Psoas compartment block (PCB) is a potentially useful but controversial technique for lower limb surgery. We have conducted a systematic review of the efficacy and safety of PCB for anaesthesia and postoperative analgesia for hip and knee surgery. Relevant studies were identified within PubMed, EMBASE, and the Cochrane Library. The main outcome measure for anaesthesia was anaesthetic efficacy. For postoperative analgesia, the severity of postoperative pain was compared. The data were subjected to meta-analysis using relative risks with 95% confidence intervals (95% CI) for dichotomous variables and weighted mean differences with 95% CI for continuous variables. Thirty publications were included. PCB is an effective intervention for analgesia after hip and knee surgery. It appears superior to opioids for pain relief after hip surgery. This analgesic benefit may be extended beyond 8 h by the use of a catheter technique. Compared with Winnie's 3-in-1 block, PCB is associated with more consistent block of the obturator nerve. PCB may be an alternative to postoperative neuraxial block. Although PCB combined with sciatic nerve block and sedation is an effective technique for minor knee surgery, there is currently insufficient data to recommend the use of this approach for hip and major knee surgery. PCB is a safe and effective alternative for analgesia after hip and knee surgery. More research is required to define its role in the intraoperative setting and confirm potentially beneficial effects on variables such as perioperative haemodynamics and blood loss.

IMPORTANCEThe development and expansion of intracranial hematoma are associated with adverse outcomes. Use of tranexamic acid might limit intracranial hematoma formation, but its association with outcomes of severe traumatic brain injury (TBI) is unclear.OBJECTIVE To assess whether prehospital administration of tranexamic acid is associated with mortality and functional outcomes in a group of patients with severe TBI. DESIGN, SETTING, AND PARTICIPANTSThis multicenter cohort study is an analysis of prospectively collected observational data from the Brain Injury: Prehospital Registry of Outcome, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) study in the Netherlands. Patients treated for suspected severe TBI by the Dutch Helicopter Emergency Medical Services between February 2012 and December 2017 were included. Patients were followed up for 1 year after inclusion. Data were analyzed from January 10, 2020, to September 10, 2020.EXPOSURES Administration of tranexamic acid during prehospital treatment. MAIN OUTCOMES AND MEASURESThe primary outcome was 30-day mortality. Secondary outcomes included mortality at 1 year, functional neurological recovery at discharge (measured by Glasgow Outcome Scale), and length of hospital stay. Data were also collected on demographic factors, preinjury medical condition, injury characteristics, operational characteristics, and prehospital vital parameters.RESULTS A total of 1827 patients were analyzed, of whom 1283 (70%) were male individuals and the median (interquartile range) age was 45 (23-65) years. In the unadjusted analysis, higher 30-day mortality was observed in patients who received prehospital tranexamic acid (odds ratio [OR], 1.34; 95% CI, 1.16-1.55; P < .001), compared with patients who did not receive prehospital tranexamic acid. After adjustment for confounders, no association between prehospital administration of tranexamic acid and mortality was found across the entire cohort of patients. However, a substantial increase in the odds of 30-day mortality persisted in patients with severe isolated TBI who received prehospital tranexamic acid (OR, 4.49; 95% CI, 1.57-12.87; P = .005) and after multiple imputations (OR, 2.05; 95% CI, 1.22-3.45; P = .007).CONCLUSIONS AND RELEVANCE This study found that prehospital tranexamic acid administration was associated with increased mortality in patients with isolated severe TBI, suggesting the judicious use of the drug when no evidence for extracranial hemorrhage is present.

A posterior lumbar plexus block or psoas compartment block (PCB) is an effective locoregional anesthetic technique for analgesia and anesthesia of the entire lower extremity including the hip. Since the first description in the early seventies, this technique has been modified based on advanced knowledge of the anatomical localization of the lumbar plexus and the improvement of technical equipment. This paper provides an overview of the history, clinical efficacy, and risk profile of the PCB focused on hip surgery. Current status and future expectations are discussed.

BackgroundCreating a patent airway by cricothyrotomy is the ultimate maneuver to allow oxygenation (and ventilation) of the patient. Given the rarity of airway management catastrophes necessitating cricothyrotomy, sufficiently sized prospective randomized trials are difficult to perform. Our Helicopter Emergency Medical Service (HEMS) documents all cases electronically, allowing a retrospective analysis of a larger database for all cases of prehospital cricothyrotomy.MethodsWe analyzed all 19,382 dispatches of our HEMS ‘Lifeliner 1’, since set-up of a searchable digital database. This HEMS operates 24/7, covering ~ 4.5 million inhabitants of The Netherlands. The potential cases were searched and cross-checked in two independent databases.ResultsWe recorded n = 18 cases of prehospital cricothyrotomy. In all 18 cases, less invasive airway techniques, e.g., supraglottic devices, were attempted before cricothyrotomy. With exception of 2 cases, at least one attempt of orotracheal intubation had been performed before cricothyrotomy. Out of the 18 cases, 4 were performed by puncture-based technique (Melker), the remaining 14 cases by surgical technique. Indications for cricothyrotomy were diverse, dividable into 9 trauma cases and 9 medical cases.The procedure was successful in all but one case (17/18, i.e., 94%; with a 95% confidence interval of 72.7–99.9%). Outcome was such that 6/18 patients arrived at the hospital alive. Long term outcome was poor, with only 2/18 patients discharged from hospital alive.ConclusionsCricothyrotomy remains, although rare, a regularly occurring requirement in (H)EMS. Our finding of a convincingly high success rate of 94% in trained hands encourages training and a timely performance of cricothyrotomy.

To evaluate the 3.02 software version of the FloTrac/Vigileo™ system for estimation of cardiac output by uncalibrated arterial pressure waveform analysis, in septic shock. Nineteen consecutive patients in septic shock were studied. FloTrac/Vigileo™ measurements (COfv) were compared with pulmonary artery catheter thermodilution-derived cardiac output (COtd). The mean cardiac output was 7.7 L min(-1) and measurements correlated at r = 0.53 (P < 0.001, n = 314). In Bland-Altman plot for repeated measurements, the bias was 1.7 L min(-1) and 95 % limits of agreement (LA) were -3.0 to 6.5 L min(-1), with a %error of 53 %. The bias of COfv inversely related to systemic vascular resistance (SVR) (r = -0.54, P < 0.001). Above a SVR of 700 dyn s cm(-5) (n = 74), bias was 0.3 L min(-1) and 95 % LA were -1.6 to 2.2 L min(-1) (%error 32 %). Changes between consecutive measurements (n = 295) correlated at 0.67 (P < 0.001), with a bias of 0.1 % (95 % limits of agreement -17.5 to 17.0 %). All changes >10 % in both COtd and COfv (n = 46) were in the same direction. Eighty-five percent of the measurements were within the 30°-330° of the polar axis. COfv with the latest software still underestimates COtd at low SVR in septic shock. The tracking capacities of the 3.02 software are moderate-good when clinically relevant changes are considered.

Levobupivacaine, bupivacaine and ropivacaine are equally effective for PCSNB in patients undergoing total hip arthroplasty. Residual pain may be due to the lack of sensory block in dermatome L1, suggesting that modification of this technique should be considered for this type of surgery.

A thorough understanding of the epidemiology, patient characteristics, trauma mechanisms, and current outcomes among patients with severe traumatic brain injury (TBI) is important as it may inform potential strategies to improve prehospital emergency care. The aim of this

Introduction: Traumatic injury is the fourth leading cause of death in western countries and the leading cause of death in younger age. However, it is still unclear which groups of patients benefit most from advanced prehospital trauma care. A minimal amount is known about the effect of prehospital physician-based care on patients with specifically traumatic brain injury (TBI). The aim of this review is to assess the effect of physician-staffed Emergency Medical Services (EMS) on the outcome of patients with severe TBI. Methods: Literature searches have been performed in the bibliographic databases of PubMed, EMBASE and The Cochrane Library. Data concerning (physician-staffed) prehospital care for patients with severe TBI were only included if the control group was based on non-physician-staffed EMS. Primarily the mortality rate and secondarily the neurological outcome were examined. Additionally, data concerning hypotension, hypoxia, length of stay (hospital and intensive care unit) and the number of required early neurosurgical interventions were taken into account. Results: The overall mortality was decreased in three of the fourteen included studies after the implementation of a physician in the prehospital setting. One study found also a decrease in mortality only for patients with a Glasgow Coma Scale of 6-8. Strikingly, two other studies reported higher mortality, one for all the included patients and one for patients with GCS 10-12 only. Neurological outcome was improved in five studies after prehospital deployment of a physician. One study reported that more patients had a poor neurological outcome in the P-EMS group. Results of the remaining outcome measures differed widely. Conclusion: The included literature did not show a clear beneficial effect of P-EMS in the prehospital management of patients with severe TBI. The available evidence showed contradictory results, suggesting more research should be performed in this field with focus on decreasing heterogeneity in the compared groups.