[Peripheral nerve block: yesterday's facts and tomorrow's challenges].
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Anesthesia, Conduction↗
Biomedical subjects
P Narchi
Publications and source records attributed to P Narchi.
Postoperative nerve irritation syndrome after epidural analgesia in a six-year-old child.
Morbidity after paediatric epidural anaesthesia is unusual. We report a case of transient nerve root irritation occurring after epidural analgesia for radical nephrectomy in a 6-yr-old boy who received a continuous infusion of bupivacaine 0.1%. The epidural catheter was inserted within the L2-L3 interspace under general anaesthesia. Several possible causes are discussed. Mechanical irritation of nerve roots by the epidural catheter in the epidural space is the most likely cause. Br J Anaesth 2004: 92: 146-8
Abdominal Pain↗
Regional analgesia after total knee replacement.
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Anesthetics, Local↗
The use of a selective axillary nerve block for outpatient hand surgery.
UNLABELLED: Although no guidelines concerning discharge criteria after axillary plexus block are available, many institutions consider recovery of motor function as a critical factor. With the midhumeral approach, the four main nerves of the upper extremity can be blocked separately using a peripheral nerve stimulator. The aim of this double-blind study was to block the radial (R) and musculocutaneous (MC) nerves with lidocaine, and the median (M) and ulnar (U) nerves with bupivacaine to recover motor function of the elbow and wrist more rapidly while maintaining long-lasting postoperative analgesia at the operative site. Patients undergoing surgery for Dupuytren's contracture were randomized into two groups in a double-blind fashion: in the control group (n = 17), each of the four nerves was infiltrated with 10 mL of a mixture of 2% lidocaine and 0.5% bupivacaine, whereas in the selective group (n = 17), the R and MC nerves were blocked with 10 mL of 2% lidocaine each and the M and U nerves were blocked with 10 mL of 0.5% bupivacaine each. Recovery of motor block was significantly faster in the selective group (231 +/- 91 vs 466 +/- 154 min). However, time to first sensation of pain was not different between groups (707 +/- 274 vs 706 +/- 291 min). In conclusion, this new approach at the midhumeral level enables the anesthesiologist to selectively administer local anesthetics on different nerves. IMPLICATIONS: In outpatients undergoing surgery for Dupuytren's contracture, a midhumeral block was used with the musculocutaneous and radial nerves blocked by lidocaine and the median and ulnar nerves blocked with bupivacaine. Recovery of motor function and time to discharge were shorter compared with patients who received the mixture on all four nerves.
Ambulatory Surgical Procedures↗
[Autotransfusion during caesarean section with blood containing p salbutamol without adverse effects].
We report the case of a patient presenting with a placenta praevia and who donated autologous blood while she had beta 2-agonist tocolysis. As the restitution of blood containing salbutamol at therapeutic concentration may induce uterine atony and cardiovascular symptoms, we monitored maternal clinical signs and plasma concentrations of salbutamol when autologous blood was retransfused after the end of Caesarean section. The maternal plasma beta 2-agonist levels during tocolysis were in agreement with the usual therapeutic concentrations. The beta 2-agonist infusion was discontinued 30 minutes before the subarachnoid blockade and the blood concentration measured at the time of skin incision was below the therapeutic threshold. The retransfusion of autologous blood neither raised the salbutamol concentration above the therapeutic threshold value, nor induced any clinical symptoms. After Caesarean section the retransfusion of autologous blood containing therapeutic concentration of salbutamol seems to be innocuous.
Adult↗
Comparison between conventional axillary block and a new approach at the midhumeral level.
We undertook this prospective, randomized study to compare the success rate, time spent performing the blocks, onset time of surgical anesthesia, presence of complete motor blockade, and lidocaine plasma concentrations between conventional axillary block and a new approach at the midhumeral level. Both techniques were performed using a peripheral nerve stimulator. Two nerves were located at the axillary crease, whereas four nerves were located at the midhumeral level. Sixty patients undergoing upper limb surgery were assigned to one of the two techniques. The sensory block was evaluated before surgery for all of the distributions of the four major nerves of the upper extremity. A subset of patients had lidocaine plasma concentrations determined. Times to perform the blocks, mean maximum plasma lidocaine concentration, and time to peak concentration were not different between groups. The success rate of the block, as well as the incidence of complete motor blockade, was greater with the midhumeral approach compared with the axillary approach. However, the onset time to complete anesthesia of the upper extremity was shorter in the axillary approach. For brachial plexus anesthesia, we conclude that the midhumeral approach provided a greater success rate than the traditional axillary approach.
Adult↗
Serious complications related to regional anesthesia: results of a prospective survey in France.
BACKGROUND: Serious complications related to regional anesthesia have previously been described primarily in case reports and retrospective surveys. The authors prospectively evaluated a multicenter series of regional anesthetics, using preplanned criteria to measure the incidence and characteristics of associated serious complications. METHODS: Requests were sent to 4,927 French anesthesiologists in advance of a subsequent 5-month study period. Participating anesthesiologists were asked for detailed reports of serious complications occurring during or after regional anesthetics performed by them during the study interval. Details regarding each complication then were obtained via a second questionnaire. RESULTS: The number of responding anesthesiolgists was 736. The number of regional anesthetics performed was 103,730, corresponding to 40,640 spinal anesthetics, 30,413 epidural anesthetics, 21,278 peripheral nerve blocks, and 11,229 intravenous regional anesthetics. Reports of 98 severe complications were received, with follow-up information being obtained for 97. In 89 cases, complications were attributed fully or partially to regional anesthesia. Thirty-two cardiac arrests, seven of which were fatal, occurred during the study. Of these, 26 occurred during spinal anesthesia, with 6 being fatal, 3 occurred during epidural anesthesia, and 3 more occurred during peripheral blocks. The higher incidence of cardiac arrest during spinal anesthesia (6.4 +/- 1.2 per 10,000 patients) compared with all other regional anesthesia (1.0 +/- 0.4 per 10,000 patients) was statistically significant (P < 0.05). Of 34 neurologic complications (radiculopathy, cauda equina syndrome, paraplegia), 21 were associated either with paresthesia during puncture (n = 19) or with pain during injection (n = 2), suggesting nerve trauma or intraneural injection. Twelve patients who had neurologic complications after spinal anesthetics had no paresthesia during needle placement and no pain on injection. Of these 12 patients (7 with radiculopathy and 5 with cauda equina syndrome), 9 received intrathecal hyperbaric lidocaine, 5%. The incidence of neurologic injury was significantly greater after spinal anesthesia (6 +/- 1 per 10,000 cases; P < 0.05) than after each of the other types of regional procedures (1.6 +/- 0.5 per 10,000 cases for the weighted average). Seizures attributed to elevated serum levels of local anesthetics occurred in 23 patients, but none suffered a cardiac arrest. CONCLUSIONS: (1) The incidence of cardiac arrest and neurologic injury related to regional anesthesia were very low, but both were more than three SDs greater after spinal anesthesia than after other regional procedures. (2) Two thirds of the patients with neurologic deficits had either a paresthesia during needle placement or pain on injection. (3) Seventy-five percent of the neurologic deficits after nontraumatic spinal anesthesia occurred in patients who had received hyperbaric lidocaine, 5%.
Adult↗
Long-term postdural puncture auditory symptoms: effective relief after epidural blood patch.
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Anesthesia, Spinal↗
[Chronic tinnitus and hearing loss caused by cerebrospinal fluid leak treated with success with peridural blood patch. Apropos of 2 cases].
Hearing loss and tinnitus are frequently encountered in ENT patients and usually require complementary investigations such as audiogram, auditive evoked potentials, CT scan, MRI... One recent etiology, that is more and more discovered, is a decrease in spinal fluid pressure secondary to a dural fluid leak that occurs after a diagnostic lumbar puncture, a spinal anesthesia, an accidental dural puncture during an epidural technique or a lumbar myelography. Postural headache which are frequently present in such a setting, may mask these auditive symptoms. Epidural injection of autologous blood (blood patch) performed by anesthesiologists, which is usually indicated to treat such postural headaches, is efficient in relieving other symptoms related to spinal fluid leak after dural puncture. We report two cases of isolated auditive complaints (hearing loss and tinnitus) which have been dramatically improved after blood patch. In conclusion, ENT surgeons should seek for a recent or even a past history of spinal puncture whenever the etiology of auditive symptoms of their patient remains unclear.
Adult↗
[New routes for infiltration: intraperitoneal injections].
Intraperitoneal administration of local anaesthetics is frequently used during gynaecological laparoscopy and especially after laparoscopic sterilization where the solution may be instilled, sprayed or infiltrated around the clip or the rings. In addition, the subdiaphragmatic instillation of local anaesthetics by the surgeon during laparoscopy is followed by a decrease in the intensity of postoperative scapular pain which is known to last 2-3 days and is due to some degree of residual pneumoperitoneum. After laparoscopic cholecystectomy, the analgesic effects of the administration of local anaesthetics via the intraperitoneal route remain controversial. The pharmacokinetic data available which confirm the safety of doses up to 100 mg of bupivacaine or 800 mg of lidocaine, should encourage the use of larger doses, especially after cholecystectomy.
Anesthetics, Local↗
[Midazolam and ambulatory surgery].
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Ambulatory Surgical Procedures↗
[Analgesia after surgery of the shoulder].
Postoperative pain after shoulder surgery is known to be intense and requires usually opioid administration. The recent use of regional anaesthesia for this type of surgery has contributed to the relief of acute postoperative pain occurring in the recovery room since the analgesic effects of block persist for several hours after surgery depending upon the selected drug. Moreover, the development of less invasive surgery (arthroscopy) and experience with regional blocks have permitted to perform minor shoulder surgery on an outpatient basis. For minor surgery, regional anaesthesia associated to a light sedation is sufficient. However, for more invasive surgery, regional anaesthesia should be associated to a light general anaesthesia as well as the insertion of a supraclavicular catheter for postoperative analgesia. A diaphragmatic paresis secondary to a blockade of the phrenic nerve is constant radiologically after interscalenic block but remains symptomless. However, in case of severe preoperative chronic respiratory insufficiency, decompensation may occur rapidly after performance of the interscalenic block.
Ambulatory Surgical Procedures↗
Addition of oral clonidine to postoperative patient-controlled analgesia with i.v. morphine.
Using a randomized, double-blind, placebo-controlled design, we have investigated, in 40 patients undergoing major abdominal surgery, the effect of oral clonidine 300 micrograms, 1 h before and 12 h after surgery on postoperative morphine requirements (evaluated by PCA). During the 24 h of the study, pain scores measured every 6 h did not differ significantly. Morphine requirements tended to be reduced in the clonidine group but the difference was not significant. There were no significant differences also in mean arterial pressure, ventilatory frequency and the incidence of pruritus and nausea. Heart rate was significantly lower until 18 h after surgery and sedation was significantly more pronounced in patients receiving clonidine. We cannot recommend routine oral administration of clonidine before surgery to improve postoperative analgesia.
Administration, Oral↗
Postoperative pain after local anesthetics for laparoscopic sterilization.
OBJECTIVE: To test the effectiveness of intraperitoneal local anesthesia in relieving postoperative pain after laparoscopic sterilization. METHODS: In a double-blind, placebo-controlled randomized study of two groups of 25 subjects each, women scheduled for tubal sterilization under general anesthesia received 80 mL of 0.5% lidocaine with 1/320,000 epinephrine intraperitoneally in the right subdiaphragmatic quadrant at the beginning of the procedure. At the end of the procedure, they received 10 mL of 2% lidocaine with 1/80,000 epinephrine injected into each mesosalpinx. Controls received saline instead of lidocaine. Shoulder and pelvic pain assessed by visual analogue pain scale, postoperative analgesic requirements, nausea or vomiting, and time to return to normal daily activities were evaluated in the ambulatory unit and after discharge during the first 48 postoperative hours. Blood samples were taken in ten subjects receiving lidocaine to evaluate peak plasma concentrations and time to peak plasma concentrations. RESULTS: Pain was significantly less in patients who received lidocaine, and the difference lasted for the duration of the study (P < .05). Analgesic requirements and time to return to normal daily activities were significantly reduced in patients who received lidocaine (P < .05). Blood samples revealed no toxic concentrations. The peak plasma concentration was 3.22 +/- 1.21 micrograms/mL, and the time to peak plasma concentration was 42 +/- 15 minutes. CONCLUSION: Intraperitoneal instillation of lidocaine-epinephrine combined with mesosalpinx infiltration of lidocaine during tubal sterilization produces effective, long-lasting analgesia and improves the postoperative course.
Adult↗
Interactions of pre-operative erythromycin administration with general anaesthesia.
Previous reports have demonstrated a gastric emptying effect of erythromycin due to a motilin-like mechanism. We studied 50 patients, scheduled for daycase laparoscopy, randomly assigned to one of two groups: Group P patients received 30 min before induction of anaesthesia, in a double-blind manner an infusion of 250 ml dextrose 5% while patients in Group E (n = 25) received 500 mg of erythromycin diluted in 250 ml dextrose 5%. An orogastric tube was inserted to measure both gastric pH using a pHmeter and residual gastric volume (RGV) using the phenol red dilutional technique. Six patients were excluded for surgical reasons. More patients in Group P (6/22) than in Group E (0/22) had RGV > 25 ml and more patients in Group P (17/22) presented with a gastric pH < 2.5 than in Group E (5/22), P < 0.05. Since coma and respiratory depression have been reported recently after midazolam and alfentanil administration in patients having received erythromycin, recovery conditions were assessed and were found to be comparable between groups. In conclusion, the administration of iv erythromycin before outpatient laparoscopy decreased residual gastric volume and increased gastric pH without affecting recovery from general anaesthesia.
Adult↗
Gastric fluid pH and volume in gynaecologic out-patients. Influences of cimetidine and cimetidine-sodium citrate combination.
Eighty consecutive ASA physical status 1 women scheduled for day-case gynaecological laparoscopy under general anaesthesia were randomly allocated during the pre-operative visit to receive one of four premedication regimes. Patients in group 1 received hydroxyzine 100 mg; patients in group 2 received hydroxyzine 100 mg and cimetidine 400 mg; patients in group 3 received hydroxyzine 100 mg and effervescent cimetidine (cimetidine 200 mg + sodium citrate 1.8 g). All were given orally in 30 ml of water, 90 min before anaesthetic induction. Patients in group 4 received effervescent cimetidine orally in 30 ml of water 5 min before anaesthetic induction. Following induction of anaesthesia, gastric pH and residual volume (phenol red dilution technique) were measured. Gastric pH was higher (P < 0.05) in groups 2, 3 and 4 (medians: 5.71, 4.84, 6.07, respectively) than in group 1 (2.18). No patient had a gastric pH < or = 2.5 in group 4 compared with 13/14 n group 1, 1/15 in group 2 and 2/14 in group 3 (P < 0.0001). Mean gastric volumes were higher (P < 0.05) in group 4 (30.4 +/- 23.2 ml) than in groups 1, 2 and 3 (11.8 +/- 6.4, 15.8 +/- 11.2, 17.2. +/- 24.4 ml, respectively). Nine of the 19 patients in group 4 had a volume higher than 25 ml. Only one patient in group 1 had both gastric pH < or = 2.5 and volume > or = 25 ml. The administration of effervescent cimetidine 5 min prior to anaesthetic induction seems to be an easy and effective method of decreasing the acidity of gastric contents in day surgery.
Adult↗
[A traditional anesthesia consultation or a "telephone interview" within the framework of ambulatory surgery?].
UNLABELLED: Preoperative assessment for anaesthesia must detect in the setting of ambulatory surgery both medical and sociopsychologic problems which may contraindicate the ambulatory aspect of the procedure. The goal of our prospective study was to assess the efficacy of a preoperative telephone interview in screening the medical and sociopsychologic problems of ambulatory patients. 1,000 consenting consecutive outpatients participated to the study and were randomly allocated to one of two groups: patients in the standard group (STD) had a consultation a few days before surgery whereas those in the telephonic group (TEL) called the anesthetist a few days before, the physical exam being performed on the day of surgery. The cancellation of the ambulatory procedure was decided upon either medical criterias (MC) or sociopsychologic criterias (from Waetchler). RESULTS: both groups were comparable regarding SPC and MC but prescription of preoperative tests was more frequent in the STD group (result statistically significant). In conclusion, this new approach is as reliable as the standard consultation in screening the SPC which remain the most frequent cause of cancellation in ambulatory surgery. Therefore this telephonic interview which is simple and reliable for screening outpatients may represent a suitable alternative to a standard consultation.
Ambulatory Surgical Procedures↗
[The use of locoregional anesthesia in the prevention of postoperative pain].
Preemptive analgesia is a new concept suggesting that postoperative pain may be attenuated if the transmission of pain is blocked before the occurrence of noxious stimuli. The widespread use of regional anesthesia whether or not associated to general anesthesia has contributed to the improvement of postoperative pain both in ambulatory surgery and inpatients. Numerous studies have demonstrated that postoperative analgesia was better after regional anesthesia when compared to general anesthesia. However, preemptive analgesia means the benefits of an analgesia technique administered before (no after) the occurrence of noxious stimuli. Unfortunately, very few studies have met this principal criteria in their design. Moreover, other criterias are also important in investigating preemptive postoperative analgesia such as: 1) the duration of preemptive analgesia (catheter,...); 2) the importance of surgical stress; 3) the multiple components of postoperative pain; 4) the analgesics used; 5) the route of administration. In conclusion, the participation of regional anesthesia in preventing postoperative pain remains controversial. Numerous studies are needed in the future. These studies should take into account the above criterias and should include a large number of patients in order to find first the type of surgery that could benefit and second, the preemptive analgesia treatment that should be used in such indications.
Anesthesia, Conduction↗