[Three-in-one block or femoral nerve block. What should be done and how?]. / Bloc "3 en 1" ou bloc fémoral. Que faut-il faire et comment le faire?

The "3 in 1" block and the femoral nerve block are widely used for lower limb surgery and postoperative analgesia. Whether these blocks are in fact a same regional block with two different names or represent definitively two different blocks remains controversial. A large number of anatomical as well as functional variations of the lumbar plexus have been described and complicate a rational analysis of the spread of local anaesthetics following these blocks. Anatomical, radiological and especially clinical data seem to confirm that these blocks are to be distinguished from one another. Femoral nerve block requires the use of a nerve stimulator and has a high success rate in the territory of the femoral nerve; a spread towards other lumbar nerves, especially the lateral femoral cutaneous nerve, is sometimes observed. The "3 in 1" block is supported by the idea of diffusion within a space that is located after going through two fascial layers. Even in experienced hands, the success predictive value is not high. However, once the "3 in 1" block is well performed, a complete anaesthesia covering the territories of the femoral nerve, the lateral femoral cutaneous nerve, and the obturator nerve occurs. Specific indications of each technique are different: major knee surgery and postoperative analgesia for the "3-in-1" block and leg surgery for femoral nerve block. The best approach for knee arthroscopy remains open for discussion.

[What do French anesthesiologists choose when they are patients themselves?]. / Que choisit l'anesthésiste français quand il est lui-même patient?

To determine whether, as patients, French anaesthesiologists prefer regional anaesthesia, like their North American colleagues, they were all mailed a questionnaire which submitted 2 different scenarios. Scenario A concerned emergency surgery for an open fracture to the right tibia, the patient-cum-anaesthetist having a full stomach. Scenario B was the elective removal of the plate a year later. Response rate was 15% (1,187 answers). For scenario A 89% of physicians preferred regional anaesthesia, while 57% preferred regional anaesthesia for scenario B. Epidural anaesthesia was twice as popular as spinal anaesthesia. Lower limb blocks were only chosen by a minority (A:5%; B:6%). Statistically significant differences were found between selected techniques, according to respondent's age, sex, medical school and type of practice, especially for scenario B. The fear of complications like regurgitation, allergic reaction, or postdural puncture headache seemed to be of less influence in the choice than the experience of the anaesthetist to carry out the anaesthetic in each scenario. It can therefore be concluded that French anaesthesiologists prefer regional anaesthesia for lower limb surgery required for themselves. However, experience of the "operator" with the technique seems to be as important as the technique itself.

[The neurostimulator in loco-regional anesthesia]. / Neurostimulateur en anesthésie loco-régionale.

The physiological basis of neurostimulation is recalled and its use for the placement of needles for neural blockade described. After an account of available equipment, the author gives his reasons for preferring some of it. Based on experience gained with more than ten thousand cases, a protocol for using neurostimulation to insure close placement of needles to the nerves to be blocked. The advantages and disadvantages of available needles are stated. The indication for the use of neurostimulation in the practice of infiltration anaesthesia are enumerated and its advantages stressed. Finally its limitations and complications are presented.

[Blocking of the brachial plexus: which technique(s) should be chosen?]. / Bloc du plexus brachial: quelle(s) technique(s) choisir?

Brachial plexus blocks for upper extremity surgery: what are the preferred techniques? Brachial plexus anaesthesia for all types of upper extremity surgical procedures cannot be adequately achieved with a single technique. At least, two approaches are required: above the clavicle, Winnie's interscalene brachial plexus block, using a neurostimulator, has become the standard technique for shoulder surgery. Below the clavicle, midhumerus approach is the most successful approach for elbow, fore arm and hand surgery, especially for outpatient surgery. The best approach for catheter insertion along brachial plexus nerves/trunks remain controversial. The supraclavicular approach using surface landmarks might be the best approach due to its efficacy in achieving complete anaesthesia of the upper extremity and the rarity of secondary displacement of the catheter. Whatever the selected approach(es) to brachial plexus nerves, nerve location it best achieved by neurostimulation and often multiple neurostimulation. Insulated needles are being increasingly used due to accuracy but, currently, there is no general agreement concerning the type of needle bevel to be preferred in regard to both safety and accuracy.

[Why choose loco-regional anesthesia for knee surgery?]. / Pourquoi choisir l'anesthésie loco-régionale pour la chirurgie du genou?

The advantages and disadvantages of both general and local or regional anaesthesia for knee surgery are presented and the patient characteristics enumerated. Regional anaesthesia reduces the frequency of postoperative thrombo-embolic accidents, diminishes blood-loss and permits good postoperative analgesia. Thus it seems to achieve better results in respect to morbidity and mortality. It requires the patient's consent and acceptance by the surgeons as well as appropriate operating theater management.

An objective assessment of nerve stimulators used for peripheral nerve blockade*.

Nerve stimulation is considered by many to be the current 'gold standard' for locating peripheral nerves. Thirteen nerve stimulators were subjected to a battery of tests performed by two independent observers under standardised conditions using a digital oscilloscope, a calibrated resistance and a novel scoring system. Individual scores were assigned for the signal waveform, current intensity, impulse duration, maximum load output and functionality of each nerve stimulator; the maximum score achievable was 20. A score of > or = 15/20 was achieved by six nerve stimulators: Stimuplex HNS 12 (B Braun); MultiStim Vario (Pajunk); Plexival (Medival, Vygon); MultiStim Sensor (Pajunk); Plexygon (Aryon, Vygon); Stimuplex HNS 11 (B Braun). Seven nerve stimulators scored < 15/20. Anaesthetists should be aware of the limitations of the nerve stimulator being used. Standardisation of features is desirable when manufacturing nerve stimulators.

[New landmarks for the subclavian approach of the brachial plexus. (With 44 clinical cases) (author's transl)]. / Nouveaux repères pour le block du plexus brachial par voie supra-claviculaire. Avec une série clinique de 44 cas.

The authors first recall the well-known techniques described by Kuhlenkampf, Winnie and others. They emphasize the sometimes difficult location of the subclavian artery, the fear of pneumothorax, especially for students learning this anesthesia method. Authors propose the use of new landmarks for brachial plexus anesthesia. These are the external jugular vein, sterno-cleido-mastoid muscle, and clavicular insertion of trapezius muscle. 44 cases of anesthesia using this method follows the description of the landmarks. The authors emphasize their low failure rate.

Extrapyramidal syndromes after premedication with droperidol in children.

Four cases of extrapyramidal hypertonic syndrome were observed in 82 children who had been premedicated with small i.m. doses of droperidol. The frequency, time of onset, clinical description and treatment of this complication are discussed.

[Six hundred and thirteen regional anaesthesias practiced in emergency cases (author's transl)]. / Six cent treize anesthésies loco-régionales pendant la garde chirurgicale.

These regional anaesthesias included brachial plexus block, spinal anaesthesia and epidural anaesthesia. In this work, few complications were noted and the failure rate is low. Authors emphasize that regional anaesthesia should, as far as possible, be used as a substitute for general anaesthesia in emergency cases.