Several indirect laryngoscopes have recently been developed, but relatively few have been formally compared. In this study we evaluated the efficacy and the usability of the Macintosh, the Glidescope®, the McGrath® and the Airtraq® laryngoscopes. Sixty anaesthesia providers (20 staff, 20 residents, and 20 nurses) were enrolled into this study. The volunteers intubated the trachea of a Laerdal SimMan® manikin in three simulated difficult airway scenarios. In all scenarios, indirect laryngoscopes provided better laryngeal exposure than the Macintosh blade and appeared to produce less dental trauma. In the most difficult scenario (tongue oedema), the Macintosh blade was associated with a high rate of failure and prolonged intubation times whereas indirect laryngoscopes improved intubation time and rarely failed. Indirect laryngoscopes were judged easier to use than the Macintosh. Differences existed between indirect devices. The Airtraq® consistently provided the most rapid intubation. Laryngeal grade views were superior with the Airtraq® and McGrath® than with the Glidescope®.

Background and objective Several video and optical laryngoscopes have been developed but few have been compared in terms of their learning curves and efficacy. Using a manikin with normal airways we compared the Glidescope, the McGrath, the Airtraq and the Macintosh laryngoscopes. Methods Sixty anaesthetists (20 staff, 20 residents and 20 nurses) participated in the study. All subjects were novice with the new devices. They intubated a Laerdal SimMan manikin (with normal airway) five times in a row with all laryngoscopes. The sequence of use of the devices was randomized. Before using a device, a presentation and a demonstration were provided. Outcome measures were: duration of intubation attempt, modified Cormack grades, dental trauma and difficulty of use. Results The Airtraq had the most favourable learning curve and mirrored the Macintosh after two intubation attempts. The Glidescope and McGrath had steep learning curves but, after five attempts, differences persisted when compared with the Macintosh and Airtraq. Time taken to visualize the glottis was similar but time taken to position the endotracheal tube was shorter for the Airtraq when compared with the Glidescope and McGrath. Indirect laryngoscopes seemed to have advantages over the Macintosh blade in terms of laryngeal exposure and potential dental trauma. Conclusions In a ‘normal airway’ model, intubation skills with the new devices appeared to be rapidly mastered. The three indirect laryngoscopes provided a better glottic exposure than the Macintosh. The Airtraq displayed the most favourable learning curve, probably reflecting differences in the techniques of endotracheal tube placement: guiding channel versus steering technique.

Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland

EDITOR: A recent French survey showed that the techniques of anaesthesia have changed dramatically since the beginning of the 1980s [1]. This is particularly true for regional anaesthesia (RA) the use of which has increased from 4% of the 3 600 000 anaesthetic procedures in 1980, to 23% of the 7 937 000 procedures in 1996. For several specific operations, the decision to undertake general anaesthesia (GA) instead of RA is easy or has proven advantages. However, in many circumstances this decision is questionable because neither technique has definite and proven advantages. The aim of this study was to determine which factors lead to the use of RA (rather than GA) in several specific surgical procedures where both anaesthetic techniques can be easily used. Material and methods describing this national survey have been recently published [1]. For this secondary analysis, seven surgical procedures were selected since they can be performed under either GA or RA (inguinal herniorraphy, repair of femoral neck fracture, hallux valgus surgery, varicose vein surgery, knee arthroscopy, carpal tunnel release and total hip replacement). RA was thus defined as RA only or with combined sedation. Independent variables describing the characteristics of patients were gender, age (yr) and American Society of Anaesthesiologists Grades (ASA I-II vs. ASA III-V). Each anaesthesia was characterized by several variables: elective (yes/no), emergency (yes/no), ambulatory condition (yes/no) and duration (min). The type of hospital was categorized into three classes: teaching hospitals, community hospitals and private centres. The presence of a postoperative pain service was unknown from the data available. Univariate analysis followed by multivariate analysis (logistic regression) was performed and adjusted odds ratio (AOR) was calculated and Wald tests computed (P = 0.05). The frequency of RA use varied markedly according to the type of surgery: inguinal herniorraphy (25%), knee arthroscopy (33%), varicose vein surgery (34%), total hip replacement (34%), hallux valgus surgery (50%), repair of femoral neck fracture (54%), carpal tunnel release (77%). RA was more frequently used for males (35% vs. 27% for arthroscopy and 27% vs. 18% for inguinal hernia surgery). There was a significant association between increasing age and RA for all types of surgery studied (Fig. 1). A high ASA score (ASA > II) was significantly associated with RA for total hip replacement and inguinal hernia surgery. Long duration of anaesthesia was associated with RA for most procedures but a shorter duration was associated with an increased use of RA for total hip replacement. Ambulatory surgery was associated with an increased use of RA for carpal tunnel release. For most procedures, teaching hospitals performed less RA than community hospitals or private centres.Figure 1: Use of RA according to patient's age and type of surgery. ━●━: total hip replacement (THR); SYMBOL: hallux valgus (HV); ―▲―: fracture of femoral neck (FFN); ·····●·····: knee arthroscopy (KA); ―◆―: inguinal hernia (IH).SymbolMultivariate analysis showed that except for carpal tunnel release, age remained a factor associated with increased RA use. The AOR for the upper quartile of age ranged between 1.6 (varicose vein surgery) and 7.8 (hallux valgus surgery). An association with ASA Grade was not observed in either situation. A long duration of anaesthesia was associated with use of RA with AOR for the upper quartile ranging from 3.8 (varicose vein surgery) to 11.3 (carpal tunnel release). By contrast, for total hip replacement, long duration was associated with use of GA. The male gender and surgery performed in a private centre were associated with increased use of RA but the odds ratio was <2 for most procedures. The main finding of this study was that, in France, use of RA for non-obstetric surgery is mainly related to increased patient age. Although RA is often felt safer by both patients [2] and physicians [3], the beneficial effects of RA on postoperative outcomes remain controversial and may not explain the increased use of regional techniques in older patients. Increased use may thus only be related to better acceptance of these techniques in this population. Increased ASA score was not associated with an increased rate of RA and was probably largely masked by the powerful effect of increased age. A (predicted) long duration of surgery was found in some surgical models to relate to an increased use of RA. However, in other models the relation was the opposite. Surgeons' acceptance of an awake patient under RA is often more difficult to obtain when a long operation is awaited and prolonged surgery may also increase patients' anxiety. Finally, their immobility for several hours is an almost impossible objective to reach. We found that ambulatory patients undergoing carpal tunnel release received RA more frequently than hospitalized patients. The perceived advantages of RA techniques relate to increased alertness, decreased postoperative pain and nausea, more rapid discharge times and decreased readmission rates [4,5]. In France, RA is more often practised in community hospitals and private centres. Physicians working in non-academic centres provide a significantly greater number of anaesthetics annually than those working in teaching hospitals [6] and probably have higher success rates with regional techniques. This study has several limitations. We explored only surgical situations in which a debate between RA and GA exists and in which large numbers were available to allow statistical analysis. Detailed information was lacking as we extracted data from the questionnaire used in the survey [1]. In conclusion, this secondary analysis of the large French survey aimed at describing anaesthetic practices in France [1] showed that the use of RA in this country is primarily related to increased patient age. Other patient-, surgical- or structure-related characteristics played a less important role in determining the use of RA. D. Benhamou Department of Anesthesia and Intensive Care Medicine; Bicêtre Hospital; Le Kremlin-Bicêtre, France F. Péquignot French National Service of Causes of Death; CépiDc-INSERM; Le Vésinet, France Y. Auroy Department of Anesthesia and Critical Care Medicine; Percy Military Hospital; Clamart, France E. Jougla French National Service of Causes of Death; CépiDc-INSERM; Le Vésinet, France F. Clergue Division of Anesthesia; Cantonal University Hospital; Geneva, Switzerland M.-C. Laxenaire Department of Anesthesia and Intensive Care Medicine; Central Hospital; Nancy, France A. Lienhart Department of Anesthesia and Intensive Care Medicine; Saint-Antoine Hospital; Paris, France

To determine on a national level the factors associated with the use of laparoscopy for digestive surgery.Nation wide study using a large representative sample (3 days of anaesthesia in France).Univariate followed by multivariate analyses of data gathered in 1996 during the survey led by the French Society of Anaesthesia and Intensive care ("SFAR") including 2847 surgical procedures for cholecystectomy, appendicectomy or inguinal herniorraphy.Independent factors associated with the use of laparoscopy were: for cholecystectomy: age (less frequent when > or =71 years: adjusted Odds ratio [AOR] 0.4), sex (more frequent in female: AOR 1.7), ASA physical status (less frequent when > or =3: AOR 0.5), private hospital (AOR 2.0), procedure scheduled at least the night before (AOR 2.1), and use of closed circuit general anaesthesia (AOR 1.6); for appendectomy: age >15 years (AOR 1.9-2.2), female (AOR 2.1), private hospital (AOR 2.7), scheduled procedure (AOR 2.1), prolonged procedure (AOR 8.4), endotracheal intubation (AOR 16.7), and closed circuit (AOR 2.7); for inguinal herniorraphy: ASA physical status (less frequent when > or =3: AOR 0.4), private hospital (AOR 3.4), prolonged procedure (AOR 5.6), and endotracheal intubation (AOR 21.6). Association with a closed circuit was confirmed for general anaesthesia using a volatile agent (AOR 1.5). Overall, ambulatory surgery was rarely performed and used only for open procedures. Regional anaesthesia was used only for inguinal open herniorraphy.These data obtained from a large national survey confirmed the higher frequency of laparoscopy in middle aged patients, female (except for inguinal herniorraphy), without important comorbidity, in private hospitals. Laparoscopy was associated with prolonged procedures and with a change in the anaesthetic technique for appendicectomy and inguinal herniorraphy: tracheal intubation was almost constantly used. Whatever the procedure, closed circuit anaesthesia was more frequently used when surgery was performed under laparoscopy, reflecting newer equipment of the hospital, private or public.

Objective. - To determine on a national level the factors associated with the use of laparoscopy for digestive surgery.Study design. - Nation wide study using a large representative sample (3 days of anaesthesia in France).Methods. - Univariate followed by multivariate analyses of data gathered in 1996 during the survey led by the French Society of Anaesthesia and Intensive care ("SFAR") including 2847 surgical procedures for cholecystectomy, appendicectomy or inguinal herniorraphy.Results. - Independent factors associated with the use of laparoscopy were: for cholecystectomy: age (less frequent when greater than or equal to71 years: adjusted Odds ratio [AOR] 0.4), sex (more frequent in female: AOR 1.7), ASA physical status (less frequent when greater than or equal to3: AOR 0.5), private hospital (AOR 2.0), procedure scheduled at least the night before (AOR 2.1), and use of closed circuit general anaesthesia (AOR 1.6); for appendicetomy: age >15 years (AOR 1.9-2.2), female (AOR 2.1), private hospital (AOR 2.7), scheduled procedure (AOR 2.1), prolonged procedure (AOR 8.4), endotracheal intubation (AOR 16.7), and closed circuit (AOR 2.7); for inguinal herniorraphy: ASA physical status (less frequent when 3: AOR 0.4), private hospital (AOR 3.4), prolonged procedure (AOR 5.6), and endotracheal intubation (AOR 21.6). Association with a closed circuit was confirmed for general anaesthesia using a volatile agent (AOR 1.5). Overall, ambulatory surgery was rarely performed and used only for open procedures. Regional anaesthesia was used only for inguinal open herniorraphy.Conclusion. - These data obtained from a large national survey confirmed the higher frequency of laparoscopy in middle aged patients, female (except for inguinal hermorraphy), without important comorbidity, in private hospitals. Laparoscopy was associated with prolonged procedures and with a change in the anaesthetic technique for appendicectomy and inguinal herniorraphy: tracheal intubation was almost constantly used. Whatever the procedure, closed circuit anaesthesia was more frequently used when surgery was performed under laparoscopy, reflecting newer equipment of the hospital, private or public. (C) 2003 editions scientifiques et medicales Elsevier SAS. Tous droits reserves.

Goal of the study: To determine over a whole country what are the factors associated with an intraoperative homologous blood transfusion and with the use of autologous techniques (preoperative autologous blood donation : PABD; acute normovolemic hemodilution: ANVH; intraoperative red cell salvage: IRCS).Study design: National enquiry using a large representative sample (3 days of anaesthesia in France).Methods: Univariate followed by multivariate analyses of data gathered in 1996 during the survey leaded by the French society of anaesthesia and intensive care (Sfar) and corresponding to 884 scheduled hip and knee prosthesis surgical procedures.Results: Factors associated with a decreased use of PABD programme were: 1- old age and high ASA physical status; 2- procedures of short duration. By contrast, an increased use of PABD was associated with anaesthetics in which a closed circuit had been used. Except for a significant association with increasing age and with absence of PABD used, no additional factor was found to be linked with ANVH. No factor among those studied was found related to the use of IRCS. Homologous blood transfusion was more frequently used in ASA greater than or equal to 3 patients, in long duration surgeries while its use was decreased in patients with PABD (odds ratio-for reduction by PABD : 4.4 [95 % confidence interval : 2.2-8.8]). Homologous blood transfusion was not related to the use of ANVH or IRCS.Conclusion: These data obtained from a large national survey confirm previously published studies and meta-analyses and are in agreement with current recommendations. An unexpected relation between PABD and closed circuit anaesthesia has been found. (C) 2002 Editions scientifiques et medicales Elsevier SAS.

BACKGROUND To identify the growth in the number of anesthetic procedures since 1980 and the changes in the practice of anesthesia, the present survey was designed to collect and analyze the anesthetic activity performed in France in 1996, from a representative sample collected in all French hospitals and clinics. METHODS This study, initiated by the French Society of Anesthesia and Intensive Care, collected information that included the characteristics of patients (age, sex, American Society of Anesthesiologists status), the techniques of anesthesia, and the nature of the procedure for which anesthesia was required. All French private, public, and military hospitals were asked to participate in the survey. In each hospital in the country, all anesthetic procedures were documented and collected during 3 consecutive days, chosen at random during a 12-month period, to obtain a representative sample of the annual activity. All data were analyzed at the INSERM (National Institute of Health and MEDICAL RESEARCH: At the conclusion of the study, 5% of hospitals were randomly assigned to be audited to check for missing data and errors. The rate of anesthetic activity was calculated as the ratio between the annual number of anesthetic procedures and the number of the general population in the same age group. RESULTS The participation rate of hospitals was 98%. The analysis of the 62,415 collected questionnaires allowed extrapolation of the anesthetic activity to 7,937,000 anesthetic procedures (95% confidence interval, +/- 387,000) performed in France in 1996. Thus, the annual rate of anesthetic procedures was 13.5 per 100 population, varying between 5.4 per 100 in girls aged 5-14 yr and 30.2 per 100 in men aged 75-84 yr. Surgery was involved in 71% of anesthesia cases. Regional anesthesia alone was performed in 20% of all surgical cases and was combined with general anesthesia in 3% of additional cases. Anesthesia for obstetric procedures represented 9% of all cases. Seventy-six percent of all anesthetic procedures started between 12:00 A.M. and 7:00 A.M. were related to obstetric activities. CONCLUSION In comparison with a previous study, the present survey shows that the number of anesthetic procedures has increased by 120% since 1980, and the rate of anesthetic procedures increased from 6.6 to 13.5 per 100 population, the major changes being observed in patients aged > or = 75 yr and in those with an American Society of Anesthesiologists physical status of 3. In the same time period, the number of regional anesthetic procedures increased 14-fold. In obstetrics, the practice of epidural analgesia extended from 1.5% to 51% of all deliveries of the country.