Ropivacaine versus placebo on postoperative analgesia and chronic pain following third molar extraction: A Prospective Randomized Controlled Study.

PURPOSE: The present study aimed at assessing the efficiency of ropivacaine on post-operative pain for extraction of third molars. METHODS: In a single centre, prospective, parallel, double blind randomised trial, patients scheduled for removal of all four third molars, ASA I-III patients<65 year-old patients were included. After intubation under general anesthesia (using intravenous remifentanil and propofol), for each of the third molars, 2mL of ropivacaine (7.5mg/mL) or placebo (0.9% saline solution) was injected into the vestibular capsule (total: 8mL) before extraction. At the end of surgery, similar analgesia was injected for both groups (intravenous paracetamol 1g and ketoprofene 100mg). The primary outcome was postoperative pain assessed by Visual Analog Scale (VAS). Postoperative consumption of analgesics (morphine titration in post-operative care unit when VAS>3/10, followed by oral tramadol 50mg after discharge), patient satisfaction, chronic pain (1-3 month), time in PACU and total hospitalization time were also recorded. RESULTS: A total of 50 patients were analysed in each group with similar characteristics (ropivacaine vs. control, for age (years) 18 [17-21] vs. 18 [17-21], for sex (female) 33 (66%) vs. 25 (50%), and BMI (kg/m2): 20 [19-23] vs. 21 [19-23]). Area Under the Curve for VAS pain (0 to 4h) was lower for Ropivacaine group: 0.43 [0.19-0.66] vs. 0.63 [0.43-0.87], P=0.005. Use of morphine in PACU (8 vs. 18, P=0.02) and median length of stay in ambulatory setting (5 vs. 6h, P=0.03) were reduced in Ropivacaine vs. Placebo group. At days 1 and 4, VAS of pain was higher in Ropivacaine group (respectively 4 vs. 2, P=0.006 and 3 vs. 2, P=0.05). At month 1 and 3, pain and DN4 score were similar between groups, with a median VAS pain score at 0 for both groups (P=0.42). No difference was observed for patient satisfaction and adverse events. CONCLUSIONS: Ropivacaine provides an immediate efficient pain relief after extraction of third molars without benefit after discharge. CLINICALTRIAL REGISTRATION: NCT01541059.

Carbetocin for prevention of postcesarean hemorrhage in women with severe preeclampsia: a before-after cohort comparison with oxytocin.

STUDY OBJECTIVE: The aim of the study was to compare the incidence of the use of additional uterotonics before and after the change of carbetocin to oxytocin for the prevention of postpartum hemorrhage after cesarean delivery in women with severe preeclampsia. DESIGN: This was an observational retrospective before-and-after study. SETTING: Operating room, postoperative recovery area. PATIENTS: Sixty women with severe preeclampsia undergoing cesarean delivery under spinal anesthesia; American Society of Anesthesiologists 3. INTERVENTIONS: Observational study. MEASUREMENTS: Blood pressure, heart rate, and biological data (hemoglobin, platelets, haptoglobin, prothrombin time index, activated partial thromboplastin time ratio, blood uric acid, aspartate aminotransferase, alanine aminotransferase, serum urea, serum creatinine, and albumin). MAIN RESULTS: The incidence of additional uterotonic administration in the carbetocin and oxytocin groups was 15% and 10%, respectively (P=.70). CONCLUSIONS: As carbetocin appears to be as effective and safe as oxytocin in preeclamptic women, its advantages make it a good uterotonic option in this particular setting.

Seizures in the peripartum period: Epidemiology, diagnosis and management.

The occurrence of seizures in the peripartum period is a rare but particularly challenging situation. Seizures in the peripartum period could result from three categories of conditions: first and most frequent is the exacerbation of a known pre-existing seizure disorder, mainly epilepsy. A therapeutic evaluation is needed; second is the new onset of seizures due to a non-pregnancy-related problem. An accurate diagnosis and a specific treatment are required; third is range of pregnancy-related conditions. The present review focuses on this third category, with a special attention to disorders occurring in the peripartum period. It is structured in two sections. The first section is a focus on eclampsia since, based on ICU admission data, it appears to be the leading cause of pregnancy-related seizures. Its epidemiology, pathophysiology, clinical diagnosis, neuro-imaging features and recommended management are reviewed. The efficacy and safety of the recommended regimens of MgSO4 therapy are discussed, as well as controversies on the alteration of these regimens and the use of MgSO4 in women with mild preeclampsia. In the second section, the other causes of pregnancy-related new onset seizures are summarized. These include posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis, thrombotic thrombocytopenic purpura, amniotic fluid embolism, and air embolism. Noteworthy is the fact that most of these pregnancy-related seizure conditions overlap with each other, mainly in terms of clinical presentations and neuro-imaging. Therefore, the diagnosis and the treatment options should be considered on a multidisciplinary basis.

Preoperative fasting does not affect haemodynamic status: a prospective, non-inferiority, echocardiography study.

BACKGROUND: The link between preoperative fasting and hypovolaemia remains unclear. We tested the hypothesis that preoperative fasting does not significantly increase the proportion of patients with hypovolaemia according to transthoracic echocardiography (TTE) criteria. METHODS: Patients of ASA status I-III and without bowel preparation were included in a non-inferiority, prospective, single-centre trial. Patients underwent passive leg raising (PLR) test and TTE at admission (Day 0) and after 8 h fasting (Day 1). The primary hypothesis was that an 8 h preoperative fasting does not increase the proportion (margin=5%) of patients with a positive PLR test ('functional approach'). The secondary hypothesis was that echocardiographic filling pressures or stroke volume (margin 10%) are not affected by preoperative fasting ('static approach'). RESULTS: One hundred patients were included and 98 analysed. After an 8 h fasting, the change in the proportion of responders to PLR was -6.1% [95% confidence interval (CI)=-16.0 to 3.8] of responders to PLR test on Day 0 when compared with Day 1. Because 95% CI was strictly inferior to 5%, there was no significant increase in the proportion of PLR responders on Day 1 when compared with Day 0. The 95% CI changes of static variables were always fewer than 10%, meaning that preoperative fasting induced significantly no relevant changes in static variables. CONCLUSION: Preoperative fasting did not alter TTE dynamic and static preload indices in ASA I-III adult patients. These results suggest that preoperative fasting does not induce significant hypovolaemia. Clinical trial registration NCT 01258361.

Single-shot intraoperative local anaesthetic infiltration does not reduce morphine consumption after total hip arthroplasty: a double-blinded placebo-controlled randomized study.

BACKGROUND: The infiltration of local anaesthetic (LA), ketorolac, and epinephrine has been suggested to be effective for analgesia after total hip arthroplasty (THA). The part of action of each component of the mixture remains unclear. We investigated the contribution of infiltration of ropivacaine alone on the morphine consumption during the first 24 h after surgery. METHODS: Sixty patients undergoing primary THA were included in this prospective randomized double-blinded placebo-controlled trial, after IRB approval and informed consent. Surgical and general anaesthetic management were standardized. At the end of surgery, 80 ml of ropivacaine 0.2% (160 mg) or saline was infiltrated. The primary endpoint was morphine consumption 24 h after surgery. The secondary endpoints were: visual analogue scale scores and opioid side-effects at H2, H4, H8, H12, H24, D1, D2, D3, D4, D5, rehabilitation programme progress, chronic pain level, analgesic consumption, and surgical result at 3 months and 1 yr after surgery. The observation period was 1 yr. RESULTS: Groups were similar for patient characteristic and perioperative characteristics. The ropivacaine wound infiltration did not reduce morphine consumption at 24 h [median (25th and 75th inter-quartile) 27 (17-37) mg in the ropivacaine group vs 24 (18-34) mg in the placebo group, P=0.51] or its side-effects. No effect was found on rehabilitation progress or chronic pain after 3 months or 1 yr, but these were not the main endpoints of the study. CONCLUSIONS: Ropivacaine infiltration alone did not reduce morphine consumption at 24 h after operation nor did it improve postoperative rehabilitation.

Does the type of fluid affect rapidity of shock reversal in an anaesthetized-piglet model of near-fatal controlled haemorrhage? A randomized study.

BACKGROUND: The optimal resuscitation fluid for the early treatment of severe bleeding patients remains highly debated. The objective of this experimental study was to compare the rapidity of shock reversal with lactated Ringer (LR) or hydroxyethyl starch (HES) 130/0.4 at the early phase of controlled haemorrhagic shock. To assess the influence of vascular permeability in this model, we measured plasma vascular endothelial growth factor (VEGF) levels during the experiment. METHODS: Thirty-six anaesthetized and mechanically ventilated piglets were bled (<30 ml kg(-1)) to hold mean arterial pressure (MAP) at 40 mm Hg for more than 30 min and were resuscitated in two randomized groups: LR (n=14) or HES (n=14) at 1 ml kg(-1) min(-1) until MAP reached its baseline value of ±10%. MAP was maintained at its baseline value for 1 h. The time and fluid volume necessary to restore the baseline MAP value were measured. RESULTS: The time to restore the baseline MAP value of ±10% was significantly lower in the HES group (P<0.001). During the initial resuscitation phase, the infused volume was 279 (119) ml in the HES group and 1011 (561) ml in the LR group (P<0.0001). During the stabilization phase, the infused volume was 119 (124) ml in the HES group and 541 (506) ml in the LR group. Biological data and plasma VEGF levels were similar between the groups. CONCLUSIONS: Restoration of MAP was four times faster with HES than with LR in the early phase of controlled haemorrhagic shock. However, there was no evidence of increased vascular permeability.

Stroke volume optimization after anaesthetic induction: An open randomized controlled trial comparing 0.9% NaCl versus 6% hydroxyethyl starch 130/0.4.

OBJECTIVE: Postinduction hypotension during general anaesthesia could be corrected by a rapid cardiac preload optimization by fluid infusion. The type of fluid to be used in this context remains debated. The aim of our study was to compare the amount of fluid challenges required to optimize stroke volume after induction of anaesthesia with colloid (HES) or crystalloid (0.9% NaCl). DESIGN: Open randomized prospective parallel-group study. PATIENTS AND METHODS: Fifty-six adult patients scheduled to undergo orthopaedic surgery under general anaesthesia were randomly assigned to receive, either 0.9% NaCl (n=28), or HES (n=28). Cardiac preload optimization directed by oesophageal Doppler was performed after induction with fluid challenges of 250ml of solution until stroke volume (SV) no longer increased by 10%. Primary endpoint was: number of fluid challenges required to achieve SV optimization. Secondary endpoints were: number of patients responding to the first fluid challenge, proportion of patients requiring ephedrine and the ephedrine dose required to restore arterial pressure. RESULTS: Percentages of responders were 61% and 63% in the 0.9% NaCl and HES groups, respectively. Number of fluid challenges necessary for SV optimization was not significantly different between 0.9% NaCl group and HES group (2 [1-2] versus 2 [1-2], P=0.33). Number of patients needing ephedrine, and well as the associated ephedrine dose, did not differ significantly. CONCLUSIONS: Our study suggests that after induction, crystalloid and colloid expand the intravascular volume with equivalent efficacy immediately after administration and correct in a similar way the postinduction hypotension.

[Controversies in neuroanaesthesia: positioning in neurosurgery]. / Controverses en neuroanesthésie-réanimation: les positions en neurochirurgie.

Positioning of the neurosurgical patient has several features such as the existence of specific positions (i.e: sitting, prone hyperlordotic, crouching ou kneeling positions) or the range of facilities for the same surgical indications. The last point, a source of controversy, is the subject of this review. Current indications for the sitting position, positioning for lumbar spine surgery and prevention of eye injuries are successively addressed.

[Prehospital analgesia with femoral nerve block following lower extremity injury. A 107 cases survey]. / Bloc fémoral en analgésie préhospitalière pour traumatisme du membre inférieur. Enquête de pratique observationnelle sur 107 cas.

OBJECTIVE: Femoral Nerve Block (FNB) has been proposed for femoral fracture analgesia in a prehospital setting. METHODS: Descriptive case-series survey. All suspected femoral fractures that were managed by our extrahospital service and had a femoral block were prospectively included. The physician was free to choose any block technique (paravascular femoral block [BFPV], nerve stimulation femoral block [BFNS], or fascia iliaca block [BFI]), as well as local anesthetic mixture and volume. Pain was assessed using a simplified verbal scale (0-4) before (T0), 10minutes after block (T1), and at hospital arrival (T2). Demographic values, actual trauma diagnosis, the technique used, the local anesthetic mixture and volume, incidents and complications were recorded. RESULTS: One hundred and seven blocks were included. Eighty-six percent of the blocks were performed by an anesthesiologist, although they represent 50% of the prehospital physician staff. Pain on the simplified verbal scale (EVS) decreased from T0 to both T1 and T2 for the whole population and also in each technique subgroup (eight BFPV, 36 BFNS, and 63 BFI). Two BFI blocks required a re-injection to be successful. Ten blocks failed (eight BFI, and two BFNS). Among those 10 failed blocks, two were first wrongly quoted as successful and two successful BFNS blocks appeared inadequate with regard to the trauma location outside the femoral dermatoma. No complication was observed. CONCLUSION: Prehospital FNB appeared to be efficacious in routine practice. Teaching FNB to non-anesthesiologist physicians is challenging.

[Anaesthetic management of brain-dead for organ donation: impact on delayed graft function after kidney transplantation]. / Pratiques anesthésiques pour prélèvement d'organes chez le sujet en mort encéphalique et pronostic du greffon rénal.

BACKGROUND: The aim of this study was to report current anaesthetic management brain-dead organ donors and to assess its impact on delayed kidney graft function (DGF). METHODS: To achieve this retrospective multicenter study, brain-dead patient records were analysed for the years 2005 to 2007. Expanded donor criteria, length of stay in ICU, duration of brain death, respect of recommended cold ischemia time, preoperative and intraoperative management, type of anaesthesia, hemodynamic and respiratory parameters during organ retrieval, and impact of anaesthesia on DGF were analysed. RESULTS: One hundred and forty-nine out of 165 files were available. Sixty-two percent of donors received anaesthetic drugs. There were no differences in demographic characteristics between the anaesthesia group (group A) and the no-anaesthesia group (group NA). In group NA, the mean arterial pressure (MAP)>65 mm Hg was more frequent (53% vs. 29%, P<0.01), but did not differ for maximal MAP. In group A, maximal heart rate was higher (120 vs. 105b/min, P=0.02) and donors received significantly more colloids (P<0.01). Independent risk factors of DGF included absence of hydroxyethyl starch infusion during the preoperative period and mechanical ventilation without PEEP. CONCLUSION: During organ retrieval, 62% of organ donors received anaesthetic drugs. Use of anaesthesia lead to lower MAP requiring more fluid challenge with colloids but did not influence the DGF.

[Sugammadex and renal failure: a case report]. / Sugammadex et insuffisance rénale: à propos d'un cas.

We report a case of delayed rocuronium-induced deep block antagonization with sugammadex, thus requiring a total of three injections and a cumulative dose of 12 mg/kg over a 30 min period. The patient was an emergency case with full stomach that had required a rapid sequence induction. Because of hyperkaliemia due to an acute renal failure, rocuronium was preferred to succinylcholine. Use of sugammadex in the acute renal failure context is discussed.

[Epidural analgesia is not the only cause of peripartum central neurologic symptoms. Report of one case of posterior reversible encephalopathy syndrome]. / L'anesthésie péridurale n'est pas la seule cause de troubles neurologiques centraux durant le travail obstétrical. Un cas de syndrome d'encéphalopathie postérieure réversible.

A young woman without any significant medical history received an epidural analgesia for labour. She suddenly presented headache, vision loss, nausea and arterial hypertension a few minutes after a 4-ml ropivacaine 0.75% bolus. The catheter was withdrawn and symptoms completely disappeared within 15 minutes. A new epidural catheter was inserted. Thereafter, the patient gave birth to a healthy newborn infant. Half an hour later, while the epidural catheter was still infusing, she presented generalized tonicoclonic seizure. Potential diagnoses were systemic toxicity of local anaesthetics and eclampsia. Accordingly, the patient received intravenous lipid emulsion and magnesium sulphate. There was no biological abnomabilities. A final diagnosis of posterior reversible encephalopathy syndrome was made with MRI showing bilateral hyperintensity areas involving the cortex of the occipital and frontal areas asymmetrically. On the sixth day, after delivery, the patient was discharged seizure-free. Repeated MRI 4 weeks after discharge was unremarkable.

[Puncture of the radial vein: a forgotten complication]. / Ponction veineuse radiale superficielle et neuropathie: une complication oubliée.

The superficial radial vein at the lateral edge of the inferior third of the forearm and of the wrist has strong anatomical relationship with the sensory superficial branch of the radial nerve. At this level, any venous puncture may be responsible for a lesion of this superficial part of the radial nerve. We report two cases of dysesthesia in the radial territory after this kind of puncture. This risk should not be neglected and venous puncture should be avoided in this area.

[Triple nerve block for ambulatory knee arthroscopy]. / Tribloc (fémoral, sciatique, obturateur) pour la chirurgie ambulatoire arthroscopique de genou: étude prospective de faisabilité et d'efficacité.

BACKGROUND: The purpose of this study was to evaluate intra- and postoperative conditions of the triple nerve block technique (femoral, obturator, sciatic block) for outpatient knee arthroscopic procedures. METHODS: After written informed consent, ASA I-III patients received a combined triple nerve block with 30-40 ml lidocaine or mepivacaine (1,5%). Blocks were performed using a nerve stimulation technique. Onset time, block failure, supplemental general anesthesia (GA) or analgesia and pain score were recorded intraoperatively. After surgery, side effects (at days 0, 1, 3, 7 and after 4 weeks), patient and surgeon satisfactions were noted. RESULTS: Three hundred and twelve patients were screened and 115 triple blocks were performed (157 chose GA, 19 spinal anaesthesia, 21 exclusion for regional anaesthesia). Failed blocks occurred for 12 (10%) patients. These 12 patients received GA before surgery incision. Time to complete block was 40 (10-60) min. Supplemental GA was required for 12 patients (12%) due to surgical (n=7, 7%) or tourniquet (n=5, 5%) pain. Intraoperative surgeon satisfaction was 90 (60-100). After surgery, time to discharge the postoperative care unit was 15 (5-60) min. Pain score at rest (Visual Analog Scale) until six hours was less than 30 /100, without any additional morphine. Two patients (< 2%) failed for ambulatory discharge criteria (no relation with triple block). At day 0, 3, 5% patients suffered PONV (8% at D1), paresthesia was noted in 1.7% at D0 (0,8% D3). No other secondary effects were observed after seven days and 91% patients "would like same anaesthesia" for next surgery. CONCLUSION: We conclude that triple nerve block provided reliable intraoperative patient and surgical conditions for outpatient knee arthroscopy. Failed block (10%) was the major reason of supplemental anaesthesia. To increase surgical turn over under triple nerve block, a preoperative room may be required (block onset time).

[Impact of Express study on clinical practice in ARDS patients: a single French ICU experience]. / Evolution des pratiques ventilatoires chez les patients en SDRA lors de la participation à un essai clinique randomisé: l'expérience d'une unité de réanimation française.

INTRODUCTION: The French Express study compared two alveolar recruitment managements (maximal versus standard) in Acute Respiratory Distress Syndrome (ARDS) patients ventilated with 6 ml/kg of ideal body weight (IBW). The objective of the present study was to assess in a single intensive care unit, the impact of Express study on the mechanical ventilation settings in non-included ARDS patients. PATIENTS AND METHODS: From 16 October 2002 to 14 January 2005 all consecutive eligible but non-included patients in Express study were studied. The maximal and minimal tidal volumes, and the minimal and maximal respiratory rates were retrospectively recorded. These parameters were compared according to the date of patient's admission and then the patients were separated in four quartiles (14, 15, 15, 15 patients). RESULTS: From the first to the last study period separated by 26 months, the mean maximal tidal volume decreased from 9.0+/-1.3 to 7.4+/-1.0 ml/kg of IBW (p=0.03), the proportion of patients ventilated with a maximal tidal volume greater than 8 ml/kg decreased from 93% to 20% (p<0.01), the median minimal respiratory rate increased from 14 to 18 b/min (p=0.03) and the proportion of patients with a respiratory rate less than 20 b/min decreased from 100% to 73% (p<0.01). There were correlations between the time of patient's admission and the maximal tidal volume (r=-0.43, p<0.01), the minimal tidal volume (r=-0.28, p<0.04) and the minimal respiratory rate (r=0.33, p<0.02). CONCLUSION: The participation in Express study led physicians to modify their mechanical ventilation settings. The maximal tidal volume decreased and the minimal respiratory rate increased in the ARDS eligible but non-included patients.

[Benefits and indications of xenon anaesthesia]. / Avantages décisifs, indications et limites de l'anesthésie au xénon.

OBJECTIVE: To analyze the current knowledge related to xenon anaesthesia. DATA SOURCES: References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service and personal files. STUDY SELECTION: All categories of articles on this topic have been selected. DATA EXTRACTION: Articles have been analyzed for biophysics, pharmacology, toxicity and environmental effects, clinical effects and using prospect. DATA SYNTHESIS: The noble gas xenon has anaesthetic properties that have been recognized 50 years ago. Xenon is receiving renewed interest because it has many characteristics of an ideal anaesthetic. In addition to its lack of effects on cardiovascular system, xenon has a low solubility enabling faster induction of and emergence from anaesthesia than with other inhalational agents. Nevertheless, at present, the cost and rarity of xenon limits widespread use in clinical practice. The development of closed rebreathing system that allowed recycling of xenon and therefore reducing its waste has led to a recent interest in this gas. CONCLUSION: Reducing its cost will help xenon to find its place among anaesthetic agents and extend its use to severe patients with specific pathologies.

[Lipid emulsions for the treatment of systemic local anesthetic toxicity: Efficacy and limits]. / Les émulsions lipidiques dans le traitement de la toxicité systémique des anesthésiques locaux : efficacité et limites.

Local anaesthetic toxicity always results from rapid and important increase in their plasma concentrations. Clinically, neurologic and cardiovascular symptoms may occur, especially life-threatening cardiac arrhythmias and cardiac depression. Resuscitating patients from cardiac toxicity was known as difficult, until the introduction of lipid emulsion therapy. From experimental data, at least two mechanisms of action can be proposed, a sink-effect and an improvement of cardiomyocyte metabolism. The present article is a mini-review of the current use of lipid emulsions for the treatment of local anaesthetic cardiac toxicity. The mechanisms of cardiac toxicity and those of lipid emulsion therapy are summarized, and the clinical experience of this therapy and its limits are presented.