[Sciatic nerve block in prehospital care]. / Bloc sciatique en médecine préhospitalière.

OBJECTIVES: Evaluate the analgesic efficiency of the sciatic nerve block in prehospital care at the time of some severe legs or feet traumas. PATIENTS AND METHODS: Retrospective, monocentric study upon a period of time 1998-2008. RESULTS: Twenty-three sciatic nerve blocks have been colligated, five by upper way and heighten by lateral popliteal lower way among which fourteen without neurostimulator. The pain decrease evaluated by the EVS at T0 (before block), T1 (10 min after block) and T2 (arriving in emergency department), has been significative, whatever the measure time interval (T0-T1, T0-T2, T1-T2), the ways used and the local anaesthetics given. The analgesia installation was faster when approaching the sciatic nerve block by the upper way and when using a neurostimulator. Only one analgesic failure was observed while doing a lateral popliteal way without neurostimulator. Any complication was reported. CONCLUSION: The sciatic nerve block done in prehospital shows a significant analgesic efficiency which would worth a deeper evaluation and a thought on its introduction in the ED physician's therapeutic gear.

[Paraumbilical block for strangulated umbilical hernia in emergency]. / Bloc paraombilical pour l'anesthésie de la hernie ombilicale étranglée en urgence.

The authors describe a strangulated umbilical hernia surgery performed in emergency with a paraumbilical block associated with a local infiltration. For this patient, 3-4 ASA status, in occlusion, with iterative vomiting and coagulation disorders, general or spinal anaesthesia were high-risk technics. Paraumbilical block, sometimes used for anaesthesia or/and analgesia for programmed umbilical hernia surgery, allowed surgery with good conditions and procured prolonged postoperative analgesia. This block, easy to perform, is an interesting alternative in emergency for general or spinal anaesthesia in high-risk patients.

[Postoperative pneumonia: nosocomial, predictable, iatrogenic, preventable or not?]. / Pneumonie postopératoire: nosocomiale, iatrogène, prévisible, évitable ou non?

We report the case of a 52-year-old man, ASA 3-4, malnourished, heavy smoker and drinker at the stage of chronic obstructive pulmonary disease and cirrhosis. The postoperative course of a cervical cancer surgery was complicated by a pneumonia with fatal outcome in the intensive care unit. Taking into account the patient's history and surgical requirements, this nosocomial infection did not appear easily preventable. The multiple risk factors and the few preventive measures usable were analyzed. In this context, the media and legal trend to make the doctors responsible for the nosocomial infections should be revised.

[Orbital haemorrhage after medial canthus episclera (sub-Tenon's) anaesthesia]. / Hématome rétrobulbaire après anesthésie épisclérale au canthus médial.

Medial canthus episclera (sub-Tenon's) anaesthesia is a technique proposed as a suitable alternative to the more classical peribulbar block because of the greater reliability and more constancy in effectiveness. We report two cases of retrobulbar haematoma after sub-Tenon's anaesthesia, one with central retina artery compression needed anterior room punction. Sub-Tenon's anaesthesia, like peribulbar anaesthesia, can give also retrobulbar haemorrhage if the insertion of the needle is not limited to the anterior orbit.

Haemodynamic heterogeneity and treatment with the calcium channel blocker nicardipine during phaeochromocytoma surgery.

BACKGROUND: Favourable outcome of phaeochromocytoma surgery requires that paroxysmal hypertension and arrhythmia be controlled, and that hypotension be prevented. Is nicardipine, a calcium channel blocking drug, always adequate? METHODS: Nineteen consecutive patients underwent surgery for phaeochromocytoma. Management was standardised with regards to anaesthesia and antihypertensive treatment. Nicardipine was used as a vasodilator and was given in order to maintain systemic vascular resistance lower than 1600 dyn.s.cm-5. RESULTS: Hypertension did not occur at any time during surgery in 6/19 patients. Blood pressure rose acutely in 3/19 patients at the time of tracheal intubation or surgical approach to the tumour, and was controlled by increased depth of anaesthesia. Hypertensive episodes occurred in 11/19 patients during tumour manipulation. Nicardipine always succeeded in maintaining low systemic vascular resistance but its dosage varied widely between patients (0.5 to 70 mg), a fact that may be accounted for by the striking intersubject variability of haemodynamic behaviour during surgery. In 7/11 patients, despite nicardipine treatment, sustained increase in blood pressure persisted with increased cardiac index, but low systemic vascular resistance. Following tumour removal, transient serious hypotension (MAP < 60 mmHg) occurred in 4 patients, and was corrected by fluid volume expansion. Perioperative incidence of hypertension or hypotension was not related to preoperative clinical status. CONCLUSION: Adequate management of patients operated upon for phaeochromocytoma requires invasive monitoring, since the mechanisms underlying hypertensive crises are heterogeneous with regards to systemic vascular resistance and not predictable from preoperative data. Nicardipine provides a good control of vasoconstriction during phaeochromocytoma surgery with limited risk of serious hypotension after tumour removal.

[Tetraplegia and functional surgery of the upper limb: what anesthesia for what surgery?]. / Tétraplégie et chirurgie fonctionnelle du membre supérieur: quelle anesthésie pour quelle chirurgie?

Surgical rehabilitation of the upper limb in quadriplegia aims to restore prehension function. Surgical restoration always involves active extension of both elbow and wrist. Anesthesia, which first aim is to allow adequate surgical conditions, must adapt to the patient's disability. In this particular setting, regional anesthesia and especially brachial plexus block techniques represents our priority choice.