Laurie Putz

Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy: a randomised controlled trial.

BACKGROUND The benefit of inducing deep neuromuscular block to improve laparoscopic surgical conditions is controversial. OBJECTIVE The goal of this study was to determine the depth of neuromuscular block needed to guarantee excellent operating conditions during laparoscopic hysterectomy. DESIGN A randomised controlled trial. SETTING A single-centre study performed between February 2011 and May 2012. PATIENTS One hundred and two women of ASA physical status 1 or 2 gave consent to participate and were allocated randomly to one of two groups. INTERVENTION Under desflurane general anaesthesia, patients in Group S (shallow block), neuromuscular blockade was induced by administration of rocuronium 0.45 mg kg−1 followed by spontaneous recovery or a rescue bolus dose of 5 mg if surgical conditions were unacceptable. In Group D (deep block), neuromuscular block was induced by administration of rocuronium 0.6 mg kg−1 and maintained by bolus doses of 5 mg if the train-of-four count exceeded two, using adductor pollicis electromyography. MAIN OUTCOME MEASURES With a stable pneumoperitoneum (13 mmHg), the surgeon scored the quality of the surgical field every 10 min as excellent (1), good but not optimal (2), poor but acceptable (3) or unacceptable (4). The groups were compared using the Cochran–Armitage trend test. The level of neuromuscular blockade was recorded each time the surgical field score exceeded 1. RESULTS For groups S and D, respectively, the maximum surgical field scores were 1 in 21 and 34 patients, 2 in 11 and 11 patients, 3 in 4 and 5 patients and 4 in 14 and 0 patients. A trend towards higher scores was demonstrated in group S (P < 0.001). Surgical field scores of 2, 3 and 4 occurred only when the train-of-four count was at least 1, 2 and 3, respectively. CONCLUSION Inducing deep neuromuscular block (train-of-four count <1) significantly improved surgical field scores and made it possible to completely prevent unacceptable surgical conditions.

Étude prospective comparant la technique de l’Airtraq™ et du Glidescope™ lors de l’intubation chez les patients obèses

OBJECTIVES Videolaryngoscope techniques are more and more in use and tend to modify our approach for patients difficult to intubate. We compared two techniques, Airtraq and Glidescope with direct laryngoscopy, with special emphasis on ease of access to airway (Intubation Difficulty Score - IDS score, duration and success of intubation) and the impact on hemodynamic variables among patients with a BMI of more than 30. STUDY DESIGN Prospective study randomised with minimisation technique. MATERIAL AND METHODS Eighty patients have been allocated by minimisation to four groups: two groups being intubated with Airtraq, each one with a different investigator, and two with Glidescope videolaryngoscope technique. Induction of anesthesia was standardly performed with total intravenous anesthesia with remifentanil, propofol in TCI mode and rocuronium in bolus. Following parameters were recorded : intubation success based on intubation time and desaturation level, its duration, its impact on hemodynamic variables, IDS score and possible dental lesions. RESULTS Intubation success was 100% for Glidescope and 80.6% for Airtraq (P=0.009). Airtraq allowed a better visualisation of the vocal cords (lower Cormack and Lehane score) than Glidescope. In contrast, alternative intubation techniques were significantly more often used in the Airtraq group. No difference could be detected between both systems on hemodynamic parameters. CONCLUSIONS In obese patients, Glidescope allows intubation relatively easily without rescue techniques.

Operating room discharge after deep neuromuscular block reversed with sugammadex compared with shallow block reversed with neostigmine: a randomized controlled trial.

OBJECTIVE To determine if reversing a deep or moderate block with sugammadex, compared with a shallow block reversed with neostigmine, reduces the time to operating room discharge after surgery and the time spent in the postanesthesia care unit. DESIGN A randomized controlled trial. SETTING Monocentric study performed from February 2011 until May 2012. PATIENTS One hundred consenting women with American Society of Anesthesiologists grade I or II were randomized into 2 groups. INTERVENTION Laparoscopic hysterectomy was performed under desflurane general anesthesia. For the neostigmine (N) group, 0.45 mg · kg-1 rocuronium was followed by spontaneous recovery. A 5-mg rescue bolus was administered only if surgical evaluation was unacceptable. At the end of surgery, 50 μg · kg-1 neostigmine with glycopyrrolate was administered. For the sugammadex (S) group, a higher intubating rocuronium dose (0.6 mg · kg-1) was followed by 5-mg boluses each time the train-of-four count exceeded 2. Sugammadex (2-4 mg · kg-1) was administered to reverse the block. All patients were extubated after obtaining a train-of-four ratio of 0.9. MEASUREMENTS The duration between the end of surgery and operating room discharge and the time spent in the postanesthesia care unit. MAIN RESULTS The time till operating room discharge was shorter and more predictable in group S (9.15±4.28 minutes vs 13.87±11.43 minutes in group N; P=.005). The maximal duration in group S was 22 minutes, compared with 72 minutes in group N. The time spent in the postanesthesia care unit was not significantly different (group S: 47.75±31.77 minutes and group N: 53.43±40.57 minutes; P=.543). CONCLUSION Maintaining a deep neuromuscular block during laparoscopic hysterectomy reversed at the end of the procedure with sugammadex enabled a faster and more predictable time till operating room discharge than did the classical combination of a shallower block reversed with neostigmine.

Jet Ventilation during Rigid Bronchoscopy in Adults: A Focused Review.

The indications for rigid bronchoscopy for interventional pulmonology have increased and include stent placements and transbronchial cryobiopsy procedures. The shared airway between anesthesiologist and pulmonologist and the open airway system, requiring specific ventilation techniques such as jet ventilation, need a good understanding of the procedure to reduce potentially harmful complications. Appropriate adjustment of the ventilator settings including pause pressure and peak inspiratory pressure reduces the risk of barotrauma. High frequency jet ventilation allows adequate oxygenation and carbon dioxide removal even in cases of tracheal stenosis up to frequencies of around 150 min−1; however, in an in vivo animal model, high frequency jet ventilation along with normal frequency jet ventilation (superimposed high frequency jet ventilation) has been shown to improve oxygenation by increasing lung volume and carbon dioxide removal by increasing tidal volume across a large spectrum of frequencies without increasing barotrauma. General anesthesia with a continuous, intravenous, short-acting agent is safe and effective during rigid bronchoscopy procedures.

Fully Covered Metallic Stents for the Treatment of Benign Airway Stenosis.

Introduction. We herein report our experience with new fully covered self-expanding metallic stents in the setting of inoperable recurrent benign tracheobronchial stenosis. Methods. Between May 2010 and July 2014, 21 Micro-Tech® FC-SEMS (Nanjing Co., Republic of Korea) were placed in our hospital in 16 patients for inoperable, recurrent (after dilatation), and symptomatic benign airway stenosis. Their medical files were retrospectively reviewed in December 2014, with focus on stents tolerance and durability data. Results. Twenty-one stents were inserted: 13 for posttransplant left main bronchus anastomotic stricture, seven for postintubation tracheal stenosis, and one for postlobectomy anastomotic stricture. Positioning was easy for all of them. Stents were in place for a mean duration of 282 days. The most common complications were granulation tissue development (35%), migration (30%), and sputum retention (15%). Fifty-five % of the stents (11/20) had to be removed because of various complications, without difficulty for all of them. None of the patients had life-threatening complications. Conclusion. Micro-Tech FC-SEMS were easy to position and to remove. While the rate of complications requiring stent removal was significant, no life-threatening complication occurred. Further studies are needed to better define their efficacy and safety in the treatment of benign airway disease.

Double-Lumen Tubes for Tracheostomized Patients

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Corrigendum to “Fully Covered Metallic Stents for the Treatment of Benign Airway Stenosis”

[This corrects the article DOI: 10.1155/2016/8085216.].

Deep Neuromuscular Blockade Improves Surgical Conditions During Gynecological Laparoscopy

Obtaining an appropriate laparoscopic workspace depends on several factors related to the patient (i.e., weight and abdominal compliance) and the procedure (i.e., body’s position, depth of anesthesia and intra-abdominal (IA) pressure). Among them, a deep neuromuscular blockade (NMB) contributes to provide the surgeon with better operating conditions. This chapter discusses the interests and challenges of muscle relaxation during gynecological laparoscopy. The introduction of sugammadex into clinical practice provides the opportunity to modify the management of neuromuscular blockade to improve the surgical conditions during laparoscopy as well as the safety of the patients. The maintenance of a rocuronium-induced deep neuromuscular block from the trocar insertion until the end of laparoscopy is no longer incompatible with rapid recovery and awakening in optimal conditions. Neuromuscular transmission (NMT) monitoring is the key to adequate management and should be used in all cases. Objective measurements allow for excellent intubation and surgical conditions, the definition of thresholds and doses for the administration of reversal agents, and the exclusion of residual blockade prior to the patient extubation.