Single-shot intraoperative local anaesthetic infiltration does not reduce morphine consumption after total hip arthroplasty: a double-blinded placebo-controlled randomized study.

BACKGROUND: The infiltration of local anaesthetic (LA), ketorolac, and epinephrine has been suggested to be effective for analgesia after total hip arthroplasty (THA). The part of action of each component of the mixture remains unclear. We investigated the contribution of infiltration of ropivacaine alone on the morphine consumption during the first 24 h after surgery. METHODS: Sixty patients undergoing primary THA were included in this prospective randomized double-blinded placebo-controlled trial, after IRB approval and informed consent. Surgical and general anaesthetic management were standardized. At the end of surgery, 80 ml of ropivacaine 0.2% (160 mg) or saline was infiltrated. The primary endpoint was morphine consumption 24 h after surgery. The secondary endpoints were: visual analogue scale scores and opioid side-effects at H2, H4, H8, H12, H24, D1, D2, D3, D4, D5, rehabilitation programme progress, chronic pain level, analgesic consumption, and surgical result at 3 months and 1 yr after surgery. The observation period was 1 yr. RESULTS: Groups were similar for patient characteristic and perioperative characteristics. The ropivacaine wound infiltration did not reduce morphine consumption at 24 h [median (25th and 75th inter-quartile) 27 (17-37) mg in the ropivacaine group vs 24 (18-34) mg in the placebo group, P=0.51] or its side-effects. No effect was found on rehabilitation progress or chronic pain after 3 months or 1 yr, but these were not the main endpoints of the study. CONCLUSIONS: Ropivacaine infiltration alone did not reduce morphine consumption at 24 h after operation nor did it improve postoperative rehabilitation.

Comparison of subgluteal sciatic nerve block duration in type 2 diabetic and non-diabetic patients.

BACKGROUND: Although animal studies demonstrated delayed recovery after nerve block in laboratory models of diabetes, the duration of the action of sciatic nerve blocks clinically in patients with diabetes remains to be determined. We studied the duration of a sciatic nerve block in type 2 diabetic patients compared with non-diabetic patients. METHODS: We prospectively included consecutive patients aged 50-80 yr, with type 2 diabetes with minor nerve injury (confirmed with 5.07 at 10 g monofilament test, n=23) and non-diabetic patients (n=49) scheduled for distal lower limb surgery. Before surgery, a subgluteal sciatic nerve block (20 ml of ropivacaine 4.75 mg ml(-1)) was performed with an ultrasound approach coupled with nerve stimulation. The primary endpoint was the sensory block duration. RESULTS: There was no significant difference between groups for age, but haemoglobin A1c and creatinine values were significantly higher in the diabetic group. There was no difference in 5.07 (10 g) monofilament testing, but the diabetic group had lower scores for the 0.4 and 0.07 g tests (P<0.01). There was no significant difference in the median onset time for the sensory block (25 vs 25 min, NS), but the median duration of the sensory block (21 vs 17 h, P<0.01) and the motor block (16 vs 12 h, P<0.01) were higher in the diabetic group. No complication occurred in either group. CONCLUSIONS: These findings demonstrate that diabetic patients with pre-existing incipient neuropathy exhibit delayed recovery from the block with ropivacaine, confirming animal studies. Clinical trial registration ClinicalTrials.gov, NCT01704612.

Reusable laryngoscope blades: a more eco-responsible and cost-effective alternative.

INTRODUCTION: Consumption of single-use medical devices has increased considerably, contributing to the excessive wastage produced during surgical procedures. The present study aimed to describe a methodology to assess the transition from single-use blades (SUB) to reusable laryngoscope blades (RUB) and to assess the ecological and economic impact of the switch. METHODS: The ecological analysis was based on the life cycle assessment method. Based on 30 operating rooms in a single tertiary university hospital, the economic analysis compared the usual SUB supplier with four RUB suppliers considering different costs: blade purchasing and depreciation, reprocessing, logistics and waste management. RESULTS: In 2021, 17,200 intubations were performed requiring about 147 RUBs. Switching from SUB to RUB led to an annual saving of 26.5 tons of CO2eq (global warming impact), equivalent to 120 000 km by car. It avoids the extraction of 6.6 tons Oileq (petroleum) and 579 kg of copper (mineral resources) per year. This action also leads to a land occupation reduction of 626 m2 per year and water savings of 221.6 m3 per year. The average cost per intubation varies from 3.16 [3.15-3.16] for SUB to 2.81 [2.77-2.85] for RUB, representing an average saving of 0.35 per intubation leading to 5783.50 annual gain [5074.00-6192.00]. RUB are preferable from 3 and 86 uses from an ecological and economic viewpoint, respectively. CONCLUSION: In a model of 17,200 intubations /year, switching SUD to RUB would save 26.5 tons of CO2eq and 6.6 tons of Oileq with 5783.50 annual gain. RUBs are ecologically and cost-effective after 3 and 86 uses, respectively.

Patient satisfaction after distal upper limb surgery under WALANT versus axillary block: A propensity-matched comparative cohort study.

Distal upper limb surgery is performed under WALANT (Wide Awake Local Anesthesia No Tourniquet) in many outpatient centers because the benefits are numerous: simple, low-cost technique, with fast turnover and short length of stay. In view of a paucity of data concerning patient satisfaction, this non-randomized cohort study was designed to compare EVAN-LR anesthesia satisfaction questionnaire results (information, pain, expectation, attention, discomfort: 0-100 points) between patients receiving WALANT or axillary nerve block (AxB). After IRB approval, patients (>18 years, stable ASA 1-3) scheduled for outpatient distal upper limb surgery were prospectively enrolled in the two groups. At discharge, patients in both groups received standard information on postoperative recovery and care, with a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The primary endpoint was EVAN-LR score before discharge. Secondary endpoints were pain relief and side-effects over a 7-day period. Results were recorded as median and 25-75% interquartile range. Propensity-score-matched analysis was performed. Over the study period, from October 2019 to November 2020, 183 patients were included; 48 WALANT patients were propensity-score matched to 48 AxB patients. Pre-procedural APAIS anxiety score was lower in the WALANT than the AxB group: 9 (IQR, 6-12) vs 12 (IQR, 8-14) (p = 0.01). EVAN-LR scores were similar between the WALANT (78 [72-82]) and the AxB group (73 [67-80]). Incidences of paresthesia and of pain (NRS pain score, opioid rescue) were similar. WALANT patients had shorter length of stay: 135 (110-175) min vs 170 (110-250) min (p = 0.01). The present study demonstrated that WALANT was associated with a high level of patient satisfaction. For clinical relevance and quality of care, WALANT should be proposed in first line for distal limb surgery.

Ecoresponsible actions in operating rooms: A health ecological and economic evaluation.

BACKGROUND: In the current context of climate change, actions must be taken to improve the hospital's ecological footprint, particularly in the operating room, which is a major consumer of medical devices. METHODS: This prospective pilot study assessed the ecological and economic impacts of sustainable actions targeting medical devices designed by a multidisciplinary working group and implemented in the 24 operating rooms of a University Hospital over one year. The ecological analysis was based on the life cycle assessment method and categorized in seven impacts. The economic impact was assessed by a micro-costing analysis and divided in four main expense items: human and material resources, logistics, and waste management. RESULTS: In total, 13 actions were implemented with the aim of reducing waste volume, improving waste sorting, and increasing eco-responsible purchases. In one year, these 13 actions allowed avoiding the emission of 203 tons eq CO2. The environmental and human toxicity benefits were 707.8 and 156.2 tons of 1.4 dichlorobenzene, respectively. Concerning non-renewable resources, these actions avoided the extraction of 9 tons of oil (petroleum) and 610 kg of copper per year. These actions led to a land occupation reduction of 1071.3 m2year and to water saving of 552 m3. From the economic side, the implementation of these actions brought a gain of €3747.9 for the first year and of €5188.2 for the following years. CONCLUSION: The integration of sustainable measures in operating rooms leads to important ecological benefits and also generating savings. This more eco-responsible approach should be considered in all healthcare establishments that generate a significant annual volume of waste.

Ropivacaine versus placebo on postoperative analgesia and chronic pain following third molar extraction: A Prospective Randomized Controlled Study.

PURPOSE: The present study aimed at assessing the efficiency of ropivacaine on post-operative pain for extraction of third molars. METHODS: In a single centre, prospective, parallel, double blind randomised trial, patients scheduled for removal of all four third molars, ASA I-III patients<65 year-old patients were included. After intubation under general anesthesia (using intravenous remifentanil and propofol), for each of the third molars, 2mL of ropivacaine (7.5mg/mL) or placebo (0.9% saline solution) was injected into the vestibular capsule (total: 8mL) before extraction. At the end of surgery, similar analgesia was injected for both groups (intravenous paracetamol 1g and ketoprofene 100mg). The primary outcome was postoperative pain assessed by Visual Analog Scale (VAS). Postoperative consumption of analgesics (morphine titration in post-operative care unit when VAS>3/10, followed by oral tramadol 50mg after discharge), patient satisfaction, chronic pain (1-3 month), time in PACU and total hospitalization time were also recorded. RESULTS: A total of 50 patients were analysed in each group with similar characteristics (ropivacaine vs. control, for age (years) 18 [17-21] vs. 18 [17-21], for sex (female) 33 (66%) vs. 25 (50%), and BMI (kg/m2): 20 [19-23] vs. 21 [19-23]). Area Under the Curve for VAS pain (0 to 4h) was lower for Ropivacaine group: 0.43 [0.19-0.66] vs. 0.63 [0.43-0.87], P=0.005. Use of morphine in PACU (8 vs. 18, P=0.02) and median length of stay in ambulatory setting (5 vs. 6h, P=0.03) were reduced in Ropivacaine vs. Placebo group. At days 1 and 4, VAS of pain was higher in Ropivacaine group (respectively 4 vs. 2, P=0.006 and 3 vs. 2, P=0.05). At month 1 and 3, pain and DN4 score were similar between groups, with a median VAS pain score at 0 for both groups (P=0.42). No difference was observed for patient satisfaction and adverse events. CONCLUSIONS: Ropivacaine provides an immediate efficient pain relief after extraction of third molars without benefit after discharge. CLINICALTRIAL REGISTRATION: NCT01541059.

[Blood requirements and transfusion practice evolution in surgery]. / Evolution des besoins transfusionnels en chirurgie.

During the years 1990, the focus was on transfusion hazards and blood savings strategies. This resulted in a decrease in labile blood products consumption. For a few years, there is a reverse tendency, with a reincrease in blood products consumption. In the same time, the limit of saving strategies has been attained, by identifying the risk of lack of transfusion (or too low transfusion threshold). A so-called multimodal blood savings strategy must be set. Vigilance is mandatory concerning the blood savings strategies that are detailed by scientific societies consensus conferences. Those strategies include a good anticipation of blood requirement, improvement of surgical techniques, pre- and intra-operative autologous transfusion, blood clotting pharmacological improvements, and anesthesia techniques. Transfusion today is relatively safe. Blood requirements must be precisely assessed to avoid going from Charybdis to Scylla i.e. from over- to under-transfusion.

[Systemic toxicity with mepivacaine following axillary block in a patient with terminal kidney failure]. / Toxicité systémique à la mépivacaïne après un bloc axillaire chez un patient insuffisant rénal chronique.

As onset time and duration of sensory block are intermediate, mepivacaine is widely used for regional anaesthesia. Few reports of systemic adverse effects are available following nerve blockade with mepivacaine. We report the case of a 54-year-old patient suffering from terminal renal failure who needs the confection of an arteriovenous shunt under axillary brachial plexus block. At completion of the injection of 25 ml (375 mg) of 1.5% mepivacaine the patient presented dysarthria, mental confusion followed by a loss of verbal contact and agitation, but no convulsion or cardiac dysrythmia. The patient received midazolam and surgery was planned the following day under general anaesthesia. Plasma mepivacaine concentration at time of neurological signs was measured at 5.1 microg/ml. Prevention and treatment of systemic toxic effects after regional anaesthesia are discussed.

Seizures in the peripartum period: Epidemiology, diagnosis and management.

The occurrence of seizures in the peripartum period is a rare but particularly challenging situation. Seizures in the peripartum period could result from three categories of conditions: first and most frequent is the exacerbation of a known pre-existing seizure disorder, mainly epilepsy. A therapeutic evaluation is needed; second is the new onset of seizures due to a non-pregnancy-related problem. An accurate diagnosis and a specific treatment are required; third is range of pregnancy-related conditions. The present review focuses on this third category, with a special attention to disorders occurring in the peripartum period. It is structured in two sections. The first section is a focus on eclampsia since, based on ICU admission data, it appears to be the leading cause of pregnancy-related seizures. Its epidemiology, pathophysiology, clinical diagnosis, neuro-imaging features and recommended management are reviewed. The efficacy and safety of the recommended regimens of MgSO4 therapy are discussed, as well as controversies on the alteration of these regimens and the use of MgSO4 in women with mild preeclampsia. In the second section, the other causes of pregnancy-related new onset seizures are summarized. These include posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis, thrombotic thrombocytopenic purpura, amniotic fluid embolism, and air embolism. Noteworthy is the fact that most of these pregnancy-related seizure conditions overlap with each other, mainly in terms of clinical presentations and neuro-imaging. Therefore, the diagnosis and the treatment options should be considered on a multidisciplinary basis.

[Delay of clinical recovery from paralysis induced by atracurium: comparison between orbicularis oculi and adductor pollicis]. / Délai de récupération clinique d'une paralysie induite par l'atracurium: comparaison entre orbiculaire des paupières et adducteur du pouce.

OBJECTIVE: To compare with train-of-four stimulation the delays of the beginning of the spontaneous recovery of the orbicularis oculi and of the adductor pollicis after profound neuromuscular blockade with atracurium. STUDY DESIGN: Prospective, comparative open study. PATIENTS AND METHODS: Twenty-eight physical class ASA 1 and 2 patients under general anaesthesia (propofol, N2O, fentanyl) and profound neuromuscular blockade with atracurium. Train-of-four stimulation, every 10 s, of the ulnar nerve at the wrist (for assessing by tactile means the response of the adductor pollicis) and of the temporal branch of the facial nerve (for assessing visually the response of the orbicularis oculi). On each site, measurement of the delay between the end of the maintenance of deep neuromuscular blockade (last dose of atracurium) and the beginning of the recovery (first response to train-of-four stimulation). RESULTS: In each case, the recovery of the orbicularis oculi began earlier than the recovery of the adductor pollicis (26 +/- 9 min vs 34 +/- 9 min, P < 0.001). The delays of recovery at each site were strongly correlated (r = 0.87; P < 0.001) but the time lag between the responses varied greatly: 1 to 21 min, mean: 8 +/- 5 min, coefficient of variation: 56.6%. CONCLUSION: The orbicularis oculi should not be monitored alone for assessment of recovery from profound neuromuscular blockade by atracurium, as it predicts poorly the time of the recovery of the adductor pollicis.

[Single-dose intraincisional levobupivacaine infiltration in caesarean postoperative analgesia: a placebo-controlled double-blind randomized trial]. / Infiltration peropératoire de lévobupivacaïne après césariennes: étude randomisée en double insu contre placebo.

OBJECTIVES: The efficacy of single-dose intraincisional infiltration with levobupivacaine in postoperative analgesia and chronic pain after caesarean sections is unknown. STUDY: A placebo-controlled double-blind randomized trial. PATIENTS AND METHODS: After ethical approval, and written inform consent, 140 women scheduled for a caesarean section were randomly assigned and received 30mL of levobupivacaine 0.5% (L group) or saline (placebo-P group) into their wound. The primary endpoint was morphine consumption (using intravenous morphine patient-controlled analgesia) for the first 24h after surgery. At 1h to 48h, side effects, pain at rest and pain 2months later were recorded. RESULTS: All included patients had similar demographic and surgical characteristics. The morphine consumption was significantly lower in the L group at h6, h8 and h12 (considering both total intake and each request). At h4, the mean total morphine consumption was 25 (12) mg in the L group versus 31 (14) mg in the P group (P=0.05). Time until discharge and side effects including nausea-vomiting (14 vs 20%), wound scar complications (6 vs 8%) and chronic pain after 2months (25% in both groups complained of small pain, and 75% no pain) were similar between the two groups (P>0.05). CONCLUSION: Single-dose local infiltration of levobupivacaine 0.5% reduced opioid requirement at 12h, with no difference after 24h. www.clinicaltrials.com, number: NCT00621907.

Stroke volume optimization after anaesthetic induction: An open randomized controlled trial comparing 0.9% NaCl versus 6% hydroxyethyl starch 130/0.4.

OBJECTIVE: Postinduction hypotension during general anaesthesia could be corrected by a rapid cardiac preload optimization by fluid infusion. The type of fluid to be used in this context remains debated. The aim of our study was to compare the amount of fluid challenges required to optimize stroke volume after induction of anaesthesia with colloid (HES) or crystalloid (0.9% NaCl). DESIGN: Open randomized prospective parallel-group study. PATIENTS AND METHODS: Fifty-six adult patients scheduled to undergo orthopaedic surgery under general anaesthesia were randomly assigned to receive, either 0.9% NaCl (n=28), or HES (n=28). Cardiac preload optimization directed by oesophageal Doppler was performed after induction with fluid challenges of 250ml of solution until stroke volume (SV) no longer increased by 10%. Primary endpoint was: number of fluid challenges required to achieve SV optimization. Secondary endpoints were: number of patients responding to the first fluid challenge, proportion of patients requiring ephedrine and the ephedrine dose required to restore arterial pressure. RESULTS: Percentages of responders were 61% and 63% in the 0.9% NaCl and HES groups, respectively. Number of fluid challenges necessary for SV optimization was not significantly different between 0.9% NaCl group and HES group (2 [1-2] versus 2 [1-2], P=0.33). Number of patients needing ephedrine, and well as the associated ephedrine dose, did not differ significantly. CONCLUSIONS: Our study suggests that after induction, crystalloid and colloid expand the intravascular volume with equivalent efficacy immediately after administration and correct in a similar way the postinduction hypotension.

[Sugammadex and renal failure: a case report]. / Sugammadex et insuffisance rénale: à propos d'un cas.

We report a case of delayed rocuronium-induced deep block antagonization with sugammadex, thus requiring a total of three injections and a cumulative dose of 12 mg/kg over a 30 min period. The patient was an emergency case with full stomach that had required a rapid sequence induction. Because of hyperkaliemia due to an acute renal failure, rocuronium was preferred to succinylcholine. Use of sugammadex in the acute renal failure context is discussed.

[Triple nerve block for ambulatory knee arthroscopy]. / Tribloc (fémoral, sciatique, obturateur) pour la chirurgie ambulatoire arthroscopique de genou: étude prospective de faisabilité et d'efficacité.

BACKGROUND: The purpose of this study was to evaluate intra- and postoperative conditions of the triple nerve block technique (femoral, obturator, sciatic block) for outpatient knee arthroscopic procedures. METHODS: After written informed consent, ASA I-III patients received a combined triple nerve block with 30-40 ml lidocaine or mepivacaine (1,5%). Blocks were performed using a nerve stimulation technique. Onset time, block failure, supplemental general anesthesia (GA) or analgesia and pain score were recorded intraoperatively. After surgery, side effects (at days 0, 1, 3, 7 and after 4 weeks), patient and surgeon satisfactions were noted. RESULTS: Three hundred and twelve patients were screened and 115 triple blocks were performed (157 chose GA, 19 spinal anaesthesia, 21 exclusion for regional anaesthesia). Failed blocks occurred for 12 (10%) patients. These 12 patients received GA before surgery incision. Time to complete block was 40 (10-60) min. Supplemental GA was required for 12 patients (12%) due to surgical (n=7, 7%) or tourniquet (n=5, 5%) pain. Intraoperative surgeon satisfaction was 90 (60-100). After surgery, time to discharge the postoperative care unit was 15 (5-60) min. Pain score at rest (Visual Analog Scale) until six hours was less than 30 /100, without any additional morphine. Two patients (< 2%) failed for ambulatory discharge criteria (no relation with triple block). At day 0, 3, 5% patients suffered PONV (8% at D1), paresthesia was noted in 1.7% at D0 (0,8% D3). No other secondary effects were observed after seven days and 91% patients "would like same anaesthesia" for next surgery. CONCLUSION: We conclude that triple nerve block provided reliable intraoperative patient and surgical conditions for outpatient knee arthroscopy. Failed block (10%) was the major reason of supplemental anaesthesia. To increase surgical turn over under triple nerve block, a preoperative room may be required (block onset time).

[Peripheral nerve block in orthopaedic surgery: multicentric evaluation of practicing professionals and impact on the activity of the recovery room]. / ALR périphérique en orthopédie: évaluation multicentrique des pratiques et impact sur l'activité de la SSPI.

OBJECTIVES: Since the last national survey on evaluation of professional practice in France, many peripheral nerve blocks techniques were developed. The aim of this study was to assess the place of such techniques and their impact on the stay in recovery room after orthopaedic surgery. STUDY DESIGN: Prospective, multicentric study. PATIENTS AND METHODS: Consecutive patients receiving a regional anaesthetic technique for orthopaedic surgery over a 15-day period were included in this multicenter study (four private clinics, two non-university and three university hospitals). Characteristics of blocks, duration of stay and activity of nurses in post-anaesthetic care unit (PACU) were recorded for each patient. RESULTS: A total of 289 blocks performed in 283 patients were analyzed. A regional anaesthetic technique was performed alone or associated with a light sedation (58 and 8% respectively) or with a general anaesthesia (44%). A continuous peripheral nerve block (mainly for femoral and iliofascial blocks) was performed in 25% of patients, mostly in university hospital and private clinics (35 and 26% respectively), but only in 3% of cases in non-university hospital. Mean duration of PACU stay was 64+/-67 minutes. This time was longer when regional anaesthesia was associated to or performed after general anaesthesia. Workload of nurses was a simple supervision in 47% of the cases (in 61% of patients receiving regional anaesthesia alone vs 21% in those with general anaesthesia, p<0.05). CONCLUSION: This survey confirms that peripheral nerve block became widely used in orthopaedic surgery. This decreases the medical workload in PACU, especially for distal upper limb surgery. Regional anaesthetic techniques must be well taught during formation cursus of residents.