Vincent Minville

The importance of increased neck circumference to intubation difficulties in obese patients.

BACKGROUND: Using the intubation difficulty scale (IDS), we sought to confirm that obese patients are more difficult to intubate than lean patients. We assessed classical bedside tests and included neck circumference. METHODS: We prospectively compared the incidence of difficult tracheal intubation in 70 obese [body mass index (BMI) ≥30 kg/m2] and 61 lean patients (BMI <30 kg/m2). The IDS scores, categorized as difficult intubation (IDS >5) or not (IDS ≤5), and the patient data, were compared between lean and obese patients. Preoperative measurements [BMI, neck circumference (at the level of the thyroid cartilage), width of mouth opening, sternomental distance, and thyromental distance], medical history of obstructive sleep apnea syndrome, and several scores (Mallampati, Wilson, El Ganzouri) were recorded. The view during direct laryngoscopy was graded, and the IDS was recorded. We then compared patients with IDS ≤5 and >5, concerning each item. RESULTS: The results indicate that difficult tracheal intubation is more frequent in obese than in lean patients (14.3% vs 3%; P = 0.03). In the patients with IDS > 5, thyromental distance, BMI, large neck circumference, and higher Mallampati score were the only predictors of potential intubation problems. CONCLUSION: We found that problematic intubation was associated with thyromental distance, increasing neck circumference, BMI, and a Mallampati score of ≥3. Neck circumference should be assessed preoperatively to predict difficult intubation.

Lactate clearance for death prediction in severe sepsis or septic shock patients during the first 24 hours in Intensive Care Unit: an observational study

BackgroundThis study was design to investigate the prognostic value for death at day-28 of lactate course and lactate clearance during the first 24 hours in Intensive Care Unit (ICU), after initial resuscitation.MethodsProspective, observational study in one surgical ICU in a university hospital. Ninety-four patients hospitalized in the ICU for severe sepsis or septic shock were included. In this septic cohort, we measured blood lactate concentration at ICU admission (H0) and at H6, H12, and H24. Lactate clearance was calculated as followed: [(lactateinitial - lactatedelayed)/ lactateinitial] x 100%].ResultsThe mean time between severe sepsis diagnosis and H0 (ICU admission) was 8.0 ± 4.5 hours. Forty-two (45%) patients died at day 28. Lactate clearance was higher in survivors than in nonsurvivors patients for H0-H6 period (13 ± 38% and −13 ± 7% respectively, p = 0.021) and for the H0-H24 period (42 ± 33% and −17 ± 76% respectively, p < 0.001). The best predictor of death at day 28 was lactate clearance for the H0-H24 period (AUC = 0.791; 95% CI 0.6-0.85). Logistic regression found that H0-H24 lactate clearance was independently correlated to a survival status with a p = 0.047 [odds ratio = 0.35 (95% CI 0.01-0.76)].ConclusionsDuring the first 24 hr in the ICU, lactate clearance was the best parameter associated with 28-day mortality rate in septic patients. Protocol of lactate clearance-directed therapy should be considered in septic patients, even after the golden hours.

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.

Opioid-induced hyperalgesia in a mice model of orthopaedic pain: preventive effect of ketamine

BACKGROUND The aim of this study was to assess the preventative effect of ketamine on the exaggerated postoperative pain observed in sufentanil-treated mice and its ability to improve the analgesic effectiveness of morphine during the postoperative period in an orthopaedic model of pain. METHODS In this study, we assessed the effects of ketamine on sufentanil enhancement of pain behaviour induced by fracture and the effects of ketamine on postoperative morphine-induced analgesia. Three tests were used to assess pain behaviour: von Frey filament application, hot-plate test, and a subjective pain scale. RESULTS When administered 1 day after surgery in mice treated with sufentanil on D0 (before surgery), morphine induced an analgesic effect as observed by the nociceptive threshold increase in saline- and ketamine-treated mice. Morphine was more effective in ketamine-treated (1 and 50 mg kg(-1)) mice. CONCLUSIONS Our results suggest that pre-emptive use of ketamine is useful in orthopaedic surgery in this mice model to diminish short- and long-term hyperalgesia, but also to improve morphine effectiveness leading to a better mobilization and more rapid rehabilitation.

Epidural versus continuous preperitoneal analgesia during fast-track open colorectal surgery: a randomized controlled trial.

Background:Effective postoperative analgesia is essential for early rehabilitation after surgery. Continuous wound infiltration (CWI) of local anesthetics has been proposed as an alternative to epidural analgesia (EA) during colorectal surgery. This prospective, double-blind trial compared CWI and EA in patients undergoing elective open colorectal surgery. Methods:Fifty consecutive patients were randomized to receive EA or CWI for 48 h. In both groups, patients were managed according to Enhanced Recovery After Surgery recommendations. The primary outcome was the dynamic pain score measured during mobilization 24 h after surgery (H24) using a 100-mm verbal numerical scale. Secondary outcomes were time to functional recovery, analgesic technique-related side effects, and length of hospital stay. Results:Median postoperative dynamic pain score was lower in the EA than in the CWI group (10 [interquartile range: 1.6–20] vs. 37 [interquartile range: 30–49], P < 0.001) and remained lower until hospital discharge. The median times to return of gut function and tolerance of a normal, complete diet were shorter in the EA than in the CWI group (P < 0.01 each). Sleep quality was also better in the EA group, but there was no difference in urinary retention rate (P = 0.57). The median length of stay was lower in the EA than in the CWI group (4 [interquartile range: 3.4–5.3] days vs. 5.5 [interquartile range: 4.5–7] days; P = 0.006). Conclusion:Within an Enhanced Recovery After Surgery program, EA provided quicker functional recovery than CWI and reduced length of hospital stay after open colorectal surgery.

Cerebral hemodynamic changes in severe head injury patients undergoing decompressive craniectomy.

Objective: To assess the intracranial hemodynamic modifications induced by a decompressive craniectomy (DC) after severe traumatic brain injury (TBI), using transcranial Doppler (TCD) ultrasonography and intracranial pressure (ICP) sensor. Mortality rate and neurological outcomes were also evaluated after this procedure. Design: A prospective study was carried out on 26 TBI patients, measuring transcranial Doppler and ICP before, immediately after, and 48 hours after the DC, allowing for statistical analysis of hemodynamic changes. The mortality rate and the neurological outcomes were assessed. Measurements and Results: After DC, ICP decreased from 37±17 to 20±13 mm Hg (P=0.0003). The global cerebral blood flow was modified with diastolic velocities rising from 23±15 to 31±13 cm/s (P=0.0038) and a pulsatility index decreasing from 1.70±0.66 to 1.18±0.37 (P=0.0012). This normalization of the global cerebral hemodynamics after the DC was immediate, symmetric, and constant during the first 48 hours. Outcome was evaluated at 6 months: good recovery or moderate disability was observed in 11 patients (42%), persistent vegetative state in 7 patients (27%), and 8 patients died (31%). Conclusions: The DC results in a significant, immediate, and durable improvement of ICP associated with a normalization of cerebral blood flow velocities in most TBI patients with refractory intracranial hypertension.

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.

Small-dose bupivacaine-sufentanil prevents cardiac output modifications after spinal Anesthesia

Spinal injection of small-dose (SD) bupivacaine decreases the likelihood of hypotension compared with large-dose (LD) bupivacaine. We assumed that a SD of bupivacaine could also prevent the decrease in cardiac output (CO). Patients undergoing elective urologic, lower abdominal, or lower limb surgery under spinal anesthesia were included in this prospective randomized study. Spinal injection consisted of 5 &mgr;g of sufentanil and either SD (7.5 mg of hyperbaric bupivacaine with glucosemonohydrate80 mg/mL; n = 19 patients) or LD (12.5 mg of hyperbaric bupivacaine with glucosemonohydrate80 mg/mL; n = 19 patients). CO (impedance cardiography), arterial blood pressure, and heart rate) were measured at 1 min before performance of spinal block and 2, 10, and 30 min after the intrathecal injection. Sensory level was also assessed at 30 min. CO was higher in the SD group as compared with the LD group from 2 min to 30 min after spinal anesthesia. Moreover, CO increased at 2 min in the SD group and decreased at 10 and 30 min in the LD group compared with baseline value. In conclusion, SD bupivacaine provides successful anesthesia and gives better CO stability than LD.

Increased creatinine clearance in polytrauma patients with normal serum creatinine: a retrospective observational study.

IntroductionThe aim of this study, performed in an intensive care unit (ICU) population with a normal serum creatinine, was to estimate urinary creatinine clearance (CLCR) in a population of polytrauma patients (PT) through a comparison with a population of non trauma patients (NPT).MethodsThis was a retrospective, observational study in a medical and surgical ICU in a university hospital. A total of 284 patients were consecutively included. Two different groups were studied: PT (n = 144) and NPT (n = 140). Within the second week after admission to the ICU, renal function was assessed using serum creatinine, 24 h urinary CLCR .ResultsAmong the 106 patients with a CLCR above 120 mL minute-1 1.73 m-2, 79 were PT and 27 NPT (P < 0.0001). Only 63 patients had a CLCR below 60 mL minute-1 1.73 m-2 with 15 PT and 48 NPT (P < 0.0001). Patients with CLCR greater than 120 mL minute-1. 1.73 m -2 were younger, had a lower SAPS II score and a higher male ratio as compared to those having CLCR lower than 120 mL minute-1. 1.73 m -2. Through a logistic regression analysis, age and trauma were the only factors independently correlated to CLCR.ConclusionsIn ICU patients with normal serum creatinine, CLCR, is higher in PT than in NPT. The measure of CLCR should be proposed as routine for PT patients in order to adjust dose regimen, especially for drugs with renal elimination.

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.