Anatomical landmarks for maxillary nerve block in the pterygopalatine fossa: A radiological study.

INTRODUCTION: The aim of this study was to describe the anatomical landmarks for maxillary nerve block in the pterygopalatine fossa. The risk of injury to the skull base and maxillary artery was assessed. METHODS: This retrospective study was based on the analysis of 61 consecutive computed tomography angiographies obtained from patients suffering from different pathologies. Anatomical relationships between optic canal (OC), foramen rotundum (FR), inferior orbital fissure (IOF) and puncture point (PP) were assessed. A "maxillary section" was virtually carried out on the CTs, following a plane passing through PP, IOF and FR in order to mimic the anaesthesia needle route. RESULTS: No gender difference was observed except for the PP-OC distance that was longer in men. The mean PP-IOF distance was of 31.9 (± 0.7mm). PP-OC (43.9±0.5) and PP-FR (44.2±0.7) distances increased significantly with the patients height (PP-FR=17.25+0.16×height (cm); PP-OC=20.54+0.13×height (cm)). The route to the skull base was curved, with an angle of 168±1.6° at the FR level. The angle to reach the OC was greater than 7°. DISCUSSION: With a 35-mm needle length, the probability to reach the IOF was high (79%), while the risk to injure the skull base (2%) and the optical nerve (0%) was low. Artery injuries were only found in 13% of cases. Therefore, a 35-mm needle length allows for the best efficacy/risk ratio in maxillary nerve block.

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.

The I-gel, a single-use supraglottic airway device with a non-inflatable cuff and an esophageal vent: an observational study in children.

BACKGROUND: The I-gel is a new single-use supraglottic airway device with a non-inflatable cuff. It is composed of a thermoplastic elastomer and a soft gel-like cuff that adapts to the hypopharyngeal anatomy. Like the LMA-ProSeal, it has an airway tube and a gastric drain tube. Little is known about its efficiency in pediatric anesthesia. METHODS: Fifty children above 30 kg, ASA I-II, undergoing a short-duration surgery were included in this prospective, observational study. We evaluated ease in inserting the I-gel, seal pressure, gastric leak, complications during insertion and removal, ease in inserting the gastric tube and ventilatory parameters during positive pressure ventilation. RESULTS: All devices were inserted at the first attempt. The mean seal pressure was 25 cmH(2)O. There was no gastric inflation and gastric tube insertion was achieved in all cases. The results appear similar to those in a previous study concerning laryngeal mask airway in terms of leak pressure and complication rates. CONCLUSION: Because the I-gel has a very good insertion success rate and very few complications, it seems to be an efficient and safe device for pediatric airway management.