Quality of life after trigeminal nerve block in refractory trigeminal neuralgia: A retrospective cohort study and literature review.

OBJECTIVE: To evaluate the effect of trigeminal nerve block (TNB) on patients' quality of life (QOL) 15 days after the procedure in patients with refractory TN. METHODS: This retrospective observational cohort study involved patients receiving TNB (levobupivacaine, clonidine, corticosteroid) between 2014 and 2018 at a postoperative pain clinic in France. Change in QOL from Day 0 (before block) to Day 15 was assessed according to SF-12. RESULTS: 21 patients (62 ± 14 y) were included in the study. Most patients (71%) were referred following surgery or dentistry. Of the 9 patients (43%) who exhibited >10% increase in SF-12 scores and so were deemed responders, SF12-physical and SF12-mental were increased by mean differences of 17 and 9 points, respectively. The mean duration of block lasted 15 ± 59 days (range 1 to 90 days) and no severe adverse effects were observed. CONCLUSION: Improved QOL was observed in approximately 50% of patients with trigeminal neuralgia (TN) two weeks after specific nerve block. The technique was easy to administer and well accepted by the patients.

Evaluation of the Analgesia Nociception Index and videopupillometry to predict post-tonsillectomy morphine requirements in children: a single-centre, prospective interventional study.

Background: Tonsil surgery causes significant and challenging postoperative pain. The Analgesia Nociception Index (ANI) and videopupillometry are two techniques of interest to monitor nociception in adults and may predict postoperative morphine requirements. We hypothesised that these techniques could predict the need for morphine after tonsillectomy in children. The main objective was to assess the prognostic significance of ANI and videopupillometry, measured at the end of surgery, on morphine consumption determined by a Face, Legs, Activity, Cry, Consolability (FLACC) scale score >3 in the Post Anesthesia Care Unit (PACU). Methods: A single-centre, prospective, interventional study evaluating children between 2 and 7 yr old undergoing tonsil surgery was performed. ANI and videopupillometry with tetanic stimulation were measured under general anaesthesia 4 min after the end of the surgical procedure. Each child was evaluated every 10 min by a nurse using the FLACC scale in the PACU and blinded to the measurements performed in the operating theatre. Results: Eighty-nine children were analysed and 39 (44%) received morphine in the PACU. Neither ANI values nor videopupillometry values were predictive of postoperative morphine consumption (areas under the receiver operating characteristic curve 0.54, 95% confidence interval [CI; 0.42-0.65], and P=0.57; and 0.52, 95% CI [0.41-0.63], and P=0.69, respectively). Neither ANI values nor videopupillometry values were correlated to the maximum FLACC scale score in the PACU with ρ=0.04 (P=0.71) and ρ=0.06 (P=0.57), respectively. Conclusions: Neither ANI nor videopupillometry performed at the end of surgery can predict morphine consumption in the PACU in children undergoing tonsillectomy.

Peripheral Nerve Block Efficacy on Refractory Neuralgia Complicating Ramsay Hunt Syndrome: A Case Report.

Several case studies have suggested the usefulness of peripheral nerve blocks in the management of various types of chronic pain that are unresponsive to standard medical treatment. We report here the case of a patient with severe neuralgia, secondary to Ramsay Hunt syndrome that was refractory to standard drug therapy. As a last resort, a block of the terminal branches of nervus intermedius was performed. Despite transient facial paralysis, pain was markedly reduced for 3 months with self-reported improved quality of life. To our knowledge, this block has never been described previously.

Nicardipine-induced acute pulmonary edema: a rare but severe complication of tocolysis.

We report four cases of acute pulmonary edema that occurred during treatment by intravenous tocolysis using nicardipine in pregnancy patients with no previous heart problems. Clinical severity justified hospitalization in intensive care unit (ICU) each time. Acute dyspnea has begun at an average of 63 hours after initiation of treatment. For all patients, the first diagnosis suspected was pulmonary embolism. The patients' condition improved rapidly with appropriate diuretic treatment and by modifying the tocolysis. The use of intravenous nicardipine is widely used for tocolysis in France even if its prescription does not have a marketing authorization. The pathophysiological mechanisms of this complication remain unclear. The main reported risk factors are spontaneous preterm labor, multiple pregnancy, concomitant obstetrical disease, association with beta-agonists, and fetal lung maturation corticotherapy. A better knowledge of this rare but serious adverse event should improve the management of patients. Nifedipine or atosiban, the efficiency of which tocolysis was also studied, could be an alternative.

Electrical impedance to detect accidental nerve puncture during ultrasound-guided peripheral nerve blocks.

PURPOSE: The objective of this study was to assess if an increase in electrical impedance was associated with intraneural (sub-epineural) needle tip placement. METHODS: Two electrical impedance measurements were carried out in each of 140 peripheral nerve blocks. The first measurement was performed at a distance of 0.5-1 cm from the nerve trunk (reference value), and the second measurement was performed close to the nerve, either immediately before local anesthetic injection if no nerve puncture was suspected, or immediately before repositioning the needle if nerve puncture was suspected. Nerve puncture was suspected if any one of the following indications was present: pain or paresthesia; motor responses with a minimal stimulating current < 0.4 mA; needle tip observed inside the nerve using ultrasound; nerve swelling after injection of local anesthetic. Electrical impedance variations were compared between the no puncture and the suspected puncture groups. RESULTS: Nerve puncture was suspected in 21 cases. The median variation [quartiles] of electrical impedance was +6.6% [-20; 36%] in the suspected puncture group (n = 21) and -10.0% [-28; 0%] in the no puncture group (n = 119) (P = 0.02). Absolute values of electrical impedance close to the nerve were greater in the suspected puncture group (15.5 kΩ [12.0; 18.0 kΩ]) vs the no puncture group (12.0 kΩ [8.9; 15.1% kΩ]) (P = 0.013). A receiver operating characteristic (ROC) curve was constructed, and the optimal cut-off for impedance was +4.3%. CONCLUSION: A > 4.3% increase in electrical impedance may indicate accidental nerve puncture during peripheral nerve block.

Predictive factors of advanced interventional procedures in a multicentre severe postpartum haemorrhage study.

PURPOSE: Severe postpartum haemorrhage (SPPH) is the leading cause of peripartum hysterectomy and maternal death. There are no easily measurable parameters that indicate the failure of medical therapy and the need for an advanced interventional procedure (AIP) to stop genital tract bleeding. The aim of the study was to define factors predictive of the need for an AIP in the management of emergent PPH. METHODS: The study included two phases: (1) an initial retrospective study of 257 consecutive patients with SPPH, allowing the determination of independent predictors of AIP, which were subsequently grouped in a predictive score, followed by (2) a multicentre study of 239 patients admitted during 2007, designed to validate the score. The main outcome measure was the need for an AIP, defined as uterine artery embolization, intraabdominal packing, arterial ligation or hysterectomy. RESULTS: Abnormalities of placental implantation, prothrombin time <50% (or an International Normalized Ratio >1.64), fibrinogen <2 g/l, troponin detectable, and heart rate >115 bpm were independently predictive of the need for an AIP. The SPPH score included each of the five predictive factors with a value of 0 or 1. The greater the SPPH score, the greater the percentage of patients needing an AIP (11% for SPPH 0, to 75% for SPPH ≥2). The AUC of the ROC curve of the SPPH score was 0.80. CONCLUSIONS: We identified five independent predictors of the need for an AIP in patients with SPPH and persistent bleeding. Using these predictors in a single score could be a reliable screening tool in patients at risk of persistent genital tract bleeding and needing an AIP.

Perioperative platelet transfusion: recommendations of the Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSaPS) 2003.

PURPOSE: To present the recommendations of the Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSaPS; French Safety Agency for Health Products). METHODS: A panel of experts reviewed and graded the literature on platelet transfusions; recommendations were formulated. MAIN FINDINGS: Threshold platelet counts (PC) for transfusions in the perioperative context have not been clearly defined and should be determined by the existence of hemorrhagic risk factors. In the case of commonly practiced invasive procedures, the recommendation is to transfuse in order to achieve PC > 50,000xmicroL(-1). In the absence of platelet dysfunction, regardless of the type of surgery, the standard hemorrhagic risk threshold for surgery is 50,000xmicroL(-1). It has not been proven that the risk threshold is different according to the type of surgery. For neurosurgery and ophthalmologic surgery involving the posterior segment of the eye, a PC of 100,000xmicroL(-1) is required. For axial regional anesthesia, a PC of 50,000xmicroL(-1) is sufficient for spinal anesthesia; a PC of 80,000xmicroL(-1) has been proposed for epidurals. During massive transfusion, prophylactic platelet infusion cannot be recommended beyond a loss of two blood volumes in less than 24 hr (Professional Consensus). As for the therapeutic transfusion of plasma and/or platelets, as much as possible, platelet deficit should be documented with test results (PC and fibrinogen) before transfusing. In the event of bleeding, platelet transfusion may precede plasma infusion. However, although this recommendation has been the subject of several professional consensus agreements, it is not based on any randomized studies. CONCLUSION: Threshold PC for perioperative transfusions have not been clearly defined and most recommendations are the result of a professional consensus.