RESUMEN
BACKGROUND: The different methods of cervical epidural injection include the median or paramedian interlaminar (PI) approach and the transforaminal (TF) approach. We hypothesized that the modified PI (mPI) approach could deliver drugs suitably and safely into the anterior epidural space compared with the TF approach. METHODS: A total of 62 patients were randomized into either the mPI group (n=31) or the TF group (n=31). Contrast to the anterior epidural space (primary outcome, grade 1-3), vascular uptake and discomfort were assessed. Furthermore, pain intensity in the arm and neck [numeric rating scale (NRS)] and the degree of symptoms (5-point Likert scale) before the procedure and 2 weeks, 1 and 3 months following the procedure were compared between two groups. Effectiveness (a secondary outcome) was defined as a ≥50% reduction on the NRS for arm and neck pain and a result of 3 or 4 on the Likert scale at 3 months following the procedure. RESULTS: Contrast to the anterior epidural space in the mPI group was significantly greater than that in the TF group (P=0.036). Vascular uptake and discomfort in the mPI group were significantly lower than those in the TF group (P<0.001, respectively). Of the patients in whom the procedure was effective, 24 (77.4%) were from the mPI group and 20 (64.5%) were from the TF group (P=0.263). CONCLUSION: This result suggests that the mPI approach allows for suitable and safe delivery of drugs into the anterior epidural space. TRIAL REGISTRY NUMBER: Institutional Review Board of Seoul National University Bundang Hospital (B-1206/159-004) and Clinical Research Information Service (KCT0000626).
Asunto(s)
Glucocorticoides/administración & dosificación , Inyecciones Epidurales/métodos , Adulto , Vértebras Cervicales/diagnóstico por imagen , Medios de Contraste/administración & dosificación , Medios de Contraste/farmacocinética , Femenino , Fluoroscopía/métodos , Humanos , Masculino , Persona de Mediana Edad , Dolor de Cuello/tratamiento farmacológico , Dimensión del Dolor/métodos , Estudios Prospectivos , Radiculopatía/tratamiento farmacológicoRESUMEN
Our hypothesis was that the incidence of malposition of a right-sided double-lumen endobronchial tube and right upper lobe collapse may increase when the distance between the carina and the distal margin of the right upper lobe orifice is less than 23 mm, measured from a computerised tomography scan. A total of 76 patients undergoing left-sided thoracic surgery were enrolled. Patients with a measured distance of <23 mm (n=38) were compared with age-, sex- and body mass index-matched patients with a distance≥23 mm (n=38). Right-sided double-lumen endobronchial tubes were used universally. We monitored endobronchial tube malposition and incidence of right upper lobe collapse throughout surgery. There was a significantly higher incidence of bronchial cuff herniation in patients with a distance<23 mm in both the supine position and the lateral decubitus position (p<0.001). The incidence of intra-operative malposition in the <23 mm group was also significantly higher than in the ≥23 mm group (31 (82%) vs 8 (21%), respectively, p<0.001). Right upper lobe collapse was detected postoperatively in five patients (13%) in the distance<23 mm group, compared to none in the ≥23 mm group. We recommend that the distance between the carina and the distal margin of the right upper lobe bronchus should be routinely measured on the pre-operative computerised tomography scan, and if it is <23 mm, consideration should be given to using a left-sided endobronchial double-lumen tube in preference to a right-sided one.
Asunto(s)
Intubación Intratraqueal/instrumentación , Intubación Intratraqueal/métodos , Pulmón/diagnóstico por imagen , Anestesia General , Broncoscopía , Femenino , Humanos , Complicaciones Intraoperatorias/prevención & control , Pulmón/anatomía & histología , Pulmón/cirugía , Masculino , Errores Médicos/prevención & control , Persona de Mediana Edad , Atelectasia Pulmonar/prevención & control , Tamaño de la Muestra , Posición Supina , Procedimientos Quirúrgicos Torácicos , Tomografía Computarizada por Rayos XRESUMEN
During fibreoptic intubation, it is often difficult to advance a tracheal tube over the fibreoptic bronchoscope. We performed a prospective randomised study to investigate the effect of the jaw-thrust manoeuvre on the ability to advance a tracheal tube during oral fibreoptic intubation. After placing the bronchoscope in the trachea, an assistant randomly applied a jaw-thrust manoeuvre (jaw-thrust group) or sham manoeuvre (control group) in 82 patients during tube advancement. The jaw-thrust group had a higher success rate on the first attempt (70.7% vs 34.1%, p = 0.002), required fewer attempts (median (IQR [range]) 1 (1-2 [1-3]) vs 2 (1-3 [1-4]), p < 0.001), and took less time [6 (4-8 [2-16]) s vs 10 (7-15 [3-40]) s, p < 0.001] for tube advancement compared with the control group. The jaw-thrust manoeuvre facilitates the advancement of a tracheal tube over the bronchoscope during oral fibreoptic intubation.
Asunto(s)
Broncoscopios , Broncoscopía/métodos , Intubación Intratraqueal/métodos , Maxilares/fisiología , Adulto , Femenino , Tecnología de Fibra Óptica , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tamaño de la Muestra , Posición SupinaRESUMEN
BACKGROUND: Three-phase bone scintigraphy (TPBS) is an established objective diagnostic method for complex regional pain syndrome (CRPS), but its validity remains controversial. The aims of this study were: (i) to re-evaluate the diagnostic performance of TPBS, and (ii) to suggest new TPBS criteria based on the proposed research criteria for CPRS in Budapest (the 2003 Budapest research criteria). METHODS: The medical records of 228 consecutive patients, evaluated using the Budapest research criteria, were retrospectively analysed. Of these, 116 patients were included in the present study, and 69 of 116 were diagnosed to have CRPS based on these criteria. The diagnostic performance of TPBS was assessed by determining its sensitivity, specificity, and positive and negative likelihood ratios, and new criteria for TPBS were identified by pattern analysis using the Budapest research criteria. RESULTS: The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of TPBS for the diagnosis of CRPS according to the Budapest research criteria were 40.0, 76.5, 1.73, and 0.78, respectively. Furthermore, D-D-D, D-D-S, and D-D-I patterns [i.e. according to decreased (D), symmetrical (S), or increased (I) tracer uptake during Phases I, II, and III] of TPBS were found to be positively predictive for CRPS. CONCLUSIONS: The diagnostic value of a positive TPBS for CRPS is low from the view point of the Budapest research criteria. Our findings suggest that a diagnosis of CRPS using the Budapest research criteria should be considered when decreased patterns of TPBS are observed during Phases I and II.
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Síndromes de Dolor Regional Complejo/diagnóstico por imagen , Adulto , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Guías de Práctica Clínica como Asunto , Cintigrafía , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
We investigated the forces required to remove thoracic epidural catheters to determine the effect of patient position on removal. Eighty-four patients undergoing open thoracotomy and thoracic patient-controlled epidural analgesia were enrolled. Catheterisation was performed under fluoroscopic guidance before surgery, and the patients were allocated to one of three position groups for removal: prone; sitting; and lateral. On the third postoperative day, the peak tension during withdrawal in the assigned position was measured. No differences in mean (SD) forces were found between groups: prone 1.61 (0.39) N, supine 1.62 (0.61) N and lateral 1.36 (0.56) N (p = 0.140). The withdrawal forces required to remove thoracic epidural catheters were not affected by the position. Thus, the position for removal can be determined by patient's choice and clinical judgement.
Asunto(s)
Analgesia Epidural/métodos , Anestesia Epidural/métodos , Posicionamiento del Paciente , Postura/fisiología , Adulto , Factores de Edad , Anciano , Analgesia Epidural/instrumentación , Analgesia Controlada por el Paciente , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Anestesia Epidural/instrumentación , Anestésicos Locales/administración & dosificación , Anestésicos Locales/uso terapéutico , Estatura/fisiología , Índice de Masa Corporal , Bupivacaína/administración & dosificación , Bupivacaína/uso terapéutico , Cateterismo , Catéteres , Remoción de Dispositivos , Espacio Epidural/diagnóstico por imagen , Femenino , Fluoroscopía , Humanos , Hidromorfona/administración & dosificación , Hidromorfona/uso terapéutico , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/tratamiento farmacológico , Posición Prona/fisiología , Estudios Prospectivos , Tamaño de la Muestra , Factores Sexuales , Vértebras TorácicasRESUMEN
BACKGROUND: the aim of this study was to determine whether or not inhalation induction with sevoflurane can prevent the withdrawal movement associated with the injection of rocuronium. METHODS: a total of 75 pediatric patients were randomly allocated to five groups (S 1.5, 2.0, 2.5, 3.0, and the control group). In the control group (n=15), 2.5% thiopental 5 mg/kg was injected intravenously. Rocuronium 0.4 mg/kg was injected immediately after loss of consciousness. In the S 1.5, 2.0, 2.5, or 3.0 group, rocuronium 0.4 mg/kg was injected at 1.5, 2, 2.5, or 3 min after inhalation induction, respectively, and the withdrawal response was recorded. End-tidal sevoflurane concentrations were recorded at the time of the rocuronium injection. The inhalation time of sevoflurane before rocuronium injection required to provide no withdrawal response in 50% and 95% of patients (IT(50) and IT(95) ) was calculated. RESULTS: the incidence of withdrawal was 80% (12/15), 71.4% (10/14), 21% (3/14), 0% (0/14), and 0% (0/15) in group C, group S 1.5, group S 2.0, group S 2.5, and group S 3.0, respectively. IT(50) of the rocuronium injection time was 1.7 min (95% CI: 1.5-1.9) and IT(95) was 2.3 min (95% CI: 2.0- 2.9). CONCLUSIONS: this study demonstrated that inhalation induction with sevoflurane can prevent the withdrawal movement induced by rocuronium in children, and IT(50) and IT(95) for the prevention of movement was 1.7 and 2.3 min, respectively.
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Androstanoles/efectos adversos , Anestesia por Inhalación , Anestésicos por Inhalación , Éteres Metílicos , Fármacos Neuromusculares no Despolarizantes/efectos adversos , Dolor/inducido químicamente , Dolor/prevención & control , Parpadeo/efectos de los fármacos , Niño , Preescolar , Femenino , Humanos , Masculino , Movimiento/efectos de los fármacos , Procedimientos Quirúrgicos Oftalmológicos , Análisis de Regresión , Rocuronio , Tamaño de la Muestra , Sevoflurano , Estrabismo/cirugíaRESUMEN
Transforaminal epidural injection is an effective method for treating spinal pain but can cause devastating complications that result from accidental vascular uptake of the injectate or a direct vascular injury. We prospectively evaluated the patient factors that might be associated with intravascular uptake during transforaminal epidural injections. A total of 2145 injections were performed on 1088 patients under contrast-enhanced real-time fluoroscopic guidance. The collected data included the patient's age, sex, body mass index, diagnosis, injection level, side of injection, history of spinal surgery at the targeted level, and the number of injections at the targeted site. The overall incidence of intravascular injection was 10.5% (224/2145). The highest incidence was at the cervical level (28/136; 20.6%), followed by the sacral level (111/673; 16.5%), the thoracic level (23/280; 8.2%) and the lumbar level (64/1056; 6.1%). The difference was significant for the cervical and sacral level compared with the lumbar and thoracic levels (p < 0.001). Intravascular injection was not associated with the other patient characteristics studied.
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Anestésicos Locales/administración & dosificación , Dolor de Espalda/terapia , Vasos Sanguíneos/lesiones , Lidocaína/administración & dosificación , Anciano , Dolor de Espalda/etiología , Femenino , Fluoroscopía , Humanos , Inyecciones Epidurales/efectos adversos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de RiesgoRESUMEN
Maintaining a low central venous pressure (CVP) has been frequently used in liver resections to reduce blood loss. However, decreased preload carries potential risks such as hemodynamic instability. We hypothesized that a low CVP with milrinone would provide a better surgical environment and hemodynamic stability during living donor hepatectomy. Thirty-eight healthy adult liver donors were randomized to receive either milrinone (milrinone group, n = 19) or normal saline (control group, n = 19) infusion during liver resection. The surgical field was assessed using a four-point scale. Intraoperative vital signs, blood loss, the use of vasopressors and diuretics and postoperative laboratory data were compared between groups. The milrinone group showed a superior surgical field (p < 0.001) and less blood loss (142 +/- 129 mL vs. 378 +/- 167 mL, p < 0.001). Vital signs were well maintained in both groups but the milrinone group required smaller amounts of vasopressors and less-frequent diuretics to maintain a low CVP. The milrinone group also showed a more rapid recovery pattern after surgery. Milrinone-induced low CVP improves the surgical field with less blood loss during living donor hepatectomy and also has favorable effects on intraoperative hemodynamics and postoperative recovery.
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Presión Sanguínea/efectos de los fármacos , Hepatectomía , Donadores Vivos , Milrinona/uso terapéutico , Vasodilatadores/uso terapéutico , Humanos , Milrinona/farmacología , Vasodilatadores/farmacologíaRESUMEN
The purpose of this study was to find the best cut-off value for the rate of change in temperature of the plantar surface of the foot for predicting the success of lumbar sympathetic block (LSB). A total of 185 LSBs were performed on 82 patients via a posterolateral approach under fluoroscopic guidance. Successful LSB was considered to have occurred when changes in the ipsilateral temperature between pre-block and post-block were > or = 2 degrees C. A receiver operating characteristic (ROC) curve for the minimum rate of temperature change was constructed as a predictor of the onset of a successful LSB. The area under the ROC curve was 0.971 at the rate of 0.4 degrees C/min with a sensitivity of 89.5% and a specificity of 91.8%. Achieving a rate of temperature change of 0.4 degrees C/min within approximately 5 min of the injection of local anaesthetic could be used as an indicator of the onset of successful LSB.
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Bloqueo Nervioso Autónomo , Síndromes de Dolor Regional Complejo/terapia , Región Lumbosacra/fisiopatología , Dimensión del Dolor , Temperatura Cutánea , Sistema Nervioso Simpático/fisiopatología , Adolescente , Adulto , Anciano , Femenino , Fluoroscopía , Pie , Humanos , Masculino , Persona de Mediana Edad , Curva ROC , Sensibilidad y Especificidad , Adulto JovenAsunto(s)
Anestésicos Intravenosos/efectos adversos , Anestésicos Intravenosos/sangre , Tos/inducido químicamente , Sistemas de Liberación de Medicamentos/métodos , Piperidinas/efectos adversos , Piperidinas/sangre , Adulto , Anciano , Anestésicos Intravenosos/administración & dosificación , Método Doble Ciego , Procedimientos Quirúrgicos Electivos , Humanos , Bombas de Infusión , Infusiones Intravenosas , Persona de Mediana Edad , Piperidinas/administración & dosificación , Estudios Prospectivos , Remifentanilo , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
BACKGROUND: Postherpetic neuralgia (PHN) is one of the most intractable pain disorders, particularly among elderly patients. Lesioning of dorsal root ganglion (DRG) using pulsed radiofrequency (PRF) has shown pain reduction for PHN. We assessed the efficacy of PRF lesioning of DRG for PHN via an open, nonrandomized study. METHODS: Forty-nine patients with PHN refractory to conservative therapy were involved. After impedance and sensory electrical nerve stimulation thresholds were assessed, PRF was performed three times adjacent to the DRG of corresponding levels at 42 degrees C for 120 s under the fluoroscopic guidance. Pain ratings were conducted on a visual analogue scale at 4-, 8- and 12-week follow-up. The data were analyzed using the one-way ANOVA test. P<0.05 was considered to be statistically significant. RESULTS: There was excellent pain relief (about 55%) at 4 weeks after PRF lesioning adjacent to the DRG and the effectiveness was maintained at the subsequent 12-week follow-up. The pain duration, age and stimulation level did not influence the outcome. There were no procedure-related complications. CONCLUSIONS: PRF lesioning of DRG showed significant pain relief compared with the conventional treatments in patients with intractable PHN. In order to elucidate the mode of action of PRF, further research is needed and the optimal electrical parameters of PRF have to be determined.
Asunto(s)
Neuralgia Posherpética/radioterapia , Ondas de Radio , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
STUDY DESIGN: Randomized study. OBJECTIVES: To evaluate the effects of thalidomide on spinal cord ischemia/reperfusion injury via reduced TNF-alpha production. SETTING: Animal experimental laboratory, Clinical Research Institute of Seoul National University Hospital, Seoul, Korea. METHODS: Spinal cord ischemia was induced in rabbits by occluding the infrarenal aorta. Rabbits in group N did not undergo ischemic insult, but rabbits in groups C (the untreated group), THA, and THB underwent ischemic insult for 15 min. The THA and THB groups received thalidomide (20 mg/kg) intraperitoneally (i.p.) before ischemia, but only the THB group received thalidomide (i.p., 20 mg/kg) after 24 and 48 h of reperfusion. After evaluating neurologic functions at 1.5 h, 3, and 5 days of reperfusion, rabbits were killed for histopathologic examination and Western blot analysis of TNF-alpha. RESULTS: The THA and THB groups showed significantly less neurologic dysfunction than the C group at 1.5 h, 3, and 5 days of reperfusion. The number of normal spinal motor neurons in ventral gray matter was higher in THA and THB than in C, but no difference was observed between THA and THB. Western blot analysis showed a significantly higher level of TNF-alpha in C than in THA and THB at 1.5 h of reperfusion, but no difference was observed between C, THA, or THB at 3 or 5 days of reperfusion. CONCLUSION: Thalidomide treatment before ischemic insult reduces early phase ischemia/reperfusion injury of the spinal cord in rabbits.