Funda Gok

Spinal needle design and size affect the incidence of postdural puncture headache in children

Background:  In adults, pencil point spinal needles are known to be less traumatic and hence to be superior compared with cutting point needles in respect of postpuncture complications. In children, only a few trials have evaluated the difference in the incidence of postdural puncture headache (PDPH) using spinal needles with different tip designs. The aim of this study was to evaluate the success rate and the incidence of PDPH and backache following spinal anesthesia (SA) with the two types of needles currently in use for children.

The effects of 45 degree head up tilt on the lumbar puncture success rate in children undergoing spinal anesthesia

Background:  There are few studies for procedural techniques of lumbar puncture (LP) for spinal anesthesia in children. There are no controlled studies on the effect of patient positioning. We designed this prospective, randomized study to compare the success rates of LP of the lateral decubitus and lateral decubitus position with a 45 degree head up tilt in children undergoing spinal anesthesia.

Ultrasound-Guided Nasogastric Feeding Tube Placement in Critical Care Patients

BACKGROUND Nasogastric feeding tube (NGT) placement is a common practice performed in intensive care units (ICUs). Complications due to the improper placement of NGT are well known. In this prospective descriptive study, the effectiveness of ultrasound (US)-guided NGT placement was investigated. MATERIALS AND METHODS Fifty-six mechanically ventilated patients monitored in the ICU were included. A linear US probe was transversely placed just cranial to the suprasternal notch, and the concentric layers of the esophagus were attempted to be viewed on the posterolateral side of the trachea (generally left) by shifting the probe. If the esophagus can be seen, an attempt was made to insert the NGT under real-time visualization of ultrasonography. Furthermore, gastric placement of the NGT tip was confirmed with abdominal radiograph. RESULTS A total of 56 patients were included in the study. For 52 (92.8%), the NGT image was obtained during placement within the esophagus. For 3 (5.3%), the esophagus could not be seen by US, and NGT was placed blindly. For 1 patient, we could not detect passing of the NGT into the stomach despite the successful visualization of esophagus. In this patient, NGT was radiographically detected in the trachea after the procedure. CONCLUSION This study revealed that passing of the NGT through the esophagus could be visualized at a high rate in real-time US among ICU patients. These data suggest that ultrasonographic visualization of the upper esophagus during NGT insertion can be used as an adjuvant method for confirmation of correct placement.

Efficacy of a low‐dose spinal morphine with bupivacaine for postoperative analgesia in children undergoing hypospadias repair

Background:  Children undergoing hypospadias repair need to be protected from highly unpleasant sensory and emotional experiences during and after surgery. We designed a double‐blinded, randomized, and placebo‐controlled study to compare the efficacy of a low‐dose (2 μg·kg−1) of intrathecal morphine with placebo for postoperative pain control of children undergoing repair of hypospadias surgery with spinal anesthesia.

Needle diameter and design influence post dural puncture headache rate in children.

appears to have been borne out by the subsequent course. Although the prompt detection of the arrhythmia and termination of sevoflurane administration were associated with a good outcome, complete heart block is a potentially serious complication. Considered with prior reports, this account suggests that clinically apparent conduction abnormalities may occur under sevoflurane anesthesia. Switching to a propofol anesthetic may manage this problem. Xiaopeng Zhang Paul G. Firth Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, MA, USA (email: xzhang17@partners.org)

Determination of optimum time for intravenous cannulation after induction with sevoflurane and nitrous oxide in children premedicated with midazolam

It has been shown that early placement of an intravenous line in children administered sevoflurane anesthesia increased the incidence of laryngospasm and movement. However, the optimal time for safe cannulation after the loss of the eyelash reflex during the administration of sevoflurane and nitrous oxide is not known.

Do infants need higher intrathecal fentanyl doses than older children

1 Arima H, Sobue K, Tanaka S et al. Difficult airway in a child with spinal muscular atrophy type I. Paediatr Anaesth 2003; 13: 342–344. 2 Arya VK, Kumar A, Makkar SS et al. Retrograde submental intubation by pharyngeal loop technique in a patient with faciomaxillary trauma and restricted mouth opening. Anesth Analg 2005; 100: 534–537. 3 Biswas BK, Bhattacharyya P, Joshi S et al. Fluoroscope-aided retrograde placement of guide wire for tracheal intubation in patients with limited mouth opening. Br J Anaesth 2005; 94: 128– 131. 4 Hung OR, Al-Qatari M. Light-guided retrograde intubation. Can J Anaesth 1997; 44: 877–882. 5 Leissner KB. Retrograde intubation with epidural catheter and Cook airway exchange catheter. Can J Anesth 2007; 54: 400–401.

Post-Spinal a Rare Complication and Treatment: Tinnitus and Epidural Blood Patch

Dear Editor, Rare auditory symptoms such as tinnitus after spinal anaesthesia have been observed (1–4). It can be accompanied by headache (1, 4) and can become chronic and affect a patient’s quality of life. In this case, we aimed to present our clinical experience regarding the relief of symptoms by an epidural blood patch in a patient who developed headache and bilateral tinnitus following spinal anaesthesia. A 31-year-old female patient, who was 58 kg in weight and 169 cm in height, was scheduled for operation under spinal anaesthesia due to venous stasis. Informed written consent was obtained. The spinal space was accessed with a 25-G Quincke needle on the first try through the L4–5 interspinous space. On observing a clear cerebrospinal fluid leak, 12.5 mg of hyperbaric bupivacaine and 15 μg of fentanyl were intrathecally administered in a volume of approximately 3 mL. The patient was admitted to the hospital on the first postoperative day due to severe headache that started from the nape of the neck and that involved the entire head. The headache was accompanied by tinnitus (ringing in both ears and motor noise) and nausea–vomiting and was more prominent in the standing and sitting positions. The patient was chiefly discomforted by the tinnitus. The headache diminished while in the lying position, but the tinnitus did not subside. An intravenous access was established in the patient, and she was hydrated. An oral caffeinated analgesic and antiemetic were started. The headache alleviated on the second day of admission, but the tinnitus remained. The patient was unable to sleep and expressed that she was extremely discomforted by this. Given that it was accompanied by headache, we thought that the patient could benefit from an epidural blood patch. Following appropriate site cleaning, approximately 12 mL of the blood patch was epidurally administered by accessing the same space. The tinnitus in the left ear immediately improved following the injection, while it disappeared within approximately 12 h in the right ear. Additionally, the complaint of pain, which lost its severity with the medical treatment, completely disappeared. Aetiology regarding symptoms related to hearing following spinal anaesthesia is not very clear. One of the proposed hypotheses is the decrease in intra-labyrinth pressure. The cochlear duct provides an anatomical connection between the cochlea and the subarachnoid distance. The composition of the perilymph in the cochlea closely resembles the cerebrospinal fluid. One of the proposed views is that a decrease in cerebrospinal fluid pressure causes a decrease in intra-labyrinth pressure and that this causes functional inability in the ear in transmitting sounds (5). Symptoms could spontaneously subside; however, there are patients who became chronic. The relationship of chronic cases with spinal anaesthesia can only be revealed by obtaining a good medical history. These patients can benefit from an epidural blood patch (1, 2, 4). In a patient who developed tinnitus following spinal anaesthesia (4 years), it was learned, upon obtaining medical history by the ear, nose and throat specialist, that the complaint started 24 h after spinal anaesthesia, and the patient was directed to an anaesthetist. The tinnitus was successfully treated by administering 20 mL of an epidural blood patch to the patient (2). A patient with postspinal 8 years tinnitus complaint underwent epidural anaesthesia for another surgical operation. The tinnitus recovered by the epidural administration of 27 mL of bolus, followed by a local anaesthetic performed by continuous infusion (3). Due to the high rate of success and ease of application, an epidural blood patch is the accepted gold standard treatment in treating postspinal headache when conservative treatments have failed. It is a treatment whose major side effects are (usually temporary) rare, and it is safe and effective. Side effects are low back pain or radicular pain during injection, generally related to the administered volume (6). For evaluating these cases, the epidural administration of any application-blood, normal saline or local anaesthetics-appears to be effective in improving auditory symptoms. In conclusion, the accompaniment of nausea–vomiting and tinnitus with headache that develops after spinal anaesthesia negatively affects the quality of life. Therefore, we think that administering an epidural blood patch without delay in the presence of auditory symptoms accompanying headache will improve the comfort of patients.

Continuous monitoring of ventilation by diaphragm ultrasonography using a new tool during procedural sedation

The number of procedures performed under sedation has increased, and so there is a need for a continuous respiratory monitoring for the initiation of interventions to prevent risk factors due to the ventilatory depression. However, continuous monitoring methods, such as clinical observation, pulse oximetry and capnography, are known to have limitations [1, 2]. The respiration is primarily driven by the diaphragm motion, and ultrasonography (USG) can be used for assessment of the diaphragm [3]. Transthoracic diaphragm USG used for evaluating the thickness, contractile activity, function or predicting extubation during the mechanical ventilation in intensive care units (ICUs) [4, 5]. Here, we report a novel technique for continuous monitoring of ventilation by diaphragm USG with a new tool during the procedural sedation. After obtaining a local ethic committee approval and written informed consent from ASA I–III patients (n=15,> 18) scheduled to undergo procedural sedation, we conducted this prospective, observational study. All patients were monitored with standard devices, including capnography with a nasal cannula. Additionally, we made a probe-holder for continuous visualization of the diaphragm motion with simple materials. The probe was held with flexible soft rubber band without metal parts. It has an adjustable velcro band according to different body shapes (Fig. 1A). The visualization of changes in thickness of the diaphragm and cyclic movement of the lung edge during respiration used for detecting respiratory pauses (> 10 s) by a clinician blinded to the capnography

Management of a patient with Opalski's syndrome in intensive care unit

Opalski syndrome is a rare vascular brainstem syndrome which is accepted as a variant of Wallenberg syndrome. Opalski syndrome should be considered in acute conditions in which typical symptoms of lateral medullary infarct are accompanied by ipsilateral hemiparesis. Other brain stem syndromes are distinguished from Opalski syndrome by the presence of contralateral hemiparesis.