Subcostal TAP block: one or two sequential injections? A cadaveric study.

BACKGROUND AND OBJECTIVES: The subcostal transversus abdominis plane block (scTAPB) provides analgesia to the anterior abdominal wall but analgesic spread following a single injection remains modest and variable. The oblique scTAPB, which is performed with a continuous injection during needle progression into the TAP along the oblique subcostal line, may extend the block to the whole anterior abdominal wall but needle progression by hydrodissection may be difficult, explaining why this block is not widely used. This study investigated if two sequential scTAPB injections (2scTAPI) may reach more nerves than a single scTAPB (1scTAPI). METHODS: After institutional approval and under ultrasound guidance, a single injection of 20 mL of blue dye was performed in 16 cadaveric subjects into the TAP along the costal margin and lateral to the semilunaris line (1scTAPI). On the opposite side, a 20 mL of green solution was split into two injections (2scTAPI), using one injection medial and one lateral to the semilunaris line. Dye spread was assessed via gross anatomical dissection using an indirect method to quantify the involvement of the anterior cutaneous branches of the intercostal nerves with each technique. A nerve was considered stained if the dye was observed in the TAP, reaching the costal margin aligned with the bony extremity of its corresponding rib. RESULTS: According to the spread to the costal margin, the estimated median number of consecutive nerves reached by dye after 2scTAPI was 5 (IQR 5-6) vs 3 (IQR 3-4) for 1scTAPI (p=0.00001). Spread after 2scTAPI suggested coverage of nerves originating from T8 to T12 in 85% of the subjects, and from T7 to T12 in 5 out of 17 cases. Spread following the 1scTAPI suggested coverage of nerves from T9 to T11 in most cases. CONCLUSIONS: In a cadaveric model, a larger spread at the costal margin was obtained after 2scTAPI, suggesting a greater coverage of anterior branches of abdominal wall nerves compared with 1scTAPI. Clinical studies are needed to confirm these results.

An observer tool to enhance learning of incoming anesthesia residents' skills during simulation training of central venous catheter insertion: a randomized controlled trial.

BACKGROUND: Central venous catheter (CVC) insertion using simulation is an essential skill for anesthesiologists. Simulation training is an effective mean to master this skill. Given the large number of residents and the limited duration of training sessions, the active practice time is limited and residents remain observers of their colleagues for much of the session. To improve learning during observation periods, the use of an observer tool (OT) has been advocated but its educational effectiveness is not well defined. METHODS: Incoming anesthesia residents were randomized to use an OT (i.e. procedural skill-based checklist) (OT+) or not (OT-) when observing other residents during a simulation bootcamp. The primary outcome was a composite score (total 60 points) evaluating CVC procedural skills rated immediately after the training. This score covers theoretical knowledge explored by multiple choice questions (MCQs) (/20), perceived improvement in knowledge and skills (/20), perceived impact on future professional life (/10) and satisfaction (/10). Measurements were repeated 1 month later. Residents in each group recorded the number of CVCs placed and their clinical outcomes (attempts, complications) during the first month of their clinical rotation using a logbook. RESULTS: Immediately after training, the composite score was similar between the two groups: 45.3 ± 4.2 (OT+, n = 49) and 44.4 ± 4.8 (OT-, n = 42) (p = 0.323). Analysis of sub-items also showed no difference. Results at 1 month were not different between groups. Analysis of the logbook showed no difference between groups. No serious complications were reported. CONCLUSIONS: The use of a procedural task-based OT by incoming anesthesia residents and used during CVC insertion simulation training was not associated with better learning outcomes, neither immediately after the session nor when re-evaluated 1 month later. The training at least once on simulator of all residents could limit the impact of OT. Further studies are necessary to define the place of OT in simulation training.

Guidelines on perioperative optimization protocol for the adult patient 2023.

OBJECTIVE: The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs. DESIGN: A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS: Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format. RESULTS: The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations. CONCLUSIONS: Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Thoracic paravertebral block: comparison of different approaches and techniques. A study on 27 human cadavers.

BACKGROUND AND OBJECTIVES: The success rate and spread of thoracic paravertebral block (TPVB) are variable and difficult to predict. It is now recommended that an ultrasound guidance technique should replace the traditional landmark technique. The objective was to compare anatomical outcomes of both techniques on cadavers. METHODS: A landmark technique (loss of resistance technique [LOR]) and a USG technique (three approaches: sagittal, transversal in-plane, transverse out-of-plane) were performed on 27 thawed non-embalmed cadavers. Each of the four approaches was performed in each body (T3-T5 and T9-T11 × right and left). A coloured solution (13 mL, saline 0.9%) was injected in the targeted thoracic paravertebral space (TPVS). A successful thoracic paravertebral injection (TPVI) was defined by the presence of dye in at least one TPVS during anatomical dissection. RESULTS: In 104 TPVIs analysed, the overall success rate was 78%. Factors associated with success were: USG versus LOR technique (85% vs. 52%, P < 0.0007), sagittal versus both transversal approaches (93%/81%/83%, P < 0.0007) and right side (86% vs. 66%). The median spread was 2 TPVS (min - max 1-5) with a median cephalad-caudal spread of 5 cm (min - max 1-18). By multivariate analysis, the sagittal approach was an independent factor of success (OR 2.75). Dye spread and pleural entry were influenced by neither the approach nor the site of injection. CONCLUSIONS: Paravertebral spread of TPVI is variable. USG technique has higher anatomical success rates than the LOR technique, the sagittal USG approach being the most successful.

Percutaneous Radiofrequency Ablation of Pulmonary Metastasis and Thoracic Paravertebral Block Under Computed Tomographic Scan Guidance: A Case Report.

Pain during and after pulmonary percutaneous radiofrequency ablation (RFA) may be severe enough to require opioids. Thoracic paravertebral block (TPVB) is a regional anesthetic technique that can relieve pain during and after abdominal or thoracic painful procedures. We report the use of TPVB to relieve postprocedural pain in a 50-year-old woman after RFA of lung metastasis. The TPVB was performed under computed tomographic guidance by the anesthesiologist. The patient was pain free (rest and mobilization) during the first postoperative 36 hours. TPVB may represent an easy, safe, and effective strategy to prevent or treat postoperative pain after pulmonary RFA.

Goal-Directed Fluid Therapy Guided by Cardiac Monitoring During High-Risk Abdominal Surgery in Adult Patients: Cost-Effectiveness Analysis of Esophageal Doppler and Arterial Pulse Pressure Waveform Analysis.

BACKGROUND: Several minimally invasive techniques for cardiac output monitoring such as the esophageal Doppler (ED) and arterial pulse pressure waveform analysis (APPWA) have been shown to improve surgical outcomes compared with conventional clinical assessment (CCA). OBJECTIVE: To evaluate the cost-effectiveness of these techniques in high-risk abdominal surgery from the perspective of the French public health insurance fund. METHODS: An analytical decision model was constructed to compare the cost-effectiveness of ED, APPWA, and CCA. Effectiveness data were defined from meta-analyses of randomized clinical trials. The clinical end points were avoidance of hospital mortality and avoidance of major complications. Hospital costs were estimated by the cost of corresponding diagnosis-related groups. RESULTS: Both goal-directed therapy strategies evaluated were more effective and less costly than CCA. Perioperative mortality and the rate of major complications were reduced by the use of ED and APPWA. Cost reduction was mainly due to the decrease in the rate of major complications. APPWA was dominant compared with ED in 71.6% and 27.6% and dominated in 23.8% and 20.8% of the cases when the end point considered was "major complications avoided" and "death avoided," respectively. Regarding cost per death avoided, APPWA was more likely to be cost-effective than ED in a wide range of willingness to pay. CONCLUSIONS: Cardiac output monitoring during high-risk abdominal surgery is cost-effective and is associated with a reduced rate of hospital mortality and major complications, whatever the device used. The two devices evaluated had negligible costs compared with the observed reduction in hospital costs. Our comparative studies suggest a larger effect with APPWA that needs to be confirmed by further studies.