[Peroperative desaturation during gynaecological laparoscopy-hysteroscopy: an unknown aetiology, pleural extravasation]

A 41-year-old patient presented several episodes of desaturation during a gynaecological laparoscopy. The major complication of this procedure is the venous air embolism. Several other side-effects have been reported: heart rate disorders, subcutaneous emphysema or pneumothorax. Pleural effusions during gynaecologic laparoscopy are apparently rare and the volume of effusion must be important to induce clinical symptoms. This fact can probably explain the frequent difficulty of diagnosis. The role of the diaphragmatic lymphatic network and other physiologic aspects are discussed in this article.

Rapacuronium 2.0 or 2.5 mg kg-1 for rapid-sequence induction: comparison with succinylcholine 1.0 mg kg-1

The purpose of this nine-centre study in 602 patients was to show that the frequency of acceptable intubating conditions after rapacuronium 2.0 or 2.5 mg kg-1 is not more than 10% lower than the frequency after succinylcholine 1.0 mg kg-1 during rapid-sequence induction of anaesthesia with fentanyl 1-2 micrograms kg-1 and thiopental 2-7 mg kg-1. Laryngoscopy and intubation were carried out 60 s after administration of muscle relaxant by an anaesthetist blinded to its identity. Intubating conditions were clinically acceptable (excellent or good) in 91.8% of patients given succinylcholine and in 84.1 and 87.6% of patients given rapacuronium 2.0 and 2.5 mg kg-1 respectively. With respect to the percentage of clinically acceptable intubating conditions, the estimated difference (and the upper limit of the one-sided 97.5% confidence interval) between succinylcholine and rapacuronium 2.0 mg kg-1 was 7.8 (14.4)% and between succinylcholine and rapacuronium 2.5 mg kg-1 it was 4.0 (10.2)%. For both comparisons, the upper limit of the one-sided confidence interval exceeded the predefined 10% difference. Hence, it could not be demonstrated that the intubating conditions with either of the two doses of rapacuronium were not inferior to those with succinylcholine 1.0 mg kg-1. The increase in heart rate was significantly greater during the first 5 min in the rapacuronium groups, but the arterial pressure increased significantly only in the succinylcholine group (P < 0.001). Respiratory side-effects were observed in 4.0, 13.5 and 18.5% of patients after succinylcholine and rapacuronium 2.0 and 2.5 mg kg-1 respectively (P < 0.05). As the non-inferiority of intubating conditions after rapacuronium 2.0 and 2.5 mg kg-1 could not be proven, succinylcholine should be considered the neuromuscular blocking agent that provides better intubating conditions for rapid-sequence induction.

Use of Anaesthesia Simulator: initial impressions of its use in two Belgian University Centers

459 trainees in Anesthesia and Intensive Care Medicine, accompanied by fully certified specialists from several Belgian University Hospital Centers, spend at least a 3 hour session at the Anaesthesia Simulator. Each session comprises three segments: the briefing, the simulation session and the debriefing. The use of simulations allows significant individualization of the learning experience. The simulator helps to develop the capacity to understand, explain a phenomenon and to resolve problems. Another important aspect of the use of the simulator involves the trainee's "right to make mistakes". This allows to widen the spectrum of executional situations, and decreases the number of dangerous situations. Two University Centers (ULg and UCL) have each organized simulator sessions despite some differences in their approaches. The simulator is a teaching tool worthy of an obligatory role in the most up-to-date training possible of modern anesthesiologist. This is all the more important given that the current practice of anesthesiology is so complex that any error could cost a human life.

Anaesthetic management of a child with Marshall-Smith syndrome

PURPOSE

The Marshall-Smith Syndrome (MSS) is a rare disease characterized by orofacial dysmorphism, failure to thrive, accelerated osseous maturation and mental retardation. It has anaesthetic implications due to upper airway problems and possible atlanto-axial instability. We present the perioperative problems (difficult intubation, airway obstruction) encountered in a child with MSS who underwent several anaesthetics during his first two years of life.

CLINICAL FEATURES

At birth, the child presented with asphyxia due to obstructive apnoea. His trachea was, therefore, intubated immediately. The morphological diagnosis of MSS was confirmed by the pathognomonic radiological appearance of the bones (bone age was eight months at the age of four days). Upper airway difficulty was caused by functional problems at the level of the hypopharynx (inspiratory collapse at the level of the velum palatinum), and was solved by the use of a nasopharyngeal airway (NPA) during the induction of anaesthesia and early postoperative period.

CONCLUSION

The use of an NPA during both induction and recovery of anaesthesia may be particularly useful to prevent upper airway problems in children with MSS.