Claude Gris

A Modified Coracoid Approach to Infraclavicular Brachial Plexus Blocks Using a Double-Stimulation Technique in 300 Patients

Infraclavicular brachial plexus block is used less than other techniques of regional anesthesia for upper-limb surgery. We describe a modified coracoid approach to the infraclavicular brachial plexus using a double-stimulation technique and assess its efficacy. Patients undergoing orthopedic surgery of the upper limb were included in this prospective study. The landmarks used were the coracoid process and the clavicle. The needle was inserted in the direction of the top of the axillary fossa (in relation to the axillary artery), with an angle of 45 degrees. Using nerve stimulation, the musculocutaneous nerve was identified first and blocked with 10 mL of 1.5% lidocaine with 1:400,000 epinephrine. The needle was then withdrawn and redirected posteriorly and medially. The radial, ulnar, or median nerve was then blocked. The block was tested every 5 min for 30 min. The overall success rate, i.e., adequate sensory block in the 4 major nerve distributions at 30 min, was 92%, and 6% of the patients required supplementation. Five patients required general anesthesia. No major complications were observed. This modified infraclavicular brachial plexus block using a double-stimulation technique was easy to perform, had frequent success, and was safe in this cohort.

Infraclavicular brachial plexus block versus humeral approach: comparison of anesthetic time and efficacy.

Most upper arm regional anesthesia techniques are successful and differences in efficacy should not dictate the choice of technique. In the present study, we compared humeral block (HB) and infraclavicular brachial plexus block (ICB) using anesthetic time (i.e., duration of the procedure + onset time) as the primary outcome measure. The block was successful when a complete sensory block was obtained in the four major nerves of the arm, and the time to complete block was recorded. Patients undergoing orthopedic surgery of the upper limb were included in a prospective randomized study and received ICB (group I, n = 60 patients) or HB (group H, n = 60 patients). Total anesthetic time was 19.5 min (95% confidence interval [CI], 17.4—21.6 min) for ICB and 20.8 min (95% CI, 18.7--22.9 min) for HB (not significant). Time to perform the block was 4.5 min (95% CI, 4-5 min) for ICB and 9.8 min (95% CI, 8.9--10.7 min) for HB (P < 0.05). The onset time was 15 min (95% CI, 13-17 min) for ICB and 11 min (95% CI, 9--13 min) for HB (P < 0.05). The success rate was 92% for ICB and 95% for HB (not significant). One self-limited vascular puncture was made in each group. HB had a faster onset time but ICB using a double-stimulation technique was faster to perform. Anesthetic time was similar with the two techniques.

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.

Postoperative analgesia after total hip arthroplasty: patient-controlled analgesia versus transdermal fentanyl patch

STUDY OBJECTIVE To determine whether a new transdermal fentanyl patch (TFP) is a good choice for the postoperative pain management of patients undergoing primary total hip arthroplasty compared with patient-controlled analgesia (PCA). DESIGN Randomized, prospective study. SETTING University hospital. PATIENTS 30 patients undergoing primary total hip arthroplasty. INTERVENTIONS Patients received either a TFP (group T; Duragesic 50 microg/h, matrix fentanyl patch, Janssen-Cilag) applied approximately 10 hours before induction of general anesthesia and PCA programmed in the postanesthesia care unit (PACU), or PCA programmed in the PACU (group P). MEASUREMENTS Intraoperative sufentanil and additional postoperative morphine administration were recorded, as well as visual analog scores and routine vital signs at predetermined intervals during the first 48 hours. MAIN RESULTS Morphine consumption on arrival in the PACU was 3.5+/-3 mg in group T versus 13+/-5 mg in group P (P<0.0001). Visual analog scores on arrival in the PACU were 37+/-22 mm in group T versus 73+/-13 mm in group P (P<0.0001). Cumulative morphine consumption at the 24th hour was 43+/-16 mg in group P and 4+/-3 mg in group T (P<0.0001). Cumulative morphine consumption at the 48th hour was 54+/-26 mg in group P and 5+/-4 mg in group T (P<0.0001). Intraoperative sufentanil consumption was 38+/-15 microg in group T versus 30+/-5 microg in group P (not significant). The sedation score was 0 in both groups during the first 48 postoperative hours. CONCLUSIONS Preoperative TFP application decreases pain scores and morphine consumption in the PACU and appears to have prolonged effects spanning the first 48 postoperative hours.

Resident Versus Staff Anesthesiologist Performance: Coracoid Approach to Infraclavicular Brachial Plexus Blocks Using a Double-Stimulation Technique

Objectives Infraclavicular brachial plexus block with double stimulation (ICB) is a safe technique for upper-limb anesthesia. However, the experience of learning this technique by anesthesiology residents has not been reported. The aim of this study was to compare staff with resident anesthesiologists in the performance of ICB. Methods Patients scheduled for orthopedic surgery of the upper limb were included in a prospective, comparative, randomized study and were given ICB by either staff anesthesiologist (Group S, n = 110 patients) or resident anesthesiologist (Group R, n = 110 patients). Results Time to perform the block was 3.9 minutes (95% confidence interval [CI95%] = 3.5 to 4.3) for Group S and 5.8 minutes (CI95% = 5.2 to 6.4) for Group R (P < .05). The onset time was 14.4 minutes (CI95% = 13.5 to 15.3) for Group S and 15.9 minutes (CI95% = 14.7 to 17.1) for Group R (P = NS). Success rate was 93% for Group S and 90% for Group R (P = NS). Supplementation was performed in 8 patients in Group S versus 11 patients in Group R (P = NS). No patient needed general anesthesia. One self-limited vascular puncture was made in Group S versus 3 in Group R (P = NS). Conclusion This report determines whether residents can perform this technique with comparable efficiency compared with staff. We conclude that ICB should be taught as part of all resident training programs.

Pneumothorax as a complication of ultrasound-guided interscalene block for shoulder surgery.

Interscalene block is often used for shoulder and upper arm surgery. This form of regional anaesthesia decreases pain, nausea, vomiting associated with general anaesthesia, length of hospital stay and improves postoperative rehabilitation. The technique has undergone many changes from first use in 1970 to the start of the use of ultrasound. Several studies have observed a better success rate. However, there is no consensus on the contribution of ultrasound in reducing the incidence of complications. We obtained the consent of the patient to publish this report. A 77-year-old woman was scheduled for the insertion of a right shoulder reverse prosthesis. The patient was classed as ASA II for obesity (BMI 34), hiatal hernia and chronic myalgia. In the operation theatre, we performed an ultrasound-guided interscalene block. A linear ultrasound probe, 38 mm, 6 to 15 MHz (Sonosite) and a 22-gauge needle of 50 mm connected to a nerve stimulator (HNS 11, B Braun) delivering a current of 0.5 mA at 2 Hz were used throughout the procedure. Indeed, combining ultrasound and neurostimulation allows the identification of nerve roots visually. An experienced resident conducted the regional anaesthesia with a posterolateral approach (in the ultrasound’s plane) supervised by a consultant anaesthesiologist. Vascular structures (carotid artery and internal jugular vein), muscular structures (anterior and middle scalene), nerve structures (nerve roots C5, C6 and C7) and bone structures (transverse process of C6 and C7) were visualised during the procedure. A musculocutaneous response (flexion of the forearm) obtained at 0.5 mA confirmed the identification of the C5 nerve root. After negative aspiration, slow and fractioned injection of 25 ml of ropivacaine 0.475% combined with 4 mg dexamethasone was performed. After induction of general anaesthesia, the patient was ventilated in a volume-controlled mode with a tidal volume of 8 ml kg 1 with an insufflation pressure of 21 cmH2O.

Neurostimulation does not increase the success rate of saphenous nerve blocks

RésuméObjectifÉvaluer la neurostimulation des fibres motrices destinées au muscle vaste médial et au muscle droit antérieur dans le but de bloquer les fibres sensitives médiales du nerf saphène.MéthodeDans un premier temps nous avons procédé à la dissection de quatre trigones fémoraux afin de choisir notre point de ponction: nous avons observé qu’au niveau du pli de flexion de la cuisse, les différentes fibres constituant le nerf fémoral étaient très ramassées les unes par rapport aux autres et que le nerf saphène avec le nerf du muscle vaste médial ne s’étaient pas encore individualisés du tronc fémoral. Dans un deuxième temps, nous avons réalisé une étude clinique prospective chez 71 patients, opérés du tiers inférieur de la jambe sous bloc sciatique et bloc du nerf saphène. Le bloc du nerf saphène a été réalisé avec 10 mL d’anesthésique local en ponctionnant au niveau du pli de flexion de la cuisse, en recherchant une des deux réponses musculaires : médiale (contraction du muscle vaste médial) ou antérieure (contraction du muscle droit antérieur avec ascension de rotule).RésultatsLe taux de succès global sur le nerf saphène est de 80 %, sans différence statistique entre les deux types de réponses. La durée moyenne de réalisation du bloc est de deux minutes et le délai moyen d’obtention de l’anesthésie est de 15 min. Aucune complication n’a été relevée hormis une ponction de l’artère fémorale sans conséquence clinique.ConclusionLa neurostimulation du muscle vaste médial est équivalente à la neurostimulation du muscle droit antérieur pour l’anesthésie du nerf saphène. A efficacité comparable, la neurosti-mulation du compartiment médial du nerf fémoral permet une économie d’anesthésique local par rapport à un bloc fémoral clas-sique.AbstractPurposeTo evaluate neurostimulation of motor components of the vastus medialis muscle and the rectus femoris muscle, with a view to blocking the medial sensory fibres of the saphenous nerve.MethodFirst we dissected four femoral trigones, in order to select our puncture point. We were able to observe that, at the flexion crease of the thigh, the different fibers that make up the femoral nerve were clustered together and the saphenous nerve and the vastus medialis nerve had not yet separated from the femoral stem. Secondly, we conducted a prospective clinical study among 71 patients who had undergone surgery on the lower third of the leg with a sciatic block and a saphenous nerve block. The saphenous nerve block was performed using 10 mL of local anesthetic, by puncturing the flexion crease of the thigh in a bid to obtain one of two muscle responses: medial (contraction of the vastus medialis muscle) or anterior (contraction of the rectus femoris muscle and elevation of the patella).ResultsThere was an overall success rate of 80% with the saphenous nerve block, with no statistical difference existing between the two response types. Average duration for the block to be completed was two minutes and it took an average of 15 min before the anesthesia took effect. No complications were encountered, apart from a puncture of the femoral artery, which was clinically inconsequential.ConclusionNeurostimulation of the vastus medialis muscle has the same effect as neurostimulation of the rectus femoris muscle with respect to anesthesia of the saphenous nerve. Neurostimulation of the medial compartment of the femoral nerve saves local anesthetic, compared to a standard femoral block.PURPOSE To evaluate neurostimulation of motor components of the vastus medialis muscle and the rectus femoris muscle, with a view to blocking the medial sensory fibres of the saphenous nerve. METHOD First we dissected four femoral trigones, in order to select our puncture point. We were able to observe that, at the flexion crease of the thigh, the different fibers that make up the femoral nerve were clustered together and the saphenous nerve and the vastus medialis nerve had not yet separated from the femoral stem. Secondly, we conducted a prospective clinical study among 71 patients who had undergone surgery on the lower third of the leg with a sciatic block and a saphenous nerve block. The saphenous nerve block was performed using 10 mL of local anesthetic, by puncturing the flexion crease of the thigh in a bid to obtain one of two muscle responses: medial (contraction of the vastus medialis muscle) or anterior (contraction of the rectus femoris muscle and elevation of the patella). RESULTS There was an overall success rate of 80% with the saphenous nerve block, with no statistical difference existing between the two response types. Average duration for the block to be completed was two minutes and it took an average of 15 min before the anesthesia took effect. No complications were encountered, apart from a puncture of the femoral artery, which was clinically inconsequential. CONCLUSION Neurostimulation of the vastus medialis muscle has the same effect as neurostimulation of the rectus femoris muscle with respect to anesthesia of the saphenous nerve. Neurostimulation of the medial compartment of the femoral nerve saves local anesthetic, compared to a standard femoral block.

La neurostimulation n’augmente pas le taux de succès du bloc du nerf saphène

RésuméObjectifÉvaluer la neurostimulation des fibres motrices destinées au muscle vaste médial et au muscle droit antérieur dans le but de bloquer les fibres sensitives médiales du nerf saphène.MéthodeDans un premier temps nous avons procédé à la dissection de quatre trigones fémoraux afin de choisir notre point de ponction: nous avons observé qu’au niveau du pli de flexion de la cuisse, les différentes fibres constituant le nerf fémoral étaient très ramassées les unes par rapport aux autres et que le nerf saphène avec le nerf du muscle vaste médial ne s’étaient pas encore individualisés du tronc fémoral. Dans un deuxième temps, nous avons réalisé une étude clinique prospective chez 71 patients, opérés du tiers inférieur de la jambe sous bloc sciatique et bloc du nerf saphène. Le bloc du nerf saphène a été réalisé avec 10 mL d’anesthésique local en ponctionnant au niveau du pli de flexion de la cuisse, en recherchant une des deux réponses musculaires : médiale (contraction du muscle vaste médial) ou antérieure (contraction du muscle droit antérieur avec ascension de rotule).RésultatsLe taux de succès global sur le nerf saphène est de 80 %, sans différence statistique entre les deux types de réponses. La durée moyenne de réalisation du bloc est de deux minutes et le délai moyen d’obtention de l’anesthésie est de 15 min. Aucune complication n’a été relevée hormis une ponction de l’artère fémorale sans conséquence clinique.ConclusionLa neurostimulation du muscle vaste médial est équivalente à la neurostimulation du muscle droit antérieur pour l’anesthésie du nerf saphène. A efficacité comparable, la neurosti-mulation du compartiment médial du nerf fémoral permet une économie d’anesthésique local par rapport à un bloc fémoral clas-sique.AbstractPurposeTo evaluate neurostimulation of motor components of the vastus medialis muscle and the rectus femoris muscle, with a view to blocking the medial sensory fibres of the saphenous nerve.MethodFirst we dissected four femoral trigones, in order to select our puncture point. We were able to observe that, at the flexion crease of the thigh, the different fibers that make up the femoral nerve were clustered together and the saphenous nerve and the vastus medialis nerve had not yet separated from the femoral stem. Secondly, we conducted a prospective clinical study among 71 patients who had undergone surgery on the lower third of the leg with a sciatic block and a saphenous nerve block. The saphenous nerve block was performed using 10 mL of local anesthetic, by puncturing the flexion crease of the thigh in a bid to obtain one of two muscle responses: medial (contraction of the vastus medialis muscle) or anterior (contraction of the rectus femoris muscle and elevation of the patella).ResultsThere was an overall success rate of 80% with the saphenous nerve block, with no statistical difference existing between the two response types. Average duration for the block to be completed was two minutes and it took an average of 15 min before the anesthesia took effect. No complications were encountered, apart from a puncture of the femoral artery, which was clinically inconsequential.ConclusionNeurostimulation of the vastus medialis muscle has the same effect as neurostimulation of the rectus femoris muscle with respect to anesthesia of the saphenous nerve. Neurostimulation of the medial compartment of the femoral nerve saves local anesthetic, compared to a standard femoral block.PURPOSE To evaluate neurostimulation of motor components of the vastus medialis muscle and the rectus femoris muscle, with a view to blocking the medial sensory fibres of the saphenous nerve. METHOD First we dissected four femoral trigones, in order to select our puncture point. We were able to observe that, at the flexion crease of the thigh, the different fibers that make up the femoral nerve were clustered together and the saphenous nerve and the vastus medialis nerve had not yet separated from the femoral stem. Secondly, we conducted a prospective clinical study among 71 patients who had undergone surgery on the lower third of the leg with a sciatic block and a saphenous nerve block. The saphenous nerve block was performed using 10 mL of local anesthetic, by puncturing the flexion crease of the thigh in a bid to obtain one of two muscle responses: medial (contraction of the vastus medialis muscle) or anterior (contraction of the rectus femoris muscle and elevation of the patella). RESULTS There was an overall success rate of 80% with the saphenous nerve block, with no statistical difference existing between the two response types. Average duration for the block to be completed was two minutes and it took an average of 15 min before the anesthesia took effect. No complications were encountered, apart from a puncture of the femoral artery, which was clinically inconsequential. CONCLUSION Neurostimulation of the vastus medialis muscle has the same effect as neurostimulation of the rectus femoris muscle with respect to anesthesia of the saphenous nerve. Neurostimulation of the medial compartment of the femoral nerve saves local anesthetic, compared to a standard femoral block.

Prophylactic phenylephrine infusion for the prevention of hypotension after spinal anesthesia in the elderly: a randomized controlled clinical trial ☆ ☆☆ ★

STUDY OBJECTIVE Hypotension frequently occurs during spinal anesthesia (SA), especially in the elderly. Phenylephrine is effective to prevent SA-induced hypotension during cesarean delivery. The objective of this study was to evaluate the efficacy and safety of prophylactic infusion of phenylephrine after SA for orthopedic surgery in the elderly. DESIGN This prospective, randomized, double-blind, and placebo-controlled study included 54 patients older than 60 years undergoing elective lower limb surgery under SA (injection of 10 mg of isobaric bupivacaine with 5 μg of sufentanyl). INTERVENTION Patients were randomized to group P (100-μg/mL solution of phenylephrine solution at 1 mL/min after placement of SA) or the control group C (0.9% isotonic sodium chloride solution). The flow of the infusion was stopped if the mean arterial blood pressure (MAP) was higher than the baseline MAP and maintained or restarted at 1 mL/min if MAP was equal to or lower than the baseline MAP. Heart rate and MAP were collected throughout the case. MEASUREMENTS Hypotension was defined by a 20% decrease and hypertension as a 20% increase from baseline MAP. Bradycardia was defined as a heart rate lower than 50 beats per minute. MAIN RESULTS Twenty-eight patients were randomized to group P and 26 patients to group C. MAP was higher in group P than in group C (92 ± 2 vs 82 ± 2 mm Hg, mean ± SD, P< .001). The number of hypotensive episodes per patient was higher in group C compared with group P (9 [0-39] vs 1 [0-10], median [extremes], P< .01), but the number of hypotensive patients was similar between groups (19 [73%] vs 20 [71%], P= 1). The time to onset of the first hypotension was shorter in group C (3 [1-13] vs 15 [1-95] minutes, P= .004). The proportion of patients without hypotension (cumulative survival) was better in group P (P= .04). The number of hypertensive episodes per patient and the number of bradycardic episodes per patient were similar between groups (P= not significant). CONCLUSION Prophylactic phenylephrine infusion is an effective method of reducing SA-induced hypotension in the elderly. Compared with a control group, it delays the time to onset of hypotension and decreases the number of hypotensive episodes per patient. More data are needed to evaluate clinical outcomes of such a strategy.

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.