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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.

Introduction Postoperative ileus(POI) and anastomotic leakage(AL) are highly associated but the direction of this link is unknown. Indeed, it has traditionally been stated that AL leads to POI(secondary POI). The objective was to statistically determine the best model of link between POI and AL by comparing different Structural Equation Models(SEM). Methods This is a retrospective analysis of a prospective multicentric database from the Francophone Group for Enhanced Recovery after surgery(GRACE) including patients undergoing colorectal resection or Hartmann reversal between 2014 and 2017. The main outcome measure was the occurrence of postoperative ileus defined by the absence of Gastrointestinal (GI)-3 recovery in or after postoperative day 4 and the occurrence of AL. Results Among the 2227 patients included, 223 patients experienced POI (10 %) and 72 patients experienced anastomotic leakage (3.2 %). In all the models, POI was significantly increased in case of male gender, older age, opioids consumption, right colectomy, chronic obstructive bronchopneumopathy disease and performance of a stoma, and reduced by Enhanced Recovery Programs (ERP) compliance ≥ 70 % and intake of Non-Steroidal Anti-Inflammatory Drugs. Open surgery was not significantly associated with POI in all the models. In contrast, the male gender was the only factor increasing AL in the model drawn with ERP risk factors for AL. In all the models, POI was highly associated with AL and statistical analyses advocate for POI leading to AL. Conclusion The findings of the present large study suggest that the more statistically probable model is the one in which POI come first before AL.

Polypharmacy is common and associated with negative health outcomes in the elderly. We report the case of an 82-year-old man with a history of polypharmacy due to coronary artery disease, myocardial infarction, ischaemic cardiomyopathy, hyperlipidaemia, hypertension and persistent atrial fibrillation who presented with memory loss, cognitive impairment, fatigue and weakness. His treatment plan included an exclusively plant, whole-food diet and moderate physical activity which resulted in a rapid reduction of hyperlipidaemia and high blood pressure and the discontinuation of statin, antihypertensive and beta blocker drug therapy. The patient also reported reversal of impaired cognition and symptoms associated with atrial fibrillation and ischaemic cardiomyopathy, including light-headedness, fatigue and weakness. This case demonstrates that dietary and lifestyle modifications have the potential to improve symptoms of cardiovascular disease and reduce polypharmacy along with associated negative consequences in the elderly.

Resume Objectifs Comparer la stabilite hemodynamique peroperatoire de deux protocoles de prise en charge anesthesique du sujet âge en chirurgie abdominale urgente. Patients et methodes Etude pilote monocentrique non randomisee. Les patients du groupe Optimisation ont ete inclus prospectivement. Dans ce groupe, apres induction par etomidate–succinylcholine, l’entretien de l’anesthesie etait realise par remifentanil–desflurane administres respectivement en objectif de concentration cerebrale (CE) et expiree afin de maintenir la valeur de l’index bispectral (BIS) entre 45 et 55. Ces patients etaient apparies a une serie historique de patients constituant le groupe Temoin. Dans ce groupe, apres induction par etomidate–succinylcholine, l’entretien de l’anesthesie etait assure par sufentanil–desflurane administres manuellement avec pour objectif le respect de la pression arterielle systolique (PAS) preoperatoire a plus ou moins 30 %. Resultats Douze patients (86 ± 5 ans) ont ete inclus dans le groupe Optimisation, 11 (86 ± 4 ans) dans le groupe Temoin. Le pourcentage du temps anesthesique ou la PAS etait comprise dans un intervalle de plus ou moins 30 % des valeurs de reference etait de 92 ± 7 % dans le groupe Optimisation et de 71 ± 29 % dans le groupe Temoin (p Conclusion La modalite d’administration des agents anesthesiques et/ou leur titration a l’aide d’un monitorage neurophysiologique ameliorent le profil hemodynamique de l’anesthesie chez le sujet âge opere en urgence d’une chirurgie abdominale.

Peroperative haemodynamic profile comparison of two anaesthetic protocols for emergency abdominal surgery of old patients.Non-randomized monocentric study. Patients in the Optimization group were prospectively studied. Anaesthesia was induced by etomidate-succinylcholine and maintained with effect site and end-tidal target controlled administration of remifentanil and desflurane respectively to keep the BIS values between 45 and 55. These patients were matched with retrospectively studied patients constituting the Control group. The latter's were anaesthetized with etomidate-succinylcholine and anaesthesia was maintained by manually controlled administration of sufentanil and desflurane to keep systolic arterial pressure (SAP) within a range of more or less 30% of preoperative baseline SAP.Twelve patients (86+/-5 yrs) were included in the Optimization group, 11 (86+/-4 yrs) in the Control group. The time spent at a SAP within more or less 30% of baseline values was 92+/-7% and 71+/-29% of total anesthesia time in the Optimization and Control groups respectively (p0.05). That spent at a SAP less than 15 and 30% of baseline values was 23+/-11% et 3+/-5% of total anaesthesia time in the Optimization group, whereas in the MAN group it was 65+/-21% and 27+/-30% respectively (p0.05). Desflurane and ephedrine consumption was less in the Optimization group as well as crystalloid or colloid volume loading.Anaesthetic agents target controlled administration and/or neurophysiologic depth of anaesthesia monitoring improve the time course of the haemodynamic effects in elderly patients undergoing abdominal surgery in emergency.

Through the National Governors' Association (NGA) project ''Critical Issues Related to Radioactive Waste and Materials Disposition Involving DOE Facilities'' NGA brings together Governors' policy advisors, state regulators, and DOE officials to examine critical issues related to the cleanup and operation of DOE nuclear weapons and research facilities. Topics explored through this project include: (1) Decisions involving disposal of mixed, low-level, and transuranic (TRU) waste and disposition of nuclear materials; (2) Decisions involving DOE budget requests and their effect on environmental cleanup and compliance at DOE facilities; (3) Strategies to treat mixed, low-level, and transuranic (TRU) waste and their effect on individual sites in the complex; (4) Changes to the FFCA site treatment plans as a result of proposals in the Department's Accelerating Cleanup: Paths to Closure plan and contractor integration analysis; (5) Interstate waste and materials shipments; and (6) Reforms to existing RCRA and CERCLA regulations/guidance to address regulatory overlap and risks posed by DOE wastes. The overarching theme of this project is to help the Department improve coordination of its major program decisions with Governors' offices and state regulators and to ensure such decisions reflect input from these key state officials and stakeholders. This report summarizes activities conducted during the quarter from October 1, 1998 through January 31, 1999, under the NGA grant. The work accomplished by the NGA project team during the past four months can be categorized as follows: (1) maintained open communication with DOE on a variety of activities and issues within the DOE environmental management complex; (2) maintained communication with NGA Federal Facilities Compliance Task Force members regarding DOE efforts to formulate a configuration for mixed low-level waste and low-level treatment and disposal, external regulation of DOE; and EM Integration activities; and (3) continued to serve as a liaison between the NGA FFCA Task Force states and the Department.