Luc Nguyen

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.

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 block in trauma patients : A comparison of patient comfort

In this prospective randomized study, we compared humeral block (HB) and infraclavicular brachial plexus block (ICB) with pain caused by the block as a primary outcome, assuming that ICB would cause less pain than HB. Patients undergoing emergency upper limb surgery were included in this study and received either ICB (group I, n = 52 patients) or HB (group H, n = 52 patients). Patients were asked to quantify the severity of the pain during the procedure using a visual analog scale from 0 to 100 mm and to identify which of the 4 components of the procedure was most unpleasant (skin transfixion, needle redirection in search of the nerves, local anesthetic injections, or electrical stimulation). The block was assessed every 5 min for 30 min after completion of the block. Overall visual analog scale scores for the block were 35 ± 27 mm in group H versus 19 ± 18 mm in group I (P < 0.0011). Electrical stimulation was the most unpleasant part of the block (group H, 29 ± 15 mm versus group I, 15 ± 10 mm) (P < 0.019). Time to perform the block was significantly shorter in group I (ICB, 6 ± 4 min versus HB, 10 ± 4 min; P < 0.0001). The onset time was 13 ± 7 min for ICB and 9 ± 3 min for HB (P < 0.05). No serious complications were observed. In summary, ICB is less painful, compared with HB, with a similar success rate.

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.

Eutectic mixture of local anesthetic (EMLA) decreases pain during humeral block placement in nonsedated patients.

BACKGROUND:We evaluated the potential role of an euctectic mixture of local anesthetic (EMLA®) cream application before performing midhumeral block. METHODS:Sixty patients undergoing surgery distal to the elbow amenable to a humeral block were prospectively recruited for the study. The patients were randomly allocated to 1 of 3 groups: Group E: topical EMLA cream 60 min before block plus 2 mL IV normal saline 5 min before procedure; Group P: topical sham cream plus 2 mL IV normal saline, and Group S: topical sham cream plus 0.1 &mgr;g/kg of sufentanil in 2 mL solution IV. Pain experienced during skin puncture, and overall pain for the whole procedure were rated using a 100-mm visual analog scale (0: no pain to 100: worst pain). RESULTS:Patients in Group E experienced less pain compared with those in Groups P and S (5 ± 3 mm vs 33 ± 20 mm and 30 ± 18 mm, respectively, P < 0.0001). The pain experienced throughout the complete humeral block was more substantial in Group P than in Group E (P = 0.01). CONCLUSION:The patients who received EMLA cream had less pain with needle puncture as well as throughout the performance of humeral block.

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.

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.

La detresse psychologique mesuree par le score de Kessler (K6) predit les douleurs postoperatoires prolongees apres chirurgie du poignet Psychological distress measured using the Kessler scale (K6) predicts long-term postoperative pain after wrist surgery

Au rédacteur en chef, La détresse psychologique préopératoire pourrait contribuer à la survenue de douleurs chroniques après chirurgie. Nous avons évalué l’aptitude prédictive de l’échelle de détresse psychologique de Kessler (K6) dans la survenue de douleurs persistant 14 jours après chirurgie du poignet réalisée sous anesthésie régionale. L’échelle K6 est constituée d’un questionnaire portant sur le sentiment de nervosité, de désespoir, d’agitation, de dépression, de découragement et d’inutilité ressenti au cours du dernier mois. Chacun des six items est noté sur 4 points, pour un score total allant de 0 à 24 points. Cette étude mono-centrique, prospective, observationnelle a été réalisée au sein du service d’anesthésie de l’hôpital Joseph Ducuing (Toulouse). Après accord institutionnel et consentement éclairé, 40 patients opérés au poignet sous anesthésie régionale ont été inclus prospectivement. Les variables démographiques, socioprofessionnelles (statut marital, accident de travail, traumatisme psychologique antérieur), psychologiques (la forme Y de Spielberger du State-Anxiety-Inventory [SAI] et du Trait-Anxiety-Inventory [TAI] de même que le K6), ainsi que la consommation d’antalgique et les douleurs préopératoires ont été relevées avant la chirurgie. Après injection de midazolam 1 mg, une anesthésie régionale échoguidée du bras était réalisée par voie axillaire avec 30 mL d’une solution de lidocaı̈ne 1,5 % adrénalinée. Les patients bénéficiaient d’une analgésie postopératoire standardisée comportant du paracétamol, du tramadol et des anti-inflammatoires. Deux semaines après l’intervention, un anesthésiologiste ne connaissant pas les réponses au questionnaire K6 contactait par téléphone les patients afin d’évaluer leur douleur postopératoire sur une échelle numérique analogique (ENA) allant de 0 à 10. L’analyse statistique a été faite par régression logistique univariée afin de retenir les variables les plus pertinentes et en déduire les rapports de cote (RC [intervalle de confiance à 95 %]), suivie d’une régression logistique multivariée par étapes descendantes sur les variables précédemment sélectionnées afin d’extraire les facteurs de risque significatifs (P \ 0,05). Les participants étaient âgés en moyenne (écart type) de 54 (15) ans. Il y avait 13 hommes et 27 femmes. Huit patients sur les 40 inclus dans l’étude (20 %) présentaient une ENA C 3 14 jours après l’intervention. L’analyse univariée montrait comme facteur de risque significatif socio-professionnel le contexte d’accident de travail (RC = 7 [1,2-39]), et comme facteurs de risque psychologique le score d’anxiété générale (RC = 1,79 [1,10-2,91]), le TAI (RC = 1,13 [1,03-1,24]) et le K6 (RC = 1,33 [1,03-1,61]). L’analyse multivariée par étapes descendantes retenait le K6 comme facteur indépendant le plus discriminant du modèle (RC = 1,33 [1,03-1,61], P \ 0,005) (Figure). Le score de Kessler apparaissait fortement corrélé au TAI (Spearman Q = 0,61; P \ 0,001), au SAI (Spearman Q = 0,59; P \ 0,001) et à l’ENA (Spearman Q = 0,53; P \ 0,001). La courbe « receiver operating characteristics » (ROC) montrait une aire sous la courbe de 0,78 (P \ 0,05). Un K6 C 10 avait une sensibilité de 75 % et une spécificité de 91 L. Nguyen, MD (&) C. Chassery, MD Hôpital Joseph-Ducuing, Toulouse, France e-mail: cush31@yahoo.fr