Comparison of real-time ultrasound approach to non ultrasound-assissted approach in paramedian lateral spinal anaesthesia for lower limb surgery

Title: Comparison of real-time ultrasound approach to non ultrasound-assissted approach in paramedian lateral spinal anaesthesia for lower limb surgery. Background: Real-time ultrasound-guided neuraxial blockade remains a largely experimental technique. We investigated if this technique might improve the approach of spinal anaesthesia in different aspects. Objectives: To compare the clinical efficacy of real-time ultrasonographic localization of the intrathecal space by comparing success rate, first needle pass and immediate complications. Methods: 60 patients with BMI less than 30 kg/m2 undergoing lower limb surgery under spinal anaesthesia were recruited. Following palpation and a pre-procedural ultrasound scan, a spinal needle introducer was inserted in-plane to the ultrasound probe. The angle of introducer was adjusted in real-time until it pointed in between two vertebral laminae. A 25G Pencan spinal needle was inserted. Successful dural puncture was confirmed by backflow of cerebrospinal fluid. This was compared to paramedian spinal anaesthesia via palpation method. Results: There were no differences in age, weight, height, BMI, or ASA grading between the two groups. Successful dural puncture on first skin puncture was significantly higher in the ultrasound group than palpation group (86.7% vs. 43.3%, P<0.01). The success rate of single needle pass was also significantly higher in the ultrasound group (46.7% vs. 20%, p=0.028). Among the overweight (BMI>25) patients, dural puncture was successful on the first skin puncture in 17 patients (85%) in ultrasound group vs. 6 patients (33.3%) in palpation group. (p=0.001). Successful rate of single needle pass was also significant in ultrasound group (50% vs. 16.7%, p = 0.033). Amongst patients with BMI<25, there were no significant difference in both groups. Duration taken for determining puncture site was (0.69+1.01) minutes in the ultrasound group and (1.60+1.19) minutes in the palpation group. (p=0.002). Conclusion: Real-time ultrasound-guidance improves the success rate of paramedian spinal anaesthesia in lateral position, especially in overweight patients. It has not much of role in patients who are thin and have easily palpable spinous process

Comparison of Dexmedetomidine 50μg versus 100μg added to 0.5% Levobupivacaine in Supraclavicular Brachial Plexus Block (BPB) for Arteriovenous Fistula (AVF) Surgery

Background: Dexmedetomidine is an alpha-2 agonist used as sedation in ICU and remote anaesthesia. Unlike Clonidine, its effect as additive in peripheral nerve block has not been widely researched upon. The aim of this study is to compare the efficacy and outcome of additive dexmedetomidine 50μg versus 100μg to levobupivacaine 0.5% in supraclavicular brachial plexus block in AVF surgery . Methodology: Forty six adult with chronic renal failure patients scheduled for AVF surgery were studied in prospective, randomized, single operator double blinded study design. The supraclavicular block was performed with the ultrasound and a nerve stimulator technique.Group A (dexmedetomidine 50μg added to 20 ml of levobupivacaine 0.5 % + 1ml of normal saline) versus Group B (dexmedetomidine 100μg added to 20 ml of levobupivacaine 0.5 %). The onset, duration of action, haemodynamic parameters changes, vascular diameter changes and sedative effects were recorded Result: The onset of sensory and block is faster in Group B (8.08 ± 1.38); (P 0.5) Both group have a stable haemodynamic profiles. Group B causes significant increased the artery (0.020 ± 0.0067); (P<0.02) and vein diameter (0.022 ± 0.0074); (P<0.001). Conclusion: Dexmedetomidine as an additive for supraclacvicular block in ESRF patient for AVF surgery causes faster onset, prolonged duration of anesthesia, increase the artery and vein diameter and produced sedation effect with stable haemodynamic parameters

Palliative brachytherapy to axilla and hypopharynx in elderly patient with hypopharyngeal squamous cell carcinoma — case report

Brachytherapy (BT) is an important local treatment of tumor and it can be applied to different anatomical sites either in a curative or palliative setting. BT can deliver large dose of radiation to the tumor while sparing the surrounding normal tissue which translates into a better therapeutic ratio compared to external beam radiotherapy. However, the evidence for the use of brachytherapy in the palliative setting is lacking in the literature. In this case report, we describe the brachytherapy technique and outcome of a patient with squamous cell carcinoma of the hypopharynx who underwent palliative brachytherapy to the hypopharynx and metastatic tumor at the right axilla.

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Sequestrated caudal catheter in a child: An anesthetic nightmare and surgical dilemma

The usage of epidural infusion for intraoperative and postoperative pain relief is widely used in certain pediatric anesthetic practice because of the effectiveness and advantages. However, there is drawback for these techniques due to its potential complications such as inadvertent intrathecal placement, local anesthetic toxicity, catheter migration, infection, and breakage of epidural catheter. Though occur infrequently, epidural catheters have been known to snap during insertion or removal. The retained catheter tip may lead to multiple complications, including nerve injury, infection, and even catheter migration. Although there are literatures recommend options for management of removal of retained catheter, there are limited reports of these occurrences, especially among children. We report a case of sequestrated sheared epidural catheter segment in a child, aiming to share this experience for the future management of patients under similar condition

Lumbar tinea versicolor and spinal anaesthesia

Infection to the meningeal layer causing meningitis is one of the most feared complications of spinal anaesthesia. Anaesthetists will avoid spinal anaesthesia for those who are having skin infection at the puncture site. However in obstetric population, anaesthetist will try their best to avoid general anaesthesia due to its unwanted effects and complications. Strict and appropriate antiseptic measures such as chlorhexidine 0.5% with 70% alcohol has been suggested to reduce risk of transmission of microorganisms into subarachnoid space. We reported a parturient who had generalized tinea versicolor at the lumbar area, safely anaesthetized under spinal anaesthesia through meticulous antiseptic skin preparation who required delivery by caesarean section. Keywords: Tinea versicolor, Spinal anaesthesia, Caesarean sectio

Renoprotective effect of highdose N-Acetylcysteine in patients who underwent cardiac surgery: an observational study

Background: The effect of N-acetylcysteine (NAC) on the prevention of acute kidney injury postcardiac surgery remains controversial. This study was designed to evaluate the effect of highdose NAC on the renal function of patients who underwent cardiac surgery. Materials and Methods: A comparative cross-sectional study involving retrospective record review. One hundred and twenty-three adult patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) were recruited. The study group (n = 40) received NAC 600 mg tablets a day prior to surgery and intravenous NAC 10 g into the CPB machine, and the control group (n = 83) did not receive any supplemental NAC. We evaluated the mean serum creatinine level at 24 and 48 h postoperatively and compared the prevalence of acute kidney injury using Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Results: There was no significant difference between serum creatinine and estimated glomerular filtration rate (eGFR) across the preoperation, 24, and 48 h postoperatively between the NAC and control groups (P > 0.05). There was no significant difference in the prevalence of acute kidney injury between the two groups (58 [47.2%] vs. 37 [44.6%]; P = 0.41). No difference was observed in the two groups’ need for renal replacement therapy, duration of ventilation, length of stay in the intensive care unit, and duration of hospitalization (P > 0.05). Conclusion: In this study, we did not detect statistically significant protection of renal function in patients who received NAC for cardiac surgery. A further randomized controlled trial in this area is needed to minimize confounding factors

Congenital Vascular Ring: Overcoming Perioperative Challenges

a two month old girl was admitted for ventricular septal defect (VSD) with heart failure and pulmonary hypertension. She had suffered from occasional stridor and fast breathing since birth. Echocardiography found a double aortic arch, and confirmed with 3D reconstructed thoracic computed tomography angiography (CTA)