Faculty Bibliography

Background and aims: Long-acting proximal blocks for upper extremity surgery lead to prolonged motor and sensory blockade.We retrospectively evaluated our routine practice consisting of a short-acting proximal block for surgical anesthesia, followed by one to three ultrasound-guided (USG) longacting distal block(s) for postoperative analgesia. Methods: The local ethics board waived review for this anonymous retrospective data analysis. Patients undergoing hand or wrist bone surgery received an axillary block using 2% lidocaine with epinephrine for surgical anesthesia, followed by one to three USG analgesic distal block(s) using 0.75% ropivacaine. Patients were prescribed standing non-opioid analgesics and NSAIDs, as well as opioid analgesics for breakthrough pain. Results: Complete data was available for 125 patients. One out of 20 ulnar blocks alone and 4 out of 70 combined median-radial blocks were ineffective (VAS > 3 at the sixth postoperative hour). Average block duration was 11:44 hrs +/- 4:13. Eighty percent of patients took their standing treatment as prescribed. Once the blocks wore off, 25% used their rescue treatment and 7% experienced mild opioid-related adverse effects. Over 86% of patients had a sleep of good or moderate quality. On POD1, fewer than 25 % of the patients had a VAS 9 3. Almost 90% of patients gave a satisfaction score between 8 and 10. No patient complained of insensate arm or of uncomfortable paresthesias. Conclusions: In this retrospective series, USG distal long-acting nerve blocks provided excellent analgesia for about 12 hours with no opioid rescue after outpatient hand and wrist bone surgery

BACKGROUND:: The evaluation of pain intensity during the immediate postoperative period is a key factor for pain management. However, this evaluation may be difficult in some circumstances. The pupillary dilatation reflex (PDR) has been successfully used to assess the analgesic component of a balanced anesthetic regimen. We hypothesized that PDR could be a reliable index of pain intensity and could guide morphine administration in the immediate postoperative period. METHODS:: One hundred patients scheduled to undergo general surgery were included in this prospective observational study. Pain intensity was assessed by using a simple five-item verbal rating scale (VRS). After patients awoke from general anesthesia, those experiencing mild or more severe pain (VRS more than 1) received intravenous morphine titration. Before and after intravenous morphine titration, the PDR induced by a standardized noxious stimulus was measured with a portable pupillometer. A receiver-operating curve was built to estimate the accuracy of PDR in objectively detecting patients requiring morphine titration. Results are given as median (95% CI). RESULTS:: On the initial evaluation, a correlation was found between VRS and PDR (rho = 0.88 [0.83-0.92], P < 0.0001). In the 39 patients that had a VRS more than 1, PDR before and after morphine titration was respectively 35% (31-43) versus 12% (10-14); P < 0.0001. The PDR threshold value corresponding to the highest accuracy to have VRS more than 1 was 23%, with 91% and 94% sensitivity and specificity, respectively. CONCLUSION:: In the immediate postoperative period, the PDR is significantly correlated with the VRS. The pupillometer could be a valuable tool to guide morphine administration in the immediate postoperative period.

PURPOSE: The management of calcaneal fractures remains challenging and often controversial. Open reduction and internal fixation with a lateral plate has been established as a standard therapy for displaced articular fractures. However, accurate subtalar joint reduction, while mandatory, is difficult to achieve, requires an extensive lateral approach, and clinical results may not be up to the difficulty of the task. METHODS: We present a treatment using a percutaneous approach and local balloon reduction followed by polymethyl-metacrylate fixation. This technique was used in four patients presenting articular subtalar fractures with displacement. RESULTS: Reduction was achieved in all cases using a posterior trans-osseous percutaneous approach. Bony fusion with conservation of the subtalar articular reduction was achieved in all cases. We present all cases with a detailed report of outcome. CONCLUSIONS: Clinical outcome after at least three years of follow-up suggests that this technique may be promising and may be used in cases with closed fractures as a primary reduction and fixation tool.

Background: Investigation of the feasibility and usefulness of pre-hospital transcranial Doppler (TCD) to guide early goal-directed therapy following severe traumatic brain injury (TBI). Methods: Prospective, observational study of 18 severe TBI patients during pre-hospital medical care. TCD was performed to estimate cerebral perfusion in the field and upon arrival at the Level 1 trauma centre. Specific therapy (mannitol, noradrenaline) aimed at improving cerebral perfusion was initiated if the initial TCD was abnormal (defined by a pulsatility index >1.4 and low diastolic velocity). Results: Nine patients had a normal initial TCD and nine an abnormal one, without a significant difference between groups in terms of the Glasgow Coma Scale or the mean arterial pressure. Among patients with an abnormal TCD, four presented with an initial areactive bilateral mydriasis. Therapy normalized TCD in five patients, with reversal of the initial mydriasis in two cases. Among these five patients for whom TCD was corrected, only two died within the first 48 h. All four patients for whom the TCD could not be corrected during transport died within 48 h. Only patients with an initial abnormal TCD required emergent neurosurgery (3/9). Mortality at 48 h was significantly higher for patients with an initial abnormal TCD. Conclusions: Our preliminary study suggests that TCD could be used in pre-hospital care to detect patients whose cerebral perfusion may be impaired

Background and aims: Practice patterns in regional anesthesia and analgesia have not been fully codified. We used a web-based questionnaire in order to gather information from anesthesiologists worldwide regarding their management for a number of common orthopedic surgical procedures. Methods: This is an observational descriptive study. Anesthesiologists worldwide were asked to fill out an online survey anonymously, including demographic data and the TYPICAL technique they would use for regional anesthesia and/or postoperative analgesia for a number of common orthopedic procedures. Data was analyzed and practice patterns were observed as global proportions. Univariate and multivariate logistic regression were used to assess the relationship of the demographic data to the practice patterns for the various procedures. Results: 3871 emails were sent; 172 bounced and 220 recipients opted out. A total of 872 responses were received, of which 762 were complete, i.e. A response rate of 762/3479 = 21.9%. Only complete responses were considered for data analysis. Detailed results will be presented at the meeting. While some procedures are managed similarly by various practitioners (e.g., shoulder arthroscopy is almost always performed with an interscalene block), others show a wide variation (e.g., similar proportions of practitioners use femoral blocks, psoas compartment blocks or epidural analgesia for hip arthroplasty, with a smaller proportion using FICB). Some variations can be correlated to demographic variables such as location, type of practice or time since completion of training. Conclusion: As in any survey, there is a self-selection bias, as practitioners who respond are likely to share certain characteristics that will skew the results. We hope, however, that this data will foster debate in the scientific community, and maybe lead to recommendations and practice advisories regarding how best to manage these procedures from the anesthetic point of view

BACKGROUND AND OBJECTIVES: The postoperative analgesic strategy may influence the magnitude of the postoperative diaphragmatic dysfunction (PODD) induced by abdominal surgery. The purpose of this physiologic study was to evaluate the effect of continuous preperitoneal wound infusion (CPWI) of ropivacaine on PODD after open colorectal surgery. METHODS: Twenty patients with American Society of Anesthesiologists physical status I or II undergoing open colorectal surgery were prospectively included during 2 consecutive 2-month periods. During the first period, we evaluated 10 consecutive patients who received conventional parenteral analgesia (intravenously administered morphine via patient-controlled analgesia and acetaminophen) without parietal analgesia (control group). These patients were compared with 10 consecutive patients who received conventional parenteral analgesia along with parietal analgesia using CPWI of 0.2% ropivacaine at 10 mL/hr for 48 hrs (CPWI group). Diaphragmatic function was assessed preoperatively and at 24 and 48 hrs postoperatively using the sniff nasal inspiratory pressure test (Psniff). Supplemental intravenously administered morphine boluses were administered as needed before Psniff assessments in the control group to reduce differences in pain intensity. RESULTS: Demographic and surgical data did not differ between the 2 groups, nor did preoperative Psniff values (71 cm H2O [SD, 20 cm H2O] vs 65 cm H2O [SD,15 cm H2O] in the control and CPWI groups, respectively). Postoperative Psniff was significantly decreased in the 2 groups, but the reduction was significantly greater in the control group than in the CPWI group both at 24 hrs (-58% [SD, 18%] vs -24% [SD, 19%]; P = 0.001) and at 48 hrs (-44% [SD, 31%] vs -11% [SD, 32%]; P = 0.027). CONCLUSIONS: Parietal analgesia delivered via a CPWI of ropivacaine reduces PODD induced by open colorectal surgery