer post-operative duration. I. L. Rapchuk (&) P. Glover Department of Anaesthesia, Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, 627 Rode Road, Chermside, QLD 4032, Australia e-mail: ivan_rapchuk@health.qld.gov.au