Anesthesia Teleconsultation: Quality, Medicoeconomic Interest, and Patient Satisfaction of Preoperative Assessment-A Prospective Observational Study

Background: Telemedicine can be defined as the use of telecommunication technology for performing medical acts remotely by health professionals. Currently in anesthesia, teleconsultation (TC) is becoming widespread, although the benefit and quality have not been well evaluated. The objective of this study was to assess the quality, the patient satisfaction, as well as the ecological and medicoeconomic impacts of the preanesthesia TC. Methods: This prospective observational multicentric study was approved by the Société Française d'Anesthésie-Réanimation ethics committee. The study took place from October 2020 to March 2021, in eight French health care institutions. Every adult patient requiring TC before elective surgery could be included. Unavailability of videoconferencing for the patient was the main exclusion criteria. Five hundred three (n) patients, scheduled for surgery, were included. Their files were analyzed for quality, 375 were successfully interviewed for the second part of the study evaluating satisfaction and medicoeconomic impact. The study's evaluation criteria were the quality of the TeleMed-Cs, the satisfaction and comprehension for the patient, and the medicoeconomic impact of a remote evaluation compared with the face-to-face consultation with the surgeon. Results: Of the 503 files, 478 (95%) were reviewed and met all the high authority of health quality criteria. The electronic format of records was associated with higher completion rate. The median satisfaction was 10.0 (IQR 8.25-10.0). The cost of a TC in anesthesia was significantly lower than that of a face-to-face surgical consultation with a median cost of 1.49€ (IQR 0.8-1.99) versus 34.81€ (IQR 14.01-91.7) p < 0.001. Conclusions: TC in anesthesia seems to be a good alternative in terms of quality, patient satisfaction, and medicoeconomic gain for our patients. By facilitating access to preoperative evaluation, it could be adopted worldwide and thus reduce surgery-related morbidity and mortality in our patients.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of upper and lower limb nerve blocks

BACKGROUND

Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks.

METHODS

We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement.

RESULTS

A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research.

CONCLUSIONS

We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Wide Awake Local Anesthesia No Tourniquet (WALANT) technique improves the efficiency of distal nerve blocks for carpal tunnel release

BACKGROUND

Axillary block is the standard for carpal tunnel release (CTR), providing effective anesthesia, and tolerance of tourniquet. Conversely, distal blocks are less used due to poor tolerance of tourniquet. Wide Awake Local Anesthesia No Tourniquet (WALANT), proposed for hand and wrist surgeries, avoids its use. This study assesses the benefits of the addition of WALANT to distal blocks during endoscopic CTR (eCTR).

METHODS

This randomized, open-label, controlled trial prospectively enrolled 60 patients scheduled for eCTR. Patients were randomized to receive distal blocks at the wrist combined to either a high arm tourniquet (Distal block group) or a WALANT in the area of surgery (Distal + Walant group). The primary endpoint was the global pain score summing pain scores related to puncture, local anesthetic injection, pneumatic tourniquet, surgical procedure, tourniquet deflation, and residual sensitivity after surgery.

RESULTS

Mean global pain score was significantly reduced in the Distal + Walant group (0.5 ± 1.4 vs. 2.2 ± 2.4; p < 0.001). No need for an additional anesthetic procedure was required in the Distal+Walant group. Even if the quality of visualization was high in both groups, it was better in the Distal block group (5 [5-5] vs. 4 [4-5]; p < 0.001). No rescue tourniquet was necessary for the Distal+Walant group. The rate of hematoma 15 days post-surgery was significantly reduced in the Distal+Walant group (20% vs. 57%; p < 0.01).

CONCLUSIONS

The addition of WALANT to distal blocks is adapted for eCTR. This combined technique decreases perioperative pain scores, provides good surgery conditions, and reduces the risk of postoperative hematoma.

CLINICAL TRIAL NUMBER AND REGISTRY URL

The trial was registered on ClinicalTrials.gov (NCT04494100) on July 31, 2020 https://clinicaltrials.gov/ct2/show/NCT04494100?term=CMC+ambroise+pare&cntry=FR&draw=4&rank=28.

[Assessment of Teleconsultation for planned orthopaedic surgery]

La téléconsultation s’est développée depuis la pandémie de COVID-19. Une étude prospective observationnelle a été conduite chez 267 patients consécutifs de chirurgie orthopédique, sur 9 semaines entre mai et juillet 2020, pour évaluer les conditions de réalisation de la téléconsultation d’anesthésie. La qualité de la consultation et la satisfaction des patients ont été appréciées. Quatre-vingt-dix pourcent des patients ont été opérés sans consultation présentielle et 97 % ont été satisfaits de la consultation. La durée moyenne de consultation était de 15 minutes. L’aide d’un tiers était nécessaire pour 46 % des patients de plus de 65 ans. La principale cause d’échec tenait à la qualité de la connexion. Deux patients ont eu un report d’intervention pour non-respect des consignes de jeun. La téléconsultation est entrée dans la pratique de l’évaluation anesthésique avec de bonnes conditions de réalisation et de fiabilité.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks

BACKGROUND

There is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques.

METHODS

We conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement.

RESULTS

Sixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified.

CONCLUSIONS

Harmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

Efficacy of parasternal block to decrease intraoperative opioid use in coronary artery bypass surgery via sternotomy: a randomized controlled trial

OBJECTIVE

This study aims to assess the effect of a preoperative parasternal plane block (PSB) on opioid consumption required to maintain hemodynamic stability during sternotomy for coronary artery bypass graft surgery.

METHODS

This double-blind, randomized, placebo-controlled trial prospectively enrolled 35 patients scheduled for coronary artery bypass graft surgery under general anesthesia with propofol and remifentanil. Patients were randomized to receive preoperative PSB using either ropivacaine (PSB group) or saline solution (placebo group) (1:1 ratio). The primary endpoint was the maximal effect-site concentration of remifentanil required to maintain heart rate and blood pressure within the recommended ranges during sternotomy.

RESULTS

Median maximum concentration of remifentanil necessary to maintain adequate hemodynamic status during sternotomy was significantly reduced in PSB group (4.2 (2.5-6.0) ng/mL) compared with placebo group (7.0 (5.2-8.0) ng/mL) (p=0.02). Mean maximum concentration of propofol used to control depth of anesthesia was also reduced (3.9±1.1 µg/mL vs 5.0±1.5 µg/mL, PSB vs placebo, respectively; p=0.02). This reduction in propofol consumption during sternotomy enabled a more adequate level of sedation to be maintained in patients (minimum patient state index was 11.7±8.7 in placebo group and 18.3±6.8 in PSB group; p=0.02). PSB reduced postoperative inflammatory response by limiting concentrations of proinflammatory cytokines IL-8, IL-18, IL-23, IL-33 and MCP-1 measured in the first 7-day after surgery (p<0.05).

CONCLUSIONS

Preoperative PSB reduced the maximum concentrations of remifentanil and propofol required to maintain hemodynamic stability and depth of anesthesia during sternotomy.

TRIAL REGISTRATION NUMBER

NCT03734159.Sébastien Bloc, M.D.^1,2; Brieuc P. Pérot, Ph.D.³; Hadrien Gibert, M.D.¹; Jean-Dominique Law Koune, M.D.¹; Yannick Burg, M.D.¹; Didier Leclerc, M.D.¹; Anne-Sophie Vuitton, M.D.¹; Christophe De La Jonquière, M.D.¹; Marine Luka, L.S.³; Thierry Waldmann, M.D.⁴; Nicolas Vistarini, M.D.⁴; Stéphane Aubert, M.D.⁴; Mickaël M. Ménager, Ph.D.³; Messaouda Merzoug, Ph.D.²; Cécile Naudin, Ph.D.²; Pierre Squara, M.D.^2,5.

Guidelines: Anaesthesia in the context of COVID-19 pandemic

OBJECTIVES

The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic.

METHODS

The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions.

RESULTS

The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms.

CONCLUSION

We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.

Impact of a Hypnotically-Based Intervention on Pain and Fear in Women Undergoing Labor

The purpose of this study was to evaluate the effects of a hypnotically-based intervention for pain and fear in women undergoing labor who are about to receive an epidural catheter. A group of 155 women received interventions that included either (a) patient rocking, gentle touching, and hypnotic communication or (b) patient rocking, gentle touching, and standard communication. The authors found that the hypnotic communication intervention was more effective than the standard communication intervention for reducing both pain intensity and fear. The results support the use of hypnotic communication just before and during epidural placement for women who are in labor and also indicate that additional research to evaluate the benefits and mechanism of this treatment is warranted.

Clinical, biological, and microbiological pattern associated with ventriculostomy-related infection: a retrospective longitudinal study

BACKGROUND

Our aim was to describe the pattern of ventriculostomy-related infection (VRI) development using a dynamic approach.

STUDY DESIGN

Retrospective longitudinal study.

METHODS

We analyzed the files of 449 neurosurgical patients who underwent placement of external ventricular drain (EVD). During the study period, CSF sampling was performed on a daily base setting. VRI was defined as a positive CSF culture resulting in antibiotic treatment. For VRI patients, we arbitrary defined day 0 (D0) as the day antibiotic treatment was started. In these patients, we compared dynamic changes in clinical and biological parameters at four pre-determined time points: (D-4, D-3, D-2, D-1) with those of D0. For all CSF-positive cultures, we compared CSF biochemical markers' evolution pattern between VRI patients and the others, considered as a control cohort.

RESULTS

Thirty-two suffered from VRI. Peripheral white blood cell count did not differ between D-4-D0. Median body temperature, CSF cell count, median Glasgow Coma Scale, CSF protein, and glucose concentrations were significantly different between D-4, D-3, D-2, and D0. At D0, 100 % of CSF samples yielded organisms in culture. The physician caring for the patient decided to treat VRI based upon positive CSF culture in only 28 % (9/32) of cases. In the control cohort, CSF markers' profile trends to normalize, while it worsens in the VRI patients.

CONCLUSIONS

We showed that clinical symptoms and biological abnormalities of VRI evolved over time. Our data suggest that VRI decision to treat relies upon a bundle of evidence, including dynamic changes in CSF laboratory exams combined with microbiological analysis.

Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients

BACKGROUND

Because recovery of an efficient swallowing reflex is a determining factor for the recovery of airway protective reflexes, we have studied the influence of the tracheostomy tube cuff pressure (CP) on the swallowing reflex in tracheotomized patients.

METHODS

Twelve conscious adult intensive care unit (ICU) patients who had been weaned from mechanical ventilation were studied. Simultaneous EMG of the submental muscles with measurement of peak activity (EMGp) and amplitude of laryngeal acceleration (ALA) were performed during reflex swallows elicited by pharyngeal injection of distilled water boluses during end expiration. After cuff deflation, characteristics of the swallowing reflex (latency time: LaT, EMGp, and ALA) were measured at CPs of 5, 10, 15, 20, 25, 30, 40, 50, and 60 cm H(2)O.

RESULTS

LaT and CP were linearly related (P<0.01). CP was inversely correlated (P<0.01) to both ALA and EMGp.

CONCLUSIONS

We demonstrated that LaT, EMGp, and ALA of the swallowing reflex were influenced by tracheostomy tube CP. The swallowing reflex was progressively more difficult to elicit with increasing CP and when activated, the resulting motor swallowing activity and efficiency at elevating the larynx were depressed.

[Wound infiltration with local anesthetics for postoperative analgesia. Results of a national survey about its practice in France]

BACKGROUND AND OBJECTIVE

Local wound infiltration is a component of multimodal postoperative (p.o.) analgesia. Its implementation in current clinical practice remains unknown. Pain and Regional Anesthesia Committee of the French Anaesthesia and Intensive Care Society (Sfar) aimed to appraise its practice.

METHOD

Postal sample survey based on representative sample of national activity were sent to heads of anaesthesiology departments. The questionnaires included 36 items on single-shot and continuous wound infiltrations (CWI) with considerations about modality of administration, drugs and development limitations. Results in mean [CI95 %].

RESULTS

Response rate was 32 % (n=120). Sample was in accordance with national representation of health institutions. Local infiltration was included in 85 % [79-91] of the p.o. analgesia protocols. Regardless of the surgery, single-shot wound infiltration and CWI were used in more than 50 % of the patients by respectively 58 % [49-67] and 18 % [11-25] of the responders. However, a significant part of the surgeons remained reluctant to CWI. Lack of information and fear of septic complications were the most reported barriers. Peritoneal instillation after laparoscopy was rarely performed, in contrast with intra-articular infiltration after knee arthroscopy, performed systematically or very frequently by 60 % [50-70] of the responders.

CONCLUSION

The practice of local wound infiltration for p.o. analgesia seems presently well established, especially for single-shot injections. CWI is less commonly performed. Several surgical reluctances remain to be overcome. Better information about effectiveness and safety are likely to still improve their practices.

Spread of local anesthetic during an ultrasound-guided interscalene block: does the injection site influence diffusion?

BACKGROUND

During interscalene block (ISB) placement, ultrasound guidance (USG) enables the practitioner to measure the spread of local anesthetic around the nerve trunks or roots, and to adjust the needle position in order to optimize diffusion. Moreover, USG helps determine the best injection level, i.e. the point from which diffusion gives the most complete brachial plexus block. The aim of this study was to compare C5 and C6 level injections and to determine which level allows the best diffusion.

METHODS

Sixty randomized patients scheduled for shoulder surgery were divided into two groups. In group C5, injection was directed toward C5 while in group C6, the C6 nerve root was targeted. Block performance time was recorded. The onset of motor and sensory block of each nerve distribution was evaluated every 10 min over a 30-min period.

RESULTS

The average time taken to perform a nerve block was 6.2+2.6 min in Group C6 and 6.0+2.1 min in Group C5 (NS). At 30 min, the number of patients with a satisfactory musculocutaneous and axillary nerve block was not notably greater in either group. By contrast, a significantly higher success rate was observed for other nerves in the C6 group as compared to the C5 group: ulnar nerve block: 93% vs. 19%, radial nerve block: 96% vs. 28%, median nerve block: 96%, vs. 69%.

CONCLUSIONS

During USG ISB placement, injection below the C6 level provided the same efficiency in analgesia after shoulder surgery as an injection cranial to the C5 nerve root but a greater success rate of anesthesia in all distal nerve areas. This technique could be very interesting for trauma cases as an alternative to a supraclavicular block and offers a high success rate and is simple to perform, potentially promoting wide use and quicker learning for beginners.

Evaluation of a new disinfection method for ultrasound probes used for regional anesthesia: ultraviolet C light

OBJECTIVES

Ultrasound-guided regional anesthesia is commonly used for block placement. At present, the risk of cross contamination from probes is not well documented. To avoid transmission of infectious agents, several methods have been used for probe disinfection and protection. The aim of this study was to evaluate the antibacterial efficacy of a new high-level disinfection method based on ultraviolet C (UV-C) light under routine conditions after block placement with an unprotected probe.

METHODS

The study was after approval by the local Ethics Committee. In the first part of the study, 15 ultrasound probes were exposed to a large inoculum of 3 bacteria. Ultraviolet C disinfection consisted of cleaning the probe with dry and disinfectant-impregnated paper followed by a 90-second UV-C disinfection cycle in a decontamination chamber. A protocol was established to retrieve the probe with sterile gloves after opening the door of the chamber. In the second part, 50 blocks were placed with ultrasound-guided regional anesthesia. The skin was first prepared with an antiseptic solution, and sterile gel was applied; no covers were used to protect the probes. The blocks were then disinfected with UV-C light. Bacteriologic samples were collected before and after the UV-C method and inoculated on chocolate agar plates.

RESULTS

During the first part of the study, all probes were infected after inoculation (>150 colony-forming units) but were considered sterile (<10 colony-forming units) after disinfection. During the second part of the study, all probes were considered sterile before and after disinfection.

CONCLUSIONS

Ultraviolet C disinfection seems relevant for ultrasound-guided regional anesthesia just before block placement. It offers simple, fast, and effective high-level disinfection. Moreover, this method should obviate the use of sterile probe covers, which can improve echogenicity.

The learning process of the hydrolocalization technique performed during ultrasound-guided regional anesthesia

BACKGROUND

Because poor echogenicity of the needle remains a safety issue, we decided to analyze the learning process of the hydrolocalization technique (Hloc) performed to continuously identify needle-tip anatomical position during many ultrasound-guided regional anesthesia procedures.

METHODS

Ten senior anesthesiologists naïve to the Hloc agreed to participate in the study. They were requested to perform 40 out-of-plane (OOP) approach ultrasound-guided axillary blocks (AB) each using the Hloc. The Hloc, which is a needle-tip localization principle, was performed by means of repetitive injections of a small amount of a local anesthetic solution (0.5-1 ml) under an ultrasound beam. Details of the learning process and skill acquisition of the Hloc were derived from the following parameters: the duration of block placement, a measure of the perceived difficulty of needle-tip visualization, a measure of block placement difficulty, and the amount of local anesthetics solution required for the technique.

RESULTS

Four hundred ABs were performed. The success rate of an ultrasound-guided AB was 98%. The Hloc was successful in all patients. Skill acquisition over time of the Hloc was associated with a significant reduction of both the duration and the perceived difficulty of ABs placement. Apprenticeship data revealed that 20 blocks were required to successfully place AB within 5 min in most cases using the Hloc.

CONCLUSION

The Hloc performed during the OOP approach of ultrasound-guided regional anesthesia is a simple technique with a relatively short learning process feasible for efficient placement of ABs.

Spread of injectate associated with radial or median nerve-type motor response during infraclavicular brachial-plexus block: an ultrasound evaluation

BACKGROUND AND OBJECTIVES

We have compared ultrasound characteristics of spread during infraclavicular brachial-plexus blocks by use of electrically evoked radial-nerve- or median-nerve-type distal motor responses to guide the injection of 30 mL of 1.5% mepivacaine.

METHODS

Consecutive patients who required surgery distal to the upper arm were prospectively included in this study. With radial- or median-evoked distal motor response at a stimulating current intensity of less than 0.5 mA, patients were distributed into 2 equal groups. An independent investigator blinded to the evoked response described ultrasound characteristics of the spread of local anesthetic and assessed block quality 30 minutes after placement. A quality diffusion score proportional to the extent and intensity of spread around the axillary artery was used, and dynamic movements during injection were noted.

RESULTS

Thirty-two patients were included. With radial-nerve-type motor response, the success rate of infraclavicular plexus block was 100%, but 3 supplemental axillary blocks were requested with median-nerve-type motor response. Quality diffusion scores were significantly higher with radial-nerve-type as compared with median-nerve-type motor response (P = .03). Injection after radial-nerve-type motor response resulted in a typical and reproducible ultrasound feature of posterior local-anesthetic spread associated with medial and upper movement of the axillary artery. With median-nerve-type motor response, failed blocks were associated with a specific posterior displacement of the axillary artery that resulted from superficial spread.

CONCLUSION

We have demonstrated that as compared with median-nerve-type motor response, injection performed after a radial-nerve-type motor response promoted reproducible and remarkable ultrasound spread characteristics associated with complete sensory block of the 3 cords at 30 minutes.

Demonstration of the spread of injectate with deep cervical plexus block: a case series

BACKGROUND AND OBJECTIVES

The authors conducted a scanographic study in order to characterize the local anesthetic spread of injectate resulting from a single-injection technique of deep cervical plexus block.

METHODS

Six consecutive American Society of Anesthesiologists II and III patients scheduled for elective carotid endarterectomy under regional anesthesia were enrolled. Deep cervical plexus block was placed via an anterolateral approach using a nerve stimulator to guide the injection on contact with the levator scapulae nerve. With specific contractions evoked at a stimulating current intensity <or=0.5 mA, a 40-mL mixture containing local anesthetics and iopamidol was injected. Thirty minutes after the block was placed, sensory and motor neural blockade was evaluated, and a helicoidal scanner of the head-neck and upper thorax was completed. Sequential cross sections spaced at 5 mm were performed from the base of the skull down to T1. A 3-dimensional volume-rendering technique was used to characterize spread of injectate, which calculated volume.

RESULTS

All patients completed C2-C4 dermatomal sensory blockade. None of the patients experienced anesthesia of the C8 and T1 dermatomes. The spread of injectate extended in a cephalocaudal direction from C1 to C7; its wider dimensions were systematically observed at the C3-C4 level. Fascia of the carotid sheath and sternocleidomastoid muscle limited the anterior spread of injectate. The trapezius limited lateral and posterior diffusion of injectate. Spread of injectate had a large volume exceeding twice that of the injectate. It has roughly a hemi cylinder shape with both ends stretched toward C1 and C7.

CONCLUSION

The authors showed that deep cervical plexus block was associated with a wide spread of injectate. The data show that the spread of injectate is enclosed within to the prevertebral layer of the deep cervical fascia.

Single-stimulation, low-volume infraclavicular plexus block: influence of the evoked distal motor response on success rate

BACKGROUND AND OBJECTIVES

We compared the success rate of single-injection infraclavicular plexus block by using electrically evoked radial, ulnar, or median nerve-type distal motor response to guide the injection of local anesthetic.

METHODS

Consecutive patients requiring surgery distal to the upper arm were prospectively included in this study over a 6-month period. No search for predetermined distal motor responses was performed. The first qualifying distal motor response evoked for a stimulating current intensity of <0.5 mA distributed patients into 3 groups of patients. The study was continued until 3 groups of 60 patients were fulfilled. Twenty to 25 minutes after the injection of 30 mL of 1.5% mepivacaine, blinded evaluation of block quality was performed. A successful block was defined by the presence of a complete sensory block of the 5 major nerve distal distributions of the arm.

RESULTS

Five hundred patients were included. The first evoked distal motor response was of radial, median, and ulnar nerve type in 46% (n = 230), 42% (n = 210), and 12% (n = 60) cases, respectively. The success rate of the infraclavicular plexus block was significantly higher when the injection was performed on a radial nerve-type response (90%) as compared with the median (74%) or ulnar (68%) nerve distal motor response. Intraoperative sedation and general anesthesia were not needed. None of the patients experienced specific complications.

CONCLUSION

We showed that evoked distal motor response influenced the success rate of single-injection infraclavicular plexus block. The highest success rate was obtained when injection was performed after radial nerve-type motor response.

Bloc plexique infraclaviculaire en monostimulation : l'injection au contact du faisceau postérieur permet de réduire le volume d'anesthésique local

OBJECTIVES

To assess the efficiency of a posterior secondary trunk single stimulation, low volume (30 ml 1.5% mepivacaine) infraclavicular brachial plexus block (ICB) technique.

STUDY DESIGN

Prospective study.

PATIENTS AND METHODS

One hundred consecutive patients scheduled for hand, forearm or elbow surgery were included. ICB was placed using a single stimulation technique. 30 ml 1.5% mepivacaine was injected when an evoked distal radial motor type response was elicited for 0.3-0.6 mA intensity current. Based upon both sensory and motor distribution ICB, characteristics and performance were assessed.

RESULTS

No patient required general anesthesia conversion. Success rate was 92%. 8 patients required a total amount of 10 complementary distal troncular blocks. No specific complication of ICB technique was accoutered. All patients completed full neurological recovery from ICB 24 hours after surgery.

CONCLUSION

30 ml mepivacaine 1.5% ICB is suitable for upper limb surgery.

Bilirubin decreases nos2 expression via inhibition of NAD(P)H oxidase: implications for protection against endotoxic shock in rats

We investigated a possible beneficial role for bilirubin, one of the products of heme degradation by the cytoprotective enzyme heme oxygenase-1 in counteracting Escherichia coli endotoxin-mediated toxicity. Homozygous jaundice Gunn rats, which display high plasma bilirubin levels due to deficiency of glucuronyl transferase activity, and Sprague-Dawley rats subjected to sustained exogenous bilirubin administration were more resistant to endotoxin (LPS)-induced hypotension and death compared with nonhyperbilirubinemic rats. LPS-stimulated production of nitric oxide (NO) was significantly decreased in hyperbilirubinemic rats compared with normal animals; this effect was associated with reduction of inducible NO synthase (NOS2) expression in renal, myocardial, and aortic tissues. Furthermore, NOS2 protein expression and activity were reduced in murine macrophages stimulated with LPS and preincubated with bilirubin at concentrations similar to that found in the serum of hyperbilirubinemic animals. This effect was secondary to inhibition of NAD(P)H oxidase since 1) inhibition of NAD(P)H oxidase attenuated NOS2 induction by LPS, 2) bilirubin decreased NAD(P)H oxidase activity in vivo and in vitro, and 3) down-regulation of NOS2 by bilirubin was reversed by addition of NAD(P)H. These findings indicate that bilirubin can act as an effective agent to reduce mortality and counteract hypotension elicited by endotoxin through mechanisms involving a decreased NOS2 induction secondary to inhibition of NAD(P)H oxidase.