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Multiple organ failure (MOF) is the leading cause of death in patients with burns requiring ICU admission. Quantifying the evolution of MOF, with the SOFA score, over the first few days after a severe burn may provide useful prognostic information. This retrospective cohort study aimed at evaluating the association between the evolution of the SOFA score between day 0 and day 3 and in-hospital mortality. All patients admitted for severe burns at the burn ICU of the Tours University Hospital between 2017 and 2020 and who stayed 3 days or more were included. Severe burns included: total body surface area burned (TBSA) ≥ 20 % or burns of any surface associated with one or more of the following items: (1) organ failure, (2) clinically significant smoke inhalation and/or cyanide poisoning, (3) severe preexisting comorbidities, (4) complex and specialized burn wound care. DeltaSOFA was defined as day 3 minus day 0 SOFA. One hundred and thirty-six patients were included. Median age was 52 years (38-70), median TBSA burned was 24 % (20-38), median day 0 SOFA was 2 (0-4) and median day 3 SOFA was 1 (0-5). In-hospital mortality was 10 %. There was a significant association between deltaSOFA and mortality that persisted after adjustment for age and TBSA (HR 1.37, 95 %CI 1.09-1.72, p 0.01). Area under the receiver operating characteristics curve for the prediction of mortality by day 0 SOFA and deltaSOFA were 0.79 (95 %CI 0.69-0.89) and 0.83 (95 %CI 0.70-0.95) respectively. After exclusion of patients with TBSA burned 15 %, deltaSOFA remained independently associated with mortality (HR 1.42 95 %CI 1.09-1.85, p 0.01). In addition, SOFA variations allowed the identification of subgroups of patients with either very low or very high mortality. In patients with severe burns, SOFA score evolution between day 0 and day 3 may be useful for individualized medical and ethical decisions. Further multicenter studies are required to corroborate the present results.

Background We aimed to determine whether high-flow nasal oxygen could reduce the incidence of decreased peripheral oxygen saturation (SpO2) compared with standard oxygen in patients at risk of hypoxaemia undergoing gastrointestinal endoscopy under deep sedation. Methods This was a multicentre, randomised controlled trial with blinded assessment of the primary outcome evaluating high-flow nasal oxygen (gas flow 70 L min−1, inspired oxygen fraction 0.50) or standard oxygen delivered via nasal cannula or face mask (6 L min−1) or nasopharyngeal tube (5 L min−1) in patients at risk of hypoxaemia (i.e. >60 yr old, or with underlying cardiac or respiratory disease, or with ASA physical status >1, or with obesity or sleep apnoea syndrome) undergoing gastrointestinal endoscopy. The primary endpoint was the incidence of SpO2 ≤92%. Secondary outcomes included prolonged or severe desaturations, need for manoeuvres to maintain free upper airways, and other adverse events. Results In 379 patients, a decrease in SpO2 ≤92% occurred in 9.4% (18/191) for the high-flow nasal oxygen group, and 33.5% (63/188) for the standard oxygen groups (adjusted absolute risk difference, –23.4% [95% confidence interval (CI), –28.9 to –16.7]; P 1 min) and manoeuvres to maintain free upper airways were less frequent in the high-flow nasal oxygen group than in the standard oxygen group (7.3% vs 14.9%, P=.02, and 11.1% vs 32.4%, P Conclusions In patients at risk of hypoxaemia undergoing gastrointestinal endoscopy under deep sedation, use of high-flow nasal oxygen significantly reduced the incidence of peripheral oxygen desaturation. Clinical trial registration NCT03829293.

Severe hypoxemia in patients with COVID-19 pneumonia might result from hypoxic pulmonary vasoconstriction, contributing to ventilation/perfusion (V/Q) mismatch. Because almitrine improves V/Q, it might reduce the risk for mechanical ventilation (MV) in such patients. Our primary objective was to determine the effect of almitrine on the need for MV at day 7.In a randomised double-blind placebo-controlled trial involving 15 ICUs, patients hospitalized for COVID-19 pneumonia and experiencing acute hypoxemic respiratory failure were randomly assigned to receive 5 days of intravenous low-dose (2 µg.kgBetween September 3, 2020 and September 25, 2021 181 patients were enrolled and randomly assigned to almitrine (n=89) or placebo (n=92). 179 patients (excluding two who withdrew from the study) were included in the intention-to-treat analysis (mean age: 60·1 years; 34% women) and analyzed. On day 7, the primary endpoint occurred in 32 patients assigned to almitrine (36%) and in 37 patients assigned to placebo (41%), for a difference of -4·3% (95% confidence interval: -18·7% to 10·2%). Secondary outcomes (28-day mortality, in-hospital mortality, ventilator-free days at day 28, days in the ICU and the hospital, and treatment discontinuation for pre-specified adverse effects) did not differ between the two groups.In patients with COVID-19 acute hypoxemic respiratory failure, low-dose almitrine failed in reducing the need for MV or death at day 7.Programme Hospitalier de Recherche Clinique (PHRC COVID 2020) funded by the French Ministry of Health, Les Laboratoires Servier (Suresnes, France) providing the study drug free of charge.

Objectives To appraise the epidemiological features of bacterial pneumonia and its impact on lung suitability for donation in brain-dead patients managed with protective ventilatory settings. Design Retrospective observational study. Setting Six ICUs from two university-affiliated hospitals. Patients Brain-dead adult patients managed in the participating ICUs over a 4-year period. Interventions None. Measurements and main results Among the 231 included patients, 145 (62.8%) were classified as ideal or extended-criteria potential lung donors at ICU admission and the remaining 86 patients having baseline contraindication for donation. Culture-proven aspiration pneumonia and early-onset ventilator-associated pneumonia occurred in 54 patients (23.4%) and 15 patients (6.5%), respectively (overall pneumonia incidence, 29.9%). Staphylococcus aureus and Enterobacterales were the most common pathogens. Using mixed-effects Cox proportional hazard models, age (adjusted hazard ratio, 0.98; 95% CI [0.96-0.99]), anoxic brain injury (3.55 [1.2-10.5]), aspiration (2.29 [1.22-4.29]), and not receiving antimicrobial agents at day 1 (3.56 [1.94-6.53]) were identified as independent predictors of pneumonia occurrence in the whole study population. Analyses restricted to potential lung donors yielded similar results. Pneumonia was associated with a postadmission decrease in the PaO2/FIO2 ratio and lower values at brain death, in the whole study population (estimated marginal mean, 294 [264-323] vs 365 [346-385] mm Hg in uninfected patients; p = 0.0005) as in potential lung donors (299 [248-350] vs 379 [350-408] mm Hg; p = 0.04; linear mixed models). Lungs were eventually retrieved in 31 patients (34.4%) among the 90 potential lung donors with at least one other organ harvested (pneumonia prevalence in lung donors (9.7%) vs nondonors (49.2%); p = 0.0002). Conclusions Pneumonia occurs in one-third of brain-dead patients and appears as the main reason for lung nonharvesting in those presenting as potential lung donors. The initiation of antimicrobial prophylaxis upon the first day of the ICU stay in comatose patients with severe brain injury could enlarge the pool of actual lung donors.

Summary Background In 2011, the company that produced thiopental in France and in the United States stopped its marketing. Because of limited evidences, the choice of the best induction agent for caesarean section remains controversial, especially in emergency. The objective of this study was to compare the effects of propofol versus thiopental on the Apgar score of the newborn. Methods Newborns delivered by elective or emergency caesarean section under general anaesthesia in a university hospital were included from January 2009 to December 2013. Two periods, according to the hypnotic drug used, were compared in this before-and-after comparative study: thiopental before May 2011 and propofol after. The primary outcome was to compare the proportion of newborns with a 5-minute Apgar Score Results 367 newborns were enrolled, 178 in thiopental group and 189 in propofol group. Demographic and clinical characteristics were similar in both groups. The occurrence of a 5-minute Apgar Score less than 7 was not influenced by the use of propofol (OR 1.40 [CI 95% 0.90–2.20] P = 0.135). Blood gas analyses and admission's rate in neonatal intensive care unit were similar in both groups. Conclusions Thiopental and propofol do not appear to present significant difference in term of outcome of the newborn after caesarean section. In this situation, propofol may probably be a reliable alternative to the supply reduction of thiopental imposed by forces. Prospective studies are required to confirm the safety of propofol, particularly in the long term.

Background The indication for antibiotic prophylaxis in burn patients remains highly controversial, with no consensus having been reached. The objective of antibiotic prophylaxis is to reduce the risk of postoperative local and systemic infections. Burn surgery is associated with a high incidence of bacteremia, postoperative infections, and sepsis. However, antibiotic prophylaxis exposes patients to the risk of selecting drug-resistant pathogens as well as to the adverse effects of antibiotics (i.e., Clostridium difficile colitis). The lack of data precludes any strong international recommendations regarding perioperative prophylaxis using systemic antibiotics in this setting. The goal of this project is therefore to determine whether perioperative systemic antibiotic prophylaxis can reduce the incidence of postoperative infections in burn patients. Methods The A2B trial is a multicenter (10 centers), prospective, randomized, double-blinded, placebo-controlled study. The trial will involve the recruitment of 506 adult burn patients with a total body surface area (TBSA) burn of between 5 and 40% and requiring at least one excision-graft surgery for deep burn injury. Participants will be randomized to receive antibiotic prophylaxis (antibiotic prophylaxis group) or a placebo (control group) 30 min before the incision of the first two surgeries. The primary outcome will be the occurrence of postoperative infections defined as postoperative sepsis and/or surgical site infection and/or graft lysis requiring a new graft within 7 days after surgery. Secondary outcomes will include mortality at day 90 postrandomization, skin graft lysis requiring a new graft procedure, postoperative bacteremia (within 48 h of surgery), postoperative sepsis, postoperative surgical site infection, number of hospitalizations until complete healing (> 95% TBSA), number of hospitalization days living without antibiotic therapy at day 28 and day 90, and multiresistant bacterial colonization or infection at day 28 and day 90. Discussion The trial aims to provide evidence on the efficacy and safety of antibiotic prophylaxis for excision-graft surgery in burn patients. Trial registration ClinicalTrials.gov NCT04292054. Registered on 2 March 2020

Background Double-lumen tracheal tube (DLT) insertion can be managed with videolaryngoscopes such as the Glidescope or indirect laryngoscopes like the Airtraq DL. No study has compared both devices when a difficult intubation is predicted. Objective Our hypothesis was that the Glidescope is superior to the Airtraq for double-lumen tube insertion in patients with a predicted or known difficult airway. Design Randomised study. Patients Adults scheduled for thoracic elective surgery, requiring one-lung ventilation with a predicted difficult intubation score of at least 7 (Arne risk index). Intervention Between March 2014 and March 2015, adult patients, scheduled for elective thoracic surgery, requiring double-lumen tracheal tube placement, and with a predicted risk (evaluated preoperatively using the Arne score) or a history of difficult intubation, were allocated to a Glidescope or an Airtraq group. Main outcome measures The primary outcome was the overall success rate of tracheal intubation after two attempts. Secondary outcomes were success rates on the first attempt, duration of intubation, need for laryngeal pressure, Cormack and Lehane grade and side-effects. Results Of 277 patients, 78 were predicted to have a difficult airway. Finally, 72 patients were enrolled. Neither the overall success rates of tracheal intubation [Glidescope group 31/36 (86%) versus Airtraq group 34/36 (94%), P = 0.43] nor the side-effects differed between groups. There was no difference concerning visualisation of the glottis using the Cormack and Lehane grade (P = 0.18) or intubation time [Glidescope group 67 s (49 to 90) versus Airtraq group 81 s (59 to 101), P = 0.28]. All patients with a previous history of difficult intubation were intubated successfully. Conclusion There is no difference in success rates of tracheal intubation with a double-lumen tube in patients with a predicted or known difficult airway when using either a Glidescope or Airtraq device. Trial registration National register of the French National Agency for Medicines and Health Products Safety No. 2014-A00143-44.

Summary Background Focus cardiac ultrasound is a great tool for quick evaluation of cardiac function in acute settings with limited time and expertise in echocardiography. Adequate training is essential for physicians willing to use this imaging technique. Aim The goal of this study was to assess the efficacy of a self-training programme using a cardiac ultrasound simulator. Methods Thirty-five trainees in cardiology, emergency medicine or anaesthesiology entered the programme, which started with an e-learning lecture on focus cardiac ultrasound, with practice on a simulator, followed by implementation on patients, and ended with self-training in image analysis on an online platform. A post-test evaluation was carried out at the end of the theoretical training, followed by a final live evaluation on patients (timed acquisition of the five reference views used in focus cardiac ultrasound, grading each view on a scale of 1 to 5). Trainees were also evaluated online regarding their interpretation of 20 video clips. Results The median (interquartile range) interpretability scores following simulator training were 5 (4–5) for the parasternal long-axis view, 5 (4–5) for the apical four-chamber view, and 4 (4–5) for the subcostal window. Interpretability was significantly inferior in the live evaluation compared with the post-test evaluation, except for the parasternal long-axis and subcostal views. The mean score for the video clips (out of 20) was 14.5 ± 2.4. Conclusions After a short self-training programme, trainees were able to acquire the main views of focus cardiac ultrasound with sufficient quality and in a short time period.

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Study objective We evaluated if the sitting or supine positions affect anxiety levels induced by the application of a facemask in children. Design Prospective, randomised study. Setting Paediatric hospital, operating room. Patients Two to twelve years old children, 1–3 ASA status, undergoing inhalation anaesthesia for elective surgery. Intervention Children were randomly assigned to a sitting or supine position. After monitoring equipment was established, inhalation was inducted by the application of the mask. Measurements Child anxiety was then assessed with the modified Yale Preoperative Anxiety Scale (mYPAS) before the application of the facemask and following mask application. Main results Overall, 99 children in the sitting group and 103 in the supine group were analysed. The mYPAS score was not different in both groups before the application of facemask (40 [28–51] versus 40 [28–53]; P = 0.99). It increased (P = 0.005) to a similar extent in both groups following mask application without difference between groups (48 [38–60] versus 48 [35–63]; P = 0.95). Side effects were not different between both groups. Conclusion In children undergoing inhalation induction, sitting or supine positions did not modify anxiety induced by the application of a facemask, nor adverse effects; therefore, children should be allowed to choose their preferred position.

Objectives The medical information on the Internet is better in English than in other languages. The information about Epidural Analgesia In Labour (EAIL) available on French-speaking websites is of poor quality. The quality of the information about EAIL should be better in English, but there is no comparison available. This study has assessed and compared the quality of the information about EAIL available on French and English-speaking websites. Method Keywords “epidural”, “epidurale” and/or “peridurale” were used in the French, Canadian and American Google® and Yahoo® search engines. Two independent assessors assessed the 20 first websites for each engine search. They used an evaluation form created from French, Canadian and American recommendations. This form assessed the structure quality (Structure Score/25) and the medical information quality (Medical Information Score/30) of the websites. The addition of both scores gives the Global Score (/55). Results Seventy-one websites were assessed, 39 French-speaking and 32 English-speaking websites. Structure, Medical Information and Global Scores (expressed as mean (SD)) were respectively 11 (4), 13 (5), 24 (8) for the French-speaking websites and 11 (4), 12 (4), 23 (7) for the English-speaking websites. There was no statistical significant difference between both languages. Conclusion Information about EAIL available on French and English-speaking websites is of poor quality and there is no difference in the information quality, whatever the language. A consideration on Internet medical information improvement is needed. A high quality dedicated website should be created and broadcasted.

IntroductionTraumatic brain injury (TBI) is a major cause of death and severe prolonged disability. Intracranial hypertension (ICH) is a critical risk factor of bad outcomes after TBI. Continuous infusion of hyperosmolar therapy has been proposed for the prevention and the treatment of ICH. Whether an early administration of continuous hyperosmolar therapy improves long-term outcomes of patients with TBI is uncertain. The aim of the COBI study (number clinicaltrial.gov 03143751, pre-results stage) is to assess the efficiency and the safety of continuous hyperosmolar therapy in patients with TBI.Methods and analysisThe COBI (COntinuous hyperosmolar therapy in traumatic Brain-Injured patients) trial is a multicentre, randomised, controlled, open-label, two-arms study with blinded adjudication of primary outcome. Three hundred and seventy patients hospitalised in intensive care unit with a TBI (Glasgow Coma Scale ≤12 and abnormal brain CT scan) are randomised in the first 24 hours following trauma to standard care or continuous hyperosmolar therapy (20% NaCl) plus standard care. Continuous hyperosmolar therapy is maintained for at least 48 hours in the treatment group and continued for as long as is necessary to prevent ICH. The primary outcome is the score on the Extended Glasgow Outcome Scale at 6 months. The treatment effect is estimated with ordinal logistic regression adjusted for prespecified prognostic factors and expressed as a common OR.Ethics and disseminationThe COBI trial protocol has been approved by the ethics committee of Paris Ile de France VIII and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. The COBI trial is the first randomised controlled trial powered to investigate whether continuous hyperosmolar therapy in patients with TBI improve long-term recovery.Trial registration numberTrial registration number isNCT03143751.

Resume Introduction Les douleurs chroniques postoperatoires ont ete essentiellement etudiees apres des chirurgies lourdes. Leur incidence varie de 10 a 50 %, dont 5 a 68 % ont des caracteristiques neuropathiques. L’objectif de cette etude prospective monocentrique etait de determiner, apres chirurgie osseuse du pied, l’incidence a un an des douleurs chroniques et des douleurs neuropathiques, ainsi que les facteurs associes a leur survenue. Methode Tous les patients operes du pied ou de la cheville (chirurgie osseuse programmee) entre 2009 et 2011 dans un centre universitaire ont ete inclus. Tous les patients recevaient une analgesie multimodale, comprenant generalement un bloc nerveux continu sciatique poplite, du paracetamol, du ketoprofene voire de la ketamine. Ils etaient contactes par telephone un an apres leur operation. Les criteres principaux d’evaluation etaient les douleurs moderees a severes a un an (DoMS, score de douleur > 3/10), au repos et a la marche, et la presence de douleurs neuropathiques (score DN2). Diverses donnees cliniques perioperatoires immediates ont ete testees en analyse multivariee. Resultats A un an, 55 des 260 patients analyses (21 %) avaient des DoMS au repos, 111 (43 %) a la marche, 9 avaient (3 %) des douleurs neuropathiques. Apres analyse multivariee, la survenue de DoMS durant la premiere nuit postoperatoire ( p = 0,048), a j1 postoperatoire ( p = 0,043), et la chirurgie de reprise ( p = 0,001), etaient associees a la presence de DoMS a un an au repos et/ou a la marche. Discussion L’incidence des DoMS un an apres chirurgie osseuse du pied est similaire a celle retrouvee apres des chirurgies plus lourdes. Celle des douleurs neuropathiques semble anecdotique. Les chirurgies osseuses de la cheville ou de l’arriere pied ne generent pas plus de douleurs chroniques que celle de l’hallux ou des orteils. Certains arguments laissent supposer que ces patients beneficieraient d’interventions plus precoces. Niveau de preuve IV, etude de cohorte, suivi prospectif observationnel.

Background Most studies of chronic postoperative pain focussed on major surgical procedures. Chronic postoperative pain occurred in 10% to 50% of patients and exhibited neuropathic features in 5% to 68% of cases. The objectives of this prospective single-centre study were to determine the rates of occurrence and associated factors of any chronic pain and of neuropathic chronic pain 1 year after orthopaedic surgery on the foot. Methods We included consecutive patients who underwent scheduled orthopaedic surgery on the foot or ankle at a university hospital centre between 2009 and 2011. All patients received a multimodal analgesia regimen that usually combined a continuous popliteal sciatic nerve block, paracetamol, and ketoprofen, with additional ketamine if deemed appropriate. A telephone interview was conducted 1 year after the surgical procedure. The main outcome measures were moderate-to-severe pain (numerical rating scale score > 3/10) 1 year after surgery at rest and during walking, and presence of neuropathic pain (defined using the DN2 score). Multivariate analysis was performed to look for associations of various perioperative clinical variables with pain. Results One year after surgery, 55 of 260 (21%) patients reported moderate-to-severe pain at rest, 111 (43%) moderate-to-severe pain during walking, and 9 (3%) neuropathic pain. By multivariate analysis, factors independently associated with moderate-to-severe pain at rest and/or during walking 1 year after surgery were moderate-to-severe pain during the first postoperative night (P = 0.048) and/or day (P = 0.043) and revision surgery (P = 0.001). Discussion The rate of occurrence of moderate-to-severe pain 1 year after orthopaedic foot surgery is similar to that seen after major surgical procedures, whereas neuropathic pain seems rare. Orthopaedic surgery on the ankle or hindfoot is not more likely to be followed by chronic pain compared to surgery for hallux valgus or toe abnormalities. There is some evidence that earlier surgery might be beneficial. Level of evidence IV, prospective observational longitudinal cohort study.

Objective Percutaneous chest drainage guidelines were published in 2010 by the British Thoracic Society. On several points (insertion technique, drain size), they seem to differ from French practices. Our objectives were to evaluate practice of pleural drainage in French University surgical intensive care units (ICU's), and to compare it with the British guidelines. Study design National phone survey. Methods Physicians working in 58 ICU's were surveyed first in 2007, and subsequently in 2012. They were read a questionnaire to evaluate the demographic characteristics of their units, their indication for pleural drainage, how they quantified pleural effusion, and their technique for drain insertion. Data from the two surveys were compared to detect an evolution in practice following the publication of the British guidelines. Results are expressed as the mean response. Results In 2007, pleural drainage indications relied on various respiratory criteria in 91% of cases (versus 95% in 2012) and/or on pleural effusion volume in 71% of cases (versus 59% in 2012). Trocars (Monod or Joly) were used in 68% of the procedures in 2007. In the rest, either blunt dissection, a Pleurocath® or the Seldinger technique was utilized. From 2007 to 2012, the Seldinger technique increased in frequency (10% versus 22%, P = 0.005) while Monod trocar usage decreased (41% vs 29%, P = 0.012). Ultrasound before pleural effusion drainage became nearly systematic in 2012 (60% vs 86%, P Conclusion The frequent use of trocar (and therefore of large drains) for pleural drainage in French ICU's differs significantly from the British guidelines.

SummaryBackgroundMultimodal analgesia combining several non-opioid analgesics is recommended for pain control after surgery. In one study of total hip arthroplasty (THA), pain relief achieved by adding ketamine to the paracetamol–ketoprofen combination was statistically significant but remained inadequate in most patients. In two other studies, the analgesic effect of nefopam was synergistic with that of ketoprofen and additive with that of paracetamol. Adding nefopam to the paracetamol–ketoprofen-ketamine combination has not been evaluated.HypothesisAdding nefopam to the paracetamol–ketoprofen–ketamine combination significantly improves analgesia after THA.Material and methodsA prospective single-centre comparative non-randomised study (control group then nefopam group) was conducted in patients undergoing THA under general anaesthesia. All patients received paracetamol–ketoprofen–ketamine and morphine/droperidol patient-controlled analgesia. The nefopam group also received a continuous infusion of nefopam (120mg/d for 48h). Pain was evaluated daily for 7days. The main evaluation criteria were morphine consumption, and pain intensity evaluated using a numerical rating scale and a validated questionnaire. To detect a 40% morphine-sparing effect by H24 (α=0.05 and β=0.2), 85 patients were needed in each group.ResultsThe two groups (90 patients/group) had no significant differences for perioperative characteristics, pain scores, morphine consumption at H24 (nefopam, 13±12mg and control, 14±13mg, P=0.39), or functional recovery. Compared to the control group, the nefopam group had lower rates of nausea/vomiting (P

Resume Introduction L’association d’antalgiques non morphiniques est recommandee pour l’analgesie postoperatoire. Dans une etude, ajouter de la ketamine a l’association paracetamol-ketoprofene diminue significativement les douleurs apres prothese totale de hanche (PTH), mais de facon encore insuffisante chez une majorite de patients. Dans deux autres etudes, l’effet analgesique du nefopam est synergique avec celui du ketoprofene, et additif avec celui du paracetamol. L’adjonction de nefopam a l’association paracetamol-ketoprofene-ketamine n’a jamais ete evaluee. Hypothese L’adjonction de nefopam au protocole paracetamol-ketoprofene-ketamine ameliore significativement l’analgesie apres PTH. Patients et methodes Une etude monocentrique prospective comparative non randomisee (groupe temoin puis groupe nefopam) a ete menee chez des patients operes d’une arthroplastie totale de hanche sous anesthesie generale. Tous ont recu l’association paracetamol-ketoprofene-ketamine, une patient controlled analgesia (PCA) de morphine/droperidol. Ils ont ete suivis quotidiennement durant sept jours. Le groupe nefopam recevait aussi du nefopam intraveineux en continu (120 mg/j, 48 heures). Detecter une epargne morphinique de 40 % a h24 (α = 0,05 et β = 0,2) necessitait 85 patients par groupe. Les criteres d’evaluation principaux etaient la consommation morphinique et l’evaluation de la douleur en se basant sur un score numerique verbal et un questionnaire valide. Resultats Les caracteristiques perioperatoires des deux groupes (90 patients par groupe), les scores de douleur, les consommations de morphine (a h24, groupe nefopam = 13 ± 12 mg, versus groupe temoin = 14 ± 13 mg, p = 0,39) et la recuperation fonctionnelle etaient non differents. Cependant, les nausees/vomissements (p Discussion Le nefopam n’apporte aucun effet antalgique supplementaire dans cette analgesie multimodale, tout en diminuant certains effets secondaires des morphiniques. Une redondance des effets du nefopam et de la ketamine pourrait en etre la cause. Ce travail souligne que chaque association d’antalgiques devrait etre cliniquement evaluee, car son resultat est difficilement previsible au vu des donnees actuellement disponibles. Niveau de preuve avec le type d’etude Niveau III, etude cas-temoin.

Resume Introduction Plusieurs techniques d’anesthesie locoregionale (ALR) sont decrites pour la chirurgie de la main. Leurs tolerance et efficacite ont ete peu evaluees. Nous avons analyse celles des blocs au poignet et au canal brachial. Patients et methodes Cohorte de patients ambulatoires operes a ciel ouvert du canal carpien, sous ALR et garrot pneumatique brachial. Divers protocoles anesthesiques etaient pratiques dans le service. Les criteres principaux etaient les douleurs superieures a 3/10 (echelle numerique simple) liees a la ponction, la neurostimulation, l’injection de mepivacaine, au garrot et au site operatoire, la necessite d’un complement peroperatoire, la survenue de malaises vagaux. Pour chaque critere principal, ont ete analyses par regression logistique : le sexe, l’âge, le cote opere, l’application d’Emla® ou une sedation (sufentanil-midazolam) avant l’ALR, un bloc au poignet ou au canal brachial, l’anesthesie des nerfs radial ou musculocutane. Resultats On note que 551 patients consecutifs ont ete analyses. Les douleurs superieures a 3/10 lors de la ponction, de l’injection de mepivacaine, du garrot et la survenue de malaises vagaux etaient associees aux blocs au poignet (p = 0,003, risque relatif (RR) = 1,86 ; p Discussion La tolerance des blocs semble moins bonne au poignet qu’au canal brachial. Le nerf musculocutane innerverait frequemment la paume de la main. Le bloc des nerfs median, ulnaire et musculocutane au canal brachial parait preferable pour la chirurgie du canal carpien.

Resume Objectif En postoperatoire, la gabapentine ameliore l’analgesie, diminue les nausees vomissements, mais augmente la sedation. La prebagaline est apparentee a la gabapentine mais a une meilleure biodisponibilite. Cette revue a evalue les effets analgesiques et la tolerance perioperatoire de la pregabaline. Type d’etude Revue systematique de la litterature. Methodes Recherche sur Pubmed (mot cle « pregabalin ») des etudes cliniques humaines randomisees comportant une administration perioperatoire de pregabaline. Une revue quantitative sur l’efficacite de la pregabaline a ete realisee, ainsi qu’une analyse des principaux effets secondaires cites dans ces etudes. Resultats Les 17 etudes analysees comportaient 23 bras testant au moins une dose de pregabaline versus placebo, chez 1577 patients, dont 884 ayant recu de la pregabaline. La pregabaline ameliorait l’analgesie dans 11 des 23 bras d’etudes. Seules trois des 12 etudes en chirurgie ambulatoire etaient positives, contre 8 des 11 etudes concernant des chirurgies plus lourdes (p = 0,04). Deux des trois etudes ayant evalue les douleurs a distance sont favorables au groupe pregabaline. La pregabaline ne diminue pas les nausees vomissements, le prurit ou les cephalees. En revanche, elle augmente la somnolence, les troubles visuels et les sensations ebrieuses durant les premieres heures postoperatoires, sans consequence clinique grave. La sedation profonde semble etre le seul effet secondaire dose dependant. Conclusion Une balance benefice risque favorable n’est objectivee que pour la chirurgie non ambulatoire. Les principales incertitudes concernent actuellement la dose et la duree d’administration optimales, ainsi que la balance-benefice risque chez les sujets âges et/ou insuffisants renaux.

Introduction The main procedure specific complication of sagittal split osteotomy of the mandibular ramus (SSOMR) is inferior alveolar nerve (IAN) injury. This can be produced by poor intraoperative visibility of the IAN due to bone bleeding. In our centre, mandibular nerve blocks (MNBs) are usually performed for intra- and post-operative analgesia. We observed that MNB seems to decrease intraoperative bleeding and thus to improve IAN visibility. Our study was performed to evaluate the effect of MNB on intraoperative bleeding during SSOMR and, secondarily, on the duration of this procedure. Material and methods Patients scheduled for bilateral SSOMR under general anaesthesia were prospectively randomized into two groups. The Block group received bilateral MNB (5mL ropivacaine 0.5% for each block) and the Control group sham MNBs (bilateral cutaneous puncture, without block). The operations were carried out under a standardised general anaesthetic. Post-operatively, the surgeon, blinded to group allocation, assessed intraoperative bone bleeding using a Numerical Rating Scale (NRS) (0: no bleeding, perfect visibility to 100: major bleeding, no visibility). Osteotomy duration, intraoperative anaesthetic requirements, and pain score in the recovery room were also recorded. Results are expressed as median [25–75th percentiles]. Results Nineteen patients were included in each group. Osteotomy under MNB had a decreased intraoperative bone bleeding score compared with controls (20 [0–40] versus 55 [20–80], p =0.0002). They had a dry surgical field more frequently (29% versus 5%, p =0.01), and a shorter mean time for the osteotomy (15 [12.25–17.75] versus 17.5 [15–21]min, p =0.009). Block patients had reduced intraoperative opioid consumption (770 [678–1430] versus 2310 [1908–3058]mcg of remifentanil, p =0.0001), and lower pain scores in the recovery room (0 [0–2] versus 3 [1–5], p =0.12). Conclusion MNB decreases intraoperative bone bleeding during SSOMR under general anaesthesia. Three hypotheses to explain this result are discussed.

Resume Objectif L’acide tranexamique (ATX) diminue les pertes sanguines totales (PST) et la transfusion homologue (TH) apres prothese totale de genou (PTG). Les PST sont exteriorisees (champ operatoire, drains) ou pas (hematomes). Les hematomes generent des douleurs et entravent la recuperation fonctionnelle. Nous avons evalue si l’ATX reduisait les hematomes et les douleurs apres PTG. Type d’etude Etude prospective non randomisee. Methode Apres accord du comite d’ethique et consentement ecrit, les patients programmes pour PTG primaire ont ete inclus (groupe temoin puis groupe ATX, 15 mg/kg a l’incision et a la fermeture). L’anesthesie generale et l’analgesie etaient standardisees (bloc sciatique, bloc femoral continu, ketamine, ketoprofene, paracetamol, PCA morphine). Volume des hematomes = PST (calculees a partir des hemogrammes de j−1 et j5, et des TH eventuelles) – saignement exteriorise (mesure). Les patients etaient suivis huit jours, puis a j180 (entretien telephonique). Cinquante patients par groupe permettaient de detecter une epargne morphinique de 50 % a j8 et une baisse des hematomes de 25 % a j5 (α = 0,05 et β = 0,2). Resultats Les donnees perioperatoires, les douleurs et les criteres fonctionnels (jusqu’a j180) etaient non differents entre les groupes temoin (n = 52) et ATX (n = 55) : la consommation morphinique a j8 etait respectivement de 35 ± 32 et 42 ± 38 mg (p = 0,29). Pourtant, l’ATX diminuait le volume des hematomes (526 ± 202 versus 337 ± 165 mL d’hematies, p Conclusion Apres PTG, l’ATX diminue le volume des hematomes, sans ameliorer l’analgesie ni la recuperation fonctionnelle jusqu’au sixieme mois postoperatoire.

Resume Objectifs Decrire l’organisation en poles dans les CHU et centres hospitaliers generaux (CHG) impliquant l’anesthesie-reanimation (AR) et en evaluer les consequences sur l’unite des differentes composantes de la discipline. Type d’etude Enquete nationale par questionnaire conduite fin 2008. Materiel Questionnaire ecrit, destinee aux chefs de service d’AR des CHU et CHG en fonction fin 2008. Methodes Analyse de 18 questions fermees et commentaires ouverts. Comparaisons de pourcentages (Khi2 – Yates, test de l’ecart reduit) ; correlation lineaire. Resultats Le pourcentage de reponses a ete de 70 % (n = 51) pour les CHU et limite a 37 % (n = 146) pour les CHG. La nouvelle gouvernance etait generalisee. Dans les CHU, les differentes composantes de la discipline AR n’ont ete separees que six fois : reanimation chirurgicale (n = 1), algologie (n = 2), Samu–Smur (n = 2), autre activite (n = 1). A l’inverse, le Samu–Smur (n = 3) et les urgences (n = 8) ont pu ailleurs etre associes a l’AR. La reanimation medicale ou polyvalente et l’AR ont ete associes dans un pole d’activite medicale (PAM) 15 fois. Dans les CHG, les recompositions ont ete quasi constantes. Ces evolutions ont ete jugees defavorables a la discipline par la majorite des chefs de service d’AR des CHG, particulierement dans les etablissements de taille moderee. Conclusion Globalement, l’unite de la discipline a ete maintenue dans les CHU, mais cela n’a pas ete le principe dominant dans les CHG.

There are no guidelines for the anaesthetic management of caesarean section in women with long QT syndrome; the description of myocardial ventricular repolarisation in healthy women during caesarean delivery could be a first step. The aim of this study was to describe modification of the QT interval, corrected for heart rate, and the interval between the peak and the end of the T-wave (Tpeak-Tend interval) during caesarean section under spinal anaesthesia. We studied 40 patients scheduled for caesarean section under spinal anaesthesia. Patients were randomly assigned to receive either ephedrine or phenylephrine to prevent hypotension. We injected 5 IU oxytocin after delivery. Corrected QT and Tpeak-Tend intervals were unchanged from pre-operative values after induction of spinal anaesthesia, but increased significantly after oxytocin injection. The choice of vasopressor did not affect the Tpeak-Tend interval. The risk-benefit balance of oxytocin bolus during caesarean delivery should be discussed with women with a history of long QT syndrome.

Postoperative analgesia via continuous perineural infusion of local anesthetics compares favorably with systemic analgesia. Elastomeric pumps increase patient satisfaction compared with electronic models. In in vitro investigations, infusions remained within 15% of their designated set rates. We assessed in vivo the infusion rate of elastomeric pumps in regional analgesia after orthopedic surgery.All consecutive elastomeric pumps were retrospectively studied during a 10-mo period. Perineural catheters were inserted preoperatively and connected postoperatively to elastomeric pumps filled with ropivacaine 0.2%. Before infusion, elastomeric pumps and ropivacaine were stored at room temperature. Two models of pumps were randomly used: Infusor LV5 (Baxter, France) or Easypump (Braun, Germany), both set at 5 mL/h. Nurses weighed the devices at the bedside using a portable electronic scale several times a day until catheter removal. Weights over time allowed accurate deflation profile assessment and flow rate calculation. An unchanged weight over time indicated either an obstructed catheter or an ineffective device.After connection to the catheter, 88 devices did not deflate (80 Easypump of 300 and 8 Infusor of 130, P0.0001). One Easypump was impossible to deflate, even after disconnection from its catheter. In two cases, catheters were obstructed. In 21 cases, catheters were removed 11 to 72 h later without being tested for patency. In 24 cases, pumps correctly deflated after catheters were injected without difficulty with a local anesthetic bolus. The remaining 40 devices spontaneously started to deflate 6 to 43 h after their connection. These 88 elastomeric pumps were associated with higher maximal visual analog scale scores during the first postoperative night than devices showing immediate deflation after connection (34 +/- 21 mm vs 26 +/- 19 mm, P = 0.006). Flow rates were calculated over a mean period of 54 +/- 18 h (Easypump) and 49 +/- 19 h (Infusor). The flow rates differed from those set by manufacturers (5 mL/h +/- 15%) in 47% of Easypump and in 34% of Infusor devices (P = 0.01).In vivo reliability of elastomeric pumps is different than in vitro. In the event of early insufficient postoperative perineural analgesia, an absence of deflation of the elastomeric pump must be considered. We recommend weighing these devices every 3 h during the first 24 h of infusion.

Resume Objectif L’analgesie post operatoire par administration intraveineuse continue de ketamine a entraine des troubles psychodysleptiques aigus angoissants chez plusieurs de nos patients. Nous avons suppose qu’ils etaient dus a des boli de ketamine accumulee dans la tubulure de perfusion. Nous avons evalue sur deux groupes successifs l’impact d’une modification des lignes de perfusion sur l’incidence de ces troubles. Methodes Un groupe retrospectif a servi de reference (pompe de ketamine classiquement connectee a la tubulure de perfusion via un robinet a 3 voies). Dans le second groupe, prospectif, la voie de la ketamine etait connectee sur le catheter veineux via une valve unidirectionnelle. Resultats L’incidence des troubles psychodysleptiques a diminue de 4 patients sur 26 (15 %) a 2 sur 116 (2 %, p = 0,01). De plus, ces troubles etaient moins intenses dans le second groupe. Conclusion L’analgesie par administration intraveineuse continue de ketamine doit se faire via une valve unidirectionnelle, afin de limiter la survenue d’effets psychodysleptiques indesirables.

Background Malposition of percutaneously inserted chest tubes is considered as a rare complication in critically ill patients. Its incidence, however, remains uncertain. The aims of the study were to assess the true incidence of chest tube malposition in critically ill patients and to identify predicting factors. Methods The authors prospectively studied 122 chest tubes percutaneously inserted in 75 consecutive critically ill patients. For clinical reasons independent of the study, thoracic computed tomography scanning was performed in 63 patients, allowing direct visualization of 106 chest tubes. Based on these findings, chest tube position was classified as intrapleural, intrafissural, or intraparenchymal. Factors predicting chest tube malposition were analyzed by univariate and multivariate analysis. Results The mean delay between chest tube placement and thoracic scan was 3.5+/-2.9 days. Twenty-two chest tubes were diagnosed as being intrafissural (21%), and 10 were diagnosed as being intraparenchymal (9%). The only predicting factor associated with the risk of malposition was the use of a trocar for the percutaneous insertion of the chest tube (P=0.032). Conclusions Malposition was detected in 30% of percutaneously inserted chest tubes, a higher incidence than previously reported. Avoiding the use of a trocar may reduce significantly the incidence of chest tube malposition.

Purpose: Normally, the aortic arch and the descending aorta are not visible using transthoracic ultrasonography. We hypothesize that lung consolidation of upper and lower lobes, by opening an acoustic window, may allow the ultrasound examination of the thoracic aorta. Methods: During a 2-month period, 18 consecutive patients hospitalized in the intensive care unit with consolidation of upper and/or lower lobes diagnosed by lung ultrasound were studied. The ascending and descending aorta and the aortic arch were systematically searched for by positioning the probe on the anterior, lateral, and posterior regions of the chest wall. Results: Among the 16 patients with left lower lobe consolidation, the descending aorta was always visible by positioning the probe on lateral and posterior parts of the chest wall. In the 4 patients with consolidation of the left upper lobe, the aortic arch was visible when positioning the probe on anterior and upper parts of the left chest wall. In the patient with right upper lobe consolidation, both the ascending aorta and the aortic arch were visible when positioning the probe on anterior and upper parts of the right chest wall. Conclusions: In critically ill patients, the presence of consolidated upper and left lower lobes may allow the ultrasound examination of the different parts of the thoracic aorta.

Background Closed-circuit endotracheal suctioning (CES) is advocated for preventing hypoxemia caused by the loss of lung volume resulting from open endotracheal suctioning (OES). However, the efficiency of CES and OES on tracheal secretion removal has never been compared in patients with acute lung injury. The authors designed a two-part study aimed at comparing gas exchange and efficiency between OES and CES performed at two levels of negative pressure. Methods Among 18 patients with acute lung injury, 9 underwent CES and OES at 3-h intervals in a random order using a negative pressure of -200 mmHg. Nine other patients underwent CES twice using two levels of negative pressure (-200 and -400 mmHg) applied in a random order. After each CES, a recruitment maneuver was performed using 20 consecutive hyperinflations. Tracheal aspirates were weighed after each suctioning procedure. Arterial blood gases were continuously recorded using an intravascular sensor. Results Open endotracheal suctioning induced a significant 18% decrease in arterial oxygen tension (Pa(O2)) (range, +13 to -71%) and an 8% increase in arterial carbon dioxide tension (Pa(CO2)) (range, -2 to +16%) that persisted 15 min after the end of the procedure. CES using -200 cm H2O did not change Pa(O2), but tracheal aspirate mass was lower compared with OES (0.6 +/- 1.0 vs. 3.2 +/- 5.1 g; P = 0.03). Increasing negative pressure to -400 cm H2O during CES did not change Pa(O2) but increased the tracheal aspirate mass (1.7 +/- 1.6 vs. 1.0 +/- 1.3 g; P = 0.02). Conclusions Closed-circuit endotracheal suctioning followed by a recruitment maneuver prevents hypoxemia resulting from OES but decreases secretion removal. Increasing suctioning pressure enhances suctioning efficiency without impairing gas exchange.

Introduction Apres hepatectomie, la regeneration hepatique induit une hypophosphatemie secondaire a une hyperphosphaturie, par modification du metabolisme du nicotinamide urinaire [1] . Notre etude visait a rechercher ce meme diabete phosphate apres un autre type de stress hepatique : la transplantation hepatique (TH). Materiel et methodes Etude prospective observationnelle. Tous les patients hospitalises en reanimation chirurgicale apres hepatectomie ou TH (hormis les insuffisants renaux dialyses), entre mars et juin 2014, ont ete suivi pendant 5 jours (ou jusqu’a sortie de reanimation). Leurs phosphatemie et fraction excretee de phosphate (FePO4 – ) ont ete relevees quotidiennement. L’hypophosphatemie etait jugee moderee (0,5–0,79 mmol/L), severe (0,35–0,49 mmol/L) ou profonde ( [2] . La FePO4 (= 100 × phosphaturie des 24 h [mmol/j] × creatininemie [mmol/L]/1000)/(creatininurie des 24 h [mmol/j] × phosphatemie [mmol/L]) etait consideree comme normale entre 10 et 20 %. Les complications pouvant etre attribuees a une hypophosphatemie ont ete colligees. Resultats Toutes les hepatectomies ont presente une hypophosphatemie (moderee : 70 %, severe : 20 %, profonde : 10 %), contre 17 (61 %, p = 0,05) TH (moderee : 70 %, severe : 18 %, profonde : 12 %). Les TH beneficiaient d’une supplementation intra-veineuse en phosphate plus precoce ( Fig. 1 ) et tendaient a presenter plus frequemment une insuffisance renale (71,4 % vs 50 %, p = 0,40). Le taux de complications n’etait pas different entre patients normo- et hypophosphatemiques (45,5 % vs 55,6 %, p = 0,84). Comme pour les hepatectomies, la FePO 4– etait elevee des j0 en post-TH. Elle diminuait au fil du temps et se normalisait entre j3 et j4. Discussion Un diabete phosphate accompagne la regeneration hepatique en post-TH, comme apres hepatectomie, mais l’hypophosphatemie n’en est pas le marqueur ideal. L’insuffisance renale et une supplementation precoce en phosphate intraveineux peuvent influencer la phosphatemie. De nombreux facteurs regissant les transferts transmembranaires du phosphate (essentiellement intracellulaire) peuvent aussi expliquer l’absence de complication des hypophosphatemies dans notre etude. La FePO 4– est elevee en post-TH immediat et se normalise apres j3. Elle pourrait etre une « sequelle physiologique appropriee » [3] de la cicatrisation hepatique.

Introduction Bien que les examens d’hemostase usuels refletent mal le risque hemorragique des patients cirrhotiques operes, des transfusions de PFC sont parfois systematiques pour en corriger les anomalies. Cette pratique est controversee en raison de l’augmentation de la volemie induite aggravant l’hypertension portale et le risque hemorragique. L’utilisation de CCP apportant les facteurs de coagulation sous faible volume est proposee. Aucune etude n’a cependant evalue son efficacite chez les patients au cours d’une THO. Le TGT refletant plus globalement l’equilibre hemostatique que les tests d’hemostase usuels, nous avons analyse les parametres du TGT apres addition in vitro de PFC ou de CCP aux echantillons de plasmas de patients cirrhotiques preleves au cours d’une THO. Patients et methodes Cette etude a ete menee sur fonds de tube dans le cadre du soin courant. Dix patients, 7H/3F, âge median 62,5 ans, Child median 11 [8–13], taux de prothrombine (TP) median 36 % [32–62] ont ete preleves a differents temps peroperatoire : avant incision (P1), en fin d’hepatectomie (P2), avant declampage porte (P3) et 30 minutes apres reperfusion (P4). Les TGT (methode CAT, concentrations finales de facteur tissulaire et de phospholipides respectivement 5 pM et 4 μM, PPP reagent® Stago) ont ete realises sur les plasmas deplaquettes avant et apres ajout de PFC (5 mL/kg) ou de CCP (Confidex® 12,5 UI/kg ou 25 UI/kg). Les resultats ont ete compares a ceux d’une population de sujets sains (n = 29 ; 22 H/7 F) (test de Mann et Whitney) et pour chaque prelevement avant et apres surcharge des plasmas (test de Wilcoxon). Resultats Les parametres du TGT des patients avant incision (P1) ainsi qu’a P2 et P3 sont similaires a ceux des sujets sains : ETPP1 basal min–max [939–1584] nM*min vs ETPsujets sains [1040–1914] nM*min p = 0,24. En revanche a P4 une generation de thrombine significativement plus basse est objectivee : ETPP4 basal [678–1222] nM*mn p Nous avons evalue l’effet de ces produits sur le TGT au temps P1 en raison de l’injection de PFC souvent realisee des le debut de la procedure. Le PFC n’entraine pas d’effet significatif ETPP1 + PFC [1008–1760] nM*mn p = 0,10 vs P1 alors que l’addition de CCP induit un effet significatif : ETPP1 + CCP 12,5 UI/kg [1920–3083] nM*mn p = 0,002 vs P1 avec une hypercoagulabilite des la plus faible concentration. Discussion Le TGT permet d’objectiver un etat hemostatique equilibre chez les patients cirrhotiques que ne reflete pas le TP. L’inefficacite du PFC a corriger la generation de thrombine in vitro a P4 est un argument qui soutient la non prescription peroperatoire systematique de ce produit sanguin. A l’inverse, l’efficacite du CCP in vitro plaide en faveur de son utilisation lors de la reperfusion (P4) mais non en debut de procedure (P1) en raison d’un risque thrombotique comme le suggere la generation tres majoree de thrombine.

Introduction La SFAR recommande de repeter l’autotest du respirateur entre deux interventions « si une partie du materiel est changee ». C’est le cas en anesthesie pediatrique (circuit pediatrique ≤ 10 kg, circuit adulte > a 10 kg) ou dans une meme salle operatoire des enfants de 2 a 80 kg peuvent se succeder. Pourtant, en pratique l’autotest a chaque changement de circuit n’est que tres peu realise que ce soit dans notre centre ou dans les autres centres de reference [1] . Les consequences d’un tel ecart de la pratique sur la ventilation des enfants ne sont pas clairement etablies. L’objectif de cette etude, sur banc d’essai avec un respirateur Primus® (Drager), etait de determiner l’impact observe sur la ventilation et sur les pressions en l’absence de realisation d’un autotest alors qu’un changement de circuit a eu lieu. Materiel et methodes Deux conditions de mesures A et B etait evaluees sur un banc comprenant : un poumon test adulte et pediatrique (QA-VT de Metron®) dont la compliance et les resistances etaient ajustees selon le poids de l’enfant, un ventilateur Primus® en mode volume controle avec TI/TE a 0,5, un circuit respiratoire, un capteur de debit et de pression (D-lite™ Sensor ou Pedi-lite™ Sensor selon le circuit) positionne immediatement a la sortie du poumon test et connecte a un moniteur Datex Ohmeda S/5®. A) autotest initial avec le circuit pediatrique (Flextube™ d’Intersurgical®) et mesures avec les VT/FR : 15/35, 20/30 et 70/24 correspondant a des poids de 2, 3 et 10 kg, puis avec le circuit adulte sans nouvel autotest avec les VT/FR : 110/22, 140/20, 210/18 et 280/16 correspondant a des poids de 15, 20, 30 et 40 kg. B) autotest initial avec le circuit adulte (Flextube™ d’Intersurgical®) et mesures avec les VT/FR : 110/22, 140/20, 210/18 et 280/16 puis avec le circuit pediatrique, sans nouvel autotest avec les VT/FR : 15/35, 20/30 et 70/24. Deux respirateurs ont ete testes dans des conditions identiques. Pour chaque condition, la moyenne des deux mesures etait retenue et il etait note : le VT expire, la pression de crete et de plateau mesurees par le moniteur Datex Ohmeda S/5®. Resultats Le non respect de l’autotest lors du changement de circuit n’a pas d’impact sur les pressions (ecart £ 1 cmH2O) ni sur la ventilation chez les plus de 10 kg. Chez les moins de 10 kg cela entraine une augmentation de la ventilation superieure a 40 %. Par rapport au volume regle, le VT expire est plus bas d’au moins 20 % chez le plus de 10 kg quel que soit le cas de figure ce qui n’est pas le cas en-deca de 10 kg ( Tableau 1 ). Discussion Notre travail met en evidence l’importance du respect de l’autotest lors du changement de circuit chez les enfants de moins de 10 kg ventiles avec un respirateur Primus®.

Background Heterogeneity and its causes must be assessed using meta-analyses (meta-analysis). Especially in meta-analysis dealing with treatment of acute postoperative pain, the type of surgery is a source of heterogeneity. We aimed to assess whether the type of surgery is considered a source of heterogeneity in meta-analysis and how it is taken into account in meta-analysis evaluating the efficacy of treatment of acute postoperative pain. We further compared meta-analysis that pooled trials of surgeries with highly heterogeneous postoperative pain levels, the heterogeneous group, with meta-analysis that pooled trials involving surgeries with homogeneous pain levels, the homogenous group. Methods The meta-analysis reports available in Issue 3, 2011 of the electronic database of the Cochrane library and pooling results of randomized or quasi-randomized controlled trials that assessed the efficacy of treatment of acute postoperative pain alone were considered. A survey of experts established a rating of the postoperative pain levels for the type of surgery. For each meta-analysis, the different pain level ratings associated with the trials included in the meta-analysis were considered and the standard deviation ( sd ) of these ratings calculated. From the distribution of sd values, we defined the heterogeneous and homogeneous groups. Results Sixty-one meta-analyses were included; all assessed heterogeneity. Twenty-six meta-analyses considered the type of surgery as a subgroup (50% vs 38% in the homogeneous group vs heterogeneous group). Forty-four reports discussed the type of surgery as a source of clinical heterogeneity (85% vs 62% for the homogeneous vs heterogeneous group). Twenty-nine meta-analyses compared ‘postoperative pain from dental surgery’ to ‘other type of surgery’. Conclusions Meta-analyses evaluating treatment of postoperative pain should explore clinical heterogeneity associated with the type of surgery for better implications for practice.

Introduction La frequence des recherches sur Internet en complement a l’information medicale [1] nous a amene a evaluer la qualite de l’information concernant la peridurale obstetricale (PO) sur Internet en 2009 et 2010. Notre etude a confirme que la qualite de l’information sur la PO etait mediocre, instable, et sans amelioration dans le temps [2] . L’objectif principal de cette etude etait d’evaluer, 3 ans apres, la qualite et l’evolution dans le temps de l’information disponible sur Internet sur la PO. L’objectif secondaire etait d’etudier l’evolution du site de la SFAR au sujet de cette information. Materiel et methodes Deux evaluateurs ont utilise la grille de notation creee en 2009 pour analyser les 20 premiers sites de Google® et Yahoo®. Cette grille evaluait la qualite de la structure du site (score QS) et la qualite de l’information medicale (QInf) en prenant comme referentiel les recommandations de pratique clinique SFAR 2006 concernant les blocs perimedullaires de l’adulte [3] . De l’addition des scores QS (sur 25 points) et QInf (sur 30 points) a resulte un score global sur 55 points. La qualite de l’information sur Internet a ete mesuree en 2013 independamment par les 2 evaluateurs puis comparee aux donnees de 2009 et 2010. La stabilite de cette information dans le temps a ete evaluee. La labellisation HONcode des sites etudies a ete repertoriee. Resultats Le score global moyen de l’ensemble des sites etait en 2009, 2010 et 2013, respectivement : 23(8), 23(8), 26(8) ; les scores moyens QS : 11(4), 11(4), 12(4) ; les scores moyens QInf : 12(6), 12(5), 14(5). En 2013, comme en 2009 et 2010, le rang de referencement d’un site dans un moteur de recherche n’etait pas lie a la qualite du site. En 2013, les sites labellises HONcode etaient toujours de meilleure qualite (29[7] vs. 23[8]). En 2013, 65 % des sites etaient presents dans l’evaluation de 2010, et 57 % dans celle de 2009. Comme en 2009 et 2010, le site le mieux note en 2013 etait doctissimo.fr. Les notes du site de la SFAR etaient 33/55 en 2009, 39/55 en 2010 et 37/55 en 2013. En 2013, il obtenait la deuxieme meilleure note de notre evaluation. Il etait reference en 20e position sur Google® et n’etait pas reference parmi les 20 premiers sites de Yahoo®. Discussion En 2013, la qualite de l’information sur Internet concernant la PO reste insuffisante. En 3 ans, il n’y a pas eu d’amelioration franche de la qualite de cette information. Bien que l’instabilite de l’information proposee sur Internet soit toujours d’actualite, doctissimo.fr est toujours le site le mieux note. Le site de la SFAR reste tres bien note mais son rang de referencement au sein des moteurs de recherche le rend toujours peu visible du grand public. En 2013, les sites doctissimo.fr et sfar.org peuvent etre proposes en complement de l’information medicale sur la PO. Un referencement optimise du site de la SFAR permettrait une meilleure information du grand public.

Introduction Le foie est le siege de la synthese de nombreuses proteines pro- ou anticoagulantes. Les patients en insuffisance hepatique aigue post-transplantation hepatique (TH) ont un deficit acquis en ces proteines entrainant des anomalies de l’hemostase. La fonction hepatique, en post-TH, est surveillee sur l’evolution du taux de prothrombine (TP) et du facteur V (V). L’antithrombine (AT) est un inhibiteur physiologique de la coagulation synthetise par le foie. L’AT agit principalement sur la thrombine et le facteur X active. Cette reaction est catalysee par l’heparine ou l’AT a un role de cofacteur. Son deficit pourrait favoriser les complications thrombotiques, avec ou sans administration concomitante d’heparine. Le but de notre etude est d’analyser l’evolution post-TH du taux d’AT en comparaison aux marqueurs habituels (TP, V) de recuperation de la fonction hepatique pour definir l’AT comme nouveau marqueur. Materiel et methodes Etude monocentrique retrospective observationnelle entre janvier 2011 et aout 2012, sur 7 jours post-TH. Validation CPP et recueil de la non-opposition. Etaient exclus les patients ayant presentes une complication postoperatoire (hemorragie, sepsis, reprise chirurgicale, transfusion de produits sanguins ou administration d’antithrombine) pouvant interferer avec la coagulation ou la recuperation du greffon hepatique. Les donnees colligees etaient : âge, scores Child Pugh, MELD, indication de la TH, TP et taux de V et AT. Le TP et les taux de V et AT sont consideres comme normaux lorsque le dosage est superieur a 60 %. Moyenne (ecart-type). Resultats Quatre vingt-huit TH en 20 mois, 57 ont ete analysees : âge 54 (12) ans, score Child 10 (2), MELD 23 (10), indication TH : 54 % alcool, 15 % NASH, 17 % VHC, 3 % VHB, 3 % reTH, 2 % CBP et 6 % autres causes dont 26 % de carcinome hepatocellulaire. Le taux d’AT se normalise a j3 comme celui de V et du TP (> 60 %). La progression du taux d’AT est supperposable a celle du TP. Le graffique suivant illustre la progression, au cours des 7 jours post-TH, du TP et des taux de V et AT ( Fig. 1 ). Discussion La normalisation du taux d’AT (> 60 %) est simultanee a celle du TP et au taux de V a j3 post-TH. Or, en post-TH, la surveillance de la recuperation du greffon sur le TP et V est essentielle mais celle des facteurs anticoagulants comme l’AT, potentiellement pro-thrombotique, apparait egalement comme tel. L’AT pourrait alors etre un nouveau marqueur de fonction hepatique post-TH, caracterisant alors l’anticoagulation.

In reference textbooks describing axillary block, the ulnar, radial, and median nerves are located in a common sheath surrounding the axillary artery. In contrast, the musculocutaneous nerve is described as lying outside this sheath in the coracobrachialis muscle. In a recent case report of ultrasound-guided axillary block, the musculocutaneous nerve was joined to the median nerve outside this muscle. Our study evaluated the prevalence of atypical musculocutaneous nerve localizations during axillary block.All patients undergoing ultrasound-guided axillary block were included from December 2006 to December 2008. Before needle insertion, musculocutaneous, median, ulnar, and radial nerves were localized using ultrasound. Nerve stimulation confirmed atypical nerve localization. After injection of local anesthetics, musculocutaneous and median nerve anatomical relationships were observed.The musculocutaneous nerve was outside the coracobrachialis muscle in 83 of the 387 analyzed blocks (22%). It was near the axillary artery in 22 cases (6%). The musculocutaneous and median nerves appeared as a common neural structure in 61 cases (16%). After local anesthetic injection, a common trunk persisted in 16 of 61 cases (26%), musculocutaneous and median nerves separated in 37 cases (61%), and 2 roots of the median nerve appeared (with or without a separated musculocutaneous nerve) in 6 cases (10%). Two cases (3%) remained undefined. Ulnar nerve location of the 83 patients with atypical musculocutaneous nerve position differed from the ones with a classical musculocutaneous nerve localization.During axillary block, the musculocutaneous nerve is outside the coracobrachialis muscle in 1 of 5 patients. This atypical location should be considered during performance of axillary blockade to avoid repeated IM puncture.

Ketamine has been shown to have a morphine-sparing effect soon after surgery. Nevertheless, whether this effect still exists after being combined with nonsteroidal antiinflammatory drugs and acetaminophen, and whether ketamine can decrease chronic pain after nononcologic surgery remain unclear. Thus, we designed a study to assess ketamine's effect on acute and chronic postoperative pain when combined with multimodal analgesia after total hip arthroplasty (THA).Patients scheduled for primary nononcologic THA using standardized general anesthesia were randomized. They received IV ketamine before incision (0.5 mg/kg), and a 24-h infusion (2 microg x kg(-1) x min(-1)) or a similar blinded saline bolus and infusion. Postoperative analgesia included IV acetaminophen, ketoprofen, plus morphine/droperidol patient-controlled analgesia for 48 h. Data pertaining to pain scores, morphine consumption, and need for crutches were collected for 6 mo after THA. Our primary outcome was 24-h morphine consumption.One hundred fifty-four patients were included (placebo, 75; ketamine, 79). Patients and operative data were similar in both groups. Ketamine decreased morphine consumption at 24 h from 19 +/- 12 mg to 14 +/- 13 mg (P = 0.004). At Day 30, ketamine decreased the proportion of patients needing 2 crutches or a walking frame from 56% to 31% (P = 0.0035). From Day 30 to Day 180, ketamine decreased the proportion of patients with persistent pain at rest in the operated hip (P = 0.008). At Day 180, 21% of placebo group patients (15 of 70) experienced pain at rest in the operated hip versus 8% (6 of 72) in the ketamine group (P = 0.036, odds ratio 0.33, 95% confidence interval 0.12-0.91, risk reduction 67%).Ketamine had a morphine-sparing effect after THA, even when morphine was combined with multimodal systemic analgesia. It also facilitated rehabilitation at 1 mo and decreased postoperative chronic pain up to 6 mo after surgery.

To assess the accuracy of a multiplane ultrasound approach to measure pleural effusion volume (PEV), considering pleural effusion (PE) extension along the cephalocaudal axis and PE area.Prospective study performed on 58 critically ill patients with 102 PEs. Thoracic drainage was performed in 46 patients (59 PEs) and lung computed tomography (CT) in 24 patients (43 PEs). PE was assessed using bedside lung ultrasound. Adjacent paravertebral intercostal spaces were examined, and ultrasound PEV was calculated by multiplying the paravertebral PE length by its area, measured at half the distance between the apical and caudal limits of the PE.Ultrasound PEV was compared to either the volume of the drained PE (59 PE) or PEV assessed on lung CT (43 PE). In patients with lung CT, the accuracy of this new method was compared to the accuracy of previous methods proposed for PEV measurement. Ultrasound PEV was tightly correlated with drained PEV (r = 0.84, p0.001) and with CT PEV (r = 0.90, p0.001). The mean biases between ultrasound and actual volumes of PE were -33 ml when compared to drainage (limits of agreement -292 to +227 ml) and -53 ml when compared to CT (limits of agreement -303 to +198 ml). This new method was more accurate than previous methods to measure PEV.Using a multiplane approach increases the accuracy of lung ultrasound to measure the volume of large to small pleural effusions in critically ill patients.

Continuous low dose infusion of intravenous ketamine for postoperative analgesia was often associated with frightening acute psychodysleptic experiences in our patients. We hypothesized they were due to boluses of ketamine accumulated in the infusion line. We evaluated on two successive groups the impact of perfusion line modifications on psychodysleptic side effects occurrence.We compared a reference historic group (in which ketamine line was connected to perfusion line) to a second prospective group (in which ketamine line was connected to the venous catheter via an unidirectional valve).Psychodysleptic experiences occurrence decreased from 4 patients of 26 (15%) to 2 of 116 (2%, p = 0.01). Moreover, these experiences were no longer associated with severe anxious symptoms like near death experiences.An unidirectional valve must be considered to limit the occurrence of low dose intravenous ketamine infusion associated psychedelic side effects, during postoperative analgesia.

Introduction En transplantation hepatique (TH), le monitorage du debit cardiaque par catheter de Swan-Ganz est la technique de reference. Elle peut neanmoins generer une morbi-mortalite non negligeable. Le Vigileo Flow Trac (versions 1.07, 1.10 et 3.02) est une technique moins invasive reposant sur l’analyse de l’onde de pouls arteriel. Dans le cadre de la TH, sa fiabilite a ete consideree comme insuffisante, bien que notablement augmentee sur les versions les plus recentes. Le but de cette etude etait d’evaluer un appareil plus recent que ces dispositifs, egalement base sur l’analyse du contour de pouls, le PulsioFlex ProAQT sensor version 2. Materiel et methodes Etude prospective observationnelle comparant les debits cardiaques mesures en continu simultanement par une Swan-Ganz (DCSwG) et le PulsioFlex (DCP). Des mesures etaient relevees toutes les 10 minutes, de l’induction anesthesique a la fermeture cutanee. Seules les mesures effectuees apres 5 minutes sans remplissage ni modification des drogues vasoactives ont ete analysees. Un meme nombre de mesure (± 1) a ete analyse par patient et par phase (avant incision, dissection, anhepathie, apres declampage). Le biais, les limites d’agrement (Bland-Altman), le pourcentage d’erreur (PE) et la capacite du Pulsioflex a detecter des variations du debit cardiaque (baisse ou augmentation > 15 %) ont ete calcules. Resultats De novembre 2012 a juin 2013, 20 patients (439 paires de mesures) ont ete analyses. Le DCSwG et le DCP etaient correles (R2 = 0,41). Le biais etait de +0,6 L/min, les limites d’agrement etaient de–4,7 L/min et +5,9 L/min. Le PE etait de 62 %. Pour detecter une diminution du DCSwG > 15 % entre 2 mesures successives, la sensibilite du PulsioFlex etait de 12 %. Discussion Les performances du PulsioFlex pour le monitorage continu du debit cardiaque en TH sont insuffisantes pour l’envisager comme alternative au catheter de Swan-Ganz.

Introduction Apres transplantation hepatique, les candidoses invasives representent la deuxieme cause d’infection. Elles sont associees a une mortalite elevee. La colonisation a levures du genre Candida est un facteur de risque de candidose invasive [1] . Si l’incidence de cette colonisation est connue lors d’un sejour en reanimation, celle presente a l’entree en reanimation apres transplantation hepatique est peu decrite, avec des definitions tres heterogenes. L’objectif de l’etude etait d’evaluer les caracteristiques de la colonisation a Candida le jour de la transplantation hepatique. Materiel et methodes Etude observationnelle monocentrique retrospective de 148 transplantes hepatiques, de janvier 2012 a decembre 2013. A l’admission en reanimation, en postoperatoire immediat de la transplantation hepatique, un ecouvillonnage etait realise sur quatre sites : oropharynx, rectum, urines et aisselles. La prevalence de la colonisation (au moins un site positif), l’index de colonisation (nombre de sites colonises sur le nombre de sites preleves) et la distribution des differentes especes de Candida etaient analyses. Resultats Durant la periode etudiee, 146 transplantes hepatiques sur 148 ont ete analyses. Pour deux patients re-transplantes en urgence, les donnees ont ete analysees a partir de la premiere transplantation. Au total, 136 patients sur 146 ont eu un ecouvillonnage a l’admission. La prevalence de la colonisation etait de 52 %. L’index de colonisation etait ≥ 0,5 dans 39 % des cas. L’oropharynx, le rectum et les urines etaient colonises dans 80 %, 52 % et 13 % des cas. Les aisselles n’etaient jamais colonisees. Candida albicans representait 47 % des levures isolees. Les 53 % de Candida non -albicans se repartissaient en 18 % de C . glabrata , 4 % de C . kefyr , 3 % de C . krusei , 1 % de C . tropicalis , 1 % de C . parapsilosis , 1 % de C . norvegiensis , 9 % de levures spp ( non- albicans et non identifiees), et 16 % avec plusieurs especes differentes ( Fig. 1 ). Discussion Plus d’un patient sur deux est colonise a Candida le jour de la transplantation hepatique, avec une majorite de C . non- albicans . Les candidoses invasives a C . non -albicans sont associees a un risque de resistance ou sensibilite diminuee au fluconazole [2] et a une mortalite plus elevee [3] . La frequence des especes non- albicans incite a controler regulierement la colonisation durant le sejour en reanimation. Dans ce contexte, la realisation d’un anti-fongigramme devrait etre plus frequemment discutee de facon collegiale chez les patients colonises a C . non- albicans et recevant une prophylaxie par fluconazole. Ceci permettrait d’adapter plus precocement l’agent antifongique en cas de survenue d’une candidose invasive.

Closed-circuit endotracheal suctioning (CES) is advocated for preventing hypoxemia caused by the loss of lung volume resulting from open endotracheal suctioning (OES). However, the efficiency of CES and OES on tracheal secretion removal has never been compared in patients with acute lung injury. The authors designed a two-part study aimed at comparing gas exchange and efficiency between OES and CES performed at two levels of negative pressure.Among 18 patients with acute lung injury, 9 underwent CES and OES at 3-h intervals in a random order using a negative pressure of -200 mmHg. Nine other patients underwent CES twice using two levels of negative pressure (-200 and -400 mmHg) applied in a random order. After each CES, a recruitment maneuver was performed using 20 consecutive hyperinflations. Tracheal aspirates were weighed after each suctioning procedure. Arterial blood gases were continuously recorded using an intravascular sensor.Open endotracheal suctioning induced a significant 18% decrease in arterial oxygen tension (Pa(O2)) (range, +13 to -71%) and an 8% increase in arterial carbon dioxide tension (Pa(CO2)) (range, -2 to +16%) that persisted 15 min after the end of the procedure. CES using -200 cm H2O did not change Pa(O2), but tracheal aspirate mass was lower compared with OES (0.6 +/- 1.0 vs. 3.2 +/- 5.1 g; P = 0.03). Increasing negative pressure to -400 cm H2O during CES did not change Pa(O2) but increased the tracheal aspirate mass (1.7 +/- 1.6 vs. 1.0 +/- 1.3 g; P = 0.02).Closed-circuit endotracheal suctioning followed by a recruitment maneuver prevents hypoxemia resulting from OES but decreases secretion removal. Increasing suctioning pressure enhances suctioning efficiency without impairing gas exchange.