Philippe Juvin

Postoperative recovery after desflurane, propofol, or isoflurane anesthesia among morbidly obese patients: a prospective, randomized study.

Recovery from anesthesia might be compromised in obese patients. Because of its pharmacological properties, desflurane might allow rapid postoperative recovery for these patients. We compared postoperative recovery for 36 obese patients randomized to receive either desflurane, propofol, or isoflurane to maintain anesthesia during laparoscopic gastroplasties. Anesthesia was induced with propofol and succinylcholine IV and was maintained with rocuronium, alfentanil, inhaled nitrous oxide, and the study drug. Immediate recovery (i.e., times from the discontinuation of anesthesia to tracheal extubation, eye opening, and the ability to state one’s name) was measured. At the time of postanesthesia care unit (PACU) admission, arterial saturation and the ability of patients to move were recorded. In the PACU, intermediate recovery was measured by using sedation and psychometric evaluations, 30, 60, and 120 min postoperatively. Data were compared between groups by using the Kruskal-Wallis and &khgr;2 tests. Results were reported as means ± sd. P < 0.05, compared with desflurane, was considered significant. Immediate recovery occurred faster, and was more consistent, after desflurane than after propofol or isoflurane (times to extubation were 6 ± 1 min, 13 ± 8 min [P < 0.05, compared with desflurane], and 12 ± 6 min [P < 0.05, compared with desflurane], respectively). At PACU admission, Spo2 values were significantly higher and patient mobility was significantly better after desflurane than after isoflurane or propofol. Sedation was significantly less pronounced with desflurane at 30 and 120 min postoperatively. In morbidly obese patients, postoperative immediate and intermediate recoveries are more rapid after desflurane than after propofol or isoflurane anesthesia. This advantage of desflurane persists at least for 2 h after surgery and is associated with both an improvement in patient mobility and a reduced incidence of postoperative desaturation. Implications In morbidly obese patients, postoperative immediate and intermediate recoveries are more rapid and consistent after desflurane than after propofol or isoflurane anesthesia.

Emergence of Elderly Patients from Prolonged Desflurane, Isoflurane, or Propofol Anesthesia

Recovery from prolonged anesthesia might be compromised in elderly patients.Desflurane (DES) may be particularly well suited to achieve a rapid postoperative recovery because of its low lipid solubility. Postoperative recovery was compared in 45 elderly patients randomized to receive either DES, isoflurane (ISO), or propofol (PRO) to maintain anesthesia. Anesthesia was induced with PRO, vecuronium, and fentanyl and maintained with N2 O, fentanyl, and the study drug. Times from end of anesthesia to tracheal extubation, eye opening and hand squeezing on command, and ability to state name and date of birth were recorded. Sedation and psychometric evaluation were tested 0.5, 1, 1.5, 2, and 24 h postoperatively. Results are given as means +/- SD. Differences among were analyzed by chi squared or analysis of variance. P < 0.05 compared with DES was considered significant. After a prolonged anesthesia (199 +/- 57 min with DES), immediate recovery times were significantly shorter with DES than with ISO or PRO (times to eye opening: 5.6 +/- 3.4 min, 11.5 +/- 8.4 min, and 11.9 +/- 7.6 min; times to extubation: 6.9 +/- 3 min, 13.1 +/- 8.9 min, 9.9 +/- 6.5 min for DES, ISO, and PRO, respectively). Intermediate recovery, as measured by psychometric testing, sedation levels, and time to discharge from the postanesthesia care unit, was similar in the three groups. In this study, DES provided a transient advantage compared with ISO or PRO with respect to early recovery after prolonged general anesthesia in elderly patients. Implications: Recovery from prolonged anesthesia can sometimes be problematic in elderly patients. We evaluated 45 elderly patients who received either desflurane, isoflurane, or propofol for anesthesia. We found that desflurane provided a transient advantage in terms of postoperative recovery, but whether this difference is clinically important remains to be demonstrated. (Anesth Analg 1997;85:647-51)

Is Peripheral Line Placement More Difficult in Obese Than in Lean Patients

IMPLICATIONS This work shows that the insertion of a peripheral venous line is more difficult in obese than in lean patients. The usual recommendation, that a central venous line should be inserted routinely in obese patients to perform anesthesia, is not valid.

Gastric residue is not more copious in obese patients.

IMPLICATIONS Previous studies have shown that obese patients have a larger volume of gastric content than lean patients do. However, methodological limitations call into question the validity of these findings. We have reexamined this issue and found identical gastric content volumes in fasting obese and lean subjects after an 8-h fast.

Postoperative death and malpractice suits : Is autopsy useful?

This report demonstrates the extremely high yield of autopsies performed in the case of postoperative death with suspicion of malpractice. They frequently identified undetected complications. They could also suggest faulty or negligent practice that would otherwise go unrecognized. This report supports the widespread use of autopsies to investigate perioperative death.

Terrorist attacks in Paris: Surgical trauma experience in a referral center

BACKGROUND On November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou. METHODS This study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records. RESULTS Forty-one patients were referred to our center, and 22 requiring surgery were hospitalized for>24h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up. CONCLUSION Rapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45days after the initial event.

The ancestors of inhalational anesthesia : The soporific sponges (XIth-XVIIth centuries) : How a universally recommended medical technique was abruptly discarded

THE history of anesthesia is intimately linked to the history of surgery. The textbooks of the Hippocratic Collection, which are the oldest surviving books of Western medicine, describe a number of elaborate surgical techniques. These procedures must have necessitated that the patient remained perfectly still, suggesting that restraints were probably used, and some degree of analgesia or partial alteration of consciousness. Methods available at the time to obtain adequate operating conditions included application of heat or cold, jugular vein compression,2 and oral administration of alcoholic beverages or potions prepared from plants with sedative effects. Sedative substances inhaled at the time, but only in nonmedical situations, such as that of the Delphic priestess, who uttered her oracles while in a trance induced as a result of the inhalation of hallucinogenic vapors. Because of these nonmedical uses of inhalation, contemporary authors consider that inhalation for surgical purposes was first used during the XMth century, in 18463. However, inhalation methods were used in the Middle Ages in Europe.* The technique consisted of placement

Iliac crest bone harvest : Should we really use continuous infusion of ropivacaine?

To the Editor:— We read with interest the study by Scavone et al. that demonstrates the absence of efficacy of a prophylactic epidural blood patch after inadvertent dural puncture. We suggest that two factors could have influenced the negative result of this trial. First, inadvertent dural puncture could have been overdiagnosed, namely when loss of resistance to saline was used to locate epidural space. This could explain the lower incidence of post–dural puncture headache and less frequent realization of therapeutic epidural blood patch reported in this study compared with others. Second, 20 ml may not be the adequate blood volume to test a prophylactic epidural blood patch. This volume has tended to increase over time to 20 ml or more, 23 5 ml in a study by Safat-Tisseront et al. The optimal blood volume may be the volume at which pain in the back, buttocks, or legs occurs, which was only achieved for seven patients in the study of Scavone et al. This higher volume may lead to either a larger patch over the dural tear or a significantly higher increase in lumbar and intracranial pressure, leading to reduced cerebral vasodilation. Olivier Pruszkowski, M.D.,* Orlando Goncalves, M.D., Claude Lentschener, M.D., Alexandre Mignon, M.D., Ph.D. *Hôpital Cochin Maternité Port-Royal, Assistance Publique–Hôpitaux de Paris, Paris, France. olivier.prus@club-internet.fr