Epidural blood patch: A narrative review.

The epidural blood patch (EBP) is one of the most effective treatments for intracranial hypotension. Anesthesiologists are familiar with performing EBPs for the treatment of dural puncture-associated intracranial hypotension following spinal anesthesia, complicated epidural analgesia, and diagnostic lumbar puncture. Increasingly, EBPs are used to treat patients with spontaneous intracranial hypotension. However, the treatment of these non-iatrogenic conditions presents new therapeutic challenges. The purpose of this narrative review is to discuss both procedural and diagnostic considerations of EBP for the various presentations of intracranial hypotension and allow the clinician to tailor treatment for the patient, especially in the setting of diagnostic dilemmas. After discussing EBP history and relevant anatomy, we review mechanisms of action and clinical indications for this intervention. The contraindications, complications, and treatment alternatives to the blood patch are examined in detail. Finally, objective methods to evaluate the effectiveness of the EBP, such as MRI or Doppler ultrasound, are presented as novel methods that may improve future diagnostic accuracy and treatment success.

Preventing Post-Lumbar Puncture Headache.

Post-lumbar puncture headache is the main adverse event from lumbar puncture and occurs in 3.5% to 33% of patients, causing functional and socio-professional disability. We searched the post-lumbar puncture headache literature and, based on this review and personal expertise, identified and addressed 19 frequently asked questions regarding post-lumbar puncture headache risk factors and prevention. Among the nonmodifiable factors, older age is associated with a lower incidence of post-lumbar puncture headache, while female sex, lower body mass index, and history of headache might be associated with increased risk. The use of atraumatic, noncutting needles is the most effective intervention for post-lumbar puncture headache prevention. These needles are not more difficult to use than cutting needles. Other commonly recommended measures (eg, fluid supplementation, caffeine) appear unhelpful, and some (eg, bed rest) may worsen post-lumbar puncture headache.

Ultrasonography for airway management.

Ultrasonography (USG) allows a new approach to the airway in anaesthesia and intensive care. USG visualises the airway from the mouth to the lungs. By exploring the entire airway, USG proposes new criteria (1) to assess the risk of difficult laryngoscopy, (2) to anticipate the management of a difficult airway, (3) to confirm the position of the endotracheal tube (ETT), and (4) to confirm that the lungs are effectively ventilated. Intraoperatively, USG may also help to resolve acute ventilatory problems such as pneumothorax, delayed selective bronchial intubation after patient positioning (Trendelenburg, prone or lateral position) or acute pulmonary oedema.

Ultrasound-guided scalp nerve blocks for neurosurgery: A narrative review.

We report in this review our clinical strategy to perform ultrasound-guided scalp nerve blocks for cranial and neurosurgical cases.

Parietal Block Using Bupivacaine in the Rat: An Anatomical, Behavioral and Histological Study.

PURPOSE: Animal models of regional anaesthesia are useful for studying the effects of blocks and improve their efficacy. The aim of our experiments was to validate a multi-site paravertebral block in the rat. MATERIAL AND METHODS: Dissection and indigo carmine dye injection were performed in five rats (3 rats were dissected and 2 were dye injected). In other groups (n=7rats/group), after inflammation inductive carrageenan injection in the abdominal wall, bupivacaine or saline was injected laterally to the spinal column at the T5, T10, L1, L4 and S1 level. The efficacy of the block on mechanical nociception was measured using von Frey hairs. In addition, we measured c-Fos immunoreactive nuclei in the cord. RESULTS: The multi-site injection showed a perinervous distribution of the injected solution without intra-thoracic, intra-abdominal or epidural diffusion. Bilateral block with a relatively small volume of bupivacaine (0.5 mL) significantly increased the threshold to mechanical pain as compared to control (p=0.007) and significantly decreased the number of c-Fos immunoreactive nuclei in the posterior horn of the spinal cord (p<0.0001). CONCLUSION: This study shows that a parietal abdominal wall block is easy to perform in the rat. This block allows investigators to explore the mechanisms of action of abdominal parietal wall blocks.

Thoracic paravertebral block: comparison of different approaches and techniques. A study on 27 human cadavers.

BACKGROUND AND OBJECTIVES: The success rate and spread of thoracic paravertebral block (TPVB) are variable and difficult to predict. It is now recommended that an ultrasound guidance technique should replace the traditional landmark technique. The objective was to compare anatomical outcomes of both techniques on cadavers. METHODS: A landmark technique (loss of resistance technique [LOR]) and a USG technique (three approaches: sagittal, transversal in-plane, transverse out-of-plane) were performed on 27 thawed non-embalmed cadavers. Each of the four approaches was performed in each body (T3-T5 and T9-T11 × right and left). A coloured solution (13 mL, saline 0.9%) was injected in the targeted thoracic paravertebral space (TPVS). A successful thoracic paravertebral injection (TPVI) was defined by the presence of dye in at least one TPVS during anatomical dissection. RESULTS: In 104 TPVIs analysed, the overall success rate was 78%. Factors associated with success were: USG versus LOR technique (85% vs. 52%, P < 0.0007), sagittal versus both transversal approaches (93%/81%/83%, P < 0.0007) and right side (86% vs. 66%). The median spread was 2 TPVS (min - max 1-5) with a median cephalad-caudal spread of 5 cm (min - max 1-18). By multivariate analysis, the sagittal approach was an independent factor of success (OR 2.75). Dye spread and pleural entry were influenced by neither the approach nor the site of injection. CONCLUSIONS: Paravertebral spread of TPVI is variable. USG technique has higher anatomical success rates than the LOR technique, the sagittal USG approach being the most successful.

Impact of Chloroprocaine on the Eligibility for Hospital Discharge in Patients Requiring Ambulatory Surgery Under Spinal Anesthesia: An Observational Multicenter Prospective Study.

INTRODUCTION: This observational study was designed to assess the use of spinal anesthesia with chloroprocaine in the context of ambulatory surgery. METHODS: A prospective, multicenter, observational study was carried out among 33 private or public centers between May 2014 and January 2015 and adult patients, scheduled for a short ambulatory surgery under spinal anesthesia with chloroprocaine. The primary outcomes were anesthetic effectiveness, defined as performance of the whole surgical procedure without any additional anesthetic agent, and the time to achieve eligibility for hospital discharge. Secondary outcomes were the effect of chloroprocaine on motor and sensory blocks, patients' satisfaction, and the use of analgesics in the first 24 h after surgery. RESULTS: Among the 615 enrolled patients, 56% were male, the mean age was 47.2 ± 15.2 years, and most patients had an ASA (American Society of Anesthesiologists) status of 1 (63.7%). Main surgical procedures performed were orthopedic (62.6%) and gynecologic (16.1%), and the mean duration of surgery was 26.7 ± 16.7 min. The overall anesthetic success rate was 93.8% (95% CI [91.5%; 95.6%]) for the 580 patients with available data for primary criteria. The failure rate was lower than 7% for all surgical procedures, except for gynecologic surgery (14.8%; 95% CI [8.1%; 23.9%]). The average times of eligibility for hospital discharge and effective discharge were 252.7 ± 82.7 min and 313.8 ± 109.9 min, respectively. The time of eligibility for hospital discharge is defined as the recovery of the patient's normal clinical parameters and the time of effective discharge is defined as the time for the patient to leave the hospital after surgery. Eligibility for patient's discharge was achieved more rapidly in private than public hospitals (236.3 ± 77.2 min vs. 280.9 ± 80.7 min, respectively, p < 0.001). CONCLUSIONS: This study showed positive results on the effectiveness of chloroprocaine as a short-duration anesthetic and could be used to reduce the time to achieve eligibility for hospital discharge. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT02152293. Registered on May 6, 2014. Date of enrollment of the first participant in the trial May 7, 2014.

Factors Determining the Choice of Spinal Versus General Anesthesia in Patients Undergoing Ambulatory Surgery: Results of a Multicenter Observational Study.

INTRODUCTION: Available short-acting intrathecal anesthetic agents (chloroprocaine and prilocaine) offer an alternative to general anesthesia for short-duration surgical procedures, especially ambulatory surgeries. Factors determining the choice of anesthesia for short-duration procedures have not been previously identified. METHODS: This observational, prospective, multicenter, cohort study was conducted between July 2015 and July 2016, in 33 private or public hospitals performing ambulatory surgery. The primary objective was to determine the factors influencing the choice of anesthetic technique (spinal or general anesthesia). Secondary outcomes included efficacy of the anesthesia, time to hospital discharge, and patient satisfaction. RESULTS: Among 592 patients enrolled, 309 received spinal anesthesia and 283 underwent general anesthesia. In both study arms, the most frequently performed surgical procedures were orthopedic and urologic (43.3% and 30.7%, respectively); 66.1% of patients were free to choose their type of anesthesia, 21.8% chose one of the techniques because they were afraid of the other, 16.8% based their choice on the expected ease of recovery, 19.2% considered their degree of anxiety/stress, and 16.9% chose the technique on the basis of its efficacy. The median times to micturition and to unassisted ambulation were significantly shorter in the general anesthesia arm compared with the spinal anesthesia arm (225.5 [98; 560] min vs. 259.0 [109; 789] min; p = 0.0011 and 215.0 [30; 545] min vs. 240.0 [40; 1420]; p = 0.0115, respectively). The median time to hospital discharge was equivalent in both study arms. In the spinal anesthesia arm, patients who received chloroprocaine and prilocaine recovered faster than patients who received bupivacaine. The time to ambulation and the time to hospital discharge were shorter (p < 0.001). The overall success rate of spinal anesthesia was 91.6%, and no significant difference was observed between chloroprocaine, prilocaine, and bupivacaine. The patients' global satisfaction with anesthesia and surgery was over 90% in both study arms. CONCLUSIONS: Patient's choice, patient fear of the alternative technique, patient stress/anxiety, the expected ease of recovery, and the efficacy of the technique were identified as the main factors influencing patient choice of short-acting local anesthesia or general anesthesia. Spinal anesthesia with short-acting local anesthetics was preferred to general anesthesia in ambulatory surgeries and was associated with a high degree of patient satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02529501. Registered on June 23, 2015. Date of enrollment of the first participant July 21, 2015.

Serratus Plane Block Is Effective for Pain Control in Patients With Blunt Chest Trauma: A Case Series.

BACKGROUND: Rib fractures occur frequently following blunt chest trauma and induce morbidity and mortality. Analgesia is a cornerstone for their management, and regional analgesia is one of the tools available to reach this objective. Epidural and paravertebral blocks are the classical techniques used, but the serratus plane block (SPB) has recently been described as an effective technique for thoracic analgesia. METHODS: This case series reported and analyzed 10 consecutive cases of SPB for blunt chest trauma analgesia in a level 1 trauma center from May to October 2018. SPB was performed with either a single shot of local anesthetic or a catheter infusion. RESULTS: Ten patients were treated with 3 single shots and 7 catheter infusions (median length 3 days [interquartile range (IQR) 2.5 to 3.5]). The Median Injury Severity Score was 16 (IQR 16 to 23), and the number of broken ribs ranged from 3 to 22. Daily equivalent oral morphine consumption was significantly decreased after SPB from 108 mg (IQR 67 to 120) to 19 mg (IQR 0 to 58) (P = 0.015). The Numeric Pain Rating Scale (NPRS) score during cough was significantly decreased from 7.3 (IQR 5.3 to 8.8) to 4 (IQR 3.6 to 4.6) (P = 0.03). The NPRS score at rest remained unchanged. One complication occurred, due to a catheter section. CONCLUSIONS: The SPB technique (with or without catheter insertion) in 10 patients who had blunt chest trauma with rib fractures is effective for cough pain control, with a significant decrease in morphine consumption.

Revision of expert panel's guidelines on postoperative pain management.

The French Society of Anaesthesia and Intensive Care Medicine (SFAR) published experts' guidelines on the care of postoperative pain. This was an update of the 2008 guidelines. Fourteen experts analysed the literature (PubMed™, Cochrane™) on questions that had not been treated in the previous guidelines, or to modify the guidelines following new data in the published literature. The used method is invariably the GRADE© method, which guarantees a rigorous work. Seventeen recommendations were formalised on the assessment of perioperative pain, and most particularly in non-communicating patients, on opioid and non-opioid analgesics and on anti-hyperalgesic drugs, such as ketamine and gabapentinoids, as well as on local and regional anaesthesia. The concept of vulnerability and therefore the identification of the most fragile patients in terms of analgesics requirements were specified. Because of the absence of sufficient data or new information, no recommendation was made about analgesia monitoring, the procedures for the surveillance of patients in conventional care structures, or perinervous or epidural catheterism.

Major Laparoscopic Intraperitoneal Surgery Performed With Combined Bilateral Subcostal Transversus Abdominal Plane Block and Celiac Plexus Block, Intravenous Sedation Without Tracheal Intubation: A Feasibility Study of 3 Cases.

OBJECTIVES: Major abdominal surgery usually requires general anesthesia with tracheal intubation and may be supplemented with neuraxial anesthesia to provide intraoperative and postoperative pain relief. Attempts at using only neuraxial anesthesia for major abdominal surgery have often been shown to be poorly effective. This report demonstrates that laparoscopic colonic surgical procedures can be performed with ultrasound-guided blocks (bilateral transversus abdominal plane block and celiac plexus block) and intravenous sedation, while avoiding general or neuraxial anesthesia. CASE REPORT: We report our preliminary experience in 3 patients (all American Society of Anesthesiologists physical status III) who underwent laparoscopic colonic surgery without general anesthesia. Intraoperative visceral analgesia was provided by single-injection ultrasound anterior celiac plexus block to which was added a bilateral subcostal transversus abdominal plane block to obtain parietal analgesia. Light intravenous sedation was added. Surgical exposure was satisfactory, and no patient complained of any symptom during the procedure. No adverse effect was recorded. Postoperative pain was minimal, and recovery was enhanced with mobilization and walking within hours after surgery. Patient satisfaction was excellent. CONCLUSIONS: To date, celiac plexus block has been used almost exclusively to relieve pancreatic cancer pain. This is the first report in which it is shown that major intra-abdominal surgery can be performed almost exclusively with regional anesthesia while avoiding adverse effects and problems associated with either general or neuraxial anesthesia. In addition, prolonged postoperative pain relief facilitated early recovery.

Percutaneous Radiofrequency Ablation of Pulmonary Metastasis and Thoracic Paravertebral Block Under Computed Tomographic Scan Guidance: A Case Report.

Pain during and after pulmonary percutaneous radiofrequency ablation (RFA) may be severe enough to require opioids. Thoracic paravertebral block (TPVB) is a regional anesthetic technique that can relieve pain during and after abdominal or thoracic painful procedures. We report the use of TPVB to relieve postprocedural pain in a 50-year-old woman after RFA of lung metastasis. The TPVB was performed under computed tomographic guidance by the anesthesiologist. The patient was pain free (rest and mobilization) during the first postoperative 36 hours. TPVB may represent an easy, safe, and effective strategy to prevent or treat postoperative pain after pulmonary RFA.

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.