Aline Colombani

Spinal anesthesia using single injection small-dose bupivacaine versus continuous catheter injection techniques for surgical repair of hip fracture in elderly patients.

Aging and disease may make elderly patients particularly susceptible to hypotension during spinal anesthesia. We compared the hemodynamic effect of continuous spinal anesthesia (CSA) and small dose single injection spinal anesthesia (SA) regarding the incidence of hypotension. Seventy-four patients aged >75 yr undergoing surgical repair of hip fracture were randomized into 2 groups of 37 patients each. Group CSA received a continuous spinal anesthetic with a titration of 2.5 mg boluses every 15 min of isobaric bupivacaine, while group SA received a single injection spinal anesthetic with 7.5 mg of isobaric bupivacaine. The overall variations in noninvasive automated arterial blood pressure were not statistically significantly different in the 2 groups at baseline and after CSA or SA (not significant). In the SA group, 68% of patients experienced at least one episode of hypotension (decrease in systolic arterial blood pressure greater than 20% of baseline value) versus 31% of patients in the CSA group (P = 0.005). In the SA group, 51% of patients experienced at least one episode of severe hypotension (decrease in systolic arterial blood pressure more than 30% of baseline value) versus 8% of patients in the CSA group (P < 0.0001). In the CSA group, 4.5 ± 2 mg of ephedrine was injected versus 11 ± 2 mg in the SA group (P = 0.005). In the CSA group, 5 mg (2.5–10) of anesthetic solution was required versus 7.5 mg in the SA group (P < 0.0001). We conclude that, in elderly patients undergoing hip fracture repair, CSA provides fewer episodes of hypotension and severe hypotension compared with a single intrathecal injection of 7.5 mg bupivacaine.

The paramedian technique : A superior initial approach to continuous spinal anesthesia in the elderly

BACKGROUND:Spinal anesthesia in elderly patients is frequently associated with significant technical difficulties. Thus, we compared the classical midline approach to the paramedian approach to perform continuous spinal anesthesia (CSA). METHODS:We prospectively studied 40 patients aged >75 yr who underwent open surgical repair of a hip fracture. These patients were randomly allocated to one of two groups: Group M: midline approach, and Group PM: paramedian approach. Patients were positioned in the lateral decubitus to receive CSA at L4-5 level. CSA was considered successful if cerebrospinal fluid was obtained through the needle. In case of initial failure in either approach, the same approach was repeated by the same operator. If two attempts were unsuccessful, the other anatomical approach was used by the same operator. If both approaches failed, a staff anesthesiologist performed a final attempt. In case of failure or insufficient block, the patient received general anesthesia. RESULTS:The success rate after the first attempt was 85% (17) for Group PM and 45% (9) for Group M (P = 0.02). All catheters were successfully introduced. No patient required general anesthesia. Vascular puncture after needle puncture was observed in six patients in Group M versus 0 in Group PM (P = 0.03), but none were of clinical consequence. No other clinically significant complications were observed. CONCLUSION:In summary, after the initial attempt, the paramedian approach is associated with an increased success rate, compared with the midline approach, during the performance of CSA in elderly patients.

The optimal motor response for infraclavicular brachial plexus block.

BACKGROUND: In this prospective study we compared the success of the infraclavicular brachial plexus block using double-stimulation in regard to the second nerve response elicited with neurostimulation. METHODS: Six-hundred-twenty-eight patients undergoing emergency upper limb surgery using infraclavicular brachial plexus block were included in this study. The musculocutaneous nerve was initially blocked and the groups were then evaluated according to the second nerve located, which was radial in 54%, median in 35%, and ulnar in 11% of patients. Blocks were performed using lidocaine 1.5% with 1/400,000 epinephrine 40 mL in all cases. The block was assessed every 5 min for 30 min after completion of the block. RESULTS: The success rate was 96% for the radial response group, 89% for the median response group, and 90% for the ulnar response group (P < 0.05). Time to perform the block and the onset time were not significantly different among groups. No serious complications were observed. CONCLUSION: We conclude that having initially located and blocked the musculocutaneous nerve, subsequent injection on a radial response resulted in a slightly more reliable success rate than injection with an ulnar or median response.

Le propofol pour réaliser une rachianesthésie en position latérale chez les victimes d’une fracture du fémur

ObjectifLe but de cette étude était d’évaluer la faisabilité et l’efficacité du propofol avant la mobilisation en décubitus latéral chez les patients âgés, victimes d’une fracture de l’extrémité supérieure du fémur, pour la réalisation d’une rachianesthésie.MéthodeUne étude prospective et descriptive a été réalisée chez 79 patients consécutifs de plus de 75 ans ayant une fracture de l’extrémité supérieure du fémur. Le propofol (0,5 mg·kg−1) était injecté au départ. Si la perte de conscience n’était pas obtenue (score de Ramsay ≤ 3/6), d’autres injections de 0,25 mg·kg−1) étaient administrées jusqu’à l’obtention d’un score de Ramsay de 4 ou 5. Ensuite, le patient était placé en décubitus latéral, le membre fracturé vers le haut. l’efficacité du propofol a été évaluée sur la grimace, ainsi que sur le souvenir d’une douleur à la mobilisation. Les données hémodynamiques et la saturation en oxygène étaient aussi notées.RésultatsUne seule injection de propofol a été nécessaire chez 43 patients, deux injections chez 34 patients et trois injections chez deux patients. Aucune grimace n’a été remarquée dans cette étude, et aucun patient n’a eu le souvenir d’une douleur lors de la mobilisation. Aucune désaturation (SpO2 < 92%), ni chute de tension (diminution de la pression artérielle systolique d’au moins 30%) n’a été observée.ConclusionLe propofol est un moyen simple et efficace d’assurer un confort pendant la mobilisation des patients âgés victimes d’une fracture de l’extrémité supérieure du fémur, pour la réalisation d’une anesthésie médullaire.AbstractPurposeThe aim of this study was to assess the feasibility and efficacy of propofol before positioning elderly patients with a femoral neck fracture in the lateral decubitus position, to perform a spinal anesthetic.MethodsIn this prospective and descriptive study, 79 consecutive patients, > 75 yr old, with a femoral neck fracture were included. Propofol, 0.5 mg·kg−1, was administered. If loss of consciousness was not obtained (Ramsay score ≤ 3/6), then additional doses of 0.25 mg.kg−1 were given until a Ramsay score of 4 or 5 was attained. Then, the patient was turned to the lateral decubitus position, the fractured side up. The efficacy of propofol was assessed by observing a grimace during positioning and asking the patients if they had recall of pain. Hemodynamic data and oxygen saturation were collected.ResultsForty-three patients required a single injection, 34 required two injections and only two patients required three injections. No grimace and no recall of pain were recorded during the study. There was no desaturation (SpO2 < 92 %), and hypotension, defined as a systolic blood pressure decrease > 30% from baseline, was observed.ConclusionPropofol is a simple and efficacious means of providing comfort while positioning elderly patients with a femoral head fracture before performing spinal anesthesia.PURPOSE The aim of this study was to assess the feasibility and efficacy of propofol before positioning elderly patients with a femoral neck fracture in the lateral decubitus position, to perform a spinal anesthetic. METHODS In this prospective and descriptive study, 79 consecutive patients, > 75 yr old, with a femoral neck fracture were included. Propofol, 0.5 mg x kg(-1), was administered. If loss of consciousness was not obtained (Ramsay score < or = 3/6), then additional doses of 0.25 mg x kg(-1) were given until a Ramsay score of 4 or 5 was attained. Then, the patient was turned to the lateral decubitus position, the fractured side up. The efficacy of propofol was assessed by observing a grimace during positioning and asking the patients if they had recall of pain. Hemodynamic data and oxygen saturation were collected. RESULTS Forty-three patients required a single injection, 34 required two injections and only two patients required three injections. No grimace and no recall of pain were recorded during the study. There was no desaturation (SpO(2) < 92 %), and hypotension, defined as a systolic blood pressure decrease > 30% from baseline, was observed. CONCLUSION Propofol is a simple and efficacious means of providing comfort while positioning elderly patients with a femoral head fracture before performing spinal anesthesia.

Propofol to facilitate spinal anesthesia in the lateral position in patients with femoral neck fracture

ObjectifLe but de cette étude était d’évaluer la faisabilité et l’efficacité du propofol avant la mobilisation en décubitus latéral chez les patients âgés, victimes d’une fracture de l’extrémité supérieure du fémur, pour la réalisation d’une rachianesthésie.MéthodeUne étude prospective et descriptive a été réalisée chez 79 patients consécutifs de plus de 75 ans ayant une fracture de l’extrémité supérieure du fémur. Le propofol (0,5 mg·kg−1) était injecté au départ. Si la perte de conscience n’était pas obtenue (score de Ramsay ≤ 3/6), d’autres injections de 0,25 mg·kg−1) étaient administrées jusqu’à l’obtention d’un score de Ramsay de 4 ou 5. Ensuite, le patient était placé en décubitus latéral, le membre fracturé vers le haut. l’efficacité du propofol a été évaluée sur la grimace, ainsi que sur le souvenir d’une douleur à la mobilisation. Les données hémodynamiques et la saturation en oxygène étaient aussi notées.RésultatsUne seule injection de propofol a été nécessaire chez 43 patients, deux injections chez 34 patients et trois injections chez deux patients. Aucune grimace n’a été remarquée dans cette étude, et aucun patient n’a eu le souvenir d’une douleur lors de la mobilisation. Aucune désaturation (SpO2 < 92%), ni chute de tension (diminution de la pression artérielle systolique d’au moins 30%) n’a été observée.ConclusionLe propofol est un moyen simple et efficace d’assurer un confort pendant la mobilisation des patients âgés victimes d’une fracture de l’extrémité supérieure du fémur, pour la réalisation d’une anesthésie médullaire.AbstractPurposeThe aim of this study was to assess the feasibility and efficacy of propofol before positioning elderly patients with a femoral neck fracture in the lateral decubitus position, to perform a spinal anesthetic.MethodsIn this prospective and descriptive study, 79 consecutive patients, > 75 yr old, with a femoral neck fracture were included. Propofol, 0.5 mg·kg−1, was administered. If loss of consciousness was not obtained (Ramsay score ≤ 3/6), then additional doses of 0.25 mg.kg−1 were given until a Ramsay score of 4 or 5 was attained. Then, the patient was turned to the lateral decubitus position, the fractured side up. The efficacy of propofol was assessed by observing a grimace during positioning and asking the patients if they had recall of pain. Hemodynamic data and oxygen saturation were collected.ResultsForty-three patients required a single injection, 34 required two injections and only two patients required three injections. No grimace and no recall of pain were recorded during the study. There was no desaturation (SpO2 < 92 %), and hypotension, defined as a systolic blood pressure decrease > 30% from baseline, was observed.ConclusionPropofol is a simple and efficacious means of providing comfort while positioning elderly patients with a femoral head fracture before performing spinal anesthesia.PURPOSE The aim of this study was to assess the feasibility and efficacy of propofol before positioning elderly patients with a femoral neck fracture in the lateral decubitus position, to perform a spinal anesthetic. METHODS In this prospective and descriptive study, 79 consecutive patients, > 75 yr old, with a femoral neck fracture were included. Propofol, 0.5 mg x kg(-1), was administered. If loss of consciousness was not obtained (Ramsay score < or = 3/6), then additional doses of 0.25 mg x kg(-1) were given until a Ramsay score of 4 or 5 was attained. Then, the patient was turned to the lateral decubitus position, the fractured side up. The efficacy of propofol was assessed by observing a grimace during positioning and asking the patients if they had recall of pain. Hemodynamic data and oxygen saturation were collected. RESULTS Forty-three patients required a single injection, 34 required two injections and only two patients required three injections. No grimace and no recall of pain were recorded during the study. There was no desaturation (SpO(2) < 92 %), and hypotension, defined as a systolic blood pressure decrease > 30% from baseline, was observed. CONCLUSION Propofol is a simple and efficacious means of providing comfort while positioning elderly patients with a femoral head fracture before performing spinal anesthesia.

245 Intérêt de l’utilisation préopératoire de l’érythropoéitine de synthèse béta lors de l’implantation d’une prothèse totale de hanche

Introduction Des etudes ont montre l’efficacite de l’utilisation preoperatoire de l’erytropoeitine de synthese alpha (alphaEPO) sur la diminution des transfusions peri-operatoires en chirurgie orthopedique. Le but de notre etude etait d’evaluer l’effet de l’administration de l’eytropoeitine de synthese beta (betaEPO) sur l’elevation preoperatoire du taux d’hemoglobine au cours de la mise en place des protheses totales de hanche (PTH) dans le but de diminuer le taux de transfusions sanguines. Materiel et methode Trois groupes ont ete etudies. Le groupe EPO (15 patients) presentait un taux inferieur a 13 gr/dl a J-30. Ils ont beneficie, en l’absence de contre-indication, de l’injection sous-cutanee de betaEPO (Neorecormon ® 30,000 unites en seringues pre-remplies) a 4 reprises (J-21, J-14, J-7, J-1). Un groupe de 101 patients presentant un taux d’hemoglobine superieur a 13 gr/dl n’a pas recu de betaEPO (groupe C). Un troisieme groupe continu (groupe T) de 42 temoins avec un taux d’hemoglobine inferieur a 13 gr/dl mais n’ayant pas recu de betaEPO a ete considere. Il n’a pas ete effectue de randomisation. Le taux d’hemoglobine a ete mesure la veille de l’intervention (J-1), le lendemain (J+ 1) et au 5 e jour (J+ 5) postoperatoire. Ont ete notes : l’indice de masse corporelle des patients (IMC), la duree operatoire et les transfusions sanguines (cell-saver, auto et allo-transfusions). Les pertes globulaires totales ont ete calculees. Un p Resultats Nos 3 groupes etaient comparables en preoperatoire (âge, sexe, IMC, duree operatoire et pertes sanguines). Le taux d’hemoglobine etait significativement superieur dans les groupes C et EPO a J-1 et a J+ 1 versus le groupe T. L’augmentation du taux d’hemoglobine etait en moyenne de 2,76 gr/dl dans le groupe EPO versus 0,05 et 0,04 respectivement dans les groupes C et T (p Discussion et conclusion Un taux d’hemoglobine bas en preoperatoire est un facteur de risque de transfusions perioperatoires lors de la mise en place de PTH. L’administration preoperatoire de betaEPO, en ameliorant le taux d’hemoglobine immediatement avant l’intervention reduit significativement les transfusions sanguines et donc reduit les risques et les complications qui leur sont liees. Elle permettrait egalement d’eviter le recours aux programmes d’autotransfusion, facteurs d’anemie pre et postoperatoires. Des indications plus larges de l’utilisation d’EPO devraient encore nous permettre de diminuer le nombre de patients transfuses en chirurgie reglee.

Le propofol pour réaliser une rachianesthésie en position latérale chez les victimes d'une fracture du fémur (Propofol to facilitate spinal anesthesia in the lateral position in patients with femoral neck fracture)

ObjectifLe but de cette étude était d’évaluer la faisabilité et l’efficacité du propofol avant la mobilisation en décubitus latéral chez les patients âgés, victimes d’une fracture de l’extrémité supérieure du fémur, pour la réalisation d’une rachianesthésie.MéthodeUne étude prospective et descriptive a été réalisée chez 79 patients consécutifs de plus de 75 ans ayant une fracture de l’extrémité supérieure du fémur. Le propofol (0,5 mg·kg−1) était injecté au départ. Si la perte de conscience n’était pas obtenue (score de Ramsay ≤ 3/6), d’autres injections de 0,25 mg·kg−1) étaient administrées jusqu’à l’obtention d’un score de Ramsay de 4 ou 5. Ensuite, le patient était placé en décubitus latéral, le membre fracturé vers le haut. l’efficacité du propofol a été évaluée sur la grimace, ainsi que sur le souvenir d’une douleur à la mobilisation. Les données hémodynamiques et la saturation en oxygène étaient aussi notées.RésultatsUne seule injection de propofol a été nécessaire chez 43 patients, deux injections chez 34 patients et trois injections chez deux patients. Aucune grimace n’a été remarquée dans cette étude, et aucun patient n’a eu le souvenir d’une douleur lors de la mobilisation. Aucune désaturation (SpO2 < 92%), ni chute de tension (diminution de la pression artérielle systolique d’au moins 30%) n’a été observée.ConclusionLe propofol est un moyen simple et efficace d’assurer un confort pendant la mobilisation des patients âgés victimes d’une fracture de l’extrémité supérieure du fémur, pour la réalisation d’une anesthésie médullaire.AbstractPurposeThe aim of this study was to assess the feasibility and efficacy of propofol before positioning elderly patients with a femoral neck fracture in the lateral decubitus position, to perform a spinal anesthetic.MethodsIn this prospective and descriptive study, 79 consecutive patients, > 75 yr old, with a femoral neck fracture were included. Propofol, 0.5 mg·kg−1, was administered. If loss of consciousness was not obtained (Ramsay score ≤ 3/6), then additional doses of 0.25 mg.kg−1 were given until a Ramsay score of 4 or 5 was attained. Then, the patient was turned to the lateral decubitus position, the fractured side up. The efficacy of propofol was assessed by observing a grimace during positioning and asking the patients if they had recall of pain. Hemodynamic data and oxygen saturation were collected.ResultsForty-three patients required a single injection, 34 required two injections and only two patients required three injections. No grimace and no recall of pain were recorded during the study. There was no desaturation (SpO2 < 92 %), and hypotension, defined as a systolic blood pressure decrease > 30% from baseline, was observed.ConclusionPropofol is a simple and efficacious means of providing comfort while positioning elderly patients with a femoral head fracture before performing spinal anesthesia.PURPOSE The aim of this study was to assess the feasibility and efficacy of propofol before positioning elderly patients with a femoral neck fracture in the lateral decubitus position, to perform a spinal anesthetic. METHODS In this prospective and descriptive study, 79 consecutive patients, > 75 yr old, with a femoral neck fracture were included. Propofol, 0.5 mg x kg(-1), was administered. If loss of consciousness was not obtained (Ramsay score < or = 3/6), then additional doses of 0.25 mg x kg(-1) were given until a Ramsay score of 4 or 5 was attained. Then, the patient was turned to the lateral decubitus position, the fractured side up. The efficacy of propofol was assessed by observing a grimace during positioning and asking the patients if they had recall of pain. Hemodynamic data and oxygen saturation were collected. RESULTS Forty-three patients required a single injection, 34 required two injections and only two patients required three injections. No grimace and no recall of pain were recorded during the study. There was no desaturation (SpO(2) < 92 %), and hypotension, defined as a systolic blood pressure decrease > 30% from baseline, was observed. CONCLUSION Propofol is a simple and efficacious means of providing comfort while positioning elderly patients with a femoral head fracture before performing spinal anesthesia.