Search

Copyright of Douleur et Analgésie is the property of John Libbey Eurotext Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives: Professional practice evaluation of anaesthesiologist for high cardiac-risk patient cares in non-cardiac surgery, and assess disparities between results and recommendations., Materials and Methods: Since June to September 2011, a self-questionnaire was sent to 5000 anesthesiologist. They were considered to be representative of national anesthesiology practitioner. Different items investigated concerned: demography, preoperative cardiac-risk assessment, modalities of specialized cardiologic advice, per- and postoperative care, and finally knowledge of current recommendations., Results: We collected 1255 questionnaire, that is to say 25% of answers. Men were 73%, 38% were employed by public hospital; 70% worked in a shared operating theatre with a general activity. With regards to preoperative assessment, 85% of anaesthetists referred high cardiac-risk patient to a cardiologist. In only 16% of answer, Lee's score appeared in anaesthesia file to assess perioperative cardiac-risk. Only 61% considered the six necessary items to optimal estimate of cardiac-risk. On the other hand, 91% measured routinely the exercise capacities by interrogation. The most frequently doing exam (49% of anaesthetist) was an electrocardiogram in elderly patient. In 96% of case, beta-blockers were given in premedication if they were usually thought. Clopidogrel was stopped by 62% of anesthetist before surgery. In this case, 38% used another medication to take over from this one. Only 7% considered revascularization in coronary patient who were effectively treated. POISE study was know by 40% of practitioner, and 18% estimated that they have changed their practice. Preoperatively, 21% organized multidisciplinary approach for high-risk patient. During surgery, 63% monitored the ST-segment. In postoperative period for cardiac-risk patient, only 11% prescribed systematically an ECG, a troponin dosage, a postoperative monitoring of ST-segment, a cardiologic advice. In case of moderate troponin elevation, they were 70% to realize at least an ECG and/or an echocardiography., Conclusion: This study highlights some difference between current recommendation concerning assessment of cardiac-risk patient in non-cardiac surgery and daily practice of anesthetist, justifying regular update of this one., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

The restoration of patients' mean arterial pressure after ineffective fluid resuscitation is obtained by vasopressive treatment such as norepinephrine. However, no guidelines exist concerning a norepinephrine infusion method: whether it be the norepinephrine concentration in the syringe, single or double pump administration via a carrier such as an isotonic saline solution, or use of minimized dead-volume extension sets. We present the case of a female patient requiring norepinephrine treatment, who quickly suffers a major haemodynamic incident (a sudden rise in systolic blood pressure above 220 mmHg associated with tachycardia up to 189 b/min). The main causes of this incident are discussed and infusion parameters considered with a view to developing an optimal infusion method for a drug with a specific therapeutic index., (Copyright © 2012 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Introduction: A questionnaire for self-assessment, the Amsterdam Preoperative Anxiety and Information Scale (APAIS) translated into French has been compared to a background questionnaire to validate their use as screening tool and assessment of anxiety and information needs of patients., Patients and Method: An epidemiological study was conducted anonymously. Patients completed a questionnaire comprising a French version of APAIS and Spielberger Anxiety Inventory (STAI). A study of correlation between scores for each questionnaire was conducted. A high level of anxiety was investigated., Results: So 1800 questionnaires were distributed, 1504 were usable. The first 100 questionnaires have confirmed the internal validity of the questionnaire APAIS. The following questionnaires in 1404 accounted 49.7% of men 55.7 ± 15.7 years old and 50.2% of women 50.8 ± 15.2 years old. The correlation coefficient (r) between STAI state and appeasement was of 0.675 (P<0.001). A score higher than 10/20 by APAIS corresponded to 73% of patients with high anxiety by Spielberger's inventory. No correlation was found between the STAI state and the need for information (r=0.252; P<0.001)., Conclusion: APAIS, in its French version, assesses anxiety and information needs of patients. This questionnaire has metrological capabilities and ease of execution that make it a screening tool for use in anesthesia consultation. A score above 10 out of 20 reflects a high level of anxiety., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objective: To analyze the current knowledge related to xenon anaesthesia., Data Sources: References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service and personal files., Study Selection: All categories of articles on this topic have been selected., Data Extraction: Articles have been analyzed for biophysics, pharmacology, toxicity and environmental effects, clinical effects and using prospect., Data Synthesis: The noble gas xenon has anaesthetic properties that have been recognized 50 years ago. Xenon is receiving renewed interest because it has many characteristics of an ideal anaesthetic. In addition to its lack of effects on cardiovascular system, xenon has a low solubility enabling faster induction of and emergence from anaesthesia than with other inhalational agents. Nevertheless, at present, the cost and rarity of xenon limits widespread use in clinical practice. The development of closed rebreathing system that allowed recycling of xenon and therefore reducing its waste has led to a recent interest in this gas., Conclusion: Reducing its cost will help xenon to find its place among anaesthetic agents and extend its use to severe patients with specific pathologies., (Copyright (c) 2010. Published by Elsevier SAS.)

Objective: The aim of this study was to assess the value of central venous oxygen saturation (ScvO(2)) for the decision of blood transfusion in comparison with the criteria of the French guidelines for blood transfusion (2003)., Study Design: Prospective, observational., Patients and Methods: Sixty patients, haemodynamically stable, for whom a blood transfusion (BT) was discussed in the postoperative course of general surgery, were included. ScvO(2) (%) and haemoglobin (g/dl) were measured before and after BT. Patients were retrospectively divided into two groups according to ScvO(2) measured before BT (< or >or=70%). Results are expressed as median., Results: The ScvO(2) before transfusion was greater or equal to 70% in 25 (47.2%) patients. Following BT, the ScvO(2) increased significantly (from 57.8 to 68.5%) in the group with initial ScvO(2) less than 70% whereas it was unchanged in patients with initial ScvO(2) greater or equal 70% (from 76.8 to 76.5%). Twenty patients (37.7%) did not meet the French guidelines for BT criteria. Eighteen patients out of 33 that met the criteria had ScvO(2) greater or equal 70% before BT while 13 patients with ScvO(2) less than 70% were not detected by these same criteria., Conclusion: ScvO(2) could be a relevant biological parameter to complete the current guidelines for BT in stable patient with a central venous catheter during the postoperative period.

Objectives: The aim of this study was to evaluate for the interest of realistic mannequin-based simulations as a tool to assess the knowledge of emergency medicine physicians in the field of difficult tracheal intubation., Study Design: Prospective., Population: Emergency physicians., Methods: Twenty-four emergency physicians were invited entering the study. The first step of the study consisted of an initial assessment of their knowledge in the field of difficult tracheal intubation. Then theoretical lectures on the tools and techniques of difficult tracheal intubation were given, followed by standard mannequin-based driven workshops. The second step was conducted six weeks later. Each physician's knowledge was re-evaluated and their ability to manage two difficult airway scenarios simulated on the AirMan simulator (Laerdal was assessed., Results: Only one physician could not complete the program. Half of them worked at the University Hospital (UH) with half of them for less than three years. Lectures and standard mannequin-based driven workshops significantly improved physician's theoretical knowledge. Practical performance during difficult airway management scenarios was poor., Conclusion: We have demonstrated that theoretical lectures and standard mannequin-based driven workshops improved overall theoretical knowledge but did not translated to practical skill during of realistic mannequin-based simulations. Realistic mannequin-based simulations teaching programs in the field of difficult tracheal intubation should be considered.

The immunonutrients composing the immunonutrition solutions such as Impact have been demonstrated to reinforce the immune defenses and limit postoperative complications. This reduction in infectious morbidity may be related to the ability of immunonutrients to prevent the postoperative imbalance of the T-CD4 lymphocyte subpopulations (Th1/Th2 ratio) and to modulate the inflammatory response. Immunonutrition also acts with the healing process, in particular with arginine, which promotes collagen synthesis. The beneficial effects of immunonutrition are important in all digestive cancer surgery, including esophageal surgery. It is administered preoperatively to all patients for at least 5 days and is recommended postoperatively for undernourished patients for at least 7 days. Finally, the reduction in postoperative morbidity decreases hospital costs, which easily compensates the additional cost of the pharmaconutrients, another argument in favor of prescribing them systematically in patients operated on for digestive cancer.

Objective: Comparison between BIS (Bispectral Index) and state (SE) and response (RE) entropy during laparotomy for inflammatory bowel disease patients (IBD) and evaluation of the variations of RE and SE during nociceptive stimulation., Study Design: Prospective, observational study., Patients and Methods: Fourteen IBD's patients undergoing laparotomy were included. Anaesthesia aimed to maintain BIS between 40 and 60 by isoflurane and nitrous oxide. Analgesia was performed by sufentanil bolus administrated according to an increase of 20% of systolic blood pressure (SBP) and heart rate compared with the baseline values. BIS, RE and SE were measured at each nociceptive stimulation. A variance analysis (Anova) was used to assess BIS, RE and SE variations throughout surgery (p<0.05 as significant). Relationship between BIS, RE and SE was assessed by Pearson correlation (p<0.01 as significant). The ability for SE and RE to predict depth of anaesthesia and intraoperative analgesia was performed by calculating area under the receiver operated curves (AUC)., Results: BIS and entropy parameters had strictly the same evolution during anaesthesia. SBP increased significantly during nociceptive stimulation while no variation of RE was observed. A significant correlation was shown between BIS, RE and SE. The evaluation of anaesthesia depth was good for RE (AUC: 0.932+/-0.26) and SE (AUC: 0.926+/-0.27). There was however no difference between RE and SE to predict analgesic requirement., Conclusion: Because RE includes muscular frequency analysis, it does not allow analgesic requirement evaluation in paralyzed patients.

"Severe sepsis" is defined by organ dysfunction due to infection-induced hypoperfusion. "Septic shock" is defined by hypotension refractory to fluid resuscitation, associated with organ dysfunctions or hypoperfusion. Mortality from severe sepsis and from septic shock is high. Guidelines to help physicians improve the survival of patients with severe sepsis comprise one part of an international project called the Surviving Sepsis Campaign. They bring together treatment innovations based on monitoring aimed at ensuring comprehensive management of tissue oxygen levels (central venous oxygen saturation: SvcO2). They are based on the optimization of early treatment, during the first six hours of severe sepsis, and ensuring no delay in fluid resuscitation. In case of septic shock, fluid resuscitation must be rapidly accompanied by administration of vasoconstrictive catecholamines. Noradrenaline is preferred to dopamine. Dobutamine is recommended when the cardiac index is less than 2.5 L x min(-1) x m(-2). Because of the relative adrenal insufficiency that occurs during septic shock, corticoids are recommended, after a synacthen test. Activated protein C is currently the only therapy produced by biotechnology that reduces mortality from severe sepsis. Global management of septic shock must form an integral part of resuscitation guidelines and include protocols for, among other things, sedation, ventilation, strict glycemic control, and prophylaxis for deep vein thrombosis and stress ulcers.

Objective: In 2003, asplenia had involved 250000 patients in France. These patients are at risk of severe infection, mostly with capsulated bacteria as pneumococci, meningococci and Haemophilus. The higher mortality and morbidity due to infection in asplenic patient led in June 2003 a French expert committee to propose preventive management based on vaccination and antibioprophylaxis., Study Design: Update article., Data Synthesis: For vaccination, two vaccines against pneumococci are available. The first one, the antipolysaccharide (Pneumo 23) is recommended for adults. It is effective for the majority of the serotypes even if its efficacy can be variable. The second one a conjugated pneumococcal vaccine (Prenevar) is used for children under two years because it has higher activity on antibiotic resistant strains therefore increasing antibiotic prophylaxis efficiency. When splenectomy is required, vaccination against pneumococci, Haemophilus (b type) and C meningococci must be performed at least 15 days before surgery, in order to get better immune stimulation. In case of emergency, vaccines have to be administrated within 30 days after surgery. Antibioprophylaxis is based on cefazolin injection before splenectomy and by postoperative intravenous amoxicillin administration. As soon as oral intake is allowed, antibioprophylaxis is continued for at least two years in adults and five years in children. Both antibiotic and vaccination have been reported to reduce pneumococcus infections.

Objective: The aim of this study was to test simulator validity to evaluate the ability of anaesthesia residents to solve two simulated scenarios., Study Design: Monocentre, prospective, randomized study., Population: Anaesthesia residents., Methods: All anaesthesia residents were invited to participate into the study but were free to decline to take part. The authors developed grading forms to evaluate preoperative preparation of anaesthesia room and two simulated scenarios which had been previously validated. All residents were evaluated on the preoperative preparation of anaesthesia room. A randomization was performed to select half of the residents to be tested on one of the simulated scenario. Two experienced anaesthesiologists scored the residents' performance. At the end of the simulated session, residents rated the realism of the scenarios., Results: Among 72 training residents in our institution, 48 participated with 24 beginning and 24 advanced residents. Median scores were similar between beginning (first and second year) and advanced residenced (third and fourth year) for the preoperative preparation of anaesthesia room (17 vs 17 for a maximal score of 25) while scores tended to be higher in advanced residents for simulated scenarios (scenario 1 [34 vs 19 for a maximal score of 55; p = 0.0009], scenario 2 [17 vs 13 for a maximal score of 45; p = 0.58]). However, numerous management errors were observed and some of them did not improve with training. Anaesthesia residents rated the simulator scenarios as realistic., Conclusion: This study suggests that mannequin-based simulator appears as a reliable and valid tool to test the performance of anaesthesia residents during critical situations.