Paravertebral Block for Anesthesia: A Systematic Review
ABSTRACT The objective of this review was to assess the safety and efficacy of thoracic and lumbar paravertebral blocks (PVBs) for surgical anesthesia through a systematic review of the peer-reviewed literature. PVBs for surgical anesthesia were compared with general anesthesia (GA) or other regional anesthetic techniques.
We searched literature databases including MEDLINE, EMBASE, and The Cochrane Library up to May 2008. Included studies were limited to eligible randomized controlled trials. Eight randomized controlled trials were included in this review, 6 of which used PVBs for anesthesia during breast surgery, and 2 trials used PVB for anesthesia during herniorrhaphy.
The ability to obtain firm conclusions was limited by the diversity of outcomes and how they were measured, which varied across studies. The PVB failure rate was not >13%, and patients were more satisfied with PVB than with GA. There was some indication that PVB could achieve shorter hospital stays than GA. PVB for anesthesia substantially reduces nausea and vomiting in comparison with GA (relative risk: 0.25, 95% CI: 0.13-0.50; P < 0.05), although it does carry a risk of pleural puncture and epidural spread of local anesthetic.
In conclusion, based on the current evidence, PVBs for surgical anesthesia at the level of the thoracic and lumbar vertebrae are associated with less pain during the immediate postoperative period, as well as less postoperative nausea and vomiting, and greater patient satisfaction compared with GA.
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ABSTRACT: New linear response formulas for unperturbed chaotic (stochastic) complex dynamical systems with time periodic coefficients are developed here. Such time periodic systems arise naturally in climate change studies due to the seasonal cycle. These response formulas are developed through the mathematical interplay between statistical solutions for the time-periodic dynamical systems and the related skew-product system. This interplay is utilized to develop new systematic quasi-Gaussian and adjoint algorithms for calculating the climate response in such time-periodic systems. These new formulas are found in section 4. New linear response formulas are also developed here for general time-dependent statistical ensembles arising in ensemble prediction including the effects of deterministic model errors, initial ensembles, and model noise perturbations simultaneously. An information theoretic perspective is developed in calculating those model perturbations which yield the largest information deficit for the unperturbed system both for climate response and finite ensemble predictions.Communications in mathematical sciences 01/2010; 8(2010). DOI:10.4310/CMS.2010.v8.n1.a8 · 1.00 Impact Factor
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ABSTRACT: Epidural anesthesia procedures are performed in approximately 75 percent of all childbirths in the United States; however, failure rates for these procedures are as high as 40 percent across all cases and 70 percent in the obese population. Due to the limitations associated with X-ray-based fluoroscopy, including exposure to ionizing radiation and lack of portability, the standard of care is to perform epidurals using palpation - i.e. without medical imaging. High-quality 3D imaging of spinal bone surfaces, obtained using a portable ultrasound device, could potentially overcome these challenges and offer physicians a safe imaging tool to increase success rates. A 4-channel handheld ultrasound system with custom 0.95 cm diameter piston transducers focused at 5 cm were designed and fabricated. The system was then used to image an excised lumbar spine in a water bath over a mechanically scanned 90 mm × 50 mm 2D plane. Positional information regarding the surface of the lumbar spine bone at each point across the 2D plane was estimated in MATLAB by detecting the position of maximum envelope-detected signal above the noise level. 3D topographical images were rendered and qualitatively compared to photographs of the actual spine. Additionally, 3D printed models of anatomically accurate lumbar vertebrae were fabricated and embedded in a graphite gelatin phantom. Imaging was conducted with a mechanically scanned 5 MHz piston transducer, 3D images were formed, and the correlation between the known surfaces and ultrasound estimated surfaces was computed. Images of the excised spine using the handheld ultrasound system yielded excellent correlation to optical images. Automated measurements (performed in MATLAB) of spinous process and epidural gap dimensions across the axis of the spine were within 0.5 mm of the actual dimensions. 3D images of the printed spine model produced a 0.88 correlation coefficient between estimated and true spine surface locations. Results in t- is paper demonstrate the feasibility of a handheld ultrasound device for low-cost, safe, and portable imaging of spinal bone anatomy in 3D, which possesses the potential for improving the success rates of epidural anesthesia procedures.Ultrasonics Symposium (IUS), 2011 IEEE International; 01/2011
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ABSTRACT: The introduction of enhanced recovery after surgery (ERAS) protocols has revolutionized preoperative and postoperative care. To date, however, the principles of enhanced recovery have not been applied specifically to patients undergoing breast surgery. Based on the core features of ERAS, individual aspects of postoperative care in breast surgery were defined. A comprehensive search of MEDLINE, PubMed, Embase and the Cochrane Library database was performed from 1980 to 2010 to determine the best evidence for perioperative care in oncological breast surgery. A graded recommendation based on the best level of evidence was then proposed for each feature of ERAS. Twelve core features of enhanced recovery after breast surgery were identified. Use of the thoracic block, from both analgesic and anaesthetic viewpoints, is well supported by evidence and should be encouraged. Trials specific to breast surgery regarding aspects such as perioperative fasting, preanaesthetic medication, prevention of hypothermia and postdischarge support are scarce, and evidence was extrapolated from non-breast trials. Trials on postoperative analgesia and prevention of postoperative nausea and vomiting in breast surgery are generally of small numbers. In addition, there is heterogeneity between studies. This review suggests that the principles of enhanced recovery can be adopted in breast surgery. A 12-point protocol is proposed for prospective evaluation.British Journal of Surgery 02/2011; 98(2):181-96. DOI:10.1002/bjs.7331 · 5.21 Impact Factor