Bilateral continuous 3-in-1 nerve blockade for postoperative pain relief after bilateral femoral shaft surgery.

We tested the effectiveness of bilateral continuous paravascular femoral nerve blocks in a patient following bilateral femoral shaft surgery in whom other analgesic regimens were considered contraindicated or of limited effectiveness. Bilateral continuous femoral paravascular nerve blocks were performed using a previously described technique. General anesthesia was subsequently used to facilitate surgery, which was a bilateral osteosynthesis using dynamic hip screws for osteolytic metastases of the proximal extremities of both femurs. A continuous infusion of lidocaine, morphine, and clonidine was established in both femoral catheters preoperatively and used postoperatively as the principle source of analgesia. Radiographic contrast was used to document the position of both catheters and to document the spread of injectate. Visual analog scale (VAS) pain scores were recorded in the recovery room and at 4, 16, 24, 48, and 72 hours postoperatively. Plasma lidocaine levels were determined by gas chromatography at 4, 16, and 48 hours postoperatively. Sensory assessment in the distribution of the femoral, lateral cutaneous, and obturator nerves was performed to confirm the presence of sensory blockade. We successfully provided analgesia with bilateral continuous femoral paravascular nerve blocks. Pain scores at rest were consistently rated good to excellent (VAS < 20 mm). Evidence of sensory conduction block was present throughout the infusion. Plasma concentrations of lidocaine were consistently below toxic levels (1.35 to 1.65 micrograms/ml). Radiographic contrast studies failed to demonstrate movement of contrast to the level of the lumbar plexus. Bilateral continuous femoral paravascular nerve blocks can be used to provide effective and safe analgesia in patients requiring aggressive analgesia in whom other techniques may be contraindicated.

[Flexible laryngeal mask airway use during surgical burn management with head mobilisation: a feasibility study]. / Intérêt du masque laryngé renforcé au cours de la chirurgie réparatrice chez les patients brûlés nécessitant une mobilisation de la tête : étude de faisabilité.

OBJECTIVE: To evaluate the feasibility and reliability of the flexible laryngeal mask airway (LMA flexible) use during scalp skin harvesting for surgical reparation of burn sequella. STUDY DESIGN: Observational prospective descriptive study. PATIENTS AND METHODS: Following local ethic committee approval, 26 patients were included in the study during their preanaesthesia visit. The general anaesthesia induction of each patient was followed by the insertion of a LMA flexible. The number of attempts required to insert the mask and the procedure were documented. The oropharyngeal leak pressure, expired tidal volume and end tidal CO(2) were recorded in five different head positions (neutral, hyperflexion, hyperextension, right and left rotation) at the start and end of surgical procedure. In all ten study periods of 2-3 min each were evaluated. RESULTS: The airway device was inserted easily in all patients. While similar in four of the five head positions (neutral: 27.9+/-8.1 cmH(2)O, hyperextension, left and right rotation), the oropharyngeal leak pressure was significantly higher in the hyperflexion position (33.3+/-7.3 cmH(2)O). The end tidal volume was stable in all positions except hyperflexion (419+/-114 ml). While this value was significantly lower than the 471+/-68 ml recorded in the neutral position, it remained greater than 7 ml/kg. No significant change was observed for end tidal CO(2) for the ten study periods. CONCLUSION: The use of LMA flexible during surgical burn repair procedures, including head mobilisation for the harvesting of scalp skin grafts is feasible.

Fatal and non fatal cardiac arrests related to anesthesia.

PURPOSE: The aim of this study was to assess the incidence and causes of cardiac arrests related to anesthesia. METHODS: All patients undergoing anesthesia over a six year period were included in a prospective study. The cardiac arrests encountered during anesthesia and the first twelve postoperative hours in the PACU or ICU were analysed. For each arrest, partially or totally related to anesthesia, the sequence of events leading to the accident was evaluated. RESULTS: Eleven cardiac arrests related to anesthesia were identified among the 101,769 anesthetic procedures (frequency: 1.1/10,000 [0.44-1.72]). Mortality related to anesthesia was 0.6/10,000 [0.12-1.06]. Age over 84 yr and an ASA physical status > 2 were found to be risk factors of cardiac arrest related to anesthesia. The main causes of anesthesia related cardiac arrest were anesthetic overdose (four cases), hypovolemia (two cases) and hypoxemia due to difficult tracheal intubation (two cases). No cardiac arrests due to alveolar hypoventilation were noted during the postoperative periods in either PACU or ICU. At least one human error was noted in ten of the eleven cardiac arrests cases, due to poor preoperative evaluation in seven. All cardiac arrests totally related to anesthesia were classified as avoidable. CONCLUSION: Efforts must be directed towards improving preoperative patient evaluation. Anesthetic induction doses should be titrated in all ASA 3 and 4 patients. The prediction of difficult tracheal intubation, and if required, the use of awake tracheal intubation techniques, should remain a priority when performing general anesthesia.

Aprotinin decreases blood loss and homologous transfusions in patients undergoing major orthopedic surgery.

BACKGROUND: Major orthopedic surgery can be associated with dramatic blood loss, thereby requiring high-volume homologous transfusions in patients unable to benefit from blood salvage techniques. The effect of aprotinin on blood loss and transfusion requirements during orthopedic surgery for either the resection of malignancies of the removal of infected hardware was prospectively studied. METHODS: Twenty-three patients scheduled for orthopedic surgery of the hip, femur, or pelvis for sepsis or malignant tumors, all under general anesthesia, were randomly allocated to receive during operation, in a blinded manner, either aprotinin administered as a bolus of 1.106 kallikrein inactivation units (KIU) followed by an infusion of 5 x 10(5) KIU/h, or the equivalent volume of saline. The anesthesia and perioperative management, as well as the designated transfusion criteria, were standardized. The total blood loss of each patient was evaluated using intraoperative suction losses, sponge weights, and postoperative volumetric drainage. Homologous transfusion requirements were noted. Hemoglobin and hematocrit measures, as well as coagulation and fibrinolytic pathway explorations, were performed before and after surgery. Deep venous thrombosis prophylaxis was applied, and the incidence of this complication was assessed. RESULTS: Twelve patients received aprotinin. Aprotinin reduced the total blood loss from a median of 5,305 ml (range, 3,000-9,770 ml) to a median of 1,783 ml (range, 1,140-4,955 ml; P < 0.05). A blood loss reduction of 56% during surgery and 68% on discharge from the postanesthesia care unit was observed. Seven units (range, 4-16) of packed erythrocytes were transfused per patient in the placebo group, and 3 (range, 2-5) were transfused in the aprotinin group (P < 0.05). In the aprotinin group, platelet counts were higher, and postoperative prothrombin times and D. Dimer values were lower. The activated partial thromboplastin time values showed no significant difference between the two groups. No side effects were observed in the aprotinin group. A deep venous thrombosis developed in one patient in the placebo group. CONCLUSION: Aprotinin treatment during major orthopedic surgery significantly reduces both blood loss and consequent homologous blood transfusion requirements.

Comparison of the three-in-one and fascia iliaca compartment blocks in adults: clinical and radiographic analysis.

UNLABELLED: The 3-in-1 (Group 1) and fascia iliaca compartment (Group 2) blocks, two single-injection, anterior approach procedures used to simultaneously block the femoral, obturator, and lateral femoral cutaneous (LFC) nerves, were compared in 100 adults after lower limb surgery. Pain control, sensory and motor blockades, and radiographically visualized spread of local anesthetic solution were studied prospectively. Both approaches provided efficient pain control using 30 mL of 2% lidocaine with 1:200,000 epinephrine and 0.5% bupivacaine and 5 mL of contrast media (iopamidol). Complete lumbar plexus blockade was achieved in 18 (38%) Group 1 and 17 (34%) Group 2 patients (n = 50 patients per group). Sensory block of the femoral, obturator, genitofemoral, and LFC nerves was obtained in 90% and 88%, 52% and 38%, 38% and 34%, and 62% and 90% of the patients in Groups 1 and 2, respectively (P < 0.05). Sensory LFC blockade was obtained more rapidly for the patients in Group 2 (P < 0.05). Concurrent internal and external spread of the local anesthetic solution under the fascia iliaca and between the iliacus and psoas muscles was noted in 62 of the 92 block procedures analyzed radiographically. Isolated external spreads under the fascia iliaca and over the iliacus muscle were noted in 10% and 36% of the patients in Groups 1 and 2, respectively (P < 0.05). The local anesthetic solution reached the lumbar plexus in only five radiographs. We conclude that the fascia iliaca compartment block is more effective than the 3-in-1 block in producing simultaneous blockade of the LFC and femoral nerves in adults. After both procedures, blockade was obtained primarily by the spread of local anesthetic under the fascia iliaca and only rarely by contact with the lumbar plexus. IMPLICATIONS: In adults, the two anterior approaches, 3-in-1 and fascia iliaca compartment blocks, provide effective postoperative analgesia. The fascia iliaca compartment technique provides faster and more consistent simultaneous blockade of the lateral femoral cutaneous and femoral nerves. Sensory block is caused by the spread of local anesthetic solution under the fascia iliaca and only rarely to the lumbar plexus.

Causes and prediction of maldistribution during continuous spinal anesthesia with isobaric or hyperbaric bupivacaine.

BACKGROUND: Many cases of cauda equina syndrome after maldistribution of local anesthetics during continuous spinal anesthesia have been reported. In experiments, a caudad route of catheter travel and the use of hyperbaric agents have been shown to induce these limited blocks. The aim of this clinical study was to verify this hypothesis and seek a predictive factor for the maldistribution of bupivacaine. METHOD: Continuous spinal anesthesia via a 19-gauge end port spinal catheter was performed in 80 elderly patients randomly assigned to receive either isobaric or hyperbaric solutions. Successive injections of 2.5 mg bupivacaine were performed at 5-min intervals until a sensory level at or cranial to T8 was obtained. Maldistribution was defined by a sensory level caudal to T12 despite a total dose of 17.5 mg of either isobaric or hyperbaric bupivacaine. After surgery, all catheters were injected with contrast media and examined radiographically. RESULTS: The frequency of maldistribution was not significantly different in the isobaric and hyperbaric groups. A caudally oriented catheter tip was found to be a major cause of maldistribution (P < 10(-5)). A thoracic sensory level could be reached in all patients presenting a limited block by simply changing the baricity of the bupivacaine, the position of the patient, or both. The sensory level obtained 10 min after the first injection of 2.5 mg isobaric or hyperbaric bupivacaine was found to be a predictive factor of maldistribution. CONCLUSIONS: Hyperbaric solutions do not appear to be a clinical factor in the development of limited block. The principle factor causing the maldistribution of bupivacaine is the caudal orientation of the tip of the end-hole catheter rather than its level or the route of catheter travel.

Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery.

BACKGROUND: Continuous passive motion after major knee surgery optimizes the functional prognosis but causes severe pain. The authors tested the hypothesis that postoperative analgesic techniques influence surgical outcome and the duration of convalescence. METHODS: Before standardized general anesthesia, 56 adult scheduled for major knee surgery were randomly assigned to one of three groups, each to receive a different postoperative analgesic technique for 72 h: continuous epidural infusion, continuous femoral block, or intravenous patient-controlled morphine (dose, 1 mg; lockout interval, 7 min; maximum dose, 30 mg/4 h). The first two techniques were performed using a solution of 1% lidocaine, 0.03 mg/ml morphine, and 2 microg/ml clonidine administered at 0.1 ml x kg(-1) x h(-1). Pain was assessed at rest and during continuous passive motion using a visual analog scale. The early postoperative maximal amplitude of knee flexion was measured during continuous passive motion at 24 h and 48 h and compared with the target levels prescribed by the surgeon. To evaluate functional outcome, the maximal amplitudes were measured again on postoperative day 5, at hospital discharge (day 7), and at 1- and 3-month follow-up examinations. When the patients left the surgical ward, they were admitted to a rehabilitation center, where their length of stay depended on prospectively determined discharge criteria RESULTS: The continuous epidural infusion and continuous femoral block groups showed significantly lower visual analog scale scores at rest and during continuous passive motion compared with the patient-controlled morphine group. The early postoperative knee mobilization levels in both continuous epidural infusion and continuous femoral block groups were significantly closer to the target levels prescribed by the surgeon than in the patient-controlled morphine group. On postoperative day 7, these values were 90 degrees (60-100 degrees)(median and 25th-75th percentiles) in the continuous epidural infusion group, 90 degrees (60-100 degrees) in the continuous femoral block group, and 80 degrees (60-100 degrees) in the patient-controlled morphine group (P < 0.05). The durations of stay in the rehabilitation center were significantly shorter: 37 days (range, 30-45 days) in the continuous epidural infusion group, 40 days (range, 31-60 days) in the continuous femoral block group, and 50 days (range, 30-80 days) in the patient-controlled morphine group (P < 0.05). Side effects were encountered more frequently in the continuous epidural infusion group. CONCLUSION: Regional analgesic techniques improve early rehabilitation after major knee surgery by effectively controlling pain during continuous passive motion, thereby hastening convalescence.

The effects of cervical epidural anesthesia with bupivacaine on pulmonary function in conscious patients.

UNLABELLED: Cervical epidural anesthesia (CEA) can affect diaphragmatic function. We investigated the effects of CEA on the diaphragm muscle performance, breathing pattern, and respiratory drive of 10 healthy patients undergoing hand surgery before and after the administration of 0.25% and 0.375% bupivacaine. The lung volumes and flows, respiratory rate (RR), minute ventilation, respiratory cycle time, occlusion pressure, maximal inspiratory pressure (MIP), and hand grip strength were determined. ETCO2 and SpO2 were continuously monitored. The diaphragmatic excursion was evaluated using ultrasonography. Although CEA allowed painless hand rehabilitation, both 0.25% and 0.375% bupivacaine impaired diaphragmatic excursion, with values decreasing from 5.6 to 4.4 and 3.3 cm (P < 0.05), respectively, during forced sniff maneuvers. In the 0.25% and 0.375% bupivacaine groups, the values of MIP decreased from 74 to 56 and 44 cm H2O, forced vital capacity decreased from 3.8 to 3.2 and 2.8 L, and hand grip strength decreased from 43.3 to 27.8 and 20.5 kg force, respectively (P < 0.05). The tidal volume decreased from 0.8 to 0.6 and 0.5 L in the 0.25% and 0.375% bupivacaine groups, respectively, the RR increased from 14 to 18 breaths/min in both groups, and the occlusion pressure increased from 1.5 to 2.1 and 2.9 cm H2O in the 0.25% and 0.375% bupivacaine groups, respectively (P < 0.05). ETCO2 increased from 35.2 to 38.1 and 39.3 mm Hg in the 0.25% and 0.375% bupivacaine groups, respectively, and SpO2 decreased by 2% +/- 1% in the 0.375% bupivacaine group. CEA affects diaphragmatic function and the resulting lung volumes and MIP values. The observed alterations in breathing pattern and the significant increase in ventilatory drive may be caused by changes in the diaphragmatic muscle tension and an augmented CO2 load. In conclusion, we do not recommend this technique for routine postoperative hand rehabilitation using the studied bupivacaine concentrations. IMPLICATIONS: We studied cervical epidural anesthesia in healthy patients undergoing hand surgery. The technique allowed painless rehabilitation but affected breathing pattern, diaphragmatic function, and respiratory drive. We cannot recommend this technique for routine clinical use.