PurposeTo ascertain the relationship among early (first 48 h) deep sedation, time to extubation, delirium and long-term mortality.MethodsWe conducted a multicentre prospective longitudinal cohort study in 11 Malaysian hospitals including medical/surgical patients (n = 259) who were sedated and ventilated ≥24 h. Patients were followed from ICU admission up to 28 days in ICU with 4-hourly sedation and daily delirium assessments and 180-day mortality. Deep sedation was defined as Richmond Agitation Sedation Score (RASS) ≤−3.ResultsThe cohort had a mean (SD) age of 53.1 (15.9) years and APACHE II score of 21.3 (8.2) with hospital and 180-day mortality of 82 (31.7 %) and 110/237 (46.4 %). Patients were followed for 2,657 ICU days and underwent 13,836 RASS assessments. Midazolam prescription was predominant compared to propofol, given to 241 (93 %) versus 72 (28 %) patients (P < 0.0001) for 966 (39.6 %) versus 183 (7.5 %) study days respectively. Deep sedation occurred in (182/257) 71 % patients at first assessment and in 159 (61 %) patients and 1,658 (59 %) of all RASS assessments at 48 h. Multivariable Cox proportional hazard regression analysis adjusting for a priori assigned covariates including sedative agents, diagnosis, age, APACHE II score, operative, elective, vasopressors and dialysis showed that early deep sedation was independently associated with longer time to extubation [hazard ratio (HR) 0.93, 95 % confidence interval (CI) 0.89–0.97, P = 0.003], hospital death (HR 1.11, 95 % CI 1.05–1.18, P < 0.001) and 180-day mortality (HR 1.09, 95 % CI 1.04–1.15, P = 0.002), but not time to delirium (HR 0.98, P = 0.23). Delirium occurred in 114 (44 %) of patients.ConclusionIrrespective of sedative choice, early deep sedation was independently associated with delayed extubation and higher mortality, and thus was a potentially modifiable risk in interventional trials.
Meralgia paresthetica is an entrapment mononeuropathy of lateral femoral cutaneous nerve, which results in localized area of paresthesia and numbness on the anterolateral aspect of the thigh. We describe the use of alcohol neurolysis of lateral femoral cutaneous nerve in a 74-year-old female who presented with paresthesia over antero-lateral aspect of her left thigh, which was consistent with meralgia paresthetica. Diagnostic block with local anaesthetic confirmed the diagnosis but only archieved temporary pain relief. Alcohol neurolysis was then offered and patient responded well with no complication. The patient experienced prolonged pain relief at 6-month follow-up, with return of ability to ambulate and perform daily activity. Alcohol neurolysis of lateral femoral cutaneous nerve is safe, effective and able to provide sustained pain relief for recurrent meralgia paresthetica.
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ÖzetPediyatrik hastalarda ultrason eşliğinde transversus abdominis plan (TAP) bloğu anestezistler arasında popülarite kazanmaktadır. Kolostomi ve stomanın kapatılması sırasında 10 yenidoğan ve bebekte ultrason eşliğinde TAP bloğu olgu çalışmasını sunuyoruz. Hebbard tarafından tanımlanan klasik TAP uygulandı ve maksimum 1 ml/kg dozda %0.25 levobupivakain enjekte edildi. Yenidoğan Ağrı Ölçeği kullanılarak 24 saat boyunca ağrı skorları değerlendirildi. Hastaların hepsinde minimal hemodinamik değişikliklerle blok başarılı oldu, ameliyat sırasında ve erken ameliyat sonrası dönemde ilave sistemik analjeziğe gerek duyulmadı. Kolostomi oluşturma ve stomayı kapatma için ultrason eşliğinde TAP bölümoğu güvenli ve etkili analjezi sağlama-da önemli bir role sahiptir.Anahtar Kelimeler: Kolostomi; pediyatrik cerrahi; transversus abdominis plan bloğu. SummaryThe application of ultrasound-guided transversus abdominis plane (TAP) block in paediatric population is gaining popularity among anaesthetists. We present a case series of ultrasound-guided TAP block in ten neonate and infants undergoing colostomy and reversal of stoma. Classical TAP as described by Hebbard was carried out and a maximum dosage of 1ml/kg of 0.25% levobupivacaine was injected. Pain score was assessed using Neonatal Infant Pain Scale for 24 hours. In all patients, the block was successful with minimal hemodynamic changes intraoperatively and no additional systemic analgesia was needed intraoperative and immediate postoperatively. Ultrasound-guided TAP block has an important role in providing safe and effective analgesia for colostomy creation and reversal of stoma surgeries in paediatric population.
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