Epidural..Revisited ..Part 1..Median approach VS Paramedian

There have been few studies comparing the midline and paramedian approach on block success.

In cadavers, using epiduroscopy, paramedian catheters were observed to cause less epidural tenting, and pass cephalad more reliably than midline catheters.

In patients, faster catheter insertion times were reported in the paramedian, and higher incidence of paraesthesia in the midline group.

Adequate local infiltration is a prerequisite for patient comfort during paramedian puncture.

The paramedian approach may be less dependent upon spine flexion.

The risk of vascular puncture during epidural catheter placement was not associated with lumbar midline or paramedian technique in parturients, while another study suggested more paraesthesia and bloody puncture in non-pregnant adults when the midline approach was used.

1-Blomberg RG. Technical advantages of the paramedian approach for lumbar epidural puncture and catheter introduction. A study using epiduroscopy in autopsy subjects.
Anaesthesia 1988; 43: 837–43
2- Leeda M, Stienstra R, Arbous MS, et al. Lumbar epidural catheter insertion: the midline vs. the paramedian approach. Eur J Anaesthesiol 2005; 22: 839–42
3-Griffin RM, Scott RP. Forum. A comparison between the midline and paramedian approaches to the extradural space. Anaesthesia 1984; 39: 584–6
4- Podder S, Kumar N, Yaddanapudi LN, Chari P. Paramedian lumbar epidural catheter insertion with patients in the sittingposition is equally successful in the flexed and unflexed spine.
Anesth Analg 2004; 99: 1829–32
22 Rigg JR, Jamrozik K, Myles PS, et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276–82

Comments

The pressure volume loop...

In the pressure-volume loop below, cardiac work is best represented by: the area of the curve the slope of the line from points C to D the distance of the line from points C to D the slope of a line from points A to D .. .. ... .... ... .... .... .... In the pressure-volume loop below, cardiac work is best represented by: the area of the curve Cardiac work is the product of pressure and volume and is linearly related to myocardial oxygen consumption. Cardiac work is best represented by the area of the curve of a pressure-volume loop.

Driving Pressure in ARDS: A new concept!

Driving Pressure and Survival in the Acute Respiratory Distress Syndrome Marcelo B.P. Amato, M.D., Maureen O. Meade, M.D., Arthur S. Slutsky, M.D., Laurent Brochard, M.D., Eduardo L.V. Costa, M.D., David A. Schoenfeld, Ph.D., Thomas E. Stewart, M.D., Matthias Briel, M.D., Daniel Talmor, M.D., M.P.H., Alain Mercat, M.D., Jean-Christophe M. Richard, M.D., Carlos R.R. Carvalho, M.D., and Roy G. Brower, M.D. N Engl J Med 2015; 372:747-755 February 19, 2015 DOI: 10.1056/NEJMsa1410639 BACKGROUND Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures, lower tidal volumes (V T ), and higher positive end-expiratory pressures (PEEPs) can improve survival in patients with the acute respiratory distress syndrome (ARDS), but the relative importance of each of these components is uncertain. Because respiratory-system compliance (C RS ) is strongly related to the volume of aerated remaining functional lung during disease (termed functional lung size)...

Anaphylaxis updates part 2- Empty Ventricle Syndrome

Patients with anaphylaxis should not suddenly sit, stand, or be placed in the upright position. Instead, they should be placed on the back with their lower extremities elevated or, if they are experiencing respiratory distress or vomiting, they should be placed in a position of comfort with their lower extremities elevated. This accomplishes 2 therapeutic goals: 1) preservation of fluid in the circulation (the central vascular compartment), an important step in managing distributive shock; and 2) prevention of the empty vena cava/empty ventricle syndrome, which can occur within seconds when patients with anaphylaxis suddenly assume or are placed in an upright position. Patients with this syndrome are at high risk for sudden death. They are unlikely to respond to epinephrine regardless of route of administration, because it does not reach the heart and therefore cannot be circulated throughout the body

sedationstation

Search This Blog