Reliability of transcranial sonography for assessment of brain midline shift in adult neurocritical patients: a systematic review and meta-analysis.

INTRODUCTION: The aim of this systematic review and meta-analysis was to determine the reliability of transcranial sonography as an alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients. EVIDENCE AQUISITION: The PubMed, EMBASE, Cochrane Library, Scopus and Web of Science databases were searched. Original studies evaluating brain midline shift in adult neurocritical patients using both transcranial sonography and computed tomography were eligible. Primary outcome measure was concordance between both methods as quantified in terms of concordance correlation coefficient. Secondary outcome measure was limits of agreement, defined as mean difference between sonography and computed tomography plus and minus 1.96 standard deviations. EVIDENCE SYNTHESIS: Twelve studies (574 patients, 689 examinations) were eligible. Ten studies (416 patients, 492 examinations) provided adequate data for evaluation of concordance. Pooling of effect sizes showed strong concordance between both methods (concordance correlation coefficient, 0.91; 95% CI, 0.87 to 0.94). Two missing studies were imputed and effect size was adjusted to 0.88 (95% CI, 0.81 to 0.93). Nine studies (442 patients, 571 examinations) provided adequate data for estimation of limits of agreement. Pooling of effect sizes showed a bias of -0.53 mm (95% limits of agreement, -1.22 to 0.16 mm). Four missing studies were imputed and bias was adjusted to -0.68 mm (95% limits of agreement, -1.31 to -0.04 mm). CONCLUSIONS: Transcranial sonography may serve as reliable alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients. Both methods have strong concordance with acceptably narrow limits of agreement.

Efficacy of dexmedetomidine as an adjuvant to Quadratus lumborum block for pediatrics undergoing laparoscopic pyeloplasty. A prospective randomized double blinded study.

BACKGROUND: We designed this study to evaluate dexmedetomidine as an adjuvant to local anesthetics in Quadratus lumborum block (QLB) in pediatrics either interfascial versus intravenous on the quality of postoperative analgesia and incidence of side effects. METHODS: Fifty pediatric patients ASA I and II, from eight to thirteen years old posted for laparoscopic pyeloplasty were randomized either to: QLB dexmedetomidine intravenous (QD IV) group or QLB dexmedetomidine interfascial (QD IF) group. A 24-h postoperative morphine consumption (primary outcome), time to first analgesic request, postoperative pain and sedation scores were compared. The recovery time after anesthesia and the incidences of intraoperative and postoperative hypotension or bradycardia were recorded. RESULTS: The median [IQR] 24 h postoperative morphine consumption in QD IF group [0.05 (0.05-0.10) mg/kg] was lower compared with QD IV group [0.15 (0.10-0.20) mg/kg] (P<0.001). Longer time to first analgesic request was noted in QD IF group [505 (395-583) min] in comparison to QD IV group [306 (258-388) min] (P<0.001). Pain scores were lower in QD IF group at six and eight hours postoperatively. Sedation scores were lower in QD IF group on admission to PACU and two hours postoperatively. Intraoperative hypotension and bradycardia were lower in QD IF group. Longer recovery time in QD IV group. CONCLUSIONS: Interfascial dexmedetomidine adjuvant to QLB provided better postoperative analgesia in terms of less morphine consumption, better pain scores and longer time to first analgesic request when compared with the IV dexmedetomidine.

Effects of local low-dose rocuronium on the quality of peribulbar anesthesia for cataract surgery.

OBJECTIVES: Peribulbar anesthesia is associated with delayed and/or incomplete orbital akinesia compared with retrobulbar anesthesia. This study examined the effects of adding rocuronium 5 mg to two different concentrations of lidocaine-bupivacaine mixture on onset time of orbital and eyelid akinesia in patients undergoing cataract surgery. METHODS: In a double-blind study, 90 patients were equally randomized to receive a mixture of 0.5 ml normal saline, 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group I), a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group II), or a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 1%, and 4 ml bupivacaine 0.25% (group III). Orbital akinesia was assessed on a 0-8 score (0 = no movement, 8 = normal) at 2 min intervals for 10 min. Time to adequate anesthesia was also recorded. Results are presented as mean±SD. RESULTS: Ocular movement score decreased during the assessment period in all groups. However, at 2 min after block administration, the score decreased to 4±2 (95% CI 3,5) in groups II and III compared with 5±2 (95% CI 4,6) in group I (P<0.01). Time to adequate condition to begin surgery was 9.8±2.9 vs. 6.9±4.1 vs. 7.9±3.9 min for groups I, II, and III, respectively (P=0.01). CONCLUSION: The addition of rocuronium 5 mg to a mixture of lidocaine 2% and bupivacaine 0.5% shortened the onset time of peribulbar anesthesia in patients undergoing cataract surgery without causing adverse effects.