Influence of Tobacco Smoking on Perioperative Risk of Venous Thromboembolism.

Venous thromboembolism (VTE) is generally considered a process very different from arterial atherosclerosis. The role of tobacco is well known in arterial thrombosis. However, its role in VTE is less obvious and remains controversial. In this mini review, we analysed the literature to identify the role of active or passive smoking in perioperative VTE and the relationship between arterial atherosclerosis and VTE. We carried an Internet search in French and English including the following keywords: deep vein thrombosis, tobacco, cigarette smoking, pulmonary embolism, postoperative, postoperative, atherosclerosis. Regarding the relationship between tobacco and VTE, a total of 9 studies were identified. Studies were ranked by the risk of VTE in relation to active or passive smoking. In conclusion, the management of smoking during the perioperative period for a short-term arrest (minimum 4-8 weeks before the intervention), or long term, allows among others a reduction of arterial or venous thrombotic events. However, it is clear that the training of anaesthesiologists in the management of smoking will contribute to the reduction of this public health problem.

Anticoagulant conversion in the elderly: pitfalls.

The prevalence of medical conditions representing a risk for thromboembolic complications and requiring antithrombotic therapy increases gradually with age. Two cases of fatal noncritical organ bleeding complication that occurred during the conversion period from initial fondaparinux to vitamin K antagonist are presented. An 81-year-old obese female patient (body mass index 43 kg/m(2)) with previous postoperative thrombosis underwent uneventful total knee replacement under spinal anesthesia. She presented with popliteal hematoma during conversion to oral anticoagulant. A 92-year-old female patient (body mass index 33 kg/m(2)) with left lower limb thrombosis was referred to our orthopedics department from her senior citizens' home for right lower limb hematoma and ischemia that occurred during conversion to oral anticoagulant. Thromboembolic and bleeding events in the elderly are real public health problems. Specific guidelines dedicated to this particular population are needed, which will improve the management of anticoagulation and decrease risk of complications.

Review of interscalene block for postoperative analgesia after shoulder surgery in obese patients.

In recent years, the prevalence of obesity has significantly increased in developed countries, a trend that has been just as apparent in France as elsewhere. Obesity may predispose to osteoarthritis, which may subject a high percentage of patients to shoulder surgery. Interscalene block remains one of the most efficient technique for postoperative analgesia after shoulder surgery. However, there are no specific guidelines or discussions in the literature about the use and management of interscalene block for obese patients. No study has yet specifically assessed obesity relative to interscalene block. Regional anesthesia offers certain advantages in obese patients: minimal airway intervention, improved postoperative analgesia, and decreased opioid consumption. In obese patients undergoing shoulder surgery, the goal of postoperative pain management is to provide comfort, early mobilization, and improved respiratory function without the worry of inadequate sedation and respiratory compromise. The ongoing debate on the relevance of obesity, for example in terms of obstructive sleep apnea syndrome, obesity hypoventilation syndrome, and other related respiratory disturbances, in relation to the choice of analgesic techniques, especially interscalene block, patient-controlled intravenous analgesia and patient monitoring, demands large-scale, well-designed studies to resolve it. Nevertheless, obesity per se should not dissuade patients from undergoing shoulder surgery under interscalene block.

Role of local anesthetic spread pattern and electrical stimulation in ultrasound-guided musculocutaneous nerve block.

STUDY OBJECTIVE: To evaluate local anesthetic spread on the frequency of success of musculocutaneous nerve block, and to determine needle-to-target-nerve distance by ultrasound imaging and electrical stimulation. DESIGN: Observational study. SETTINGS: Private hospital. PATIENTS: 48 ASA physical status I and II adults (16 men and 32 women) scheduled for elective carpal tunnel release or wrist ganglion cyst surgery in an outpatient setting. INTERVENTIONS: The musculocutaneous nerve (MCN) was identified by ultrasound. An insulated needle connected to an electrical stimulator in the "off" position was inserted in the biceps side of the probe in the plane of the ultrasound beam. The needle tip was placed in the vicinity of the MCN. MEASUREMENTS: Local anesthetic spread pattern was determined by ultrasound imaging. The lowest effective current intensity was registered. The average depth of the MCN was measured by ultrasound. MAIN RESULTS: In all patients, the local anesthetic solution spread was uneven. In 32% of patients (15/47), motor response was still elicited with electrical stimulation intensity lower or equal to 0.3 mA. In 26% of patients (12/47), motor response disappeared with electrical stimulation intensity higher or equal to 0.6 mA. In 42% of patients (20/47), motor response disappeared at intensities between 0.3 mA and 0.5 mA. CONCLUSIONS: A high success rate of MCN anesthesia occurred with non-circumferential spread of local anesthetic solution. Electrical current intensity was not a reliable indicator of needle-to-target-nerve distance.

Lower limb neuropathy after spinal anesthesia in a patient with latent thiamine deficiency.

We present the case of a 65-year-old man with latent thiamine deficiency who manifested lower limb neuropathy after receiving spinal anesthesia. We discuss our care of this patient and include a discussion of thiamine deficiency generally, its possible origins, symptoms, and recommended techniques for treatment of these patients.

Femoral nerve injury complicating continuous psoas compartment block.

OBJECTIVES: The objective of this case report is to describe a femoral nerve injury after a psoas compartment block (PCB) and to discuss the probable mechanisms of injury and neuron regeneration. To date, this is the first report of severe femoral nerve injury after PCB. CASE REPORT: A 60-year-old, American Society of Anesthesiologists II woman underwent right total knee replacement under general anesthesia and continuous PCB for postoperative analgesia. Postoperatively, she showed signs of severe femoral nerve injury. A physical therapy program and muscle electrical stimulation were instituted and continued for 6 months. The patient recovered completely with no residual motor or sensory deficit and had no other complication. CONCLUSIONS: Severe nerve injuries after regional anesthesia techniques remain infrequent and probably unreported. Our case report suggests that severe femoral nerve injury should be added to the list of reported complications during PCB. This case report is also encouraging because it shows the possibility of a good recovery after such injury.

Toxic effects of epidural analgesia with ropivacaine 0.2% in a diabetic patient.

A 51-year-old ASA physical status II, non-insulin-dependent diabetic male patient manifested lower limb nerve injury after receiving postoperative epidural analgesia with ropivacaine 0.2%. The case is presented, including a discussion of the relation between local anesthetic toxicity and diabetic neuropathy.

Early rehabilitation after anterior cruciate ligament reconstruction under regional analgesia: a case report.

Patients undergoing major knee surgery may experience postoperative pain, which could be exacerbated by early postoperative continuous passive motion or active mobilization. This pain may result in poor functional recovery. Use of regional analgesia techniques to achieve more consistent pain relief and to facilitate rapid rehabilitation can play an important role in optimizing postoperative outcome after anterior cruciate ligament repair (ACLR). This case study concerns a 20-year-old male soldier, otherwise healthy, who underwent ACLR. We inserted a catheter in the fascia iliaca compartment and performed postoperative analgesia with low-concentration ropivacaine by using an elastomeric pump. The patient started early rehabilitation under fascia iliaca compartment analgesia. We discuss the case and the influence of regional analgesia techniques on postoperative and clinical outcomes.