Non-invasive ventilation after surgery

After surgery, hypoxemia and/or acute respiratory failure (ARF) mainly develop following abdominal and/or thoracic surgery. Anesthesia, postoperative pain and surgery will induce respiratory modifications: hypoxemia, pulmonary volumes decrease and atelectasis associated to a restrictif syndrome and a diaphragm dysfunction. Maintenance of adequate oxygenation in the postoperative period is of major importance, especially when pulmonary complications such as ARF occur. Although invasive endotracheal mechanical ventilation has remained the cornerstone of ventilatory strategy for many years for severe acute respiratory failure, several studies have shown that mortality associated with pulmonary disease is largely related to complications of postoperative reintubation and mechanical ventilation. Therefore, major objectives for anesthesiologists and surgeons are first to prevent the occurrence of postoperative complications and second if ARF occurs is to ensure oxygen administration and carbon dioxide CO₂ removal while avoiding intubation. Non-invasive ventilation (NIV) does not require endotracheal tube or tracheotomy and its use is well established to prevent ARF occurrence (prophylactic treatment) or to treat ARF to avoid reintubation (curative treatment). Studies shows that patient-related risk factors, such as chronic obstructive pulmonary disease (COPD), age older than 60 years, American Society of Anesthesiologists ASA class of II or higher, obesity, functional dependence, and congestive heart failure, increase the risk for postoperative pulmonary complications. Rationale for postoperative NIV use is the same as the post-extubation NIV use plus the specificities due to the respiratory modifications induced by the surgery and anesthesia. Postoperative NIV improves gas exchange, decreases work of breathing and reduces atelectasis. The aims of this article are (1) to review the main respiratory modifications induced by surgery and anesthesia which justify postoperative NIV use (2) to offer some recommendations to apply safely postoperative NIV and (3) to present the main results obtained with preventive and curative NIV in a surgical context.     

Enquête de pratique sur l’analgésie péridurale en dehors de l’obstétrique

Objectives

To describe the current use of epidural anesthesia (EA) apart from obstetrics, and to explain the reasons of its low utilization.

Study design

Observational study.

Methods

A survey of practice with a self-questionnaire was sent by e-mail and available on Internet. Answers were compared between groups doing or not an epidural analgesia with exact Fisher tests (P < 0.05 statistically significant).

Results

Among the 176 anesthesiologists who answered to the questionnaire, only 21.4% never used epidural analgesia. The main reasons were alternatives therapeutics such as PCA with opioids or TAP block (24/38 vs. 46/140). TAP block was the most common alternative used by more than 50% of anesthesiologists. Loss of competence (4/30 vs. 0/39) was rarely the reason to its low utilization. The low accessibility to specialized postoperative units was recognized in both groups as a limiting factor to do an epidural but not the fear of neurological complications. Those who never perform epidural analgesia were statistically more often physicians between 40 and 50 years (12/38 vs. 19/140). Heparin, aspirin and clopidogrel are no longer contraindications according to anesthesiologists less than 40 years old (50/68 vs. 31/68; 44/68 vs. 31/68; 37/68 vs. 23/68 respectively) but not for older.

Conclusions

Epidural analgesia is performed more often by younger anesthesiologists. This survey suggests the need of specific postoperative area to allow anesthesiologist to perform and supervise safely this technique. Recommendations of the French society of Anesthesiologists are also poorly applied.     

Intubation difficile : il faut suivre les recommandations

Intubation and ventilation impossible mask is a dramatic situation with potentially serious consequences. We report the case of a patient of 43 years, followed for a goiter, which was scheduled for a total thyroidectomy under general anesthesia. Preoperative evaluation is not noted signs of compression or tracheal deviation, and there were no criteria predictive of intubation or difficult mask ventilation. The induction of anesthesia was standard. Mask ventilation was effective allowing paralysis. The standard laryngoscopy showed a score of Cormack and Lehane grade IV. Several attempts at intubation were made leading to a situation of intubation and ventilation impossible mask with deep desaturation. A tracheostomy was done urgently. The patient was operated on, six months later, with a fiber optic intubation. Through this case, the authors draw attention to the difficulty of achieving an emergency tracheotomy in the presence of goiter and emphasize the need for integration of different modes of learning and retention of management skills of the upper airway.     

Anesthetic management of 52 deliveries in parturients with idiopathic thrombocytopenic purpura

Objectives

To study the anesthetic management of parturients with idiopathic thrombocytopenic purpura (ITP) which is a frequent cause of thrombocytopenia in pregnant women and may lead to a dilemma since a low platelet count usually dictates not to perform epidural anesthesia.

Materials and methods

We report a retrospective study assessing the anesthetic management of 39 parturients with ITP corresponding to 52 deliveries found in a database of 10,203 deliveries over a 52-month-period.

Results

On the day of delivery, 32 parturients (61.5%) had a platelet count less than 100,000/mm³ and 19 (36.5%) received a neuraxial block. Six parturients with a platelet count less than 100,000 mm³ (19%) received neuraxial analgesia. The lowest platelet count among women who received epidural analgesia was 88,000/mm³. No anesthetic or neurological complication occurred.

Conclusion

Regional anesthesia should not necessary be withheld in ITP when the platelet count is less than 100,000/mm³.     

Hypokaliemic periodic paralysis and pregnancy: perinatal management. A case report

Familial hypokalemic periodic paralysis (FHPP) is a rare inherited disease characterized by a dysfunction of the membrane ion channels. Clinical manifestations are attacks of hypokaliemia with flaccid muscle paralysis. Paralysis is sometimes severe but always reversible with symptomatic treatment. Pregnancy and delivery have been reported to exacerbate FHPP. Authors report a case of FHPP during pregnancy with a favourable outcome. Vaginal delivery is usually possible with monitoring and epidural analgesia, avoiding active maternal expulsive efforts (passive descent of the fetus and elective outlet forceps) and other stimulating factors (carbohydrate loads, maternal stress, betamimetics, epinephrine...). Administration of IV potassium supplementation is often necessary.     

Lidocaine intoxication in newborn following maternal pudendal anesthesia: report of three cases

Pudendal nerve block may be indicated during instrumental delivery in situations where peridural anesthesia is unavailable. We report three cases of neonatal lidocaine intoxication following maternal pudendal block during delivery. Clinical features were hypotonia, pupillary mydriasis fixed to light, apnea, cyanosis and seizures. Two neonates required mechanical ventilation. Lidocaine was found in the serum of two babies. In all three cases, recovery was complete. The pharmacokinetics of lidocaine in a highly vascularized perineum during labor increase the risk of neonatal intoxication. A possible intoxication by local anesthetics should be considered in neonates presenting an acute distress in the delivery room.     

Inhalation gastrique : épidémiologie et facteurs de risque

Objective

To determine the epidemiology and risk factors for gastric aspiration in a French university hospital.

Methods

Files were prospectively selected from a computer database of rare and severe complications between January 2002 et April 2007. Medical files were then analyzed according to a predetermined list of specific items.

Results

Forty patients suffered from gastric aspiration among 117 033 anaesthesias (4 medical files lost) (31/100,000 global incidence). All occurred during general anaesthesia, 83% at induction, 8% in the recovery room, half of the cases for emergent cases (15% of emergency). In emergency, the incidence of gastric aspiration increased by 4.5. Only 14 patients (39%) had a “full stomach”, 17 (47%) other risk factors and five (14%) none. A rapid induction–intubation sequence with a Sellick manoeuvre was performed in only 50% of patients with a full stomach and in 23.6% of those with other risk factors. Gastric aspiration occurred in three patients with a laryngeal mask. Aspiration was associated with clinical symptoms in 21 patients. Eleven patients developed an ARDS (5 deaths).

Discussion

The incidence of gastric aspiration was slightly higher in this series than in other published series. Rapid induction–intubation sequence with Sellick manoeuvre is not always used in patients with a full stomach. Restraining this technique only to these latter patients does not guarantee practionners to avoid the risk of gastric aspiration. There is a large need to define which patients are at higher risk of gastric aspiration by national recommendations of clinical practice.     

Enquête sur les pratiques françaises d’analgésie en chirurgie thoracique (réalisée avec le concours de l’ARCOTHOVA)

Objective

To assess the current practice of analgesia after thoracotomy and thoracoscopy in France.

Study design

Cross-sectional practice survey.

Material

Anaesthetist physicians, each referent for one of the French centres practicing thoracic surgery, during year 2012.

Methods

Electronic questionnaire about the activity of the centre in thoracic surgery, and modalities and estimated frequencies of different analgesic techniques. Primary assessment was the estimated percentage of acts, after imputation from original data.

Results

Eighty-four centres out of 103 (82 %) answered the questionnaire. Coupling locoregional to general anaesthesia involved 74 % of thoracotomies and 35 % of thoracoscopies. A practice (i.e. for more than 5 % of patients) of epidural analgesia was declared by 68 centres (81 %), and by 27 centres (32 %) for paravertebral block. The most current practices for epidural analgesia were: thoracic puncture, intraoperative initiation, ropivacaïne 0.2 % plus sufentanil, patient-controlled administration with infusion plus bolus, application more than 48 hrs post surgery. The practice rates for technique of paravertebral block were: Eason & Wyatt 34 %, ultrasound-guided 24 %, internal 42 %. The most frequent systemic analgesia was patient-controlled intravenous morphine. Ketamine was used in 60 % of the cases.

Conclusions

French practice of analgesia after thoracic surgery improved quality during the last decade, but more than one patient on four (compared to 8 % in UK) may have neither epidural nor paravertebral block, while such techniques are nowadays considered as standard.