Subarachnoid space of the optic nerve sheath and intracranial hypertension: a macroscopic, light and electron microscopic study.

PURPOSE: The optic nerve (ON) is an extension of the central nervous system via the optic canal to the orbital cavity. It is accompanied by meninges whose arachnoid layer is in continuity with that of the chiasmatic cistern. This arachnoid layer is extended along the ON, delimiting a subarachnoid space (SAS) around the ON. Not all forms of chronic intracranial hypertension (ICH) present papilledema. The latter is sometimes asymmetric, unilateral, or absent. The radiological signs of optic nerve sheath (ONS) dilation, in magnetic resonance imaging, are inconsistent or difficult to interpret. The objective of this study was to analyze the anatomy, the constitution, and the variability of the SAS around the ON in its intraorbital segment to improve the understanding of the pathophysiologic mechanism of asymmetric or unilateral or absent papilledema in certain ICH. METHODS: The study was carried out on nine cadaveric specimens. In four embalmed specimens, macroscopic analysis of the SAS of the ONS were performed, with description about density of the arachnoid trabecular meshwork in three distinct areas (bulbar segment, mid-orbital segment and the precanal segment). In three other embalmed specimens, after staining of SAS by methylene blue (MB), we performed macroscopic analysis of MB progression in the SAS of the ONS. Then, in two non-embalmed specimens, light and electron microscopy (EM) analysis were also done. RESULTS: On the macroscopic level, after staining of SAS, we found in all cases that MB progressed on 16 mm average throughout the SAS of the ONS without reaching the papilla. In four embalmed specimens, in the SAS of the ONS, the density of the arachnoid trabecular meshwork showed inter-individual variability (100%) and intra-individual variability with bilateral variability (50%) and/or variability within the same ONS (88%). On the microscopic level, the arachnoid trabeculae of the ONS are composed of dense connective tissue. The EM perfectly depicted its composition which is mainly of collagen fibers of parallel orientation. CONCLUSION: The variability of the SAS around the ONS probably impacts the symmetrical or asymmetrical nature of papilledema in ICH.

Cebranopadol: novel dual opioid/NOP receptor agonist analgesic.

WHAT IS KNOWN AND OBJECTIVE: Chronic pain presents a difficult clinical challenge because of the limited efficacy, the limiting adverse-effect profile or the abuse potential of current analgesic options. Cebranopadol is a novel new agent in clinical trials that combines dual agonist action at opioid and nociceptin/orphanin FQ peptide (NOP) receptors. It is the first truly unique, centrally acting analgesic in several years. We here review the basic and clinical pharmacology of cebranopadol. METHODS: Published literature and Internet sources were searched to identify information related to the basic science (pharmacology and medicinal chemistry) and development (clinical trial) information on the mechanism of dual opioid and NOP receptor pharmacologic action in general, and for cebranopadol in particular. The identified sources were reviewed and the information synthesized. RESULTS: The preclinical testing of cebranopadol has characterized it as a dual opioid and NOP receptor agonist that displays antinociceptive and antihyperalgesic action in a variety of acute and chronic pain models in animals. Unlike most current traditional opioids, it is generally more potent against neuropathic than nociceptive pain. Several phase 2 clinical trials have been completed. WHAT IS NEW AND CONCLUSION: Despite the medical need, a truly novel centrally acting analgesic has not been developed in many years. Cebranopadol represents a truly novel mechanistic approach. Its actual place in pain pharmacotherapy awaits the results of phase 3 clinical trials.

Cerebral blood flow modulation by transcutaneous cranial electrical stimulation with Limoge's current.

OBJECTIVES: Transcutaneous cranial electrical stimulation (TCES) delivers a high-frequency (166 kHz) pulsed biphasic balanced current with a pulse repetition frequency of 100 Hz with 40% duty cycle through a negative electrode and two positive electrodes over the skull. TCES has a proven ability to potentiate anesthesia and analgesia, although the physiological mechanisms of this effect remain unclear. We hypothesized that the mechanism is a modulation of CBF in the central endogenous opioid system. This study aimed at determining the effects of TCES on CBF to elucidate its physiological mechanism. METHODS: Thirty-six healthy volunteers were randomly assigned to active or placebo TCES, and all assessments were double blind. TCES was performed using the Anesthelec™ device. In the stimulated group, an active cable was used, and in the control group (sham), the cable was inactive. CBF was measured by XeCT™ before and after two hours of TCES. RESULTS: Globally, CBF was unchanged by TCES. However, locally, TCES induced a significant CBF decrease in the brainstem and thalamus, which are structures involved in pain and anxiety (TCES and control CBF decrease were 18.5 and 11.9 mL/100g brain tissue/min, respectively). CONCLUSION: TCES can modulate local CBF but it has no effect on overall CBF. [Clinical Trials. gov number: NCT00273663].

Wound infiltration with magnesium sulphate and ropivacaine mixture reduces postoperative tramadol requirements after radical prostatectomy.

PURPOSE: This prospective, randomized, double-dummy study was undertaken to compare the effects of magnesium sulphate (MgSO(4)) administered by the intravenous vs. the infiltration route on postoperative pain and analgesic requirements. METHODS: Forty ASA I or II men scheduled for radical retropubic prostatectomy under general anaesthesia were randomized into two groups (n=20 each). Two medication sets A and B were prepared at the pharmacy. Each set contained a minibag of 50 ml solution for IV infusion and a syringe of 45 ml for wound infiltration. Group MgSO(4).IV patients received set A with 50 mg/kg MgSO(4) in the minibag and 190 mg of ropivacaine in the syringe. Group MgSO(4)/L received set B with isotonic saline in the minibag and 190 mg of ropivacaine +750 mg of MgSO(4) in the syringe. The IV infusion was performed over 30 min at induction of anaesthesia and the surgical wound infiltration was performed during closure. Pain was assessed every 4 h, using a 100-point visual analogue scale (VAS). Postoperative analgesia was standardized using IV paracetamol (1 g/6 h) and tramadol was administered via a patient-controlled analgesia system. The follow-up period was 24 h. RESULTS: The total cumulative tramadol consumption was 221 +/- 64.1 mg in group MgSO4.IV and 134 +/- 74.9 mg in group MgSO(4).L (P<0.01). VAS pain scores were equivalent in the two groups throughout the study. No side-effects, due to systemic or local MgSO(4) administration, were observed. CONCLUSION: Co-administration of MgSO(4) with ropivacaine for postoperative infiltration analgesia after radical retropubic prostatectomy produces a significant reduction in tramadol requirements.

Pharmacological control of head motion during cerebral blood flow imaging with CT or MRI.

Uncontrolled head motion during CT/MRI cerebral blood flow (CBF) imaging has been estimated between 3 and 15% of the cases. We present a pharmacological approach which permitted us to maintain the incident at 0.06% with few side effects. The protocol involves the systematic use of general anesthesia (sevoflurane) in children below five years and those with mental retardation. In anxious, claustrophobic or agitated adults, mild sedation with propofol, midazolam or hydroxyzine was used with mild effects on CBF. We strongly recommend the availability of basic cardiorespiratory resuscitation equipment and a recovery room before any sedation or general anesthesia is undertaken.

Peritumoral edema and prognosis in intracranial meningioma surgery.

Peritumoral brain edema (PTBE) is often associated with meningiomas. PTBE is probably implicated in the complications occurring in intracranial meningiomas. The goal of this study was to determine the exact implication of PTBE in prognosis. Thirty consecutive patients who underwent surgery for intracranial meningiomas were investigated over a 1-year period. We focused on the clinical and radiological status before and after surgery, and postoperative complications. Multiple regression analysis revealed a close correlation (p<0.05) between PTBE and symptoms, type of arterial supply, difficulty of surgical removal, and postoperative complications. PTBE is likely implicated in the morbidity of intracranial meningiomas. We suggest predictive factors for difficult surgical resection, and emphasise the importance of medical preoperative management and post-operative follow-up.

Paediatric care in relation to the 2014-2015 Ebola outbreak and general reporting of deaths in Sierra Leone.

Setting: All peripheral health units countrywide in Sierra Leone and one hospital in Port Loko. Objectives: Sierra Leone was severely affected by the 2014-2015 Ebola outbreak, whose impact on paediatric care and mortality reports merits assessment. We sought to compare the periods before, during and after the Ebola outbreak, the countrywide trend in morbidities in children aged < 5 years and exit outcomes in one district hospital (Port Loko). During the Ebola outbreak period, gaps in district death reporting within the routine Health Management Information System (HMIS) were compared with the Safe and Dignified Burials (SDB) database in Port Loko. Design: This was a retrospective records analysis. Results: The average number of monthly consultations during the Ebola outbreak period declined by 27% for malaria and acute respiratory infections and 38% for watery diarrhoea, and did not recover to the pre-Ebola levels. For measles, there was an 80% increase during Ebola, which multiplied by 6.5-fold post-Ebola. The number of unfavourable hospital exit outcomes was 52/397 (13%) during Ebola, which was higher than pre-Ebola (47/496, 9%, P = 0.04). Of 6565 deaths reported in the Port Loko SDB database, only 2219 (34%) appeared in the HMIS, a reporting deficit of 66%. Conclusion: The Ebola disease outbreak was associated with reduced utilisation of health services, and appears to have triggered a measles epidemic. Almost 70% of deaths were missed by the HMIS during the Ebola outbreak period. These findings could guide health system responses in future outbreaks.

Contexte : Toutes les unités périphériques de santé dans le pays et un hôpital à Port Loko, Sierra Leone.Objectifs : La Sierra Leone a été gravement affectée par l'épidémie d'Ebola de 2014­2015. Son influence sur les soins pédiatriques et les rapports de décès mérite une évaluation. Cette étude compare, avant, pendant et après l'épidémie d'Ebola, la tendance de la morbidité des enfants âgés de <5 ans dans tout le pays et, dans un hôpital de district (Port Loko), les résultats à la sortie. Pendant Ebola, les lacunes des rapports de décès du district au sein du système d'information de la gestion de la santé de routine (HMIS) ont été comparées à la base de données SDB (enterrement en sécurité et digne) de Port Loko.Schéma : Une analyse rétrospective de dossiers.Résultats : Le nombre moyen de consultations par mois pendant Ebola a décliné de 27% pour le paludisme et les infections respiratoires aiguës et de 38% pour la diarrhée aqueuse, et ce nombre n'est pas remonté aux niveaux d'avant Ebola. Pour la rougeole, il y a eu une augmentation de 80% pendant Ebola qui a été multipliée par 6,5 après Ebola. Sur 397 sorties d'hôpital, 52 ont eu un résultat défavorable (13%) pendant Ebola, ce qui a été plus élevé qu'avant Ebola (47/496, 9% ; P = 0,04). Sur 6565 décès rapportés dans la base de données SDB de Port Loko, seulement 2219 (34%) sont apparues dans le HMIS (déficit de rapportage = 66%).Conclusion : L'épidémie d'Ebola a été associée à une réduction de l'utilisation des services de santé, et semble avoir déclenché une épidémie de rougeole. Près de sept décès sur dix ont été manqués par le HMIS pendant Ebola. Ces résultats pourraient guider les ripostes du système de santé lors de futures épidémies.

Marco de referencia: Todas las unidades periféricas de salud en el territorio nacional de Sierra Leona y un hospital de Port Loko.Objetivos: El brote epidémico de fiebre hemorrágica del Ébola afectó de manera considerable a Sierra Leona durante el 2014 y el 2015. La evaluación de la repercusión de la epidemia sobre la atención pediátrica y la notificación de las defunciones es digna de interés. Se comparó la evolución de la morbilidad de los niños < 5 años de edad en todo el país y los desenlaces del alta hospitalaria en un hospital distrital (Port Loko), antes de la epidemia del Ébola, durante el brote y después del mismo. Durante la epidemia se compararon las deficiencias de notificación de defunciones del distrito en el sistema corriente de información sobre gestión sanitaria, con respecto a la base de datos de la inhumación segura y digna (SDB) en Port Loko.Método: Un análisis retrospectivo de historias clínicas.Resultados: Durante la epidemia del Ébola, el promedio mensual de consultas por paludismo e infección respiratoria aguda disminuyó un 27% y el promedio de consultas por diarrea líquida disminuyó un 38%; tras la epidemia no se recuperaron las cifras anteriores al brote. Al contrario, se observó un aumento de 80% de las notificaciones de sarampión durante la epidemia y una cifra 6,5 veces más alta después del brote epidémico. Durante la epidemia del Ébola ocurrieron desenlaces hospitalarios desfavorables en 52 de 397 pacientes (13%), lo cual representa un aumento con respecto al período anterior al brote, que fue de 47 en 496 hospitalizaciones (9%, P = 0,04). De las 6565 defunciones notificadas en la base de datos SDB de Port Loko, solo 2219 aparecían en el sistema corriente de información sobre gestión sanitaria (34%), lo cual corresponde a una deficiencia de notificación del 66%.Conclusión: El brote epidémico del Ébola ocasionó una disminución de la utilización de los servicios de salud y al parecer desencadenó una epidemia de sarampión. Durante el brote, faltaban en el sistema corriente de información sobre gestión sanitaria cerca de siete de cada diez defunciones. Estos resultados deben contribuir a orientar las respuestas de los sistemas de salud durante los futuros brotes epidémicos.

Crystallization and a preliminary X-ray diffraction study of isozyme 3-3 of glutathione S-transferase from rat liver.

Crystals of the homodimeric isozyme 3-3 of glutathione S-transferase from rat liver have been obtained with the hanging drop method of vapor diffusion from ammonium sulfate solutions. The successful crystallization of the enzyme required the presence of both the enzyme inhibitor (9R, 10R)-9, 10-dihydro-9-(S-glutathionyl)-10-hydroxyphenanthrene and the detergent beta-octylglucopyranoside. The crystals belong to the monoclinic space group C2, with cell dimensions of a = 88.24(8) A, b = 69.44(4) A, c = 81.28(5) A, beta = 106.01(6) degrees, and contain four dimeric enzyme molecules per unit cell. The crystals diffract to at least 2.2 A and are suitable for X-ray crystallographic structure determination at high resolution.

Comparative overview of brain perfusion imaging techniques.

Numerous imaging techniques have been developed and applied to evaluate brain hemodynamics. Among these are: Positron Emission Tomography (PET), Single Photon Emission Computed Tomography (SPECT), Xenon-enhanced Computed Tomography (XeCT), Dynamic Perfusion-computed Tomography (PCT), Magnetic Resonance Imaging Dynamic Susceptibility Contrast (DSC), Arterial Spin-Labeling (ASL), and Doppler Ultrasound. These techniques give similar information about brain hemodynamics in the form of parameters such as cerebral blood flow (CBF) or volume (CBV). All of them are used to characterize the same types of pathological conditions. However, each technique has its own advantages and drawbacks. This article addresses the main imaging techniques dedicated to brain hemodynamics. It represents a comparative overview, established by consensus among specialists of the various techniques. For clinicians, this paper should offers a clearer picture of the pros and cons of currently available brain perfusion imaging techniques, and assist them in choosing the proper method in every specific clinical setting.

Regional cerebral blood flow measurements with Xenon-CT in the prediction of delayed encephalopathy after carbon monoxide intoxication.

Reported evaluations of CBF with Xe/CT were performed in 11 patients during the lucid interval following CO intoxication. Results were compared with clinical and SPECT data. Two patients developed neuropsychiatric behavior (delayed encephalopathy) one month following the initial recovery. The symptoms persisted in one of them 15 months later. Their CBF values as well as those in most of the other patients, monitored at the basal ganglia and white matter areas, were in relation with the clinical outcome, However, further studies with a larger number of patients, are needed to confirm the predictive significance of Xe/CT measurements for the long term sequelae of CO poisoning.

Effects of premedication with oral hydroxyzine on patient motion during inhalation of 32% xenon for regional cerebral blood flow mapping.

Because of its anesthetic properties, inhalation of 30-35% Xenon is associated with uncontrolled patient motion in 3-15% of the cases. This constitutes a major setback to regional cerebral blood flow studies with Xenon-enhanced computed tomography (Xe-CT CBF). The present study attempted to determine the effects of oral premedication with hydroxyzine (H) in the control of motion. Patients scheduled for Xe-CT CBF, aged 20-55 years, were randomly allocated to 3 groups: H 50 mg (n = 41), H 100 mg (n = 36) or Placebo (n = 43). The drugs were administered orally 90 minutes before Xenon inhalation. This consisted a gas mixture of 32% Xe and 25% oxygen. Motion was classified as controlled or uncontrolled depending on whether CBF data acquisition was possible or not. Anxiolysis and sedation were evaluated by a visual analogue scale. Motion was significantly reduced in the H 50 mg (0.8% vs 2.5% in the H 100 mg and 6.7% in the Placebo group). An anxiolytic effect of hydroxyzine was suggested.

Assessment of regional cerebral blood flow by xenon-enhanced computed tomography during mastication in humans.

It is suggested that mastication stimulates the brain and accelerates its energy-consuming metabolism. This study was designed to determine its effects on regional cerebral blood flow (rCBF) using xenon-enhanced computed tomography (Xe-CT). Seven male volunteers, aged 24-57 years, inhaled 30% xenon in a 4 minutes wash-in and 4 minutes wash-out protocol. CT was scanned every 54.5 seconds. The subjects were instructed to chew a gum continuously at a rate of 1 bite per second except at the time of CT scanning (5.5 seconds). A second CBF was done 20 minutes later. Subtraction (mastication-baseline) maps were created. CT images were taken at three levels so as to include the cortex, basal ganglia, limbic system, brainstem and cerebellum. The results demonstrated a significant rCBF increase in the fronto-temporal cortex, caudate nucleus, thalamus and minor increase in the rolandic areas, insula, cingulate and cerebellum. Further studies are needed to validate the clinical significance of these findings.

Epidemiology of elderly patients' burns in the South West of France.

A retrospective study of 716 patients aged 60 years and above (324 men, 392 women) was undertaken in order to determine quality control in burns management in the South West of France. The following epidemiological data was obtained: high hospitalization rate (7 per cent of the general admissions); monthly and seasonal periodicity; predominance of indoor accidents (86 per cent) with domestic accidents being more frequent in women (63 vs. 37 per cent). Outdoor accidents were mainly recreational and were five times more frequent in men than in women. The overall mortality was 39 per cent and was influenced by the burns extent, depth, predisposing factors and early management. More burns occurred in urban areas (53 per cent) but mortality was higher in patients from rural areas (62 vs. 38 per cent). It was observed that delay in management, especially fluid resuscitation of patients from the rural areas, was partly responsible for this outcome. Propositions were made to diffuse more information on the importance of early management of burns in rural areas.

[Osmotic cerebral oedema: the role of plasma osmolarity and blood brain barrier]. / Osmolarité plasmatique et barrière hématoencéphalique: l'oedème cérébral osmotique.

There are five types of oedema: vasogenic, cytotoxic, interstitial, hyperemic and osmotic. The differences lie on the type and localization of the oedema, the state of the blood-brain barrier (BBB) and the pathological context. Under physiological conditions, the osmolarity of extra cellular fluids (ECFs) is equal on both sides of the BBB. However, the pathophysiological variations of circulating osmolarity (including acute hyponatremia and hypernatremia) do not affect, at the same time, the osmolarity of cerebral ECFs. This situation generates an osmotic gradient on either side of the BBB. The latter, if intact, behaves like a semi-permeable membrane allowing water transport according to the osmotic laws. Depending on its direction, water movement could induce cerebral liquid inflation (i.e. osmotic oedema) or cerebral dehydration. In case of osmotic insult, cerebral cell modify their active osmotic molecular contents in order to limit volume variation. There are two types of osmoactive molecules, organic (i.e. ideogenic osmoles: amino acids, polyols and trimethylamines) and non organic (i.e. electrolytes). In the event of plasma hypotonicity, cerebral cells expel active osmotic molecules to reduce the osmotic gradient and water movement thereby reducing edema. The opposite reaction is observed in the case of hypertonic insult. This cerebral osmoregulation becomes more effective, the slower the osmotic disorder. It explains, for example, why patients with chronic and severe hyponatremia could be asymptomatic. Severe osmotic oedema is observed mainly in water intoxication, acute hyponatremia or too rapid reduction of hyperosmolarity. However, osmotic oedema is not limited to extreme clinical circumstances. Hyponatremia, even modest, could modify cerebral blood volume and impair osmoregulation. Generally these minor modifications do not affect normal brain tissue. In the presence of cerebral lesion, osmoregulation operates only in areas of preserved BBB. The pathological zones are therefore exposed to osmotic oedema (even in cases of moderate hyponatremia) with deterioration of both clinical status and intracranial pressure. This authentic phenomenon could be insidious and difficult to differentiate from osmotic central oedema. Hyponatremia constitutes an authentic secondary cerebral insult of systemic origin, an entity clearly identified by experimental studies to justify the choice between crystalloids and colloids in neuroanaesthesia and neurointensive care. These studies have revealed an increase in water content in normal brain tissues after administration of hypotonic solutions. The increase in plasma osmolarity as a treatment modality using mannitol or hypertonic saline is based on the same concepts. The most remote indication is the occurrence of a reactive mydriasis in the context of trauma for example. More recently, therapeutic hypernatremia has been proposed to control intracranial hypertension.

[Spectral analysis of the ECG R-R interval permits early detection of vagal responses to neurosurgical stimuli]. / L'analyse spectrale de l'intervalle R-R de l'ECG permet la détection précoce des réponses vagales aux stimuli neurochirurgicaux.

OBJECTIVE: To assess the efficacy of ECG spectral analysis, compared with heart rate (HR) monitoring in the detection of vagal response to surgical stimuli. METHODS: Twenty Asa II-III patients (age: 65 +/- 13 years) scheduled for surgery of cerebellopontine angle or implantation of sacral root stimulator were examined. Target controlled infusion of propofol (2-4 microg x ml(-1)) and remifentanil (4 ng x ml(-1)) was guided by the bispectral index (Bis). Arterial pressure via a radial catheter, pulse oximetry and end tidal CO2 were continuously monitored. Spectral analysis was achieved by connecting a computer to the cardiorespiratory monitor. Online power spectrum densities were calculated from the ECG R-R interval by software based on the fast Fourier transform (LabView, National Instruments, USA). Low frequency (LF: 0.04-0.15Hz) and high frequency (HF: 0.15-0.4Hz) were associated with sympathetic and parasympathetic activities respectively. We defined vagal reaction as a decrease in FC or an increase in HF >10% of the prestimuli value. HF and FC were compared according to the detection delay (by a Student t test with p < 0.05 considered significant) and a concordance test with a kappa coefficient (kappa): -1 = total discordance to 1 = total concordance. RESULTS: Twelve vagal reactions (observed in 8 patients) were detected within 5.5 +/- 1.3 s (HF) and 12.4 +/- 1.6 (FC); p < 0.001. Concordance between the 2 parameters was 95% (kappa =0.9). CONCLUSION: The ECG spectral analysis is a non-invasive technique, which permits the detection of intra-operative vagal reactions earlier than conventional monitoring of HR.

[Methods for measuring spinal cord blood flow]. / Méthodes de mesure du débit sanguin médullaire.

This study aimed to review the techniques used most currently for measuring spinal cord blood blow flow (SCBF) in animals, i.e. the hydrogen clearance, labelled microspheres, 133Xe clearance and 14C-antipyrine autoradiographic methods. All four techniques may only be used in animals, because of their invasiveness. Flow figures varied greatly with the method, the spinal level at which measurements were carried out, and the species of animal. However, results tend to suggest that SCBF is very similar to cerebral blood flow in that it is controlled by chemical, autoregulatory and metabolic factors. Approaches to measuring SCBF in man may be made using stable xenon-enhanced computed tomographic imaging (Xes-CT) in the same way as for measuring cerebral blood flow. The calculation of SCBF is based on Fick's principle transformed by Kety and Schmidt. After a reference CT section has been obtained, twelve 8 mm thick sections are carried out whilst the patient breathes a 30% xenon-70% air/oxygen mixture. This series of views enables the SCBF to be calculated in four steps. Quantitative analysis in eight human subjects gave a mean SCBF of 58.8 +/- 5.96 ml x 100 g-1 x min-1. However, this method has a low signal to noise ratio. Moreover, the qualitative analysis of the parametric views of flow demonstrate tissue heterogeneity, partly due to the patient's movements (breathing movements). However, the method is non invasive, safe, and reproducible. As it can measure very low values of blood flow, the study of ischaemic spinal lesions is made possible, although some technical and software improvements are still required.

[Cerebrospinal fluid shunting: anesthetic particularities]. / Les dérivations du liquide céphalorachidien: particularités anesthésiques.

The symptomatic treatment of hydrocephalus remains cerebrospinal fluid (CSF) drainage to an external reservoir (external CSF drainage) or to an internal cavity mainly the peritoneum or the right atrium via a unidirectional valve (internal CSF drainage) and finally by endoscopic ventriculocisternostomy. Local anaesthesia is adequate for external CSF drainage in adults and children above 10 years while general anaesthesia is required in all other cases. The main problems encountered in these patients are difficult intubation and full stomach associated with increased intracranial pressure. The anaesthetic approach should favour homeostasis. With the exception of ketamine and enflurane, the majority of anaesthetic drugs can be used. Anti-epileptic drug are mandatory. Antibioprophylaxis mainly against staphylococcus is systematic in internal CSF drainage. Rapid emergence from anaesthesia and extubation should be encouraged. Complications (infectious, mechanical and bleeding kinds) are frequent and are often the cause of reinterventions or revisions of the device, exposing the patients to iterative anaesthesia. Furthermore, patients with shunts are at risk of malfunction of the device when exposed to situations like pregnancy, magnetic resonance imaging, or laparoscopy. Under these circumstances, it is recommended to associate the neurosurgical team in the management of these patients and to verify that the shunt is working well before and after the procedure or event.

[Anterior sacral root stimulation with dorsal rhizotomy (Brindley technique)]. / Neurostimulation des racines sacrées antérieures avec rhizotomies postérieurs (technique de Brindley ).

Patients with spinal cord lesions are exposed to vesico-sphincter dysfunctions which can aggravate the vital or functional prognosis. The pathophysiological characteristics of these neurogenic bladders explains the usefulness of surgical treatment. The objective of the Brindley technique is to improve both voiding and effective continence. Any patient with a stable supra-sacral spinal cord lesion (paraplegia, tetraplegia) with a reflex bladder (incontinence, vesico-sphincter dyssynergia resistant to medical treatment with the risk of upper urinary tract involvement) can benefit from the Brindley technique. The electrodes are placed on the anterior sacral roots in order to obtain the desired micturation. Posterior sacral rhizotomies are indispensable to the technique as they suppress detrusor and sphincter hyperreflexia and improve continence thereby protecting the upper urinary tract. About 90% of the patients considered have an improved quality of life after implantation of the Brindley stimulator. The bladder capacity was constantly improved and the majority of the patients become continent. Micturation was excellent with low residual volume and low rate of urinary tract infections. Complications are analyzed in this review of the literature. The Brindley technique is an excellent alternative to medical treatment in these highly distressed patients. It restores satisfactory continence and improves psychological as well as economical constraints related to auto/hetero catheterisations performed several times a day.

Management program decreases postoperative nausea and vomiting in high-risk and in general surgical patients: a quality improvement cycle.

BACKGROUND: Preventing postoperative nausea and vomiting (PONV) is a major priority for postsurgical patient care. Our objective was to assess the efficacy of a multimodal postoperative nausea and vomiting (PONV) approach, which was associated with a continuous quality improvement program, in maintaining a low PONV incidence in the PACU. METHODS: Consecutive adult patients scheduled for surgery (ambulatory surgery or not) were prospectively included. PONV data were recorded in the PACU and over a 24-hour period. The management program was based on a multimodal approach with both changes in anesthetic techniques and anti-emetics, and on a three-stage protocol including: 1) phase I: institutional practice phase based on prospective observational study; 2) protocol implementation; 3) phase II: prospective observational study associated with feedback, scientific session and evaluation to guideline adherence. We used the Apfel risk scoring system to identify patients at high risk of PONV. Feedback with audit results and didactic sessions were scheduled quarterly in the Phase II. RESULTS: Thirty-seven/395 (9.4%) and 151/3864 (3.9%) patients experienced PONV in the PACU during Phase I and Phase II respectively (P<0.001). Among the patients with an Apfel risk score that included at least two risk factors, 16.6% and 4.2% experienced PONV in the PACU during Phase I and Phase II respectively (P<0.001). CONCLUSION: We highlight the association with a sharp decrease in PONV incidence over a one-year period and a multimodal PONV approach using feedback to clinicians associated with continuous quality improvement program.