1
|
Ramin S, Bringuier S, Martinez O, Sadek M, Manzanera J, Deras P, Choquet O, Charbit J, Capdevila X. Continuous peripheral nerve blocks for analgesia of ventilated critically ill patients with multiple trauma: a prospective randomized study. Anaesth Crit Care Pain Med 2023; 42:101183. [PMID: 36496124 DOI: 10.1016/j.accpm.2022.101183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sedation of ventilated critically ill trauma patients requires high doses of opioids and hypnotics. We aimed to compare the consumption of opioids and hypnotics, and patient outcomes using sedation with or without continuous regional analgesia (CRA). METHODS Multiple trauma-ventilated patients were included. The patients were randomized to receive an intravenous analgesia (control group) or an addition of CRA within 24h of admission. A traumatic brain injury (TBI) patients group was analyzed. The primary endpoint was the cumulative consumption of sufentanil at 2 days of admission. Secondary endpoints were cumulative and daily consumption of sufentanil and midazolam, duration of mechanical ventilation, intensive care unit (ICU) stay, and safety of CRA management. RESULTS Seventy six patients were analyzed: 40 (67.5% males) in the control group and 36 (72% males) in the CRA group, respectively. The median [IQR] Injury Severity Score was 30.5 [23.5-38.5] and 26.0 [22.0-41.0]. The consumption of sufentanil at 48h was 725 [465-960] μg/48h versus 670 [510-940] μg/48h (p = 0.16). Daily consumption did not differ between the groups except on day 1 when consumption of sufentanil was 360 [270-480] μg vs. 480 [352-535] μg (p = 0.03). Consumptions of midazolam did not differ between the groups. No difference was noted between the groups according to the secondary endpoints. CONCLUSIONS CRA does not decrease significantly sufentanil and midazolam consumption within the first 5 days after ICU admission in multiple trauma-ventilated patients. The use of peripheral nerve blocks in heavily sedated and ventilated trauma patients in the ICU seems safe.
Collapse
Affiliation(s)
- Severin Ramin
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Sophie Bringuier
- Department of Medical Statistics, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Orianne Martinez
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Meriem Sadek
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Jonathan Manzanera
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Pauline Deras
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Olivier Choquet
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France
| | - Jonathan Charbit
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Xavier Capdevila
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France; Inserm U 1298, Neuro Sciences Institute, University of Montpellier, Montpellier, France.
| |
Collapse
|
2
|
Boussemart P, Quintard H. Continuous peripheral nerve block for analgesia in the severe polytraumatized patient: Better analgesia for fewer opioids used? Anaesth Crit Care Pain Med 2023; 42:101215. [PMID: 36894054 DOI: 10.1016/j.accpm.2023.101215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 03/09/2023]
Affiliation(s)
- P Boussemart
- Département d'anesthésie reanimation, Service d'anesthésie-réanimation Neurochirugicale, CHU Lille, France.
| | - H Quintard
- Intensive Care Unit, University Hospital of Geneva, Geneva, Switzerland
| |
Collapse
|
3
|
Meng Q, Ji C, Ma Z, Chen BW, Zhang H, Li J, Cong L, Qu F, Gao S. A case report: extracorporeal membrane oxygenation for multitrauma patient with pneumorrhagia. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2023. [DOI: 10.1186/s43168-023-00182-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Abstract
Background
Extracorporeal membrane oxygenation (ECMO) can be used as salvage therapy for multitrauma patients with acute respiratory distress syndrome (ARDS) when conventional treatment fails to maintain oxygenation. However, controversy exists between ECMO application and the risk of bleeding due to systemic anticoagulation during the treatment. Non-heparin introduction seems to be a possible solution for this dilemma, owing to technical improvements in the device and management methods of ECMO.
Case presentation
A 58-year-old woman suffered from blunt thoracic, pelvic, and right lower limb fractures due to a falling accident, which resulted in acute respiratory distress syndrome (ARDS). Although the patient received intubation and mechanical ventilation (MV), respiratory failure was not alleviated. Venous-venous (V-V) ECMO was used as a salvage therapy. With the support of V-V ECMO, we safely cleared blood clots in the bronchus and avoided secondary lung injury caused by pressure trauma and oxygen poisoning of the MV. We introduced heparin-free ECMO management as a solution to reduce the risk of bleeding associated with pulmonary contusion and other organ injuries. To prevent thrombosis, we set the blood rate of ECMO to 4.0 L/min, which is much higher than the usual parameter. During ECMO, coagulation factors, such as prothrombin time, activated partial thromboplastin time, and D-dimer, were examined. ECMO was maintained for 5 days without any complications; MV was stopped on the 13th day, extubated on the 24th day, and discharged from ICU on the 28th day.
Conclusion
ECMO with non-heparin could be an optimal treatment for multitrauma patients with ARDS when traditional treatment cannot sustain oxygenation. High blood flow rate could prevent thrombosis through ongoing ECMO therapy without systemic anticoagulation. In addition, monitoring D-dimer value change (Δ D-dimer) may be better than D-dimer value in predicting clot formation in the membrane oxygenator.
Collapse
|
4
|
Pollock GA, Lo J, Chou H, Kissen MS, Kim M, Zhang V, Betz A, Perlman R. Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review. Br J Anaesth 2023; 130:e80-e91. [PMID: 36096943 DOI: 10.1016/j.bja.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/27/2022] [Accepted: 07/02/2022] [Indexed: 01/06/2023] Open
Abstract
Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.
Collapse
Affiliation(s)
- Gabriel A Pollock
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Jessie Lo
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Henry Chou
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael S Kissen
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michelle Kim
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vida Zhang
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Betz
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ryan Perlman
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
5
|
Regional anesthesia and analgesia for trauma: an updated review. Curr Opin Anaesthesiol 2022; 35:613-620. [PMID: 36044292 DOI: 10.1097/aco.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW This narrative review is an updated summary of the value of regional anesthesia and analgesia for trauma and the special considerations when optimizing pain management and utilizing regional analgesia for acute traumatic pain. RECENT FINDINGS In the setting of the opioid epidemic, the need for multimodal analgesia in trauma is imperative. It has been proposed that inadequately treated acute pain predisposes a patient to increased risk of developing chronic pain and continued opioid use. Enhanced Regional Anesthesia techniques along with multimodal pain therapies is thought to reduce the stress response and improve patient's short- and long-term outcomes. SUMMARY Our ability to save life and limb has improved, but our ability to manage acute traumatic pain continues to lag. Understanding trauma-specific concerns and tailoring the analgesia to a patient's specific injuries can increase a patient's immediate comfort and long-term outcome as well.
Collapse
|
6
|
Bello C, Sauter AR, Doll D, Luedi MM. Ultrasound Offers a Change to Refine ATLS Standards. Anesth Analg 2022; 134:e3-e4. [PMID: 34908553 DOI: 10.1213/ane.0000000000005781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Corina Bello
- Department of Anesthesiology, Spitalregion Rheintal, Werdenberg, Sarganserland, Grabs, Switzerland
| | - Axel R Sauter
- Division of Emergencies and Critical Care, Department of Anaesthesiology and Department of Research and Development, Oslo University Hospital, Oslo, Norway
| | - Dietrich Doll
- Department of Surgery, Catholic Clinics Oldenburger Münsterland gGmbH, St. Marienhospital Vechta, Teaching Hospital of the Medizinische, Hochschule Hannover University, Vechta, Germany
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
7
|
In Response. Anesth Analg 2022; 134:e4. [PMID: 34908554 DOI: 10.1213/ane.0000000000005782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|