Epidural Needle Research Articles

Epidural Needle Guidance Using Viscoelastic Tissue Response.

Objective: We designed, prototyped, and tested a system that measures the viscoelastic response of tissue using nondestructive mechanical probing, with the goal of aiding clinical providers during epidural needle placement. This system is meant to alert clinicians when an epidural needle is about to strike bone during insertion. Methods: During needle insertion, the system periodically mechanically stimulates and collects viscoelastic response information data from the tissue at the needle’s tip using an intra-needle probe. A machine-learning algorithm detects when the needle is close to bone using the series of observed stimulations. Results: Tests run on ex vivo pig spine show that the system can reliably determine if the needle is pointed at and within 3 mm of bone. Conclusion: Our technique can successfully differentiate materials at and in front of the needle’s tip. However, it does not provide the 5 mm of forewarning that we believe would be necessary for use in clinical epidural needle placement. The technique may be of use in other applications requiring tissue differentiation during needle placement or in the intended application with further technical advances. Clinical and Translational Impact Statement: This Early/Pre-Clinical Research evaluates the feasibility of a method for helping clinical providers receive feedback during epidural needle insertion—thereby reducing complication rates—without significant alterations from current workflow.

Chronic sacral neuromodulation for pelvic floor dysfunction in children with spina bifida

To estimate the effectiveness of chronic sacral neurostimulation for neurogenic lower urinary tract dysfunction in children with spina bifida. Eight patients with spina bifida and neurogenic lower urinary tract dysfunction underwent surgical treatment. Three patients had detrusor-sphincter dyssynergia and urinary incontinence. Five patients had detrusor overactivity and urine retention. Conservative treatment was failed in all cases. We implanted quadripolar test electrode on the S3 root through Tuohy needle under fluoroscopic control. Test stimulation was ineffective in three children with detrusor overactivity. Five patients with positive response to stimulation underwent implantation of chronic neurostimulation system. We estimated the efficacy of neurostimulation considering symptoms of neurogenic lower urinary tract dysfunction, urinary diary, PAD test and complex urodynamic examination data. Positive clinical effects were observed in 3 patients with detrusor-sphincter dyssynergia and 2 patients with detrusor overactivity. Clinical effect included improvement in urine leakage and higher bladder volume. In patients with urinary retention, we revealed voluntary urination and less number of daily catheterization procedures. In one patient, clinical effect of chronic stimulation regressed within 3 month after surgery. Preliminary results of chronic sacral neuromodulation confirmed its advisability in children with neurogenic lower urinary tract dysfunction. Patients with detrusor-sphincter dyssynergia had better results compared to those with detrusor overactivity.

SAFETY OF USING DURAL PUNCTURE EPIDURAL ANALGESIA AS A METHOD OF LABOR ANALGESIA.

The aim: To evaluate the clinical characteristics of complications and side effects of CSE and DPE as a method of analgesia. Materials and methods: The study included 137 patients who had a vaginal birth using one of two, CSE or DPE methods of analgesia. All of them were divided into two groups: Group I - 54 women (DPE group) and Group II - 83 women (CSE group). In group I, an epidural kit with a Tuohy G18 needle, G20 catheter, and a Whitacre G25 x 120 mm spinal needle was passed through the epidural needle for puncture of dura mater and removed after cerebrospinal fluid receiving, the epidural catheter was conducted on 3-4 cm. The initial dose of anesthetic was: 3 ml of Naropin 0.12% - test dose and 17 ml of working solution (Naropin 0.12% + Fentanyl 2 μg / ml) - main dose. In group II, a spinal-epidural kit with Tuohy G18 needle, catheter G20, spinal needle "Whitacre" G27 x 132 mm for dura mater puncture was used. Bupivacaine 1.5 mg + Fentanyl 15 mcg, 1 ml solution was administered spinally. To maintain analgesia in both groups - the patient-controlled analgesia with a working solution (Naropin 0.12% + Fentanyl 2 μg / ml) with a bolus of 8 - 10 ml, lockout 15 minutes. Results: The higher frequency of hypotension in childbirth when using CSE - 4 women (4.8%) vs 1 woman (1.9%) in the DPE group. Inadequate or insufficient analgesia in group I was found in 2 women (3.7%), and in group II in 4 women (4.8%). The severity of monolateral block in group I was not high and did not cause significant discomfort in women. The higher incidence of monolateral blockade was in group II, in three cases there was a need for additional anesthesiologist interventions and catheter manipulations. In the CSE group there were two cases (2.4%) of severe itching in women, in group I such an adverse reaction was absent. No complication such as PDPH was documented in either group. Conclusions: 1. The use of the DPE technique showed a lower frequency of complications compared to CSE. 2. The use of a G 25 spinal needle for puncture of the dura mater does not lead to an increase in the frequency of PDPH. 3. DPE technique using G25 spinal needles reduces the need for additional manipulations with the epidural catheter to overcome unilateral blockades.

The Reinforced Ma-Griffith Method Combined with Minimally Invasive Small-Incision Suture for Acute Achilles Tendon Rupture.

ObjectiveTo evaluate the treatment effects of the reinforced Ma‐Griffith method combined with a minimally invasive small incision(M‐G/MISI) in the treatment of acute Achilles tendon rupture.MethodsFrom January 2012 to January 2020, a retrospective study was carried out on thirty‐one patients with acute Achilles tendon ruptures that were treated using the M‐G/MISI. Patient with acute Achilles tendon rupture was operated on in the prone position. The M‐G/MISI begin with making a small incision to debride the stumps of ruptured tendon. Then M‐G/MISI was used to suture the distal and proximal Achilles tendons with the help of a epidural puncture needle and polydioxanone synthetic absorbable suture (PDS) Ⅱ line. Finally the stumps of ruptured tendon was reattached. After the surgery, the affected limb was fixed with either a plaster slab below the knee brace or a functional brace. Removal of plaster external fixation and partial weight‐bearing with crutches five weeks after the operation; Complete weight‐bearing nine weeks after the operation; jogging permitted 12 weeks after the operation; Patients were allowed to resume normal activities six months after the operation.ResultsAll 31 patients in this study were male. Nineteen of these patients had Achilles tendon rupture on the right lower extremity, while 12 had ruptures on the left lower extremity. The patients had a mean age of 33.35 ± 7.13 years (range, 18‐52 years). The mean operation time was 79.58 ± 22.67 minutes (range, 40‐167 minutes). The mean time from injury to operation was 4.19 ± 2.01 days (range, 1‐8 days), and the mean hospital stay was 9.87 ± 3.88 days (range, 5‐22 days). The new technique had a small incision with a mean length of 3.94 ± 1.82 cm (range, 2‐6 cm). The mean intraoperative blood loss was 16.77 ± 13.76 mL (range, 10‐50 mL) and the mean follow‐up time was 21.35 ± 10.18 months (range, 6‐50 months). No wound infection, fistula, skin necrosis, sural nerve damage, deep venous thrombosis or tendon re‐rupture was found. One year after the surgery, all patients reported 97.00 (range, 93‐100 points) AOFAS ankle‐hindfoot score points and the mean ATRS was 97.39 (range, 91‐100) points.ConclusionThe reinforced Ma‐Griffith method, combined with a minimally invasive small incision suture, is a simple, effective, minimally invasive technique and low‐cost surgical method for the treatment of acute Achilles tendon rupture.

Augmenting the training space of an epidural needle insertion simulator with HoloLens

ABSTRACT The goal of this study is to explore the potential of the Optical See-Through Augmented Reality (OST-AR) in the training of median and paramedian epidural anaesthesia administration. To this end, we propose EpiduralLens, an epidural needle insertion simulator that augments the training space by resorting to a dummy, a HoloLens, an AR target, 3D sound feedback, and voice commands. The proposed system projects relevant 3D anatomical information and visual guides that are placed on and around the dummy, which are complemented with aural feedback that guides the instruction process. EpiduralLens was evaluated by 6 anaesthesiologists. The results of the formal evaluation sessions indicate that our prototype had high acceptability by the experts, verifying that combining an aural interface with 3D visual interface is a useful way to aid immersion and improve the learnability of trainees. Moreover, the participants showed interest in using the application in future sessions as a training aid for median and paramedian epidural anaesthesia administration.

A Protocol on Comparative Evaluation of Epidural and Spinal Technique of Labour Analgesia in Rural Women of Central India and their Perceptions Regarding Pain Relief in Labour

Background: Labour pain while giving birth is one of the most excruciatingly painful and emotionally stressful experience for a woman that has piqued the interest of several academicians. Labour pain is induced due to the uterine ischemia, expansion of vagina and birth canal, muscle contractions, and pressure on the bladder. To relieve the severe pain during labour, analgesia is required, which offers pain relief without the loss of consciousness. Regional analgesia (Epidural and spinal) are most commonly used for offering pain relief to women.
 Aim: To evaluate whether low dose spinal analgesia is a better alternative to lumbar epidural analgesia for pain relief in labour.
 Objectives - Primary objective is to evaluate efficacy of lumbar epidural and spinal analgesia for pain relief in labour. Secondary objective is to evaluate the perceptions of women towards the use of labour analgesia, to evaluate the maternal and fetal outcome and to evaluate the barriers affecting the use of lumbar epidural and spinal analgesia for women during labour.
 Methods: In this randomized control trial study, where 60 patients are present in each group. Patients in GROUP E, epidural analgesia will be given using 18-gauge Touhy epidural needle by a loss of resistance to air technique, and after confirmation of space, an epidural catheter will be inserted cranially in L3 - L4 or L4-L5 interspace, and a dose of 15ml of 0.125% bupivacaine with 25µg of fentanyl would be given slowly. Group S patients will receive subarachnoid block using 25-gauge needle inserted and directed to reach the intrathecal space between L3 - L4 or L4 - L5 intervertebral space. After a successful Dural puncture with acceptable CSF flow, 0.1% bupivacaine 2ml with 25µg fentanyl will be given via spinal needle. Throughout the duration of delivery, hemodynamic monitoring including SPO2, ECG, heart rate and blood pressure of mother and fetal heart rate would be monitored under the guidance of obstetrician and anesthesiologists. Patient will be assessed every 5min for the first 15 min, and then every 15 minutes until additional analgesia was requested. The severity of labour pain would be assessed using visual analogue scale. (0 = no pain; 10 = severe pain). Within the first 24 - 48 hours postpartum patient will fill the self-administered questionnaires.
 Results: The groups are expected to be similar. However, Low dose spinal analgesia may be a better alternative to lumbar epidural analgesia in providing effective pain relief for women in labour in terms of cost effectiveness. There are no results found as it is just a protocol. Results are yet to come.
 Conclusions: The study would offer new insights and knowledge into the use of epidural and spinal analgesia in India, particularly Wardha. The perceptions of women, towards labour analgesia, its consequences or side effects, and the myths associated with its use will be comprehended.

Pneumovesicoscopic ureteral reimplantation with intravesical tailoring of obstructive megaureter in pediatric patient

According to available data, there are only few articles describing pneumovesicoscopic (PNV) ureteral reimplantation (UR) for obstructive megaureter without tailoring and with exvivo tailoring in children. To present our experience of the PNV UR using intravesical ureteral tailoring for symptomatic primary obstructive megaureter in children. Between 2014 and 2020, 42 patients (mean age: 3.1 years) underwent a correction of primary obstructive megaureter (POM) via a vesicoscopic approach. Nine of them with the megaureter (diameter > 25mm) underwent the intravesical ureteral tailoring. The analysis included only 9 patients who underwent intravesical tailoring of the ureter using the original technique. The dilated ureter is fixed intravesical by the loop in extended position. This simplifies the tailoring step of the ureter. The tailoring is performed by continuous suture (Star). 43 UR were analyzed (1 bilateral, 1 with diverticulum, 1 with ureterocele). The mean operative time was 142min (83-235min). The mean manipulation time for intravesical tailoring of the megaureter was 18min. After the surgery, the average kidney function doesn't reduce. We observed an increase in renal function by an average of 7% in three patients after the surgery. One patient required a conversion. It was in the early stages of mastering the technique. All patients underwent US 1-3 weeks 3-6-12 months after the operation, the size of the pelvic system and ureter decreased. Eight patients are asymptomatic, and only one has the clinical changes (a persistent leukocyturia, the size of the pelvic-ureteric segment, and the ureter remain unchanged or increased). According to the VCUG vesicoureteral reflux was detected in this case. An endoscopic correction used successful. This possibility of applying our technique is confirmed according to folow-up data and should be used in other researches. The drainage of the ureter with an external stent for 1 month helps to form properly the neo-ureterovesical anastomosis and to prevent episodes of ureteral obstruction as a result the incidence of urinary tract infections reduces in the postoperative period. The use of the Tuohy needle with the loop simplifies the fixation of the ureter. This helps to make the intravesical tailoring of the megaureter easier and faster. It is original and less traumatic for the ureter than existing methods.

Color Doppler ultrasonography of an agitated solution is predictive of accurate catheter placement for a continuous popliteal sciatic nerve block

BackgroundContinuous peripheral nerve catheters (PNCs) have been shown to provide superior postoperative analgesia, decrease opioid consumption, and improve patient satisfaction compared with single injection techniques. In order to achieve success and reliability, accurate catheter positioning is an essential element of PNC placement. An agitated solution of normal saline, D5W, or a local anesthetic solution can be produced by the introduction of air to the injectate, creating air bubbles that can enhance ultrasonographic visualization and possibly improve block success.MethodsEighty-three patients were enrolled. Ultrasound-guided continuous popliteal sciatic nerve blocks were performed by positioning the tip of a Tuohy needle between the tibial and common peroneal branches of the sciatic nerve and threading a catheter. An agitated local anesthetic solution was injected through the catheter, viewed with color Doppler ultrasound and video recorded. A peripheral block score (lower score = greater blockade, range 0-14) was calculated based upon the motor and sensory testing at 10, 20, and 30 min after block completion. The color Doppler agitation coverage pattern for the branches of the sciatic nerve was graded as follows: complete (> 50%), partial (> 0%, ≤ 50%), or none (0%).ResultsThe degree of nerve blockade at 30 min as judged by median (10th, 90th percentile) peripheral block score was significant for partial or complete color Doppler coverage of the sciatic nerve injectate compared to no coverage [3 (0, 7) vs 8 (4, 14); p < 0.01] and block onset was faster (p = 0.03). The block success was higher in groups with partial or complete coverage of the branches of the sciatic nerve vs no coverage (96% vs 70%; p = 0.02).ConclusionsInjection of an agitated solution through a popliteal sciatic perineural catheter is predictive of accurate catheter placement when partial or complete coverage of the sciatic nerve branches is visualized with color Doppler ultrasound.Trial registrationNCT01591603

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

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

Single Incision Laparoscopic Percutaneous Extraperitoneal Closure of Internal Ring for Incarcerated Inguinal Hernia in Children: A Single Center Experience with 104 Cases.

Introduction: The aim of this report is to present our technique and outcomes of single incision laparoscopic percutaneous extraperitoneal closure of internal ring (SILPEC) for incarcerated inguinal hernia (IIH) in children. Patients and Methods: The medical records of all children undergoing emergency SILPEC for IIH after unsuccessful attempted manual reduction between June 2016 and September 2020 at our center were reviewed. For SILPEC, two trocars 3.5-6 mm were placed through a single umbilical incision. A 17G epidural needle and a small wire-lasso were used for extraperitoneal closure of the internal ring. Results: From a total of 2904 consecutive patients with inguinal hernia (IH) undergoing SILPEC, 104 patients (3.6%) had IIH. There were 84 boys and 20 girls with a median age of 18.5 months (ranged 1 month to 11 years). At the time of surgery under general anesthesia IIH was found to be spontaneously reduced in 26.9%; the hernia contents were bowel in 52.9%, great omentum in 13.5%, and ovary in 6.7% of the patients. All hernias were successfully reduced without additional ports or conversion to open surgery. Patent contralateral processus vaginalis (PCPV) was detected intraoperatively in 44.2% of the cases. The median operative time was 24 minutes for unilateral and 30 minutes for bilateral procedures. The median postoperative stay was 1 day. At a median follow-up of 28 months, there was no case of hydrocele, testicular atrophy, or iatrogenic cryptorchism. The postoperative cosmesis was excellent as all patients were virtually scarless. Recurrence occurred in 1.9% with no significant difference (P = .669) compared to the 1.4% recurrence rate of the 2800 patients with ordinary IH undergoing elective SILPEC during the same study period. Conclusions: SILPEC for IIH in children is feasible, safe, with excellent postoperative cosmesis, and no significant difference in hernia recurrence between emergency SILPEC for IIH and elective SILPEC for ordinary IH.

Augmented Reality Assisted Surgical Navigation System for Epidural Needle Intervention.

An augmented reality (AR)-assisted surgical navigation system was developed for epidural needle intervention. The system includes three components: a virtual reality-based surgical planning software, a patient and tool tracking system, and an AR-based surgical navigation system. A three-dimensional (3D) path plan for the epidural needle was established on the preoperative computed tomography (CT) image. The plan is then registered to the intraoperative space by 3D models of the target vertebrae using skin markers and real-time tracking information. In the procedure, the plan and tracking information are transmitted to the head-mounted display (HMD) through a wireless network such that the device directly visualizes the plan onto the back surface of the patient. The physician determines the entry point and inserts the needle into the target based on the direct visual guidance of the system. An experiment was conducted to validate the system using two torso phantoms that mimic human respiration. The experimental results demonstrated that the time and the number of X-rays required for needle insertion were significantly decreased by the proposed method (43.6±20.55sec, 2.9±1.3times) compared to those of the conventional fluoroscopy-guided approach (124.5 ± 46.7s, 9.3±2.4times), whereas the average targeting errors were similar in both cases. The proposed system may potentially decrease ionizing radiation exposure not only to the patient but also to the medical team.

Continuous Spinal Anaesthesia in a Leprosy Patient with Femur Fracture

Introduction: Leprosy is a chronic infectious disease caused by Mycobacterium leprae and affects the skin and nerves. Leprosy patients in which peripheral neuropathy and the involvement of other organs may have dysautonomia in the heart and respiratory system and autonomic involvement. Case Report: A 65 year-old patient was posted for fixing of right intertrochanteric with left subtrochanteric fracture femur. The possibility of a difficult airway was considered because of the mouth and nose deformities. Difficult airway equipment, such as a fibre-optic bronchoscopy and laryngeal mask (LMA) were made available. The patient’s vitals were normal. The haemogram and biochemistry measurements were normal. Under aseptic conditions in the sitting position at the L3–4 level, the subarachnoid space was identified with a 18-G Tuohy needle, the catheter was threaded into subarachnoid space and fixed at 10cm.1.2 mL(6mg) of 0.5% hyperbaric bupivacaine (6mg) administered. After 1hour from the starting of procedure, again 1.2 ml(6mg) of 0.5% hyperbaric bupivacaine administered through the catheter. Level achieved till T10. BP was 72/42mmHg, treated with 12mg Mephentermine. Inj.Fentanyl 50mcg given through the catheter and the catheter was removed. Conclusion: Appropriate assessment before anaesthesia and preparation are important in the management of anaesthesia of patients with leprosy. Regional anaesthesia can be used as an alternative for patients without autonomic neuropathy and with a suspicion of systemic involvement and with difficult intubation Keywords: Continuous spinal anaesthesia; Leprosy; Regional anaesthesia.

Comparison of landmark and real-time ultrasound-guided epidural catheter placement in the pediatric population: a prospective randomized comparative trial.

BackgroundEpidural block placement in pediatric patients is technically challenging for anesthesiologists. The use of ultrasound (US) for the placement of an epidural catheter has shown promise. We compared landmark-guided and US-guided lumbar or lower thoracic epidural needle placement in pediatric patients.MethodsThis prospective, randomized, comparative trial involved children aged 1–6 years who underwent abdominal and thoracic surgeries. Forty-five children were randomly divided into two groups using a computer-generated random number table, and group allocation was performed by the sealed opaque method into either landmark-guided (group LT) or real-time ultrasound-guided (group UT) epidural placement. The primary outcome was a comparison of the procedure time (excluding US probe preparation). Secondary outcomes were the number of attempts (re-insertion of the needle), bone contacts, needle redirection, skin-to-epidural distance using the US in both groups, success rate, and complications.ResultsThe median (interquartile range) time to reach epidural space was 105.5 (297.0) seconds in group LT and 143.0 (150) seconds in group UT (P = 0.407). While the first attempt success rate was higher in the UT group (87.0% in UT vs. 40.9% in LT; P = 0.004), the number of bone contacts, needle redirections, and procedure-related complications were significantly lower.ConclusionsThe use of US significantly reduced needle redirection, number of attempts, bone contact, and complications. There was no statistically significant difference in the time to access the epidural space between the US and landmark technique groups.

OPIOID-FREE ANESTHESIA IN CORONARY ARTERY BYPASS GRAFTING (CABG) SURGERY, DURING A DRUG SHORTAGES PERIOD IN THE COVID 19 PANDEMIC

IntroductionDescribe the effectiveness of opioid-free multimodal anesthetic/analgesic technique for CABG surgery during drug shortages period in COVID 19 pandemic.MethodsFour patients with moderate and elevated EUROSCORE II, underwent to 2 and 3 vessel myocardial revascularization, three patients were undertaken Off-pump and the last one On-pump, using the same anesthetic/analgesic technique to assess pain control, opioid requirement in 48 hours, hemodynamical stability, time at the intensive care unit, delirium, postoperative nausea and vomiting (PONV).Standard basic and invasive monitoring was used and a sedline monitor to measure hypnotic depth. In a sitted position a bilateral erector spinae block (ESPB) guided by ultrasound was placed at T6 and T7 level with a 17G Tuohy needle, through which 10 ml of 0.25% bupivacaine + 10 ml of 0.5% lidocaine without epinephrine was administered, with a catheter placement to continue analgesic management in postoperative period.Anesthetic induction was performed with dexmedetomidine at 0.6 mcg/kg/h during preoxygenation for 5 minutes, lidocaine at 1 mg/kg, Propofol at 1 to 1.5 mg/kg, rocuronium between 0.6 and 1.2 mg/kg, dexamethasone 8 mg and the first paracetamol dose of 15 mg/kg was given. The maintenance was target with sedline monitor using PSI and performed with sevoflurane between 0.7 and 0.8 CAM, dexmedetomidine between 0.4 and 0.6 mcg/kg/h, ketamine 0.2 mg/kg/h and within the skin closure the infusion through erector spinae catheters was started between 5-8 ml/h of bilateral 0.125% bupivacaine, continued with paracetamol 15 mg/kg every 8 hours. The protocol considered using opioids as a rescue therapy with hydromorphone or morphine according to pain, quantifying the requirement in the first 48 hours.ResultsPain assessment through Visual Analogue Scale (VAS) showed peak value at 24 hours (VAS mean value of 7), with lower levels at first 12 and 48 hours (mean values of 3 and 4 respectively). Correspondingly, opioid use was increased in the first 24 hours, a mean of 6,9 mg between morphine equivalent doses, with a posterior drop (a mean value of 1,6 mg) in all patients but one. All patients required vasopressor and inotropic in two cases, however with low doses and adequate progressive withdrawal. No patient presented PONV or delirium in the first 48 hours.DiscussionOpioid-free anesthesia is a feasible strategy in patients undergoing CABG surgery, it gives an adequate depth anesthetic parameters keeping adequate hemodynamic stability, with an optimal control of both endocrine and metabolic changes and having acceptable time of stay in the intensive care unit with no increase in morbidity and mortality outcomes. We believe this experience gives the support to continue affording care of urgency cardiac surgery and could be extrapolated to non-cardiac surgery.

Correlation of preprocedural ultrasound estimated epidural depths in transverse median and posterior sagittal oblique view and body mass index with procedural epidural depths in patients scheduled for surgery under lumbar epidural anaesthesia.

Background and Aims:Preprocedural lumbar ultrasound (US) is employed for the estimation of epidural depth (ED). This study observed the correlation of preprocedural ED in transverse median (TM), parasagittal oblique (PSO) view, and body mass index (BMI) with procedural ED.Methods:In a prospective study, 100 female patients, aged 40–65 years, with American Society of Anesthesiologists physical status I/II, BMI 18.5–30 kg m−2 scheduled for surgeries under lumbar epidural blocks were included. In the TM group, preprocedural ultrasonography (USG) was performed in TM view and ED was calculated, whereas in the PSO group, the paramedian sagittal view was used and corresponding markings were done for epidural needle insertion in the midline and paramedian planes, respectively. The primary outcome was the correlation of procedural ED and preprocedural ED in TM and PSO views, respectively. The secondary outcomes included correlation of procedural ED with BMI, comparability of preprocedural, and procedural ED in TM and PSO views. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) v19.0 (International Business Machines, USA).Results:The preprocedural and procedural ED was less in the TM group (4.43 ± 0.75 and 4.44 ± 0.75 cm) in comparison to those in the PSO group (4.86 ± 0.53, 4.90 ± 0.54; P = 0.001). Strong correlation was observed in preprocedural and procedural ED [r2 = 0.996 and 0.995]. The procedural ED had strong correlation with BMI [r2 = 0.600, P = 0.001] in the TM group, and weak correlation [r2 = 0.367] in the PSO group [P = 0.01]. The procedural ED was comparable to preprocedural ED in TM and PSO groups.Conclusion:Preprocedural US scanning provides an accurate estimate of actual EDs in TM and PSO view.

Single-port Laparoscopy with Modified Needle Hook-assisted Extracorporeal High Ligation of Hernia Defects (Suwardi’s Technique): An Experience from Single-center Hospital

BACKGROUND: Laparoscopy has long been used for the evaluation of hernia defects on the contralateral side when performing herniated tears in children. In 1997, El Gohary first reported laparoscopic treatment of hernia repair in a female patient. Since then, laparoscopic inguinal hernia ligation has been performed in various medical institutions with a variety of methods including closing the defect intraperitoneally and extracorporeal ligation of the herniated ring defect. CASE PRESENTATION: Data were taken from January 2016 to December 2020 in the Pediatric Surgery Department of Dr. Moewardi General Hospital, Surakarta. A total of 22 cases, consisting of 19 boys and 3 girls aged 1–14 years (mean 5 years), underwent single-port laparoscopy with modified extracorporeal ligation of hernial defects using an epidural needle. From the results of surgery from January 2016 to December 2020, there were 22 patients with a follow-up period of 6 months who were carried out with a single port without the assistance of forceps and hydrodissection with a single-port laparoscopic technique that had been modified extracorporeally using an epidural needle and were able to evaluate the contralateral side. Thus, it shortened the operating period and the patient was able to be discharged 24 h postoperatively without any complications. CONCLUSION: From 22 patients who used single-port technique with modified extracorporeal ligation of hernia defects using epidural needles, the results were shorter operation time, without complications and satisfying cosmetic results.

Recent Updates in Obstetric Analgesia

Analgesia for a parturient is an important element of care provided by an anesthesiologist as a member of the multidisciplinary team. Neuraxial anesthesia is considered the gold standard. With increasing evidence of safety and efficacy of various available techniques and equipment, including ultra-short–acting opioids, local anesthetics, newer combined spinal–epidural needles, monitors, patient-controlled infusion pumps, and point-of-care ultrasound, obstetric care has become less challenging with higher patient satisfaction rates and better safety profiles. Recent articles spanning the last few years on important related topics, including care of the parturient during COVID, newer developments, enhanced recovery after cesarean (ERAC) protocols, and patients with unique profiles, are discussed in this update on obstetric analgesia.

Efficacy and safety of prophylactic intrathecal normal saline for prevention of Post Dural Puncture Headache among women undergoing cesarean section under spinal anesthesia: A randomized controlled trial

BackgroundPost-Dural Puncture Headache is the commonest complication of spinal anesthesia. Body of evidence revealed that Conservative management failed to show significant benefit and epidural needle and catheter techniques didn’t provide conclusive evidence. On the other hand, intrathecal injection of normal saline is a simple technique and cost-effective in a resource-limited setup but it is not well examined on its effectiveness and safety profiles. Methods and materialsAfter Obtaining Ethical clearance from IRB, 152 mothers scheduled for cesarean section under spinal anesthesia were allocated randomly into two groups. Data analysis was done with SPSS version 22. Descriptive statistics were run to see the overall distribution of the study subjects. Unpaired student’s T-test for continuous symmetric data and Mann-Whitney U test for non-normally distributed data were used. Categorical data were analyzed with Chi-square and fisher’s exact test where appropriate. A generalized estimating equation model was used to investigate the interaction of repeated measurements of NRS pain scores of PDPH. ResultThe overall incidence of PDPH was 29.6% while the proportion of patients who experienced PDPH was the highest among patients with control as compared to intervention( 36.8% vs 22%) respectively. The GEE model revealed that the NRS pain score was 0.7, 0.4, and 0.2 unit higher at 12, 24, and 48 respectively in control as compared to the intervention Conclusionprophylactic intrathecal normal saline could be an option in a resource-limited setup where the appropriate spinal needle is not accessible and management of moderate and severe PDPH is not feasible RegistrationThe protocol was registered prospectively in Clinical Trials.gov (NCT04393766).

A paramedian approach for dorsal root ganglion stimulation placement developed to limit lead migration and fracture.

Dorsal root ganglion stimulation (DRG-S), has demonstrated superiority in the treatment of complex regional pain syndrome and causalgia. Lead migration and fracture impact DRG-S therapeutic stability. Lead anchoring reduces DRG-S lead migration without increasing lead fracture. Lead fracture may be related to lead entrapment in the superficial fascial plane. A novel medialized approach for lead placement and anchoring is presented to address these issues. We suggest an alternative technique for implanting percutaneous DRG-S leads at the T10-L5 levels. A novel medialized ipsilateral technique for lead placement and anchoring for single, bilateral, and adjacent segment placement is presented. The Tuohy needle puncture site is medial to the pedicle and adjacent to the spinous process, two vertebral levels caudad to the target foramen. Trajectory is maintained in the sagittal plane, to access the caudad interlaminar space near the midline. This technique allows for ipsilateral or contralateral lead placement. After epidural access, the introducer sheath is rotated toward the targeted foramen and advanced. The guidewire followed by the lead is passed, and once lead position is confirmed, tension "S" loops are created, followed by anchoring to the deep fascia. We describe a new paramedian technique for DRG-S lead placement. We propose it will decrease DRG-S complication rates through anchoring to reduce migration and by avoiding the fascial planes thought to be responsible for fracture. Long-term outcomes applying our proposed techniques are required for determining the true impact, however, early anecdotal results suggest that these new techniques are favorable.

Radiating pain during epidural needle insertion and catheter placement cannot be associated with postoperative persistent paresthesia: a retrospective review

BackgroundIt has been suggested that radiating pain during spinal or epidural needle insertion and catheter placement can be an indicator of needle-related nerve injury. In this study, using a historical cohort, we investigated what factors could be associated with postoperative persistent paresthesia. In addition, we focused on radiating pain during epidural needle insertion and catheterization.MethodsThis was a retrospective review of an institutional registry containing 21,606 anesthesia cases. We conducted multivariate logistic analysis in 2736 patients, who underwent epidural anesthesia, using the incidence of postoperative persistent paresthesia as a dependent variable and other covariates, including items of the anesthesia registry and the postoperative questionnaire, as independent variables in order to investigate the factors that were significantly associated with the risk of persistent paresthesia.ResultsOne hundred and seventy-six patients (6.44%) were found to have persistent paresthesia. Multivariate analysis revealed that surgical site at the extremities (odds ratio (OR), 12.5; 95% confidence interval (CI), 2.77–56.4; the reference was set at abdominal surgery), duration of general anesthesia (per 10 min) (OR, 1.02; 95% CI, 1.01–1.03), postoperative headache (OR, 1.78; 95% CI, 1.04–2.95), and days taken to visit the consultation clinic (OR, 1.03; 95% CI, 1.01–1.06) were independently associated with persistent paresthesia. Radiating pain was not significantly associated with persistent paresthesia (OR, 1.56; 95% CI, 0.69–3.54).ConclusionRadiating pain during epidural procedure was not statistically significantly associated with persistent paresthesia, which may imply that this radiating pain worked as a warning of nerve injury.