Difficult intubation and extubation in adult anaesthesia.

OBJECTIVE: To provide an update to French guidelines about "Difficult intubation and extubation in adult anaesthesia 2006". DESIGN: A consensus committee of 13 experts was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Few recommendations were ungraded. METHODS: The panel focused on 6 questions: 1) Why must oxygen desaturation be avoided during intubation and what preoxygenation and oxygenation techniques should be used to prevent it? 2) Should videolaryngoscopes be used instead of standard laryngoscopy with or without a long stylet to achieve a better success rate of intubation after the first attempt during anticipated difficult intubation off fiberoptic intubation? 3) Should TCI or target controlled inhalation anaesthesia (TCIA) be used instead of bolus sedation for airway control in the event of suspected or proven difficulty in a patient spontaneously breathing? 4) What mode of anaesthesia should be performed in patients with difficult intubation criteria and potentially difficult mask ventilation? 5) In surgical patients, what criteria predict difficulties encountered during postoperative tracheal extubation? 6) Should decision trees and algorithms be employed to direct decision-making for the management of difficult intubation, whether foreseen or not? (based on the information from the preceding five issues). Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE® methodology. RESULTS: The SFAR Guideline panel provided 13 statements on difficult intubation and extubation in adult anaesthesia. After two rounds of discussion and various amendments, a strong agreement was reached for 99% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), 8 have a low level of evidence (Grade 2±). No recommendation was provided for one question. CONCLUSIONS: Substantial agreement exists among experts regarding many strong recommendations for the best care of patients with difficult intubation and extubation in adult anaesthesia.

[Mastectomy in ambulatory hospitalization or 24hours: Feasibility, satisfaction and preferences of the patients]. / Mastectomie en hospitalisation ambulatoire ou de 24heures : faisabilité, satisfaction et préférences des patientes.

The aim of this study is to analyze the feasibility of ambulatory hospitalization or 24hours hospitalization for breast cancer treatment by mastectomy, as well as the satisfaction and the preferences of patients with regard to these ways of hospitalization. METHODS: This observational retrospective study listed the patients operated for breast cancer who had required a mastectomy at the institute Paoli-Calmettes between the 1st of January 2013 and June 30th, 2015. A questionnaire of satisfaction was proposed to the patients regarding their mode of hospitalization. RESULTS: One hundred and thirteen patients were included among which 29 were in the ambulatory group and 84 in the 24hours hospitalization group. The complications were represented by the rate of hematomas (3.5 %), which required a surgical resumption for two of the patients in the 24hours hospitalization group and for one patient in the ambulatory group (P=0.75). Patient's satisfaction rate was globally high: 72.7 % regardless of the mode of hospitalization (P=0.064). CONCLUSION: The realization of mastectomy in ambulatory hospitalization seems feasible when the organization in pre- and postoperative is anticipated with a high degree of satisfaction of the patients. The psychological impact of this radical surgery seems to be a factor to be taken into account and requires a meticulous selection of the patients.

[Nutritional assessment of patients before surgery]. / Évaluation nutritionnelle à la consultation d'anesthésie.

The identification of nutritional status is one of the objectives of the anaesthesia consultation often difficult to achieve routinely. It usually requires the use of multiple indicators, which are complex for a non-nutrition specialist. In preoperative period, nutritional assessment should be easy to do in order to identify patients who are malnourished or at risk of malnutrition and relevant information about nutritional risk should be registered in the patient chart. To facilitate this evaluation, we propose a stratification of nutritional risk in four grades (NG) using three types of simple and validated parameters: preoperative nutritional status (BMI, weight loss, eventually serum albumin), comorbidities and kind of surgery. This stratification can develop a tailored nutritional care for each patient.

[French clinical guidelines for prevention of perianaesthetic dental injuries: long text]. / Bris dentaires périanesthésiques: texte long.

INTRODUCTION: Dental injuries represent the most common claims against the anaesthesiologists. Dental lesions are frequent complications of orotracheal intubation and major causal factors are, firstly, preexisting poor dentition, and, secondly, difficult laryngoscopy and tracheal intubation. The aim of this work was to prioritize propositions for prevention in perianaesthetic dental injury and for care in case of dental trauma. METHOD: A GRADE consensus procedure consisting of three rounds was conducted. A purposively selected heterogeneous panel (n=15) of experts, comprising 10 practitioners in anesthesiology, one practitioner who is jurist and anaesthesiologist, two practitioners in maxillofacial surgery, and two practitioners in dentist surgery. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the board members. The guidelines represent the best current evidence based on literature search and professional opinion. RESULTS: The entire panel completed all three rounds and 31 plus six propositions were written for adult and paediatric clinical practice in anaesthesiology, respectively. The experts highlight the interest of preoperative visit for minimizing dental injuries: the practitioner must identify risk factors for difficult intubation and ventilation, describe precisely patient's preoperative dental condition, including upper incisor most commonly involved teeth in dental trauma. Patients have to be informed by practitioner for risk dental injury and anaesthesiology staff must choose his anesthesia protocol before the induction of intubation narcosis, avoiding insufficient anaesthesia and lack of experience by the anaesthesiologist. The choice of accurate proceeding during laryngoscopy, tracheal intubation and extubation for example, can aid in the prevention of dental injury, reduce the number of claims and the cost of litigation process. DISCUSSION: These guidelines delineate an approach for the prevention of perianaesthetic dental trauma and for the immediate or urgent care in case of perianaesthetic dental injury.

[Why should we inform the patients after difficult tracheal intubation?]. / Pourquoi une fiche d'information du patient après une intubation difficile?

Unanticipated difficult tracheal intubation may be challenging to anaesthesiologists. It is still associated with morbidity or mortality. Previous difficult intubation is vital information to organize appropriate airway management. Unfortunately, previous studies in the literature have shown that there is poor communication of this information. We propose in this article an airway alert form, following several criteria published in the literature. This is, in our opinion, an important step to improve the efficiency of guidelines on airway management and the overall quality of the anaesthesia process. Its efficacy to decrease morbidity related to difficult tracheal intubation remains to be demonstrated.

[Air embolism: an unusual complication of endoscopic retrograde cholangiopancreatography]. / Embolie gazeuse: une complication rare de la cholangiopancréatographie rétrograde endoscopique.

We report the case of a 60-year-old-woman with a myeloma who was hospitalized with a cholestasis. An endoscopic retrograde cholangiopancreatography was scheduled under general anaesthesia with oral intubation. As the biliary prothesis was placed an air embolism happened. The symptomatic treatment allowed a complete recovery. This complication is rare. The pathophysiology is not well known, we discuss the possible mechanisms.

New metabolic and pharmacokinetic characteristics of thiocolchicoside and its active metabolite in healthy humans.

Thiocolchicoside (TCC) has been prescribed for several years as a muscle relaxant drug, but its pharmacokinetic (PK) profile and metabolism still remain largely unknown. Therefore, we re-investigated its metabolism and PK, and we assessed the muscle relaxant properties of its metabolites. After oral administration of 8 mg (a therapeutic dose) of 14C-labelled TCC to healthy volunteers, we found no detectable TCC in plasma, urine or faeces. On the other hand, the aglycone derivative obtained after de-glycosylation of TCC (M2) was observed and, in addition, we identified, as the major circulating metabolic entity, 3-O-glucuronidated aglycone (M1) obtained after glucuro-conjugation of M2. One hour after oral administration, M1 plus M2 accounted for more than 75% of the circulating total radioactivity. The pharmacological activity of these metabolites was assessed using a rat model, the muscle relaxant activity of M1 was similar to that of TCC whereas M2 was devoid of any activity. Subsequently, to investigate the PK profile of TCC in human PK studies, we developed and validated a specific bioanalytical method that combines liquid chromatography and ultraviolet detection to assay both active entities. After oral administration, TCC was not quantifiable with an lower limit of quantification set at 1 ng/mL, whereas its active metabolite M1 was detected. M1 appeared rapidly in plasma (tmax=1 h) and was eliminated with an apparent terminal half-life of 7.3 h. In contrast, after intramuscular administration both active entities (TCC and M1) were present; TCC was rapidly absorbed (tmax=0.4 h) and eliminated with an apparent terminal half-life of 1.5 h. M1 concentration peaked at 5 h and this metabolite was eliminated with an apparent terminal half-life of 8.6 h. As TCC and M1 present an equipotent pharmacological activity, the relative oral pharmacological bioavailability of TCC vs. intramuscular administration was calculated and represented 25%. Therefore, to correctly investigate the PK and bioequivalence of TCC, the biological samples obtained must be assayed with a bioanalytical method able to specifically analyse TCC and its active metabolite M1.

[Airway equipment and its maintenance for a non difficult adult airway management (endotracheal intubation and its alternative: face mask, laryngeal mask airway, laryngeal tube)]. / De quel matériel doit-on disposer pour la prise en charge des voies aériennes et quelles sont les alternatives à la sonde d'intubation (masque facial, masque laryngé et tube laryngé)? Quelle maintenance pour ce matériel?

The airway equipment for a non difficult adult airway management are described: endotracheal tubes with a specific discussion on how to inflate the balloon, laryngoscopes and blades, stylets and intubation guides, oral airways, face masks, laryngeal mask airways and laryngeal tubes. Cleaning and disinfections with the maintenance are also discussed for each type of airway management.

SL651498: an anxioselective compound with functional selectivity for alpha2- and alpha3-containing gamma-aminobutyric acid(A) (GABA(A)) receptors.

SL651498 [6-fluoro-9-methyl-2-phenyl-4-(pyrrolidin-1-yl-carbonyl)-2,9-dihydro-1H-pyrido[3,4-b]indol-1-one] is a novel pyridoindole derivative that displays high affinity for rat native GABA(A) receptors containing alpha(1) (K(i) = 6.8 nM) and alpha2 (K(i) = 12.3 nM) subunits, and weaker affinity for alpha5-containing GABA(A) receptors (K(i) = 117 nM). Studies on recombinant rat GABA(A) receptors confirm these data (K(i), alpha1beta2gamma2 = 17, alpha2beta2gamma2 = 73, alpha5beta3gamma2 = 215 nM) and indicate intermediate affinity for the alpha3beta2gamma2 subtype (K(i) = 80 nM). SL651498 behaves as a full agonist at recombinant rat GABA(A) receptors containing alpha2 and alpha3 subunits and as a partial agonist at recombinant GABA(A) receptors expressing alpha1 and alpha5 subunits. SL651498 elicited anxiolytic-like activity similar to that of diazepam [minimal effective dose (MED): 1-10 mg/kg, i.p.] in three conflict models, in the elevated plus-maze, the light/dark test, and the defense test battery in rats and mice. Results from activity tests and electroencephalogram analysis indicated that SL651498 induced muscle weakness, ataxia, or sedation at doses much higher than those producing anxiolytic-like activity (MED > or = 30 mg/kg, i.p.). Repeated treatment for 10 days with SL651498 (30 mg/kg, i.p., b.i.d.) in mice was not associated with the development of tolerance to its anticonvulsant effects or physical dependence. Furthermore, SL651498 was much less active than diazepam in potentiating the depressant effects of ethanol in mice. The "anxioselective" profile of SL651498 points to a major role for GABA(A) alpha2 subtype in regulating anxiety and suggests that selectively targeting GABA(A) receptor subtypes can lead to drugs with increased clinical specificity.

[Management of pain in pancreatic cancer]. / Prise en charge de la douleur du cancer du pancréas.

Pain remains an indicator of progression of cancer of the pancreas. Regular pain evaluation combined with early analgesic treatment improves the duration and quality of life. New modes of morphine administration and specific chemotherapy can improve this management. Neurolysis is more effective in the case of recent pain, previously controlled by anti-inflammatory drugs. The endoscopic ultrasound (EUS)-guided technique allows celiac block during EUS examination for local staging. Early introduction of palliative surgery and analgesic procedures can reduce the morbidity and mortality of these procedures. A graduated multidisciplinary pain management program allows optimal pain control.

[Proprioceptive and cutaneous evoked somatosensory potentials in the baboon: cycles of GABAergic excitability and inhibition]. / Potentiels évoqués somesthésiques proprioceptifs et cutanés chez le babouin: cycles d'excitabilité et inhibitions GABAergiques.

Double stimulations induce deep and long-lasting inhibition (0-300 ms) of the P16-N30 components of somatosensory potentials (SEP) evoked by sciatic or sural nerve stimulation. This inhibition is evidenced on both S1 and M1 cortical areas, demonstrating similar course and duration, whatever the source (right or left limb) and/or the modality (extero- or proprioceptive) of conditioning and testing afferences. The depth of this inhibition depends on the relative amplitude of the conditioning to testing SEP. After muscle injection of a subconvulsive dose of bicuculline, tSEPs are facilitated when individually elicited. When double stimulations are used, the inhibition of the SEP test is sharply reduced (with a 30-ms interstimulus delay). However, disinhibition of the conditioned SEP does not depend on separate individual SEP facilitations. Cortical GABAergic type a circuits are likely to be involved in inhibition of the conditioned SEP. This inhibition would be a non-invasive image of inhibitions that preserve the specificities of sensory messages in primary areas.

Ultrasound contrast agent in intravascular echography: an in vitro study.

The intravascular ultrasound image of the intraluminal contour depends on the difference between acoustic impedances of the media which create the endoluminal interface. There are several limitations to the visualization and detection of this interface. These limitations are due to artifacts encountered during image formation and to anatomical complexity. The purpose of this study is to obtain intraluminal contour enhancement using ultrasound contrast agent (UCA). Therefore, our objective was to address the feasibility of this technique by documenting the following: (i) the acoustic properties of UCA at 30 MHz; (ii) in vitro experimentation with tube or postnecrotic artery; and (iii) suitable digital processing. The images obtained with UCA (enhanced image quality) and subtracted from those without UCA provided, after simple digital processing, accurate visualization of the arterial lumen. The image obtained exhibits an even, high-contrast intraluminal edge. Such characteristics facilitate contour extraction by the automated contour detection procedures.

[Evoked somatosensory potentials in the baboon: intracortical localization and nature studies using pharmacology and analysis of sources of current]. / Potentiels évoqués somesthésiques chez le babouin: localisation intracorticale et nature étudiées par pharmacologie et analyse des puits et sources de courants.

SEPs were elicited by stimulation of the sciatic (proprioceptive) or sural (exteroceptive) nerves. SEPs were recorded through epidural chronic electrodes implanted in the related S1 cortical surface. They were studied after systemic or local cortical administration of subconvulsive doses of bicuculline (a specific GABAa antagonist). A powerful increase in the amplitude of the P16 component, along with an inhibition of the N30 component were observed. From a cortical Current Source Densities analysis, the P16 facilitation was shown to result from blockade of the GABAa inhibitory synapses on the somas of pyramidal cells that are responsible for the P16 wave. Reduction of the N30 wave was attributed to a bicuculline-induced reduction of an axo-dendritic depolarisation of the apical dendrites belonging to pyramidal cells. A neurophysiological model of the SEP primary waves elicited by the thalamocortical proprioceptive or cutaneous inputs is suggested.

[Somatosensory evoked potentials: morphology and interareal S1-M1 relationships in the baboon (Papio papio)]. / Potentiels évoqués somesthésiques: morphologie et relations interaréales SI-MI chez le singe (Papio papio).

Primary somatosensory potentials (SEPs) were elicited by electrical stimulation of the medial sciatic (proprioceptive) or sural (cutaneous) nerves. They were detected by contacts on SI and MI dura on both cortical sides against a cephalic reference. SEPs were averaged (n = 20). Primary SI SEP consisted of positive, then negative, PI6/N30 waves. N30 was absent from MI records. Local electrocoagulation of the SI cortex on one side has entailed some reduction, but not suppression of together the homolateral MI and contralateral SI and MI SEP. The residual SEPs have increased in latencies by a few milliseconds. Additional coagulation of the MI area on the same side has resulted in loss of the SI and MI SEP on the opposite hemisphere when evoked by a stimulation ipsilateral to this intact cortex. Normal SEPs were elicited from the intact cortex by any of the used stimulation. No evoked signal could be evidence from the lesioned areas. It was concluded that negligible passive electrical diffusion from any SEP area was present onto any of the other SEP reception sites. From close comparison between the different records, we came to the following propositions: each of the SI and MI areas harbours a neural mass generator for SEPs elicited by contralateral nerve stimulation. SI and MI SEPs cannot be directly elicited by ipsilateral stimulus. SI and MI SEP ipsilateral to the nerve stimulation are due to some cortico-cortical trans-sagittal excitatory message arising from the contralateral SI/MI areas. Data stand for exteroceptive or proprioceptive stimulation as well. The absence of ipsilateral direct spino-cortical projection for SEP evidenced under barbiturate does also exist in the baboon after total recovery of surgery. A scheme is given which summarizes these active relationships between somesthetic areas.

Differential effects of midazolam and zolpidem on sleep-wake states and epileptic activity in WAG/Rij rats.

Hypnotic drugs are known to possess antiepileptic activity. Therefore, the effects of the benzodiazepine hypnotic midazolam (10 mg/kg) and the novel imidazopyridine hypnotic zolpidem (10 mg/kg) on sleep-wake states and on the number of spike-wave discharges were evaluated in WAG/Rij rats. Rats of this strain are considered to be a model for generalized absence epilepsy. Animals were implanted with chronic monopolar EEG electrodes and, after recovery from surgery, the EEG was recorded for 6 h during the dark period on 3 consecutive days. Sleep recordings were analyzed using Hjorth's parameters and number and duration of spike-wave discharges were visually determined. It was found that both drugs facilitated nonREM sleep at the cost of wakefulness. Both hypnotics also reduced the number and duration of spike-wave discharges. The initial decrease after midazolam, however, was followed by a rebound reflecting a poorer quality of vigilance expressed as an increase in spike-wave discharges. The strong antiabsence activity of zolpidem mimics that of midazolam and is well correlated with their equipotent hypnotic action and anticonvulsant effect in the isoniazid test.