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Resume Objectif Les indications d’assistance circulatoire et/ou respiratoire de courte duree (ACRCD) ont augmente ces dernieres annees. Le but de cette enquete etait de caracteriser cette activite en France en 2009. Type d’etude Etude epidemiologique. Materiel et methodes Chaque centre de chirurgie cardiothoracique a recu un questionnaire valide par la Societe francaise de perfusion concernant l’activite, les materiels et l’organisation utilises pour l’ACRCD. Les donnees ont ete exprimees en pourcentage ou mediane [25 e –75 e percentiles]. Resultats Quarante-et-un centres sur 61 (67 %) ont repondu. Cette activite a ete realisee respectivement par 33 (80,5 %), 36 (87,8 %) et 39 (95,1 %) des centres en 2007, 2008 et 2009 a raison de dix [4–26], 18 [6–29] et 18 [5–33] cas par centre par an. En 2009, les types d’ACRCD posee ont ete veino-arterielles dans 39 centres (95,1 %), veino-veineuses dans 27 (65,9 %) et arterio-veineuse dans 4 (9,8 %), a raison de 18 [5–32], 5 [2–7] et 1,5 [1–17] cas respectivement. Vingt-neuf centres (70,7 %) ont pose des ACRCD en dehors du bloc operatoire, et 24 (58,5 %) en dehors du contexte de chirurgie cardiothoracique. Une unite mobile d’assistance circulatoire a ete creee dans huit centres (19,5 %), mais 21 (51,2 %) ont pose des ACRCD hors etablissement, a des distances allant de 10 [5–55] a 100 [15–200] km, le Samu etant presque toujours sollicite (90,5 %), l’helicoptere rarement (19 %). Conclusion L’activite d’ACRCD a augmente en France ces dernieres annees. Sa delocalisation hors du bloc operatoire a ete importante et consommatrice de ressources humaines et logistiques, modifiant l’activite des perfusionnistes.

A 71-year-old valvular patient with cardiac arrhythmia, low ejection fraction, administered angiotensin converting enzyme inhibitor underwent aortic and mitral valvular replacement. Starting during normothermic cardiopulmonary bypass (CPB), hypotension occurred, refractory to phenylephrine, noradrenaline, terlipressin, hydrocortisone and dexchlorpheniramine. After 3 hr of CPB biventricular hyperkinesia, severe hypotension and metabolic acidosis persisted despite volume loading, sodium bicarbonate, adrenaline infusion and intraaortic conterpulsation. Refractory asystole occurred 5 hr postoperatively. The responsability of sepsis and anaphylaxis were ruled out and post-CPB vasoplegic syndrome appeared to be involved. Moderate and severe vasoplegic syndromes are discussed with regards to risk factors, physiology and treatment, including prophylaxis with vasopressin and methylene blue.

Resume Objectifs Connaitre les principaux outils de monitorage de la precharge dependance en anesthesie ainsi que leurs applications et limites potentielles. Source de donnees La banque de donnees PubMed ( http://www.ncbi.nlm.nih.gov/entrez/query.fcgi ) a ete interrogee avec les mots cles suivants : fluid responsiveness, cardiopulmonary interactions, preload dependence, hypovolemia, cardiac output. Synthese des donnees Lorsqu’ils sont mesures en conditions optimales, les parametres dynamiques de reponse au remplissage vasculaire sont superieurs aux parametres statiques pour la prediction de la reponse au remplissage vasculaire chez les patients sous ventilation mecanique et anesthesie generale. Ces parametres dynamiques reposent sur les interactions cardiopulmonaires et permettent d’evaluer la precharge dependance d’un patient, c’est-a-dire sa capacite a transformer une augmentation de precharge ventriculaire en augmentation de debit cardiaque. Depuis peu, il est possible de mesurer de maniere automatique et continue ces parametres dynamiques. Ce monitorage peut se faire de maniere invasive a partir de l’analyse de la courbe de pression arterielle, ou de maniere non invasive a partir de la courbe de plethysmographie. Chacune des techniques presente un certain nombre de complications. Par ailleurs, il est possible que ces outils puissent etre utilises pour l’optimisation du remplissage vasculaire au bloc operatoire.

R-wave obtained from the electrocardiogram depends on ventricular stroke volume. We assessed the relationship between respiratory variations in R-wave (DeltaRDII) and in pulse pressure (DeltaPP) during general anesthesia.R-wave amplitude was measured from standard lead II (RDII). Maximal RDII (RDIImax) and minimal RDII (RDIImin) were determined over one respiratory cycle. DeltaRDII was calculated as 100 x [RDIImax-RDIImin]/([RDIImax + RDIImin]/2. DeltaRDII and DeltaPP were simultaneously recorded.There was a significant relationship (r = 0.79; P0.001) between DeltaRDII and DeltaPP. A DeltaRDII13% detected patients with a DeltaPP13% with an 89% sensitivity, and an 88% specificity.DeltaRDII and DeltaPP are related in this setting.

Resume Introduction La circulation extracorporelle (CEC) est un acte technique medical pouvant etre accompli par des infirmier(e)s, a condition qu’un medecin puisse intervenir a tout moment. Aucune formation initiale formalisee n’est requise, pouvant entrainer une heterogeneite de formation et de pratiques. Les responsabilites respectives des medecins et des paramedicaux autour de la CEC ne sont pas clairement definies. Objectifs Les objectifs de cette enquete ont ete : de denombrer les professionnels de la perfusion ; d’evaluer la formation des perfusionnistes ; d’identifier le(s) medecin(s) considere(s) comme responsable(s) et leurs qualifications lors d’actes pratiques par des paramedicaux ; de mettre en evidence les evolutions depuis l’enquete de 1997. Type d’etude Enquete de pratiques professionnelles. Methodes Questionnaire envoye aux perfusionnistes exercant en France. Resultats Le taux de reponses a ete, a partir de simulations, estime a 71 %. Il a ete mis en evidence un vieillissement des perfusionnistes (mediane 49 ans vs 40 ans en 1997), une diminution de la proportion de medecins formes ; 13 % des perfusionnistes ont eu une formation en adequation avec les recommandations professionnelles ; 25 % ont estime travailler en presence d’un medecin pouvant intervenir a tout moment ; 61 % ont dit travailler sous la responsabilite d’un seul medecin ; il n’existait pas de referent CEC dans 26 % des unites de perfusion. Conclusion Il est urgent de definir les responsabilites respectives des personnels medicaux et paramedicaux de la CEC, ce d’autant que cette technique se developpe en dehors des blocs operatoires de chirurgie cardiaque.

La endarterectomia carotidea es una de las intervenciones vasculares que se realiza con mayor frecuencia. Se ha demostrado que, en pacientes seleccionados adecuadamente, la endarterectomia carotidea puede reducir el riesgo relativo de accidente vascular cerebral en un 50%, si se compara con el tratamiento medico como unica terapia. Su realizacion constituye un doble desafio: primero, el que deriva de la particularidad de esta intervencion quirurgica, que requiere un pinzamiento carotideo, y sus consecuencias, y despues, el relacionado con el estado generalmente polivascular de estos pacientes; es necesario, por tanto, prevenir la doble morbimortalidad, neurologica y cardiaca, de dicha intervencion. La endarterectomia carotidea se realizaba tradicionalmente bajo anestesia general, pero cada vez se recurre mas al bloqueo plexico cervical para este procedimiento quirurgico. Algunos equipos utilizan tambien la anestesia peridural cervical o la anestesia vigil. En la actualidad, varios estudios recomiendan la anestesia locorregional, porque parece que reduce la morbimortalidad y permite una monitorizacion cerebral simple y continua. Las complicaciones postoperatorias deben detectarse con rapidez para poder aplicar un tratamiento urgente.

Resume Objectifs Connaitre les principales cardiopathies congenitales susceptibles d'etre rencontrees chez l'adulte, leur physiopathologie, leurs complications et les grands principes de leur prise en charge anesthesique dans le cadre de la chirurgie non cardiaque. Source de donnees La banque de donnees Pubmed ( http://www.ncbi.nlm.nih.gov/entrez/query.fcgi ) a ete interrogee avec les mots cles suivants : congenital heart disease, congenital cardiac disease, atrial septal defect, ventricular septal defect, Eisenmenger syndrom, cavopulmonary shunt, tetralogy of fallot, endocarditis . Synthese des donnees Actuellement, pres de la moitie des patients porteurs d'une cardiopathie congenitale sont des adultes. Ces patients peuvent etre regroupes en trois groupes distincts : ceux qui ont eu une chirurgie correctrice, ceux qui n'ont eu qu'une chirurgie palliative et ceux qui n'ont pas ete operes. Dans le cadre de la chirurgie non cardiaque, les anesthesistes–reanimateurs seront amenes a prendre en charge de plus en plus de patients adultes porteurs d'une cardiopathie congenitale. Devant la complexite et la grande variete des malformations existantes, il est recommande de prendre contact avec un centre specialise pratiquant l'anesthesie de ce type de pathologie des que la pathologie rencontree est complexe. Les complications principales chez ces patients sont les troubles du rythme cardiaque, l'hypoxie, la defaillance cardiaque et les embolies gazeuses paradoxales. La prise en charge anesthesique de ces patients ne peut se faire sans une bonne comprehension de l'anatomie et de la physiologie cardiaque. Enfin, pour les pathologies les plus a risque, il est recommande de realiser l'anesthesie dans un centre specialise.

We report 13 cases of coronary stent patients, undergoing a non cardiac surgery. Despite an heterogenous perioperative management of antiplatelet agents, none of these patients developed any significant complications. Recently, several case reports of postoperative drug eluting stent thrombosis have been reported. However, the actual incidence of this dramatic event is not known. This confirms the need to perform prospective studies or registries of patients with coronary stents undergoing non cardiac surgery, in order to propose evidence-based recommendations on perioperative antiplatelet management in such patients.

Resume Une etude recente a mis en cause la securite d'emploi de l'aprotinine en chirurgie cardiaque. Sa parution dans une grande revue medicale a emu beaucoup d'anesthesistes reanimateurs. 11 s'agissait d'une etude observationnelle. Par consequent, le present travail a pour but d'analyser les donnees des dernieres meta-analyses disponibles concernant l'efficacite et la securite d'emploi des antifibrinolytiques. Quatre meta-analyses publiees entre 1994 et 2006 et regroupant entre 33 et 61 patients sont rapportees. Ces travaux permettent de confirmer l'efficacite de l'aprotinine et de 1'acide tranexamique pour diminuer significativement le nombre de transfusions homologues ainsi que le nombre de patients recevant au moins une unite de concentres globulaires. L'aprotinine a egalement permis la reduction du nombre de re-explorations chirurgicales en phase postoperatoire. En comparaison avec les sujets ne recevant pas d'antifibrinolytique, il n'y a pas de difference significative concernant la mortalite et les principales complications peri-operatoires (infarctus myocardique, accident vasculaire cerebral, insuffisance renale aigue). Par contre, la prise en compte des accidents vasculaires cerebraux dans 18 essais a montre que l'utilisation de 1'aprotinine 6tait assocee a une reduction de 1'incidence des accidents vasculaires cerebraux. Les raisons pouvant expliquer les resultats de l'etude observationnelles sont donnees. Les travaux utilisant la methodologie de la ≪ medecine basee sur les preuves ≫ doivent continuerguider le medecin dans ses choix therapeutiques.

Resume Objectif Analyser l'impact d'un protocole de nutrition artificielle apres chirurgie cardiovasculaire et thoracique. Type d'etude Enquete retrospective sur les pratiques. Patients et methodes Echantillons de patients consecutifs d'un service de reanimation postchirurgie cardiovasculaire et thoracique, ayant un sejour superieur a huit jours, groupes en trois periodes et separees par l'ecriture d'un protocole de nutrition artificielle : groupe 1 (G1 : 34 patients) periode du 1 er mars au 30 juin 2000 ; ecriture du protocole et information des praticiens en fevrier 2001 ; groupe 2 (G2 : 15 patients) periode du 1 er mai au 30 juin 2001, et groupe 3 (G3 : 40 patients) periode du 1 er mars au 30 juin 2003. L'analyse statistique a ete realisee par une analyse de variance. Quand l'analyse montrait une significativite, les comparaisons entre les trois moyennes ont ete realisees par un test de Newman-Keuls. p Resultats La duree de la nutrition artificielle etait inferieure a sept jours respectivement dans 35 ; 40 et 22 % des cas dans les G1, G2 et G3 (NS). La prescription de la nutrition enterale a progresse, representant 49 % des prescriptions postoperatoires dans le G1, 40 % dans le G2, et 100 % dans le G3 ( p p p Conclusion Le protocole institue a ete suivi d'une majoration des apports de micronutriments, du rapport glucidolipidique, et de la surveillance de la nutrition artificielle. En revanche, les apports caloricoazotes restent inferieurs aux recommandations.

Resume Cet article decrit la prise en charge hemodynamique de la periode postoperatoire de chirurgie cardiaque. Nous abordons les consequences physiologiques de la circulation extracorporelle et nous decrivons les moyens de monitorage, les therapeutiques et les principales complications hemodynamiques de la chirurgie cardiaque.

Resume Objectifs. – Evaluer l’attitude des anesthesistes concernant l’administration perioperatoire des betabloquants (BB), notamment l’introduction preoperatoire de BB pour prevenir la survenue de complications cardiaques postoperatoires. Methodes. – Realisation d’une enquete de pratique par envoi d’un questionnaire comportant 20 items aupres de 700 anesthesistes des departements de l’Ain, de l’Isere, de la Loire et du Rhone. Resultats. – Le taux de reponses etait de 30 %. Quatre-vingt-huit pour cent des repondeurs declaraient administrer le traitement BB prescrit de facon chronique le jour de l’intervention chirurgicale avec la premedication. Trente-sept pour cent des repondeurs introduisaient frequemment ou systematiquement un traitement BB en periode preoperatoire chez les patients a risque cardiovasculaire devant subir une chirurgie majeure. Le BB le souvent prescrit etait l’atenolol (68 %). Soixante et onze pour cent des praticiens introduisant des BB en periode preoperatoire demandaient un avis cardiologique avant la prescription du traitement par BB. Conclusion. – La poursuite perioperatoire d’un traitement BB pris de facon chronique parait faire partie de la pratique courante. En revanche, la prescription preoperatoire d’un traitement BB chez le patient a haut risque cardiovasculaire reste insuffisante et correlee a un avis cardiologique.

Atropine is commonly administered when sinus bradycardia occurs in the operating room. It can also be administered to block muscarinic effects when neostigmine is used to counteract muscle relaxants. Timely administration of atropine plays a critical role in the management of sinus bradycardia. Syringes of atropine are usually prepared ahead of time to minimize the time to injection. If not administered, those standard syringes are discarded. Prefilled syringes of atropine have been commercialized in order to decrease the rate of wastage of standard syringes. However, commercial syringes are very expensive compared to ampoules.

Background Recent investigations showed that isoflurane can induce pharmacological preconditioning. The present study aimed to compare the potency of four different halogenated anaesthetics to induce preconditioning. Methods Anaesthetized open-chest rabbits underwent 30 min of coronary artery occlusion followed by 3 h of reperfusion. Before this, rabbits were randomized into one of five groups and underwent a treatment period consisting of either no intervention for 45 min (control; n = 10), or 30 min of 1 MAC halogenated anaesthetic inhalation followed by 15 min of washout. End-tidal concentrations of halogenated agents were 3.7% for sevoflurane (n = 11), 1.4% for halothane (n = 9), 2.0% for isoflurane (n = 11), and 8.9% for desflurane (n = 11). Area at risk and infarct size were assessed by blue dye injection and tetrazolium chloride staining. Results Mean (SD) infarct size was 54 (18)% of the risk area in untreated controls and 40 (18)% in the sevoflurane group (P>0.05, ns). In contrast, mean infarct size was significantly smaller in the halothane, isoflurane, and desflurane groups: 26 (18)%, 32 (18)% and 16 (17)%, respectively (P Conclusions Halothane, isoflurane and desflurane induced pharmacological preconditioning, whereas sevoflurane had no significant effect. In this preparation, desflurane was the most effective agent at preconditioning the myocardium against ischaemia.

The Berlin definition for acute respiratory distress syndrome (ARDS) is a new proposal for changing the American-European consensus definition but has not been assessed prospectively as yet. In the present study, we aimed to determine (1) the prevalence and incidence of ARDS with both definitions, and (2) the initial characteristics of patients with ARDS and 28-day mortality with the Berlin definition.We performed a 6-month prospective observational study in the ten adult ICUs affiliated to the Public University Hospital in Lyon, France, from March to September 2012. Patients under invasive or noninvasive mechanical ventilation, with PaO2/FiO2300 mmHg regardless of the positive end-expiratory pressure (PEEP) level, and acute onset of new or increased bilateral infiltrates or opacities on chest X-ray were screened from ICU admission up to discharge. Patients with cardiogenic pulmonary edema were excluded. Patients were further classified into specific categories by using the American-European Consensus Conference and the Berlin definition criteria. The complete data set was measured at the time of inclusion. Patient outcome was measured at day 28 after inclusion.During the study period 3,504 patients were admitted and 278 fulfilled the American-European Consensus Conference criteria. Among them, 18 (6.5 %) did not comply with the Berlin criterion PEEP ≥ 5 cmH2O and 20 (7.2 %) had PaO2/FiO2 ratio ≤200 while on noninvasive ventilation. By using the Berlin definition in the remaining 240 patients (n = 42 mild, n = 123 moderate, n = 75 severe), the overall prevalence was 6.85 % and it was 1.20, 3.51, and 2.14 % for mild, moderate, and severe ARDS, respectively (P0.05 between the three groups). The incidence of ARDS amounted to 32 per 100,000 population per year, with values for mild, moderate, and severe ARDS of 5.6, 16.3, and 10 per 100,000 population per year, respectively (P0.05 between the three groups). The 28-day mortality was 35.0 %. It amounted to 30.9 % in mild, 27.9 % in moderate, and 49.3 % in severe categories (P0.01 between mild or moderate and severe, P = 0.70 between mild and moderate). In the Cox proportional hazard regression analysis ARDS stage was not significantly associated with patient death at day 28.The present study did not validate the Berlin definition of ARDS. Neither the stratification by severity nor the PaO2/FiO2 at study entry was independently associated with mortality.

Paediatric pulmonary arterial hypertension (PAH) is a challenge for the paediatric anaesthetist. Due to its high morbidity and mortality, support should be provided by a dedicated team. Understanding the pathophysiology of PAH allows performing an appropriate therapeutic approach. In case of high vascular pulmonary resistance, the main objectives of anaesthetic management are to maintain an optimal pulmonary flow and to avoid the decrease in systemic arterial pressure. Haemodynamic monitoring is essential to detect the onset of an acute PAH crisis but also to give direct information on the efficacy of treatment.

A 71-year-old valvular patient with cardiac arrhythmia, low ejection fraction, administered angiotensin converting enzyme inhibitor underwent aortic and mitral valvular replacement. Starting during normothermic cardiopulmonary bypass (CPB), hypotension occurred, refractory to phenylephrine, noradrenaline, terlipressin, hydrocortisone and dexchlorpheniramine. After 3 hr of CPB biventricular hyperkinesia, severe hypotension and metabolic acidosis persisted despite volume loading, sodium bicarbonate, adrenaline infusion and intraaortic conterpulsation. Refractory asystole occurred 5 hr postoperatively. The responsability of sepsis and anaphylaxis were ruled out and post-CPB vasoplegic syndrome appeared to be involved. Moderate and severe vasoplegic syndromes are discussed with regards to risk factors, physiology and treatment, including prophylaxis with vasopressin and methylene blue.

A 55-year-old male with a history of positive HIV serology and polycythemia vera underwent coronary artery bypass graft surgery with normothermic extracorporeal circulation. Following heparin administration the activated clotting time (ACT) was 633 seconds (Hemocron with kaolin). Lower than expected arterial and venous oxygen partial pressures together with high pressure (350 mmHg) in the arterial line upstream of the oxygenator were observed. Because of these signs the oxygenator was changed during the procedure. The outcome was uneventful. Electronic microscopic examination of the oxygenator membrane and thermic exchanger revealed fibrin and platelet deposits. Similar cases are described in the literature during polycythemia vera. Therefore the prevention might be a preoperative treatment with antiplatelet therapy in polycytemia vera.

The objectives are to present the different minimally invasive cardiac surgery techniques to repair the mitral valve, TAVI and MitraClip, as well as the implications for the anaesthetist. Evaluate retrospectively the anaesthesist methods, change in monitoring and how the patients are selected. The mitral valve repair by minithoracotomy and video-surgery requires selective left intubation and monitoring by TEE. The TAVI methods seem to be working best under local anaesthesia and sedation for haemodynamic and neurologic monitoring. The MitraClip surgery requires an extensive monitoring during and after surgery. In conclusion, the care of patients that are candidates for a TAVI requires the same level of expertise as anaesthesiology in cardiac surgery. The number of procedures performed under sedation will increase. These patients require multidisciplinary care (surgeons, cardiologists, sonographers and anaesthesiologists) due to comorbidities, and the possible haemodynamic, neurologic and vascular complications. These patients have an Euroscore greater than 20% and a STS score greater than 10%. In our experience, 80% of the cases are done femorally, 17% of the cases are done through the subsclavian artery (Corevalve(®)). 80% of the patients have surgery with a local anaesthesia and sedation. 20% of the patients get surgery with general anaesthesia. For the Edwards-Sapien(®) valve, when the femoral approach is impossible, the patient can get surgery with general anaesthesia using the transapical access.

Plethysmographic variability index (PVI) is an accurate predictor of fluid responsiveness in mechanically ventilated patients. However, the site of measurement of the plethysmographic waveform impacts its morphology and its respiratory variation. The goal of this study was to investigate the ability of PVI to predict fluid responsiveness at three sites of measurement (the forehead, ear, and finger) in mechanically ventilated patients under general anaesthesia.We studied 28 subjects after induction of general anaesthesia. Subjects were monitored with a pulmonary artery catheter and three pulse oximeter sensors (the finger, ear, and forehead). Pulse pressure variation, central venous pressure, cardiac index (CI), and PVI measured at the forehead, ear, and finger (PVI(forehead), PVI(ear), and PVI(finger)) were recorded before and after fluid loading (FL). Subjects were responders to volume expansion if CI increased15% after FL.Areas under the receiver-operating curves to predict fluid responsiveness were 0.906, 0.880, and 0.836 for PVI(forehead), PVI(ear), and PVI(finger), respectively (P0.05). PVI(forehead), PVI(ear), and PVI(finger) had a threshold value to predict fluid responsiveness of 15%, 16%, and 12% with sensitivities of 89%, 74%, and 74% and specificities of 78%, 74%, and 67%, respectively.PVI can predict fluid responsiveness in anaesthetized and ventilated subjects at all three sites of measurement. However, the threshold values for predicting fluid responsiveness differ with the site of measurement. These results support the use of this plethysmographic dynamic index in the cephalic region when the finger is inaccessible or during states of low peripheral perfusion.

To evaluate whether intensivists would accept to optimize their orderings of biological samplings, x-rays and target drugs and to assess the consequence on patient's outcome.Monocentric evaluation of medical economic procedure.Meetings of consultants, registrars and residents started on Dec 21, 2006 with two to three sessions a year in order to evaluate the process of medical ordering. The physicians and pharmacists gave the results of orderings at each meeting. Orderings of systematic samplings, bedside x-rays and unjustified expansive drugs were discouraged, but target samplings and lung ultrasonography were encouraged. New residents were systematically taught about this programme. Meanwhile, monthly morbidity-mortality meetings were pursued in order to assess the consequences of this politics.While ICU total production increased by 3.4% and potentially evitable deaths decreased by 34%, annual expenses decreased by approximatively € 777,000 from 2006 to 2008. This was due to decreased orderings in biology by 30%, bedside x-rays by 10%, computed tomographic scans by 16% and target drugs by 35%. However, an increased ordering in four target drugs was observed in 2008 as compared with 2007.Multidisciplinary optimization of medical ordering can be efficient in ICU. However, a profit-sharing with ordering physicians would be necessary to prolong these effects.

Les complications liees a l’immobilite, a l’alitement et aux gestes plus ou moins invasifs en reanimation font l’objet d’une prevention reposant sur des procedures ecrites enseignees a tous les soignants. En effet, leur survenue prolonge souvent le sejour, augmente la charge en soins, induit des couts supplementaires et met parfois en jeu le pronostic vital.

L’ensemble de ces gestes est simple a mettre en place. Cependant, dans le cadre de l’urgence, ces gestes faciles a realiser en salle de cours se revelent souvent oublies ou mal effectues au prejudice de la victime en periode de stress. Pour maintenir ces acquis, il est donc necessaire de revoir ces gestes lors de la formation continue afin d’avoir des automatismes durant ces periodes anxiogenes.

Massive haemoptysis are rare in pregnant woman. Besides usual causes of haemoptysis, cases of idiopathic haemoptysis have been described during pregnancy, probably with a hormonal role. A pregnant woman at 22 weeks amenorrhoea was admitted in intensive care unit for massive and recurrent haemoptysis, enhanced by bouts of hypertension in a context of preeclampsia. Arteriography showed bronchial hypervascularisation, with abnormally dilated bronchial arteries, and a lot of collateral arteries. Three sessions of bronchial artery embolization have been performed with success. The management of idiopathic haemoptysis in pregnant woman seems to be based on the usual algorithm of management, emphasizing on the control of blood pressure, and the key role of interventional radiology.

Cardiopulmonary bypass (CPB) is a medical act that can be performed by nurses as long as they are constantly supervised by a physician. No initial formalized training course is required. The personal responsibilities of nurses and physicians about CPB have not been defined.The purpose of this study was: to list perfusionists; to evaluate the training of perfusionists; to determine which physicians are considered as in charge during actions performed by paramedics, as well as their qualification; to point out the changes since 1997.Professional practice assessment.A questionnaire was sent to all perfusionists in activity in France.There were 71% of replies. We found an aging of perfusionists (median 49 years vs. 40 years in 1997), a fall in the proportion of trained physicians (13% of perfusionists had a training course in adequacy with professional guidelines, 25% of perfusionists said they worked with a physician who could intervene at all time, and 61% declared only one physician was in charge). There is no CPB referent in 26% of perfusion units.An urgent need appears to define the respective responsibilities of medical and paramedical perfusion staff, especially as this technique spreads out of the conventional cardiac surgery operating theatres.

To describe preload dependence monitoring tools currently available as well as their limits and potential applications in the anaesthesiology setting.References were obtained from PubMed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: fluid responsiveness, cardiopulmonary interactions, preload dependence, hypovolemia, cardiac output.When measured in optimal conditions, dynamic parameters are the best predictors of fluid responsiveness as compared to static indicators in patients under general anaesthesia and mechanical ventilation. These dynamic parameters rely on cardiopulmonary interactions and allow evaluating preload dependence and the ability of the heart to transform an increase in preload into an increase in cardiac output. Recently, it is possible to monitor these dynamic parameters either invasively (from the arterial pressure waveform) or noninvasively (from the plethysmographic waveform). These tools have intrinsic limitations. However, they have potential to be used for fluid optimization during anaesthesia.

Thoracic bioimpedance has been proposed for cardiac output (CO) determination and monitoring without calibration or thermodilution (ICG Monitor 862146, Philips Medical System, Philips, Suresnes, France). The accuracy and clinical applicability of this technology has not been fully evaluated in the cardiac surgery setting. We designed this prospective study to compare the accuracy of the ICG Monitor (CO(ICG)) versus pulmonary artery catheter standard bolus thermodilution (CO(PAC)) in patients after cardiac surgery or having benefited from cardiac surgery.Prospective, monocentric.We studied 13 patients in the postoperative period. CO(ICG) and CO(PAC) were determined at the arrival in the intensive care unit and every four hours. Bland-Altman and Critchley and Critchley's analysis were used to assess the agreement between CO(ICG) and CO(PAC).CO(PAC) ranged from 2.6 to 11.0 l/min and CO(ICG) ranged from 1.8 to 11.7 l/min. There was a significant relationship between CO(PAC) and CO(ICG) (r=0.61 ; p0.001). Agreement between CO(PAC) and CO(ICG) was -0.5+/-1.3 l/min (Bland-Altman analysis). Percentage error between the two methods was 49% (Critchley and Critchley's analysis).We found clinically unacceptable agreement between CO(ICG) and CO(PAC) in this setting. Despite its non invasiveness, this device cannot be recommended for CO monitoring in the postoperative period following cardiac surgery.

Steinert disease, the most common myopathy in adults, is a challenge for anaesthesiologists and critical care physicians during the perioperative time. The risk of myotonic crisis, malign hyperthermia and the increased sensitivity to anaesthetic drugs shouldn't be forgotten. On contrary, Steinert disease is rarely revealed in the postoperative period. It should be evoked in case of postoperative pulmonary complications such as difficult weaning with neurological symptoms like hypotonia or muscular weakness.

BACKGROUND AND OBJECTIVE Patients with impaired renal function are at risk of developing renal dysfunction after abdominal aortic surgery. This study investigated the safety profile of a recent medium-molecular-weight hydroxyethyl starch (HES) preparation with a low molar substitution (HES 130/0.4) in this sensitive patient group. METHODS Sixty-five patients were randomly allocated to receive either 6% hydroxyethyl starch (Voluven); n = 32) or 3% gelatin (Plasmion); n = 33) for perioperative volume substitution. At baseline, renal function was impaired in all study patients as indicated by a measured creatinine clearance < 80 mL min(-1). The main renal safety parameter was the peak increase in serum creatinine up to day 6 after surgery. RESULTS Both treatment groups were compared for non-inferiority (pre-defined non-inferiority range hydroxyethyl starch < gelatin + 17.68 micromol L(-1) or 0.2 mg dL(-1). Other renal safety parameters included minimum postoperative creatinine clearance, incidence of oliguria and adverse events of the renal system. Baseline characteristics, surgical procedures and the mean total infusion volume were comparable. Non-inferiority of hydroxyethyl starch vs. gelatin could be shown by means of the appropriate non-parametric one-sided 95% CI for the difference hydroxyethyl starch-gelatin [-infinity, 11 micromol L(-1)]. Oliguria was encountered in three patients of the hydroxyethyl starch and four of the gelatin treatment group. One patient receiving gelatin required dialysis secondary to surgical complications. Two patients of each treatment group died. CONCLUSION As we found no drug-related adverse effects of hydroxyethyl starch on renal function, we conclude that the choice of the colloid had no impact on renal safety parameters and outcome in patients with decreased renal function undergoing elective abdominal aortic surgery.

Recently published studies have shown that intraoperative fluid optimization decreases postoperative morbidity and hospital stay [1]. On the other hand, if inappropriate, volume expansion may have deleterious effects. Therefore, preload dependence and fluid responsiveness assessments are of major importance during surgery. Static indicators of fluid responsiveness such as central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), or left ventricular end diastolic area index (LVEDAI) are invasive or uneasily available and have been shown to be poor predictors of fluid responsiveness [2, 3, 4, 5, 6]. Dynamic indicators, relying on the respiratory variations in stroke volume or its surrogates in mechanically ventilated patients, have been shown to be superior to static indicators for the prediction of fluid responsiveness [2, 3, 4, 5, 6]. However, they are either invasive (respiratory variations in arterial pulse pressure (ΔPP), stroke volume variations) with their associated complications [7, 8], technically challenging (respiratory variations in pulse Doppler aortic flow velocity, inferior vena cava diameter) or not widely available (oesophageal Doppler [9]).

Arterial oxygen saturation (SaO(2)) monitoring using pulse oximeter (SpO(2)) is mandatory in the intensive care unit. The aim was to assess bias and precision of new (SpO(2)ng) and old (SpO(2)og) pulse oximeter technologies in the postoperative period following pediatric cardiac surgery in cyanotic children.Prospective, monocentric.Ten patients (7 days to 53 months old) were studied in the postoperative period following palliative cardiac surgery. SaO(2), SpO(2)og, and SpO(2)ng were obtained every 4 hours. SaO(2) of arterial blood sample was obtained from an intra-arterial catheter located in the radial artery, on the same side as the oximeters. Bias and precision were assessed using Bland-Altman analysis.We obtained 136 SaO(2) determinations. Mean SaO(2) was 76+/-15%. SpO(2)og was significantly different from SaO(2), while SpO(2)ng was not different from SaO(2). In 21 (15%) cases, SpO(2)og was not available whereas SpO(2)ng was available in 136 (100%) cases. In the remaining 115 cases, SpO(2)ng's precision was significantly better than SpO(2)og's precision.SpO(2)ng is more accurate and more reliable than SpO(2)og for SaO(2) monitoring in the postoperative period following pediatric cardiac surgery in cyanotic children.

We report a case of enterovirus related pericarditis associated to mediastinitis in a hospitalised 53-year-old male after heart surgery. Mediastinitis caused by enterovirus has not previously been described.

Volatile agents can mimic ischaemic preconditioning leading to a decrease in myocardial infarct size. The present study investigated if a 15 min sevoflurane administration before cardiopulmonary bypass (CPB) has a cardioprotective effect in patients undergoing coronary surgery.Seventy-two patients were randomized in two centres. The intervention group (S) received 1 MAC sevoflurane administrated via the ventilator for 15 min followed by a 15 min washout before CPB, the control group did not. The primary outcome was the postoperative troponin Ic peak. A biopsy of the atrium was taken during canulation for enzyme dosages. Results are expressed as mean (SD).Neither troponin Ic nor tissular enzyme measurement exhibited any difference between the groups: peak of troponin Ic was 4.4 (5.6) in S group vs 5.2 (6.6) ng ml(-1) in control group (ns). Intratissular ecto-5'-nucleotidase activity was 7.1 (4.3) vs 8.5 (11.9), protein kinase C activity was 27.1 (15.7) vs 29.2 (28.7), tyrosine kinase activity was 101 (54.1) vs 98.5 (63.3), and P38 MAPKinase activity was 131.1 (76.1) vs 127.1 (86.8) nmol mg protein(-1) min(-1) in S group and control group, respectively (ns). However there were fewer patients with low postoperative cardiac index in S group (11% in S vs 35% in control group, P0.05) when considering the per protocol population. In S group, 25% of patients required an inotropic support during the postoperative period, vs 36% of patients in control group (ns).This study did not show a significant preconditioning signal after 15 min of sevoflurane administration. The 15 min duration might be too short or the concentration of sevoflurane too low to induce cardioprotection detected by troponin I levels.

The aim of our study was to assess the effect of NutriPDA, a personal digital assistant (PDA)-based clinical decision-support system (CDSS) for the management of artificial nutrition. A CDSS was developed and implemented on a handheld computer for use in the ICU after cardiovascular and thoracic surgery.System impact was assessed in a prospective "before/after" cohort trial.After informed consent we studied 61 patients in the postcardiovascular and thoracic surgery ICU (age17 years, duration of artificial nutrition3 days, length of stay8 days). Patients were divided into two groups (before and after the use of NutriPDA: Group A: 32 patients (4-month period in 2005); group B: 29 patients (4-month period in 2006).There were no significant differences in anthropometric and clinical parameters between the 2 groups. Energetic intakes were80% of basal energetic expenditures in 21% and 1% of patients, respectively (P0.01). Caloric and nitrogen intakes were below international recommendation in Group A: 20+/-4 kcal/kg/d (mean+/-SD), 104+/-30 mg/kg/d, but not in Group B: 26+/-5 kcal/kg/d, 196+/-41 mg/kg/d (P0.01).NutriPDA was found to be able to optimize artificial nutrition by improving caloric intake in ICU. This new software has potential clinical applications.

To be aware of the different grown-up congenital heart diseases. To know their physiopathology, adverse events and the way to manage patients presenting with these pathologies in the anaesthesia for non cardiac surgery setting.References were obtained from Pubmed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: congenital heart disease, congenital cardiac disease, atrial septal defect, ventricular septal defect, Eisenmenger syndrom, cavopulmonary shunt, tetralogy of fallot, endocarditis.Nowadays, there are equal numbers of adults and children with congenital heart disease. These patients can be divided into three different groups: patients with corrective surgery, patients with palliative surgery, and patients with uncorrected congenital heart disease. In the non cardiac surgery setting, anaesthetists will have to cope with increasing number of adult patients with grown-up congenital heart disease. Because of the complexity and the severity of these lesions it is highly recommended to contact referral centers for the management of these patients. The most frequent complications in this setting are: arrhythmia, hypoxia, cardiac failure, and paradoxal air embolism. Anaesthesia management in this setting requires perfect comprehension of the physiology and anatomy. For the most severe pathologies, it is recommended to refer these patients to referral centres.

We report 13 cases of coronary stent patients, undergoing a non cardiac surgery. Despite an heterogenous perioperative management of antiplatelet agents, none of these patients developed any significant complications. Recently, several case reports of postoperative drug eluting stent thrombosis have been reported. However, the actual incidence of this dramatic event is not known. This confirms the need to perform prospective studies or registries of patients with coronary stents undergoing non cardiac surgery, in order to propose evidence-based recommendations on perioperative antiplatelet management in such patients.

Respiratory variations in pulse oximetry plethysmographic waveform amplitude (DeltaPOP) are related to respiratory variations in arterial pulse pressure (DeltaPP) in the critical care setting. The aims of this study were to test the hypothesis that in mechanically ventilated patients undergoing general anaesthesia, DeltaPOP calculation is feasible and can detect changes in preload.Twenty-five mechanically ventilated patients were studied immediately after induction of general anaesthesia. Haemodynamic data (mean arterial pressure [MAP], central venous pressure [CVP], DeltaPP and DeltaPOP) were recorded at baseline, before and after tilting the patient from anti-Trendelenburg to Trendelenburg position in order to induce preload changes.Change from anti-Trendelenburg to Trendelenburg position induced changes in MAP (58 +/- 9 to 67 +/- 10 mmHg, P0.05), CVP (4 +/- 4 to 13 +/- 5 mmHg, P0.05), DeltaPP (14 +/- 8 to 7 +/- 5%, P0.05) and DeltaPOP (17 +/- 12 to 9 +/- 5%, P0.05). There was a significant relationship between DeltaPOP in anti-Trendelenburg position and percent change in MAP after volume expansion (r = 0.82; P0.05).DeltaPOP can be determined in the operating room and is influenced by changes in preload. This new index has potential clinical applications for the prediction of fluid responsiveness.