[Regional anesthesia: an extra-benefit for our patients]. / L'anesthésie locorégionale, un plus pour nos patients ....

Regional anesthesia is gaining popularity. It provides various benefits, including high quality postoperative analgesia. This leads to a diminished postoperative opioid consumption, less sensitization of peripheral and central neurons, and a reduced risk of persistent chronic pain. Moreover, regional blocks optimize functional recovery after surgery and improve the outcome of cancer patients who undergo surgery. They also reduce the risk of postoperative complications, especially wound complications. Also, regional blocks are frequently used in the management of chronic pain. Finally, in recent years, technological progress (such as the use of ultrasonography) has made these anesthesia techniques safer and more comfortable for the patient.

Norepinephrine and ephedrine do not counteract the increase in cutaneous microcirculation induced by spinal anaesthesia.

BACKGROUND: Neuraxial anaesthesia improves tissue perfusion and tissue oxygen tension. Vasodilation induced by this technique may result in hypotension requiring the administration of vasoactive drugs. The use of peripheral vasoconstrictors might counteract the improved tissue perfusion and its potentially beneficial effects. We therefore investigated the effect of i.v. norepinephrine and ephedrine on skin perfusion using laser-Doppler flowmetry (LDF) in patients during spinal anaesthesia. METHODS: Skin blood flow expressed in perfusion units (PU) provided by LDF was measured simultaneously at the foot and the manubrium levels in 44 patients during spinal anaesthesia with a sensory level below T5. Norepinephrine infusion was then titrated to normalize mean arterial pressure (MAP) in 23 patients (Group NOR). Ephedrine (max. 10 mg) was administered in 21 patients (Group EPH). Changes in relative PU were compared between the two sites of measurements in each group during drug administration. The same doses of norepinephrine were assessed in 11 normal volunteers to assure comparable vasoreactivity at the foot and manubrium levels. RESULTS: Spinal anaesthesia resulted in a 10% decrease in MAP (P<0.001), an increase in relative PU values at the foot level (P<0.001), and a decrease at the sternum level (P<0.05). Norepinephrine and ephedrine produced a significant increase in relative PU values at the foot level when compared with the sternum level (NOR: P=0.02; EPH: P=0.0035). In volunteers, norepinephrine decreased cutaneous perfusion similarly at the manubrium and foot levels. CONCLUSIONS: Improved skin perfusion induced by spinal anaesthesia was not counteracted by the use of norepinephrine or ephedrine.

[Necrotizing fasciitis: diagnosis and treatments]. / Fasciites nécrosantes : stratégie diagnostique et thérapeutique.

The necrotizing fasciitis is a medico-surgical emergency, characterized by the rapid speard of the infection in the subcutaneous tissue, involving fascia superficialis. Peaucity of cutaneous findings early in the course of the disease makes diagnosis a challenge for physician. Pain out of proportion to clinical findings, fever and signs of systemic toxicity are the keys in identification of necrotizing fasciitis. Delayed diagnosis lead to sepsis syndrom and/or multiple organ failure and correlate with poor oucome. Radiolographs, CT-scan or MRI are main radiologic studies, but such procedures should never delay surgical intervention. Intravenous antibiotics, fluid and electrolyte management and analgesia are needed in addition to radical debridment. Clindamycin, hyperbaric oxygen therapy and intravenous immunoglobulins are discussed treatments. Only prompt recognition and immediat care warrant a lower mortality and morbidity for this life-threatening infection.