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.

[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.

Evaluation of the stability and quality of sleep using Hjorth's descriptors.

Hjorth's descriptors (NSD) (activity, mobility, and complexity) provide a useful tool for evaluating micro- and macrostructural elements of sleep. In rats, the automatic analysis of sleep recordings by means of NSD calculated from SM and Vis derivations allow different sleep stages to be discriminated. Activity distribution over the total recording permits the definition of a global effect on the EEG. Moreover, the quality of sleep can be evaluated by the variations of the SM activity distribution by considering different classes of amplitude. Index and rate of unstable amplitude segments (UAS) constitute useful parameters to analyse the stability and quality of sleep with different models of insomnia and after pharmacological treatment. The UAS in rats can be compared to CAPs in humans. The NSD are also able to define quality and stability of human sleep. EEG analysis using NSD provides a novel perspective for the analysis of the stability and quality of rat and human sleep. This microstructural analysis of sleep appears to be a useful tool for pharmaco-EEG studies.

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.

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.

[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.

[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.

[Spinal reflexes and somatosensory evoked potentials studied in the baboon in the presence of anti-arrhythmic drugs]. / Réflexes spinaux et potentiels évoqués somesthésiques étudiés chez le babouin en présence de drogues anti-arythmiques.

Intragastric administration of the anti-arrhythmic drugs CM 7857 (Sanofi) or disopyramide, as expected, significantly reduced the heart rate in normal baboons at rest. At the same time, the variability in the heart rate increased. In vitro studies by Sanofi have previously shown the anti-arrhythmic effects of these drugs, i.e., a slowing of the transmembrane currents evidenced in several categories of heart cells especially when activated. Similar ion currents are known to be involved in extracardiac sensory-motor activities. However the H-reflex in soleus underwent no systematic changes in latency or amplitude with the drugs; the non-nociceptive early and nociceptive late polysynaptic responses elicited in the tibialis anterior muscle by sural nerve stimulation demonstrated a barely perceptible increase in integrated EMG value. No change could be seen in latency or amplitude of the cortical potentials evoked by sciatic or sural stimulation which was also used for reflex responses. Overall there was no definitive evidence of change in the extra-cardiac sensory-motor responses in the normal awake monkey, after administration of relatively high doses of the cardio-active compounds.

[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.

[Animal modeling and experimental pharmacology of human spasticity]. / Modélisation animale et pharmacologie expérimentale de la spasticité humaine.

The first part of the paper exposes the basic characteristics of the human spasticity which should be modeled: No hypertonia at rest; velocity-dependent myotatic responses, and fatigability. To model a syndrome including these signs is a related but different problem. Results and limits of the clinical neurophysiology concerning the spasticity are briefly quoted. Animal models would better assist the human neurophysiology when having their neuroanatomy closer to the human one. The second part confirms that a local unilateral excision of the ad hoc sensorimotor cerebral cortice of the Baboon induces a permanent palsy of the contralateral foot and leg, and after delay signs of spasticity in the Sol. Neither clasp-knife phenomenon nor fatigability is observed. There is no sign of motoneuron hyper-excitability. A GABA-related pharmacology suggests a significant defect in the presynaptic inhibition of the reflexogenic IA in-put, and possibly a defect in a post-synaptique gabaergic inhibition. Finally the monkey is considered as a valuable support for modeling the human spasticity, symptom and possibly syndrome.

[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.

[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.

[Recovery after anesthesia with propofol in otorhinolaryngologic surgery of brief duration]. / Le réveil après anesthésie au propofol pour chirurgie ORL de courte durée.

This study was designed to assess recovery from total intravenous anaesthesia with propofol for short ENT procedures. Twenty-six patients (ASA I and II) were assigned to two groups of thirteen: one breathed air (Laser laryngeal microsurgery), the second N2O-O2 (FIO2 : 0.5) (various ENT procedures). The induction sequence was exactly the same for both groups: oral premedication with 10 mg diazepam one hour before surgery, I mg pancuronium bromide, 2 micrograms X kg-1 fentanyl, denitrogenation within 3 min, after which propofol was delivered (2.5 mg X kg-1). When the eye-lash reflex had disappeared (time recorded), 1.5 mg X kg-1 suxamethonium was given and laryngotracheal intubation carried out. A continuous infusion of propofol (9 mg X kg-1 X h-1) was started. Surgery began 5 +/- 2 min after the start of propofol infusion. The durations of anaesthesia, surgery and propofol infusion were similar in both groups. To have good surgical conditions, it was necessary to give repeated doses of propofol for 15 patients. Thus, the total dose of propofol was significatively different between the two groups: 24.5 +/- 6.7 mg X kg-1 X h-1 in group "air" versus 16 +/- 3.6 mg X kg-1 X h-1 in group "N2O-O2" (p less than 0.001). Extubation occurred within 16 +/- 8 min in group "air", being more rapid in group "N2O-O2" (11 +/- 9 min; no significant difference). Recovery was assessed with two psychomotor tests: choice reaction time (CRT) and tracing test (TT).(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of an additional dose of propofol on intraocular pressure in patients over 60 years of age]. / Effets d'une dose additionnelle de propofol sur la pression intraoculaire chez les sujets de plus de 60 ans.

Changes in intraocular pressure (IOP) and mean arterial pressure (MAP) were studied in fifty patients, ASA 1 or 2, aged more than 60 years and scheduled for surgery of the anterior chamber of the eye. The exclusion criteria were: arterial hypertension, raised IOP, obesity, renal or hepatic disease, treatment likely to alter IOP, and a possibly difficult intubation. The patients were randomly assigned to groups P1 (n = 25) and P2 (n = 25). All were given lorazepam 1 mg orally 90 min before induction, which was carried out with propofol 1.5 mg.kg-1 and vecuronium 0.1 mg.kg-1. Patients in group P1 were intubated as soon as the train-of-four response (TOF) had been abolished. Those in group P2 were given an additional 0.7 mg.kg-1 dose of propofol before intubation. MAP, heart rate and IOP were measured before and after induction, and 1, 2 and 3 min after intubation. IOP decreased after induction, and remained below the baseline values at all times in both groups. MAP had a similar course in both groups up to 1 min after intubation: a decrease after induction followed by an increase after intubation. In group P1, MAP remained above control values 2 and 3 min after intubation, whereas in P2 it remained below. From this study, it can be concluded that using an additional dose of propofol in elderly patients was not useful for avoiding the rise in IOP due to endotracheal intubation. This was all the more so as the haemodynamic effects of such a dose of propofol could have deleterious effects in these patients.

[Failure of gastric lavage in severe drug poisoning. Value of esophagogastric fibroscopy]. / Echec du lavage gastrique dans une intoxication médicamenteuse grave. Intérêt de la fibroscopie oeso-gastrique.

A case is reported of massive drug self-poisoning (more than 200 pills associated with slices of oranges) in which repeated gastric lavage failed to empty the stomach. An attempt to split up the amalgamated pills, adherent to the gastric mucosa, by fibre-optic gastroscopy failed and a gastrotomy was required. Endoscopy together with gastric lavage is indicated in certain situations to quickly empty the stomach and so shorten the course of the poisoning. Indications are the large number of pills swallowed, a poor result of the treatment, a worsening of the clinical condition despite treatment, and three positive gastric toxicological assays within the first 24 h.

[Training evaluation of the nursing staff in patient-controlled analgesia]. / Evaluation d'un enseignement de l'auto-analgésie au personnel infirmier.

Intravenous patient-controlled analgesia (PCA) is an effective technique to relieve most forms of acute postoperative pain. However it is not easy to apply. An adequate training of the nursing staff has been for a safe and successful use in the recovery room and the wards as well. Our study was aimed to assess such a training. The most common errors during training period included the incorrect preparation of syringes and the inadequate use of i.v. lines. Errors in programming were spontaneously rectified by using a special procedure. Specific acute pain nurse teams were trained. To optimize the pump use and promote safety and efficacy, special protocols and procedures were devised. PCA is now accepted as a normal nurse procedure. There is no longer any resistance against the introduction of PCA in the wards. Training of nursing staff for the use of PCA devices is essential in order to avoid "human errors". PCA has become routine for the management of postoperative pain.

[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.