ABSTRACT
Traumatic penetrating injuries to the back are uncommon in children. This type of injury presents many considerations for airway management to the anesthesiologist, including having to secure the airway in a prone position. Although there have been several reports about intubation in the prone position for adult patients in emergency conditions, such studies on pediatric patients are rare. We present the case of a male child with an impaled steel shaft connected to a toy car wheel in his lower back, requiring an emergent operation under general anesthesia. Due to resource limitations, the patient was intubated using an adult-sized video laryngoscope in the prone position. The patient remained stable during the operation and was discharged without complications. A postoperative discussion was held later to review the case and gain insights from the rest of the anesthesiology team. Prone intubation in pediatric patients can be safely accomplished using various techniques, depending on the urgency of the need, the availability of resources, and the knowledge and skills of the provider. The authors hope that their colleagues can learn from sharing this experience.
ABSTRACT
OBJECTIVES: Traditionally, caudal epidurals are performed by a landmark-guided approach using the loss of resistance technique. Improvisations to increase the success rate can be attained by implementing modalities, namely neurostimulation and ultrasound, but there is a paucity of literature comparing these 3 approaches. Here, we compare the 3 techniques in terms of the success rate. MATERIALS AND METHODS: The primary outcome of this study was to compare the success rate of the 3 techniques, and the secondary outcome was the blood or cerebrospinal fluid aspiration during the procedure. It was a prospective, randomized, open-label parallel-group study. Three hundred children aged 1 to 5 years scheduled for circumcision, hypospadias repair, and minor lower extremity surgeries were enrolled after taking written informed consent from the parents. RESULTS: Demographic profiles were comparable in terms of age, weight, sex distribution, and types of surgeries. Success rates in landmark-guided, neurostimulation-guided, and ultrasound-guided were 97%, 97%, and 98%, respectively which was comparable (P=0.879). There was no significant difference in the incidence of blood or cerebrospinal fluid aspiration. DISCUSSION: We found a similar success rate of the caudal epidural block by using landmark-guided, nerve stimulation-guided, or ultrasound-guided techniques in children aged 1 to 5 years with normal anatomy.
Subject(s)
Anesthesia, Epidural , Nerve Block , Child , Humans , Male , Prospective Studies , Ultrasonography , Ultrasonography, InterventionalABSTRACT
Fluid management has been widely recognized as an important component of the perioperative care in patients undergoing major procedures including spine surgeries. Patient- and surgery-related factors such as age, length of the surgery, massive intraoperative blood loss, and prone positioning, may impact the intraoperative administration of fluids. In addition, the type of fluid administered may also affect post-operative outcomes. Published literature describing intraoperative fluid management in patients undergoing major spine surgeries is limited and remains controversial. Therefore, we reviewed current literature on intraoperative fluid management and its association with post-operative complications in spine surgery.
ABSTRACT
Regional anesthesia has been considered a great tool for maximizing post-operative pain control while minimizing opioid consumption. Post-operative rebound pain, characterized by hyperalgesia after the peripheral nerve block, can however diminish or negate the overall benefit of this modality due to a counter-productive increase in opioid consumption once the block wears off. We reviewed published literature describing pathophysiology and occurrence of rebound pain after peripheral nerve blocks in patients undergoing orthopedic procedures. A search of relevant keywords was performed using PubMed, EMBASE, and Web of Science. Twenty-eight articles (n = 28) were included in our review. Perioperative considerations for peripheral nerve blocks and other alternatives used for postoperative pain management in patients undergoing orthopedic surgeries were discussed. Multimodal strategies including preemptive analgesia before the block wears off, intra-articular or intravenous anti-inflammatory medications, and use of adjuvants in nerve block solutions may reduce the burden of rebound pain. Additionally, patient education regarding the possibility of rebound pain is paramount to ensure appropriate use of prescribed pre-emptive analgesics and establish appropriate expectations of minimized opioid requirements. Understanding the impact of rebound pain and strategies to prevent it is integral to effective utilization of regional anesthesia to reduce negative consequences associated with long-term opioid consumption.
