Propofol versus sevoflurane for fiberoptic intubation under spontaneous breathing anesthesia in patients difficult to intubate.

BACKGROUND: The most recommended technique for the management of patients with a difficult airway is fiberoptic intubation (FOI). The aim of this study was to compare propofol and sevoflurane for FOI performance in patients who were difficult to intubate. METHODS: Seventy-eight patients scheduled for maxillo-facial surgery were included in this prospective, randomized study. The airway was topically anesthetized with lidocaine 5% before performance of FOI with propofol TCI (group P) or sevoflurane (group S). The following parameters were recorded: rate of success, duration of the induction and of the FOI, BIS and PETCO2 values. A visual analogic scale (VAS) was used to monitor the technical difficulties as well as the recall of patients and their satisfaction. The respiratory and hemodynamic complications were also evaluated. RESULTS: Induction and procedure duration were significantly shorter in group S compared with group P. The rate of successful FOI was not different: 38 cases (97%) in group P and 35 cases (90%) in group S. No significant differences were observed between groups regarding BIS values and VAS values for technical difficulties and for patient recall and satisfaction. The incidence of hypertension or tachycardia was significantly higher in group S compared with group P. The incidence of respiratory complications was not significantly different between the groups, but three patients experienced obstructive dyspnea with hypoxemia. CONCLUSION: Propofol and sevoflurane provide a high success rate for the performance of FOI in patients who are difficult to intubate.

[The LTD laryngeal tube: a new single-use airway device]. / Le tube laryngé à usage unique LTD: un nouveau dispositif supralaryngé.

OBJECTIVES: Clinical study of a new supraglottic single use airway device, the LTD with evaluation of insertion, efficiency during intermittent positive pressure ventilation and side effects. STUDY DESIGN: Prospective, open clinical study. PATIENTS AND METHODS: Fifty adult patients [33 years (26-55)] were scheduled for elective surgery (orthopaedic, plastic or maxillo-facial) under general anaesthesia less than two hours in dorsal position. No patient presented clinical sign of difficult airway management or risk of regurgitation. We studied easiness and delay for insertion, oro-pharyngeal leak pressure, peak airway pressure with positive pressure ventilation and side effects during the first 24 hours. RESULTS: Insertion was successful in 94%. Median insertion time was 38 s (32-45). Difficulties of insertions were found in 25%. Oro-pharyngeal leak pressure, always superior than peak pressure [18 cmH2O (15-21)] increased from 26 cmH2O (22-32.5) to 34 cmH2O (29-40) at the end of the surgery. No case of gastric inflation, regurgitation or SpO2<95% were noticed. Moderate sore throat incidence was 6% in recovery room, 15% at the sixth hour and absent at the 24th hour. CONCLUSION: The learning curve was low< or =10. Insertion is easy. The quality of airway protection allows secure positive pressure ventilation. Postoperative side effects are minor and transient.

[Should adjuvant treatments (antiplatelet agents, anticoagulants, normovolaemic haemodilution and vasodilators) be used in cervicofacial and maxillofacial free flaps reconstructive surgery?]. / Faut-il utiliser des traitements adjuvants (agents antiplaquettaires, anticoagulants, hémodilution normovolémique et vasodilatateurs) pour les lambeaux micro-anastomosés en chirurgie cervicofaciale et maxillofaciale?

The ENT and maxillo-facial reconstruction with free flaps has become a standard. The objective of the adjuvant treatments is to limit failures (approximately 6%) related to ischaemia/reperfusion. French surgical centres use specific protocols depending on the surgeon. They used antiplatelet agent, anticoagulants, normovolemic hamodilution and vasodilators. Many experimental studies are available. However, there is no clinical study to recommend the use of antiplatelet agents (combination with heparin increase the risk of pre- and postoperative bleeding), of normovolemic hemodilution (pulmonary oedema) and of vasodilators. After analysis of one of the only prospective study, we propose the use of heparin following a deep vein thrombosis preventive protocol. Due to the limited number of the patients and difficulty to have homogenous series, it is impossible to draw new recommendations, even if ischemic preconditioning techniques offer new research horizons.

[Postoperative antero-external tibial compartment syndrome: co-responsibility of the operating table]. / Syndrome postopératoire des loges tibiales antéro-externes: coresponsabilité de la table opératoire.

A 26-year-old, ASA1 patient underwent maxillofacial surgery under general anaesthesia, of 12-hour duration in the supine position. Postoperatively he developed rhabdomyolysis and acute renal failure. In the subsequent days, a bilateral leg compartment syndrome occurred with anterior tibial motor nerve injury requiring fasciotomies and excision of necrotic muscles. Several aetiological factors may have contributed to this accident: a long-lasting procedure, controlled hypotension and inappropriate position of the lower limbs. A laboratory study showed that the hardness of some new operating tables could be responsible for this complication. Some prophylactic measures are therefore required before the use of such devices.