Search

Summary Background Flexible ureteroscopy (fURS) is one of the recommended treatments for urinary stones. Urosepsis is one of the most frequent complications of fURS however its predictive factors remain uncertain. Our objective was to assess the septic complications rates of fURS and to determinate predictive factors of these complications in patients undergoing fURS. Methods Our retrospective analysis included all patients admitted for any fURS for stone disease in our center from December 2009 to April 2013. Patients’ medical history, urine culture, stone composition, surgical and anesthetic characteristics were collected. The primary endpoint was defined by the presence of any septic complication (i.e. postoperative fever, urosepsis, septic shock or death). We used multivariate logistic regression to assess predictive factors of septic complication related to fURS. Results Two hundred and eighty-two patients were included in this study. Urosepsis rate was 9.8% while 18.9% developed postoperative hyperthermia (> 37.5 °C). In multivariate analysis, the predictive risk factors of septic complication were: a neurologic disorder (OR = 6.1; CI95%: 2.9–17.1), a history of urinary tract infection (UTI) (OR = 19.6; CI95%: 7.3–52.1), exposure to peroperative nitrous oxide (OR = 3.2; CI95%: 1.5–6.8) and intraoperative use of a laser (OR = 8.0; CI95%: 13.0–30.3). Conclusion The use of fURS is associated with relatively frequent septic complications. Patients with neurologic disorders or a history of UTI carry an increased risk of postoperative complications. Limitations should be drawn with the use of peroperative nitrous oxide. These results should be further validated. Level of evidence 3. Retrospective cohort study.

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.

Objectifs Decrire un concept d’hopital de jour pour evaluation preoperatoire standardisee avant chirurgie lourde en neuro-urologie et en evaluer la faisabilite et les resultats. Methodes Un hopital de jour (HdJ) pour evaluation avant chirurgie lourde en neuro-urologie a ete mise en place au sein de notre service d’urologie. Tous les patients ayant beneficie de cet HdJ de janvier 2017 a juillet 2019 etaient eligibles. Les donnees etaient recueillies de maniere retrospective a partir des comptes rendus standardises d’HdJ. Le critere de jugement principal etait le taux d’exhaustivite des donnees recueillies lors de cet HdJ. Les criteres de jugement secondaires comprenaient la description des modifications de prise en charge suite a cet HdJ – dans la revision des indications chirurgicales ou dans les examens, consultations ou traitements complementaires proposees au decours. Resultats Au total, 80 patients ont beneficie de cet HdJ, avec un taux d’exhaustivite global des donnees recueillies de 37,1 %. Le taux de realisation des examens tels que le bilan urodynamique (55,2 % vs 88,9 %) ou la tomodensitometrie abdominopelvienne (41,9 % vs 73,7 %) augmentait entre 2017 et 2019. De meme pour les consultations d’anesthesie (9,7 % vs 89,5 %) ou de stomatherapie (45,2 % vs 84,2 %). Alors qu’une intervention chirurgicale lourde etait envisagee avant l’HdJ, elle n’etait finalement retenue que chez 78,8 % des patients a la fin de l’HdJ. En outre, une modification/adaptation du projet chirurgical neuro-urologique etait acte chez 38,7 % des patients. Au decours de l’HdJ, 72,5 % et 41,3 % des patients se voyait proposer respectivement au moins une consultation specialisee ou un examen complementaire ( Fig. 1 ). Conclusion La mise en place d’une evaluation standardisee preoperatoire en HdJ est faisable avec une bonne exhaustivite des examens, sous reserve d’une coordination avec les nombreux intervenants. Son interet semble confirme par l’adaptation du projet chirurgical chez plus d’un tiers des patients. L’impact de cette evaluation sur les suites chirurgicales reste neanmoins a etudier.

International audience; Hemodynamic optimization begins with a medical assessment to identify the high-risk patients. This stratification is needed to customize the choice of hemodynamic support that is best adapted to the patient's level of risk, integrating the use of the least invasive procedures. The macro-circulatory hemodynamic approach aims to maintain a balance between oxygen supply (DO2) and oxygen demand (VO2). Volume replacement plays a crucial role based on the titration of fluid boluses according to their effect on measured stroke volume or indices of preload dependency. Good function of the microcirculatory system is the best guarantee to achieve this goal. An assessment of the DO2/VO2 ratio is needed for guidance in critical situations where tissue hypoxia may occur. Overall, all of these strategies are based on objective criteria to guide vascular replacement and/or tissue oxygenation in order to improve the patient's post-operative course by decreasing morbidity and hospital stay.

L’anestesia per chirurgia della tiroide interessa pazienti di tutte le eta. La valutazione preoperatoria deve definire il loro stato tiroideo, l’impatto locale della patologia tiroidea sulla filiera aerea e i rischi legati al terreno. L’exeresi della ghiandola tiroide non costituisce mai un’urgenza assoluta, di modo che l’eutiroidismo deve essere assicurato prima dell’intervento. La preparazione medica, diminuendo l’ormonosintesi o gli effetti centrali e periferici degli ormoni tiroidei, e particolarmente indicata per prevenire l’eccezionale ma temibile crisi tireotossica. Per la cervicotomia, l’anestesia generale e la tecnica di elezione. Essa potra essere associata a un blocco del plesso cervicale superficiale per migliorare l’analgesia perioperatoria. Il decorso postoperatorio e, generalmente, semplice. Il monitoraggio postoperatorio si dedica a ricercare le complicanze emorragiche che possono mettere in gioco la prognosi vitale e le lesioni degli elementi a contatto con la ghiandola come le paratiroidi e i nervi ricorrenti. La lesione ricorrenziale, quando bilaterale, puo essere associata a un distress respiratorio acuto la cui gestione delicata richiede un ambiente di rianimazione. Nonostante una semplificazione della gestione dei pazienti tiroidectomizzati, queste gravi complicanze costituiscono una limitazione importante a una pratica ambulatoriale sistematica di questa chirurgia.

La anestesia para la cirugia tiroidea concierne a pacientes de todas las edades. La evaluacion preoperatoria busca apreciar el estado de la glandula tiroidea, la repercusion local de la patologia tiroidea sobre la via aerea y los riesgos relacionados con las caracteristicas del paciente. La exeresis de la glandula tiroidea no es nunca una urgencia absoluta, por lo que se debe garantizar una situacion de eutiroidismo antes de la cirugia. La preparacion medica, disminuyendo la hormonosintesis o los efectos centrales y perifericos de las hormonas tiroideas, esta particularmente indicada para prevenir la aparicion del excepcional pero temible acceso tirotoxico. Para la cervicotomia, la tecnica de eleccion es la anestesia general. Se puede asociar a un bloqueo del plexo cervical superficial para mejorar la analgesia perioperatoria. Los cuidados postoperatorios suelen ser simples. La vigilancia postoperatoria se debe esforzar en investigar la posible presencia de las complicaciones hemorragicas que pueden poner en riesgo el pronostico vital y las lesiones de los elementos en contacto con la glandula, como las glandulas paratiroideas y los nervios recurrentes. La lesion del nervio recurrente, cuando es bilateral, se asocia a una dificultad respiratoria aguda cuyo delicado tratamiento precisa que se realice en un contexto de reanimacion. A pesar de una simplificacion del manejo de los pacientes tras tiroidectomia, estas posibles complicaciones graves constituyen una importante limitacion a una practica sistematica de esta cirugia en regimen ambulatorio.

La cirugia por cancer de esofago se asocia a una morbimortalidad perioperatoria elevada, debido a complicaciones pulmonares y quirurgicas, sobre todo la fistula anastomotica. La evolucion de las tecnicas quirurgicas y de anestesia-reanimacion ha permitido mejorar el enfoque de la comprension de los mecanismos fisiopatologicos y un manejo mejor a la hora de prevenir y tratar estas complicaciones. La busqueda preoperatoria de los factores de riesgo de morbimortalidad permite identificar los pacientes con riesgo de complicacion. Ademas, la morbilidad pulmonar se ve influida por la estrategia anestesica que asocia la analgesia peridural, la optimizacion de la reposicion vascular y la ventilacion protectora. Estos procedimientos anestesicos tambien favorecen la rehabilitacion y la extubacion precoces. En este contexto, la anestesia general asociada a una analgesia locorregional es la tecnica de eleccion. La vigilancia postoperatoria debe ser multidisciplinaria para diagnosticar y tratar precozmente las complicaciones. El lugar de un tratamiento inmunomodulador, como la corticoterapia, aun esta por definir.

Background The operative risk of hepatectomy under antiplatelet therapy is unknown. This study sought to assess the outcomes of elective hepatectomy performed with or without aspirin continuation in a well balanced matched cohort. Methods Data were retrieved from a multicentre prospective observational study. Aspirin and control groups were compared by non-standardized methods and by propensity score (PS) matching analysis. The main outcome was severe (Dindo–Clavien grade IIIa or more) haemorrhage. Other outcomes analysed were intraoperative transfusion, overall haemorrhage, major morbidity, comprehensive complication index (CCI) score, thromboembolic complications, ischaemic complications and mortality. Results Before matching, there were 118 patients in the aspirin group and 1685 in the control group. ASA fitness grade, cardiovascular disease, previous history of angina pectoris, angioplasty, diabetes, use of vitamin K antagonists, cirrhosis and type of hepatectomy were significantly different between the groups. After PS matching, 108 patients were included in each group. There were no statistically significant differences between the aspirin and control groups in severe haemorrhage (6·5 versus 5·6 per cent respectively; odds ratio (OR) 1·18, 95 per cent c.i. 0·38 to 3·62), intraoperative transfusion (23·4 versus 23·7 per cent; OR 0·98, 0·51 to 1·87), overall haemorrhage (10·2 versus 12·0 per cent; OR 0·83, 0·35 to 1·94), CCI score (24 versus 28; P = 0·520), major complications (23·1 versus 13·9 per cent; OR 1·82, 0·92 to 3·79) and 90-day mortality (5·6 versus 4·6 per cent; OR 1·21, 0·36 to 4·09). Conclusion This observational study suggested that aspirin continuation is not associated with a higher rate of bleeding-related complications after elective hepatic surgery.

The aim of our in-vitro study was to assess the impact of infusion set characteristics on the accuracy of morphine doses in patient-controlled analgesia. Two infusion sets differing in conception and dead-space volume were assessed: a standard set and a low dead-space volume Y-set. The patient-controlled analgesia programme parameters were as follows: bolus equal to 1 ml at 100 ml.h(-1) ; lockout intervals equal to 5 and 10 min; and carrier fluid flow rate equal to 10 and 50 ml.h(-1) . Morphine concentration was determined by an ultraviolet spectrophotometric method. The morphine doses were significantly different from one set to the other during bolus and lockout intervals, whatever the patient-controlled analgesia programme. The average doses were approximately 1.3-6.0 times higher with the low dead-space volume Y-set during bolus. Our study underlines the impact of infusion set characteristics on the accuracy of morphine patient-controlled analgesia doses.

Resume Objectif Evaluer la qualite de la formation a l’intubation difficile chez des medecins urgentistes par la mise en situation sur simulateur realiste. Type d’etude Etude prospective. Population Medecins urgentistes. Methodes Vingt-quatre medecins urgentistes ont ete sollicites pour participer a cette investigation. L’etude consistait dans un premier temps a evaluer les connaissances theoriques, a apporter un enseignement theorique et pratique sur mannequin, et six semaines apres, a mesurer l’acquis theorique et a tester les capacites pratiques lors de la mise en situation de gerer les voies aeriennes difficiles sur simulateur realiste. Resultats Un seul medecin n’a pas pu suivre la formation dans son integralite. La moitie des medecins urgentistes exercaient en CHU depuis plus de trois ans. La formation theorique et pratique a permis l’acquisition des techniques de gestion des voies aeriennes difficiles ainsi qu’une amelioration des capacites a hierarchiser ces techniques dans un algorithme. En revanche, la mise en situation sur simulateur revele des lacunes indiscutables dans la gestion des scenarios d’intubation difficile. Conclusion L’enseignement de l’intubation difficile chez les medecins urgentistes s’accompagne d’une amelioration des connaissances theoriques et pratiques, mais ne semble pas suffisante pour ameliorer les performances lors de la mise en situation sur simulateur. Il semble important de reflechir sur l’integration de la simulation comme mode d’enseignement et d’evaluation.

L’anestesia della chirurgia tiroidea riguarda pazienti di qualsiasi eta. La valutazione preoperatoria mira a valutare lo stato tiroideo, la ripercussione locale della patologia tiroidea sulla filiera aerea e i rischi legati al contesto clinico. L’exeresi della tiroide non costituisce mai un’urgenza assoluta, tanto da richiedere prima dell’intervento l’eutiroidismo. La preparazione medica, riducendo l’ormonosintesi o gli effetti centrali e periferici degli ormoni tiroidei, e particolarmente indicata per prevenire la rarissima ma temibile crisi tireotossica. Per la cervicotomia l’anestesia generale e la tecnica di scelta. Essa potra essere associata a blocco del plesso cervicale superficiale per migliorare l’analgesia perioperatoria. I postumi operatori sono semplici nella maggior parte dei casi. Il monitoraggio postoperatorio mira a controllare le complicanze emorragiche che possono mettere in gioco la prognosi vitale e le lesioni degli elementi in contatto con la ghiandola, come le paratiroidi e i nervi ricorrenti. La lesione ricorrenziale, quando e bilaterale, puo essere associata a un’insufficienza respiratoria acuta la cui delicata gestione richiede un ambiente di rianimazione. Questa morbilita dopo tiroidectomia e favorita dai reinterventi e dalla chirurgia oncologica, che necessita di dissezioni estese. Nonostante una semplificazione della gestione dei pazienti tiroidectomizzati, queste gravi complicanze rappresentano un limite importante per la messa in atto di questa chirurgia in ambulatorio.

La mortalidad de la sepsis grave (definida como una disfuncion o hipoperfusion organica inducida por una infeccion) y del shock septico (hipotension arterial refractaria a la reposicion liquida, asociada a la disfuncion o hipoperfusion organica) tratada en una unidad de reanimacion sigue siendo elevada (del orden del 45%), mientras que se espera un aumento de su incidencia en los proximos 25 anos (por el incremento de su deteccion). No obstante, se ha podido registrar recientemente una disminucion significativa de su mortalidad en varios ensayos terapeuticos aislados, basados en una monitorizacion dirigida hacia el tratamiento global de la oxigenacion tisular o que empleaba nuevas vias de tratamiento, que son sobre todo la utilizacion de corticoides en dosis moderadas, la modulacion de la activacion de la hemostasia por la proteina C activada y la aplicacion sistematica de referenciales de cuidados en la reanimacion. Al igual que en el infarto de miocardio, la combinacion de estas nuevas medidas terapeuticas debe realizarse en un ambito global de optimizacion precoz y rapida (6-24 horas). Este nuevo esquema de tratamiento deberia garantizar en el futuro una reduccion considerable de la mortalidad y de la morbilidad de la sepsis (reduccion esperada del 25% durante los proximos 5-10 anos).

The aim of this retrospective study was to evaluate the outcome and prognostic parameters of patients over 85 years of age undergoing major abdominal emergency surgery. The medical records of 45 consecutive patients aged over 85 years who underwent major abdominal emergency surgery between May 1999 and November 2001 were reviewed. The mean patient age was 88 years. Eight patients were American Society of Anesthesiologists (ASA) IV or V, 21 were ASA III, and 16 were ASA I or II. We performed 38 median and 7 right subcostal laparotomies. Perioperative mortality was 26.6% (3 times higher than that of the overall population at the same age). Perioperative complications occured in 29.5% of patients. Ten patients returned home after surgery, of whom 70% remained alive at the end of the study. Twenty-three left the hospital for a long-term care institution or post-acute care unit: of these 20% remained alive at the end of the study. Among ASA I or II patients, 43.7% remained alive at the end of the study, although 18.7% died within 1 month of the surgery. Among ASA III, IV, or V patients, only 17.2% remained alive at the end of the study, and 34.5% died within 1 month of the surgery. None of patients classified as ASA IV or V survived for more than 6 month after surgery. With an overall mortality rate of about 30%, and with the clear correlation between increased mortality and higher ASA scores, the place of palliative treatment must remain a major consideration for patients in this age group classified ASA III or higher. When surgery is performed, early return home, should be encouraged.

Summary Background and objective: Because gastric mucosal PCO 2 must be referenced to arterial values via a gastric-to-arterial PCO 2 gap (Pg–aCO 2 ), the gastric-to-end-tidal PCO 2 difference (Pg– et CO 2 ) may be proposed as a surrogate method to monitor Pg–aCO 2 . However, the influence of arterial-to-end-tidal PCO 2 (Pa– et CO 2 ) on its value remains unknown. Pa– et CO 2 may be enhanced by a low cardiac output and subsequent reduced perfusion of the lungs. This study was designed to compare such gaps observed during abdominal surgery in patients with or without preoperative cardiac dysfunction. Methods: Haemodynamic, metabolic and tonometric variables were measured in seven patients with Crohn's disease and in five patients with chronic heart failure scheduled for abdominal surgery. Data were collected before skin incision (T0); at extractor placement (T1), 30 (T2) and 60 (T3) min later; at organ extraction (T4), 30 (T5) and 60 (T6) min later, and at the end of surgery (T7). Results: Gradients appeared larger in the cardiac group. The difference was significant for Pg– et CO 2 during the whole study period, while it was only reached at T1–T2 for Pa– et CO 2 and at T5–T6 for Pg–aCO 2 . Gaps did not change significantly over the peroperative time points in either group. No major haemodynamic variations were registered in either group. Conclusions: In patients with preoperative chronic heart failure, Pg– et CO 2 remained constant throughout a major general surgical procedure and was only moderately influenced by the Pa– et CO 2 gap. In these patients, Pg– et CO 2 may be used as a reliable index of gastrointestinal perfusion after control of PaCO 2 .

The peri-operative management of patients undergoing surgery for phaeochromocytoma or paraganglioma with calcium channel blockers (CCB) and their impact on postoperative morbidity and mortality were studied. The medical records of 105 patients undergoing surgery between 1991 and 2002 were analysed retrospectively. In all patients, the calcium channel blocker nicardipine was used for the peri-operative management of haemodynamic changes. Sixty-five patients (61.9%) showed transient intra-operative hypertension. Systolic blood pressure (SBP) > 220 mmHg and SBP > 180 mmHg for > 10 consecutive minutes was observed in 14 (13%) and four patients (2.8%), respectively. SBP 10 consecutive minutes occurred in 13 patients (12.3%). Eleven patients (10.4%) developed postoperative complications and three patients died (2.8%). The median (range) ICU and hospital length of stay were, respectively, 1 (0-7) day and 10 (2-35) days. The sole use of calcium channel blockers for the peri-operative management of phaeochromocytoma and paraganglioma resection does not prevent all haemodynamic changes; however, its use was associated with a low morbidity and mortality.

Resume Le monitorage de la saturation en O 2 du sang veineux mele (SvO 2 ) obtenue a l’aide de catheters arteriels pulmonaires munis de fibres optiques trouve sa place dans la prise en charge des patients en etat de choc. La SvO 2 est un reflet de la balance entre le transport en O 2 systemique et la consommation en O 2 (VO 2 ) par les tissus. Le monitorage concomitant du debit cardiaque (DC) continu et de la SvO 2 , rendu possible par certains catheters arteriels pulmonaires, facilite l’interpretation des modifications de la SvO 2 . En effet, une diminution de SvO 2 peut resulter d’une baisse de la saturation arterielle en O 2 , de l’hemoglobine ou du DC ou d’une augmentation de VO 2 . La SvO 2 est un outil d’appreciation de l’extraction peripherique de l’O 2 (EO 2 ) selon une relation SvO 2 = 1 – EO 2 . La SvO 2 ne permet pas correctement l’appreciation de l’oxygenation tissulaire lorsqu’il existe un trouble de l’EO 2 comme au cours du choc septique. La saturation en O 2 du sang veineux central (ScvO 2 ) est plus facilement mesurable que la SvO 2 et il existe une bonne correlation entre ces deux parametres. L’utilisation recente de la ScvO 2 au sein d’un service d’urgence dans un protocole d’optimisation initiale de l’hemodynamique au cours du sepsis severe a permis une diminution absolue de la mortalite hospitaliere de 16 % ( p = 0,009).

International guidelines recommend noradrenaline (NA) as the vasopressor of choice to treat septic shock. The aim of this study was to determine the best way to infuse patients with NA.The in vitro study was designed to measure NA concentration at the end of each studied assembly line. Three infusion systems used the double pump method and three single pumps, which differed as regards NA concentrations (0,2 - 0,5 - 1 mg/h), dead space volume of the devices and the use of saline. Infusion systems were compared according to the time necessary to reach an NA mass flow rate steady-state plateau after the onset of infusion or after a flow change.Times were significantly different between the six methods for infusing NA. The system using the double syringe method with a standard extension set was the longest to reach the steady state after the onset of infusion [40.00 min (19.57 - 49.22)]. The steady-state plateau was obtained most rapidly with the double-syringe pump systems using very low dead-space volume extension sets and single-syringe pump systems containing diluted noradrenaline at the beginning of NA infusion.A combination of a low dead-space volume extension set and a double pump method with a constant saline flow rate at 5 ml/h might be the solution to provide the most reliable NA infusion delivery.

Background: Crohn’s disease is associated with vascular injury and dysregulation of the intestinal immune system which together can provide disturbance of mesenteric circulation functional properties. Aim: To evaluate the vascular reactivity of mesenteric arteries from patients with Crohn’s disease. Methods: Phenylephrine-induced contractions were assessed from 10 patients with Crohn’s disease and 8 control organ donors. NG-nitro-L-arginine-methyl-ester (L-NAME) was used to test the presence of inducible NO synthase. Endothelium dependent and independent relaxation was assessed using acetylcholine, bradykinin, calcium ionophore A23187 and sodium nitroprusside. Results: The contractile response to phenylephrine was significantly decreased in arteries without endothelium from patients with Crohn’s disease. Exposure to the NO synthase inhibitor L-NAME restored the contractile response to phenylephrine. Relaxation remained unaltered in both groups. Conclusion: These data provide direct evidence for fading of contraction caused by phenylephrine in Crohn’s disease. The restored mesenteric artery tone by a specific NO synthase inhibitor suggests that an increased production for NO in vascular smooth muscle might be responsible of this altered vascular reactivity.

Professional practice evaluation of anaesthesiologist for high cardiac-risk patient cares in non-cardiac surgery, and assess disparities between results and recommendations.Since June to September 2011, a self-questionnaire was sent to 5000 anesthesiologist. They were considered to be representative of national anesthesiology practitioner. Different items investigated concerned: demography, preoperative cardiac-risk assessment, modalities of specialized cardiologic advice, per- and postoperative care, and finally knowledge of current recommendations.We collected 1255 questionnaire, that is to say 25% of answers. Men were 73%, 38% were employed by public hospital; 70% worked in a shared operating theatre with a general activity. With regards to preoperative assessment, 85% of anaesthetists referred high cardiac-risk patient to a cardiologist. In only 16% of answer, Lee's score appeared in anaesthesia file to assess perioperative cardiac-risk. Only 61% considered the six necessary items to optimal estimate of cardiac-risk. On the other hand, 91% measured routinely the exercise capacities by interrogation. The most frequently doing exam (49% of anaesthetist) was an electrocardiogram in elderly patient. In 96% of case, beta-blockers were given in premedication if they were usually thought. Clopidogrel was stopped by 62% of anesthetist before surgery. In this case, 38% used another medication to take over from this one. Only 7% considered revascularization in coronary patient who were effectively treated. POISE study was know by 40% of practitioner, and 18% estimated that they have changed their practice. Preoperatively, 21% organized multidisciplinary approach for high-risk patient. During surgery, 63% monitored the ST-segment. In postoperative period for cardiac-risk patient, only 11% prescribed systematically an ECG, a troponin dosage, a postoperative monitoring of ST-segment, a cardiologic advice. In case of moderate troponin elevation, they were 70% to realize at least an ECG and/or an echocardiography.This study highlights some difference between current recommendation concerning assessment of cardiac-risk patient in non-cardiac surgery and daily practice of anesthetist, justifying regular update of this one.

Morbidity after oesophageal cancer surgery remains high, mainly due to major postoperative pulmonary complications (MPPCs). The aim of this study was to test the hypothesis that hybrid minimally invasive oesophagectomy (HMIO) decreases the 30-day MPPC rate without compromising oncological outcomes.Consecutive patients undergoing curative oesophagectomy for cancer by laparoscopic gastric mobilization and open thoracotomy (HMIO) between January 2004 and December 2009 were matched to randomly selected patients undergoing a totally open approach during the same study interval. Matching variables were age, sex, cancer stage, location of the primary tumour, histological subtype, American Society of Anesthesiologists grade, malnutrition, neoadjuvant chemoradiation and epidural analgesia.MPPCs at 30 days were significantly less frequent after HMIO compared with open surgery (15·7 versus 42·9 per cent; P0·001). Postoperative in-hospital mortality and overall morbidity rates were 4·3 and 47·5 per cent respectively, again significantly lower in the HMIO group: 1·4 versus 7·1 per cent (P = 0·018) and 35·7 versus 59·3 per cent (P0·001). In multivariable analysis, HMIO, adenocarcinoma subtype, epidural analgesia and surgery after 2006 were independent protective factors against MPPCs, and HMIO was independently protective against acute respiratory distress syndrome (ARDS). Lymph node yields and survival were similar in the two groups.HMIO for oesophageal cancer, using laparoscopic gastric mobilization and open right thoracotomy, offered a substantial and independent protective effect against MPPCs, including ARDS, without compromising oncological outcomes.

There is a growing interest in the involvement of anesthetic agents in the etiology of postoperative cognitive dysfunction. Recent animal studies suggest that acute anesthesia induces transient hyperphosphorylation of tau, an effect essentially ascribed to hypothermia. The main aim of the present study was to investigate effects, in normothermic conditions, of acute or repeated exposure to sevoflurane, a halogenated anesthetic agent, on hippocampal tau phosphorylation and spatial memory in adult mice.5 to 6-month-old C57Bl6/J mice were submitted to acute (1 h) or repeated (five exposures of 1h every month) anesthesia using 1.5 or 2.5% sevoflurane, in normothermic conditions. In the acute protocol, animals were sacrificed 1 and 24 h after exposure. In the chronic protocol, spatial memory was evaluated using the Morris water maze following the fourth exposure, and tau phosphorylation evaluated 1 month following the last exposure using bi- and mono-dimensional electrophoresis.Acute sevoflurane anesthesia in normothermic conditions led to a significant dose-dependent and reversible hippocampal tau phosphorylation, 1 h following the end of exposure (P0.001). Conversely, repeated anesthesia led to persistent tau hyperphosphorylation and significant memory impairments, as seen in the retention phase of the Morris water maze in sevoflurane-anesthesized animals. These pathologic features may be related to the activation of both Akt and Erk pathways.The present study demonstrates, in mice, that sevoflurane exposure is associated with increased tau phosphorylation through specific kinases activation and spatial memory deficits. These data support a correlation between exposures to this anesthetic agent and cognitive decline.

The restoration of patients' mean arterial pressure after ineffective fluid resuscitation is obtained by vasopressive treatment such as norepinephrine. However, no guidelines exist concerning a norepinephrine infusion method: whether it be the norepinephrine concentration in the syringe, single or double pump administration via a carrier such as an isotonic saline solution, or use of minimized dead-volume extension sets. We present the case of a female patient requiring norepinephrine treatment, who quickly suffers a major haemodynamic incident (a sudden rise in systolic blood pressure above 220 mmHg associated with tachycardia up to 189 b/min). The main causes of this incident are discussed and infusion parameters considered with a view to developing an optimal infusion method for a drug with a specific therapeutic index.

To analyze the current knowledge related to xenon anaesthesia.References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service and personal files.All categories of articles on this topic have been selected.Articles have been analyzed for biophysics, pharmacology, toxicity and environmental effects, clinical effects and using prospect.The noble gas xenon has anaesthetic properties that have been recognized 50 years ago. Xenon is receiving renewed interest because it has many characteristics of an ideal anaesthetic. In addition to its lack of effects on cardiovascular system, xenon has a low solubility enabling faster induction of and emergence from anaesthesia than with other inhalational agents. Nevertheless, at present, the cost and rarity of xenon limits widespread use in clinical practice. The development of closed rebreathing system that allowed recycling of xenon and therefore reducing its waste has led to a recent interest in this gas.Reducing its cost will help xenon to find its place among anaesthetic agents and extend its use to severe patients with specific pathologies.

The immunonutrients composing the immunonutrition solutions such as Impact have been demonstrated to reinforce the immune defenses and limit postoperative complications. This reduction in infectious morbidity may be related to the ability of immunonutrients to prevent the postoperative imbalance of the T-CD4 lymphocyte subpopulations (Th1/Th2 ratio) and to modulate the inflammatory response. Immunonutrition also acts with the healing process, in particular with arginine, which promotes collagen synthesis. The beneficial effects of immunonutrition are important in all digestive cancer surgery, including esophageal surgery. It is administered preoperatively to all patients for at least 5 days and is recommended postoperatively for undernourished patients for at least 7 days. Finally, the reduction in postoperative morbidity decreases hospital costs, which easily compensates the additional cost of the pharmaconutrients, another argument in favor of prescribing them systematically in patients operated on for digestive cancer.

A questionnaire for self-assessment, the Amsterdam Preoperative Anxiety and Information Scale (APAIS) translated into French has been compared to a background questionnaire to validate their use as screening tool and assessment of anxiety and information needs of patients.An epidemiological study was conducted anonymously. Patients completed a questionnaire comprising a French version of APAIS and Spielberger Anxiety Inventory (STAI). A study of correlation between scores for each questionnaire was conducted. A high level of anxiety was investigated.So 1800 questionnaires were distributed, 1504 were usable. The first 100 questionnaires have confirmed the internal validity of the questionnaire APAIS. The following questionnaires in 1404 accounted 49.7% of men 55.7 ± 15.7 years old and 50.2% of women 50.8 ± 15.2 years old. The correlation coefficient (r) between STAI state and appeasement was of 0.675 (P0.001). A score higher than 10/20 by APAIS corresponded to 73% of patients with high anxiety by Spielberger's inventory. No correlation was found between the STAI state and the need for information (r=0.252; P0.001).APAIS, in its French version, assesses anxiety and information needs of patients. This questionnaire has metrological capabilities and ease of execution that make it a screening tool for use in anesthesia consultation. A score above 10 out of 20 reflects a high level of anxiety.

The aim of this study was to assess the value of central venous oxygen saturation (ScvO(2)) for the decision of blood transfusion in comparison with the criteria of the French guidelines for blood transfusion (2003).Prospective, observational.Sixty patients, haemodynamically stable, for whom a blood transfusion (BT) was discussed in the postoperative course of general surgery, were included. ScvO(2) (%) and haemoglobin (g/dl) were measured before and after BT. Patients were retrospectively divided into two groups according to ScvO(2) measured before BT (oror=70%). Results are expressed as median.The ScvO(2) before transfusion was greater or equal to 70% in 25 (47.2%) patients. Following BT, the ScvO(2) increased significantly (from 57.8 to 68.5%) in the group with initial ScvO(2) less than 70% whereas it was unchanged in patients with initial ScvO(2) greater or equal 70% (from 76.8 to 76.5%). Twenty patients (37.7%) did not meet the French guidelines for BT criteria. Eighteen patients out of 33 that met the criteria had ScvO(2) greater or equal 70% before BT while 13 patients with ScvO(2) less than 70% were not detected by these same criteria.ScvO(2) could be a relevant biological parameter to complete the current guidelines for BT in stable patient with a central venous catheter during the postoperative period.

The aim of this study was to assess outcome after surgical revascularization for chronic intestinal ischemia (CII).From 1980 until 2003, 34 patients underwent revascularization for CII. Records were reviewed for operative technique, perioperative mortality and long-term outcomes. CII was diagnosed on the basis of clinical, arteriographic and angio-magnetic resonance imaging (MRI) criteria. Revascularization patency was monitored by arteriography, color duplex ultrasound scanning (CDS), computed tomography (CT)-scanning or angio-MRI.The celiac artery (CA) was severely diseased in 26 cases and the superior mesenteric artery (SMA) in 30 cases. Four patients presented single-vessel, 15 patients two-vessel, and 15 three-vessel involvement. Revascularization was performed by either simple (N=15) or double (N=19) bypass grafting. In 2 patients bypass grafting was combined with reimplantation. One patient underwent reimplantation alone. Median follow-up was 45 months. The 30-day mortality rate was 3%; there were 22 late death (64%). Primary revascularization patency was 94% at 1 month and 79.4% at 4 years. Clinical success rates were 85% and 70% respectively at 1 month and at 4 years.To choose the most suitable intervention, the Authors distinguished isolated CII treatable by single SMA revascularization from the digestive arteritis affecting the supramesocolic level of the abdomen, which requires double CA and SMA revascularization.

The aim of this study was to evaluate for the interest of realistic mannequin-based simulations as a tool to assess the knowledge of emergency medicine physicians in the field of difficult tracheal intubation.Prospective.Emergency physicians.Twenty-four emergency physicians were invited entering the study. The first step of the study consisted of an initial assessment of their knowledge in the field of difficult tracheal intubation. Then theoretical lectures on the tools and techniques of difficult tracheal intubation were given, followed by standard mannequin-based driven workshops. The second step was conducted six weeks later. Each physician's knowledge was re-evaluated and their ability to manage two difficult airway scenarios simulated on the AirMan simulator (Laerdal was assessed.Only one physician could not complete the program. Half of them worked at the University Hospital (UH) with half of them for less than three years. Lectures and standard mannequin-based driven workshops significantly improved physician's theoretical knowledge. Practical performance during difficult airway management scenarios was poor.We have demonstrated that theoretical lectures and standard mannequin-based driven workshops improved overall theoretical knowledge but did not translated to practical skill during of realistic mannequin-based simulations. Realistic mannequin-based simulations teaching programs in the field of difficult tracheal intubation should be considered.

Comparison between BIS (Bispectral Index) and state (SE) and response (RE) entropy during laparotomy for inflammatory bowel disease patients (IBD) and evaluation of the variations of RE and SE during nociceptive stimulation.Prospective, observational study.Fourteen IBD's patients undergoing laparotomy were included. Anaesthesia aimed to maintain BIS between 40 and 60 by isoflurane and nitrous oxide. Analgesia was performed by sufentanil bolus administrated according to an increase of 20% of systolic blood pressure (SBP) and heart rate compared with the baseline values. BIS, RE and SE were measured at each nociceptive stimulation. A variance analysis (Anova) was used to assess BIS, RE and SE variations throughout surgery (p0.05 as significant). Relationship between BIS, RE and SE was assessed by Pearson correlation (p0.01 as significant). The ability for SE and RE to predict depth of anaesthesia and intraoperative analgesia was performed by calculating area under the receiver operated curves (AUC).BIS and entropy parameters had strictly the same evolution during anaesthesia. SBP increased significantly during nociceptive stimulation while no variation of RE was observed. A significant correlation was shown between BIS, RE and SE. The evaluation of anaesthesia depth was good for RE (AUC: 0.932+/-0.26) and SE (AUC: 0.926+/-0.27). There was however no difference between RE and SE to predict analgesic requirement.Because RE includes muscular frequency analysis, it does not allow analgesic requirement evaluation in paralyzed patients.

The peri-operative management of patients undergoing surgery for phaeochromocytoma or paraganglioma with calcium channel blockers (CCB) and their impact on postoperative morbidity and mortality were studied. The medical records of 105 patients undergoing surgery between 1991 and 2002 were analysed retrospectively. In all patients, the calcium channel blocker nicardipine was used for the peri-operative management of haemodynamic changes. Sixty-five patients (61.9%) showed transient intra-operative hypertension. Systolic blood pressure (SBP)220 mmHg and SBP180 mmHg for10 consecutive minutes was observed in 14 (13%) and four patients (2.8%), respectively. SBP80 mmHg for10 consecutive minutes occurred in 13 patients (12.3%). Eleven patients (10.4%) developed postoperative complications and three patients died (2.8%). The median (range) ICU and hospital length of stay were, respectively, 1 (0-7) day and 10 (2-35) days. The sole use of calcium channel blockers for the peri-operative management of phaeochromocytoma and paraganglioma resection does not prevent all haemodynamic changes; however, its use was associated with a low morbidity and mortality.