Exclusion of complications of central venous catheters: Ultrasound versus X-ray.

INTRODUCTION: The placement of central venous catheters (CVC) is a frequent procedure in intensive care. It is not devoid of complications, the diagnosis of which relied for a long time on the chest X-ray. Currently, ultrasound appears to be an interesting alternative. AIM: To report the impact of the use of ultrasound on the time to exclusion of mechanical complications after CVC placement. METHODS: This is a prospective, multicenter, comparative, double-blind study. Were included the patients in whom the placement of a CVC was decided. After placement, a chest X-ray was ordered and an ultrasound was performed to look for signs of misplacement and pneumothorax. The two examinations were interpreted by two different doctors. The primary endpoint between the ultrasound group and the RTX group was the time "T1" represented by the time required to exclude complications. RESULTS: 30 patients were included in our study. The mean ultrasound T1time was significantly lower than the mean radiological T1time (p=0.000). Only one case of pneumothorax was observed. It was first detected by ultrasound. For the 29 other patients, exclusion of pneumothorax was confirmed by ultrasound and chest X-ray. No misplacement type complications detected. This was confirmed by ultrasound and radiological exclusions. CONCLUSION: Ultrasound is a faster tool than RTX in excluding mechanical complications after CVC placement. It guarantees a non-irradiating examination as efficient as chest X-ray for intensive care patients.

Hypobaric bupivacaine for continuous spinal anesthesia in elderly hip fracture: Effects on hemodynamic (A randomized controlled trial).

INTRODUCTION: Continuous spinal anesthesia for surgical repair of hip fracture in elderly patients has been shown to preserve hemodynamics better than general and single shoot spinal anesthesia. However, hypotension still occurs, even with continuous spinal anesthesia. AIM: This study aimed to demonstrate that hypobaric bupivacaine is more effective in preserving hemodynamics than isobaric bupivacaine when patients are operated in lateral position. METHODS: It was a prospective randomized controlled single-blind study conducted in an orthopaedic institute during two years (2017-2018). One hundred and ten patients aged more than 65 years, scheduled for hip fracture repair, were randomized to receive either hypobaric or isobaric bupivacaine. Repeated doses of 2.5 mg bupivacaine were injected until sensory blockade reached T12. Hypotension and severe hypotension were defined as a decrease of more than 20% and 30% from the baseline systolic arterial blood pressure and were treated with ephedrine. Statistical analysis used Chi2 and Student tests to compare either number and percentage or mean and median. P<0.05 was significant. RESULTS: Less patients experienced hypotension and severe hypotension in hypobaric group than in isobaric group (respectively 53% vs. 73%; p<0.05 and 22% vs. 53%; p< 0.01). Ephedrine consumption was significantly lower in hypobaric group (1.9 mg vs. 5.6 mg; p<0.01). CONCLUSION: Hypobaric bupivacaine may be used rather than isobaric bupivacaine for further preserving hemodynamics in continuous spinal anesthesia for hip fracture surgery in elderly.

Analgesia nociception index as a tool to predict hypotension after spinal anaesthesia for elective caesarean section.

Arterial hypotension is the main disadvantage of spinal anaesthesia (SA) for caesarean delivery with deleterious effects on maternal-foetal outcomes. Recently, a non-invasive device 'analgesia nociception index' (ANI) has been developed to evaluate the parasympathetic component of the nervous autonomous system. The aim of this study was to evaluate the ability of ANI to predict the risk of hypotension after SA for elective caesarean section. One hundred patients scheduled for elective caesarean delivery under SA were recruited in this observational prospective study. Hemodynamic and ANI parameters were recorded in supine position (TB), in sitting position (T0), after induction of SA (T1) and then every three minutes (T2, T3, Tn) until the end of surgery or having resort to ephedrine. After SA, women were classified into two groups according to occurrence of hypotension (group H, n = 80) or not (group C, n = 20). The variations of ANI between T2 and T0 were significantly higher in the group H as compared to the control group. A threshold of 4.5 points decrease in instantaneous ANI value could predict maternal hypotension. ANI is a simple and effective tool in predicting the risk of SA-related hypotension.Impact statementWhat is already known on this subject? Arterial hypotension is the main disadvantage of spinal anaesthesia for caesarean delivery with deleterious effects on maternal-foetal outcomes. The balance between the sympathic and parasympathic systems could be used to predict the onset of hypotension following spinal anaesthesia. Analgesia nociception index (ANI) is an index calculated based on heart rate variability HRV analysis, designed originally to evaluate the antinociception/Nociception balance.What do the results of this study add? We have shown that the analysis of HRV with ANI was a predictor of maternal hypotension after spinal anaesthesia.What are the implications of these findings for clinical practice and/or further research? ANI is an effective tool in predicting the risk of spinal anaesthesia-related hypotension. These findings are of potential clinical importance in the obstetrical anaesthesia setting. Further studies are required in order to implement this simple tool and optimise prophylactic measures especially vasopressors.

Adductor canal block: Effect of volume of injectate on sciatic extension.

CONTEXT: Spread of local anesthetic within adductor canal to peroneal and tibial nerves is described in literature. This spread could be volume-dependent. AIMS: In this study, we compared the diffusion of two volumes of 0.375% ropivacaine to popliteal fossa. SETTINGS AND DESIGN: This was a prospective, randomized controlled, single-blind study conducted in Kassab Orthopaedic Institute of Tunis for 1 year (2018). MATERIALS AND METHODS: A total of 42 patients, American Society of Anesthesiologists I/II scheduled for knee arthroscopy under spinal anesthesia scheduled to receive adductor canal block, were randomized into two groups: group N received 20 mL of ropivacaine 0.375% and group H received 40 mL. We evaluated sensory motor blocks of both peroneal and tibial nerves at 30 and 60 min. STATISTICAL ANALYSIS USED: Chi-square or Fisher's exact test was used to compare the number and percentage. P <0.05 was significant. RESULTS: At 60 min, complete sensory block of the peroneal nerve was obtained for 16 patients in group H versus 15 patients in group N with no statistically significant difference (P = 0.60). The difference was also not significant (P = 0.27) for the tibial nerve: 14 patients for group H versus 16 for group N. Motor blockade was rare in the two nerve territories. CONCLUSION: Spread of 0.375% ropivacaine to popliteal fossa resulted in high rate of complete sensory blockade of both peroneal and tibial nerves. Diffusion of local anesthetic was not volume-dependent.