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BACKGROUND: Spinal anesthesia in elderly patients is frequently associated with significant technical difficulties. Thus, we compared the classical midline approach to the paramedian approach to perform continuous spinal anesthesia (CSA). METHODS: We prospectively studied 40 patients aged >75 yr who underwent open surgical repair of a hip fracture. These patients were randomly allocated to one of two groups: Group M: midline approach, and Group PM: paramedian approach. Patients were positioned in the lateral decubitus to receive CSA at L4-5 level. CSA was considered successful if cerebrospinal fluid was obtained through the needle. In case of initial failure in either approach, the same approach was repeated by the same operator. If two attempts were unsuccessful, the other anatomical approach was used by the same operator. If both approaches failed, a staff anesthesiologist performed a final attempt. In case of failure or insufficient block, the patient received general anesthesia. RESULTS: The success rate after the first attempt was 85% (17) for Group PM and 45% (9) for Group M (P = 0.02). All catheters were successfully introduced. No patient required general anesthesia. Vascular puncture after needle puncture was observed in six patients in Group M versus 0 in Group PM (P = 0.03), but none were of clinical consequence. No other clinically significant complications were observed. CONCLUSION: In summary, after the initial attempt, the paramedian approach is associated with an increased success rate, compared with the midline approach, during the performance of CSA in elderly patients.

BACKGROUND The lateral sciatic mid-femoral block (LSMF), proved to be reliable, safe, and effective on both branches of the sciatic nerve with a single injection. However, we do not know which component of the sciatic nerve (the tibial [T] or the common peroneal [CP]) produces a better success rate when performing a LSMF with a single injection technique. In this prospective study we compared the success rate of the T motor response with the CP motor response. METHODS Ninety-five patients undergoing ankle or foot surgery were enrolled. Thirty milliliters of 0.475% ropivacaine was injected at the first evoked motor response, either T or CP, with a minimal intensity between 0.3 and 0.5 mA. RESULTS Seventy-two patients were included in group T and 23 in group CP. The block was considered a success when a complete sensory block of the sciatic nerve was obtained. The success rate was 90% (65) for the T response and 70% (16) for the CP response (P < 0.05). Time to perform the block (CP: 4.5 +/- 3 min vs T: 4.5 +/- 4 min; P = NS) as well as sensory and motor onset times were not significantly different between groups. No complications were observed in either group. CONCLUSION We conclude that the evoked motor response of the T branch is associated with a higher success rate than a CP response using the modified LSMF block.

In this cadaveric study we assessed the level of the emergence of the musculocutanous nerve (MCN) relative to needle insertion site during infraclavicular block.Forty brachial plexi from 20 embalmed adult cadavers were dissected. The MCN was exposed from its origin on the lateral cord to its penetration into the coracobrachialis muscle. The point of emergence of the MCN from the lateral cord relative to a line drawn directly caudad from the anteromedial tip of the coracoid process was measured. A needle was placed predissection using our previously described technique, and the distance from the needletip to the emergence of the MCN was measured.MCN often emerged distal to the coracoid process. At the needle insertion site, 80% of MCN had already emerged from the lateral cord. The distance of emergence ranged from 8.5 cm proximal to 12 cm distal to the coracoid process.This anatomical study suggests that MCN may be one of the factors explaining MCN block failure for the single-injection technique of infraclavicular block using lateral needle trajectory.

International audience; STUDY OBJECTIVE: To determine whether a new transdermal fentanyl patch (TFP) is a good choice for the postoperative pain management of patients undergoing primary total hip arthroplasty compared with patient-controlled analgesia (PCA). DESIGN: Randomized, prospective study. SETTING: University hospital. PATIENTS: 30 patients undergoing primary total hip arthroplasty. INTERVENTIONS: Patients received either a TFP (group T; Duragesic 50 microg/h, matrix fentanyl patch, Janssen-Cilag) applied approximately 10 hours before induction of general anesthesia and PCA programmed in the postanesthesia care unit (PACU), or PCA programmed in the PACU (group P). MEASUREMENTS: Intraoperative sufentanil and additional postoperative morphine administration were recorded, as well as visual analog scores and routine vital signs at predetermined intervals during the first 48 hours. MAIN RESULTS: Morphine consumption on arrival in the PACU was 3.5+/-3 mg in group T versus 13+/-5 mg in group P (P

Migraine is a frequent neurological pathology. However, the diagnosis can be difficult to establish, especially when it is accompanied with an atypical aura that can be confounded with a stroke. We describe a case of 38-yr-old patient who presented just after general anesthesia with a perioperative acute migraine with atypical aura which was wrongly treated as a serious cerebral stroke. The patient had not mentioned migraine in her history before the surgery. This lack of information led to unnecessary therapy.