Inadvertent Injection of Ciprofloxacin Instead of Ropivacaine Through Epidural Catheter.

Purpose: Patient harm is often due to medication errors related to neuraxial and peripheral misconnection. We report a case of inadvertent injection of ciprofloxacin into the epidural space and discuss the strategies that could prevent such an incident. Summary: A 74-year-old woman presented a recurrence of an ovarian cancer. The recent discovery of an intrabdominal recurrence on CT-scan led us to propose a new surgical procedure. A thoracic epidural analgesia was performed prior to general anesthesia. Postoperative pain was controlled with patient-controlled epidural analgesia (PCEA) with ropivacaine-epinephrine. During the first night, abdominal pain appeared. During the second day, a nurse discovered that the bag connected to the pump contained ciprofloxacin and not ropivacaine. After aspiration of 2.5 ml sent to laboratory for analysis, the epidural catheter was removed. The investigation revealed the different causes leading to such an error. Three days after, the patient returned home, without any adverse symptoms. Conclusion: This is the first report of the inadvertent administration of ciprofloxacin into the epidural space via a patient-controlled epidural analgesia technique. As there is no effective treatment for such errors, we discuss the neurological risk of ciprofloxacin and prevention strategy mainly based on organizational and human factors.

Open abdominal vacuum pack technique for the management of severe abdominal complications after cytoreductive surgery in ovarian cancer.

INTRODUCTION: The aim of this study was to evaluate the indications and management of grade III-IV postoperative complications in patients requiring vacuum-assisted open abdomen after debulking surgery for ovarian carcinomatosis. METHODS: Retrospective study of prospectively collected data from patients who underwent a cytoreductive surgery by laparotomy for an epithelial ovarian cancer that required postoperative management of an open abdomen. An abdominal vacuum-assisted wound closure (VAWC) was applied in cases of abdominal compartmental syndrome (ACS) or intra-abdominal hypertension, to prevent ACS. The fascia was closed with a suture or a biologic mesh. The primary aim was to achieve primary fascial closure. Secondary outcomes considered included complications of cytoreductive surgery (CRS) and open abdominal wounds (hernia, fistula). RESULTS: Two percent of patients who underwent CRS required VAWC during the study's patient inclusion period. VAWC indications included: (i) seven cases of gastro-intestinal perforation, (ii) three necrotic enterocolitis, (iii) two intestinal ischemia, (iv) three anastomotic leakages and (v) four intra-abdominal hemorrhages. VAWC was used to treat indications (i) to (iv) (which represented 73.7% of cases), to prevent compartmental syndrome. Primary fascia closure was achieved in 100% of cases, in four cases (21.0%) a biologic mesh was used. Median hospital stay was 65 days (range: 18-153). Four patients died during hospitalization, three of these within 30 days of VAWC completion. CONCLUSION: VAWC for managing open abdominal wounds is a reliable technique to treat surgical post-CRS complications in advanced ovarian cancer and reduces the early post-operative mortality in cases presenting with severe complications.

European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): Peripheral nerves blocks and neuraxial anaesthesia.

Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.

European Society of Anaesthesiology guidelines on peri-operative use of ultrasound-guided for vascular access (PERSEUS vascular access).

: Ultrasound for diagnostic and procedural purposes is becoming a standard in daily clinical practice including anaesthesiology and peri-operative medicine. The project of European Society of Anaesthesiology (ESA) Task Force for the development of clinical guidelines on the PERioperative uSE of Ultra-Sound (PERSEUS) project has focused on the use of ultrasound in two areas that account for the majority of procedures performed routinely in the operating room: vascular access and regional anaesthesia. Given the extensive literature available in these two areas, this paper will focus on the use of ultrasound-guidance for vascular access. A second part will be dedicated to peripheral nerve/neuraxial blocks. The Taskforce identified three main domains of application in ultrasound-guided vascular cannulation: adults, children and training. The literature search were performed by a professional librarian from the Cochrane Anaesthesia and Critical and Emergency Care Group in collaboration with the ESA Taskforce. The Grading of Recommendation Assessment (GRADE) system for assessing levels of evidence and grade of recommendations were used. For the use of ultrasound-guided cannulation of the internal jugular vein, femoral vein and arterial access, the level evidence was classified 1B. For other accesses, the evidence remains limited. For training in ultrasound guidance, there were no studies. The importance of proper training for achieving competency and full proficiency before performing any ultrasound-guided vascular procedure must be emphasised.

Prospective cohort study assessing chronic pain in patients following minor surgery for breast cancer.

PURPOSE: Pain after tumorectomy and sentinel lymph node dissection is poorly reported in the literature. We carried out a prospective survey aimed at assessing pain three months after such minor surgery for breast cancer. METHODS: The study was approved by the local ethics committee. Most surgeries followed a standard protocol involving general anesthesia with no regional analgesia technique, laryngeal mask, sufentanil and propofol for induction, and multimodal analgesia during the postoperative period. Three months after the surgery, a questionnaire was sent to the patients with a pre-stamped envelope for return. The questions probed responses required to calculate a Brief Pain Inventory score and modified neuropathic pain score (DN3). RESULTS: Over a 5-month period, 150 patients (aged 60 (11) years, body mass index of 25 (6) kg/m2) were included in the final analysis. In the recovery room, 43% of patients required morphine at a mean dose of 5.2 (1.8) mg. Three months post surgery, 60 patients (40%) reported persistent pain for which 62% took analgesic drugs. We found no risk factor associated with this persistent pain among our studied population. Neuropathic pain was noted in 61% of patients who reported persistent pain primarily associated with periareolar incision. CONCLUSIONS: Pain persisted up to three months after minor surgery for breast cancer in 40% of patients with mostly a neuropathic component (61%).

Even a "pigtail" distal end catheter can enter the epidural space after continuous paravertebral block.

A woman with a medical history of breast cancer presented with chronic pain of the right hemithorax. To alleviate pain, a continuous paravertebral block was performed using a pigtail end catheter, introduced using ultrasound visualization (transversal technique at the inferior articular process of T6). Complete pain relief was observed. A few hours later, urinary retention was diagnosed and discharge from the ambulatory setting was canceled. On the following day, a new injection of local anesthetics through the catheter triggered paresthesia in the contralateral leg and a new urinary retention was diagnosed. A CT scan confirmed the epidural misplacement of the catheter. The latter was withdrawn, and the patient was released to home after the complete disappearance of her neurological symptoms. This case report highlights the risk of inadvertently misplacing the catheter into the epidural space during thoracic paravertebral block, even with a "pigtail" distal end type of catheter.

Radiation dose reduction during venous access port implantation: the importance of upgrading equipment and radiation-protection training.

BACKGROUND: Implantable central venous port systems are widely used in oncology. We upgraded our fluoroscopy machines, and all anesthetists completed two training courses focusing on the risks of ionizing radiation for patients and health workers. AIMS: This study aimed to evaluate the impact of upgrading the machines and the radiation-protection training on ionizing radiation exposure during venous port system implantation. METHODS: We retrospectively analyzed consecutive venous port implantations between 2019 and 2022. The older fluoroscopy machines were replaced by two new machines. A first training session about health worker radioprotection was organized. The medical staff completed a second training course focused on protecting patients from ionizing radiation. We defined four distinct time intervals (TI): venous port implantations performed with the old equipment, the new fluoroscopy machines, after the first training course, and after the second training course. The air kerma-area product (KAP) was compared between these four TI and fluoroscopy times and the number of exposures only with the new machines. RESULTS: We analyzed 2587 procedures. A 93% decrease in the median KAP between the first and last TI was noted (median KAP = 323.0 mGy.cm2 vs. 24.0 mGy.cm2, p < 0.0001). A decrease in the KAP was observed for each of the 11 anesthetists. We also noted a significant decrease in the time of fluoroscopy and the number of exposures. CONCLUSIONS: Upgrading the fluoroscopy equipment and completing two dedicated training courses allowed for a drastic decrease patient exposure to ionizing radiation during venous access port implantation by non-radiologist practitioners.

Safety in Healthcare: From the Flight Deck to the Operating Room.

The recent health crisis has increased the workload and the stress levels of healthcare professionals around the world. Such stressful working environments are conducive to an increased incidence of medical errors. Implementing education and training specifically focused on human and organizational factors can promote teamwork and decrease the risk of error. Such techniques have been extensively deployed, most notably in commercial aviation. Numerous tools have been developed to reduce the risk of error associated with routine tasks, forgetting a task and handling alarm situations during commercial flights. Many of these tools can be transferred to the healthcare sector. After a brief recap about the importance of the working environment, this narrative review aims to highlight several specific tools used in commercial aviation that can be readily transferred to the operating theatre.

Benefits of cardiac coherence combined with medical hypnosis on preoperative anxiety before cancer surgery: the COHEC II study trial protocol.

INTRODUCTION: Preoperative anxiety is a frequent problem that can lead to complications both during anaesthesia and in the postoperative period, especially in oncology. Studies have shown that it can be managed using non-pharmacological approaches, but few works have evaluated psychoeducational programmes. The aim of the COHErence Cardiaque (COHEC) II Study is to evaluate the combination of medical hypnosis (MH) and cardiac coherence (CC) training to manage preoperative anxiety in patients with cancer. METHODS AND ANALYSIS: COHEC II is an ongoing multicentre randomised clinical trial carried out in three French comprehensive cancer centres. In total, 296 patients who will undergo surgery for cancer will be recruited during 18 months and will be randomised in the control arm or the intervention arm. Patients in the intervention arm will follow a daily programme that combines MH and CC, starting 7 days before surgery. The control arm will receive the standard treatment to manage preoperative anxiety. The primary endpoint is the anxiety level on surgery day, measured using a Visual Analogue Scale. Secondary endpoints are patient adherence to the programme, satisfaction and postsurgery recovery quality. ETHICS AND DISSEMINATION: The study protocol was approved by the French Ethics Committee (Comité de Protection des Personnes EST-II) on 24 November 2021 and will be carried out following the good practice guidelines and the Declaration of Helsinki. Results will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER: NCT05197972.

Guidelines on human factors in critical situations 2023.

OBJECTIVE: To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care. DESIGN: A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based. METHODS: We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organisation, 3/ working environment and 4/ training. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology. RESULTS: The experts' synthesis work and application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions. CONCLUSION: Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.

Influence of Deep Serratus Anterior Plane Block on Chronic Pain at 3 Months After Breast-Conserving Surgery: Prospective, Cohort Study.

OBJECTIVES: In 2015, we evaluated our practices regarding pain after breast-conserving surgery. Thereafter, we have adapted our practices by performing a systematic deep serratus plane block before the surgical incision. In 2019, we assessed the impact of these changes in terms of chronic pain. The main objective of this study was to evaluate the prevalence of chronic pain 3 months after this type of surgery. MATERIALS AND METHODS: All patients treated with breast-conserving surgery as outpatients were included in this prospective study between April and July 2019. After inducing general anesthesia, 20 mL of ropivacaine 3.75 mg/mL were injected under the serratus muscle. Morphine titration was performed in the recovery room according to pain scores. A pain and quality of life questionnaire was sent 3 months after surgery. A backward logistic regression model was applied to calculate the adjusted odds ratios. RESULTS: The final analysis involved 137 patients. Three months after surgery, 43 patients (31%) reported persistent pain related to the surgery. Maximum pain in the last 24 hours was moderate to severe in 60% of cases, 16 patients (35%) took painkillers. Morphine titration in the recovery room was required in 25 patients (18%). Younger age and the use of lidocaine to prevent after injection of propofol during general anesthesia induction appeared to be protective factors for the risk of pain at 3 months (secondary endpoints). DISCUSSION: No persistent pain at 3 months was reported in 69% of cases. Furthermore, the use of a deep serratus anterior plane block before the surgical incision has limited the need for morphine titration in the recovery room to <1 patient in 5. These evaluations of professional practices should be encouraged.

Unexplained pain after scheduled limb surgery.

Orthopedic surgery can lead to pain that is poorly if at all explicable, both in the immediate postoperative period and at longer term, impairing the surgical result and necessitating a multidisciplinary approach of multimodal analgesia throughout the patient's care pathway. Preoperatively, patients at high risk of postoperative pain need to be identified and referred to a pain specialist to optimize pain management. Surgical and anesthesiological measures then need to be taken intraoperatively to limit the risk of pain. Finally, and most importantly, when pain does occur postoperatively, the surgeon needs to be able to treat any obvious cause and then rapidly to call in a pain specialist to identify the underlying causes and treat them effectively.

Adverse drug reactions to local anaesthetics: a review of the French pharmacovigilance database.

BACKGROUND: Some evidence of significant patient morbidity or mortality has been reported with the use of local anaesthetics (LAs). The most common adverse drug reactions (ADRs) to LAs are neurological (seizures) and cardiac (conduction disorders, cardiac arrests). However, little is known about other adverse drug reactions (ADRs). OBJECTIVE: The aim of this study was to characterize the safety profile of the LAs lidocaine, bupivacaine, mepivacaine, ropivacaine and levobupivacaine. STUDY DESIGN: We studied ADRs occurring between 1995 and 2006 reported to the French Pharmacovigilance System. MAIN OUTCOME MEASURE: For each ADR, we noted type of LA, type of ADR, its seriousness and the causality assessment score. RESULTS: We identified 727 reports (corresponding to 0.3% of patients in the database) in which LA was suspected as the cause of 1157 different ADRs. Sixty-one patients (8.7%) were children aged<18 years. Lidocaine (36.0%) and bupivacaine (35.4%) were the LAs most often involved. The most frequently reported ADRs were failure of the block (27.7%), followed by neurological (22.1%), allergic (19.4%) and cardiovascular (15.3%) complications. Eight patients died. Spinal anaesthesia performed with bupivacaine represented 90% of failed blocks. Seizures were the most frequent neurological complications, leading to death in four cases. Twenty-two of 111 cardiovascular complications were cardiac arrest (three of which were fatal). CONCLUSION: To our knowledge, this is the first analysis of safety profiles of LAs in a non-selected population, using data collected in a pharmacovigilance database. The present study confirmed the frequency and seriousness of both neurological and cardiovascular complications. Other less well documented ADRs were identified, such as spinal anaesthesia failures with bupivacaine and allergic reactions following LA injections.

Immediate- and delayed-type allergic reactions to amide local anesthetics: clinical features and skin testing.

PURPOSE: Amide type local anesthetic agents are among the most commonly used drugs in medicine. Several adverse drug reactions (ADRs) have been previously described with their use. Among them, allergic reactions are considered rare. The aim of this study was to describe the main characteristics of ADRs induced by amide type local anesthetic drugs. METHODS: We studied reports recorded in the French Pharmacovigilance database and the GERAP database over a 12-year period (1995-2006). For each report, we detailed the clinical features and skin tests used. Delayed or immediate-type allergic reactions and cross-reactivity between amide type local anesthetics were also analyzed. RESULTS: We identified 16 reports (seven from the Pharmacovigilance database and nine from the GERAP database). Local anesthetic allergic reactions occurred mostly in young females (F/M sex ratio = 14:2). An immediate-type allergic reaction was encountered in 11/16 cases. Lidocaine was the local anesthetic most often involved (11/16). Prick test, intradermal reaction, and challenge tests were used to confirm the diagnosis. A cross-reactivity between the different amide type local anesthetics was found in six cases (lidocaine-mepivacaine in all cases). CONCLUSIONS: This is the largest series of immediate-type local anesthetic allergic reactions reported in the literature. Cutaneous symptoms are the main features even though more serious symptoms may occur. Intradermal reaction and challenge tests are very helpful. Because cross-reactivity is not scarce, skin tests should involve several local anesthetics.

A case report of sustained resolution of cancer pain by continuous perineural infusion of local anaesthetic.

BACKGROUND: Opioids are currently offered as first-line treatment for chronic pain from cancer. Continuous regional analgesia could be an alternative to opioids. However, the required duration of catheterization and the sustained analgesic effects of this technique after catheter removal have yet to be clarified. CASE REPORT: We report the case of a patient with a shoulder desmoid tumour for which monitoring of tumour progression was the sole therapeutic strategy. Analgesia took the form of patient-controlled infusion of local anaesthetics through an interscalene catheter. Due to the need of an MRI control 45 days later, the pump was stopped. The persistence of pain relief 48 hr later led to the decision to remove the perineural catheter. No pain was reported by the patient over the following 42 days. CONCLUSIONS: In this patient, it would seem that continuous analgesia allowed for a sustained resolution of pain from the shoulder-located tumour. One hypothesis is that local anaesthetics play a direct role in the erasure of pain memory. This hypothesis needs to be tested with a large patient cohort. SIGNIFICANCE: This case report provides new insights into the treatment of cancer pain. The most interesting finding is that the pain did remained absent after 45 days of continuous infusion of local anaesthetics through an interscalene catheter. We postulated that local anaesthetic drugs have an impact on pain memory.

Analgesic Drug Prescription After Carpal Tunnel Surgery: A Pharmacoepidemiological Study Investigating Postoperative Pain.

BACKGROUND AND OBJECTIVES: Carpal tunnel syndrome is a frequent cause of neuropathic pain of the upper limb. Surgery is often proposed in second-line treatment, leading to an expected decrease in analgesic drug consumption. The main objective of this study was to investigate the variations in analgesic drug prescriptions, with a special focus on constant or increasing prescription patterns, before and after surgery for carpal tunnel syndrome. METHODS: We designed a retrospective cohort study of French beneficiaries from the health insurance system in Midi-Pyrénées area. All patients undergoing carpel tunnel surgery during a specified period were identified and included. Definition of increased or constant prescription of analgesics was based on the comparison of the accumulated defined daily doses received by months and a difference between early preoperative (2 months before) and late postoperative period (2-12 months after surgery) superior to a -3.5 margin. We performed 4 multivariate logistic regression models to identify factors associated with increased or constant analgesic drug prescription patterns (for all analgesics, opioid, antineuropathic, nonopioid drugs). RESULTS: Among the 3665 patients included, 3255 (89%) received at least 1 analgesic drug during the late postoperative period (39% [n = 1426] for opioids and 15% [n = 563] for antineuropathic drugs). Prescription of analgesic, opioid, or antineuropathic drugs was maintained or increased in the late postoperative period in 11%, 5%, and 3% of the population, respectively. High levels of preoperative pain and female sex were associated with an increase in opioid use, whereas inpatient surgery (vs ambulatory surgery), high levels of preoperative pain, and psychiatric disorders were found to be associated with an increase in antineuropathic drug use. CONCLUSIONS: This study revealed that approximately 3% to 5% of patients undergoing carpal tunnel surgery had persistent and even increased use of opioid or antineuropathic drugs more than 2 months after surgery, in relation with possible chronic postoperative pain. Considering the incidence of carpal tunnel syndrome, the risks associated with persistent opioid use in this population should be further monitored.

Spinal anaesthesia in outpatient and conventional surgery: A point of view from experienced French anaesthetists.

INTRODUCTION: The objective of this investigation was to evaluate the practice of spinal anaesthesia among French anaesthetists in inpatient and outpatient settings. METHODS AND MATERIALS: A questionnaire was sent to members of the French Association of Anaesthetists involved in regional anaesthesia during the first 4months of 2015. The questionnaire included items on the practice of spinal anaesthesia (type of needle, local anaesthetic available, puncture and disinfection techniques, etc.) and on the anaesthetic techniques usually used in 5 surgical situations eligible for outpatient surgery (knee arthroscopy, inguinal hernia, transobturator tape, haemorrhoids, varicose veins in the lower limbs). RESULTS: Responses from 703 anaesthesiologists were analysed. Spinal anaesthesia was usually performed in a sitting position (76%) using a Whitacre needle (60%) with a 25 G (57%) diameter. Ultrasound before puncture was reported in 26% of cases due to obesity or spinal abnormalities. Among the 5 surgical situations eligible for outpatient spinal anaesthesia, the technique was typically proposed in 29-49% of cases. Bupivacaine was the most used local anaesthetic. Concerns over delays in attaining readiness for hospital discharge, urine retention, operation length, and surgeon's preference were the main reasons for choosing another anaesthetic technique in these situations. DISCUSSION: New local anaesthetics are beginning to be used for outpatient spinal anaesthesia due to their interesting pharmacodynamic profile in this context. This study will provide a basis for evaluating future changes in practice.

A modified mid-femoral approach to the sciatic nerve block: a correlation between evoked motor response and sensory block.

BACKGROUND: The lateral sciatic mid-femoral block (LSMF), proved to be reliable, safe, and effective on both branches of the sciatic nerve with a single injection. However, we do not know which component of the sciatic nerve (the tibial [T] or the common peroneal [CP]) produces a better success rate when performing a LSMF with a single injection technique. In this prospective study we compared the success rate of the T motor response with the CP motor response. METHODS: Ninety-five patients undergoing ankle or foot surgery were enrolled. Thirty milliliters of 0.475% ropivacaine was injected at the first evoked motor response, either T or CP, with a minimal intensity between 0.3 and 0.5 mA. RESULTS: Seventy-two patients were included in group T and 23 in group CP. The block was considered a success when a complete sensory block of the sciatic nerve was obtained. The success rate was 90% (65) for the T response and 70% (16) for the CP response (P < 0.05). Time to perform the block (CP: 4.5 +/- 3 min vs T: 4.5 +/- 4 min; P = NS) as well as sensory and motor onset times were not significantly different between groups. No complications were observed in either group. CONCLUSION: We conclude that the evoked motor response of the T branch is associated with a higher success rate than a CP response using the modified LSMF block.

Hypnosis and Axillary Compartment Block for Breast Cancer Surgery: A Case Report.

Hypnosis has been proven to be a powerful tool in the management of anxiety and pain. It allows for an increase of pain threshold, which can reach the level of surgical analgesia. Recently injection of local anesthetics around the serratus muscle has been presented as an alternative to paravertebral block for cancer breast surgery. We report the successful use of hypnosis in combination with an axillary compartment block for lumpectomy and axillary lymph node dissection.