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Nml S1 and S2. No M/R/G Lungs: CTAB¡ð PRPPJPPPPP  &"# çÿ J     ó(ŸšAnesthetic PlanŸ øPremed relaxation - Midazolam Neuroaxial anesthesia SPINAL  Lidocaine w/ Fentanyl O2 by NC Propofol for light sedation PRN ¡\4)4($((ó ŸšAnesthetic ManagementŸ â18G PIV R hand Premeds: Midazolam 2mg Standard monitors and O2 NC (2L) SPINAL  from sitting position w/ 25G Whitacre via introducer at L3-4 on 1st attempt w/o parasthesias. Dosage  1.7 ml of 5% Lidocaine (in Dextrose) with 25mcg Fentanyl ¡&òZ‘_ó ŸšAnesthetic ManagementŸš0Patient positioned in lithotomy, arms padded and tucked, skin temp probe, warm blankets upper body Propofol sedation at 25 mcg/kg/min Procedure over 50 minutes; no stone identified; tube removed and ureteral stent placed Patient comfortable throughout Transport to PACU and discharge without incident ¡.-ZZ- ó$ŸšPost-Op ProblemsŸš¯4 days post-op (Surgical f/u visit) Pt reported lower back ache/pain radiating down posterior aspect bilateral legs. Pain started same day of surgery Increased to steady ache¡*u;u(;&ó†8ŸšPost-Op ProblemsŸšâPt seen in anesthesia pre-op clinic (sent by surgeon) No motor or sensory deficits noted Deep tendon reflexes intact No bowel or bladder incontinence No point tenderness at spinal site No swelling, erythema, or evidence of DVT¡:6Z­Z6(¬"óŠ:ŸšPost-Op ProblemsŸš»Discussion w/ patient Pt reassured this was probably transient event Pt told to treat with rest and NSAIDS Pt asked to call or return in 3-5 days if symptoms unresolved or any worsening ¡6Š(¥"óŒ;Ÿš ResolutionŸ °Pt had been quite understanding in clinic and promised to follow up Pt was contacted 4 days later  symptoms had resolved No further complaints by patient either via anesthesia contact or through surgical follow-up ¡ØÙó’>Ÿš.Should we use Lidocaine for Spinal Anesthesia?¡//(ó5ŸšTransient Neurologic SymptomsŸšA constellation of symptoms following spinal anesthesia Generally associated with (but not limited to) Lidocaine as the anesthetic agent ¡fS((( (%(óŽ<ŸšTransient Neurologic SymptomsŸš©Symptoms Bilateral burning, aching, crampy, or radiating pain that may extend through buttocks & thighs to lower extremities Average pain score of 6.2 (1-10 scale) ¡J ž($óu0ŸšTransient Neurologic SymptomsŸšµSymptoms Onset generally within 12-24 hours of surgery Symptom duration: ~ 6 hrs to 10 days (spontaneous resolution) NO motor or sensory deficits have ever been reported w/ TNS ¡B ª (©$óQ$Ÿš Lidocaine and Spinal Anesthesia¡!!(Ÿ °1948  5% hyperbaric Lidocaine introduced 1968  1st prospective safety study for intrathecal use was published (Phillips et al) Conclusion  SAFE for spinal anesthesia Used for many years w/o published complications¡BZXZ2( (M(Xóv1ŸšLidocaine and Spinal Anesthesia¡ (Ÿ  1991  Cauda Equina Syndrome documented in case reports (10/11 cases utilized Lidocaine) Spinal microcatheters removed from US market¡*Y-Y(-$ó6ŸšLidocaine and Spinal Anesthesia¡ (Ÿ F1993   transient radicular irritation (TRI) reported w/ single dose Lidocaine (Schneider et al) Leads to further reports & impetus for fresh safety appraisal ¡Bc?a(?$óa(Ÿš1Transient Neurologic Symptoms Etiology or Cause?¡2(&Ÿš_Local agent toxicity Needle trauma Neural ischemia (2nd to sciatic stretching) Muscle spasm ¡6`Z5, ,%,(óy2Ÿš1Transient Neurologic Symptoms Etiology or Cause?¡2(&Ÿšj Myofascial trigger points Early mobilization Irritation of dorsal root ganglion Patient positioning ¡`ZdZZZ(d,*(ób)Ÿš Etiology or Cause? ¡((&(Ÿš&Process of having block probably not the cause very low incidence w/ Bupivacaine Neurotoxicity unto itself does not appear to effect outcome Concentration / Dose / Vasoconstrictors Similarly, solution type does not appear to be a contributing factor Baricity / Osmolarity / addition of Glucose¡À0"<(E,!(( ("(((((($(,  ó]'Ÿš The Evidence¡(ŸšÐ17 prospective, randomized controlled studies + an epidemiologic study Clear evidence that TNS is significantly higher w/ Lidocaine than any other agent Bupivacaine / Procaine / Mepivacaine / Prilocaine ¡Lš2F(R(2"óz3Ÿš The Evidence¡(Ÿš‹Incidence varies w/ type of surgery (& hence patient positioning) Lithotomy 30 to 36% Arthroscopic knee 18 to 22% Supine 4 to 8% ¡òB    B( $  $    $   ó„7Ÿš The Evidence¡(ŸšäEpidemiologic Study - Freedman et al Relative risk (RR) for TNS comparison: Lidocaine to Bupivacaine: 5.1 Lidocaine to Tetracaine: 3.2 Lithotomy to other positions: 2.6 Outpatient to inpatient: 3.6 Obese to nonobese: 1.6 ¡&'“( &&&""""""""""    óe*Ÿš The Evidence¡(Ÿ èEpidemiologic Study - Freedman et al Overall incidence Lidocaine  11.9% Bupivacaine  1.3% Tetracaine  1.6% ¡Ì&7( & $$$$ $$$  óg+Ÿš The Evidence¡(ŸšXEpidemiologic Study-Freedman et al. Greater than 90% TNS resolved in 7days Nonfactors: ¡V%4( ('$ $$ªL ói,Ÿš The Evidence¡(Ÿ lProspective Incidence study  Pollack et al Incidence: Lidocaine 16% vs Bupivacaine 0% 5% hyperbaric Lidocaine 16% vs 2% isobaric Lidocaine 16% Arthroscopy 13% vs Hernia 5% ¡- }(  ( ($ $$$$$$ $$ $$ $$$ók-Ÿš The Evidence¡(Ÿ –Dilution Incidence study  Pollack et al Incidence by Lidocaine concentration groups: 2% Lidocaine: 15.8% 1% Lidocaine: 22.2% 0.5% Lidocaine: 17.1% Not statistically signif. (P=0.756) ¡.Z.ZiZZZ(  (,($$$$$$$$ " $  (óˆ9Ÿš The Evidence¡(Ÿš×Cochrane Collaboration Review Lidocaine vs other local anesthetics Overall risk for TNS statistically significant (p=0.0002) Relative Risk ~7 times higher 1 in 7 patients developed TNS after Lidocaine spinal ¡ŠCX5(%&X$5(   $(óO#Ÿš(Transient Neurologic Symptoms Treatment¡)( &Ÿ nNot much evidence evaluating efficacy of Treatments 1st NSAIDS  ibuprofen, naproxen, ketorolac Rest / leg elevation / heating pads 2nd Opioids Muscle relaxants  cyclobenzapine, etc¡fžZ4((üÞþ(üÞþM((üÞþ(üÞþ1(ó{4Ÿš(Transient Neurologic Symptoms Treatment¡)( &Ÿ ä 3rd Physical Therapy Trigger point injections Reassurance to patient  symptoms are transient and will resolve ¡hZqZZ((üÞþ(üÞþn(óm.Ÿš)Transient Neurologic Symptoms Prevention¡&*( (Ÿ Patient selection  risk factors Ambulatory patients Lithotomy position Knee arthroscopy Selection of anesthetic agent (or modality) ¡Z"9, (9&,(óT&ŸšTransient Neurologic Symptoms¡(Ÿš÷Diagnosis of exclusion All other more serious causes for symptoms must be excluded first: Epidural hematoma Epidural abscess Spinal nerve injury Anterior spinal artery syndrome Cauda equina syndrome Choroprocaine back pain Adhesive arachnoiditis ¡8ZZžZZ"›óo/ŸšTransient Neurologic Symptoms¡(Ÿ †TRANSIENT process Diagnosis of Exclusion Informed consent  patient should be aware of this possibility as well as its transient nature Consider Bupivacaine or other modality for higher risk pts ¡:Ã<(L;(ó=ŸšTransient Neurologic Symptoms¡(Ÿ (Treat with reassurance and NSAIDs Note incidence in QA as well as among colleagues If you don t ask, you won t hear& Do your post-op evaluations! ¡0TAR(AóJ"Ÿš ReferencesŸšˆFreedman JM et al. Transient neurologic symptoms after spinal anesthesia: an epidemiologic study of 1863 patients. Anesthesiology. 1998; 89(3): 633-41. Morisaki H et al. Transient neurologic syndrome in 1045 patients after 3% lidocaine spinal anesthesia. Anesthesia & Analgesia. 1998; 86(5): 1023-26. Pollack J. Transient Neurologic Symptoms: Etiology, Risk Factors, and Management. Regional Anesthesia & Pain Medicine. 2002; 27(6): 581-586. Pollack J et al. ProspectiveStudy of the incidence of transient radicular irritaion in patients undergoing spinal anesthesia. Anesthesiology. 1996; 84(6): 1361-67 Pollack J et al. Dilution of spinal lidocaine does not alter the incidence of transient neurologic symptoms. Anesthesiology. 1999; 90(2): 445-50. Zaric D et al. Transient neurologic symptoms (TNS) following spinal anaesthesia w/ lidocaine vs other local anaesthetics. 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†ÿÿÿ¬Ìÿÿ™ÿ°úÌÿ™ˆ8Š0º___PPT10‹ë.9 Åð÷K^îï i€ Šðžððð6ð( ð ðð~ ð s ð*€8Ej1¿ÿĈð­ `}ðà  j1 ð žðx ð c ð$€ÜEj1¿ÿĈðP 0àðà j1 ð žðH ð ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€B Šðžàð@ð6ð( ð ð@ð~ ð@ s ð*€Kj1¿ÿĈð­ `}ðà  j1 ð žðx ð@ c ð$€dLj1¿ÿĈð ` ðà j1 ð žðH ð@ ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€5 Šðž0ðÐð6ð( ð ðÐð~ ðÐ s ð*€Rj1¿ÿĈð­ `}ðà  j1 ð žðx ðÐ c ð$€4Uj1¿ÿĈð ` ðà j1 ð žðH ðÐ ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€$ Šðž ðð6ð( ð ðð~ ð s ð*€€]j1¿ÿĈð­ ``ðà  j1 ð žðx ð c ð$€x^j1¿ÿĈð` `ððà j1 ð žðH ð ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€6 ŠðžPðØð6ð( ð ðØð~ ðØ s ð*€øoj1¿ÿĈð­ `}ðà  j1 ð žðx ðØ c ð$€Ìpj1¿ÿĈðP `àðà j1 ð žðH ðØ ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€< Šðžðð6ð( ð ðð~ ð s ð*€yj1¿ÿĈð­ `}ðà  j1 ð žðx ð c ð$€Üyj1¿ÿĈð ` ðà j1 ð žðH ð ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€- Šðž@ ðTð6ð( ð ðTð~ ðT s ð*€ü€j1¿ÿĈð­ `}ðà  j1 ð žðx ðT c ð$€Ðj1¿ÿĈð ` ðà j1 ð žðH ðT ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€7 Šðžpðàð6ð( ð ðàð~ ðà s ð*€p“j1¿ÿĈð­ `}ðà  j1 ð žðx ðà c ð$€0”j1¿ÿĈð ` ðà j1 ð žðH ðà ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +î ï i€.  ð` ð\ð°ð( ð ð\ð~ ð\ s ð*€ŽŸj1¿ÿĈð­ `@ðà  j1 ð žðr ð\ s ð*…‡¿ÀÿC"ñ¿ÿ?ðà ð ðx ð\ c ð$€€¥j1¿ÿĈð@€0ðà j1 ð žðH ð\ ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€+ Šðž ðDð6ð( ð ðDð~ ðD s ð*€˜¬j1¿ÿĈð­ `}ðà  j1 ð žðx ðD c ð$€l­j1¿ÿĈð ` ðà j1 ð žðH ðD ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€8 Šðžðèð6ð( ð ðèð~ ðè s ð*€Ô¶j1¿ÿĈð `Ððà  j1 ð žðx ðè c ð$€x·j1¿ÿĈðpðPðà j1 ð žðH ðè ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€= Šðž0ðð6ð( ð ðð~ ð s ð*€`Âj1¿ÿĈð­ `}ðà  j1 ð žðx ð c ð$€4Ãj1¿ÿĈ𐀠ðà j1 ð žðH ð ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€/ Šðž€ ðdð6ð( ð ðdð~ ðd s ð*€ÀÍj1¿ÿĈð­ `}ðà  j1 ð žðx ðd c ð$€”Îj1¿ÿĈðð ðà j1 ð žðH ðd ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îVï i€0 mðe  ðlðýð( ð ðlð~ ðl s ð*€tÙj1¿ÿĈð­ `}ðà  j1 ð žðx ðl c ð$€HÚj1¿ÿĈð0À€ ðà j1 ð žðý¢ ðl ƒ ð0€|Òj1¿ƒ¿Àÿð À  𝟚5Age Sex h/o back pain Lidocaine dose or concentration¡6 6ª+Š𚢠ðl £ ð<€àéj1…‡¿ƒ¿Àÿð ` Ô w  ð<Ÿ¡ ª ð ¢ ðl ƒ ð0€4íj1¿ƒ¿Àÿðò 0 @m 𪟚dInclusion of epinephrine in solution Needle type/size/manner of insertion Position during injection.¡e eŠðH ðl ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€1 ŠðžÀ ðtð6ð( ð ðtð~ ðt s ð*€øüj1¿ÿĈð­ `pðà  j1 ð žðx ðt c ð$€Ìýj1¿ÿĈð0ðÀðà j1 ð žðH ðt ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€2 ŠðžÐð|ð6ð( ð ð|ð~ ð| s ð*€œèc1¿ÿĈð­ `}ðà  c1 ð žðx ð| c ð$€@éc1¿ÿĈð `ðà c1 ð žðH ð| ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€? Šðžpð(ð6ð( ð ð(ð~ ð( s ð*€øùc1¿ÿĈð­ `}ðà  c1 ð žðx ð( c ð$€Ìúc1¿ÿĈð `ðà c1 ð žðH ð( ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€# Šðžð ðð6ð( ð ðð~ ð s ð*€,g1¿ÿĈð­ `}ðà  g1 ð žðx ð c ð$€g1¿ÿĈ𐠀 ðà g1 ð žðH ð ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€9 Šðž°ððð6ð( ð ððð~ ðð s ð*€šg1¿ÿĈð­ `}ðà  g1 ð žðx ðð c ð$€|g1¿ÿĈð ` ðà g1 ð žðH ðð ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€3 Šðžð„ð6ð( ð ð„ð~ ð„ s ð*€(&g1¿ÿĈð­ `}ðà  g1 ð žðx ð„ c ð$€ü&g1¿ÿĈð ` ðà g1 ð žðH ð„ ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€& ŠðžP ðð6ð( ð ðð~ ð s ð*€T.g1¿ÿĈð­ `}ðà  g1 ð žðx ð c ð$€(/g1¿ÿĈð `àðà g1 ð žðH ð ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€4 Šðž ðŒð6ð( ð ðŒð~ ðŒ s ð*€dAg1¿ÿĈð^ `.ðà  g1 ð žðx ðŒ c ð$€ÜAg1¿ÿĈðÐ ``ðà g1 ð žðH ðŒ ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€C ŠðžðHð6ð( ð ðHð~ ðH s ð*€äHg1¿ÿĈð­ `}ðà  g1 ð žðx ðH c ð$€žIg1¿ÿĈð ` ðà g1 ð žðH ðH ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +îï i€" Šðž0ðPð6ð( ð ðPð~ ðP s ð*€ÌRg1¿ÿĈð­ `}ðà  g1 ð žðx ðP c ð$€ Sg1¿ÿĈð `ðà g1 ð žðH ðP ƒ ð0ƒ“ŽŸ‹”Þœh¿ÿ ?ð ™ÿÿÿ€ÿÿÿ3fÿ{FІÑìEɄˆ‘Љº___PPT10‹ië.àÄ0‹0M+Dñ='ñ ¹ÿÿÿÿ=ñ @Bñ +ðñ 0 ð‡0ðLðð( ð ðLð^ ðL S ð¿ÿHð·ž(K ðà  þð ðL c ð$€H©þ¿ÿHðÞ °0)ðà  þ 🚠ðH ðL ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.çÄ0ÚJðKñ 0 ËðÃ@ðPð[ð( ð ðPð^ ðP S ð¿ÿHð·ž(K ðà  g1ðœ ðP c ð$€0Àg1¿ÿHðÞ °0)ðà  g1 ðQŸš=Stone unable to be retrieved; wire unable to pass beyond it. ðH ðP ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.çÄð“ó¯ðñ 0 ˜ðPðTð(ð( ð ðTð^ ðT S ð¿ÿHð·ž(K ðà  VðŠ ðT c ð$€°V¿ÿHðÞ °0)ðà  V 🪠ðH ðT ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.çİ¥ó¿ðñ 0 ˜ð`ðXð(ð( ð ðXð^ ðX S ð¿ÿHð·ž(K ðà  VðŠ ðX c ð$€ V¿ÿHðÞ °0)ðà  V 🪠ðH ðX ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.çĐE ÷ðRñ 0 ÒðÊpð\ðbð( ð ð\ð^ ð\ S ð¿ÿHð·ž(K ðà  VðÄ ð\ c ð$€Œ V¿ÿHðÞ °0)ðà  V ðXŸ (STOP for questions& ¡ðH ð\ ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.èÄ0Ž'‘ðñ 0 œð”ðdð,ð( ð ðdð^ ðd S ð¿ÿHð·ž(K ðà  VðŽ ðd c ð$€V¿ÿHðÞ °0)ðà  V ð"Ÿš85mg lidocaineðH ðd ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.éÄ€o@›ðÂñ 0 Bð: ðhðÒð( ð ðhð^ ðh S ð¿ÿHð·ž(K ðà  Vð4 ðh c ð$€PV¿ÿHðÞ °0)ðà  V ðȟ –Post operative evaluation policy? Reason for post-op calls on outpatients& ¡LZLðH ðh ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðñ 0 ˆð€°ð°ðð( ð ð°ðd ð° c ð$¿ÿHˆð·ž(K ðà  Vðt ð° s ð*€Ø'V¿ÿHˆðÞ °0)ðà  V ðŸ ÐSTOP for questions& what are you going to don with this situation? Surgeons call you for advice/input& ¡iZiðH ð° ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð$ñ 0 €ðœðÄð4ð( ð ðÄðd ðÄ c ð$¿ÿHˆð·ž(K ðà  Vð ðÄ s ð*€ü5V¿ÿHˆðÞ °0)ðà  V 🪠ðH ðÄ ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.çÄð“ó¯ð$ñ 0 €ðœ ðÌð4ð( ð ðÌðd ðÌ c ð$¿ÿHˆð·ž(K ðà  Vð ðÌ s ð*€\;V¿ÿHˆðÞ °0)ðà  V 🪠ðH ðÌ ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.èÄðÆ²šð–ñ 0 ðððŠð( ð ððd ð c ð$¿ÿHˆð·ž(K ðà  Vð ð s ð*€@V¿ÿHˆðÞ °0)ðà  V 𐟚`Anterior or Posterior distribution 50% pts c/o pain to lower legs 50-100%pts c/o lower back pain¡aZaðH ð ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð@ñ" 0 Àðž@ðTðPð( ð ðTðd ðT c ð$¿ÿHˆð·ž(K ðà  Vð¬ ðT s ð*€tNV¿ÿHˆðÞ °0)ðà  V ð:Ÿ¡Zª ðH ðT ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðŠñ# 0 &ð ðð¶ð( ð ððd ð c ð$¿ÿHˆð·ž(K ðà  Vð ð s ð*€ ZV¿ÿHˆðÞ °0)ðà  V ð Ÿ :Although transient in nature, TNS can be very uncomfortable for patients and extremely difficult to treat. Most of the evidence regarding treatment is anecdotal. NSAIDS are the most successful treatment modality w/ pt generally reporting good pain relief. Muscle relaxers due to potential muscle spasm second to continued pain stimulus. Trigger point injections  some case reports of success 2 wks after spinal anesthesia. Question as to whether symptoms at this point were TNS or more classic muscle spasms initiated by TNS (now faded). ¡JZ£XC³ðH ð ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðêñ$ 0 jðb ð ðúð( ð ð ðd ð  c ð$¿ÿHˆð·ž(K ðà  VðV ð  s ð*€ôoV¿ÿHˆðÞ °0)ðà  V ð䟠-5% hyperbaric lidocaine good  predictable onset and limited duration lidocaine (3-5 min onset and 60-90 min) / procaine bupivicaine/tetracaine (~10min onset and 90-120 min) -phillips et al in Anesthesiology, 10,440 pts (93% OB), note: 284 (~3%) had aching pain (similar to TNS?) and 91 refused subsequent spinal anesthesia) ¡8IZ '}wðH ð  ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð ñ& 0 Œð„` ððð( ð ððd ð c ð$¿ÿHˆð·ž(K ðà  Vðx ð s ð*€ìV¿ÿHˆðÞ °0)ðà  V ðŸ ÖEpidural hematoma  0-2d / motor weakness, radicular back pain, sens deficit / MRI surg decompress Epidural abscess - 2-7d / backache, progressive neuro symp, ?fever / ABX, possible surgical drainage Spinal nerve injury  0-2d : 1-12wks / pain w/ needle or injuect, paresthesia over distrib / EMG to assess Anterior spinal artery sydrome  immediate / postop painless paraplegia / may respond to vasodilat drugs Cauda equina syndrome- 0d / pain on injectionvariable neuro deficit, progressive / CT;MRI  no treatment Choroprocaine back pain  immediate : 1-4 hr / low back pain / epidural opiods Adhesive arachnoiditis¡lZlðH ð ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðØñ' 0 XðP ðHðèð( ð ðHðd ðH c ð$¿ÿHˆð·ž(K ðà  VðD ðH s ð*€œ”V¿ÿHˆðÞ °0)ðTà  Vˆ<Š4º___PPT9‹¬ ðŽŸ $Pollack J. Transient Neurologic Symptoms: Etiology, Risk Factors, and Management. Regional Anesthesia & Pain Medicine. 2002; 27(6): 581-586. RCTs to study various aspects of TNS Other agents: bupivacaine= no incidence [longer discharge times, less motor block] Procaine= [less reliable, increased n/v and pruritis] Mepivacaine= Prilocaine=?best alternative but not available in US Lithotomy  3 studies / Arthroscopic  4 studies / Supine  2 studies Easier to understand great variance in studies evaluating incidence of TNS¡N“-Z¿“-Z’“-Z¿’ðH ðH ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðÈñ( 0 Hð@P ðXðØð( ð ðXðd ðX c ð$¿ÿHˆð·ž(K ðà  Vð4 ðX s ð*€à«V¿ÿHˆðÞ °0)ðTà  Vˆ<Š4º___PPT9‹¬ ð~Ÿ  RCTs to study various aspects of TNS Other agents: bupivacaine= no incidence [longer discharge times, less motor block] Procaine= [less reliable, increased n/v and pruritis] Mepivacaine= Prilocaine=?best alternative but not available in US Lithotomy  3 studies / Arthroscopic  4 studies / Supine  2 studies Easier to understand great variance in studies evaluating incidence of TNS¡X5“-Z¿“-Z’“-Z5¿‘ðH ðX ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð„ñ) 0 ðüp ð`ð”ð( ð ð`ðd ð` c ð$¿ÿHˆð·ž(K ðà  Vðð ð` s ð*€ÀV¿ÿHˆðÞ °0)ðTà  Vˆ<Š4º___PPT9‹¬ ð:Ÿ ÂBlock process - Type of needle and placement / Pt position during procedure Neurotoxicity  CES incidence increased by higher concentration, higher doses, addition of vasoconstrictors. These do not correspond with increased incidence with lidocaine spinals Studies tested hypothesis of concentrations 5%-0.5%, different doses, w/ and w/o epinephrine ¡\º“-ZŠ“-Z“-ZªŠðH ð` ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðñ* 0 œð” ðhð,ð( ð ðhðd ðh c ð$¿ÿHˆð·ž(K ðà  Vðˆ ðh s ð*€ø×V¿ÿHˆðÞ °0)ðTà  Vˆ<Š4º___PPT9‹¬ ðÒŸ œ6092 of 8400 (73%)  2555 (random select  42%)  1883 responded (74%) 47% lidocaine / 40% bupivacaine / 13% tetracaine RR  ratio of incidence of 1 group to incidence of another group [not absolute risk] ¡ϓ-ZÏðH ðh ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðšñ+ 0 (ð ° ðpðžð( ð ðpðd ðp c ð$¿ÿHˆð·ž(K ðà  Vð ðp s ð*€LçV¿ÿHˆðÞ °0)ðTà  Vˆ<Š4º___PPT9‹¬ ð^Ÿ Î6092 of 8400 (73%)  2555 (random select  42%)  1883 responded (74%) 47% lidocaine / 40% bupivacaine / 13% tetracaine RR  ratio of incidence of 1 group to incidence of another group [not absolute risk] significant factors - lithotomy, outpatient anesthesia, obesity Spectrum of risk: 3.1% for inpts not having litotomy to 24.3 for outpts in lithotomy ¡te“-Z’-Z“-ZÍ+FðH ðp ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðñ, 0 ˆð€Ð ðxðð( ð ðxðd ðx c ð$¿ÿHˆð·ž(K ðà  Vðt ðx s ð*€W¿ÿHˆðÞ °0)ðTà  Vˆ<Š4º___PPT9‹¬ 🟠>Randomized, double-blinded  159 pts by power analysis 3 groups: 5% hyperbaric lidocaine (w/ epi) vs 2% isobaric lidocaine (no epi) vs 0.75% hyperbaric bupivacaine (no epi) Reported onset: 12-24hrs and duration b/t 6hr and 4 d Pain average = 6.2 No symptoms in any pt at 2 wk followup¡dB“-Zn“-Zp“-Z6 npðH ðx ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðÔñ- 0 TðLð ð€ðäð( ð ð€ðd ð€ c ð$¿ÿHˆð·ž(K ðà  Wð@ ð€ s ð*€ØW¿ÿHˆðÞ °0)ðTà  Wˆ<Š4º___PPT9‹¬ ðŠŸ >Prospective randomized, double-blinded  109 pts by power analysis Procedure was knee arthroscopy Incidence almost identical to studies with 5% lidocaine (19%)¡0 “-ZB]ðH ð€ ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðÐñ. 0 PðHðˆðàð( ð ðˆðd ðˆ c ð$¿ÿHˆð·ž(K ðà  Wð< ðˆ s ð*€Œ"W¿ÿHˆðÞ °0)ðbà  WˆJŠBº___PPT9‹$¬ ðxŸšºLithotomy 30-36% / knee arthro 18-22% / Lidocaine still used due to: short duration of action / intense blockade / quick recovery / suitability for day case surgery Other agents: Bupivicaine= low to no incidence [longer discharge times, less motor block] Procaine= [less reliable, increased n/v and pruritis] Mepivacaine= controversy concerning incidence (nil to 37% in european studies) Prilocaine=?best alternative but not available in US¡¢µ“-Z“-Z)  LºðH ðˆ ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð>ñ/ 0 Ÿð¶0ððNð( ð ððd ð c ð$¿ÿHˆð·ž(K ðà  Wðª ð s ð*€ 'W¿ÿHˆðÞ °0)ðà  W ð8Ÿ¡ª ðH 𐠃 ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð ñ0 0 Šð‚@ðÔðð( ð ðÔðd ðÔ c ð$¿ÿHˆð·ž(K ðà  Wðv ðÔ s ð*€ÜCW¿ÿHˆðÞ °0)ðà  W ðŸ ÔGenerally lasts 2-3 d, maybe as long as 5-6 d, 10d is longest duration noted in a study Neurological examination; MRIs; & electro pathological testing have failed to demonstrate any abnormalities in pts with TNS  Pollack et al, 2000¡ëZëðH ðÔ ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðîñ1 0 nðf`ðÜðþð( ð ðÜðd ðÜ c ð$¿ÿHˆð·ž(K ðà  WðZ ðÜ s ð*€šRW¿ÿHˆðÞ °0)ðà  W ð蟠‚-CES: loss bladder and bowel function, paraplegia, motor weakness, sensory loss onset day of surgery; no treatments; thought due to pooling of anesthetic at lumbosacral nerve roots  toxicity ¡JQZp“-Z“-ZQpðH ðÜ ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðÈñ2 0 Hð@€ðäðØð( ð ðäðd ðä c ð$¿ÿHˆð·ž(K ðà  Wð4 ðä s ð*€ dW¿ÿHˆðÞ °0)ðTà  Wˆ<Š4º___PPT9‹¬ ð~Ÿ  RCTs to study various aspects of TNS Other agents: bupivacaine= no incidence [longer discharge times, less motor block] Procaine= [less reliable, increased n/v and pruritis] Mepivacaine= Prilocaine=?best alternative but not available in US Lithotomy  3 studies / Arthroscopic  4 studies / Supine  2 studies Easier to understand great variance in studies evaluating incidence of TNS¡X5“-Z¿“-Z’“-Z5¿‘ðH ðä ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðÈñ3 0 Hð@ ðìðØð( ð ðìðd ðì c ð$¿ÿHˆð·ž(K ðà  Wð4 ðì s ð*€àyW¿ÿHˆðÞ °0)ðTà  Wˆ<Š4º___PPT9‹¬ ð~Ÿ  RCTs to study various aspects of TNS Other agents: bupivacaine= no incidence [longer discharge times, less motor block] Procaine= [less reliable, increased n/v and pruritis] Mepivacaine= Prilocaine=?best alternative but not available in US Lithotomy  3 studies / Arthroscopic  4 studies / Supine  2 studies Easier to understand great variance in studies evaluating incidence of TNS¡X5“-Z¿“-Z’“-Z5¿‘ðH ðì ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðLñ4 0 ÌðÄÀðôð\ð( ð ðôðd ðô c ð$¿ÿHˆð·ž(K ðà  Wðž ðô s ð*€@W¿ÿHˆðÞ °0)ðà  W ðFŸ ÖNone of these change the course & they only diminish or treat the symptoms! Although transient in nature, TNS can be very uncomfortable for patients and extremely difficult to treat. Most of the evidence regarding treatment is anecdotal. NSAIDS are the most successful treatment modality w/ pt generally reporting good pain relief. Muscle relaxers due to potential muscle spasm second to continued pain stimulus. Trigger point injections  some case reports of success 2 wks after spinal anesthesia. Question as to whether symptoms at this point were TNS or more classic muscle spasms initiated by TNS (now faded). ¡TlZM€XC³ðH ðô ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð$ñ5 0 €ðœàðð4ð( ð ððd ð c ð$¿ÿHˆð·ž(K ðà  Wð ð s ð*€Ä£W¿ÿHˆðÞ °0)ðà  W 🪠ðH ð ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.çĐE ÷ð ñ6 0  ð˜ ðð0ð( ð ððd ð c ð$¿ÿHˆð·ž(K ðà  WðŒ ð s ð*€x¬W¿ÿHˆðÞ °0)ðà  W ðŸ êSchneider et al was a Case report of 4 patients (lithotomy position)  aching pain in buttocks and lower extremities.¡vZvðH ð ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð€ñ7 0 ðø@ððð( ð ððd ð c ð$¿ÿHˆð·ž(K ðà  Wðì ð s ð*€Œ¹W¿ÿHˆðÞ °0)ðTà  Wˆ<Š4º___PPT9‹¬ ð6Ÿ øProspective, blinded, multicenter  1,863 pts 6092 of 8400 (73%)  2555 (random select  42%)  1883 responded (74%) 47% lidocaine / 40% bupivacaine / 13% tetracaine RR  ratio of incidence of 1 group to incidence of another group [not absolute risk] ¡"ý“-.ÏðH ð ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð€ñ8 0 $ð`ð$ðŽð( ð ð$ðd ð$ c ð$¿ÿHˆð·ž(K ðà  Wð ð$ s ð*€ìÇW¿ÿHˆðÞ °0)ðà  W 𞟠n I was paged to pre-op clinic and went to see patient ¡8Z8ðH ð$ ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðNñ9 0 ÎðÆ€ð,ð^ð( ð ð,ðd ð, c ð$¿ÿHˆð·ž(K ðà  Wðº ð, s ð*€ŒÑW¿ÿHˆðÞ °0)ðTà  Wˆ<Š4º___PPT9‹¬ ðŸ Ð14 RCTs included in final analysis  2004 Relative risk = lidocaine vs bupivacaine, prilocaine, procaine¡i“-iðH ð, ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðpñ: 0 ððè°ð4ð€ð( ð ð4ðd ð4 c ð$¿ÿHˆð·ž(K ðà  WðÜ ð4 s ð*€ÚW¿ÿHˆðÞ °0)ðà  W ðjŸ :Discussion with faculty led to Dx TNS: there had been some email discussion re: this pathology months earlier with other case noted by an attnd at that time& ¡žZžðH ð4 ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð|ñ; 0 üðôÐð<ðŒð( ð ð<ðd ð< c ð$¿ÿHˆð·ž(K ðà  Wðè ð< s ð*€€çW¿ÿHˆðÞ °0)ðà  W ðvŸ FFollowed course of TNS to the  T ¡$Z$ðH ð< ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ð–ñ< 0 ðððDðŠð( ð ðDðd ðD c ð$¿ÿHˆð·ž(K ðà  Wð ðD s ð*€ŒòW¿ÿHˆðÞ °0)ðà  W 𐟚`Anterior or Posterior distribution 50% pts c/o pain to lower legs 50-100%pts c/o lower back pain¡aZaðH ðD ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-ðJñ= 0 ÊðÂðLðZð( ð ðLðd ðL c ð$¿ÿHˆð·ž(K ðà  Wð¶ ðL s ð*€j¿ÿHˆðÞ °0)ðà  W ðDŸ Have post anesthesia follow-up policy in place; post-ops are important to learn and to maintain patient satisfaction with anesthetic care& ¡‹‹ðH ðL ƒ ð0ƒ“Þœh”Þò¿ÿ ?ð ÿÿÿ€€€»àã33™™™™Ìˆ8Š0º___PPT10‹ë.êÄ sA-rˆP\{\‰£í‹ ‘ “ `²pŽãËåè>ê^ì žîÜð$`+–Šóņ¶öxŽâø5K¢7ûJ0á¬ýÔvO@“Ñôÿª¢TXÙV” ] ºšaÕ±·ˆXÙÁä$pÄ)ÎÉž.eÌÈ3ÁÖ€7ïÛ|<sÁY°gy§§¬Â>ÔBlŽ«Œ*ÔÊFšLjR.„ŸY>¯ê[„ðB¿_ȘšcüÎFfe›œižm‘o†Þ6r™ õeˆu’2þÿà…ŸòùOh«‘+'³Ù0ÄT hp€ ° ŒÈ è ô  äSlide 1University of MichiganSlitrsiCAS78Microsoft PowerPointn@ÐÆ4pm@€e[ݶûÃ@pÆäsÅ«GšSÿÿÿÿ‰g  Ì)¡'  ÑÁ ÷€€€€€€€€€ÀÀÀÀÜÀŠÊð """)))UUUMMMBBB999ÿ|€ÿPP֓ÌìÿïÖÆççÖ­©3f™Ì333f3™3Ì3ÿ3f3fff™fÌfÿf™3™f™™™Ì™ÿ™Ì3Ìf̙ÌÌÌÿÌfÿ™ÿÌÿ333f3™3Ì3ÿ333333f33™33Ì33ÿ33f33f3ff3™f3Ìf3ÿf3™33™3f™3™™3̙3ÿ™3Ì33Ì3fÌ3™Ì3ÌÌ3ÿÌ33ÿ3fÿ3™ÿ3Ìÿ3ÿÿ3f3fff™fÌfÿf3f33ff3f™3fÌ3fÿ3fff3fffff™ffÌff™f3™ff™f™™f̙fÿ™fÌf3Ìf™ÌfÌÌfÿÌfÿf3ÿf™ÿfÌÿfÿÌÌÿ™™™3™™™Ì™™33™f™Ì3™ÿ™f™3f™f3™™f™Ìf™ÿ3™3™™f™™™™™Ì™™ÿ™™Ì™3̙fÌf™Ì™Ì̙ÿ̙ÿ™3ÿ™f̙™ÿ™Ìÿ™ÿÿ™Ì3™f̙ÌÌÌ3™33Ìf3̙3ÌÌ3Ìÿ3ÌfÌ3fÌff™™fÌÌfÌÿf™™Ì3™Ìf™Ì™™Ì̙Ìÿ™ÌÌÌ3ÌÌfÌ̙ÌÌÌÌÌÿÌÌÿÌ3ÿÌfÿ™™ÿÌÌÿÌÿÿÌ3Ìfÿ™ÿ3Ì33ÿf3ÿ™3ÿÌ3ÿÿ3ÿfÿ3fÿff̙fÿÌfÿÿf̙ÿ3™ÿf™ÿ™™ÿ̙ÿÿ™ÿÌÿ3ÌÿfÌÿ™ÌÿÌÌÿÿÌÿ3ÿÿfÿ̙ÿÿÌÿÿÿfffÿfÿÿfffÿÿfÿfÿÿ¥!___www†††–––ËË˲²²×××ÝÝÝãããêêêñññøøøÿûð  €€€€ÿÿÿÿÿÿÿÿÿÿÀ4¡'A Ìx ÐÀ( xK€€€€€€€€€ÀÀÀÀÜÀðÊŠ """)))UUUMMMBBB999€|ÿPPÿ“ÖÿìÌÆÖïÖç琩­3f™Ì3333f3™3Ì3ÿff3fff™fÌfÿ™™3™f™™™Ì™ÿÌÌ3Ìf̙ÌÌÌÿÿfÿ™ÿÌ3333f3™3Ì3ÿ3333333f33™33Ì33ÿ3f3f33ff3f™3fÌ3fÿ3™3™33™f3™™3™Ì3™ÿ3Ì3Ì33Ìf3̙3ÌÌ3Ìÿ3ÿ33ÿf3ÿ™3ÿÌ3ÿÿff3fff™fÌfÿf3f33f3ff3™f3Ìf3ÿffff3fffff™ffÌf™f™3f™ff™™f™Ìf™ÿfÌfÌ3f̙fÌÌfÌÿfÿfÿ3fÿ™fÿÌÌÿÿ̙™™3™™™™Ì™™33™f™3̙ÿ™f™f3™3f™f™™f̙3ÿ™™3™™f™™™™™Ì™™ÿ™Ì™Ì3fÌf™Ì™™Ì̙Ìÿ™ÿ™ÿ3™Ìf™ÿ™™ÿ̙ÿÿ̙3Ìf̙Ì̙3Ì33Ì3fÌ3™Ì3ÌÌ3ÿÌfÌf3™ffÌf™Ìf̙fÿ̙̙3̙f̙™Ì™Ì̙ÿÌÌÌÌ3ÌÌfÌ̙ÌÌÌÌÌÿÌÿÌÿ3™ÿfÌÿ™ÌÿÌÌÿÿÌ3ÿfÿ™Ì3ÿ33ÿ3fÿ3™ÿ3Ìÿ3ÿÿfÿf3Ìffÿf™ÿfÌÌfÿÿ™ÿ™3ÿ™fÿ™™ÿ™Ìÿ™ÿÿÌÿÌ3ÿÌfÿ̙ÿÌÌÿÌÿÿÿ3Ìÿfÿÿ™ÿÿÌffÿfÿffÿÿÿffÿfÿÿÿf!¥___www†††–––ËË˲²²×××ÝÝÝãããêêêñññøøøðûÿ€  €€€ÿÿÿÿÿÿÿÿÿÿÿÿ_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_……_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_……_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………__…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_……_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_……_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_………_……†f®fgCŒgŒCŒ¢…_………_………__…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_…_