Dose-response relationships of intravenous and perineural dexamethasone as adjuvants to peripheral nerve blocks: a systematic review and model-based network meta-analysis.

BACKGROUND: Superiority of perineural over intravenous dexamethasone at extending nerve block analgesia has been suggested but without considering the dose-response relationships for each route of administration. METHODS: Randomised control studies that evaluated intravenous or perineural dexamethasone as an adjuvant to unilateral peripheral nerve blocks in adults were searched up to October 2023 in MEDLINE, Central, Google Scholar, and reference lists of previous systematic reviews. The Cochrane Risk-of-Bias tool was used. A maximum effect (Emax) model-based network meta-analysis was undertaken to evaluate the dose-response relationships of dexamethasone. RESULTS: A total of 118 studies were selected (9284 patients; 35 with intravenous dexamethasone; 106 with perineural dexamethasone; dose range 1-16 mg). Studies with unclear or high risk of bias overestimated the effect of dexamethasone. Bias-corrected estimates indicated a maximum fold increase in analgesia duration of 1.7 (95% credible interval (CrI) 1.4-1.9) with dexamethasone, with no difference between perineural and intravenous routes. Trial simulations indicated that 4 mg of perineural dexamethasone increased the mean duration of analgesia for long-acting local anaesthetics from 11.1 h (95% CrI 9.4-13.1) to 16.5 h (95% CrI 14.0-19.3) and halved the rate of postoperative nausea and vomiting. A similar magnitude of effect was observed with 8 mg of intravenous dexamethasone. CONCLUSIONS: Used as an adjuvant for peripheral nerve block, intravenous dexamethasone can be as effective as perineural dexamethasone in prolonging analgesic duration, but is less potent, hence requiring higher doses. The evidence is limited because of the observational nature of the dose-response relationships and the quality of the included studies. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42020141689.

Changes in Practices After Implementation of a Patient Blood Management Program in French Surgical Departments: The National Multicenter Observational PERIOPES Study.

BACKGROUND: Patient blood management (PBM) is an evidence-based approach recommended to improve patient outcomes. Change in practices is often challenging. We report here data from French surgical departments before and after a standardized implementation of a PBM program. METHODS: This was a national, multicenter, observational study in surgical centers ("expert" centers with an already established protocol for preoperative anemia or "pilot" centers). Data from consecutive surgical patients of different specialties were retrieved before and after the implementation of a PBM program. Primary outcome variables (preoperative anemia treatment rates, transfusion rates, and length of hospital stay) before and after the implementation of a PBM program were analyzed with segmented regression adjusted on confounders (American Society of Anesthesiologists [ASA] scores and centers). RESULTS: A total of 1618 patients (ASA physical status III and IV, 38% in the first period and 45% in the second period) were included in expert (N = 454) or pilot (N = 1164) centers during the first period (January 2017-August 2022) and 1542 (N = 440 and N = 1102, respectively) during the second period (January 2020-February 2023). After implementation of the PBM program, the rate of preoperative anemia treatment increased (odds ratio, 2.37; 95% confidence interval [CI], 1.20-4.74; P = .0136) and length of hospital stay in days decreased (estimate, -0.11; 95% CI, -0.21 to -0.02; P = .0186). Transfusion rate significantly decreased only in expert centers (odds ratio, 0.17; 95% CI, 0.03-0.88; P = .0354). CONCLUSIONS: PBM practices in various surgical specialties improved significantly after the implementation of a PBM program. However, too many patients with preoperative anemia remained untreated.

Hypnosis as an alternative to general anaesthesia for paediatric superficial surgery: a randomised controlled trial.

BACKGROUND: Reducing perioperative anxiety and controlling pain in children are essential to optimise recovery and outcomes for both children and their parents. By acting on sensory and affective modulation of anxiety and pain, hypnosis is widely used in medical care, especially in anaesthesia. This randomised controlled clinical trial was designed to compare general anaesthesia and intraoperative hypnosis support for perioperative management of children undergoing superficial surgery. METHODS: Children aged 7-16 yr scheduled for day-case superficial surgery were included and randomly assigned to one of the following two groups: general anaesthesia group or hypnosis group. The primary outcome was length of hospital stay. Child and parent anxiety, child pain, and the occurrence of postoperative negative behavioural changes were also evaluated. RESULTS: Sixty children of mean age 10.3 (standard deviation: 2.6) yr were enrolled in the study. Hypnosis was successful in all but one case. The median (25th-75th percentile) length of hospital stay was shorter in the hypnosis group (120 [95-145] vs 240.5 [218-275] min; P<0.001). The general anaesthesia group was associated with a greater incidence of high levels of preoperative anxiety in children (30 vs 11%; P=0.001) and parents (55 vs 30%; P=0.05). Pain scores did not differ between groups. No negative postoperative behavioural changes were reported. CONCLUSIONS: In children aged 7-16 yr, hypnosis appears to be feasible and accepted. The quality of the perioperative experience and the rapid recovery support the use of hypnosis as an effective and safe alternative to general anaesthesia for paediatric superficial surgery. CLINICAL TRIAL REGISTRATION: NCT02505880.

Evaluation of Anemia and Iron Deficiency in French Surgical Departments: The National Multicenter Observational PERIOPES Study.

BACKGROUND: Assessment of anemia and iron deficiency before surgery is pivotal for patient blood management (PBM), but few data on current practices are available in the French context. The objective of this study was to describe anemia and iron deficiency management and blood transfusion use in surgical departments in France. METHODS: This was a national multicenter cross-sectional study in 13 public hospitals and 3 private ones (all with an interest for PBM). Data of consecutive surgical patients from different specialties were retrieved from their chart between July 30, 2019, and December 31, 2021. Data included hemoglobin, iron workup, treatment with oral/intravenous iron or erythropoiesis-stimulating agent, and transfusions. RESULTS: Data from 2345 patients (median age, 68 years; women, 50.9%; American Society of Anesthesiologists [ASA] physical status III-IV, 35.4%) were obtained. Only 5 centers had a formalized PBM program. At preoperative anesthesia visit, hemoglobin (Hb) level was assessed in 2112 (90.1%) patients and anemia diagnosed in 722 of them (34.2%). Complete iron workup was performed in 715 (30.5%) of the 2345 patients. Iron deficiency anemia was present in 219 (30.3%) of the 722 anemic patients. Among patients with anemia, only 217 (30.1%) of them were treated. A total of 479 perioperative blood transfusions were reported in 315 patients. Restrictive transfusion was not applied in 50% of transfusion episodes, and the single-unit red blood cell transfusion was also not frequent (37.2%). CONCLUSIONS: Our observational study showed that preoperative anemia was frequent, but iron deficiency was often not assessed and few patients were treated. There is an urgent need for PBM implementation in these centers.

Perioperative Iron Deficiency in Patients Scheduled for Major Elective Surgeries: A French Prospective Multicenter Cross-Sectional Study.

BACKGROUND: The management of perioperative iron deficiency is a component of the concept of patient blood management. The objective of this study was to update French data on the prevalence of iron deficiency in patients scheduled for major surgery. METHODS: The CARENFER PBM study was a prospective cross-sectional study in 46 centers specialized in orthopedic, cardiac, urologic/abdominal, or gynecological surgery. The primary end point was the prevalence of iron deficiency at the time of surgery (D-1/D0) defined as serum ferritin <100 µg/L and/or transferrin saturation (TSAT) <20%. RESULTS: A total of 1494 patients (mean age, 65.7 years; women, 49.3%) were included from July 20, 2021 to January 3, 2022. The prevalence of iron deficiency in the 1494 patients at D-1/D0 was 47.0% (95% confidence interval [CI], 44.5-49.5). At 30 days after surgery, the prevalence of iron deficiency was 45.0% (95% CI, 42.0-48.0) in the 1085 patients with available data. The percentage of patients with anemia and/or iron deficiency increased from 53.6% at D-1/D0 to 71.3% at D30 ( P < .0001), mainly due to the increase of patients with both anemia and iron deficiency (from 12.2% at D-1/D0 to 32.4% at D30; P < .0001). However, a treatment of anemia and/or iron deficiency was administered preoperatively to only 7.7% of patients and postoperatively to 21.7% (intravenous iron, 14.2%). CONCLUSIONS: Iron deficiency was present in half of patients scheduled for major surgery. However, few treatments to correct iron deficiency were implemented preoperatively or postoperatively. There is an urgent need for action to improve these outcomes, including better patient blood management.

Performance of the decarboxylation index to predict CO2 removal and minute ventilation reduction under extracorporeal respiratory support.

BACKGROUND: The aim of this study was to assess the interdependence of extracorporeal blood flow (Qec) and gas flow (GF) in predicting CO2 removal and reduction of minute mechanical ventilation under extracorporeal respiratory support. METHODS: All patients who benefited from V-V ECMO and high-flow ECCO2 R in our intensive care unit over a period of 18 months were included. CO2 removal was calculated from inlet/outlet blood port gases during the first 7 days of oxygenator use. The relationship between the Qec × GF product (named decarboxylation index and expressed in L2 /min2 ) and CO2 removal or expired minute mechanical ventilation reduction (EC MV ratio) was studied using linear regression models. RESULTS: Eighteen patients were analyzed, corresponding to 24 oxygenators and 261 datasets. CO2 removal was 393 ml/min (IQR, 310-526) for 1.8 m2 oxygenators and 179 ml/min (IQR, 165-235) for 1.3 m2 oxygenators. The decarboxylation index was associated linearly with CO2 removal (R2  = 0.62 and R2  = 0.77 for the two oxygenators, respectively) and EC MV ratio (R2  = 0.72 and R2  = 0.62, respectively). The 20L2 /min2 value (considering Qec = 2 L/min and GF = 10 L/min) was associated with an EC MV ratio between 61% and 29% for 1.8 m2 oxygenators, and between 62% and 38% for 1.3 m2 oxygenators. CONCLUSION: The decarboxylation index is a simple parameter to predict CO2 removal and EC MV ratio under extracorporeal respiratory support.

Comparison of continuous with single-injection regional analgesia on patient experience after ambulatory orthopaedic surgery: a randomised multicentre trial.

BACKGROUND: The optimal approach to improving patient experience and analgesia after ambulatory orthopaedic surgery remains unclear. METHODS: This multicentre, randomised clinical trial compared single-injection nerve block analgesia with home delivery of continuous nerve block analgesia by remote-controlled electronic pump. The primary outcome was patient-reported satisfaction (Evaluation du Vecu de l'Anesthesie Generale [EVAN-G]; 0-100) assessed on postoperative Day 2. Secondary outcomes focused on pain, opioid consumption, quality of rehabilitation, activity tracking using a wearable electronic device, and 90-day quality of life. RESULTS: We randomly assigned 294 patients to continuous pump delivery or single injection. For subjects with normal level of pain catastrophising (Pain Catastrophizing Scale <30; n=211), median global EVAN-G was higher with the electronic pump compared with the single injection (78 [69-86] vs 72 [63-84]; P=0.03), as were pain satisfaction scores (P=0.01). For the maximum pain levels, the numerical rating scale score was 2.0 (1.0-5.0) in the electronic-pump group vs 5.0 (3.0-7.0) in the single-injection group on the first 2 days after surgery (P<0.0001). Total opioid consumption in morphine equivalent was higher with single injection (mean [standard deviation]): 70.5 [73.8] vs 31.9 [54.2] mg; P<0.01). The groups did not differ in early rehabilitation on Day 1 or quality of life on Day 45. Electronic activity tracking indicated higher activity in the electronic-pump group (P<0.01). CONCLUSIONS: Self-reported patient satisfaction at home was better with continuous nerve block analgesia via electronic pump vs single injection, without impairing early rehabilitation. Single-injection analgesia was associated with higher pain levels and opioid consumption and lower satisfaction. Patient catastrophising negatively affected the experience of pain. CLINICAL TRIAL REGISTRATION: NCT02720965.

Posterior Quadratus Lumborum Block in Total Hip Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Pain management is important for ensuring early mobilization after hip arthroplasty; however, the optimal components remain controversial. Recently, the quadratus lumborum block has been proposed as an analgesic option. The current study tested the hypothesis that the posterior quadratus lumborum block combined with multimodal analgesia decreases morphine consumption after hip arthroplasty. METHODS: This study was a prospective, randomized, double-blind, placebo-controlled trial. Before general anesthesia, 100 participating patients scheduled for elective total hip arthroplasty were randomly allocated to receive a 30-ml injection posterior to the quadratus lumborum muscle with either 0.33% ropivacaine (n = 50) or normal saline (n = 50). For all patients, multimodal analgesia included systematic administration of acetaminophen, ketoprofen, and a morphine intravenous patient-controlled analgesia. The primary outcome was total intravenous morphine consumption in the first 24 h. Secondary outcomes recorded intraoperative sufentanil consumption; morphine consumption in the postanesthesia care unit; pain scores at extubation and at 2, 6, 12, and 24 h; motor blockade; time to first standing and ambulation; hospital length of stay; and adverse events. RESULTS: There was no significant difference in the 24-h total morphine consumption (ropivacaine group, median [interquartile range], 13 [7 to 21] versus saline group, 16 [9 to 21] mg; median difference, -1.5; 95% CI, -5 to 2; P = 0.337). Pain scores were not different between the groups (ß = -0.4; 95% CI, -0.9 to 0.2; P = 0.199). There was no statistical difference between the two groups in intraoperative sufentanil consumption, morphine consumption in the postanesthesia care unit, motor blockade, times to first standing (median difference, 0.83 h; 95% CI, -1.7 to 3.4; P = 0.690) and ambulation (median difference, -1.85 h; 95% CI, -4.5 to 0.8; P = 0.173), hospital length of stay, and adverse events. CONCLUSIONS: After elective hip arthroplasty, neither morphine consumption nor pain scores were reduced by the addition of a posterior quadratus lumborum block to a multimodal analgesia regimen.

Real-Time Injection Pressure Sensing and Minimal Intensity Stimulation Combination During Ultrasound-Guided Peripheral Nerve Blocks: An Exploratory Observational Trial.

BACKGROUND: Nerve damage can occur after peripheral nerve block (PNB). Ultrasound guidance does not eliminate the risk of intraneural injection or nerve injury. Combining nerve stimulation and injection pressure (IP) monitoring with ultrasound guidance has been suggested to optimize needle tip location in PNB. In this prospective observational study, we hypothesized that measured pairs of IP and minimum intensity of stimulation (MIS) might differentiate successive needle tip locations established by high-resolution ultrasound during PNB. METHODS: For this exploratory study, 240 observations for 40 ultrasound-guided PNBs were studied in 28 patients scheduled for orthopedic surgery. During the progression of the needle to the nerve observed by ultrasonography, the IP was measured continuously using a computerized pressure-sensing device with a low flow rate of solution. Stimulation thresholds and electrical impedance were obtained by an impedance analyzer coupled to the nerve stimulator at 6 successive needle positions. The median (quartile) or mean (95% confidence interval [CI]) was reported. A mixed model analysis was used, and the sample was also explored using a classification and regression tree (CART) algorithm. RESULTS: Specific combinations of IP and MIS were measured for subcutaneous, epimysium contact, intramuscular, nerve contact (231 mm Hg [203-259 mm Hg] and 1.70 mA [1.38-2.02 mA]), intraneural location (188 mm Hg [152-224 mm Hg] and 0.58 mA [0.46-0.70 mA]), and subparaneural location (47 mm Hg [41-53 mm Hg] and 1.35 mA [1.09-1.61 mA]). The CART algorithm shows that the optimal subparaneural needle tip position might be defined by the lowest pressure (<81.3 mm Hg) and MIS (<1.5 mA) cutoffs. CONCLUSIONS: Our exploratory study evaluated concepts to generate hypotheses. The combinations of IP and MIS might help the physician during a PNB procedure. A low IP and low MIS might confirm a subparaneural location, and a high IP and a low MIS might be an alert for the intraneural location of the needle tip.

Macintosh Videolaryngoscope for Intubation in the Operating Room: A Comparative Quality Improvement Project.

BACKGROUND: "Macintosh"-videolaryngoscopes (VLs) are VLs that allow both direct and indirect laryngoscopy for intubation. We describe the decision-making and implementation-processes that our hospital used regarding the choice of device. We compared the performances of 4 Macintosh-VLs both in direct and indirect laryngoscopy. METHODS: A quality-improvement-project for airway management aiming at implementing Macintosh-VL for all intubation procedures performed in the operating room, involving 4 Macintosh-VLs (McGrath-Mac, C-MAC-S, C-MAC-S-Pocket-Monitor [PM], and APA). Three consecutive steps were described: (1) direct laryngoscopy with Macintosh-VL, (2) indirect laryngoscopy with Macintosh-VL (intubation attempt with Macintosh-style blade in case of Cormack I or II), (3) intubation attempt with hyperangulated blade in case of Cormack III/IV or failure of Macintosh-style blade. The main end point was the need to move to step III and use a hyperangulated blade. A mixed-effects multivariable logistic regression analysis was performed to compare devices on the main end point while considering site as a random effect. Comparison of means was performed using analysis of variance and Tukey's test for multiple comparisons (number of laryngoscopy attempts, numeric rate scale [NRS] difficulty of intubation and NRS user-friendliness). Comparison of percentages was performed using a χ2 test for the need to move to step III and a Kruskal-Wallis test for the quality of image (bad, passable, good, very good, excellent). A P value ≤.008 was considered statistically significant. RESULTS: From May to September 2017, 589 patients were included. Using the McGrath-Mac (22/180 [12%]) was associated with less use of hyperangulated blade than using the C-MAC-S (39/132 [30%], odds ratio [OR] [99.2% confidence interval {CI}] 0.34 [0.16-0.77], P = .0005), the APA (35/138 [25%], OR [99.2% CI] 0.42 [0.19-0.93]; P = .004), but not the C-MAC-S-PM (29/139 [21%], OR [99.2% CI] 0.53 [0.23-1.2]; P = .04).Overall, the number of intubation attempts was significantly lower using the McGrath Mac than the C-MAC-S or the C-MAC-S-PMVLs. Subjective appreciation of intubation difficulty and user-friendliness of the devices showed respectively lower and higher NRS scores for the McGrath-Mac compared to the other devices, whereas subjective assessment of image quality showed higher quality for the C-MAC-S and C-MAC-S-PM compared to the APA or McGrath-Mac. CONCLUSIONS: Among 4 single-use Macintosh-VLs, glottic visualization in direct and indirect laryngoscopy with the Macintosh-style blade was significantly improved with the McGrath-Mac compared to other Macintosh-VLs, leading to a less frequent need to resort to the hyperangulated blade and reduced overall number of intubation attempts.

Structural recirculation and refractory hypoxemia under femoro-jugular veno-venous extracorporeal membrane oxygenation.

The performance of each veno-venous extracorporeal membrane oxygenation (vv-ECMO) configuration is determined by the anatomic context and cannula position. A mathematical model was built considering bicaval specificities to simulate femoro-jugular configuration. The main parameters to define were cardiac output (QC ), blood flow in the superior vena cava (QSVC ), extracorporeal pump flow (QEC ), and pulmonary shunt (kS-PULM ). The obtained variables were extracorporeal flow ratio in the superior vena cava (EFRSVC  = QEC /[QEC  + QSVC ]), recirculation coefficient (R), effective extracorporeal pump flow (Qeff-EC  = [1 - R] × QEC ), Qeff-EC /QC ratio, and arterial blood oxygen saturation (SaO2 ). EFRSVC increased logarithmically when QEC increased. High QC or high QSVC /QC decreased EFRSVC (range, 68%-85% for QEC of 5 L/min). R also increased following a logarithmic shape when QEC increased. The R rise was earlier and higher for low QC and high QSVC /QC (range, 12%-49% for QEC of 5 L/min). The Qeff-EC /QC ratio (between 0 and 1) was equal to EFRSVC for moderate and high QEC . The Qeff-EC /QC ratio presented the same logarithmic profile when QEC increased, reaching a plateau (range, 0.67-0.91 for QEC /QC  = 1; range, 0.75-0.94 for QEC /QC  = 1.5). The Qeff-EC /QC ratio was linearly associated with SaO2 for a given pulmonary shunt. SaO2  < 90% was observed when the pulmonary shunt was high (Qeff-EC /QC  ≤ 0.7 with kS-PULM  = 0.7 or Qeff-EC /QC  ≤ 0.8 with kS-PULM  = 0.8). Femoro-jugular vv-ECMO generates a systematic structural recirculation that gradually increases with QEC . EFRSVC determines the Qeff-EC /QC ratio, and thereby oxygen delivery and the superior cava shunt. EFRSVC cannot exceed a limit value, explaining refractory hypoxemia in extreme situations.

Effect of a temporary lying position on cerebral hemodynamic and cerebral oxygenation parameters in patients with severe brain trauma.

BACKGROUND: Temporary transition from the half-seated position (HSP) to the lying position (LyP) is often associated with an increase in intracranial pressure (ICP) during management of patients with severe traumatic brain injury (TBI). This study was designed to assess the impact of the temporary LyP on cerebral perfusion and oxygenation in cases of severe TBI. METHOD: Patients with a severe blunt TBI with indication of ICP monitoring were prospectively included. Patients underwent standardized management according to the international guidelines to minimize secondary insults. For each patient, a maneuver to a LyP for 30 min was performed daily during the first 7 days of hospitalization. ICP, cerebral perfusion pressure (CPP), mean velocity (Vm), pulsatility index (PI), regional cerebral oxygen saturation (rScO2), jugular venous oxygen saturation (SvjO2)) were compared in the HSP and the LyP. RESULTS: Twenty-four 24 patients were included. The median Glasgow coma scale score was 6 (interquartile range (IQR), 3-8), the median injury severity score was 32 (IQR, 25-48), and the mean age was 39 ± 16 years. On day 1, ICP (+ 6 mmHg (IQR, 4-7 mmHg)) and CPP (+ 10 mmHg (IQR, 5-14 mmHg) were significantly increased in the LyP compared with the HSP. Vm increased significantly in the LyP on the mainly injured side (+ 6 cm/s (IQR, + 0-11 cm/s); P = 0.01) and on the less injured side (+ 4 cm/s (IQR, + 1-8 cm/s); P < 0.01). rScO2 behaved similarly (+ 2 points (IQR, + 2-4 points) and + 3 points (IQR, + 2-5 points), respectively; P < 0.001). Mixed models highlighted the significant association between the position and CPP, Vm, rScO2, with more favorable conditions in the lying position. CONCLUSIONS: Within the first week of management, the temporary LyP in cases of severe TBI was associated with a moderate increase in CPP, Vm, and rScO2despite a moderate increase in ICP.

Preoperative erythropoietin within a patient blood management program decreases both blood transfusion and postoperative anemia: a prospective observational study.

BACKGROUND: In orthopedic surgery, a patient blood management program (PBM) has been proposed to reduce blood transfusion. The aim of this observational study was to assess, within a PBM, the specific efficacy of preoperative erythropoietin (EPO). STUDY DESIGN AND METHODS: In a single hospital, 723 patients undergoing elective primary hip or knee arthroplasty were prospectively studied. The PBM included EPO if preoperative hemoglobin was lower than 13 g/dL, intraoperative administration of tranexamic acid, use of recommended transfusion thresholds, and postoperative infusion of iron. Blood transfusion and hemoglobin were noted until discharge. Major thromboembolic or cardiovascular events were assessed during admission and 1 month after discharge. RESULTS: Transfusion was noted in 2.5% patients with EPO. Transfusion rate was higher in patient for whom EPO was not indicated (13.6% transfusion rate; odds ratio [OR], 13.7; 95% confidence interval [CI], 2.6-66; p = 10-3 ) or if erythropoietin was indicated but not administrated (36.8% transfusion rate; OR, 18.2; 95% CI, 3.9-84.5; p < 10-3 ). Hemoglobin was significantly higher during the postoperative period in patients with erythropoietin. At hospital discharge, 57% of patients were anemic if EPO was used compared to 88% when EPO was not indicated and 87% when EPO was indicated but not administered (p < 10-6 ). There were no significant differences in the odds of major complications between patients with or without EPO. CONCLUSIONS: Within a PBM, preoperative treatment of anemia with EPO decreased both the rate of blood transfusion and postoperative anemia. Further studies are necessary to confirm these results.

Early detection of intraneural and intravascular injections with real-time injection pressure monitoring in cadavers.

BACKGROUND AND OBJECTIVES: Injection pressure monitoring can help detecting the needle tip position and avoid intraneural injection. However, it shall be measured at the needle tip in order to be accurate and reproducible with any injection system and non operator-dependent. With an innovative system monitoring the injection pressure right at the needle tip we show that it is possible to early detect an intraneural and also an intravascular injection. METHODS: We performed supraclavicular block-like procedures under real-time ultrasound guidance on two fresh cadaver torsos using a sensing needle with an optical fiber pressure sensor within the shaft continuously measuring injection pressure at the needle tip. A total of 45 ultrasound-guided injections were performed (15 perineural, 15 intraneural and 15 intravenous injections). RESULTS: Mean (SD) injection pressure after only 1 mL injected volume was already significantly higher for the intraneural compared to the perineural injections: 70.46 kPa (11.72) vs 8.34 (4.68) kPa; P < .001. Mean (SD) injection pressure at 1 mL injected volume was significantly lower for the intravascular compared to the perineural injections: 1.51 (0.48) vs 8.34 (4.68) kPa; P < .001. CONCLUSIONS: Our results show that injection pressure monitoring at the needle tip has the potential to help identifying an accidental intraneural or intravascular injection at a very early stage.

The Frontal Bone Window for Transcranial Doppler Ultrasonography in Critically Ill Patients: Validation of a New Approach in the ICU.

BACKGROUND AND OBJECTIVE: The temporal bone window (TBW) for transcranial Doppler (TCD) often fails to insonate the anterior cerebral artery (ACA). The frontal bone window (FBW) has never been evaluated in intensive care units (ICU). The main objective was to determine the ability of the FBW to assess ACA velocities in critically ill patients. METHODS: A prospective study was conducted in two ICUs of the Montpellier University Hospital (France), between November 2014 and September 2016. Adult patients admitted to ICU for brain injury, with a Glasgow Coma Scale score ≤ 13, were enrolled within 3 days after admission. A first TCD examination was carried out bilaterally through the TBW and FBW by an intensivist expert in TCD, repeated by the same examiner, and 15 min later by an intensivist certified in TCD, designated as non-expert, blinded. The success of the FBW examinations was defined by the ability to measure the ACA velocities. Intra- and interobserver agreements were analyzed according to the Bland and Altman method. RESULTS: A total of 147 patients were analyzed. The FBW succeeded in insonating the ACA in 66 patients [45%, CI (37-53)], 45 bilaterally and 21 unilaterally. For 16 patients (11%), the FBW was the only way to measure ACA velocities. By combining the two techniques, the ACA success rate increased from 62% CI (54-70) to 73% CI (65-79) (P = 0.05). Intra- and interobserver mean biases and 95% limits of agreement for ACA systolic velocity measurements through the FBW were 1 (- 33 to 35) and 2 (- 34 to 38) cm s-1, respectively. For paired TBW and FBW measures of ACA velocities, mean biases (± SD) for ACA systolic, and mean and diastolic velocities were relatively close to zero, but negatives (- 7 ± 33, - 2 ± 19, - 1 ± 15 cm s-1, respectively), highlighting that ACA velocities were lower with the FBW (A2 segment) than TBW (A1 segment). The correlation coefficient for ACA systolic velocities measured by the FBW and TBW was R = 0.47, CI (0.28-0.62). No risk factors for failure of the FBW were identified. CONCLUSIONS: In ICU, the FBW was able to insonate the ACA in 45% of patients admitted for brain injury, without the use of contrast agents. The FBW could improve the detection of ACA vasospasms.

A simple CT score to quantify pelvic and retroperitoneal hematoma associated with pelvic fractures predicts transfusion needs, pelvic hemostatic procedures, and outcome.

BACKGROUND: Pelvic and retroperitoneal hematoma (PRH) in case of pelvic fracture may lead to early hemorrhagic shock. Quantifying PRH remains challenging in clinical practice. The goal of this study was to determine the statistical association between a semi-quantitative scoring system for PRH assessed with computed tomography (CT) and transfusion needs, pelvic hemostatic procedures, and outcome. METHODS: All consecutive severe trauma patients with pelvic ring fracture between 2010 and 2015 were included in this retrospective study. PRH was quantified using semi-quantitative analysis on admission CT scan. The pelvis and retroperitoneal cavity was assessed as 10 compartments. Hematoma was counted as 0 (absent), 1 (minimal or moderate), and 2 (large or bilateral) for each compartment (maximum score of 20). The patients were divided into the following 3 groups: no or minimal PRH (score 0-5), moderate PRH (6-9), and large PRH (10-20). These groups were compared in terms of initial transfusion needs, massive transfusion, hemostatic procedures, and outcome. Logistic regression and receiver operating characteristic (ROC) curves were analyzed. RESULTS: The study included 311 patients with pelvic fracture (mean age 41.9, [SD] 19.9 years; mean ISS 27.4, [SD] 19.4; unstable fractures, 32%; ≥5 units of packed red blood cells, 37%; massive transfusion, 19%; multiple organ failure, 29%; mortality, 13%), divided into no or minimal PRH group (128 (22%)), moderate PRH group (115 (37%)), and large PRH group (68 (22%)). Increasing PRH was found to increase transfusion needs and massive transfusions, with a higher number of pelvic hemostatic procedures, multiple organ failures, increasing need for mechanical ventilation, and prolonged hospitalization; mortality was also increased. These significant statistical associations were confirmed by logistic regression models (odds ratio, 1.2-12.1 for moderate PRH, 3.1-30.2 for large PRH) and ROC curve analysis (area under the ROC curve, 0.59-0.76). CONCLUSION: Semi-quantitative assessment of PRH on admission CT scan allows to predict transfusion needs, hemostatic procedures, and worse outcome of severe trauma patients with pelvic fracture.

Cervical anaerobic vertebral osteomyelitis following surgical tracheotomy: a case report.

BACKGROUND: We report a rare case of anaerobic vertebral osteomyelitis associated with surgical tracheotomy which has never been reported to the best of our knowledge. CASE PRESENTATION: A healthy 39-year-old man was admitted to intensive care for a severe brain trauma injury where a surgical tracheotomy was performed. He was discharged to a rehabilitation centre after 54 days hospital stay. During rehabilitation, he developed progressive and febrile tetraplegia associated with cervical pain, requiring an intensive care readmission. A polymicrobial anaerobic bloodstream infection was revealed and magnetic resonance imaging diagnosed cervical vertebral osteomyelitis. Both the type of anaerobic micro-organisms found and the timing of the symptoms strongly suggest that the surgical tracheotomy was responsible for this rare case of cervical vertebral osteomyelitis. The patient was successfully treated by a prolonged antimicrobial therapy and by surgical laminectomy. CONCLUSIONS: Tracheotomy may generate anaerobic bacteraemia and related osteomyelitis in the specific setting of severe trauma patients. Clinicians should consider anaerobic vertebral osteomyelitis when they are confronted with a febrile tetraplegia after tracheotomy.

Transversus Abdominal Plane Block in Children: Efficacy and Safety: A Randomized Clinical Study and Pharmacokinetic Profile.

BACKGROUND: The transversus abdominis plane (TAP) block has become a common regional anesthesia technique for pain management in a wide variety of abdominal procedures. Evidence to support any particular local anesthetic regimen as well as pharmacokinetic and systemic toxicity risks of TAP block remain insufficiently studied in children. The aim of this study was to compare the analgesic effects and investigate pharmacokinetic profile of levobupivacaine after ultrasound-guided TAP block using a low volume/high concentration (LVHC) or a high volume/low concentration (HVLC) solution in children. METHODS: This prospective randomized study included children scheduled for day-case inguinal surgery. Children were randomized to receive TAP block using 0.4 mg·kg levobupivacaine as either HVLC (0.2 mL·kg of 0.2% levobupivacaine) or LVHC (0.1 mL·kg of 0.4% levobupivacaine). The primary outcome was the number of children who required opioid rescue analgesia postoperatively. Pharmacokinetic profile study of levobupivacaine was also performed. RESULTS: Seventy patients were equally randomized, and 65 were included in the final analysis. Seventy-one percent of patients did not require any postoperative opioid analgesia. The number of patients who received rescue analgesia was 12 (35%) in the LVHC group and 7 (23%) in the HVLC group (relative risk, 0.64; 95% confidence interval [CI], 0.29-1.42; P = .26). Mean pain scores (FLACC [faces, legs, activity, cry, and consolability]) at postanesthesia care unit discharge did not differ between LVHC and HVLC groups, respectively, 0.39 ± 0.86 and 1 ± 1.71 with mean group difference -0.60 (95% CI, -1.27 to 0.06; P = .08). The pharmacokinetic profile of levobupivacaine was comparable in the 2 groups: the mean total and free levobupivacaine peak concentrations were 379 ± 248 and 3.95 ± 3.16 ng·mL, respectively, occurring 22.5 ± 11 minutes after injection. The highest total and free levobupivacaine concentrations collected, respectively, 1360 and 15.1 ng·mL, remained far below theoretical toxic thresholds. CONCLUSIONS: In children, quality of postoperative pain control provided by TAP block using levobupivacaine 0.4 mg·kg administered as either HVLC or LVHC did not differ and was associated with a very low risk of local anesthetic systemic toxicity.

Ultrasound-Guided Continuous Thoracic Erector Spinae Plane Block Within an Enhanced Recovery Program Is Associated with Decreased Opioid Consumption and Improved Patient Postoperative Rehabilitation After Open Cardiac Surgery-A Patient-Matched, Controlled Before-and-After Study.

OBJECTIVES: Open cardiac surgery may cause severe postoperative pain. The authors hypothesized that patients receiving a bundle of care using continuous erector spinae plane blocks (ESPB) would have decreased perioperative opioid consumption and improved early outcome parameters compared with standard perioperative management. DESIGN: A consecutive, patient-matched, controlled before-and-after study. SETTING: Two tertiary teaching hospitals. PARTICIPANTS: The study comprised 67 consecutive patients undergoing elective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: In a controlled before-and-after trial, this study compared a historical group of 20 consecutive open cardiac surgery patients matched with a prospective group of 47 consecutive patients receiving continuous bilateral ESPB (0.25 mL/kg/side of ropivacaine 0.5%) after general anesthesia induction. For postoperative analgesia, both groups received paracetamol. The control group received intravenous (IV) morphine, 0.5 mg/h, and IV nefopam, 100 mg/24 h. In the ESPB group, 8 hours after the loading dose, catheters were connected to a pump infusing intermittent automatic boluses of ropivacaine 0.2% every 6 hours. If needed, for both groups, rescue analgesia was provided with IV ketorolac, 30 mg, and IV morphine, 30 µg/kg. MEASUREMENTS AND MAIN RESULTS: Morphine consumption in the first 48 hours was significantly decreased in the ESPB group (40 [25-45] mg in the control group compared with 0 [0-0] mg in the ESPB group [p < 0.001]) as was intraoperative sufentanil (0.8 [0.6-0.9] µg/kg/h and 0.2 [0.16-0.3] µg/kg/h, respectively; p < 0.001). Times to chest tube removal, first mobilization, pain (Visual Analogue Scale) values 2 hours after chest tube removal, pain values at rest 1 month after surgery, and postoperative adverse events were significantly decreased in the ESPB group. There was no difference for extubation time and pain during first mobilization. CONCLUSION: The authors report for the first time that the use of a bundle of care including a continuous bilateral ESPB is associated with a significant decrease in intraoperative and postoperative opioid consumption, optimized rapid patient mobilization, and chest tube removal after open cardiac surgery.

Diagnostic performance of prothrombin time point-of-care to detect acute traumatic coagulopathy on admission: experience of 522 cases in trauma center.

BACKGROUND: Early identification of acute traumatic coagulopathy is a key challenge during initial management to determine whether to initiate early hemostatic support. We assessed the performance of prothrombin time (PT) at point-of-care in trauma patients to detect moderate and severe coagulopathy on admission. STUDY DESIGN AND METHODS: All admitted consecutive trauma patients were analyzed retrospectively between April 2014 and July 2015. PT was measured on admission with both a PT point-of-care device (PTr-CGK) and a standard coagulation test (PTr-STD). The results for PTr-CGK and PTr-STD were compared using analysis of agreement, precision, and accuracy. The diagnostic performance of PTr-CGK to predict coagulopathy was established by analysis of receiver operating characteristic curves. The predictive performance of different thresholds and risk factors for misclassification were also studied. RESULTS: Over a 16-month period, 522 patients were included. PTr-CGK estimated PTr-STD with a bias of 0.00 (95% confidence interval [CI], -0.48 to 0.50) and a precision of 0.25. The optimal threshold was 1.4 to predict severe coagulopathy (sensitivity 81% [95% CI, 68%-94%], negative predictive value 98% [95% CI, 97%-99%]), and 1.2 for moderate coagulopathy (sensitivity 80% [95% CI, 72%-88%], negative predictive value 94% [95% CI, 91%-96%]). A low PTr-CGK in the presence of severity criteria (Injury Severity Score ≥ 16, Trauma Associated Severe Hemorrhage score ≥ 12, hemoglobin level < 7 g/dL, fibrinogen level < 2 g/L, base deficit ≥ 6 mmol/L) was strongly associated with a false-negative risk. CONCLUSIONS: The PT point-of-care device is reliable and accurate for the early identification of coagulopathic trauma patients.