Rachianesthésie à la bupivacaïne à 0,5 % sans glucose. Effets de l''âge

The effects of age on the characteristics of spinal anaesthesia with plain bupivacaine were investigated in 29 adult patients (less than 50 yr : group I), and 37 older patients (greater than or equal to 80 yr : group II). Three millilitres of 0.5% solution (15 mg) were injected at the L3-L4 interspace in the lateral position; the patients were turned supine immediately afterwards. The onset, extent and duration of sensory and motor blockade, the cardiovascular effects and the quality of anaesthesia were evaluated. Anaesthesia was unsatisfactory in one patient in group I and two patients in group II; they required a supplement with intravenous inhalation anaesthesia. These patients were not included in the analysis of the variables studied. The time to maximum spread was significantly shorter in the group I : 7.3 min versus 9.9 min in group II. A higher sensory spinal blockade was obtained in the older age group (T 10.4 versus T 11.2). There were no significant difference between the two groups in the mean time from the injection to recovery from analgesia in the two uppermost segments (121 min versus 107 min). The mean duration of analgesia at the L2 level did not differ significantly (149 min versus 164 min). All the patients had complete motor blockade of lower limbs. Only the Bromage's degrees 2 and 1 were greater in the elderly's group. In the older group, there was a tendency to a greater decrease in systolic arterial pressure from the preanaesthetic values (-20.9% versus -13%). But moderate falls in mean and diastolic arterial pressures were observed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Analgésie contrôlée par le patient : étude de la demande en fentanyl chez le brûlé à la phase aiguë

This study assessed over the first post-burn week the patients' demands for opiates delivered with a PCA device, changes in opioid delivery along the day, especially during painful events and the incidence of side effects. Twenty-two patients (8 women, 14 men), mean age 33 years (± 12 SD), mean BSA 21 % (± 13 SD), mean deep dermal burn 12 % (± 11 SD) were included. Fentanyl was delivered by i.v. route using a PCA device during the first 6 days post burn. Bolus dose was fixed at 1 μg · kg⁻¹, lock-out time at 30 min and the 4 h limit dose at 7 μg · kg⁻¹. The following data were collected every day : satisfied and non-satisfied demands, total daily dose, demands during and after dressing change period (4 h), during afternoon (10 h) and overnight periods (10 h). Heart rate (HR), respiratory rate (RR), blood pressure (BP), Paco₂ and Spo₂ were also monitored. The mean total daily demands were similar from D1 to D6 (28 ± 7). Around 7 demands/day were not satisfied. The mean total daily satisfied demands were also the same : 21 ± 5. Individual demands were over a wide range (minimum : 15, maximum : 41 demands/day for total demands and 13 and 34 respectively for the satisfied ones). Mean fentanyl delivery was 1,7 ± 0,1 μg · kg⁻¹ · h⁻¹ during dressing period, 0,9 ± 0,3 μg · kg⁻¹ · h⁻¹ during afternoon period (10 h) and 0,5 ± 0,2 during overnight period (10 h). No-satisfied demands were around 4 boluses during dressing change period, 2 boluses during afternoon period, and one bolus during overnight period. Neither HR nor BP were modified for more than 20 % of control values ; RR never decreased under 12 c · min⁻¹ and Paco₂ remained unchanged. This study showed that the provision of analgesia in burn injury requires large doses of opioids. Individual demands are scattered over a wide range. The need for analgesics remains unchanged for several days. A PCA device is an efficient and safe tool for administration of opioids. Analgesia is appropriate, except during the dressing period.     

Protocole d''anesthésie du porc. Effets de la saignée sur la circulation et l''équilibre acido-basique

Haemodynamic parameters and their variations after the loss of 250 and 500 ml of blood under anaesthesia were studied in nine, 11 to 12 week-old, domestic swine weighing 37.4 +/- 2.6 kg. Premedication consisted of 2 ml azaperone i.m. Anaesthesia was induced with thiopentone, followed by suxamethonium to allow the easy placement of a cuffed endotracheal tube. Anaesthesia was maintained with phenoperidine and pancuronium. The animals were mechanically ventilated with a 50/50 nitrous oxide-oxygen mixture. A catheter was inserted in each of the femoral artery, upper hepatic vein, vena cava and portal vein. Right atrial, pulmonary and wedge pressures were measured; stroke volume, systemic and pulmonary resistances were calculated (fC 90 c X min-1, Pa 82 mmHg, Pra 4.7 mmHg, Ppa 24 mmHg, Ppw 11.6 mmHg, Q 4.45 l X min-1 and Rsa 1460 dyn X s X cm-5). The swine were then bled. After a bleed of 250 ml (t1), the haemodynamic parameters were significantly modified. After another bleed of 250 ml (t2), the heart rate only was significantly higher than at t1; but the blood transfusing could not re-establish a normal haemodynamic state. Blood samples were obtained to measure pH and total CO2 in a systemic artery, and the upper hepatic veins, vena cava and portal vein: the results suggested that the liver took part in the removal of acid metabolites.     

Effet de l''administration continue de nimodipine à la phase aiguë d''un traumatisme médullaire chez le babouin

This study was carried out to assess the putative improvement of spinal cord blood flow obtained with a calcium channel blocker after acute spinal cord injury in ten baboons. The injury was generated by compressing the cord at L1 level for 5 seconds with a balloon catheter inflated to 2 bars with Ringer's solution. Subsequently, five monkeys received a saline infusion, and five others a nimodipine infusion (0.04 mg.kg-1 x h-1), for seven days. Spinal cord blood flow (SCBF) was measured using a scanographic technique with stable xenon. Somatosensory evoked potentials (SEP), magnetic resonance imaging (MRI) and a histological study of the spine were carried out a different times of the study. SCBF and SEP were recorded before injury. Thereafter SCBF was measured every thirty minutes during the four hours following the injury, as well as on day 7. SEP and MRI were recorded on days 1 and 7. The histological study was carried out on the eighth day. Three spinal cord and vertebral segments were collected, fixed, sliced and stained. SCBF before injury was not significantly different in either group (39.8 +/- 15.9 ml x 100 g-1 x min-1 for the treatment group 40.9 +/- 16.3 ml x 100 g-1 x min-1 for the control group). During the injury, there were major variations between animals. The results were expressed as percentages of each animal's control SCBF (before injury). Immediately after injury, SCBF increased in both groups. However, in the control group, SCBF decreased more than in the treatment group on the seventh day after injury (80 to 90% vs 25 to 50%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Optimisation de la prise en charge anesthésique en chirurgie abdominale urgente chez le sujet âgé

ObjectivesPeroperative haemodynamic profile comparison of two anaesthetic protocols for emergency abdominal surgery of old patients.Patients and methodsNon-randomized monocentric study. Patients in the Optimization group were prospectively studied. Anaesthesia was induced by etomidate–succinylcholine and maintained with effect site and end-tidal target controlled administration of remifentanil and desflurane respectively to keep the BIS values between 45 and 55. These patients were matched with retrospectively studied patients constituting the Control group. The latter's were anaesthetized with etomidate–succinylcholine and anaesthesia was maintained by manually controlled administration of sufentanil and desflurane to keep systolic arterial pressure (SAP) within a range of more or less 30% of preoperative baseline SAP.ResultsTwelve patients (86 ± 5 yrs) were included in the Optimization group, 11 (86 ± 4 yrs) in the Control group. The time spent at a SAP within more or less 30% of baseline values was 92 ± 7% and 71 ± 29% of total anesthesia time in the Optimization and Control groups respectively (p < 0.05). That spent at a SAP less than 15 and 30% of baseline values was 23 ± 11% et 3 ± 5% of total anaesthesia time in the Optimization group, whereas in the MAN group it was 65 ± 21% and 27 ± 30% respectively (p < 0.05). Desflurane and ephedrine consumption was less in the Optimization group as well as crystalloid or colloid volume loading.ConclusionAnaesthetic agents target controlled administration and/or neurophysiologic depth of anaesthesia monitoring improve the time course of the haemodynamic effects in elderly patients undergoing abdominal surgery in emergency.     

Les facteurs associés à l'évolution de la sciatique commune. À propos de 1092 cas

La sciatique commune constitue par sa fréquence et son retentissement socioprofessionnel un problème de santé publique.Méthode. – À travers une étude rétrospective de 1092 cas de sciatique commune, nous précisons les caractéristiques épidémiologiques, cliniques, radiologiques et thérapeutiques et nous cherchons les facteurs associés à une mauvaise évolution afin de mieux apprécier le pronostic de cette affection.Résultats. – L'âge moyen de nos patients est de 45,0 ± 13,3 ans avec une prédominance féminine (61,8 % des cas). Les antécédents de lombalgies sont notés dans 35,2 % des cas. La sciatique est mono-radiculaire dans 68 % des cas et touche essentiellement la racine L5. La cause de la sciatique est une hernie discale dans 58,4 % des cas. Le traitement médical initial est efficace dans 75 % des cas. À six mois, le résultat de tous les traitements confondus est satisfaisant dans 76,5 % des cas.Conclusion. – Pour l'ensemble de la série, et en étude multivariée, les facteurs associés à une mauvaise évolution à six mois de recul sont : le travail de force (p = 0,049, Odds ratio (OR) = 1,69 ; IC = [1,01–2,86]) et l'obésité (p = 0,05, OR = 1,5 ; IC = [1,01–2,47]).As an extremely common symptom and major source of lost productivity, mechanical sciatica places a heavy burden on public health.Methods. – We retrospectively reviewed 1092 medical records to determine the epidemiological, clinical, imaging study, and therapeutic characteristics of mechanical sciatica. We also looked for factors associated with adverse outcomes.Results. – Mean patient age was 45.0 ± 13.3 years, and 61.8% of patients were women. A history of low back pain was noted in 35.2% of cases. A single nerve root was involved in 68% of cases, and L5 was the most commonly affected root. Disk herniation was the cause in 58.4% of patients. First-line conservative treatment provided relief in 75% of cases, and the overall 6-month outcome was favorable in 76.5% of cases.Conclusion. – The multivariate analysis conducted in the overall patient population showed that factors associated with adverse 6-month outcomes were heavy labor (odds ratio [OR], 1.69; 95% confidence interval [95% CI], 1.01–2.86; P = 0.049) and obesity (OR, 1.5; 95% CI, 1.01–2.47; P = 0.05).     

Le midazolam comme agent de prémédication intramusculaire: Définition des posologies en fonction de l'âge

In order to determine the optimal posology of midazolam as an intramuscular premedicant according to age, three groups of 25 patients were constituted. The mean age of group 1 receiving 0.12 mg · kg⁻¹, was 31.6 ± 7.3 years, the mean age of group 2, receiving 0.16 mg · kg⁻¹, was 31.8 ± 7.6 years and the mean age of group 3, receiving 0.10 mg · kg⁻¹, was 73.8 ± 8.2 years. The results were the following : sedation of anxiety was good or very good in respectively 80 p. 100 and 95 p. 100 of patients in groups 2 and 3, versus 48 p. 100 in group 1; a reversible sleep was obtained in 18 p. 100 of cases in group 2 and 44 p. 100 in group 3; no patient was asleep in group 1; overall clinical results were found satisfactory in 80 p. 100 of patients in group 2, and 95 p. 100 in group 3 versus 48 p. 100 in group 1.Neither incident nor adverse reactions were to be reported. There was no modification in respiratory rate; the slight hemodynamic modifications which appeared can be attributed to atropin sulfate administered together with midazolam. In conclusion, the appropriate posology of midazolam administered intra-muscularly decreases with age, from 0.16 mg · kg⁻¹ for the thirty years old patients to 0.10 mg · kg⁻¹ for the seventy years old patients. Midazolam exhibits a remarkable cardiorespiratory neutrality event in the elderly.     

Organisation de l’anesthésie des enfants dans un hôpital non pédiatrique

The author reviews the guidelines and the possible organization of anaesthesia and surgery in a non-paediatric hospital.     

Enquête européenne sur la pratique de la simulation médicale pédiatrique

ObjectiveTo present the effective applications of paediatric medical simulation in terms of education, evaluation, density, development, goals and constraints.Study designSurvey realized within 38 paediatric simulation centres (PSC) in Europe, identified by Web search and through the Society in Europe for Simulation Applied to Medicine (SESAM^©).ResultsTwenty centers answered the questionnaire (52%). Ninety-four percent of the PSC had beforehand acquired an experience of adult medical simulation, 94.6% of the PSC were created before 2006. Ninety percent of the PSC owned at least one high-fidelity pediatric simulator. The 80% of the PSC indicated multiple funding sources. Eighty percent of the PSC had at least one specific instructor for the paediatric simulation (average = 2.7 paediatric instructors per centre). The PCS reported to get onto various topics: neonatology (25% of the PCS), prehospital medicine (36.8%), paediatric anaesthesiology (74%) and paediatric intensive care (89%). Simulation allowed 70% of the centers to lead some research project. Ninety-five percent of the centers agreed about an European collaboration on research projects or about the mutualization of the created scenarios.ConclusionThe material, financial and human means of the interviewed centres are consequential but heterogeneous in Europe. MSP offers numerous and various application fields and generates some research activity.