Search

Introduction In elderly patients, goal-directed haemodynamic therapy (GDHT), depth of anaesthesia monitoring and lung-protective ventilation have been shown to improve postoperative outcomes. The aim of this study was to evaluate current practices concerning strategies of anaesthesia optimisation in patients aged ≥ 75 years. Patients and methods A multicentre observational study was performed from February to May 2015 in 23 French academic centres. On 30 consecutive days in each centre, patients ≥ 75 years with at least one major comorbidity undergoing elective or emergency procedures (femoral-neck fractures surgery, intraperitoneal abdominal surgery or vascular surgery) were included. Patient characteristics and data related to GHDT, management of hypotension, monitoring of temperature and depth of anaesthesia, lung ventilation, point of care haemoglobin testing were collected. Results In total, 807 patients were included. Only 2% of patients [95% CI: 1–3] received GHDT in full accordance with guidelines. Depth of anaesthesia monitoring was largely performed (53% [95% CI: 50–56]). The multifaceted strategy of lung-protective ventilation combining low tidal volumes (6–8 mL/kg), PEEP of 5–8 cm cmH2O, and repeated recruitment manoeuvres, was performed in only 4% [95% CI: 3–5] of patients. A centre effect was a major determinant of variation concerning implementation of these strategies. Discussion In patients’ ≥ 75 years, strategies of anaesthesia optimisation are not in accordance with eligible guidelines. Implementation of these techniques varies independently of factors related to the patient or the type of surgery and may be dependent on the generated constraints.

Resume Objectifs Identifier les facteurs lies a la survenue d’une acidose neonatale severe en cas de cesarienne programmee. Methodes Etude cas-temoins, menee entre 1997 et 2016 chez des femmes a terme ayant eu une cesarienne programmee sous rachianesthesie. Les cas etaient les femmes dont le nouveau-ne avait un pH arteriel neonatal Resultats Parmi les 5014 cesariennes programmees de la periode d’etude, 38 acidoses neonatales severes ont ete observees (incidence de 0,76 % IC95 [0,54–1,04]). Comparees a 72 temoins, les 36 cesariennes avec acidose neonatale severe etaient associees a une obesite maternelle plus frequente (IMC ≥ 30 kg/m2), a des doses d’ephedrine plus elevees, a des delais incision-naissance plus longs et a davantage de difficultes d’extraction. Apres regression logistique, seule l’obesite maternelle restait associee a une elevation significative du risque d’acidose neonatale severe, ORa = 3,73, IC 95 % (1,11–12,56). Conclusions En cas de cesarienne programmee, le principal facteur lie a la survenue d’une acidose neonatale severe est l’existence d’une obesite maternelle.

Solitary fibrous tumors (SFTs) of the spine are exceedingly rare tumors of mesenchymal origin. Most spinal SFTs arise from the thoracic spine, followed by cervical spine, and last lumbar spine with only 6 cases reported in literature. SFTs represent a wide range of neoplasms, ranging from benign to malignant. These tumors can develop a late recurrence, even after a decade or more of initial presentation, requiring long-term follow-up. We present a case of recurrent SFT of the lumbar spine with vertebral body involvement, presenting more than a decade after initial resection. It was initially misdiagnosed as a paraganglioma. To the best of our knowledge, there have been only 3 previous cases reporting SFT with vertebral body involvement.

Background In 2008, in France, 222 patients died because they did not receive the graft they expected. The main objective of this study was to determine the attitude of private practice physicians concerning organ donation. Methods A postal questionnaire was sent to all private practice office-based physicians in the Nord-Pas de Calais region. This questionnaire was elaborated with a panel of physicians and sociologists. It was sent with the monthly journal of the regional union of private physicians of June 2008. Results Two hundred and seventy eight questionnaires were returned. One hundred and thirty four (48.2%) respondents declared they knew what the regulations about organ donation were. The majority of respondents approved organ donation. Information to patients was provided during visits by 34.53% (96) of practitioners. For those who were knowledgeable about regulations, 50.75% of them talked about organ donation. Physicians who had already had experience with organ donation were more inclined to talk about it with other patients. The practitioners described three actions they felt could have a positive influence on family acceptance: providing information before death, talking about organ donation in an appropriate sensitive way, and relying on the confidence established by a solid patient-physician relationship. Conclusion Almost 90% of private physicians who responded to the survey were in favor of organ donation but only 34.5% delivered information and discussed the issue with their patients. The physicians coped with the topics more easily when they had experienced cases and when they were informed about existing regulations. A specific educational program on the current regulations and how to interact with patients on this subject during a visit could be a first answer to the problem and would be welcomed by practitioners.

To assess the difficulty in both laryngoscopy and tracheal intubation related to goitre and to identify factors predictive of difficult intubation due to this condition.Prospective observational.We used the Intubation Difficulty Scale (IDS) in 80 consecutive patients with large goitre (defined by the inability to palpate the cricoid cartilage, the presence of endothoracic goitre, tracheal deviation of more than 1cm or tracheal stenosis on the chest x-ray) and 77 control patients.Cormack grades 3-4 were more frequent at initial laryngoscopy in patients with goitre (23/80 vs. 9/77; p0.05), but the difference was no longer significant after application of an external laryngeal pressure (8/80 vs. 5/77). IDS scores (median [25th-75th percentiles]) were higher in the goitre group (1 [0 - 4]) than in the control group (0 [0 - 1]; p=0.001), corresponding to an increase in slightly difficult intubation (IDS 1-5: 36/80 vs. 15/77; p0.05). However, incidence of moderate to major difficulty in intubation (IDS5: 8/80 vs. 7/77) as well as time to completion of intubation were similar in both groups. Tracheal stenosis (or =30%) and reduced mouth opening (4.4cm) were the only significant predictors of increased difficulty in intubation in patients with a goitre.Large goitres are usually associated with slight difficulty in intubation only. Increased difficulty should be expected when severe tracheal stenosis is present on chest x-ray, especially when associated with a reduced mouth opening.

Resume La noradrenaline est le medicament recommande en premiere intention dans les consensus nationaux et internationaux pour le traitement hemodynamique du choc septique, parallelement au remplissage vasculaire. Cependant, aucune recommandation n’encadre le sevrage en noradrenaline qui suit necessairement cette prise en charge hemodynamique. Or, les proprietes pharmacodynamiques justifiant l’utilisation de la noradrenaline au cours du choc septique, a savoir vasoconstriction veineuse et arterielle, permettent de « normaliser » rapidement l’hemodynamique macrocirculatoire au prix potentiel d’une malperfusion regionale et/ou microcirculatoire, d’autant plus que le remplissage n’aura pas ete optimise. Le sevrage en noradrenaline, qui « relâche » la contrainte exercee sur la circulation veineuse, constitue donc une etape pendant laquelle tout defaut de remplissage initial ou secondaire peut se reveler. Les rares etudes disponibles sur le sujet montrent que le mode de sevrage habituel en noradrenaline est arbitraire et prolonge inutilement son utilisation potentiellement deletere. Le sevrage en noradrenaline pourrait se concevoir comme une epreuve fonctionnelle hemodynamique au cours de laquelle serait evaluee la precharge-dependance, demasquant un eventuel besoin en remplissage permettant de poursuivre et accelerer le sevrage ou, au contraire, un etat de « noradrenaline dependance » a respecter mais a reevaluer regulierement. De telles epreuves de sevrage pourraient etre envisagees precocement dans la prise en charge hemodynamique du choc septique, lors de toute stabilisation hemodynamique apparente, afin de prevenir ou eviter d’aggraver des troubles de perfusion regionales et microcirculatoires. Ainsi, l’enjeu du sevrage de la noradrenaline pourrait prendre une nouvelle dimension et meriter plus d’attention.

The aim of this study was to verify whether a relationship exists between neuroleptic malignant syndrome (NMS) and anaesthetic-induced malignant hyperthermia (MH) or not. The in vitro halothane-caffeine tests were performed on muscle tissue obtained from 32 patients with documented NMS episodes. The diagnosis of NMS relied on Levenson's criteria. The results, expressed in accordance with the criteria of the European MH Group, defined 29 subjects as MH non-susceptible. Three patients were classified as MH equivocal. These findings demonstrate the lack of any link between NMS and MH. Therefore, patients with a history of NMS are not likely to be at risk of developing MH and special measures against MH are not required for anaesthesia in these patients.

Sepsis syndrome and the systemic inflammatory response syndrome (SIRS) are characterized by a diffuse, ineffective tissue and cellular utilization of oxygen, and hemodynamic collapse with peripheral vasodilation and myocardial depression. Although the mechanisms responsible for sepsis-induced myocardial depression remain debatable, various investigators have focused during recent years on the influence of sepsis on myocardial function. Clinical and experimental studies that have attempted to assess cardiac function indicate the presence of true, intrinsic myocardial depression, independent of changes in load or heart rate.

Diabetes mellitus (DM) is a common problem in anaesthetic practice since over two per cent of surgical patients are concerned. One fourth are insulin-dependent (IDDM) and three fourth non insulin dependent diabetes (NIDDM), according to a large French anaesthetics survey [1]. This frequency is strongly increasing [2]. During a long period, the anaesthetic management has been focused on the glycaemic control, and several regimens have been proposed to obtain a tight perioperative control of glycaemia, even if this necessity remains unproved [3]. Progress in insulins, bedside monitoring of glycaemia and constant infusion techniques have pushed into the background the risks due to glycaemic impairments during the operative period [2].