[Association of physiotherapy under continuous brachial plexus analgesia and shoulder arthrographic-distension for treatment of resistant shoulder-hand syndrome]

OBJECTIVE

Evaluation of treatment of shoulder-hand syndromes resistant to conventional therapeutic. This approach consists of an intensive treatment based on arthrographic distension with rapid mobilization of the shoulder under general anaesthesia and on active rehabilitation under regional analgesia using infraclavicular brachial plexus catheter.

MATERIAL AND METHODS

It was a retrospective study of twenty-five consecutive patients with severe shoulder-hand syndrome treated between 2007 and 2012. Besides their persistent pain, these patients presented a functional disability of their shoulder, wrist and hand. Treatment was initiated at least three months after diagnosis. All were assessed at the admission and six months later.

RESULTS

After treatment, pain was reduced by at least three points at the NS in 64% of the patients. Twelve patients described a complete recovery of their shoulder function; eleven patients described a normal hand function recovery and six patients a partial recovery allowing regular life. Nineteen patients evaluated their functional improvement of more than 50%. Only two patients with more than one year of chronic pain reported no improvement after treatment.

CONCLUSION

After failure of the physiotherapy and analgesic treatment, there are no clear consensual procedures and guidelines remains discussed. The current study combined different approaches with a significant improvement of this complex regional pain syndrome called shoulder-hand syndromes.

[Airway equipment and its maintenance for a non difficult adult airway management (endotracheal intubation and its alternative: face mask, laryngeal mask airway, laryngeal tube)]

The airway equipment for a non difficult adult airway management are described: endotracheal tubes with a specific discussion on how to inflate the balloon, laryngoscopes and blades, stylets and intubation guides, oral airways, face masks, laryngeal mask airways and laryngeal tubes. Cleaning and disinfections with the maintenance are also discussed for each type of airway management.

Hypercapnia during transperitoneal and retroperitoneal endoscopic spinal surgery: a prospective study

STUDY OBJECTIVE

To evaluate the effect of carbon dioxide (CO(2)) pneumoperitoneum and retropneumoperitoneum insufflation on CO(2) excretion.

DESIGN

Prospective study.

SETTING

Operating room and recovery room in a teaching hospital.

PATIENTS

29 patients scheduled for orthopedic spine fusion surgery.

INTERVENTIONS

Patients received either transperitoneal insufflation (n = 12) or retroperitoneal insufflation (n = 17).

MEASUREMENTS AND MAIN RESULTS

Increases in the partial pressure of end-tidal CO(2) (PetCO(2)) and arterial CO(2) tension (PaCO(2)) during retropneumoperitoneum exceeded those obtained during pneumoperitoneum. Furthermore, PetCO(2) increased faster during retroperitoneum and did not reach a plateau. Finally, 76% of the patients in this group required ventilatory adjustment due to high PetCO(2) levels.

CONCLUSIONS

This study may focus attention on the need for continuous ventilatory adjustments during transperitoneal endoscopic surgery.

[Locoregional intravenous anesthesia]

OBJECTIVE

To analyse current data on intravenous regional anaesthesia (IVRA), its benefits and drawbacks.

DATA SOURCES

Articles were obtained from a Medline search using the following search terms: 'intravenous regional anaesthesia', alone or combined with 'local anaesthetic agents', 'toxicity'.

STUDY SELECTION

Following articles in English and in French have been selected: main articles, original articles, update and review articles, letters to the editor and recent editorials.

DATA EXTRACTION

Physiopathological and pharmacological data were extracted for involved mechanisms and means for improving this technique.

DATA SYNTHESIS

IVRA is a reliable and efficient technique with a lower cost than general anaesthesia and well adapted for limb surgery in the ambulatory patient. Depending on the site of the surgical field, the pneumatic tourniquet is set either on the arm, forearm or wrist for the upper limb or thigh, calf or ankle for the lower limb. When set in periphery, less local anaesthetic agent is required. A wide tourniquet requires a lower inflation pressure than a double cuff tourniquet. A single cuff is as efficient as a dual cuff if shape, size and inflating pressure are appropriate. The limb occlusion pressure (LOP) is the minimal pressure required to occlude blood flow. It is assessed with either a pulse oximeter or Doppler for determination of the lowest cuff inflating pressure. The cuff is inflated to 50 mmHg above LOP. Oozing in the surgical field can be decreased by the re-exsanguination technique. Currently, lidocaine is the only local anaesthetic released in France for IVRA. Addition of a muscle relaxant, a NSAID or clonidine allows the dose of local anaesthetic agent to be decreased and improves postoperative analgesia.

[Treatment of severe cardiogenic pulmonary edema with continuous positive-pressure ventilation using a cuffed cannula Copa]

We report the use of a cuffed oropharyngeal airway (Copa), in a patient with an acute respiratory failure from a cardiogenic pulmonary oedema, for continuous positive pressure ventilation. Considering the ease of use and the lack of laryngeal stimulation, this device can be considered for mechanical ventilation in selected cases with acute cardiac failure. There are two contra-indications: prolonged mechanical ventilation, because of the lack of airway protection from gastro-oesophageal reflux, and normal consciousness, as the patient cannot swallow. This device can be considered when starting intensive therapy including mechanical ventilation in patients with acute respiratory failure of foreseen short duration.

[Anesthesia and non-conventional transmissible agents (or prion diseases)]

The transmissible spongiform encephalopathies (TSE) represent a group of neurodegenerative diseases with lethal outcome. They include Creutzfeldt-Jakob disease (CJD) and kuru, among others in humans, scrapie in sheep and spongiform encephalopathy in cattle (bovine spongiform encephalopathy: BSE). Some are autosomal dominant disorders like CJD, Gerstmann-Straüssler-Scheinker disease (GSS), with point mutation of the prion protein gene. Most of these diseases are idiopathic rather than sporadic, latrogenic CJD could be obtained by central inoculation (neurosurgical instruments or dura mater grafts) or by peripheral inoculation (pituitary hormone therapy). A new variant clinicopathological type of CJD (nvCJD) has been reported. The nvCJD has strain characteristics distinct from other types of CJD, close to those of BSE transmitted (studies with intracerebral inoculation), consistent with BSE being the source of this new disease. All of these spongiform encephalopathies (SE) are characterized by spongiform degeneration of the brain, reactive gliosis in the cortical and subcortical gray matter, neuronal loss and presence of the abnormal isoform of the cellular prion protein (PrPc). In prion disease, PrPc undergoes conformational changes involving a shift from alpha-helix to beta-sheet structure. These neurologic lesions are characterized by major variations from case to case. Neuropathological studies in sporadic CDJ have emphasized phenotypic variations. Clinical presentation with a wide spectrum of manifestations is a rapidly progressive dementia, associated with myoclonus or akinetic mutism and cortical blindness. The clinical course is atypical and when the characteristic triphasic abnormal EEG of CJD is absent, there is an urgent need for a premortem diagnostic test. Histopathological examination of a brain biopsy carries a risk of major morbidity and may miss the site of disease. The 14-3-3 immunoassay of cerebrospinal fluid strongly supports a diagnosis of CJD. Western blot analysis of human tonsil biopsy may allow an early or preclinical diagnosis. It has been suggested that CJD might be transmitted by blood products derived from patients with CJD during the prodromal stage, although CJD linked aetiologically to blood transfusion has not been demonstrated. In animal studies, intracerebral inoculation of infected cells has been associated with development of disease, but never after peripheral inoculation into the blood stream. For the most part of conformational changes of PrPc, the remarkable resistance of the infectious agent (PrP alone or combined) to ordinary sterilising procedures is a major problem. Because of this resistance, current recommendations are to recognize patients at risks and to use disposable medical devices. This is particularly true in anaesthesia during endotracheal intubation, spinal anaesthesia, and to a lesser extent with peripheral nerve blocks. All instruments used for patients with CJD must be destroyed. The economic consequences of these measures have highlighted the essential importance of an early diagnosis.

[From fat emboli to fat embolism syndrome]

The occurrence of a fat embolism syndrome (FES) can be explained by two hypothetic mechanisms. In the mechanical hypothesis, bone marrow enters into the cardiovascular system during an intramedullary peak pressure. This peak could occur during either long bone fracture and/or intramedullary nailing or cemented or noncemented arthroplasty. According to the biochemical hypothesis, the FES could occur in nontraumatic conditions such as lipid emulsion infusion or sickle cell disease. The C-reactive protein is a possible factor for destabilizing plasma fat (chylomicrons or Intralipid liposomes). Treatment with heparin has been reported to interfere with lipid metabolism through a "creaming" phenomenon. Plasma fatty acids increase lipid peroxidation, with potential severe oxidative stress of lung. Vascular lung injury is increased by granulocytes and the clotting cascade is activated by neutral fat. After a symptom-free period, the full clinical picture is characterized by pulmonary insufficiency with hypoxaemia, neurological impairment, pyrexia and petechial haemorrhages. The accurate incidence cannot be assessed as many subclinical forms remain unrecognized. Transoesophageal echocardiography with color-flow Doppler allows considerable insight into the sequence of embolic events and patent foramen ovale (PFO). A PFO induces an increase in right-to-left shunt in case of an elevated intrapulmonary pressure. PFO might elicit systemic manifestations of the FES, particularly with neurological impairment. Carotid ultrasonography helps to visualize embolism. Magnetic resonance imaging of cerebral fat emboli is a better diagnostic tool for detecting brain embolism than computerized tomography. Quantification of cells containing fat droplets in bronchoalveolar lavage material could also be helpful. Pulmonary microvascular cytology analysis of capillary blood samples obtained through a pulmonary artery catheter in combination with blood gas changes are of value for earlier stage FES. Prophylactic and therapeutic measures are aimed to counteract the various mechanisms leading to FES. The decrease in time delay of fracture management is probably the most effective prophylactic means. A reaming procedure can be noxious, particularly in a patient with a severe thoracic trauma. The insertion without reaming of a small diameter nail, plating or external fixation have several advantages. Albumin infusion is recommended for restoration of blood volume and binding of fatty acids. Among pharmacologic measures, only corticosteroids have a proven benefit, not only for prophylaxis but also for therapy. Aprotinin and heparin are beneficial in counteracting blood cell aggregation. A prophylactic use of vena cava filters has been advocated. Prevention or early treatment of hypovolaemia and hypoxaemia are essential.

Spinal controlled delivery of bupivacaine from DL-lactic acid oligomer microspheres

Bupivacaine-loaded microspheres made from DL-polylactic acid oligomers of different molecular weights (MW 2000 and 9000 g/mol, named PLA 2000 and PLA 9000, respectively) which displayed different in vitro release profiles were administered via the spinal route to rabbits. In comparison to the drug administered as a solution (2 mg as equivalent base), PLA 2000 and PLA 9000 microspheres (10 mg as equivalent base) led to a slower uptake of the drug in the systemic circulation, as suggested by the mean maximal plasma concentrations: 326 +/- 81, 321 +/- 57 and 64 +/- 54 ng/mL, respectively. Pharmacodynamic evaluation of the anesthetic action, by means of intensity and time course of motor blockade, indicated a sustained release. In comparison to the drug solution, the PLA 2000 microspheres led to an increase duration of median maximal blockade (172 min versus 44.5 min). The PLA 9000 microspheres failed to reach maximal blockade as a result of a too low release rate.