Anesthésie péridurale cervicale

Cervical epidural anaesthesia (CEA) results in an effective sensory blockade of the superficial cervical (C1/C4) and brachial plexus (C5/T1-T2). It is used both intraoperatively and in the treatment of postoperative or chronic pain. The approach to the epidural space at the C7-T1 interspace is not technically difficult. Patients are placed in the sitting position, increasing the negative pressure in the epidural space, with the head flexed on the thorax, in order to open the lowest cervical interspace. A 18-gauge Tuohy needle is inserted by a midline approach into the C6-C7 or C7-T1 interspace. A catheter may be inserted and left in place for postoperative analgesia. Local anaesthetics are administered either alone, or in combination with opiates. The CEA blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac ouput and contractility. The mean blood pressure is unchanged or decreased, depending on periphereal systemic vascular resistance changes. The baroreflex activity is also partly impaired. Sympathetic blockade also decreases myocardial ischaemia. The cardiovascular changes induced by CEA are also partly due to the systemic effect of the local anaesthetic. The respiratory effects are minimal and depend on the extent of the blockade and the concentration of the local anaesthetic. A moderate restrictive syndrome occurs. Since the phrenic nerves originate from C3 to C5, ventilation may be impaired by CEA. Extension of the block may also impair intercostal muscle function, with a risk of respiratory failure when a CEA is used in patients with compromised respiratory function. The potential specific complications, mainly cardiovascular and respiratory, are the exacerbation of the effects of CEA. Side effects such as bradycardia, hypotension and acute ventilatory failure in relation to respiratory muscle paralysis, may be observed. Close monitoring of haemodynamics, respiratory rate and level blockade is required. Cervical epidural anaesthesia may be used either alone, or in combination with general anaesthesia depending on the surgical procedure. This technique seems to be effective in carotid artery surgery since sensitive and reliable information on cerebral function may be obtained. It is also for shoulder and upper limb surgery as well as for pharyngolaryngeal surgery, providing efficient operative anaesthesia and postoperative analgesia. CEA is used for relief of chronic pain in the head and neck or cancer pain due to Pancoast-Tobias syndrome. It seems to be effective for treating pain in patients with unstable angina pectoris or acute myocardial infarction.     

Règles de la prévention des infections nosocomiales en médecine et chirurgie du pied et de la cheville

Nosocomial infections are contracted in a health care setting. Prevention of these infections depends on hand hygiene, the use of disposable material and double gloving for orthopaedic surgery on the foot.     

Anesthésie locorégionale pour chirurgie endoscopique du canal carpien

Local anaesthesia for surgical endoscopic release of carpal ligament is obtained with a block of the median nerve associated with subcutaneous infiltration of the areas of entrance and exit of the endoscope. A palmar application of Emla® cream makes the needle puncture painless. The accidental puncture of the median nerve, which occurs when the needle is inserted too rapidly, is the only potential complication. It is easily prevented by pushing the needle gently forward and orientating the bevel parallel to the axis of the nerve. The use of a neurostimulator and needle with a blunt tip can be an alternative. We used this technique in more than 1 500 patients. Only one accidental puncture of the nerve due to a technical error occurred.     

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 du plexus brachial par voie axillaire pour chirurgie urgente: comparaison de trois méthodes d'approche

ObjectivesTo compare three techniques of brachial plexus blockade for emergency surgery of the upper limb.Study designProspective, randomised study.PatientsOne hundred eleven patients admitted to an emergency surgical service, randomly assigned to three groups.MethodsThe patients were given 2% lidocaine with epinephrine 20 mL and 0.5% bupivacaine 20 mL. The three groups were as follows: brachial plexus block using a peripheral nerve stimulator (group St, n = 38); transarterial brachial plexus blockade with injection of 2/3 of the anaesthetic in back of and 1/3 in front of the artery (group TAP, n = 36); transarterial brachial plexus blockade with one single injection in back of the artery (group TP, n = 37). The success rate, time required to perform the technique, latency of analgesia, quality of motor blockade, and adverse effects were compared between the three groups. Analysis of variance was used to compare quantitative data and χ² test were used for qualitative data.ResultsRates of success varied between 65 and 75%. Success rates, latency of analgesia and quality of motor blockade were not significantly different between groups. Time to perform the technique was longer when using a nerve stimulator.ConclusionAs these three techniques for brachial plexus block in emergency surgery are comparable, no one can be recommended instead of the others.     

Technique d'anesthésie locorégionale simplifiée pour la chirurgie du pouce

Finger surgery is a frequent procedure, of short duration unless in case of major trauma, and often performed in emergency circumstances. In order to improve this type of treatment, we have developed distal blockade techniques. The double innervation in the thum requires two punctures ; a) dorsal, in order to block the superficial branch of the radial nerve ; b) palmar, through the flexor tendon sheath, allowing the blockade of the digital nerves, outing from the median nerve. We use bupivacaine 0.5 % without adrenaline, which offers high quality anaesthesia and analgesia. This technique can be used outside the operating room, in emergency or X-ray rooms. It allows thumb anaesthesia, either alone for short duration or in an addition to a plexus blockade whose effect in the radial nerve area would be insufficient.     

Anesthésie pour chirurgie vasculaire cérébrale anévrismale

The two major neurological complications of subarachnoid haemorrhage (SAH) due to an intracranial aneurysm are rebleeding and delayed cerebral ischaemia related to cerebral vasospasm. The best way to prevent rebleeding is early surgery. Even when surgery is performed within the first 72 hours posthaemorrhage, the risk of cerebral ischaemia due to vasospasm is high. Conventional medical treatment of cerebral vasospasm includes haemodilution, hypervolaemia and increase of arterial blood pressure. Haemodilution is of limited value as the patients suffering from SAH have usually a low haematocrit. The effectiveness of hypervolaemia is controversial and it may worsen cerebral and pulmonary oedema. Systemic hypertension is an effective therapy of vasospasm, but which can only be used once the aneurysm is controlled. Nimodipine and nicardipine, two calcium antagonists, have a beneficial effect on neurologic outcome following SAH. Today, it is still debated whether the beneficial effect of nimodipine results from the vascular effect of the drug or from a direct cerebral cytoprotective mechanism. Early surgery implies that surgeons operate on brains in acute inflammatory state. Thus, it is mandatory to use peroperative techniques improving cerebral exposure. These techniques include infusion of mannitol, lumbar cerebrospinal fluid (CSF) drainage, administration of anaesthetic agents known to decrease cerebral blood flow (CBF) and hypocapnia. Usually, the effect of CSF drainage is very effective and sufficient by itself. The second objective in the peroperative period is to avoid ischaemia. In areas with decreased flow distal to vasospasm, autoregulation is impaired and CBF is directly dependent on cerebral perfusion pressure. Furthemore, the safe practice of transient clipping of vessels supplying the aneurysm has dramatically reduced the indications of controlled hypotension. During temporary clipping, some authors recommend a pharmacological brain protection using barbiturates, etomidate or propofol, but this practice has not been validated by randomized studies. However, it is generally agreed that the arterial pressure should be increased during temporary clipping to improve collateral blood flow and to maintain it after the aneurysm has been secured. To conclude, together with lumbar CSF drainage and transient clipping, the anaesthetic management of the patients should include : maintenance of the arterial blood pressure close to its preoperative level, maintenance of Paco₂ between 30 and 35 mmHg and of normovolaemia through replacement of fluid and blood losses. After completion of surgery, recovery from anaesthesia should be rapid to allow fast diagnosis of neurological complications. The monitoring of the status of consciousness is the key of the diagnosis of early postoperative complications.     

Anesthésie pour cœliochirurgie en pédiatrie

The increasing use of laparoscopic surgery in children is associated with the enlargement of the spectrum of indications to appendicectomy, extramucosal pylorotomy and cure of œsophageal reflux. It is also linked with new problems, mainly due to physiologic modifications elicited by pneumoperitoneum and patient's posture. Although sufficient data are not yet available, the respiratory and cardiovascular modifications are probably similar to those occurring in adults, at least in children more than 4-month-old, as long as the intra-abdominal pressure remains under 15 mmHg. The use of higher intra-abdominal pressures has not been reported in children. In this case, the cardiovascular changes consist mainly in an increase in arterial pressure. In some children, non specific decreases in heart rate and in blood pressure can be observed. The latter can be elicited by a surgical complication, hypovolaemia, head-elevated position or deep anaesthesia. In the newborn and infant under 6 months, intra-abdominal pressures of 15 mmHg or more carry a risk of low cardiac output due to a decrease in contractility and compliance of the left ventricle. In this group of age it is therefore recommended to establish a pressure not higher than 6 mmHg. Moreover, in these very young children, the risk for reopening of the right-left shunts can result in heart insufficiency and systemic gas embolism. Peroperative respiratory changes include an increase in Petco₂ and more rarely a decrease in Sa_o2. The interpretation of the former depends on the site of gas sampling in the anaesthetic system. It is easily controlled by an increased minute ventilation. Various causes, such as bronchial intubation, inhalation of gastric contents or gas embolism, can decrease Sao₂. Contra-indications for laparoscopic surgery include hypovolaemia, heart diseases, increased intracranial pressure and alveolar distension. Therefore newborns are patients at high risk in so far as their foramen ovale or their ductus arteriosus is patent, the pulmonary arterial resistances remain increased and a bronchodysplasia is existing. In some cases a special disease is often associated. As an example recurrent bronchitis or asthma is associated with an œsophageal reflux and a sickle-cell disease in patients with cholelithiasis. These patients require special pre-, per- and postoperative care for prevention of complications. Anaesthesia for laparoscopic surgery does not require a major extension of the usual security regulations. Special attention must be paid to arterial pressure. Therefore end-expiratory concentration of the halogenated anaesthetic agent should not be kept higher than 1.5 times the MAC related to the age during maintenance of anaesthesia. A swift postanaesthetic recovery has to be planned when surgery of the abominal wall is not required at the end of the procedure. Up today the reported complications are related to surgery. However a risk for anaesthetic complications is existing. Their optimal prevention can be obtained by training anaesthetists in centres experienced in paediatric anaesthesia.     

L’imagerie du pied et de la cheville en France en 2012. Considérations personnelles

The author, a senior musculoskeletal radiologist, involved since a long time in foot and ankle imaging, reports his real-life personal experience of the different kinds of foot imaging in France in 2012, with their up and downside, and their possible excesses.     

Anesthésie de contact à la cocaïne pour chirurgie endonasale. Cinétique et tolérance clinique d'une solution concentrée

• Objective :To assess the pharmacokinetics and clinical tolerance of a 33 % cocaine solution administered topically for intranasal surgery.• Study design :Clinical prospective open trial.• Patients and methods :Twelve ASA I patients scheduled for intranasal surgery were sedated with midazolam 2 mg and fentanyl 50 μg. Topical anaesthesia was obtained with aqueous 33 % cocaine HCl 360 mg, lidocaine HCl 140 mg, adrenaline 0.04 mg and naphazoline 0.4 mg. Venous blood samples were taken before cocaine application and 15, 30, 45, 60, 90, 120, 150, 180, 240 min later. The plasma was immediately separated and the samples were frozen. The concentration of cocaine was measured by HPLC. Potential cardiotoxic and neurotoxic effects were clinically monitored.• Results :The mean dose of cocaine applied was 5.85 ± 1.3 mg · kg⁻¹ and the dose actually delivered was 4 ± 1.5 mg · kg⁻¹. The Cmax was 859 ± 503 ng · mL⁻¹ after a Tmax to 47 ± 17 min. The mean elimination half-life was 87 ± 19 min (mean ± SD). The total clearance and the volume of distribution were respectively 4 521 ± 1 858 mL. min⁻¹ and 568 ± 273 L. No clinical evidence of toxicity was found.• Conclusions :This study shows that it is possible to perform major intranasal surgery under topical anaesthesia with a concentrated solution (33 %) of cocaine at a high dose (6 mg · kg⁻¹). These results differ completely with data obtained in addicts.     

La chirurgie du couple de torsion du pied dans la polyarthrite rhumatoïde

Abductus valgus flat foot is the most common hind foot deformity in patients with rheumatic diseases. When conservative treatments (insoles and orthopaedics shoes) are not enough, surgery can be a good option. If only the talonavicular joint is affected, it can be fused. If hind foot valgus deformity is reductible, we perform a posterior tibial tendon repair associated to subtalar joint arthoereisis with an endorthesis. If hind foot deformity is severe and non-reductible, we fuse the talonavicular and subtalar joints through a double approach. We usually leave the calcaneocuboid joint not fused.     

Utilisation du sévoflurane pour la chirurgie du phéochromocytome

Resection of phaeochromocytoma is associated with sudden changes in arterial pressure. Pharmacodynamic and pharmacokinetic properties of sevoflurane are suitable for maintenance of haemodynamic stability. We report two cases of phaeochromocytoma resection using sevoflurane. Intraoperative hypotensive or hypertensive events have been rapidly controlled, most often only by adjustment of the end-expiratory fraction of sevoflurane. © 1998 Elsevier, Paris