2017-18 HSC Section 3 Green Book

E.

Boselli

et al.

/ Anaesth

Crit

Care

Pain Med

35

(2016)

31–36

optimal

sole

regional

anaesthesia

[5] . Combined with

general

anaesthesia,

intubation

conditions

without

using

muscle

relaxants intubation

infraorbital

nerve

blocks

have

demonstrated

beneficial

initiated after

tracheal

bilateral

[13] . Mechanical ventilation was with a mixture of 60–70% O 2

on

postoperative

pain

following

outpatient

nasal

surgery

and 30–40% air,

then

further adjusted

effects

In

these

studies,

infraorbital

nerve

blocks were

performed

keep

end-tidal

CO 2

pressure

between

30

and

35

mmHg.

[6,7] . using

to

the

intraoral approach, although

the extraoral approach may

to keep

the

Anaesthesia was maintained using desflurane adjusted

be

used

[8] .

The

efficacy

of

extraoral

versus

intraoral dental surgery

alveolar

concentration

between

0.8

and

1.2

and

remi-

also

minimal fentanil

0.2 m g/kg/min.

nerve

blocks

are

reported

to

be

similar

during

at

0.05

to

Two

grams

of

cefazoline were

infraorbital

but

to

date,

there

are

no

data

concerning

nasal

for

antimicrobial

prophylaxis.

surgery,

administered

rhinoseptoplasty

involves branch

regions

innervated by

the

tracheal

intubation,

an

experienced performed a infratrochlear

senior

anaes- facial blocks supine

[9] . Moreover, infratrochlear

Following

nerve,

a

terminal

of

the

ophthalmic

nerve

to

the

study drug

bilateral

thesiologist blinded

sensation

to

the

skin

of

the

upper

nasal

dorsum

and

consisting

of

infraorbital

and

nerve

providing sidewalls,

block, [5,8] .

but

infratrochlear

nerve [8,10] .

blocks

have

been

poorly

The

patient’s

head was

placed

on

a

central

line

in

a

in

this

indication

The

infraorbital

nerve

block

was

performed

using locate

an

investigated

position.

to determine whether

the use of bilateral

the

infraorbital

ridge

to

the

We conducted a study

extraoral approach by palpating

(Rhexis 1 ,

infraorbital

nerve

blocks

in

addition

to

infratrochlear

foramen

[8] . A 25 G needle

LCA Pharmaceu-

extraoral

infraorbital

blocks

with

0.25%

levobupivacaine

during

outpatient desflurane

Chartres,

France) was forward until

inserted

laterally

to

the

nostril

then

nerve

tical,

under

general

anaesthesia

using

it was

felt beneath

the finger

locating

rhinoseptoplasty

moved 1–2 cm

remifentanil

reduces

the

dose

of

perioperative morphine.

foramen

( Fig.

1 )

to

avoid

penetrating

globe

injury

[14] .

By

and

the

care

to

not

enter

the

foramen

itself

and

after

negative

taking

of

blood,

the

anaesthesiologist

slowly

injected

4 mL

of

aspiration

and methods

2. Material

study

drug

contained

in

syringe

1

(0.25%

levobupivacaine

for

the

LB

or

isotonic

saline

for

the

control

group).

The

infratro-

Group chlear

Study

design

2.1.

block

was

performed

by

infiltrating

1 mL

of

the

study

the

needle

inserted

1 cm

above

the

inner

canthus

solution with

single-centre,

prospective,

randomised,

double-blind

con-

This

2 )

[5] .

The

same

study

solution

was

also

injected

into

the

( Fig.

trial was

sponsored

by

the Hospices

Civils

de

Lyon

(HCL/P

trolled

region

using

the

same

techniques.

One minute

of

contralateral pressure was

approved Protection

by

the

local

attributed

ethics

committee identifier

2012.774), ( Comite´ de

applied

to

the

injection

points

to

prevent

haema-

III ,

study

des

Personnes

Sud-Est

tomas.

2013-017B)

and

registered

in

the

French

(EUDRACT

number

CPP

patient

received

8 mg

intravenous

dexamethasone

and

a

Each

and 10 m g/mL

2012-005831-97) identifier NCT01872728) databases for Clinical Trials. The trial was performed between June and December 2013 at the E´ douard-Herriot Hospital, Hospices Civils de Lyon, Lyon, France. Methodology followed CONSORT guidelines [11] . All ASA physical status I–II patients undergoing outpatient rhinoseptoplasty were screened during anaesthesia consultations. Rhinoseptoplasty was indicated by the surgeon for patients with nasal obstruction and deformation of the external framework of the nose. Exclusion criteria were age less than 18 years, pregnancy, ASA classification III–IV, known allergy to levobupivacaine or other local anaesthetics, preoperative chronic pain or incapacity to provide informed consent. Patients presenting an allergy to any study agent or local or systemic signs of infection during the study period were withdrawn from the study. After written informed consent was obtained, patients were randomly assigned by the pharmacy using a computer-generated list with a 1:1 ratio to two parallel arms receiving bilateral facial blocks (syringe 1) using either 0.25% levobupivacaine (Group LB) or isotonic saline as a placebo (control group). Patients in the control group also received intravenous morphine as part of their multimodal analgesia and patients in Group LB received isotonic saline as the corresponding placebo (syringe 2). All study solutions were prepared in identical syringes by a pharmacist not involved in clinical management and were presented to the anaesthesiologist in a blinded manner [12] . The patient, surgeon, anaesthesiologist, and clinical research assistant collecting the data were all blinded to the solutions administered. and American (ClinicalTrials.gov

local

infiltration of

a mixture of 1%

lidocaine

10 mL

routinely used by

surgeons

to

reduce bleeding during

epinephrine

[15] .

Combined

with

dexamethasone,

patients

also

surgery received

1.25 mg

intravenous

droperidol

during

the

procedure

for antiemetic prophylaxis. Rhinoseptoplasty was

then performed

[16] . The bony and cartilaginous

via endonasal or open approaches

carved

so

as

to

improve nasal

airflow. An

extracorpo-

septum was

technique

was

used

if

required.

The

dorsal

hump

was both

real

and

then

lateral

osteotomies were

performed

on

removed,

of

the

nose.

At

the

end

of

surgery,

patients

received

an

sides

dressing,

and

intranasal

plastic

splints.

external

Anaesthetic

technique

2.2.

oral

premedication

via

hydroxyzine

0.5–1

mg/kg

and

After

in

the via

operating

room,

patients

were

continuously

arrival

electrocardiography,

pulse

oxymetry

and

non-

monitored

blood

pressure

measurements

recorded

every

five

invasive

induction was performed after three minutes

minutes. Anaesthesia

Fig.

1.

Infraorbital

nerve

block

landmarks.

The

arrow

represents

the

needle

preoxygenation

via

facemask

with

0.25–0.5 mg/kg

ketamine,

of

lateral

to medial with a stop before

the finger

direction, which should be horizontal,

2–4 m g/kg

propofol

and

remifentanil

to

provide

2.5–3 mg/kg

locating

the

foramina,

to

avoid

penetrating

globe

injury

[14] .

247