The current literature provides fundamental insights regarding the neurotoxic potency of various general anesthetic drugs in neonates and small infants. Therefore, considerations to minimize the use of general anesthetic drugs in this age group are required. The use of caudal and epidural anesthesia under sedation is one possibility to minimize the use of general anesthetic drugs. A large number of surgical procedures can be managed with this anesthetic concept. Training, practical hand skills, good infrastructure, a well-defined indication, and a team approach including the entire operation room staff are the major prerequisites to implement these techniques in the daily clinical practice. This review article discusses all present aspects and possible future evolutions of caudal and epidural anesthesia under sedation.
SummaryEffective pain therapy after shoulder surgery is the main prerequisite for safe management in an ambulatory setting. We evaluated adverse events and hospital re-admission using a database of 509 interscalene catheters inserted during ambulatory shoulder surgery. Adverse events were recorded for 34 (6.7%) patients (9 (1.8%) catheter dislocations diagnosed in the recovery room, 9 (1.8%) catheter dislocations at home with pain, 2 (0.4%) pain without catheter dislocation, 1 (0.2%) 'secondary' pneumothorax without intervention and 13 (2.6%) other). Twelve (2.4%) patients were re-admitted to hospital (8 (1.6%) for pain, 2 (0.4%) for dyspnoea and 2 (0.4%) for nausea and vomiting), 9 of whom had rotator cuff repair. A well-organised infrastructure, optimally trained medical professionals and appropriate patient selection are the main prerequisites for the safe, effective implementation of ambulatory interscalene catheters in routine clinical practice.
Based on our pharmacodynamic and pharmacokinetic results, we suggest that the body weight of 50 kg it is feasible to perform effective and safe caudal blockade in children up to 50 kg body weight.
Objective/Background:Ultrasound (US) facilitates central venous catheter (CVC) placement in children. A new supraclavicular approach using the brachiocephalic vein (BCV) for US-guided CVC placement in very small children has been recently described. In 2012, we changed our departmental standard and used the left BCV as preferred puncture site during CVC placement. In our retrospective analysis, we compared US-guided cannulation of the BCV with other puncture sites (control).Design/Materials and Methods:We performed a retrospective analysis of all CVC cannulations from October 2012 to October 2013 in our department. For cannulation of the BCV, the in-plane technique was used to guide the needle into the target vein.Results:We performed CVC cannulations in 106 children (age 1-day to 18 years). In 29 patients, the weight was <4.5 kg. CVC placement was successful in all patients. The left BCV could be used in 81.1% of all cases. In a Poisson regression model of punctures regressed by age, weight or group (left BCV vs. control), age, weight or the cannulation site did not influence the number of punctures. In a logistic regression model of complications (yes vs. no) regressed by the group (left brachiocephalic vs. control) an odds ratio of 0.15 was observed (95% confidence interval 0.03-0.72, P likelihood ratio test = 0.007).Conclusion:US-guided puncture of the left BCV is a safe method of CVC placement in children. The use of the left BCV was associated with a high success rate in our retrospective analysis.
SummaryThis observational study was designed to investigate the anatomical changes of the lumbar spine over the course of pregnancy using serial ultrasound scans. We performed paramedian scans on 58 women at the L2-3, L3-4 and L4-5 levels; these were done at four periods of 11+0-13+6, 19+0-23+0, 28+0-32+0 and 38+0-40+0 weeks gestation. At each intervertebral level, the length of the interlaminar space, length of the visible intervertebral posterior dura and depth of the posterior dura mater from the skin were measured. The length of the interlaminar space and length of the visible intervertebral posterior dura mater were longer, and the depth of the posterior dura mater was shallower, with ascending spinal interspace. The depth of the posterior dura mater increased during pregnancy, although it plateaued between the third and fourth measurement periods. The other spinal measurements were not affected by gestation. These findings indicate that the L2-3 level is the most appropriate puncture site for epidural anaesthesia in pregnant women. Our results ought to be embraced as a departure point towards developing neuraxial insertion techniques guided or aided by ultrasound.
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