Journal of clinical anesthesia
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Review Case Reports
Thoracic epidural analgesia in a child with multiple traumatic rib fractures.
The morbidity and mortality associated with blunt thoracic trauma are significant and can be multisystem in nature. Of these, pulmonary complications, including ventilatory impairment secondary to pain, have been recognized to be the most consequential. Although several analgesic strategies have emerged, thoracic epidural analgesia (TEA) has arguably demonstrated superior efficacy and is used frequently in adults. ⋯ This low rate of use likely reflects one or more of several factors potentially encountered when considering the use of TEA in pediatric chest wall trauma. Among them are (1) uncertainty regarding safety and efficacy; (2) the technical challenges of pediatric thoracic epidural placement, including technique and equipment concerns; and (3) drug selection, dosing, and toxicity. The following case review describes the successful application of TEA in a 4-year-old boy after multiple traumatic rib fractures and associated pneumothorax and pulmonary contusion.
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Randomized Controlled Trial
Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve.
The femoral, lateral femoral cutaneous, and obturator nerves (ONs) can reportedly be blocked using a single-injection deep to the fascia iliaca (FI) at the level of the inguinal ligament. Two commonly used methods (the FI compartment and 3-in-1 blocks) have produced inconsistent results with respect to local anesthetic distribution and effect on the ON. To date, no study of either method has been performed using advanced imaging techniques to document both needle placement and local anesthetic distribution. We report the outcome of a series of 3-in-1 and FI blocks performed using ultrasound to guide needle position and magnetic resonance imaging (MRI) to define local anesthetic distribution. ⋯ Ultrasound and MRI show consistent superior extension of local anesthetic to the level of the retroperitoneum for both techniques. There was reliable clinical effect on the femoral and lateral femoral cutaneous nerves. However, none of the injections produced evidence of ON block either at the level of the retroperitoneum or the inguinal ligament.
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To assess whether the use of intraoperative opioids is associated with poor recurrence-free survival (RFS) and overall survival (OS) after lung cancer surgery. ⋯ Our study demonstrates a very weak association between the use of intraoperative opioids and cancer recurrence after laryngeal squamous cell carcinoma surgery.
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Accidental dural puncture (ADP) is known as a complication of epidural anesthesia. Although puncture site and advanced age have been reported to increase the risk of ADP, all related factors have not been fully investigated. We retrospectively investigated factors related to ADP in patients undergoing surgery. ⋯ Accidental dural puncture occurred in 0.49% of all surgical patients undergoing epidural anesthesia and was significantly related to those who received a puncture in lower thoracic and lumbar intervertebral spaces, whereas age was also an independent factor.
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Dilution is often required to obtain appropriate concentrations of intrathecal morphine for analgesia. We compared techniques of diluting by measuring the quantity of morphine actually obtained in the final solution. ⋯ There is significant variability in the concentration of morphine actually contained in final solutions after dilution. Morphine presented in different premixed concentrations increases the risk of error. We advocate technique 5 as described above, whereas technique 1 should be prohibited.