Locoregional Anesthesia Research Articles

Obstetrical complications in hereditary fibrinogen disorders: the Fibrinogest study

BackgroundWomen with hereditary fibrinogen disorders (HFDs) seem to be at an increased risk of adverse obstetrical outcomes, but epidemiologic data are limited. ObjectivesWe aimed to determine the prevalence of pregnancy complications; the modalities and management of delivery; and the postpartum events in women with hypofibrinogenemia, dysfibrinogenemia, and hypodysfibrinogenemia. MethodsWe conducted a retrospective and prospective multicentric international study. ResultsA total of 425 pregnancies were investigated from 159 women (49, 95, and 15 cases of hypofibrinogenemia, dysfibrinogenemia, and hypodysfibrinogenemia, respectively). Overall, only 55 (12.9%) pregnancies resulted in an early miscarriage, 3 (0.7%) resulted in a late miscarriage, and 4 (0.9%) resulted in an intrauterine fetal death. The prevalence of live birth was similar among the types of HFDs (P = .31). Obstetrical complications were observed in 54 (17.3%) live birth pregnancies, including vaginal bleeding (14, 4.4%), retroplacental hematoma (13, 4.1%), and thrombosis (4, 1.3%). Most deliveries were spontaneous (218, 74.1%) with a vaginal noninstrumental delivery (195, 63.3%). A neuraxial anesthesia was performed in 116 (40.4%) pregnancies, whereas general or no anesthesia was performed in 71 (16.6%) and 129 (44.9%) pregnancies, respectively. A fibrinogen infusion was administered in 28 (8.9%) deliveries. Postpartum hemorrhages were observed in 62 (19.9%) pregnancies. Postpartum venous thrombotic events occurred in 5 (1.6%) pregnancies. Women with hypofibrinogenemia were at an increased risk of bleeding during the pregnancy (P = .04). ConclusionCompared with European epidemiologic data, we did not observe a greater frequency of miscarriage, while retroplacental hematoma, postpartum hemorrhage, and thrombosis were more frequent. Delivery was often performed without locoregional anesthesia. Our findings highlight the urgent need for guidance on the management of pregnancy in HFDs.

PO-02-106 GENERAL ANESTHESIA VERSUS CONSCIOUS SEDATION WITH LOCOREGIONAL ANESTHESIA IN S-ICD IMPLANTATION: A MONOCENTRIC RETROSPECTIVE ANALYSIS

In patients not requiring pacing, the subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as a safe and effective alternative to the transvenous implantable cardioverter-defibrillator (TV-ICD) for the treatment of life-threatening ventricular arrhythmias. The S-ICD’s larger size requires a larger pocket for insertion and peri-procedural lead tunnelling carries high nociceptive potential, resulting historically in 65% of S-ICD implantations being performed under general anesthesia (GA). This study seeks to demonstrate that conscious sedation with locoregional anesthesia (CS-LA) is a safe and effective alternative to general anesthesia (GA) in S-ICD implantation. A total of 138 S-ICD implantations (90 under CS-LA) at our institution between 2013 and 2020 were studied The CS-LA technique was performed with conscious sedation, local anesthesia of the pocket and xyphoid incision sites, and post-procedural intercostal nerve blocade of the 4th to 7th intercostal spaces with a mixture of 10mL of 0.5% bupivacaine and 20mL of 2% lidocaine without epinephrine. Analgesic efficacy in the 24 post-operative hours was evaluated by Numerical Pain Rating Scale (NPRS) score and by total analgesic medication dosage received. Safety was evaluated by comparing the incidence of significant adverse events (AE): hypotension <80 mmHg or requiring vasopressors, bradycardia <40 bpm, or desaturation <90% for more than two minutes or requiring non-invasive ventilation maneuvers. Post-procedural pain at 15 minutes and at 24 hours was significantly less in the CS-LA group, with a difference of -0.90 (p=0.04) and -1.21 (p=0.004) respectively. Post-procedural opioid consumption was 10.64mg of per os morphine equivalents (p=0.046) lower than in the CS-LA group. No significant difference in the likelihood of at least one adverse event occurring was noted, with CS-LA demonstrating OR 1.95 (95% CI [0.86, 4.40], p=0.11) for at least one AE. Only one patient in the CS-LA arm required conversion to GA, due to excessive agitation during the procedure. S-ICD implantation under CS-LA was superior at 15 minutes and 24 hours to GA in terms of analgesic efficacy and post-procedural patient comfort. CS-LA’s safety profile was similar to GA, with no significantly increased risk of suffering at least one adverse event.

Correlation between high-resolution computed tomography appearance and histopathological features in the diagnosis of interstitial lung diseases. A real-life study.

According to current guidelines, a surgical biopsy is rarely required when a high-confidence radiologic interstitial lung disease (ILD) diagnosis is made on thin-section high-resolution computed tomography (HRCT). Nevertheless, disowning HRCT scans diagnosed by biopsy are more common than presumed. Our study aimed to describe the concordance rate between HRCT scans and pathological diagnoses of ILDs obtained by surgical biopsy. The current guideline suggests the use of surgical lung biopsy (SLB) in patients with newly detected ILD of unknown cause. Patients who underwent mini-invasive surgical biopsies for interstitial lung diseases from January 2018 to August 2022 were analyzed. The HRCT scans were reviewed by an observer blinded to the patient's clinical information. The concordance between histological and HRCT-scan were assessed. Data from 104 patients with uncertain low confidence diagnosis of interstitial lung diseases at HRCT were analyzed. Most of the patients are male (65; 62.5%). The more frequent HRCT pattern were: alternative diagnoses (46; 44.23%), UIP probable (42; 40.38%), UIP indeterminate (7; 6.73%), and non-specific interstitial pneumonia (NSIP) (9, 8.65%). The more common histological diagnosis was UIP definite (30; 28.84%), hypersensitivity pneumonia [HP](19; 18.44%), NSIP (15; 14.42%), sarcoidosis (10; 9.60%). In 7 (20%) cases, the final pathological finding denies HRCT-scans diagnoses; indeed, a moderate agreement was observed between HRCT-scan findings and the definitive histological diagnosis (kappa index: 0.428). HRCT-scan has limitations if the objective is to define interstitial lung diseases accurately. Consequently, pathological assessment should be taken into account in order to provide more accurate tailored treatment strategies because the risk is to wait from 12 to 24 months to ascertain if the ILD will be treatable as progressive pulmonary fibrosis (PPF). Undeniably true, video-assisted surgical lung biopsy (VASLB) with endotracheal intubation and mechanical ventilation is associated with a risk of mortality and morbidity that is far from nil. Nevertheless, in recent years a VASLB approach performed in awake subjects under loco-regional anesthesia (awake-VASLB) has been suggested as an effective method to obtain a highly confident diagnosis in patients with diffuse pathologies of the lung parenchyma.

Effect of rectus sheath anaesthesia versus thoracic epidural analgesia on postoperative recovery quality after elective open abdominal surgery in a French regional hospital: the study protocol of a randomised controlled QoR-RECT-CATH trial

IntroductionEnhanced recovery after surgery (ERAS) protocols increase patient well-being while significantly reducing mortality, costs and length-of-stay after surgery. A key component is multimodal analgesia that prevents postoperative pain and facilitates...

A Rare Presentation of Palmar Metacarpophalangeal Dislocation of the Long Fingers: A Case Report and Review of the Literature

Background: Metacarpophalangeal dislocation is a rare condition in traumatology, and its management remains unclear due to the limited number of reported cases and studies. This study aims to compare our approach and outcomes with those reported in the literature, to gain a better understanding of the variability in management and outcomes across different cases and settings. Case report: Here, we present the case of a 32-year-old male patient who sustained palmar metacarpophalangeal dislocation following a traffic accident. The diagnosis was confirmed through hand X-ray, and we successfully performed reduction under locoregional anesthesia using external maneuvers. Early rehabilitation was initiated, and the patient had a satisfactory 6-month follow-up result, with full recovery of joint amplitudes and comparable pinch strength. Discussion: It appears that several mechanisms can lead to this condition, and diagnosis is typically made through radiography or MRI. Closed reduction by external maneuvers is often successful, but surgery may be necessary in cases of irreducibility or instability. Different surgical approaches may be used depending on the specific type of dislocation, with the dorsal approach being preferred for hyperflexion dislocations and the palmar approach being preferred for hyperextension dislocations or cases with an unknown mechanism. Conclusion: More research is needed to better understand this rare condition and its optimal management.

Predictive factors for respiratory complications in pediatric anesthesia

We conducted a prospective observational, descriptive, and analytical study covering all patients under 16 years of age who were admitted to the operating room for scheduled or urgent surgery between July and August 2022. The purpose of this study was to identify the epidemiological characteristics of our population, describe the means of upper airway management in our practice, and analyze postoperative respiratory complications in pediatric anesthesia and their predictive factors. A total of 200 children were included in this study, with an average age of six years and an average weight of 21 kg. Of these, 53 (26.5%) underwent sedation with propofol 3 mg/kg and ketamine 1 mg/kg or a combination of a hypnotic (propofol or ketamine) and fentanyl at the dose of 2 gamma/kg. General anesthesia was used for 93 (46.5%) patients, while the remaining 54 (27%) were operated on under locoregional anesthesia associated with sedation. Depending on the type of surgery and anesthesia, the upper airway management protocol was chosen: 85 (42.5%) patients were operated on under an oxygen mask, 12 (6%) under a face mask, 10 (5%) under a laryngeal mask and 93 (46.5%) were intubated. Postoperative respiratory complications occurred in 28 patients (14%), with desaturation being the most common complication (10.5%). In multivariate statistical analysis, the factors found to be associated with the occurrence of postoperative respiratory complications were: weight less than 10 kg (p = 0.006, OR = 4.16 [1.54-11.22]) and unipulmonary ventilation (p = 0.008, OR = 14.77 [2.09-104.02]).

General versus loco-regional anesthesia for endovascular aortic aneurysm repair.

Aortic aneurysms occur when the aorta, the body's largest artery, grows in size, and can occur in the thoracic or abdominal aorta. The approaches to repair aortic aneurysms include directly exposing the aorta and replacing the diseased segment via open repair, or endovascular repair. Endovascular repair uses fluoroscopic-guidance to access the aorta and deliver a device to exclude the aneurysmal aortic segment without requiring a large surgical incision. Endovascular repair can be performed under a general anesthetic, during which the unconscious patient is paralyzed and reliant on an anesthetic machine to maintain the airway and provide oxygen to the lungs, or a loco-regional anesethetic, for which medications are administered to provide the person with sufficient sedation and pain control without requiring a general anesthetic. While people undergoing general anesthesia are more likely to remain still during surgery and have a well-controlled airway in the event of unanticipated complications, loco-regional anesthesia is associated with fewer postoperative complications in some studies. It remains unclear which anesthetic technique is associated with better outcomes following the endovascular repair of aortic aneurysms. To evaluate the benefits and harms of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repair. We used standard, extensive Cochrane search methods. The latest search was 11 March 2022. We searched for all randomized controlled trials that assessed the effects of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repairs. We used standard Cochrane methods. Our primary outcomes were: all-cause mortality, length of hospital stay, length of intensive care unit stay. Our secondary outcomes were: incidence of endoleaks, requirement for re-intervention, incidence of myocardial infarction, quality of life, incidence of respiratory complications, incidence of pulmonary embolism, incidence of deep vein thrombosis, and length of procedure. We planned to use GRADE methodology to assess the certainty of evidence for each outcome. We found no studies, published or ongoing, that met our inclusion criteria. We did not identify any randomized controlled trials that compared general versus loco-regional anesthesia for endovascular aortic aneurysm repair. There is currently insufficient high-quality evidence to determine the benefits or harms of either anesthetic approach during endovascular aortic aneurysm repair. Well-designed prospective randomized trials with relevant clinical outcomes are needed to adequately address this.

French multicentre prospective evaluation of radiofrequency ablation in the management of haemorrhoidal disease

PurposeThe aim of this study was to evaluate the efficacy and safety of radiofrequency ablation (RFA) in the management of haemorrhoidal disease with 1 year’s follow-up.MethodThis prospective multicentre study assessed RFA (Rafaelo©) in outpatients with grade II–III haemorrhoids. RFA was performed in the operating room under locoregional or general anaesthesia. Primary endpoint was the evolution of a quality-of-life score adapted to the haemorrhoid pathology (HEMO-FISS-QoL) 3 months after surgery. Secondary endpoints were evolution of symptoms (prolapsus, bleeding, pain, itching, anal discomfort), complications, postoperative pain and medical leave.ResultsA total of 129 patients (69% men, median age 49 years) were operated on in 16 French centres. Median HEMO-FISS-QoL score dropped significantly from 17.4/100 to 0/100 (p < 0.0001) at 3 months. At 3 months, the rate of patients reporting bleeding (21% vs. 84%, p < 0.001), prolapse (34% vs. 91.3%, p < 0.001) and anal discomfort (0/10 vs. 5/10, p < 0.0001) decreased significantly. Median medical leave was 4 days [1–14]. Postoperative pain was 4/10, 1/10, 0/10 and 0/10 at weeks 1, 2, 3 and 4. Seven patients (5.4%) were reoperated on by haemorrhoidectomy for relapse, and three for complications. Reported complications were haemorrhage (3), dysuria (3), abscess (2), anal fissure (1), external haemorrhoidal thrombosis (10), pain requiring morphine (11). Degree of satisfaction was high (+ 5 at 3 months on a − 5/+ 5 scale).ConclusionRFA is associated with an improvement in quality of life and symptoms with a good safety profile. As expected for minimally invasive surgery, postoperative pain is minor with short medical leave.Clinical trial registration and dateClinical trial NCT04229784 (18/01/2020).

Loco-regional analgesia in oncology. Influence on cancer recurrence rate. Literature review.

Introduction. A major role and, at the same time, a question mark, both for patients and doctors, is the possibility that drugs and anesthetic techniques influence cancer metastasis. Cancer is the leading cause of death worldwide. This trend will continue in the future. Most of the deaths of cancer patients are due to complications arising from metastases. The metastasis process of a tumor depends on its intrinsic properties and interaction with the host. The treatment of tumors by performing a surgical intervention, radical or palliative, has a significant impact. For these reasons, the rate of survival and migration of cancer cells in the perioperative period is studied quite insistently and complexly. Thus, surgical intervention and anesthetic support in cancer patients becomes of great importance, because it represents the vulnerable link, both from the point of view of the operation itself, as well as the possibility that drugs, anesthetic techniques may or may not influence tumor metastasis. Material and methods. Primary scientific studies published from 1996 to 2021 dedicated to loco-regional anesthesia and its influence on the perioperative period and on cancer metastasis were studied. To achieve the proposed goal, scientific sources PubMed, Medscape, SCOPUS, MEDLINE were researched. Keywords used for searching: loco-regional anesthesia, fascia plane anesthesia, metastasis. More than 80 reference sources were identified, 67 were selected for analysis. Results and discussions. The surgical procedure, itself, performed for curative purposes, also known as tumor resection – is a risk factor for metastasis by creating an environment with high potential for tumor cell survival. This stimulates tumor growth and angiogenesis, can remodel lymphatic pathways, allowing metastasis of tumor cells. Hemotransfusion is associated with increased risk of metastasis. Regional anesthesia could reduce cancer recurrence through several mechanisms. Conclusions. Regional anesthesia could reduce cancer recurrence by reducing the need for opioids or inhaled anesthetics, or by reducing the stress response during surgery. There is scientific in vitro evidence of a protective effect of systemic lidocaine on recurrent cancer, although relevant clinical data are limited.

Multimodal evaluation of locoregional anaesthesia efficacy on postoperative pain after robotic pulmonary lobectomy for NSCLC: a pilot study.

The primary objectives of the study were to analyse the robotic approach and ultrasound-guided paravertebral block compared to thoracoscopic intercostal nerve block after robotic pulmonary lobectomy on postoperative pain and opioids use. The secondary objectives were to analyse and compare patients' necessity of additional antalgic drugs and patients' performance during respiratory therapy, following robotic surgery and in the two groups. Consecutively, 52 patients undergoing robotic pulmonary lobectomies were treated either with ropivacaine-based intercostal nerve block or paravertebral block from February 2022 to October 2022. When necessary, morphine was administered at day 1. Acetaminophen was administered as an additional antalgic drug on demand up to 3 g per day. Pain was measured 1 h after the end of the surgical procedure and daily through the pain numeric rating scale (NRS). Morphine administration rate and per day and total additional administrations of acetaminophen were recorded. Pain and opioids administration was measured 1 month after the procedure. Data were analysed in the overall population and in the intercostal nerve block group VS paravertebral block group. Overall, 34.6% of the patients required morphine administration and 51.7% of the patients required at least daily acetaminophen administration up to discharge. At 1 month postoperatively, four patients presented with chronic pain and one still was under opioid medication. At intergroup analysis, the paravertebral block group demonstrated lower NRS at fixed time points (p < 0.0001) and lower morphine consumption (45.7%VS11.8%; p = 0.02). Acetaminophen rescue administration at fixed time points was lower in the paravertebral block group (p < 0.0001) and mobility and dynamic pain resulted in better results (p = 0.03; p = 0.04). At 1 month, no differences were found between study groups. Similarly to other minimally invasive techniques, postoperative pain may arise after robotic pulmonary lobectomy. Paravertebral bloc can help to reduce postoperative pain as well as morphine and antalgic drugs administration and improve early mobilization.

Pelvic limb anesthesia and analgesia in dogs undergoing tibial plateau leveling osteotomy (TPLO): A survey of board-certified anesthesiologists.

To report the locoregional anesthesia and analgesia preferences of veterinary anesthesiologists for use in dogs undergoing a TPLO and determine any association with specialty college, time from board-certification, or employment sector. Cross sectional study. Diplomates of the American (ACVAA) and European (ECVAA) Colleges of Veterinary Anesthesia and Analgesia. An electronic survey was distributed to diplomates and responses were used to determine associations between preferred methods. The survey response rate was 28% (141/500) with 69% (97/141) of ACVAA diplomates and 31% of diplomates with ECVAA (44/141) certification. Peripheral nerve block (PNB) was preferred by 79% (111/141) of all diplomates, lumbosacral epidural (LE) by 21% (29/141), and peri-incisional infiltration (PI) by <1% (1/141). There was no association (p=.283) with specialty college. There was an association (p < .001) with time from board-certification with increased preference for LE when >10-years from certification and PI preferred by only those board-certified >20-years ago. There was an association with employment sector (p=.003) with more academic diplomates preferring LE. Anesthesiologists reported that treatment decisions were affected by various factors including time pressure and surgeon influence. Diplomates of ACVAA and ECVAA prefer PNB as the locoregional method of pelvic limb anesthesia in dogs undergoing TPLO. A greater percentage of newer and private practice diplomates prefer PNB while a larger percentage of senior and academic diplomates prefer LE. Decision making is multifactorial and includes perceived time pressure and surgeon influence. Veterinary anesthesiologists prefer and frequently use PNB in dogs undergoing TPLO and surgeon influence may affect their chosen treatment.

The effect of ultrasound-guided erector spinae plane block combined with dexmedetomidine for postoperative pain management in lumbar spine surgery: A case-based discussion

BackgroundUltrasound-guided erector spinae plane blocks (US-ESPB) can be valid resources of simple and safe execution in a multimodal approach to postoperative pain management in lumbar spine surgery. It has been shown that the use of multimodal anesthesia reduces the use of intraoperative and postoperative opioids, and also improves analgesia. A growing body of evidence supports that the adjuvant use of dexmedetomidine in locoregional anesthesia significantly prolongs the analgesia and potentiates the effect of the block, without clinically significant side effects.Case presentationA series of six consecutive patients received bilateral ultrasound-guided erector spinae plane blocks with local anesthetics and dexmedetomidine as part of a multimodal analgesic therapy after lumbar spine surgery. Treatment adequacy was evaluated using numerical rating scale (NRS) and overall benefit of analgesic score (OBAS); overall the observed results were satisfactory for all patients.ConclusionBilateral US-ESPB appears to be helpful in providing adequate postoperative analgesia after lumbar spine surgery. It is simple and safe, and so it is unique when compared to other blockages. The addition of Dexmedetomidine as an adjuvant seems to improve analgesic effectiveness and durability.

Trauma-Related Clinical Practice Variation in Dutch Emergency Departments.

Structural insights in the use of protocols and the extent of practice variation in EDs are lacking. The objective is to determine the extent of practice variation in EDs in The Netherlands, based on specified common practices. We performed a comparative study on Dutch EDs that employed emergency physicians to determine practice variation. Data on practices were collected via a questionnaire. Fifty-two EDs across The Netherlands were included. Thrombosis prophylaxis was prescribed for below-knee plaster immobilization in 27% of EDs. Vitamin C was prescribed in 50% of EDs after a wrist fracture. Splitting of applied casts to the upper or lower limb was performed in one-third of the EDs. Analysis of the cervical spine after trauma was performed by the NEXUS criteria (69%), the Canadian C-spine Rule (17%) or otherwise. The imaging modality for cervical spine trauma in adults was a CT scan (98%). The cast used for scaphoid fractures was divided between the short arm cast (46%) and the navicular cast (54%). Locoregional anaesthesia for femoral fractures was applied in 54% of the EDs. EDs in The Netherlands showed considerable practice variation in treatments among the subjects studied. Further research is warranted to gain a full understanding of the variation in practice in EDs and the potential to improve quality and efficiency.

Erector spine plane block as single loco-regional anesthesia in non-intubated video-assisted thoracic surgery for unfit patients: a case-match study.

In the present study, we analyzed the safety and efficacy of non-intubated video-assisted thoracoscopy (NI-VATS) for the diagnosis and palliation of malignant pleural effusion in the elderly population using erector-spinae plane block (ESPB) as single loco-regional anesthesia. From January 2016 to December 2020 a consecutive series of 158 patients who underwent surgery for malignant pleural effusion was analyzed. Of these, 20 patients were operated using ESPB NI-VATS, while 138 were operated under general anesthesia (GA). After propensity score matching, the NI-VATS population was older (81 vs. 76years p 0.006), and had more severe pre-existing comorbidities, evaluated using Charlson Comorbidity Index (p = 0.029) and ASA score (p < 0.001). GA and NI-VATS patients did not differ in terms of postoperative opioid consumption, complication rate and postoperative hospitalization. Both short- and long-term efficacy of talc poudrage was equal in the two populations. The overall length of stay in the operative room was significantly shorter for the NI-VATS than for the GA-VATS group (67.5 vs. 105min, p < 0.001), and operative time significantly differed in the two groups (35 vs. 47.5min, respectively, p < 0.001). ESPB NI-VATS can be a safe and effective option for the diagnosis and palliation of malignant pleural effusion for elderly and frail patients.

A call for immediate climate action in anesthesiology: routine use of minimal or metabolic fresh gas flow reduces our ecological footprint

PurposeClimate change is a global threat, and inhalational anesthetics contribute to global warming by altering the photophysical properties of the atmosphere. On a global perspective, there is a fundamental need to reduce perioperative morbidity and mortality and to provide safe anesthesia. Thus, inhalational anesthetics will remain a significant source of emissions in the foreseeable future. It is, therefore, necessary to develop and implement strategies to minimize the consumption of inhalational anesthetics to reduce the ecological footprint of inhalational anesthesia.SourceWe have integrated recent findings concerning climate change, characteristics of established inhalational anesthetics, complex simulative calculations, and clinical expertise to propose a practical and safe strategy to practice ecologically responsible anesthesia using inhalational anesthetics.Principal findingsComparing the global warming potential of inhalational anesthetics, desflurane is about 20 times more potent than sevoflurane and five times more potent than isoflurane. Balanced anesthesia using low or minimal fresh gas flow (≤ 1 L·min-1) during the wash-in period and metabolic fresh gas flow (0.35 L·min-1) during steady-state maintenance reduces CO2 emissions and costs by approximately 50%. Total intravenous anesthesia and locoregional anesthesia represent further options for lowering greenhouse gas emissions.ConclusionResponsible anesthetic management choices should prioritize patient safety and consider all available options. If inhalational anesthesia is chosen, the use of minimal or metabolic fresh gas flow reduces the consumption of inhalational anesthetics significantly. Nitrous oxide should be avoided entirely as it contributes to depletion of the ozone layer, and desflurane should only be used in justified exceptional cases.

Introduction to interventional radiology's role in palliative care for children with cancer: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

As palliative care continues to be an area of increasing emphasis in pediatric oncology programs, it is important to raise awareness about minimally invasive, image-guided procedures that can supplement more conventional palliative interventions, such as systemic analgesics, external beam radiation, and locoregional anesthesia. These procedures, when performed for appropriately selected patients, can often facilitate discharge from an inpatient facility, and help patients meet their end-of-life goals. This article specifically discusses three palliative procedures performed by interventional radiologists that can assist pediatric palliative care teams in: (a) percutaneous thermal ablation of painful bone metastases, (b) cryoneurolysis, and (c) tunneled drainage catheter placement for malignant pleural effusions and ascites.

The Frail Elderly Patient and the Need for a Video Store on Regional Anaesthesia Blocks

The Frail Elderly Patient and the Need for a Video Store on Regional Anaesthesia Blocks

Uncommon traumatic lip injury

Trauma to the lips is the most common type of facial injury. The prominence of the lips and the close correlation with the teeth, make it a vulnerable aesthetic unit. We here report the case of a 20-year-old student presenting two hours after maxillofacial trauma following a traffic accident involving a head-on collision between two motorcyclists. The student had fallen on the handlebars of his motorbike injuring his upper lip. Maxillofacial examination showed involvement of the nasogenial sulcus with elevation of the right nasal wing, a notch in the right upper hemi-lip, well colored, and whose endo-buccal extension was embedded in the vestibule, giving an appearance of "right unilateral cleft lip". Radiological evaluation showed air-fluid levels with solution of continuity of the medial wall of the right maxillary sinus. The diagnosis of traumatic incarceration of the right upper hemi-lip with not displaced fracture of the right maxilla was retained. This can cause unilateral or incomplete right upper cleft lip, or a wound with loss of substance involving the right upper hemi-lip. It is a very uncommon lesion of the upper lip requiring urgent repair, given the risk of ischemia and labial necrosis. The patient was operated under locoregional anesthesia. The right upper hemi-lip was embedded with incarceration due to non-displaced fracture at the level of the nasal notch. Disincarceration was performed, resulting in minimal labial loss with a vestibular detachment, repaired by direct suture. Patient's outcome was good.

Emergency C-Section on Multi-Scar Uterus: Maternal and Fetal Prognosis at the Nianankoro Fomba Hospital in Segou, Mali

Background: Multi-scar uterus is a uterus with two or more scars due to surgery or trauma. Objective: The aim was to compare the maternal and fetal prognosis of emergency C-sections of bi-scar uteruses to those of uteruses with at least 3 scars at the Nianankoro Fomba Hospital in Segou. Materials and Methods: It was a descriptive and analytical cross-sectional study with prospective data collection over a 24-month period from March 20, 2018, to March 20, 2020. Results: In 2 years, we collected 103 emergency C-sections for multi-scar uterus out of 1198 C-sections with a frequency of 8.6%. The age group of 20 to 35 years was the most represented with 86.4%. The bi-scar uteruses were the most frequent with 77.7%. In 71.8% of cases, the C-section was performed during the latent phase of labor. The C-section was performed under loco-regional anesthesia in 89.3% of cases. Difficulties in hemostasis and bladder injury were the most frequent intraoperative accidents. Surgical site infection was the main postoperative complication. No maternal deaths were recorded. The perinatal prognosis was marked by 4.3% fresh stillbirths in bi-scar uterus against 3.7% in three or more scar uteruses and including 2 fresh stillbirths and 1 macerated. We did not record any early neonatal deaths after C-section. Conclusion: The frequency of emergency C-sections in patients with a multi-scar uterus remains very high in our hospital. A better awareness of the patients, their spouses and all the actors involved in the management of pregnancies and childbirth, can contribute to curb this trend.

Administration of Nebulised Ketamine for Managing Pain in the Intensive Care Unit of Obstetrics and Gynaecology

Introduction: The use of inhaled ketamine to manage a variety of painful conditions has been endorsed by the American College of Emergency Physicians and the American Academy of Emergency Medicine. Nebulized analgesia has multiple benefits, including rapid, effective and titratable analgesic delivery. The aim of our study is to assess the efficacy and safety of intranasal analgesic-dose ketamine compared to multimodal analgesia in patients presenting with acute postoperative pain or headache after a spinal anaesthetic in the intensive care unit of obstetrics and gynaecology. Materials and Methods: This was a prospective descriptive study, with hospital Ethics Committee approval and written informed consent from study participants. We compared the effect of nebulized ketamine and multimodal analgesia postoperatively in 120 patients belonging to the physical status I - II of the American Society of Anesthesiologists, in the intensive care unit of obstetrics and gynaecology, at the Ibn Rochd University Hospital Center in Casablanca from June 2021 to June 2022. Results: We included 120 patients in our study divided into two groups of 60 patients: the average age was 35 years, with extremes ranging from 18 to 45 years, All patients were hospitalized for postoperative care: all women underwent locoregional anaesthesia with a standard dose according to the service protocol (10 mg of bupivacaine, 25γ of fentanyl, 100γ of morphine), where pain was the common denominator. Among these patients, 59 were admitted for management of postpartum haemorrhage, 43 for postoperative monitoring, 15 for post-spinal anaesthesia headache and 3 for pelviperitonitis. The results of the pain assessment 30 minutes after the ketamine nebulization were marked by a request for analgesia in 12 patients, which is 20% of group A, including 5 patients, whose visual analogue scale (VAS) on admission was between 5 and 7, and 7 patients whose VAS at admission was ≥8; all these patients received a second dose of ketamine by nebulization; the evaluation 30 min after the second dose was marked by a request for analgesia in 4 patients, which is 7% of Group A; in all these patients the VAS at admission was ≥8. Of the total number of patients of Group A, only 4 received morphine when they were requested for analgesia after the second dose of nebulized ketamine. Conclusion: The primary outcome of nebulized ketamine use is a significant reduction in VAS pain score. We believe that nebulized ketamine has a potential effect of reducing pain in the intensive care unit of obstetrics and gynaecology; this may be an additional analgesic modality for clinicians to provide rapid, effective and non-invasive pain relief.