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During liver transplantation, graft ischemia-reperfusion injury leads to a systemic inflammatory response producing postoperative organ dysfunctions. The aim of this observational and prospective study was to compare the impact of Solution de conservation des organes et tissus(SCOT) 15 and University of Wisconsin (UW) preservation solutions on early cytokine release, postreperfusion syndrome and postoperative organ dysfunctions.

Les dernières recommandations sur la gestion des voies aériennes décrivent une nouvelle technique d’abord sous glottique: la cricothyroïdotomie par technique SMS (Scalpel, Mandrin long béquillé, Sonde d’intubation). Utilisée en ultime recours pour des patients non intubables et non ventilables, cette technique semble intéressante à connaître dans un contexte de nombreuses victimes car elle est simple, reproductible et nécessite du matériel facilement disponible en nombre. Elle permet l’abord direct de la trachée par la membrane intercricothyroïdienne avec protection des voies aériennes, l’utilisation de matériels connus permettant une meilleure confiance des praticiens et propose une alternative en cas de difficulté de repérage. Nous en décrivons sa réalisation technique étape par étape et rappelons sa place au sein des algorithmes de gestion des voies aériennes. Le choix de cette technique est un exemple de l’évolution des pratiques adaptées à la prise en charge d’un afflux massif de victimes et doit s’inscrire dans une réflexion globale quant à la réponse médicale optimale dans ces situations. Recommendations on airway management describe a new technique: Scalpel-bougie-tube technique for cricothyroidotomy. Used as ultimate solution in can’t intubate can’t ventilate situation, this technique is simple, reproducible and seems interesting to be known in a case of rescue and particularly in a context of many victims: it requires readily available equipment. It allows direct approach of trachea by intercricothyroid membrane with airways protection, use of known materials allowing a better confidence of doctors and offers an alternative in case of difficulty locating. We describe its technical realization step by step and its place within the algorithms of management of the airways. The choice of this technique is an example of the evolution of practices adapted to the management of mass casualty incident and must be part of a global reflection on the optimal medical response in these situations.

Recent guidelines have emphasized actively avoiding fever to improve outcomes in patients who are comatose following resuscitation from cardiac arrest (ie, out-of-hospital cardiac arrest). However, whether targeted temperature management between 32 °C and 36 °C (TTM32-36) can improve neurologic outcome in some patients remains debated.

Un traumatizzato grave è un paziente vittima di un trauma violento che può aver causato lesioni multiple e/o pericolose per la vita o la prognosi funzionale. La gestione preospedaliera mira da una parte a immobilizzare il paziente per evitare l’aggravamento di lesioni instabili, a realizzare una prima valutazione delle lesioni potenziali o in atto e a correggere i distress vitali e, dall’altra, a orientare il paziente verso la struttura di cure più appropriata. Fin dall’arrivo in ospedale, questa gestione diagnostica e terapeutica è completata in maniera esaustiva. Dopo aver verificato la preparazione realizzata nella fase preospedaliera, in particolare gli accessi vascolari e il controllo delle vie aeree, devono essere realizzati precocemente una via d’accesso centrale e una misurazione invasiva della pressione arteriosa. Tra gli esami di laboratorio urgenti, devono essere rapidamente ottenuti emoglobinemia, coagulazione ed emogasanalisi. Il bilancio lesionale iniziale comporta una radiografia del torace, una radiografia del bacino e un’ecografia FAST (focused assessment with sonography for traumas), che permettono di prendere le decisioni terapeutiche urgenti: drenaggio toracico, arteriografia per embolizzazione e laparotomia emostatica. Dopo la correzione dei distress vitali, questo bilancio è, poi, completato da una TC cerebrale senza contrasto e, poi, cervico-toraco-addomino-pelvica con mezzo di contrasto e, se necessario, da radiografie convenzionali. Una rivalutazione clinica nel quadro del bilancio terziario è indispensabile per non misconoscere alcune lesioni traumatiche spesso dimenticate. Le indicazioni della diagnostica per immagini e della chirurgia devono sempre valutare il rapporto rischio/beneficio di ogni atto. Il monitoraggio e la gestione terapeutica del paziente devono essere continui durante la realizzazione della diagnostica per immagini e al momento dei trasporti, di qualunque genere. L’addestramento dell’equipe traumatologica è essenziale, poiché questi pazienti devono essere gestiti in centri multidisciplinari che dispongano di tutte le attrezzature necessarie e di equipe esperte nel difficile esercizio costituito dalla gestione ospedaliera di un paziente traumatizzato grave.

Un traumatizado grave es un paciente que ha sufrido un traumatismo violento que puede haberle provocado lesiones múltiples y/o que comprometen el pronóstico vital o funcional. La atención prehospitalaria consiste, por una parte, en inmovilizar al paciente para evitar la agravación de lesiones inestables, efectuar la primera evaluación de las lesiones potenciales o comprobadas y corregir los parámetros vitales alterados y, por otra, en trasladar al paciente al centro de salud más adecuado. Desde el ingreso en el hospital, la conducta diagnóstica y terapéutica debe ser exhaustiva. Tras verificar las medidas adoptadas en la fase prehospitalaria, en particular las vías de acceso vasculares y el control de las vías respiratorias, de forma precoz se abre una vía de acceso central y se efectúa una medición invasiva de la presión arterial. Las pruebas de laboratorio urgentes son la determinación de la hemoglobinemia, la hemostasia y los gases en sangre. El estudio por imagen inicial comprende una radiografía del tórax, una radiografía de la pelvis y una ecografía FAST (focused assessment with sonography for traumas, ecografía focalizada para traumatismo abdominal), que permiten tomar las decisiones terapéuticas urgentes: drenaje torácico, arteriografía para embolización y laparotomía para hemostasia. Después de corregir los parámetros vitales, la evaluación se completa con una tomografía computarizada (TC) cerebral sin inyección de medio de contraste, seguida de TC cervical y toracoabdominopélvica con inyección de medio de contraste y, si es necesario, radiografías convencionales. Una nueva exploración física en el contexto de la evaluación terciaria es indispensable para no pasar por alto otras lesiones. Para las indicaciones del estudio por imagen y de la cirugía debe tenerse en cuenta la relación riesgo/beneficio de cada acto. La monitorización y la acción terapéutica deben continuar mientras se efectúan los estudios por imagen y durante los traslados de cualquier tipo. El entrenamiento del equipo de traumatología es fundamental, ya que estos pacientes deben ser atendidos en centros multidisciplinares que cuenten con los recursos técnicos necesarios y con equipos experimentados en la difícil tarea del tratamiento hospitalario de un paciente con traumatismo grave.

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Résumé: Objectif: En France, l’augmentation de la part des séjours en hospitalisation ambulatoire est un objectif de santé publique afin de réduire la durée des séjours hospitaliers. Nous rapportons ici la faisabilité de la mise en place d’une filière de chirurgie ambulatoire d’urgence au sein du service des urgences. Matériel et méthodes: Une étude observationnelle prospective de cette activité a été conduite au sein de notre hôpital. Les caractéristiques des patients, le descriptif de l’acte chirurgical, la durée de séjour, les rappels téléphoniques et les réadmissions ont été colligés. Les résultats sont exprimés en médianes [interquartile 25–75 %]. Résultats: De mai 2011 à avril 2012, nous avons inclus 70 patients consécutifs âgés de 34 ans. Les spécialités représentées étaient la chirurgie viscérale (56 %), l’orthopédie (37 %), la chirurgie maxillofaciale (4 %) et l’urologie (3 %). Parmi les 70 patients, 61 (87,2 %) sont restés dans la procédure ambulatoire sans aucune réadmission. Quatre patients (5,7 %) ont été exclus pour des suites chirurgicales complexes, 3 (4,2 %) pour absence d’accompagnant au moment de la sortie et 2 (2,8 %) pour nausées-vomissements. Le rappel téléphonique d’un patient a eu lieu pour analgésie insuffisante. La durée médiane de séjour a été de 11,2 [8,7–12,2] heures. Conclusion: La mise en place d’une filière de chirurgie ambulatoire en urgence évitant une hospitalisation est possible après une formation auprès des anesthésistes, des chirurgiens et des urgentistes. Cette filière est compatible avec la prise en charge sûre des patients. Cette activité doit être envisagée dans le cadre des urgences et non plus exclue de principe.

L’exclusion endovasculaire des anévrysmes de l’aorte abdominale est associée à une réduction de la mortalité et morbidité précoces. En vue d’une réduction supplémentaire du risque, notamment celui lié à l’anesthésie générale (AG), l’hypnose semble représenter une alternative, chez les patients à haut risque. L’objectif de cette étude est d’évaluer la contribution de l’hypnose associée à l’anesthésie locale (AL) dans cette chirurgie.

The effects of halogenated anaesthetics on cross-bridge (CB) kinetics are unclear. As halogenated anaesthetics do not markedly modify the intracellular calcium transient in the diaphragm, we used an isolated rat diaphragm preparation to assess the effects of halothane and isoflurane on CB kinetics.

Propacetamol is widely used in the management of postoperative pain. It decreases morphine requirements but its effect on the incidence of morphine-related adverse effects remains unknown.

Postoperative morphine titration frequently induces sedation. The assumption is made that patients sleep when their pain is relieved. Some patients complain of persistent pain when they awake. We studied the time-course of sedation and analgesia to understand the determinants of patients' sleep during morphine titration.

Background. Postoperative morphine titration frequently induces sedation. The assumption is made that patients sleep when their pain is relieved. Some patients complain of persistent pain when they awake. We studied the time‐course of sedation and analgesia to understand the determinants of patients’ sleep during morphine titration.Methods. Seventy‐three patients requiring morphine titration in a post‐anaesthetic care unit after major surgery, were studied. Fifty‐two patients slept (Sleep group) and 21 did not (Awake group). When a patient slept during titration, morphine was discontinued. Visual analogue pain scale (VAS), Ramsay score (RS), and the bispectral index (BIS) were recorded at the beginning of titration (STonset), at sleep onset (STsleep), then 5, 10, 20, and 30 min afterwards (ST4).Results. In the Sleep group, mean (sd) RS increased from 1.7 (0.4) to 2.4 (0.6) (P<0.05 vs STonset) and BIS decreased from 95 (5.0) to 89.8 (10.2) between STonset and STsleep (P<0.05), RS remained stable thereafter. Conversely, RS and BIS remained unaltered in the Awake group. The reduction in VAS was comparable between groups (from 78 (17) to 39 (21), and from 64 (16) to 30.4 (11), respectively). Even though mean (sd) VAS was 39 (21) at ST4 in the Sleep group, 13 patients (25%) maintained a VAS above 50 mm.Conclusion. We observed dissociated effects of morphine on the time‐course of sedation and analgesia with sedation occurring first, followed by analgesia. Therefore, morphine‐induced sedation should not be considered as an indicator of an appropriate correct level of analgesia during i.v. morphine titration.Br J Anaesth 2002; 89: 697–701

The inotropic effects of halogenated anaesthetics on diaphragmatic muscle remain a matter of debate. Their effects on its relaxation are poorly understood, although diaphragmatic relaxation is recognized as an important physiological process that may interfere with diaphragmatic performance, fatigue and arterial blood flow.

L’exclusion endovasculaire des anévrysmes de l’aorte abdominale est associée à une réduction de la mortalité et morbidité précoces. En vue d’une réduction supplémentaire du risque, notamment celui lié à l’anesthésie générale (AG), l’hypnose semble représenter une alternative, chez les patients à haut risque. L’objectif de cette étude est d’évaluer la contribution de l’hypnose associée à l’anesthésie locale (AL) dans cette chirurgie.

Recording of cortical somatosensory evoked potentials (CSEP) enables monitoring of spinal cord function. We studied the effects of propofol, propofol-nitrous oxide or midazolam during sufentanil anaesthesia on CSEP monitoring during major spinal surgery. Thirty patients with normal preoperative CSEP were allocated randomly to one of the following anaesthesia regimens: propofol (2.5 mg kg-1 followed by 10-6 mg kg-1 h-1) with or without nitrous oxide, or midazolam (0.3 mg kg-1 followed by 0.15 mg kg-1 h-1) combined with sufentanil 0.5 microgram kg-1 h-1 in the propofol and midazolam groups, or 0.25 microgram kg-1 h-1 in the propofol-nitrous oxide group. CSEP were elicited by alternate right and left tibial posterior nerve stimulation and recorded before and after induction (15 min, 1, 2 and 3 h), and during skin closure. CSEP latencies were not significantly modified in the three groups. CSEP amplitude decreased significantly in the propofol-nitrous oxide group (from mean 2.0 (SEM 0.3) to 0.6 (0.1) microV; P < 0.05) but not in the propofol (from 1.8 (0.6) to 2.2 (0.3) microV) or midazolam (1.7 (0.5) to 1.6 (0.5) microV) groups. The time to the first postoperative voluntary motor response (recovery) delay was significantly greater in the midazolam group (115 (19) min) compared with the propofol and propofol-nitrous oxide groups (43 (8) and 41 (3) min, respectively). Consequently, the use of propofol without nitrous oxide can be recommended during spinal surgery when CSEP monitoring is required.

The load dependence (LD) of relaxation was studied in the diaphragm of rabbits with congestive heart failure (CHF). CHF (n= 15) was induced by combined chronic volume and pressure overload. Aortic insufficiency was induced by forcing a catheter through the aortic sigmoid valves, followed 3 wk later by abdominal aortic stenosis. Six weeks after the first intervention, animals developed CHF. Sham-operated animals served as controls (C; n= 12). Diaphragm mechanics were studied in vitro on isolated strips, at 22°C, in isotonic and isometric loading conditions. Contractility was lower in the CHF group, as reflected by lower total tension: 1.11 ± 0.10 in CHF vs. 2.38 ± 0.15 N/cm2in C in twitch (P< 0.001) and 2.46 ± 0.22 in CHF vs. 4.90 ± 0.25 N ⋅ cm−2in C in tetanus (P< 0.001). The index LD was used to quantify the load dependence of relaxation: LD is <1 in load-dependent muscles and tends toward 1 in load-independent muscles. LD was significantly higher in CHF than in C rabbits, in both twitch (0.99 ± 0.01 vs. 0.75 ± 0.03;P< 0.001) and tetanus (0.95 ± 0.02 vs. 0.84 ± 0.02; P< 0.001). In the CHF rabbits’ diaphragm, the fall in total tension was linearly related to the fall in load dependence of relaxation. The decrease in load dependence of relaxation in CHF animals suggests sarcoplasmic reticulum abnormalities. Impairment of the sarcoplasmic reticulum may also partly account for the decrease in contractile performance of diaphragm in CHF animals.

Objective: To assess the additive effect of inhaled nitric oxide (NO) and intravenous almitrine bismesylate (ALM) on gas exchange. Design: Prospective self-controlled study. Setting: 3 medico-surgical intensive care units. Patients: 17 patients with severe hypoxemia (PaO2/FIO2ratio: 88±30mmHg, venous admixture: 47±7%) and elevated mean pulmonary artery pressure (MPAP: 30±5mmHg) due to adult respiratory distress syndrome (ARDS). Interventions: 5 conditions were studied: 1) baseline, 2) 5 to 10ppm of NO during 30min, 3) discontinuation of NO during 30min, 4) ALM infusion (0.5mg/kg) during 30min, 5) ALM infusion (0.5mg/kg) during 30min in combination with 5 to 10ppm of NO. Measurement and results: The PaO2/FIO2ratio rose from 88±30 to 98±37mmHg (NS) with NO alone, and from 92±25 to 130±56mmHg (p&lt;0.01) with NO+ALM (p&lt;0.05 vs NO alone). Seven patients were considered as “NO-responders” (rise in PaO2/FIO2ratio of 10mmHg or more with NO); in this subgroup the PaO2/FIO2ratio rose from 87±30 to 128±39mmHg (p&lt;0.05) with NO alone, and from 93±20 to 169±51mmHg (p&lt;0.01) with NO+ALM (p&lt;0.05 versus NO alone). MPAP decreased from 30±5 to 26±5mmHg (p&lt;0.01) with NO alone, increased slightly from 28±5 to 31±5mmHg (NS) with ALM alone and decreased to 27±5mmHg (p&lt;0.05) with NO+ALM. Conclusions: NO+ALM had additive effects on gas exchange while decreasing MPAP in patients with ARDS. The effects of NO alone were small and non significant, except in a subgroup of 7 patients in whom the combination of both therapies had the more pronounced results.

La préhabilitation peut être définie comme un conditionnement préopératoire des patients afin d’améliorer les résultats fonctionnels après chirurgie. Certaines études ont montré une meilleure récupération fonctionnelle après chirurgie colorectale, mais son impact en chirurgie hépato-bilio-pancréatique (HPB) n’est pas démontré. L’objectif de cette étude est de réaliser une revue systématique de la littérature et une méta-analyse des données actuellement disponibles sur la préhabilitation en chirurgie HPB.

L’exclusion endovasculaire des anévrysmes de l’aorte abdominale est associée à une réduction de la mortalité et morbidité précoces. En vue d’une réduction supplémentaire du risque, notamment celui lié à l’anesthésie générale (AG), l’hypnose semble représenter une alternative, chez les patients à haut risque. L’objectif de cette étude est d’évaluer la contribution de l’hypnose associée à l’anesthésie locale (AL) dans cette chirurgie.

Le traumatisme sévère est associé à un risque élevé de morbidité et de mortalité. L’atteinte thoracique est souvent présente. Le but de l’étude était de déterminer si les facteurs pronostiques du traumatisme sévère sont modifiés par la sévérité de l’atteinte thoracique.

Dantrolene is the only known effective treatment for malignant hyperthermia. However, its effects on the myopathic diaphragm remain unknown. The effects of dantrolene 10(-8) to 10(-4) mol litre-1 on diaphragm muscle strips in normal (n = 12) and myopathic hamsters (n = 13) were investigated in vitro in response to tetanic stimulation. We studied contraction under isotonic and isometric conditions. Data are presented as mean (SD) percent of baseline. Dantrolene induced a negative inotropic effect in normal and myopathic hamsters but no significant difference was observed between groups (active force at 10(-4) mol litre-1; 34 (7) vs 32 (11)%; ns). We conclude that dantrolene induced a comparable negative inotropic effect on diaphragm muscle in normal and myopathic hamsters.