Fabien Espitalier

Mandibular nerve block can improve intraoperative inferior alveolar nerve visualization during sagittal split mandibular osteotomy

INTRODUCTION The main procedure specific complication of sagittal split osteotomy of the mandibular ramus (SSOMR) is inferior alveolar nerve (IAN) injury. This can be produced by poor intraoperative visibility of the IAN due to bone bleeding. In our centre, mandibular nerve blocks (MNBs) are usually performed for intra- and post-operative analgesia. We observed that MNB seems to decrease intraoperative bleeding and thus to improve IAN visibility. Our study was performed to evaluate the effect of MNB on intraoperative bleeding during SSOMR and, secondarily, on the duration of this procedure. MATERIAL AND METHODS Patients scheduled for bilateral SSOMR under general anaesthesia were prospectively randomized into two groups. The Block group received bilateral MNB (5 mL ropivacaine 0.5% for each block) and the Control group sham MNBs (bilateral cutaneous puncture, without block). The operations were carried out under a standardised general anaesthetic. Post-operatively, the surgeon, blinded to group allocation, assessed intraoperative bone bleeding using a Numerical Rating Scale (NRS) (0: no bleeding, perfect visibility to 100: major bleeding, no visibility). Osteotomy duration, intraoperative anaesthetic requirements, and pain score in the recovery room were also recorded. Results are expressed as median [25-75th percentiles]. RESULTS Nineteen patients were included in each group. Osteotomy under MNB had a decreased intraoperative bone bleeding score compared with controls (20 [0-40] versus 55 [20-80], p=0.0002). They had a dry surgical field more frequently (29% versus 5%, p=0.01), and a shorter mean time for the osteotomy (15 [12.25-17.75] versus 17.5 [15-21]min, p=0.009). Block patients had reduced intraoperative opioid consumption (770 [678-1430] versus 2310 [1908-3058]mcg of remifentanil, p=0.0001), and lower pain scores in the recovery room (0 [0-2] versus 3 [1-5], p=0.12). CONCLUSION MNB decreases intraoperative bone bleeding during SSOMR under general anaesthesia. Three hypotheses to explain this result are discussed.

Glidescope versus Airtraq DL for double-lumen tracheal tube insertion in patients with a predicted or known difficult airway: A randomised study.

BACKGROUND Double-lumen tracheal tube (DLT) insertion can be managed with videolaryngoscopes such as the Glidescope or indirect laryngoscopes like the Airtraq DL. No study has compared both devices when a difficult intubation is predicted. OBJECTIVE Our hypothesis was that the Glidescope is superior to the Airtraq for double-lumen tube insertion in patients with a predicted or known difficult airway. DESIGN Randomised study. PATIENTS Adults scheduled for thoracic elective surgery, requiring one-lung ventilation with a predicted difficult intubation score of at least 7 (Arné risk index). INTERVENTION Between March 2014 and March 2015, adult patients, scheduled for elective thoracic surgery, requiring double-lumen tracheal tube placement, and with a predicted risk (evaluated preoperatively using the Arné score) or a history of difficult intubation, were allocated to a Glidescope or an Airtraq group. MAIN OUTCOME MEASURES The primary outcome was the overall success rate of tracheal intubation after two attempts. Secondary outcomes were success rates on the first attempt, duration of intubation, need for laryngeal pressure, Cormack and Lehane grade and side-effects. RESULTS Of 277 patients, 78 were predicted to have a difficult airway. Finally, 72 patients were enrolled. Neither the overall success rates of tracheal intubation [Glidescope group 31/36 (86%) versus Airtraq group 34/36 (94%), P = 0.43] nor the side-effects differed between groups. There was no difference concerning visualisation of the glottis using the Cormack and Lehane grade (P = 0.18) or intubation time [Glidescope group 67 s (49 to 90) versus Airtraq group 81 s (59 to 101), P = 0.28]. All patients with a previous history of difficult intubation were intubated successfully. CONCLUSION There is no difference in success rates of tracheal intubation with a double-lumen tube in patients with a predicted or known difficult airway when using either a Glidescope or Airtraq device. TRIAL REGISTRATION National register of the French National Agency for Medicines and Health Products Safety No. 2014-A00143-44.

Note techniqueBloc percutané du nerf mandibulaire à travers l’échancrure sigmoïdienne, guidé par neurostimulation, en chirurgie de la facePercutaneous mandibular nerve block using neuro-stimulation guiding through the sigmoid indentation in facial surgery

INTRODUCTION Mandibular nerve block is a simple and effective but rarely used technique. It decreases peri-operative pain in mandibular osteotomy. It improves surgical field visibility by decreasing bleeding. Mandibular nerve block allows cutaneous surgery without general anesthesia and is one of the alternative treatments for chronic facial pain. TECHNICAL NOTE The mandibular nerve is located using a needle connected to a neurostimulator. After local disinfection, a neurostimulation needle is inserted below the zygomatic arch, between the coronoid apophysis in front, and the condyle process in back, with a 45 to 60° angle. The needle is pushed to a 40 mm depth. Masticator muscle contraction confirms mandibular nerve stimulation. After a careful negative aspiration, 5 mL of ropivacaine 0.5% are injected slowly, and in increments. DISCUSSION The complications with this technique, such as failure or arterial puncture, are rare and limited if a nerve stimulator is used. Patients comfort is improved by intravenous remifentanil sedation in target control infusion mode, associated to prior use of prilocaine and lidocaine cutaneous cream.

Bloc percutané du nerf mandibulaire à travers l’échancrure sigmoïdienne, guidé par neurostimulation, en chirurgie de la face

INTRODUCTION Mandibular nerve block is a simple and effective but rarely used technique. It decreases peri-operative pain in mandibular osteotomy. It improves surgical field visibility by decreasing bleeding. Mandibular nerve block allows cutaneous surgery without general anesthesia and is one of the alternative treatments for chronic facial pain. TECHNICAL NOTE The mandibular nerve is located using a needle connected to a neurostimulator. After local disinfection, a neurostimulation needle is inserted below the zygomatic arch, between the coronoid apophysis in front, and the condyle process in back, with a 45 to 60° angle. The needle is pushed to a 40 mm depth. Masticator muscle contraction confirms mandibular nerve stimulation. After a careful negative aspiration, 5 mL of ropivacaine 0.5% are injected slowly, and in increments. DISCUSSION The complications with this technique, such as failure or arterial puncture, are rare and limited if a nerve stimulator is used. Patients comfort is improved by intravenous remifentanil sedation in target control infusion mode, associated to prior use of prilocaine and lidocaine cutaneous cream.

Therapeutic decision-making process in the intensive care unit: role of biological point-of-care testing.

*Corresponding author: Dr. Antoine Guillon, CHRU Tours, Service de Réanimation Polyvalente, CHRU Bretonneau, 2 Bd Tonnellé, 37044 Tours Cedex 9, France, Phone: +0033247471322, Fax: +0033247396536, E-mail: antoine.guillon@univ-tours.fr; and Université François Rabelais, Faculté de Médecine, Tours, France Adrien Auvet and Mai-Anh Nay: CHRU Tours, Service de Réanimation Polyvalente, Tours, France; CHRU Tours, Département d’Anesthésie et Réanimation, Tours, France; and Université François Rabelais, Faculté de Médecine, Tours, France Leslie Grammatico-Guillon: Université François Rabelais, Faculté de Médecine, Tours, France; and CHRU Tours, Service d’information médicale d’épidémiologie et d’économie de la santé, UREH, Tours, France Fabien Espitalier: CHRU Tours, Département d’Anesthésie et Réanimation, Tours, France Pierre-François Dequin: CHRU Tours, Service de Réanimation Polyvalente, Tours, France; and Université François Rabelais, Faculté de Médecine, Tours, France Letter to the Editor

Giant pseudoaneurysm of the left ventricle

SGB, MRA showed an enlarged STA trunk, and the anastomotic artery was detected. Magnetic resonance angiography demonstrated 20% higher signal intensity in the MCA at the anastomotic lesion (Fig. 1). During and after SGB, the patient’s neurological status did not change. Stellate ganglion block is a feasible way to increase the blood flow in the STA. Stellate ganglion block decreases cerebral vascular tone without affecting autoregulation or the capacity of cerebral blood vessels to react to changes in carbon dioxide concentrations. We applied SGB in our patient to increase the blood flow in the anastomotic lesion through the graft artery; we hypothesized that SGB could decrease cerebral vascular tone and prevent acute elevation of blood pressure in the MCA. The higher signal intensity in the STA and graft artery on MRA after SGB could be explained by the increased local blood flow. After SGB, signal intensity changes on MRA are mainly observed in the ipsilateral external cranial vessels and not in the ipsilateral internal cranial vessels, besides the ophthalmic artery. The higher signal intensity in the MCA after SGB in our patient indicated haemodynamic changes after the increase in blood flow in the anastomotic artery. Although increased MCA blood flow causes cerebral hyperperfusion in 18–24% patients after STA-MCA bypass for occlusive cerebrovascular disease, the increased STA blood flow in the graft artery did not cause cerebral hyperperfusion in our patient. This results in this patient emphasize the possible clinical application of SGB for improving blood flow in the graft artery and MCA after STA-MCA bypass without causing cerebral hyperperfusion.