TAP blocks increased anaesthesia time by 14 min on average but offered no clinically important benefit over local anaesthetic port-site infiltration to paediatric patients undergoing laparoscopic appendicectomy.
We describe a technique for using a portable ultrasound scanner (38 mm broadband (10-5 MHz) linear array transducer (Sonosite Titan® SonoSite, Inc. 21919 30th Drive SE Bothell, W.A.)) to guide dorsal penile nerve block in children under general anaesthesia. Real-time scanning is used to guide bilateral injections into the subpubic space, deep to Scarpa's fascia either side of the midline fundiform ligament. Scanning can confirm that the local anaesthetic has spread to contact the deep fascia on each side. A subcutaneous wheal of local anaesthetic along the penoscrotal junction completes the block.
Safe and effective regional anaesthesia requires local anaesthetics to be placed in close proximity to nerves without injury to the target nerves or adjacent structures. In this region, postoperative analgesia for male circumcision in children has commonly been provided by a landmark-based dorsal penile nerve block (DPNB-LM) or by caudal epidural analgesia (CEA). Recently, we described a new technique of ultrasound-guided dorsal penile nerve block (DPNB-US) 1. This report describes a retrospective analysis of the effectiveness and safety of these three analgesic techniques in our institution over a six-year period. MATERIALS AND METHODS After approval from the institutional research and ethics committee, a retrospective audit was performed to compare analgesic techniques used for all patients presenting for circumcision surgery between January 2001 and August 2007 with the same anaesthetist (first investigator) and surgeon (third investigator). Blocks were performed by either the first investigator or an anaesthesia trainee under the supervision of the first investigator. Information was gathered from each patient's medical record. All records and required information were present. During this period, one of three different regional anaesthetic techniques was utilised for postoperative analgesia in combination with general anaesthesia: CEA, DPNB-LM and DPNB-US. Choice of regional anaesthetic technique reflected three different periods in the practice of the first investigator. From 1997 until 2002 this was primarily DPNB-LM (thus the audit period included the last portion of this period), from 2002 until 2006 CEA, and from 2006 until August 2007 DPNB-US. The nerve blocks were all placed after induction of general anaesthesia. The clinical data audited included patient demographics, preoperative medications, intraoperative opioid administration, administration of morphine in the recovery ward, total dose of * F.
Serious complications from tricyclic antidepressant (TCA) overdose are uncommon 1,2,3. We present a case of massive imipramine overdose complicated by ventricular fibrillation and a prolonged period of cardiovascular collapse. A total of 400 mmol of sodium bicarbonate, 5 mg of adrenaline and 80 mg of sotalol were given during 50 minutes of cardiac arrest. The patient made a full recovery with no apparent neurological sequelae. The highest TCA plasma level we could find in the published literature was 4873 ng/ml 4 ; our patient's peak TCA level was 6000 ng/ml. Tricyclic antidepressant overdose is a common cause of intensive care unit admission. It has a low mortality rate.
Postoperative analgesia for male circumcision surgery has been traditionally provided by a landmark based Dorsal Penile Nerve Block (DPNB‐LM) (1) or by Caudal Epidural Analgesia (CEA). In this study we report on a retrospective analysis of the effectiveness and safety of CEA, DPNB‐LM and Dorsal Penile Nerve block – Ultrasound guided (DPNB‐US) in our institution over a 6 year period. Information was gathered from each patient's medical record. A total of 216 circumcisions were performed on patients aged from 5 months to 15 years. A total of 115 patients received CEA, 46 DPNB‐LM and 55 DPNB‐LM. Patients in the DPNB‐LM group required rescue morphine administration in the Recovery unit more frequently (30.4%) than either the DPNB‐US (3.5%) or CEA groups (3.6%). Similarly, the DPNB‐LM group required a larger total dose of morphine, and had longer recovery ward stays than CEA or DPNB‐US groups. Time to first analgesia was greatest for the CEA group whilst there was no significant difference between time to first analgesia for DPNB‐LM and DPNB‐US. About 63% of patients in the DPNB‐LM group, 1.7% of CEA and 5.5% of the DPNB‐US required intraoperative opiates (P<0.0001). There was no difference in time to hospital discharge.
Patient demographics, premedication and procedure duration
CEA n = 115 DPNB‐LM n = 46 DPNB‐US n = 55 P‐value (mean comparison byanova, proportions by Chi‐square)
ASA 1 (n) (%)106 (92.2)41 (89.1)46 (83.6)0.5Mean weight in (kg) ±sd14 ± 623 ± 1721 ± 17<0.0001Mean age (years) ±sd3 ± 25 ± 45 ± 4<0.0001Paracetamol premedication (n) (%)109 (95)46 (100)49 (89)0.06Midazolam premedication (n) (%)92 (80)29 (63)39 (71)0.07Mean duration of procedure in (min) ±sd49 ± 1150 ± 1451 ± 120.64
Outcomes
Outcomes CEA n = 115 DPNB‐LM n = 46 DPNB‐US n = 55 P‐value Difference (confidence interval) and individual P‐value after correction for multiple comparison
Patients requiring morphine in recovery (%)4 (3.6)14 (30.4)2 (3.5)<0.0001Mean morphine in recovery (μg/kg ±sd)1.7 ± 10.116.9 ± 39.20.5 ± 2.7<0.001DPNB‐LM v Caudal 15.2 (7.1‐23.2) (P<0.0001)DPNB‐LM v DPNB‐US 16.4 (7.2‐25.6) (P=0.0001)DPNB‐US v Caudal 1.2 (‐6.3‐8.8) (P=0.9)Mean Duration of recovery ward stay (min) ±sd69 ± 2384 ± 4962 ± 160.0009DPNB‐LM v Caudal 14.8 (2.6‐26.9) (P=0.01)DPNB‐LM v DPNB‐US 22.1 (8.2‐36.0) (P=0.0007) DPNB‐US v Caudal 7.3 (‐4.1‐18.7) (P=0.3)Mean Time to first analgesia (min) ±sd179 ± 8990 ± 76132 ± 680.0004DPNB‐LM v Caudal 89.5 (38.2‐140.8) (P=0.0002)DPNB‐LM v DPNB‐US 42.1 (11.1‐95.2) (P=0.2) DPNB‐US v Caudal 47.4 (‐3.8‐98.7) (P=0.0.08)Intraoperative opiates (n) (%)2 (1.7%)29 (63%)3 (5.5%)<0.0001Mean Time to hospital discharge (min) ±sd273 ± 137296 ± 189250 ± 1580.3PONV requiring treatment (n)10500.06
Reference
1 Sandeman DJ, Dilley AV. Ultrasound guided dorsal penile nerve block in children. Anaesth Int Care 2007; 35(2): 266–269.
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