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We describe the case of four patients who had undergone breast surgery. The post-operative analgesia consisted in levobupivacaine administered through a catheter placed between the pectoralis minor and the pectoralis major using ultrasound guided technique. The quality of the analgesia was excellent quality. No side-effects were encountered., (Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Objectives: The efficacy of single-dose intraincisional infiltration with levobupivacaine in postoperative analgesia and chronic pain after caesarean sections is unknown., Study: A placebo-controlled double-blind randomized trial., Patients and Methods: After ethical approval, and written inform consent, 140 women scheduled for a caesarean section were randomly assigned and received 30mL of levobupivacaine 0.5% (L group) or saline (placebo-P group) into their wound. The primary endpoint was morphine consumption (using intravenous morphine patient-controlled analgesia) for the first 24h after surgery. At 1h to 48h, side effects, pain at rest and pain 2months later were recorded., Results: All included patients had similar demographic and surgical characteristics. The morphine consumption was significantly lower in the L group at h6, h8 and h12 (considering both total intake and each request). At h4, the mean total morphine consumption was 25 (12) mg in the L group versus 31 (14) mg in the P group (P=0.05). Time until discharge and side effects including nausea-vomiting (14 vs 20%), wound scar complications (6 vs 8%) and chronic pain after 2months (25% in both groups complained of small pain, and 75% no pain) were similar between the two groups (P>0.05)., Conclusion: Single-dose local infiltration of levobupivacaine 0.5% reduced opioid requirement at 12h, with no difference after 24h. www.clinicaltrials.com, number: NCT00621907., (Copyright © 2012 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

The process of inserting a perineural catheter on femoral region for a regional anesthesia is quite common amongst hospital practices. The resulting infectious complications, although rare, remain potentially serious. For instance, many cases of severe sepsis were described in medical literature. In this paper, we will be presenting two cases of infections that were under serious investigation and led to major improvements of practice in the related hospitals. At the same time, we will give a reminder of good practices in inserting perineural catheters., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Introduction: The reduction of postoperative pain after surgery of inguinal hernia is an objective of lot of studies. The subfasciale infiltration of the wound may be an efficient technique., Methods: This study was designed as a randomized, double blind, prospective study, comparing two treatment groups: a group infiltrated by bupivacaine (Gr B), and second one infiltrated by a placebo (Gr P). A part of demographic parameters and ASA class, the postoperative pain intensity at rest and at coughing, the morphine consumption and the secondary effects were compared. Patient's satisfaction and postoperative chronic pain at 3 and 6 months were also analyzed., Results: Concerning demographic parameters, ASA class and secondary effects, we didn't find any meaningful difference between the two groups. However, there was a significant reduction of postoperative pain in the bupivacaine group as well at rest as coughing. Gr P patients have more morphine consumption and they were unsatisfied and accused more chronic pain., Discussion: Wound infiltration is still a simple and efficient technique in postoperative pain reduction. With this technique, hernia surgery may become ambulatory., (Copyright 2009 Elsevier Masson SAS. All rights reserved.)

Objective: To assess the efficacy of spinal clonidine combined with bupivacaine and sufentanil and its effects on maternal and foetal outcome., Study Design: Prospective double-blind randomized study., Patients and Methods: One hundred and five patients requesting labour analgesia had combined spinal epidural analgesia with intrathecal bupivacaine 2.5 mg and were randomly assigned to receive in addition either sufentanil 5 microg (S5), sufentanil 5 microg and clonidine 30 microg (C30), or sufentanil 10 microg (S10). Onset time, duration of analgesia, visual analogue scores, blood pressure, ephedrine requirements, heart rate, nausea, pruritus, sedation, motor block, foetal heart rate abnormalities, mode of delivery and Apgar scores were recorded., Results: Mean duration of spinal analgesia was significantly longer in patients receiving spinal clonidine compared to patients in S5 group (144+/-61 min versus 95+/-37 min). The onset time of analgesia was significantly shorter in S10 group (3+/-1 min) versus C30 group (4+/-1 min) and S5 group (4+/-1 min) (P=0.002). Hypotension was significantly more frequent in C30 group (29 versus 3% and 3% in S5 and S10 groups) (p=0,001). Foetal heart rate abnormalities and sedation were also significantly more frequent in C30 group. Mode of delivery (spontaneous, instrumental or caesarean delivery) and Apgar scores were unaffected by clonidine treatment., Conclusion: Intrathecal clonidine 30 mug prolongs analgesia. However, it increases the incidence of hypotension, and abnormal foetal heart rate patterns. Thus, this study confirms that the use of 30 mug intrathecal clonidine for labour analgesia is not recommended.

Neuraxial blockade is usually not recommended in patients with aortic stenosis. However, neuroaxial blockade techniques such as continuous spinal or epidural anaesthesia can be tailored to minimize potentially dramatic consequences of decrease in systemic vascular resistance, often encountered after standard single shot spinal anaesthesia. We report the cases of two severe aortic stenosis patients (aortic valve area<0.5 cm2) that underwent hip surgery under continuous spinal anaesthesia. Small doses of isobaric 0.25% bupivacaine titrated to limit total dose below 5 mg, injected through the intrathecal catheter allowed the control of haemodynamic parameters. No clinical complication occurred in these two patients.

The objective of this study is to assess both intra and post operative analgesia in infants undergoing umbilical hernia repair under general anaesthesia with neither opioid nor muscle relaxant, associated with a para umbilical block. It's a prospective study covering a 15 months period. The study included 75 infants (age = 5 months - 13 years; body weith = 6 kg - 35 kg). General anaesthesia was induced with either thiopentone or halothane and, maintained with halothane in a N2O - O2 50 VOL % mixture. Para-umbilical block was obtained using 1 ml/kg of 0.25% marcaïne. Pain was assessed using time course of respiratory rate, heart rate and mean arterial pressure. A change of more than 20% in one of these variables was considered criterion of poor analgesia. Intraoperative analgesia was adequate in all patients but four, 5 minutes after incision. Surgical conditions were considered as being godd or satisfactory in 90.6% and 9.4% of cases, respectively. Post operative analgesia, assessed 1 and 6 hours after completion of surgery was convenient in 93.3% of infants. The block appears as simple, most after efficient and safe in umbilical surgery.

Purpose: To compare the efficacy of 1% ropivacaine with a mixture of 0.5% bupivacaine and 2% lidocaine in peribulbar anesthesia for elective cataract surgery., Material and Methods: Prospective double-blinded study, enrolling 100 patients randomly assigned to two different groups. Group 1 received 9 ml of 1% ropivacaine and group 2 received 4.5 ml of 0.5% bupivacaine and 4.5 ml of 2% lidocaine. Both groups received 1 ml of hyaluronidase to reach a total volume of 10 ml., Results and Conclusion: No difference between the groups was noted during the study regarding not only onset time, but also the duration of anesthesia and perioperative analgesia. A greater incidence of pain on injection was significantly reported in group 2 (p<0.001). Patients in group 1 had less need for top-up injection and showed better ocular akinesia (p<0.01).

Objectives: To describe pharmacology and toxicology of ropivacaine. To assess the clinical efficacy of ropivacaine when used for postoperative epidural analgesia and to provide recommendations for clinical practice., Data Sources: Search in the Medline data base of original articles in French and English published since 1995, using the following key words: ropivacaine, postoperative analgesia, epidural, caudal block., Study Selection: Prospective randomised studies in adults and children were selected. Letters to editors and editorials were excluded., Data Extraction: Articles have been analyzed: to determine the dose of ropivacaine required for postoperative epidural analgesia, to assess the benefits of combination of epidural ropivacaine and additives (opioids or other), to compare epidural ropivacaine and bupivacaine and to assess the use of ropivacaine via caudal route for paediatric postoperative analgesia., Data Synthesis: 20 mg h-1 of ropivacaine is required to provide effective analgesia. This dose produces a motor block in a significant number of patients. Combination with an opioid allows for a reduction in ropivacaine requirement and subsequently in the incidence of motor blockade. In adults, equipotency ratio of ropivacaine and bupivacaine varies between 1.5/1 and 1/1 depending upon the concentration used. At equipotent doses, early postoperative mobilisation is facilitated with ropivacaine. In case of paediatric caudal analgesia, this ratio is close to 1., Conclusions: Epidural ropivacaine combined with opioid provide good postoperative pain relief. Reduction in the incidence of motor blockade and safe toxicological profile make this local anaesthetic a suitable alternative of bupivacaine for postoperative epidural analgesia.

Episcleral single injection anesthesia in the caruncle ovoïds the rare but potentially dangerous complications and incidents of classic local anesthesia. Excellent motor and sensory block is obtained with a single injection in the anatomic marks are well defined. We have practiced this technique since February 1999 for cataract surgery in 350 cases. The different surgical techniques used were manual extracapsular extraction in 52% of cases, phacosection through tunnel incision in 38%, and phacoemulsification in 10%. Our preliminary results show good acceptance of the episcleral anesthesia for both patients and surgeons. Because it is effective and safe, this anaesthtic technique may be an alternative to classic anesthetic techniques in all cases where topical anesthesia is not indicated.

Objective: To compare analgesia produced after surgery for severe hand trauma, by a continuous axillary block obtained either with a continuous injection (CA) or controlled by the patient (PCA)., Study Design: Prospective, randomized study., Patients: Forty-two ASA physical class 1 and 2 patients were enrolled over a twelve-month period and randomly allocated either into the CA or the PCA group., Methods: After recovery from the surgical block, the axillary plexus was located using a nerve stimulator and a 20 G catheter (Contiplex B Braun) inserted over 5 centimeters into the axillary sheath. In the CA group (n = 21) patients received 0.1 mL.kg-1.h-1 of 0.25% bupivacaine and in the PCA group (n = 21) patients received 0.1 mL.kg-1 boluses of 0.25% bupivacaine with a one hour lock-out period. Data collected were pain intensity rated according to he visual analog scale (VAS), the total volume of bupivacaine injected, the quantity of nalbuphine administered as 10 mg boluses when VAS was = 5, and the patient's satisfaction after removal of the catheter. Statistical analysis used Student t test, ANOVA and chi 2 test., Results: The mean duration of catheter use was 5 +/- 3 days. During this period the amount of bupivacaine was significantly reduced in the PCA group when compared to the CA group (P < 0.001). Similarly, the PCA group required significantly less nalbuphine. Finally, in this group, the satisfaction index was higher than in the CA group (95 versus 52% respectively, P < 0.01)., Conclusion: Continuous axillary plexus blockade provides safe and effective postoperative analgesia. With the PCA technique results a lower quantity of bupivacaine is required and patient's satisfaction better.

The Shouldice operation remains the gold standard of inguinal hernia surgery. The authors describe the details of the surgical and anesthesiological technique of this intervention. The actual place of conventional open hernia surgery is discussed in the light of the rapidly developing laparoscopic approach.

Inguinal hernia surgical treatment is the most frequently performed general surgical procedure. Its medical and economic involvements imposed and efficient and perfectly defined management. We report the conclusions of randomized series over the last 10 years about inguinal hernia treatment. The Shouldice procedure associated to local anesthesia and antibio-prophylaxy remains the gold standard for the treatment of inguinal hernia.

Lichtenstein's technique for surgical cure of primary inguinal hernia using local anaesthesia is described. Since 1984, 3250 primary hernia operations were performed at the Lichtenstein Hernia Institute. There were 4 recurrences due to technical errors which are described. This tension-free technique is a reliable, simple and effective procedure. Patients return to normal activity within 2 to 14 days. Studies one 22300 operations performed by several surgeons produced similar results for post-operative recurrence and complications.

Potentiated local anaesthesia has been generally used for repair of inguinal hernia since the Shouldice technique was first introduced in France in the early 80s. The technique requires a correct understanding of inguinal innervation and the properties of the local anaesthetic. The local anaesthetic is injected into the abdomino-genital and genito-crural nerves and at the line of incision allowing smooth surgical repair. Potentiation relieves patient apprehension. This method can be used for all types of inguinal hernia, whether simple or complicated and in all patients. There is no limitation for age or general condition. Contraindications are rare and include allergy or uncontrolled (no pacemaker) arrhythmias.

Among the various techniques of anaesthesia, local anaesthesia, posterior perineal block and caudal block allow most of the surgical procedures involving the anal canal to be performed. Practical modalities of the various techniques, choice of drugs and selection of the various indications are reported.

Two cases are reported of patients with phantom limb pain after lower limb amputation and requiring surgery of their stump. The stumps were revised and the remaining femoral shaft shortened. Both had spinal anaesthesia for this procedure, with an association of bupivacaine and 150 micrograms of clonidine. In one patient, the phantom pain did not resume for one month, and in the other for three days. The return of pain was preceded by the sensation of a phantom limb. These cases suggest that alpha 2 adrenergic agonists could play a major part in the treatment of phantom limb pain.

A block of the penile nerves provides a sensory blockade of the penis. In adults, surgery can thus be carried out on the foreskin, glans, corpus cavernosum, corpus spongiosum or penile urethra. The two dorsal nerves of the penis can be blocked by two different routes. In the median technique, only one injection is performed in the subpubic space, near the posterior inferior aspect of the symphysis. In the bilateral technique, each penile nerve is blocked separately at the level of the penile root. Whichever technique is used, additional subcutaneous infiltration of the penile root improves the quality of analgesia. Bupivacaine without adrenaline is used at a concentration of 0.25% or 0.5%. In the median technique, bilateral diffusion of the anaesthetic solution has been demonstrated in ten patients by adding contrast medium to the anaesthetic solution. On the other hand, contralateral diffusion was only found in six of ten patients after an unilateral injection. These results substantiate the value of the bilateral technique in the adult. Both techniques were used in a group of 80 patients, aged 17 to 87 years. In 47 patients no other agent was administered, while the remaining 33 had either additional sedation or a general anaesthetic. Among the latter, three had a partial failure of the block. Postoperative analgesia, which was of excellent quality, covered an average of 10 hours. Neither local nor general incident occurred. Penile block is a reliable technique for regional anaesthesia. Because it is easy to carry out, and comfortable for the patient, this technique may be suggested to adults requiring penile surgery.

Prolonged continuous epidural analgesia allows perithecal infusion with fentanyl and bupivacaine for 5 postoperative days after thoracic surgery. This study included 27 thoracotomized patients randomised into two groups: group X consisted of 15 subjects, group Y consisted of 12 subjects. Each patient received 33 micrograms/hr or fentanyl for 48 hours, associated with 0.25% bupivacaine in group X, and 0.125% bupivacaine in group Y. Over the three last days, the infusion rate of both drugs was decreased in the two groups. No significant clinical difference appeared between X and Y. No clinical respiratory depression occurred. In group Y, mean plasma bupivacaine concentrations remained significantly lower (p less than 0.05). Mean fentanyl levels did not increase beyond 0.8 ng/ml. The use of 0.125% bupivacaine improved the margin of safety but did not impair clinical analgesia in the study. This method provides good analgesia for thoracotomized patients.

Retrospective study of one years is performed on 334 patients who undergo transurethral surgery. Spinal anesthesia is used in 263 cases, general anesthesia in 71. Spinal administration of local anesthetics (lidocaine hyperbaric 5% or bupivacaine 0.5%) or opioid (Pethidine 1 mg/kg) have been used in old patients without any complication. The advantages are less blood uses, early stand up, no discontinuity in oral nutrition. For our team there are only few contra-indications for spinal anesthesia: blood coagulation abnormalities or some very rare heart diseases.

Gastrointestinal atony must be considered as a reflex response to surgical intervention, due to activation of sympathetic nerves. Following colonic surgery, the duration of this response may be notably extended and the ensuing intestinal distension becomes the paramount factor of a persisting ileus. Blocking the sympathetic fibers prevents intestinal distension. Introducing appropriate catheter into the peridural space up to the level of the 10th--11th thoracic vertebra makes it possible to realize a segmental continuous block between T6--L2, where gastrointestinal sympathetic innervation actually originates. Using bupivacaine at low concentration (0.125% with epinephrine 1/400,000) reduces untoward effect on circulation and may even prove beneficial if volaemia is effective. In addition, it produces a selective block on the visceromotor fibers which allows a differential diagnosis of the ileus, without risking to pass over a perforation of the gut whenever a coexisting mechanical factor is suspected.