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International audience; Objectives: To provide an update to the 1999 French guidelines on “Muscle relaxants and reversal in anaesthesia”, a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. Methods: The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. Results: The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. Conclusion: Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.

The purpose of this review is to discuss the optimal use of neuromuscular blocking agents (NMBA) during ambulatory surgery, and to provide an update on the routine use of neuromuscular monitoring and the prevention of residual paralysis.The number of major surgical procedures performed in ambulatory patients is likely to increase in the coming years, following the development of laparoscopic and thoracoscopic procedures. To successfully complete these procedures, the proper use of NMBA is mandatory. The use of NMBA not only improves intubating conditions but also ventilation. Recent studies demonstrate that NMBA are much more the solution rather than the cause of airway problems. There is growing evidence that the paralysis of the diaphragm and the abdominal wall muscles, which are resistant to NMBA is of importance during laparoscopic surgery. Further studies are still required to determine when deep neuromuscular block [posttetanic count (PTC)5] is required perioperatively. There is now a consensus to use perioperatively neuromuscular monitoring and particularly objective neuromuscular monitoring in combination with reversal agents to avoid residual paralysis and its related morbidity (e.g. respiratory complications in the PACU).Recent data suggest that it is now possible to obtain a tight control of neuromuscular block to maintain optimal relaxation tailored to the surgical requirements and to obtain a rapid and reliable recovery at the end of the procedure.

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.

IntroductionDexamethasone is a drug used to prolong the postoperative analgesia in children after peripheral nerve blockade, although the dose usually used (0.2 mg/kg) has not been studied yet. This study is a monocentric, prospective, randomised, placebo-controlled, double-blinded study in a university hospital in France. The primary objective of the study is to evaluate the efficacy of 0.2 mg/kg intravenous dexamethasone on early postoperative pain in children aged 6–15 years, who require a lower limb peripheral nerve block following general anaesthesia.Methods and analysisEighty children, aged 6–15 years, undergoing surgery for which peripheral nerve lower limb blockade with ropivacaine following general anaesthesia are included. The inclusion criteria are: children aged 6–15 years, with American Society of Anaesthesiologists physical status I or II and scheduled for surgery requiring a peripheral block of the lower limb for analgesic purposes, with a preoperative anaesthetic evaluation between 90 and 2 days before the surgery, with informed consent from legal representatives. General anaesthesia is performed. The patient receives, according to his group, either 0.2 mg/kg of dexamethasone intravenously at the start of anaesthetic induction or the same volume of placebo. Then, the peripheral block of the lower limb is performed with ropivacaine. The primary outcome is the total doses of opioid administered (in mg/kg of morphine equivalent) within 24 hours postoperatively. The secondary objectives are the evaluation of the effect of a single-dose intravenous dexamethasone at the time of anaesthetic induction, on the following parameters: onset of postoperative pain, duration of motor block, postoperative nausea and vomiting within 24 hours.Ethics and disseminationThis study is conducted according to the principles of the Declaration of Helsinki and has been approved by the French national ethics committee and the National Drug Safety Agency. Findings of this study will be widely disseminated through conference presentations, reports, factsheets and academic publications.Trial registration numberNCT03618173.

Resume La chimiohyperthermie intraperitoneale (CHIP) est un traitement chirurgical de la carcinose peritoneale. Elle a pour objectif d’ameliorer la survie des patients mais comporte une morbidite perioperatoire. Elle associe deux techniques successives : une etape de cytoreduction chirurgicale macroscopique la plus complete possible puis la mise en contact peroperatoire de la cavite abdominale avec un solute de chimiotherapie chauffee a 42 °C pour traiter la carcinose microscopique. L’evaluation preoperatoire doit tenir compte de la fonction renale et de la tolerance cardiovasculaire peroperatoire au remplissage vasculaire necessaire a une diurese forcee notamment en cas de chimiotherapie nephrotoxique comme le cisplatine. Les desordres hydro-electrolytiques per- et postoperatoires dependent du type de chimiotherapie et du bain intraperitoneal l’accompagnant. En cas d’utilisation d’un bain glucose, il est primordial d’anticiper et de traiter l’hyperglycemie par une insulinotherapie demarree tres precocement durant la CHIP. L’analgesie peridurale est la technique de reference et s’applique sur plusieurs jours apres la chirurgie. Le traitement de la douleur et la nutrition sont des elements cles de la rehabilitation postoperatoire precoce de ces patients.

The purpose of this article is to present the consequences and incidence of residual paralysis and define solutions to reduce the risk of its occurrence. Small degrees of residual paralysis, defined as a train-of-four (TOF) ratio

Objective The aim of this study was to evaluate the cost of an operating room using data from our hospital. Using an accounting-based method helped us. Methods Over the year 2012, the sum of direct and indirect expenses with cost sharing expenses allowed us to calculate the cost of the operating room (OR) and of the post-anaesthesia care unit (PACU). Results The cost of the OR and PACU was € 10.8 per minute of time offered. Two thirds of the direct expenses were allocated to surgery and one third to anaesthesia. Indirect expenses were 25% of the direct expenses. The cost of medications and single use medical devises was € 111.45 per anaesthesia. The total cost of anaesthesia (taking into account wages and indirect expenses) was € 753.14 per anaesthesia as compared to the total cost of the anaesthesia. The part of medications and single use devices for anaesthesia was 14.8% of the total cost. Conclusion Despite the difficulties facing cost evaluation, this model of calculation, assisted by the cost accounting controller, helped us to have a concrete financial vision. It also shows that a global reflexion is necessary during financial decision-making.

Resume La prevention de la curarisation residuelle repose sur le monitorage de la curarisation ainsi que sur l’utilisation large des antagonistes. Selon une enquete de pratique sur l’utilisation en France des curares chez l’adulte en anesthesie seul 52 % des praticiens declaraient d’utiliser le monitorage de la curarisation en cas d’administration de curare en dose unique et 74 % en cas d’administration repetee. Cette meme enquete revelait egalement que l’utilisation des agents anticholinesterasique tel que la neostigmine reste episodique et le risque de curarisation residuelle est sous-estime. Le developpement d’une nouvelle classe pharmacologique (les cyclodextrines) capable de lever la curarisation pourrait induire des modifications dans notre maniere de gerer la curarisation. Cet article a comme but de revoir les principes du monitorage de la curarisation et d’evaluer si le sugammadex remet en question la place du monitorage neuromusculaire dans la prevention de la curarisation residuelle.

Sugammadex, a cyclodextrin, is a novel agent designed to encapsulate selectively steroidal neuromuscular blocking agents such as rocuronium and vecuronium as well. One molecule of sugammadex is able to encapsulate only one molecule of muscle relaxant. This original pharmacological property allows a very rapid reversal of muscle paralysis. After sugammadex injection, a train of four ratio higher than 0.9 is obtained in less than 5 minutes in all the patients whatever the degree of muscle paralysis at the time of reversal and even when anesthesia is maintained with halogenated agents. However, in order to preserve this efficacy, the dose of sugammadex needs to be adjusted to the degree of muscle paralysis at the time of reversal : 2 mg/kg after obtaining 2 responses at the adductor pollicis muscle after a train of four stimulation, 4 mg/kg with a post-tetanic count between 1 and 3 responses, and 12 to 16 mg/kg in case of rescue reversal (3 to 15 minutes after 0.6 to 1.2 mg/kg rocuronium). Even if the original property of sugammadex lets us think that per-operative neuromuscular transmission monitoring would not be furthermore useful, the assessment of the exact degree of muscle paralysis before reversal is mandatory for choosing the right dose of sugammadex.

Sugammadex is a new molecule derived from a known pharmacological class : the cyclodextrins known and used in human for many years. It was recently demonstrated that cyclodextrins could encapsulate and bind strongly steroidal neuromuscular blocking agents. Among cyclodextrins gamma-cyclodextrins proved to be more efficient. The binding of cyclodextrins to rocuronium and compound's water solubility was greatly improved by addition of 8 side chains to glycopyranoses units and the presence of a negative charge to the end of these side-chains. Animal studies have clearly demonstrated that sugammadex is faster in onset than anticholinesterase agents and is specific of steroidal neuromuscular blocking agents. It cannot reverse neuromuscular block induced by succinylcholine or benzylisoquinolines such as atracurium or cisatracurium. In human, the dose of sugammadex required to reverse shallow block is 2 mg/kg approximately whereas 4 mg/kg is needed to reverse deep level of neuromuscular block with a few responses at the post tetanic count at the adductor pollicis. The use of sugammadex was not associated with recurrence of block when an adequate dose was administered.

The first part of this article presents an update of the basic considerations of neuromuscular monitoring. It emphasises the need to assure supramaximal stimulation, to place the stimulating electrodes correctly and to use appropriate sites for nerve stimulation as well as appropriate stimulation patterns. The second part focuses on current developments and ongoing discussion. The authors describe the performance of acceleromyography and the need for initial calibration when using these quantitative devices.

Background and Aims An association between the inflammatory reactions estimated by several biomarkers and organ dysfunction has been reported in brain-dead organ donors (BDOD). Procalcitonin (PCT), a biomarker of inflammation due to bacterial infection, is increased among BDOD. However, is not known whether infection changes PCT values in BDOD. Materials and Methods We retrospectively analyzed 82 BDOD including several demographic and clinical parameters, bacterial culture results, antibiotics prescription, and plasma values of PCT measured before organ harvesting. Infection was diagnosed to be either a positive bacterial culture (restricted definition) and/or prescription of antibiotics (extended definition). Results The median PCT value was 1.5 (interquartile range [IQR], 0.4 to 6.9; range, 0 to 526 ng/mL; n = 82). Thirty-eight (46%) and 24 (29%) patients had PCT values >2 ng/mL and >5 ng/mL, respectively. Median PCT values among infected (1.18; IQR, 0.27 to 6.55 ng/mL) versus noninfected (1.57; IQR, 0.53 to 7.15 ng/mL) BDOD (restricted definition) were not different ( P = .36). The area under the receiver operating characteristic curve using PCT to predict infection (restricted definition) was 0.52. Specificity of PCT to predict infection was above 80% at PCT values >9 ng/mL. Conclusion Our results confirmed PCT values are increased in BDOD, suggesting that this was not related to an infectious cause (whatever definition was used) unless PCT values are high.

The aim is to perform a literature search on the role of pregnancy in the rupture of renal angiomyolipoma. Articles published from 1952 to 2004 in the Medline database were searched using the keywords renal angiomylipoma and pregnancy. Pathologies associated with angiomylipoma (lymphangioleiomyomatosis and Bourneville tuberous sclerosis) were taken into account. Seventy-two cases of association of renal angiomyolipoma and pregnancy were found, out of which 58 presented a haemorrhage. In only 26% of the cases, renal angiomyolipoma had been documented prior to pregnancy. Clinical presentation was similar to cases occurring among non pregnant women: abdominal pains (88%), hypotension or shock (33%) and hematuria (24%). Average size of the rupture was 11,7 cm. Rupture does not occur solely with the first pregnancy but occurred equally during the first, second and third pregnancy. Average gestation age upon occurrence of haemorrhage was 27 weeks with a minimum at ten weeks. Therapeutic strategies at the time of shock or hypotension were total nephrectomy in 79% of the cases, 7% polar nephrectomy, 7% embolisation followed by nephrectomy and 7% abstention. A causal role of pregnancy in the atraumatic rupture of angiomyolipoma is not clearly defined. Nevertheless, many arguments (whether it be abdominal mechanical pressure, hormonal or histological ones) suggest that a pregnancy could increase the risk of renal angiomyolipoma rupture. These patients should have a medical follow-up period at closer intervals during their pregnancy and the postpartum phase.

Background Acceleromyography is regularly used as an isolated test to detect residual paralysis. The performance of acceleromyography, however, has not been investigated for the setting where calibration is impossible. This study first evaluated the reliability of a single acceleromyographic train-of-four (TOF) ratio (T4/T1) to detect residual paralysis and compared it with tactile estimation of fade after double-burst stimulation and 100-Hz, 5-s tetanus. The second part of the study investigated whether uncalibrated acceleromyographic TOF ratio can predict time to complete recovery. Methods Anesthesia was induced and maintained with propofol and sufentanil. In the first part of the study (n = 40) neuromuscular blockade was assessed by mechanomyography. After signal stabilization 0.15 mg/kg cisatracurium was given. At the end of surgery a first physician evaluated manual fade after double-burst stimulation, then, in the same patient, a single acceleromyographic TOF ratio was recorded; thereafter a second physician, unaware of the results, assessed fade after a 100-Hz, 5-s tetanus. Sensitivity, specificity, and negative and positive predictive value of the three tests to detect a mechanomyographic TOF > or =0.9 were calculated. In the second part of the study (n = 25) neuromuscular recovery was assessed simultaneously with mechanomyography and uncalibrated acceleromyography (current set manually at 60 mA); the time intervals from acceleromyographic TOF ratios of 0.6, 0.7, 0.8, and 0.9 until complete recovery, i.e., adductor pollicis mechanomyography 0.9 TOF ratios, were determined. Results The sensitivity of double burst stimulation was 29% (95% confidence interval [CI], 13-45%), its specificity was 100%, the negative predictive value was 29% (95% CI, 13-45%), and the positive predictive value was 100%. For a single acceleromyographic TOF ratio the respective values were 70% (95% CI, 54-86%), 88% (95% CI, 67-100%), 47% (95% CI, 23-71%) and 95% (95% CI, 86-100%). The respective values for 100-Hz, 5-s tetanus were 74% (95% CI, 59-89%), 55% (95% CI, 23-88%), 38% (95% CI, 12-64%), and 85% (95% CI, 72 -99%). At an uncalibrated acceleromyographic TOF ratio was 0.6, complete recovery occurred within 16 min (95% CI, 13.5-17.8 min). At acceleromyographic TOF ratios of 0.7, 0.8, and 0.9 this time interval was 12.5 min (95% CI, 10.2-14.8 min), 8 min (95% CI, 6.1-9.9 min), and 4 min (95% CI, 2.7-5.8 min), respectively. Conclusions Acceleromyographic TOF performed better than double-burst stimulation or 100 Hz tetanus, but it did not reliably detect low degrees of residual paralysis when used as an isolated test at the end of surgery. The uncalibrated acceleromyographic TOF ratio, however, did predict the time to complete recovery.

Background The incidence of residual paralysis, i.e., a mechanomyographic train-of-four (TOF) ratio (T4/T1) less than 0.9, remains frequent. Routine acceleromyography has been proposed to detect residual paralysis in clinical practice. Although acceleromyographic data are easy to obtain, they differ from mechanomyographic data, with which they are not interchangeable. The current study aimed to determine (1) the acceleromyographic TOF ratio that detects residual paralysis with a 95% probability, and (2) the impact of calibration and normalization on this predictive acceleromyographic value. Methods In 60 patients, recovery from neuromuscular block was assessed simultaneously with mechanomyography and acceleromyography. To obtain calibrated acceleromyographic TOF ratios in group A, the implemented calibration modus 2 was activated in the TOF-Watch S; to obtain uncalibrated acceleromyographic TOF ratios in group B, the current was manually set at 50 mA (n = 30 for each). In addition, data in group B were normalized (i.e., dividing the final TOF ratio by the baseline value). The agreement between mechanomyography and acceleromyography was assessed by calculating the intraclass correlation coefficient. Negative predictive values were calculated for detecting residual paralysis from acceleromyographic TOFs of 0.9, 0.95, and 1.0. Results Group A : For a mechanomyographic TOF of 0.9 or greater, the corresponding acceleromyographic TOF was 0.95 (range, 0.86-1.0), and the negative predictive values for acceleromyographic TOFs of 0.9, 0.95, and 1.0 were 37% (95% CI, 20-56%), 70% (95% CI, 51-85%), and 97% (95% CI, 83-100%), respectively. Group B: Without normalization, an acceleromyographic TOF of 0.97 (range, 0.68-1.18) corresponded to a mechanomyographic TOF of 0.9 or greater, with negative predictive values for acceleromyographic TOFs of 0.9, 0.95, and 1.0 being 40% (95% CI, 23-59%), 60% (95% CI, 41-77%), and 77% (95% CI, 58-90%), respectively. After normalization, an acceleromyographic TOF of 0.89 (range, 0.63-1.06) corresponded to a mechanomyographic TOF of 0.9 or greater, and the negative predictive values of acceleromyographic TOFs of 0.9, 0.95, and 1.0 were 89% (95% CI, 70-98%), 92% (95% CI, 75-99%), and 96% (95% CI, 80-100%), respectively. Conclusion To exclude residual paralysis reliably when using acceleromyography, TOF recovery to 1.0 is mandatory.

Background Reversal of the residual effect of rocuronium or cisatracurium by neostigmine may be slow and associated with side-effects. This randomized, safety-assessor-blinded study compared the efficacy of sugammadex, a selective relaxant binding agent for reversal of rocuronium-induced neuromuscular block, with that of neostigmine for reversal of cisatracurium-induced neuromuscular block. The safety of sugammadex and neostigmine was also evaluated. Methods Adult surgical patients (ASA class I–III) were randomized to sugammadex 2.0 mg kg−1 for reversal of block induced by rocuronium 0.6 mg kg−1, or neostigmine 50 µg kg−1 for reversal of block induced by cisatracurium 0.15 mg kg−1. Anaesthesia was induced and maintained using i.v. propofol and remifentanil, fentanyl, or sufentanil. Neuromuscular function was monitored using acceleromyography (TOF-Watch® SX). Sugammadex or neostigmine was administered at reappearance of T2. The primary efficacy variable was time for recovery of the train-of-four (TOF) ratio to 0.9. Results Eighty-four patients were randomized, 73 of whom received sugammadex (n=34) or neostigmine (n=39). Time from start of administration of reversal agent to recovery of the TOF ratio to 0.9 was 4.7 times faster with sugammadex than with neostigmine (geometric mean=1.9 vs 9.0 min, P

Patients who are given a single dose of succinylcholine normally undergo a short-acting depolarizing phase I neuromuscular block but rarely a phase II block. Prolonged neuromuscular blockade occurs after a single dose of succinylcholine in case of genetically determined abnormal plasma butyrylcholinesterase activity. It is mandatory to use monitoring to detect this side effect. We report a case of a patient with abnormal plasma butyrylcholinesterase activity undergoing a six-hour prolonged neuromuscular phase II block, after a single dose of succinylcholine.

A 40 year-old 2nd gesta pregnant woman (34.5 weeks of amenorhea) was admitted to hospital for abdominal pain and arterial hypotension which were rapidly related to a retroperitoneal haematoma due to left kidney bleeding. Emergency cesarean delivery under general anaesthesia was undertaken because of foetal distress. Exploration of the retroperitonal space after foetal extraction confirmed the presence of a large haematoma and abnormal left renal morphology. The retroperitoneal space was drained without any further intervention. Subsequently, abdominal and thoracic computerised tomographic examination showed bilateral dysplasia of the kidneys and pulmonary cysts consistent with the diagnosis of renal angiomyolipoma and pulmonary lymphangioleiomyomatosis. The case report is of interest because of the circumstances of discovery of the disease and because nephrectomy was not necessary to control the bleeding of the left kidney. Six months after the incident the patient and the child are in good condition.

L’anesthesie fait appel a des moyens pharmacologiques et des techniques : les techniques d’anesthesie generale (AG) et les techniques d’anesthesie locoregionale (ALR). L’ALR a pour but d’interrompre transitoirement et selectivement la transmission des influx nociceptifs grace a l’injection d’un anesthesique local au voisinage d’une structure nerveuse. L’ALR peut etre utilisee seule sans sedation = bloc anesthesique (ex. : bloc de membre en orthopedie). ALR et AG peuvent aussi etre associees (ex. : bloc paravertebral thoracique (BPV) pour la chirurgie mammaire = bloc antalgique), car l’ALR ne suffit pas a elle seule a couvrir la periode operatoire. Le BPV consiste a injecter un anesthesique local au niveau des racines des nerfs rachidiens qui emergent du canal rachidien par le foramen intervertebral dans l’espace paravertebral. Il etait peu utilise en chirurgie mammaire a cause du risque de pneumothorax car il etait realise a l’aveugle » grace a des reperes anatomiques [1]. La ponction echoguidee a recemment permis de rehabiliter ce bloc en termes de securite et de fiabilite [2].

Resume Objectif Rechercher et evaluer l'influence du propofol sur les concentrations de ciclosporine et de lipoproteines, transporteuses de ciclosporine. Type d'etude Etude prospective ouverte. Patients Quinze patients, (13 transplantes renaux, un tranplante rein-cœur et un rein-pancreas), dont le traitement immunosuppresseur comportait de la ciclosporine a doses stables, et devant beneficier d'un geste chirurgical compatible avec une poursuite de leur traitement oral. Methode Les dosages sanguins suivants ont ete realises: concentration sanguine residuelle de ciclosporine la veille et le lendemain de l'anesthesie; ciclosporinemie, cholesterolemie et triglyceridemie, HDL cholesterol, avant et a la fin de l'anesthesie. Resultats La duree moyenne de l'anesthesie etait de 85 ± 59 min (extremes 30–210 min). Les doses d'agents anesthesiques etaient de 175 ± 82 μg de fentanyl, 2,8 ± 0,8 mg de midazolam et 696 ± 497 mg de propofol. Les concentrations sanguines residuelles de ciclosporine etaient de 142 ± 47 ng·mL −1 la veille de l'anesthesie, et de 128 ± 46 ng mL −1 le lendemain ( P = 0,08), les doses de ciclosporine etant identiques. Les variations du cholesterol n'etaient pas significatives; en revanche, celles des triglycerides (1,46 ± 0,66 vs 1,97 ± 0,81 g·L −1 ), des lipoproteines HDL (0,54 ± 0,20 vs 0,47 ± 0,18 g·L −1 ) et LDL (1,44 ± 0,42 vs 1,28 ± 0,37 g·L −1 ) l'etaient. Conclusion Cette etude montre qu'une anesthesie comportant l'administration de propofol n'entraine pas de variation significative des concentrations sanguines residuelles de ciclosporine.

Postoperative curarization following a single dose of rocuronium is a known risk quickly diagnosed through the monitoring of neuromuscular blockade. Different etiologies can cause a prolonged block. We report the case of a misdiagnosis of prolonged neuromuscular blockade by a failure in the monitoring system of curarization.

Recently, three case reports have suggested the possible efficacy of sugammadex in anaphylactic shock refractory to conventional treatment induced by rocuronium. We report a new case of severe anaphylactic reaction to rocuronium treated with sugammadex. After 18 minutes of conventional treatment because of persistent cardiocirculatory failure and bronchospasm, a bolus of 2000 mg (18 mg/kg) of sugammadex was injected. This was associated with rapid correction of arterial hypotension and bronchoconstriction. The underlying pathophysiological mechanisms that explain the potential beneficial effect of sugammadex in this context are unknown but it is important to know that refractory anaphylactic shock to rocuronium can be potentially corrected with sugammadex.

Sugammadex reverses neuromuscular blockade by chemical encapsulation of nondepolarizing neuromuscular blocking drugs (rocuronium and vecuronium). The imprint of this new molecule has recently been supplemented with a section on haemostasis notifying a longer clotting time without documented clinical consequences. This has resulted in recommendations on the use of sugammadex in the presence of coagulation disorders (pharmacologically-induced or not). The objective of this study was to analyze the experience gathered with this molecule on clinically-evaluated bleeding. No study on this subject is currently available.This is a retrospective study over 1 year between August 2009 and August 2010. All patients with laparotomies for cancer surgery requiring suction drains were included. Patients were allocated to groups according to the type of reversal (without sugammadex versus sugammadex 2 or 4 mg/kg). The endpoint was clinically-evaluated postoperative bleeding (reoperation for haemostasis, blood-stained laparotomy dressings in the post-anaesthesia care unit [PACU], cumulative volume collected in suction drains upon arrival in PACU and then after 2 hours and the next morning at 6a.m).One hundred and ninety-three patients were included in three groups, 78 in the group "without sugammadex", 95 in "sugammadex 2mg/kg" and 20 in "sugammadex 4 mg/kg". There were no reoperations for haemostasis. The comparison among different groups for the endpoint of bleeding showed no significant difference.In this retrospective study performed in patients at high risk of postoperative bleeding, sugammadex at doses of 2 and 4 mg/kg was not associated with increased bleeding. This study, the first in this field, suggests that future prospective investigations should target patients receiving 4 or 16 mg/kg of sugammadex and/or with documented preoperative abnormal coagulations tests.

Suxamethonium was first administered to volunteers and patients more than 40 years ago and since that time has been probably one of the most valuable but controversial drugs in the anaesthetist's armamentarium. Its ability to produce rapid and profound muscle relaxation of short duration is unrivalled, and because of this, it is used widely despite a miscellany of side effects which can be recited by anaesthetists within their first few months of training. As many of these are well known, this article will concentrate on only a few of the more topical side effects, where new information is available, and assess the future role of suxamethonium in the context of a new generation of ‘designer’ competitive muscle relaxants.

Patients who are given a single dose of succinylcholine normally undergo a short-acting depolarizing phase I neuromuscular block but rarely a phase II block. Prolonged neuromuscular blockade occurs after a single dose of succinylcholine in case of genetically determined abnormal plasma butyrylcholinesterase activity. It is mandatory to use monitoring to detect this side effect. We report a case of a patient with abnormal plasma butyrylcholinesterase activity undergoing a six-hour prolonged neuromuscular phase II block, after a single dose of succinylcholine.

The effects of rocuronium, 0.25 or 0.5 mg · kg, were measured simultaneously on the adductor muscles of the larynx and adductor pollicis in 14 adult patients. Anaesthesia was induced and maintained with propofol and fentanyl. Tracheal intubation was performed without muscle relaxants. The recurrent laryngeal and ulnar nerves were both stimulated supramaximally, at the notch of the thyroid cartilage and at the wrist respectively, using train-of-four stimulation. The laryngeal response was evaluated by measuring the pressure change in the cuff of a tracheal tube positioned between the vocal cords. Onset time, intensity of blockade and duration of action were less at the larynx than at the adductor pollicis. After rocuronium, 0.25 mg · kg−1, the onset time (interval between injection and maximal TI blockade) was 1.6 ± 0.1 min and 3.0 ± 0.3 min (mean ± SEM) at the laryngeal muscles and adductor pollicis, respectively (P < 0.01 between muscles). Maximum blockade was 37 ± 8% and 69 ± 8%, respectively (P < 0.05), and time to 90% TI recovery was 7 ± 1 min and 20 ± 4 min, respectively (P < 0.05). With 0.5 mg· kg−1, the onset time was also more rapid at the vocal cords (1.4 ± 0.1 min) than at the adductor pollicis (2.4 ± 0.2 min, P < 0.001). Maximum blockade was 77 ± 5% and 98 ± 1 %, respectively (P < 0.01), and time to 90% TI recovery was 22 ± 3 min and 37 ± 4 min, respectively (P < 0.01). It is concluded that with rocuronium onset and recovery are faster at the laryngeal adductor muscles, but blockade is less intense than at the adductor pollicis. These findings are similar to the observations made previously with vecuronium, except that rocuronium had a faster onset at both muscles.

Background Low degrees of residual paralysis (i.e., a train-of-four [TOF] ratio > 0.4) are relatively frequent, difficult to detect, and still potentially harmful. Unfortunately, the appropriate dose of anticholinesterase for this situation has not been determined. This may be of clinical interest because a high dose of neostigmine given at a shallow level of neuromuscular block may produce neuromuscular weakness. The purpose of this study was to investigate the dose-effect relationship of neostigmine to antagonize residual paralysis corresponding to a TOF ratio of 0.4 and 0.6. Methods Recovery after 10, 20, 30 microg/kg neostigmine or placebo given at either 0.4 or 0.6 TOF ratio was assessed by acceleromyography in 120 patients undergoing intravenous anesthesia. Time to a 0.9 and 1.0 TOF ratio was measured, and the probability of successful reversal within 10 min after the respective neostigmine doses was calculated. In addition, the dose of neostigmine needed to achieve the recovery targets in 5 or 10 min was also determined. Results When given at a TOF ratio of either 0.4 or 0.6, time to 0.9 and 1.0 TOF ratio was significantly shorter with any dose of neostigmine than without. The probability of successful reversal after 20 microg/kg neostigmine was 100% when a TOF ratio of 0.9 was the target; for a TOF ratio of 1.0, the probability was 93% and 67%, dependent on whether the dose of neostigmine was given at TOF ratio of 0.6 or 0.4, respectively. With a dose of 30 microg/kg, a TOF ratio of 1.0 is expected to be reached within approximately 5 min. Low doses of neostigmine are required to reach a TOF ratio of 0.9 or to accept an interval of 10 min. Conclusion Reduced doses (10-30 microg/kg) of neostigmine are effective in antagonizing shallow atracurium block. For successful reversal within 10 min, as little as 20 microg/kg neostigmine may be sufficient. These dose recommendations are specific for atracurium and an intravenous anesthetic background.

Sugammadex is a new molecule derived from a known pharmacological class : the cyclodextrins known and used in human for many years. It was recently demonstrated that cyclodextrins could encapsulate and bind strongly steroidal neuromuscular blocking agents. Among cyclodextrins gamma-cyclodextrins proved to be more efficient. The binding of cyclodextrins to rocuronium and compound's water solubility was greatly improved by addition of 8 side chains to glycopyranoses units and the presence of a negative charge to the end of these side-chains. Animal studies have clearly demonstrated that sugammadex is faster in onset than anticholinesterase agents and is specific of steroidal neuromuscular blocking agents. It cannot reverse neuromuscular block induced by succinylcholine or benzylisoquinolines such as atracurium or cisatracurium. In human, the dose of sugammadex required to reverse shallow block is 2 mg/kg approximately whereas 4 mg/kg is needed to reverse deep level of neuromuscular block with a few responses at the post tetanic count at the adductor pollicis. The use of sugammadex was not associated with recurrence of block when an adequate dose was administered.

Neuromuscular monitoring and routine use of reversal agents are key elements in the prevention of residual paralysis. According to a nation-wide survey up to 52 % of anaesthesiologists in France apply regularly neuromuscular monitoring after a single intubating dose of a neuromuscular blocking agent and 74 % in case of repetitive administration. However, reversal is rather the exception than routine and, still according to this survey, the risk of residual paralysis largely underestimated. The development of a new class of reversal agents (cyclodextrins) may further modify the management of neuromuscular blockade in clinical practice. The article aims to revise the principles of neuromuscular monitoring and evaluate whether its use is still mandatory when sugammadex is used.

Sugammadex, a cyclodextrin, is a novel agent designed to encapsulate selectively steroidal neuromuscular blocking agents such as rocuronium and vecuronium as well. One molecule of sugammadex is able to encapsulate only one molecule of muscle relaxant. This original pharmacological property allows a very rapid reversal of muscle paralysis. After sugammadex injection, a train of four ratio higher than 0.9 is obtained in less than 5 minutes in all the patients whatever the degree of muscle paralysis at the time of reversal and even when anesthesia is maintained with halogenated agents. However, in order to preserve this efficacy, the dose of sugammadex needs to be adjusted to the degree of muscle paralysis at the time of reversal : 2 mg/kg after obtaining 2 responses at the adductor pollicis muscle after a train of four stimulation, 4 mg/kg with a post-tetanic count between 1 and 3 responses, and 12 to 16 mg/kg in case of rescue reversal (3 to 15 minutes after 0.6 to 1.2 mg/kg rocuronium). Even if the original property of sugammadex lets us think that per-operative neuromuscular transmission monitoring would not be furthermore useful, the assessment of the exact degree of muscle paralysis before reversal is mandatory for choosing the right dose of sugammadex.

Hyperthermic intraperitoneal chemoperfusion (HIPEC) is an innovative treatment of the peritoneal carcinomatosis with potential iatrogenicity. This observational study was designed to improve our understanding of HIPEC's impact on the renal and respiratory functions, on temperature, blood cells counts, body fluids/electrolytes and acid-base balance.We retrospectively analyzed the perioperative care of 20 patients that underwent HIPEC with oxaliplatin (n=19) and mitomycin C (n=1). The abdominal cavity was filled with the peritoneal dialysis fluid with dextrose 5%: volume of 2L/m(2). Follow-up for the study was stopped on postoperative day 7.The main changes were appearing just after the HIPEC procedure: increased diuresis, lactic acidosis, hyponatremia and hyperglycaemia (despite aggressive intravenous insulin therapy). In our series, there was no renal failure or impact on blood cells counts until the 7(th) day, neither some changes on the arterial blood gases.Hyperglycemia might explain increased diuresis of lactic acidosis and the rapid installation of hyponatremia. Taken together, these results suggest that glycemic control must be improved in order to avoid the other metabolic disturbances.

This study was undertaken to compare the potency of vecuronium in patients anaesthetized in Montreal or Paris. Anaesthesia was induced with thiopentone and maintained with N2O, and intermittent boluses of thiopentone and fentanyl in 18 patients in Paris and 19 in Montreal. Neuromuscular blockade was measured using train-of-four stimulation of the ulnar nerve. The force of contraction of the adductor pollicis muscle was measured. Single doses of vecuronium, 20, 30, or 40 micrograms.kg-1 were given by random allocation. Dose response curves were constructed by obtaining the linear regression of the logit of the first response (T1) neuromuscular blockade versus log dose. The patients in Paris required 27% more vecuronium (95% confidence limits 5-53%; P = 0.01) for the same intensity of blockade. In Montreal, the ED50 and ED90 (+/- SEE for the mean) values were 26.0 +/- 1.4 and 44.2 +/- 2.5 micrograms.kg-1 compared with 33.0 +/- 3.3 and 71.9 +/- 7.2 micrograms.kg-1 in Paris respectively. The patients were comparable with respect to age, sex, height and weight. These results confirm, for vecuronium, the transatlantic difference in potency of neuromuscular blocking drugs which was previously observed with d-tubocurarine between London and New York.

The recurrent laryngeal nerve was stimulated with surface electrodes to produce vocal cord adduction, and the response was measured as pressure changes in the inflatable cuff of a tracheal tube positioned between the vocal cords. To test the linearity of the system, a model of the larynx consisting of a syringe barrel was constructed, and weights were applied to two bands of tissue simulating the vocal cords. Tests on Mallinckrodt size-7.5 tubes showed that the pressure increase produced by a given force was independent of baseline pressure in the range 10-30 mmHg. In addition, the pressure inside the inflatable cuff was linear with increasing weight (or force) for a baseline pressure of 10 mmHg. Thirty ASA physical status 1 or 2 adults were anesthetized with propofol and fentanyl. Tracheal intubation was performed in the absence of muscle relaxants, and the inflatable cuff of the tracheal tube was positioned between the vocal cords. Pressure inside the cuff was measured with an air-filled transducer. Stimulation was produced at different sites along the course of the recurrent laryngeal nerve. A surface electrode placed over the notch of the thyroid cartilage produced consistent adduction of the cords, measured as an increase of 8.9 +/- 5.1 mmHg (mean +/- standard deviation [SD]) in the cuff pressure. Neuromuscular blocking drugs produced train-of-four fade, and large doses abolished the response completely, ruling out direct muscle stimulation. It is concluded that this assembly can provide useful information on intrinsic laryngeal muscle function.

The differences between neuromuscular blockade of the adductor muscles of the vocal cords and the adductor pollicis were examined in 20 adult women anesthetized with fentanyl and propofol. Vecuronium 0.04 or 0.07 mg/kg was given as a single bolus by random allocation. The force of contraction of the adductor pollicis was recorded. Laryngeal response was measured as pressure changes in the cuff of the tracheal tube positioned between the vocal cords. Train-of-four stimulation was applied to the recurrent laryngeal nerve at the notch of the thyroid cartilage and to the ulnar nerve at the wrist. Neuromuscular blockade had a faster onset, was less intense, and recovered more rapidly at the vocal cords. With 0.04 mg/kg, maximum blockade of first twitch (T1) was 55 +/- 8 (mean +/- standard error of the mean [SEM]) and 88 +/- 4% at the vocal cords and the adductor pollicis, respectively (P = 0.006). Onset time was 3.3 +/- 0.1 and 5.7 +/- 0.2 min, respectively (P = 0.000001), and time to 90% T1 recovery was 11.3 +/- 1.6 and 26.1 +/- 1.8 min, respectively (P = 0.001). With 0.07 mg/kg, onset time was unchanged; maximum blockade was more intense, being 88 +/- 4 and 98 +/- 1%, respectively (P = 0.04 between muscles); and time to 90% T1 recovery was 23.3 +/- 1.8 min at the vocal cords versus 40.3 +/- 2.9 min at the adductor pollicis (P = 0.001). Approximately 1.73 times as much vecuronium was required at the larynx compared with the dose required at the adductor pollicis for the same intensity of blockade.(ABSTRACT TRUNCATED AT 250 WORDS)

To improve ventilation monitoring during direct laryngoscopy, we have developed a high frequency jet ventilator which allows the aspiration of tracheal gas for carbon dioxide analysis (PtCO2) through the injector after stopping the ventilator. In 41 patients undergoing direct laryngoscopy, PaCO2 and PtCO2 were measured simultaneously during high frequency jet ventilation under general anaesthesia. PtCO2 and PaCO2 correlated significantly (r = 0.88), but PtCO2 underestimated PaCO2 by 0.84 (SD 0.72) kPa. The arterial to tracheal PCO2 difference was influenced by airway obstruction.

A 40 year-old 2nd gesta pregnant woman (34.5 weeks of amenorhea) was admitted to hospital for abdominal pain and arterial hypotension which were rapidly related to a retroperitoneal haematoma due to left kidney bleeding. Emergency cesarean delivery under general anaesthesia was undertaken because of foetal distress. Exploration of the retroperitonal space after foetal extraction confirmed the presence of a large haematoma and abnormal left renal morphology. The retroperitoneal space was drained without any further intervention. Subsequently, abdominal and thoracic computerised tomographic examination showed bilateral dysplasia of the kidneys and pulmonary cysts consistent with the diagnosis of renal angiomyolipoma and pulmonary lymphangioleiomyomatosis. The case report is of interest because of the circumstances of discovery of the disease and because nephrectomy was not necessary to control the bleeding of the left kidney. Six months after the incident the patient and the child are in good condition.

The aim is to perform a literature search on the role of pregnancy in the rupture of renal angiomyolipoma. Articles published from 1952 to 2004 in the Medline database were searched using the keywords renal angiomylipoma and pregnancy. Pathologies associated with angiomylipoma (lymphangioleiomyomatosis and Bourneville tuberous sclerosis) were taken into account. Seventy-two cases of association of renal angiomyolipoma and pregnancy were found, out of which 58 presented a haemorrhage. In only 26% of the cases, renal angiomyolipoma had been documented prior to pregnancy. Clinical presentation was similar to cases occurring among non pregnant women: abdominal pains (88%), hypotension or shock (33%) and hematuria (24%). Average size of the rupture was 11,7 cm. Rupture does not occur solely with the first pregnancy but occurred equally during the first, second and third pregnancy. Average gestation age upon occurrence of haemorrhage was 27 weeks with a minimum at ten weeks. Therapeutic strategies at the time of shock or hypotension were total nephrectomy in 79% of the cases, 7% polar nephrectomy, 7% embolisation followed by nephrectomy and 7% abstention. A causal role of pregnancy in the atraumatic rupture of angiomyolipoma is not clearly defined. Nevertheless, many arguments (whether it be abdominal mechanical pressure, hormonal or histological ones) suggest that a pregnancy could increase the risk of renal angiomyolipoma rupture. These patients should have a medical follow-up period at closer intervals during their pregnancy and the postpartum phase.

The number of cardiac transplantation procedures does not increase because of the lack of donor hearts despite an increase in the number of brain-dead organ donors. The criteria used to select a donor heart are not formally standardized. The aim of the present study was to analyze the criteria that contribute to the selection of a donor heart.Descriptive, retrospective study.Clinical parameters, the initial causes that lead to brain death, maximum doses of catecholamines, several biochemical markers of myocardial ischaemia/necrosis as well as several echocardiography criteria were extracted from a prospectively collected database. Univariate and multivariate (logistic regression) analyses were performed with the "harvested heart" as dependent variable and the above-cited independent variables.One hundred and eighty consecutive brain-dead patients admitted from 1st October 1998 to 31st December 2000 out of which 112 gave at least one organ were analyzed. Among these 112 patients, 59 (39 males and 20 females) were pre-selected as potential heart donors. Only 44 hearts were harvested. Logistic regression analysis showed that harvesting of the heart was more probable if the donor were a male, had no left ventricle systolic wall motion abnormalities, had low doses of norepinephrine and low serum troponin Ic concentrations.After an initial phase of selection, the final decision to harvest a heart is based on several criteria. These results should be an incentive to conceive a score that could allow a more formal decision process for heart harvesting.

We report a case of Budd-Chiari syndrome revealing a polycythemia vera and complicated by heparin-induced thrombocytopenia. A surgical porto-caval shunt was inserted with danaparoid as anticoagulant during the peri-operative period. The doses of danaparoid were as follows: a continuous intravenous infusion of 200 U/h with a target between 0.5 et 0.8 U/ml antifactor Xa activity during the preoperative period, followed by 100 U/h with a target of 0.3 U/ml during the peroperative period; an increase in doses of danaparoid to 150 and 200 U/h with a target above 0.5 U/ml was used during the postoperative period. This case report is a rare situation of hypercoagulable state, in a surgical context, treated with danaparoid.

Introduction Afin de participer au mieux a la reduction des depenses de sante, les differents acteurs hospitaliers doivent gerer au plus juste l’utilisation de leurs ressources humaines et financieres. Ces preoccupations economiques ont deja fait l’objet de publications assez difficiles a comparer. Nous presentons un moyen de calcul du cout du bloc operatoire valide par la comptabilite analytique des controleurs de gestion participant a l’etude nationale des couts (ENCC) [1] . Materiel et methodes Le calcul du cout de fonctionnement d’un bloc operatoire est comparable au cout de production d’une entreprise. Ce cout represente la somme des depenses realisees directement pour produire des biens ou des services. Le service est ici represente par une operation chirurgicale sous anesthesie. Le poste de production choisi est l’ensemble du bloc operatoire et la SSPI. La repartition est composee des charges directes (salaires, medicaments et materiel) et indirectes. Ces charges sont affectees selon les recommandations du guide de comptabilite analytique hospitaliere [2] . Les charges indirectes n’ont pas de lien immediat avec le cout de production mais sont indispensables a sa realisation et necessitent la mise en place de clefs de repartition : l’ingenierie biomedicale (valeur de l’actif brut medical immobilise), la sterilisation (volume sterilise), la pharmacie (l’euro de charges de depenses medicaments), les services administratifs a caractere general (l’euro des charges directes), le service des ressources humaines (l’effectif du bloc), le service hotelier, l’entretien et la maintenance de l’etablissement (surface utilisee), le brancardage (nombre de courses effectuees), la structure financiere (l’euro des charges directes) et la structure immobiliere (surface utilisee). Resultats Pour l’annee 2012, le cout du bloc operatoire avec la SSPI etait de 10,8€ par min ( Tableau 1 ). Deux tiers des charges directes revenaient a la chirurgie pour 1/3 l’anesthesie. Le cout d’une anesthesie etait de 111,45€ d’un point de vue uniquement medicaments et consommables medicaux ((cout medicament d’anesthesie + cout consommables medicaux d’anesthesie)/nombre d’anesthesies (n = 2150). Il est de 753,14€ par rapport au cout total de l’anesthesie de l’etablissement ((charges directes de l’anesthesie + 1/3 des charges indirectes)/nombre d’anesthesies). La part des medicaments et consommables pour l’anesthesie etait de 14,8 % du cout total. Discussion Malgre des difficultes auxquelles se heurte le calcul d’un cout, ce modele de calcul se valide par la comptabilite analytique issu d’une methodologie nationale, permet d’etre reproductible et comparable. Cela montre egalement qu’un raisonnement global est necessaire lors de prise de decisions financieres.

The diagnostic and therapeutic approaches for evaluation and management of cardiac function in brain-dead patients vary from country to country. The aim of the present study was to describe the results of the evaluation of brain-dead patients as potential cardiac donors in a French teaching hospital that manages the largest number of brain-dead patients in France.Demographic parameters, the causes of brain death, clinical evolution, hemodynamic parameters, doses of inotropic and/or vasopressive drugs, the results of echocardiographic examination, and several biochemical markers of myocardial cell injury were retrospectively collected.Seventy-one consecutive brain-dead patients admitted to the intensive care unit of the Academic Hospital of Nancy from October 1st, 1998 to September 30, 1999 were analyzed. Twenty-nine patients were considered as potential heart donors: 22 males and 7 females aged 33 +/- 3 years (Mean + SEM). The cause of brain death was head trauma in 17 cases (59%), cerebrovascular disease in 10 cases (34%), and cerebral anoxia related to cardiac arrest in 2 cases (7%). Eighteen hearts (18/29 or 66%) were harvested and transplanted with a favorable outcome at one month in 17 cases. In 11 cases, the heart was not harvested, nine (9/29 or 31%) because of myocardial dysfunction upon subsequent echocardiographic examination and 2 because of the lack of matched recipients.Comparison of these results with those of other groups suggests that hormonal substitution with insulin and triiodothyronine in the presence of myocardial dysfunction could be of potential interest to correct myocardial dysfunction and increase the number of donor hearts.