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| Ultrasound Innovation Award |
| Online Abstract Submission |
| (Author: Sandeep Diwan ) |
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| Abstract |
| Type: New block technique |
| Title: Ultrasound guided thoracic placement of the catheter by the caudal route in neonates. |
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| Disclosure Statements |
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My research & development of my invention is supported by a commercial company |
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| Abstract |
| Introduction. Epidural catheters placement via the caudal route are more desirable than direct insertion because of the potential risks of spinal cord damage associated with direct placement. 1 , 3 Radiographic imaging techniques and neurostimulation for are recommended for the exact positioning of the thoracic catheters have been described.4 , 5 This study was carried out to understand the feasibility with ultrasound positioning of the epidural catheter placed in the thoracic region via the caudal route. Material and Methods. In one year 22 neonates underwent thoracotomies and lapratomies for various surgical emergiencies. Thoracotomy for repair of trachea esophageal fistula N=10 Subcostal lapratomy for reduction of diaphgragmatic hernia N=04 Lapratomies for intestinal obstruction N=08 All these neonates received a standard anesthetic technique. Thiopentone,suxamethonium,nitrous in oxygen and halothane. A muscle relaxant and analgesics were administered if surgeon felt the need and the heart rate increased beyond 30% of the existing respectively. Atracurium0.4mg/kg BW Fentanyl 1mcg/kg BW. Technique . The entire spinal canal is sagittaly scanned in the lumbar and the thoracic area for anamolies. The neonate are given a lateral position, prepped and draped. An 18 g needle is introduced in the caudal space and a 18 g catheter is slowly introduced. The catheter is followed by the sagittal scan of the spinal cord. The catheters are placed in the lower thoracic area for abdominal lapratomies, upper thoracic area for thoracotomies. The drug movements could be observed with 0.5, 1 and 2ml of 0.25% bupivacaine. If the desired position of the tip of the catheter was acceptable, the catheter was fixed at this level. Figure 1 – 7 Results. The epidural catheters were observed on ultrasound in the lower thoracic area for all the abdominal lapratomies. 0.125% Bupivacaine 2ml was adequate for perioperative analgesia. Incision related increases in heart rate were not observed in any of these cases. Median Heart rate - 106/min. Innovative anesthetic management of Tracheo esopheageal fistula. Neonates were on spontaneous ventilation. The catheter was cited at T 3-4. A 2.5 ml of 0.125% Bupivacaine was injected in increments. The spread was observed under the ultrasound. As the drug reached the lower cervical levels the respiration ceased Ventilation was now controlled with and assisted on Ayres T piece. No analgesics and neuromuscular relaxants were administered. Neonates were back to spontaneous ventilation at 35-40 mins. At the end of the surgical procedure 0.125% 1-1.5ml of bupivacaine was injected to provide adequate pain relief. The spread was observed under Ultrasound. All catheters were removed at 72hrs and at 24 hrs if suspicion of infection. Discussion In infants less than 6 months the posterior elements of the spinal canal are incompletely ossified allowing an acoustic window for sonographic imaging. Vertebral column are seen as echogenic structures ventral to the spinal cord. The echogenic vertebral arches produce ventral shadows on axial scans. The paravertebral muscles appear as hypoechoic areas adjacent to the laminae. The arachnoid–dura mater complex of the thecal sac corresponds to the echogenic border of the spinal canal dorsal and ventral to the subarachnoid space Epidural blockade in neonates and infants is challenging. The LOR approach has been associated with complications and adverse outcomes at the thoracic and lumbar area - dural puncture or unintentional spinal cord trauma. Caudal catheters can be passed to lumbar and thoracic cord levels. Predetermined catheter length is not a reliable sign of successful placement of the catheter within the thoracic epidural space. Neurostimulation was used by Ban Tsui and coll for thoracic placement of caudally introduced catheters. No other guidance provides visualisation of the catheter tip and the spread of the drug in the operating suite except the ULTRASOUND. The position of the epidural catheter tip is an important factor in determining whether satisfactory epidural analgesia will be achieved. This study confirms : Ultrasonography currently offers the only method whereby the position of the epidural catheter. Caudal catheter catheters are successfully traced upto the lower cervical levels with the ultrasound. |
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| Clinical Significance |
| Ultrasound has proved its worth in precise location of te tip of epidural catheter in neonatal epidural space. |
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| Ultrasound Equipment |
| Manufacturer: Sonosite |
| Model: Titan |
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| Probe Used |
| Type: Linear |
| Size: L38 |
| Frequency: 5-10 |
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| Files |
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1. Filename: Figure3.doc
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