Appréciation de la place de l’anesthésie locorégionale pour la prise en charge des plaies de la face aux urgences

Objective

Defining the place of regional anaesthesia (RA) for facial wounds in an emergency department.

Study Design

Prospective observational study conducted in the emergency department of a regional hospital.

Patients and methods

Two hundred and forty-six successive patients with one or more facial wounds were included from 1st august 2004 to 31st december 2004. Data on patient, operator, wound (measured by the number of stitches), anaesthetic method (RA, local anaesthesia [LA], or no anaesthesia), method of repairing skin, duration of intervention, operator comfort (verbal numeric scale [VNS] from 0 to 10) and pain feeled by the patient (visual analogic scale [VAS] from 0 to 10) in the different stages of care were collected.

Results

Compared to the LA, the RA of the face decreased the number of punctures (1.36 vs 4.38 punctures, p < 0.001) and the quantity of local anaesthetic injected (2.8 ml vs 5.3 ml, p < 0.01) for wounds requiring more than 10 stitches. It has improved operator comfort (VNS = 10 [8–10] vs 8 [6.75–10] (p < 0.01)). Its effectiveness during skin repair was equivalent to that of the LA by infiltration (VAS 0 [0–1] vs 0 [0–1]).

Conclusion

When practicable, the RA of the face is a better technique than the LA for facial wounds treatment.     

Bloc iliofascial et troubles cognitifs postopératoires chez la personne âgée

Objective

The aim of this study was to assess the influence of a regional analgesia technique on the incidence of postoperative cognitive dysfunction (POCD) after hip surgery, in elderly patients.

Patients and methods

Patients, aged over 65 years, were assigned in two groups according to the anaesthesia technique: group NKT (general anaesthesia with target concentration infusion of propofol and remifentanil, with a 0.1 mg/kg-bolus of morphine at the end of surgery), group KT (preoperative iliaca compartment block with catheter and then general anaesthesia without bolus of morphine). Postoperative analgesia was similar in both groups: paracetamol, tramadol, and subcutaneous morphine if verbal pain scale equal or greater than 2 (0.1 mg/kg). POCD was defined as a decrease in Mini Mental Status (MMSE) equal or greater than 2 points and was monitored during 2 days. Consumption of opioids, pain scores and side effects were recorded.

Results

Sixty-five patients were included: 34 in NKT group and 31 in KT group. MMSE scores were higher in the KT group at day1 and day2 (p = 0.01 and 0.0004, respectively). POCD was less frequent in group KT at day2 (6 % vs 41 % ; p = 0.001) and pain scores were lower during the first 48 hours (p = 0.03). Remifentanil consumption was lower in KT group (0.43 ± 0.18 mg vs 0.61 ± 0.25 mg, p = 0.002). Total amount of morphine, including the bolus in NKT group, was significantly lower in KT group (7 [5–17] mg vs 0 [0–5] mg, p < 10⁻⁶).

Conclusion

Postoperative analgesia by iliaca compartment block with catheter seems to provide a decrease in the incidence of POCD after hip surgery in elderly patients.

Study design

Prospective, observational study.     

Expérience d’un système de recueil d’évènements indésirables en anesthésie

Objectives

This article summarizes functioning and results of anaesthesia adverse effects reporting system over its first 18 months, from August 2006 to February 2008.

Study design

Monocentric retrospective study.

Methods

Reporting system is available 24/24 h, 7/7 to every employee with an individual password. A committee with anaesthesiologists, nurses and risk management engineer examines every notification by two months. We evaluated number of reports, type of reporter, type of dysfunction reported and solutions. Numerical data are compared with a Student t test or X² test. A p-value of less than 0.05 g being considered as statistically significant.

Results

One hundred and eighty-five reports were registered for the first 18 months (1% of anesthesia activity) with a slowdown with time (p = 0.02). Eighty-six percent of the statements were made by anesthesiologists, but some physicians had never reported. Malfunctions shared between different services (identity, operating room organisation) are rarely solved (67%) compared to specific anesthesia problems (93%) (p < 0.001).

Conclusion

The reporting system is simple and available but some professionals don’t declare, generating reporting bias. This network underlines major general dysfunctions (identity) but ways to solve are limited to date.     

Intérêt du mélange sérum salé hypertonique–hydroxyéthylamidon lors du choc hémorragique

Objective

Assessment of haemodynamic, respiratory and renal effects of hypertonic saline–hydroxyethyl starch (HyperHES^®) in critically ill-patients with hemorrhagic shock.

Patients and methods

Seventeen mechanically ventilated patients with hemorragic shock benefiting from a cardiovascular monitoring by PiCCO device and requiring rapid volume loading. Two hundred and fifty milliliters of HyperHES^® were given over 5 minutes. The efficacy of volume loading was assessed by the measure of the systolic arterial pressure (SAP), cardiac index (CI), stroke volume variation (SVV) and the indexed systemic vascular resistance (iSVR). Studied parameters were assessed at baseline, 5, 30, 60 and 180 minutes after the end of HyperHES^® infusion.

Results

SAP (105 ± 23 vs 77 ± 10; p < 0.001) and CI (4.8 ± 1.1 vs 3.5 ± 0.9; p < 0.001) were significantly increased whereas iSVR (1175 ± 310 vs 1501 ± 337; p < 0.01) and SVV (13 ± 7 vs 20 ± 5; p < 0.01) were significantly decreased 5 minutes after the HyperHES^® infusion. Sodium (145 ± 6 vs 136 ± 5; p < 0.001) and chloride (118 ± 7 vs 107 ± 6; p < 0.001) were increased 5 minutes after the infusion. The PaO₂/FiO₂ ratio as the extravascular lung water was not influenced by the infusion. The follow-up of renal parameters during the three first days (creatinemia, uremia and diuresis) did not revelead significant variations.

Conclusion

In patients with hemorrhagic shock, the infusion of hypertonic saline (7.5%) hydroxyethyl starch association was followed by an increase in SAP, CI serum sodium and chloride concentrations.

Study design

Prospective observational study.     

Effet d’une dose unique intramusculaire de déxaméthasone sur la douleur après circoncision. Étude randomisée contrôlée

Objective

To assess the effect of a preoperative single dose of dexamethasone associated with penile block on pain after circumcision.

Study design

Prospective randomized controlled study.

Patients and methods

Forty male children aged 2 to 5 years, scheduled for circumcision under general anaesthesia, combined with penile block, were randomized into two groups. The dexamethasone group received dexamethasone 0.4 mg/kg preoperatively. The control group received the same volume of normal saline. Data compared between two groups were: postoperative pain assessed by the Objective Pain Scale collected in the recovery room, at 8 and 24 hours postoperatively (h0, h8 and h24), time to first analgesic request and the quality of sleep on the first postoperative night.

Results

Pain scores at h0 were similar between the two groups. The dexamethasone group showed significantly lower pain scores at h8 [0 (0–1) vs. 2 (0–3); P = 0.04] and h24 [0 (0–0) vs. 0 (0–1); P = 0.02]. The time to first analgesic administration was also significantly delayed in the dexamethasone group compared to the control group (240 vs 180 min; P = 0.035). The quality of sleep was also better in children in the dexamethasone group (P = 0.018).

Conclusion

This study showed that the combination of a preoperative single dose of dexamethasone 0.4 mg/kg with penile block significantly improves the quality of analgesia after circumcision.     

Photodynamic Diagnosis of Non–muscle-invasive Bladder Cancer with Hexaminolevulinate Cystoscopy: A Meta-analysis of Detection and Recurrence Based on Raw Data

Background

Studies on hexaminolevulinate (HAL) cystoscopy report improved detection of bladder tumours. However, recent meta-analyses report conflicting effects on recurrence.

Objective

To assess available clinical data for blue light (BL) HAL cystoscopy on the detection of Ta/T1 and carcinoma in situ (CIS) tumours, and on tumour recurrence.

Design, setting, and participants

This meta-analysis reviewed raw data from prospective studies on 1345 patients with known or suspected non–muscle-invasive bladder cancer (NMIBC).

Intervention

A single application of HAL cystoscopy was used as an adjunct to white light (WL) cystoscopy.

Outcome measurements and statistical analysis

We studied the detection of NMIBC (intention to treat [ITT]: n = 831; six studies) and recurrence (per protocol: n = 634; three studies) up to 1 yr. DerSimonian and Laird's random-effects model was used to obtain pooled relative risks (RRs) and associated 95% confidence intervals (CIs) for outcomes for detection.

Results and limitations

BL cystoscopy detected significantly more Ta tumours (14.7%; p < 0.001; odds ratio [OR]: 4.898; 95% CI, 1.937–12.390) and CIS lesions (40.8%; p < 0.001; OR: 12.372; 95% CI, 6.343–24.133) than WL. There were 24.9% patients with at least one additional Ta/T1 tumour seen with BL (p < 0.001), significant also in patients with primary (20.7%; p < 0.001) and recurrent cancer (27.7%; p < 0.001), and in patients at high risk (27.0%; p < 0.001) and intermediate risk (35.7%; p = 0.004). In 26.7% of patients, CIS was detected only by BL (p < 0.001) and was also significant in patients with primary (28.0%; p < 0.001) and recurrent cancer (25.0%; p < 0.001). Recurrence rates up to 12 mo were significantly lower overall with BL, 34.5% versus 45.4% (p = 0.006; RR: 0.761 [0.627–0.924]), and lower in patients with T1 or CIS (p = 0.052; RR: 0.696 [0.482–1.003]), Ta (p = 0.040; RR: 0.804 [0.653–0.991]), and in high-risk (p = 0.050) and low-risk (p = 0.029) subgroups. Some subgroups had too few patients to allow statistically meaningful analysis. Heterogeneity was minimised by the statistical analysis method used.

Conclusions

This meta-analysis confirms that HAL BL cystoscopy significantly improves the detection of bladder tumours leading to a reduction of recurrence at 9–12 mo. The benefit is independent of the level of risk and is evident in patients with Ta, T1, CIS, primary, and recurrent cancer.     

Evaluation of the spontaneous breathing trial in burn intensive care patients

Background

The extubation failure rate in our burn patients is 30%.

Objective

To evaluate the influence of the 30 min spontaneous breathing trial on extubation outcome in burn patients.

Methods

A prospective, observational study in a burn intensive care unit. All adult patients requiring mechanical ventilation for >24 h and meeting the inclusion criteria underwent a 30 min spontaneous breathing trial (SBT). Extubation was undertaken after a successful SBT.

Results

Of 49 planned extubations, 9 failed (18%), much lower than the 30% extubation failure rate identified prior to the implementation of the SBT. The duration of ventilation was significantly shorter (p = 0.04) in the patients who passed a SBT and those who failed extubation were significantly older (p = 0.003). The logistic regression analysis identified that age independently predicted extubation outcome. Patients who failed extubation, after a successful SBT, had a significantly longer duration of ventilation (p = 0.0001) and ITU length of stay (p = 0.001).

Conclusions

The incidence of extubation failure was much lower and the duration of ventilation significantly shorter in patients who were extubated after a successful SBT. These findings support the use of the SBT in burn patients. Age independently predicts extubation outcome in burn patients who have passed a SBT.     

Facteurs prédictifs de défaillance d’organes chez les patients admis en réanimation pour hémorragie digestive aiguë

Introduction

Gastrointestinal hemorrhage is an emergency requiring usually an admission in intensive care unit (ICU), which may prove abusive secondarily. The aim of this study was to identify predictive risk factors of organ failure in patients admitted for GH in our ICU.

Design

Retrospective and observational

Methods and measurements

Between January 2008 and December 2011, all patients admitted in our ICU for gastrointestinal hemorrhage were consecutively included. The primary endpoint was the occurrence of at least an organ failure. We realized an univariate analysis then a backward regression to identify independent risk factors associated with the occurrence of at least one organ failure during the ICU hospitalization.

Results

During this period study, 441 consecutive patients with a mean age of 67 ± 15 years were included. The median ICU length of stay was of 4 (3–7) days and 116 (26% [IC95%: 22–30]) patients presented at least one organ failure. The multivariate analysis identified predictive risk factors of organ failure: history of cirrhosis (OR = 3.5 [IC95%: 1.9–6.7], P < 0.001) and an increase in troponin at the admission above the 99th percentile (OR = 3.1 [IC95%: 1.8–5.5], P < 0.001).

Conclusion

Our results confirmed that a large proportion of patients admitted in ICU for the primary diagnosis of gastrointestinal hemorrhage developed any organ failure. The history of cirrhosis and the systemic consequences of the hemorrhagic syndrome as myocardial damage represents important risk factors of morbidity and mortality and thus should be considered during the management.     

CEACAM1: A Novel Urinary Marker for Bladder Cancer Detection

Background

Carcinoembryonic antigen-related cell adhesion molecule 1 (biliary glycoprotein; CEACAM1) is expressed in normal bladder urothelium and in angiogenically activated endothelial cells, where it exhibits proangiogenic properties.

Objective

The aim of this study was to evaluate the value of urinary CEACAM1 for detection of urothelial carcinoma of the bladder (UCB).

Design, setting, and participants

This prospective study included 175 patients.

Measurements

Immunohistochemistry for CEACAM1 was performed on UCB sections of 10 patients. Enzyme-linked immunosorbent assay (ELISA) for CEACAM1 was performed on urine specimens of healthy volunteers (n = 30), patients with benign prostatic hyperplasia (BPH; n = 5), severe cystitis (n = 5), non–muscle-invasive UCB (n = 72), muscle-invasive UCB (n = 21), or past history of UCB without evidence of disease (n = 42). Western blot analysis was performed on a subgroup of these subjects (n = 53).

Results and limitations

CEACAM1 immunostaining in normal urothelium disappears in noninvasive UCB but appears in endothelial cells of adjacent vessels. Western blotting revealed presence of CEACAM1 in the urine of no healthy volunteers, of 76% of noninvasive UCB patients, and of 100% of invasive UCB patients. ELISA analysis confirmed that urinary CEACAM1 levels were significantly higher in UCB patients compared with control subjects (median: 207 ng/ml vs 0 ng/ml; p < 0.001). The area under the curve for UCB detection was 0.870 (95% confidence interval [CI]: 0.810–0.931). In multivariable logistic regression analyses that adjusted for the effects of age and gender, higher CEACAM1 levels were associated with cancer presence (hazard ratio [HR]: 2.89; 95% CI: 2.01–4.15; p < 0.001) and muscle-invasive cancer (HR: 5.53; 95% CI: 1.68–18.24; p = 0.005). The cut-off level of 110 ng/ml yielded sensitivity of 74% and specificity of 95% for detecting UCB. Sensitivity was 88% for detecting high-grade UCB and 100% for detecting invasive-stage UCB. Larger studies are necessary to establish the diagnostic and prognostic roles of this highly promising novel marker in UCB.

Conclusions

Urinary CEACAM1 levels discriminate UCB patients from non-UCB subjects. Moreover, urinary levels of CEACAM1 increased with advancing stage and grade.     

Athermal Division and Selective Suture Ligation of the Dorsal Vein Complex During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of Technique and Outcomes

Background

Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP).

Objective

To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC).

Design, settings, and participants

Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures.

Surgical procedure

RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection.

Measurements

Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day.

Results and limitations

Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p < 0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p < 0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147 min, p < 0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6 ml, p = 0.033), and one DVC-SSL versus zero SL-DVC were transfused (p = 0.442). Overall (12.2% vs 12.0%, p = 1.0) and apical (1.3% vs 2.7%, p = 0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p < 0.001) and continence (61.4% vs 39.6%, p < 0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE] ± standard error [SE]: 16.84 ± 2.56, p < 0.001), and better 5-mo urinary function (PE ± SE: 19.93 ± 3.09, p < 0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07–5.57, p < 0.001).

Conclusions

DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control.     

Comparison of Oncologic Outcomes for Open and Laparoscopic Nephroureterectomy: A Multi-Institutional Analysis of 1249 Cases

Background

Data regarding the oncologic efficacy of laparoscopic nephroureterectomy (LNU) compared to open nephroureterectomy (ONU) are scarce.

Objective

We compared recurrence and cause-specific mortality rates of ONU and LNU.

Design, setting, and participants

Thirteen centers from three continents contributed data on 1249 patients with nonmetastatic upper tract urothelial carcinoma (UTUC).

Measurements

Univariable and multivariable survival models tested the effect of procedure type (ONU [n = 979] vs LNU [n = 270]) on cancer recurrence and cancer-specific mortality. Covariables consisted of institution, age, Eastern Cooperative Oncology Group (ECOG) performance status score, pT stage, pN stage, tumor grade, lymphovascular invasion, tumor location, concomitant carcinoma in situ, ureteral cuff management, previous urothelial bladder cancer, and previous endoscopic treatment.

Results and limitations

Median follow-up for censored cases was 49 mo (mean: 62). Relative to ONU, LNU patients had more favorable pathologic stages (pT0/Ta/Tis: 38.1% vs 20.8%, p < 0.001) and less lymphovascular invasion (14.8% vs 21.3%, p = 0.02) and less frequently had tumors located in the ureter (64.5 vs 71.1%, p = 0.04). In univariable recurrence and cancer-specific mortality models, ONU was associated with higher cancer recurrence and mortality rates compared to LNU (hazard ratio [HR]: 2.1 [p < 0.001] and 2.0 [p = 0.008], respectively). After adjustment for all covariates, ONU and LNU had no residual effect on cancer recurrence and mortality (p = 0.1 for both).

Conclusions

Short-term oncologic data on LNU are comparable to ONU. Since LNU was selectively performed in favorable-risk patients, we cannot state with certainty that ONU and LNU have the same oncologic efficacy in poor-risk patients. Long-term follow-up data and morbidity data are necessary before LNU can be considered as the standard of care in patients with muscle-invasive or high-grade UTUC.     

Comparaison de trois modes ventilatoires au cours du transport postopératoire immédiat du patient opéré de chirurgie cardiaque

Objective

Compare three ventilatory strategies during the immediate postoperative transfer of cardiac surgical patient.

Study design

Prospective, comparative and observational study.

Patients and methods

After approval by our local ethical committee, 330 patients undergoing on-pump cardiac surgery were consecutively included. Patients suffering from chronic obstructive pulmonary disease, exhibiting intraoperative hypoxemia or requiring nitric oxide were excluded. The ventilatory mode was left at the discretion of the anesthesiologist and included: controlled mechanical ventilation (FiO₂ = 1, N = 124) or (FiO₂ = 0.6, N = 106), and manual ventilation using rebreathing bag (N = 100). A blood gas analysis was performed immediately prior to connecting patient at ventilator at the arrival in ICU.

Results

The mean duration of transfer was 3.9 ± 1.4 min. Invasive pressure monitoring was used in all patients. The pulse oxymetry and electrocardiogram were respectively used in 78% and 24% of patients. PaO₂ values less than 100 mmHg and those more than 300 mmHg were more frequently found in patients ventilated by rebreathing bag (42%) and mechanical ventilation FiO₂ 1 (52%), respectively. No significant difference was found between groups regarding PaCO₂ values.

Conclusion

When rebreathing bag is used for transfer in ICU, severe decrease in PaO₂ may be observed. In absence of intraoperative hypoxemia, a mechanical ventilation with FiO₂ 0.6 seems to be the most suitable ventilatory strategy for such short immediate postoperative transfer.     

Prise en charge anesthésique des transplantations hépatiques : évolution des pratiques périopératoires en France entre 2004 et 2008

Objectives

To determine the evolution of French perioperative anaesthetic practices in liver transplantation between 2004 and 2008.

Study design

Phone survey.

Methods

In 2004 and 2008, a similar questionnaire has been administered by phone to a senior anaesthesiologist from each French centre performing adult liver transplantation (n = 21). Results were compared using Fisher test and p < 0.05 was considered significant.

Results

Between 2004 and 2008, there was a trend towards an increase of centres performing transplantation for more than 40% of Child C patients (p = 0.1). Simultaneously, work force dedicated to liver transplantation cases has been reduced since in 2008, one anaesthesiologist was in charge in 90% of the centres (p = 0.06 vs 2004). Perioperative practices remained largely heterogeneous between centres with regard to hemodynamic monitoring, fluid and blood products management, antifibrinolytics use or postoperative analgesia.

Conclusions

This French survey has shown a reduction of work force dedicated to a liver transplantation from 2004 to 2008 simultaneously with a trend towards a greater severity of liver recipients. Practices heterogeneity reflect at least in part, unresolved questions about the best perioperative management for liver transplantation and the need for guidelines. Working for standardization of our practices and multicentric trials could allow gaining a better understanding of what should be the good practices in perioperative management of liver transplantation.     

Douleur et troubles comportementaux après adénoïdectomie et pose d’aérateurs transtympaniques chez l’enfant

Objectives

The purpose of this study was to evaluate postoperative pain in the hospital and at home as well as behavioural changes at home following outpatient adenoidectomy (VG) and ear tube (ATT) surgery.

Study design

Prospective cohort study.

Patients and methods

Sixty-four children (mean age 4.3 ± 2.4 years): 28 VG, 16 (ATT), 20 dual surgeries (VG-ATT). Postoperative pain was evaluated (arrival in recovery room, departure from wake-up room, departure from hospital) using the Objective Pain Scale (OPS). Parents evaluated their child's pain at home over a period of seven days using a numeric pain scale. Behavioural changes were measured with the Post-Hospital Behaviour Questionnaire (PHBQ).

Results

At arrival in the recovery room, OPS = 3.5 [0–6]. A statistically significant difference (p < 0.05) was shown between the VG group (OPS = 5 [2.25–7.75]), and the ATT (OPS = 0 [0–5.5]) and VG-ATT (OPS = 2 [0–5.75]) groups. OPS was 1.0 [0–2] when leaving the recovery room, and OPS was 0 [0–1] when leaving the hospital. Numeric pain scale scores recorded at home were extremely low. Postoperatively, 75% of parents at Day 1 and 40.6% at Day 7 reported at least one postoperative behavioural change.

Discussion

In all three groups, parents reported frequent postoperative behaviour changes despite adequate analgesia.

Conclusion

The relatively high frequency of postoperative behaviour changes in this population demonstrates the need to systematically evaluate those changes in order to improve overall paediatric care.     

Tribloc (fémoral,sciatique, obturateur) pour la chirurgie ambulatoire arthroscopique de genou : étude prospective de faisabilité et d’efficacité

Background

The purpose of this study was to evaluate intra- and postoperative conditions of the triple nerve block technique (femoral, obturator, sciatic block) for outpatient knee arthrsopic procedures.

Methods

After written informed consent, ASA I-III patients received a combined triple nerve block with 30–40 ml lidocaine or mepivacaine (1,5%). Blocks were performed using a nerve stimulation technique. Onset time, block failure, supplemental general anesthesia (GA) or analgesia and pain score were recorded intraoperatively. After surgery, side effects (at days 0, 1, 3, 7 and after 4 weeks), patient and surgeon satisfactions were noted.

Results

Three hundred and twelve patients were screened and 115 triple blocks were performed (157 choosed GA, 19 spinal anaesthesia, 21 exclusion for regional anaesthesia). Failed blocks occurred for 12 (10%) patients. These 12 patients received GA before surgery incision. Time to complete block was 40 (10–60) min. Supplemental GA was required for 12 patients (12%) due to surgical (n = 7, 7%) or tourniquet (n = 5, 5%) pain. Intraoperative surgeon satisfaction was 90 (60–100). After surgery, time to discharge the postoperative care unit was 15 (5–60) min. Pain score at rest (Visual Analog Scale) until six hours was less than 30 /100, without any additionnal morphine. Two patients (< 2%) failed for ambulatory discharge criteria (no relation with triple block). At day 0, 3, 5% patients suffered PONV (8% at D1), paresthesia was noted in 1.7% at D0 (0,8% D3). No other secondary effects were observed after seven days and 91% patients “would like same anaesthesia” for next surgery.

Conclusion

We conclude that triple nerve block provided reliable intraoperative patient and surgical conditions for outpatient knee arthroscopy. Failed block (10%) was the major reason of supplemental anaesthesia. To increase surgical turn over under triple nerve block, a preoperative room may be required (block onset time).     

Gender and Age Differences in the Perception of Bother and Health Care Seeking for Lower Urinary Tract Symptoms: Results from the Hospitalised and Outpatients’ Profile and Expectations Study

Background

Few comparisons have been made of health care seeking behaviour for lower urinary tract symptoms (LUTS) between men and women, as well as trends across age groups.

Objective

To investigate the bother from LUTS and effect on health care seeking in both men and women of different age groups and in comparison between the two genders.

Design, setting, and participants

A representative cross section of each of 13 clinics of a general academic hospital, with equal numbers of subjects recruited in each of six design cells that were defined by age (18–40, 41–60, 61–80 yr) and gender.

Intervention

A 2-h in-person interview, conducted by a trained psychologist/interviewer in a clinic office.

Measurements

Severity of LUTS was measured by the International Prostate Symptom Score (IPSS). Treatment seeking was measured by a single item. A bother question was modified to assess overall bother. Impact on quality of life (QoL) was measured by the IPSS QoL question.

Results and limitations

The final study sample comprised 415 patients. More women than men reported the presence of LUTS (85.5% vs 75.2%; p = 0.01). LUTS were more bothersome in women (25.4% of women vs 17.6% of men with bother “some” or “a lot”; p = 0.02). Severity of LUTS increased with age in both genders (men: p < 0.001; women: p = 0.03). Bother from LUTS increased as severity of symptoms increased in both genders (p < 0.001) but was associated with age only in men (p < 0.001). QoL showed similar results as bother. Although men and women had equal prevalence of treatment seeking (27.9% vs 23.7%; p = 0.40), men, but not women, were more likely to seek treatment as age (p < 0.01) and severity of LUTS (p < 0.001) increased. In multivariate logistic regressions, only bother from LUTS was associated with treatment seeking in women, compared with bother, age, and the presence of voiding symptoms in men.

Conclusions

In our hospital-based sample, differences in LUTS frequency, bother, and health care seeking profiles between men and women suggest a different perception and response to LUTS between the two genders.     

Retrograde Versus Antegrade Nerve Sparing During Robot-assisted Radical Prostatectomy: Which Is Better for Achieving Early Functional Recovery?

Background

Although the retrograde approach to nerve sparing (NS) aimed at maximizing NS during robot-assisted radical prostatectomy (RARP) has been described, its significant benefits compared to the antegrade approach have not yet been investigated.

Objective

To evaluate the impact of NS approaches on perioperative, pathologic, and functional outcomes.

Design, setting, and participants

Five hundred one potent (Sexual Health Inventory for Men [SHIM] score >21) men underwent bilateral full NS and were followed up for a minimum of 1 yr. After propensity score matching, 344 patients were selected and were then categorized into two groups.

Surgical procedure

RARP with antegrade NS (n = 172) or RARP with retrograde NS (n = 172).

Outcome measurements and statistical analysis

Functional outcomes were assessed using validated questionnaires. Multivariable logistic regression models were applied.

Results and limitations

Positive margin rates were similar (11.1% vs 6.9%; p = 0.192), and no correlation with the NS approach was found on regression analysis. At 3, 6, and 9 mo, the potency rate was significantly higher in the retrograde approach (65% vs 80.8% and 72.1% vs 90.1% and 85.3% vs 92.9%, respectively). The multivariable model indicated that the NS approach was an independent predictor for potency recovery at 3, 6, and 9 mo, along with age, gland size, and hyperlipidemia. After adjusting for these predictors, the hazard ratio (HR) for the retrograde relative to the antegrade approach was 2.462 (95% confidence interval [CI], 1.482–4.089; p = 0.001) at 3, 4.024 (95% CI, 2.171–7.457; p < 0.001) at 6, and 2.145 (95% CI, 1.019–4.514; p = 0.044) at 9 mo. Regarding continence, the recovery rates at each time point and the mean time to regaining it were similar, and the method of NS had no effect on multivariable analysis. The absence of randomization is a major limitation of this study.

Conclusions

In patients with normal erectile function who underwent bilateral full NS, a retrograde NS approach facilitated early recovery of potency compared to that with an antegrade NS approach without compromising cancer control.     

Effets de l’hydroxyzine sur l’acceptation du masque à l’induction de l’enfant

Objective

To evaluate the effectiveness of hydroxyzine as a premedication agent for the acceptance of facial mask during induction of general anaesthesia in children.

Study design

Prospective randomized single-blind study including ASA 1 and 2 children, aged between 1 and 9 years and undergoing outpatient surgery.

Patients and methods

Patients were randomly allocated to receive orally either 1 mg/kg hydroxyzine (G1) or water 0.1 ml/kg (G2) one hour before induction of standardized inhalational anaesthesia. Tolerance of facial mask was assessed with a 3-points scale (good, moderate or poor). Chi-square and Student's t-test were used in statistical analysis; p values less than 0.05 were considered statistically significant.

Results

One hundred patients were included (G1 = 49, G2 = 51). Demographic data were similar in both groups. Acceptance of facial mask was significantly better in G1 than in G2 (p = 0,002).

Conclusion

Hydroxyzine provided better acceptance of facial mask than placebo during induction of general anaesthesia in children.     

Repérage de la membrane cricothyroïdienne en phase d’apprentissage : valeur ajoutée de l’échographie ?

Objectives

Emergency cricothyroidotomy is recommended as life-saving maneuver when mask ventilation and tracheal intubation are impossible. It requires the puncture of the cricothyroid membrane (CTM) whose clinical identification is difficult. The objective of this study is to evaluate if ultrasound can help locating the CTM by comparing palpation and ultrasonographic evaluation.

Patients and methods

After ultrasound localization of CTM by a referent physician in two overweight volunteers, twelve residents without prior anatomy recall, defined by palpation an entry point for CTM. After a rapid training in CTM ultrasound localization, residents identified an ultrasound-guided puncture point. For each puncture site were registered: relevance, time and ease to localization. Six months later, residents renewed clinical and ultrasound identification of CTM on the same subjects.

Results

The CTM was accurately identified by palpation and ultrasound by 46% and 100% of residents respectively (P < 0.05). Six months later, residents remained more effective identifying CTM with ultrasound than with palpation (78% vs. 33%) (P < 0.05). Time to localization of CTM by palpation in the 2 volunteers was 15 s [11–18] and 24 s [9–39] (average [CI 95%]) whereas it was 21 s [16–25 s] and 28 s [19–36] by ultrasound respectively (ns). The ultrasound identification of CTM was also considered easier than clinical identification.

Conclusion

Following a limited training phase, ultrasound allowed a more effective localization of CTM by residents when compared to clinical palpation in overweight patients. This benefit remained significant when assessment was repeated 6 months later.     

Efficacité d’une manœuvre de recrutement alvéolaire associée à une pression expiratoire positive sur la mécanique respiratoire en cœliochirurgie bariatrique

Objective

To evaluate recruitment manoeuvre (RM) efficiency associated with a 10 cmH₂O positive end expiratory pressure (PEEP) on respiratory mechanic estimated by lung compliance (Ctp) and PEEP to ZEEP expiratory volume delta (Δ VTE) during laparoscopic bariatric surgery in patients with morbid obesity.

Study design

Prospective randomized study.

Methods

Twenty-six obese patients (BMI > 40 kg/m²) undergoing laparoscopic bariatric surgery. The recruitment group received an RM followed by a 10 cmH₂O PEP versus only 10 cmH₂O PEP in the control group. Ctp was measured during the intervention and functional residual capacity (FRC) was estimated measuring Δ VTE during a PEP to ZEP manoeuvre. Mann and Whitney tests as well as a t-test were used (significance p < 0.05).

Results

In the RM group, a significant improvement of 52 ± 14 ml/cmH₂O was noted versus a 36 ± 10 ml/cmH₂O in the PEP group (p = 0,004). This improvement was transitory and no statistically significant Δ VTE difference was noted between the groups at the end of the intervention (360 [90–770] ml [MRA] and 310 [190–450] ml [PEP]).

Conclusion

In patients with morbid obesity undergoing laparoscopic bariatric surgery, an RM conducted prior the pneumoperitoneum temporarily improves lung mechanics but without any change of the end expiratory lung volume at the end of the surgery in comparison with PEP alone. The RM was well tolerated.