A Retrospective Analysis of the Clinical Effectiveness of Supraclavicular, Ultrasound-guided Brachiocephalic Vein Cannulations in Preterm Infants.

BACKGROUND: The aim of this retrospective analysis was to evaluate the clinical effectiveness of the supraclavicular ultrasound-guided cannulation of the brachiocephalic vein in preterm infants. METHODS: The ultrasound probe was placed in the supraclavicular region so as to obtain the optimum sonographic long-axis view of the brachiocephalic vein. By using a strict in-plane approach the brachiocephalic vein was cannulated by advancing a 22- or 24-gauge iv cannula from lateral to medial under the long axis of the ultrasound probe under real-time ultrasound guidance into the vein. RESULTS: One hundred and forty-two cannulations in infants weighing between 0.59 and 2.5 kg (median: 2.1; CI: 2.0 to 2.2) were included. Ultimate success rate was 94% (134 of 142). One cannulation attempt was required in 100 (70%) patients, two attempts in 21 (15%), and three attempts in 13 (9%). The smaller the weight of the infant the more attempts were needed. More attempts also were needed for the right brachiocephalic vein, which was primarily targeted in 75 (53%) neonates. One (1%) inadvertent arterial puncture was noted. CONCLUSIONS: This supraclavicular, in-plane, real-time, ultrasound-guided cannulation of the brachiocephalic vein seems to be a convenient and effective method to insert central venous catheters in preterm infants.

Ultrasound-guided supraclavicular cannulation of the right brachiocephalic vein in small infants: a consecutive, prospective case series.

BACKGROUND: The supraclavicular ultrasound (US)-guided cannulation of the brachiocephalic vein (BCV) is one option of central venous line placement in infants. AIM: The aim of this prospective study was to evaluate whether there was an association between the optimum ultrasonographic view as obtained of the entire longitudinal extension of the right BCV and the ease of supraclavicular cannulation when using a strict in-plane technique via a linear US probe in small infants. METHODS: The US probe was placed in the right supraclavicular region. If the optimum obtainable sonographic view presented the entire longitudinal extension of the right BCV demonstrating clearly its path caudally alongside the pleura, it was graded as I. If, however, only a circular view, i.e., the initial part of the right BCV was obtainable via US, it was graded as II. The right BCV was cannulated by advancing a 22-gauge i.v. cannula from lateral to medial strictly under the long axis of the US probe under direct US vision into the vein. RESULTS: Seventy-nine infants weighing between 0.8 and 4.5 kg (Median: 3.4 ± 0.09) were included. In 50 (63.3%) patients, the sonographic view was graded as I and in 29 (36.7%) as II. The proportion of patients successfully cannulated on the first attempt was significantly smaller in patients graded as II, i.e., circular, sonographic view of the right BCV than in patients graded as I, i.e., sonographic view of the entire longitudinal extension of the right BCV (41% vs 90%; chi-square analysis: P < 0.01). CONCLUSION: The sonographic view obtainable of the entire longitudinal extension of the right BCV resulted in significantly fewer required cannulation attempts.

Ultrasound-guided rectus sheath block for pyloromyotomy in infants: a retrospective analysis of a case series.

OBJECTIVES: To analyze the applicability of US-guided rectus sheath block and to find out the efficacy of analgesia provided using this method without the need for opioids in conventional Hypertrophic pyloric stenosis (HPS) surgery in infants. BACKGROUND: This study describes the provision of intra- as well as postoperative analgesia by the use of an ultrasound-guided rectus sheath block in infants undergoing conventional HPS surgery under general anesthesia. METHODS/MATERIALS: The anesthetic protocols of 26 infants undergoing HPS surgery were reviewed retrospectively. RESULTS: The weight of the infants ranged from 2.6 to 4.6 kg. The rectus sheath block was regarded as successful in all patients as there was no heart rate increase upon surgical skin incision in any of the patients. Two out of 26 (7.6%) babies needed additional intraoperative rescue analgesia and were administered fentanyl at 20 and 40 min after skin incision. Two more (a total of 4; 15.3%) babies required postoperative analgesia and were administered tramadol droplets and liquid ibuprofen at 15, 120 and 150 min postoperatively. Duration of surgery was significantly longer in those two patients who required intraoperative rescue analgesia (Wilcoxon-Mann-Whitney test: P < 0.05). These were also the only two patients who received one intra- and one postoperative dose of opioid each (7.6%). CONCLUSION: US-guided rectus sheath block seems to be a simple and quick method for the provision of intra- and postoperative analgesia in infants undergoing conventional HPS surgery.

Ultrasound-guided supraclavicular cannulation of the brachiocephalic vein in infants: a retrospective analysis of a case series.

BACKGROUND: In this study, we analyze the impact of the choice of either the left or right brachiocephalic vein (BCV) on the cannulation success when using the ultrasound-guided supraclavicular in-plane technique approach to the longitudinally viewed BCV in infants. METHODS: The central vascular protocols of 183 infants were reviewed retrospectively. RESULTS: The weight ranged from 0.7 to 10 kg. Central venous catheter placement was eventually successful in 98.9%. In 141 patients (82.9%), the left BCV was successfully punctured on the first attempt, in 23 patients (13.5%) after 2 and in 6 patients (3.5%) after 3 attempts. The right BCV was successfully punctured on the first attempt in five patients (38.4%), in three patients (15.3%) after two and in five patients (38.4%) after three attempts, respectively. Significantly more puncture attempts were required for the right BCV (chi-square analysis: P < 0.01). There was also a significant improvement of the success rate over the time course of the case series (Jonckheere-test: P < 0.01). CONCLUSION: It seems to be easier to cannulate the left BCV than the right BCV when using this ultrasound-guided supraclavicular strict in-plane technique. Gaining experience with this method seems to improve the cannulation success.

Comparison of catheter-related infection and tip colonization between internal jugular and subclavian central venous catheters in surgical neonates.

BACKGROUND: The primary aim of this study was to compare catheter-associated infections and tip contaminations between percutaneously placed central venous catheters in the internal jugular and subclavian veins in surgical neonates undergoing major noncardiac surgery. METHODS: The prospectively computerized protocols of 295 procedures were analyzed retrospectively. RESULTS: One hundred twenty-nine internal jugular venous (group I) and 107 subclavian venous catheters (group S) were included. The median postconceptual age was 37 weeks in group I and 38 in group S. The weight ranged from 580 g to 4.5 kg in group I and from 820 g to 4.5 kg in group S at the time of insertion. Significantly more catheter-associated infections were observed in group I (15.5 vs. 4.7%; chi-square analysis: P < 0.01). The internal jugular venous catheters were also associated with a significantly increased probability of an earlier onset of a catheter-associated infection compared with the subclavian venous catheters (log rank test: P < 0.01; Cox model: P < 0.01). This probability was only slightly increased by a lower weight (Cox model: P = 0.075), and it was not increased by a lower age (Cox model: P = 0.93). Significantly more catheter tips were contaminated by pathogens in group I (55.8 vs. 33.6%; chi-square analysis: P < 0.01). CONCLUSION: The internal jugular venous catheters were associated with a higher infection rate as well as earlier onset of catheter-associated infection compared with the subclavian venous catheters.

Midazolam does not reduce emergence delirium after sevoflurane anesthesia in children.

BACKGROUND: Behavioral disturbance in children following sevoflurane anesthesia is a relatively frequent event. The aim of this study was to evaluate whether a higher dose of preoperatively administered rectal midazolam compared with a lower would alleviate this phenomenon. Furthermore the impact of these two doses of midazolam on sedation at induction of anesthesia was compared. METHODS: A total of 115 children presenting for minor surgery under anesthesia were included in the study. The children were randomized to receive rectally either 1 mg.kg(-1) midazolam (group H) or 0.5 mg.kg(-1) midazolam (group L). General anesthesia was induced with propofol or sevoflurane and maintained with 1.5% sevoflurane in the inspiratory limb. Prior to the start of surgery a regional block was performed to ensure adequate pain relief. Behavior on emergence was assessed using a three point scale. In case of severe agitation propofol was administered IV. RESULTS: The children in group H were significantly better sedated preoperatively (P < 0.01). There was no significant difference in emergence behavior: 42.1% of children in group H compared with 36.2% of children in group L exhibited severe agitation requiring sedation with propofol (P = 0.37). However, regardless of the preoperative dose of midazolam more children under the age of 36 months (61.4%) were severely distressed at emergence compared with older children (16.7%) (P < 0.01). CONCLUSIONS: A higher dose of 1 mg.kg(-1) rectal midazolam results in much better sedated children on induction of anesthesia than 0.5 mg.kg(-1). This, however, does not result in a reduced incidence of emergence delirium after sevoflurane anesthesia. Regardless of the premedication negative behavioral changes occur more frequently in children younger than 3 years of age.

A prospective study comparing the analgesic efficacy of levobupivacaine, ropivacaine and bupivacaine in pediatric patients undergoing caudal blockade.

BACKGROUND: The aim of our study was to compare postoperative analgesic efficacy, analgesic duration and motor blockade of levobupivacaine, ropivacaine and bupivacaine administered caudally in equal concentrations to children undergoing elective minor surgery. METHODS: In the study, 182 children, aged 1-7 years, undergoing either inguinal hernia repair or orchidopexy, were randomly allocated to one of the three groups. They received via a caudal extradural either 1 ml x kg(-1) levobupivacaine 0.2% (Group L) or 1 ml x kg(-1) ropivacaine 0.2% (Group R) or 1 ml x kg(-1) bupivacaine 0.2% (Group B). RESULTS: No statistically significant difference was noted in age, weight, duration of the operation or level of the caudal block between the groups. The onset of analgesia was significantly later after levobupivacaine. Postoperative pain scoring evaluated with Children's and Infant's Postoperative Pain Scale observational scale showed no statistical difference between groups. Median postoperative analgesia was 5.75 h (SEMed: +/- 0.65) in Group L, 5.7 h (SEMed: +/- 0.8) in Group R and 5.35 h (SEMed: +/- 1.3) in Group B the difference being statistically nonsignificant. CONCLUSIONS: The degree of motor block was significantly less after ropivacaine and levobupivacaine during the first 2 h postoperatively.

Axillary brachial plexus block for treatment of severe forearm ischemia after arterial cannulation in an extremely low birth-weight infant.

Severe limb ischemia after arterial catheterization in neonates and premature infants is a well-recognized problem. The usual treatment of ischemic injuries includes removal of the catheter and elevation of the effected limb. If unsuccessful, tissue necrosis and loss may follow. We report the case of a 700 g infant with severe distal forearm ischemia after right radial and ulnar artery catheterization. Immediate removal of the arterial line did not improve ischemia. Thirty-six hours later a brachial plexus block via the axillary approach with 0.5 ml bupivacaine 0.125% was performed resulting in rapid improvement, restricting ischemia eventually to fingers II-V as well as the distal part of the thumb. Brachial plexus blockade and active vasodilatation in tiny neonates after severe local ischemia are discussed.

The role of opioid analgesics in rheumatoid disease in the elderly population.

Adequate pain therapy is an important aspect in the treatment of the elderly patient with rheumatoid disease. Problems with traditional NSAIDs include potentially serious gastrointestinal, cardiovascular and renal adverse effects, especially in the elderly. In addition, the selective cyclo-oxygenase-2 inhibitors have been associated with renal and cardiovascular adverse effects which may limit their use in the elderly with renal or cardiovascular disease. Opioids provide a treatment option for the management of pain in elderly patients with rheumatoid disease in whom pain control under standard management is poor; however, various therapeutic difficulties are encountered in the heterogeneous elderly population (increased risk of adverse effects, multimorbidity, and polypharmacy). Lower initial opioid dosage, prolonged dosage intervals and slower dosage titrations are advisable because of altered pharmacokinetics and pharmacodynamics. Kidney function should be tightly monitored and a timely use of laxatives is to be encouraged. Randomised clinical studies of opioids in musculoskeletal pain (e.g. osteoarthritis) have increasingly extended the scientific basis for their use. However, no randomised controlled clinical trials have examined the efficacy and the benefit/risk ratio of opioids in rheumatoid arthritis. Opioids also demonstrate an analgesic effect following local peripheral application. This opens the way to new therapeutic options in the future through the development of systemic peripherally selective opioids without CNS adverse effects.