Opioid-free versus opioid-sparing anaesthesia in ambulatory total hip arthroplasty: a randomised controlled trial.

BACKGROUND: Enhanced recovery after surgery pathways are essential for ambulatory surgery. They usually recommend lower intraoperative opioid use to avoid opioid-related adverse effects. This has led to opioid-sparing anaesthesia (OSA) techniques, with the extreme approach of opioid-free anaesthesia (OFA) mostly with dexmedetomidine. As evidence is lacking in day-case primary total hip arthroplasty, this study was performed to assess the potential benefits in postoperative analgesia of OFA over OSA. METHODS: In this single-centre, prospective, triple blind study, we randomly allocated 80 patients undergoing day-case primary THA under general anaesthesia. Patients received a total intravenous anaesthesia with a laryngeal mask and multimodal analgesic regimen with non-opioid analgesics. The OSA group received low dose of sufentanil, and the OFA group received dexmedetomidine The primary outcome was the opioid consumption in the first 24 h in oral morphine equivalents (OME). RESULTS: There was no difference in median cumulative OME consumption at 24 h between the OSA and OFA groups (12 [0-25] mg vs 16 [0-30] mg, respectively; P=0.7). Pain scores were similar and low in both groups with comparable walking recovery time. Adverse events were sparse and equivalent in both groups except for dizziness, which was more frequent in the OSA group (P<0.05). CONCLUSIONS: In day-case total hip arthoplasty under general anaesthesia, opioid-free anaesthesia and opioid-sparing anaesthesia both provide early recovery and effective postoperative pain relief. When compared with opioid-sparing anaesthesia, opioid-free anaesthesia does not decrease opioid consumption in the first 24 h. These findings do not suggest any significant benefit from complete intraoperative avoidance of opioids. CLINICAL TRIAL REGISTRATION: NCT0507270.

Combined proximal or distal nerve blocks for postoperative analgesia after total knee arthroplasty: a randomised controlled trial.

BACKGROUND: Many regional anaesthetic techniques have been proposed to manage pain after total knee arthroplasty, but the best approach is unclear. We compared opioid consumption in the first 48 h between two different regional anaesthesia strategies in patients undergoing total knee arthroplasty. METHODS: In this single-centre, prospective study, we randomly allocated 90 patients to a combination of IPACK (interspace between popliteal artery and capsule of the posterior knee), triangle femoral and obturator nerve blocks (distal group), or a combination of sciatic, femoral, obturator, and lateral femoral cutaneous nerve blocks (proximal group). All patients received an opioid-sparing general anaesthesia regimen. The primary outcome was opioid consumption in the first 48 h. Secondary outcomes included opioid consumption in the first 24 h and verbal rating pain scores in the first 48 h. RESULTS: There was no difference in median cumulative oral morphine equivalent consumption at 48 h between the distal and the proximal block groups (33 [18-78] mg vs 30 [22-51] mg, respectively; P=0.29). Median oral morphine equivalent consumption at 24 h was higher in the distal group compared with the proximal group (30 [13-59] vs 15 [0-18], respectively; P<0.001). Verbal rating pain scores were lower in the proximal group compared with the distal group on arrival to the postanaesthesia care unit and at 6 and 12 h. CONCLUSIONS: In patients undergoing total knee arthroplasty under total intravenous general anaesthesia with a multimodal analgesia regimen, proximal nerve blocks resulted in improved pain scores in the first 12 h and reduced opioid consumption in the first 24 h when compared with distal nerve blocks. No difference in pain scores or opioid consumption was seen at 48 h. CLINICAL TRIAL REGISTRATION: NCT04499716.

Machine learning methods to improve bedside fluid responsiveness prediction in severe sepsis or septic shock: an observational study.

BACKGROUND: Passive leg raising (PLR) predicts fluid responsiveness in critical illness, although restrictions in mobilising patients often preclude this haemodynamic challenge being used. We investigated whether machine learning applied on transthoracic echocardiography (TTE) data might be used as a tool for predicting fluid responsiveness in critically ill patients. METHODS: We studied, 100 critically ill patients (mean age: 62 yr [standard deviation: 14]) with severe sepsis or septic shock prospectively over 24 months. Transthoracic echocardiography measurements were performed at baseline, after PLR, and before and after a standardised fluid challenge in learning and test populations (n=50 patients each). A 15% increase in stroke volume defined fluid responsiveness. The machine learning methods used were classification and regression tree (CART), partial least-squares regression (PLS), neural network (NNET), and linear discriminant analysis (LDA). Each method was applied offline to determine whether fluid responsiveness may be predicted from left and right cardiac ventricular physiological changes detected by cardiac ultrasound. Predictive values for fluid responsiveness were compared by receiver operating characteristics (area under the curve [AUC]; mean [95% confidence intervals]). RESULTS: In the learning sample, the AUC values were PLR 0.76 (0.62-0.89), CART 0.83 (0.73-0.94), PLS 0.97 (0.93-1), NNET 0.93 (0.85-1), and LDA 0.90 (0.81-0.98). In the test sample, the AUC values were PLR 0.77 (0.64-0.91), CART 0.68 (0.54-0.81), PLS 0.83 (0.71-0.96), NNET 0.83 (0.71-0.94), and LDA 0.85 (0.74-0.96) respectively. The PLS model identified inferior vena cava collapsibility, velocity-time integral, S-wave, E/Ea ratio, and E-wave as key echocardiographic parameters. CONCLUSIONS: Machine learning generated several models for predicting fluid responsiveness that were comparable with the haemodynamic response to PLR.

Perineural dexamethasone attenuates liposomal bupivacaine-induced delayed neural inflammation in mice in vivo.

BACKGROUND: Liposomal bupivacaine (Exparel®) is a sustained-release formulation of bupivacaine for use in surgical infiltration anaesthesia. We analysed the histological nerve toxicity and clinical effectiveness of perineural Exparel® alone or with added dexamethasone in a mouse model. METHODS: We assigned 98 mice receiving a perineural sciatic nerve injection into seven groups: sham (n=14, perineural saline), B (n=14, perineural bupivacaine), BDIP (n=14, perineural bupivacaine + intraperitoneal dexamethasone), BDPN (n=14, perineural bupivacaine + perineural dexamethasone), E (n=14, perineural Exparel®), EDIP (n=14, perineural Exparel® + intraperitoneal dexamethasone), and EDPN (n=14, perineural Exparel® + perineural dexamethasone). The duration of thermoalgesic and motor block was evaluated in 49 mice (seven mice randomly selected by group) every 30 min until recovery. Mice were killed for sciatic nerve histological assessment at 14 or 28 days. RESULTS: The median duration of motor block was 90, 120, 120, 120, 180, and 180 min and the duration of thermoalgesic block was 240, 300, 360, 360, 360, and 420 min for groups B, BDIP, BDPN, E, EDIP, and EDPN, respectively. The B group mice showed mild neural inflammation at 14 days and the E group mice showed mild neural inflammation at 28 days. Addition (intraperitoneal or perineural) of dexamethasone reduced neural inflammation induced by bupivacaine, whereas only perineural dexamethasone reduced neural inflammation induced by Exparel®. CONCLUSIONS: Perineural or systemic dexamethasone had a protective effect against the neural inflammation induced by bupivacaine, and perineural dexamethasone attenuated delayed inflammation induced by perineural Exparel®.

Diaphragmatic paralysis in obese patients in arthroscopic shoulder surgery: consequences and causes.

PURPOSE: Ambulatory process in arthroscopic shoulder surgery has boomed over past decades. Some anesthetic techniques such as interscalene block (ISB) and its surrogates are associated with diaphragmatic paralysis and might compromise outpatient procedure. HYPOTHESIS: This study aims to assess consequences of diaphragmatic paralysis in obese patients. METHODS: This prospective observational study screened patients with body mass index (BMI) ≥ 30 kg/m2 undergoing acromioplasty or supraspinatus tendon repair. Surgery was performed using brachial plexus block, and the method of brachial plexus block was left at the discretion of attending anesthesiologists. Post-operative hemidiaphragmatic paralysis was evaluated using M-mode ultrasonography and its consequences on patient ventilation were assessed: occurrence of hypoxic episode defined as oxygen saturation less than 90% (by pulse oximeter) in room air, dyspnea and failure of ambulatory procedure. Causes of diaphragmatic paralysis were also analyzed. RESULTS: Ninety-one patients were screened, 82 patients were included in this study and 37 patients (45%) presented diaphragmatic paralysis. Compared to patients without diaphragmatic paralysis, diaphragmatic paralysis was associated with dyspnea [10 (27%) versus 1 (2%); p = 0.0019], occurrence of patients presenting at least one hypoxic episode [6 (16%) versus 1 (2%); p = 0.02] and failure of ambulatory process [10 (27%) versus 1 (2%); p = 0.009]. The combination of axillary and suprascapular nerve blocks, but also low volume ISB, was found to be protective against diaphragmatic paralysis when compared to high volume ISB [Odds ratios 0.0019 (0.001-0.026) and 0.0482 (0.008-0.27), respectively; p < 0.001]. CONCLUSION: In patients with BMI ≥ 30 kg/m2 undergoing arthroscopic shoulder surgery, diaphragmatic paralysis is associated with dyspnea, occurrence of hypoxic episodes and failure of ambulatory procedure. High volume ISB and also, to a lesser extent, low volume ISB were found to be responsible for diaphragmatic paralysis. TRIAL REGISTRY NUMBER: Registration n° 2014-202.

Doppler renal resistive index for early detection of acute kidney injury after major orthopaedic surgery: a prospective observational study.

BACKGROUND: Postoperative acute kidney injury (AKI) is a cause of morbidity and mortality. Its diagnosis requires better markers than variations in diuresis or postoperative serum creatinine. OBJECTIVES: The aim of this study was to evaluate the accuracy of Doppler renal resistive index for early detection of AKI after hip or knee arthroplasty. DESIGN: A prospective observational study. SETTING: A single-centre study in a university hospital. PATIENTS: Fifty men and women older than 65 years, requiring hip or knee replacement with at least two perioperative AKI risk factors, including diabetes, arteritis, chronic heart or renal dysfunction, and prescription of angiotensin-converting enzyme (ACE) inhibitors. Exclusion criteria were poor abdominal echogenicity, arrhythmia, respiratory failure or agitation. INTERVENTION: Renal resistive index was measured preoperatively and in the postanaesthesia care unit. RESULTS: Sixteen patients presented with AKI in the postoperative period. Resistive index was increased in this group in both the preoperative [0.72 (0.69 to 0.73) vs. 0.66 (0.58 to 0.71); P = 0.01] and postoperative periods [0.75 (0.71 to 0.75) vs. 0.67 (0.62 to 0.72); P = 0.0001]. Resistive index evaluated by ROC curves and AUC to detect AKI was 0.862 [95% confidence interval (95% CI) 0.735 to 0.943]. The most accurate cut-off value was a postoperative resistive index of 0.705 (sensitivity = 94%, specificity = 71%, LR+ = 3.19 and LR- = 0.09). The grey area between 0.705 and 0.73, corresponding to the inconclusive zone, included 26% (13/50) of all the patients. CONCLUSION: Postoperative resistive index appears to be effective for early detection of AKI after major orthopaedic surgery. Resistive index can be measured in the postoperative care unit in patients at risk of AKI. TRIAL REGISTRATION NUMBER: 29-0512.

Subarachnoid hemorrhage induces an early and reversible cardiac injury associated with catecholamine release: one-week follow-up study.

INTRODUCTION: The occurrence of cardiac dysfunction is common after subarachnoid hemorrhage (SAH) and was hypothesized to be related to the release of endogenous catecholamines. The aim of this prospective study was to evaluate the relationship between endogenous catecholamine and cardiac dysfunction at the onset and during the first week after SAH. METHODS: Forty consecutive patients admitted for acute SAH without known heart disease were included. Catecholamine plasma concentrations and transthoracic echocardiography (TTE) were documented on admission, on day 1 (D1), and day 7 (D7). RESULTS: At baseline, 24 patients had a World Federation of Neurosurgical Societies score (WFNS) of one or two; the remaining 16 had a WFNS between three and five. Twenty patients showed signs of cardiac dysfunction on admission, including six with left ventricle (LV) systolodiastolic dysfunction and 14 with pure LV diastolic dysfunction. On admission, norepinephrine, epinephrine, dopamine, B-type Natriuretic Peptide (BNP) and Troponin Ic (cTnI) plasmatic levels were higher in patients with the higher WFNS score and in patients with altered cardiac function (all P <0.05). Among patients with cardiac injury, heart function was restored within one week in 13 patients, while seven showed persistent LV diastolic dysfunction (P = 0.002). Plasma BNP, cTnI, and catecholamine levels exerted a decrease towards normal values between D1 and D7. CONCLUSION: Our findings show that cardiac dysfunction seen early after SAH was associated with both a rapid and sustained endogenous catecholamine release and WFNS score. SAH-induced cardiac dysfunction was regressive over the first week and paralleled the normalization of catecholamine concentration.

Patent foramen ovale appearance with association of left ventricular assist device and mechanical ventilation.

We report on a 62-year-old man referred to the cardiac intensive care unit less than 24 hours after anterior ST-segment elevated myocardial infarction. The patient developed cardiogenic shock requiring elective intubation, vasopressor, and inotropic support. Emergency coronary angiography, revascularization, and insertion of an intraaortic balloon pump were performed. Nevertheless, the hemodynamic situation remained unstable, and a left ventricular assist device (LVAD) was inserted. Severe hypoxemia occurred several minutes after initiating the Impella Recover LD/LP 5.0 (Abiomed, Danvers, MA). Transesophageal echocardiography allowed diagnosis of patent foramen ovale. The shunt resulted from abnormal left-to-right pressure gradient due to left ventricular unloading and increased right ventricular afterload induced by mechanical ventilation. Transesophageal echocardiography was used to regulate both LVAD output and positive end-expiratory pressure settings to optimize oxygen transport. Because patent foramen ovale is common in humans, transesophageal echocardiography should be performed systematically after LVAD insertion.

Total knee arthroplasty under quadruple nerve block with ropivacaine 0.32%: effect of addition of intravenous dexmedetomidine to intravenous dexamethasone on analgesic duration.

BACKGROUND AND OBJECTIVES: Peripheral nerve blocks reduce postoperative pain and enhance recovery after total knee arthroplasty (TKA). This study aims to assess the benefits of addition of intravenous dexmedetomidine (DexM) to intravenous dexamethasone on the analgesic duration of quadruple nerve blocks. METHODS: This double-blind, randomized, controlled trial prospectively enrolled 90 patients scheduled for TKA under quadruple nerve blocks (sciatic, femoral, obturator, and lateral femoral cutaneous nerves blocks) with 70 mL, 0.32% ropivacaine. All patients received systemic dexamethasone 10 mg. Patients were randomized to receive DexM (2 µg/kg, intravenous) or placebo (1:1 ratio). The primary endpoint was the duration of analgesia defined as the time to first request for rescue analgesia (oxycodone). RESULTS: Kaplan-Meier curves for the first analgesic request were similar between groups (log-rank test; p=0.27). Median (IQR) duration of analgesia was similar between placebo (1575 min (1211-1952)) and DexM (1470 min (1263-1700)) groups (p=0.56). Cumulative consumption of oxycodone at the 48th hour was 20 mg (10-30) and 30 mg (20-40) in placebo and DexM groups, respectively (p=0.14). The day after surgery, 93% and 89% of patients were able to walk in placebo and DexM groups, respectively (p=0.46). Intravenous DexM was associated with bradycardia, hypotension and longer recovery room stay (p<0.05 for all comparisons). CONCLUSIONS: In a multimodal analgesic regimen, addition of systemic DexM (2 µg/kg) to systemic dexamethasone does not prolong the analgesic duration of quadruple nerve block with ropivacaine 0.32% after TKA. TRIAL REGISTRATION NUMBER: NCT03834129.

Obturator nerve block does not provide analgesic benefits in total hip arthroplasty under multimodal analgesic regimen: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Although regional analgesia is considered an important component of optimal pain management, use of peripheral nerve blocks for total hip arthroplasty remains controversial. Since the obturator nerve innervates the anteromedial part of the joint capsule, we hypothesized that an obturator nerve block would decrease the opioid consumption after total hip arthroplasty. METHODS: In this single center, prospective, triple blinded study, we randomly allocated 60 patients undergoing total hip arthroplasty under opioid-sparing total intravenous general anesthesia to a preoperative obturator nerve block or a sham block (placebo group) using 20 mL of ropivacaine 0.2% or saline, respectively. All patients received a multimodal analgesic regimen with non-opioid analgesics including periarticular local infiltration analgesia. The primary outcome was the intravenous opioid consumption in the post-anesthesia care unit. RESULTS: Median (IQR) intravenous oxycodone consumption in the post-anesthesia care unit was 4 (2, 7.5) mg in the obturator nerve block group and 3 (0, 4) mg in the placebo group (p=0.05). There were no differences in pain scores between groups in the first 24 hours except at arrival on the surgical ward with significant higher pain scores in the placebo group (p=0.03). The ability to stand up and walk within 24 hours was comparable between groups as was the time to first walk (180 (90, 720) vs 240 (120, 780) min for the obturator nerve block and placebo groups, respectively; p=0.62). CONCLUSIONS: Obturator nerve block did not improve postoperative opioid consumption after total hip arthroplasty performed under general anesthesia with a multimodal analgesic regimen. TRIAL REGISTRATION NUMBER: NCT04085640.

Effect of fluid challenge on renal resistive index after major orthopaedic surgery: A prospective observational study using Doppler ultrasonography.

BACKGROUND: A postoperative renal resistive index (RRI)>0.70 has the best threshold to early predict acute kidney injury (AKI). The response of RRI to a postoperative fluid challenge (FC) is unknown. The aim of our study was to assess the impact of a FC on RRI in suspected hypovolaemia patients after orthopaedic surgery. DESIGN: In this single-centre observational study, we prospectively screened 156 patients in the recovery room after having undergone a hip or knee replacement. INTERVENTIONS: Forty-six patients with a RRI>0.70 and requiring FC were included. RRI and cardiac output (CO) were measured before and immediately after a fluid challenge with 500mL of isotonic saline. A decrease in RRI>5% was considered significant (renal responders). RESULTS: Overall, FC resulted in a consistent decrease in RRI (from 0.74 [0.72-0.79] to 0.70 [0.68-0.73], P<0.01). Thirty-four patients (74%) showed a significant decrease in their RRI (from 0.74 [0.73-0.79] to 0.69 [0.67-0.72], P<0.05, versus non-responders: from 0.73 [0.72-0.75] to 0.72 [0.71-0.79], P=NS). CO increased equally among renal responders and non-responders (P=0.56). No correlation was found between changes in RRI and CO (r2=0.04; P=0.064). AKI was more common in renal non-responders (7/12) than in responders (3/34, P=0.001). CONCLUSIONS: After major orthopaedic surgery, a FC can decrease RRI in suspected hypovolaemia patients at risk of postoperative AKI, but the changes are not correlated to changes in CO. Decreases in RRI were associated with better renal outcome.

[Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study]. / Paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom: um estudo coorte prospectivo.

BACKGROUND AND OBJECTIVES: The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block. METHODS: Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥ 25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed. RESULTS: Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale (NRS) at 24 hours did not differ between groups. CONCLUSIONS: Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.

A New Step Toward Evidence of In Vivo Perineural Dexamethasone Safety: An Animal Study.

BACKGROUND AND OBJECTIVES: The aim of this study was to analyze histological nerve toxicity of perineural dexamethasone administration in combination with ropivacaine on mice. Efficacy of perineural dexamethasone in combination with regional anesthesia is clearly demonstrated. However, the safety of this procedure is still a matter of debate. METHODS: A sciatic nerve block was performed on 90 mice. Five groups, each containing 18 mice assigned randomly, were used in these experiments: the sham group (isotonic saline solution), R group (perineural ropivacaine), D group (perineural dexamethasone), RDPN group (perineural ropivacaine and perineural dexamethasone), and the RDS group (perineural ropivacaine and systemic dexamethasone). Sensory and motor blocks were evaluated every 30 minutes for 14 hours. Fourteen and 28 days after this procedure, 9 mice in each group were killed for sciatic nerve histological assessment. RESULTS: No statistical difference was observed between different groups for Wallerian degeneration (P = 0.28 at day 14 and P = 0.22 at day 28) and perineural inflammation (P = 0.9 at day 14). Motor and sensory block durations were tested for each group. A statistical difference was observed for motor block duration between the RDPN group (150 minutes [127-172 minutes]), the RDS group (120 minutes [90-120 minutes]), and the R group (60 minutes [60-90 minutes]). Sensory block duration was also statistically different: 660 minutes (660-720 minutes) in the RDPN group, 480 minutes (427-660 minutes) in RDS group, 330 minutes (240-410) in the R group. CONCLUSIONS: A combination of ropivacaine and perineural dexamethasone allows longer sensory block duration compared with ropivacaine alone or ropivacaine and systemic dexamethasone, without increased neural toxicity.

Perineural Versus Systemic Dexamethasone in Front-Foot Surgery Under Ankle Block: A Randomized Double-Blind Study.

BACKGROUND AND OBJECTIVES: Among the different adjuvants, dexamethasone is one of the most accepted to prolong the effect of local anesthetics. This study aims to determine the superiority of perineural over systemic dexamethasone administration after a single-shot ankle block in metatarsal osteotomy. METHODS: We performed a prospective, double-blind, randomized study. A total of 100 patients presenting for metatarsal osteotomy with an ankle block were randomized into 2 groups: 30 mL ropivacaine 0.375% + perineural dexamethasone 4 mg (1 mL) + 2.5 mL of systemic saline solution (PNDex group, n = 50) and 30 mL ropivacaine 0.375% + 1 mL of perineural saline solution + intravenous dexamethasone 10 mg (2.5 mL) (IVDex group, n = 50). The primary end point was the duration of analgesia defined as the time between the performance of the ankle block and the first administration of rescue analgesia with tramadol. RESULTS: Time period to first rescue analgesia with tramadol was similar in the IVDex group and the PNDex group. Data are expressed as mean (SD) or median (range). Duration of analgesia was 23.2 (9.5) hours in the IVDex group and 19 (8.2) hours in the PNDex group (P = 0.4). Consumption of tramadol during the first 48 hours was 0 mg (0-150 mg) in the IVDex group versus 0 mg (0-250 mg) in the PNDex group (P = 0.59). Four (8%) and 12 (24%) patients reported nausea or vomiting in the IVDex group and the PNDex group, respectively (P = 0.03). CONCLUSIONS: In front-foot surgery, perineural and systemic administrations of dexamethasone are equivalent for postoperative pain relief when used as an adjuvant to ropivacaine ankle block. CLINICAL TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov, identifier NCT02904538.

The hemodynamic "target": a visual tool of goal-directed therapy for septic patients.

OBJECTIVE: To improve understanding of the hemodynamic status of patients with sepsis by nursing teams through the attainment of hemodynamic parameters using a pentaxial "target" diagram as a clinical tool. Parameters include cardiac index (CI), arterial oxygen saturation (SaO2), mean arterial pressure (MAP), arterial blood lactate, and central venous oxygen saturation (ScvO2). DESIGN: Prospective descriptive study. SETTING: The intensive care unit of a university hospital. PATIENTS: During a 6-month period, 38 intubated septic shock patients were included in the study. Survivors and nonsurvivors were compared. INTERVENTIONS: MAP, CI, SaO2, ScvO2 and lactate were measured at 0, 6, 12, 24, 36, and 48 h. Measurements were recorded on the target diagram along with the norepinephrine infusion rate and the hemoglobin (Hb) level. The number of lactate and ScvO2 measurements achieved during the target period were compared to a 6-month retrospective control period just before starting the protocol. We assessed the nurse knowledge status prior to the introduction of target diagram. We then performed a post-test after implementing the new recording technique. MEASUREMENTS AND RESULTS: The nursing team expressed a positive attitude toward the target concept. The mean number of lactate and ScvO2 measurements performed for each patient during the control period was significantly lower than during the target period, and those values were rarely used as goal values before the introduction of the target diagram. At 24 hours, 46% of the survivors had achieved all the goal parameter values of the target diagram, compared to only 10% of nonsurvivors (P = .01). CONCLUSION: The target diagram is a visual multiparametric tool involving all the medical and nursing team that helps achieve goal-directed therapy for septic patients. The number of goal values reached at each time point during the first 48 hours was closely linked to mortality.

Fortuitous Diagnosis of Preexisting Neuropathy During Ultrasound-Guided Regional Anesthesia Performance: A Case Report.

Ultrasound-guided regional anesthesia requires the anesthesia provider to interpret new information. This article reports on the case of a 38-year-old man scheduled for a fifth metacarpal fracture repair. Ultrasound nerve examination revealed abnormal pathology of the axillary brachial plexus consisting of an increased volume of the terminal nerves of the brachial plexus. Ultrasound scanning initiated the subsequent diagnosis of multifocal motor neuropathy. Regional anesthesia was abandoned in favor of general anesthesia. Ultrasonography training needs to be expanded in the coming years to include awareness of the abnormal pathology, as it might impact the choice of anesthetic procedure and patient outcome.

Regional Anesthesia With Noninvasive Ventilation for Shoulder Surgery in a Patient With Severe Chronic Obstructive Pulmonary Disease: A Case Report.

Interscalene block (ISB) impairs ipsilateral lung function and generally is not used for patients with respiratory insufficiency. We present a 49-year-old man with chronic obstructive pulmonary disease scheduled for shoulder surgery. He was given a regional technique with an ISB (short-acting local anesthetic to minimize duration of diaphragmatic dysfunction) and suprascapular and axillary nerves blocks (long-acting local anesthetic). He was supported with noninvasive ventilation during the time of hemidiaphragmatic paralysis as documented by serial ultrasound examination. A discussion about ISB and its alternatives (general anesthesia versus brachial plexus block versus selective peripheral nerve blocks) always should occur for patients at risk for pulmonary complications.

The Doppler renal resistive index for early detection of acute kidney injury after hip fracture.

BACKGROUND: Postoperative acute kidney injury (AKI) is linked to an increase in morbidity and mortality, particularly in elderly populations. This study's aim was to assess the accuracy of the Doppler renal resistive index (RI) in detecting AKI at an early stage after hip fracture surgery. METHODS: This prospective single-centre study included 48 patients suffering hip fractures requiring surgery and who presented risk factors for the development of AKI. The RI was calculated preoperatively and postoperatively in patients without pain and with haemodynamic and respiratory stability. The occurrence of AKI was determined by measurements of serum creatinine according to AKIN criteria. RESULTS: Twenty-nine patients (60%) developed AKI during the first five postoperative days, without need for dialysis. The RI was increased in patients who developed postoperative AKI 0.68 (0.67-0.71) vs. 0.72 (0.7-0.73); P=0.014 for the preoperative index; and 0.6 (0.58-0.68) vs. 0.74 (0.71-0.76); P<0.0001 for the postoperative index. A postoperative index superior or equal to 0.706 is a marker for the early detection of AKI with a high sensitivity and a high specificity (76% and 89%, respectively). CONCLUSION: The calculation of the RI during the perioperative periods of hip fracture surgery predicts early and effectively the postoperative occurrence of AKI, thus allowing treatment to be anticipated so as to improve patient prognosis.

Prophylactic phenylephrine infusion for the prevention of hypotension after spinal anesthesia in the elderly: a randomized controlled clinical trial.

STUDY OBJECTIVE: Hypotension frequently occurs during spinal anesthesia (SA), especially in the elderly. Phenylephrine is effective to prevent SA-induced hypotension during cesarean delivery. The objective of this study was to evaluate the efficacy and safety of prophylactic infusion of phenylephrine after SA for orthopedic surgery in the elderly. DESIGN: This prospective, randomized, double-blind, and placebo-controlled study included 54 patients older than 60 years undergoing elective lower limb surgery under SA (injection of 10 mg of isobaric bupivacaine with 5 µg of sufentanyl). INTERVENTION: Patients were randomized to group P (100-µg/mL solution of phenylephrine solution at 1 mL/min after placement of SA) or the control group C (0.9% isotonic sodium chloride solution). The flow of the infusion was stopped if the mean arterial blood pressure (MAP) was higher than the baseline MAP and maintained or restarted at 1 mL/min if MAP was equal to or lower than the baseline MAP. Heart rate and MAP were collected throughout the case. MEASUREMENTS: Hypotension was defined by a 20% decrease and hypertension as a 20% increase from baseline MAP. Bradycardia was defined as a heart rate lower than 50 beats per minute. MAIN RESULTS: Twenty-eight patients were randomized to group P and 26 patients to group C. MAP was higher in group P than in group C (92 ± 2 vs 82 ± 2 mm Hg, mean ± SD, P< .001). The number of hypotensive episodes per patient was higher in group C compared with group P (9 [0-39] vs 1 [0-10], median [extremes], P< .01), but the number of hypotensive patients was similar between groups (19 [73%] vs 20 [71%], P= 1). The time to onset of the first hypotension was shorter in group C (3 [1-13] vs 15 [1-95] minutes, P= .004). The proportion of patients without hypotension (cumulative survival) was better in group P (P= .04). The number of hypertensive episodes per patient and the number of bradycardic episodes per patient were similar between groups (P= not significant). CONCLUSION: Prophylactic phenylephrine infusion is an effective method of reducing SA-induced hypotension in the elderly. Compared with a control group, it delays the time to onset of hypotension and decreases the number of hypotensive episodes per patient. More data are needed to evaluate clinical outcomes of such a strategy.