Obstetric anaesthesia and analgesia
David M. Luesley, Mark D. Kilby in Obstetrics & Gynaecology, 2016
The epidural space is identified by the loss of resistance to depression of a syringe plunger as a Tuohy needle is advanced (Fig. 52.1) through the ligamentum flavum. A catheter is then threaded through the Tuohy needle (Fig. 52.2) to facilitate bolus top-ups or a continuous infusion. The subarachnoid space, which contains CSF, is a few millimetres deeper, inside the meninges. Needles used for deliberate spinal injection are much finer than Tuohy needles (Fig. 52.3). Unlike local anaesthetics, which prevent the conduction of nerve impulses, opioids act on specific receptors in the spinal cord. Synergistic mixtures of local anaesthetic and opioids (usually fentanyl) have permitted significant reductions in the amount of local anaesthetic used. Side effects specific to opioids are respiratory depression (in the most unlikely event of cephalad spread of opioid to the brainstem) and pruritus.
Spinal Cord Stimulation for Chronic Pain
Alexander R. Vaccaro, Christopher M. Bono in Minimally Invasive Spine Surgery, 2007
A Tuohy needle is inserted percutaneously, with the bevel directed cranially and dorsally, via a paramedian approach (Fig. 1). The needle is angled at 30° to 45° from the skin and directed cranially toward the L1–L2 or T12–L1 interspace. The image intensifier is used to guide needle placement, and epidural location is verified with the “loss of resistance” technique. The wire electrode is introduced through the Tuohy needle and advanced with C-arm guidance to the T9–T10 level (Fig. 2). The electrode can be steered by adjusting the position of the needle or by placing a small bend in the wire stiffener within the electrode. For a patient with low back pain or bilateral leg pain, a midline position is preferred; however, the anatomic midline may not correspond to the physiologic midline in terms of stimulating paresthesias. For patients with unilateral symptoms, a single electrode may suffice; for those with axial or bilateral leg pain, a second electrode should be placed using the same technique in order to maximize the potential for paresthesia coverage and pain relief (Fig. 3). The optimum position of the electrode for patients with lower extremity pain is usually at the T9–T10 interspace.
Spinal fluid leakage
Michael Y. Wang, Andrea L. Strayer, Odette A. Harris, Cathy M. Rosenberg, Praveen V. Mummaneni in Handbook of Neurosurgery, Neurology, and Spinal Medicine for Nurses and Advanced Practice Health Professionals, 2017
Persistent leaks require CSF diversion through external drainage. This is most commonly done via a lumbar drain. In order to place a lumbar drain, a 19-gauge catheter is threaded percutaneously through a 17-gauge Tuohy needle that has been inserted into the lumbar subarachnoid space. Initial insertion of the Tuohy needle is performed in analogous fashion to a lumbar puncture. After 10–20 cm of the catheter has been threaded through the needle, the needle is removed over the catheter. The proximal end of the catheter is then connected to a sterile drainage system. The site of catheter insertion into the skin should be covered with a waterproof dressing, and the catheter should be taped to prevent disconnection or pulling. Some providers suggest that antibiotics should be administered while the catheter is within the subarachnoid space; however, evidence of the utility of this measure is lacking. Drainage should be continued for 3–5 days after the leak has stopped in order to maximize healing potential. Daily samples of CSF should be obtained for culture, Gram stain, cell count with differential, glucose, and protein. If antibiotics were used, they should be continued 8–24 hours after removal of the catheter. If the patient gets out of bed, the drain should be temporarily clamped to prevent sudden overdrainage.
Advances in CSF shunt devices and their assessment for the treatment of hydrocephalus
Published in Expert Review of Medical Devices, 2021
Kamran Aghayev, Sheikh MA Iqbal, Waseem Asghar, Bunyad Shahmurzada, Frank D. Vrionis
LPS are considered less invasive than ventricular shunts. Historically (and occasionally nowadays) they employed a simple thin elastic tube inserted into the lumbar subarachnoid space via Tuohy needle. The other end is placed into the peritoneal cavity. Thin diameter, long length and internal slit valve are the principal mechanisms to restrict the flow. However, it is highly recommended to use additional valve/reservoir because if not used LPS shunts may result in orthostatic over drainage and acquired Chiari I malformation [9–11]. Singh et al. have conducted a comparative study for VPS and LPS and demonstrated 45.2 and 16.2%, respectively. They also show significantly different infection rates of 16.9 and 5.4% (p = 0.01) [12]. In a different study, conducted on an analytical cohort of 1182 patients where 347 patients underwent LPS and 735 patients underwent VPS placement, comparative failure rates of were 34.6 and 31.7%, respectively [13]. In the light of the aforementioned studies, it can be concluded that different studies report varying failure rates for different shunts. However, it can be seen that VPS currently are the most common shunt type used by most neurosurgeons.
Continuous thoracic epidural versus continuous paravertebral analgesia in patients undergoing open renal surgery: Evaluation of pulmonary function; randomized double-blinded clinical trial
Published in Egyptian Journal of Anaesthesia, 2023
Shimaa Abbas Hassan, Khaled Abdelrahman, Ahmed M. Mandor, George Magdy, Mohamed Galal, Fatma Gadelrab Askar, Amr M. A. Thabet
In group E (cTEB), ultrasound screening was done to identify the needle insertion point, angle of insertion, and depth of epidural space. The procedure was performed in a sitting position. The needle entry point was situated between T7 and T8 vertebrae. An 18-G, 80-mm Tuohy needle (B. Braun; Perifix® 400) was used and 3–5 cm of a 20-G epidural catheter with flexible tip (B. Braun; Perifix® standard) was inserted into the epidural space using the loss-of-resistance technique. Four ml of lidocaine 1% with 1: 200,000 epinephrine (0.005 mg/ml) were administered as a test dose to rule out intravascular. Initially 7.5–12 mL of Bupivacaine 0.25% was administered via the epidural catheter and bupivacaine 0.125% was continuously infused at a rate of 5 ml/h up to 15 ml/h with 5–10 ml bolus injection of infusion mixture injected for prominent postoperative pain.
Patient-controlled fascia iliaca compartment block versus fentanyl patient-controlled intravenous analgesia in patients undergoing femur fracture surgery
Published in Egyptian Journal of Anaesthesia, 2018
Shaimaa F. Mostafa, Gehan M. Eid, Rehab S. Elkalla
At the end of the surgical procedure, group II patients received an US-guided FICB [12]. The block was performed using a high-frequency 5–10MHz linear transducer Sonosite Micromaxx (SonoSite, Inc. Bothell, WA). Firstly, sonographic visualization of the two fascial planes, the fascia lata and the fascia iliaca was performed as two hyperechoic lines, with the probe positioned on the thigh just inferior to the inguinal ligament in a transverse orientation and one-third of the distance between the pubic tubercle and the anterior superior iliac spine. A Tuohy needle (PERIFIX, B. BRAUN, Melsungen, Germany) was introduced percutaneously from lateral-to-medial then directed parallel to the transducer to allow continuous visualization of full needle length. The needle tip was visualized penetrating firstly the fascia lata and then the fascia iliaca and a 20 G catheter was introduced for about 15cm past the needle tip then tunneled through the skin. A loading dose of 35ml levobupivacaine 0.125% was injected. The catheter was removed after 48h.
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