ResearchPad - local-and-regional-anesthesia https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Social approach and place aversion in relation to conspecific pain in dairy calves]]> https://www.researchpad.co/article/elastic_article_14573 Despite scientific interest in animal empathy, and growing public concern for farm animal welfare, the empathic abilities of farm animals remain under researched. In this study, we investigated empathic responses of young Holstein dairy calves to conspecifics recovering from hot-iron disbudding, a painful procedure common on dairy farms. A combination of social approach and place conditioning was used. First, ‘observer’ calves witnessed two ‘demonstrator’ calves recover from either a painful procedure (hot-iron disbudding and sedation) or a sham procedure (sedation alone) in distinct pens. Observer calves spent more time in proximity and paid more attention to calves recovering from the painful procedure compared to sham calves (proximity: 59.6 ± 4.3%; attention: 54.3 ± 1.5%). Observers were then tested for conditioned place aversion (in the absence of demonstrators) at 48h, 72h and 96h after the second demonstration; observers tended to avoid the pen associated with conspecific pain during the second of the three tests, spending 34.8 ± 9.6% of their time in this pen. No strong evidence of pain empathy was found, but our tentative results encourage further research on empathy in animals.

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<![CDATA[Evaluation of the responsiveness of outcome measures after spine injection: A retrospective study]]> https://www.researchpad.co/article/5c803c65d5eed0c484ad8887

Discrepancies in patients’ responses to various outcome measures challenge clinicians’ evaluation of treatment outcomes. Therefore, we aimed to 1) evaluate the concordance of outcome measures after spine injection, 2) determine the patient variables that lead to discordant responses, and 3) suggest practical outcome measure for spine injections with good responsiveness. From October 2014 to November 2014, 164 patients with neck or low back pain who visited our outpatient clinics and had spine injections on the previous visit were enrolled. We asked patients to report changes in their symptom in the form of outcome measures: numeric rating scale, Oswestry disability index, neck disability index, residual symptom percentage and global perceived effect. The responses were categorized into three groups according to the degree of change; not improved, minimally improved, and significantly improved. The concordances of these categorized answers were evaluated. When “significantly improved” was considered as true improvement, 46 (28%) of the 164 patients had discordant responses to the four measures. There was no significant patients’ variable that affects discordance in the outcome measures. Good agreement was shown between the global perceived effect and residual symptom percentage, while the Oswestry disability index had poor agreement with the other measurements. The calculated numeric rating scale and residual symptom percentage also had low levels of agreement. However, patients with severe pre-treatment pain tended to have better agreement. In conclusion, this result suggest that the residual symptom percentage may be a more practical for clinicians and better represent patients’ improvements after spine injection.

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<![CDATA[The incidence of post-intubation hypertension and association with repeated intubation attempts in the emergency department]]> https://www.researchpad.co/article/5c6b266fd5eed0c484289a8b

Background

Studies in the non-emergency department (ED) settings have reported the relationships of post-intubation hypertension with poor patient outcomes. While ED-based studies have examined post-intubation hypotension and its sequelae, little is known about, post-intubation hypertension and its risk factors in the ED settings. In this context, we aimed to identify the incidence of post-intubation hypertension in the ED, and to test the hypothesis that repeated intubation attempts are associated with an increased risk of post-intubation hypertension.

Methods

This study is a secondary analysis of the data from a multicenter prospective observational study of emergency intubations in 15 EDs from 2012 through 2016. The analytic cohort comprised all adult non-cardiac-arrest patients undergoing orotracheal intubation without pre-intubation hypotension. The primary exposure was the repeated intubation attempts, defined as ≥2 laryngoscopic attempts. The outcome was post-intubation hypertension defined as an increase in systolic blood pressure (sBP) of >20% along with a post-intubation sBP of >160 mmHg. To investigate the association of repeated intubation attempts with the risk of post-intubation hypertension, we fit multivariable logistic regression models adjusting for ten potential confounders and patient clustering within the EDs.

Results

Of 3,097 patients, the median age was 69 years, 1,977 (64.0%) were men, and 991 (32.0%) underwent repeated intubation attempts. Post-intubation hypertension was observed in 276 (8.9%). In the unadjusted model, the incidence of post-intubation hypertension did not differ between the patients with single intubation attempt and those with repeated attempts (8.5% versus 9.8%, unadjusted P = 0.24). By contrast, after adjusting for potential confounders and patient clustering in the random-effects model, the patients who underwent repeated intubation attempts had a significantly higher risk of post-intubation hypertension (OR, 1.56; 95% CI, 1.11–2.18; adjusted P = 0.01).

Conclusions

We found that 8.9% of patients developed post-intubation hypertension, and that repeated intubation attempts were significantly associated with a significantly higher risk of post-intubation hypertension in the ED.

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<![CDATA[VPAC1 receptors play a dominant role in PACAP-induced vasorelaxation in female mice]]> https://www.researchpad.co/article/5c79afecd5eed0c4841e3a63

Background

PACAP and VIP are closely related neuropeptides with wide distribution and potent effect in the vasculature. We previously reported vasomotor activity in peripheral vasculature of male wild type (WT) and PACAP-deficient (KO) mice. However, female vascular responses are still unexplored. We hypothesized that PACAP-like activity is maintained in female PACAP KO mice and the mechanism through which it is regulated differs from that of male PACAP KO animals.

Methods

We investigated the vasomotor effects of VIP and PACAP isoforms and their selective blockers in WT and PACAP KO female mice in carotid and femoral arteries. The expression and level of different PACAP receptors in the vessels were measured by RT-PCR and Western blot.

Results

In both carotid and femoral arteries of WT mice, PACAP1-38, PACAP1-27 or VIP induced relaxation, without pronounced differences between them. Reduced relaxation was recorded only in the carotid arteries of KO mice as compared to their WT controls. The specific VPAC1R antagonist completely blocked the PACAP/VIP-induced relaxation in both arteries of all mice, while PAC1R antagonist affected relaxation only in their femoral arteries.

Conclusion

In female WT mice, VPAC1 receptors appear to play a dominant role in PACAP-induced vasorelaxation both in carotid and in femoral arteries. In the PACAP KO group PAC1R activation exerts vasorelaxation in the femoral arteries but in carotid arteries there is no significant effect of the activation of this receptor. In the background of this regional difference, decreased PAC1R and increased VPAC1R availability in the carotid arteries was found.

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<![CDATA[Surgical approach and the impact of epidural analgesia on survival after esophagectomy for cancer: A population-based retrospective cohort study]]> https://www.researchpad.co/article/5c50c449d5eed0c4845e8444

Background

Esophagectomy for esophageal cancer carries high morbidity and mortality, particularly in older patients. Transthoracic esophagectomy allows formal lymphadenectomy, but leads to greater perioperative morbidity and pain than transhiatal esophagectomy. Epidural analgesia may attenuate the stress response and be less immunosuppressive than opioids, potentially affecting long-term outcomes. These potential benefits may be more pronounced for transthoracic esophagectomy due to its greater physiologic impact. We evaluated the impact of epidural analgesia on survival and recurrence after transthoracic versus transhiatal esophagectomy.

Methods

A retrospective cohort study was performed using the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database. Patients aged ≥66 years with locoregional esophageal cancer diagnosed 1994–2009 who underwent esophagectomy were identified, with follow-up through December 31, 2013. Epidural receipt and surgical approach were identified from Medicare claims. Survival analyses adjusting for hospital esophagectomy volume, surgical approach, and epidural use were performed. A subgroup analysis restricted to esophageal adenocarcinoma patients was performed.

Results

Among 1,921 patients, 38% underwent transhiatal esophagectomy (n = 730) and 62% underwent transthoracic esophagectomy (n = 1,191). 61% (n = 1,169) received epidurals and 39% (n = 752) did not. Epidural analgesia was associated with transthoracic approach and higher volume hospitals. Patients with epidural analgesia had better 90-day survival. Five-year survival was higher with transhiatal esophagectomy (37.2%) than transthoracic esophagectomy (31.0%, p = 0.006). Among transthoracic esophagectomy patients, epidural analgesia was associated with improved 5-year survival (33.5% epidural versus 26.5% non-epidural, p = 0.012; hazard ratio 0.81, 95% confidence interval [0.70, 0.93]). Among the subgroup of esophageal adenocarcinoma patients undergoing transthoracic esophagectomy, epidural analgesia remained associated with improved 5-year survival (hazard ratio 0.81, 95% confidence interval [0.67, 0.96]); this survival benefit persisted in sensitivity analyses adjusting for propensity to receive an epidural.

Conclusion

Among patients undergoing transthoracic esophagectomy, including a subgroup restricted to esophageal adenocarcinoma, epidural analgesia was associated with improved survival even after adjusting for other factors.

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<![CDATA[Suprapubic bladder drainage and epidural catheters following abdominal surgery—A risk for urinary tract infections?]]> https://www.researchpad.co/article/5c5217e7d5eed0c48479586d

Background

Epidural catheters are state of the art for postoperative analgesic in abdominal surgery. Due to neurolysis it can lead to postoperative urinary tract retention (POUR), which leads to prolonged bladder catheterization, which has an increased risk for urinary tract infections (UTI). Our aim was to identify the current perioperative management of urinary catheters and, second, to identify the optimal time of suprapubic bladder catheter removal in regard to the removal of the epidural catheter.

Methods

We sent a questionnaire to 102 German hospitals and analyzed the 83 received answers to evaluate the current handling of bladder drainage and epidural catheters. Then, we conducted a retrospective study including 501 patients, who received an epidural and suprapubic catheter after abdominal surgery at the University Hospital Würzburg. We divided the patients into three groups according to the point in time of suprapubic bladder drainage removal in regard to the removal of the epidural catheter and analyzed the onset of a UTI.

Results

Our survey showed that in almost all hospitals (98.8%), patients received an epidural catheter and a bladder drainage after abdominal surgery. The point in time of urinary catheter removal was equally distributed between before, simultaneously and after the removal of the epidural catheter (respectively: ~28–29%). The retrospective study showed a catheter-associated UTI in 6.7%. Women were affected significantly more often than men (10,7% versus 2,5%, p<0.001). There was a non-significant trend to more UTIs when the suprapubic catheter was removed after the epidural catheter (before: 5.7%, after: 8.4%).

Conclusion

The point in time of suprapubic bladder drainage removal in relation to the removal of the epidural catheter does not seem to correlate with the rate of UTIs. The current handling in Germany is inhomogeneous, so further studies to standardize treatment are recommended.

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<![CDATA[Electric stimulation-guided epidural analgesia for vaginal delivery: A randomized prospective study]]> https://www.researchpad.co/article/5c42436ed5eed0c4845e0193

Background

The failure rate of epidural anesthesia using the loss of resistance technique is 13–23%.

Objectives

To investigate the efficacy of epidural electric stimulation-guided epidural analgesia in vaginal delivery.

Study design

An open label randomized prospective study.

Methods

Laboring women were randomized to two groups: epidural catheter insertion using only a loss of resistance technique or a loss of resistance technique with confirmation by electric stimulation. Catheters in both groups were initially tested with 3 ml of 1% lidocaine and those with any evidence of motor blockade were considered intrathecal. Sensory blockade and an 11 point numerical rating score for pain were assessed 30 minutes after administration of an epidural bolus of 10 ml of 0.22% ropivacaine with fentanyl. Successful epidural analgesia was defined as a decrease of 2 or more in the pain score and a bilateral L1-T10 sensory blockade.

Results

Thirty-one patients were randomized to each group. The first 20 patients in each group were enrolled in a pilot study and were also included in the final analysis. One patient in the electric stimulation group was excluded owing to dural puncture by the Tuohy needle. One patient in each group demonstrated motor blockade after test dose and were considered failures. The number (% (95% confidence interval)) of successful cases were 29 out of 30 (97% (85, 100%)) in the electric stimulation group and 24 out of 31 (77% (61, 89%)) in the loss of resistance group (P = 0.053). However, analysis of only patients with absence of motor blockade revealed that 29 out of 29 (100% (92, 100%)) patients in the electric stimulation group and 24 of 29 (80% (63, 91%)) patients in the loss of resistance group had adequate analgesia (P = 0.024).

Conclusions

Although limited by lack of blinding, small study size and inclusion of pilot study data, this study suggests epidural electric stimulation improves the success rate of subsequent labor analgesia.

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<![CDATA[Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials]]> https://www.researchpad.co/article/5c3e509dd5eed0c484d838d6

Objective

To evaluate the analgesic efficacy of dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plane (TAP) block for the patients after abdominal surgery.

Methods

PubMed, CENTRAL, EMBASE, Web of science were searched to identify eligible randomized controlled trials (RCTs) that compared dexamethasone added to local anesthetics in ultrasound-guided TAP block with control for postoperative analgesia in adult patients undergoing abdominal surgery. Primary outcomes included postoperative pain intensity, the time to the first request for additional analgesics, and opioid consumption over 24 h after surgery. Secondary outcome was the incidence of postoperative nausea and vomiting. Analysis was performed by RevMan 5.3 software and the quality of evidence was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.

Results

Nine RCTs involving 575 patients were included. Compared to the control, dexamethasone added to local anesthetics in ultrasound-guided TAP block significantly decreased visual analogue scale (VAS) scores at rest at 4h (mean difference [MD] = -1.01; 95% confidence intervals [CI], -1.29 to -0.73; P<0.00001; moderate quality of evidence), 6h (MD = -1.21; 95% CI, -1.74 to -0.69; P<0.00001; low quality of evidence), and 12h after surgery (MD = -0.79; 95% CI, -0.97 to -0.60; P<0.00001; moderate quality of evidence). No difference was found at 2h (MD = -0.64; 95% CI, -1.35 to 0.08; P = 0.08; low quality of evidence) and 24 h (MD = -0.41; 95% CI, -0.91 to 0.09; P = 0.11; moderate quality of evidence) in VAS scores. The time to the first request for additional analgesics was prolonged in the dexamethasone group (MD = 3.08; 95% CI, 2.37 to 3.78; P<0.00001; moderate quality of evidence). Opioid consumption over 24 h after surgery was also reduced (MD = -5.42; 95% CI, -8.20 to -2.63; P = 0.0001; low quality of evidence). Meanwhile, the incidence of postoperative nausea and vomiting was significantly decreased in the dexamethasone group (risk ratios [RR] = 0.40; 95% CI, 0.28 to 0.58; P<0.00001; high quality of evidence). No complications were reported in all the included studies.

Conclusions

Dexamethasone added to local anesthetics in ultrasound-guided TAP block was a safe and effective strategy for postoperative analgesia in adult patients undergoing abdominal surgery.

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<![CDATA[Continuous neuromuscular blockade infusion for out-of-hospital cardiac arrest patients treated with targeted temperature management: A multicenter randomized controlled trial]]> https://www.researchpad.co/article/5c2151bad5eed0c4843fb98a

Introduction

The aim of this trial was to investigate the effect of a continuous infusion of a neuromuscular blockade (NMB) in comatose out-of-hospital cardiac arrest (OHCA) subjects who underwent targeted temperature management (TTM).

Methods

In this open-label, multicenter trial, subjects resuscitated from OHCA were randomly assigned to receive either NMB (38 subjects) or placebo (43 subjects) for 24 hours. Sedatives and analgesics were given according to the protocol of each hospital during TTM. The primary outcome was serum lactate levels at 24 hours after drug infusion. The secondary outcomes included in-hospital mortality, a poor neurological outcome at hospital discharge, changes in lactate levels, changes in the PaO2:FiO2 ratio over time and muscle weakness as assessed by the Medical Research Council (MRC) scale.

Results

Eighty-one subjects (NMB group: median age, 65.5 years, 30 male patients; placebo group: median age, 61.0 years, 29 male patients) were enrolled in this trial. No difference in the serum lactate level at 24 hours was observed between the NMB (2.8 [1.2–4.0]) and placebo (3.6 [1.8–5.2]) groups (p = 0.238). In-hospital mortality and a poor neurologic outcome at discharge did not differ between the two groups. No significant difference in the PaO2:FiO2 ratio over time (p = 0.321) nor the MRC score (p = 0.474) was demonstrated.

Conclusions

In OHCA subjects who underwent TTM, a continuous infusion of NMB did not reduce lactate levels and did not improve survival or neurological outcome at hospital discharge. Our results indicated a limited potential for the routine use of NMB during early TTM. However, this trial may be underpowered to detect clinical differences, and future research should be conducted.

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<![CDATA[Patient-reported outcomes associated with different restorative techniques in pediatric dentistry: A systematic review and MTC meta-analysis]]> https://www.researchpad.co/article/5c12cf17d5eed0c484913ecb

Background

Despite the increasing number of studies evaluating patient reported outcome measures (PROs), there is no clearness regarding which restorative treatment offers major benefits based on the pediatric patient perspective.

Aim

To compare different restorative techniques in pediatric dentistry regarding patient-reported outcomes.

Design

Literature searching was carried out on prospective studies indexed in PubMed, Scopus and OpenGrey. A Mixed Treatment Comparisons (MTC) meta-analysis was undertaken considering the results from reviewed studies. Anxiety, pain and quality of life were extracted as mean with standard deviation, percentage of pain, and mean difference of scores with standard deviation, respectively. For direct comparisons, data were combined using a random-effect model. Heterogeneity was assessed with the I2 statistic. For indirect comparisons, fixed and random effects were chosen through comparison of competing models based on the Deviance Information Criteria (DIC). The expected efficacy ranking based on the posterior probabilities of all treatment rankings was also calculated.

Results

An initial search resulted in 4,322 articles, of which 17 were finally selected. Due to unavailability of data, only pain, anxiety and oral health related quality of life (OHRQoL) were statistically analyzed. The difference in means (95% CI) of anxiety between treatments using only hand instruments with or without chemomechanical agents were -5.35 (-6.42 to -4.20) and -5.79 (-7.77 to -3.79) respectively when compared to conventional treatment using rotary instruments and/or local anesthesia. Regarding pain, there was a trend for treatments without rotary instruments and local anesthesia to be less frequently reported as painful. No statistical difference was found intragroup nor among treatments for OHRQoL.

Conclusions

Anxiety and pain are directly related with more invasive restorative treatments. On the other hand, quality of life is not improved regardless of the restorative technique used. Further well-designed prospective studies regarding PROs in children are still necessary.

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<![CDATA[Topographical study of the trapezius muscle, greater occipital nerve, and occipital artery for facilitating blockade of the greater occipital nerve]]> https://www.researchpad.co/article/5b8acdf140307c144d0de05b

The aim of this study was to clarify the topographical relationships between the greater occipital nerve and the trapezius muscle and between the greater occipital nerve and the occipital artery in the occiput in order to increase the success rate of greater occipital nerve blockade. Fifty-six halved heads of 28 cadavers were used in this study. The piercing points and the courses of the greater occipital nerve and occipital artery were analyzed by dividing a line connecting between the external occipital protuberance and mastoid process into three equal parts. A circle with a radius of 2 cm drawn at the medial trisection point of this line was divided into four equal sectors. The greater occipital nerve simply passed the lateral border of the trapezius muscle and then pierced the fascia connecting the cranial attachment of the trapezius muscle with the sternocleidomastoid muscle in 62.5% of the specimens, whereas it pierced the muscle itself in the other 37.5%. The greater occipital nerve and occipital artery pierced the fascia within the 2-cm-radius circle in 85.7% and 98.2% of the specimens, respectively. The piercing points of the greater occipital nerve and occipital artery were observed most frequently in the inferomedial (42.9%) and inferolateral (37.5%) sectors of the circle, respectively. The greater occipital nerve and occipital artery pierced the same sector of the circle and accompanied each other in 51.8% of the specimens. These results are expected to improve the understanding of the topographical relationships between the greater occipital nerve and trapezius muscle and between the greater occipital nerve and occipital artery in the occiput, and thus provide helpful information for the management of occipital neuralgia.

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<![CDATA[Push Force Analysis of Anchor Block of the Oil and Gas Pipeline in a Single-Slope Tunnel Based on the Energy Balance Method]]> https://www.researchpad.co/article/5989daadab0ee8fa60baa35b

In this paper, a single-slope tunnel pipeline was analysed considering the effects of vertical earth pressure, horizontal soil pressure, inner pressure, thermal expansion force and pipeline—soil friction. The concept of stagnation point for the pipeline was proposed. Considering the deformation compatibility condition of the pipeline elbow, the push force of anchor blocks of a single-slope tunnel pipeline was derived based on an energy method. Then, the theoretical formula for this force is thus generated. Using the analytical equation, the push force of the anchor block of an X80 large-diameter pipeline from the West—East Gas Transmission Project was determined. Meanwhile, to verify the results of the analytical method, and the finite element method, four categories of finite element codes were introduced to calculate the push force, including CAESARII, ANSYS, AutoPIPE and ALGOR. The results show that the analytical results agree well with the numerical results, and the maximum relative error is only 4.1%. Therefore, the results obtained with the analytical method can satisfy engineering requirements.

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<![CDATA[Safety and Efficacy Studies of Vertebroplasty, Kyphoplasty, and Mesh-Container-Plasty for the Treatment of Vertebral Compression Fractures: Preliminary Report]]> https://www.researchpad.co/article/5989dab3ab0ee8fa60bac13b

To evaluate the clinical safety and efficacies of percutaneous vertebroplasty (PVP), percutaneous kyphoplasty (PKP), and percutaneous mesh-container-plasty (PMCP) for the treatment of vertebral compression fractures (VCFs), a retrospective study of 90 patients with VCFs who had been treated by PVP (n = 30), PKP (n = 30), and PMCP (n = 30) was conducted. The clinical efficacies of these three treatments were evaluated by comparing their PMMA cement leakages, cement patterns, height restoration percentages, wedge angles, visual analogue scales (VAS), and oswestry disability index (ODI) at the pre- and post-operative time points. 6.67%, 3.33%, and 0% of patients had PMMA leakage in PVP, PKP, and PMCP groups, respectively. Three (solid, trabecular, and mixed patterns), two (solid and mixed patterns), and one (mixed patterns) types of cement patterns were observed in PVP, PKP, and PMCP groups, respectively. PKP and PMCP treatments had better height restoration ability than PVP treatment. PVP, PKP, and PMCP treatments had significant and similar ability in pain relief and functional recovery ability for the treatment of VCFs. These results indicate minimally invasive techniques were effective methods for the treatment of VCFs. Moreover, these initial outcomes suggest PMCP treatment may be better than both PVP treatment and PKP treatment.

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<![CDATA[Anaesthetic Tricaine Acts Preferentially on Neural Voltage-Gated Sodium Channels and Fails to Block Directly Evoked Muscle Contraction]]> https://www.researchpad.co/article/5989dad9ab0ee8fa60bb9330

Movements in animals arise through concerted action of neurons and skeletal muscle. General anaesthetics prevent movement and cause loss of consciousness by blocking neural function. Anaesthetics of the amino amide-class are thought to act by blockade of voltage-gated sodium channels. In fish, the commonly used anaesthetic tricaine methanesulphonate, also known as 3-aminobenzoic acid ethyl ester, metacaine or MS-222, causes loss of consciousness. However, its role in blocking action potentials in distinct excitable cells is unclear, raising the possibility that tricaine could act as a neuromuscular blocking agent directly causing paralysis. Here we use evoked electrical stimulation to show that tricaine efficiently blocks neural action potentials, but does not prevent directly evoked muscle contraction. Nifedipine-sensitive L-type Cav channels affecting movement are also primarily neural, suggesting that muscle Nav channels are relatively insensitive to tricaine. These findings show that tricaine used at standard concentrations in zebrafish larvae does not paralyse muscle, thereby diminishing concern that a direct action on muscle could mask a lack of general anaesthesia.

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<![CDATA[Postoperative pain treatment after total knee arthroplasty: A systematic review]]> https://www.researchpad.co/article/5989db50ab0ee8fa60bdbd36

Introduction

The aim of this systematic review was to document efficacy, safety and quality of evidence of analgesic interventions after total knee arthroplasty (TKA).

Methods

This PRISMA-compliant and PROSPERO-registered review includes all-language randomized controlled trials of medication-based analgesic interventions after TKA. Bias was evaluated according to Cochrane methodology. Outcomes were opioid consumption (primary), pain scores at rest and during mobilization, adverse events, and length of stay. Interventions investigated in three or more trials were meta-analysed. Outcomes were evaluated using forest plots, Grading of Recommendations Assessment, Development and Evaluation (GRADE), L’Abbe Plots and trial sequential analysis.

Results

The included 113 trials, investigating 37 different analgesic interventions, were characterized by unclear/high risk of bias, low assay sensitivity and considerable differences in pain assessment tools, basic analgesic regimens, and reporting of adverse events. In meta-analyses single and continuous femoral nerve block (FNB), intrathecal morphine, local infiltration analgesia, intraarticular injection of local anaesthetics, non-steroidal anti-inflammatory drugs, and gabapentinoids demonstrated significant analgesic effects. The 24-hour morphine-sparing effects ranged from 4.2 mg (CI: 1.3, 7.2; intraarticular local anaesthetics), to 16.6 mg (CI: 11.2, 22; single FNB). Pain relieving effects at rest at 6 hours ranged from 4 mm (CI: -10, 2; gabapentinoids), to 19 mm (CI: 8, 31; single FNB), and at 24 hours from 3 mm (CI: -2, 8; gabapentinoids), to 16 mm (CI: 8, 23; continuous FNB). GRADE-rated quality of evidence was generally low.

Conclusion

A low quality of evidence, small sample sizes and heterogeneity of trial designs prohibit designation of an optimal procedure-specific analgesic regimen after TKA.

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<![CDATA[Effect of Topically Applied Anaesthetic Formulation on the Sensitivity of Scoop Dehorning Wounds in Calves]]> https://www.researchpad.co/article/5989daafab0ee8fa60baacd2

The post-operative effects of three formulations of topical anaesthetic and a cornual nerve block on the sensitivity of scoop dehorning wounds in calves were compared in two trials. In Trial 1, 21 female Holstein dairy calves aged 8 to 24 weeks were randomly allocated to two groups: (1) scoop dehorning with a post-operative application of a novel topical anaesthetic powder (DTAP, n = 10); and (2) scoop dehorning with a post-operative application of a novel topical anaesthetic ethanol liquid (DTAE, n = 11). In Trial 2, 18 castrated male and 18 female Hereford beef calves aged 16 to 20 weeks were randomly allocated to four groups: (1) scoop dehorning with a pre-operative cornual nerve block of lignocaine (DCB, n = 9); (2) scoop dehorning with a post-operative application of the novel topical anaesthetic ethanol liquid from Trial 1 (DTAE, n = 9); (3) scoop dehorning with a post-operative application of a topical anaesthetic gel (DTAG, n = 9); and (4) sham dehorning (CON, n = 9). Sensitivity was assessed by scoring the behavioural response of calves to stimulation of the wound or skin at time points before and after treatment. In Trial 1, DTAP calves had a greater probability of displaying more severe responses than DTAE calves at 90 and 180 min (P < 0.001). In Trial 2, at 1 h, DTAG calves had a greater probability of displaying more severe responses than CON calves. At 2 h onwards, all dehorned calves had a greater probability of displaying more severe responses than CON calves (P < 0.001). There were no differences between the responses of DCB, DTAG and DTAE calves at any time point. Topical anaesthetic formulations result in almost immediate but temporary anaesthesia of the wound following scoop dehorning in calves and may provide a practical option for pain relief on-farm.

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<![CDATA[Determination of Normal Ranges of Shock Index and Other Haemodynamic Variables in the Immediate Postpartum Period: A Cohort Study]]> https://www.researchpad.co/article/5989da28ab0ee8fa60b8167c

Objective

To determine the normal ranges of vital signs, including blood pressure (BP), mean arterial pressure (MAP), heart rate (HR) and shock index (SI) (HR/systolic BP), in the immediate postpartum period to inform the development of robust obstetric early warning scores.

Study Design

We conducted a secondary analysis of a prospective observational cohort study evaluating vital signs collected within one hour following delivery in women with estimated blood loss (EBL) <500ml (316 women) delivering at a UK tertiary centre over a one-year period. Simple and multiple linear regression were used to explore associations of demographic and obstetric factors with SI.

Results

Median (90% reference range) was 120 (100–145) for systolic BP, 75 (58–90) for diastolic BP, 90 (73–108) for MAP, 81 (61–102) for HR, and 0.66 (0.52–0.89) for SI. Third stage Syntometrine® administration was associated with a 0.03 decrease in SI (p = 0.035) and epidural use with a 0.05 increase (p = 0.003). No other demographic or obstetric factors were associated with a change in shock index in this cohort.

Conclusion

This is the first study to determine normal ranges of maternal BP, MAP, HR and SI within one hour of birth, a time of considerable haemodynamic adjustment, with minimal effect of demographic and obstetric factors demonstrated. The lower 90% reference point for systolic BP and upper 90% reference point for HR correspond to triggers used to recognise shock in obstetric practice, as do the upper 90% reference points for systolic and diastolic BP for obstetric hypertensive triggers. The SI upper limit of 0.89 in well postpartum women supports current literature suggesting a threshold of 0.9 as indicating increased risk of adverse outcomes.

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<![CDATA[In vivo images of the epidural space with two- and three-dimensional optical coherence tomography in a porcine model]]> https://www.researchpad.co/article/5989db53ab0ee8fa60bdcb7f

Background

No reports exist concerning in vivo optical coherence tomography visualization of the epidural space and the blood patch process in the epidural space. In this study, we produced real-time two-dimensional and reconstructed three-dimensional images of the epidural space by using optical coherence tomography in a porcine model. We also aimed to produce three-dimensional optical coherence tomography images of the dura puncture and blood patch process.

Methods

Two-dimensional and three-dimensional optical coherence tomography images were obtained using a swept source optical coherence tomography (SSOCT) system. Four laboratory pigs were intubated and ventilated after the induction of general anesthesia. An 18-gauge Tuohy needle was used as a tunnel for the optical coherence tomography probe to the epidural space. Two-dimensional and three-dimensional reconstruction optical coherence tomography images of the epidural space were acquired in four stages.

Results

In stage 1, real-time two-dimensional and reconstructed three-dimensional optical coherence tomography of the lumbar and thoracic epidural space were successfully acquired. In stage 2, the epidural catheter in the epidural space was successfully traced in the 3D optical coherence tomography images. In stage 3, water injection and lumbar puncture were successfully monitored in all study animals. In stage 4, 10 mL of fresh blood was injected into the epidural space and two-dimensional and three-dimensional optical coherence tomography images were successfully acquired.

Conclusions

These animal experiments suggest the potential capability of using an optical coherence tomography-based imaging needle in the directed two-dimensional and three-dimensional visualization of the epidural space. More investigations involving humans are required before optical coherence tomography can be recommended for routine use. However, three-dimensional optical coherence tomography may provide a novel, minimally invasive, and safe way to observe the spinal epidural space, epidural catheter, lumbar puncture hole, and blood patch.

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<![CDATA[Impact of Endobronchial Ultrasound (EBUS) Training on the Diagnostic Yield of Conventional Transbronchial Needle Aspiration for Lymph Node Stations 4R and 7]]> https://www.researchpad.co/article/5989daceab0ee8fa60bb55f7

Background

There is sparse literature on whether training in endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) improves the diagnostic yield of conventional TBNA (cTBNA).

Objectives

The aim of this study was to evaluate the diagnostic yield of cTBNA before and after the introduction of EBUS.

Methods

This was a retrospective analysis of patients who underwent cTBNA at our center. The study was divided into two periods, before and after the introduction of EBUS at our facility. The diagnostic yield of cTBNA was compared between the study periods. Rapid on-site cytological examination was not available.

Results

A total of 1,050 patients (61.6% men; mean age 45.6 years) underwent cTBNA during the study period (849 before EBUS; 201 after EBUS). Sarcoidosis (n = 527) followed by bronchogenic carcinoma (n = 222) formed the most common indications for performing cTBNA. There was a significant increase in both the success of obtaining a representative sample (from 71% to 85%), and the diagnostic yield (from 33% to 49.5%) of cTBNA, after the introduction of EBUS. The increase in the diagnostic yield of cTBNA after introduction of EBUS remained significant even after adjusting for years of performing cTBNA and the type of anesthesia (topical vs. sedation and topical) on a multivariate analysis.

Conclusion

The diagnostic yield of cTBNA at our facility increased after the introduction of EBUS-TBNA. However, given the retrospective nature of the study, prospective studies are required to confirm our findings.

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<![CDATA[Risk of Hemorrhage during Needle-Based Ophthalmic Regional Anesthesia in Patients Taking Antithrombotics: A Systematic Review]]> https://www.researchpad.co/article/5989da80ab0ee8fa60b9a26d

Background

Patients undergoing ophthalmic surgery are usually elderly and, due to systemic disease, may be on long-term therapy, such as antithrombotic agents. Rates of hemorrhagic complications associated with invasive procedures may be increased by the use of anticoagulants and antiplatelet agents.

Objective

To compare the incidence of hemorrhagic complications in patients undergoing needle-based ophthalmic regional anesthesia between patients on antithrombotic therapy and those not on such therapy.

Methods

A systematic review was conducted by two independent reviewers based on searches of Cochrane, LILACS, PubMed, Scopus, Web of Science, and the “gray” literature (Google Scholar). The end search date was May 8, 2015, across all databases.

Results

Five studies met the eligibility criteria. In three studies, individual risk of bias was low, and in two of them, moderate. In all studies, no differences regarding mild to moderate incidence of hemorrhagic complications were found between patients using antithrombotics (aspirin, clopidogrel, and warfarin) and those not using them. Rates of severe hemorrhagic complication were very low (0.04%) in both groups, supporting the safety of needle blocks, even in patients using antithrombotics. High heterogeneity across studies prevented meta-analysis. Limitations to these results include low statistical power in three experimental studies and a large 95% confidence interval in the two retrospective cohorts.

Conclusion

In this review, none of the selected studies showed significant bleeding related to needle-based ophthalmic regional anesthesia in association with the use of aspirin, clopidogrel, or vitamin K inhibitors. Since the available data is not powerful enough to provide a reliable evaluation of the true effect of antithrombotics in this setting, new studies to address these limitations are necessary.

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