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Background: Patients receiving anti-platelet agents for secondary cardiovascular prevention frequently require non-cardiac surgery. A substantial proportion of these patients have their anti-platelet drug discontinued before operation; however, there is uncertainty about the impact of this practice. The aim of this study was to compare the effect of maintenance or interruption of aspirin before surgery, in terms of major thrombotic and bleeding events.Methods: Patients treated with anti-platelet agents for secondary prevention and undergoing intermediate- or high-risk non-cardiac surgery were included in this multicentre, randomized, placebo-controlled, trial. We substituted non-aspirin anti-platelets with aspirin (75 mg daily) or placebo starting 10 days before surgery. The primary outcome was a composite score evaluating both major thrombotic and bleeding adverse events occurring within the first 30 postoperative days weighted by their severity (weights were established a priori using a Delphi consensus process). Analyses followed the intention-to-treat principle.Results: We randomized 291 patients (n=145, aspirin group, and n=146, placebo group). The most frequent surgical procedures were orthopaedic surgery (52.2%), abdominal surgery (20.6%), and urologic surgery (15.5%). No significant difference was observed neither in the primary outcome score [mean values (SD)=0.67 (2.05) in the aspirin group vs 0.65 (2.04) in the placebo group, P=0.94] nor at day 30 in the number of major complications between groups.Conclusions: In these at-risk patients undergoing elective non-cardiac surgery, we did not find any difference in terms of occurrence of major thrombotic or bleeding events between preoperative maintenance or interruption of aspirin. [ABSTRACT FROM AUTHOR]

Background Patients receiving anti-platelet agents for secondary cardiovascular prevention frequently require non-cardiac surgery. A substantial proportion of these patients have their anti-platelet drug discontinued before operation; however, there is uncertainty about the impact of this practice. The aim of this study was to compare the effect of maintenance or interruption of aspirin before surgery, in terms of major thrombotic and bleeding events. Methods Patients treated with anti-platelet agents for secondary prevention and undergoing intermediate- or high-risk non-cardiac surgery were included in this multicentre, randomized, placebo-controlled, trial. We substituted non-aspirin anti-platelets with aspirin (75 mg daily) or placebo starting 10 days before surgery. The primary outcome was a composite score evaluating both major thrombotic and bleeding adverse events occurring within the first 30 postoperative days weighted by their severity (weights were established a priori using a Delphi consensus process). Analyses followed the intention-to-treat principle. Results We randomized 291 patients (n=145, aspirin group, and n=146, placebo group). The most frequent surgical procedures were orthopaedic surgery (52.2%), abdominal surgery (20.6%), and urologic surgery (15.5%). No significant difference was observed neither in the primary outcome score [mean values (sd)=0.67 (2.05) in the aspirin group vs 0.65 (2.04) in the placebo group, P=0.94] nor at day 30 in the number of major complications between groups. Conclusions In these at-risk patients undergoing elective non-cardiac surgery, we did not find any difference in terms of occurrence of major thrombotic or bleeding events between preoperative maintenance or interruption of aspirin.ClinicalTrials.gov identifier. NCT00190307. [ABSTRACT FROM AUTHOR]

Abstract: Only few studies have focused on the issues raised by discontinuing sedation in ICU patients. Several lines of evidence allow defining the risk factors for the occurrence of a weaning syndrome due to discontinuation of sedatives and analgesics in ICU patients. These primarily include a prolonged (more than seven days) period of continuous intravenous administration of high doses of hypnotics and opioids. Weaning from sedation is tightly linked to weaning from the ventilator and this area should be the target of research work in the near future. [Copyright &y& Elsevier]

Background: Volatile agents can mimic ischaemic preconditioning leading to a decrease in myocardial infarct size. The present study investigated if a 15 min sevoflurane administration before cardiopulmonary bypass (CPB) has a cardioprotective effect in patients undergoing coronary surgery.Methods: Seventy-two patients were randomized in two centres. The intervention group (S) received 1 MAC sevoflurane administrated via the ventilator for 15 min followed by a 15 min washout before CPB, the control group did not. The primary outcome was the postoperative troponin Ic peak. A biopsy of the atrium was taken during canulation for enzyme dosages. Results are expressed as mean (SD).Results: Neither troponin Ic nor tissular enzyme measurement exhibited any difference between the groups: peak of troponin Ic was 4.4 (5.6) in S group vs 5.2 (6.6) ng ml(-1) in control group (ns). Intratissular ecto-5'-nucleotidase activity was 7.1 (4.3) vs 8.5 (11.9), protein kinase C activity was 27.1 (15.7) vs 29.2 (28.7), tyrosine kinase activity was 101 (54.1) vs 98.5 (63.3), and P38 MAPKinase activity was 131.1 (76.1) vs 127.1 (86.8) nmol mg protein(-1) min(-1) in S group and control group, respectively (ns). However there were fewer patients with low postoperative cardiac index in S group (11% in S vs 35% in control group, P < 0.05) when considering the per protocol population. In S group, 25% of patients required an inotropic support during the postoperative period, vs 36% of patients in control group (ns).Conclusions: This study did not show a significant preconditioning signal after 15 min of sevoflurane administration. The 15 min duration might be too short or the concentration of sevoflurane too low to induce cardioprotection detected by troponin I levels. [ABSTRACT FROM AUTHOR]

The primary goal of sedation is to achieve security and comfort of mechanically ventilated ICU patients. Delivery of pharmacologic agents must avoid over sedation, which increases morbidity by prolongation of the duration of mechanical ventilation. Similarly, under sedation may favour life-threatening events such as accidental extubation. Many clinical scales have been generated to regularly measure the level of sedation (consciousness and tolerance to the ICU environment). No electrophysiological monitor (BIS) has proved reliability for measuring the depth of sedation or analgesia yet. The presence of brain damage in ICU patients makes the level of sedation impossible to interpret. Glasgow coma scale, which is exclusively devoted to the consciousness domain, is the only recommendation that can be made in neurocritical care at the present time. [Copyright &y& Elsevier]

An anomalous dependence of the threshold current on the stripe width is observed for gain-guided strained-layer InGaAs/GaAs quantum well lasers. The threshold current increases strongly as the stripe width is reduced from relatively large values. This is attributed to the huge lateral loss caused by an unusually large index antiguide which manifests itself in the far-field behavior. This large loss also leads to a population of higher quantized energy levels in the InGaAs quantum well strongly reducing the lasing wavelength by as much as 61 nm. [ABSTRACT FROM AUTHOR]

GaAs/AlGaAs light-emitting diodes (LED’s) with nipi active regions have been successfully fabricated using sequential n and p diffusions to selectively contact the doping superlattice. By doing sequential patterned sulfur and zinc diffusions, a lateral injection LED can be readily fabricated. Excellent current-voltage characteristics were achieved with reverse breakdown voltages in excess of 9.5 V, indicating that the selective contacts were nearly optimum. cw outputs of 500 μW at 50 mA drive current have been observed. The LED output spectrum was seen to tune with applied bias at a rate of about 650 meV/V at low temperatures. [ABSTRACT FROM AUTHOR]

Abstract: Claims in anesthesia and intensive care remains high, despite the reduction of morbidity and mortality associated with this activity. The absence of a national register makes it difficult to quantify. The Medical Committee of MACSF-Sou Medical Group, professional liability insurer of more than half of French physicians, provided us support. The amount of compensation paid is growing and the scope of compensated damage is expanded by the Dintilhac mission. The Act of March 4, 2002 has fully confirmed the principle of medical liability for misconduct. Generally, compensation for bodily injury is based on the demonstration of a causal link between a wrongful event and injury. The proof of fault lies with the applicant. Information accountable to patients and nosocomial infection are a particular setting. The Act of March 4, 2002 has also defined the concept of therapeutic risk. With the establishment of the Regional Commissions of Conciliation and Compensation (RCCI) and the National Office for Compensation of Medical Accident (Oniam), it is now possible for a patient to be compensated for an injury resulting from an accident Medical non-offending, while acknowledging the lack of accountability of the practitioner. The expertise conducted by an RCCI is adversarial. For the practitioner called to the cause, it is important to prepare for both substance and form, with the assistance of the medical board''s insurance company. [Copyright &y& Elsevier]

Background: Manufacturers recommend maintaining anaesthesia at a bispectral index (BIS) or state entropy (SE) index value between 40 and 60.Methods: We prospectively studied 102 patients receiving propofol-sufentanil anaesthesia administered by anaesthetists blinded to these indices. The main endpoint was crude agreement (P(0)), defined as the proportion of agreement between BIS and SE index among three categories: <40, between 40 and 60, and >60. Discrepancies in recommendation (DR) were also considered. A DR is type 1 if BIS or SE is <40, while the other is simultaneously >60. A DR is type 2 when BIS and SE index values are on different sides of a threshold (40 or 60) with three subtypes according to the magnitude of their difference. A linear multiple regression was performed to identify covariates that are independently associated with P(0).Results: In total, 12 147 pairs of values were studied. P(0) was 59.9 (24.5%) [mean (sd)]. Thirty-three patients presented more than 50% discordant pairs and only seven patients presented more than 95% concordant pairs. Type 1 DR occurred in only 1.1% of all the pairs. The median (inter-quartile range) number of type 2 DR varied from 5 (3-8) to 2 (1-3) according to the degree of difference. Multivariate analysis showed that age (P=0.0004) and electrode position (P=0.0084) were independently associated with P(0). An increase in the age of 10 yr decreases P(0) by 5%.Conclusions: The agreement between BIS and SE indices is moderate and deteriorates as patients' age increases. This study cannot determine which index is best adapted for elderly patients. Additional work comparing both indices with raw EEG traces is warranted. [ABSTRACT FROM AUTHOR]

The cavity length dependence of the threshold current for separate confinement quantum well lasers with a single well, three wells, and six wells is studied. Only the single quantum well laser showed the anomalous increase of threshold current at short cavity length. Comparison of the experimental results with theoretical calculations concludes that the polarization enhancement of the oscillator strength in a quantum well has to be taken into account in the gain spectrum calculation of the quantum well laser. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Apnea test during brain death assessment in mechanically ventilated and ECMO patients," by M. Giani and colleagues in the 2016 issue.

Background: Mismatch negativity (MMN) is the neurophysiological correlate of cognitive integration of novel stimuli. Although MMN is a well-established predictor of awakening in non-sedated comatose patients, its prognostic value in deeply sedated critically ill patients remains unknown. The aim of this prospective, observational pilot study was to investigate the prognostic value of MMN for subsequent awakening in deeply sedated critically ill patients.Methods: MMN was recorded in 43 deeply sedated critically ill patients on Day 3 of ICU admission using a classical 'odd-ball' paradigm that delivers rare deviant sounds in a train of frequent standard sounds. Individual visual analyses and a group level analysis of recordings were performed. MMN amplitudes were then analysed according to the neurological status (awake vs not awake) at Day 28.Results: Median (inter-quartile range) Richmond Assessment Sedation Scale (RASS) at the time of recording was -5 (range, from -5 to -4.5). Visual detection of MMN revealed a poor inter-rater agreement [kappa=0.17, 95% confidence interval (0.07-0.26)]. On Day 28, 30 (70%) patients had regained consciousness while 13 (30%) had not. Quantitative group level analysis revealed a significantly greater MMN amplitude for patients who awakened compared with those who had not [mean (standard deviation) = -0.65 (1.4) vs 0.08 (0.17) μV, respectively; P=0.003).Conclusions: MMN can be observed in deeply sedated critically ill patients and could help predict subsequent awakening. However, visual analysis alone is unreliable and should be systematically completed with individual level statistics. [ABSTRACT FROM AUTHOR]

Background: Severe sepsis has a high mortality rate. There is increasing evidence that human mesenchymal stem cells possess immunomodulatory properties in sepsis, particularly those from adipose tissue. We hypothesised that micro-fragmented human fat, obtained with minimal alteration of the stromal vascular niche, attenuates the inflammatory response and improves outcome in a murine model of sepsis.Methods: Micro-fragmented fat, lipoaspirate, or saline was administered intraperitoneally 2 h after caecal ligation and puncture (CLP) in C57Bl/6RJ ketamine-xylazine anaesthetised mice. The primary endpoint was the inflammatory score. Secondary endpoints included survival, physiological, histological, and biological parameters.Results: In CLP mice, micro-fragmented fat administration significantly decreased the median (range) inflammatory score compared with saline [17 (14-20) vs 9 (8-12), P=0.006]. Secondary endpoints were also significantly improved in micro-fragmented fat-treated compared with saline-treated CLP mice. Improvement in inflammatory score and in survival was suppressed when micro-fragmented fat was co-administered with liposomes loaded with clodronate (macrophage toxin) or NS-398 (cyclo-oxygenase 2 inhibitor), but not with SC-560 (cyclo-oxygenase 1 inhibitor).Conclusions: In a murine model of severe sepsis, micro-fragmented fat improved early inflammatory status and outcome, at least in part, by a cyclo-oxygenase-2-mediated mechanism. The potential therapeutic value of micro-fragmented fat in severe sepsis warrants further investigation. [ABSTRACT FROM AUTHOR]

Background: Sleep deprivation is common in anaesthesia residents, but its impact on performance remains uncertain. Non-technical skills (team working, situation awareness, decision making, and task management) are key components of quality of care in anaesthesia, particularly in crisis situations occurring in the operating room. The impact of sleep deprivation on non-technical skills is unknown. We tested the hypothesis that in anaesthesia residents sleep deprivation is associated with impaired non-technical skills.Methods: Twenty anaesthesia residents were randomly allocated to undergo a simulation session after a night shift [sleep-deprived (SLD) group, n =10] or after a night of rest [rested (R) group, n =10] from January to March 2015. The simulated scenario was a situation of crisis management in the operating room. The primary end point was a composite score of anaesthetists' non-technical skills (ANTS) assessed by two blinded evaluators.Results: Non-technical skills were significantly impaired in the SLD group [ANTS score 12.2 (interquartile range 10.5-13)] compared with the R group [14.5 (14-15), P <0.02]. This difference was mainly accounted for by a difference in the team working item. On the day of simulation, the SLD group showed increased sleepiness and decreased confidence in anaesthesia skills.Conclusions: In this randomized pilot trial, sleep deprivation was associated with impaired non-technical skills of anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario.Trial Registration: NCT02622217. [ABSTRACT FROM AUTHOR]

Background: Automated titration of propofol and remifentanil guided by the bispectral index (BIS) has been used for numerous surgical procedures. Orthotopic liver transplantation (OLT) uniquely combines major changes in circulating volume, an anhepatic phase, and ischaemia-reperfusion syndrome. We assessed the behaviour of this automated controller during OLT.Methods: Adult patients undergoing OLT were included in this pilot study. Consumption of propofol and remifentanil was calculated for each surgery period (dissection, anhepatic, and liver reperfusion phases). Arterial blood samples were collected at several time points to allow comparison of actual with calculated propofol and remifentanil concentrations. Data are presented as median [25th and 75th percentiles] or percentage (95% confidence interval).Results: Thirteen patients were studied. System performance, defined as the percentage of time with BIS in the range 40-60, was 88% (86-94) of the total duration of anaesthesia. Propofol requirement was decreased during the anhepatic phase compared with the dissection phase (2.9 [1.9-5.0] mg kg(-1) h(-1) and 4.6 [3.5-8.1] mg kg(-1) h(-1); P<0.03) while remifentanil consumption was unchanged (0.11 [0.09-0.19] µg kg- (1) min(-1)). Bland-Altman analysis showed a weak concordance for propofol (bias of 0.7 µg ml(-1) and limits of agreement of -2.2 to +3.7 µg ml(-1)) and remifentanil (bias of 1.3 ng ml(-1) and limits of agreement -4.3 to +6.8 ng ml(-1)). No adverse events were reported during anaesthesia.Conclusions: This pilot study indicates that automated titration of propofol and remifentanil guided by the BIS is feasible during OLT. [ABSTRACT FROM AUTHOR]

The article focuses on a study on risk factors of percutaneous cannulation failure by intensivists for veno‑arterial extracorporeal life support for refractory cardiac arrest. It mentions predictive factors for unsuccessful percutaneous ECLS cannulation. It also mentions feasibility of ultrasound-guided percutaneous femoral cannulation by intensivists.

Résumé L’anesthésie-réanimation s’est engagée depuis plusieurs décennies dans la recherche de l’excellence tant dans le domaine clinique que dans celui de la recherche. L’exigence de notre discipline s’applique également à la sélection des universitaires. L’objectif de cet article est, d’une part, de porter à la connaissance de la discipline les critères d’évaluation indispensables à l’inscription sur liste d’aptitude aux fonctions de maitre de conférences des universités – praticien hospitalier (MCU-PH) et de professeur des universités – praticien hospitalier (PU-PH) en anesthésie-réanimation, et d’autre part, de décrire en détail le long processus conduisant à cette inscription. Since several decades, anesthesia care and intensive care, as well, are engaged in the way of excellence in clinical care and research. This requirement is also applied for the selection of professor and academic workers. The goals of this article are twice: first to diffuse this knowledge at the medical community and second to describe in details the long process leading to the final appointment. [ABSTRACT FROM AUTHOR]

Purpose: To assess the feasibility and validity of ultrasonographic measurement of gastric antral cross-sectional area (usCSA) in critically ill patients to predict gastric volume and the use of computed tomography (CT) as a reference to measure gastric volume. Method: This single-center, prospective, cross-sectional study included 55 critically ill patients who had an abdominal CT scan. usCSA measurements were performed within the hour preceding the CT scan. Gastric volumes were measured on the CT scan using semiautomatic software. The feasibility rate, performing conditions (% 'good' and 'poor'), internal and external validity of antral usCSA measurements, performed by an ICU physician, were assessed to predict gastric volume. Results: Antral usCSA measurements were feasible in 95 % of cases and were positively correlated with gastric volume measured by the CT scan when performed in 'good' conditions (65 %) ( r = 0.43). There was good reproducibility of measurements (intraclass correlation coefficient of 0.97, CI 95 % 0.96-0.99) and there was clinically acceptable agreement between measurements performed by radiologists and intensivists (bias −0.12 cm). The receiver operating characteristic curve identified a cutoff value of 3.6 cm that discriminated an 'at-risk stomach' (volume >0.8 mL/kg) at a sensitivity of 76 % and a specificity of 78 %. Conclusions: Ultrasonographic measurement of antral CSA is feasible and reliable in the majority of critically ill patients. This technique could be useful to manage critically ill patients at risk of aspiration or with enteral feeding. [ABSTRACT FROM AUTHOR]

Background: Rapid diagnosis of coagulopathy in the bleeding patient using point-of-care (POC) devices would be ideal. The Hemochron Signature Elite(®) (HC(®)) is a POC device that determines international normalized ratio (INR) and activated partial thromboplastin time (aPTT). The aim of the study was to evaluate the agreement for INR and aPTT between the HC(®) and standard laboratory values in acute haemorrhage.Methods: This was a single-centre observational prospective study including patients with acute haemorrhage. Laboratory INR and aPTT were compared with simultaneous measurements performed with the HC(®). The diagnostic performance of HC(®) was determined; bias and limits of agreement were calculated according to the method of Bland and Altman.Results: Seventy-two pairs of measurements from 39 patients were analysed. The bias between the INR-HC(®) and aPTT-HC(®) measurements and the central laboratory were 0.02 and -1.13, respectively. The Spearman's correlation coefficients for the INR-HC(®)/INR-lab and the aPTT-HC(®)/aPTT-lab were 0.68 and -0.29, respectively. Twenty-seven per cent of INR-HC(®) values and 89% of the aPTT-HC(®) values exceeded the predefined limits of agreement. The INR-HC(®) measurement identified patients with a central laboratory INR >1.5 with a sensitivity, specificity, and positive and negative predictive values of 83%, 70%, 76%, and 77%, respectively.Conclusions: The results showed a lack of agreement between the INR-HC(®) and the aPTT-HC(®) measurements and the standard laboratory in the context of acute haemorrhage. The INR-HC(®) showed moderate performance as a decision-making tool to detect coagulopathy in the context of acute haemorrhage. [ABSTRACT FROM AUTHOR]

Background Rapid diagnosis of coagulopathy in the bleeding patient using point-of-care (POC) devices would be ideal. The Hemochron Signature Elite® (HC®) is a POC device that determines international normalized ratio (INR) and activated partial thromboplastin time (aPTT). The aim of the study was to evaluate the agreement for INR and aPTT between the HC® and standard laboratory values in acute haemorrhage. Methods This was a single-centre observational prospective study including patients with acute haemorrhage. Laboratory INR and aPTT were compared with simultaneous measurements performed with the HC®. The diagnostic performance of HC® was determined; bias and limits of agreement were calculated according to the method of Bland and Altman. Results Seventy-two pairs of measurements from 39 patients were analysed. The bias between the INR-HC® and aPTT-HC® measurements and the central laboratory were 0.02 and −1.13, respectively. The Spearman's correlation coefficients for the INR-HC®/INR-lab and the aPTT-HC®/aPTT-lab were 0.68 and −0.29, respectively. Twenty-seven per cent of INR-HC® values and 89% of the aPTT-HC® values exceeded the predefined limits of agreement. The INR-HC® measurement identified patients with a central laboratory INR >1.5 with a sensitivity, specificity, and positive and negative predictive values of 83%, 70%, 76%, and 77%, respectively. Conclusions The results showed a lack of agreement between the INR-HC® and the aPTT-HC® measurements and the standard laboratory in the context of acute haemorrhage. The INR-HC® showed moderate performance as a decision-making tool to detect coagulopathy in the context of acute haemorrhage. [ABSTRACT FROM AUTHOR]

Résumé: Objectifs: Évaluer les pratiques professionnelles des médecins anesthésistes-réanimateurs (AR) concernant la prise en charge périopératoire des patients coronariens en chirurgie non cardiaque et apprécier l’écart par rapport aux recommandations en vigueur. Méthodes: Un auto-questionnaire a été envoyé de juin à septembre 2011, auprès de 5000 AR, représentatifs des AR exerçant en France métropolitaine. Les différents items concernaient : la démographie, l’évaluation préopératoire du risque cardiovasculaire, le recours à un avis cardiologique spécialisé et la modalité, la prise en charge per- et postopératoire de ce type de patient, et enfin leur connaissance des recommandations en vigueur. Résultats: Dans les neuf régions prospectées, 1255 AR ont répondu, soit un taux de réponse de 25 %. Parmi les répondeurs, 73 % étaient des hommes et 38 % travaillaient dans le public ; 70 % travaillaient dans un bloc opératoire commun avec une activité polyvalente. Concernant l’évaluation préopératoire, 85 % des AR adressaient les patients à haut risque à un cardiologue. Dans 16 % des cas seulement, le score de Lee figurait dans le dossier d’anesthésie et avait été utilisé pour évaluer le risque cardiaque en périopératoire. Seulement 61 % des AR prenaient en compte les six facteurs de ce score nécessaires à la bonne évaluation du risque cardiaque. En revanche, 91 % des AR évaluent systématiquement la capacité à l’effort par l’interrogatoire. L’examen préopératoire le plus fréquemment réalisé (49 % des AR répondants) était un ECG chez les patients âgés. Dans 96 % des cas, les bêtabloquants pris habituellement par les patients étaient prescrits lors de la prémédication. Dans 62 % des cas, les AR arrêtaient systématiquement le clopidogrel avant l’intervention chez les patients à risque. En cas d’arrêt, 38 % utilisaient un relais, dont 29 % par héparine de bas poids moléculaire. Sept pour cent des AR envisageaient une revascularisation chez les patients ayant une coronaropathie connue et stable sous traitement. L’étude POISE était connue par 40 % des AR et 18 % estimaient qu’elle avait modifié leur pratique. Vingt et un pour cent des AR réalisaient en préopératoire des réunions pluridisciplinaires pour les patients à risque. Vingt-cinq pour cent des AR disposaient d’algorithmes de prise en charge des patients à risque cardiaque élevé. Soixante-trois pour cent des AR monitoraient le segment ST en peropératoire. En postopératoire, seuls 11 % des AR demandaient systématiquement chez les patients à risque coronarien : un ECG, un dosage de troponine, une surveillance postopératoire, un suivi cardiologique à distance. En cas d’élévation modérée de la troponine, 70 % des AR réalisaient a minima un ECG et/ou une échographie. Conclusion: Cette enquête met en évidence des écarts entre les recommandations concernant la prise en charge périopératoire du patient coronarien en chirurgie non cardiaque en vigueur et la pratique quotidienne des médecins anesthésistes, justifiant des mises à jour régulières de celles-ci. [ABSTRACT FROM AUTHOR]

Gram-negative bacilli are unusual agents of skin and soft tissue infections. Most previous cases have been reported in cirrhotic or immunocompromised patients, including a single case in a liver transplant recipient. The present report describes 3 cases of fatal skin or soft tissue infections caused by Escherichia coli that occurred in the postoperative course of liver transplantation. The 3 patients were profoundly immunosuppressed as a result of pre-transplant cirrhosis and the postoperative administration of a potent immunosuppressive therapy. Skin and soft tissue infections developed within the first week after liver transplantation, while graft liver function was satisfactory. The 3 patients presented with fever and skin lesions with or without bullae. Despite prompt appropriate antibiotic therapy and surgical debridement, the outcome was rapidly fatal (24 h on average). E. coli was isolated from subcutaneous tissues in 2 cases and from several blood cultures in the third one. The 3 isolates belonged to distinct phylogenetic groups, and did not harbor most of the virulence factors usually reported in extraintestinal pathogenic E. coli isolates. Our report suggests that E. coli can cause severe skin or soft tissue infection in the postoperative course of liver transplantation. The onset of infection is very early and the outcome is extremely poor, despite prompt adapted medical and surgical treatment. Host factors, rather than E. coli bacterial virulence potential, appear to be the major determinants of severity in these patients. [ABSTRACT FROM AUTHOR]

Background: Perioperative coordination facilitates team communication and planning. The aim of this study was to determine how often deviation from predicted surgical conditions and a pre-established anaesthetic care plan in major abdominal surgery occurred, and whether this was associated with an increase in adverse clinical events. Methods: In this prospective observational study, weekly preoperative interdisciplinary team meetings were conducted according to a joint care plan checklist in a tertiary care centre in France. Any discordance with preoperative predictions and deviation from the care plan were noted. A link to the incidence of predetermined adverse intraoperative events was investigated. Results: Intraoperative adverse clinical events (ACEs) occurred in 15 % of all cases and were associated with postoperative complications [relative risk (RR) = 1.5; 95 % confidence interval (1.1; 2.2)]. Quality of prediction of surgical procedural items was modest, with one in five to six items not correctly predicted. Discordant surgical prediction was associated with an increased incidence of ACE. Deviation from the anaesthetic care plan occurred in around 13 %, which was more frequent when surgical prediction was inaccurate (RR > 3) and independently associated with ACE (odds ratio 6). Conclusion: Surgery was more difficult than expected in up to one out of five cases. In a similar proportion, disagreement between preoperative care plans and observed clinical management was independently associated with an increased risk of adverse clinical events. [ABSTRACT FROM AUTHOR]

Background Manufacturers recommend maintaining anaesthesia at a bispectral index (BIS) or state entropy (SE) index value between 40 and 60. Methods We prospectively studied 102 patients receiving propofol–sufentanil anaesthesia administered by anaesthetists blinded to these indices. The main endpoint was crude agreement (P0), defined as the proportion of agreement between BIS and SE index among three categories: <40, between 40 and 60, and >60. Discrepancies in recommendation (DR) were also considered. A DR is type 1 if BIS or SE is <40, while the other is simultaneously >60. A DR is type 2 when BIS and SE index values are on different sides of a threshold (40 or 60) with three subtypes according to the magnitude of their difference. A linear multiple regression was performed to identify covariates that are independently associated with P0. Results In total, 12 147 pairs of values were studied. P0 was 59.9 (24.5%) [mean (sd)]. Thirty-three patients presented more than 50% discordant pairs and only seven patients presented more than 95% concordant pairs. Type 1 DR occurred in only 1.1% of all the pairs. The median (inter-quartile range) number of type 2 DR varied from 5 (3–8) to 2 (1–3) according to the degree of difference. Multivariate analysis showed that age (P=0.0004) and electrode position (P=0.0084) were independently associated with P0. An increase in the age of 10 yr decreases P0 by 5%. Conclusions The agreement between BIS and SE indices is moderate and deteriorates as patients' age increases. This study cannot determine which index is best adapted for elderly patients. Additional work comparing both indices with raw EEG traces is warranted. ClinicalTrials.gov Identifier NCT00391963. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Whole-body CT scan is the cornerstone of trauma-related injury assessment. Several lines of evidence indicate that significant number of injuries may remain undetected after the initial hot report of CT. Missed injuries (MI) represent an important issue in trauma patients, for they may increase morbidity, mortality and costs. The aim of this study was to examine incidence and predictors of MI in trauma patients undergoing whole-body CT scan. Methods: 177 CT scan performed upon admission of trauma patients during year 2005 were reviewed by a radiologist blinded to patient''s initial data. MI was defined as injuries not written in the initial report. Patients with and without MI were compared to determine predictors of MI by multivariable analysis. Results: 157 MI were diagnosed in 85 (47%) patients. MI was predominantly encoded AIS 2 (57%) or 3 (29%). Patients with MI had significantly higher SAPSII, higher ISS and were more frequently sedated. Age over 50 years (OR: 4.37, p =0.003) and ISS over 14 (OR: 4.17, p <0.0001) were independent predictors of MI. Median ISS after encoding MI was significantly higher than initial ISS (22 vs. 20 p <0.0001). After adjustment for severity, mortality and length of stay were not different between patients with or without MI. Conclusion: Trauma patients, especially aged and severe, experienced a high rate of missed injuries in the initial hot report which appeared to be predominantly minor and musculoskeletal, advocating a CT scan second reading. [Copyright &y& Elsevier]

BACKGROUND: The SepsiChip project explored transcriptional modulation associated with ventilator-associated pneumonia (VAP) in patients admitted to the intensive care unit for trauma. Genome-wide expression analysis may help to identify potential diagnostic markers for diseases. The current study examined the changes in blood transcriptome during VAP. METHODS: The authors prospectively included 165 trauma patients, and 41 developed VAP. Whole blood samples were collected at admission and at VAP. To predict VAP, the admission samples were compared by microarray in patients who did or did not develop VAP. To identify diagnosis markers, paired samples of 35 patients who developed VAP were analyzed. Using NanoString (Seattle, WA), the results were confirmed in the patients who developed VAP. Trauma patients who did not develop VAP served as controls to eliminate a time effect. RESULTS: The injury severity scores of the patients who did or did not develop VAP were 36 and 29, respectively. No predictive biomarker was identified. For patients who developed VAP, a transcriptional signature was identified between the two sampling times. However, this signature was a generalized pattern related to trauma, independent of the infectious process. Genes involved in the proinflammatory response were down-regulated in the patients who developed VAP, but this difference was not statistically significant. CONCLUSIONS: In contrast to clinical assessment, transcriptional analysis of whole blood samples cannot predict or diagnose VAP in trauma patients. Differentiating infection from inflammation seems challenging. [ABSTRACT FROM AUTHOR]

Abstract: Emergency medical services (EMS) received an increasing number of calls for patients aged 80 and older. The goal of the present study was to evaluate outcome and functional dependence of patients aged 80 and older who EMS managed in the prehospital theater. This prospective study was conducted over 1 year (September 2007–August 2008), all consecutive patients aged 80 and older managed by a medical team during the study period were included. Characteristics of patients, including previous health status and functional dependence, were recorded on-the scene by the attending physician. Three-month mortality was recorded, as well as ADL score. Data are expressed as mean values±standard deviations, medians and interquartile ranges (IQRs), and percentages and compared using univariate and multivariate analysis. P <0.05 was considered the threshold for significance. Five hundred twenty-three patients were included. Mean age was 86±5. Median ADL index was 2 (IQR 0–9), and 63% of patients were living at home. At 3 months, the survival rate was 66% (n =273) and the proportion of patients living at home was 64% (P =0.9), the median ADL index of survivors was 2 (IQR 0–8) vs 1 (IQR 0–6) initially for this subpopulation, P =0.01. Our study confirms utility and efficacy of full access of elderly persons to advanced life support especially for self-patients and not restricted based on aging per se. The development and daily use of tools for rapid assessment of autonomy should enable practitioners to innovate and thus, adapt their management. [Copyright &y& Elsevier]

S. Janny, F. Bert, F. Dondero, F. Durand, P. Guerrini, P. Merckx, M.H. Nicolas-Chanoine, J. Belghiti, J. Mantz, C. Paugam-Burtz. Microbiological findings of culture-positive preservation fluid in liver transplantation. Transpl Infect Dis 2011: 9-14. All rights reserved Bacterial and fungal infections are the leading cause of mortality in liver transplant (LT) recipients. Few studies have examined the incidence of culture-positive preservation fluid (PF) and the outcome of related recipients. The aim of this study was to determine the incidence and the microbiologic findings of PF positive cultures, and to evaluate the impact on morbidity and mortality of LT recipients. A retrospective analysis of PF cultures performed after 477 LTs from cadavaric grafts between January 2001 and February 2008 was conducted. Forty-five (9.5%) PFs were found to be positive with 1 or 2 pathogens. The demographic profiles of recipients of PF with positive or negative cultures were similar. Enterobacteriaceae species were the most frequent organisms ( n=30), followed by Staphylococcus aureus ( n=5), coagulase-negative staphylococci ( n=5), enterococci ( n=4), and yeasts ( n=3). Mortality rate at 1 month was not significantly different in recipients with positive or sterile PF cultures (88.1% vs. 87.7%, respectively). The rate of bacteremia among LT recipients with positive or negative PF cultures was not statistically different. Systemic infections caused by the pathogen cultured from the PF occurred in 8 (18%) of the 45 recipients, including bacteremia (4/8) or intra-abdominal sepsis (5/8). Causative organisms were Enterobacteriaceae species ( n=5), Candida species ( n=2), and Enterococcus faecium ( n=1). Among the 8 patients who developed infection with the PF organism, 4 (50%) died in the intensive care unit (ICU) vs. an ICU mortality rate of 8% (3/37) in those who did not develop infection with the PF organism ( P<0.05). Infection occurred less frequently in recipients who received antimicrobial therapy with activity against the PF isolate than in those without appropriate treatment (41% vs. 3.8%, P<0.005). Those who develop infection with organisms recovered from PF cultures appear to have high early mortality rates; therefore, appropriate antimicrobial therapy against organisms cultured from PF should be given. [ABSTRACT FROM AUTHOR]

Abstract: Background and objective: Postoperative nausea and vomiting (PONV) is a frequent and unpleasant side effect occurring after anaesthesia and surgery. In the present study, we hypothesized that an educational strategy based on systematic preoperative assessment of the simplified Apfel''s score decreased the incidence of PONV in a population of adult surgical patients. Methods: All consecutive patients admitted in the postanaesthesia care unit (PACU) for elective surgery under general anaesthesia were included and PONV occurring in the PACU recorded. An educational strategy consisting in printing the items allowing calculation of the simplified Apfel''s score on the records of the preanaesthetic visit, and encouraging anaesthetists to measure and record it was set up. Meetings dedicated to PONV prevention by emphasis on the current guidelines were regularly organized. The primary endpoint was the incidence of PONV occurring in the PACU. Results: One hundred and ninety-one patients were included during the control period (08/01/07 to 28/02/07) and 193 after the educational strategy (01/03/07 to 30/04/07). The incidence of PONV was decreased in the second period from 19.37% to 11.4% (p =0.0340). The rate of administration of intraoperative prophylactic anti-emetics in high-risk groups increased from 36.4% to 52.8% (p =0.049). The prescription rate of anti-emetic prophylaxis correlated with the PONV risk derived from the simplified Apfel''s score in the second period of the study (p =0.1415 before, vs. p =0.0005 after). Conclusion: An educational strategy based on systematic preoperative measurement and recording of the simplified Apfel''s score is efficient to decrease markedly the incidence of PONV in a population of adult surgical patients. [Copyright &y& Elsevier]

Purpose: Guidelines for advanced life support of cardiac arrest (CA) emphasize continuous and effective chest compressions as one of the main factors of cardiopulmonary resuscitation (CPR) success. The use of an automated load distributing chest compression device for CPR is promising but initial studies on survival show contradictory results. The aim of this study was to evaluate the effects of AutoPulse on blood pressure (BP) in out-of-hospital CA patients.Methods: This prospective study included adult patients presenting with in refractory out-of-hospital CA. Invasive arterial BP produced by AutoPulse was compared to BP generated by manual CPR (Active Compression Decompression). Systolic, diastolic and mean BP and end-tidal carbon dioxide were recorded before and after initiating the automated band device for each patient. The comparison of diastolic BP produced by manual CPR versus automated chest compressions was the primary end point.Results: Hemodynamics in 29 patients are reported and analyzed. Median diastolic BP increased after starting AutoPulse from 17[11-25] mmHg to 23[18-28] mmHg (P < 0.001). Median systolic BP increased from 72[55-105] mmHg to 106[78-135] mmHg (P = 0.02). Mean BP increased from 29[25-38] mmHg to 36[30-15] mmHg (P = 0.002). On the other hand, End-Tidal CO(2) did not increase significantly with AutoPulse (21[13-36] vs. 22[12-35] mmHg, P = 0.80).Conclusions: In patients with out-of-hospital CA, the use of AutoPulse is associated with an increased diastolic BP compared to manual chest compressions. While its benefit to survival has yet to be demonstrated, the increase in diastolic and mean BP is a promising outcome for AutoPulse use. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To assess the current use of sedation and analgesia in a large sample of French intensive care units (ICUs) and to define structural characteristics of the units that use a written procedure. Study design: Self-reported survey. Participants: Three hundred and sixty French ICUs were presented the questionnaire in September 2007. Results: Surveys were received from 228 (60.6%) ICUs. Midazolam was used in more than 50% of the patients in 79.2% of the ICUs and propofol in 22.2% of the ICUs. Sufentanil was the most frequently used morphinic. A sedation-scale was used in 68.8% of the units (80.3% Ramsay score). Sedation was assessed at least every 4hours in 61% of ICUs. A pain-scale was used in 88.9% of the ICUs, but only 12.5% in the non-communicant patients. A written procedure was used in 29.4% of the units only. In multivariate analysis, use in the ICU of a written procedure for the early management of patients with septic shock and/or intensive insulin therapy was the single variable significantly associated with presence of a written procedure for sedation and analgesia (respectively OR 4.37; p <0.0001 and OR 5.64; p =0.032). Conclusion: Although more than two-third of the responding ICUs reported the use of sedation-and-pain-scales, frequency of assessment was low, and objective assessment of pain in the non-communicating patients was extremely uncommon. Similarly, the use of written procedure was low. The use of sedation-analgesia written procedure in an ICU seems strongly influenced by a more global involvement of the ICU in the protocolisation of complex care. These findings support the reinforcement of educational programs. [Copyright &y& Elsevier]

Background: While outcome continuously improves after liver transplantation, sepsis remains the leading cause of early postoperative mortality. Diagnosis of infections remains particularly difficult in these patients. This study used plasma profiling coupling Proteinchip array with surface-enhanced laser desorption ionization time-of-fly mass spectrometry to search for biomarkers of postoperative sepsis in patients who underwent liver transplantation.Methods: Diagnosis of sepsis at day 5 relied on widely accepted clinical signs and positive culture of microbiologic samples. Profiles of day 5 plasma were obtained from SELDI-TOF CM10 chip (BioRad, Marnes-la-Coquette, France) analysis. Mean peak intensity of proteins was compared between septic and nonseptic plasma by U test followed by analysis of the area under the receiver-operating characteristic for the significant peaks. Diagnostic performance of significant proteins was established in a derivation set and in a validation set.Results: In the derivation set of 31 patients with and 30 without infection, 23 plasma protein peaks were differentially expressed between patients with and without sepsis. Combination of five peaks allowed sepsis diagnosis with a positive likelihood ratio of 12.5 and a C-statistics of 0.72, 95% CI 0.57-0.85. In the validation set of 31 patients with infection and 34 without infection, the five peaks were differentially expressed as well and allowed day 5 sepsis diagnosis with a positive likelihood ratio of 5.1 and C-statistics of 0.74 (0.58-0.85).Conclusion: A combination of five plasma protein peaks may provide material for useful diagnostic biomarkers of postoperative sepsis in patients undergoing liver transplantation. However, these proteins remain to be identified. [ABSTRACT FROM AUTHOR]