[Combined lumbar plexus-sciatic nerve block in the emergency surgery for pertrochanteric fracture: an alternative technique in patients at high risk of anaesthetic complications]. / Bibloc lombaire et sciatique plexique pour la chirurgie urgente des fractures pertrochantériennes: une technique alternative chez les patients à haut risque anesthésique.

INTRODUCTION: emergency surgery for pertrochanteric femoral fractures (PFF) in patients at high risk of anaesthetic complications is a real challenge for surgeons due to the increased intraoperative risk. We report our experience with combined lumbar plexus-sciatic nerve block as an alternative anesthetic technique for these fractures. METHODS: we conducted a three-year descriptive, single-center, cross-sectional study including patients with a history of recent pertrochanteric femoral fractures (PFF) at high risk anaesthetic complications. Combined lumbar plexus-sciatic nerve block was performed using the common neurostimulation technique. A mixture of 20ml of lidocaine 2% and bupivacaine 0.5% (50/50) was injected into each block. The primary endpoint was the effectiveness of lumbar plexus-sciatic nerve block assessed through the rates from anesthesia-related failures defined as need for conversion into general anaesthesia (GA). The secondary endpoints were: 1) anesthetic technique, 2) intraoperative hemodynamic, respiratory and neurological impairment, and 3) outcomes and potential postoperative complications. RESULTS: the study included 30 patients. The average age of patients was 74 ± 10 years. The average admission time in the Department of Emergency Surgery was 12(5-36) hours. The average duration of the procedure was 15.20 ± 3.45 minutes. No conversion into GA was necessary. There were no statistically significant differences between the various recorded intraoperative hemodynamic and respiratory parameters (MAP, HR, SpO2) (p > 0,05). Surgical procedure duration was 46 ± 5 minutes. Surgical satisfaction was 9.7 ± 0.1. The first post-operative analgesic treatment was started after 8(1-24) hours. All patients had complete sensorimotor recovery. CONCLUSION: combined lumbar plexus-sciatic nerve block is an anesthetic alternative for urgent PFF surgery in patients at high risk of anaesthetic complications: reduced operative delays, anesthetic efficiency, hemodynamic and intraoperative respiratory stability, absence of complications due to other anesthetic techniques, rapid admission to recovery room, and good postoperative analgesia.

Opioid-free anesthesia under single injection paravertebral block combined with sevoflurane for pediatric renal surgery: a prospective observational pilot study.

Even though several studies have demonstrated the effectiveness of opioid free anesthesia (OFA) strategies in pediatric patients, OFA has not been studied in pediatric renal surgery. We, therefore, conducted a prospective observational pilot study on a total of 26 children to assess the feasibility and efficacy of using a single injection ultrasound-guided paravertebral block (PVB) at T10 level with 0.4 mL/kg bupivacaine 0.25% in combination with sevoflurane as an OFA technique in elective open renal surgery. A successful PVB (defined in terms of both hemodynamic change after the skin incision and the use of rescue analgesia) was observed in 25 children (96%). The interval between PVB and skin incision was 21 min [IQR (18-25)]. End tidal sevoflurane concentration was 2.1% [IQR (1.8-2.4)]. The median time between extubation and waking was 2.5 min [IQR (1-4)]. The median Face, Legs, Activity, cry, Consolability score in post-anesthesia care unit was 1.00 [IQR (0-2)]. Blood pressure falls were not significant at different measurement times. None of the patients had complications related to PVB, and only one patient had post-operative vomiting. PVB is an attractive method that can procure an effective OFA in combination with sevoflurane in pediatric renal surgery.

Unusual localization of bleeding under acenocoumarol: Spinal subdural hematoma.

BACKGROUND: The spinal subdural hematoma (SSH) is an extremely rare entity which represents only 4.1% of all spinal hematomas. It needs accurate diagnosis and rapid intervention because of the major neurological risk induced by spinal compression. Several etiologies have been reported: anticoagulant treatments, haematological disorders, arterio-venous malformation, repeated attempts at lumbar punctures and tumors. We report the case of an 82-year-old patient under acenocoumarol for atrial fibrillation who presented with paraplegia secondary to SSH. CASE REPORT: An 82-year-old patient with a history of ischemic heart disease and atrial fibrillation under acenocoumarol was admitted to emergency department with sudden onset of paraplegia and intense back pain associated with urinary incontinence and anal sphincter disorder. On examination his lower limb power was MRC grade 0 out of 5 in all ranges of movement bilaterally and a complete bilateral anesthesia reaching the T12 dermatome was noted. Biological test results showed an International Normalized Ratio at 10. Magnetic resonance imaging revealed a posteriorly located spinal hematoma at T12 level, measuring 36 mm with spinal cord compression. After correction of hemostasis disorders the patient was admitted to the operating room for a T11-L1 laminectomy with evacuation of the subdural hematoma. Muscle power showed a gradual improvement in the lower limbs estimated at 3/5 with regression of sphincter disorders but unfortunately a sequellar sensory impairment persisted. CONCLUSION: SSH is a rare situation of acenocoumarol bleeding incident, it should be evoked in any patient treated by this molecule with signs of spinal cord compression.

Erector spinae plane block for pediatric hip surgery -a case report.

Surgical repair of the hip is considered an extremely painful procedure. Managing pain in this surgery is challenging even with several available options, each with limitations. Erector spinae plane (ESP) block is a novel technique that has been used in different types of surgery, with promising results. Herein, we describe a case of a successful ESP block for pediatric hip surgery. In the future, ESP block could be an alternative technique for providing effective analgesia.

Anaesthetic management for awake craniotomy in brain glioma resection: initial experience in Military Hospital Mohamed V of Rabat.

The awake brain surgery is an innovative approach in the treatment of tumors in the functional areas of the brain. There are various anesthetic techniques for awake craniotomy (AC), including asleep-awake-asleep technique, monitored anesthesia care, and the recent introduced awake-awake-awake method. We describe our first experience with anesthetic management for awake craniotomy, which was a combination of these techniques with scalp nerve block, and propofol/rémifentanil target controlled infusion. A 28-year-oldmale underwent an awake craniotomy for brain glioma resection. The scalp nerve block was performed and a low sedative state was maintained until removal of bone flap. During brain glioma resection, the patient awake state was maintained without any complications. Once, the tumorectomy was completed, the level of anesthesia was deepened and a laryngeal mask airway was inserted. A well psychological preparation, a reasonable choice of anesthetic techniques and agents, and continuous team communication were some of the key challenges for successful outcome in our patient.

Anesthetic management of spontaneous cervical epidural hematoma during pregnancy: a case report.

BACKGROUND: Spontaneous spinal epidural hematoma during pregnancy is a quite rare event requiring emergent decompressive surgery in the majority of cases to prevent permanent neurological damage. Therefore, there is little data in the literature regarding anesthetic management of cervical localization during pregnancy. The potential for difficult airway management with the patient under general anesthesia is one of the major concerns that needs to be addressed to prevent further cord compression. Anesthetic management should also include measures to maintain the mean arterial pressure to improve spinal cord perfusion. Furthermore, spine surgery in pregnant patients needs special consideration in terms of positioning and in the postoperative period. CASE PRESENTATION: We present a case of a 35-year-old white woman at 21 weeks of gestation with a spontaneous cervical epidural hematoma. Fiberoptic bronchoscope-guided nasal intubation was a safe option to ensure a higher rate of successful endotracheal intubation while minimizing the risk of aggravating the injury. Her care posed other multiples challenges that required a multidisciplinary team approach. CONCLUSIONS: The case of our patient serves as a reminder of this rare condition and its implications regarding anesthesia.

Unplanned Intensive Care Unit Admission following Elective Surgical Adverse Events: Incidence, Patient Characteristics, Preventability, and Outcome.

CONTEXT: Adverse events (AEs) are a persistent and an important reason for Intensive Care Unit (ICU) admission. They lead to death, disability at the time of discharge, unplanned ICU admission (UIA), and prolonged hospital stay. They impose large financial costs on health-care systems. AIMS: This study aimed to determine the incidence, patient characteristics, type, preventability, and outcome of UIA following elective surgical AE. SETTINGS AND DESIGN: This is a single-center prospective study. METHODS: Analysis of 15,372 elective surgical procedures was performed. We defined UIA as an ICU admission that was not anticipated preoperatively but was due to an AE occurring within 5 days after elective surgery. STATISTICAL ANALYSIS: Descriptive analysis using SPSS software version 18 was used for statistical analysis. RESULTS: There were 75 UIA (0.48%) recorded during the 2-year study period. The average age of patients was 54.64 ± 18.02 years. There was no sex predominance, and the majority of our patients had an American Society of Anesthesiologist classes 1 and 2. Nearly 29% of the UIA occurred after abdominal surgery and 22% after a trauma surgery. Regarding the causes of UIA, we observed that 44 UIA (58.7%) were related to surgical AE, 24 (32%) to anesthetic AE, and 7 (9.3%) to postoperative AE caused by care defects. Twenty-three UIA were judged as potentially preventable (30.7%). UIA was associated with negative outcomes, including increased use of ICU-specific interventions and high mortality rate (20%). CONCLUSIONS: Our analysis of UIA is a quality control exercise that helps identify high-risk patient groups and patterns of anesthesia or surgical care requiring improvement.

Anesthestic management of Kassabach-Meritt Phenomenon in an adult: case report.

BACKGROUND: Kasabach-Merritt phenomenon (KMP) is characterized by a vascular tumor with profound thrombocytopenia and consumptive coagulopathy that may presents significant challenges for anesthesiologist. CASE PRESENTATION: An 87-year-old man presented with kaposiform hemangioendothelioma involving the right leg in critical condition due to massive bleeding. Hematology investigations indicated the presence of KMP. Association of this type of tumor with KMP in adults has never been reported. CONCLUSION: The present case report lays an emphasis on the potential difficulties during anesthetic management of this rare condition.

Use of sugammadex in parotid surgery: a case report.

BACKGROUND: Parotid surgery is a common ear, nose, and throat procedure. Facial nerve paralysis is the main feared complication following this surgery. To avoid this paralysis, intraoperative facial nerve monitoring is often used, but neuromuscular blocking agents interfere with this technique. Therefore, the neuromuscular blocking agent used should have a short duration of muscle relaxation. With the discovery of sugammadex, a steroidal neuromuscular blocking agent has acquired the potential to be used in place of succinylcholine. CASE PRESENTATION: A 41-year-old African woman was scheduled for a parotidectomy at our hospital. Rocuronium-induced neuromuscular block was reversed intraoperatively with sugammadex to facilitate identification of facial nerve function. The facial nerve was identified without incident, and surgical conditions were good for the removal of the tumor. During postoperative follow-up, no evidence of residual paralysis has been noted. CONCLUSIONS: In parotid surgery, the use of sugammadex allows free use of a steroidal neuromuscular blocking agent for intubation and thus intraoperative facial nerve monitoring can be done safely.