Anesthésie pour chirurgie de la main chez des patients atteints d'épidermolyse bulleuse

• Objective :To report on the anaesthetic management with axillary block of patients suffering from recessive dystrophic epidermolysis bullosa (RDEB), undergoing repetitive surgery of the hand.• Study design :Retrospective analysis of a case series.• Patients :Twenty-two patients, including 11 children less than 8-year-old and with a body weight under 20 kg, treated since 1988, were considered.• Methods :For surgery, including usually three stages at a 7-day interval, an axillary block was placed when feasible, after oral premedication midazolam (0.1–0.2 mg·kg⁻¹) with a 25 gauge needle in patients of less than 30 kg of body weight and 22 gauge beyond. The local anaesthetic mixture included 2% lidocaine (5–10 mg·kg⁻¹) and 0.5% bupivacaine (2–3 mg·kg⁻¹). A catheter for repetitive injections had not been inserted. For children less than 10-year-old a parent was present in the theater during all the course of operation.• Results :Between 1988 and 1995, 22 patients underwent 160 operative interventions on 54 hands. Regional anaesthesia was used in 142 cases, including 140 axillary and 2 interscalene blocks. General anaesthesia was only required in 20 cases, either alone or associated with regional anaesthesia. The success rate of axillary blocks was 98%.• Discussion :For surgery of the hand in patients with RDEB, we switched in 1988 from general anaesthesia with ketamine to axillary block, even in young children, as it is closer to the no-touch principle, which is essential to prevent from blistering. In comparison to general anaesthesia, regional anaesthesia raises neither the problems of airway and vascular access, nor those of instrumental monitoring. The main factors of success with regional anaesthesia are technical skills, expertise in the management of patients with RDEB and parental presence in the operating room which makes the procedure less stressful for children.     

Anesthésie-réanimation pour occlusion endovasculaire des anévrismes intracrâniens rompus par des spires électriquement détachables

The endovascular occlusion of ruptured intracranial aneurysms with electrically detachable coils is a therapeutic approach which seems to be a promising technique. General anaesthesia is considered as being the most adapted for its realisation, as it provides complete immobility and as controlled ventilation and extended monitoring offer optimal conditions for undelayed treatment of haemorrhagic and thromboembolic complications. The available equipment should be the same as that used for conventional surgical treatment of ruptured aneurysms. Anticoagulation is required to prevent thromboembolic complications during and after the procedure. Most teams administer heparin.     

Échocardiographie transœsophagienne pour le diagnostic des lésions traumatiques des grands vaisseaux intrathoraciques chez 150 patients: Influence de la courbe d'apprentissage

ObjectivesTo evaluate the role of transoesophageal echocardiography (TOE) in the management of patients with suspected traumatic lesions of the thoracic aorta (TLA) and its branches; to assess the influence of the learning curve on the diagnostic accuracy of TOE for the identification of TLA.Study designRetrospective study.PatientsThe study included 150 patients (age: 41 ± 17; Injury Severity Scale score: 31 ± 17) who were admitted during a 4-year period for severe blunt chest trauma and who underwent a TOE study.MethodsTOE were performed with either a monoplane (n = 54) or a multiplane probe (n = 96). In all cases, TLA were confirmed by angiography, computed tomography, surgery, or necropsy. Initially performed routinely, angiography was subsequently indicated when the TOE study was inconclusive or when a disruption of supraaortic arteries was suspected. Echocardiographic studies were reviewed by an experienced reader who was unaware of the medical history and initial conclusions. To evaluate the influence of the learning curve on the diagnostic accuracy of TOE, these conclusions were compared with the initial interpretations.ResultsA TLA was recognized in 25 patients out of 150 (17%), and evidenced using TOE in 22 of them. Three false negative and two false positive TOE results (needless thoracotomy) were recorded. After a learning period, the rate of inconclusive TOE studies decreased (18/150 vs 7/150: P < 0.05) and no false positive finding was recorded. The sensitivity and specificity of TOE for the diagnosis of TLA were 88 and 100%, and positive and negative predictive values were 100 and 97%, respectively.ConclusionsTOE is an accurate imaging technique for the diagnosis of TLA located at the aortic isthmus. However aortography becomes essential when injuries of the aorta branches are suspected. A learning period is required to improve the specificity of TOE for this indication.     

Quelle place pour la sphinctérotomie endoscopique dans le traitement des pancréatites aiguës?

Study aimA prospective study was undertaken in order to evaluate the effects of endoscopic sphincterotomy on the evolution of biliary and idiopathic acute pancreatitis.Patients and methodsAmong 320 patients with acute pancreatitis observed from 1986 to 1996, 118 were excluded from the study for etiologicial reasons and 137 were included for an endoscopic sphincterotomy within 72 hours from their admission. There were nine technical failures and 128 endoscopic sphincterotomies were performed. Sixty-five eligible patients were not included for logistic problems or patients' refusal; they can be considered as a “control group”.ResultsThe mortality rate of endoscopic sphincterotomy was 0 and the morbidity rate 2.1%. The mortality rate of acute pancreatitis was 3.1% in the sphincterotomy group vs 7.6% in the control group (P=0.1 ) (NS) and the morbidity rate 25% versus 32% (P≥0.1) (NS).ConclusionThese results suggest that endoscopic sphincterotomy could be beneficial in acute biliary or idiopathic pancreatitis but they are not statistically significant. Endoscopic sphincterotomy does not increase the severity of acute pancreatitis and can be considered particularly in cases of gallstone pancreatitis but it should be performed less than 48 hours after the onset of acute pancreatitis.