Christophe Baillard

L’anesthésie loco-régionale neuraxiale ne devrait plus être utilisée en chirurgie vasculaire

RésuméObjectif: La pratique de l’anesthésie loco-régionale neuraxiale (ALR-N) en chirurgie vasculaire chez un patient anticoagulé et souvent exposé à un traitement antiplaquettaire est discutée en termes de bénéfices et de risques.Constatations principales: Proposer une ALR-N en chirurgie vasculaire consiste à accorder à cette technique un bénéfice médical net pour le patient.Le risque hémorragique de l’ALR-N réalisée chez les patients anti-coagulés et/ou sous anti-agrégeant n’est plus à démontrer. Les anticoagulants augmentent le risque d’hématome péri-médullaire et il est à présent déconseillé de réaliser une ALR-N chez un patient qui est ou va être anti-coagulé efficacement. En chirurgie vasculaire, l’utilisation de ces traitements est la règle, ceux-ci répondant à une nécessité chirurgicale et fréquemment médicale. Les traitements anti-agrégeants ne peuvent être interrompus pendant la période péri-opératoire sans risquer de nuire à l’état cardiovasculaire des patients. En outre leur maintien ou leur introduction favorise la perméabilité des pontages vasculaires. Leur association au traitement anticoagulant majore de fait le risque hémorragique.En terme de morbidité et de mortalité péri-opératoire vasculaire, la péridurale ou la rachianesthésie n’ont jamais vraiment fait la preuve de leur supériorité sur l’anesthésie générale, sans que cet avantage potentiel ne soit toutefois définitivement exclu. La réduction de la morbi-mortalité liée à l’anesthésie générale laisse néanmoins peu d’espoir d’objectiver un jour une différence.Conclusion: Le choix d’une ALR-N ne peut désormais se concevoir que dans un nombre très limité de cas et ne peut donc être envisagée qu’au cas par cas en chirurgie vasculaire, en adoptant, à chaque fois, un raisonnement de type bénéfice-risque.AbstractObjectives: Neuraxial blockade (spinal or epidural anesthesia) is still widely used in patients undergoing vascular surgery. However, the combined administration of anticoagulants and antiplatelet agents may compromise the safety of this technique with regards to the potential occurrence of a spinal or of an epidural hematoma. We review the benefits and risks of neuraxial blockade in light of the evolution of anticoagulation for vascular surgery.Main findings: Vascular surgery generally requires a high level of intraoperative anticoagulation. An increasing number of patients are also treated pre and post-operatively with antiplatelet agents. Their administration cannot be interrupted without serious risks to the patients’ cardiovascular system and, further their continued use during surgery may improve graft permeability. Recent reports have emphasized the danger of neuraxial anesthesia in patients receiving low dose anticoagulation. So, high doses of heparins should carry an ever higher risk of serious complications in patients undergoing neuraxial blockade. Furthermore, no published data has ever demonstrated convincingly the benefit of either epidural or spinal anesthesia over general anesthesia. No differences have ever been documented in terms of cardio-vascular morbidity, graft patency, and mortality.Conclusion: Routine neuraxial blockade cannot be recommended in patients undergoing vascular surgery. The decision to perform a neuraxial block in such a patient may only be taken on a case by case basis, after careful consideration of expected benefits and potential risks.

Inappropriate adrenoreceptor blockade prior to phaeochromocytoma removal is perhaps a ‘timely reappraisal’?

Hôpitaux de Paris, Biĉetre Hospital, Le Kremlin Biĉetre, France, †Department of Molecular Genetics and Hormonology, Assistance Publique-Hôpitaux de Paris, Biĉetre Hospital, Le Kremlin Biĉetre, France, ‡University of Paris-Sud, Le Kremlin Biĉetre, France, §INSERM UMR-1185, Le Kremlin Biĉetre, France and ¶Otorhinolaryngology Department, Bicêtre Hospital, Le Kremlin Bicêtre, France E-mail: jacques.young@aphp.fr

Laparoscopic Adrenalectomy in Elderly Patients

With increase life expectancy, surgical indications in elderly become more frequent. The aim of this study was to analyze indications and outcome of laparoscopic adrenalectomy in patients over 75. Between 1994 and 2014, 641 patients underwent laparoscopic adrenalectomy. Preoperatively, all patients had a standardized preoperative work-up. Patients over 75 were compared with a control group of younger patients. The median age was 52 years (41 to 61) and 3.6% of patients (n=23) were over 75. Patients over 75 were more frequently operated for malignant lesion (21.7% vs. 4.7%; P=0.005). There was no postoperative mortality. Conversion rate was 3.4% (n=22), with no significant difference between the groups. The overall morbidity and severe morbidity rates were, respectively, 16.9% and 3.3%, with no significant difference between the groups. In experienced team and for selected patients, laparoscopic adrenalectomy after 75 years is safe, without increased postoperative morbidity, as compared with younger population.

Impact of Video Technology for Improving Success of Medial Canthus Episcleral Anesthesia in Ophthalmology

Background and Objectives Efficient learning of regional anesthesia in ophthalmology remains challenging because trainees are afforded limited opportunity to practice ocular anesthesia. The aim of this prospective, randomized, blinded study was to determine whether teaching with video improves regional anesthesia skills of residents in ophthalmology. Methods From January to October 2016, 32 novice anesthesiology residents were evaluated while performing medial canthus episcleral procedures during a 5-day rotation. Residents were randomly assigned to either receive or not receive a video review of their performance at day 3. The primary outcome was a comparison of akinesia using a 12-point scale before incision assessed by the blinded surgeon. Results A total of 288 blocks were performed by 32 residents and were assessed by 3 surgeons before the intervention (144 blocks) and after the intervention (144 blocks). Residents in the review group improved to a greater degree compared with residents in the no-review group. The median overall akinesia scores for the review and no-review groups were similarly low (6; interquartile range [IQR], 2–11; and 6 [IQR, 2–9], respectively) on day 1 of the rotation, whereas anesthesia performed by residents in the video group provided a better akinesia score (12 [IQR, 10–12] vs 8 [IQR, 6–10]; P < 0.001) on day 5 of the rotation. Conclusions Video-assisted teaching significantly improves performance of medial canthus episcleral anesthesia performed by novice trainees.