Anaesthetic practices for scheduled caesarean delivery: a 2005 French national survey.

BACKGROUND AND OBJECTIVE: It is not known whether anaesthetic practices for ASA I parturients undergoing scheduled caesarean delivery have changed since the last (1996) survey and how practices reflect current recommendations. METHODS: A 26-item survey questionnaire (organization of the maternity unit, preoperative evaluation, technical aspects describing regional or general anaesthesia, oxytocic and antibiotic drugs, postoperative analgesia) was distributed to all French obstetric units (excluding overseas). RESULTS: The response rate was 73% (451/621). Preoperative evaluation included a recent platelet count in 97% of responding units, and information was given to patients in 84% of cases. Antibiotic prophylaxis in accordance with French guidelines was used in 78% of units. Anaesthetic techniques were single-shot spinal, epidural, combined spinal epidural and general anaesthesia in decreasing order (92.5, 4.5, 2 and 1%, respectively). Effervescent cimetidine was the first choice in 62% of units. Cricoid pressure and succinylcholine were routinely used in 66 and 77% of units, respectively. Oxytocin was used appropriately in 65% of units. In addition to spinal or epidural opioids, paracetamol, NSAIDs and nefopam were added postoperatively in 98, 68 and 19% of units, respectively. Poorer practices were found in units having a lower annual delivery rate. CONCLUSIONS: Overall practice was in accordance with national guidelines or practice patterns defined by the expert committee. Regional anaesthesia and postoperative analgesia-related techniques particularly were adequate. Some deficits were of limited importance (antibiotic prophylaxis and oxytocin administration), whereas others (use of succinylcholine and cricoid pressure) remain of concern.

Stopping or maintaining oral anticoagulation in patients undergoing photoselective vaporization of the prostate (SOAP) surgery for benign prostate obstruction: study protocol for a multicentre randomized controlled trial.

BACKGROUND: Lower urinary tract symptoms related to benign prostatic obstruction (BPO) are frequent in men aged > 50 years. Based on the use of innovative medical devices, a number of transurethral ablative techniques have recently been developed for the surgical treatment of BPO. In recent years, GreenLight photoselective vaporization of the prostate (PVP) has been considered as a non-inferior alternative to transurethral resection of the prostate. The GreenLight PVP is usually considered as an interesting surgical option for patients treated via oral anticoagulants (OACs) with regard to its haemostatic properties. The aim of this study was to assess the impact of maintaining OAC treatment in patients undergoing PVP. METHODS: This study is a multicentre, open-label, randomized controlled trial (RCT) designed to show the non-inferiority of PVP surgery in patients with BPO treated with OACs. This study is designed to enrol 386 OAC-treated patients (treated with vitamin K antagonists and direct oral anticoagulants) who are undergoing PVP for BPO. Patients will be randomized (1:1) to either maintain or stop OAC treatment during the perioperative course. The intervention group will maintain OAC treatment until the day before surgery and resume OAC treatment the day after surgery, whereas the control group will stop OAC treatment (with or without low-molecular-weight heparin bridging therapy) according to the anaesthesia guidelines. The primary outcome of interest to be assessed is the 30-day complications rate according to the Clavien-Dindo classification. The secondary endpoint will examine the 30-day rate of haemorrhagic and thrombotic events. This study will provide 80% power to show non-inferiority, defined as not worse than a 10% (non-inferiority margin) inferior change in the proportion of patients with good outcomes (Clavien-Dindo score < 2), using two-tailed 95% confidence intervals. DISCUSSION: This first multicentre RCT in the field is underway to evaluate the safety and efficacy of PVP in patients with ongoing OAC therapy. The study results could influence the perioperative management of OACs in BPO surgery with a high level of evidence. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03297281 . Registered on 29 September 2017.

The feasibility and efficacy of short axillary catheters for emergency upper limb surgery: a descriptive series of 120 cases.

We prospectively evaluated the feasibility and efficacy of a simple method for inserting 5.1-cm brachial plexus catheters using a fascial click technique. In 120 patients, after inserting an axillary catheter by a resident and verifying adequate position using a nerve stimulator, 0.7 mL/kg 1% mepivacaine was injected. Success of blockade (analgesia at 40 min in the 4 terminal nerves), analgesia efficacy, and resident autonomy were recorded. The primary success rate was 87%. Reinjections were performed preoperatively and perioperatively in 40% and 50% of patients, respectively. The resident completed the technique in 91% of cases. We conclude that this technique is easily performed by residents in training and is associated with frequent success for anesthesia and postoperative analgesia.

The effect of a lidocaine test dose on analgesia and mobility after an epidural combination of neostigmine and sufentanil in early labor.

We previously demonstrated the effectiveness of epidural sufentanil and the cholinesterase inhibitor, neostigmine, to initiate selective labor analgesia. Because the traditional lidocaine plus epinephrine test dose (TD) may alter the effect of subsequent epidural drugs, we undertook this investigation to evaluate the impact of a lidocaine TD on analgesia from a combination of epidural neostigmine plus sufentanil administered in early labor. Eighty healthy parturients were randomly allocated to two groups to receive a 3 mL-TD, either lidocaine 2%-epinephrine (1:200,000) or saline-epinephrine (1:200,000), followed 3 min later by epidural neostigmine 500 microg plus sufentanil 10 microg. Pain scores were recorded for 30 min after injection, as was the time elapsed from initial bolus until request for supplemental analgesia. Thirty minutes after injection, adequacy of motor function was evaluated by the parturient's ability to sit, stand up, bend her knees, and walk. Lidocaine TD hastened the onset (5 min vs 15 min) and increased duration (122 +/- 53 min vs 98 +/- 54 min; P = 0.02) of analgesia from epidural neostigmine plus sufentanil bolus. In contrast, the TD did not significantly impair the ability to sit, stand up, or bend the knees. The ability to ambulate, however, was reduced (57% vs 82%; P = 0.04). In conclusion, a traditional lidocaine TD significantly enhances the analgesic effect from the epidural neostigmine plus sufentanil combination, but affects ambulation in early labor.

Spinal anesthesia failure after local anesthetic injection into cerebrospinal fluid: a multicenter prospective analysis of its incidence and related risk factors in 1214 patients.

BACKGROUND AND OBJECTIVES: Different mechanisms have been proposed to explain spinal anesthesia failure even after LA injection into the subarachnoid space. The aim of this prospective multicenter study was to assess the incidence of spinal anesthesia failure, excluding technical problems, and then to suggest independent factors leading to failure. METHODS: Consecutive spinal anesthetic procedures performed in 21 centers were included. Exclusion criteria were contraindications to spinal anesthesia and technical difficulties. Primary end point was the calculation of failure incidence. Factors leading to spinal anesthesia failure were investigated. RESULTS: One thousand two hundred fourteen spinals were included. Failure rate, reported by 17 of 21 centers, was 3.2% (95% confidence interval [CI], 2.2-4.2). A total failure (no sensory block) was noted in 41% of the 39 cases of failed block. Patients in the failure group were younger as compared with patients in the success group. Using backward logistic regression, factors associated with failure were the number of puncture attempts at 3 or more (odds ratio [OR], 2.86; 95% CI, 1.20-6.79) and the absence of the use of an adjuvant medication with the local anesthetic injected (OR, 2.32; 95% CI, 1.2-4.5). Age older than 70 years (OR, 0.3; 95% CI, 0.20-0.93) was associated with a decrease of failure. CONCLUSIONS: The results of this study showed that the incidence of spinal anesthesia failure was 3.2%. The number of puncture attempts at 3 or more and the absence of adjuvant medication associated with local anesthetic were independent factors associated with the increased risk of failure. The failure of spinal anesthesia was rare in patients older than 70 years.

Epidural administration of neostigmine and clonidine to induce labor analgesia: evaluation of efficacy and local anesthetic-sparing effect.

BACKGROUND: Epidural clonidine produces analgesia without motor impairment, and is associated with a local anesthetic-sparing effect during labor. The authors have recently demonstrated that epidural neostigmine initiates selective labor analgesia devoid of adverse effects. Both drugs possess common analgesic mechanisms mediated through spinal acetylcholine release. This study evaluates their epidural combination in parturients. METHODS: At the beginning of labor, parturients were randomly allocated to one of five groups to receive one of the following after a test dose: 150 microg epidural clonidine, 750 microg neostigmine, or 75 microg clonidine combined with 250, 500, or 750 microg neostigmine. A pain score (visual analog scale, 0-100) was recorded before administration and at regular intervals until request for a supplemental injection. Subsequent analgesia was provided by continuous epidural infusion of ropivacaine. RESULTS: Parturients did not differ regarding demographic data and initial pain score. Clonidine 150 microg , neostigmine 750 microg , and 75 microg clonidine plus 250 microg neostigmine produced ineffective and short-lasting effects. Clonidine 75 microg plus 500 microg neostigmine and 75 microg clonidine plus 750 microg neostigmine presented comparable durations of 90 +/- 32 and 108 +/- 38 min (mean +/- SD), respectively, and final analgesic efficacies, with 72.2% and 84%, respectively, of the parturients reporting a visual analog scale score of less than 30 out of 100 after 30 min. Ropivacaine use was significantly reduced in all clonidine groups (average, 9.5 mg/h) in comparison with neostigmine alone (17 +/- 3 mg/h). No adverse effects were observed for 75 mug clonidine combined with any dose of neostigmine while maternal sedation (20%) and hypotension (33%) occurred with 150 microg clonidine alone. CONCLUSIONS: Epidural clonidine, 75 microg , with 750 microg neostigmine is an effective combination to initiate selective labor analgesia without adverse effects. Clonidine use further reduces local anesthetic consumption throughout the course of labor.

The sciatic nerve block in emergency settings: a comparison between a new anterior and the classic lateral approaches.

BACKGROUND: Anterior and lateral approaches to the sciatic nerve block are performed with the patient in the supine position. This could be an important advantage when mobilization to the limb involved is limited or painful, particularly in emergency conditions. The aim of this prospective, randomized study was to compare these two sciatic nerve blockades performed in an emergency setting. MATERIAL/METHODS: 59 patients undergoing post-traumatic lower extremity surgery under a sciatic nerve block were randomly assigned to either a lateral or an anterior approach. After appropriate positioning of the 150-mm insulated needle using a nerve stimulator, 25 ml of ropivacaine 0.75% were injected. Time to perform the block, sciatic nerve depth, success rate, and patient's comfort were analyzed. RESULTS: The mean time to perform the block was 4.9+/-4.0 min in the anterior group and 6.1+/-6.9 min in the lateral group (NS). The mean depth of sciatic nerve localization was 107+/-17 mm in the anterior group and 91+/-20 mm in the lateral group (P<0.05). Although the success was similar in both group (77% in the anterior group vs 79% in the lateral group), the number of technical failure (sciatic nerve stimulation impossible) was higher with the anterior approach (86% vs 33%; p<0.05). CONCLUSIONS: These data suggest that both techniques are of similar value in an emergency setting.