Annales françaises d'anesthèsie et de rèanimation
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Reviewing problems related to the airway management in obstetrics, taking into account the recent evolutions of the anaesthetic practices in obstetrics. ⋯ Airway management in obstetrics remains a true challenge for various reasons. The physiological and anatomical modifications related to pregnancy are responsible for a faster hypoxemia, a reduction of the diameter of the pharyngolaryngal tract, as well as an increase of the risk of inhalation of gastric contents after 16 weeks of amenorrhea. The emergency or extreme emergency context and the presence of diseases like obesity or preeclampsia raise the risks of difficulties with airway management. The logical evolution of the practices, with the considerable rise of the regional anesthesia/analgesia limits the training and the maintenance of competences for intratracheal intubation in obstetrics. The training per simulation appears particularly interesting on the subject and this approach needs to be developed. The literature indicates that the incidence of difficult intubation is of one per 30. The impossible intubation is one per 280 in obstetrics, eight times greater than in the general population. No criterion of difficult intubation is sufficiently predictive alone. In obstetrics as in other contexts, the association of several criteria will permit to anticipate a difficult intubation. There is a worsening of the Mallampati during the pregnancy and during labour. To limit the risk of a difficult management of the airway in obstetrics, it will be paramount and capital, in addition to give priority to the regional anaesthesia/analgesia each time possible, to perform a careful and repeated evaluation of the predictive criteria of difficult intubation or ventilation. The inhalation of gastric fluid will systematically be prevented. The adapted material and algorithms for difficult intubation must be available in the labour wards. In case of a difficult intubation during an emergency caesarean section, the SFAR algorithms must be applied. In case of a "cannot intubate can ventilate situation", the possibility of carrying on the Caesarean maintaining the Sellick manoeuvre should be considered. The place of the laryngoscopy assisted by videolaryngoscope in this context clearly remains to be defined. Even if in the literature some cases of successful intubation through these devices suggest an interest, there is a clear deviance between the guidelines and the practices concerning general anaesthesia performed at the end of the labour. Indeed they should be systematically performed with rapid sequence induction and tracheal intubation. A reflexion on this theme is necessary in order to grant the practices to the recommendations.
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Damage control is a strategy of care for bleeding trauma patients, involving minimal rescue surgery associated to perioperative resuscitation. The purpose of this review is to draw up a statement on current knowledge available on damage control. ⋯ Historical damage control surgery, that consist of abbreviated laparotomy with second-look after resuscitation, is now included in a wider concept called "damage control resuscitation", addressing the lethal triad (coagulopathy, hypothermia and acidosis) at an early phase. Care is focused on coagulopathy prevention. Early resuscitation, or damage control ground zero, has been improved: aggressive management of hypothermia, bleeding control techniques, permissive hypotension concept and early use of vasopressors. Transfusion practices also have evolved: early platelets and coagulation factors administration, use of hemostatic agents like recombinant FVIIa, whole blood transfusion, denote the damage control hematology. Progress in surgical practices and development of arteriographic techniques lead to wider indications of damage control strategy.