Ultrasound-guided lumbar plexus block(ULPB) can be performed using two approaches: a parasagital (PSA) or transversal(TA). The PSA and TA have been described targeting the location of transverse process of the 4th lumbar vertebra (L4). A higher approach may promote organ puncture complication. We hypothised that TA ULPB might promote a higher level of puncture than expected.
Methods
After informed consent, 50 volunteers were studied. Each volunteer was landmarked bilaterally, using PSA and an invisible ink pen from T12 to L5 transverse process location. A landmarked horizontal line parralel from both iliac crests was drawn. We named this line "C". Once we obtained the typical image of ULPB using TA passing from line C, we oriented caudaly and cephalad the probe to visualise the lumbar plexus on the level directly above and under. We named these lines ">C" for the level above and "<C" for the level under.
Results
The demographic characteristics are described on the table below. On 100 compared approaches,we reported that a ULPB with a TA is projected between the transversal process of L3 and L4 ( 51%), L4 (21%) and L3 (9%). By tilting the probe we can access up to L1 transverse process ( 1%). Lumbar plexus was not visualized in 12% of cases in PSA and in 1% in TA.
Conclusions
A TA for an UPLB leads to an unexpected higher level than L4. We recommend to perform a previsualization with a PSA to strictly identify a L4 level of puncture.
To assess the usefulness of BAL in diagnosing bacterial pneumonia in mechanically ventilated patients, 80 BAL fluid samples obtained from 72 patients with lung infiltrates were studied using the following parameters: infected cell count (polymorphonuclear leukocytes or macrophages with intracellular organisms), microscopic examination of stained smears, and quantitative culture with the determination of the simplified bacterial index (SBI) and the predominant species index (PSI). Of the 80 BAL samples studied, 56 were performed under antibiotic therapy. Bacterial pneumonia was the final diagnosis in 28 cases. The SBI is the sum of the whole numbers of each bacterial concentration expressed as a common logarithm. The PSI is the whole number of the predominant microorganism's concentration expressed as a common logarithm. The discriminative value of each test was assessed using a receiver operating characteristic (ROC) curve, whereby the possibility of establishing a cutoff value used to discriminate between the presence or absence of pneumonia is evaluated. The percentage of infected cells was higher in the pneumonia group (8.8 +/- 18.1 versus 0.4 +/- 1.1%, p < 10(-3), but no cutoff value could be proposed. Under microscopic examination, the presence of bacteria was noted with a significantly greater frequency in the pneumonia group (sensitivity 67.8% and specificity 82.7%). A total of 58 BAL samples were positive when cultured. The SBI was significantly higher in the pneumonia group (6.5 +/- 2.9 versus 1.6 +/- 1.7, p < 10(-4).(ABSTRACT TRUNCATED AT 250 WORDS)
Objective To identify factors associated with poor postoperative pain experience by examining patient-related and procedural variables. Methods An exploratory secondary analysis was conducted on data from 971 adult patients undergoing elective surgery under general anesthesia across five French teaching hospitals. Preoperative anxiety was assessed using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). Pain, sleep quality and well-being were measured preoperatively and postoperatively using visual analog scales (VAS). The primary endpoint was the patient experience measured by the Evaluation du Vécu de l'Anesthésie Generale (EVAN-G) questionnaire on postoperative day 1, with poor pain experience defined as a score below the 25th percentile on the EVAN-G pain dimension. Univariate and multivariate logistic regression analyses were performed to identify factors associated with poor pain experience. Results Poor pain experience was reported by 271 patients (27.9%). Multivariate analysis identified intraoperative use of remifentanil and sufentanil as an independent predictor of poor pain experience with an OR of 26.96 (95% CI 2.17 to 334.23, p=0.01). Additionally, age (OR 0.97, p=0.003), absence of premedication (OR 0.49, p=0.035) and orthopedic surgery (OR 0.29, p=0.005) were associated with a lower likelihood of poor pain experience. Conversely, American Society of Anesthesiologists (ASA) 3 status (OR 5.09, p=0.028), postoperative anxiolytic use (OR 8.20, p<0.001), amnesia (OR 1.58, p=0.001), higher VAS pain (p<0.001) and lower well-being scores (p=0.007) on day 1 were predictors of poor pain experience. Conclusion The intraoperative use of remifentanil and sufentanil is independently associated with poorer postoperative pain experience. These findings highlight the need to reassess intraoperative analgesic strategies to enhance patient outcomes and reduce postoperative complications.
