J.-L. Bourgain

Postoperative pulmonary complications : epidural analgesia using bupivacaine and opioids versus parenteral opioids

BackgroundDifferent types of analgesia have been proposed for the prevention of postoperative respiratory complications. The aim of this prospective, double-blind randomized study was to compare the impact of epidural bupivacaine and opioids versus parenteral opioids on respiratory complications in patients who had undergone major abdominal surgery. MethodsOne hundred fifty-three patients undergoing abdominal surgery for cancer were randomly allocated to receive either general anesthesia with intravenous fentanyl and postoperative analgesia with subcutaneous morphine (SC group) or general anesthesia combined with epidural bupivacaine and epidural bupivacaine plus morphine for postoperative pain relief (EP group). Analgesia was tested on a visual analog pain scale. Pulmonary complications were evaluated according to clinical complications, chest radiographs, arterial blood gas analysis, and pulmonary function tests. The evaluation was carried out on the day before the operation and on the first 5 postoperative days. Particular attention also was paid to the episodes of arterial hypotension and hemoglobin oxygen de-saturation during the 1st postoperative night. ResultsPain relief was significantly better in the EP group than In the SC group (P < 0.05) especially during recovery and on the 1st and 2nd postoperative days. In the EP group, vital capacity decreased less on the 1st postoperative day (P < 0.05) and arterial oxygen tension was greater in the recovery room (P < 0.05). However, no statistically significant difference was observed between the SC and EP groups in the incidence of clinical pulmonary complications (31% and 27%, respectively) and radiographic chest abnormalities (52% and 46%, respectively). The EP group recovered intestinal function earlier (P < 0.05), but significantly more patients in this group had episodes of systolic hypotension (21% vs. 8%; P < 0.05) during the 1st postoperative night. The length of the hospital stay was similar in both groups of treatment. ConclusionsEpidural analgesia with a combination of local anesthetic and opioid improves patient comfort. However, this type of analgesia does not decrease the incidence of postoperative pulmonary complications, does not reduce the length of the hospital stay, and carries the risk of complications from episodic systemic hypotension.

Comparison of the intubating laryngeal mask airway with the fiberoptic intubation in anticipated difficult airway management.

Background The intubating laryngeal mask airway (ILMA; Fastrach ™; Laryngeal Mask Company, Henley-on-Thames, UK) may provide an alternative technique to fiberoptic intubation (FIB) to facilitate the management of the anticipated difficult airway. The authors therefore compared the effectiveness of the ILMA with FIB in patients with anticipated difficult intubation. Methods One hundred patients, with at least one difficult intubation criteria (Mallampati class III or IV, thyromental distance < 65 mm, interincisor distance < 35 mm) were enrolled (FIB group, n = 49; ILMA group, n = 51) in this prospective randomized study. Anesthesia was induced with propofol and maintained with alfentanil and propofol after an efficient mask ventilation has been demonstrated. The success of the technique (within three attempts), the number of attempts, duration of the successful attempt, and adverse events (oxygen saturation < 90%, bleeding) were recorded. Results The rate of successful tracheal intubation with ILMA was 94% and comparable with FIB (92%). The number of attempts and the time to succeed were not significantly different between groups. In case of failure of the first technique, the alternative technique always succeeded. Failures in FIB group were related to oxygen desaturation (oxygen saturation < 90%) and bleeding, and to previous cervical radiotherapy in the ILMA group. Adverse events occurred significantly more frequently in FIB group than in ILMA group (18 vs. 0%, P < 0.05). Conclusion The authors obtained a high success rate and comparable duration of tracheal intubation with ILMA and FIB techniques. In patients with previous cervical radiotherapy, the use of ILMA cannot be recommended. Nevertheless, the use of the ILMA was associated with fewer adverse events.

Stratégies et algorithmes de prise en charge d’une difficulté de contrôle des voies aériennes: Question 5☆

O. Langeron *, J.-L. Bourgain , O. Laccoureye , A. Legras , G. Orliaguet e a Département d’anesthésie-réanimation, hôpital de la Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, université Pierre-et-Marie-Curie, 47, boulevard de l’Hôpital, 75013 Paris, France b Département d’anesthésie-réanimation, institut Gustave-Roussy, 39, rue Camille-Desmoulins, 94805 Villejuif, France c Service d’ORL et de chirurgie cervicofaciale, hôpital européen Georges-Pompidou, université René-Descartes–Paris-V, 75015 Paris, France d Service de réanimation médicale, hôpital Bretonneau, 37000 Tours, France e Département d’anesthésie-réanimation, hôpital Necker, Assistance publique-Hôpitaux de Paris, université René-Descartes–Paris-V, 75015 Paris, France

A comparison of propofol and remifentanil target-controlled infusions to facilitate fiberoptic nasotracheal intubation.

INTRODUCTION: Successful fiberoptic intubation requires both patient comfort and good intubating conditions. In this study we compared the efficacy and ease of titration of propofol (P) and remifentanil (R) target-controlled infusions (TCI) during fiberoptic intubation. METHODS: Sixty patients requiring fiberoptic nasotracheal intubation were randomized to receive (P) or (R) effect-site TCI. After topical anesthesia, TCI was set to 2.5 &mgr;g/mL (P) or 1.5 ng/mL (R) then titrated by 1 &mgr;g/mL (P) or 0.5 ng/mL (R) increments according to patient reactions. Targets and level of sedation were recorded at each step as well as total dose, number of adjustments, intubating conditions, discomfort, and recall assessed after surgery. RESULTS: Intubation duration, success rate, and number of increments did not differ between groups. Intubating conditions were good in both groups, with a final target of 3.9 ± 1.4 &mgr;g/mL (P) or 2.4 ± 0.8 ng/mL (R) (total dose 142 ± 55 mg and 77 ± 27 &mgr;g, respectively). There was no difference in minimal Spo2 and maximal end-tidal CO2 after intubation. No laryngospasm or significant hemodynamic instability was observed. There was one major hypoxemia due to obstructive apnea in group P. Patients in group P were significantly more sedated and less cooperative. Recall was more frequent in group R, whereas pain scores were equally low in both groups. CONCLUSION: Both R and P TCI can be rapidly titrated to achieve good intubating conditions and patient comfort. R allows for more patient cooperation, making it safer when spontaneous ventilation is paramount.

Biting the laryngeal mask: an unusual cause of negative pressure pulmonary edema.

Purpose: To describe negative pressure pulmonary edema due to biting of the laryngeal mask tube at emergence from general anesthesia.Clinical features: A healthy patient underwent general anesthesia using a laryngeal mask airway and mechanical ventilation. During recovery, the patient strongly bit the laryngeal mask and made very forceful inspiratory efforts until the mask was removed. Five minutes later, the patient developed dyspnea and had an hemoptysis of 50 ml fresh blood. Chest radiograph showed bilateral alveolar infiltrates. Pharyngo-laryngeal examination was normal. Bronchoscopy revealed no injury but diffuse pink frothy edema fluid. Clinical examination and chest radiograph became normal after 12 hr of nasal oxygen therapy confirming airway obstruction as the most available cause of this pulmonary edema.Conclusion: Airway obstruction due to biting of a laryngeal mask tube may result in negative pressure pulmonary edema.RésuméObjectif: Décrire un œdème pulmonaire à pression négative causé par la morsure du tube du masque laryngé (ML) au réveil de l’anesthésie générale.Éléments cliniques: Un patient en santé a subi une anesthésie générale avec ML et ventilation artificielle. Pendant la récupération, il a fortement mordu le ML et a énergiquement tenté d’inspirer jusqu’au retrait du masque. Cinq minutes plus tard, il a développé une dyspnée et a présenté une hémoptysie de 50 ml de sang frais. La radiographie pulmonaire a montré des infiltrats alvéolaires bilatéraux. L’examen pharyngo-laryngé était normal. La bronchoscopie n’a révélé aucune lésion, mais des sérosités diffuses, rosées et spumeuses. L’examen clinique et la radiographie pulmonaire étaient normaux après 12 h d’oxygénothérapie nasale, confirmant ainsi l’obstruction des voies aériennes comme cause la plus probable de cet œdème pulmonaire.Conclusion: L’obstruction des voies aériennes causée par une morsure du tube du masque laryngé peut causer un œdème pulmonaire à pression négative.

Pressure‐controlled ventilation is superior to volume‐controlled ventilation with a laryngeal mask airway in children

Background:  This prospective, randomized, crossover study had two purposes: first, to determine whether pressure‐controlled ventilation (PCV) is safer than volume‐controlled ventilation (VCV) by preventing gastric insufflation in children ventilated through an laryngeal mask airway (LMA); second, to assess whether the measurement of LMA leak pressure (Pleak) is useful for preventing leakage during positive pressure ventilation (PPV).

Limits of laryngeal mask airway in patients after cervical or oral radiotherapy

PurposeTo test the efficacy of the LMA in patients with previous oral or cervical radiotherapy, without upper airway obstruction.MethodsIn nine patients after oral or cervical radiotherapy, efficiency of ventilation was assessed after induction of general anaesthesia and LMA insertion. Fibreoptic examination through the tube was performed to check the position of LMAResultsIn patients who had had oral radiotherapy, all five had limited mouth opening and in two, LMA insertion was difficult but permitted good ventilation. In the four patients who had had cervical radiotherapy, LMA insertion was easy but, in two, the lungs were difficult to ventilate and, in two, the lungs could not be ventilated and orotracheal intubation was required.ConclusionIn patients with limitation of mouth opening after oral radiotherapy, LMA may represent an alternative to tracheal intubation. In patient with cervical sclerosis after radiotherapy; the use of LMA should be avoided.RésuméObjectifTester l’efficacité du masque laryngé chez des patients ayant subi une radiothérapie orale ou cervicale, sans obstruction des voies aériennes supéneures.MéthodesChez neuf patients ayant subi de la radiothérapie, la qualité de la ventilation a été appréciée après induction de l’anesthésie générale. Une fibroscopie à travers le tube a été effectuée pour apprécier la position du masque laryngé.RésultatsChez les patients qui ont eu une radiothérapie orale, cinq avaient une limitation de l’ouverture de bouche. Chez deux d’entre eux, la pose du masque a été difficile mais a permis une bonne ventilation. Chez les quatre patients ayant eu une radiothérapie cervicale, la pose a été facile; la ventilation a été difficile chez deux d’entre eux et impossible chez les deux autres, nécessitant l’intubation trachéale.ConclusionChez les patients ayant une limitation de l’ouverture buccale après radiothérapie orale, le masque laryngé peut être une alternative à l’intubation. Chez les patients ayant une sclérose cervicale après radiothérapie de sclérose cervicale consécutive à la radiothérapie, il faut éviter d’utiliser le masque laryngé.

[Difficult airway algorithms and management: question 5. Société Française d'Anesthésie et de Réanimation].

O. Langeron *, J.-L. Bourgain , O. Laccoureye , A. Legras , G. Orliaguet e a Département d’anesthésie-réanimation, hôpital de la Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, université Pierre-et-Marie-Curie, 47, boulevard de l’Hôpital, 75013 Paris, France b Département d’anesthésie-réanimation, institut Gustave-Roussy, 39, rue Camille-Desmoulins, 94805 Villejuif, France c Service d’ORL et de chirurgie cervicofaciale, hôpital européen Georges-Pompidou, université René-Descartes–Paris-V, 75015 Paris, France d Service de réanimation médicale, hôpital Bretonneau, 37000 Tours, France e Département d’anesthésie-réanimation, hôpital Necker, Assistance publique-Hôpitaux de Paris, université René-Descartes–Paris-V, 75015 Paris, France

Pour ou contre les circuits anesthésiques accessoires. II. Arguments contre leur utilisation

When compared to the circle system alternative breathing systems (ABS) are of no benefit. When the only indication of an ABS is emergency oxygen administration it should be connected to the O2 pipeline upstream from the flowmeter bank and the vaporiser. The use of an ABS for anaesthesia maintenance is no longer justified because of the difficulties in monitoring pressure, flow and concentrations of the gas mixture, the cost of gas and vapour administered at a high flow and the resulting pollution. The use of an ABS for very short anaesthetics is only acceptable if the administered gas mixture is monitored.When compared to the circle system alternative breathing systems (ABS) are of no benefit. When the only indication of an ABS is emergency oxygen administration it should be connected to the O2 pipeline upstream from the flowmeter bank and the vaporiser. The use of an ABS for anaesthesia maintenance is no longer justified because of the difficulties in monitoring pressure, flow and concentrations of the gas mixture, the cost of gas and vapour administered at a high flow and the resulting pollution. The use of an ABS for very short anaesthetics is only acceptable if the administered gas mixture is monitored.

Respiratory mechanics in anaesthetised patients after neostigmine-atropine. A comparison between patients with and without chronic obstructive pulmonary disease

The aim of this study was to compare the effects of pharmacological reversal of neuromuscular blockade on static compliance and resistance in patients with and without chronic obstructive pulmonary disease (COPD). Twenty patients were studied: 12 patients were free of respiratory disease (NCOPD) and had normal pulmonary function tests. Eight subjects (COPD) had a clinical history of chronic bronchitis and a FEV1 < 70% of the predicted value. All patients were anaesthetised with a continuous infusion of methohexitone and alfentanil. Airway pressure (Paw) was recorded continuously. Static compliance (Crs) was calculated from the relationship between 21 syringe volume (250 ml step) and Paw. Total respiratory resistance (Rrs) was measured at two levels of inspiratory flow and tidal volume. These measurements were made before vecuronium (control), after injection of vecuronium to abolish the first neuromuscular response to train of four, 5 and 15 min after administration of neostigmine 40 μgkg‐1 and atropine 10 μg kg‐1. In COPD patients Crs and Rrs were significantly greater (1450 ± 580 ml kPa‐1 and 1.06 ± 0.68 kPa l‐1 ‐s‐1) than in normal patients (1000±380 ml‐kPa‐1 and 0.58 ± 0.22 kPa‐1‐l‐s‐1) (P < 0.01). In both groups Crs and end‐expiratory pulmonary volume were similar before injection of vecuronium and after neostigmine‐atropine administration. In both groups, Rrs was not altered significantly by neostigmine‐atropine for the two inspiratory flows. These results suggest that neostigmine‐atropine mixture is associated with small changes in respiratory mechanics, and the changes are similar in COPD compared with normal patients.