Notice bibliographique
Résumé
To the Editor: The case report by Kasai et al. (1) and the accompanying editorial by Rose (2) remind us that the potential for serious risk is inherent with every neuraxial procedure performed. Rose (2) has provided us with some commonsense guidelines to help us prevent such complications. We personally concur with his conclusions but wish to bring attention to two new avenues of research. Techniques are being developed to help make neuraxial procedures safer, particularly in heavily sedated or anesthetized patients. Entry into the epidural or intrathecal space can be reliably demonstrated electrically (3,4). Previous studies (5–7) have demonstrated that a motor response evoked by 1 mA or less indicates the catheter is either in the subarachnoid space (SA) or close to a nerve root (subdural, 0.3 mA; SA, 0.4 mA; immediate proximity to a nerve root, 0.5 mA). These observations support the potential application of electrical epidural stimulation or Tsui test (3–8) as an adjunct method to identify the precise location of a needle or catheter in the epidural space. A modification of the Tsui test can be used to help guide an insulated needle into the caudal or epidural space (9–10). In a porcine model, Tsui et al. (10) have demonstrated that the test can be used to reliably detect entry of an insulated Tuohy needle into the epidural space. By using supramaximal delivered currents and ensuring the subject has not been paralyzed, proximity to any motor neuron (nerve, nerve root, or spinal cord) can be reliably detected. This is done by sequentially reducing the current to a level where the motor response just disappears, while advancing the Tuohy needle using a continuous loss-of-resistance (LOR) technique. Entry into the epidural space will be signaled by a LOR and the simultaneous recurrence of the motor response (at an appropriate myotomal level) with a delivered current well above 1 mA. If, at any time, a motor response occurs at a current below 1 mA, proximity to a nerve structure is assured and further advancement of the needle is not advised as it may risk injury. The use of a nerve stimulator to perform peripheral nerve blocks in anesthetized patients has not been demonstrated to enhance safety (11). However, epidural stimulation, unlike peripheral nerve localization, uses a supramaximal current sufficient to stimulate any motor nerve structure within several centimeters. The principle goal when performing a peripheral nerve block is to seek the minimal current sufficient to stimulate a motor nerve (generally <0.5 mA) (11,12). Although there is only a single published laboratory study examining this application, the test has the potential to monitor a motor response in clinical settings where paresthesia cannot be reported. This technique has potential to make neuraxial procedures safer and should not be overlooked. Investigators in Europe have developed expertise in visualizing the epidural space with ultrasound (13,14). Real-time imaging with ultrasound may further enhance the safety of neuraxial procedures (15). While we agree with Dr. Rose (2) that further research is necessary to verify the “broadly held belief that epidural analgesia is associated with better postoperative analgesia,” we feel we also need to address more philosophical issues. For example, what is a reasonable risk? Furthermore, as Dr. Rose implies (2), how can we acquire a fully informed consent when we do not fully understand the nature of the risk? Research into the pathogenesis of spinal epidural hematoma formation, evolution, and incidence is desperately needed. Scott A. Lang Ban Tsui, MD, MSC, FRCP(C) Thomas Grau, MD
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,000 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,001 | 0,003 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».