B. Vivien

Peribulbar versus retrobulbar anesthesia for ophthalmic surgery: an anatomical comparison of extraconal and intraconal injections.

BackgroundPeribulbar and retrobulbar anesthesia have long been opposed on the basis of the existence of an intermuscular membrane, which is supposed to separate the intraconal from the extraconal spaces in a water-tight fashion. A local anesthetic injected outside the cone should spread through this septum to reach the nerves to be blocked. The existence of this septum is questioned. The aim of this study was to compare the spread of a colored latex dye injected intraconally or extraconally to simulate both retrobulbar and peribulbar anesthesia. MethodsThe authors used 10 heads from human cadavers. For each head, one eye was injected intraconally, and the other eye was injected extraconally. The heads were then frozen and sectioned into thin slices following various planes. They were then photographed and observed. ResultsThere was no evidence of the existence of an intermuscular septum separating the intraconal and extraconal spaces. Those two spaces appeared to be part of a common spreading space, the corpus adiposum of the orbit. ConclusionsThese results are in accord with the fact that clinical studies were not able to clearly demonstrate that retrobulbar anesthesia is more efficient than peribulbar anesthesia. On the basis of a similar clinical efficacy of the two techniques as a result of similar spreading of the local anesthetic injected, and a potentially higher risk of introducing the needle into the muscular cone, the authors recommend replacing retrobulbar anesthesia with peribulbar anesthesia.

Ophthalmic regional anesthesia: medial canthus episcleral (sub-tenon) anesthesia is more efficient than peribulbar anesthesia: A double-blind randomized study.

Background Regional anesthesia and especially peribulbar anesthesia commonly is used for cataract surgery. Failure rates and need for reinjection remains high, however, with peribulbar anesthesia. Single-injection high-volume medial canthus episcleral (sub–Tenon’s) anesthesia has proven to be an efficient and safe alternative to peribulbar anesthesia. Methods The authors, in a blind study, compared the effectiveness of both techniques in 66 patients randomly assigned to episcleral anesthesia or single-injection peribulbar anesthesia. Motor blockade (akinesia) was used as the main index of anesthesia effectiveness. It was assessed using an 18-point scale (0–3 for each of the four directions of the gaze, lid opening, and lid closing, the total being from 0 = normal mobility to 18 = no movement at all). This score was compared between the groups 1, 5, 10, and 15 min after injection and at the end of the surgical procedures. Time to onset of the blockade also was compared between the two groups, as was the incidence of incomplete blockade with a need for supplemental injection and the satisfaction of the surgeon, patient, and anesthesiologist. Results Episcleral anesthesia provided a quicker onset of anesthesia, a better akinesia score, and a lower rate of incomplete blockade necessitating reinjection (0 vs. 39%;P < 0.0001) than peribulbar anesthesia. Even after supplemental injection, peribulbar anesthesia had a lower akinesia score than did episcleral anesthesia. Peribulbar anesthesia began to wear off during surgery, whereas episcleral anesthesia did not. Conclusion Medial canthus single-injection episcleral anesthesia is a suitable alternative to peribulbar anesthesia. It provides better akinesia, with a quicker onset and more constancy in effectiveness.

Medial canthus episcleral (sub‐Tenon) anesthesia imaging

Medial canthus single injection periocular anesthesia is an alternative technique to classical regional anesthesia techniques for cataract surgery. The occurrence of a chemosis at the end of this injection has made us question ourselves about the real site of injection. The purpose of this anatomic study was to identify this site with precision, and to describe the spreading of the injected solution. Various volumes of colored liquid latex were injected when using this technique on 10 human orbits. They were deeply frozen and sectioned in thin slices. The site of injection is clearly the episceral (sub‐Tenon) space. This is a gliding space through which pass the ciliary nerves supplying the globe sensitivity. This could explain the high quality of the analgesia of the globe. With the larger volumes injected, spreading of the latex was detected in the orbicularis palpebra. This probably explains the good akinesia of the lids obtained without any facial block. Spreading of the latex to the rectus muscles sheaths should explain the good akinesia of the globe, but was only partially proved in this study. We conclude that the medial canthus single injection periocular anesthesia is an episcleral (sub‐Tenon) injection which may explain good anesthesia. Clin. Anat. 11:390–395, 1998.

Sédation et analgésie en structure d’urgence. Réactualisation 2010 de la Conférence d’experts de la Sfar de 1999

Sedation and analgesia in emergency structure. Reactualization 2010 of the Conference of Experts of Sfar of 1999 B. Vivien *, F. Adnet , V. Bounes , G. Chéron , X. Combes , J.-S. David , J.-F. Diependaele , J.-J. Eledjam , B. Eon , J.-P. Fontaine , M. Freysz , P. Michelet , G. Orliaguet , A. Puidupin , A. Ricard-Hibon , B. Riou , E. Wiel , J.-E. de La Coussaye o,4,** a Samu de Paris, département d’anesthésie-réanimation, hôpital Necker–Enfants-Malades, université Paris Descartes–Paris-5, 149, rue de Sèvres, 75730 Paris cedex 15, France b EA 3409, Samu 93, hôpital Avicenne, université Paris-13, 125, rue de Stalingrad, 93009 Bobigny, France c Samu 31, pôle de médecine d’urgences, hôpitaux universitaires, université de Toulouse, 1, avenue Jean-Poulhès, place du Dr.Baylac, 31059 Toulouse cedex 9, France d Département des urgences pédiatriques, hôpital Necker–Enfants-Malades, université Paris Descartes–Paris-5, 149, rue de Sèvres, 75730 Paris cedex 15, France e Département d’anesthésie-réanimation-urgences, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69493 Pierre-Bénite, France f Smur pédiatrique régional de Lille, centre hospitalier régional universitaire de Lille, université Lille-2, Nord-de-France, 5, avenue Oscar-Lambret, 59037 Lille cedex, France g Structure des urgences, hôpital Lapeyronie, université 1, 191, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France h Pôle réanimation urgence, service d’aide médicale urgente hyperbarie (RUSH), réanimation des urgences, CHU de SainteMarguerite, 270, boulevard Sainte-Marguerite, 13009 Marseille, France i Service d’accueil des urgences, hôpital Saint-Louis, université Paris-7, 1, avenue Claude-Vellefaux, 75010 Paris, France j Samu 21, département d’anesthésie-réanimation, centre hospitalier universitaire de Dijon, faculté de médecine, 3, rue du Faubourg-Raines, BP 1519, 21033 Dijon cedex, France Annales Françaises d’Anesthésie et de Réanimation 31 (2012) 391–404

Severity assessment in trauma patient.

Severity assessment in trauma patients is mandatory. It started during initial phone call that alerts emergency services when a trauma occurred. On-call physician assesses severity based on witness-provided information, to adapt emergency response (paramedics, emergency physicians). Initial severity assessment is subsequently improved based on first-responder provided informations. Whenever information comes, it helps providing adequate therapeutics and orientating the patient to the appropriate hospital. Severity assessment is based upon pre-trauma medical conditions, mechanism of injury, anatomical lesions and their consequences on physiology. Severity information can be summarized using scores, yet those are not used in France, except for post-hoc scientific purposes. Triage is usually performed using algorithms. Whatever the way triage is performed, triage tools are based on mortality as main judgement criterion. Other criteria should be considered, such as therapeutics requirements. The benefit of biomarkers of ultrasonography at prehospital setting remains to be assessed.

Sédation et analgésie en structure d’urgence. Jusqu’où ne pas aller trop loin ?

C’est en 1999–2000 que la Société française d’anesthésie et de réanimation (Sfar) publie la première Conférence d’experts sur la « Sédation et/ou l’analgésie en situation extrahospitalière » [1]. Celle-ci recommandait notamment l’utilisation de l’induction en séquence rapide pour intuber le patient en service mobile d’urgence et de réanimation (Smur), que le médecin présent soit anesthésiste-réanimateur ou médecin urgentiste. Alors que bien souvent la connaissance de recommandations officielles par les médecins de la discipline concernée atteint péniblement les 10 %, celle-ci est connue d’environ 70 % des médecins urgentistes [2]. En effet, le choix s’était basé sur le principe médical simple de la meilleure efficience pour le malade et non pas sur l’autorisation d’utiliser des techniques moins efficaces, mais transférables à une autre discipline. L’appropriation de ces techniques par les médecins urgentistes a été réalisée grâce à l’application des recommandations de la Conférence d’experts en se donnant les moyens de formation, notamment par l’intermédiaire des collèges régionaux. Si l’on a souvent considéré qu’il s’agissait d’un transfert de compétences, il convient de rappeler que celui-ci n’existe pas entre médecins : c’est le savoir qui est partagé pour que chacun aboutisse à la connaissance. On peut être reconnaissant à la Sfar d’avoir accepté et accompagné cette conférence d’experts quelque peu polémique à l’époque. Depuis, les mentalités ont changé, les anciennes sociétés savantes de l’urgence ont fusionné pour créer l’actuelle Société française de médecine d’urgence (SFMU), une nouvelle discipline, la médecine d’urgence, est née, basée sur l’exercice à la fois préet intrahospitalier. La Conférence d’experts vieillissait et surtout elle ne concernait que la partie préhospitalière de la spécialité. Dans un numéro récent des Annales françaises de médecine d’urgence, Légaut et al. [3] témoignent de cette évolution des pratiques. Ces

Epinephrine administration in non-shockable out-of-hospital cardiac arrest

Background Epinephrine is recommended for the treatment of non‐shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate. Objective We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30 min of advanced life support (ALS). Methodology A retrospective observational cohort study using the Paris SAMU 75 registry including all non‐traumatic OHCA. All OHCA receiving epinephrine during the first 30 min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports. Results Among 1532 patients with OHCA, 776 (51%) had initial non‐shockable rhythm. Fifty‐four patients were excluded for missing data. The mean value of cumulative dose of epinephrine was 10 ± 4 mg in patients who failed to achieve ROSC (ROSC−) and 4 ± 3 mg (p = 0.04) for those who achieved ROSC. ROC curve analysis indicated a cut‐off point of 7 mg total cumulative epinephrine associated with ROSC− (AUC = 0.89 [0.86–0.92]). Using propensity score analysis including age, sex and no‐flow duration, association with ROSC− only remained significant for epinephrine > 7 mg (p ≤10–3, OR [CI95] = 1.53 [1.42–1.65]). Conclusion An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC− was reported with a threshold of 7 mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30 min of ALS.