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Different characteristics of bars (cross-sectional shape, diameter, distal extension etc.) lead to different biomechanical behavior (retention and stress) with implants and peri-implant tissues.Aim: To evaluate the impact of implant-supported removable prostheses bar designs in fully edentulous arch (in the maxilla and/or mandibula), with 4 implants or more, on the peri-implant soft and hard tissues.Two reviewers searched for observational studies, RCT and in vitro studies, published on five main databases and three from the grey literature, without restrictions on November 2023.Of the 3049 selected articles, four met the inclusion criteria. Four RCT evaluated peri-implant health tissues in full edentulous arches with 4 or 6 implants rehabilitated with implant bar overdentures. One prospective study with 5 years follow-up evaluated the success/survival rate of implants and implant bar overdentures. Overall, 261 subjects were enrolled in our systematic review with 1176 implants. Overdentures' survival rate was 100%. There was a trend that plaque indices and gingival indices were low in all of the studies, however no statistical analysis was done due to the lack of information.Due to the lack of information in the included studies, we cannot confirm if bar characteristics affect the peri-implant tissues health., (© 2024. The Author(s).)

Introduction: Intraoperative monitoring of nociception has made great progress in adult anesthesia. However, pediatric data are scarce. The Nociception Level (NOL) is one of the most recent indexes of nociception. Its originality is that it provides a multiparametric assessment of nociception. In adults, NOL monitoring allowed lower perioperative opioid requirements, hemodynamic stability, and qualitative postoperative analgesia. So far, the NOL has never been used in children. Our objective was to validate the ability of NOL to provide a quantitative assessment of nociception in anesthetized children., Methods: In 5-12 years old children anesthetized with sevoflurane and alfentanil (10 µg kg -1 ), before surgical incision, we performed three standardized tetanic stimulations (5 s, 100 Hz) of different intensities (10-30-60 mA) in a randomized order. NOL, heart rate, blood pressure and Analgesia-Nociception Index variations were assessed after each stimulation., Results: Thirty children were included. Data were analyzed with a covariance pattern linear mixed regression model. NOL increased after the stimulations (p < 0.05 at each intensity). NOL response was influenced by stimulation intensity (p < 0.001). Heart rate and blood pressure were barely modified by the stimulations. Analgesia-Nociception Index decreased after the stimulations (p < 0.001 at each intensity). Analgesia-Nociception index response was not influenced by stimulation intensity (p = 0.064). NOL and Analgesia-Nociception Index responses were significantly correlated (Pearson r = 0.47; p < 0.001)., Conclusions: NOL allows a quantitative assessment of nociception under anesthesia in 5-12 years-old children. This study provides a solid basis for all future investigations on NOL monitoring in pediatric anesthesia., Registration: NCT05233449., (Copyright © 2023 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Importance: General anesthesia and procedural sedation are common practice for mechanical thrombectomy in acute ischemic stroke. However, risks and benefits of each strategy are unclear., Objective: To determine whether general anesthesia or procedural sedation for anterior circulation large-vessel occlusion acute ischemic stroke thrombectomy are associated with a difference in periprocedural complications and 3-month functional outcome., Design, Setting, and Participants: This open-label, blinded end point randomized clinical trial was conducted between August 2017 and February 2020, with final follow-up in May 2020, at 10 centers in France. Adults with occlusion of the intracranial internal carotid artery and/or the proximal middle cerebral artery treated with thrombectomy were enrolled., Interventions: Patients were assigned to receive general anesthesia with tracheal intubation (n = 135) or procedural sedation (n = 138)., Main Outcomes and Measures: The prespecified primary composite outcome was functional independence (a score of 0 to 2 on the modified Rankin Scale, which ranges from 0 [no neurologic disability] to 6 [death]) at 90 days and absence of major periprocedural complications (procedure-related serious adverse events, pneumonia, myocardial infarction, cardiogenic acute pulmonary edema, or malignant stroke) at 7 days., Results: Among 273 patients evaluable for the primary outcome in the modified intention-to-treat population, 142 (52.0%) were women, and the mean (SD) age was 71.6 (13.8) years. The primary outcome occurred in 38 of 135 patients (28.2%) assigned to general anesthesia and in 50 of 138 patients (36.2%) assigned to procedural sedation (absolute difference, 8.1 percentage points; 95% CI, -2.3 to 19.1; P = .15). At 90 days, the rate of patients achieving functional independence was 33.3% (45 of 135) with general anesthesia and 39.1% (54 of 138) with procedural sedation (relative risk, 1.18; 95% CI, 0.86-1.61; P = .32). The rate of patients without major periprocedural complications at 7 days was 65.9% (89 of 135) with general anesthesia and 67.4% (93 of 138) with procedural sedation (relative risk, 1.02; 95% CI, 0.86-1.21; P = .80)., Conclusions and Relevance: In patients treated with mechanical thrombectomy for anterior circulation acute ischemic stroke, general anesthesia and procedural sedation were associated with similar rates of functional independence and major periprocedural complications., Trial Registration: ClinicalTrials.gov Identifier: NCT03229148.

Importance: Delayed admission of patients with surgical emergencies to the operating room occurs frequently and is associated with poor outcomes. In France, where 3 distinct organizational pathways in hospitals exist (a dedicated emergency operating room and team [DET], a dedicated operating room in a central operating theater [DOR], and no dedicated structure or team [NOR]), neither the incidence nor the influence of delayed urgent surgery is known, and no guidelines are available to date., Objective: To examine the overall frequency of delayed admission of patients with surgical emergencies to the operating room across the 3 organizational pathways in hospitals in France., Design, Setting, and Participants: This prospective multicenter cohort study was conducted in 10 French tertiary hospitals. All consecutive adult patients admitted for emergency surgery from October 5 to 16, 2020, were included and prospectively monitored. Patients requiring pediatric surgery, obstetrics, interventional radiology, or endoscopic procedures were excluded., Exposures: Emergency surgery., Main Outcomes and Measures: The main outcome was the global incidence of delayed emergency surgery across 3 predefined organizational pathways: DET, DOR, and NOR. The ratio between the actual time to surgery (observed duration between surgical indication and incision) and the ideal time to surgery (predefined optimal duration between surgical indication and incision according to the Non-Elective Surgery Triage classification) was calculated for each patient. Surgery was considered delayed when this ratio was greater than 1., Results: A total of 1149 patients were included (mean [SD] age, 55 [21] years; 685 [59.9%] males): 649 in the DET group, 320 in the DOR group, and 171 in the NOR group (missing data: n = 5). The global frequency of surgical delay was 32.5% (95% CI, 29.8%-35.3%) and varied across the 3 organizational pathways: DET, 28.4% (95% CI, 24.8%-31.9%); DOR, 32.2% (95% CI, 27.0%-37.4%); and NOR, 49.1% (95% CI, 41.6%-56.7%) (P < .001). The adjusted odds ratio for delay was 1.80 (95% CI, 1.17-2.78) when comparing NOR with DET., Conclusions and Relevance: In this cohort study, the frequency of delayed emergency surgery in France was 32.5%. Reduced delays were found in organizational pathways that included dedicated theaters and teams. These preliminary results may pave the way for comprehensive large-scale studies, from which results may potentially inform new guidelines for quicker and safer access to emergency surgery.

This paper describes the development and implementation of an anesthesia data warehouse in the Lille University Hospital. We share the lessons learned from a ten-year project and provide guidance for the implementation of such a project. Our clinical data warehouse is mainly fed with data collected by the anesthesia information management system and hospital discharge reports. The data warehouse stores historical and accurate data with an accuracy level of the day for administrative data, and of the second for monitoring data. Datamarts complete the architecture and provide secondary computed data and indicators, in order to execute queries faster and easily. Between 2010 and 2021, 636 784 anesthesia records were integrated for 353 152 patients. We reported the main concerns and barriers during the development of this project and we provided 8 tips to handle them. We have implemented our data warehouse into the OMOP common data model as a complementary downstream data model. The next step of the project will be to disseminate the use of the OMOP data model for anesthesia and critical care, and drive the trend towards federated learning to enhance collaborations and multicenter studies., (© 2022. The Author(s).)

Purpose: Individuals in late pregnancy are at risk of significant hemodynamic variations, especially during Cesarean delivery. Although non-invasive monitoring might enable the early detection of variations in cardiac output (CO), clinical validation is lacking., Methods: In a prospective, single-center study, we measured CO simultaneously with finger plethysmography and transthoracic echocardiography in 100 third-trimester pregnant individuals in the supine and left lateral decubitus (LLD) positions., Results: A Bland-Altman analysis revealed a mean (standard deviation) bias of 1.36 (1.04) L·min -1 in the supine position (95% limits of agreement, -0.68 to 3.4 L·min -1 ; percent error, 26.6%), indicating overestimation by finger plethysmography. The intra-class correlation coefficient was 0.43 (95% confidence interval [CI], 0.33 to 0.51). Regarding the changes in CO induced by the supine-to-LLD transition, the concordance rate in a four-quadrant plot was 98.3% (95% CI, 91.1 to 99.9%)., Conclusion: Our study showed a poor reliability of finger plethysmography for static measurement of CO. Nevertheless, finger plethysmography had a reasonably high concordance rate for the detection of CO changes secondary to positional changes in late-pregnant individuals. STUDY REGISTRATION DATE: www., Clinicaltrials: gov (NCT03735043); registered 8 November 2018., (© 2022. Canadian Anesthesiologists' Society.)

Background: Hypotension and blood pressure (BP) variability during endovascular therapy (EVT) for acute ischemic stroke (AIS) due to an anterior large vessel occlusion (LVO) is associated with worse outcomes. However, the optimal BP threshold during EVT is still unknown given the lack of randomized controlled evidence. We designed the DETERMINE trial to assess whether an individualized BP management during EVT could achieve better functional outcomes compared to a standard BP management., Methods: The DETERMINE trial is a multicenter, prospective, randomized, controlled, open-label, blinded endpoint clinical trial (PROBE design). AIS patients with a proximal anterior LVO are randomly assigned, in a 1:1 ratio, to an experimental arm in which mean arterial pressure (MAP) is maintained within 10% of the first MAP measured before EVT, or a control arm in which systolic BP (SBP) is maintained within 140-180 mm Hg until reperfusion is achieved or artery closure in case of EVT failure. The primary outcome is the rate of favorable functional outcomes, defined by a modified Rankin Scale (mRS) between 0 and 2 at 90 days. Secondary outcomes include excellent outcome and ordinal analysis of the mRS at 90 days, early neurological improvement at 24 h (National Institutes of Health Stroke Scale), final infarct volume, symptomatic intracranial hemorrhage rates, and all-cause mortality at 90 days. Overall, 432 patients will be included., Discussion: DETERMINE will assess the clinical relevance of an individualized BP management before reperfusion compared to the one size fits all approach currently recommended by international guidelines., Trial Registration: ClinicalTrials.gov , NCT04352296. Registered on 20th April 2020., (© 2022. The Author(s).)

Introduction: Intraoperative monitoring of nociception has recently made substantial progress in adult anesthesia. In contrast, pediatric data are scarce. Newborn-Infant Parasympathetic Evaluation (NIPE index, Mdoloris Medical Systems, Loos, France) is the first nociception index specifically designed for young children. It is a dimensionless index comprised between 0 and 100. Two previous studies suggested that NIPE could indeed 'detect' nociception in anesthetized children. The objective of our study was to investigate if NIPE allowed to detect and to provide a quantitative assessment of nociception in children., Methods: Children were anesthetized with sevoflurane, and received a bolus of alfentanil (10 µg/kg before intubation). Before surgical incision, each participant received three tetanic stimulations (5 s, 100 Hertz) with a 5 min interval, in a randomized order: 10, 30 and 60 milliamps. NIPE and heart rate variations were assessed after each stimulation., Results: Thirty children (2.4±1.6 years) were included. Mean delay between alfentanil and the first stimulation was 19±4 min. Mean baseline NIPE was 75±10. NIPE variation after the stimulations was significant at 10, 30 and 60 mA (linear mixed regression model, p<0.001). The intensity of stimulation significantly influenced the amplitude of NIPE variation (linear mixed regression model p<0.001), but had no statistically significant effect on heart rate variation (p=0.52)., Discussion: NIPE might allow a quantitative assessment of nociception in young children in these anesthetic conditions. This study provides a basis for future research investigating the potential benefits of NIPE-guided intraoperative analgesia in pediatric anesthesia., Trial Registration Number: NCT04381637., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Orthognathic surgery can cause substantial bleeding. Recent meta-analyses concluded that there is a statistically significant reduction in perioperative blood loss with the preventive use of tranexamic acid (TA). However, the mean reported difference in bleeding was moderate, and the clinical relevance of this blood-sparing effect remains debated. We therefore conducted a prospective, double-blind, randomized, placebo-controlled equivalence study of the effect of TA in patients undergoing Lefort I or bimaxillary osteotomies. Our main outcome measure was total blood loss on postoperative day 1. The equivalence margin was ± 250 ml for the difference in blood loss and its 95% confidence interval. One hundred and forty-seven patients were randomized, of which 122 underwent bimaxillary osteotomies. Blood loss in the treatment group was 682 ± 323 vs. 875 ± 492 ml. The mean difference in bleeding was -132 [-243; -21] ml as per-protocol, but -193 [-329; -57] ml in intention-to-treat: the limits of this confidence interval exceeded the margin of equivalence. Similar results were obtained when analysing only patients undergoing bimaxillary osteotomy. Haemoglobin decreased by 1.8 ± 1.2 g/dl with TA, vs. 2.6 ± 1.1 g/dl with placebo (p<0.001). Our study did not demonstrate equivalence between TA and placebo on perioperative blood loss in orthognathic surgery. TA may reduce blood loss but without evidence of clinical consequences., (Copyright © 2021 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Perioperative hypersensitivity reactions may be difficult to diagnose during general anesthesia. Postinduction hypotension is the most common sign but is not specific. It was recently suggested that low end-tidal carbon dioxide (ETco2) might be a marker of anaphylaxis (Ring and Messmer grades III to IV immediate hypersensitivity reactions) in hypotensive patients under mechanical ventilation. To test this hypothesis, the authors compared ETco2 in patients with a diagnosis of anaphylaxis and in patients with severe hypotension from any other cause after the induction of anesthesia., Methods: This was a retrospective single-center case-control study in which two groups were formed from an anesthesia data warehouse. The anaphylaxis group was formed on the basis of tryptase/histamine assay data and allergy workup data recorded over the period 2010 to 2018. The control (hypotension) group consisted of all patients having experienced severe hypotension (mean arterial pressure less than 50 mmHg for 5 min or longer) with a cause other than anaphylaxis after anesthesia induction in 2017., Results: The anaphylaxis and hypotension groups comprised 49 patients (grade III: n = 38; grade IV: n = 11) and 555 patients, respectively. The minimum ETco2 value was significantly lower in the anaphylaxis group (median [interquartile range]: 17 [12 to 23] mmHg) than in the hypotension group (32 [29 to 34] mmHg; P < 0.001). The area under the receiver operating characteristic curve (95% CI) for ETco2 was 0.95 (0.91 to 0.99). The sensitivity and specificity (95% CI) for the optimal cutoff value were 0.92 (0.82 to 0.98) and 0.94 (0.92 to 0.99), respectively. In multivariable analysis, minimum ETco2 was associated with anaphylaxis after adjusting for confounders and competing predictors, including arterial pressure, heart rate, and peak airway pressure (odds ratio [95% CI] for ETco2: 0.51 [0.38 to 0.68]; P < 0.001)., Conclusions: In case of severe hypotension after anesthesia induction, a low ETco2 contributes to the diagnosis of anaphylaxis, in addition to the classical signs of perioperative immediate hypersensitivity., (Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved.)

The ANI is a nociception monitor based on the high frequency parts of heart rate variability. Tracheal intubation may induce potentially deleterious hemodynamic disturbances or motor reactions if analgesia is inadequate. We investigated whether ANI modification generated by a standardized moderate short tetanic stimulation performed before laryngoscopy could predict hemodynamic or somatic reactions to subsequent intubation. We designed a prospective, interventional, monocentric, pilot study. Regional ethics board approved the study, written informed consent was obtained from each participant. Before laryngoscopy, under steady-state total intravenous anaesthesia with propofol and remifentanil, the ulnar nerve was stimulated with a 5 s tetanus (70 mA, 50 Hz). After another steady-state period, orotracheal intubation was performed. ANI variation, hemodynamic parameters and somatic reactions associated with tetanus and intubation were collected. To assess the predictability of hemodynamic or somatic reaction during laryngoscopy by tetanus-induced ANI variation, we calculated the area under the corresponding Receiver Operating Characteristic curve (AUCROC) and the 95% confidence intervals. Thirty-five patients were analyzed. ANI decreased by 21 ± 17 after tetanus. Regarding the ability of tetanus-induced ANI variation to predict hemodynamic or somatic reactions during subsequent intubation, the AUCROCs [95% CI] were 0.61 [0.41-0.81] and 0.52 [0.31-0.72] respectively. ANI varied after a short moderate tetanic stimulation performed before laryngoscopy but this variation was not predictive of a hemodynamic or somatic reaction during intubation.Trial registration NCT04354311, April 20th 2020, retrospectively registered., (© 2021. Springer Nature B.V.)

Background: Electronic health records (EHRs, such as those created by an anesthesia management system) generate a large amount of data that can notably be reused for clinical audits and scientific research. The sharing of these data and tools is generally affected by the lack of system interoperability. To overcome these issues, Observational Health Data Sciences and Informatics (OHDSI) developed the Observational Medical Outcomes Partnership (OMOP) common data model (CDM) to standardize EHR data and promote large-scale observational and longitudinal research. Anesthesia data have not previously been mapped into the OMOP CDM., Objective: The primary objective was to transform anesthesia data into the OMOP CDM. The secondary objective was to provide vocabularies, queries, and dashboards that might promote the exploitation and sharing of anesthesia data through the CDM., Methods: Using our local anesthesia data warehouse, a group of 5 experts from 5 different medical centers identified local concepts related to anesthesia. The concepts were then matched with standard concepts in the OHDSI vocabularies. We performed structural mapping between the design of our local anesthesia data warehouse and the OMOP CDM tables and fields. To validate the implementation of anesthesia data into the OMOP CDM, we developed a set of queries and dashboards., Results: We identified 522 concepts related to anesthesia care. They were classified as demographics, units, measurements, operating room steps, drugs, periods of interest, and features. After semantic mapping, 353 (67.7%) of these anesthesia concepts were mapped to OHDSI concepts. Further, 169 (32.3%) concepts related to periods and features were added to the OHDSI vocabularies. Then, 8 OMOP CDM tables were implemented with anesthesia data and 2 new tables (EPISODE and FEATURE) were added to store secondarily computed data. We integrated data from 5,72,609 operations and provided the code for a set of 8 queries and 4 dashboards related to anesthesia care., Conclusions: Generic data concerning demographics, drugs, units, measurements, and operating room steps were already available in OHDSI vocabularies. However, most of the intraoperative concepts (the duration of specific steps, an episode of hypotension, etc) were not present in OHDSI vocabularies. The OMOP mapping provided here enables anesthesia data reuse., (©Antoine Lamer, Osama Abou-Arab, Alexandre Bourgeois, Adrien Parrot, Benjamin Popoff, Jean-Baptiste Beuscart, Benoît Tavernier, Mouhamed Djahoum Moussa. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 29.10.2021.)

Background: The Pupillary Pain Index is a recent pupillometric index designed to assess the level of analgesia under general anesthesia in children and adults. If analgesia is inadequate, acute nociceptive stimuli such as skin incision may induce significant hemodynamic disturbances., Aims: Our aim was to investigate the potential relationship between pre-incision Pupillary Pain Index and heart rate increase following skin incision in children., Methods: This was a prospective, non-randomized, registered pilot study. We included children undergoing surgery under general anesthesia. Pupillary Pain Index was assessed 2 min before skin incision. Then, heart rate maximal variation (Δ HR ) and pupillary diameter maximal variation (Δ PD ) in the minute following incision were recorded. Spearman coefficient was calculated to characterize the relationship between Pupillary Pain Index and Δ HR or Δ PD . Using receiver operating characteristic curve analysis, we also studied the predictive value of pre-incision Pupillary Pain Index for heart rate and pupillary diameter reactivity., Results: 53 patients were included (10 ± 4 years, 40 ± 19 kg). There was a modest correlation between pre-incision Pupillary Pain Index and Δ HR (Spearman rs = 0.35 [0.05-0.57], p = .011), and between pre-incision Pupillary Pain Index and Δ PD (Spearman rs = 0.54 [0.33-0.71], p < .001). Regarding the predictive value of Pupillary Pain Index for heart rate or pupillary diameter reactivity, the corresponding areas under the receiver operating characteristic curves were 0.90 [0.82-0.99] and 0.78 [0.65-0.93], respectively. A threshold of Pupillary Pain Index <3 predicted the absence of heart rate reactivity at incision with a good performance (negative predictive value = 1)., Conclusions: In children, pre-incision Pupillary Pain Index was moderately correlated with post-incision nociception. Pre-incision Pupillary Pain Index had good predictive performances for heart rate or pupillary diameter reactivity to skin incision. Pre-incision Pupillary Pain Index <3 might predict the absence of heart rate reaction to incision., (© 2021 John Wiley & Sons Ltd.)

Background: Postoperative pain in spine surgery is an issue. Erector spinae plane block (ESPB) may reduce such postoperative pain, but its usefulness has never been evaluated in the specific context of trauma surgery. We thus studied the effect of bilateral ultrasound-guided ESPB on postoperative pain and opioid requirement after percutaneous lumbar arthrodesis for trauma., Methods: All patients who underwent percutaneous lumbar arthrodesis for spine trauma between December 2019 and March 2020 were retrospectively studied. Some patients received preoperative bilateral ESPB (30 mL of 0.375% ropivacaine on each side; ESPB group), others received the standard of care (i.e., postoperative muscular infiltration with 30 mL of 0.75% of ropivacaine; control group), according to the preference of the anesthesiologist in charge of the patient. The rest of the management was identical in all patients. The primary outcome was the cumulative morphine consumption at 24 hours postoperatively. Secondary outcomes included pain score at various time points until 24 hours., Results: Fifty-five patients were included, of whom 24 received an EPSB and 31 received the standard of care. The cumulative morphine consumption (mean [standard deviation]) at 24 hours was 13 (12) mg in the ESPB group, and 35 (17) mg in the control group (P < 0.001). Pain scores were significantly lower in the ESPB group compared with the control group up to 9 hours after surgery (P < 0.01)., Conclusions: In this pilot study, compared with standard analgesia, ESPB reduced opioid requirement and postoperative pain after percutaneous lumbar arthrodesis for trauma. A randomized controlled trial is required to prove this effectiveness., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Clinical dashboards summarize indicators of high-volume patient data in a concise, user-friendly visual format. There are few studies of the use of dashboards to improve professional practice in anesthesiology. The objective of the present study was to describe the user-centered development, implementation and preliminary evaluation of clinical dashboards dealing with anesthesia unit management and quality assessment in a French university medical center. User needs and technical requirements were identified in end user interviews and then synthesized. Several representations were then developed (according to good visualization practice) and submitted to end users for appraisal. Lastly, dashboards were implemented and made accessible for everyday use via the medical center's network. After a period of use, end user feedback on the dashboard platform was collected as a system usability score (range 0 to 100). Seventeen themes (corresponding to 29 questions and 42 indicators) were identified. After prioritization and feasibility assessment, 10 dashboards were ultimately implemented and deployed. The dashboards variously addressed the unit's overall activity, compliance with guidelines on intraoperative hemodynamics, ventilation and monitoring, and documentation of the anesthesia procedure. The mean (standard deviation) system usability score was 82.6 (11.5), which corresponded to excellent usability. We developed clinical dashboards for a university medical center's anesthesia units. The dashboards' deployment was well received by the center's anesthesiologists. The dashboards' impact on activity and practice after several months of use will now have to be assessed.

Despite a large body of evidence, the implementation of guidelines on hemodynamic optimization and goal-directed therapy remains limited in daily routine practice. To facilitate/accelerate this implementation, a panel of experts in the field proposes an approach based on six relevant questions/answers that are frequently mentioned by clinicians, using a critical appraisal of the literature and a modified Delphi process. The mean arterial pressure is a major determinant of organ perfusion, so that the authors unanimously recommend not to tolerate absolute values below 65 mmHg during surgery to reduce the risk of postoperative organ dysfunction. Despite well-identified limitations, the authors unanimously propose the use of dynamic indices to rationalize fluid therapy in a large number of patients undergoing non-cardiac surgery, pending the implementation of a "validity criteria checklist" before applying volume expansion. The authors recommend with a good agreement mini- or non-invasive stroke volume/cardiac output monitoring in moderate to high-risk surgical patients to optimize fluid therapy on an individual basis and avoid volume overload. The authors propose to use fluids and vasoconstrictors in combination to achieve optimal blood flow and maintain perfusion pressure above the thresholds considered at risk. Although purchase of disposable sensors and stand-alone monitors will result in additional costs, the authors unanimously acknowledge that there are data strongly suggesting this may be counterbalanced by a sustained reduction in postoperative morbidity and hospital lengths of stay. Beside existing guidelines, knowledge and explicit clinical reasoning tools followed by decision algorithms are mandatory to implement individualized hemodynamic optimization strategies and reduce postoperative morbidity and duration of hospital stay in high-risk surgical patients.

Background/objectives: The present study aimed at evaluating the impact on the early outcome of patients with ruptured intracranial aneurysms., Methods: Our study prospectively included 26 consecutive patients with ruptured intracranial aneurysm managed at our institution in context of COVID-19 pandemic between March 1st, 2020 and April, 26th, 2020 (2020 group). A group control included other 28 consecutive patients managed at the same institution for the same disease in 2019, during the same time frame (2019 group). On admission, poor neurological status was defined as WFNS score >3. Severe radiological status was defined by the presence of intracerebral hematoma, or/and acute hydrocephalus requiring further EVD or/and the presence of vasospasm on presentation. Statistical analysis was performed to compare the 2 distinct groups., Results: Rates of poor neurological presentation and severe radiological presentation on hospital admission were higher in the 2020 group (p = 0.01 and p = 0.02, respectively). The delayed hospital admission was 2.7 days in 2020 group and 0.75 days in 2019 group (p = 0.005). Therefore, vasospasm's rate on presentation was also higher in the 2020 group (p = 0.04)., Conclusion: To our knowledge, this is one of the first studies demonstrating influence of the COVID-19 pandemic on patients with urgent and severe intracranial aneurysmal disease. In case of recurrent COVID-19 pandemic, educating the population concerning specific symptoms such as sudden headache, neurological deficit or even sudden chest pain should be emphasized., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: To identify factors related to the occurrence of severe neonatal acidosis in case of planned caesarean section., Methods: Case-control study conducted between 1997 and 2016 among women with planned caesarean delivery at term. Cases were women whose neonates had neonatal arterial pH<7,0. For each case, two planned caesarean sections with neonatal pH≥7,0 were selected as controls. Women whose fetus had a congenital malformation and those whose anesthesia was not spinal anesthesia were excluded., Results: Among the 5014 planned cesarean sections of the study period, 38 severe neonatal acidosis were observed (incidence of 0,76% CI95 [0,54-1,04]). Compared to 72 controls, the 36 caesareans with severe neonatal acidosis were associated with more frequent maternal obesity (BMI≥30kg/m 2 ), higher ephedrine doses, longer time from skin incision to infant delivery, and more extraction difficulties. After logistic regression, only maternal obesity remained associated with a significant increase in the risk of severe neonatal acidosis, ORa=3,73, 95%CI (1,11-12,56)., Conclusions: In case of planned cesarean section, the main risk factor for severe neonatal acidosis is the existence of maternal obesity., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: The present trial was designed to assess whether individualized strategies of fluid administration using a noninvasive plethysmographic variability index could reduce the postoperative hospital length of stay and morbidity after intermediate-risk surgery., Methods: This was a multicenter, randomized, nonblinded parallel-group clinical trial conducted in five hospitals. Adult patients in sinus rhythm having elective orthopedic surgery (knee or hip arthroplasty) under general anesthesia were enrolled. Individualized hemodynamic management aimed to achieve a plethysmographic variability index under 13%, and the standard management strategy aimed to maintain a mean arterial pressure above 65 mmHg during general anesthesia. The primary outcome was the postoperative hospital length of stay decided by surgeons blinded to the group allocation of the patient., Results: In total, 447 patients were randomized, and 438 were included in the analysis. The mean hospital length of stay ± SD was 6 ± 3 days for the plethysmographic variability index group and 6 ± 3 days for the control group (adjusted difference, 0.0 days; 95% CI, -0.6 to 0.5; P = 0.860); the theoretical postoperative hospital length of stay was 4 ± 2 days for the plethysmographic variability index group and 4 ± 1 days for the control group (P = 0.238). In the plethysmographic variability index and control groups, serious postoperative cardiac complications occurred in 3 of 217 (1%) and 2 of 224 (1%) patients (P = 0.681), acute postoperative renal failure occurred in 9 (4%) and 8 (4%) patients (P = 0.808), the troponin Ic concentration was more than 0.06 μg/l within 5 days postoperatively for 6 (3%) and 5 (2%) patients (P = 0.768), and the postoperative arterial lactate measurements were 1.44 ± 1.01 and 1.43 ± 0.95 mmol/l (P = 0.974), respectively., Conclusions: Among intermediate-risk patients having orthopedic surgery with general anesthesia, fluid administration guided by the plethysmographic variability index did not shorten the duration of hospitalization or reduce complications.

Objectives: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic., Methods: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions., Results: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms., Conclusion: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context., (Copyright © 2020 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Background: Intraoperative use of hydroxyethyl starch (HES) may increase the risk of postoperative acute kidney injury (AKI). Data from large populations are lacking. We aimed to assess whether intraoperative administration of 6% HES 130/0.4 is associated with AKI in non-cardiac surgery., Methods: This retrospective study used the electronic records concerning elective abdominal, urologic, thoracic and peripheral vascular surgeries from 2010 to 2015. HES and non-HES patients were compared using a propensity score matching. Postoperative AKI, defined by stage 3 of the Kidney Disease Improving Global Outcomes (KDIGO) score, was the primary outcome. Because the use of HES markedly decreased in 2013, additional analyses, restricted to the 2010-2012 period, were also performed., Results: In total, 23,045, and 11,691 patients were included in the whole, and restricted periods, respectively. The reduction in HES use was not accompanied by any change in the incidence of AKI. Unadjusted association between HES and KDIGO 3 AKI was significant (OR [95% CI] of 2.13 [1.67, 2.71]). For the whole period, 6460 patients were matched. Odd ratios for KDIGO 3 and all-stage AKI when using HES (10.3±4.7mL.kg -1 ) were 1.20 (95% CI [0.74, 1.95]), and 1.21 (95% CI [0.95, 1.54]), respectively. There was no association with the initiation of renal replacement therapy or in-hospital mortality either. Similar results were found for the restricted period., Conclusion: The intraoperative use of moderate doses of 6% HES 130/0.4 was not associated with increased risk of AKI. No conclusion can be drawn for higher doses of HES., (Copyright © 2020 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Endovascular thrombectomy is the standard of care for anterior circulation acute ischaemic stroke (AIS) secondary to emergent large vessel occlusion in patients who qualify. General anaesthesia (GA) or conscious sedation (CS) is usually required to ensure patient comfort and avoid agitation and movement during thrombectomy. However, the question of whether the use of GA or CS might influence functional outcome remains debated. Indeed, conflicting results exist between observational studies with better outcomes associated with CS and small monocentric randomised controlled trials favouring GA. Therefore, we aim to evaluate the effect of CS versus GA on functional outcome and periprocedural complications in endovascular mechanical thrombectomy for anterior circulation AIS., Methods and Analysis: Anesthesia Management in Endovascular Therapy for Ischemic Stroke (AMETIS) trial is an investigator initiated, multicentre, prospective, randomised controlled, two-arm trial. AMETIS trial will randomise 270 patients with anterior circulation AIS in a 1:1 ratio, stratified by centre, National Institutes of Health Stroke Scale (≤15 or >15) and association of intravenous thrombolysis or not to receive either CS or GA. The primary outcome is a composite of functional independence at 3 months and absence of perioperative complication occurring by day 7 after endovascular therapy for anterior circulation AIS. Functional independence is defined as a modified Rankin Scale score of 0-2 by day 90. Perioperative complications are defined as intervention-associated arterial perforation or dissection, pneumonia or myocardial infarction or cardiogenic acute pulmonary oedema or malignant stroke evolution occurring by day 7., Ethics and Dissemination: The AMETIS trial was approved by an independent ethics committee. Study began in august 2017. Results will be published in an international peer-reviewed medical journal., Trial Registration Number: NCT03229148., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cutaneous mucormycoses, mainly due to Lichtheimia (Absidia), have occurred on several occasions in the Burn Unit of the University Hospital of Lille, France., Aim: To investigate the potential vector role of non-sterile bandages used to hold in place sterile gauze used for wound dressing., Methods: Mycological analysis by conventional culture, Mucorales real-time polymerase chain reaction (qPCR), and Lichtheimia species-specific qPCR were performed on eight crepe and six elasticized bandages that were sampled on two independent occasions in March 2014 and July 2016. Characteristics of the seven Lichtheimia mucormycoses which occurred in burn patients between November 2013 and July 2016 were also collected to assess the epidemiological relationship between potentially contaminated bandages and clinical infections., Findings: One Lichtheimia corymbifera strain was isolated from a crepe bandage by culture, and Lichtheimia spp. qPCR was positive in six out of eight crepe and four out of six elasticized bandages. Using species-specific qPCR, Lichtheimia ramosa, Lichtheimia ornata, and L. corymbifera were identified in six out of ten, five out of ten, and four out of ten bandages, respectively. In patients with mucormycosis, L. ramosa and L. ornata were present in five and two cases, respectively., Conclusion: Our data support the utility of Mucorales qPCR for epidemiological investigations, the potential role of these bandages in cutaneous mucormycoses in burn patients in our centre, and, consequently, the need for sterile bandages for the dressing of extensive wounds., (Copyright © 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Prosthetic treatment for elderly patients is a challenge that addresses both patient- and technology-mediated dental concerns. This report describes the fabrication of a cobalt-chromium crown without an impression using a digitized and scanned temporary crown to provide excellent integration.

This report describes an innovative technique to remove post-and-core restorations. The WAM'X Super Quick post removal device permits a secure mechanical traction technique that can adapt to variable root angulations. Pivoting prongs mounted on forceps allow post removal while preserving the ferrule effect to improve resistance to fractures.

Essentials An immediate supply of plasma in case of trauma-induced coagulopathy is required. The Traucc trial compared French Lyophilised Plasma (FLyP) and Fresh Frozen Plasma (FFP). FLyP achieved higher fibrinogen concentrations compared with FFP. FLyP led to a more rapid coagulopathy improvement than FFP., Summary: Background Guidelines recommend beginning hemostatic resuscitation immediately in trauma patients. We aimed to investigate if French lyophilized plasma (FLyP) was more effective than fresh frozen plasma (FFP) for the initial management of trauma-induced coagulopathy. Methods In an open-label, phase 3, randomized trial (NCT02750150), we enrolled adult trauma patients requiring an emergency pack of 4 plasma units within 6 h of injury. We randomly assigned patients to receive 4-FLyP units or 4-FFP units. The primary endpoint was fibrinogen concentration at 45 min after randomization. Secondary outcomes included time to transfusion, changes in hemostatic parameters at different time-points, blood product requirements and 30-day in-hospital mortality. Results Forty-eight patients were randomized (FLyP, n = 24; FFP, n = 24). FLyP reduced the time from randomization to transfusion of first plasma unit compared with FFP (median[IQR],14[5-30] vs. 77[64-90] min). FLyP achieved a higher fibrinogen concentration 45 min after randomization compared with FFP (baseline-adjusted mean difference, 0.29 g L -1 ; 95% confidence interval [CI], 0.08-0.49) and a greater improvement in prothrombin time ratio, factor V and factor II. The between-group differences in coagulation parameters remained significant at 6 h. FLyP reduced fibrinogen concentrate requirements. Thirty-day in-hospital mortality rate was 22% with FLyP and 29% with FFP. Conclusion FLyP led to a more rapid, pronounced and extended increase in fibrinogen concentrations and coagulopathy improvement compared with FFP in the initial management of trauma patients. FLyP represents an attractive option for trauma management, especially when facing logistical issues such as combat casualties or mass casualties related to terror attacks or disasters., (© 2017 International Society on Thrombosis and Haemostasis.)

Importance: Perioperative hypotension is associated with an increase in postoperative morbidity and mortality, but the appropriate management strategy remains uncertain., Objective: To evaluate whether an individualized blood pressure management strategy tailored to individual patient physiology could reduce postoperative organ dysfunction., Design, Setting, and Participants: The Intraoperative Norepinephrine to Control Arterial Pressure (INPRESS) study was a multicenter, randomized, parallel-group clinical trial conducted in 9 French university and nonuniversity hospitals. Adult patients (n = 298) at increased risk of postoperative complications with a preoperative acute kidney injury risk index of class III or higher (indicating moderate to high risk of postoperative kidney injury) undergoing major surgery lasting 2 hours or longer under general anesthesia were enrolled from December 4, 2012, through August 28, 2016 (last follow-up, September 28, 2016)., Interventions: Individualized management strategy aimed at achieving a systolic blood pressure (SBP) within 10% of the reference value (ie, patient's resting SBP) or standard management strategy of treating SBP less than 80 mm Hg or lower than 40% from the reference value during and for 4 hours following surgery., Main Outcomes and Measures: The primary outcome was a composite of systemic inflammatory response syndrome and dysfunction of at least 1 organ system of the renal, respiratory, cardiovascular, coagulation, and neurologic systems by day 7 after surgery. Secondary outcomes included the individual components of the primary outcome, durations of ICU and hospital stay, adverse events, and all-cause mortality at 30 days after surgery., Results: Among 298 patients who were randomized, 292 patients completed the trial (mean [SD] age, 70 [7] years; 44 [15.1%] women) and were included in the modified intention-to-treat analysis. The primary outcome event occurred in 56 of 147 patients (38.1%) assigned to the individualized treatment strategy vs 75 of 145 patients (51.7%) assigned to the standard treatment strategy (relative risk, 0.73; 95% CI, 0.56 to 0.94; P = .02; absolute risk difference, -14%, 95% CI, -25% to -2%). Sixty-eight patients (46.3%) in the individualized treatment group and 92 (63.4%) in the standard treatment group had postoperative organ dysfunction by day 30 (adjusted hazard ratio, 0.66; 95% CI, 0.52 to 0.84; P = .001). There were no significant between-group differences in severe adverse events or 30-day mortality., Conclusions and Relevance: Among patients predominantly undergoing abdominal surgery who were at increased postoperative risk, management targeting an individualized systolic blood pressure, compared with standard management, reduced the risk of postoperative organ dysfunction., Trial Registration: clinicaltrials.gov Identifier: NCT01536470.

Background: Slow gait is common in dementia, but it remains unknown whether the slowing happens many years prior to dementia onset. We therefore examined the relationship between slow baseline gait speed (GS), change in GS, and the hazard of incident dementia in a community dwelling of elderly people., Methods: A total of 3,663 participants dementia-free at baseline (mean age, 73.5 years) were followed up for 9 years from a prospective cohort (Three-City study, France) for incident dementia (all-cause, Alzheimer's disease, vascular dementia, and other causes). GS over 6 m was assessed 4 times over the follow-up using two photoelectric cells. We used a multistate model to estimate the hazard ratio (HR) of dementia for baseline GS and tested a washout period of 4 to 7 years. The role of GS change between 65 and 85 years was examined using linear mixed models and joint models for survival and longitudinal data., Results: A total of 296 participants developed dementia during the follow-up. In age/sex-adjusted models, 1-SD (0.204 m/s) lower GS was associated with an increased hazard of dementia (HR = 1.59, 95% confidence interval [CI] = 1.39, 1.81, p < .001), with associations evident when gait assessments were taken from 4 years (HR = 1.46; CI = 1.26, 1.68) and 7 years (HR=1.30; CI = 1.00, 1.70) prior to dementia onset. Independently of baseline GS, those with a steeper decline had a higher hazard of dementia (HR per 1 SD [0.007 m/s/year] decrease = 3.39 [1.37-8.43], p = .009)., Conclusions: Gait is slower up to 7 years prior to clinical onset of dementia. Decline in GS is also more accelerated, suggesting strong links between cognitive and motor function in older adults., (© The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

An innovative technique based on the analysis of instantaneous heart rate variability helps to improve the prevention and management of pain and discomfort. Simple to implement, this non-invasive technique is based on the continuous recording of the electrocardiograph signal., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: In 2007, the multidisciplinary European Task Force for Advanced Bleeding Care in Trauma published guidelines for the management of the bleeding trauma patient. The present study aimed to assess compliance with the European guidelines during the first 24 h in a level I trauma centre and to determine whether compliance impacts mortality., Methods: This was a retrospective study of consecutive bleeding trauma patients referred to a university hospital in France between 2010 and 2014. A reference document was developed on the basis of the European guidelines to transform the guidelines pragmatically into 22 objectively measurable criteria. We measured per-patient and per-criterion compliance rates and assessed the impact of guideline compliance on mortality., Results: A total of 121 bleeding trauma patients were included. The median (interquartile range) per-patient compliance rate was 75 (65-82)% and the per-criterion compliance rate 64 (57-81)%. Mortality rates were 18 and 32% at 24 h and 30 days, respectively. After adjusting for injury severity, per-patient compliance rates were associated with decreased mortality at 24 h (odds ratio per 10% increase in patient compliance score, 0.43; 95% confidence interval 0.26-0.71; P = 0.0001) and at 30 days (odds ratio per 10% increase in patient compliance score, 0.47; 95% confidence interval 0.31-0.72; P = 0.0004)., Conclusions: We found that compliance with protocols based on European guidelines impacts trauma outcome, because patient compliance was associated with survival. Further work is needed to improve adherence to these guidelines, with ongoing monitoring to ensure best practice and optimal patient outcome., (© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Abnormal values of vital parameters such as hypotension or tachycardia may occur during anesthesia and may be detected by analyzing time-series data collected during the procedure by the Anesthesia Information Management System. When crossed with other data from the Hospital Information System, abnormal values of vital parameters have been linked with postoperative morbidity and mortality. However, methods for the automatic detection of these events are poorly documented in the literature and differ between studies, making it difficult to reproduce results. In this paper, we propose a methodology for the automatic detection of abnormal values of vital parameters. This methodology uses an algorithm allowing the configuration of threshold values for any vital parameters as well as the management of missing data. Four examples illustrate the application of the algorithm, after which it is applied to three vital signs (heart rate, SpO2, and mean arterial pressure) to all 2014 anesthetic records at our institution., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Obesity, whose prevalence is increasing, is associated with poor functional status at older ages. However, much of this evidence is cross-sectional with little known about longitudinal associations. We examined associations of body mass index (BMI), and change in BMI, with change in objective [walking speed (WS)] and self-reported (disability) measures of motor decline. Analyses included participants (65-85 years) from the Dijon center of the Three-City study (France) with up to five WS (N = 4007) and six disability assessments (N = 4478) over 11 years. Data were analyzed using regression models for repeated measures. Mean baseline WS was 153 cm/s. Compared to normal weight persons, obese participants at baseline walked slower and reported more disability; they also experienced 45% faster WS decline (-18.63 vs. -12.85 cm/s/10 years, P = 0.002). Participants who lost or gained weight had 47% (-18.85 cm/s/10 years, P < 0.001) and 33% (-17.08 cm/s/10 years, P = 0.002) respectively greater WS decline than participants in the normal BMI change category. 24% of participants reported disability at least once during the follow-up, those who lost or gained weight had a 1.63 and 1.34 respectively higher odds of disability than participants in the normal BMI change category (P = 0.001). Associations remained after adjustment for covariates. In conclusion, obesity is associated with worse motor performances, a higher risk of disability, and faster motor decline. Our results underline the interest of repeated BMI and motor assessments to identify those at higher risk of disability.

AIMS are optimized to find and display data and curves about one specific intervention but is not retrospective analysis on a huge volume of interventions. Such a system present two main limitation; (1) the transactional database architecture, (2) the completeness of documentation. In order to solve the architectural problem, data warehouses were developed to propose architecture suitable for analysis. However, completeness of documentation stays unsolved. In this paper, we describe a method which allows determining of substitution rules in order to detect missing anesthesia events in an anesthesia record. Our method is based on the principle that missing event could be detected using a substitution one defined as the nearest documented event. As an example, we focused on the automatic detection of the start and the end of anesthesia procedure when these events were not documented by the clinicians. We applied our method on a set of records in order to evaluate; (1) the event detection accuracy, (2) the improvement of valid records. For the year 2010-2012, we obtained event detection with a precision of 0.00 (-2.22; 2.00) min for the start of anesthesia and 0.10 (0.00; 0.35) min for the end of anesthesia. On the other hand, we increased by 21.1% the data completeness (from 80.3 to 97.2% of the total database) for the start and the end of anesthesia events. This method seems to be efficient to replace missing "start and end of anesthesia" events. This method could also be used to replace other missing time events in this particular data warehouse as well as in other kind of data warehouses.

Background: Hemodynamic optimization during surgery is of major importance to decrease postoperative morbidity and length of hospital stay. However, conventional cardiac output monitoring is rarely used at the bedside. Recently, the plethysmographic variability index (PVI) was described as a simplified alternative, using plug-and-play noninvasive technology, but its clinical utility remains to be established., Methods/design: The hemodynamic optimization using the PVI (OPVI) trial is a multicenter randomized controlled two-arm trial, randomizing 440 patients at intermediate risk of postoperative complications after orthopedic surgery. Hemodynamic optimization was conducted using either the PVI (PVI group) or conventional mean arterial pressure (control group). The anesthesiologist performed the randomization the day before surgery using an interactive web response system, available 24 hours a day, 7 days a week. The randomization sequence was generated using permutated blocks and stratified by center and type of surgery (knee or hip arthoplasty). Patients and surgeons, but not anesthesiology staff, were blinded to the allocation group. The primary outcome measure is the length of hospital stay following surgery. The attending surgeon, who was blinded to group assessment, determined hospital discharge. Secondary outcome measures are theoretical length of hospital stay, determined using a dedicated discharge-from-hospital checklist, postoperative arterial lactate level in the recovery room, postoperative troponin level, presence of serious postoperative cardiac complications, and postoperative acute kidney insufficiency., Discussion: The OPVI trial is the first multicenter randomized controlled study to investigate whether perioperative hemodynamic optimization using PVI during orthopedic surgery could decrease the length of hospital stay and postoperative morbidity., Trial Registration: ClinicalTrials.gov NCT02207296 .

Background: Dynamic indices, such as pulse pressure variation (PPV), are inaccurate predictors of fluid responsiveness in mechanically ventilated patients with low tidal volume. This study aimed to test whether changes in continuous cardiac index (CCI), PPV, and stroke volume variation (SVV) after a mini-fluid challenge (100 ml of fluid during 1 min) could predict fluid responsiveness in these patients., Methods: We prospectively studied 49 critically ill, deeply sedated, and mechanically ventilated patients (tidal volume <8 ml kg(-1) of ideal body weight) without cardiac arrhythmias, in whom a fluid challenge was indicated because of circulatory failure. The CCI, SVV (PiCCO™; Pulsion), and PPV (MP70™; Philips) were measured before and after 100 ml of colloid infusion during 1 min, and then after the additional infusion of 400 ml during 14 min. Responders were defined as subjects with a ≥15% increase in cardiac index (transpulmonary thermodilution) after the full (500 ml) fluid challenge. Areas under the receiver operating characteristic curves (AUCs) and the grey zones were determined for changes in CCI (ΔCCI100), SVV (ΔSVV100), and PPV (ΔPPV100) after 100 ml fluid challenge., Results: Twenty-two subjects were responders. The ΔCCI100 predicted fluid responsiveness with an AUC of 0.78. The grey zone was large and included 67% of subjects. The ΔSVV100 and ΔPPV100 predicted fluid responsiveness with AUCs of 0.91 and 0.92, respectively. Grey zones were small, including ≤12% of subjects for both indices., Conclusions: The ΔSVV100 and ΔPPV100 predict fluid responsiveness accurately and better than ΔCCI100 (PiCCO™; Pulsion) in patients with circulatory failure and ventilated with low volumes., (© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Introduction: The purpose of this study was to evaluate the clinical relevance of high values of central venous-to-arterial carbon dioxide difference (PCO2 gap) in high-risk surgical patients admitted to a postoperative ICU. We hypothesized that PCO2 gap could serve as a useful tool to identify patients still requiring hemodynamic optimization at ICU admission., Methods: One hundred and fifteen patients were included in this prospective single-center observational study during a 1-year period. High-risk surgical inclusion criteria were adapted from Schoemaker and colleagues. Demographic and biological data, PCO2 gap, central venous oxygen saturation, lactate level and postoperative complications were recorded for all patients at ICU admission, and 6 hours and 12 hours after admission., Results: A total of 78 (68%) patients developed postoperative complications, of whom 54 (47%) developed organ failure. From admission to 12 hours after admission, there was a significant difference in mean PCO2 gap (8.7 ± 2.8 mmHg versus 5.1 ± 2.6 mmHg; P = 0.001) and median lactate values (1.54 (1.1-3.2) mmol/l versus 1.06 (0.8-1.8) mmol/l; P = 0.003) between patients who developed postoperative complications and those who did not. These differences were maximal at admission to the ICU. At ICU admission, the area under the receiver operating characteristic curve for occurrence of postoperative complications was 0.86 for the PCO2 gap compared to Sequential Organ Failure Assessment score (0.82), Simplified Acute Physiology Score II score (0.67), and lactate level (0.67). The threshold value for PCO2 gap was 5.8 mmHg. Multivariate analysis showed that only a high PCO2 gap and a high Sequential Organ Failure Assessment score were independently associated with the occurrence of postoperative complications. A high PCO2 gap (≥6 mmHg) was associated with more organ failure, an increase in duration of mechanical ventilation and length of hospital stay., Conclusion: A high PCO2 gap at admission in the postoperative ICU was significantly associated with increased postoperative complications in high-risk surgical patients. If the increase in PCO2 gap is secondary to tissue hypoperfusion then the PCO2 gap might be a useful tool complementary to central venous oxygen saturation as a therapeutic target.

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., (Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Objective: The Analgesia Nociception Index (ANI) monitor measures the relative parasympathetic tone as a surrogate for the antinociception/nociception balance during general anesthesia. The aims of this observational study were to test whether ANI could early detect hemodynamic reactivity (HemodR) during propofol anesthesia, measure pain in conscious patients after surgery, and determine ANI predictive thresholds., Materials and Methods: After institutional approval and informed consent, adult patients scheduled for total knee replacement were included. Propofol was administered using a target-controlled infusion device, and sufentanil was administered at induction and in case of "HemodR," defined as a 20% increase in heart rate or systolic blood pressure. Data were collected before the start of surgery (NoStim), in case of "HemodR," and after awakening before and after the pain had been treated by truncular analgesia. Nonparametric tests were conducted. Thresholds were determined using an receiver operating characteristic analysis. Results are presented as median (interquartile range)., Results: A total of 27 patients have been analysed. ANI decreased from 82 (30) at "NoStim" to 47 (22) at "HemodR," whereas heart rate increased moderately from 61 (14) to 65 (18) and systolic blood pressure increased significantly from 91 mm Hg (16 mm Hg) to 151 mm Hg (25 mm Hg). Receiver operating characteristic analysis led to a threshold of 63 for "HemodR" detection (sensitivity=80%, specificity=88%, area under the curve=0.92), whereas ANI performance in awake patients was lower., Discussion: ANI measures during propofol anesthesia are coherent with the evolution of the analgesia/nociception balance, although its performance decreases in awake patients. Further clinical validation should focus on demonstrating the benefit of maintaining ANI over 63 during surgery.

Clinical research is of major importance to today's society, as scientific evidence is increasingly demanded as a basis for progress, whether this involves developing new healthcare products, improving clinical practice and care protocols or progress in prevention. Clinical research therefore requires professionals who are both experienced and increasingly well trained. Against this background, allied health professionals are becoming involved more and more, both as team members supporting clinical research projects and as managers or coordinators of projects in their own field. Clinical research activities provide an ideal opportunity for continuing professional development. All of this means that the professional skills of the allied health professions and clinical research support professions must be enhanced, their role promoted in the context of lecturer status and in the longer term, their status recognised by the supervisory authorities., (© 2014 Société Française de Pharmacologie et de Thérapeutique.)

Background: Walking speed (WS) predicts mortality. However, it is unclear if decline in WS increases prior to death. We examined whether (a) WS declined faster in persons who died during the follow-up compared with those who remained alive and (b) adding change in WS to a model including age, sex, and baseline WS improved prediction of mortality., Methods: Data are from 4,016 participants of the Dijon center of the Three-City study (France), aged 65-85 years. Fast WS (FWS) was measured up to five times over a 12-year period. Mortality was ascertained until 2012., Results: Linear mixed models using a backward time scale showed that FWS declined faster in 908 participants who died during the follow-up (annual change = -0.031 m/s) than in those who survived (-0.021 m/s), corresponding to a difference of -0.009 (95% confidence interval = -0.013 to -0.005) m/s. Compared with "normal" change in FWS (annual change ≥-0.04 m/s), "substantial" decline (<-0.08 m/s) was associated with a 1.4-fold greater risk of mortality (hazards ratio = 1.40, confidence interval = 1.02-1.92) and small decline (-0.08 to -0.04 m/s) with a 1.2-fold greater risk (hazards ratio = 1.18, confidence interval = 0.89-1.57). The net reclassification index when adding these categories of change in FWS to the model adjusted for age, sex, and baseline FWS was 19.0% (0.6, 36.8%)., Conclusion: Participants who died during the follow-up had a steeper decline in FWS than the others. Both baseline FWS and FWS decline predict mortality.

Psychomotor disadaptation syndrome (PDS) was first described in France by the Dijon geriatric school, 25 years ago, and named "psychomotor regression syndrome". The initial clinical description still remains without modifications. However, progress has been made both in understanding its physiopathology and management, and its name has been changed into PDS in the late 1990s. Since the early 2000s, it was also termed frontal-sub-cortical dysfunction syndrome. PDS results from decompensation of postural function, gait and psychomotor automatisms linked to posture and motor programming impairment related to fronto-sub-cortical lesions. PDS is characterized by retropulsion, non-specific gait disorders, neurological signs (including akinesia, reactional hypertonia, and impaired reactive postural responses and protective reactions) and psychological disorders (fear of standing and walking as an acute feature or cognitive processing retardation and anhedonia as a chronic feature). PDS occurrence is linked to three factors implicated in functional reserve impairment due to frontal-sub-cortical structures disturbances: aging, chronic affections (mainly of degenerative or vascular origin), and acute organic or functional factors which induce cerebral blood flow decrease. Multidisciplinary management, including medical motor physiotherapy and psychological approach, is required for patients with PDS care.

Background: Vascular risk factors contribute to motor decline in the elderly persons. We investigated the relationship between lipid-lowering drugs (LLDs) use and decline in walking speed (WS) in older adults., Methods: Data on 4,009 community-dwelling men and women, aged ≥65 years at baseline, are drawn from the Dijon (France) center of the Three-City study. "Fast" WS was assessed over 6 m at baseline and at 4, 6, 8, and 10 years of follow-up. Mixed linear models were used to determine the relationship between LLDs and change in WS over the follow-up., Results: At baseline, 1,295 (32%) participants used LLDs (statins, n = 643; fibrates, n = 652); mean fast WS was 152.9cm/s and not significantly different between LLDs users and nonusers. In models adjusted for age, sex, cholesterol level, and other covariates, WS decline was 25% slower in LLDs users (difference with nonusers: 0.58cm/s/y, 95% CI: 0.30, 0.86; p < .001). Both fibrates and statins were associated with slower decline, but only the effect of statins was robust in analyses that took missing values into account. The beneficial effect was more pronounced in those on LLDs continuously over the follow-up., Conclusion: Fast WS declined less in those on LLDs, suggesting that the effect of LLDs, statins in particular, extend beyond that on cardiovascular disease in the elderly persons. However, these effects were modest and their clinical relevance is unclear.

Objective: The reserve hypothesis accounts for the lack of direct relationship between brain pathology and its clinical manifestations. Research has mostly focused on cognition; our objective is to examine whether the reserve hypothesis applies to motor function. We investigated whether education, a marker of reserve, modifies the association between white matter lesions (WMLs), a marker of vascular brain damage, and maximum walking speed (WS), an objective measure of motor function. We also examined the cross-sectional and longitudinal association between education and WS., Methods: Data are from 4,010 participants aged 65-85 years in the longitudinal Three-City-Dijon Study with up to 4 WS measures over 10 years. We examined the interaction between education and WMLs for baseline WS. We studied the association between education and repeated WS measures using linear mixed models, and the role of covariates in explaining the education-WS association., Results: Education was strongly associated with baseline WS; the difference in mean WS between the high and low education groups (0.145 m/s, 95% confidence interval = 0.125-0.165) was equivalent to 7.4 years of age. WMLs were associated with slow WS only in the low education group (p interaction = 0.026). WS declined significantly over time (-0.194 m/s/10 years, 95% confidence interval = -0.206, -0.182), but education did not influence rate of decline. Anthropometric characteristics, parental education, general health, and cognition had the strongest role in explaining the baseline education-WS association., Conclusions: Participants with more education were less susceptible to WMLs' effect on motor function. Higher education was associated with better motor performances but not with motor decline. These results are consistent with the passive reserve hypothesis.

To understand the relationship between surface morphology and proton conduction of polymer electrolyte thin films, perfluorinated ionomer Nafion® thin films were prepared on different substrates such as glassy carbon (GC), hydrophilic-GC (H-GC), and platinum (Pt) as models for the ionomer film within a catalyst layer. Atomic force microscopy coupled with an electrochemical (e-AFM) technique revealed that proton conduction decreased with film thickness; an abrupt decrease in proton conductance was observed when the film thickness was less than ca. 10 nm on GC substrates in addition to a significant change in surface morphology. Furthermore, thin films prepared on H-GC substrates with UV-ozone treatment exhibited higher proton conduction than those on untreated GC substrates. However, Pt substrates exhibited proton conduction comparable to that of GCs for films thicker than 20 nm; a decrease in proton conduction was observed at ∼5 nm thick film but was still much higher than for carbon substrates. These results indicate that the number of active proton-conductive pathways and/or the connectivity of the proton path network changed with film thickness. The surface morphology of thinner films was significantly affected by the film/substrate interface and was fundamentally different from that of the bulk thick membrane.

Background: Cardiac output (CO) is rarely monitored during surgery, and arterial pressure remains the only hemodynamic parameter for assessing the effects of volume expansion (VE). However, whether VE-induced changes in arterial pressure accurately reflect changes in CO has not been demonstrated. The authors studied the ability of VE-induced changes in arterial pressure and in pulse pressure variation to detect changes in CO induced by VE in the perioperative period., Methods: The authors studied 402 patients in four centers. Hemodynamic variables were recorded before and after VE. Response to VE was defined as more than 15% increase in CO. The ability of VE-induced changes in arterial pressure to detect changes in CO was assessed using a gray zone approach., Results: VE increased CO of more than 15% in 205 patients (51%). Areas under the receiver operating characteristic curves for VE-induced changes in systolic, diastolic, means, and pulse pressure ranged between 0.64 and 0.70, and sensitivity and specificity ranged between 52 and 79%. For these four arterial pressure-derived parameters, large gray zones were found, and more than 60% of the patients lay within this inconclusive zone. A VE-induced decrease in pulse pressure variation of 3% or more allowed detecting a fluid-induced increase in CO of more than 15% with a sensitivity of 90% and a specificity of 77% and a gray zone between 2.2 and 4.7% decrease in pulse pressure variation including 14% of the patients., Conclusion: Only changes in pulse pressure variation accurately detect VE-induced changes in CO and have a potential clinical applicability.

The analgesia nociception index (ANI) is an online heart rate variability analysis proposed for assessment of the antinociception/nociception balance. In this observational study, we compared ANI with heart rate (HR) and systolic blood pressure (SBP) during various noxious stimuli in anaesthetized patients. 15 adult patients undergoing laparoscopic appendectomy or cholecystectomy were studied. Patients received target controlled infusions of propofol (adjusted to maintain the Bispectral index in the range [40-60]) and remifentanil (with target increase in case of haemodynamic reactivity [increase in HR and/or SBP >20% of baseline]), and cisatracurium. Medical staff was blind to the ANI monitor. ANI and haemodynamic data were recorded at predefined times before and during surgery, including tetanic stimulation of the ulnar nerve before start of surgery. Anaesthesia induction decreased HR and SBP, while high ANI values (88 [17]) were recorded, indicating parasympathetic predominance. In 10 out of 11 patients, tetanic stimulation led to a transient (<5 min) decrease in ANI to 48 (40) whereas HR and SBP did not change. After start of surgery, ANI decreased to 60 (39) and decreased further to 50 (15) after the pneumoperitoneum was inflated, while there was no significant change in HR or SBP. When haemodynamic reactivity occurred, ANI had further decreased to 40 (15). After completion of surgery, ANI returned to 90 (34). ANI seems more sensitive than HR and SBP to moderate nociceptive stimuli in propofol-anaesthetized patients. Whether ANI monitoring may allow preventing haemodynamic reactivity to noxious stimuli remains to be demonstrated.