Aysu Kocum

Femoral and sciatic nerve block with 0.25% bupivacaine for surgical management of diabetic foot syndrome: an anesthetic technique for high-risk patients with diabetic nephropathy

A case series of patients with diabetic nephropathy, who underwent lower limb debridement or amputation below the knee during successful combined sciatic and femoral nerve block with bupivacaine 0.25%, is presented. Because impaired nerve conduction in diabetes mellitus results in lower local anesthetic agent requirement, a dose-sparing, minimal effective concentration for surgical anesthesia for peripheral nerve blockade may be more favorable for patients with diabetes and chronic renal disease.

A combination of ketamine and dexmedetomidine sedation with caudal anesthesia during incarcerated inguinal hernia repair in three high-risk infants

indicated because of a suspected intestinal perforation. His general condition was bad, tachypnoic, with an enlarged abdomen. His BW was 3350 g. Laboratory results were normal, but for a low level of thrombocytes. He received one dose of platelets before the operation. We performed balanced anesthesia. For fluid replacement, besides cristaloids with albumin 20%, he received erythrocytes, FFP and HES 130 ⁄ 0.4, 20 mLÆh. The operation lasted 4 h. The patient was stable during the operation. Laboratory values and coagulation status remained unchanged. Hydroxyethyl starch 130 ⁄ 0.4 is a relatively new colloid, approved by the FDA on 27 December 2007. It is a poly (O-2-hydroxyethyl) starch in 0.9% NaCl, with an average molecular weight of 130 000 D and a degree of substitution of 0.4 (HES 130 ⁄ 0.4) and osmolality 308 mOsmol l. When compared with albumin, it is seven times cheaper. Standl et al. (1) reported that there is no difference regarding perioperative stabilization of hemodynamics, coagulation parameters, blood gas analyses and other laboratory values between albumin and HES 130 ⁄ 0.4 in children. Moreover they claimed no significant differences in the amount of red blood cells, fresh frozen plasma or platelet concentrations in the two groups. We report two neonates who underwent major surgeries and received HES 130 ⁄ 0.4 along with albumin. Patients were stable during and after the operation. There were no changes in the coagulation status (platelet count, bleeding time, coagulation time, prothrombin time and partial thromboplastin time), although some larger investigations reported some changes (2). No other adverse events occurred. A question remains on the use of colloids vs crystalloids for fluid resuscitation in cricitally ill patients (3), and also which colloid solution is the best (4), particularly in relation to newborns. This case report shows that using HES 130 ⁄ 0.4 can be useful in newborns who undergo major surgeries, with no significant adverse effects, especially in a situation when one does not have other preferable colloids and blood or blood products at one’s disposal. Further studies are needed in this regard. Irina Milojevic* Dusica Simic† Marija Markovic* Ivana Budic *Department of Anesthesiology, University Children’s Hospital, Belgrade, Serbia †ICU, University Children’s Hospital, Belgrade, Serbia ‡Department of Anesthesiology, Children’s Hospital, Nis, Serbia (email: mirina@sbb.co.yu) References

Intravenous paracetamol and dipyrone for postoperative analgesia after day-case tonsillectomy in children: a prospective, randomized, double blind, placebo controlled study

UNLABELLEDnTonsillectomy is associated with severe postoperative pain for which, several drugs are employed for management.nnnOBJECTIVEnIn this double-blind, placebo-controlled study we aimed to evaluate the efficacy of intravenous paracetamol and dipyrone when used for post-tonsillectomy analgesia in children.nnnMETHODn120 children aged 3-6 yr, undergoing tonsillectomy with or without adenoidectomy and/or ventilation tube insertion were randomized to receive intraoperative infusions of paracetamol (15 mg/kg), dipyrone (15 mg/kg) or placebo (0.9% NaCl). Evaluation was carried out at 0.25, 0.50, 1, 2, 4, 6h postoperatively. Pethidine 0.25 mg/kg was utilized as rescue analgesic. Cumulative pethidine requirement was the primary outcome. Pain intensity measurement, pain relief, sedation level, nausea and vomiting, postoperative bleeding and any other adverse effects were noted.nnnRESULTSnNo significant difference was found in pethidine requirement between paracetamol and dipyrone groups. Cumulative pethidine requirement was significantly less in paracetamol and dipyrone groups vs. placebo. No significant difference was observed between groups in postoperative pain intensity scores throughout the study.nnnCONCLUSIONnIntravenous paracetamol is found to have a similar analgesic efficacy as intravenous dipyrone and they both help to reduce the opioid requirement for postoperative analgesia in pediatric day-case tonsillectomy.

Comparison of ropivacaine 0.2% and 0.25% with lidocaine 0.5% for intravenous regional anesthesia

STUDY OBJECTIVEnTo compare the anesthetic effects of two different concentrations and doses of ropivacaine (0.2% and 0.25%) with those of a conventional dose of lidocaine 0.5%.nnnDESIGNnProspective, randomized, double-blinded, clinical investigation.nnnSETTINGnLarge metropolitan university hospital.nnnPATIENTSn66 adult ASA physical status I and II patients undergoing forearm and hand surgery.nnnINTERVENTIONSnPatients were randomly allocated to three groups to receive intravenous regional anesthesia (IVRA). Study groups were: ropivacaine 0.2% (Group I, n = 22), ropivacaine 0.25% (Group II, n = 22), and lidocaine 0.5% (Group III, n = 22).nnnMEASUREMENTSnTourniquet tolerance times and regression of sensory analgesia were noted. Verbal numerical pain scores (VNS), cumulative analgesic consumption, and side effects were recorded during surgery and postanesthesia care unit (PACU). Time to first pain medication intake and number of patients receiving analgesics in the PACU were recorded.nnnMAIN RESULTSnAdditional tolerance times for the distal tourniquet were significantly higher in the ropivacaine 0.25% group than the other two groups. Regression of sensory anesthesia was fastest in the lidocaine group. During the PACU stay, VNSs were significantly lower in the first 20 minutes in the ropivacaine groups than the lidocaine group. Time to first intake of pain medication in the PACU was soonest in the lidocaine group. The number of patients given analgesics in the PACU was highest in the lidocaine group. The number of patients taking > two tablets of tramadol was significantly lowest in the ropivacaine 0.25% group. No serious side effects were observed in any study group.nnnCONCLUSIONnLonger tolerance times for the distal tourniquet, prolonged analgesia after tourniquet release, and lower analgesic requirements postoperatively make ropivacaine 0.2% and 0.25% an alternative to lidocaine for IVRA.

An Alternative Central Venous Route for Cardiac Surgery: Supraclavicular Subclavian Vein Catheterization

OBJECTIVEnTo evaluate the clinical success rate, safety, and usefulness for intraoperative central venous pressure monitoring, and the intravenous access of the supraclavicular subclavian vein approach when compared with the infraclavicular subclavian vein approach and the internal jugular vein approach for central venous catheterization during open-chest cardiac surgery.nnnDESIGNnA prospective, randomized, single-center study.nnnSETTINGnA university hospital.nnnPARTICIPANTSnOne hundred ninety-five patients scheduled for open-chest cardiac surgery.nnnINTERVENTIONSnThe study population consisted of patients for whom central vein catheterization was intended during cardiac surgery. Patients were randomized to 3 groups according to the route of central vein catheterization: the supraclavicular group: the supraclavicular approach for the subclavian vein (n = 65); the infraclavicular group: the infraclavicular approach for the subclavian vein (n = 65); and the jugular group: the internal jugular vein approach (n = 65). After the induction of anesthesia, central venous catheterization was performed according to the assigned approach.nnnMEASUREMENTS AND MAIN RESULTSnThe success rates for the assigned approach were 98%, 98%, and 92% for the supraclavicular, infraclavicular, and jugular groups, respectively (p > 0.05). The success rates in the first 3 attempts in patients who were catheterized successfully according to the assigned approach were 96%, 100%, and 96% for the supraclavicular, infraclavicular, and jugular groups, respectively (p > 0.05). There was no difference among groups in catheter insertion time (p > 0.05). After sternal retraction, central venous pressure trace loss and difficulty in fluid infusion were significantly more frequent in the infraclavicular group (21%) when compared with the supraclavicular (3%) and jugular groups (0%) (p = 0.01). There was no difference among groups in terms of catheter malposition, complications during catheterization, and rate of catheter-related infection.nnnCONCLUSIONnThe supraclavicular approach for subclavian vein catheterization is an acceptable alternative for central venous access during cardiac surgery in terms of procedural success rate, ease of placement, rate of complications, and usability after sternal retractor expansion.

Duchenne muscular dystrophy: how I do it? Regional or general anesthesia?

1 Allegaert K, Naulaers G. Procedural sedation of neonates with chloral hydrate: a sedation procedure does not end at the end of the acquisition of images. Paediatr Anaesth 2008; 18: 1270– 1271. 2 Beauve B, Dearlove O. Sedation of children under 4 weeks of age for MRI examination. Paediatr Anaesth 2008; 18: 892–3. 3 Allegaert K, Daniels H, Naulaers G et al. Pharmacodynamics of chloral hydrate in former preterm infants. Eur J Pediatr 2005; 164: 403–7. 4 Cote C, Zaslavsky X, Downes JJ et al. Postoperative apnea, airway obstruction in former preterm infants after inguinal herniorraphy. Anesthesiology 1995; 82: 809–22.

Comparison of Intrathecal Levobupivacaine Combined with Sufentanil, Fentanyl, or Placebo for Elective Caesarean Section: A Prospective, Randomized, Double-Blind, Controlled Study ☆

Background The addition of opioids to local anesthetics contributes to the quality of spinal anesthesia and postoperative analgesia. Objective In our prospective, randomized, double-blind, controlled study, our aim was to compare the effect of low-dose sufentanil plus levobupivacaine or a fentanyl plus levobupivacaine mixture on anesthesia quality, block characteristics, newborn and mother well-being, surgeon satisfaction, and duration of postoperative analgesia. Methods Ninety-three patients were randomized into 3 groups (n = 31). Patients in Group C received 0.5% levobupivacaine (2.2 ± 0.2 mL), Group S received 2.5 µg sufentanil plus 0.5% levobupivacaine (2.2 ± 0.2 mL), and Group F received 10 µg fentanyl plus 0.5% levobupivacaine (2.2 ± 0.2 mL) intrathecally completed to a volume of 3 mL with the addition of saline in all groups. Patients’ demographics, sensory and motor block characteristics, hemodynamics, Apgar scores, umbilical blood gas values, maternal side effects, surgeon satisfaction score, time to first analgesia requirement, and additional analgesic use within 24 hours were recorded. Results In Group S and Group F, target levels of sensory and motor block were achieved more rapidly (P < 0.001). The hemodynamic values were lower (P < 0.05), and the duration of sensory blockade and the time of first analgesic requirement were longer (P < 0.001) in Group S. Additional analgesic requirement during first 24-hour period was lowest in Group S, and highest in Group C (P < 0.001). Apgar scores and umbilical blood gas samples were similar between groups. Postoperative pruritus was more frequent in Group S (P < 0.001) and surgeon satisfaction score was significantly lower in Group C (P = 0.003). Conclusions We suggest that the addition of sufentanil and fentanyl to intrathecal levobupivacaine during caesarean section surgery is more effective than the administration of levobupivacaine alone. The addition of sufentanil to levobupivacaine allowed rapid onset time for sensory and motor block levels. It also extended the duration of postoperative analgesia and led to a decrease in total analgesic requirement. ClinicalTrials.gov identifier: NCT01858090.

The efficacy of intravenous paracetamol versus dipyrone for postoperative analgesia after day-case lower abdominal surgery in children with spinal anesthesia: a prospective randomized double-blind placebo-controlled study

BackgroundA multimodal and preventative approach to providing postoperative analgesia is becoming increasingly popular for children and adults, with the aim of reducing reliance on opioids. We conducted a prospective, randomized double-blind study to compare the analgesic efficacy of intravenous paracetamol and dipyrone in the early postoperative period in school-age children undergoing lower abdominal surgery with spinal anesthesia.MethodsSixty children scheduled for elective lower abdominal surgery under spinal anesthesia were randomized to receive either intravenous paracetamol 15xa0mg/kg, dipyrone 15xa0mg/kg or isotonic saline. The primary outcome measure was pain at rest, assessed by means of a visual analog scale 15xa0min, 30xa0min, 1xa0h, 2xa0h, 4xa0h and 6xa0h after surgery. If needed, pethidine 0.25xa0mg/kg was used as the rescue analgesic. Time to first administration of rescue analgesic, cumulative pethidine requirements, adverse effects and complications were also recorded.ResultsThere were no significant differences in age, sex, weight, height or duration of surgery between the groups. Pain scores were significantly lower in the paracetamol group at 1xa0h (Pu2009=u20090.030) and dipyrone group at 2xa0h (Pu2009=u20090.010) when compared with placebo. The proportion of patients requiring rescue analgesia was significantly lower in the paracetamol and dipyrone groups than the placebo group (vs. paracetamol Pu2009=u20090.037; vs. dipyrone Pu2009=u20090.020). Time to first analgesic requirement appeared shorter in the placebo group but this difference was not statistically significant, nor were there significant differences in pethidine requirements, adverse effects or complications.ConclusionAfter lower abdominal surgery conducted under spinal anesthesia in children, intravenous paracetamol appears to have similar analgesic properties to intravenous dipyrone, suggesting that it can be used as an alternative in the early postoperative period.Trial registrationClinical Trials.gov. Identifier: NCT01858402.

Intrathecal catheterization after unintentional dural puncture during orthopedic surgery

PurposeWe investigated whether inserting an intrathecal catheter and leaving it in place for 24xa0h after an unintentional dural puncture in orthopedic patients reduced the incidence of post-dural puncture headache (PDPH).MethodsThe study consisted of 427 patients in whom a total of 21 unintentional dural punctures had occurred during orthopedic surgery performed between 2002 and 2006. Seven patients (phase I; evaluated retrospectively) each underwent placement of an epidural catheter at another level after dural puncture during the period January 2002 to February 2004. Fourteen patients (phase II; evaluated prospectively) received an epidural catheter through the dural tear after an unintentional dural puncture during the period February 2004–March 2006ResultsIn phase I, 5 of the 7 patients experienced PDPH, and one required an epidural blood patch. In phase II, only one of the 14 patients complained of PDPH, which resolved after 48xa0h of medical therapy. No patient experienced paresthesia, neurologic or hemorrhagic complication, or infection.ConclusionInserting an epidural catheter through the dural tear following an unintentional dural puncture and leaving it in place for 24xa0h significantly reduces the incidence of PDPH.

Spinal anesthesia for inguinal hernia repair in 8-year-old child with myasthenia gravis

SIR—Myasthenia gravis (MG) is an autoimmune disease characterized by weakness and fatigue of the voluntary muscles, because of the presence of acetylcholine receptor antibodies (1). The incidence is 2–10 ⁄ 100 000 cases per year (2). Children account for 11–29% of all patients with MG (3). Anesthesia concerns for MG patients focus on avoiding muscle relaxants and monitoring for postoperative respiratory failure. The use of regional or local anesthesia seems warranted whenever possible. Spinal anesthesia has advantages of reduced drug dosage, profound sensory and motor block, lack of systemic effects, avoidance of tracheal intubation and decreased need for opioid administration (4). Although spinal anesthesia is widely used in the pediatric age group, surprisingly we have not seen any report concerning its use in a myasthenic child. This report describes a pediatric case with MG, who underwent successful inguinal hernia repair under spinal anesthesia. An 8-year-old, 25-kg girl with MG presented for inguinal hernia repair. She had MG for 3 years and was classified as Osserman (5) Grade IIa with obvious ptosis and mild generalized weakness. She was taking pyridostigmine 15 mg five times daily. On the day of surgery, the morning dose of pyridostigmine was continued and no other premedication was given. An infusion of 0.5% dextrose and 0.2% sodium NaCl was given at a rate of 5 mlÆkg hÆ6 h before anesthesia and continued throughout the operation. Following the establishment of routine monitoring, the patient was sedated with 2-mg midazolam i.v. Oxygen was administered at 3 lÆmin by facemask. She was placed in a lateral decubitus position and after an additional doses of 1-mg midazolam, lumbar puncture was performed using a midline approach at the L5-S1 intervertebral space with a 27 gauge 90-mm Whitacare pencil point spinal needle (Becton Dickinson, S. Agustin del Guadalix, Madrid, Spain); 1.6 ml 0.5% hyperbaric bupivacaine was given intrathecally. In the supine position, bilateral motor block occurred within 2 min and sensory block was achieved approaching T6-7 level verified by pin prick test after 5 min. She remained comfortable and hemodynamically stable throughout the 45 min of surgery, which was uneventful. Postoperatively, she was monitored in the recovery room until regression of the sensory block and after complete resolution of the sedation she was transferred to the pediatric surgery ward. Sensory and motor function completely recovered 2 h after the surgical procedure. The patient had only one episode of nausea in the postoperative first hour and was discharged from the hospital 6 h later. Overall no complication occurred. Several studies have been published on the use of spinal anesthesia in high-risk newborns and infants at risk of postoperative apnea (6,7) and also for older children with muscular and neuromuscular disease which increase risk of postoperative respiratory failure (4). Caudal-epidural block with inhalation anesthesia is the most commonly used regional anesthetic technique in children. However, this requires a higher volume of local anesthetic and the use of inhalation anesthesia (8). Potentiation of neuromuscular blocking drugs by local anesthetics has been reported. These agents decrease the sensitivity of the postjunctional membrane to acetylcholine, which causes weakness in myasthenia. Ester anesthetics, which are metabolized by cholinesterase, may cause problems particularly in patients taking anticholinesterases. Regional and local anesthesia should be performed using reduced doses of amide, rather than ester, local anesthetics to avoid high blood levels of drug in circulation (1). Spinal anesthesia produces excellent block with light sedation levels maintaining protective airway reflexes (8) and provides an appropriate alternative regional anesthesia method. However, high-spinal anesthesia should be particularly avoided in patients with MG because it may lead to deterioration of intercostal muscle movement. Using intrathecal opioids should be avoided to minimize the risk of respiratory muscle weakness and central respiratory depression in these patients. It is controversial whether anticholinesterase therapy should be maintained or discontinued before surgery (9,10). Anticholinesterases may potentiate vagal responses and increase bronchial secretions. Anticholinesterase drugs can also inhibit plasma cholinesterase activity with a subsequent decrease in the metabolism of ester local anesthetics (9). We decided to continue anticholinesterase therapy before surgery in this patient. As the block level did not rise higher than the T6 level and respiratory reflexes were intact throughout, we did not need to administer atropine and this prevented any complication that might arise secondary to this drug. In children, sufficient duration of anesthesia for surgery is consistently less than seen in adults. In the report of Dohi et al. (11), motor function returned after a mean of 114 min in children aged over 5 years compared with 336 min in adults. The reasons are unclear but presumably include age-related differences in cerebrospinal fluid volume, diameter and surface area of the spinal cord and nerve roots and rate of absorption of local anesthetic from 1220 CORRESPONDENCE