French practice of emergency resuscitative thoracotomy. A study based on the Traumabase Registry.

AIM OF THE STUDY: Emergency resuscitative thoracotomy (ERT) has been described as a potentially life-saving procedure for trauma patients who have been admitted in refractory shock or with recent loss of sign of life (SOL). This nationwide registry analysis aimed to describe the French practice of ERT. PATIENTS AND METHODS: From 2015 to 2021, all severe trauma patients who underwent ERT were extracted from the TraumaBase→ registry. Demographic data, prehospital management and in-hospital outcomes were recorded to evaluate predictors of success-to rescue after ERT at 24-hour and 28-day. RESULTS: Only 10/26 Trauma centers have an effective practice of ERT, three of them perform more than 1 ERT/year. Sixty-six patients (74% male, 49/66) with a median age of 37 y/o [26-51], mostly with blunt trauma (52%, 35/66) were managed with ERT. The median pre-hospital time was 64mins [45-89]. At admission, the median injury severity score was 35 [25-48], and 51% (16/30) of patients have lost SOL. ERT was associated with a massive transfusion protocol including 8 RBCs [6-13], 6 FFPs [4-10], and 0 PCs [0-1] in the first 6h. The overall success-to-rescue after ERT at 24-h and 28-d were 27% and 15%, respectively. In case of refractory shock after penetrating trauma, survival was 64% at 24-hours and 47% at 28-days. CONCLUSIONS: ERT integrated into the trauma protocol remains a life-saving procedure that appears to be underutilized in France, despite significant success-to-rescue observed by trained teams for selected patients.

Protocol for TRAUMADORNASE: a prospective, randomized, multicentre, double-blinded, placebo-controlled clinical trial of aerosolized dornase alfa to reduce the incidence of moderate-to-severe hypoxaemia in ventilated trauma patients.

BACKGROUND: Acute respiratory distress syndrome continues to drive significant morbidity and mortality after severe trauma. The incidence of trauma-induced, moderate-to-severe hypoxaemia, according to the Berlin definition, could be as high as 45%. Its pathophysiology includes the release of damage-associated molecular patterns (DAMPs), which propagate tissue injuries by triggering neutrophil extracellular traps (NETs). NETs include a DNA backbone coated with cytoplasmic proteins, which drive pulmonary cytotoxic effects. The structure of NETs and many DAMPs includes double-stranded DNA, which prevents their neutralization by plasma. Dornase alfa is a US Food and Drug Administration-approved recombinant DNase, which cleaves extracellular DNA and may therefore break up the backbone of NETs and DAMPs. Aerosolized dornase alfa was shown to reduce trauma-induced lung injury in experimental models and to improve arterial oxygenation in ventilated patients. METHODS: TRAUMADORNASE will be an institution-led, multicentre, double-blinded, placebo-controlled randomized trial in ventilated trauma patients. The primary trial objective is to demonstrate a reduction in the incidence of moderate-to-severe hypoxaemia in severe trauma patients during the first 7 days from 45% to 30% by providing aerosolized dornase alfa as compared to placebo. The secondary objectives are to demonstrate an improvement in lung function and a reduction in morbidity and mortality. Randomization of 250 patients per treatment arm will be carried out through a secure, web-based system. Statistical analyses will include a descriptive step and an inferential step using fully Bayesian techniques. The study was approved by both the Agence Nationale de la Sécurité du Médicament et des Produits de Santé (ANSM, on 5 October 2018) and a National Institutional Review Board (CPP, on 6 November 2018). Participant recruitment began in March 2019. Results will be published in international peer-reviewed medical journals. DISCUSSION: If early administration of inhaled dornase alfa actually reduces the incidence of moderate-to-severe hypoxaemia in patients with severe trauma, this new therapeutic strategy may be easily implemented in many clinical trauma care settings. This treatment may facilitate ventilator weaning, reduce the burden of trauma-induced lung inflammation and facilitate recovery and rehabilitation in severe trauma patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03368092. Registered on 11 December 2017.

Parasacral approach to block the sciatic nerve: a 400-case survey.

BACKGROUND AND OBJECTIVES: Parasacral sciatic nerve block has been shown to be easy to perform, but studies reported to date involve a total of only 155 patients. The aim of this study was to assess the efficacy of parasacral sciatic nerve block in a larger group of patients. METHODS: Four hundred consecutive parasacral blocks were evaluated prospectively. The level of expertise of the practitioner, the time to perform the block, the lowest current intensity of nerve stimulation, the injected volume, the onset time, the success or failure of the block, and complications were recorded. RESULTS: The time required to perform the block was 7 +/- 5 minutes. The lowest stimulation-current intensity was 0.4 +/- 0.1 mA, and the injected volume was 27 +/- 4 mL. The onset time was 13 +/- 7 minutes for both motor and sensory block in all nerve distributions. The success rate was 94% (376 of 400 cases). Nine supplemental injections were performed successfully, thus increasing the success rate to 96%. General anesthesia or heavy sedation was performed in 15 cases (3.8%). There was no difference in failure rate between more experienced and less experienced anesthesiologists. CONCLUSIONS: In this prospective 400-case study, we confirmed previous findings that the parasacral approach is effective, easy to perform, and easy to teach, even when performed by relatively inexperienced physicians. The parasacral approach is, therefore, an effective alternative to other approaches of sciatic nerve blockade.

Infraclavicular plexus block: multiple injection versus single injection.

BACKGROUND AND OBJECTIVES: This prospective, randomized, and multicentered study was undertaken to evaluate the success rate of coracoid infraclavicular nerve block performed with a nerve stimulator when either 1 or 3 motor responses were sought. METHODS: Eighty patients who presented for elbow, forearm, or wrist surgery were randomly allocated to one of the following groups: in group 1 (single stimulation), 30 mL local anesthetic (LA) was injected after locating only 1 of the median, ulnar, or radial motor responses. In group 2 (multistimulation), 3 responses were located: musculocutaneous, median or ulnar, and radial response, corresponding, respectively, to the lateral, medial, and posterior cords. A total of 10 mL LA was injected on each response. Bupivacaine 0.5% and lidocaine 2% with epinephrine 1:200000 (1:1 vol) were used as the LA mixture. Sensory and motor blocks were tested by a blinded observer. RESULTS: Block duration was slightly increased in the multistimulation group (P =.004). The onset time of sensory and motor block was faster in each nerve distribution, particularly in the radial, musculocutaneous, and antebrachial nerves. The success of anesthesia increased in the multistimulation group. The success rate of the block, without any additional block, sedation, or general anesthesia, increased from 40% in the single stimulation group to 72.5% in the multistimulation group (P <.0001). If the brachial and antebrachial cutaneous nerves were not included in the evaluation, success rate reached 87.5%. CONCLUSIONS: We conclude that by performing an infraclavicular block with stimulation of all 3 cords of the brachial plexus, the success rate is higher than when only a single stimulation is used.

Continuous lumbar plexus block: Use of radiography to determine catheter tip location.

BACKGROUND AND OBJECTIVES: The purpose of this article is to document where a lumbar plexus catheter introduced by the posterior approach will track and to evaluate the benefit of using systematic radiographic verification of catheter placement. METHODS: A continuous lumbar plexus block (CLPB) by the posterior approach was performed on 169 consecutive adult patients scheduled for major hip, thigh, or knee surgery. Each catheter was verified by radiography using 10 mL contrast medium. The correct position of the catheter showed a caudally and laterally oriented contrast spindle. RESULTS: Epidural spread of the contrast medium occurred in 3 of 169 patients (1.8%). Only 1 patient had a clinically relevant epidural spread of local anesthetic. Successful block of the lumbar plexus was achieved in the other 166 cases. CONCLUSIONS: Epidural spread of local anesthetic during lumbar plexus block should be expected to be relatively common. It can be easily identified clinically with fractionated doses of local anesthetic. The catheter tip was identified in the epidural space by radiographic verification in only 1.8% of cases. This expensive procedure is therefore unnecessary except when an unusual location is suspected, but not necessary to confirm a catheter assumed to be correctly positioned.

Postoperative analgesia by femoral nerve block with ropivacaine 0.2% after major knee surgery: continuous versus patient-controlled techniques.

BACKGROUND AND OBJECTIVES: This prospective study compared the efficacy and adverse effects after knee surgery of ropivacaine 0.2% administered as patient-controlled femoral analgesia (PCFA), as a continuous femoral infusion (Inf), or as both (PCFA+Inf). METHODS: Before general anesthesia, 140 adults scheduled to undergo major knee surgery received a sciatic/fascia iliaca nerve block with 0.75% ropivacaine (40 mL). After surgery, they were randomly assigned to receive, through the femoral catheter, an infusion of 0.2% ropivacaine administered as PCFA (boluses of 10 mL with a lockout time of 60 minutes), Inf (10 mL/h), or PCFA + Inf (5 mL/h plus boluses of 5 mL with a lockout time of 60 minutes). Pain was assessed at rest, on mobilization, and during physiotherapy using a visual analog scale (VAS). Additional use of intravenous (IV) analgesics was noted. RESULTS: Patients in all 3 groups experienced similar pain relief at rest, on mobilization, and after physiotherapy (P >.05). Additional use of analgesics and overall patient satisfaction (excellent or good in 80% of cases) were also similar in all groups. However, total postoperative ropivacaine consumption was lower in the PCFA group, 150 mL/48 h (90.5 to 210); than in the Inf group, 480 mL/48 h (478 to 480); and the PCFA + Inf group, 310 mL/48 h (280 to 340) (P <.05). Adverse events were similar in all 3 groups (hypotension, vomiting, insomnia). No paresthesia or motor block were observed. CONCLUSION: All 3 strategies provided effective pain relief. PCFA resulted in a lower consumption of ropivacaine (toxic and financial impact). PCFA + Inf does not improve postoperative analgesia.

Effect of patient-controlled perineural analgesia on rehabilitation and pain after ambulatory orthopedic surgery: a multicenter randomized trial.

BACKGROUND: Efficacy of continuous perineural and patient-controlled ropivacaine infusion at home after orthopedic surgery was compared with patient-controlled intravenous morphine for functional recovery and postoperative analgesia in a multicenter randomized trial. METHODS: Eighty-three patients scheduled to undergo acromioplasty or hallux valgus surgery received an interscalene (n = 40) or popliteal (n = 43) peripheral nerve block with 30 ml ropivacaine, 0.5%. After randomization, patients were discharged home 24 h after surgery with a disposable infusion pump delivering either patient-controlled intravenous morphine (n = 23) or perineural 0.2% ropivacaine infusion, either continuous infusion without bolus (n = 30) or basal infusion plus bolus (n = 30). The patients recorded pain scores on movement and/or walking and were directed to take paracetamol and rescue analgesics if necessary. The time necessary to be able to walk for 10 min; daily activities on days 1, 2, and 3; adverse events; and overall satisfaction scores were noted and graded by the patient. RESULTS: Basal-bolus ropivacaine decreased the time to 10 minutes' walk, optimized daily activities (P < 0.01), and decreased the amount of ropivacaine used. The morphine group had greater pain scores and consumption of morphine and ketoprofen compared with both ropivacaine groups (P < 0.05). The incidence of nausea/vomiting, sleep disturbance, and dizziness increased, and the patient satisfaction score decreased in the morphine group (P < 0.05). CONCLUSIONS: After ambulatory orthopedic surgery, 0.2% ropivacaine delivered as a perineural infusion using a disposable elastomeric pump with patient-controlled anesthesia bolus doses optimizes functional recovery and pain relief while decreasing the consumption of rescue analgesics and ropivacaine, and the number of adverse events.

Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients.

BACKGROUND: Continuous peripheral nerve block (CPNB) is the technique of choice for postoperative analgesia after painful orthopedic surgery. However, the incidence of neurologic and infectious adverse events in the postoperative period are not well established. This issue was the aim of the study. METHODS: Patients scheduled to undergo orthopedic surgery performed with a CPNB were prospectively included during 1 yr in a multicenter study. Efficacy of postoperative analgesia, bacteriologic cultures of the catheter, and acute neurologic and infectious adverse events were evaluated after surgery in 1,416 patients at arrival in the postanesthesia care unit, at hour 1, and every 24 h up to day 5. Risk factors for adverse events were determined using logistic regression. RESULTS: The median duration of CPNB was 56 h. Both general anesthesia and CPNB were performed in 73.6% of the patients. Postoperative analgesia was effective in 96.3%, but an increase in pain scores was noted at hour 24 (P = 0.01). Hypoesthesia or numbness occurred in 3% and 2.2%, respectively, and paresthesia occurred in 1.5%. Three neural lesions (0.21%) were noted after continuous femoral nerve block. Two of these patients were anesthetized during block procedure. Nerve damage completely resolved 36 h to 10 weeks later. Cultures from 28.7% of the catheters were positive. Three percent of patients had local inflammatory signs. The bacterial species most frequently found were coagulase-negative staphylococcus (61%) and gram-negative bacillus (21.6%). A Staphylococcus aureus psoas abscess (0.07%) was reported in one diabetic woman. Independent risk factors for paresthesia/dysesthesia were postoperative monitoring in intensive care, age less than 40 yr, and use of bupivacaine. Risk factors for local inflammation/infection were postoperative monitoring in intensive care, catheter duration greater than 48 h, male sex, and absence of antibiotic prophylaxis. CONCLUSION: CPNB is an effective technique for postoperative analgesia. Minor incidents and bacterial colonization of catheters are frequent, with no adverse clinical consequences in the large majority of cases. Major neurologic and infectious adverse events are rare.

Continuous parasacral sciatic block: a radiographic study.

UNLABELLED: Parasacral sciatic blockade results in anesthesia of the entire sacral plexus. In this study we sought to determine the spread of the local anesthetic injected through a parasacral catheter, the anatomical location of the inserted catheters, and the extent and reliability of the blockade. In this study, 87 consecutive patients undergoing major lower limb surgery were enrolled. After placement of the catheter and injection of 8 mL of radio-opaque contrast dye, radiographic images were evaluated for dispersion of the injectate. Sensory and motor evaluations were also performed. Radiographic analysis of the injectates revealed that nearly all catheters (86 catheters, 99%) were in the correct anatomical position. The mean volume of local anesthetic injection was 21 +/- 3 mL. All patients developed a full sensory block of all three major components of the sciatic plexus (tibial, common peroneal, and posterior cutaneous nerve of the thigh). We conclude that the parasacral sciatic block results in frequent success of blockade of all three major components of the sciatic plexus and it has a small risk of complications. Contrast radiography can be used to document the catheter placement. IMPLICATIONS: The parasacral sciatic block results in a frequent success rate of blockade of all three major components of the sciatic plexus (tibial, common peroneal, and cutaneous nerve of thigh). A contrast radiography can be used to confirm the proper position of the catheter.