Abstract

a B s t r a c t

BacKgroUND: Post-dural puncture headache (PDPH) is one of the most common complications of neuraxial anesthesia after an accidental dural puncture. this study aimed to test non-interventional alternatives to treat PDPH. our goals were to compare the effectiveness of nebulized dexmedetomidine (DeX) versus neostigmine/atropine in the conservative management of PDPH.

MetHoDs: a randomized double-blind controlled study of ninety (90) women divided into three equal groups: group c (given nebulization of saline 0.9% placebo in four ml), group N (given nebulization of 20 µ/kg neostigmine and 10 µ/ kg atropine diluted in four ml normal saline), and group D (given nebulization of dexmedetomidine 1 µg/kg diluted in four ml normal saline). Nebulization was done twice daily for three days, and a Visual analogue scale pain score (Vas) was recorded for seventy-two hours after the intervention for the three groups with a Vas score equal or less than three being the cutoff value.

RESULTS: VAS was significantly decreased in dexmedetomidine, and neostigmine/atropine groups compared to the

control group at six hours (median Vas: 5, 2, and 2 for groups c, N, and D respectively [P=0.001]). there was a significant difference in VAS trends between the three groups (at six, twelve, twenty-four, thirty-six, and forty-eight hours [P=0.001], and at seventy-two hours [P=0.003]). No patients in group D, but one patient in group N and seven patients in group c needed an epidural blood patch.

coNclUsioNs: Nebulized dexmedetomidine and neostigmine/atropine had a rapid effect on relieving PDPH after cesarean section.

Abstract:

Background: In everyday pediatric anesthesia practice, clinicians frequently exchange an already inserted endotracheal tube because of a leak or resistance causing significant morbidity. We investigated the accuracy of two ultrasound measurements; the transverse cricoid diameter and epiphyseal diameter of the distal radius in the prediction of endotracheal tube size that best fits in children compared to age-based formulas.

Patients: One hundred children (1–6 years) who underwent elective surgery with endotracheal tube whether cuffed (n=50) or uncuffed (n=50) were enrolled. The primary endpoint was the agreement between the reference tube size for which its outer diameter selected based on transverse cricoid diameter and the final Best-Fit-ETT. The Correlation and Bland Altman agreement tests were conducted between Best-Fit-ETT outer diameter and ultrasound measured outer diameter, and between Best-Fit-ETT inner diameter and inner diameter calculated by agebased formulas.

Results: The agreement rate between transverse cricoid diameter based endotracheal tube size and Best-Fit-ETT size was 88% in cuffed group compared to 90% in uncuffed group. A significant positive correlation was reported between the outer diameter of Best-Fit-ETT, and the outer diameter measured by the two ultrasound methods. A lower degree of positive correlation was reported between the inner diameter of Best-Fit-ETT, and the inner diameter calculated by age-based formulas. Bland Altman's analysis showed agreement between Best-Fit-ETT outer diameter and epiphyseal diameter of the distal radius in both groups and with transverse cricoid diameter in the cuffed group, with no agreement with age-based formulas in either group.

Conclusions: Both transverse cricoid diameter and epiphyseal diameter of the distal radius are reliable predictors of the size of Best-Fit-ETT pediatric endotracheal tube compared to age-based formulas. To save time and effort, we recommend the US measurement of the epiphyseal diameter of distal radius in the preoperative visit and documenting the predicted tube size with the preoperative assessments.  

Key Words: Children, Endotracheal tube size, prediction, ultrasound, subglottic, distal radius.

Trial registration: ClinicalTrials.gov (Identifier: NCT03560895).

Background

Audit is an attempt to improve the quality of medical care by measuring the performance in relation to desired standards, whereas re‑audit demonstrates improvements that have been made.

Patients and methods

A prospective study was performed through a medical audit of 100 patients at the endoscopy unit of El‑Rajhi Hospital University between January and December 2017. Revision of upper endoscopy, including indications, preparations, and complications, was done.

Results

The mean age was 59 years. The most frequent comorbidities were liver cirrhosis (70%) and diabetes mellitus (25%). All patients were indicated for endoscopy, as the majority (70%) of patients required urgent upper endoscopy secondary to upper gastrointestinal tract bleeding

in contrast to the previous study as 4% of patients were not indicated. There was an increase in the percentage of complications in our study owing to the increased percentage of postband ulcers (92%) in comparison with the previous study (90%).

Conclusion

Improvement in our practice was noticed after recommendations of the previous audit regarding preparation and indications. It is important that a re‑audit takes place following the implementation of changes.