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Objectif : évaluer l'effet synergique d'un inhibiteur sélectif de la recapture sérotoninergique (ISRS) et d'un inhibiteur sélectif de la cyclo-oxygénase 2 (ISCOx-2) dans la prise en charge des céphalées postrachianesthésie en milieu obstétrical (CPRAO). Patientes et méthodes : étude multicentrique randomisée contrôlée de non-infériorité en double aveugle sur une période de 12 mois dans six hôpitaux au sud-est de la République Démocratique du Congo, ayant inclus toutes les patientes opérées ou analgésiées sous rachianesthésie pour une indication obstétricale et ayant présenté les céphalées caractéristiques d'une brèche dure-mérienne, sans autres causes connues. Les patientes étaient reparties dans quatre groupes : A = réhydratation + paracétamol, B = réhydratation + célécoxib, groupe C = réhydratation + néfopam et 4 = réhydratation + célécoxib + néfopam (groupe d'étude). Résultats : le protocole associant le célécoxib et le néfopam montre son efficacité dans la réduction des CPRAO dès les deux premiers jours avec une diminution progressivement significative de l'anxiété et de la durée de séjour. Par ailleurs, la majorité des patientes (75,6 %) avait manifesté un grand niveau global de satisfaction avec ce protocole. Conclusion : étant donné la bonne tolérance et l'accessibilité de ces produits, nous suggérons l'utilisation de ce protocole pour sa validation dans notre milieu et ailleurs. [ABSTRACT FROM AUTHOR]

Context and objective: Acute generalized peritonitis has high morbidity and mortality in Sub-Saharan Africa. Although spinal anesthesia has accepted in mesocolic surgery, it remains nevertheless contraindicated in peritonitis, due to hemodynamics disorders that it causes. The objective of this study was to present the results of spinal anesthesia in patients operated on for generalized acute peritonitis. Patients and Methods: This was a prospective study that involved 115 patients classified ASA III and IV, operated under spinal anesthesia (RA) combining a local anesthetic and morphine, for generalized acute peritonitis of various etiologies at Saint Luc Hospital in Kisantu, between March 1, 2008 and Feb 28, 2011. Hemodynamic parameters, level of analgesia and adverse effects of opioids were studied. Results: Blood pressure remained stable per and postoperatively. Preoperative tachicardia (134 beats/min on average) was normalized per and postoperatively. Respiratory rate decreased from an average of 26 cycles per minute preoperatively to 14 postoperatively. Analgesia was sufficient. Adverse effects were pruritus (10%) and nausea or vomiting (14%). No respiratory depression was recorded. Conclusion: Due to its satisfactory results, spinal anesthesia deserves to be used in generalized acute peritonitis, provided preoperative hemodynamic stability. [ABSTRACT FROM AUTHOR]

Context and objective: Acute generalized peritonitis has high morbidity and mortality in Sub-Saharan Africa. Although spinal anesthesia has accepted in mesocolic surgery, it remains nevertheless contraindicated in peritonitis, due to hemodynamics disorders that it causes. The objective of this study was to present the results of spinal anesthesia in patients operated on for generalized acute peritonitis. Patients and Methods: This was a prospective study that involved 115 patients classified ASA III and IV, operated under spinal anesthesia (RA) combining a local anesthetic and morphine, for generalized acute peritonitis of various etiologies at Saint Luc Hospital in Kisantu, between March 1, 2008 and Feb 28, 2011. Hemodynamic parameters, level of analgesia and adverse effects of opioids were studied. Results: Blood pressure remained stable per and postoperatively. Preoperative tachicardia (134 beats/min on average) was normalized per and postoperatively. Respiratory rate decreased from an average of 26 cycles per minute preoperatively to 14 postoperatively. Analgesia was sufficient. Adverse effects were pruritus (10%) and nausea or vomiting (14%). No respiratory depression was recorded. Conclusion: Due to its satisfactory results, spinal anesthesia deserves to be used in generalized acute peritonitis, provided preoperative hemodynamic stability. [ABSTRACT FROM AUTHOR]

Introduction: the aim of this study was to evaluate Target the effect of the addition of clonidine or magnesium sulfate of morphine, administered through IT on the duration of analgesia after spinal anesthesia for cesarean section. Patients and Methods- 75 women in labor, ASA I or II, proposed programmed or semi-urgent caesarean section, were included in this study. They were randomized into three groups: Group morphine or witness (GM), Magnesium Group (GMg), clonidine group (CG). The primary endpoint was the time between the completion of spinal anesthesia and the first analgesic request. Results - The time to first analgesic request was superior, 286.76 (52.25) mn in the GC and 237.40 (73.67) mnin GMg against 209.68 (36.09)mn GM (p <0.001) in connection with the literature data. The EVA average scores at rest and during exercise in the first 24 postoperative hours were lower in groups and GC GMg compared to GM. Overall satisfaction was good in parturients with no significant difference in the groups. The duration of motor block was 193.68 (33.37) min in the GC against 141.76 (29.80) min in GM and 135.92 (23.14) min in the GMg (p <0.001). We noted a significant incidence of somnolence. Hemodynamic parameters were similar between the three groups. Conclusion - In parturients operated on by cesarean section under spinal anesthesia, the addition of 75 mg magnesium sulfate or 75μg clonidine 100 μg of morphine in IT prolongs significantly the duration of the first analgesic postoperatively demand and reduced scores pain 24 hours without increasing the incidence of adverse effects. [ABSTRACT FROM AUTHOR]

Nous rapportons le cas d'un patient de 78 ans, sans antécédents pathologiques notables, qui a bénéficié d'une résection transuréterale d'une hypertrophie bénigne de prostate de 50g sous rachianesthésie. Ce patient a présenté, 90 minutes après le début de l'intervention, des nausées vomissements, brouillard visuel et bradycardie en rapport avec un TURP syndrome. L'ionogramme a objectivé une natrémie à 118meq/l, d'où sa mise sous sérum salé hypertonique à 3% avec bonne évolution. Cette observation décrit une forme typique mais modérée du TURP syndrome dont la prise en charge était facilitée par l'état d'éveil du patient permis grâce à la rachianesthésie.

La rachianesthésie (RA) est la première anesthésie locorégionale. Elle comporte des effets secondaires et des risques qu'il faut pouvoir éviter, prévenir ou traiter précocement. C'est le cas d'une patiente opérée sous rachianesthésie qui a présenté quelques jours après l'interventionde céphalées intenses associées à des nausées et des vomissements évoluant dans un contexte de fièvre. La ponction lombaire mettait en évidence un liquide trouble avec la présence de cocci gram + à l'examen direct, ce qui a permis de poser le diagnostic d'une méningite bactérienne et dont l'évolution a été favorable après antibiothérapie.

Les méningites sont des complications rares mais graves des anesthésies péridurales et des rachianesthésies. Les méningites bactériennes sont essentiellement dues à des cocci à Gram positif, ce qui sous-entend une contamination exogène pouvant être le témoin d'une faute d'asepsie. L'évolution est le plus souvent favorable sous traitement, mais au prix d'un accroissement des dépenses de santé et parfois d'importantes séquelles neurologiques. Nous présentons un cas de méningite bactérienne au décours d'une rachianesthésie effectué pour césarienne.

Les erreurs médicamenteuses constituent une complication très redoutable en anesthésie. La fréquence des erreurs médicamenteuses par administration serait de l'ordre 1/10 000 à 1/1000. Nous rapportons un cas d'injection accidentelle de bupivacaine en intraveineuse directe. Il s'agissait d'un jeune patient classé ASA I qui était prévu pour cure chirurgicale d'une hydrocèle unilatérale sous rachianesthésie. Une injection de 12,5 mg de bupivacaine et 25 g de fentanyl étaient injectés après un reflux net du liquide céphalorachidien sans incident. Après installation de la rachianesthésie, le début de l'intervention était autorisé sans incidents. Une sédation de confort était décidée. Juste après apparaissait des troubles de rythme à type tachycardie ventriculaire avec une élévation de taux de troponines en post opératoire. L'évolution était marquée par une normalisation de la troponine au troisième jour post opératoire et sorti de l'hôpital au cinquième jour.

INTRODUCTION: la rachianesthésie est courante en obstétrique. L'hypotension artérielle maternelle apparaît dans 50-80%. Elle affecte l'équilibre acido-basique et l'état clinique du nouveau-né. Pour y remédier, l'usage de vasoconstricteurs est incontournable. L'éphédrine était de loin de premier choix en obstétrique. Dans les pays développés, elle est co-administrée avec la phényléphrine. A Madagascar, seule l'éphédrine reste disponible. Notre étude consiste à déterminer les facteurs de risque d'apparition du score d'Apgar inférieur à 7 chez les nouveau-nés. METHODES: une étude rétrospective transversale, analytique, était effectuée à la Maternité de Befelatanana, Antananarivo Madagascar (Décembre 2010-Décembre 2011). Nous avons inclus 344 césariennes opérées sous rachianesthésie. Le critère principal de jugement était l'observation de score d'Apgar inférieur ou égal à 7 à la première minute. Les données étaient analysées sur logiciel Epi Info version 6.04 (IC à 95%, p bilatéral = 0.05). RESULTATS: le score d'Apgar était inférieur ou égal à 7 dans 42%. Les facteurs de risque retrouvés étaient la césarienne en urgence, la dose d'éphédrine dépassant 30mg ainsi que la baisse de la pression artérielle diastolique supérieure à 10% par rapport à sa valeur initiale (p respectif =0.05). CONCLUSION: la précarité de l'état clinique des nouveau-nés à la naissance est multifactorielle. La baisse de la pression artérielle diastolique associée à une dose élevée d'éphédrine est néfaste. De plus, l'augmentation de la catécholaminémie maternelle puis fétale l'aggrave.

Les erreurs médicamenteuses constituent une complication très redoutable en anesthésie. La fréquence des erreurs médicamenteuses par administration serait de l'ordre 1/10 000 à 1/1000. Nous rapportons un cas d'injection accidentelle de bupivacaine en intraveineuse directe. Il s'agissait d'un jeune patient classé ASA I qui était prévu pour cure chirurgicale d'une hydrocèle unilatérale sous rachianesthésie. Une injection de 12,5 mg de bupivacaine et 25 μg de fentanyl étaient injectés après un reflux net du liquide céphalorachidien sans incident. Après installation de la rachianesthésie, le début de l'intervention était autorisé sans incidents. Une sédation de confort était décidée. Juste après apparaissait des troubles de rythme à type tachycardie ventriculaire avec une élévation de taux de troponines en post opératoire. L'évolution était marquée par une normalisation de la troponine au troisième jour post opératoire et sorti de l'hôpital au cinquième jour. [ABSTRACT FROM AUTHOR]

We report the case of a 78-year old patient, with no particular past medical history, who underwent transurethral resection of the prostate (50 g) under spinal anesthesia for benign hypertrophy. 90 minutes after the beginning of the procedure, the patient had nausea, vomiting, visual fog and bradycardia, suggesting TURP syndrome. Ionogramme objectified a serum sodium level of 118meq/L, hence the patient was treated with 3% hypertonic saline solution, with good evolution. This study describes a common but moderate occurrence of TURP syndrome whose management was facilitated by patient's alertness during spinal anesthesia. [ABSTRACT FROM AUTHOR]

Résumé But Le but de cette étude était de comparer l’efficacité du coremplissage par le HEA 130/0,4 à celle du sérum salé isotonique dans la prévention de l’hypotension artérielle après la rachianesthésie pour césarienne programmée. Type d’étude Prospective, randomisée. Matériel et méthodes Cent-vingt parturientes classées ASA I et II programmées pour une césarienne ont été incluses dans cette étude. Les parturientes ont été tirées au sort pour recevoir un coremplissage rapide par 500 mL de sérum salé isotonique 0,9 % (groupe C) ou par 500 mL de HEA 130/0,4 (Voluven ® ) (groupe V). Le protocole de la rachianesthésie ainsi que celui de l’administration d’éphédrine ont été standardisés dans les deux groupes. Le critère de jugement principal était l’incidence de l’hypotension au cours de la césarienne programmée sous rachianesthésie. Résultats Quarante-trois patientes du groupe C et 24 du groupe V ont présenté une hypotension ( p = 0,001). La dose d’éphédrine utilisée était statistiquement plus faible dans le groupe V comparée au groupe C ( p = 0,005). Les nausées, les vomissements ainsi que les céphalées sont plus fréquentes dans le groupe C ( p = 0,006). Les scores d’Apgar et le gaz du sang du cordon étaient comparables dans les deux groupes. Conclusion Le coremplissage par le HEA 130/0,4 a été plus efficace que le coremplissage par le sérum salé isotonique pour prévenir la survenue de l’hypotension au cours d’une césarienne programmée sous rachianesthésie. En effet, il a permis de diminuer l’incidence, la durée de l’hypotension, les besoins en éphédrine ainsi que la survenue de céphalées et de vomissements. Objective The aim of this study was to compare the efficacy of HES 130/0.4 coloading compared to normal saline solution for prevention of hypotension during spinal anesthesia for elective caesarean section. Study design Prospective, randomized. Patients and methods One hundred and twenty ASA I and II patients scheduled for elective caesarean section were recruited. Patients were randomized to receive either 500 mL of HES 130/0.4 (Voluven ® ) coloading (Group V) or 500 mL of normal saline solution coloading (Group C). Spinal anesthesia technique and ephedrine administration were standardized in both groups. The primary endpoint was the incidence of maternal hypotension during spinal anesthesia for elective caesarean section. Results Hypotension occurred in 43 patients in group C and 24 patients in group V ( p = 0.001). Ephedrine consumption was significantly lower in group V ( P = 0.005). Nausea, vomiting and headache incidence was higher in group C ( p = 0.006). Apgar scores and umbilical blood gazes were comparable between groups. Conclusion HES 130/0.4 coload was more effective than normal saline solution to prevent hypotension following spinal anesthesia for elective cesarean section. HES 130/0.4 coload reduced the incidence, the duration of longest hypotension, the need for ephedrine and the adverse maternal effects. [ABSTRACT FROM AUTHOR]

Introduction: la rachianesthésie est courante en obstétrique. L'hypotension artérielle maternelle apparaît dans 50-80%. Elle affecte l'équilibre acido-basique et l'état clinique du nouveau-né. Pour y remédier, l'usage de vasoconstricteurs est incontournable. L'éphédrine était de loin de premier choix en obstétrique. Dans les pays développés, elle est co-administrée avec la phényléphrine. A Madagascar, seule l'éphédrine reste disponible. Notre étude consiste à déterminer les facteurs de risque d'apparition du score d'Apgar inférieur à 7 chez les nouveau-nés. Méthodes: une étude rétrospective transversale, analytique, était effectuée à la Maternité de Befelatanana, Antananarivo Madagascar (Décembre 2010- Décembre 2011). Nous avons inclus 344 césariennes opérées sous rachianesthésie. Le critère principal de jugement était l'observation de score d'Apgar inférieur ou égal à 7 à la première minute. Les données étaient analysées sur logiciel Epi Info version 6.04 (IC à 95%, p bilatéral < 0.05). Résultats: le score d'Apgar était inférieur ou égal à 7 dans 42%. Les facteurs de risque retrouvés étaient la césarienne en urgence, la dose d'éphédrine dépassant 30mg ainsi que la baisse de la pression artérielle diastolique supérieure à 10% par rapport à sa valeur initiale (p respectif

Résumé: Le syndrome de post-ponction lombaire (SPPL) est défini par l’International Headache Society comme des céphalées attribuées à des troubles moteurs intracrâniens non vasculaires en rapport avec une hypotension du LCR. Responsable de céphalées typiquement positionnelles, le tableau clinique s’accompagne également de troubles digestifs (nausées, vomissements), de troubles visuels ou auditifs dus à l’atteinte de nerfs crâniens voire de radiculalgies liées à l’étirement des nerfs rachidiens cervicaux. Le mécanisme physiopathologique est lié à une hypotension intracrânienne de LCR, consécutive à la brèche méningée. Les modifications de l’hémodynamique cérébrale (vasodilatation) et le déplacement rostro-caudal des principales structures intracrâniennes sont les principales conséquences de la fuite de LCR dont le débit n’est pas corrélé à l’intensité des céphalées. Divers traitements symptomatiques adjuvants (antalgiques, alitement, vasoconstricteurs…) sont proposés dans le cadre d’une attitude conservatrice purement médicale, mais leur efficacité semble très modeste. En rétablissant la pression intracrânienne du LCR par « contre-pression » dans l’espace péridural, l’injection de sang autologue ou « blood-patch » (BP) s’impose comme le traitement de référence du SPPL. De réalisation simple dans des conditions stériles, le BP présente un taux de succès supérieur à 80 % avec un amendement rapide des céphalées. Certaines modalités sur la procédure (délai de réalisation, volume à injecter, type de solutés…) doivent encore faire l’objet de recommandations scientifiques. [ABSTRACT FROM AUTHOR]

Ultrasound is a new tool in anesthesia and intensive care practices in order to improve management and outcomes. We describe current applications of ultrasonography in obstetric anesthesia as: aid to perform neuraxial blockades, guidance for central and peripheral venous catheterism and use in post-cesarean analgesia (transversus abdominis plane block). [ABSTRACT FROM AUTHOR]

Regional anaesthesia (epidural and spinal) is the cornerstone of obstetric anaesthesia and analgesia. In the beginning of the 21 century, about 80% of the parturient take benefits from these techniques during labour and delivery. However, very few situations represent absolute or relative contraindications to regional anaesthesia. The adequate knowledge of these contraindications prevents to expose our patients to an increased risk of complications of regional techniques but also avoid depriving them of their benefits in the name of false contraindications. This paper reviews the problems of patient refusal, site of puncture's infection, intracranial hypertension, hypovolemia, inherited and acquired coagulopathy, allergy to local anaesthetics, hyperthermia, cardiopathy, neurological diseases, spinal abnormalities, cervical dilation and lumbar tattoo. All together, it estimated that less than 0.5% of the parturient are contraindicated to regional anaesthesia in obstetrics. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the efficacy of HES 130/0.4 preload compared to normal saline solution for prevention of hypotension during spinal anaesthesia for elective caesarean section. Study design: Prospective, randomized. Patients and methods: Sixty ASA I patients scheduled for elective caesarean section were randomized to receive either 1000mL of normal saline solution preload (Group C) or 500mL of HES 130/0.4 preload (Group V) within 15minutes prior to spinal anaesthesia. Spinal anaesthesia techniques and ephedrine administration was standardized in both groups. The primary endpoint was the incidence of maternal hypotension before fetal extraction. Results: The incidence of hypotension before fetal extraction was significantly lower in group V compared to group C (40% vs 66%, P =0.03). Ephedrine consumption was significantly lower in group V (7.6±13mg vs 16.4±15mg). Lowest systolic blood pressure was significantly higher in group V (96±14 vs 85±14mmHg, P =0.005). Incidence of adverse maternal effects and neonatal consequences were similar in both groups. Conclusion: HES 130/0.4 preload reduced the incidence of hypotension, the duration of longest hypotension, and the need for ephedrine during spinal anaesthesia for elective caesarean section. However, the efficacy of HES 130/0.4 alone in prevention of maternal hypotension during spinal anaesthesia for caesarean section is still insufficient. [Copyright &y& Elsevier]

Abstract: Objective: To detail specificity of regional anaesthesia techniques in the obese patient. Data sources: Articles were selected from Medline database using the combination of the following keywords: obesity, peripheral nerve block, spinal anaesthesia, epidural, morbidity, mortality. Study selection: Most recent original articles or review have mainly been selected. Some case reports that highlighted specific points were added. Data extraction: Articles were analyzed for advantages and drawbacks, and risks of different techniques in obese patient. Data synthesis: Techniques avoiding obese patient''s mobilization are recommended. The use of skin landmarks may be challenging for both central and peripheral blocks. Ultrasound techniques should improve block performance, even though deep fat layers seem limit sound diffusion. Success rate and incidence of complications are usually increased after regional anaesthesia technique in obese patient. The reduction of intrathecal local anesthetic dose remains controversial in this population. Conclusion: Regional anaesthesia techniques could represent an alternative to general anaesthesia (less cardiorespiratory complications). However, many specific considerations have to be taken into account. [Copyright &y& Elsevier]

Abstract: Objective: In order to reduce the risk of postoperative apnoea, awake spinal anaesthesia or awake caudal anaesthesia are recommended for hernia surgery in newborn babies and former premature infants aged less than 60 weeks of amenorrhoea. However, additional sedation is sometimes necessary. Our working hypothesis was that a general anaesthesia with a face mask (sevoflurane) with no opiates nor neuromuscular blocking agents, maintaining the infant''s spontaneous breathing and combined with a caudal anaesthesia, could provide a safe and effective alternative. Study design: The epidemiological and technical data about the patient and the anaesthesia, as well as any per- and postoperative complications, were collected prospectively and analysed retrospectively. Patients and methods: Ninety-eight infants undergoing hernia surgery were included during the period from 2003 to 2008. Results: Caudal anaesthesia proved successful at first attempt in 69% of the infants (term or premature). Three attempts were needed in 8% of the infants born at term and 2% of the infants born prematurely. One failure was recorded. Seven patients presented one episode of peroperative apnoea; they were easily taken care of by means of brief face mask ventilation. The follow-up of these seven infants did not reveal any reappearance of postoperative apnoea/bradypnoea. Conclusion: The technique proposed is an effective alternative to the awake locoregional anaesthesia techniques: it provides excellent conditions for surgery and presents similar perioperative morbidity and risk of postoperative apnoea. [Copyright &y& Elsevier]

Abstract: Objective: The aim of the survey was to describe current practice in management of hypotension during spinal anaesthesia for elective caesarean section in Lorraine. Study design: Cross-sectional study by a mail survey. Methods: A 20-item postal questionnaire was sent to all anaesthetists working in public or private hospital with a maternity unit in Lorraine. Results: The response rate was 65%. Fifty-one percent of the respondents did not have a written procedure for the management of spinal-induced hypotension. Fluid preloading with or without vasopressor was the most common practice. Colloids were used by 20% of the respondents. For prevention of hypotension, 37% used ephedrine, 28% used phenylephrine mostly in association with ephedrine and 9% based their choice on heart rate. Twenty-six percent did not administer any vasopressor to prevent hypotension. First choice vasopressor for treatment of hypotension was ephedrine. Anaesthetists in academic practice were more likely to use coloading and phenylephrine administration, but none of them used colloids for pre- or coloading. Conclusion: Management of hypotension during spinal anaesthesia for elective caesarean section was significantly influenced by the type of practice. [Copyright &y& Elsevier]

Abstract: To determine neuraxial anesthesia practices in obstetric departments in Languedoc-Roussillon in parturient with large lumbar tattoo covering the puncture area. “A prospective anonymous survey was sent to anaesthesiologists” including a clinical case scenario with a tattooed woman. Questionnaire included items on neuraxial anaesthesia in various circumstances, reasons for the decision process, and “consensus management” or not “within the unit”. Fifty-four anaesthesiologists answered (response rate: 57%). Fifty-seven percent would perform an epidural anaesthesia (EA) through the tattoo. Thirty-nine percent would not; among which two third only would propose an alternative for EA. Elective or emergency caesarean section would prompt most of the anaesthesiologists to perform a spinal anaesthesia, especially in parturients with Mallampati Class III (93%) versus Class I (70%) airway. Seventy percent of responders reported no consensual management in their unit. Our study illustrates this lack of consensus in obstetrical units and among anaesthesiologists along with a variable attitude linked with the obstetrical and anaesthesiological situation. [Copyright &y& Elsevier]

Meningitis is a rare but serious complication of epidural and spinal anesthesia. Bacterial meningitis is mainly caused by Gram-positive cocci, implying an exogenous contamination which suggests a lack of asepsis. The evolution is usually favorable after treatment, but at the expense of increased health care costs and, sometimes, of significant neurological sequelae. We report a case of bacterial meningitis after spinal anesthesia for caesarean section. [ABSTRACT FROM AUTHOR]

Objective: Evaluate the effects of skin infiltration with ropivacaine 0,75% on postoperative pain after caesarean section in the first 24h. Patients and methods: A prospective randomized double blind study was realized during three months in Auxerre Hospital. All ASA 1–2 patients presenting for elective caesarean section under spinal anesthesia were enrolled in the study. Drug addicts and patients with chronic pain were excluded from the study. The patients were randomly divided into two groups to receive skin infiltration 20ml of ropivacaine 0,75% (Gr R) or skin infiltration of 20ml of 0,9% saline solution. All patients received systematically propacetamol 1g per six hours and ketoprofen 50mg per six hours. Intravenous morphine titration was delivered to patients with a simple numerical scale greater or equal to three (SNS≥3). Postoperative pain (SNS), morphine consumption and adverse reactions were compared. Results: From July to September 2005, 42 patients were enrolled in the study. The SNS was lower in the Gr R. Total morphine consumption was reduced in the Gr R. The incidence of the adverse effects were higher in the Gr P. One case of parietal haematoma was detected in the Gr P, the evolution of which was favorable. Discussion and conclusion: Skin infiltration of ropivacaine 0,75% is a simple technique able to reduce postoperative pain score and morphine consumption after caesarean section. [Copyright &y& Elsevier]

Abstract: The interscalenic block prolonged by a catheter allows an optimal analgesia for important surgery of the shoulder. Its realization is easy but exposes to potentially serious complications. We report a case of spinal anaesthesia due to the accidental catheterization of the medullar canal at the time of an interscalenic block. An examination by tomodensitometry showed images of myelography explained by the injection of non ionic contrast media agent in the catheter at the time of X-ray control. The regression of neurological signs was fast and without after-effect. This observation recalls that in spite of all the safety measures, the realization of locoregional anaesthesia can be burdened with accidents. The proscription of a major sedation and the use of short needles are elementary rules to realize the interscalenic block. The improvement of puncture techniques, ultra-sound location or use of stimulative catheters can decrease the risk of this kind of accident. [Copyright &y& Elsevier]

Abstract: Objective: To analyze the different preventive and curative strategies for the management of hypotension during spinal anaesthesia for caesarean section. Data sources: Data related to hypotension during spinal anesthesia for caesarean section were searched in the Medline database. Trials published in English or French were reviewed. Data synthesis: Hypotension during caesarean section under spinal anaesthesia is very frequent (55 to 90%) if not prevented. It can induce complications for the mother and/or the fetus. Crystalloid preload alone is ineffective. Colloid preload is effective but might be better used as a second line treatment. Ephedrine has been the vasopressor of choice for long, but has a weak prophylactic efficacy. In addition, it can induce maternal cardiovascular adverse effects and fetal acidosis. Prophylactic phenylephrine, with or without ephedrine according to maternal heart rate, is at least as effective as ephedrine, with less adverse effects. Crystalloid loading at the time of spinal injection (“co-/post-loading”) enhances the haemodynamic control provided by vasopressors. Conclusion: Hypotension during spinal anesthesia for caesarean section must be systematically detected, prevented and treated without delay. The association of vasopressor(s) (phenylephrine with or without ephedrine) with a rapid crystalloid loading at the time of spinal injection represents the most interesting strategy nowadays. [Copyright &y& Elsevier]

Abstract: Obstetric anaesthesia is a « young » discipline, with constant novelties from a clinical, scientific and academic standpoint. While there is still no official sub-specialty in obstetric anesthesia, this field has become more diversified because of the growing maternal request for labor analgesia, a constant and perhaps even increasing rate of caesarean deliveries of 20–30% depending on institutions and countries, and also due to the raise in “high risk” pregnancies in women carrying various medical conditions such as complex congenital cardiopathies. In their anesthesia training, most residents rotate in the delivery room for three months on average, which should allow them to acquire good practical skills when performing regional analgesia and anesthesia for labor and delivery. It has been shown that performing 75 epidurals in the obstetric context is sufficient to provide good technical expertise, when appropriate supervision is provided by a present and devoted staff. General anaesthesia remains the critical point, because this technique is less and less performed in pregnant women. It should be recommended to develop training programs to improve the technical skills for intubation in pregnant women, which is why anaesthesia simulators may have an important role in the future. In terms of the theoretical knowledge, good academic training programs are required. The physiology of pregnancy and the physiopathology of pregnancy-related disorders justify a thorough and rigorous teaching in order to reduce both maternal and neonatal morbidity and mortality. [Copyright &y& Elsevier]

Abstract: Objective. – Estimate the relevance of the Tuffier line, which connects both iliac crests, in analyzing the location of the puncture point for spinal anaesthesia for pregnant women. Study design. – Prospective. Patients and methods. – The age, weight, height, body mass index (BMI) and uterine height, (HU) of 121 patients admitted in the delivery room in July 2005, were recorded. The intersection point of the Tuffier line with the rachis was recorded in seating and sleeping positions. The corresponding vertebral level was verified by counting thorny apophyses from C7. Results. – The Tuffier line crossed the rachis at the expected level for 29.7% of the patients. The intersection point was below the expected in 6.6% of the cases and above in 63.7% of the cases. Only the weight and the BMI were significantly connected with stronger probability of error (p =0.001). Conclusion. – The error level with this method is important and comparable to error level in the series published in patients who are not pregnant woman. The main risk is the spinal injury, since the level of ending of the spinal cord is variable. It seems safe to use another method of location, especially with patients experiencing excessive weight. [Copyright &y& Elsevier]

Abstract: Introduction. – Fractured neck of femur is encountered more frequently as life expectancy increases. All anaesthetic techniques aim to avoid deleterious fall in arterial blood pressure. The haemodynamic effects of hypobaric unilateral spinal anaesthesia have been rarely assessed in patients over 80 year’s old. This study aims to do that in a prospective manner. Patients and methods. – Twenty-five patients were enrolled. Following a preload with HES 240/0.576 % (Hesteril®) (5 ml/kg) and the administration of an iliofascial block, patients were placed in the lateral decubitus position, operative side uppermost. 3.5 ml of 0.12% hypobaric bupivacaine was administered intrathecally at a rate of 0.25 ml/secondes. Patients were kept in position for 15 minutes. Systolic, mean and diastolic arterial pressures, heart rate, SaO2 % and ephedrine consumption were recorded at five minutes intervals as was the rate of onset, height and duration of sensory and motor block and extent of bilateralization. Patient and surgeon satisfaction scores were also recorded. Results. – No significant changes in systolic, mean and diastolic pressures, or SaO2 % occurred. Median onset times of sensory and motor block were 8±5 and 16±7 minutes on the operative side and 30±15 and 36±15 minutes on the contralateral side in those with bilateralization, respectively. The maximum height of sensory block was T 6 for sept patients, T 8 for huit patients and T 8–T 10 for the remainder. Mean duration of sensory and motor block was 134±26 and 119±24 minutes on the operative side and 100±26 and 98±25 minutes on the contralateral side, respectively. In 12 patients (48%) bilateralization of their block occurred. Patients and surgeons rated the technique highly. Conclusion. – Hypobaric unilateral spinal anaesthesia is a simple technique, produces satisfactory operative conditions and induces very little haemodynamic change in the elderly population. [Copyright &y& Elsevier]

A clinical case of spontaneous ventricular dysrythmia in a 47-year-old patient scheduled for ankle osteosynthesis is reported. During initial peripheral vein canulation, a spontaneous ventricular tachycardia occurred and disappeared spontaneously in about 3 min. It was decided to proceed with surgery. Thirty minutes after spinal anaesthesia, asystole occurred. Normal sinus rhythm was rapidly restored after basic life support. There was no harmful consequence for the patient. He had a history of repetitive monomorphic ventricular tachycardia (Gallavardin type). The aetiologies of asystole after spinal anaesthesia are well known and will be not discussed in the text. Although the origin of the asystole is unclear in this case, the literature on Gallavardin’s syndrome is reviewed, showing that a prolonged and complex preoperative assessment is not mandatory in this syndrome. [Copyright &y& Elsevier]

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We described a case of discitis and meningitis following spinal anaesthesia for transurethral resection of the prostate. The patient received antibiotics for a month before surgery, because of Klebsiella prostatitis. Spinal anaesthesia was performed in L3-L4 interspace by using 22G Quincke needle. Bacteriaemia occurred during the first postoperative hours. Ten days after spinal anaesthesia, patient suffered from lumbar pain, exacerbated by vertebral percussion, and motor weakness within lower limb, which was marked on right side. MRI examination showed L3-L4 discitis with psoas abcess in regard, and epiduritis marked around L3 right spinal root. CSF examination confirmed meningitis but no bacteria was found. Antibiotics were administered over a 6 weeks period, and then patient discharged from hospital without neurological sequellae. Infectious discitis related to disk puncture during spinal anaesthesia and postoperative bacteriaemia was likely in our patient. [Copyright &y& Elsevier]

Objective – To evaluate the effect of intrathecal clonidine in children.Study design – A prospective randomised study.Patients and methods – 45 children, 6 to 15 years old, were randomised in two groups; receiving either 0.5% hyperbaric bupivacaine or 0.5% hyperbaric bupivacaine added to clonidine 2 μg·kg–1. We assessed quality and length of motor and sensory blocks and side effects of clonidine: hypotension, bradycardia and sedation.Results – Clonidine was associated with prolongation of motor block, 190 ± 42 min vs 150 ± 35 min (p < 0.01), but the difference was not significant. Postoperative analgesia was longer in clonidine group, 490 ± 35 min vs 200 ± 50 min (mean ± SD), p < 0.001. Clonidine was associated with higher incidence of hypotension 54 vs 36% and bradycardia 30 vs 0%.Conclusion – These data suggest that intrathecal clonidine 2 μg·kg–1 is associated with extending duration of postoperative analgesia but with moderate side effects. [Copyright &y& Elsevier]

Abstract: After an uneventful caesarean delivery under spinal anaesthesia (hyperbaric bupivacaine 10mg, sufentanil 5μg and morphine 50μg), hypothermia (nadir 34°C) was recorded in a ASA 1 patient. Partial recovery was rapidly obtained with 400μg of naloxone but full recovery was obtained after seven hours of active rewarming with a forced-air warming blanket. Suggested pathophysiology and incidence of this hypothermia are described. [Copyright &y& Elsevier]

Abstract: Two cases of patients in whom neuraxial anesthesia was planned for labor and delivery and who had a pre-existing intracranial arachnoid cyst are reported. Anesthesia was used in one patient and was uneventful. The pathophysiology of these cysts and factors which can precipitate the occurrence of symptoms, are reviewed and cases previously described in the literature are examined. Management should be individualized and based on evaluation of preexisting neurological symptoms. In most cases and although CT scan and MRI images may show an intracranial cyst with impressive development, patients remain asymptomatic and neuraxial regional anesthesia can be used safely, provided the patient has agreed and the neurologist in charge has been informed. [Copyright &y& Elsevier]

Abstract: We report a case of severe and differed respiratory depression to a 70-year-old patient after spinal anaesthesia for prostatic adenomectomy. Ten milligram of bupivacaine, 30μg of clonidine and 100μg of morphine has been administrated intrathecally. The anaesthesia has lasted 4h and, 16h after the induction, the patient had a respiratory depression with bradypnea (5c/min), hypoxia (SpO2 80%) and sedation (scale 3 of Wilson). The evolution was favourable after intravenous injection of naloxone and oxygenotherapy. The use of low dose intrathecal morphine can involve a respiratory depression. Intrathecal association of morphine and clonidine must be careful used among old patients and require a monitoring during the first 24h. [Copyright &y& Elsevier]

Abstract: The authors report a case of subdural haematoma after spinal anaesthesia. A 36-year-old woman underwent phlebectomy under spinal anaesthesia. Two days later, she complains of severe headache without neurological signs, not responding to bed rest and analgesics. Magnetic resonance imaging showed a small acute subdural haematoma in the right parieto-occipital region. On the forth day, she was given a blood-patch, which improved rapidly the patient. Recovery was complete. [Copyright &y& Elsevier]

Abstract: Objective. – To study effect of injection rate on spinal blockade and haemodynamic of spinal bupivacaine for Caesarean section. Study design. – Prospective and randomized. Patients and methods. – Sixty ASA I-II patients scheduled for elective Caesarean section were randomized to receive either fast (20 seconds, group R, n =30) or slow (60 seconds, group L, n =30) spinal injection of 10 mg of hyperbaric bupivacaine 0.5% associated with 25 μg of fentanyl and 100 μg of morphine. Sensory and motor blockade and haemodynamic parameters were recorded. Results. – Profiles of sensory and motor block were similar in both groups. Variations of arterial blood pressure and total dose of ephedrine were not different between R and L groups. However, the number of patient with systolic blood pressure lower than 100 mmHg were significantly lower in L group than in R group (p =0.04). Incidences of adverse effects were similar in both groups. Conclusion. – Result of the present study suggests that a slow rate of injection would induce lower incidence of hypotension induced by spinal bupivacaine for Caesarean section. [Copyright &y& Elsevier]

Moya Moya is a rare disease of uncertain origin, characterised by stenosis of one or both of the internal carotid arteries and responsible of several neurological signs. We present the case of a boy with Moya Moya disease who was scheduled for an epiphisiodesis of the lateral malleola and had a spinal anaesthesia with hyperbaric bupivacaine 0.5% 10 mg without any perioperative complications. Any anaesthetic method could be used, provided special attention is given to avoid changes of capnea and blood pressure to preserve cerebral blood flow and palliate to cerebral flow steal. [Copyright &y& Elsevier]