Diagnostic and therapeutic application of thoracic epidural in a child with intractable cardiac arrhythmias: A case report.

A 3-year-old boy presented with episodes of uneasiness and transient loss of consciousness. Atrial tachyarrhythmias with rapid ventricular rate was diagnosed and initially unsuccessfully treated with oral antiarrhythmic drugs. Subsequent Holter monitoring revealed ventricular arrhythmias. Despite pharmacologic treatment, he needed numerous cardioversions. Surgical sympathectomy was planned. Initially, sympathectomy was achieved using a continuous high thoracic epidural block and was performed to ascertain the efficacy of the thoracic sympathectomy. This successfully reduced the ventricular arrhythmias and the need for antiarrhythmic agents. The epidural infusion was also used for pain relief following the subsequent surgical sympathectomy.

C Arm confirmation of lung isolation in pediatric patients undergoing video-assisted thoracoscopic decortication: A retrospective case series.

Video-assisted thoracoscopic surgery (VATS) is a frequently performed procedure in children which requires an efficient technique for lung isolation. Unavailability of appropriate size double-lumen tubes (DLT) for children and fiber optic scopes inspired us to create our own technique for lung isolation. This retrospective case series aims to describe our technique of C arm-aided endotracheal tube (ETT) placement for one-lung ventilation in these patients. 15 patients, aged 3 months to 10 years posted for VATS were recruited. Standard monitoring, general anesthesia and Lung isolation done as per the described protocol. Mean, standard deviation, and 95% Confidence interval was used. The mean age and weight was 43.93 months was 16.4 kg respectively. All right bronchus intubations were achieved in the first attempt. Of the 8 left bronchus intubations, 4 needed more than one attempt with a stylet inserted with a gentle J-shaped curve. Mild desaturation, seen in 2 patients during surgery was corrected with neck extension and increasing the FiO2. None of the cases required withdrawal of the tube into the trachea. One-lung anesthesia was achieved successfully in all the cases using C Arm with routine ETT.

Ultrasound determination of the dural sac to sacrococcygeal membrane distance in premature neonates.

BACKGROUND: Caudal epidural analgesia is the most common regional anesthetic performed in infants. Dural puncture, the most common serious complication, is inversely proportional to age. Measuring the distance from the sacrococcygeal membrane to the dural sac may prevent dural puncture. This study measures the sacrococcygeal membrane to dural sac distance using ultrasound imaging to determine feasibility of imaging and obtaining measurements. METHODS: Sacral ultrasound imaging of 40 preterm neonates was obtained in left lateral decubitus, a typical position for caudal blockade. No punctures were made. The sacrococcygeal membrane and termination of the dural sac were visualized, and the distance measured. The spinal levels of the conus medullaris and dural sac termination were recorded. RESULTS: 20 males and 20 females former preterm neonates with an average weight (SD; range) of 1740 (290; 860-2350) g and average age (SD; range) of 35.0 (1.35; 32.2-39) weeks gestational age at the time of imaging. The average sacrococcygeal membrane to distal dural sac distance (SD; range) was 17.4 (3.1; 10.6-26.3) mm. Overall, the weights correlated positively with the distance but the coefficient of variation was large at 23%. The conus medularis terminated below the L3 level and dural sac below the S3 level in 20% and 10% of subjects respectively with hip flexion. CONCLUSION: Ultrasound can be used to measure the sacrococcygeal membrane to dura distance in preterm neonates prior to needle insertion when performing caudal block and demonstrates large variability. Ultrasound imaging may identify patients at risk for dural puncture. When ultrasound is not available, needle insertion less than 3 mm/kg beyond the puncture of the sacrococcygeal membrane should prevent dural contact in 99.9% of neonates.

Comparison of Landmark-guided, Nerve Stimulation-guided, and Ultrasound-guided Techniques for Pediatric Caudal Epidural Anesthesia: A Prospective Randomized Controlled Trial.

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.

Fascia iliaca compartment block: How far does the local anaesthetic spread and is a real time continuous technique feasible in children?

BACKGROUND AND AIMS: The fascia iliaca compartment block (FICB) is commonly administered in children for anterolateral thigh surgery. The actual spread of the local anaesthetic (LA) beneath the fascial layers in children is not known. We hypothesised that in children there could be a possibility of the LA to reach lumbar plexus with the dose we used. METHODS: This study included 25 children, aged 1-15 years for lower limb surgeries after standardised general anesthesia, the FICB was done with ultrasonography. Radio-opaque dye was tagged to LA and the fluoroscopic study was performed. The catheter was placed under ultrasonography. The primary objective was to investigate the fluoroscopic demonstration of the extent of LA spread by our technique and drug volume which is not known in children. The secondary objectives were to evaluate the intraoperative and postoperative analgesic efficacy, complications if any, of the continuous FICB catheters placed by our method. RESULTS: In all patients, the visualisation of ilium and iliacus muscle, the fascia iliaca and needle tip was possible. The fluoroscopic imaging showed that the LA did not spread till the lumbar plexus in 20 patients. In 5 patients, delineated the psoas muscle and reached the L4 vertebral level. The analgesia was adequate. In the postoperative period, 92% had sufficient pain relief. Mild soakage was an issue with catheters. CONCLUSION: Although single shot fascia iliaca compartment block has limited spread of local anaesthetic in children, it is efficacious. Continuous fascia iliaca compartment block is feasible and effective in this age group.

Public Awareness of the Emergency Medical Services in Maharashtra, India: A Questionnaire-based Survey.

Background and objectives The most widely used emergency medical services (EMS) model in India is the '108' emergency service which primarily functions as an emergency response system to attend patients in need of critical care, trauma and accident victims. This is an observational cross-sectional study which was conducted using a questionnaire that asks the participants about their awareness and opinion of the current EMS system. The results of this study will enable us to ascertain the level of awareness of EMS among the population and address any misconceptions if they exist. Materials and methods All participants had to complete a 24-item self-administered questionnaire consisting of eight socio-demographic questions and 16 questions based on the EMS system. Questions regarding the development of the '112' unified emergency service were also included. The convenient sampling method was used for data collection. The distribution of responses was examined using frequencies and percentages. Further analysis was done using the Chi-square test to compare responses between various subgroups based on the age, gender, profession, and level of education. Results A total of 1220 people from the state of Maharashtra responded to the survey and the maximum responses were from Mumbai. Majority of the respondents (59.2%) were from the age group of 15 to 30 years and, most of our responders had received education at the graduate level or above (78.2%). Only 17.5% of the respondents said that they will try to check for responsiveness if they saw a person lying unconscious by the side of the road with the scene being free of any danger. Interestingly, 78.9% of the healthcare professionals who participated in this survey would not check for responsiveness. Only 76.2% of the respondents knew that '108' is the number to dial in case of a medical emergency and about a quarter of them was not aware of it. It may seem that a good number of people are aware of the number. However, with the high number of fatalities occurring every day due to lack of medical facilities and a high current annual death toll on the roads, 100% of the population should know the emergency number. Only 20.2% of the respondents had called the EMS and asked for an ambulance. 68.5% of the respondents would immediately move out of the way and 27.5% of them would move out of their way if the ambulance's lights and sirens were on. About two-thirds of the respondents were unaware of the development of a unified emergency number (112). However, a large majority (82.9%) were in favor of having a unified emergency number instead of a different number for each emergency. Only 43.8% of the respondents were of the opinion that the current EMS coverage was inadequate. 24.9% of the participants rated the current EMS as good, whereas 53.5% rated the EMS average and 16.9% rated it poor. Conclusions An effort should be made to make 100% of the population aware of this service. The first step for increasing awareness would be starting various advertisement campaigns. The next step would be to implement the unified emergency number (112) to address all kinds of distress calls such as police, fire, and ambulance. A very small proportion of the population is trained in first-aid or basic trauma life support. Awareness campaigns and training sessions for the general public should be conducted for the same. It is also necessary to spread awareness and help the populace know about the Good Samaritan law.