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Abstract: The launch on the market of a new compound is always an important event for a specialty, particularly when the mechanism of action is completely new. It is the case with sugammadex, a cyclodextrin able to encapsulate specifically and only nondepolarizing steroidal muscles relaxant, rocuronium or vecuronium. The clinical trials which have been performed for sugammadex approval have demonstrated promising results. Sugammadex is able to rapidly reverse (2–5 min) different levels of neuromuscular blockade: moderate (e.g., T2 recovery), deep (e.g., PTC 1-2 recovery) and also few minutes (3–15) after rocuronium administration. Thus, the sugammadex''s onset time is about 10 times more rapid than neostigmine without the need of concomitantly atropine administration. Sugammadex has only been tested in small sample size of patients. Therefore, the exact place in the anesthetic practice, the potential indications, the safety profile on a large-scale, thus remain to determine. In particular, how it will modify our current practices characterized to date by 1) under-use of neuromuscular monitoring, 2) a marginal practice of reversal and 3) a wide use of benzylisoquinolines : atracurium and cis-atracurium? Finally, what will be the medical strategies to justify an additional cost when compared to neostigmine? [Copyright &y& Elsevier]

Abstract: Guidelines about the use of neuromuscular blocking agents based on a national consensus conference have been published in 2000. A survey was carried out to assess adherence to these guidelines. An online questionnaire was designed from the different guidelines concerning the use of muscle relaxant for tracheal intubation and surgery, monitoring and antagonism of neuromuscular blockade. In addition, question about the knowledge of the pharmacodynamics of neuromuscular blocking agents were asked. Analysis concerned 1230 answers from senior anaesthetists. Tracheal intubation is facilitated by the use of a competitive agent or by succinylcholine by 58 and 8% of responders respectively. Atracurium and cisatracurium were most frequently used (49 and 44%, respectively). The duration of effect of an intubating dose of atracurium, vecuronium or rocuronium was estimated equal or below 60min by more than half of responders, whereas that of cisatracurium was longer. Fifty-two or 74% of responders used neuromuscular monitoring, whether a single or repeated dose of muscle relaxant was administered. Antagonism of neuromuscular blockade was systematic, frequent, and episodic or excluded by 6, 26, 55 and 13% of responders, respectively. Monitoring and antagonism of neuromuscular blockade are underused despite the guidelines. Underestimation of the risk of postoperative residual curarization is linked to the underestimation of the duration of competitive neuromuscular blocking agents. [Copyright &y& Elsevier]

Objective. – Define the pressure–volume relationship of the cuff of paediatric cuffed tracheal tubes.Study design. – Experimental study.Material and methods. – The cuff pressure was measured after incremental 0.1 ml filling volumes for 6 sizes (3.0 to 5.5 mm of internal diameter) of paediatric high volume–low pressure cuffed–tracheal tubes. The pressure–volume relationship of the cuff was assessed with and without resistance to the filling. Results were expressed with medium ± SD.Result. – Each increment increased the cuff pressure, without resistance, of 7.3 ± 1.7 mmHg for sizes 3.0, 3.5 and 4.0, 4.8 ± 1.6 mmHg for size 4.5, and 2.3 ± 0.9 mmHg for sizes 5 and 5.5. The resistance decreased the filling volume of the cuff for each size of tracheal tubes.Conclusion. – The margin of safety provided by cuff of smallest cuffed tracheal tubes is too small. Then, the smallest sizes (3.0 to 4.5) should not be called low pressure–high volume cuff. [Copyright &y& Elsevier]

Orbitary exenteration for tumor may concern ethmoidal wall, and may create a large communication between the orbital cavity and the cavum. We present the case of a patient scheduled for ocular prothetic surgery after an unilateral orbitary exenteration. After intravenous induction of the general anaesthesia, anaesthesiologist failed to achieve adequate facial mask ventilation because of a great gas leakage from cavum to orbital cavity. Inserting packing in the orbitary cavity allowed to decrease gas leakage and to get adequate facemask ventilation. We recommend orbitary radiographic and clinical evaluations for patient with orbitary exenteration before general anaesthesia to evaluate the communication between the orbital cavity and the cavum. Such an anatomic communication may result in inefficient facial mask ventilation. [Copyright &y& Elsevier]