Simulated fluid resuscitation for toddlers and young children: effect of syringe size and hand fatigue.

BACKGROUND: In small children, fluid resuscitation requires rapid administration of a relatively large fluid volume. This is often achieved manually. The optimal syringe size is unknown. OBJECTIVES: The purpose of this study was to determine which syringe delivers fluid in the shortest time. The secondary outcome was to determine which syringe was associated with hand fatigue. METHODS: Participants (n = 20) performed a simulated fluid resuscitation using four syringe sizes: 5 ml, 10 ml, 20 ml, and 60 ml. The 'pull and push' method was used to transfer 250 ml of lactated Ringer's solution from a bag, through IV tubing, into a container. Fluid transfer time (seconds) and hand fatigue were measured. RESULTS: A 'U'-shaped curve was identified between syringe size and transfer time (P < 0.0001). The 10-ml and 20-ml syringes did not differ significantly (231 ± 43 vs 228 ± 45 s, P > 0.2, respectively). The 5-ml and 60-ml syringes did not differ significantly (273 ± 69 s vs 295 ± 64, P = 0.2, respectively). However, the 5-ml syringe required significantly more time than the 10-ml (by 42 s, P = 0.002) or the 20-ml (by 45 s, P = 0.001) syringes. The 60-ml syringe also required significantly more time than the 10-ml (by 64 s, P < 0.0001) or 20-ml (by 67 s, P = 0.0001) syringe. Although all participants transferred the 250 ml, hand fatigue increased as syringe size increased: 5 ml (n = 3), 10 ml (n = 4), 20 ml (n = 7), and 60 ml (n = 15). Most participants preferred using the 10-ml syringe (n = 11/20), followed by 20-ml (n = 6/20), 5-ml (n = 3/20), and 60-ml (n = 0/20) syringes. CONCLUSION: Manual fluid resuscitation using the 'pull and push' method is most rapidly accomplished with the 10-ml or 20-ml syringes. The 60-ml syringe is associated with the most hand fatigue. Participants most preferred the 10-ml or 20-ml syringes.

STOP-Bang and prediction of difficult airway in obese patients.

STUDY OBJECTIVE: To determine if a high score (≥ 3) on the STOP-Bang screening questionnaire for obstructive sleep apnea (OSA) predicts whether obese patients are at high risk for OSA and increased risk of difficult airway. DESIGN: Prospective, questionnaire-based clinical assessment. SETTING: University-affiliated hospital. PATIENTS: 127 ASA physical status 2 and 3 patients, who were scheduled for elective bariatric surgery. INTERVENTIONS: Patients were allocated to three groups. Group 1 patients had a previous history of OSA, Group 2 patients had no history of OSA but did have a high STOP-Bang score (≥ 3), and Group 3 patients had no history of OSA but did have a low STOP-Bang score (< 3). Groups 2 and 3 only were assessed using the STOP-Bang questionnaire. After induction and intubation of the patient, an anesthesiologist who was blinded to the three study group allocations completed an airway questionnaire on the three study groups. MEASUREMENTS: The frequency of difficult airway, difficult mask ventilation with or without muscle relaxation, poor visualization of the vocal cords, difficulty in blade insertion, and difficult intubation were compared. MAIN RESULTS: The group of patients with high STOP-Bang scores (Group 2) and those patients previously diagnosed with OSA (Group1) showed a higher risk for difficult airway than the patients with low STOP-Bang scores (Group 3; P < 0.001). CONCLUSION: The STOP-Bang score may be used as an effective predictor of difficult airway in obese patients. Obese surgical patients with unknown/undiagnosed OSA status should be evaluated using the STOP-Bang questionnaire score.

Ultrasonographic modification of Cormack Lehane classification for pre-anesthetic airway assessment.

BACKGROUND: The major drawback of Cormack Lehane classification for airway assessment is its dependence on invasive direct laryngoscopy and hence it is inapplicable for pre-anesthetic assessment of airway in patients with no prior history of tracheal intubation. STUDY OBJECTIVES: The purpose of the study was to compare and correlate the ultrasound view of the airway and the Cormack Lehane classification of the direct laryngoscopy. METHODS/STUDY PROCEDURES: The present study was conducted on patients scheduled for elective surgery and requiring general anesthesia with direct laryngoscopy and endotracheal intubation. In the pre-operative holding area, the following measurements were obtained with the oblique-transverse ultrasound view of the airway: (a) the distance from the epiglottis to the midpoint of the distance between the vocal folds, (b) the depth of the pre-epiglottic space, and (c) the total time taken by the operator to achieve the final ultrasonic image. The data was then compared with the Cormack Lehane classification during direct laryngoscopy in the operating room. Subsequently based on the correlation data, the ultrasonographic modification of Cormack-Lehane Classification was developed. RESULTS: It was observed that there was a correlation of the distance between the epiglottis and the vocal cords (E-VC) with the Cormack Lehane Grading; correlation was strong negative with regression coefficient of -0.966 (95% CI -1.431 to -0.501; p = 0.0001). Subsequently, the correlation of the pre-epiglottis space (Pre-E) with the Cormack Lehane Grading was strong in positive direction with regression coefficient of0.595 (95% CI 0.261 to 0.929; p = 0.0008). Finally the ratio of Pre-E and E-VC distances with the Cormack Lehane Grading had the strongest positive correlation with regression coefficient of 0.495 (95% CI 0.319 to 0.671; p < 0.0001). Based on these statistical calculations and after rearranging the data, we found that prediction of Cormack Lehane (CL) grades can be adequately (67%-68% sensitivity) made by the ratio of Pre-E and E-VC distances (Pre-E/E-VC) {0 < [Pre-E/E-VC] < 1 approximately CL grade 1; 1 < [Pre-E/E-VC] < 2 approximately CL grade 2; and 2 < [Pre-E/E-VC] < 3 approximately CL grade 3}. The average time taken to complete the ultrasound examination of airway in the preoperative area was 31.7 +/- 12.4 seconds. CONCLUSION: The non-invasive ultrasonographic modification of invasive Cormack Lehane classification for pre-anesthetic airway assessment can supplement the presently available noninvasive modalities of pre-anesthetic airway assessment including the Mallampati Classification.

Management of complex regional pain syndrome type I in upper extremity-evaluation of continuous stellate ganglion block and continuous infraclavicular brachial plexus block: a pilot study.

UNLABELLED: Interventional pain management techniques play an important role in the multidisciplinary approach to management of complex regional pain syndrome (CRPS). In this preliminary study we compared the efficacy of continuous stellate ganglion (CSG) block with that of continuous infraclavicular brachial plexus (CIBP) block in management of CRPS type I of upper extremity. METHODS: Thirty-three patients with CRPS type I of upper extremity were randomly assigned to either CSG or CIBP group. Patients were treated for 1 week with continuous infusion of 0.125% bupivacaine at 2and 5mL/h, respectively. Catheter was removed at 1 week and patients were followed up for 4 weeks. The outcome was evaluated in terms of neuropathic pain scale score (NPSS), edema scores (Grades 0-2), and range of motion (ROM) of all upper extremity joints (Grades 0-2). RESULTS: CIBP group showed statistically significant improvement in NPSS compared with CSG group during the first 12 hours after the procedures (P value <0.05). After 12 hours, the NPSS was comparable between the groups. At 4 weeks, both groups showed clinically significant improvement in edema score and ROM of all upper extremity joints when compared with the baseline. CONCLUSION: This preliminary study suggests that CIBP block and CSG block may be feasible and effective interventional techniques for the management of CRPS type I of upper extremities. Hence, we recommend a larger well-randomized, well-controlled, clinical trial to confirm our findings and determine if any significant difference exists between the groups in terms of long-term pain relief and functional restoration.

Ketamine as an adjuvant in sympathetic blocks for management of central sensitization following peripheral nerve injury.

UNLABELLED: Proliferation of NMDA receptors and role of glutamate in producing central sensitization and 'wind up' phenomena in CRPS [complex regional pain syndrome] forms a strong basis for the use of Ketamine to block the cellular mechanisms that initiate and maintain these changes. In this case series, we describe 3 patients of CRPS Type II with debilitating central sensitization, heat/mechano allodynia and cognitive symptoms that we termed 'vicarious pain'. Each of these patients had dramatic relief with addition of Ketamine as an adjuvant to the sympathetic blocks after conventional therapy failed. CASE REPORTS: All 3 patients suffered gunshot wounds and developed characteristic features of CRPS Type II. Within 2-3 weeks they developed extraterritorial symptoms typical of central sensitization. The generalized mechanical allodynia and debilitating heat allodynia described to be rare in human subjects had life altering affect on their daily life. Case 2 and 3 also described an unusual cognitive phenomenon i.e. visual stimuli of friction would evoke severe pain in the affected limb that we have termed as 'vicarious pain'. They responded positively to sympathetic blocks but the sympatholysis did not bring relief to the heat and mechanical allodynia. Addition of Ketamine 0.5 mg/kg to the sympathetic blocks elicited resulted in marked relief in the allodynia. CONCLUSION: Ketamine has a special role in patients with debilitating heat allodynia and positive cognitive symptoms via its action on central pain pathway. As an adjuvant in sympatholytic blocks it has a targeted action without significant neuropsychiatric side effects.

Transsacrococcygeal approach to ganglion impar block for management of chronic perineal pain: a prospective observational study.

BACKGROUND: The ganglion impar or ganglion of Walther is a solitary retroperitoneal structure at the level of sacrococcygeal junction. It provides the nociceptive and sympathetic supply to the perineal structures. Chronic Perineal Pain (CPP) has been effectively managed by ganglion impar block. In this study we analyze the feasibility, safety, and efficacy of ganglion impar block by transsacrococcygeal approach. DESIGN: An observational report. METHODS: In this prospective study, 16 consecutive patients who required ganglion impar block for CPP were followed for two months. After informed and written consent, the ganglion impar was blocked under aseptic precautions, using a transsacrococcygeal approach. The Visual Analogue Scale for pain (VAS) at presentation time required for the pain to reduce by 50% to be considered effective and VAS was recorded at different time points during 2-month follow-up, and time required to perform the procedure, number of attempts, and any complications were also noted. RESULTS: All the blocks were effective with a mean duration of 12+/-3 minutes for 50% reduction in VAS. The mean duration required to perform the procedure in neurolytic block patients was 7.8+/-2 minutes and 5.7+/-1 minutes in therapeutic block patients. There were no adverse events. All the patients had significant pain relief during 2 month follow-up (p <0.05 compared to baseline). The mean VAS at 2 months was about 2. Statistical analysis was done by using paired "t"/Wilcoxon signed rank test. CONCLUSION: A transsacrococcygeal approach for a ganglion impar block is a technically feasible and safe technique. We recommend this technique for neurolysis or radiofrequency ablation of the ganglion impar and for diagnostic blocks, especially when the diagnosis and further plan of management is dependent on the response of the diagnostic block.