Experimental validation of the CompuFlo® epidural controlled system to identify the epidural space and its clinical use in difficult obstetric cases.

BACKGROUND: This prospective study was designed to validate the CompuFlo® device and to assess its use in difficult epidural placement. METHODS: In the first part of the study, 30 parturients requesting labor epidural analgesia were recruited. The block was performed by an expert anesthesiologist, with the Tuohy needle connected to the CompuFlo® device to evaluate the agreement between the anesthesiologist's reported sensation and the variation of pressure recorded by the CompuFlo®. In the second part of the study, 56 consecutive parturients, for whom at least two complete needle reinsertions were made by trainees during epidural placement for labor analgesia, were enrolled. CompuFlo® was used as a rescue tool for the subsequent attempt. RESULTS: In all cases epidural analgesia was successful and no complications were noted. There was a good correlation between the operator's feelings and the delta of pressure recorded by the CompuFlo®, for both identification of the ligamentum flavum and of the epidural space (Rho = 0.79; tau = 0.67). In the second part of the study, all the difficult blocks performed with the CompuFlo® were successful after a single attempt. The pressure curves of false loss-of-resistance were significantly different from the true loss-of-resistance (P <0.0001) DISCUSSION: CompuFlo® was validated as a tool to identify the epidural space. It may also assist trainees in successful epidural placement in difficult cases.

Transversus abdominis plane block for analgesia after Cesarean delivery. A systematic review.

Cesarean delivery is a major surgical procedure, after which a woman can experience substantial postoperative discomfort or pain. Inadequate postoperative analgesia is one of the most common reasons for poor patient satisfaction following cesarean delivery. Although spinal or systemic opioids are currently the gold standard to achieve effective analgesia, they are often associated with side effects. In the last few years there has been growing interest in abdominal plane blocks, with promising data on their efficacy. The transversus abdominis plane (TAP) block is a regional analgesic technique which is gaining acceptance in postoperative analgesia for lower abdominal surgeries. In this systematic review of articles published as of 31 December 2013, we searched the principal medical databases for randomized controlled trials that assessed the efficacy of ultrasound (US)-guided TAP block following cesarean delivery and reported on postoperative opioid consumption and pain score, opioid-related side-effects and patient satisfaction. Although controversy surrounds the utility of US-guided TAP block in cesarean section, evidence suggests that when correctly executed as part of a multimodal analgesic regimen, TAP block may reduce postoperative opioid consumption and opioid-related side effects, improving postoperative pain control and patient satisfaction. Further studies are necessary to explore this field of research.

Long-term use of neonatal helmet-CPAP: a case report.

In a recent short-term physiological study, we demonstrated a new continuous positive airway pressure (CPAP) system (neonatal helmet-CPAP) that could be a feasible device for managing preterm infants needing continuous distending pressure with better tolerability than nasal-CPAP. However, its application for a long-term period has never been reported in neonates. Here, we describe the use of neonatal helmet-CPAP in a neonate with persistent pulmonary hypertension of the newborn. Twenty minutes after neonatal helmet-CPAP placement, the baseline post-ductal tcSaO2 (66%) and alveolar-arterial gradient O2 improved from 66% and 648 mmHg to 100% and 465 mmHg, respectively. The neonatal helmet-CPAP was applied for 48 hours and was well-tolerated by the patient without complications. Long-term use of neonatal helmet-CPAP appears feasible and well-tolerated. Comparative trials are needed.

Prospective, randomized comparison of ProSeal and Classic laryngeal mask airways in anaesthetized neonates and infants.

BACKGROUND: When compared with the Classic laryngeal mask airway (cLMA), the recently introduced ProSeal laryngeal mask airway (PLMA) has modified features to produce higher airway seal pressures and enable ventilation in circumstances where the cLMA might fail. The first neonatal size 1 PLMA recently became available. This study was designed to compare the effectiveness of the size 1 cLMA and PLMA during positive pressure ventilation in anesthetized neonates and infants. METHODS: Forty-six consecutive patients undergoing elective cardiac surgical procedures were randomized for initial airway management with the cLMA or PLMA. Insertion time (IT), number of placement attempts, ease of placement, quality of the initial airway, maximum tidal volume (TVmax), and airway pressure at which an audible leak in the mouth (P(leak)) occurred were collected. All data were recorded before performing tracheal intubations. RESULTS: IT and success rate were similar for both LMAs. The initial quality of the airway was significantly better for the PLMA (P<0.05). TVmax and P(leak) were significantly higher for PLMA (77 vs 58 ml, P<0.02 and 29.8 vs 24.4 cm H2O, P<0.02). No adverse events were recorded during the study. CONCLUSIONS: The size 1 PLMA forms a more effective seal than size 1 cLMA in neonates. This might allow the PLMA to be used in those newborn infants requiring high airway pressures for ventilation.

Myotonia congenita and regional anaesthesia with peripheral nerve stimulation: a case report.

Myotonia congenita is a rare disorder caused by a defect in the skeletal muscle chloride channel function, which may cause sustained membrane depolarisation. We report a case regarding a 52-year-old man affected by this muscular pathology and scheduled for shoulder surgery that was performed under sedation and peripheral nerve block. The international literature does not elucidate clear preference toward a particular anaesthesia technique, but we believe that in this setting, regional anaesthesia and complete monitoring should be preferentially utilized when possible. In any case, the anaesthesia plan should be prudent and avoid exposure to known dangerous anaesthetics.

The size 1 LMA-ProSeal: Comparison with the LMA-Classic during pressure controlled ventilation in a neonatal intubation manikin.

BACKGROUND: The classic laryngeal mask airway (cLMA) has been demonstrated to be effective for airway management during neonatal resuscitation. However, high airway pressures, when required, cannot be achieved with this device. A neonatal prototype of the LMA-ProSeal (PLMA), which might improve the oropharyngeal leak pressure, has recently been produced. The airway sealing pressures of the cLMA and the PLMA were compared in a neonatal manikin. METHODS: A neonatal PLMA and a neonatal cLMA were positioned at random in a neonatal intubation manikin (Neonate Airway Trainer; Laerdal, Norway). A Dräeger pressure controlled ventilator (Dräeger 8000; Dräegerwerk AG, Germany) was connected to the airway tubes and increasing inspiratory pressures (from 10 to 40 cm H2O) of positive pressure ventilation applied. The peak and the mean airway pressures obtained with each device were recorded. RESULTS: The airway pressures obtained with PLMA were significantly higher than those obtained with cLMA (p < 0.01) at levels of positive pressure ventilation of 25, 30, 35 and 40 cm H2O. CONCLUSIONS: The neonatal PLMA allows higher airway pressure ventilation than the cLMA, in a neonatal intubation manikin. If confirmed clinically, this may have important implications during neonatal resuscitation when high airway pressures are required.

The laryngeal mask airway: potential applications in neonates.

The laryngeal mask airway is a safe and reliable airway management device. This review describes the insertion techniques, advantages, limitations, and potential applications of the laryngeal mask airway in neonates.

The effects of epidural analgesia and uterine contractions on fetal oxygen saturation during the first stage of labour.

The aim of this study was to investigate the effects of (1) maternal epidural analgesia and (2) uterine contractions on fetal oxygen saturation. After informed consent 18 women were included in our prospective, non-blinded, observational study. After 30 min of monitoring fetal oxygen saturation and uterine contractions, all the parturients, at cervical dilatation >/= 3 cm, received epidural analgesia for labour: a Pajunk epidural catheter was passed through a 17-gauge Tuohy needle and left in the lumbar epidural space (insertion level L3-4 or L2-3). Sufentanil 10 microg and 0.1% ropivacaine 15 mL were injected into the epidural catheter. A second and third 15-mL epidural dose of 0.1% ropivacaine were administered on patient demand. Fetal oxygen saturation was unaffected by epidural analgesia and there was no change in fetal SpO(2)following an uncomplicated epidural top-up. SpO(2)values (%) 30 s before, during and after contraction were 47.6 +/- 2.4, 52.5 +/- 5.3 and 42.9 +/- 7.2 respectively. These changes were significant. A contraction appeared to inject a bolus of oxygenated blood into the fetus, causing an initial increase in fetal oxygenation followed by a decline. The lowest SpO(2)values observed occurred 120 s after the start of contractions.

The Post-anaesthetic Recovery in Obesity Surgery: comparison between two anaesthetic techniques.

Forty morbidly obese patients, scheduled for restrictive gastric surgery, were anaesthetized with two different techniques. In group A (20 patients) anesthesia was induced and maintained with Propofol (total intravenous anesthesia, TIVA); in group B (20 patients) anesthesia was induced with Thiopental and maintained with Isoflurane (balanced anesthesia). At the end of surgery, recovery time (RT) and recovery score (RS) were assessed according to a modified Aldrete score. There was no difference of RS between group A and group B. RT was shorter (though not statistically significant) in group A than in group B. Our experience suggests that both techniques can be safely used in these patients, but with TIVA, patients appeared more awake and cooperative earlier. Such an advantage may be useful to prevent serious complications (thromboembolism and pulmonary failure) in the postoperative period.