Intracuff Pressure and Tracheal Morbidity Influence of Filling Cuff with Saline during Nitrous Oxide Anesthesia

Background: Diffusion of nitrous oxide into the cuff of the endotracheal tube results in an increase in cuff pressure. Excessive endotracheal tube cuff pressure may impair tracheal mucosal perfusion and cause tracheal damage and sore throat. Filling the cuff of the endotracheal tube with saline instead of air prevents the increase in cuff pressure due to nitrous oxide diffusion. This method was used to test whether tracheal morbidity is related to excess in tracheal cuff pressure during balanced anesthesia. Methods: Fifty patients with American Society of Anesthesiologists physical status I or II were randomly allocated to two groups with endotracheal tube cuffs initially inflated to 20 -30 cm H 2 O with either air (group A) or saline (group S). Anesthesia was maintained with isoflurane and nitrous oxide. At the time of extubation, a fiberoptic examination of the trachea was performed by an independent observer, and abnormalities of tracheal mucosa at the level of the cuff contact area were scored. Patients assessed their symptoms (sore throat, dysphagia, and hoarseness) at the time of discharge from the postanesthesia care unit and 24 h after extubation on a 101-point numerical rating scale. Results: Cuff pressure increased gradually during anesthesia in group A but remained stable in group S. The incidence of sore throat was greater in group A than in group S in the postanesthesia care unit (76 vs. 20%) and 24 h after extubation (42 vs. 12%; P < 0.05). Tracheal lesions at time of extubation were seen in all patients of group A and in eight patients (32%) of group S (P < 0.05). Conclusion: Excess in endotracheal tube cuff pressure during balanced anesthesia due to nitrous oxide diffusion into this closed gas space causes sore throat that is related to tracheal mucosal erosion

Validation des stratégies de prise en charge des situations d intubation difficile (Du bloc opératoire au préhospitalier)

Nos objectifs ont été d évaluer l utilisation de plusieurs dispositifs dans le cadre de la prise en charge des situations d intubation difficile imprévue survenant au bloc opératoire et dans un contexte d urgence extra hospitalière puis de valider leur efficacité lorsqu ils furent intégrés dans des algorithmes précis de prise en charge. Nous avons évalué différents types de lames de laryngoscopes utilisées pour l intubation en urgence et avons montré que les lames en métal usage unique étaient aussi performantes que les lames réutilisables. Nous avons évalué le masque laryngé d intubation Fastrach au bloc opératoire et en médecine d urgence pré hospitalière. Nous avons montré l efficacité du long mandrin béquillé et du masque laryngé d intubation Fastrach lorsqu ils furent utilisés dans des algorithmes évalués d abord au bloc opératoire puis en médecine d urgence pré hospitalière.Our objectives were to assess some difficult intubation devices used for difficult airway management occurring in operating room and in emergency pre hospital setting and to valid their use when integrated in predefined difficult airway management algorithms. We have assessed different types of laryngoscope blades used for emergency intubation and have reported that single use metal blades were as effective as reusable ones. We have assessed intubating laryngeal mask airway in operating room and in prehospital setting. We have reported the great efficiency of the Gum elastic bougie and ILMA when used in difficult airway management algorithms assessed in operating room and in the pre hospital setting.PARIS13-BU Sciences (930792102) / SudocSudocFranceF

Le médecin généraliste face au don d'organes

En France, de nombreux patients en attente de transplantation décèdent alors qu ils sont en liste d attente de greffe et prés de la moitié des patients recensés en état de mort encéphalique ne sont pas prélevés, le plus souvent pour cause de refus familial. Devant ce paradoxe associant pénurie d organes et refus familial de prélèvement, nous avons sollicité les médecins de famille pour savoir s ils étaient prêts à s investir auprès de leur patientelle, dans une démarche de promotion du don d organes et au coté des familles dans leur relation avec les équipes hospitalières. Nous avons créé un site Internet dédié permettant de sonder 10% des médecins généralistes du Val-d Oise. Les questions posées étaient renseignées en ligne. Elles nous ont permis de caractériser la population de praticiens, d évaluer leur degré de sensibilisation aux problèmes de la greffe d organes, de mesurer leur niveau de connaissance dans les domaines du don et du prélèvent d organes, de quantifier leur investissement potentiel auprès de leur patientelle, dans une démarche de promotion du don d organes, et au coté des familles dans leur relation avec les équipes hospitalières. Nous avons pu observer à travers ce travail que les médecins généralistes du Val d Oise se considèrent majoritairement comme des médecins de famille. Ils sont sensibilisés aux problèmes de la greffe mais démontrent certaines lacunes dans leurs connaissances sur la mort encéphalique et le don d organes. Ils expriment une réelle volonté de mobilisation pour la promotion du don et pour l assistance aux familles. Notre travail suggère que le médecin de famille pourrait jouer un rôle déterminant dans l aboutissement de la démarche de prélèvement d organes. Par son action promotionnelle du don, il pourrait être le dépositaire de la volonté de ces patients. En tant que conseiller familial et témoin de la volonté d un patient en état de mort encéphalique, il pourrait simplifier les relations entre les préleveurs hospitaliers et une famille en détresse.PARIS13-BU Serge Lebovici (930082101) / SudocSudocFranceF

REFLEXE DE DEGLUTITION ET TRACHEOTOMIE (INFLUENCE DE LA PRESSION DU BALLONNET (DES ANESTHESIOLOGIE REANIMATION CHIRURGICALE))

PARIS6-Bibl. St Antoine CHU (751122104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Case Report Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step

We report a case of prehospital "cannot intubate" and "cannot ventilate" scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20 min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2 min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm

Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step

We report a case of prehospital “cannot intubate” and “cannot ventilate” scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20 min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2 min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm