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Doğan SSA, Doğan Ö, Doğan Ö, Başkurt NA. Protective potential of different mouthguard thicknesses against perianaesthetic dental trauma: a patient specific-finite element study. Comput Methods Biomech Biomed Engin 2024; 27:1346-1356. [PMID: 37592845 DOI: 10.1080/10255842.2023.2247515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/22/2023] [Indexed: 08/19/2023]
Abstract
Perianaesthetic dental trauma is a common anaesthesia-related complication. Theprevious studies have shown a lack of knowledge regarding mouthguard usage and controversial results related to perianaesthetic dental trauma prevention. This study aimed to conduct a finite element analysis of the compressive and tensile stresses on the tooth-periodontal ligament-bone complex using custom-made mouthguards of different thicknesses and glass fibre splints to prevent perianaesthetic dental trauma. Custom-fitted ethylene-vinyl acetate mouthguards of two different thicknesses (2 and 3 mm) and glass fibre splint were modelled. A linear static finite element analysis was performed by applying a rigid Macintosh laryngoscope to the palatal surface of the maxillary central incisors at 150 N. The model without a mouthguard and glass fibre splint showed the highest stress values at the palatinal root surfaces during the impact. Increasing the mouthguard thickness significantly decreased the stress-strain values regardless of the presence of the glass fibre splint. Maximum stresses in the group using the 3 mm mouthguard were the lowest compared with the other groups.
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Affiliation(s)
- Suat Serhan Altıntepe Doğan
- University of Afyonkarahisar Health Science, Faculty of Dentistry, Department of Periodontology, Afyonkarahisar, Turkey
| | - Özgür Doğan
- University of Afyonkarahisar Health Science, Faculty of Dentistry, Department of Pediatric Dentistry, Afyonkarahisar, Turkey
| | - Özge Doğan
- Emergency Department, University of Health Sciences, Istanbul Training and Research Hospital, Istanbul, Turkey
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Cui G, Zhao L, Chi C, Liang S, Liu Z. The feasibility and accuracy of the method for selecting the optimal size of double-lumen tube in thoracic surgery: a prospective, randomized controlled trial. Sci Rep 2024; 14:17539. [PMID: 39080380 PMCID: PMC11289487 DOI: 10.1038/s41598-024-68349-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
Double-lumen tubes (DLTs) are commonly used for one-lung ventilation (OLV) in thoracic surgery and the selection of an optimal size of DLTs is still a humongous task. The purpose of this study was to assess the feasibility and accuracy of the method for selecting an optimal size of DLTs in thoracic surgery. Sixty adult patients requiring a left side double-lumen tube (LDLT) for elective thoracoscopic surgery were included in this study. All patients were randomly allocated to the following two groups: Cuffs Collapsed group (CC group, n = 30) and Cuffs Inflated group (CI group, n = 30). In the Cuffs Collapsed group, the outer diameter of LDLT (the outer diameter of the tracheal and bronchial cuffs when they were collapsed as the outer diameter of the LDLT) matched with the inner diameter of the trachea and bronchus measured by the anesthesiologist on the chest CT slice; In the Cuffs Inflated group, the outer diameter of LDLT (the outer diameter of the tracheal and bronchial cuffs when they were inflated as the outer diameter of the LDLT) matched with the inner diameter of the trachea and bronchus measured by the anesthesiologist on the chest CT slice. The primary outcomes were the incidences of airway complications postoperative such as hoarseness and sore throat. The time of intubation and alignment, the incidences of LDLT displacement and adjustment, the peak airway pressure, the plateau airway pressure and the end-tidal carbon dioxide were also recorded. The incidences of airway complications postoperative such as sore throat and hoarseness were lower in the CI group than the CC group (P < 0.05), the intubation times was shorter in the CI group than the CC group (P < 0.05), while the peak airway pressure, the plateau airway pressure and the end-tidal carbon dioxide during two-lung ventilation and one-lung ventilation were no significant difference between two groups (P > 0.05). The method which matched the inner diameter of the trachea and bronchus measured on chest CT slice with the outer diameter of the tracheal and bronchial cuffs when they were inflated to select an appropriate size of LDLT can reduce the incidence of airway complications.Trials registration: Clinical Trials: gov. no. NCT05739318. Registered at https://classic.clinicaltrials.gov 22/02/2023.
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Affiliation(s)
- Guangying Cui
- Department of Anesthesiology, First Hospital of Qinhuangdao, N.O. 258, Wenhua Road, Qinhuangdao, Hebei, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Li Zhao
- Department of Thoracic Surgery, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Cheng Chi
- Department of Anesthesiology, First Hospital of Qinhuangdao, N.O. 258, Wenhua Road, Qinhuangdao, Hebei, China
- Graduate School of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Shujuan Liang
- Department of Anesthesiology, First Hospital of Qinhuangdao, N.O. 258, Wenhua Road, Qinhuangdao, Hebei, China
| | - Zhuo Liu
- Department of Anesthesiology, First Hospital of Qinhuangdao, N.O. 258, Wenhua Road, Qinhuangdao, Hebei, China.
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Pediatric morbidity after oral surgery procedures under general anaesthesia: A systematic review. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101262. [PMID: 35961509 DOI: 10.1016/j.jormas.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/06/2022] [Accepted: 08/07/2022] [Indexed: 11/21/2022]
Abstract
The aim of this study is to carry out a systematic review of the existing literature on postoperative morbidity after general anaesthesia (GA) in the dental care of paediatric patients, its frequency, characteristics and association with the intervention performed. MATERIAL AND METHODS An exhaustive search of the literature published up to 23 February 2022 was carried out in PubMed, Web of Science, Cochrane and EBSCO, with the following strategy: (infant OR child OR adolescent) AND (Oral Surgical Procedures OR Dentistry, Operative) AND Anesthesia, General AND Postoperative Complications. RESULTS The most frequent reason for the indication of general anaesthesia was dental caries and its complications (up to 91.0% of patients), followed by lack of cooperation/anxiety and/or fear for dental procedures in the office (between 39.8 and 47.9%). There is a higher prevalence for treatments in the special patient group reaching 87.7% compared to 63.3% in healthy patients. The main comorbidities recorded were: physical or mental disability, neurological, haematological, cardiac disorders, asthma, Down's syndrome; it was not possible to establish their association with the intervention performed. Regarding complications, complaints occurred between 43.0 and 98.9% of cases within the first 24 hours, the main reason being pain (between 14.0% and 95.0%). CONCLUSIONS Pediatric dental procedures under GA carry a very low risk of major complications, but have a virtually universal incidence of minor complications.
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Diakonoff H, De Rocquigny G, Tourtier JP, Guigon A. Medicolegal issues of peri-anaesthetic dental injuries: A 21-years review of liability lawsuits in France. Dent Traumatol 2022; 38:391-396. [PMID: 35639817 PMCID: PMC9539868 DOI: 10.1111/edt.12770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Abstract
Background/Aim Peri‐anaesthetic dental injuries (PDI) represent a major source of potential malpractice claims against anesthesiologists. Studies about the medico‐legal aspects of PDI have mainly focused on liability insurance cases thus not encompassing those cases brought to court. The aim of this study was to assess the medico‐legal issues of PDI‐related liability lawsuits in France. Material and Methods A review of judicial decisions pertaining to PDI was conducted on a French legal database, spanning the period between January 2000 and October 2021. Characteristics of decisions, patients and anesthesiologists, peri‐operative care, dental injuries, and convictions were collected when available for analysis. Results Twenty‐four judicial decisions fulfilled the inclusion criteria and were analyzed. All cases of dental injuries took place during elective surgery, 16 in the private sector and 8 in the public sector. Most injuries concerned two or more teeth and the most predominant dental injuries were luxation or avulsion (70.8% of cases). Eight cases resulted in a final verdict in favor of the plaintiff, four in the private sector (conviction rate: 25%), and four in the public sector (conviction rate: 50%). The causes of conviction were either a lack of information (5/8), a breach in the standard of care or technical negligence (3/8). The average amount of indemnification for the plaintiff was 3614 Euros (3753 Euros in 2022 inflation‐adjusted Euros) excluding legal fees. Conclusions The analysis of PDI‐related liability lawsuits shows that medico‐legal issues differ from those of PDI‐related insurance claims. Avulsion and luxation of multiple anterior teeth during elective surgery appear to be a risk factor for liability lawsuits. In addition, inadequacy of patient information about PDI‐risk seems to be a risk factor for conviction. Lastly, dental injuries are less at risk of civil conviction than other anesthesia‐related damages.
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Affiliation(s)
- Hadrien Diakonoff
- Université Paris Cité, Faculté de santé, UFR d'odontologie, Montrouge, France.,Service de médecine bucco-dentaire, hôpital Henri Mondor, Créteil, France.,Institut droit et santé, INSERM UMR_S 1145, Université de Paris, Paris, France
| | - Gaël De Rocquigny
- Service d'anesthésie-réanimation, Hôpital d'Instruction des Armées Bégin, Saint-Mandé, France
| | - Jean-Pierre Tourtier
- Service d'anesthésie-réanimation, Hôpital d'Instruction des Armées Bégin, Saint-Mandé, France
| | - Aurore Guigon
- Service d'odontologie, Hôpital d'Instruction des Armées Bégin, Saint-Mandé, France
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Kotani T, Inoue S, Kawaguchi M. Perioperative Dental Injury Associated With Intubated General Anesthesia. Anesth Prog 2022; 69:3-9. [PMID: 35377930 PMCID: PMC8985457 DOI: 10.2344/anpr-68-03-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 04/28/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Factors related to perioperative dental injury have likely changed as a variety of airway devices and preventive measures have been introduced. This retrospective chart review used data from an institutional registry to evaluate the incidence, timing, and contributing factors of patient self-reported dental injury and to assess the impact of dental injury on patient satisfaction. METHODS Multivariate logistic analysis was performed on the records of 14,820 patients using the incidence of dental injury as the dependent variable and covariates in the anesthesia registry and a postoperative questionnaire as independent variables to investigate factors significantly associated perioperative dental injury. In addition, satisfaction with the anesthesia service was compared between patients with and without injury using a matched-pair population. RESULTS A total of 101 dental injuries were identified. Of those, 25% were associated with intubation and extubation in the operating room, while most other injuries occurred postoperatively. Duration of anesthesia (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.03) and emergency surgery (OR, 1.92; 95% CI, 1.11-3.30) were independently associated with perioperative dental injury. Dental injury did not significantly decrease a patient's satisfaction with the anesthesia service (P = .441). CONCLUSION Most perioperative dental injuries are unrelated to anesthesia procedures. However, the duration of anesthesia and emergency surgery were significantly associated with perioperative dental injury, while decreased patient satisfaction was not.
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Affiliation(s)
- Taichi Kotani
- Department of Anesthesiology and Division of Intensive Care, Nara Medical University, Nara, Japan
| | - Satoki Inoue
- Department of Anesthesiology and Division of Intensive Care, Nara Medical University, Nara, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology and Division of Intensive Care, Nara Medical University, Nara, Japan
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Wilson CP, Romano E, Vasan NR. Comparison of Dental Injury Rates in Perioperative Intubation and Suspension Laryngoscopy for Otolaryngology Procedures. OTO Open 2021; 5:2473974X211065021. [PMID: 34926975 PMCID: PMC8671680 DOI: 10.1177/2473974x211065021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/13/2021] [Indexed: 11/16/2022] Open
Abstract
Objective Direct laryngoscopy is an essential skill during perioperative intubation and otolaryngology procedures. Dental injury is a common complication of direct laryngoscopy. However, the technique and tools used by anesthesiologists, nurse anesthetists, and others during perioperative intubation and by ear, nose, and throat surgeons for their procedures are different. The purpose of this review is to explore the literature for all studies detailing rates of dental injury in each of these settings and to compare them to see if the approaches have a significant difference in rate of dental injury. Data Sources PubMed. Review Methods A comprehensive search of PubMed was performed through February 2021 with search terms “dental” and “intubation” or “laryngoscopy.” PRISMA guidelines were followed. Studies documenting rates of dental injuries during intubation or during laryngologic procedures were included, and the 2 groups were compared. Results Twenty-three studies met inclusion criteria: 17 in the perioperative intubation group and 6 in the suspension laryngoscopy group. There was an increased incidence of dental injury in the perioperative intubation group (4.86%) as compared with the suspension laryngoscopy group (1.70%). Conclusions The difference in dental injury rate between the groups could be due to the differences in direct laryngoscopy technique or tools used, the presence vs absence of a dental guard, or a combination of these factors. More studies need to be performed to develop definitive and specific conclusions to recommend changes that prevent dental injury.
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Affiliation(s)
- Caleb P Wilson
- Department of Otolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Erica Romano
- Department of Otolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Nilesh R Vasan
- Department of Otolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Doğan Ö, Altıntepe Doğan SS, Altıntepe N, Şahin ND, Çelik İH. An analysis of anesthetists' awareness, knowledge, and attitudes toward peri-anesthetic dental trauma. Dent Traumatol 2021; 37:786-794. [PMID: 34216178 DOI: 10.1111/edt.12702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND/AIM Peri-anesthetic dental trauma is a common anesthesia-related complication. It is the reason for a significant number of malpractice lawsuits against anesthetists through insurance companies. The frequency, outcomes, and risk factors related to peri-anesthetic dental trauma have been well documented. The aim of this study was to evaluate anesthetists' awareness, knowledge, and attitudes toward peri-anesthetic dental trauma. MATERIAL AND METHODS This nationwide, cross-sectional, descriptive study comprising 220 anesthetists was conducted in Turkey between June 2019 and May 2020. A specific questionnaire was created using Google Forms and delivered to 591 participants via WhatsApp. Pearson's Chi-squared test and the Fisher-Freeman-Halton tests were used to analyze the results. RESULTS The overall response rate was 37.2% (220 out of 591 participants). Of the 80.5% of the participants who encountered peri-anesthetic dental trauma during their practice, 32.8% had encountered avulsion and 32.8% reported that they had caused soft tissue injuries. More than one-third of the participants (38.9%) stated that the patient group that was the most at-risk for peri-anesthetic dental trauma was older people with missing teeth. Half of the participants (50.9%) stated that avulsed teeth could be replanted; among them, 21.8% and 11.8% specified that the ideal replantation time was <30 min and that the ideal storage medium for the avulsed tooth was fresh milk, respectively. Furthermore, 88.1% of the participants noted that peri-anesthetic dental trauma occurred more frequently during emergency intubations and only 20.9% were aware of custom-made mouthguards. CONCLUSIONS Anesthetists lack knowledge around peri-anesthetic dental trauma and its interventions.
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Affiliation(s)
- Özgür Doğan
- Department of Pediatric Dentistry Afyonkarahisar, School of Dentistry, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Suat Serhan Altıntepe Doğan
- Department of Periodontology Afyonkarahisar, School of Dentistry, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Nihan Altıntepe
- Department of Anaesthesiology and Reanimation, Cemil Taşcıoğlu, City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Necibe Damla Şahin
- Department of Pediatric Dentistry Tokat, School of Dentistry, Tokat Gaziosmanpasa University, Afyonkarahisar, Turkey
| | - İsmail Haktan Çelik
- Department of Pediatric Dentistry Afyonkarahisar, School of Dentistry, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
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Galvão AK, Cabral GM, Miranda AF, Baeder FM, Santos MT. Tooth avulsion accidents due to urgent and emergency orotracheal intubation. Med Oral Patol Oral Cir Bucal 2020; 25:e353-e358. [PMID: 32040466 PMCID: PMC7211367 DOI: 10.4317/medoral.23375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/14/2019] [Indexed: 11/16/2022] Open
Abstract
Background Intubation is necessary during critical situations to reduce the risk of death. In Brazil, a need exists to determine the prevalence of tooth avulsions in emergency and urgent care. The objective of this study was to identify the causes of orotracheal intubation (OTI), the number of tooth avulsions, and the avulsed teeth that result from urgent and emergency intubation.
Material and Methods The sample consisted of 116 patients (total group) in intensive care units (ICUs) distributed across Group 1 (G1), which was composed of 71 patients from an urgent-care hospital, and Group 2 (G2), which was composed of 45 patients from an emergency hospital. Clinical examinations showed dental alveolus with signs of recent exodontia in the upper and lower anterior regions. Sociodemographic data and the reason for intubation were evaluated. The Shapiro-Wilk normality test, chi-square test, Fisher’s exact test, Mann-Whitney U test, and univariate logistic regression were performed with a significance level of 5%.
Results The avulsion prevalence was 4.3%, with more cases receiving emergency intubation (n=4). All avulsions occurred in adults, and a significant difference (p=0.011) was observed with regard to the elderly. A 1-year reduction in age increased the chance of tooth avulsion during intubation by 1.09 times; being female increased the chance by 2.88 times.
Conclusions Pulmonary problems were the major causes of intubation, with the highest tooth avulsion prevalence observed during emergency intubation. The avulsed teeth were 11, 12, 13, 22, 32, and 33 across all cases. Key words:Tooth avulsion, tooth injuries, intubation, intensive care units, emergencies.
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Affiliation(s)
- A-K Galvão
- Universidade Cruzeiro do Sul Rua Constantino de Sousa, 454, apto 141 zip code: 04605-001, São Paulo - SP, Brazil
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Gawlak D, Mańka-Malara K, Świderska M, Kosieradzki M, Trzebicki J, Mierzwińska-Nastalska E. The assessment of the performance and usability of custom intraoral mouthguards during surgery with endotracheal intubation – A preliminary study. J Clin Anesth 2020; 60:26-27. [DOI: 10.1016/j.jclinane.2019.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 06/19/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
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Dental injury associated with anaesthesia: An 8-year database analysis of 592 claims from a major French insurance company. Anaesth Crit Care Pain Med 2017; 37:49-53. [PMID: 28838826 DOI: 10.1016/j.accpm.2017.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/25/2017] [Accepted: 04/13/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Dental injury is the most common incident associated with anaesthesia. Regarding recent recommendations on informed consent and changes in airway management practices, a large series of claims related to dental injury has not been recently described. The aim of this study was to analyse a recent database in order to describe the characteristics of dental injury in France. METHODS A database that prospectively collected claims reported to Le Sou Médical-MACSF between January 2003 and December 2010, was analysed. Five hundred and ninety-two cases were reported. The following characteristics were analysed: number and type of teeth injured, mechanism of injury, anaesthetic procedure, risk factors and dental outcome after injury. RESULTS Amongst the 1514 claims related to anaesthesia, 592 (39.2%) were classified as dental damage. Preoperative informed consent concerning possible perioperative dental injury was documented in only 34.8% of patients. Only one tooth was affected in 65.2% of patients, dental bridge injury in 12.8% of cases and damage to two or more teeth in 14% of patients. Incisors were involved in 50% of cases. Fracture was the most common type of injury (64.2%). Poor dentition was the most common risk factor (23.1%) followed by difficult intubation (15.4%). Both risks were combined in only 7.6% of cases. Tracheal intubation was the highest risk procedure (41.6%). CONCLUSION Dental injury remains the most common anaesthesia-related claim. Dental examination and documentation in patient medical files requires improvement and better informed consent on dental injury risk needs to be provided to patients.
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Robak O, Vaida S, Somri M, Gaitini L, Füreder L, Frass M, Szarpak L. Inter-center comparison of EasyTube and endotracheal tube during general anesthesia in minor elective surgery. PLoS One 2017; 12:e0178756. [PMID: 28575056 PMCID: PMC5456362 DOI: 10.1371/journal.pone.0178756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 05/18/2017] [Indexed: 12/27/2022] Open
Abstract
Background The EasyTube® (EzT) is a supraglottic airway device (SAD) enabling ventilation irrespective of its placement into the esophagus or trachea. Data obtained on SADs from multicenter studies, performed in highly specialized centers cannot always be transferred to other sites. However, data on comparability of different sites are scarce. This study focused on inter-site variability of ventilatory and safety parameters during general anesthesia with the EzT. Methods 400 patients with ASA physical status I-II undergoing general anesthesia for elective surgery in four medical centers (EzT group (n = 200), ETT group (n = 200)). Mallampati classification, success of insertion, insertion time, duration of ventilation, number of insertion attempts, ease of insertion, tidal volumes, leakage, hemodynamic parameters, oxygenation, and complications rates with the EasyTube (EzT) or endotracheal tube (ETT) in comparison within the sites and in between the sites were recorded. Results Intra-site and inter-site comparison of insertion success as primary outcome did not differ significantly. The inter-site comparison of expiratory minute volumes showed that the volumes achieved over the course of anesthesia did not differ significantly, however, mean leakage at one site was significantly higher with the EzT (0.63 l/min, p = 0.02). No significant inter-site differences in heart rate, blood pressure, or oxygenation were observed. Sore throat and blood on the cuff after removal of the device were the most frequent complications with significantly more complications at one site with the EzT (p = 0.01) where insertion was also reported significantly more difficult (p = 0.02). Conclusion Performance of the EzT but not the ETT varied between sites with regard to insertion difficulty, leakage, and complications but not insertion success, ventilation, hemodynamics, and oxygenation parameters in patients with ASA physical status 1–2 during general anesthesia undergoing minor elective surgery.
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Affiliation(s)
- Oliver Robak
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
- * E-mail:
| | - Sonia Vaida
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Centre, Hershey, PA, United States of America
| | - Mostafa Somri
- Department of Anesthesiology, Bnai Zion Medical Centre, Haifa, Israel
| | - Luis Gaitini
- Department of Anesthesiology, Bnai Zion Medical Centre, Haifa, Israel
| | - Lisa Füreder
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Frass
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Lukasz Szarpak
- Department of Emergency Medicine, Medical University of Warsaw, Warsaw, Poland
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Robak O, Vaida S, Gaitini L, Thierbach A, Urtubia R, Krafft P, Frass M. The EasyTube during general anesthesia for minor surgery: A randomized, controlled trial. Medicine (Baltimore) 2017; 96:e7195. [PMID: 28640104 PMCID: PMC5484212 DOI: 10.1097/md.0000000000007195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The EasyTube (EzT) is a supraglottic airway device that is used for emergency airway situations. Ventilation during general anesthesia should also be feasible, but literature on the EzT is scarce. We evaluated the EzT in comparison with the endotracheal tube (ETT) in its use during general anesthesia in a comparative study. METHODS A total of 400 patients with American Society of Anesthesiologists (ASA) physical status I to II scheduled for minor surgery in 4 centers were randomized for ventilation via the ETT or EzT. RESULTS In all patients, the EzT and the ETT could be inserted within 3 attempts. In all EzT patients, the inspiratory and expiratory minute volumes (6.64 ± 0.71 and 6.34 ± 0.69 L/min) were sufficient to reach target oxygenation values, similar to ETT patients (P = .59). Mean peak pressure, mean plateau pressure, and mean dynamic compliance did not differ between the groups. Sore throat and blood on the cuff after removal were the most frequent complications in both groups. CONCLUSION Ventilation for up to 1 hour during general anesthesia in patients with ASA physical status I to II with the EzT is feasible and safe.
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Affiliation(s)
- Oliver Robak
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sonia Vaida
- Department of Anaesthesiology, Penn State Milton S. Hershey Medical Centre, Hershey, PA
| | - Luis Gaitini
- Department of Anaesthesiology, Bnai Zion Medical Centre, Haifa, Israel
| | - Andreas Thierbach
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, University of Mainz and Klinikum Idar-Oberstein, Idar-Oberstein, Germany
| | - Ricardo Urtubia
- Department of Anaesthesiology Clinica Vespucio, Faculty of Medicine, Universidad Finis Terrae, Santiago, Chile
| | - Peter Krafft
- Department of Anaesthesiology and General Intensive Care, Medical University of Vienna and Rudolfstiftung, Vienna, Austria
| | - Michael Frass
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Abstract
Dental trauma as a result of anaesthesia practice is a relevant issue concerning morbidity and litigation. The investigator aimed to consolidate pertinent information on this issue to aid in the redressal of such an occurrence. A review of this relevant literature alongwith the author’s suggestions towards the management of the various kinds of dental trauma sustained as a result of anaesthesia practice is presented.
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Affiliation(s)
- Vaibhav Sahni
- Maharishi Markandeshwar College of Dental Sciences and Research, Haryana 133203, India
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Gawlowski P, Smereka J, Madziala M, Szarpak L, Frass M, Robak O. Comparison of the Macintosh laryngoscope and blind intubation via the iGEL for Intubation With C-spine immobilization: A Randomized, crossover, manikin trial. Am J Emerg Med 2016; 35:484-487. [PMID: 28041757 DOI: 10.1016/j.ajem.2016.11.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 11/29/2016] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Endotracheal intubation (ETI) using a Macintosh laryngoscope (MAC) requires the head to be positioned in a modified Jackson position, slightly reclined and elevated. Intubation of trauma patients with an injured neck or spine is therefore difficult, since the neck usually cannot be turned or is already immobilized in order to prevent further injury. The iGEL supraglottic airway seems optimal for such conditions due to its blind insertion without the need of a modified Jackson position. METHODS Prospective, randomized, crossover study in 46 paramedics. Participants performing standard intubation and blind intubation via iGEL supraglottic airway device in three airway scenarios: Scenario A - normal airway; Scenario B - manual inline cervical immobilization, performed by an independent instructor; scenario C: cervical immobilization using a standard Patriot cervical extraction collar. RESULTS In Scenario A, nearly all participants performed ETI successfully both with MAC and iGEL (100% vs. 95.7%). The time to intubation (TTI) using the MAC and iGEL amounted to 19 [IQR, 18-21]s vs. 12 [IQR, 11-13]s (P<0.001). Head extension angle as well as tooth compression were significantly better with the iGEL compared to the MAC (P<0.001). In scenario B and C, the results with the iGEL were significantly better than with MAC for all analyzed variables (TTI, success of first intubation attempt, head extension angle, tooth compression and VAS scores). CONCLUSION We showed that blind intubation with the iGEL supraglottic airway was superior to ETI performed by paramedics in a simulated cervical immobilization scenario in a manikin in terms of success rate, time to definite tube placement, head extension angle, tooth compression, and rating.
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Affiliation(s)
- Pawel Gawlowski
- Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland
| | - Jacek Smereka
- Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Madziala
- Department of Emergency Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Lukasz Szarpak
- Department of Emergency Medicine, Medical University of Warsaw, Warsaw, Poland.
| | - Michael Frass
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Oliver Robak
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
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15
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Ruíz-López Del Prado G, Blaya-Nováková V, Saz-Parkinson Z, Álvarez-Montero ÓL, Ayala A, Muñoz-Moreno MF, Forjaz MJ. [Design and validation of an oral health questionnaire for preoperative anaesthetic evaluation]. Rev Bras Anestesiol 2016; 67:6-14. [PMID: 27692805 DOI: 10.1016/j.bjan.2016.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/17/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Dental injuries incurred during endotracheal intubation are more frequent in patients with previous oral pathology. The study objectives were to develop an oral health questionnaire for preanaesthesia evaluation, easy to apply for personnel without special dental training; and establish a cut-off value for detecting persons with poor oral health. METHODS Validation study of a self-administered questionnaire, designed according to a literature review and an expert group's recommendations. The questionnaire was applied to a sample of patients evaluated in a preanaesthesia consultation. Rasch analysis of the questionnaire psychometric properties included viability, acceptability, content validity and reliability of the scale. RESULTS The sample included 115 individuals, 50.4% of men, with a median age of 58 years (range: 38-71). The final analysis of 11 items presented a Person Separation Index of 0.861 and good adjustment of data to the Rasch model. The scale was unidimensional and its items were not biased by sex, age or nationality. The oral health linear measure presented good construct validity. The cut-off value was set at 52 points. CONCLUSIONS The questionnaire showed sufficient psychometric properties to be considered a reliable tool, valid for measuring the state of oral health in preoperative anaesthetic evaluations.
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Affiliation(s)
- Gema Ruíz-López Del Prado
- Hospital Clínico Universitario, Departamento de Medicina Preventiva y Salud Pública, Valladolid, Espanha
| | - Vendula Blaya-Nováková
- Hospital General Universitario Gregorio Marañón, Servicio de Medicina Preventiva y Gestión de Calidad, Madri, Espanha; Instituto de Salud Carlos III, Agencia de Evaluación de Tecnologías Sanitarias, Madri, Espanha
| | - Zuleika Saz-Parkinson
- Instituto de Salud Carlos III, Agencia de Evaluación de Tecnologías Sanitarias, Madri, Espanha; Hospital Clínico San Carlos, Instituto de Investigación Sanitaria, Madri, Espanha
| | - Óscar Luis Álvarez-Montero
- Hospital Universitario Infanta Leonor, Departamento de Otorrinolaringología, Madrid, Espanha; Hospital Universitario Puerta de Hierro, Departamento de Otorrinolaringología, Madri, Espanha
| | - Alba Ayala
- Instituto de Salud Carlos III, Escuela Nacional de Sanidad, Madri, Espanha
| | - Maria Fe Muñoz-Moreno
- Hospital Clínico Universitario, Unidad de Investigación Biomédica, Valladolid, Espanha
| | - Maria João Forjaz
- Instituto de Salud Carlos III, Escuela Nacional de Sanidad, Madri, Espanha.
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16
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Ham SY, Kim J, Oh YJ, Lee B, Shin YS, Na S. Risk factors for peri-anaesthetic dental injury. Anaesthesia 2016; 71:1070-6. [DOI: 10.1111/anae.13560] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2016] [Indexed: 11/27/2022]
Affiliation(s)
- S. Y. Ham
- Department of Anaesthesiology and Pain Medicine; Yonsei University College of Medicine; Seoul Korea
| | - J. Kim
- Department of Anaesthesiology and Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - Y. J. Oh
- Department of Anaesthesiology and Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
| | - B. Lee
- Department of Anaesthesiology and Pain Medicine; Yonsei University College of Medicine; Seoul Korea
| | - Y.-S. Shin
- Department of Anaesthesiology and Pain Medicine; CHA Bundang Medical Center; CHA University; Seongnam Korea
| | - S. Na
- Department of Anaesthesiology and Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul Korea
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17
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Kang SH, Chang JH. Displacement of deciduous tooth into hypopharynx due to endotracheal intubation. J Dent Anesth Pain Med 2016; 16:61-65. [PMID: 28879297 PMCID: PMC5564120 DOI: 10.17245/jdapm.2016.16.1.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/11/2016] [Accepted: 03/16/2016] [Indexed: 11/15/2022] Open
Abstract
Intubation may lead to several dental complications. Furthermore, a tooth damaged during intubation may be subsequently dislocated. In the present case, the upper primary incisor was avulsed during intubation and, unbeknownst to the anesthesiologist, displaced to the larynx. We report here on the findings and indicate appropriate treatment. Intubation for general anesthesia in children can result in tooth damage and/or dislocation of primary teeth with subsequent root resorption. Prevention is key, and thus it is critical to evaluate the patient's dental status before and after intubation. Furthermore, anesthesiologists and dentists should pay close attention to this risk to prevent any avulsed, dislocated, or otherwise displaced teeth from remaining undetected and subsequently causing serious complications.
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Affiliation(s)
- Sang-Hoon Kang
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jung Hyun Chang
- Department of Otorhinolaryngology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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18
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Ruíz-López Del Prado G, Blaya-Nováková V, Saz-Parkinson Z, Álvarez-Montero ÓL, Ayala A, Muñoz-Moreno MF, Forjaz MJ. Design and validation of an oral health questionnaire for preoperative anaesthetic evaluation. Braz J Anesthesiol 2016; 67:6-14. [PMID: 28017172 DOI: 10.1016/j.bjane.2015.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/17/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Dental injuries incurred during endotracheal intubation are more frequent in patients with previous oral pathology. The study objectives were to develop an oral health questionnaire for preanaesthesia evaluation, easy to apply for personnel without special dental training; and establish a cut-off value for detecting persons with poor oral health. METHODS Validation study of a self-administered questionnaire, designed according to a literature review and an expert group's recommendations. The questionnaire was applied to a sample of patients evaluated in a preanaesthesia consultation. Rasch analysis of the questionnaire psychometric properties included viability, acceptability, content validity and reliability of the scale. RESULTS The sample included 115 individuals, 50.4% of men, with a median age of 58 years (range: 38-71). The final analysis of 11 items presented a Person Separation Index of 0.861 and good adjustment of data to the Rasch model. The scale was unidimensional and its items were not biased by sex, age or nationality. The oral health linear measure presented good construct validity. The cut-off value was set at 52 points. CONCLUSIONS The questionnaire showed sufficient psychometric properties to be considered a reliable tool, valid for measuring the state of oral health in preoperative anaesthetic evaluations.
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Affiliation(s)
- Gema Ruíz-López Del Prado
- Hospital Clínico Universitario, Departamento de Medicina Preventiva y Salud Pública, Valladolid, Spain
| | - Vendula Blaya-Nováková
- Hospital General Universitario Gregorio Marañón, Servicio de Medicina Preventiva y Gestión de Calidad, Madrid, Spain; Instituto de Salud Carlos III, Agencia de Evaluación de Tecnologías Sanitarias, Madrid, Spain
| | - Zuleika Saz-Parkinson
- Instituto de Salud Carlos III, Agencia de Evaluación de Tecnologías Sanitarias, Madrid, Spain; Hospital Clínico San Carlos, Instituto de Investigación Sanitaria, Madrid, Spain
| | - Óscar Luis Álvarez-Montero
- Hospital Universitario Infanta Leonor, Departamento de Otorrinolaringología, Madrid, Spain; Hospital Universitario Puerta de Hierro, Departamento de Otorrinolaringología, Madrid, Spain
| | - Alba Ayala
- Instituto de Salud Carlos III, Escuela Nacional de Sanidad, Madrid, Spain
| | - Maria Fe Muñoz-Moreno
- Hospital Clínico Universitario, Unidad de Investigación Biomédica, Valladolid, Spain
| | - Maria João Forjaz
- Instituto de Salud Carlos III, Escuela Nacional de Sanidad, Madrid, Spain.
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19
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Barletta M, Kleine SA, Quandt JE. Assessment of v-gel supraglottic airway device placement in cats performed by inexperienced veterinary students. Vet Rec 2015; 177:523. [DOI: 10.1136/vr.103407] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2015] [Indexed: 12/26/2022]
Affiliation(s)
- M. Barletta
- Department of Large Animal Medicine; College of Veterinary Medicine, University of Georgia; Athens GA 30602 USA
| | - S. A. Kleine
- Department of Small Animal Medicine & Surgery; College of Veterinary Medicine, University of Georgia; Athens GA 30602 USA
| | - J. E. Quandt
- Department of Small Animal Medicine & Surgery; College of Veterinary Medicine, University of Georgia; Athens GA 30602 USA
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20
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Brandão Ribeiro de Sousa JM, de Barros Mourão JI. Tooth injury in anaesthesiology. Braz J Anesthesiol 2015; 65:511-8. [DOI: 10.1016/j.bjane.2013.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 04/15/2013] [Indexed: 11/28/2022] Open
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Abstract
BACKGROUND AND OBJECTIVES Dental injury is the most common complication of general anaesthesia and has significant physical, economic and forensic consequences. The aim of this study is to review on the characteristics of dental injury associated with anaesthesiology and existing methods of prevention. CONTENTS In this review, the time of anaesthesia in which the dental injury occurs, the affected teeth, the most frequent type of injury, established risk factors, prevention strategies, protection devices and medico-legal implications inherent to its occurrence are approached. CONCLUSIONS Before initiating any medical procedure that requires the use of classic laryngoscopy, a thorough and detailed pre-aesthetic evaluation of the dental status of the patient is imperative, in order to identify teeth at risk, analyze the presence of factors associated with difficult intubation and outline a prevention strategy that is tailored to the risk of dental injury of each patient.
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22
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Mourão J, Neto J, Luís C, Moreno C, Barbosa J, Carvalho J, Tavares J. Dental injury after conventional direct laryngoscopy: a prospective observational study. Anaesthesia 2013; 68:1059-65. [DOI: 10.1111/anae.12342] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 11/30/2022]
Affiliation(s)
| | - J. Neto
- Institute of Biomedical Sciences Abel Salazar; University of Oporto; Oporto; Portugal
| | - C. Luís
- Department of Anaesthesia; Centro Hospitalar São João; EPE; Oporto; Portugal
| | - C. Moreno
- Department of Anaesthesia; Centro Hospitalar São João; EPE; Oporto; Portugal
| | - J. Barbosa
- Center for Medical Education; University of Oporto; Oporto; Portugal
| | - J. Carvalho
- Faculty of Dental Medicine; University of Oporto; Oporto; Portugal
| | - J. Tavares
- Department of Surgery; Faculty of Medicine; University of Oporto; Oporto; Portugal
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23
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Asahi Y, Omichi S, Adachi S, Kagamiuchi H, Kotani J. Ventilation via cut nasotracheal tube during general anesthesia. Anesth Prog 2013; 60:11-4. [PMID: 23506278 DOI: 10.2344/11-00031.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Many patients with disabilities need recurrent dental treatment under general anesthesia because of high caries prevalence and the nature of dental treatment. We evaluated the use of a nasal device as a possible substitute for flexible laryngeal mask airway to reduce the risk of unexpected failure accompanying intubation; we succeeded in ventilating the lungs with a cut nasotracheal tube (CNT) with its tip placed in the pharynx. We hypothesized that this technique would be useful during dental treatment under general anesthesia and investigated its usefulness as part of a minimally invasive technique. A prospective study was designed using general anesthesia in 37 dental patients with disabilities such as intellectual impairment, autism, and cerebral palsy. CNT ventilation was compared with mask ventilation with the patient in 3 positions: the neck in flexion, horizontal position, and in extension. The effect of mouth gags was also recorded during CNT ventilation. The percentages of cases with effective ventilation were similar for the 2 techniques in the neck extension and horizontal positions (89.2-97.3%). However, CNT ventilation was significantly more effective than mask ventilation in the neck flexion position (94.6 vs 45.9%; P < .0001). Mouth gags slightly reduced the rate of effective ventilation in the neck flexion position. Most dental treatments involving minor oral surgeries were performed using mouth gags during CNT ventilation. CNT ventilation was shown to be superior to mask ventilation and is useful during dental treatment under general anesthesia.
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Affiliation(s)
- Yoshinao Asahi
- Department of Dentistry, Morinomiya Hospital, Osaka City, Japan.
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24
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Nouette-Gaulain K, Lenfant F, Jacquet-Francillon D, Belbachir A, Bournigault-Nuquet A, Choquet O, Claisse A, Dujarric F, Francon D, Gentili M, Majoufre-Lefebvre C, Marciniack B, Péan D, Yavordios PG, Leone M. [French clinical guidelines for prevention of perianaesthetic dental injuries: long text]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:213-23. [PMID: 22377414 DOI: 10.1016/j.annfar.2012.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Dental injuries represent the most common claims against the anaesthesiologists. Dental lesions are frequent complications of orotracheal intubation and major causal factors are, firstly, preexisting poor dentition, and, secondly, difficult laryngoscopy and tracheal intubation. The aim of this work was to prioritize propositions for prevention in perianaesthetic dental injury and for care in case of dental trauma. METHOD A GRADE consensus procedure consisting of three rounds was conducted. A purposively selected heterogeneous panel (n=15) of experts, comprising 10 practitioners in anesthesiology, one practitioner who is jurist and anaesthesiologist, two practitioners in maxillofacial surgery, and two practitioners in dentist surgery. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the board members. The guidelines represent the best current evidence based on literature search and professional opinion. RESULTS The entire panel completed all three rounds and 31 plus six propositions were written for adult and paediatric clinical practice in anaesthesiology, respectively. The experts highlight the interest of preoperative visit for minimizing dental injuries: the practitioner must identify risk factors for difficult intubation and ventilation, describe precisely patient's preoperative dental condition, including upper incisor most commonly involved teeth in dental trauma. Patients have to be informed by practitioner for risk dental injury and anaesthesiology staff must choose his anesthesia protocol before the induction of intubation narcosis, avoiding insufficient anaesthesia and lack of experience by the anaesthesiologist. The choice of accurate proceeding during laryngoscopy, tracheal intubation and extubation for example, can aid in the prevention of dental injury, reduce the number of claims and the cost of litigation process. DISCUSSION These guidelines delineate an approach for the prevention of perianaesthetic dental trauma and for the immediate or urgent care in case of perianaesthetic dental injury.
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Affiliation(s)
- K Nouette-Gaulain
- Pôle d'anesthésie réanimation, service d'anesthésie-réanimation III, université Bordeaux-Segalen, hôpital des enfants, centre hospitalier universitaire de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France.
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