RESUMO
A case is reported of inadvertent insertion of a brachial plexus catheter into the cervical epidural space, at the sitting of an interscalene block for postoperative analgesia, during the recovery from general anaesthesia after surgical repair of a rupture of the rotator cuff of the shoulder. No features of cervical epidural anaesthesia were seen after the first injection of local anaesthetic, as it was made through the catheter insertion cannula. Once inserted, the catheter position was checked prior to the second injection of local anaesthetic. The X-ray obtained after catheter opacification showed the penetration of contrast medium into the epidural space. In our case, two out of the three means of prevention of this complication were not possible: a) sitting of the interscalene block before induction of anaesthesia, as the insertion conditions of the catheter are better in a conscious, sitting patient; b) adequate cannula orientation (namely medial, dorsal and slightly caudal); c) routine X-ray control of the catheter position before the first injection, associated with careful clinical monitoring for 30 min after each local anaesthetic injection.
Assuntos
Plexo Braquial , Bloqueio Nervoso/efeitos adversos , Cateterismo/efeitos adversos , Vértebras Cervicais , Espaço Epidural/diagnóstico por imagem , Humanos , Doença Iatrogênica , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Dor Pós-Operatória/terapia , Radiografia , Manguito Rotador/cirurgiaRESUMO
Morbidity and mortality following multiple trauma are high in elderly patients. Head trauma has a particularly poor prognosis. However intensive care may improve the survival rate and the quality of life in survivors, allowing those to return home.
Assuntos
Traumatismo Múltiplo/mortalidade , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Traumatismo Múltiplo/terapia , Prognóstico , Fatores de Risco , Ferimentos e Lesões/mortalidadeRESUMO
INTRODUCTION: Mechanical ventilation can initiate ventilator-associated lung injury and postoperative pulmonary complications. The aim of this study was to evaluate (1) how mechanical ventilation was comprehended by anaesthetists (physician and nurses) and (2) the need for educational programs. METHODS: A computing questionnary was sent by electronic-mail to the entire anaesthetist from Alsace region in France (297 physicians), and to a pool of 99 nurse anaesthetists. Mechanical ventilation during anaesthesia was considered as optimized when low tidal volume (6-8mL) of ideal body weight was associated with positive end expiratory pressure, FiO2 less than 50%, I/E adjustment and recruitment maneuvers. RESULTS: The participation rate was 50.5% (172 professionals). Only 2.3% of professionals used the five parameters for optimized ventilation. Majority of professionals considered that mechanical ventilation adjustment influenced the patients' postoperative outcome. Majority of the professionals asked for a specific educational program in the field of mechanical ventilation. DISCUSSION: Only 2.3% of professionals optimized mechanical ventilation during anaesthesia. Guidelines and specific educational programs in the field of mechanical ventilation are widely expected.
Assuntos
Assistência Perioperatória/estatística & dados numéricos , Respiração Artificial/efeitos adversos , Anestesia/métodos , Correio Eletrônico , França , Pesquisas sobre Atenção à Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Cuidados Intraoperatórios/métodos , Enfermeiros Anestesistas , Enfermeiras e Enfermeiros , Médicos , Respiração com Pressão Positiva , Respiração Artificial/métodosRESUMO
OBJECTIVE: Ultrasonography is in continuing expansion in anesthesiology and critical care medicine (ACCM). It is an operator-dependent tool whose contribution is partly related to the quality of the user's initial and subsequent training. Within the framework of the ACCM residency, the French north-east anesthesiology residents have an initiation to ultrasonography by 24 hours of formal lectures. The evaluation of this teaching has not yet been performed. The objective of this survey is to depict this learning and delineate the expectations of the residents. METHODS: An anonymous computerized self-rated survey, published on a specific internet website, was performed between September 2011 and January 2012, and addressed to the ACCM residents of the French north-east anesthesiology residency by the local coordinators. It consisted in several items: current abilities and aims in echography, equipment availability and frequency of use, existence of a potential independent ultrasonography training, desired improvements, evaluation of the teaching and interest of rendering it mandatory, potential interest in creating a form of assessment. RESULTS: In total, 105 questionnaires were analyzed (response rate 44%). The distribution of respondents was homogeneous from the 1st to the 5th year of residency. Thirty percent of residents had good knowledge or mastered echocardiography. Ultrasound-guiding during vascular access was the best acquired technique: 73% masterized or had good knowledge of it. The results were more mitigated regarding ultrasound-guided regional anesthesia (UGRA) (60%), trans-cranial echography (46%), FAST-echo (23%), pleuro-pulmonary echography (38%). At the end of the ACCM residency, 69% wished to master echocardiography and 86% UGRA. The echograph was used more than once a week (76%) and of easy access (93%). The teaching was mainly theoretical; 76% of the residents were unsatisfied and nine out of ten had followed an echography training outside the ACCM residency courses or intended to do so. Moreover, 78% wished a mandatory echography learning, with seminars and a strengthened practical training: 94% considered workshops indispensable, and 62% simulation sessions. An assessment of knowledge was found useful, particularly in practical form. The realization of a training rotation with echographic orientation was desired by 78% of respondents. CONCLUSION: A clear gap exists between the real capability in echocardiography and the intended one. UGRA and echocardiography raise a particular interest. The practical training in ultrasonography using simulation and workshops is to be favored.
Assuntos
Anestesiologia/educação , Internato e Residência , Ultrassonografia , Atitude do Pessoal de Saúde , Competência Clínica , Ecocardiografia , Avaliação Educacional , França , Humanos , Programas Obrigatórios , Satisfação Pessoal , Avaliação de Programas e Projetos de Saúde , Ensino/métodos , Ultrassonografia/instrumentação , Ultrassonografia/estatística & dados numéricos , Ultrassonografia Doppler Transcraniana , Ultrassonografia de IntervençãoRESUMO
Intravenous thrombolytic therapy for ischemic stroke was performed on a 75-year-old patient at recovery from cervicocephalic superficial surgery. The patient recovered totally from ischemic stroke and no neurologic sequelae was observed. Thrombolytic therapy must be performed in an intensive care unit in order to manage some bleeding events which can occur.
Assuntos
Afasia de Broca/etiologia , Fibrinolíticos/uso terapêutico , Infarto da Artéria Cerebral Média/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêutico , Doença Aguda , Idoso , Anticoagulantes/uso terapêutico , Aspirina/uso terapêutico , Colesteatoma/radioterapia , Colesteatoma/cirurgia , Otopatias/radioterapia , Otopatias/cirurgia , Orelha Externa/cirurgia , Enoxaparina/uso terapêutico , Transfusão de Eritrócitos , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico , Excisão de Linfonodo , Angiografia por Ressonância Magnética , Hemorragia Pós-Operatória/induzido quimicamente , Hemorragia Pós-Operatória/terapia , Recidiva , Ativador de Plasminogênio Tecidual/efeitos adversosRESUMO
PURPOSE: To identify preoperative factors associated with high blood losses during liver transplantation for chronic end-stage liver disease. METHODS: Four hundred and ten consecutive patients were included in this retrospective study. Blood losses were calculated, based on transfusion requirements. The population was divided into two groups: the upper quartile was defined as the high blood loss (HBL) group and the lower three quartiles as the low blood loss group. Fourteen preoperative variables were collected. Qualitative variables consisted of the type of hepatopathy, Child-Pugh's classification, sex, the surgical team's experience, previous abdominal surgery and portal hypertension. Quantitative variables were age, hemoglobin concentration Hb, platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen concentration, fibrin degradation products (FDP) and euglobulin lysis time. Univariate analysis and stepwise multivariate analysis were conducted. RESULTS: Patients in the HBL group required 12 units of red blood cell or more to maintain a Hb >/= 100g*L(-1). HBL was associated with severe liver disease, previous abdominal surgery, use of a venovenous bypass and little surgical experience in orthotopic liver transplantation (OLT). In the HBL group several hemostatic parameters were more disturbed before surgery. The multivariate analysis disclosed three independent variables associated with HBL: Hb and FDP concentrations and previous upper abdominal surgery. When combined, these resulted in a high specificity (98%) but low sensitivity to predict blood loss. CONCLUSION: Despite our efforts we were unable to identify predictive risk factors of bleeding during OLT even in a homogeneous population. Centres should evaluate their practice individually in an attempt to identify patients at high risk of being transfused.
Assuntos
Perda Sanguínea Cirúrgica/estatística & dados numéricos , Transfusão de Sangue/estatística & dados numéricos , Transplante de Fígado , Abdome/cirurgia , Análise de Variância , Contagem de Eritrócitos , Feminino , Hemostasia , Humanos , Hepatopatias/etiologia , Hepatopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Prognóstico , Estudos Retrospectivos , Fatores de RiscoRESUMO
We report a case of a major venous argon embolism during argon beam coagulation of a liver biopsy. The essential signs were an abrupt reduction in end-tidal carbon dioxide partial pressure, in SpO2 and in systolic arterial pressure, at the time of coagulation. Spontaneous recovery was observed within 10 min. Precautions in respect of usage are highlighted.
Assuntos
Argônio/efeitos adversos , Eletrocoagulação/efeitos adversos , Embolia Aérea/etiologia , Complicações Intraoperatórias , Fígado/cirurgia , Adulto , Biópsia , Dióxido de Carbono/análise , Feminino , Hemostasia Cirúrgica/efeitos adversos , Humanos , Hipotensão/etiologia , Fígado/patologia , Oxigênio/sangue , Pressão Parcial , Volume de Ventilação PulmonarRESUMO
BACKGROUND: Brachial plexus is usually approached by the supraclavicular or axillary route. A technique for selective blockade of the branches of the plexus at the humeral canal using electrolocation has recently been proposed. The aim of the present study was to assess the feasibility of this technique in the ambulatory patient and to determine the optimal sequence of nerve-blocking. METHODS: The nerves originating from the brachial plexus were located in the humeral canal, at the junction of the proximal and the middle third of the arm, with a stimulator and blocked using either lidocaine or a mixture of lidocaine and bupivacaine, depending on the anticipated duration of surgery. The minimal stimulating intensity eliciting an adequate response, type of local anaesthetic and injected volume, and time of onset of surgical anaesthesia were collected. RESULTS: The study included 503 consecutive ambulatory patients due to undergo surgery of the elbow, wrist or hand in one year. Suitable anaesthesia was obtained with the humeral blockade in 82.1% of cases. In the remaining 17.9%, an additional block at the elbow was required, mainly for ulnar and median nerves. The onset times of sensory blocks were the longest for the median nerve, similar for the radial and ulnar nerves, shorter for the musculocutaneous nerve and the shortest for the medial brachial and antebrachial cutaneous nerves. The difference was more significant with the lidocaine-bupivacaine mixture, than with lidocaine alone (P<0.001 vs P<0.05, respectively). The onset times of motor blocks were the longest for the median nerve (P<0.05) and the shortest for the musculocutaneous nerve (P<0.001). Neither nervous nor vascular complications occurred. CONCLUSION: This study shows that the nerve block at the humeral canal is an efficient and safe technique. Considering the onset times of nerve blocks, the following sequence for blockade can be recommended: median, ulnar, radial, musculocutaneous, medial (brachial and antebrachial) cutaneous nerves. The selective blockade of the main nerves of the upper limb at the humeral canal can be recommended for surgery of the forearm and the hand in the ambulatory patient.