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PubMed1985

Regional ventilation in infancy. Reversal of adult pattern.

There is evidence that in infants with unilateral lung disease, oxygenation improves when the good lung is uppermost--the reverse of the situation in adults. We performed krypton-81m ventilation scanning in 18 infants and very young children (11 days to 27 months old) with and without abnormal chest radiographs. Scanning was performed with the subject supine, in the left decubitus posture (right lung uppermost), and in the right decubitus posture (right lung dependent). Fractional ventilation to the right lung fell when that lung was dependent and rose when it was uppermost (P less than 0.001). This pattern was seen regardless of the appearance of the chest radiograph. The distribution of ventilation away from dependent lung regions represents a reversal of the adult pattern, which may be due to differences between infants and adults in lung mechanics and diaphragmatic function. This study adds further weight to the argument that infants and very young children with unilateral lung disease should be positioned with their normal lung uppermost to optimize gas exchange. It also offers a rational explanation for the observation that infants with unilateral gas trapping can be successfully treated by placing them so that the diseased lung is dependent.

Age Factors↗
PubMedDate not supplied

Anemia in patients with traumatic spinal cord injury.

Anemia is often a complication following spinal cord injury which interferes with the patient's rehabilitation. Hematological profiles of 65 male patients with traumatic spinal cord injury revealed a 52.3% incidence of mild anemia. The age, duration or level of injury had no correlation with the incidence and type of anemia. The anemia was normocytic-normochromic in 32%, normocytic mild hypochromic in 56%, and microcytic hypochromic in 12% of the patients. Factors in pathogenesis included decubitus ulcers, urinary tract infections, acute and chronic blood loss, and folic acid deficiency due to psychosocial maladjustment, alcohol and/or drug abuse. Often, multiple factors were operative in changing proportions. The success of management depends on a careful assessment of causes and removal of inciting factors. The most common type of anemia was that due to chronic disorder, associated with either decubitus ulcers and/or urinary tract infections. Since this type of anemia mimics iron deficiency in presentation it should be differentiated from the latter by evaluation of iron status. Normal hemoglobin levels can be attained only after the chronic disorder is eliminated. Unpredictable fluctuations of hemoglobin level secondary to changes in plasma volume due to autonomic hyperreflexia are common in SCI patients, and should be taken into account for diagnosis and follow-up in therapy.

Adult↗
PubMed1996

Body position effects on EMG activity of sternocleidomastoid and masseter muscles in patients with myogenic cranio-cervical-mandibular dysfunction.

This study was conducted in order to determine the effects of body position on integrated electromyographic (IEMG) activity of sternocleidomastoid and masseter muscles in 17 patients with myogenic cranio-cervical-mandibular dysfunction. EMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the sternocleidomastoid and masseter muscles (contralateral to the habitual side of sleeping of each patient), in the following body positions: standing, seated, supine, and lateral decubitus position. Significant higher EMG activities were recorded in the sternocleidomastoid muscle in the lateral decubitus position and in the supine position (except during swallowing), whereas a significant higher EMG activity was recorded in the masseter muscle during maximal voluntary clenching in standing and seated positions. The EMG pattern observed suggests that the presence of parafunctional habits and body position could be closely correlated with the clinical symptomatology in the sternocleidomastoid and masseter muscles at wakening and during waking hours, respectively, in patients with myogenic cranio-cervical-mandibular dysfunction.

Adult↗
PubMed1997

Body position effects on sternocleidomastoid and masseter EMG pattern activity in patients undergoing occlusal splint therapy.

This study was conducted in order to determine the effects of body position on electromyographic (EMG) activity of sternocleidomastoid and masseter muscles, in 15 patients with myogenic cranio-cervical-mandibular dysfunction undergoing occlusal splint therapy. EMG activity was recorded by placing surface electrodes on the sternocleidomastoid and masseter muscles (contralateral to the habitual sleeping side of each patient). EMG activity at rest and during swallowing of saliva and maximal voluntary clenching was recorded in the following body positions: standing, supine and lateral decubitus. In the sternocleidomastoid muscle significant higher EMG activities at rest and during swallowing were recorded in the lateral decubitus position, whereas during maximal voluntary clenching EMG activity did not change. In the masseter muscle significant higher EMG activity during maximal voluntary clenching in a standing position was observed, whereas EMG activity at rest and during swallowing did not change. The opposite pattern of EMG activity supports the idea that there may exist a differential modulation of the motor neuron pools of the sternocleidomastoid and masseter muscles, of peripheral and/or central origin. This suggests that the presence of parafunctional habits and body position could be closely correlated with the clinical symptomatology in these muscles in patients with myogenic craniomandibular dysfunction.

Adult↗
PubMed1998

Body position effects on EMG activity of sternocleidomastoid and masseter muscles in healthy subjects.

This study was conducted in order to determine the effects of body position on integrated electromyographic (IEMG) activity of sternocleidomastoid and masseter muscles in 20 healthy subjects. EMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the sternocleidomastoid and masseter muscles (contralateral to the habitual side of sleeping of each subject), in the following body positions: standing, seated, supine, and lateral decubitus position. Significant higher EMG activities were recorded in the sternocleidomastoid muscle in the lateral decubitus position, whereas significant lower EMG activities were recorded in the masseter muscle in the supine position. This finding supports the idea that there may exist a differential modulation of the motor neuron pools of the sternocleidomastoid and masseter muscles of peripheral and/or central origin. Significant differences in the EMG pattern as well as in the levels of EMG activities upon variations in body positions were observed between healthy subjects and patients with myogenic craniomandibular dysfunction reported by Palazzi, et al.

Adolescent↗
PubMed2003

Effects of laterotrusive occlusal scheme and body position on bilateral sternocleidomastoid EMG activity.

This study was conducted to determine the effects of laterotrusive occlusal scheme and body position on bilateral sternocleidomastoid electromyographic (EMG) activity. The study was performed on 20 healthy subjects with natural dentition and bilateral molar support. During laterotrusive occlusal excursion (working side), each individual had to present canine guidance on one side and group function on the opposite side, without balancing-side contacts. Integrated EMG (IEMG) recordings were performed by placing bipolar surface electrodes on the right and left sternocleidomastoid muscles. IEMG activity was recorded seated upright with the head unsupported and in the right and the left lateral decubitus body positions (head, neck and body horizontally aligned), under the following experimental conditions: 1. Maximal voluntary clenching in the intercuspal position; 2. Laterotrusive occlusal excursion with canine guidance; 3. Laterotrusive occlusal excursion with group function. Bilateral sternocleidomastoid IEMG activity with canine guidance or group function was significantly lower than the intercuspal position in both body positions. In the seated upright position, significantly lower activity was observed with canine guidance than in group function. In the lateral decubitus position activity was similar with both laterotrusive occlusal schemes and significantly higher than seated upright. Results suggest that both laterotrusive occlusal scheme and body position have significant influence on sternocleidomastoid IEMG activity. The clinical relevance of both factors is discussed.

Adult↗
PubMed1998

Improvements in video-endoscopic sympathicotomy for the treatment of palmar, axillary, facial, and palmar-plantar hyperhidrosis.

Video-endoscopic sympathicotomy for the treatment of palmar, axillary, facial and palmar-plantar hyperhidrosis was modified as to the type of surgical access and the level of incision in the sympathetic chain and communicating rami, depending on the clinical indications. Under general anaesthesia, using a single lumen endotracheal tube, the patient is put in lateral decubitus and pneumothorax is induced. The patient is then placed in ventral decubitus, with the head elevated, to make two punctures in the posterior axillary line, at the level of the 4th and 7th intercostal spaces, to introduce two ports of 5 and 10 mm in size, respectively. The sympathetic chain and the communicating rami are viewed and severed, according to the indications, at different levels to treat palmar, axillary, facial and palmar-plantar hyperhidrosis and combinations of the above. The operation is performed on both sides of the thorax during the same period of anaesthesia. One hundred-forty patients (280 procedures) have been operated on from 1993 to 1997 using this technique. All were operated on as outpatients. Our results are: 100% of those with facial and palmar hyperhidrosis and 96% of those with axillar hyperhidrosis were cured, and 94% with plantar hyperhidrosis were relieved from 50 to 100%, with the follow-up of between one and 47 months.

Adolescent↗
PubMed2004

End-stage renal disease and dialysis in hereditary amyloidosis TTR V30M: presentation, survival and prognostic factors.

Classical familial amyloid polyneuropathy may have a course with progressive renal impairment. We studied 62 patients (24 males, 38 females) with FAP, transthyretin variant V30M, and end-stage renal disease (ESRD) treated with hemodialysis, all referred to a single center over a period of 11 years. Clinical course, morbidity and survival after dialysis were analyzed. Patient's mean age at first dialysis was 51.5 +/- 10.7 years, and mean duration of neuropathy was 10.2 +/- 3.8 years. The most frequent form of presentation of FAP nephropathy was nephrotic proteinuria with renal dysfunction. In the year prior to dialysis, renal function declined rapidly, and fluid overload was the main indication to initiate treatment. The presence of decubitus ulcers, significant disability, venous catheter for definitive vascular access for long-term treatment, and permanent bladder catheter, were related to death during the first year of dialysis. The mean duration of renal replacement therapy was 21 months, with a 54.5% one year, and 38.4% two year treatment survival. However, when the duration of neurological symptoms at first dialysis exceeded 10 years, survival was significantly lower. Infections, (41% were decubitus ulcers with sepsis) were the cause of early, as well as late mortality. Early creation of vascular access for hemodialysis, surveillance of skin wounds, and intervention on neurogenic bladder are essential to improve the prognosis of ESRD in FAP.

Adult↗
PubMed1997

New experimental model of ureteropelvic junction obstruction allowing easy access for percutaneous surgery.

To assess the usefulness of an experimental model of ureteropelvic junction (UPJ) obstruction designed to facilitate subsequent percutaneous surgery, a right UPJ obstruction was created in 10 pigs by an open retroperitoneal surgical approach. With the pig in the left lateral decubitus position, a 0.038-inch Terumo guidewire was inserted via a 1-cm longitudinal upper-third ureterotomy and advanced up and down so as to bridge the UPJ from the flank to the urogenital opening. A UPJ obstruction was then induced by securing two 2-0 chromic gut ties, separated by an interval of 1 cm, over the Terumo guidewire and a 6F ureteral catheter, which was removed immediately after this procedure. After closure of the ureterotomy, the kidney was anchored horizontally to the muscle wall, and the Terumo guidewire was coiled subcutaneously in the flank and fixed to the urogenital opening. Each pig developed marked hydronephrosis, diagnosed by ultrasonography, after a mean interval of 8.3 days. Retrograde ureteropyelography confirmed this pronounced dilation of the right collecting system above a tight UPJ stricture (mean length 1.17 cm). Subsequent percutaneous access to the UPJ over the Terumo guidewire in the lateral decubitus position was facilitated by the almost-horizontal plane of dilation (mean operating time 14 minutes). Pathologic examination of the UPJ revealed mild periureteral fibrosis, but the muscle layer and urothelium remained normal. We have developed a reliable and reproducible model of secondary UPJ obstruction especially designed for percutaneous surgery. This model should provide a better understanding of current endoscopic techniques such as endopyelotomy and could help to promote new treatment concepts such as percutaneous endoscopic pyeloplasty.

Anastomosis, Surgical↗
PubMed1999

Laparoscopic adrenalectomy in the elderly.

Laparoscopic adrenalectomy has recently been shown to be a safe and effective procedure for treating a variety of benign adrenal tumors. Advanced age, with its concomitant comorbid conditions, has been believed to be associated with more postoperative complications in laparoscopic procedures. The purpose of this study was to evaluate the outcome of laparoscopic adrenalectomy in patients age 65 and older. From June 1992 to February 1998, 14 patients (4 men and 10 women) with a mean age of 69 years underwent 17 laparoscopic adrenalectomies. In 12 procedures, a transperitoneal lateral decubitus flank approach was used. The lesion was a nonfunctioning adenoma in three patients, aldosterone adenoma in four, Cushing's syndrome in four, and pheochromocytoma in one. A retroperitoneal lateral decubitus approach was used in five procedures. The lesion was a nonfunctioning adenoma in one patient, aldosterone adenoma in one, Cushing's adenoma in one, and pheochromocytoma in two. Seventy-eight percent of these patients had comorbid conditions, including hypertension, diabetes, chronic obstructive airway disease, coronary artery disease, and cardiac dysrhythmia. The preoperative physical status was as ASA Class II in 11 patients and ASA III in 3. Two of the 17 laparoscopies were converted to open surgery (11%), in one because of difficulties in dissecting extraperitoneally a mass >8 cm, and in the other because of difficulties in localization of a 3-cm mass. The median surgical time was 95 +/- 33 minutes. The mean analgesia requirements were 3 doses of (range 2-7) ketorolac. There were no deaths. Postoperative morbidity consisted of pulmonary atelectasis in one patient and urinary tract infection in two patients. The median hospital stay was 3 days (range 2-4 days). We conclude that laparoscopic adrenalectomy in the elderly population is safe and offers low morbidity, fast recovery, and a short hospital stay. Age alone should not be a contraindication to treating adrenal tumors laparoscopically.

Adrenal Gland Neoplasms↗
PubMed1984

Floating pulmonary embolus: unusual cause of recurrent syncope.

A 69-year old woman was admitted because of recurrent syncopal episodes. In hospital, she had repeated attacks of near fainting or syncope when she was turned into the left decubitus position. Continuous arterial pressure monitoring revealed that severe hypotension initiated these events. Secondarily, the heart rate dropped markedly. The symptoms quickly reversed when the patient was turned back into the supine or right decubitus position. Angiography revealed a large, riding and partly floating pulmonary embolus that obstructed the pulmonary circulation to a variable degree, apparently influenced by the patient's body position. During subsequent emergency surgery the angiographic findings were confirmed. It appears that the severe hypotensive episodes were caused by intermittent high degree obstruction of the pulmonary circulation by the floating pulmonary embolus, a mechanism that, to our knowledge, has not previously been described as a cause of recurrent syncope.

Aged↗
PubMed2004

Postural effects on pharyngeal protective reflex mechanisms.

STUDY OBJECTIVES: Pharyngeal muscle dilators are important in obstructive sleep apnea pathogenesis because the failure of protective reflexes involving these muscles yields pharyngeal collapse. Conflicting results exist in the literature regarding the responsiveness of these muscles during stable non-rapid eye movement sleep. However, variations in posture in previous studies may have influenced these findings. We hypothesized that tongue protruder muscles are maximally responsive to negative pressure pulses during supine sleep, when posterior tongue displacement yields pharyngeal occlusion. DESIGN: We studied all subjects in the supine and lateral postures during wakefulness and stable non-rapid eye movement sleep by measuring genioglossus and tensor palatini electromyograms during basal breathing and following negative pressure pulses. SETTING: Upper-airway physiology laboratory of Sleep Medicine Division, Brigham and Women's Hospital. SUBJECTS/PARTICIPANTS: 17 normal subjects. MEASUREMENTS AND RESULTS: We observed an increase in genioglossal responsiveness to negative pressure pulses in sleep as compared to wakefulness in supine subjects (3.9 percentage of maximum [%max] +/- 1.1 vs 4.4 %max +/- 1.0) but a decrease in the lateral decubitus position (4.1 %max +/- 1.0 vs 1.5 %max +/- 0.4), the interaction effect being significant. Despite this augmented reflex, collapsibility, as measured during negative pressure pulses, increased more while subjects were in the supine position as compared with the lateral decubitus position. While the interaction between wake-sleep state and position was also significant for the tensor palatini, the effect was weaker than for genioglossus, although, for tensor palatini, baseline activity was markedly reduced during non-rapid eye movement sleep as compared with wakefulness. CONCLUSION: We conclude that body posture does have an important impact on genioglossal responsiveness to negative pressure pulses during non-rapid eye movement sleep. We speculate that this mechanism works to prevent pharyngeal occlusion when the upper airway is most vulnerable to collapse eg, during supine sleep.

Adult↗
PubMed1993

Mast cells in human ulcers.

The distributions of mast cells in decubitus, venous stasis, and arteriosclerotic human skin ulcers were studied. Mast cells were found primarily in the papillary dermis but were also numerous in the reticular dermis of the three types of ulcers. There were mast cells inside the epidermis and many more in granulation tissue. Intraepidermal mast cells were more numerous in venous stasis ulcers than in decubitus or arteriosclerotic ulcers. Many of the mast cells in these areas appeared to be intact. There were also some free and intracellular granules that stained like those in mast cells, in necrotic and granulation tissue. These findings raise questions about the role of mast cells in the epidermis and in necrosis and repair of skin ulcers.

Adipose Tissue↗
PubMed1995

Spinal anesthesia in outpatient knee surgery: 22-gauge versus 25-gauge Sprotte needle.

Spinal anesthesia in day-care surgery is still controversial because of the possibility of postdural puncture headache (PDPH). The use of the Sprotte needle with a conical tip that spreads the dural fibers may reduce the incidence of PDPH. The aim of this study was to compare the 22-gauge and 25-gauge Sprotte needles with respect to PDPH and postoperative complaints in out-patients undergoing arthroscopy. The rate of spinal anesthesia failure and the feasibility of unilateral spinal anesthesia when using a low dose of anesthesia was also verified. For this randomized, prospective study, 234 patients undergoing elective arthroscopy were chosen. Patients were allocated randomly to have spinal anesthesia with either a 22-gauge or 25-gauge Sprotte needle. Dural puncture was performed with the patient in a lateral flexed decubitus position. After the injection of anesthetic solution (0.5-1.2 mL of 1% bupivacaine in 8% glucose) patients remained in the lateral decubitus position for 30 min. The time to regression of analgesia, time of micturition, and all postoperative complaints were recorded. The most frequent side effect was backache (10.2%) with a more frequent incidence in the group using the 22-gauge needle (14.5% and 5.9%, respectively). PDPH was recorded in only one patient (0.8%) in the group using the 22-gauge needle. The failure rate was 0.8%. Unilateral anesthesia was achieved in 88% of 213 patients. Our data indicate that the use of spinal block is a suitable technique in the ambulatory setting, with a low rate of unplanned hospital admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

The effects of solution concentration and epinephrine on lateral distribution of hyperbaric tetracaine spinal anesthesia.

In a search of a differential spinal block between dependent and nondependent sides, we investigated whether the use of a larger concentration of hyperbaric tetracaine (T) and/or the omission of epinephrine (E) would provide differential spread in patients left for 15 min in the lateral decubitus position. Spinal anesthesia was performed in the lateral decubitus position with the operated side dependent in 60 patients scheduled for lower limb surgery. All patients remained lateral for 15 min after spinal injection before being turned supine. They received 12 mg of T in 10% dextrose and E 0.2 mg was added when predicted duration of surgery was more than 90 min. The concentration of T to be used for each patient was randomized. This resulted in four groups of 15 patients: T 0.5% + E (control group), T 1% + E, T 0.5%, and T 1%. A unilateral anesthesia was defined as the presence of an adequate sensory (L-1 or higher) and/or motor (3 degrees) blockade on the dependent side and the absence of one or both modalities on the nondependent side, or as a duration of sensory (regression to L-2) and motor (1 degrees of recovery) blockade 20% longer on the dependent compared to the nondependent side. None of the 60 patients showed unilateral sensory block. A comparable number of patients in all groups showed unilateral motor block: four in T 0.5% + E, two in T 1% + E, four in T 0.5%, and five in T 1%. Likewise, a comparable number of patients in all groups showed a prolonged duration of sensory and motor block, respectively: six and eight in T 0.5% + E, six and nine in T 1% + E, six and eight in T 0.5%, and seven and seven in T 1%. In conclusion, although a preferential distribution of hyperbaric T toward the dependent side in patients of all four groups was noticed, the use of a larger concentration of T, omission of E, or combination of these two factors did not provide a more marked differential spread when compared to the standard solution of T 0.5% + E.

Adrenergic Agonists↗
PubMed1997

Does dextrose affect analgesia or the side effects of intrathecal sufentanil?

UNLABELLED: Intrathecal (i.t.) sufentanil provides rapid effective pain relief for early labor, but it also produces undesirable side effects, which may be primarily related to cephalad spread. Although the combination of dextrose and positioning the patient head-up limits the spread of other spinally administered drugs, these factors have not been examined in laboring women receiving i.t. sufentanil. We hypothesized that the addition of dextrose to i.t. sufentanil injected with women in the sitting position would limit cephalad spread and side effects. Sixty-six healthy nulliparous parturients in early labor were randomized to receive 2-mL i.t. injections of sufentanil 10 micrograms plus saline with patients in either the lateral decubitus or sitting position, sufentanil 10 micrograms plus dextrose 7.5% with patients in either the lateral decubitus or sitting positions, or plain dextrose 7.5%. Pain scores using a 10-cm visual analog pain scale, sensory block height, and side effects were recorded. Dextrose 7.5% did not affect cephalad spread, as measured by block height to pin testing, but it did significantly reduce the duration of analgesia and the incidence of pruritus from i.t. sufentanil administered to patients in the sitting position compared with patients in the lateral position. In contrast, patient position had no effect on analgesia or side effects in patients receiving i.t. sufentanil in saline. I.t. dextrose alone had no effect. IMPLICATIONS: The authors conclude that the addition of dextrose to intrathecal sufentanil injected into patients in the sitting position reduces the duration of analgesia without significantly reducing side effects with the exception of pruritus, and therefore does not improve the clinical utility of intrathecal sufentanil.

Adult↗
PubMed1998

The effects of maternal position during induction of combined spinal-epidural anesthesia for cesarean delivery.

UNLABELLED: Combined spinal-epidural anesthesia (CSE) is a popular technique for cesarean delivery. Regional blocks in obstetrics are often performed with the parturient in the sitting position because the midline may be recognized more easily than in the lateral decubitus position. When conventional spinal anesthesia is performed in the sitting position, the patient is placed supine immediately after drug injection. In contrast, when CSE is performed with the woman sitting, there is a delay in assuming the supine position because of epidural catheter placement, which may affect the incidence of hypotension. Healthy women, at term of pregnancy, about to undergo an elective cesarean section under CSE, were randomly assigned to the sitting or lateral recumbent position for initiation of the block. All parturients were given 1000 mL of lactated Ringer's solution in the 15 min preceding induction and an additional 300-500 mL while the actual block was being performed. On completion of the CSE, they were turned to the supine position with left uterine displacement. A second anesthesiologist, blinded to the woman's position during CSE, evaluated the sensory level of anesthesia, maternal heart rate, blood pressure, oxygen saturation, need for ephedrine, and occurrence of nausea and vomiting. Results are expressed as mean +/- SD. Twelve women were studied in the sitting group and 10 were studied in the lateral recumbent group. The severity and duration of hypotension were greater in those parturients who had CSE induced in the sitting (47%+/-7% and 6+/-3 min, respectively) compared with the lateral recumbent position (32%+/-14% and 3+/-2 min, respectively). Women in the sitting group also required twice as much ephedrine (38+/-18 mg) to correct hypotension compared with the other group (17+/-12 mg). In conclusion, the severity and duration of hypotension were greater when CSE was induced in the sitting compared with the lateral decubitus position. IMPLICATIONS: We studied the induction of combined spinal-epidural anesthesia (CSE) in the sitting versus lateral recumbent positions in healthy women undergoing a scheduled cesarean delivery. The severity and duration of hypotension were greater when CSE was induced in the sitting position. Thus, the position used for induction of CSE should be among the factors considered when there is greater maternal or fetal risk from hypotension.

Adult↗
PubMed1997

Changes in the position of epidural catheters associated with patient movement.

BACKGROUND: Epidural catheter movement has been noted with change of patient position and can result in inadequate anesthesia. This study was designed to measure movement and to develop a technique that minimizes catheter displacement. METHODS: In 255 parturients requesting epidural anesthesia for labor or cesarean section, a multiorificed lumbar epidural catheter was inserted with the patient in the sitting flexed position. The distance to the epidural space, length of catheter inserted, and amount of catheter position change as the patient moved from the sitting flexed to sitting upright and then to the lateral decubitus position were measured before the catheter was secured to the skin. Adequacy of analgesia, the need for catheter manipulation, and whether the patient was considered obese were noted. Data were grouped according to body mass index (BMI): < 25, 25-30, and > 30 kg/m2. RESULTS: The groups did not differ with respect to the length of catheter initially inserted or changes in catheter position between initial taping and removal. The distance to the epidural space differed significantly among the groups, increasing with greater BMI. Catheters frequently appeared to be drawn inward with position change from the sitting flexed to lateral decubitus position, with the greatest change seen in patients with BMI > 30. Only nine catheters were associated with inadequate analgesia, four of which were replaced. No analgesic failures occurred in the BMI > 30 group. In patients judged by the anesthesiologist to be obese or to have an obese back, BMI was greater, and distance to the epidural space and the magnitude of catheter movement with position change were greater than in those who were not obese. CONCLUSIONS: Epidural catheters moved a clinically significant amount with reference to the skin in all BMI groups as patients changed position. If catheters had been secured to the skin before position change, many would have been pulled partially out of the epidural space. To minimize the risk of catheter displacement, particularly in obese patients, we recommend that multiorificed catheters be inserted at least 4 cm into the epidural space and that patients assume the sitting upright or lateral position before securing the catheter to the skin.

Anesthesia, Obstetrical↗