To assess the accuracy of the ultrasound (US) to predict the depth to reach lumbar intrathecal and epidural spaces in order to decrease the number of puncture attempts. Thirty-one patients (25 males and 6 females), ASA I or II participated in this study. The transversal ultrasound image of the lumbar spine was obtained at the level of the L3–L4 space. An anesthesiologist without prior information performed the spinal anesthesia through the predicted target area. The distance between the skin and the anterior portion of the flavum ligamentum which is supposedly the bottom limit of the intrathecal depth or an approximation of the depth of the epidural space (ED-US) was measured by ultrasound and it was compared with the distance between the skin and the anterior portion of the flavum ligamentum on the needle (ED-N). ED-US and ED-N were respectively 5.15 ± 0.95 cm and 5.14 ± 0.97 cm; these distances were not significantly different (p > 0.0001). A significant correlation r = 0.982 [95% CI 0.963–0.992, p > 0.0001] was observed between the ED-US and ED-N measurements. Bland-Altman analysis showed an accuracy of 0.18 cm; tolerated variations ranged from −0.14 cm to −0.58 cm. This study supports the idea that the US transversal plane allows the identification of axial anatomical structures and provides physicians with efficient information to perform spinal anesthesia. Avaliar a fidelidade da ecografia para prever a profundidade dos espaços intratecais lombares e epidurais, a fim de limitar o número de tentativas de punção. 31 pacientes (25 homens e seis mulheres), ASA I ou II participaram deste estudo. A imagem devolvida pelo ultrassom da espinha lombar foi executada no interespaço vertebral L3–L4 em plano transversal. Em seguida, um anestesista não previamente informado executou a anestesia espinal através do ponto previsto como alvo. A distância entre a pele e a parte anterior do flavum ligamentum que é supostamente o limite inferior da profundidade intratecal, ou uma aproximação da profundidade do espaço epidural (ED-US), foi medida por ultrassom sendo comparada com a distância entre a pele e a parte anterior do espaço do flavum ligamentum na agulha (ED-N). Os ED-US e os ED-N foram, respectivamente, de 5,15 ± 0,95 cm e de 5,14 ± 0.97 cm; essas distâncias não eram significativamente diferentes (p > 0,0001). A correlação significativa r = 0,982 [CI 95% 0,963–0,992, p > 0,0001] foi observada entre as medidas de ED-US e de ED-N. A análise Bland-Altman mostra uma precisão de 0,18 cm, com limites tolerados de −0,14 cm a −0,58 cm. Este estudo corrobora a utilidade da ultrassonografia em plano transversal que permite identificar as estruturas anatômicas axiais, podendo fornecer aos médicos informações eficientes para a execução da anestesia espinal. Evaluar la fidelidad de la ecografía para prever la profundidad de los espacios intratecales lumbares y epidurales, con el fin de limitar el número de intentos de punción. Treinta y un (31) pacientes (25 hombres y seis mujeres), ASA I o II participaron en el estudio. La imagen devuelta por el ultrasonido de la espina lumbar fue ejecutada en el interespacio vertebral L3–L4 en plano transversal. Inmediatamente un anestesiólogo no previamente informado ejecutó la anestesia espinal a través del punto previsto como diana. La distancia entre la piel y la parte anterior del flavum ligamentum que supuestamente es el límite inferior de la profundidad intratecal, o una aproximación de la profundidad del espacio epidural (ED-US), se midió por ultrasonido siendo comparada con la distancia entre la piel y la parte anterior del espacio del flavum ligamentum en la aguja (ED-N). Los ED-US y los ED-N fueron respectivamente de 5,15 ± 0,95 cm y de 5,14 ± 0.97 cm. Esas distancias no eran significativamente diferentes (p > 0,0001). La correlación significativa r = 0,982 [CI95% 0,963–0,992, p > 0,0001] fue observada entre las medidas de ED-US y de ED-N. El análisis Bland-Altman muestra una precisión de 0,18 cm, con límites tolerados de −0,14 cm a −0,58 cm. Este estudio corrobora la utilidad del ultrasonido en el plano transversal permitiendo identificar las estructuras anatómicas axiales, y pudiendo suministrar a los médicos informaciones eficientes para la ejecución de la anestesia espinal.
Background Dr. Scott Reuben allegedly fabricated data. The authors of the current article examined the impact of Reuben reports on conclusions of systematic reviews. Methods The authors searched in ISI Web of Knowledge systematic reviews citing Reuben reports. Systematic reviews were grouped into one of three categories: I, only cited but did not include Reuben reports; II, retrieved and considered, but eventually excluded Reuben reports; III, included Reuben reports. For quantitative systematic reviews (i.e., meta-analyses), a relevant difference was defined as a significant result becoming nonsignificant (or vice versa) by excluding Reuben reports. For qualitative systematic reviews, each author decided independently whether noninclusion of Reuben reports would have changed conclusions. Results Twenty-five systematic reviews (5 category I, 6 category II, 14 category III) cited 27 Reuben reports (published 1994-2007). Most tested analgesics in surgical patients. One of 6 quantitative category III reviews would have reached different conclusions without Reuben reports. In all 6 (30 subgroup analyses involving Reuben reports), exclusion of Reuben reports never made any difference when the number of patients from Reuben reports was less than 30% of all patients included in the analysis. Of 8 qualitative category III reviews, all authors agreed that one would certainly have reached different conclusions without Reuben reports. For another 4, the authors' judgment was not unanimous. Conclusions Carefully performed systematic reviews proved robust against the impact of Reuben reports. Quantitative systematic reviews were vulnerable if the fraudulent data were more than 30% of the total. Qualitative systematic reviews seemed at greater risk than quantitative.
Since 2011, data on patients exposed to direct oral anticoagulants (DOAs) while undergoing invasive procedures have accumulated. At the same time, an increased hemorrhagic risk during perioperative bridging anticoagulation without thrombotic risk reduction has been demonstrated. This has led the GIHP to update their guidelines published in 2011. For scheduled procedures at low bleeding risk, it is suggested that patients interrupt DOAs the night before irrespective of type of drug and to resume therapy six hours or more after the end of the invasive procedure. For invasive procedures at high bleeding risk, it is suggested to interrupt rivaroxaban, apixaban and edoxaban three days before. Dabigatran should be interrupted according to the renal function, four days and five days if creatinine clearance is higher than 50mL/min and between 30 and 50mL/min, respectively. For invasive procedures at very high bleeding risk such as intracranial neurosurgery or neuraxial anesthesia, longer interruption times are suggested. Finally, bridging with parenteral anticoagulation and measurement of DOA concentrations can no longer routinely be used.
Abstract Background Continuous intravenous administration of lidocaine may decrease the duration of ileus and pain after abdominal surgery. Methods Three databases (Medline, Embase and the Cochrane Controlled Trials Register) were searched to retrieve randomized controlled trials comparing continuous intravenous lidocaine infusion during and after abdominal surgery with placebo. Study design was scored using the Oxford Quality Score based on randomization, double-blinding and follow-up. Outcome measures were duration of ileus, length of hospital stay, postoperative pain, and incidence of nausea and vomiting. Results Eight trials were selected. A total of 161 patients received intravenous lidocaine, with 159 controls. Intravenous lidocaine administration decreased the duration of ileus (weighted mean difference (WMD) − 8·36 h; P < 0·001), length of hospital stay (WMD − 0·84 days; P = 0·002), postoperative pain intensity at 24 h after operation on a 0–100-mm visual analogue scale (WMD − 5·93 mm; P = 0·002), and the incidence of nausea and vomiting (odds ratio 0·39; P = 0·006). Conclusion Continuous intravenous administration of lidocaine during and after abdominal surgery improves patient rehabilitation and shortens hospital stay.
