FRCPCPurpose: To examine the reliability of low current electrical epidural stimulation to confirm epidural catheter placement. Methods: Forty patients with epidural catheters (I 9G Arrow Flextip plus) already in place for post-operative pain management were studied. An adapter (Arrow-Johans ECG Adapter) was attached to the connector of the epidural catheter. The epidural catheter and adapter were filled with normal saline. The cathode lead of the nerve stimulator was attached to the metal hub of the adapter. Catheter placement was judged to be correct or incorrect, depending upon the presence or absence of truncal or limb movement to I Hz stimulation (I -10 mA). A standard test dose (3 ml lidocaine 1.5% with 1:200,000 epinephrine) was then injected. The efficacy of the epidural morphine was assessed independently. Results: The sensitivity and specificity of the test was 100% and 91.6% compared with the standard test dose. The positive and negative predictive value was 96% and 100%. In predicting the clinical effect of epidural morphine, the sensitivity and specificity was 96. I% and 76.9%. The positive and negative predictive value was 89% and 90%. The correlation of unilateral or bilateral motor response from the test and sensory response from the lidocaine test with sensitivity and specificity was 91.6% and 53.0%. The predictive value for unilateral response was 61% and for bilateral was 88%. Conclusion: This study establishes this test as a simple, objective and reliable technique for confirmation of epidural catheter placement.Objectif: D&erminer la fiabilit~ d'une stimulation p&idurale ~lectrique de faible intensit~ utilis~e pour confirmer la raise en place d'un cath&er p&idural. M&hode : Quarante patients, ~. qui on avait d~j~ install~ un cath&er p&idural (Arrow Flex-tip plus 19G) pour traiter la douleur post op&atoire, ont particip~ ~ I'&ude. Un adaptateur (Arrow-Johans EXG Adapter) a ~t~ fix~ au connecteur du cath&er. Ce cath&er et I'adaptateur ont ~t~ remplis de s&um physiologique. I'~lectrode cathodique du neurostimulateur a ~t~ fix~e ~ la garde m~tallique de I'adaptateur. La mise en place du cath&er &ait jug~e correcte ou incorrecte selon la pr&ence ou I'absence d'un mouvement du tronc ou d'un membre une stimulation de I Hz (I-10 mA). Une dose-test standard (3 ml de lidocaine ~ 1,5 % avec I : 200 000 d'~pin~phrine) a ~t~ inject~e par la suite. Eefficacit~ de la morphine p&idurale a ~t~ &alu~e s~par~ment. R&ultats : La sensibitit~ et la sp&ificit~ du test &aient de 100 % et de 91,6 % en comparaison avec la dosetest standard. Les valeurs de la prediction positive et n~gative ~taient de 96 % et de 100 %. Concemant la pr~-diction de I'effet clinique de la morphine p6ridurale, la sensibilit~ et la sp~cificit~ &aient de 96, 1% et de 76,9 %. Les valeurs de la prediction positive et n~gative &aient de 89 % et 90 %. La corr&tion entre une r~ponse motrice unilat&ale ou bilat&ale au test et une r~ponse sensorielle au test de lidocaine avec sensibilit~ et sp&i-ficit~ &ait de 91,6 % et 53,0 %. La valeur predictiv...

No abstract

Purpose To determine the effect of adjunctive epidural local anesthetic and opioid infusion on disease recurrence following radical prostatectomy for adenocarcinoma under general anesthesia. Methods This article describes a secondary analysis of subjects undergoing radical prostatectomy who had participated previously in a randomized controlled trial evaluating pain control, blood loss, and the need for perioperative allogeneic blood transfusion. The patients were randomly allocated to receive either general anesthesia alone (control group; n = 50) or combined general/ epidural anesthesia (study group; n = 49). A long-term follow-up chart review was undertaken to determine clinically evident or biochemical (Prostate Specific Antigen [0.2 ng Á mL -1 ) recurrence of prostate cancer. Comparison by group was undertaken using survival analysis.Results Median disease-free survival for the study as a whole was 1644 days, and the longest recorded survival was 3403 days. Biochemical recurrence of prostate cancer was observed in 11/49 study subjects and 17/50 control subjects. There was one death from prostate cancer in each group and a total of five deaths in the study group and six deaths in the control group. The hazard ratio for recurrence in the study group compared with the control group was 1.33 (95% confidence intervals 0.64-2.77; P = 0.44 by log-rank test). Conclusion No difference was observed between the epidural and control groups in disease-free survival at a median follow-up time of 4.5 years. There is a need for large randomized controlled trials to determine the ability of epidural analgesia to alter disease recurrence rates following radical prostatectomy. RésuméObjectif De´terminer l'effet d'une the´rapie adjuvante d'anesthe´sique local pe´ridural et perfusion d'opioı¨des sur la re´currence de la maladie apre`s une prostatectomie radicale pour ade´nocarcinome sous anesthe´sie ge´ne´rale. Méthode Cet article de´crit une analyse secondaire de patients ayant subi une prostatectomie radicale, lesquels avaient pre´ce´demment participe´a`une e´tude randomise´e contrôle´e e´valuant le contrôle de la douleur, les pertes sanguines et le besoin de transfusions sanguines alloge`nes en pe´riode pe´riope´ratoire. Les patients ont e´te´randomise´s a`recevoir soit une anesthe´sie ge´ne´rale seule (groupe te´moin; n = 50) ou une combinaison d'anesthe´sie ge´ne´rale et pe´ridurale (groupe a`l'e´tude; n = 49). Une re´vision des dossiers de suivi a`long terme a e´te´entreprise afin de

It is well documented that a higher electrical current is required to elicit a motor response following a normal saline (NS) injection during the placement of stimulating catheters for peripheral nerve block. We present three cases of continuous brachial plexus catheter placement in which Dextrose 5% in water (D5W) was used to dilate the perineural space instead of NS. Three brachial plexus blocks (two interscalene and one axillary) were performed in three different patients for pain relief. In each case, an insulated needle was advanced towards the brachial plexus. A corresponding motor response was elicited with a current less than 0.5 mA after needle repositioning. A stimulating catheter was advanced with ease after 3-5 ml of D5W was injected to dilate the perineural space. A corresponding motor response was maintained when the current applied to the stimulating catheter was less than 0.5 mA. Local anesthetic was then injected and the motor response immediately ceased. All blocks were successful and provided excellent pain relief with the continuous infusion of local anesthetics.