Opioid-free anesthesia under single injection paravertebral block combined with sevoflurane for pediatric renal surgery: a prospective observational pilot study.

Even though several studies have demonstrated the effectiveness of opioid free anesthesia (OFA) strategies in pediatric patients, OFA has not been studied in pediatric renal surgery. We, therefore, conducted a prospective observational pilot study on a total of 26 children to assess the feasibility and efficacy of using a single injection ultrasound-guided paravertebral block (PVB) at T10 level with 0.4 mL/kg bupivacaine 0.25% in combination with sevoflurane as an OFA technique in elective open renal surgery. A successful PVB (defined in terms of both hemodynamic change after the skin incision and the use of rescue analgesia) was observed in 25 children (96%). The interval between PVB and skin incision was 21 min [IQR (18-25)]. End tidal sevoflurane concentration was 2.1% [IQR (1.8-2.4)]. The median time between extubation and waking was 2.5 min [IQR (1-4)]. The median Face, Legs, Activity, cry, Consolability score in post-anesthesia care unit was 1.00 [IQR (0-2)]. Blood pressure falls were not significant at different measurement times. None of the patients had complications related to PVB, and only one patient had post-operative vomiting. PVB is an attractive method that can procure an effective OFA in combination with sevoflurane in pediatric renal surgery.

Priapism following erector spinae plane block for the treatment of a complex regional pain syndrome.

Erector spinae plane block (ESPB) is a novel block where local anesthetic is deposited between the erector spinae muscle and the underlying transverse process. Safety of this technique is emphasized in the majority of reports, but with a continued increase of its use, the number of related complications and side effects is likely to expand. We report the case of a patient treated with ESPB for a complex regional pain syndrome, complicated by the development of a priapism.

Nebulized ketamine to avoid mechanical ventilation in a pediatric patient with severe asthma exacerbation.

Asthma is a major cause of morbidity and mortality despite advances in outpatient treatment. Sometimes, children fail to respond to standard treatment and can potentially require mechanical ventilation. We describe a case of a 26-month-old girl with a severe asthma exacerbation successfully managed by ketamine administration via nebulization route that permitted to avoid mechanical ventilation. Nebulized ketamine might be a reasonable option to avoid mechanical ventilation in children who fail to respond to standard treatment of severe asthma exacerbation.

Unplanned Intensive Care Unit Admission following Elective Surgical Adverse Events: Incidence, Patient Characteristics, Preventability, and Outcome.

CONTEXT: Adverse events (AEs) are a persistent and an important reason for Intensive Care Unit (ICU) admission. They lead to death, disability at the time of discharge, unplanned ICU admission (UIA), and prolonged hospital stay. They impose large financial costs on health-care systems. AIMS: This study aimed to determine the incidence, patient characteristics, type, preventability, and outcome of UIA following elective surgical AE. SETTINGS AND DESIGN: This is a single-center prospective study. METHODS: Analysis of 15,372 elective surgical procedures was performed. We defined UIA as an ICU admission that was not anticipated preoperatively but was due to an AE occurring within 5 days after elective surgery. STATISTICAL ANALYSIS: Descriptive analysis using SPSS software version 18 was used for statistical analysis. RESULTS: There were 75 UIA (0.48%) recorded during the 2-year study period. The average age of patients was 54.64 ± 18.02 years. There was no sex predominance, and the majority of our patients had an American Society of Anesthesiologist classes 1 and 2. Nearly 29% of the UIA occurred after abdominal surgery and 22% after a trauma surgery. Regarding the causes of UIA, we observed that 44 UIA (58.7%) were related to surgical AE, 24 (32%) to anesthetic AE, and 7 (9.3%) to postoperative AE caused by care defects. Twenty-three UIA were judged as potentially preventable (30.7%). UIA was associated with negative outcomes, including increased use of ICU-specific interventions and high mortality rate (20%). CONCLUSIONS: Our analysis of UIA is a quality control exercise that helps identify high-risk patient groups and patterns of anesthesia or surgical care requiring improvement.

Anesthestic management of Kassabach-Meritt Phenomenon in an adult: case report.

BACKGROUND: Kasabach-Merritt phenomenon (KMP) is characterized by a vascular tumor with profound thrombocytopenia and consumptive coagulopathy that may presents significant challenges for anesthesiologist. CASE PRESENTATION: An 87-year-old man presented with kaposiform hemangioendothelioma involving the right leg in critical condition due to massive bleeding. Hematology investigations indicated the presence of KMP. Association of this type of tumor with KMP in adults has never been reported. CONCLUSION: The present case report lays an emphasis on the potential difficulties during anesthetic management of this rare condition.

Erector spinae plane block for rescue analgesia following caesarean delivery.

Pain after caesarean section is still a common and important source of patient dissatisfaction in many obstetric centres. With intrathecal morphine combined with multimodal analgesia, approximately 5­10% of patients experience severe breakthrough pain after caesarean delivery that is difficult to manage [1]. Planned erector spinae plane (ESP) block can result in excellent postoperative analgesia associated with high patient satisfaction after caesarean delivery [2, 3]. However, the role of this block for rescue analgesia following caesarean section has never been described. We present a case in which bilateral ESP block was used as rescue analgesia in a woman who had severe postoperative pain following elective caesarean delivery under spinal anaesthesia combined with multimodal analgesia. The patient described in this case gave written consent for publication of this observation.

Salbutamol-induced severe lactic acidosis in acute asthma.

Selective beta-adrenoceptor agonists are worldwide prescribed to manage bronchial obstruction. However, they expose to a potential risk of hyperlactatemia and lactic acidosis even with normal doses. The mechanism still poorly understood and suggested that salbutamol diverts the metabolism of pyruvate acid from Krebs cycle toward lactate formation. We report the case of a 42-year-old patient, admitted to intensive care unit for acute severe asthma. He presented a transient lactic acidosis over the first 48 h, following an excessive use of salbutamol. The metabolic acidosis caused tachypnea, as a compensatory mechanism, leading to respiratory failure. The diagnosis of salbutamol-induced lactic acidosis must be made by elimination and only accepted after deleting the other causes. The main clinical character is the worsening of dyspnea despite regression of bronchospasm. It is transient and usually normalizes within 24-48 h after stopping or decreasing doses of salbutamol.

[Combined lumbar plexus-sciatic nerve block in the emergency surgery for pertrochanteric fracture: an alternative technique in patients at high risk of anaesthetic complications]. / Bibloc lombaire et sciatique plexique pour la chirurgie urgente des fractures pertrochantériennes: une technique alternative chez les patients à haut risque anesthésique.

INTRODUCTION: emergency surgery for pertrochanteric femoral fractures (PFF) in patients at high risk of anaesthetic complications is a real challenge for surgeons due to the increased intraoperative risk. We report our experience with combined lumbar plexus-sciatic nerve block as an alternative anesthetic technique for these fractures. METHODS: we conducted a three-year descriptive, single-center, cross-sectional study including patients with a history of recent pertrochanteric femoral fractures (PFF) at high risk anaesthetic complications. Combined lumbar plexus-sciatic nerve block was performed using the common neurostimulation technique. A mixture of 20ml of lidocaine 2% and bupivacaine 0.5% (50/50) was injected into each block. The primary endpoint was the effectiveness of lumbar plexus-sciatic nerve block assessed through the rates from anesthesia-related failures defined as need for conversion into general anaesthesia (GA). The secondary endpoints were: 1) anesthetic technique, 2) intraoperative hemodynamic, respiratory and neurological impairment, and 3) outcomes and potential postoperative complications. RESULTS: the study included 30 patients. The average age of patients was 74 ± 10 years. The average admission time in the Department of Emergency Surgery was 12(5-36) hours. The average duration of the procedure was 15.20 ± 3.45 minutes. No conversion into GA was necessary. There were no statistically significant differences between the various recorded intraoperative hemodynamic and respiratory parameters (MAP, HR, SpO2) (p > 0,05). Surgical procedure duration was 46 ± 5 minutes. Surgical satisfaction was 9.7 ± 0.1. The first post-operative analgesic treatment was started after 8(1-24) hours. All patients had complete sensorimotor recovery. CONCLUSION: combined lumbar plexus-sciatic nerve block is an anesthetic alternative for urgent PFF surgery in patients at high risk of anaesthetic complications: reduced operative delays, anesthetic efficiency, hemodynamic and intraoperative respiratory stability, absence of complications due to other anesthetic techniques, rapid admission to recovery room, and good postoperative analgesia.

Erector spinae plane block for pediatric hip surgery -a case report.

Surgical repair of the hip is considered an extremely painful procedure. Managing pain in this surgery is challenging even with several available options, each with limitations. Erector spinae plane (ESP) block is a novel technique that has been used in different types of surgery, with promising results. Herein, we describe a case of a successful ESP block for pediatric hip surgery. In the future, ESP block could be an alternative technique for providing effective analgesia.

Unusual localization of bleeding under acenocoumarol: Spinal subdural hematoma.

BACKGROUND: The spinal subdural hematoma (SSH) is an extremely rare entity which represents only 4.1% of all spinal hematomas. It needs accurate diagnosis and rapid intervention because of the major neurological risk induced by spinal compression. Several etiologies have been reported: anticoagulant treatments, haematological disorders, arterio-venous malformation, repeated attempts at lumbar punctures and tumors. We report the case of an 82-year-old patient under acenocoumarol for atrial fibrillation who presented with paraplegia secondary to SSH. CASE REPORT: An 82-year-old patient with a history of ischemic heart disease and atrial fibrillation under acenocoumarol was admitted to emergency department with sudden onset of paraplegia and intense back pain associated with urinary incontinence and anal sphincter disorder. On examination his lower limb power was MRC grade 0 out of 5 in all ranges of movement bilaterally and a complete bilateral anesthesia reaching the T12 dermatome was noted. Biological test results showed an International Normalized Ratio at 10. Magnetic resonance imaging revealed a posteriorly located spinal hematoma at T12 level, measuring 36 mm with spinal cord compression. After correction of hemostasis disorders the patient was admitted to the operating room for a T11-L1 laminectomy with evacuation of the subdural hematoma. Muscle power showed a gradual improvement in the lower limbs estimated at 3/5 with regression of sphincter disorders but unfortunately a sequellar sensory impairment persisted. CONCLUSION: SSH is a rare situation of acenocoumarol bleeding incident, it should be evoked in any patient treated by this molecule with signs of spinal cord compression.

[Ischemic stroke revealing Fahr's syndrome]. / Accident vasculaire cérébral ischémique révélant un syndrome de Fahr.

Fahr's syndrome is defined as the presence of bilateral intracerebral, symmetrical, nonarteriosclerotic calcifications involving the basal ganglia. Their detection during stroke is exceptional. Phosphocalcium metabolism should be investigated with human parathyroid hormone (HPH) dosage. Diagnosis is based on the evaluation of clinical and laboratory data as well as on radiological imaging. Long-term antiepileptic treatment can cause basal ganglia calcification resulting in Fahr's syndrome. Prognosis is favorable. The correction of phosphocalcium metabolism usually leads to significant improvement.

Stercoral colitis mimicking appendicitis.

BACKGROUND: Stercoral colitis is an inflammatory process involving the colonic wall related to fecal impaction. This rare condition is associated with high morbidity-mortality. FINDINGS: We report a case of a 78-year-old woman with a history of dementia under clozapine who presented a clinical and sonographic presentation of acute appendicitis. The worsening of her clinical condition prompted us to review our diagnosis and modify our approach using the CT scan which was consistent with stercoral colitis. This report concerns an atypical presentation of this condition. CONCLUSIONS: The present case highlights the ability of severe forms of fecal impaction to precipitate very rare and life-threatening complications like stercoral colitis. It also points the importance of including stercoral colitis in the differential diagnosis of acute appendicitis in altered patients under anticholenergic drugs and the critical role of the CT scan as a crucial radiologic adjunct.

Anesthetic management of spontaneous cervical epidural hematoma during pregnancy: a case report.

BACKGROUND: Spontaneous spinal epidural hematoma during pregnancy is a quite rare event requiring emergent decompressive surgery in the majority of cases to prevent permanent neurological damage. Therefore, there is little data in the literature regarding anesthetic management of cervical localization during pregnancy. The potential for difficult airway management with the patient under general anesthesia is one of the major concerns that needs to be addressed to prevent further cord compression. Anesthetic management should also include measures to maintain the mean arterial pressure to improve spinal cord perfusion. Furthermore, spine surgery in pregnant patients needs special consideration in terms of positioning and in the postoperative period. CASE PRESENTATION: We present a case of a 35-year-old white woman at 21 weeks of gestation with a spontaneous cervical epidural hematoma. Fiberoptic bronchoscope-guided nasal intubation was a safe option to ensure a higher rate of successful endotracheal intubation while minimizing the risk of aggravating the injury. Her care posed other multiples challenges that required a multidisciplinary team approach. CONCLUSIONS: The case of our patient serves as a reminder of this rare condition and its implications regarding anesthesia.