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Cervical arterial abnormalities are associated with intracranial aneurysm but their frequency and association with outcome in case of aneurysmal subarachnoid haemorrhage (aSAH) remains unknown. Data were retrospectively extracted from a prospective database. Consecutive angiographies of aSAH patients on a 13-month period were reviewed as well as consecutive angiographies of SAH patients without evidence of aneurysm on a 20-month period. Occurrence of secondary neurological complications was collected with 3-month functional outcome (modified Rankin Scale ≥ 3 was considered as poor outcome). Cervical arterial abnormalities on angiographies were classified into two subcategories: trajectory and lumen vessel abnormalities. Forty-five patients displayed aneurysmal rupture (aSAH) while 39 patients had no evidence of aneurysm (non-aneurysmal SAH). Prevalence of cervical arterial abnormalities in aSAH and non-aneurysmal SAH patients were 82% (n = 37) and 64% (n = 25), respectively (p = 0.082). Lumen vessel abnormalities were significantly more frequent in case of aSAH (n = 31; 69%) than non-aneurysmal SAH: (n = 9; 23%; p < 0.001). Twenty-eight (62%) aSAH patients experienced poor outcome at 3 months. Lumen vessel abnormalities were significantly associated with 3-month poor outcome (74% (n = 23) versus 36% (n = 5); p = 0.021) without any significant increased occurrence of secondary complications such arterial vasospasm or delayed cerebral ischemia. Cervical arterial abnormalities are frequent in a cohort of aSAH patients. Lumen vessel abnormalities are associated with 3-month poor outcome. [ABSTRACT FROM AUTHOR]

Objectives: The goal of the present study was to examine changes of middle cerebral artery (VMCA) blood flow velocity in patients scheduled for shoulder surgery in beach chair position. Design: Prospective observational study. Setting: Operating room, shoulder surgery. Patients: Fifty-three consecutive patients scheduled for shoulder surgery in beach chair position. Interventions: Transcranial Doppler performed after induction of general anesthesia (baseline), after beach chair positioning (BC1), during surgery 20minutes (BC2), and after back to supine position before stopping anesthesia (supine). Measurements: Mean arterial pressure (MAP), end-tidal CO2, and volatile anesthetic concentration and VMCA were recorded at baseline, BC1, BC2, and supine. Postoperative neurologic complications were searched. Main Results: Beach chair position induced decrease in MAP (baseline: 73±10mm Hg vs lower MAP recorded: 61±10mm Hg; P<.0001) requiring vasopressors and fluid challenge in 44 patients (83%). There was a significant decrease in VMCA after beach chair positioning (BC1: 33±10cm/s vs baseline: 39±14cm/s; P=.001). The VMCA at baseline (39±2cm/s), BC2 (35±14cm/s), and supine (39±14cm/s) were not different. The minimal alveolar concentration of volatile anesthetics, end-tidal CO2, SpO2, and MAP were not different at baseline, BC1, BC2, and supine. Conclusion: Beach chair position resulted in transient decrease in MAP requiring fluid challenge and vasopressors and a moderate decrease in VMCA. [ABSTRACT FROM AUTHOR]

Purposes: Chest compressions require physical effort leading to increased fatigue and rapid degradation in the quality of cardiopulmonary resuscitation overtime. Despite harmful effect of interrupting chest compressions, current guidelines recommend that rescuers switch every 2 minutes. The impact on the quality of chest compressions during extended cardiopulmonary resuscitation has yet to be assessed.Basic Procedures: We conducted randomized crossover study on manikin (ResusciAnne; Laerdal). After randomization, 60 professional emergency rescuers performed 2 × 10 minutes of continuous chest compressions with and without a feedback device (CPRmeter). Efficient compression rate (primary outcome) was defined as the frequency target reached along with depth and leaning at the same time (recorded continuously).Main Findings: The 10-minute mean efficient compression rate was significantly better in the feedback group: 42% vs 21% (P< .001). There was no significant difference between the first (43%) and the tenth minute (36%; P= .068) with feedback. Conversely, a significant difference was evident from the second minute without feedback (35% initially vs 27%; P< .001). The efficient compression rate difference with and without feedback was significant every minute, from the second minute onwards. CPRmeter feedback significantly improved chest compression depth from the first minute, leaning from the second minute and rate from the third minute.Principal Conclusions: A real-time feedback device delivers longer effective, steadier chest compressions over time. An extrapolation of these results from simulation may allow rescuer switches to be carried out beyond the currently recommended 2 minutes when a feedback device is used. [ABSTRACT FROM AUTHOR]

Objective Little is known about changes in near-infrared spectroscopy-derived tissue hemoglobin index (HbI). The authors tested the hypothesis that absolute values and changes in brain hemoglobin index (HbI b ) and skeletal muscle hemoglobin index (HbI m ) could differ from the reference arterial hemoglobin (Hb) during fluid challenge. Design A prospective, monocenter observational study. Setting A 16-bed cardiac surgical intensive care unit in a teaching university hospital. Participants Fifty consecutive adult patients. Interventions Investigation before and after a fluid challenge. Measurements and Main Results Simultaneous comparative Hb, HbI b and HbI m data points were collected from a blood-gas analyzer and the EQUANOX device (Nonin Medical Inc., Plymouth, MN). Correlations were determined by linear regression. No significant relationship was found between absolute values of Hb and HbI b before ( R 2 = 0.04, p = 0.627) and after ( R 2 = 0.00006, p = 0.956) fluid challenge. No significant relationship was found between absolute values of Hb and HbI m before ( R 2 = 0.030, p = 0.226) and after ( R 2 = 0.05, p = 0.117) the fluid challenge. No significant relationship was found between changes in Hb and HbI b ( R 2 = 0.26, p = 0.263) and between changes in Hb and HbI m ( R 2 = 0.001, p = 0.801) after the fluid challenge. Bland-Altman analysis showed a poor concordance between changes in Hb and HbI b , and changes in Hb and HbI m, with large limits of agreement. Conclusions HbI b and HbI m cannot be used to provide continuous noninvasive estimation of Hb, and trends in HbI b and HbI m cannot be considered as noninvasive surrogates for the trend in Hb after cardiac surgery. [ABSTRACT FROM AUTHOR]

Objective To evaluate the impact of a simple written algorithm of early postoperative beta-blocker administration on daily practices. Design A prospective, single center observational study. Setting A 16-bed cardiac surgical intensive care unit in a university teaching hospital. Patients One hundred twenty-five consecutive adult patients chronically treated with beta-blockers and scheduled for conventional cardiac surgery. Interventions Two successive 4-month phases: Phase 1 = uncontrolled early postoperative beta-blocker administration (n = 73) and phase 2 = beta-blocker administration by an institutional written algorithm using incremental doses of bisoprolol and/or esmolol (n = 52). Measurements and Main Results The main endpoint was the number of patients receiving beta-blockers on the morning of postoperative day 1. Secondary endpoints were the number of patients receiving beta-blockers on the morning of postoperative day 1 and reaching the targeted therapeutic goal and the incidence of postoperative atrial fibrillation in the intensive care unit. A 79% increase in the number of patients receiving beta-blockers on the morning of postoperative day 1 (42% v 75%, p<0.001) was observed during the second phase of the study. The number of patients receiving beta-blockers on the morning of postoperative day 1 and reaching the targeted therapeutic goal was increased significantly by 127% (33% v 75%, p<0.001). The incidence of atrial fibrillation was similar between both phases of the study: 37% versus 31%, p = 0.567. Conclusions A simple written algorithm markedly improved early postoperative continuation of beta-blockers in chronically treated patients undergoing conventional cardiac surgery. [ABSTRACT FROM AUTHOR]

Objectives: Arterial pulse pressure variation (PPV) and digital plethysmographic variability index (PVI) have been proposed to predict fluid responsiveness during anesthesia and in critically ill patients. The present study aimed to compare the clinical utility of PPV and PVI in predicting fluid responsiveness after elective cardiac surgery. Design: A prospective observational study. Setting: A university hospital. Participants: Eighty-seven adult patients. Interventions: Admission to the intensive care unit after cardiac surgery. Investigation before and after fluid challenge. Measurements and Main Results: The discrimination of both PPV and PVI in predicting fluid responsiveness was compared by using areas under the receiver operating characteristics curves (ROCAUC). Sensibility analyses were conducted after exclusion of patients with a low perfusion index, patients receiving norepinephrine, and patients with right ventricular dysfunction. Fifty-seven (71%) patients were responders and twenty-three (29%) were nonresponders. ROCAUC were 0.73 [95% CI: 0.63-0.83] versus 0.60 [95% CI: 0.48-0.71] for PPV and PVI in the whole cohort of patients, respectively (p = 0.020). The inconclusive class of responses included 47 (59%) and 62 (77%) patients, respectively (p = 0.010); whereas the discrimination of PVI remained low whatever the subgroup of patients, the discrimination of PPV markedly increased in patients without perfusion index≤1.3 (ROCAUC = 0.83 [95% CI: 0.68-0.93]) and in patients without right ventricular dysfunction (ROCAUC = 0.85 [95% CI: 0.67-0.95]). Conclusions: PVI is not discriminant and probably inaccurate to predict fluid responsiveness after elective cardiac surgery. PPV could be of potential interest after exclusion of patients with a low perfusion index and right ventricular dysfunction. [Copyright &y& Elsevier]

PURPOSES: Cardiac arrest survival depends on celerity and efficiency of life support action. Guidelines emphasized the chest compression (CC) quality and feedback devices are encouraged. The purpose is to study the impact of the CPRmeter feedback device on resuscitation performed by untrained rescuers. BASIC PROCEDURES: This is a prospective randomized crossover study on manikins (Resusci Anne). One hundred and forty four students inexperienced in cardiopulmonary resuscitation representing untrained rescuers were included. Participants performed 2 minutes of CC without interruption with (group G) or without (group B) feedback. Four months passed between the 2 crossover phases to avoid resilience effect. Data collected by the CPRmeter device were: CC rate, depth and release. MAIN FINDINGS: Efficient CC rate ([simultaneous and correct CC rate, depth and release] primary outcome) (absolute difference [95% CI]) was significantly improved in group G (71%) compared to group B (26%; [45 {36-55}]; P < .0001). Adequate depth rate (>38 mm) was significantly improved in group G (85%) compared to group B (43%; [42 {33-52}]; P < .0001). Adequate CC rate (90-120/min) was significantly improved in group G (81%) compared to group B (56%; [25 {15-35}]; P < .0001). The average CC rate and depth in group G were significantly less dispersed around the mean compared to group B (test of variance P < .007; P < .015 respectively). PRINCIPAL CONCLUSIONS: The use of the CPRmeter significantly improved CC quality performed by students inexperienced in cardiopulmonary resuscitation. [ABSTRACT FROM AUTHOR]

Purpose: The present study aimed to compare peripheral regional tissue oxygen saturation (rSO2) values and desaturation/resaturation rates given by INVOS and EQUANOX devices. Materials and methods: Twenty healthy volunteers were investigated during 4 experimental steps: baseline, hyperoxia, ischemia, and reperfusion. For each volunteer, 2 sensors INVOS and 2 sensors EQUANOX were placed on both left and right calves. Blood pressure, heart rate, and peripheral pulse oximetry were monitored. Results: Peripheral rSO2 ranged from 40% to 95% (INVOS) and from 47% to 100% (EQUANOX): 81 ± 12 vs 82 ± 9 (P = .469). A significant relationship was found at baseline between absolute values of INVOS and EQUANOX (n = 40; R2 = 0.159; P = .011). Bias was -0.4%, and limits of agreement were ±15.1%. The percent maximum differences vs baseline values during dynamic maneuvers were 33% ± 19% (95% confidence interval, 24-42) and 21% ± 14% (95% confidence interval, 15-28) for INVOS and EQUANOX, respectively. No significant relationship was observed between percent maximum differences in INVOS and EQUANOX (n = 20; R2 = 0.128; P = .122). Rates of desaturation/ resaturation during occlusive vascular tests were 3.65% per minute vs 2.36% per minute (P = .027) and 30.42% per minute vs 16.28% per minute (P = .004) for INVOS and EQUANOX, respectively. Conclusions: INVOS and EQUANOX are not comparable in measuring both absolute values and dynamic changes of peripheral rSO2 and near-infrared spectroscopy-derived parameters during occlusion vascular tests. [ABSTRACT FROM AUTHOR]

Background: Results of bilobectomy for non-small cell lung cancer have rarely been studied. Methods: Retrospective analysis was conducted on patients with non-small cell lung cancer having undergone bilobectomy from January 1999 to June 2012 at our institution. Analysis aimed at determining perioperative mortality and morbidity, and at studying prognostic factors for long-term survival using the 7th TNM classification. Results: A total of 103 patients (85 males; mean age 62 years) underwent upper-middle bilobectomy (n = 54) or lower-middle bilobectomy (n = 49). Histologic examination revealed 51 adenocarcinomas, 43 squamous cell carcinomas and 9 other cell carcinomas. Perioperative mortality was 0.97%. The overall morbidity rate was 71%, whereas the rate of life-threatening complications was 9.6%. Complications were more frequent in men (p = 0.032), in patients with chronic pulmonary obstructive diseases (p = 0.030) and after lower-middle bilobectomy (p = 0.0016). The overall 5-year Kaplan-Meier survival rate was 57.8%. In univariate analysis, factors associated with increased survival were the following: pathologic stage (stage I 74.9%, stage II 64.1%, stage III 28.8%, p = 0.0018); nodal status (N0 vs N1, p = 0.011; N0 vs N2, p = 0.0015; N0 vs N+, p = 0.0008); R status (R0 vs R1, p = 0.0032), and smoking status (past smoker or nonsmoker vs active smoker, p = 0.00054). Multivariate analysis revealed that active smokers (RR = 3.87, CI 95% [1.83 to 8.21]; p = 0.00042) and increasing stage (stage 0: RR=1; stage I: RR = 1.98, CI 95% [1.38 to 2.83]; stage II: RR = 3.90, CI 95% [1.90 to 8.02]; stage III: RR=7.72, CI 95% [2.62 to 22.73]; stage IV: RR = 15.25, CI 95% [3.61 to 64.40]; p = 0.0042) were significantly associated with poorer survival. Conclusions: Bilobectomy can be performed with low mortality, acceptable morbidity and long term survival in accordance with TNM staging. [Copyright &y& Elsevier]

Objective: Little is known about changes in near-infrared spectroscopy (NIRS)-derived cerebral (rSO2b) and somatic (rSO2s) oxygen saturation during a fluid challenge. The authors tested the hypothesis that they could differ from central venous oxygen saturation (ScvO2) and from one site to another. Design: A prospective observational study. Setting: A teaching university hospital. Participants: Fifty consecutive adult patients. Interventions: Admission to the intensive care unit after cardiac surgery and investigation before and after a fluid challenge. Measurements and Main Results: Simultaneous comparative ScvO2, rSO2b, and rSO2s data points were collected from a blood-gas analyzer and the EQUANOX monitor (Nonin Medical, Inc, Plymouth, MN). Correlations were determined by linear regression. Multiple stepwise linear regression models were used to assess independent variables associated with changes in ScvO2, rSO2b, and rSO2s. A statistically significant relationship was found between absolute values of ScvO2 and rSO2b (r = 0.42, p < 0.001) but not between absolute values of ScvO2 and rSO2s (r = 0.18, p = 0.066). No relationship was found between percent changes in ScvO2 and rSO2b (r = 0.05, p = 0.715) and between percent changes in ScvO2 and rSO2s (r = 0.02, p = 0.886) after the fluid challenge. Cardiac index contributed to the prediction of changes in ScvO2 (regression coefficient = −4.09, p = 0.006), whereas the mean arterial pressure contributed to the prediction of changes in rSO2b (regression coefficient = −0.05, p = 0.027). Conclusions: rSO2b and rSO2s cannot be used to provide noninvasive estimation of ScvO2, and trends in rSO2b and rSO2s cannot be considered as noninvasive surrogates for the trend in ScvO2 after cardiac surgery. Different independent variables contribute to the prediction of ScvO2, rSO2b, and rSO2s. [Copyright &y& Elsevier]

Objectives: The influence of the cardiac surgical procedure on B-type natriuretic peptide (BNP) for the identification of high-risk patients has not been evaluated. This study aimed to compare the prognostic utility of pre- and postoperative BNP in predicting adverse long-term outcome after coronary artery bypass graft (CABG) surgery and aortic valve replacement (AVR). Design: A retrospective study. Setting: A university teaching hospital. Participants: One hundred eighty-nine patients. Measurements and Main Results: Preoperative, early postoperative (24 hours), and late postoperative (day 5) BNP levels were measured. Major adverse cardiac events (MACEs) within 12 months after surgery were chosen as study endpoints. The predictive abilities of BNP measurements were compared using receiver operating characteristic (ROC) curves. Patients were stratified by CABG surgery (n = 100) and AVR (n = 89). Thirty-four (18%) patients experienced 44 MACEs over the study period. Preoperative BNP values were significantly different between groups. Postoperative BNP gradually increased by 431% on day 5 after CABG surgery and by 100% after AVR (both p < 0.001 v preoperative values). Pre- and early postoperative BNP values were accurate in predicting MACEs after AVR (areas under the ROC curves: 0.78 [95% confidence interval, 0.66-0.90] and 0.76 [95% confidence interval, 0.62-0.89], respectively) and inaccurate after CABG surgery (0.54 [95% confidence interval, 0.38-0.70] and 0.54 [95% confidence interval, 0.36-0.73], respectively). The late postoperative BNP value was of limited value. Conclusions: BNP measurements should take into account the type of cardiac surgery. Whatever the time of measurement, BNP accurately predicts long-term adverse outcome in valve surgery patients. A late postoperative BNP measurement is useless after cardiac surgery. [Copyright &y& Elsevier]

Objectives: The authors hypothesized that bioimpedance cardiography measured by the Endotracheal Cardiac Output Monitor (ECOM; ConMed, Utica, NY) is a convenient and reliable method for both cardiac index (CI) assessment and prediction in fluid responsiveness. Design: A prospective observational study. Setting: A teaching university hospital. Participants: Twenty-five adult patients. Interventions: Admission to the intensive care unit after conventional cardiac surgery and investigation before and after a fluid challenge. Measurements and Main Results: Simultaneous comparative CI data points were collected from transpulmonary thermodilution (TD) and ECOM. Correlations were determined by linear regression. Bland-Altman analysis was used to compare the bias, precision, and limits of agreement. The percentage error was calculated. Pulse-pressure variations (PPVs) and stroke-volume variations (SVVs) before fluid challenge were collected to assess their discrimination in predicting fluid responsiveness. A weak but statistically significant relationship was found between CITD and CIECOM (r = 0.31, p = 0.03). Bias, precision, and limits of agreement between CITD and CIECOM were 0.08 L/min/m2 (95% confidence interval, −0.11 to 0.27), 0.68 L/min/m2, and −1.26 to 1.42 L/min/m2, respectively. The percentage error was 51%. A nonsignificant positive relationship was found between percent changes in CITD and CIECOM after fluid challenge (r = 0.37, p = 0.06). Areas under the ROC curves for both PPV and SVV to predict fluid responsiveness were 0.86 (95% confidence interval, 0.67-1.06) and 0.89 (95% confidence interval, 0.74-1.04, respectively; p = 0.623). Conclusions: Continuous measurements of CI under dynamic conditions are consistent and easy to obtain with ECOM although not interchangeable with transpulmonary thermodilution. SVV given by ECOM is a dynamic parameter that predicts fluid responsiveness with good accuracy and discrimination. [Copyright &y& Elsevier]

Background: This study was conducted to determine the frequency, predictors, and clinical impact of adverse events (AEs) related to invasive procedures in the intensive care unit (ICU). Methods: This was a prospective observational study of ICUs in a university hospital. Results: A total of 893 patients requiring invasive procedures were admitted over a 1-year period. Among these, 310 patients (34.7%) experienced a total of 505 AEs. The mean number of AEs per patient was 1.6 ± 1.1 (range, 1-7). Infectious AEs were significantly more frequent than mechanical AEs (60.4% vs 39.6%; P = .01). Factors independently associated with AE occurrence were isolation of multidrug-resistant bacteria at ICU admission, >5 invasive procedures, and ICU length of stay >8 days. Thirty-three AEs (6.5%) resulted in severe clinical impact, including 24 deaths. Ventilator-associated pneumonia (VAP) accounted for 62.5% of the deaths related to AEs. Conclusions: One-third of critically ill patients experienced AEs related to invasive procedures. Severe AEs were associated with 11% of all ICU deaths. VAP was the most frequent AE related to death. An improved assessment of the risk–benefit balance before each invasive procedure and increased efforts to decrease VAP prevalence are needed to reduce AE-related mortality. [Copyright &y& Elsevier]

Objectives: Although B-type natriuretic peptide (BNP) strongly predicts cardiac morbidity and mortality, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) has a modest predictive value to identify a composite operative risk after cardiac surgery. The authors tested the hypothesis that a single preoperative BNP measurement would be superior to standard EuroSCORE in predicting composite adverse outcomes after cardiac surgery. Design: A prospective observational study. Setting: A teaching university hospital. Participants: Two hundred eight adult patients. Interventions: Conventional cardiac surgery with cardiopulmonary bypass. Measurements and Main Results: The preoperative additive EuroSCORE and BNP measurement were performed in all patients. Postoperative nonfatal major adverse cardiac events (malignant ventricular arrhythmia, myocardial infarction, and cardiac dysfunction), all-cause mortality, and prolonged lengths of stay were chosen as study endpoints. Predictive abilities of both EuroSCORE and BNP were assessed using logistic regression and compared with receiver operating characteristic (ROC) curves. Thirty-six (17%, 95% confidence interval [CI], 12%-22%) patients experienced 49 events over the study period. The areas under the ROC curves assessing the utility of EuroSCORE and BNP in predicting adverse outcome and prolonged in-hospital stay were 0.59 (95% CI, 0.48-0.69) versus 0.76 (95% CI, 0.68-0.85; p < 0.001) and 0.65 (95% CI, 0.57-0.74) versus 0.71 (95% CI, 0.63-0.80; p = 0.147), respectively. Using logistic regression, BNP considered as a dichotomized variable was the only independent predictor of adverse cardiac outcome (adjusted odds ratio = 10.7; 95% CI, 4.1-27.8; p < 0.001). Conclusions: Preoperative BNP measurement is a strong, independent, and more accurate predictor of adverse outcome than EuroSCORE in patients undergoing cardiac surgery. BNP could be considered as a simple and objective tool for the detection of high-risk patients after cardiac surgery. [Copyright &y& Elsevier]

Objective: Recently, a new device for minimally invasive direct cardiac massage (MIDCM) has been developed. In animal models of cardiopulmonary resuscitation MIDCM has been shown to provide better organ perfusion than external chest compressions (ECC) massage. Since this device has been developed to improve cardiopulmonary resuscitation in humans, its use must be simple. Thus, we measured the time required for the insertion of the MIDCM device on human cadavers. Design: After a 1 h theoretical course, physicians and surgeons were asked to use the MIDCM device on human cadavers. We measured the time from the cutaneous incision to the first direct cardiac compression. Main results: The mean time required for the insertion of the MIDCM device was 16±11 s (range 8–58 s). The insertion time required for each group of physicians were as follows, 15±8 s for anaesthesiologists (range 8–28 s), 11±2 s for cardiac surgeons (range 9–15 s), 42±14 s for cardiologists (range 27–58 s), and 12±4 s for intensive care physicians (range 8–18). All participants compared the insertion of the MIDCM device favorably with the insertion of a chest drain. Conclusion: The MIDCM device can be placed in a few seconds in human cadavers by physicians familiar with chest drain insertion. Theoretical course and training with the device may be useful especially for those who are not familiar with chest drain insertion. [Copyright &y& Elsevier]

Background Mitochondria play a key role in cell metabolism and ATP production, but also in the regulation of cell death and notably upon episodes of myocardial ischemia-reperfusion. In a context of myocardial infarction, these injuries are increased in patients with type 2 diabetes mellitus when compared to non-diabetic patients. Whereas diabetes mellitus was shown to alter mitochondrial protein expression and metabolism in rodent experimental models, there are only few data available in human. The aim of this study was to assess the metabolism and protein expression in subsarcolemmal (SSM) and interfibrillar (IFM) mitochondria extracted from human atrial appendages in diabetic and non-diabetic patients. Material and methods SSM and IFM mitochondria were isolated from human right atrial appendages in type 2 diabetes mellitus and non-diabetic patients. Electron transport chain (ETC) activities were assessed using spectrophotometric and polarographic methods. Proteomic study was performed using isobaric tags for relative and absolute quantitation (iTRAQ) labeling and matrix-assisted laser desorption/ionisation-time of flight (MALDI-TOF) mass spectrometry analysis. Results Differences between IFM and SSM mitochondria were observed on both ETC complexes activities and expression of mitochondrial proteins. However, functional studies on ETC did not reveal any significant difference between diabetic and non-diabetic patients in both SSM and IFM mitochondria. No difference was found between mitochondria from diabetic and nondiabetic patients using polarographic method. In addition, expression of mitochondrial proteins from both mitochondrial population (SSM and IFM) did not differ when comparing diabetic and non-diabetic patients. Conclusion Our study provides no evidence for a deleterious impact of type 2 diabetes mellitus on mitochondrial ETC activity and protein expression that would explain the higher susceptibility to ischemia-reperfusion compared to non-diabetic patients. The author hereby declares no conflict of interest [ABSTRACT FROM AUTHOR]

Introduction Atrial fibrillation (AF) is the most common complication after cardiac surgery and is responsible for significant morbidity and mortality. To assess whether preconditioning with renin-angiotensin-aldosterone system agents could limit myocardial tissue injury, we tested the force of contraction of human right atrial trabeculae during hypoxia-reoxygenation when exposed to aldosterone and/or potassium canrenoate. Materials and methods We studied the effect of aldosterone and/or mineralocorticoid receptor (MR) antagonist potassium canrenoate administration prior to hypoxia-reoxygenation and in normoxic condition on force of contraction in 51 human right atrial trabeculae obtained from patients scheduled for coronary artery bypass surgery or aortic valve replacement. We also tested if adosterone exposure results in changes in levels of ERK1/2 phosphorylation. Results The force of contraction of trabeculae was significantly reduced by aldosterone administration under normoxic or hypoxia-reoxygenation conditions. The rapid onset of this effect - 25 minutes - suggests a nongenomic mechanism. When compared with controls, potassium canrenoate by itself was not able to induce cardioprotection. However, coadministration of aldosterone and potassium canrenoate preconditioned isolated human atrial myocardium exposed to hypoxia - reoxygenation. This effect could be MR-dependent or not because both aldosterone and potassium canrenoate have some nongenomic MR-independent actions. Preliminary results showed that aldosterone exposure increased ERK1/2 phosphorylation levels. Conclusion Potassium canrenoate-induced cardioprotection prevents the deleterious effect of aldosterone on human atrial myocardial tissue. Further research required to determine the mechanism involved and the potential beneficial in clinical practice in order to reduce the incidence of postoperative atrial fibrillation. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Data on contrast-induced acute kidney injury (CI-AKI) in intensive care unit (ICU) are scarce and controversial. The objectives of the study were to evaluate the incidence and characteristics of CI-AKI in a surgical ICU. Materials and Methods: We conducted a 13-month prospective observational study. Three definitions were compared to characterize CI-AKI: Barrett and Parfrey criteria; Risk of renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function and End stage renal disease (RIFLE) classification; and Acute Kidney Injury Network (AKIN) criteria. Patients hospitalized in surgical ICU who had received an injection of contrast medium, who were not on renal replacement therapy, who had stable serum creatinine before injection, and no other etiology for new acute kidney injury were included. Results: One hundred one patients were included. The frequency of CI-AKI was 17%, 19%, and 19% according to Barrett and Parfrey criteria; RIFLE classification; and AKIN criteria, respectively. Diabetes mellitus, creatinine clearance less than 60 mL/min, and concomitant aminoglycoside administration were associated with CI-AKI. Statistically significant associations were found between CI-AKI and renal replacement therapy with all 3 definitions and between CI-AKI and mortality when AKIN criteria were used. Conclusions: These results show that CI-AKI is not inconsequential in critically ill patients. In the present study, AKIN criteria appear to be most relevant to define CI-AKI. Further studies are required to explore CI-AKI prevention in ICU. [Copyright &y& Elsevier]

Background: Current practice guidelines for red blood cell (RBC) transfusion in ICUs are based on haemoglobin threshold, without consideration of oxygen delivery or consumption. We aimed to evaluate an individual physiological threshold-guided by central venous oxygen saturation ScvO2.Methods: In a randomised study in two French academic hospitals, 164 patients who were admitted to ICU after cardiac surgery with postoperative haemoglobin <9 g dl-1 were randomised to receive a transfusion with one unit of RBCs (haemoglobin group) or transfusion only if the ScvO2 was <70% (individualised group). The primary outcome was the number of subjects receiving at least one unit of RBCs. The secondary composite outcome was acute kidney injury, stroke, myocardial infarction, acute heart failure, mesenteric ischaemia, or in-hospital mortality. One- and 6-month mortality were evaluated during follow-up.Results: The primary outcome was observed for 80 of 80 subjects (100%) in the haemoglobin group and in 61 of 77 patients (79%) in the individualised group (absolute risk -21% [-32.0; -14.0]; P<0.001). There was no significant difference in the secondary outcome between the two groups. Follow-up showed a non-significant difference in mortality at 1 and 6 months.Conclusions: An individualised strategy based on an central venous oxygen saturation threshold of 70% allows for a more restrictive red blood cell transfusion strategy with no incidence on postoperative morbidity or 6-month mortality.Clinical Trial Registration: NCT02963883. [ABSTRACT FROM AUTHOR]

• General anesthesia for surgery during childhood is a recurring phenomenon. • Anesthesia neurotoxicity is still debated. • A rich preclinical literature describes a wide range of neurotoxicity mechanisms. • The clinical literature about anesthesia neurotoxicity is controversial. • Translational research will open up new avenues of research about anesthesia neurotoxicity. In 2017, the Food and Drug Administration published a safety recommendation to limit the exposure to general anesthesia as much as possible below the age of three. Indeed, several preclinical and clinical studies have questioned the possible toxicity of general anesthesia on the developing brain. Since then, recent clinical studies tried to mitigate this alarming issue. What is true, what is false? Contrary to some perceptions, the debate is not over yet. Only stronger translational research will allow scientists to provide concrete answers to this public health issue. In this review, we will provide and discuss the more recent data in this field, including the point of view of preclinical researchers, neuropsychologists and pediatric anesthesiologists. Through translational research, preclinical researchers have more than ever a role to play to better understand and identify long-term effects of general anesthesia for pediatric surgery on brain development in order to minimize it. [ABSTRACT FROM AUTHOR]

The present study aimed at evaluating the effect of a haemodynamic algorithm using SV maximisation by non-invasive photoplethysmography (interventional group) on the incidence of postoperative complications compared with a control group using intermittent mean arterial pressure. The non-blinded parallel-group trial randomised low-risk patients undergoing colorectal surgery into either interventional group or control group. The primary outcome was the incidence of patients with at least one complication during the 30 days following surgery. The secondary outcomes were the total number of complications, the length of hospital stay and postoperative mortality. A meta-analysis of randomised trials comparing perioperative haemodynamic optimisation (interventional group) using photoplethysmography with control group was performed to assess the external validity. Among 160 randomised patients, 159 were analysed (80 and 79 in interventional and control groups, respectively). Demographic characteristics were similar in both groups. Postoperative complications occurred in 40 (50%) and 34 (43%) patients in the interventional and control groups, respectively (P = 0.471). There were no significant differences between the two groups regarding the total number of complications (P = 0.078), the hospital length of stay (P = 0.960), or postoperative mortality (P = 1.000). In the meta-analysis including 1089 patients in 7 randomised controlled studies, 203 (38%) and 221 (40%) patients suffered from at least one complication following surgery [risk ratio 0.89 (95% CI 0.68–1.17), P = 0.407] in interventional and control groups, respectively. Based on the findings of the present study and meta-analysis, a haemodynamic perioperative algorithm using SV maximisation by non-invasive photoplethysmography cannot reduce postoperative morbidity. [ABSTRACT FROM AUTHOR]

Abstract Objective Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject. Design A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation ; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence ; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie ; SFR), French Defence Health Service (Service de Santé des Armées ; SSA), French Society of Urology (Association Française d'Urologie ; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique ; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive ; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Methods Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE® methodology. Results The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ±), 11 have a low level of evidence (Grade 2 ±). Conclusions Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture. [ABSTRACT FROM AUTHOR]

Abstract Background Blended learning, which combines internet-based platform and lecturing, is used in anaesthesiology and critical care teaching. However, the benefits of this method remain unclear. Methods We conducted a prospective, multicentre, non-randomised work between 2007 and 2014 to study the effect of blended learning on the results of first year anaesthesia and critical care residents in comparison with traditional teaching. Blended learning was implemented in Rouen University Hospital in 2011 and residents affiliated to this university corresponded as the blended learning group. The primary outcome was the resident's results as measured with multiple-choice questions between blended learning and control groups after beginning blended learning (post-interventional stage). The secondary outcomes included residents’ results between pre and post-interventional stages and homework's time. Moreover, comparison between control and blended learning group before beginning blended learning (pre-interventional stage) was performed. Results From 2007 to 2014, 308 residents were included. For the pre-interventional period, the mean score in the blended learning group (n = 53) was 176 (CI 95% 163 to 188) whereas the mean score in the control group (n = 106) was 167 (CI 95% 160 to 174) (no difference). For the post-interventional period, the mean score in blended learning group (n = 54) was 232 on 300 (CI95% 227–237) whereas the mean score in the control group (n = 95) is 215 (CI95% 209–220) (P < 0.001). In the two groups, comparison between pre and post-interventional stages showed the increase of mean score, stronger for blended learning group (32% and 28% in blended learning and control group, P < 0.05). The average time of homework in the blended learning group was 27 h (CI 95% 18.2–35.8) and 10 h in the control group (CI 95% 2–18) (P < 0.05). Conclusions This work suggests the positive effect of blended learning (associating internet-based learning and flipped classroom) on the anaesthesia and critical care residents’ knowledge by increasing their homework's time. [ABSTRACT FROM AUTHOR]

Background Myocardial ischaemia reperfusion injury following cardiac surgery with cardiopulmonary bypass (CPB) increases postoperative mortality. Setting techniques to protect the heart during this critical period therefore represents a considerable challenge. Method A randomised controlled study in Caen University Hospital Centre, investigated whether the clinical cardio protective effects of administration sevoflurane before cardiopulmonary bypass during coronary artery bypass graft surgery (CABG) could translate into protected atrial trabeculae contractility against hypoxia–reoxygenation in vitro. Patients undergoing elective on-pump CABG surgery were allocated to receive either sevoflurane ( n = 24) or no halogenated volatile anaesthetic ( n = 21). Main outcome measures: the relationship between sevoflurane exposure before CPB and the incidence of major adverse cardiac events, with primary endpoint: the postoperative troponin I peak level, and secondary endpoints: the inotropic support, and the duration of stay in intensive unit and in-hospital stay were chosen as study endpoints. The right atrial was collected at the beginning of bypass surgery for the in vitro experimentation. Isometrically contracting isolated human right atrial trabeculae obtained from the two groups were exposed to 30-min hypoxia followed by 60-min reoxygenation. Results The patients receiving sevoflurane prior to aortic clamping significantly exhibited less cardiac Troponin I (1.39 [0.34–2.97] vs. 2.80 [2.54–3.64] ng·mL −1 in Control; P = 0.03) and required a reduced inotropic drug support ( P < 0.001). Isolated trabeculae from patients receiving sevoflurane enhanced the recovery of force after reoxygenation compared to the Control group (79 ± 5% vs. 53 ± 8% of baseline in Control; P < 0.001). Conclusions Administration of sevoflurane before CPB induced cardioprotection in patients undergoing CABG and preconditioned human myocardium against hypoxia-reoxygenation in vitro. [ABSTRACT FROM AUTHOR]

Background Sleep deprivation has been associated with an increased incidence of medical errors and can jeopardise patients’ safety during medical crisis management. The aim of the study was to assess the effect of sleep deprivation on the management of simulated anaesthesia crisis by residents in anaesthesiology. Methods A randomised, comparative, monocentric crossover study involving 48 residents in anaesthesia was performed on a high fidelity patient simulator. Each resident was evaluated in a sleep-deprived state (deprived group, after a night shift duty) and control state (control group, after a night of sleep). Performance was assessed through points obtained during crisis scenario 1 (oesophageal intubation followed by anaphylactic shock) and scenario 2 (anaesthesia-related bronchospasm followed by ventricular tachycardia). Sleep periods were recorded by actigraphy. Two independent observers assessed the performances. The primary endpoint of the study was the score obtained for each scenario. Results Resident's crisis management performance is associated with sleep deprivation (scenario 1: control = 39 [33–42] points vs. deprived = 26 [19–40] points, P = 0.02; scenario 2: control = 21 [17–24] vs. deprived = 14 [12–19], P = 0.01). The main errors observed were: error in drug administration and dose, delay in identification of hypotension, and missing communication with the surgical team about situation. Conclusions The present study showed that sleep deprivation is associated with impairment of performance to manage crisis situations by residents in anaesthesia. [ABSTRACT FROM AUTHOR]

Pregnancies complicated by congenital or acquired heart diseases are at high risk of maternal, obstetrical and neonatal poor outcomes. During the period 2000–2014, 197 pregnancies occurring in 147 women with heart disease were managed in our institution. A maternal cardiac event complicated 13 pregnancies. Obstetrical and neonatal complications occurred respectively in 35.0% (95% CI [28.3–41.7]) and 37.0% (95% CI [30.3–43.7]) of pregnancies. All complications were more frequent amongst cardiomyopathies or obstructive and conotruncal lesions, whereas left-to-right shunts were less prone to present with complications. Complications occurred between the end of the second trimester and the middle of the third trimester or during the post-partum period. Caesarean section was the mode of delivery in 37% (95% CI [30.3–43.7]) of cases, and general anaesthesia was performed in 8.6% of cases (95% CI [4.7–12.5]). Although reporting relatively mild heart diseases, this retrospective study shows an evolution in the management of pregnancies complicated by cardiopathies. Vaginal delivery under locoregional anaesthesia can be achieved in many pregnancies, whereas others require strict multi-disciplinary follow-up in a specialized centre. The creation of a large, multi-centric registry might help improve and personalize the management of these high-risk pregnancies. [ABSTRACT FROM AUTHOR]

Background The intraoperative modulation of opioids continues to be based on clinical signs. This may result in adverse events such as sympathetic reactivity or opioid-induced hyperalgesia. Recently, the Analgesia/Nociception Index (ANI), a non-invasive 0–100 index derived from heart rate variability analysis, has been proposed for nociception assessment. However, the ability of the ANI to adequately guide intraoperative opioid administration has never been demonstrated. We designed a prospective study to evaluate the ability of the ANI to guide remifentanil administration in vascular surgery. Methods One hundred and eighty adults presenting for elective surgery were included. All received total intravenous anaesthesia with propofol adjusted to entropy and remifentanil adjusted to the ANI. The primary endpoint was the number of patients without any episode of reactivity defined as a 20% increase in heart rate or arterial pressure or the occurrence of movement. Secondary endpoints included opioid use and maximal pain rate in the first postoperative day. Results Anaesthesia was achieved without any episode of reactivity in 160 (89%) patients. Twenty-five episodes of reactivity occurred in 20 (11%) patients. The median remifentanil dose was 0.042 [0.040–0.044] μg.kg − 1 .min −1 . At 24 hours, the maximal NRS pain score was 2 [2,3]. One hundred and fifty-five patients (86%) did not receive any postoperative opioids, whereas 25 (14%) received a median dose of 5[5–10] mg of oxycodone. Conclusion This prospective study demonstrated that the ANI can be used to adequately guide intraoperative remifentanil administration during vascular surgery. Such guidance resulted in low remifentanil consumption, low postoperative pain rates and low opioid rescue analgesia. [ABSTRACT FROM AUTHOR]

The 5th edition of The European recommendations for the management of major bleeding and coagulopathy following trauma leaves room for various coagulation factor administration strategies. The present study examines these strategies reporting prevalence and timing of administration, quantity dispensed, and transfusion ratios in French trauma centers and their compliance with recommendations alongside associated mortality data. All adult patients, admitted directly to participating centers between 2011 and 2019, were extracted from a trauma registry. Two subpopulations were studied: severe hemorrhage (SH) and massive transfusion (MT) groups. A total of 19,396 patients were included, among whom 8.4% (1630) experienced SH and 3% (579) received MT. Within the first 24 hours, 10% received fresh frozen plasma (FFP), rising to 93% and 99% in the subgroups of patients experiencing SH and MT respectively. Only, 8% received fibrinogen concentrate (FC), increasing to 75% and 92% in subgroups SH and MT respectively. Co-administration of FFP and FC became the dominant strategy with 68% of patients at 6 h and 72% at 24 h in SH subgroup. In unadjusted data, mortality was systematically lower in groups that complied with recommendations, a lower mortality than expected was mostly observed in contrast to non-compliant subgroups. The per-patient compliance to studied recommendations was 21% and 22% in SH and MT subgroups. The main hemostatic strategy for major bleeding combined the administration of both FFP and FC, favoring an early additional supply of fibrinogen. Compliance with the recommendations was low in SH and MT subgroups. [ABSTRACT FROM AUTHOR]

Objectives To assess the trending ability of calibrated pulse contour cardiac index (CI PC ) monitoring during haemodynamic changes (passive leg raising [PLR] and fluid loading) compared with transpulmonary thermodilution CI (CI TD ). Method Seventy-eight mechanically-ventilated patients admitted to intensive care with calibrated pulse contour following cardiac surgery were prospectively included and investigated during PLR, and after fluid loading. Fluid responsiveness was defined as a ≥ 15% CI TD increase after a 500 ml bolus. Areas under the empiric receiver operating characteristic curves (ROC AUC ) for changes in CI PC (ΔCI PC ) during PLR to predict fluid responsiveness and after fluid challenge to predict an increase at least 15% in CI TD after fluid loading were calculated. Results Fifty-five patients (71%) were classified as responders, 23 (29%) as non-responders. ROC AUC for ΔCI PC during PLR in predicting fluid responsiveness, its sensitivity, specificity, and percentage of patients within the inconclusive class of response were 0.67 (95% CI = 0.55–0.77), 0.76 (95% CI = 0.63–0.87), 0.57 (95% CI = 0.34–0.77) and 68%, respectively. Bias, precision and limits of agreements and percentage error between CI PC and CI TD after fluid challenge were 0.14 (95% CI: 0.08–0.20), 0.26, –0.37 to 0.64 l min −1 m −2 , and 20%, respectively. The concordance rate was 97% and the polar concordance at 30° was 91%. ROC AUC for ΔCI PC in predicting an increase of at least 15% in CI TD after fluid loading was 0.85 (95% CI: 0.76–0.92). Conclusion Although ΔCI PC after fluid loading could track the direction of changes of CI TD and was interchangeable with bolus transpulmonary thermodilution, PLR could not predict fluid responsiveness in cardiac surgery patients. [ABSTRACT FROM AUTHOR]

Objective Arterial pulse pressure variation (PPV) has been used as an accurate index to predict fluid responsiveness. However, many confounding factors have been recently described. The aims of this study were to assess the conditions of applicability of PPV in intensive care units (ICU). Study design A one-day French national survey. Patients and methods A form assessing the suitability of PPV was completed by practitioners for each critically-ill patient included on a set day. Results Four hundred and sixty-five patients were included in 36 ICUs. A regular sinus rhythm was noted in 408 (88%) patients and the presence of an arterial line in 324 (70%) patients. One hundred and twenty-seven (27%) patients were mechanically ventilated without spontaneous breathing. Only six patients (1.3%) had no confounding factors modifying the threshold value of the PPV. Conclusion The incidence of ICU patients in whom PPV was suitable and without confounding factors were respectively 18% and 1.3% in this one-day French national survey. [ABSTRACT FROM AUTHOR]

Objective The aims of the study were to assess the knowledge of intensivists and/or anaesthesiologists concerning respiratory arterial pulse pressure variation (PPV) and to define the criteria used to indicate a fluid challenge. Study design A prospective observational study. Patients and methods Intensivists and anaesthesiologists from one region of France were evaluated for their knowledge about the prerequisites (continuous arterial pressure monitoring, regular sinus rhythm, mechanical ventilation without spontaneous breathing) and confounding factors shifting the threshold value of PPV (low tidal volume, decreased pulmonary compliance, low heart rate/respiratory rate ratio, right ventricular dysfunction, and/or intra-abdominal hypertension) using clinical vignettes. Criteria used by physicians to indicate a fluid challenge were also collected. Results One hundred and forty-five physicians were included in the study. Among them, 87 (60%) knew prerequisites but none of them had full knowledge of all confounding factors. Criteria used to perform a fluid challenge were mainly PPV and the passive leg-raising test for the residents and PPV, blood pressure, oliguria and hydric balance for the qualified physicians. Conclusions PPV was widely employed to indicate a fluid challenge and 60% of the physicians knew the prerequisites. However, the physicians did not correctly interpret all confounding factors. [ABSTRACT FROM AUTHOR]

The authors, the publisher regret that the following mentions were missing from the original publication of these Guidelines, apologise for any inconvenience caused. SFAR: Sylvain Ausset, Ecole du Val-de-Grâce, Hôpital d'instruction des armées Percy, 1 rue du Lieutenant Raoul Batany, 92190 Clamart, France Jean-Paul Beregi (SFR), Jacques Bessereau (SFMU), Xavier Bobbia (SFMU), Julien Brun (SFAR), Élodie Brunel (SFAR), Clément Buléon (SFAR), Jacques Choukroun (SFMU), Xavier Combes (SFMU), Jean Stéphane David (SFAR), François-Régis Desfemmes (AFU-SSA), Delphine Garrigue (SFMU), Jean Luc Hanouz (SFAR), Eric Kipnis (SFAR), Isabelle Plénier (SFCD), Frédéric Rongieras (SOFCOT-SSA), Benoît Vivien (SFMU). [Extracted from the article]

During labour, the effects of adding a programmed intermittent epidural bolus (PIEB) baseline analgesic regimen to patient-controlled epidural analgesia (PCEA) remain uncertain. This single centre prospective double-blinded controlled study randomised nulliparous women over 35 weeks of gestational age in a PCEA + PIEB or PCEA only group. After an epidural analgesia catheter was inserted, a specific pump administered a solution of levobupivacaine 0.625 mg mL−1, sufentanil 0.25 µg mL−1, and clonidine 0.375 µg mL−1. In both groups the PCEA mode delivered an 8 mL bolus with a lockout period of 8 min. In the PCEA + PIEB group, women also received a programmed 8 mL bolus every 60 min. Additional bolus were allowed if required. The primary outcome was the hourly consumption of levobupivacaine from epidural catheter placement to new-born delivery. Secondary outcome were motor block, oxytocin use, sufentanil consumption, additional bolus required, instrumental vaginal delivery, unplanned caesarean section, pain during labour and women's satisfaction. Analysis included 162 and 155 women in the PCEA and PCEA + PIEB groups, respectively. The median [IQR] hourly consumption of levobupivacaine was significantly lower in the PCEA group (9.9 (7.8–12.4] mg h−1) as compared to the PCEA + PIEB group (11.2 [7.9–14.3] mg h−1; p = 0.046). The difference between medians was 1.3 mg h−1 95 % CI (0.1–2.9). There was no difference between groups for secondary outcomes. PCEA only modestly decreased the hourly consumption of local anaesthetic as compared to PCEA + PIEB but the difference was not clinically relevant. [ABSTRACT FROM AUTHOR]

Nous rapportons 2 cas survenus en 2016 au CHU de Caen où la fiabilité de l’épreuve globulaire de compatibilité (EGC), « dernier verrou de l’incompatibilité ABO » a été en défaut : cas 1 : à la suite de la transfusion au bloc des urgences de 14 concentrés de globules rouges O, 12 plasmas AB et 3 concentrés de plaquettes, en moins de 4 heures en contexte d’urgence vitale, à un patient polytraumatisé A–, l’EGC réalisée avant la pose du 13 e CGR, isogroupe a abouti à constater une situation d’incompatibilité (CGR A/patient O). Après concertation entre le prescripteur et l’EFS, le CGR A a finalement été transfusé en référence au carton de l’EGC du 1 er CGR administré où le patient était clairement identifié de groupe A ; cas 2 :au cours d’une hospitalisation hors-hématologie d’une patiente B+, présentant une hémopathie en rechute après allogreffe, l’EGC a conduit à la lecture d’un groupe O pour la patiente et B pour le CGR. Après concertation entre les correspondants d’hémovigilance EFS et CHU, le CGR B a été retourné à l’EFS et un CGR O délivré, même si cette lecture était la conséquence évidente de la transfusion, vérifiée à l’EFS de CGR exclusivement O (20) au cours des 5 mois précédents. Discussion et conclusion Si l’analyse de ces situations conduit tout d’abord à éviter de les provoquer, notamment en optimisant le circuit d’acheminement des tests pré-transfusionnels, la communication avec l’EFS et en privilégiant la transfusion de CGR isogroupes aux patients régulièrement transfusés, les règles d’interprétation de l’EGC doivent rester claires et univoques à l’égard de tous les médecins et infirmiers. Ainsi, en contexte d’urgence transfusionnelle, la conservation du carton de l’épreuve globulaire de compatibilité du 1 er CGR administré permet de continuer à confronter le groupe des CGR à transfuser au groupe du patient, et non pas à celui des hématies circulantes chez le patient, et de lui restituer toute sa pertinence et sa valeur de sécurité transfusionnelle. [ABSTRACT FROM AUTHOR]