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PubMed2000

Improved epidural analgesia in the parturient in the 30 degree tilt position.

PURPOSE: To compare the incidence of incomplete analgesia when epidural local anesthetic is administered with the parturient supine in a 30 degree leftward tilt or in the left lateral decubitus position. METHODS: After placement of a multiorifice catheter 5 cm into the epidural space, 293 women in active labour were randomly positioned either to the left lateral decubitus position (lateral group) or supine with a 30 degree leftward tilt (tilt group) and then received 13 mL bupivacaine 0.25%. The success of the epidural block was determined by asking the patient if she required additional medication 15 min later. The incidence of complications (fetal heart rate decelerations, hypotension, and ephedrine usage) was noted. RESULTS: In the lateral group, 38% required additional medication compared with 24% in the tilt group (P = 0.006). There were no differences between groups in the incidence of maternal hypotension or fetal heart rate decelerations, but more women (10%) received ephedrine in the lateral than in the tilt group (4%), P = 0.035. CONCLUSIONS: Placing the parturient supine with a 30 degree leftward tilt is associated with a greater success rate of labour epidural analgesia without an increase in complications than in women in the left lateral decubitus position. This advantage should be considered when positioning the parturient after epidural catheter placement.

Adult↗
PubMed2003

The iliac angle: a sonographic marker of trisomy 21 during the midtrimester: dependency of fetal lying?

The aim of this study was to evaluate the efficiency of the fetal iliac wing angle measurements in the detection of trisomy 21 during the second trimester and the impact of the fetal position on this measurement. During a 43-month period, the iliac wing angle was prospectively measured in 695 fetuses at genetic ultrasonography performed before amniocentesis. The iliac wing angle measurements were performed in a true axial section of the fetal pelvis and the relative position of the fetal spine was recorded (decubitus, lateral). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio (LR) were computed for multiple cutoff angles. The prevalence of trisomy 21 was 1.4%; 447 fetuses were in lateral position, 240 fetuses were in decubitus position, including, respectively, 2 and 8 fetuses with trisomy 21 (8 fetuses with other chromosomal anomalies were excluded). In euploid fetuses, the mean iliac wing angle was 83.7 degrees in decubitus and 68.7 degrees in lateral position; in fetuses with trisomy 21 the respective mean angles were 104.9 degrees and 102.5 degrees. A receiver operating characteristics (ROC) curve provided an absolute cutoff angle of 90 degrees, predicting trisomy 21 with a sensitivity of 100%, a specificity of 72.4%, an NPV of 100%, a PPV value of 11.1%, and an LR of 3.6. The measurement of iliac wing angles in an axial section of the fetal pelvis is dependent on spine orientation and provides an efficient cutoff angle for the exclusion of trisomy 21 in patients at risk.

Adolescent↗
PubMed2005

Spondylolisthesis with postural slip reduction shows different motion patterns with video-fluoroscopic analysis.

To compare the motion of lumbar spondylolisthesis between the standing and decubitus positions and to identify the radiological parameters concerning segmental instability, the lumbar sagittal motion of 5 volunteers and 14 patients was recorded using video-fluoroscopy in both positions. Still images at three frames per second were captured, and the motion pattern was compared between the two positions. Patients were classified into two subgroups according to the degree of postural slip reduction. In the volunteer group, the motion patterns were not particularly different between the two positions. In the small postural reduction group, the motion patterns were not particularly different between the two positions, except in one patient for whom the range of motion (ROM) at the upper adjacent level increased in the decubitus position. In the large postural reduction group, a motion pattern change was observed. The ROM at the slip level in three patients increased, and in the remaining four patients the angle at the midpoint in ROM at the slip level shifted to the extension side in the decubitus position. This condition (anterior slip being reduced in the supine position, with disc angle and average disc height increased) is thought to result from anterior column deficiency and the vertical laxity of the surrounding soft tissues. A biomechanically stable fusion technique is recommended for surgical management.

Adolescent↗
PubMed1995

Efficacy of gentian violet in the eradication of methicillin-resistant Staphylococcus aureus from skin lesions.

The efficacy of gentian violet (Gv) in eradicating methicillin-resistant Staphylococcus aureus (MRSA) in decubitus ulcers was investigated. Decubitus ulcers (a total of 18 cases) were scrubbed with Gv aqueous solution 0.1% and ointment containing Gv 0.1% was applied daily. MRSA was not detected in these lesions for 3-34 days (average, 10.5 +/- 2.5 days) after the application of Gv ointment. Before this trial, all patients were treated with povidone-iodine and antibiotics; however, those treatments were not effective in eradicating MRSA from skin lesions. Skin irritation and other systemic side effects caused by Gv were not observed. Our data suggest that Gv is a useful agent for treatment of the decubitus ulcers infected with MRSA.

Aged↗
PubMed1991

Which position is more comfortable for the parturient during identification of the epidural space?

The purpose of this study was to determine which of the two positions used by anesthesiologists to identify the epidural space is more comfortable for pregnant patients. We evaluated both the lateral decubitus position and the sitting position in 90 term parturients who were either not in labor or were in early labor (<or= 4 cm cervical dilation). Exclusion criteria included: (1) oxytocin administration; (2) opioid administration within 12 h; (3) multiple gestation; and (4) previous history of cesarean delivery. Patients were positioned in the left lateral decubitus and sitting positions for 60 s each to achieve maximal flexion of the lumbar spine. Patients were questioned as to which position they felt would be more comfortable during the time necessary to identify the epidural space and place an epidural catheter. Among all patients neither position was clearly superior with regard to patient comfort. However, patients who preferred the left lateral decubitus position weighed less (Wt 78 +/- 2 kg vs 87 +/- 3 kg, P = 0.012) and had lower body mass indices (Wt[kg]/Ht[M]2) (27.4 +/- 0.9 vs 31.3 +/- 1.0, P = 0.006) than patients who preferred the sitting position.

Journal Article↗
PubMed2005

"Beauty is only skin deep": prevalence of dermatologic disease on a palliative care unit.

Skin disease affects the palliative care patient population because of their immunosuppressed state and decreased mobility; however, the prevalence of skin disease in this population has not been studied. We collected dermatologic histories and examinations of patients admitted to a hospital-based tertiary palliative care unit. Repeat examinations were performed to assess the incidence of cutaneous disease, as well as the progression of existing conditions. Sixteen of 65 patients admitted during 9 consecutive weeks participated in regular examinations. Six patients developed decubitus ulcers or had progression of existing ulcers. Dermatitis, xerosis, and pruritus were common diagnoses. Six patients sustained cutaneous trauma. Of the 49 non-participating patients, 4 developed decubitus ulcers, 1 had a drug reaction, and 3 had cutaneous infections. Palliative care patients are prone to developing decubitus ulcers and cutaneous infections. Aggressive control of systemic symptoms may exacerbate skin disease. Consideration of dermatologic conditions is an important factor in optimizing skin control in this population.

Aged↗
PubMed1999

New echocardiographic windows for quantitative determination of aortic regurgitation volume using color Doppler flow convergence and vena contracta.

Color Doppler images of aortic regurgitation (AR) flow acceleration, flow convergence (FC), and the vena contracta (VC) have been reported to be useful for evaluating severity of AR. However, clinical application of these methods has been limited because of the difficulty in clearly imaging the FC and VC. This study aimed to explore new windows for imaging the FC and VC to evaluate AR volumes in patients and to validate this in animals with chronic AR. Forty patients with AR and 17 hemodynamic states in 4 sheep with strictly quantified AR volumes were evaluated. A Toshiba SSH 380A with a 3.75-MHz transducer was used to image the FC and VC. After routine echo Doppler imaging, patients were repositioned in the right lateral decubitus position, and the FC and VC were imaged from high right parasternal windows. In only 15 of the 40 patients was it possible to image clearly and measure accurately the FC and VC from conventional (left decubitus) apical or parasternal views. In contrast, 31 of 40 patients had clearly imaged FC regions and VCs using the new windows. In patients, AR volumes derived from the FC and VC methods combined with continuous velocity agreed well with each other (r = 0.97, mean difference = -7.9 ml +/- 9.9 ml/beat). In chronic animal model studies, AR volumes derived from both the VC and the FC agreed well with the electromagnetically derived AR volumes (r = 0.92, mean difference = -1.3 +/- 4.0 ml/beat). By imaging from high right parasternal windows in the right decubitus position, complementary use of the FC and VC methods can provide clinically valuable information about AR volumes.

Adolescent↗
PubMed2002

The effects of time-to-surgery on mortality and morbidity in patients following hip fracture.

PURPOSE: There is a perception that the standard of care is to repair hip fractures surgically within 24 hours of hospitalization. However, it is unclear whether this reduces mortality or morbidity. SUBJECTS AND METHODS: We performed a retrospective study in consecutive hip fracture patients, aged 60 years or older, who underwent surgical repair. Patients with metastatic cancer, trauma, or a fracture occurring >48 hours before admission were excluded. The primary outcome was long-term (up to 18 years) mortality. Secondary outcomes included 30-day mortality and decubitus ulcers, serious bacterial infections, myocardial infarction, and thromboembolism. Analyses were adjusted for medical conditions; the comparison group comprised patients who underwent surgery for hip fracture repair within 24 to 48 hours because there were no patients with active medical problems who underwent surgery within 24 hours. RESULTS: Of the 8383 patients, surgery was delayed for more than 24 hours in 2464 patients (29%) for medical reasons and in 1341 patients (16%) without active medical problems. Compared with those who underwent surgery 24 to 48 hours after admission to the hospital, patients who underwent surgery more than 96 hours after admission did not have increased long-term mortality (hazard ratio = 1.07; 95% confidence interval [CI]: 0.95 to 1.21), although the risk of decubitus ulcer was increased (odds ratio = 2.2; 95% CI: 1.6 to 3.1). There were no associations between time-to-surgery and the other secondary outcomes. CONCLUSION: Time-to-surgery in hip fracture patients was not associated with short- or long-term mortality after adjusting for active medical problems. Other than increasing the risk of decubitus ulcer formation, waiting did not appear to affect patients' outcomes adversely.

Aged↗
PubMed1990

Cost-effectiveness of treating incontinence in severely mobility-impaired long term care residents.

Severely mobility-impaired residents in long term care facilities are usually incontinent. The incontinence and immobility predispose this group to decubitus ulcers and urinary tract infections that have been described as adding to the "consequence costs of incontinence" of $80 million per year. In this quasi-experimental study of ten subjects, a mechanical lift (Clinilift) was used with a two-hour schedule to improve incontinence. Subjects showed improvement in not only dryness but also volume of urine voided and the frequency of decubitus ulcers and UTIs. Because this incontinence treatment is labor intensive, the costs of treating incontinence increased by $2.90 over the cost of providing incontinent care. When the costs of decubitus ulcers and urinary tract infections are considered, however, the treatment savings were $13.38 per patient per day.

Activities of Daily Living↗
PubMedDate not supplied

[Valdivia supine position as the best option for percutaneous surgery of renal calculi in morbidly obese patients].

INTRODUCTION: Treatment of the morbidly obese patient with symptomatic renal calculi is an interesting urological challenge. Extracorporeal shock wave lithotripsy is frequently not possible for several reasons, and many urological centers match these patients as one of the residual indications for open surgery of kidney lithiasis. MATERIAL AND METHOD: Two patients with body mass index more than 50 k/m2 and symptomatic kidney stones were treated with percutaneous nephrolithotomy in the supine position described by Valdivia (slightly lateralized supine decubitus). Standard instrumentation for percutaneous surgery and the semi-rigid ureteroscopy were used, through an Amplatz sheath proximally transfixed with a polypropylene stitch, so to avoid its lost under the fatty skin. Both patients were rendered stone-free without significant morbidity. DISCUSSION: The advantages of Valdivia position in those patients are clear, both for the commodity of the surgical team, -because time may be spared and help needed to mobilized the patient is less-, as well as for what concerns to the anesthesia, because cardio-respiratory restrictions created by a general anesthesia in prone are greater and more severe in the obese patient. This position seems to be more suitable than other ones recommended for percutaneous nephrolithotomy in the obese patients, such as prone decubitus on a surgical saddle, or lateral decubitus position, that may compromise the radiological control of the operation.

Female↗
PubMed2003

Rescuer position for tracheal intubation on the ground.

BACKGROUND: Emergency oral tracheal intubations in the pre-hospital setting can be more difficult because the rescuer's position with respect to a patient lying on the ground may not provide optimal conditions for intubation. Since optimal visualisation of the larynx often depends on the force generated during laryngoscopy, we measured the pressure required for intubation (P(i)) as well as the maximum pressure (P(max)) that can be generated with the laryngoscopy blade in seven intubator positions. METHODS: Nineteen hospital personnel with intubation experience participated in this study. A modified #3 Macintosh laryngoscope blade was used to measure the pressure exerted on the tongue of a manikin placed on the ground during intubation. The following positions were studied: standard, sitting, prone, kneeling, left and right lateral decubitus and straddling. RESULTS: Intubating in the straddling position required the lowest P(i), as a percent of P(max) (68+/-14%). This was significantly less than the prone, right lateral decubitus and sitting positions. (Tukey's W procedure, P<0.05) CONCLUSION: The straddling position affords the intubator significantly more reserve force than the prone, right lateral decubitus or sitting position. We suggest that the straddling position may be an advantageous position for pre-hospital intubations especially when visualisation of the glottis is difficult.

Adult↗
PubMed2003

A retrospective study to determine the incidence of pressure ulcers in burn patients using a low air loss pressure relieving mattress.

In immobilized patients, unrelieved pressure can create decubitus ulcers over bony prominences. Those burn patients who require prolonged bed rest, are prone to the development of such problems. Various methods of reducing pressure on these areas, including frequent turning and the use of air fluidized and low air loss beds, have been adopted to attempt to prevent the development of this complication. The Pegasus Renaissance alternating pressure mattress is such a device, intended to reduce the incidence of decubitus ulcers. It was introduced at our burn unit and evaluated over a 29-month period. During the study period, 186 (13.4%) of 1390 acutely burned patients, believed to be at high risk for the development of decubiti, were placed on this mattress. Other patients were treated in the standard hospital bed. Care was otherwise the same. No decubitus ulcers developed in any of the patients treated on the Pegasus Renaissance mattress.

Adolescent↗
PubMed2003

A retrospective study to determine the incidence of pressure ulcers in burn patients using an alternating pressure mattress.

In immobilized patients, unrelieved pressure can create decubitus ulcers over bony prominences. Those burn patients who require prolonged bed rest, are prone to the development of such problems. Various methods of reducing pressure on these areas, including frequent turning and the use of air fluidized and low air loss beds, have been adopted to attempt to prevent the development of this complication. The Pegasus Renaissance alternating pressure mattress is such a device, intended to reduce the incidence of decubitus ulcers. It was introduced at our burn unit and evaluated over a 29-month period. During the study period, 186 (13.4%) of 1390 acutely burned patients, believed to be at high risk for the development of decubiti, were placed on this mattress. Other patients were treated in the standard hospital bed. Care was otherwise the same. No decubitus ulcers developed in any of the patients treated on the Pegasus Renaissance mattress.

Adolescent↗
PubMed2003

Pain assessment in elderly patients with severe dementia.

The purpose of this study was to assess the reliability and validity of facial expressions as pain indicators in patients with severe dementia. Based on interviews with patients who could report pain, we defined characteristics of decubitus ulcers associated with reports of pain during dressing changes. We then evaluated 9 patients who had ulcers with these characteristics but were unable to communicate verbally because of severe dementia. We videotaped their facial expressions before and during their decubitus ulcer dressing change. We showed the videotape segments, in random order, to 8 medical students and 10 nurses. The 18 viewers were asked to infer the presence or absence of pain based on their observations of the patients' facial expressions and vocalizations. The dressing change of decubitus ulcers extending beyond the subcutaneous tissue, covering an area of at least 9 cm(2), and with a moist surface, was always reported as painful by study patients able to report (95% confidence interval of 69-100%). The intraclass correlation coefficient for the answers of the 18 viewers evaluating each videotape segment for the presence of pain was 0.64. Sensitivity, specificity, and positive and negative predictive values of viewers' ratings of facial expressions and vocalizations as a measure of the presence of pain were: 0.70, 0.83, 0.90, and 0.81. The intraclass correlation coefficient for the answers rating pain intensity was only 0.10, indicating only slight agreement beyond chance. Assuming dressing changes of ulcers reported as painful by communicative patients are also painful in non-verbal severely demented patients, clinician observations of facial expressions and vocalizations are accurate means for assessing the presence of pain, but not its intensity, in patients unable to communicate verbally because of advanced dementia.

Aged↗
PubMed2003

Unilateral spinal block for outpatient knee arthroscopy: a dose-finding study.

STUDY OBJECTIVE: To evaluate the onset time, success rate, and recovery profile of unilateral spinal anesthesia produced with 4 mg, 6 mg, and 8 mg of 0.5% hyperbaric bupivacaine. DESIGN: Prospective, randomized, blinded study. SETTING: Outpatient anesthesia unit at a University Hospital. PATIENTS: 90 ASA physical status I and II outpatients, who were scheduled for elective knee arthroscopy. INTERVENTIONS: After standard intravenous midazolam premedication (0.05 mg/kg) and crystalloid infusion (7 mL/kg) were given, patients were placed in the lateral decubitus position on the operative side, and randomly allocated to receive spinal block with either 4 mg (Group 4, n = 30), 6 mg (Group 6, n = 30), or 8 mg (Group 8, n = 30) of 0.5% hyperbaric bupivacaine injected slowly (3 mL/min) with the needle orifice directed toward the dependent side using a 25-gauge Whitacre needle. The lateral decubitus position was maintained for 15 minutes. MEASUREMENTS AND MAIN RESULTS: The onset time of surgical block was 13 +/- 5 minutes in Group 4 and 10 +/- 4 minutes in Group 6 (p = 0.006), and 9 +/- 4 minutes in Group 8 (p = 0.002). The maximum level of sensory block on the operative and nonoperative sides was, respectively, T(10) (T(12)-T(6)) and / (/-L(2)) in Group 4 (p = 0.0005), T(8) (T(12)-T(6)) and / (/-L(5)) in Group 6 (p = 0.0005), and T(7) (T(12)-T(5)) and / (/-T(10)) in Group 8 (p = 0.0005). A strictly unilateral sensory block was observed in 27 Group 4 patients (90%), 28 Group 6 patients (93%) and 23 Group 8 patients (77%) (p = 0.28). Complete unilateral motor block was observed in 29 Group 4 patients (97%), 28 Group 6 patients (93%), and 28 Group 8 patients (93%) (p = 0.80). No failed blocks were reported. Complete regression of spinal anesthesia required 71 +/- 20 minutes in Group 4 (range: 40 to 110 min), 82 +/- 25 minutes in Group 6 (range: 30 to 160 min), and 97 +/- 37 minutes in Group 8 (range: 50 to 120 min) (p = 0.003). CONCLUSIONS: Hyperbaric bupivacaine 4 mg injected slowly through pencil-point directional needles in patients who are maintained in the lateral decubitus position for 15 minutes provided a surgical block that was mostly restricted to the operative side and adequate to perform knee arthroscopy, with a faster recovery profile than when a 6 mg or 8 mg dose was used.

Adult↗
PubMed1980

Regional lung function in bilateral diaphragmatic paralysis.

1. The distribution of regional function in the lungs of six patient with bilateral diaphragmatic paralysis was investigated by continuous inhalation and infusion of the radioactive gases 81mKr and 85mKr during tidal breathing. 2. In the supine and right lateral decubitus postures the vertical distribution of ventilation per unit alveolar volume was less in the dependent zones, the reverse of that found in normal subjects. In the upright posture ventilation was slightly decreased at the lung base. Perfusion per unit alveolar volume was more uniformly distributed than normally in the upright posture, and decreased from superior to inferior in the supine posture. In the lateral decubitus posture, perfusion of the lower lung was greater than that of the upper. Ventilation/perfusion ratios were more uniformly distributed in the patients than in normal subjects, except in the right lateral decubitus posture. 3. Alterations in the distribution of ventilation may be explained in terms of the altered mechanical interaction of chest wall, mediastinal and abdominal contents, with selective use of intercostal and accessory muscles. The effects on the distribution of blood flow are probably related to the low end-expiratory lung volume.

Adult↗
PubMed1980

[Diagnostic value of abdominal plain films in acute pancreatitis (author's transl)].

Duodenal distension is in connection with corresponding clinical symptoms--the pathognomonic symptom of acute pancreatitis, provided that the film is taken in left lateral decubitus position. In 90% of 192 cases of acute pancreatitis, proven by surgery or high amylase concentration, duodenal distension was diagnosed on the film taken in left lateral decubitus position. If there is the temptative diagnosis of acute pancreatitis and no duodenal distension is demonstrable, this may result from a fluidfilled stomach without air after vomiting or a stomach tube, through which the air may escape. In these cases we give an effervescent powder to demonstrate duodenal distension. The combination of duodenal atony and distension of the small or large bowel is found very often as a sign of spread pancreatic enzymes along definite anatomic planes in the abdomen like transverse mesocolon and small bowel mesentery. The abdominal plain film taken in supine and left lateral decubitus position gives many important informations solving differential diagnostic problems concerning processes in the upper abdomen and determines further diagnostic and therapeutic proceedings considerably.

Acute Disease↗
PubMed1999

Effects of two types of pillows on bilateral sternocleidomastoid EMG activity in healthy subjects and in patients with myogenic cranio-cervical-mandibular dysfunction.

This study was conducted in order to determine the effects of two types of pillows on bilateral electromyographic (EMG) activity of the sternocleidomastoid muscles. The study was performed on 15 patients with myogenic cranio-cervical mandibular dysfunction (CMD) and 15 healthy subjects. EMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the right and left sternocleidomastoid muscles. EMG activity was recorded in the supine position and in the lateral decubitus position (according to each individual's normal resting habit), with their eyes closed and with the head supported by means of: 1. a Sleep Easy Pillow (Interwood Marketing Groups, Concord, Ontario, Canada) and 2. a Standard Pillow (INDUVET). In the lateral decubitus position a significantly higher contralateral than ipsilateral EMG activity at rest in the sternocleidomastoid muscles was observed with both types of pillows in all the sample studied (ANOVA and Duncan's Multiple-Range Test). Asymmetrical bilateral EMG activity in the lateral decubitus position with both types of pillows in healthy subjects and in patients with myogenic CMD, suggests that if this body posture is prolonged, it could be important in the genesis of sternocleidomastoid hyperactivity.

Adult↗