Risk of rectal puncture due to needle entry into the presacral space: Importance of measuring the distance between the rectum and sacrococcyx, and the thickness of the sacrococcyx.
- 作者列表："Kwon YS","Lee N","Lee HS","Youn EJ","Lee SK","Kim Y","Lee JJ
:During ganglion impar block, the needle may approach the presacral space and the sacrum may be penetrated during caudal anesthesia. Because the rectum is in front of the sacrococcyx and is thus at risk for puncture, it is important to determine the distance between the sacrococcyx and rectum, as well as the thickness of the sacrococcyx.Computed tomography was used to measure the distance between the rectum and sacrococcyx, as well as the thickness of the sacrococcyx. The distances between the coccyx and rectum, sacrococcygeal joint and rectum, sacral level 5 ('sacrum 5') and rectum, and 'sacrum 4 to 5 junction' and rectum were measured. The results were compared based on the presence or absence of stools in the rectum. The thickness of the sacrococcyx was measured at the sacrum 4 to 5 junction and sacrococcygeal joint.In total, 1264 patients were included in this study. All distances were less than 1 mm in both males and females, with the exception of the distance between the coccyx and rectum in males. In both males and females, there was no significant difference in distance between the sacrococcyx and rectum according to the presence or absence of feces in the rectum, but there was a difference in the distance between sacrum 5 and the rectum in males (P = .048). Several male and female patients showed thicknesses of less than 5 mm at the sacrococcygeal joint.Some patients have a distance of less than 1 mm between the sacrum and rectum. Practitioners should exercise caution when applying a needle to the presacral space. If the sacrum is accidentally penetrated during caudal block, rectum puncture cannot be ruled out. Excretion of feces does not influence the distance between the sacrococcyx and rectum in females.
: 在神经节撞击阻滞期间，针可以接近骶前间隙，并且在尾部麻醉期间可以穿透骶骨。由于直肠位于骶尾骨的前面，因此有穿刺的危险，因此确定骶尾骨和直肠之间的距离以及骶尾骨的厚度是很重要的。计算机断层扫描用于测量直肠和骶尾骨之间的距离，以及骶尾骨的厚度。测量尾骨与直肠、骶尾部关节与直肠、骶骨水平5 (“骶骨5”) 与直肠、 “骶骨4 ~ 5交界处” 与直肠之间的距离。根据直肠中是否存在粪便来比较结果。在骶骨4 ~ 5交界处及骶尾部关节处测量骶尾骨厚度，共1264例患者纳入本研究。除男性尾骨和直肠之间的距离外，男性和女性的距离均小于1mm mm。在男性和女性中，根据直肠中有无粪便，骶尾骨与直肠的距离没有显著差异，但男性骶骨5与直肠的距离有差异 (p = .048)。一些男性和女性患者显示骶尾部关节的厚度小于5 mm。一些患者骶骨和直肠之间的距离小于1 mm。行医者在骶前间隙进针时应谨慎。如果骶尾部阻滞时不小心刺入骶骨，不能排除直肠穿刺。粪便的排泄不影响女性骶尾骨和直肠之间的距离。
METHODS:BACKGROUND:Anxiety and distress behaviors during anesthesia induction are associated with negative postoperative outcomes for pediatric patients. Documenting behavioral responses to induction is useful to evaluate induction quality at hospitals and to optimize future anesthetics for returning patients, but we lack a simple tool for clinical documentation. The Induction Compliance Checklist is a tool for grading induction behaviors that is well validated for research purposes, but it is not practical for routine documentation in busy clinical practice settings. The Child Induction Behavioral Assessment tool was developed to provide a simple and easy to use electronic tool for clinical documentation of induction behaviors. The aim of this study was to test the Child Induction Behavioral Assessment tool's concurrent validity with the Induction Compliance Checklist and the interrater reliability. METHODS:This prospective, observational study included 384 pediatric patients undergoing anesthesia inhalation induction. Concurrent validity with the Induction Compliance Checklist and interrater reliability of the Child Induction Behavioral Assessment were evaluated. Two researchers alternated scoring the Induction Compliance Checklist. The 2 researchers independently scored the Child Induction Behavioral Assessment. The anesthesia clinician caring for the patient also independently scored the Child Induction Behavioral Assessment by completing their routine documentation in the patient's medical record. Two age groups were evaluated (ages 1-3 and 4-12 years old). RESULTS:Clinicians' and researchers' Child Induction Behavioral Assessment scores demonstrated a strong correlation with the Induction Compliance Checklist (P < .0001). There was an excellent agreement between the 2 researchers' Child Induction Behavioral Assessment scores for the younger and older age groups, respectively (Kappa [95% CI] = 0.97 (0.94-0.99); K = 0.94 (0.89-0.99)]. The agreement between the researchers and the 117 clinicians who documented Child Induction Behavioral Assessment assessments in the medical record was good overall (intraclass correlation coefficient = 0.70), with fair agreement with the 1- to 3-year-old patients (intraclass correlation coefficient = 0.56) and good agreement for the 4- to 12-year-old patients (intraclass correlation coefficient = 0.74). CONCLUSIONS:The Child Induction Behavioral Assessment scale is a simple and practical electronic tool used to document pediatric behavioral responses to anesthesia inductions. This study provides evidence of the tool's validity and reliability for inhalation inductions. Future research is needed at other hospitals to confirm validity.
METHODS:BACKGROUND:Fentanyl and morphine are the 2 most commonly added opioids to bupivacaine for spinal anesthesia during cesarean delivery. Numerous clinical trials have assessed efficacy and safety of different doses of fentanyl added to intrathecal bupivacaine for spinal anesthesia, yet its benefit, harm, and optimal dose remain unclear. This study aimed to systematically review the evidence of the efficacy of fentanyl when added to intrathecal bupivacaine alone and when added to bupivacaine with morphine for spinal anesthesia during cesarean delivery. METHODS:Key electronic databases (PubMed, Embase, and Cochrane Library) were searched for randomized controlled trials in the cesarean delivery population. The primary outcome was the failure rate of spinal anesthesia, as assessed by the need for either conversion to general anesthesia or intraoperative analgesic supplementation. Two reviewers independently extracted the data using a standardized electronic form. Results are expressed as relative risks or mean differences with 95% CIs. RESULTS:Seventeen randomized controlled clinical trials (most judged as low or unclear risk of bias) with 1064 participants provided data for the meta-analysis. Fentanyl added to intrathecal bupivacaine alone reduced the need for intraoperative supplemental analgesia (relative risk, 0.18; 95% CI, 0.11-0.27; number needed to treat, 4) and the incidence of nausea/vomiting (relative risk, 0.41; 95% CI, 0.24-0.70; number needed to treat, 6.5), with longer time to first postoperative analgesia request (mean difference, 91 minutes; 95% CI, 69-113). No difference was observed regarding the need for conversion to general anesthesia (relative risk, 0.67; 95% CI, 0.12-3.57), the incidence of hypotension, the onset of sensory block, or the duration of motor block. However, the addition of intrathecal fentanyl was associated with higher incidence of intraoperative pruritus (relative risk, 5.89; 95% CI, 2.07-16.79; number needed to harm, 13.5). The inclusion of fentanyl to intrathecal bupivacaine-morphine compared to intrathecal bupivacaine-morphine alone conferred a similar benefit, with a significantly reduced need for intraoperative supplemental analgesia (relative risk, 0.16; 95% CI, 0.03-0.95; number needed to treat, 9). Analysis using a funnel plot indicated a possibility of publication bias in included studies. CONCLUSIONS:Current evidence suggests a benefit of using fentanyl as both an additive to intrathecal bupivacaine alone and to intrathecal bupivacaine combined with morphine for cesarean delivery under spinal anesthesia. The possibility of publication bias, small sample size, and high risk of bias in some of the included studies warrant treating the results with caution.
METHODS::Ophthalmic pediatric regional anesthesia has been widely described, but infrequently used. This review summarizes the available evidence supporting the use of conduction anesthesia in pediatric ophthalmic surgery. Key anatomic differences in axial length, intraocular pressure, and available orbital space between young children and adults impact conduct of ophthalmic regional anesthesia. The eye is near adult size at birth and completes its growth rapidly while the orbit does not. This results in significantly diminished extraocular orbital volumes for local anesthetic deposition. Needle-based blocks are categorized by relation of the needle to the extraocular muscle cone (ie, intraconal or extraconal) and in the cannula-based block, by description of the potential space deep to the Tenon capsule. In children, blocks are placed after induction of anesthesia by a pediatric anesthesiologist or ophthalmologist, via anatomic landmarks or under ultrasonography. Ocular conduction anesthesia confers several advantages for eye surgery including analgesia, akinesia, ablation of the oculocardiac reflex, and reduction of postoperative nausea and vomiting. Short (16 mm), blunt-tip needles are preferred because of altered globe-to-orbit ratios in children. Soft-tip cannulae of varying length have been demonstrated as safe in sub-Tenon blockade. Ultrasound technology facilitates direct, real-time visualization of needle position and local anesthetic spread and reduces inadvertent intraconal needle placement. The developing eye is vulnerable to thermal and mechanical insults, so ocular-rated transducers are mandated. The adjuvant hyaluronidase improves ocular akinesia, decreases local anesthetic dosage requirements, and improves initial block success; meanwhile, dexmedetomidine increases local anesthetic potency and prolongs duration of analgesia without an increase in adverse events. Intraconal blockade is a relative contraindication in neonates and infants, retinoblastoma surgery, and in the presence of posterior staphylomas and buphthalmos. Specific considerations include pertinent pediatric ophthalmologic topics, block placement in the syndromic child, and potential adverse effects associated with each technique. Recommendations based on our experience at a busy academic ophthalmologic tertiary referral center are provided.