Arthur Atchabahian

Objective assessment of the immediate postoperative analgesia using pupillary reflex measurement: a prospective and observational study.

Background: The evaluation of pain intensity during the immediate postoperative period is a key factor for pain management. However, this evaluation may be difficult in some circumstances. The pupillary dilatation reflex (PDR) has been successfully used to assess the analgesic component of a balanced anesthetic regimen. We hypothesized that PDR could be a reliable index of pain intensity and could guide morphine administration in the immediate postoperative period. Methods: One hundred patients scheduled to undergo general surgery were included in this prospective observational study. Pain intensity was assessed by using a simple five-item verbal rating scale (VRS). After patients awoke from general anesthesia, those experiencing mild or more severe pain (VRS more than 1) received intravenous morphine titration. Before and after intravenous morphine titration, the PDR induced by a standardized noxious stimulus was measured with a portable pupillometer. A receiver-operating curve was built to estimate the accuracy of PDR in objectively detecting patients requiring morphine titration. Results are given as median (95% CI). Results: On the initial evaluation, a correlation was found between VRS and PDR (&rgr; = 0.88 [0.83–0.92], P < 0.0001). In the 39 patients that had a VRS more than 1, PDR before and after morphine titration was respectively 35% (31–43) versus 12% (10–14); P < 0.0001. The PDR threshold value corresponding to the highest accuracy to have VRS more than 1 was 23%, with 91% and 94% sensitivity and specificity, respectively. Conclusion: In the immediate postoperative period, the PDR is significantly correlated with the VRS. The pupillometer could be a valuable tool to guide morphine administration in the immediate postoperative period.

The use of 2-chloroprocaine for spinal anaesthesia

Spinal anaesthesia is a safe and reliable anaesthetic modality for surgical procedures on the lower part of the body. However, because of the description of transient neurologic symptoms (TNS), most practitioners have abandoned intrathecal lidocaine. Chloroprocaine (2‐chloroprocaine, CP) has been one candidate to replace lidocaine for short procedures, despite the fact that neurologic sequelae have been described following the intrathecal injection of large doses of preservative‐containing CP intended for epidural use. The National Library of Medicines Medline and the EMBASE databases were searched for the time period 1966 to April 2012. Fourteen studies of the use of intrathecal CP were analysed, including seven volunteer and seven clinical studies. Preservative‐free CP appears to be a reliable local anaesthetic for short procedures. The duration of the surgical block can be adjusted by varying the dose between 30 and 60 mg. Two double‐blind randomised controlled studies demonstrate decreased time to ambulation and discharge when CP is used for spinal anaesthesia when compared with other local anaesthetics. The addition of fentanyl appears to prolong the surgical block without significantly prolonging the time to discharge. There have been five possible cases of TNS following CP spinal anaesthesia in over 4000 patients, and a regressive incomplete cauda equina syndrome has been described. The short duration of spinal CP makes it a strong contender for outpatient anaesthesia. It appears to have a lower risk of TNS than lidocaine.

Parietal analgesia decreases postoperative diaphragm dysfunction induced by abdominal surgery: a physiologic study.

Background and Objectives: The postoperative analgesic strategy may influence the magnitude of the postoperative diaphragmatic dysfunction (PODD) induced by abdominal surgery. The purpose of this physiologic study was to evaluate the effect of continuous preperitoneal wound infusion (CPWI) of ropivacaine on PODD after open colorectal surgery. Methods: Twenty patients with American Society of Anesthesiologists physical status I or II undergoing open colorectal surgery were prospectively included during 2 consecutive 2-month periods. During the first period, we evaluated 10 consecutive patients who received conventional parenteral analgesia (intravenously administered morphine via patient-controlled analgesia and acetaminophen) without parietal analgesia (control group). These patients were compared with 10 consecutive patients who received conventional parenteral analgesia along with parietal analgesia using CPWI of 0.2% ropivacaine at 10 mL/hr for 48 hrs (CPWI group). Diaphragmatic function was assessed preoperatively and at 24 and 48 hrs postoperatively using the sniff nasal inspiratory pressure test (Psniff). Supplemental intravenously administered morphine boluses were administered as needed before Psniff assessments in the control group to reduce differences in pain intensity. Results: Demographic and surgical data did not differ between the 2 groups, nor did preoperative Psniff values (71 cm H2O [SD, 20 cm H2O] vs 65 cm H2O [SD,15 cm H2O] in the control and CPWI groups, respectively). Postoperative Psniff was significantly decreased in the 2 groups, but the reduction was significantly greater in the control group than in the CPWI group both at 24 hrs (−58% [SD, 18%] vs −24% [SD, 19%]; P = 0.001) and at 48 hrs (−44% [SD, 31%] vs -11% [SD, 32%]; P = 0.027). Conclusions: Parietal analgesia delivered via a CPWI of ropivacaine reduces PODD induced by open colorectal surgery.

Balloon reduction and cement fixation in intra-articular calcaneal fractures: a percutaneous approach to intra-articular calcaneal fractures

PurposeThe management of calcaneal fractures remains challenging and often controversial. Open reduction and internal fixation with a lateral plate has been established as a standard therapy for displaced articular fractures. However, accurate subtalar joint reduction, while mandatory, is difficult to achieve, requires an extensive lateral approach, and clinical results may not be up to the difficulty of the task.MethodsWe present a treatment using a percutaneous approach and local balloon reduction followed by polymethyl-metacrylate fixation. This technique was used in four patients presenting articular subtalar fractures with displacement.ResultsReduction was achieved in all cases using a posterior trans-osseous percutaneous approach. Bony fusion with conservation of the subtalar articular reduction was achieved in all cases. We present all cases with a detailed report of outcome.ConclusionsClinical outcome after at least three years of follow-up suggests that this technique may be promising and may be used in cases with closed fractures as a primary reduction and fixation tool.

Pre-hospital transcranial Doppler in severe traumatic brain injury: a pilot study

Background: Investigation of the feasibility and usefulness of pre‐hospital transcranial Doppler (TCD) to guide early goal‐directed therapy following severe traumatic brain injury (TBI).

Out-of-hospital traumatic cardiac arrest: an underrecognized source of organ donors

Whereas the gap between organ supply and demand remains a worldwide concern, resuscitation of out‐of‐hospital traumatic cardiac arrest (TCA) remains controversial. The aim of this study is to evaluate, in a prehospital medical care system, the number of organs transplanted from victims of out‐of‐hospital TCA. This is a descriptive study. Victims of TCA are collected in the out‐of‐hospital cardiac arrest registry of the French North Alpine Emergency Network from 2004 to 2008. In addition to the rates of admission and survival, brain‐dead patients and the organ transplanted are described. Among the 540 resuscitated patients with suspected TCA, 79 were admitted to a hospital, 15 were discharged alive from the hospital, and 22 developed brain death. Nine of these became eventually organ donors, with 31 organs transplanted, all functional after 1 year. Out‐of‐hospital TCA should be resuscitated just as medical CA. With a steady prevalence in our network, 19% of admitted TCA survived to discharge, and 11% became organ donors. It is essential to raise awareness among rescue teams that out‐of‐hospital TCA are an organ source to consider seriously.

Efficacy and safety of ultrasound-guided distal blocks for analgesia without motor blockade after ambulatory hand surgery.

PURPOSE To assess the suitability of ultrasound-guided (USG), single-injection distal block(s) for pain management after outpatient hand and wrist bone surgery. METHODS We conducted a retrospective review of 125 of 198 consecutive ambulatory surgery patients who underwent hand and wrist bone surgery between June 2010 and January 2012. All patients received a USG axillary block using a short-acting local anesthetic (lidocaine) and secondary 1, 2, or 3 (median, radial, or ulnar) USG distal analgesic block(s) using a long-acting local anesthetic (ropivacaine). All patients were contacted by phone on the first postoperative day. All patients received a concomitant prescription of acetaminophen and nonsteroidal anti-inflammatory drugs with opioids as a rescue treatment. Effectiveness and duration of the distal nerve blocks, compliance with analgesic treatment and rescue opioids requirement, opioid-related side effects, prolonged upper limb motor block, quality of sleep on first postoperative night, and patient satisfaction were evaluated. RESULTS Most distal analgesic blocks were effective (120 of 125; 96%), with an average duration of nearly 12 hours On the first day after surgery, 28 patients (23%) had a numeric verbal scale greater than 3, although 14 of them had taken the rescue opioids. No patient reported prolonged motor blockade or insensate limb. Opioid-related side effects occurred in 23% of patients. CONCLUSIONS After hand and wrist bone surgery, USG selective distal blocks using a long-acting local anesthetic, combined with oral analgesics, were effective in a large majority of patients. However, pain control was suboptimal for some especially painful procedures such as wrist surgery, trapeziometacarpal arthrodesis, and finger amputation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Refractory cardiac arrest in a rural area: mechanical chest compression during helicopter transport.

Out‐of‐hospital refractory cardiac arrest patients can be transported to a hospital for extracorporeal life support (ECLS), which can be either therapeutic or performed for organ donation. Early initiation is of vital importance and the main limitation when considering ECLS. This explains that all reported series of cardiac arrest patients referred for ECLS were urban ones. We report a series of rural out‐of‐hospital non‐heart‐beating patients transported by helicopter.

Prilocaine spinal anesthesia for ambulatory surgery: A review of the available studies☆

Transient neurologic symptoms (TNS) led to the abandonment of intrathecal lidocaine. We reviewed the published literature for information about the duration of action and side effects of intrathecal prilocaine, which has been recently reintroduced in Europe. Medline and EMBASE databases were searched for the time period from 1966 to 2015. Fourteen prospective and one retrospective study were retrieved. The duration of the surgical block can be adjusted using doses between 40 and 80mg. Hyperbaric prilocaine in doses as low as 10mg can be used for perianal procedures. Four cases of TNS in 486 patients were reported in prospective studies, and none in 5000 cases in a retrospective data set. Spinal prilocaine appears to be safe and reliable for day case anesthesia. However, as chloroprocaine has a shorter duration and a lower risk of TNS and urinary retention, the indications for prilocaine remain to be defined.

Long-term Functional Outcomes after Regional Anesthesia: A Summary of the Published Evidence and a Recent Cochrane Review.

population-based average effects or biomarkers as evidence of meaningful improvement in care are unconvincing in this day and age. Outcomes suitable as arguments for the sustained value of regional anesthesia should instead be patient centered. Patient preferences, shared decision-making, and individualized tailored care are the hallmarks of this new paradigm in outcomes research, differentiating it from previous concepts of comparative effectiveness research. Much needs to be done to define and investigate patient-centered outcomes in anesthesiology and pain medicine, especially long-term outcomes. Pay for performance is another emerging concept, forcing us to emphasize our unique contribution to the quality of patient outcomes. What is the added value that anesthesiologists providing patients regional anesthesia contribute in the long run in the perioperative surgical home, where these anesthesiology subspecialists serve as the shepherds guiding the individualized perioperative recovery process? Outcomes suitable as arguments for the sustained value of regional anesthesia should be patient centered. Pain, Function, and Cognition as Cornerstones of Meaningful Long-term Recovery In this chapter, we examine the clinical evidence suggesting that regional anesthesia has meaningful benefits for our patients and society beyond the immediate perioperative period. Although there are several other outcomes of interest, such as morbidity and mortality or cancer recurrence, we focus on three long-term outcomes after elective surgery based on their particular importance: (1) Persistent pain (2) Joint function (3) Cognitive outcomes We also selected these outcomes because their impact and significance are easy to convey to any interlocutor—surgical colleague, lay person, hospital administrator, or politician— regardless of their previous training or experience. FOCUS 1: REGIONAL ANESTHESIA FOR THE PREVENTION OF PERSISTENT PAIN AFTER SURGERY