[Use of a single-use fiberscope for the training in tracheal intubation under fiberscopy on labyrinth]. / Utilisation d'un fibroscope à usage unique pour la formation sur labyrinthe à l'intubation sous fibroscope.

GOAL OF THE STUDY: To evaluate a single-use fiberscope, the Ascope-Trainer, for the training in the intubation under fiberscope. TYPE OF STUDY: Prospective randomized study approved by the local ethic committee. METHODOLOGY: After evaluation of their level of expertise, "experienced" or "novices" in intubation under fiberscope, the doctors attending the Training for Referents in Difficult Airway Management performed a test on labyrinth with a standard fiberscope (T1). After they were assigned to two groups, training with the Ascope-Trainer (group A, n=35) or with a classic fiberscope (group C, n=29), they trained during 15 minutes and performed a new test (T2). An analysis of variance was used to compare means. A goal for the training was determined according to the "experienced" doctors' mean T1. A test of Khi(2) was used for the comparison of the number of participants having reached this goal as well as the progress in both groups A and C. RESULTS: The T1 in the "experienced" group was 76 ± 31 s and the training improved significantly T2 (53 ± 17 s). Considering the novices, T2 was significantly lower than T1 in the group A (77 ± 38 s versus 135 ± 68 s) as well as in C (64 ± 28 s versus 122 ± 60 s), and the proportion of the novices having reached the goal of training was comparable in both groups. CONCLUSIONS: Because its use is similar to the standard fiberscope, the Ascope-Trainer may be interesting for this type of training.

[Perioperative aspects of blood transfusion in paediatrics]. / Aspects périopératoires de la transfusion sanguine en pédiatrie.

In pediatric elective surgery, the main indications of blood transfusion are cardiac surgery, neurosurgery and abdominal tumors. Blood saving techniques are also available. The transfusion threshold has to take into account the physiological age-related particularities. Underestimation of blood loss and delayed transfusion are associated with a severe morbidity. In the absence of specific literature, the management of hemorrhagic shock is based on extrapolation of the adult recommendations.

[New training tools in haemovigilance]. / Nouveaux outils de formation en hémovigilance.

The transfusion of blood and blood products is a complex, multi-professional task which is liable to errors from donor to recipient. Simulation is a new training tool in medicine which may result with an improvement for safety and quality of care without any risk for the patient. Different simulators are available: haptic system and low fidelity mannequin for technical skills, software, full scale intermediate to high fidelity mannequin, actors and virtual reality. For haemovigilance training, actors and intermediate to high fidelity mannequins could be used to simulate complex professional situations with identity mistake and crisis management. The environment of full scale simulation is expensive and need technical and pedagogic skills.

[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.

Propofol versus sevoflurane for fiberoptic intubation under spontaneous breathing anesthesia in patients difficult to intubate.

BACKGROUND: The most recommended technique for the management of patients with a difficult airway is fiberoptic intubation (FOI). The aim of this study was to compare propofol and sevoflurane for FOI performance in patients who were difficult to intubate. METHODS: Seventy-eight patients scheduled for maxillo-facial surgery were included in this prospective, randomized study. The airway was topically anesthetized with lidocaine 5% before performance of FOI with propofol TCI (group P) or sevoflurane (group S). The following parameters were recorded: rate of success, duration of the induction and of the FOI, BIS and PETCO2 values. A visual analogic scale (VAS) was used to monitor the technical difficulties as well as the recall of patients and their satisfaction. The respiratory and hemodynamic complications were also evaluated. RESULTS: Induction and procedure duration were significantly shorter in group S compared with group P. The rate of successful FOI was not different: 38 cases (97%) in group P and 35 cases (90%) in group S. No significant differences were observed between groups regarding BIS values and VAS values for technical difficulties and for patient recall and satisfaction. The incidence of hypertension or tachycardia was significantly higher in group S compared with group P. The incidence of respiratory complications was not significantly different between the groups, but three patients experienced obstructive dyspnea with hypoxemia. CONCLUSION: Propofol and sevoflurane provide a high success rate for the performance of FOI in patients who are difficult to intubate.

[The LTD laryngeal tube: a new single-use airway device]. / Le tube laryngé à usage unique LTD: un nouveau dispositif supralaryngé.

OBJECTIVES: Clinical study of a new supraglottic single use airway device, the LTD with evaluation of insertion, efficiency during intermittent positive pressure ventilation and side effects. STUDY DESIGN: Prospective, open clinical study. PATIENTS AND METHODS: Fifty adult patients [33 years (26-55)] were scheduled for elective surgery (orthopaedic, plastic or maxillo-facial) under general anaesthesia less than two hours in dorsal position. No patient presented clinical sign of difficult airway management or risk of regurgitation. We studied easiness and delay for insertion, oro-pharyngeal leak pressure, peak airway pressure with positive pressure ventilation and side effects during the first 24 hours. RESULTS: Insertion was successful in 94%. Median insertion time was 38 s (32-45). Difficulties of insertions were found in 25%. Oro-pharyngeal leak pressure, always superior than peak pressure [18 cmH2O (15-21)] increased from 26 cmH2O (22-32.5) to 34 cmH2O (29-40) at the end of the surgery. No case of gastric inflation, regurgitation or SpO2<95% were noticed. Moderate sore throat incidence was 6% in recovery room, 15% at the sixth hour and absent at the 24th hour. CONCLUSION: The learning curve was low< or =10. Insertion is easy. The quality of airway protection allows secure positive pressure ventilation. Postoperative side effects are minor and transient.

[Should adjuvant treatments (antiplatelet agents, anticoagulants, normovolaemic haemodilution and vasodilators) be used in cervicofacial and maxillofacial free flaps reconstructive surgery?]. / Faut-il utiliser des traitements adjuvants (agents antiplaquettaires, anticoagulants, hémodilution normovolémique et vasodilatateurs) pour les lambeaux micro-anastomosés en chirurgie cervicofaciale et maxillofaciale?

The ENT and maxillo-facial reconstruction with free flaps has become a standard. The objective of the adjuvant treatments is to limit failures (approximately 6%) related to ischaemia/reperfusion. French surgical centres use specific protocols depending on the surgeon. They used antiplatelet agent, anticoagulants, normovolemic hamodilution and vasodilators. Many experimental studies are available. However, there is no clinical study to recommend the use of antiplatelet agents (combination with heparin increase the risk of pre- and postoperative bleeding), of normovolemic hemodilution (pulmonary oedema) and of vasodilators. After analysis of one of the only prospective study, we propose the use of heparin following a deep vein thrombosis preventive protocol. Due to the limited number of the patients and difficulty to have homogenous series, it is impossible to draw new recommendations, even if ischemic preconditioning techniques offer new research horizons.

[Postoperative antero-external tibial compartment syndrome: co-responsibility of the operating table]. / Syndrome postopératoire des loges tibiales antéro-externes: coresponsabilité de la table opératoire.

A 26-year-old, ASA1 patient underwent maxillofacial surgery under general anaesthesia, of 12-hour duration in the supine position. Postoperatively he developed rhabdomyolysis and acute renal failure. In the subsequent days, a bilateral leg compartment syndrome occurred with anterior tibial motor nerve injury requiring fasciotomies and excision of necrotic muscles. Several aetiological factors may have contributed to this accident: a long-lasting procedure, controlled hypotension and inappropriate position of the lower limbs. A laboratory study showed that the hardness of some new operating tables could be responsible for this complication. Some prophylactic measures are therefore required before the use of such devices.