Clément Chassery

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 The needle was then withdrawn and redirected posteriorly and medially.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.

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.

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.

Hématome péridural chez une parturiente au décours d'un choc hémorragique

RésuméObjectifĽhématome péridural est une complication exceptionnelle mais grave de ľanesthésie péridurale. Nous rapportons un cas ďhématome péridural en obstétrique, survenu aprèas le retrait accidentel du cathéter péridural en période ďhypocoagulabilité au décours ďun choc hémorragique.Éléments cliniquesUne patiente avait bénéficié ďune anesthésie péridurale pour le travail, aprèas vérification du bilan ďhémostase. Une hémorragie et des troubles importants de ľhémostase (plaquettes: 16 x 10-9·L-1; temps de prothrombine: 85 sec) sont survenus en post-partum. La situation hémodynamique a été rétablie aprèas une anesthésie générale, une transfusion de produits sanguins, un remplissage et une ligature des artèares hypogastriques. Le retrait accidentel du cathéter péridural a été constaté en période ďhypocoagulabilité. La patiente a par la suite présenté un déficit neurologique évoquant une compression médullaire par un hématome péridural. La réalisation ďune imagerie par résonance magnétique a montré la présence ďun hématome péridural étendu de T3 à L5 de caractèare peu compressif, faisant choisir ľoption ďune abstention thérapeutique avec une surveillance clinique et radiologique rapprochée. La patiente n’a pas présenté de séquelles par la suite.ConclusionEn présence ďun hématome péridural, le recours à une chirurgie de décompression médullaire en urgence reste nécessaire dans la majorité des cas. Ľoption ďune surveillance neurologique est de plus en plus décrite comme une autre solution intéressante dans certains cas mais reste mal codifiée.AbstractPurposeEpidural hematoma is a rare but serious complication of epidural anesthesia. We report a case of epidural hematoma, occurring in an obstetric patient after the epidural catheter had been withdrawn accidentally after an episode of hemorrhagic shock leading to a hypocoagulable state.Clinical featuresA patient had the epidural catheter inserted during labour when coagulation was normal. She had a postpartum hemorrhage with alteration of coagulation (platelets 16 x 10-9·L-1, thrombin time: 85 sec. Vital signs returned to normal after a general anesthetic, transfusion of blood products, volume repletion and ligation of hypogastric arteries. It was then noticed that the epidural catheter had been withdrawn inadvertently while the patient was hypocoagulable. The patient then developed neurological signs consistent with spinal cord compression due to an epidural hematoma. A hematoma extending from T3 to L5 was diagnosed by magnetic resonance imaging. Because the cord had minimal compression, no specific action was undertaken, other than clinical and radiological follow-up. There were no long-term sequelae.ConclusionIn the presence of an epidural hematoma, surgery for emergency cord decompression is usually required. Another option that receives increasing attention is to monitor neurological function, but the indications for this expectant treatment are not well defined.PURPOSE Epidural hematoma is a rare but serious complication of epidural anesthesia. We report a case of epidural hematoma, occurring in an obstetric patient after the epidural catheter had been withdrawn accidentally after an episode of hemorrhagic shock leading to a hypocoagulable state. CLINICAL FEATURES A patient had the epidural catheter inserted during labour when coagulation was normal. She had a postpartum hemorrhage with alteration of coagulation (platelets 16 x 10(-9) x L(-1), thrombin time: 85 sec. Vital signs returned to normal after a general anesthetic, transfusion of blood products, volume repletion and ligation of hypogastric arteries. It was then noticed that the epidural catheter had been withdrawn inadvertently while the patient was hypocoagulable. The patient then developed neurological signs consistent with spinal cord compression due to an epidural hematoma. A hematoma extending from T3 to L5 was diagnosed by magnetic resonance imaging. Because the cord had minimal compression, no specific action was undertaken, other than clinical and radiological follow-up. There were no long-term sequelae. CONCLUSION In the presence of an epidural hematoma, surgery for emergency cord decompression is usually required. Another option that receives increasing attention is to monitor neurological function, but the indications for this expectant treatment are not well defined.

Epidural hematoma after hemorrhagic shock in a parturient

RésuméObjectifĽhématome péridural est une complication exceptionnelle mais grave de ľanesthésie péridurale. Nous rapportons un cas ďhématome péridural en obstétrique, survenu aprèas le retrait accidentel du cathéter péridural en période ďhypocoagulabilité au décours ďun choc hémorragique.Éléments cliniquesUne patiente avait bénéficié ďune anesthésie péridurale pour le travail, aprèas vérification du bilan ďhémostase. Une hémorragie et des troubles importants de ľhémostase (plaquettes: 16 x 10-9·L-1; temps de prothrombine: 85 sec) sont survenus en post-partum. La situation hémodynamique a été rétablie aprèas une anesthésie générale, une transfusion de produits sanguins, un remplissage et une ligature des artèares hypogastriques. Le retrait accidentel du cathéter péridural a été constaté en période ďhypocoagulabilité. La patiente a par la suite présenté un déficit neurologique évoquant une compression médullaire par un hématome péridural. La réalisation ďune imagerie par résonance magnétique a montré la présence ďun hématome péridural étendu de T3 à L5 de caractèare peu compressif, faisant choisir ľoption ďune abstention thérapeutique avec une surveillance clinique et radiologique rapprochée. La patiente n’a pas présenté de séquelles par la suite.ConclusionEn présence ďun hématome péridural, le recours à une chirurgie de décompression médullaire en urgence reste nécessaire dans la majorité des cas. Ľoption ďune surveillance neurologique est de plus en plus décrite comme une autre solution intéressante dans certains cas mais reste mal codifiée.AbstractPurposeEpidural hematoma is a rare but serious complication of epidural anesthesia. We report a case of epidural hematoma, occurring in an obstetric patient after the epidural catheter had been withdrawn accidentally after an episode of hemorrhagic shock leading to a hypocoagulable state.Clinical featuresA patient had the epidural catheter inserted during labour when coagulation was normal. She had a postpartum hemorrhage with alteration of coagulation (platelets 16 x 10-9·L-1, thrombin time: 85 sec. Vital signs returned to normal after a general anesthetic, transfusion of blood products, volume repletion and ligation of hypogastric arteries. It was then noticed that the epidural catheter had been withdrawn inadvertently while the patient was hypocoagulable. The patient then developed neurological signs consistent with spinal cord compression due to an epidural hematoma. A hematoma extending from T3 to L5 was diagnosed by magnetic resonance imaging. Because the cord had minimal compression, no specific action was undertaken, other than clinical and radiological follow-up. There were no long-term sequelae.ConclusionIn the presence of an epidural hematoma, surgery for emergency cord decompression is usually required. Another option that receives increasing attention is to monitor neurological function, but the indications for this expectant treatment are not well defined.PURPOSE Epidural hematoma is a rare but serious complication of epidural anesthesia. We report a case of epidural hematoma, occurring in an obstetric patient after the epidural catheter had been withdrawn accidentally after an episode of hemorrhagic shock leading to a hypocoagulable state. CLINICAL FEATURES A patient had the epidural catheter inserted during labour when coagulation was normal. She had a postpartum hemorrhage with alteration of coagulation (platelets 16 x 10(-9) x L(-1), thrombin time: 85 sec. Vital signs returned to normal after a general anesthetic, transfusion of blood products, volume repletion and ligation of hypogastric arteries. It was then noticed that the epidural catheter had been withdrawn inadvertently while the patient was hypocoagulable. The patient then developed neurological signs consistent with spinal cord compression due to an epidural hematoma. A hematoma extending from T3 to L5 was diagnosed by magnetic resonance imaging. Because the cord had minimal compression, no specific action was undertaken, other than clinical and radiological follow-up. There were no long-term sequelae. CONCLUSION In the presence of an epidural hematoma, surgery for emergency cord decompression is usually required. Another option that receives increasing attention is to monitor neurological function, but the indications for this expectant treatment are not well defined.

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.

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.

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.