Etomidate versus propofol for electroconvulsive therapy: An intraindividual comparative study during the COVID-19 pandemic.

OBJECTIVES: The Coronavirus disease 2019 (COVID-19) pandemic markedly influenced mental health care practices, notably regarding electroconvulsive therapy (ECT). This was due to the redistribution of anesthetic agents used during ECT such as propofol, for intensive care units. Because in our center propofol was switched to etomidate to avoid ECT activity discontinuation, we undertook this study in order to compare Propofol and Etomidate regarding electroencephalographic seizure duration and stimulus intensity. METHODS: We performed a retrospective and comparative study, each patient being its own control. We included patients with at least two courses of ECT on propofol and two others with etomidate over the period from September 2019 to April 2021, regardless of the psychiatric diagnosis. Our data collection process notably targeted stimulus intensity, seizure duration recorded using electroencephalography, and medication used for anesthetic induction. RESULTS: Overall, we included 18 patients with a male: female ratio of 1:2.6 and a mean (and standard deviation) age of 62.7±13.4 years. We found that the mean intensity of stimulation was significantly lower with etomidate when compared to propofol (425.3±250.0 vs. 658.9±280.2 mC, P=0.001). The mean duration of electroencephalographic seizure was significantly higher with etomidate in comparison to propofol (53.5±16.6 vs. 35.0±12.2seconds, P<0.001). CONCLUSION: By using each patient as its own control, our study found that etomidate, while compared to propofol, was related to a lower level of stimulatory intensity and a longer electroencephalographic seizure duration.

Cosmetic male genital surgery: a narrative review.

Background and Objective: Through the centuries the appearance of the male genitalia has always been an important concern for men, symbolizing virility, potency and sexual contentment. Correction of perceived deficiencies and deformities of the male genitalia can be addressed by aesthetic surgery as well as the enhancement its external aspect. If the social acceptance of cosmetic surgery, particularly of women's breasts, dates from the early 1950s, male intimate cosmetic surgery emerged from the shadows about 10 years ago with a medical community still very suspicious and reproachful. The present paper aims to describe and discuss the current state of the art regarding male intimate cosmetic surgery. Methods: A narrative review of the literature was performed using publications from January 2000 to September 2022. The publications were retrieved from the PubMed database using Medical Subject Headings (MeSH) terms and keywords. The authors' goal is to narrate the aesthetic non-surgical and surgical enhancement procedures of the male apparatus. Key Content and Findings: This narrative review examines the diverse procedures associated with male genitalia aesthetics. Conclusions: Aesthetics of the male genitalia is now an unavoidable and important part of aesthetic surgery worldwide with an increasing demand. Nonsurgical and surgical techniques described in the literature should be reviewed.

Ultrasound guidance allows faster peripheral IV cannulation in children under 3 years of age with difficult venous access: a prospective randomized study.

OBJECTIVES: Ultrasound-guided peripheral venous access (USG-PIVA) presents many advantages over the reference 'blind' technique in both adults and children in emergency situations. AIM: To compare USG-PIVA with the blind technique in children <3 years undergoing general anesthesia. METHODS: After obtaining the approval of the ethics committee and informed consent from the parents, we included all children <3 years scheduled to undergo general anesthesia [surgery, magnetic resonance imaging (MRI)], who presented difficult venous access. The children were randomized into two groups: the US group (USG-PIVA) and the B group (blind). The primary endpoint was time to cannulation (from tourniquet placement to successful IV cannulation), compared between USG-PIVA group and B group by intention-to-treat analysis. Secondary outcomes were success rate at the first puncture, number of punctures, and diameter of the catheters. Cannulations requiring >15 min were considered as failures. In case of failure in group B, USG-PIVA was attempted for a further 15 min. RESULTS: Twenty children were included in each group. Groups were comparable for sex, age, and BMI. Significant differences were observed in median time to cannulation (63.5 s vs 420.5 s, USG-PIVA vs B respectively, P < 0.001); median number of punctures (1 vs 2.5, USG-PIVA vs B, P = 0.004); and success rate at first cannulation (85% vs 35%, USG-PIVA vs B, P = 0.0012). In contrast, overall success rate did not differ significantly between groups (90% vs 85%, USG-PIVA vs B, P = 0.63). CONCLUSIONS: Ultrasound-guided peripheral venous access leads to faster peripheral IV access and should therefore be recommended in children presenting with difficult venous access.

Is Thiel's embalming method widely known? A world survey about its use.

INTRODUCTION: Thiel's embalming technique, first described by Thiel in 1992, conserves texture and colour in cadavers close to that observed in the living. It would appear that few anatomy laboratories use this method, and literature describing its use worldwide is sparse. The aim of our study was to conduct a worldwide survey on the use of this method. METHODS: A questionnaire was sent out by mail to 311 anatomy laboratories or institutes across the five continents. There were six multiple choice questions to assess the level of awareness of Thiel's method, the frequency of its use among respondent institutions, the most frequently used solutions for conservation of cadavers and perceived obstacles to the use of Thiel's technique. RESULTS: 109/311 (35%) centres replied to the questionnaire; 56% of centres had previously heard of Thiel's technique, but only 11 centres (10% of respondents) used it regularly, and all of these were in Europe. Formalin remains the most widely used conservation solution around the world. CONCLUSIONS: Thiel's embalming technique is not widely known, and therefore, little used. The main obstacle to its wider use is likely the language barrier, since most of the publications describing Thiel's method are in German, which is not widely spoken outside of a few European countries.

Flexibility of Thiel's embalmed cadavers: the explanation is probably in the muscles.

INTRODUCTION: The flexibility of cadavers conserved using Thiel's embalming method remains unexplained. We aimed to perform microscopic comparison of muscle and tendon fibres from fresh cadavers (FC), formaldehyde-preserved cadavers (FPC) and cadavers conserved by Thiel's method (TC). METHODS: Muscle and tendon biopsies performed on FC, FPC and TC were conditioned and stained by Masson's trichrome, Sirius red and Ramon y Cajal, then studied under optical microscope. Alignment and integrity of the muscle and tendon fibres were studied. RESULTS: We observed a modification of the muscle fibres in all specimens from TC, regardless of the type of staining used. The muscle fibres taken from FC and FPC were relatively well conserved, both in terms of alignment and integrity. We did not observe any modification of collagen in either muscle or tendon fibres. CONCLUSIONS: The considerable fragmentation of the muscle proteins, probably caused by certain corrosive chemicals, (e.g. boric acid) present in Thiel's embalming solution, could explain the suppleness of the TC. However, we cannot exclude the possibility of alterations in tendon or muscle collagen, since the experimental methods we used, did not allow for the study of collagen ultrastructure.

Spatial relationships between lingual nerve and mandibular ramus: original study method, clinical and educational applications.

Lingual nerve damage complicating oral surgery would sometimes require electrographic exploration. Nevertheless, direct recording of conduction in lingual nerve requires its puncture at the foramen ovale. This method is too dangerous to be practiced routinely in these diagnostic indications. The aim of our study was to assess spatial relationships between lingual nerve and mandibular ramus in the infratemporal fossa using an original technique. Therefore, ten lingual nerves were dissected on five fresh cadavers. All the nerves were catheterized with a 3/0 wire. After meticulous repositioning of the nerve and medial pterygoid muscle reinsertion, CT-scan examinations were performed with planar acquisitions and three-dimensional reconstructions. Localization of lingual nerve in the infratemporal fossa was assessed successively at the level of the sigmoid notch of the mandible, lingula and third molar. At the level of the lingula, lingual nerve was far from the maxillary vessels; mean distance between the nerve and the anterior border of the ramus was 19.6 mm. The posteriorly opened angle between the medial side of the ramus and the line joining the lingual nerve and the anterior border of the ramus measured 17 degrees . According to these findings, we suggest that the lingual nerve might be reached through the intra-oral puncture at the intermaxillary commissure; therefore, we modify the inferior alveolar nerve block technique to propose a safe and reproducible protocol likely to be performed routinely as electrographic exploration of the lingual nerve. What is more, this original study protocol provided interesting educational materials and could be developed for the conception of realistic 3D virtual anatomy supports.

Comparison of fresh and Thiel's embalmed cadavers according to the suitability for ultrasound-guided regional anesthesia of the cervical region.

INTRODUCTION: Ultrasound-guided punctures are a new technique in anesthesia. However, training in these techniques requires conditions resembling real life as far as possible for learning purposes. Several models are available, but none associates realistic anatomy and lifelike sensations of the passage of fascias. The aim of our study was to compare fresh and Thiel's embalmed cadavers for ultrasound-guided punctures. METHODS: Eight fresh cadavers and eight Thiel's embalmed cadavers were investigated. The cervical region was scanned with an ultrasound probe. Age, sex and body mass index (BMI) were recorded. Visibility of he structures, including sternocleidomastoid (SCM) muscle, anterior and middle scalene muscles, thyroid gland, nerve and the needle, was evaluated as 0 (not visible or bad visibility) or 1 (good visibility). The feeling ("pop") of passing the fascias was noted as 0 (not felt) or 1 (felt). The possibility of nerve displacement with the needle, the difficulty of intraneural injection and the possibility of nerve penetration and nerve swelling were all recorded as 0 (not possible) or 1 (possible). RESULTS: The two groups were comparable in terms of sex, age and BMI. Visibility of the SCM muscle and the needle was better in the Thiel group. Moreover, the "pop" feeling and nerve swelling were significantly more frequently present in the Thiel group. There was no significant difference in terms of the other results between the two groups. CONCLUSIONS: Cadavers embalmed according to Thiel's method should be recommended for ultrasound-guided punctures as a realistic and lifelike model.

Cricoid cartilage and esophagus: CT scan study of the dynamic variability of their relative positions.

INTRODUCTION: Cricoid pressure occludes the esophagus (E) by compressing it between the cricoid cartilage (CC) and the body of the sixth cervical vertebra (C6). This technique is used to prevent passive regurgitation during the induction of anesthesia in patients at high risk for regurgitation. Failures of this technique had been described and a possible displacement of the E relative to the CC had been reported, but there is no study about displacement during antero-posterior movements of the head. AIM: The aim of our study was to evaluate the displacement of the CC relative to the cervical E, during flexion and extension movements of the head. MATERIALS AND METHODS: We retrospectively studied X-ray computed tomography (CT) images of 21 patients with suspected cervical trauma. Patients were in the supine position. In the first series of images, the head was positioned at maximal flexion by means of a support placed under the external occipital protuberance. In the second series of images, the head was maintained in extension by means of a support placed under the shoulders. Each position was obtained as far as possible within the limits of pain and restricted movement. In flexion and extension, we used the lowest slice from the cricoid cartilage. The variables measured were: diameters of CC (CD) and E (OD), left and right lateral displacements of E. RESULTS: A total of 13 CT were analyzed. CD and OD as well as OD/OC ratios did not vary significantly in flexion and extension. We noticed 61.5 and 92.3% (respectively in flexion and in extension) of left or right displacement: 23% of patients presented right displacement in both flexion and extension; 38.5% of patients did not present any right displacement in flexion or in extension; 61.5% of patients presented left displacement in both flexion and extension. More generally, almost 92% of patients presented displacement either in flexion or extension, or both. DISCUSSION: In our study, it can be seen that the E is clearly displaced with regard to the CC, that this displacement is favored by extension. Only 2/13 patients have an "over than 3 mm" displacement in extension whereas 5/13 in flexion. So, even if there are more displacements in extension, they are inferior to 3 mm and may not be considered as significant considering the occlusion of E. According to our results, the extension position of the head produces more displacement of the E but should preserve the containment of the cricoid pressure if we consider the thickness of the E wall.

A comparison of two emergency cricothyroidotomy kits in human cadavers.

BACKGROUND: We compared two emergency cricothyroidotomy kits designed to avoid lesions during insertion, one based on the Seldinger technique (ST), the other based on the concept of a mechanical detection of the posterior wall of the larynx, with regard to insertion time, success rate, and complication rate. METHODS: Cricothyroidotomy was performed under fiberoptic control in 40 human cadavers embalmed according to Thiel's technique. The set chosen for use was randomized: new technique (NT) or ST. Duration of the procedure, success rates, and incidence of laryngeal injuries were compared. Traumatic lesions observed with the fiberoptic bronchoscope were anatomically confirmed after dissection. RESULTS: The two groups had comparable epidemiological and anatomical records. Cricothyroidotomy was performed faster with the NT than with the ST (median 54 vs 71 s, P = 0.01). Failure rates were comparable between groups (4 vs 1, P = 0.34), and there were fewer major complications in the posterior tracheal wall with the ST (0 vs 8, P = 0.003). In the ST group, only minor punctiform lesions of the posterior trachea wall were observed in four cases. CONCLUSIONS: In this model, despite a shorter insertion time, the NT produced more lesions and more failures than the ST.

Non-dominant hand quicker to insert peripheral venous catheters under echographic guidance: A randomised trial.

BACKGROUND: Ultrasound guidance for venous catheter placement requires the use of both hands. An accurate and stable ultrasound image is fundamental for obtaining good quality images, consequently permitting accurate needle placement. We hypothesized that the dominant hand could be used to perform echography, leaving the non-dominant hand available for peripheral venous catheter (PVC) insertion. METHODS: Prospective, open-label, randomized, crossover study. Group 1 inserted the PVC with the dominant hand, and held the probe with the non-dominant hand in a first series of 20 insertions, and vice versa in a second series of 20 insertions performed 11days later. Group 2 punctured with the non-dominant hand in Series 1 and vice versa in series 2. The study population comprised female student nurses (aged 20-30years) who had learned neither ultrasound techniques nor catheter insertion. The primary endpoint was time to successful puncture. We recorded age, sex, video game use, and the laterality of hands, feet and eyes. RESULTS: One left-handed and nine right-handed nurses were randomized to each group. Puncture by the non-dominant hand was significantly quicker in both series (P<0.001). There was no difference between groups for time to successful puncture with the dominant hand; however a significant difference was found for the non-dominant hand (P<0.01). According to multivariate analysis, the time to successful puncture was significantly lower when the non-dominant hand was used to puncture (adjusted difference 5.6s, P<0.0001). CONCLUSION: Using the dominant hand to hold the ultrasound probe and the non-dominant hand to puncture and insert the catheter achieves successful insertion in a significantly shorter time.

Accuracy in obtaining 100 µg from 10 mg of morphine for spinal anesthesia.

STUDY OBJECTIVE: Dilution is often required to obtain appropriate concentrations of intrathecal morphine for analgesia. We compared techniques of diluting by measuring the quantity of morphine actually obtained in the final solution. DESIGN: This is an experimental study by 3 experienced anesthesiologists. SETTING: The setting is at a university teaching hospital. PATIENTS: There are no patients. INTERVENTIONS: There are no interventions. MEASUREMENTS: Five techniques for obtaining 100 µg from 10 mg/mL were compared: technique 1 (T1) = extraction up to 0.1 graduation on a 1-mL syringe, followed by simple dilution (SD). Technique 2 (T2) = As for T1 but syringe was shaken to mix solution. Technique 3 (T3): SD with 10-mL syringe. Technique 4 (T4): Double dilution with 10-mL syringe. Technique 5 (T5): Extraction up to the 0.1 graduation of a 1-mL syringe, then SD, then shake solution by hand. Three tests using high-performance liquid chromatography with ultraviolet were performed on each syringe prepared 3 consecutive times, namely, at the first (beginning, B), fifth (middle, M) and last (end, E) milliliter or 0.1 mL (depending on syringe type). MAIN RESULTS: Average overall concentrations were 208 ±19, 199 ±24, 120 ±13, 136 ±9, and 119 ±16 µg/0.1 mL, T1-T5, respectively. By Kruskal-Wallis test, we classified the techniques according to the magnitude of the difference between the observed concentration of morphine and the desired (theoretical) concentration of 100 µg/0.1 mL. In ascending order, techniques ranked as follows: T5 (smallest difference), T3, T4, T2, and T1 (greatest difference) (P = .0001). CONCLUSIONS: There is significant variability in the concentration of morphine actually contained in final solutions after dilution. Morphine presented in different premixed concentrations increases the risk of error. We advocate technique 5 as described above, whereas technique 1 should be prohibited.

A new anatomical technique to investigate nerves by imagery.

INTRODUCTION: We describe a novel post mortem technique that makes it possible to visualise the nerve structure of the brachial plexus using imaging. MATERIALS AND METHODS: We dissected in situ the brachial plexus of a cadaver preserved by formaldehyde. A preparation composed of a mixture of baryte powder, water and colorant, was applied to all sides of the brachial plexus and blood vessels of the region under study. A high resolution CT scan was performed. With the aid of Mimics (Materialise) software, segmentation of all the nerve and vascular structures on each of the 650 slices obtained was performed. The Mimics software then compiled all the slices to generate a 3-dimensional STL image. RESULTS: The image obtained was printed with a stereolythography printer, to produce a plastic model representing part of the cervico-thoracic spinal cord, the ribs, sternum, scapula, humerus, and clavicle, with the left brachial plexus and the subclavian, axillary and brachial veins and arteries. CONCLUSIONS: This technique has the potential for a wide range of uses: for teaching anatomy, to improve teaching of medical techniques, 3-dimensional modelisation of other nerve structures. The advantage is that the model obtained is a faithful and realistic reproduction.

Comparison of two techniques for retrograde tracheal intubation in human fresh cadavers.

BACKGROUND: During retrograde tracheal intubation, the short distance existing between the cricothyroid membrane and vocal cords may be responsible for accidental extubation. The insertion of a catheter into the trachea before the removal of the guide wire may help to cope with this problem. This work was conducted to study the impact of such a modification on the success rate and the duration of the procedure. METHODS: Procedures of retrograde tracheal intubation following the classic and modified techniques were randomly performed in cadavers (n = 70). The duration of the procedure from the puncture of the cricothyroid membrane to the inflation of the balloon of the endotracheal tube was measured, and, at the end of the procedure, the position of the endotracheal tube was checked under laryngoscopy. The procedure was considered to have failed if it had taken more than 5 min or when the endotracheal tube was not positioned in the trachea. RESULTS: The mean time to achieve tracheal intubation was similar in both groups (123 +/- 51 vs. 127 +/- 41 s; not significant), but intubation failed significantly more frequently with the classic technique (22 vs. 8 failures; P < 0.05). All failures were related to incorrect positioning of the endotracheal tube. In four cases, both techniques failed. CONCLUSIONS: This efficient, simple modification of the technique significantly increases the success rate of the procedure, without prolonging its duration. These data should be confirmed in clinical conditions but may encourage a larger use of the retrograde technique in cases of difficult intubation.